Chapter 32 Heart Failure Flashcards
Exam 2
the priority concept for this chapter
perfusion
an interrelated concept of this chapter is IMMUNITY, why?
expends too much energy to stay in homeostasis, that it lowers the body’s energy to fight off diseases
What is heart failure?
- the heart can’t pump enough blood to meet the metabolic needs of the body
- results from several acute & chronic cardiovascular problems
- classification system A to D based on physical exam, diagnostic tests, symptoms
comorbitities/ progression
the more issues you have the more diagnostic testing you will need.. the more progressed you are…
the most common cause of heart failure
-other causes of heart failure
CAD
(HTN, cardiomyopathy, substance abuse, valve disease)
What results from common chronic health problems with acute exacerbations requiring multiple hospitalization?
heart failure
Types of heart failure
- Left-Sided Heart Failure
-systolic dysfunction
-diastolic dysfunction - Right-Sided Heart Failure
- High-Output Heart Failure
ejection fraction
:the percentage of blood ejected from the heart during systole
Normal ejection fraction?
50%- 70%
cardiomyopathy
:a subacute or chronic disease of cardiac muscle, and the cause may be unknown.
Preload
:volume of blood in ventricles at end of diastole (end diastolic pressure)
-right side
Afterload
:resistance left ventricle must overcome to circulate blood
-left side
contractility
:the heart strength with pumping and its force
Heart Failure Causes Mneumonic
- Faulty heart valves (floppy or stiff)
- Arrhythmias (any rhythm that is not normal sinus)
- Infarction (MI) (heart attack)
- Lineage (family line) (genes; family hx)
- Uncontrolled HTN
- Recreational Drug Use [cigarettes (1= 4hrs); caffiene]
- Envaders (instead of Invaders) (infections, bacteria, viruses)
The most common type of heart failure
left-sided heart failure (aka: Congestive Heart Failure, CHF)
The 2 types of Left-Sided Heart Failure are?
- Systolic
- Diastolic
systolic
the squeeze; resistance; pumping out
diastolic
relaxation to receive
Left-Sided HF=
Left ventricle cannot pump blood out efficiently
Left-Sided HF
As the left ventricle (LV) continues to fail, what happens to the cardiac output (CO)?
it drops
Left-Sided HF
When blood is not effectively pumped out into the body and it backs up into the lungs, what does this cause?
- pulmonary congestion
- dyspnea
- activity intolerance
Left-Sided HF
Blood is not effectively pumped out into the body so…
it backs up into the left atrium then into the lungs
Left-Sided HF
If LV failure persists:
- pulmonary edema
- right-sided heart failure
Left-Sided HF
systolic dysfunction:
- occurs when the LV can’t pump enough blood out to the systemic circulation
- EF% falls
- Blood backs up into the pulmonary circulation causing increased pressure in the pulmonary venous system
Causes of Systolic Dysfunction:
- MI
- Dilated cardiomyopathy arrhythmias
ICD
internal cardiac defibrillator
the harder/ longer your heart works..
the weaker the heart gets –> overworked –> tired –> can’t resist lethal arrhythmias
the weaker the heart, more of a risk of?
for having Vfib or pulseless
ICD shocks pt into what?
normal sinus rhythm
Who qualifies for an ICD?
pt who has low EF (<30%)
2nd subtype of Left-Sided HR?
Diastolic Dysfunction
With Diastolic Dysfunction the left ventricle loses its ability to what?
relax normally
Why does the LV lose it’s ability to relax during Diastolic Dysfunction?
- because the muscle has become stiff (stenotic)
- the heart can’t properly fill with blood during the resting period between each beat
to maintain cardiac output, what is needed
higher volumes in the ventricles
WIth the heart not being able to properly fill with blood during the resting period between each beat results in what?
the development of pulmonary congestion & peripheral edema (because of the backing up of fluid)
Diastolic Dysfunction is a what problem?
filling problem
Causes of Diastolic Dysfunction?
- LV hypertrophy
- Hypertension
- Cardiomyopathy
- MI
- Cardiac tamponade
This form of HF is less common due to systolic dysfunction and treatment is not as clear.
Diastolic Dysfunction
Left Ventricular Failure causes Decreased Cardiac Output. What are the s/s?
- fatigue
- weakness
- oliguria during the day (nocturia at night)
- angina
- confusion, restlessness
- dizziness
- tachycardia, palpitations
- pallor
- weak peripheral pulses
- cool extremities
Left Ventricular Failure causes Pulmonary Congestion. What are the s/s?
- Hacking cough, worse at night
- dyspnea/ breathlessness
- crackles or wheezes in lungs
- frothy, pink-tinged sputum
- tachypnea
- S3/S4 summation gallop
Right-Sided HF=
result from ineffective pumping of “used” blood received from the body to get it back into the lungs for O2
Right-Sided Heart Failure –>
Rest of the body
Left-Sided Heart Failure –>
lungs (but not always)
What is the most common cause of Right-Sided Heart Failure?
Left-Sided Heart Failure (right side overworked r/t >fluid pressure from left HF)
What are some causes of Right-Sided Heart Failure?
- Left-Sided Heart Failure
- Right-Sided Ventricular MI or Pulmonary Embolus
- Arrhythmias
- Volume overload
- Mitral & pulmonic valve stenosis
- cardiomyopathy
What’s going on in Right-Sided HF?
the left-side isn’t doing it’s part, and causes the right- side to be overworked
What happens when blood isn’t pumped effectively through the right ventricle to the lungs?
blood backs up into the right atrium and into the peripheral circulation
Right-Sided HF
What happens when blood backs up into the peripheral circulations?
- patient gains weight
- peripheral edema
- engorgement of the kidney and other organs
- jugular vein distention
- ascites
- essentially backflow to the rest of the body… causing edema/ overload
What will the patient present with when experiencing Right-Sided HF?
- weight gain
- peripheral edema
- decreases CO
- distended neck veins (jugular)
- enlarged liver (built-up pressure congesting the hepatic vein)
Right Ventricular Failure causes:
- systemic congestion
- jugular distention
- enlarged liver and spleen
- anorexia and nausea
- dependent edema (legs and sacrum)
- distended abdomen
- swollen hands and fingers
- polyuria at night
- weight gain
- increased blood pressure (from excess volume) or decreased blood pressure (from failure)
systolic heart failure problem?
pumping problem
High-Output Heart Failure
- increased metabolic needs or hyperkinetic conditions
- rare type of HF
- occurs when the body’s need for blood is unusually high
- heart failure symptoms exist even though the heart is working well
- not enought blood to meet the demand
What can cause High-Output HF?
- pregnancy
- severe anemia
- hyperthyroidism
- septicemia
- high fever
Why would severe anemia cause High-Output Heart Failure?
requires the heart to pump more blood each minute to deliver enough oxygen to the tissues of the body
Why would hyperthyroidism cause High-Output Heart Failure?
increases the body’s overall metabolism, thus increasing the demand for blood flow
All types of HF eventually lead to reduced CO, which triggers what to improve CO at the expense of increased ventricular work?
Compensatory Mechanisms
Compensatory Mechanisms
- increased sympathetic activity
- activation of the RAAS (kidneys)
- Ventricular dilation [increase in pre-load; makes the heart work harder (stretched out rubber band)]
- Ventricular hypertrophy (increased ventricular muscle mass allowing the heart ot pumpagainst stronger resistance= weaker heart muscle & increased the O2 demand on the heart)
- Other:
-MI (immune response) [increase in inflammation & irritation]
-B-type natriuretic peptide (BNP) [the more the ventricle has to stretch the more hormone it releases (BNP), increases fluid= increased BNP = increased ventricle stretch= increased BNP= HF]
-low CO
-endothelin (potent vasocontrictor)
Early signs of Left-Sided HF
- dyspnea (difficulty breathing)
- orthopnea (short of breath while laying down)
- paroxysmal nocturnal dyspnea (difficulty breathing at night)
- fatigue
- nonproductive cough (congested but not enough to cough it up)
Later signs of Left-Sided HF
- crackles on auscultation
- hemoptysis (coughing up blood/ blood is backed up in the lungs- coughing up blood)
- displacement of the PMI (apical) toward the left anterior axillary line (point of max impulse- lungs are full so it pushes heart out of the way)
- tachycardia
- cool, cynaotic skin
- confusion (not oxygenated; brain isn’t getting enough O2)
Clinical S/S of Right-Sided HF
- neck vein distention
- hepatojugular reflux & hepatomegaly
- RUQ pain
- anorexia and nausea
- nocturia
- weight gain
- pitting edema
- ascites or anasarca (general swelling of the whole body)
LEFT- SIDED HEART FAILURE- mnemonic
- D dyspnea
- Y yellow secretions (SS=infection)
- S stridor, decreased SaO2
- P pulmonary crackles, pulse increased
- N nasal flaring, grunting, retracting
- E elevation in the RR
- A activity intolerance
Right-Sided Heart Failure mnemonic
- E enlarged liver (hepatomegaly)
- D distended neck veins
- E enlarged spleen
- M most edema in LE
- A ascites, anorexia
What will a Chest X-ray tell us re: HF?
interstitial edema, pleural effusions, cardiomegaly
What will a ECG tell us re: HF?
may indicate hypertrophy, ischemic changes, or infarction & reveal tachycardia
What will LABS tell us re: HF?
abnormal liver function, elevated BUN
What will ABGs tell us re: HF?
may reveal hypoxemia from impaired gas exchange
What will ECHO tell us re: HF?
may reveal LV hypertrophy, dilation, and abnormal contractility
What will a PAP tell us re: HF?
increased, decreased CO/ CL
What will a LEXI-SCAN (stress test) tell us re: HF?
may be <40% in diastolic dysfunction
What is the best indicator for EF?
Heart Cath
What is the goal of therapy?
to increase perfusion with adequate cardiac output
Digoxin
anti-arrhythmias
If electrolyte imbalance Digoxin could causes what? S/S?
toxicity; yellow or green halos in their vision
Nonsurgical options for treating HF
- continuous positive airway pressure (CPAP) [keeps alveoli open to force out fluid]
- cardiac resynchronization therapy (CRT) [Bi ventricular pacing - perm pacemaker/ or combined w/ defib]
- cardioMEMS implantable monitoring system placed in pulm. artery- keeps an eye on pap –> datea downloaded to dr office, who in turn adjusts the med dosage per data]
- investigative gene therapy [end-stage heart failure; for pts who can’t have other interventions; replaces genes through a series of injections]
What’s our plan of action re: HF?
- Diuretics (to reduce fluid volume)
- Vasodilators (decrease preload & afterload {svr})
- Inotropes (augment contractility {cardiac output})
Inotropes
- Digatalis
- Carvedilol
- Metoprolol [suc (EXT REL) and tartrate]
Nonpharm Measures to treat HF
- limit salt intake to 2g/ daily (approx. 1 tsp)
- decrease and/or avoid alcohol intake (no more than 1 drink/ daily)
- possible fluid intake restriction
- avoid smoking
- mild exercise is encouraged (in general)
- weight loss (if applicable) healthy bmi encouraged
Surgical Management of HF
- CABG
- CABG, VAD, ICD, or Biventricular pacemaker
Coronary Artery Bypass Graft (CABG)
:Surgical procedure in which occluded arteries are bypassed with the patient’s own venous or arterial blood vessels or synthetic grafts
Nursing Considerations: HF
- sit pt in fowler’s position
- monitor O2 sat/ ABGs
- cardiac monitoring: note any changes in rate/ rhythm (irregular- AFIB, PVCs)
- assess respiratory status frequently (changes quickly; flash pulm. edema –> frothy pink sputum= emergency)
- daily weights (1-2 lbs overnight or 3lbs wkly; fluid retention) (same time of day, same type of clothing, same weighing method)
- hourly I&Os
- Labs (BNP, ABG, BUN/ Creatitine, electrolyes (esp. potassium levels)
Heart Failure Self-Management Health Teaching (MAWDS)
Medications:
* take meds as prescribed & do not run out
* know the purpose & side effects of each drug
* avoid NSAIDs to prevent sodium and fluid retention
Activity:
* stay as active as possible but don’t overdo it
* know your limits
* be able to carry on a conversation while exercising
Weight:
* weigh each day at the same time on the same scale to monitor for fluid retention
Diet:
* limit daily sodium intake to 2-3g/ day as prescribed
* limit daily fluid intake to 2L
Symptoms:
* Note any new or worsening symptoms & notify the health care provider immediately
Nursing Safety Priority- Education HF S/S
Teach the patient and caregiver to immediately report to the primary health care provider the occurrence of any of these symptoms, which could indicate worsening or recurrent heart failure:
* rapid weight gain (3lb in a week or 1-2lb overnight)
* decrease in exercise tolerance lasting 2-3 days
* cold symptoms (cough) lasting more than 3-5 days
* excessive awakening at night to urinate
* development of dyspnea or angina at rest or worsening angina
* increased swelling in the feet, ankles, or hands
frothy, pink-tinged sputum
a sign of life-threatening pulmonary edema
impaired tissue perfusion and pulmonary congestion are associated with which ventricular failure?
left ventricular failure
systemic venous congestion and peripheral edema are associated with which ventricular failure?
right ventricular failure
Left ventricular failure is associated with decreased cardiac output and elevated pulmonary venous pressure. It appears as:
- weaknes
- fatigue
- dizziness
- acute confusion
- pulmonary congestion
- breathlessness
- oliguria (scant urine output)
An irregular heart rhythm resulting from premature atrial contractions (PACSs), premature ventricular contractions (PVCs), or atrial fibrillation (AF) is come in what?
heart failure
What is often the first sign of HF?
a third heart sound called S3 gallop- which is an early diastolic filling sound indicating an increase in left ventricular pressure
What is the most reliable indicator of fluid gain and loss?
weight (daily weights)
Any impairment of renal function resulting from inadequate perfusion causes what?
elevated blood urea nitrogen & serum creatinine; decreased creatinine clearance levels
Hemoglobin & hematocrit tests should be performed to indentify HF resulting from anemia. If the patient has fluid volume excess, the hematocrit levels may be what?
low as a result of hemodilution
BNP is used for dxing which HF in particular?
diastolic HF
BNP is the body’s response to what?
decreased cardiac output (CO) from either left or right ventricular dysfunction
What will a UA reveal? (heart failure lab assessment)
proteinuria, high specific gravity; microalbuminuria
What is microalbuminuria (UA) a early indicator of?
decreased compliance of the heart and occurs BEFORE the BNP rises; serves as an “early warning detector” that lets the primary health care provider know that the heart is experiencing early signs of decreased compliance long before symptoms occur
What diagnostic imaging is considered the best tool in dxing heart failure?
echocardiography
PAP
pulmonary artery pressure
Which drug class is the drug class of choice in the treatment of HR?
ACE inhibitors
All types of HF lead to reduced CO, which triggers what?
compensatory mechanisms that improve CO at the expense of increased ventricular work
