CHF (Chronic) Flashcards
What is CHF?
A cardiovascular condition in which the heart is unable to pump an adequate amount of blood. It is not a disease, but a syndrome.
What are the most common causes of CHF?
HTN (hypertension), CAD (coronary artery disease), and MI’s (most common)
Does the right or left side of the heart cause the most problems?
Left-sided causes most problems of heart failure.
What increase with each hospitalization?
mortality rates increase
What is the most common reason for hospital readmissions in adults >65
Heart failure
What are some risk factors for CHF?
CAD Advancing age HTN Smoking Diabetes Obesity High cholesterol
What is pre-load?
Myocardial stretch of the heart and the amount of volume allowed to completely fill the ventricle.
What is the difference between HF and MI?
MI is not enough blood flow.
HF is due to pump problem.
What is after load?
Resistance the left ventricle has to overcome in order to force blood out of the left ventricle into the aorta.
What is Contractility?
The amount of contraction force the muscle has. (heart)
What is heart Rate?
Number of contractions per min. 60-100
What is the Etiology of HF?
May be caused by any interference with mechanisms that control Cardiac Output
What is a major issue with HF?
Increased vascular volume.
Know if patients have increase or decrease volume
Weigh patients
Heart failure can be described as…
systolic (progressing forward) or diastolic (backward)
Discribe systolic.
Most common cause of CHF; inadequate delivery of blood into the arterial system due to a decreased ability of the myocardial muscle to contract (MI), increased afterload (HTN), or mechanical abnormalities (valve problem).
What is systolic classified as?
Problem with pump (contractility)
<45% Ejection fraction (EF)
EF: amount of blood ejected from LV with each contraction
(nl: 50-60%)
Describe diastolic?
Nothing to do with contractility. Is a disorder of relaxation and filling due to stiff ventricular walls. Less flexible and more rigid (big problem with venous engorgement and it’s very common to have normal EF with diastolic heart failure)
Can a client have mixed systolic and diastolic HF?
Yes. Problems with contraction and also with the relax and refill.
In addition to systolic and diastolic, HF can be classified as?
Right sided or left sided.
Which is the most common left or right?
Left.
What is left sided HF?
is a disturbance of the contractile function of the LV; may result from LV MI, mitral/aortic valve disease, HTN.
What are symptoms of left sided HF?
Symptoms will always be pulmonary (shortness of breath, crackles, dypsnea, altered LOC or altered mental status, fast RR)-go to lungs S3
What is right sided HF?
Is a disturbance of the contractile function of the RV; may result from a PE, right vent. MI, but most commonly from L sided failure.
What are the symptoms of right sided HF?
Symptoms in the periphery (edema, JVD, organ enlargement-hypotemegaly, enlargement of spleen, weight gain, ascites-fluid collection in abdomen)
Sympathetic Nervous System Activation?
usually the first compensatory mechanisms to occur in response to a low CO. Epinephrine and Norepinephrine are released to: try to increase the cardiac output (HR), make more forceful contraction of heart (increased contractility), vasoconstriction.
What are Compensatory Mechanisms?
Sympathetic Nervous System Activation Hormonal Response Ventricular Dilation Ventricular hypertrophy Counterregulatory Mechanism
Why does the sympathetic nervous system activation release Epinephrine and Norepinephrine?
try and increase the cardiac output (HR), make more forceful contraction of heart (increased contractility), vasoconstriction.
What order does the sympathetic nervous system take place?
First to respond but least effective
What consists of the Hormonal Response?
decreased glomerular blood flow to kidneys makes the kidneys think there is a decreased volume. In response, the kidneys release renin, which converts angiotensinogen to angiotensin.
Angiotensin causes:
a. adrenal cortex to release aldosterone (makes us retain water and sodium)
b. cause an increase in peripheral vasoconstriction (which increases BP)
A decreased cerebral blood flow causes the Posterior Pituitary:
Secrete ADH
What does the secretion of ADH do?
retain, increase water retention (increase volume)
What consists of Ventricular Dilation?
heart chambers enlarge and then are so stretched out they lose elasticity and ability causing poor contractility
What consists of Ventricular hypertrophy?
have an increase in muscle mass of the heart and wall of the heart will thicken
What are the SE to the increased muscle mass of the heart?
less effective at pumping, needs more oxygen because it’s bigger, and also more prone to dysrhythmias
Counterregulatory Mechanism:
B-type natriuretic peptide (BNP) is released by stretched myocardium.
BNP is released to:
Released to decrease pre-load and decrease afterload, and basically vasodilates. If its greater than 100, its diagnostic for heart failure
Higher the number, the worse the failure
Cardiac compensation is occurring when:
all of these mechanisms maintain CO for adequate tissue perfusion.
Cardiac decompensation occurs when:
these mechanisms can no longer maintain CO and tissue perfusion is tissue perfusion is compromised.
When does Acute Decompensated Heart Failure (ADHF) occur?
occurs as a result of an acute event and there is no time for compensatory mechanism to be initiated. (aggressive IV diuretics to decrease pre-load and afterload)
What are examples of ADHF?
Pulmonary edema is an example.
Frothy sputum
What intervention must a nurse do for ADHF?
aggressive IV diuretics to decrease pre-load and after-load
What are some HF clinical manifestations?
Fatigue Dyspnea Tachycardia Edema Nocturia Skin changes Behavioral Chest pain Weight gain
Fatigue:
one of the earliest symptoms, noticed with usual activities
What causes fatigue?
(cause: low cardiac output) Anemia can cause the fatigue. Decreased profusion is a decrease in RBC production.
Dyspnea:
common manifestation (Ask to identify breathing as a problem-ask about how many pillows or sleeping on recliner, ask about a cough (sometimes dry hacking cough is one of the first signs patient really notices) PND (paroxysmal nocturnal dyspnea).
What is the main intervention for dyspnea?
Face is red, raise the head. Face is pale, raise the tail
Tachycardia:
early manifestation (compensatory mechanism)-heart is trying to compensate and improve cardiac output. (If pt is on a beta blocker, tachycardia will not occur).
What can prevent tachycardia?
Beta-blocker
Edema:
a weight gain of 3 pounds or greater within 2 days is significant
Teach client to weight themselves every day, at the same time, on the same scale.
Dependent edema:
lower extremities if they’re up walking
if bedridden, its on back, sacral
Edema on the liver:
hepatomegalia
Edema: abdominal cavity
ascites
Pulmonary edema:
you know by hearing crackles upon
auscultation. Pleural cavity can be affected.
Nocturia:
decreased urinary output during the day and when they lie down, fluid moves back to the vasculature then increases GFR, then they have to use it at night
Skin changes:
dusky, cool, clammy, and usually shiny because it’s swollen, can be tight.
Behavioral:
Changes due to decrease blood flow. Change in LOC, personality change might be the first sign of hypoxia (behavior and change in LOC)
Chest pain:
because of poor coronary perfusion and increased work load of the heart
Weight gain:
daily weighed(exacerbation-more than 3 pounds in 2 days)keep diary of the weights
What are some complications with HF?
Pleural Effusion Dysrhythmias Left Ventricular Thrombus Hepatomegaly Renal Failure
Pleural Effusion:
due to increased pressure so you have fluid collection in the pleural space (they’ll drain it, Chest tube, thoracentesis)
Dysrhythmias:
stretching of the heart can alter electrical pathway (one common dysrhytmia is a.fib-at risk for clots , risk for fatal dysrhythmias
Left Ventricular Thrombus:
at risk for clot because of poor blood flow from the left ventricle (need anticoagulants)
Hepatomegaly:
enlarges to the point that it gets fibrotic, can go into liver failure. Put at risk for cirrhosis.
Renal Failure:
decreased Cardiac output leads to decreased GFR which can lead to renal failure
Management of Chronic Heart Failure:
a) Primary goal is to correct underlying problems if possible
b) maximize CO
c) treat symptoms
d) preserve organ function
What is causes hypoxemia…
by inadequate oxygenation in the lungs. Can be helped with reduction of activity to decrease cardiac work and/or by supplemental O2 administration.
What is Cardiac Resynchronization Therapy (CRT)?
Coordinates left and right contractility through biventricular pacing. This improves CO and therefore quality of life. Permanent pace maker-pace atria and ventricles-increase cardiac output.
Implantable cardioverter/defibrillator (ICD):
Pace maker and if it detects d-fib: it will shock the pt.
What is IABP (Inter Aortic Balloon Pump), or VAD?
go in the body and pump for the heart as you’re waiting for your transplant
Ventricular Assist Devices (VAD)?
may be use for a couple of years while waiting on a heart transplant. External.
What are two types of diagnostics testing for HF?
Echocardiagram and/or nuclear imaging studies
BNP (B-Type Naturetic Peptide)
Echocardiagram and/or nuclear imaging studies
can help diagnose and measure EF. (EF: 65-75%) decrease with HF
Shows size of heart, non-invasive, good tool for diagnostics
Also nuclear images is good
BNP?
Greater than 100 is HF
What are the 3 main objects for managing HF?
a) mobilize edematous fluid: by increasing urinary output
b) decrease pulmonary venous pressure
c) decrease pre-load and increase cardiac output
What are the 6 types of drugs used for HF?
1) Diuretics
2) Vasodilators
3) Beta-blockers
4) Morphine
5) Positive Inotropes
6) Angiotensin II Receptor Blockers (ARB’s)
Diuretics:
are used to decrease edema in the interstitial and pulmonary tissues; and to decrease preload.
What test should be monitored for diuretics?
Potassium, BUN, Creatine
What are adverse effects of diuretics?
Potassium secretion
ototoxicity
nephrotoxicity
What are the 3 types of Vasodilators?
ACE-Inhibitors
Nitrates
Human b-Type Naturetic peptide
What do ACE-Inhibitors do?
Block the conversion of angiotensin I to II, which is a potent vasoconstrictor. This decreased SVR causes increased CO. Although BP is decreased, tissue perfusion is enhanced due to increased CO and diuresis is enhanced due to a suppression of aldosterone. ACE and diuretics given together have proven to decrease mortality rates in pts. with HF.
What are the SE of ACE Inhibitors?
hypotension, hyperkalemia, monitor first dose because of hypotensive episode), don’t skip doses because it will cause rebound hypertension, risk for angioedema (edema in airway) Allergic reaction.
What do Nitrates do?
Causes vasodilation by acting directly on the smooth muscle of the vascular system. The primary result in decreased preload and afterload.
Why shouldn’t ED meds be taken together?
causes severe hypertension
What is Human b-Type Naturetic peptide?
Nesiritide (natrecor) is a synthetic form of human BNP that can be given IV on an outpt. basis that can significantly improve outcomes for pts. with HF.
Vasodilator only used only for acute HF.
What do Beta-Blockers do?
Useful in that they block the negative effects of the SNS, specifically an elevated HR.
What are SE of Beta-Blockers?
cause sweating, palpitations and headache
What are SE of Beta-Blocker overdose?
profound bradycardia and hypotension and bronchospasm
What should a nurse check before and after giving a
Beta-Blocker?
BP.
Best to take standing and sitting BP on pts. Never stop drugs quickly (rebound).
What does Morphine do?
veno dilator. Dilates veno system and pulmonary vascular system. Decreases per load and anxiety.
What is a Positive Inotropes?
digitalis
What do digitalis do?
work by increasing contractility (inotropic action) and decreasing the speed of conduction (chronotropic action).
What is dig toxicity SE?
GI changes, then visual disturbances (halo,yellow vision) late S/S-dysrhythmias
What are dig levels?
normal 0.9-2.0
What is one of the most common causes for dig toxicity?
Hypokalemia
What decreases the effects of dig?
Hyperkalemia
Why are Angiotensin II Receptor Blockers (ARB’s) given?
Given to pts who don’t tolerate ACE inhibitors. Some cannot tolerate ACE inhibitors because of cough. Dry hacking cough.
What does Bidil specifically treat?
specifically used to treat HF in african americans. Is a combination of isosorbide dinitrate (nitrate) and hydralazine (a vasodilator).
What is the most important nutritional advice for HF clients?
Restrict sodium! Less than 2 grams a day!
What type of diet should be used by HF clients?
The DASH (dietary approach to stop hypertension) diet used for pts. with HTN is also beneficial for pts. trying to control the symptoms of HF.
How should patients monitor their fluid weight?
Weigh everyday on the same scale at the same time.
What weight fluctuation should a client report to HCP?
3-5 lbs in one week or more than 2-3 in 2 days
What are acute HF interventions?
ice chips, chewing gum, strict I&O in the hospital.
Given IV diuretics and IV medicines,give a lot of oxygen, monitor for hypoxemia(look for behavior changes), High Fowlers position, monitor crackles in lungs
Pt teaching..
Teach about home meds How to check their pulse or family member how to check it, know S/S of dig toxicity to report Teach how to monitor BP Prevent sickness (take vaccines) DASH diet Fluid restriction if renal involvement Avoid OTC meds unless approved by physician Don’t add salt to food Eat small frequent meals Weigh daily Alternate rest with activity Don’t over exert Go to doctors appointments on schedule Report immediately the weight change
