Heart Failure Flashcards
what is it?
the clinical syndrome described as the inability of the heart to pump an adequate amount of oxygenated blood to meet the body’s demands (adequate cardiac output)
problem with filling
poor compliance or lack of space to fill
contracting problem
poor contractility
Facts
- most common reason for hospitalization in adults >65
- there is no cure , only preventative measures and treatment of symptoms
Primary risk factors
- coronary artery disease (CAD)
- advancing age
HF 101
The goal is to improve cardiac output
Cardiac output
the amount of blood ejected out of the ventricles each minute
co=sv x hr
Cardiac index
is cardiac output adjusted for body size
ci= co/bsa bsa= height x weight /3600
Stroke volume
the amount of blood ejected from the ventricles with each ventricular systole (contraction)
Hemodynamics
co = 4-8 liters /min CI= 2.5-4 liter/min SV= 60-130mls
3 parts of stroke volume
- preload
- afterload
- contractility
Preload
- measurement of volume
- amount of blood in the heart at the end of diastole
- increased with volume replacement
- decreased by blood loss and diuretics
Afterload
- measurement of resistance
- influenced by vascular resistance, blood pressure, blood viscosity, and aortic /pulmonic stenosis
contractility
- cannot directly measure but can be seen with echocardiogram
- the strength of myocardial contraction
- influenced by preload
Frank starling’s law (or curve)
- as you increase preload contractility will improve…to a point
- too much preload can overstretch the heart and weaken the cardiac muscle causing worsened contractility
what causes the heart to fail
- impaired myocardial function (endocarditis,CAD, cardiomyopathy)
- increased cardiac workload(hypertension, anemia, valve disorders)
- non- cardiac conditions( volume overload, massive pulmonary embolus)
Compensatory mechanisms in the heart
- when the heart begins to fail the body attempts to compensate
- initially these mechanisms are helpful but ultimately they harm the patient only worsening their heart failure
compensation cascade in heart failure
- decreased cardiac output stimulates the SNS to release norepinephrine
- norepinephrine increases HR and contractility but also causes vasoconstriction
- vasoconstriction increases venous return to the heart which increases ventricular filling
- overfilling stretches the heart causing myocardial hypertrophy
- the hypertrophied ventricle has deceased contractility which in turn decreases cardiac output
Heart failure affects every body system
respiratory- fluid overload (pulmonary edema)
neuro- poor cardiac output( confusion, lethargy)
integumentary- poor perfusion and edema puts patients at risk for skin breakdown(swollen, cyanotic)
gastrointestinal- liver congestion and enlargement, ascites, malnutrition
urinary- poor renal perfusion
the kidney’s role in heart failure
- decreased renal perfusion (low cardiac output)
- angiotensin and aldosterone are released
- causes increased anti diuretic hormone
- ADH causes the kidneys to reabsorb more water
- this combination of increased sodium and water leads to a further increase preload
- the weak heart cannot handle the excess fluid (preload) and congestion worsens , heart becomes more dilated and cardiac output drops even more
Types of heart failure
- systolic
- diastolic
- right
- left
Systolic heart failure
-decreases in the amount of blood ejected from the ventricle
causes:
- heart attack
- increased preload
- cardiomyopathy
- mechanical abnormalities
Diastolic heart failure
-when the heart cant fill effectively due to increased resistance to filling
Causes:
- left ventricular hypertrophy from chronic hypertension
- aortic stenosis
- hypertrophic cardiomyopathy
LEFT SIDED HEART FAILURE
- most common type of HF from left ventricular dysfunction
- the fluid back up reaches the pulmonary bed and causes pulmonary edema
SIGNS AND SYMPTOMS OF LEFT SIDED HEART FAILURE
-capillary refill >3 sec
-orthopnea
-dyspnea on exertion nocturnal dyspnea
-cough with frothy sputum (indicative of pulmonary edema)(pink in color)
- tachypnea
-diaphoresis
-basilar crackles or rhonci
-cyanosis
-hypoxia (respiratory acidosis)
- elevated pulmonary artery pressure
low o2=low cardiac output
PULMONARY EDEMA
- the accumulation of fluid in the interstitial tissue and alveoli of the lungs
- rapid interventions necessary of death is eminent
- treat people with :
diuretics
nitrates
morphine
PULMONARY EDEMA ASSESSMENT FINDINGS
cough with frothy sputum blood tinged crackles, wheezes, rhonchi tachycardia hypotension or hypertension orthopnea dyspnea, tachypnea use of accessory muscles cyanosis cool and clammy skin
RIGHT SIDED HEART FAILURE
- not as common as left sided
- usually caused by left sided HF
- other causes include
tricuspid valve problems
pulmonic valve problems
pulmonary hypertension
pulmonary embolus
coronary artery disease of the vessels that feed the right heart
WHAT HAPPENS IN RIGHT SIDED HEART FAILURE
- increased pressure from the pulmonary vasculature causes the right heart to become distended
- the right heart cant effectively empty and fluid backs up in the systemic circulation
- abdominal organs become congested and peripheral tissues become edematous
RIGHT SIDED HEART FAILURE SIGNS AND SYMPTOMS
- hepatomegaly
- splenomegaly
- dependent pitting edema
- venous distention
- hepatojugular reflux
- oliguria
- arrhythmias
- elevated cvp pressure
- elevated right atrial/ventrical pressure
- narrowing pulse pressure
- murmur or tricuspid insufficiency
- audible s3 and s4 heart tones
- fatigue/weakneses
- abdominal pain
- anorexia
- weight gain
- ascites
- enlarged right atrium/ ventricle
DIAGNOSING AND MONITORING HF
- chest x ray- cardiomegaly , pleural effusions
- echocardiogram- wall motion abnormalities, valvular problems, ejection fraction
- electrocardiogram- dysrhythmias
- cardiac catheterization- valves, ejection fraction
- pulmonary artery catheter- response to diuretic therapy pulmonary pressures (ICU)
CHEST XRAY
black- air
white- something
EJECTION FRACTION
the amount of blood ejected during systole compared to the amount of blood in the heart at the end of diastole
- normal =50-70%
- HF=
DIAGNOSTIC LABS
- beta natriuretic peptide(BNP)
GOALS FOR TREATMENT FOR HF
- slow the progression of HF
- Reduce cardiac workload
- improve cardiac function
- control fluid retention
ex;sodium
ACE INHIBITORS
- blocks the RAAS in kidney
- reduce afterload through vasodilation
- reduce ventricular remodeling through suppression of myocyte growth
- decreases preload and left ventricular filling pressures which increase cardiac output
example:
lisinopril
trandolapril
catopril
ARBS
- angiotensin II receptor blockers
- affect similar to ace inhibitors
example:
irbesartan
losartan
valsartan
DIURETICS
-inhibit the absorption of sodium and water and promote their excretion
example: Lasix bumex Diamox hydrochlorothiazide spirolactone
DIgoxin
-cardiac glycoside inhibits the sodium -potassium
pump system and increase cardiac contractility
- increases the refractoriness of AV node which decreases the ventricular response to strial rate (lowers HR)
- is used as a first line drug for pt with HDF who are in AFIB
DIGITALIS S&S
- nausea
- vomiting
- bradycardia
- confusion
BETA BLOCKERS
- improves left ventricular function by inhibiting the sympathetic nervouse system
- anti-arrhythmic properties
- slows HR
- works on contractility
examples:
carvedilol, metoprolol, atenolol
CALCIUM CHANNEL BLOCKERS
softens heart muscle
NITRATES
-cause vasodilation of the vessels which help to decrease cardiac oxygen demand, cardiac preload and afterload while increasing cardiac output.
example: nipride ntg hydralazine prazosin amiodipine
SYMPATHOMIMETIC AGENTS
stimulate the heart to improve the force of contraction
example:
dopamine
dobutamine
PHOSPHODIASTERASE INHIBITORS
increases contractility and causes vasodilation resulting in decreased afterload and increased cardiac output
example:
amrinone
mirinone
NONPHARMACOLOGICAL TREATMENTS FOR HF
- Intra-Aortic balloon pump (IABP placement)
- Ventricular assistive device (VAD) implantation
- Heart transplant
IABP
- balloon placed in aorta that inflates during diastole and deflates during systole
- offers afterload reduction through vacuum effect and increases coronary perfusion upon inflation
- temporarily solution to improve cardiac output for patients in cardiogenic shock
- multiple risks associated with IABP
- decreases workload, only used for two weeks
VENTRICULAR ASSIST DEVICE PLACEMENT
- electromechanical pump which augments or fully replaces the work of the ventricle
- most commonly used in the left ventricle, attaches in the apex of the LV-> blood is redirected through a hose and the pump which allows the blood to bypass the aortic valve -> blood enters the system circulation in the ascending aorta
- “bridge to transplant” “destination therapy”
- patents are at high risk for bleeding
HEART TRANSPLANT
- surgery involves removing the recipients heart , except for the posterior right and left atrial walls and their venous connections
- recipients heart is replaced with the donor heart
- anti rejection medication usually started in OR
- patient is at high risk for infection (compromise host) for rest of their life
FK506 lab done daily
HEART TRANSPLANT LIST
- placed on list according to severity of HF
- waiting period is long, many die
- candidacy is determined by a multi disciplinary health care team
- psych evaluations are done
LIFE WITH A TRANSPLANT
- HIGH DOSE OF IMMONOSUPRESSANTS
- strict regiment
- endomyocardial biopsies
- high risk of infection that lead to complications
- rejection of heart
HEART FAILURE ASSSESSMENT
- monitor vitals/oxygenation/ neuro status
- daily weight
- breath sounds
- capillary refill
- assess for signs: peripheral edema/JVD/ hepatomegaly/ ascities
- pain level
- output
- electrolytes
BASIC NURSING CARE FOR HEART FAILURE PATIENTS
- ABC’s
- oxygen therapy
- continuous cardiac/ pulse oximetry monitoring
- HOB 30 degrees
- pharmacological therapy
- cluster care
- monitor restlessness, anxiety, pain, bowels
- restrict sodium and fluid intake (strict iand o)
PATIENT AND FAMILY DISCHARGE TEACHING
- mediaction
- diet/fluid restrictions
- smoking cessation support
- the importance of follow up Dr’s appointments
- daily weights self- monitoring community resources
