Heart Failure

Question 1

Define heart failure

Answer 1

Heart failure (HF) is a pathologic state in which the heart is unable to pump blood in sufficient amounts to meet the body’s metabolic needs (decreased CO)

Question 2

signs and symptoms

Answer 2

Left-sided heart failure:
Pulmonary edema
Coughing
Dyspnea

Right-sided heart failure:
Jugular vein distention
Ascites
Pedal edema

Question 3

Identify diagnostic studies performed for heart failure

Answer 3

Diagnostic studies:BNP,Echocardiography to determine ejection fraction (EF),Echocardiogram

Question 4

decompensated heart failure

Answer 4

Decompensated heart failure refers to a deterioration, which may present either as an acute episode of pulmonary oedema or as lethargy and malaise, a reduction in exercise tolerance, and increasing breathlessness on exertion.

Question 5

compensated heart failure

Answer 5

In compensated heart failure, symptoms are stable, and many overt features of fluid retention and pulmonary oedema are absent.

Question 6

inotropic

Answer 6

Positive inotropic drugs – increase the force of myocardial contraction
Negative inotropic drugs – reduce the force of contraction

Question 7

chronotropic

Answer 7

Positive chronotropic drugs – increase rate at which heart beats/ increase heart rate
Negative chronotropic drugs – reduce rate at which heart beats/ reduce heart rate

Question 8

dromotropic

Answer 8

Positive dromotropic drugs – drugs that accelerate conduction through the conduction system of the heart/ accelerate how quickly electrical impulses travel through the conduction system of the heart  sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, and Purkinje fibers.
Negative dromotropic drugs – drugs that reduce conduction through the heart

Question 9

Diuretics (furosemide, Lasix) MOA

Answer 9

Decreases Na, Cl, and K reabsorption in thick ascending limb of the loop of Henle in the nephron which results in profound diuresis

Question 10

Drug effects diuretics

Answer 10

Reduced blood volume decreases venous pressure (preload) and arterial pressure (afterload). Reduced pulmonary and peripheral edema.

Question 11

Indications diuretics

Answer 11

Acute and chronic HF

Question 12

Dosages and Routes diuretics

Answer 12

Oral: 20-80 mg/daily or BID; max dose 600 mg/day
IV: 20-40 mg/dose IV x 1, may increase by 20mg q 2 hours.

Question 13

Adverse effects diuretics

Answer 13

Hypokalemia (↑ risk of digoxin toxicity)

Severe hypotension

Question 14

Nursing implications diuretics

Answer 14

Assess patient’s fluid volume status
Assess vital signs
Assess labs

Question 15

Patient education diuretics

Answer 15

Avoid taking late in the afternoon due to nocturia.
Eat foods rich in potassium (bananas, oranges, potatoes, tomatoes, meats, fish, wheat bread, legumes). K+ supplement may be necessary
Report signs of hypokalemia (e.g. lethargy, weakness, leg cramps) to provider immediately

Question 16

labs to monitor when taking diuretics

Answer 16

Monitor electrolytes, renal and hepatic function, serum glucose, and uric acid levels before and periodically throughout therapy. Commonly ↓ serum potassium. May cause ↓ serum sodium, calcium, and magnesium concentrations. May also cause ↑ BUN, serum glucose, creatinine, and uric acid levels.

Question 17

Drugs that inhibit the RAAS e.g. ACE inhibitors MOA (pril meds)

Answer 17

Inhibits ACE which prevents the conversion of angiotensin I to angiotensin II (a powerful vasoconstrictor). Also reduces aldosterone secretion. Suppress degradation of kinins (vasodilator).

Question 18

drug effects ace inhibitors

Answer 18

Arteriolar and venous dilation results in reduced preload, afterload, ↓ pulmonary & pedal edema, and increased cardiac output. ↑ kinins reduces cardiac remodeling.

Question 19

indications ace

Answer 19

Cornerstone of HF therapy

Question 20

Adverse effects ace

Answer 20

Hypotension (0.9-6.7%)
Cough (9%)
Hyperkalemia
Angioedema

Question 21

Drugs that inhibit the SNS e.g. beta-blockers(lol meds) MOA

Answer 21

Protect heart from excessive sympathetic stimulation

Question 22

Drug effects beta- blockers

Answer 22

Improve LV ejection fraction (1-3 months), slow the progression of HF, reduce need for hospitalization, and prolong survivial.

Question 23

Dosages and routes beta blockers

Answer 23

Start low and go slow. Excessive beta blockade can reduce ventricular contractility

Question 24

Contraindications beta blockers

Answer 24

Heart block

Question 25

Adverse effects beta blockers

Answer 25

Fluid retention/ worsening HF
Bradycardia/ heart block
Hypotension

Question 26

Cardiac Glycosides Mechanism of action

Answer 26

Inhibits the sodium-potassium adenosine triphosphatase pump. This cause an accumulation of calcium within the cardiac myocytes. The calcium then augments contractile force by facilitating the interaction of myocardial actin and myosin.

Question 27

Drug effects glycosides

Answer 27

Positive inotropic effect increases the force of ventricular contraction which increases cardiac output. Increased CO, can reverse all the overt manifestations of HF.

Question 28

Indications: glycosides

Answer 28

Second-line heart failure; atrial fibrillation

Question 29

Precautions: glycosides

Answer 29

Lasix (secondary to risk of hypokalemia)

Question 30

Adverse effects: glycosides

Answer 30

Digoxin toxicity

Cardiac dysrhythmia

Question 31

digoxin (Lanoxin)

Very narrow therapeutic window.

Answer 31

Drug levels must be monitored
0.5 to 0.8 ng/mL (old upper limit 2 ng/mL)
Low potassium levels increase its toxicity. Electrolyte (serum K+) levels must be monitored.
Normal range 3.5 – 5 mEq / L

Question 32

Nursing implications: glycosides

Answer 32

Monitor vital signs
Monitor for EKG changes
Monitor labs – K+, digoxin level (CRITICAL)

Question 33

Patient education: glycosides

Answer 33

Teach to monitor pulse rate and regularity
Signs and symptoms of dig toxicity (anorexia, nausea, vomiting, yellow tinge to vision, halos)
Monitor for signs and symptoms of hypokalemia (lethargy, muscle weakness, leg cramps)

Question 34

Mechanism of action/drug effects:Vasodilator

ex.Bidil (37.5 mg of hydralizine/ 20 mg isosorbide dinitrate)

Answer 34

Isosorbide dinitrate (Isordil) belongs to same family as nitroglycerin. Causes selective dilation of veins which ↓preload and reduces congestive symptoms.
Hydralize (Apresoline) causes selective dilation of arterioles which can improve cardiac output (decreased afterload) and renal blood flow (increase urine output/decrease volume)

Question 35

B-type Natriuretic Peptide Mechanism of action/ Drug effects:
Examples:
nesiritide (Natrecor)

Answer 35

A synthetic form of BNP produced by recombinant DNA technology. Causes suppression of RAAS, suppression of SNS, direct dilation of arterioles and veins (↓ preload and ↓ afterload).

Question 36

Indication/ Route: B-type

Answer 36

Acutely decompensated CHF via continuous intravenous infusion only.