Heart Failure, Chronic Heart Failure, Congestive Heart Failure Flashcards
Cardiac Hemodynamics
What is the basic function of the HEART?
-is to pump blood
Cardiac Hemodynamics
Cardiac Output?
Cardiac Output: Amount pumped per minute
Cardiac Hemodynamics
Stroke Volume?
Stroke Volume: The Amount of Blood pumped out of the ventricle with each contraction
Cardiac Hemodynamics
formula of Cardiac Output (CO)
CO = Heart Rate(HR) x SV
Cardiac Hemodynamics
Preload?
Preload: The Amount of blood presented to the ventricle just before Systole
- Ventricular wall stretches to accommodate (compliance
- Venous return (Amount of blood entering ventricle during diastole) and elasticity determines preload
Cardiac Hemodynamics
Compliance/Elasticity decreases when:
- the muscle thickens (hypertrophic cardiomyopathy)
- There is increased fibrotic tissue within the ventricle
- Little or no compliance= stiff ventricle
Cardiac Hemodynamics
Non compliant ventricle has a?
Noncompliant ventricle has a higher intraventricular pressure than a compliant ventricle
Cardiac Hemodynamics
Higher Pressure increases?
Higher pressure increases the workload of the heart and leads to heart failure, if not corrected
Cardiac Hemodynamics
Afterload?
Afterload: The amount of resistance to the ejection of blood from the ventricle
- In order to eject blood, ventricle needs to overcome resistance caused by tension in the aorta and other vessels
- An increase in afterload causes the ventricle to work harder and decreases the amount of blood ejected
- When afterload increases, the workload of the heart must increase to overcome the resistance and eject blood
Cardiac Hemodynamics
Contractility?
The Force of the contraction is related to the status of the myocardium.
Significant loss of myocardial cells can decrease contractility and cause HF
Afterload can be reduced by medications to match the lower contractility and maintain adequate CO.
Cardiac Hemodynamics
Major Factors that determines Afterload?
Diameter and density of the great vessels
- Aorta
- Pulmonary artery
The Opening and competence of semilunar valves
- Pulmonic valve
- Aortic valve
When the valves open easily resistance is lower
When there is vasoconstriction, hypertension, narrow valve openings (stenosis) resistance
what is HEART FAILURE?
The inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. HEART FAILURE(HF)= CONGESTIVE HEART FAILURE (CHF)
Often referred to as CHF because many patients experience pulmonary or peripheral congestion.
Heart Failure sign and symptoms?
Currently heart failure is recognized as a clinical syndrome characterized by signs and symptoms of:
- Fluid overload
- Inadequate tissue perfusion
Fluid overload and decreased tissue perfusion result when the heart cannot generate a CO sufficient to meet the body’s demands.
The term HF indicates disease in which there is a problem with contraction of the heart (systolic dysfunction) or filling of the heart (diastolic dysfunction)
-May or may not cause pulmonary or systemic congestion
Facts about Heart Failure
Some cases reversible, depending on the cause
More often, HF is a progressive, life-long diagnosis managed with lifestyle changes and medications to prevent acute congestive episodes
5 Million in U.S. have HF
550,000 new cases diagnosed yearly
- Can affect all ages
- More often elderly
Heart failure is the most common reason for hospitalization of patients over 65 yrs
- The second most common reason for visits to doctors
- High rate of re-admissions
- Cost: $25 billion and rising
- Prevention and early intervention to arrest the progression are major health initiatives in U.S.
Types of Heart Failure?
Two types of HF, identified by assessment of left ventricular functioning, usually by echocardiogram.
- Systolic Heart Failure
- Characterized by a weakened heart muscle
- More common
- Diastolic Heart Failure
- Characterized by a stiff & noncompliant heart muscle making it difficult for the ventricle to fill
How to determine the type of Heart Failure?
- An assessment of the Ejection Fraction (EF) is performed .
- EF= an indication of the blood ejected with each contraction
- —-EF=Amount of blood at the end of diastole LESS the amount of blood at the end of systole and then calculating the percentage of blood that’s ejected
- —-Normal EF= 55-65% of ventricular volume (ventricle does not completely empty)
- In HF, the EF Fraction is normal in diastolic HF and severely reduced in systolic HF
Diagnosis and Assessment of Heart Failure?
- -The initial diagnosis and assessment of the severity and progression of CHF can be made using echo and exercise testing with gas analysis. The most commonly used echo measure is the EF. This is rated as:
- -45%–70%, normal
- -35%–45%, mildly impaired
- -25%–35%, moderately impaired
- -<15%, end-stage/transplant candidates
- -5% is compatible with life, but not long life
Classification of Heart Failure?
Ejection Fraction = The hallmark of HF
Severity classified according to the patient’s symptoms
Stage A: High risk for developing heart failure
- hypertension
- coronary artery disease
- diabetes mellitus
- family history of cardiomyopathy
Stage B: Asymptomatic heart failure
- previous myocardial infarction
- left ventricular systolic dysfunction
- asymptomatic valvular disease
Stage C: symptomatic heart failure
- known structure heart disease
- shortness of breath and fatigue
Stage D: refractory end-stage heart failure
- marked symptoms at rest despite maximal medical therapy( those who are hospitalized or cannot be safely discharged from the hospital without specialized intervention)
NY Heart Association Classification of Heart Failure?
Patient Symptoms
Class I (Mild) No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath).
Class II (Mild) Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.
Class III (Moderate) Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.
Class IV (Severe)
Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.
Pathophysiology of Heart Failure?
- Heart Failure results from a variety of cardiovascular conditions which cause decreased contraction (systole) or decreased filling(diastole) or both
- Chronic Hypertension
- Coronary Artery Disease
- Valvular Disease - Significant myocardial dysfunction usually occurs before the patient experiences symptoms
- As heart failure develops, the body tries to cope by activating neurohormonal mechanisms – this results in the symptoms the clients usually exhibit
* The compensatory mechanisms of HF = ‘the Vicious Cycle of HF’ - As the heart’s workload increases, contractility of the myocardial muscle fibers decreases & hypertrophy of the heart results. The heart cannot respond to the increased load and the failure becomes worse.
pathophysiology of Systolic Heart Failure?
vasoconstriction(decreased)—>renin causes release of Angioten—> FLUID VOLUME OVERLOAD(Angiote)
pathophysiology of Diastolic Heart Failure?
increased number & size of—>less blood in the ventricles—> same neurophormonal response
Etiology of Heart Failure?
- Atherosclerosis of Coronary Arteries: Primary Cause of HF
- Coronary Artery Disease: Present in more than 60% of patients with HF
- Myocardial Infarction
- Cardiomyopathy
- Hypertension: Increases afterload, leading to hypertrophy of muscle fibers
- Valvular Disorders
Flow chart of Heart damage, ventricular overload, decreased ventricular contraction
- tachycardia, ventricular dilation, myocardial hyperthropy
- Decreased cardiac output
- Decreased renal perfusion
- increased sodium retention
- increased osmotic pressure
- increased ADH
- increased water reabsorption
- fluid overload edema
- – then back to 1.
Clinical Manifestation of Hear Failure?
- Signs and Symptoms of Heart Failure most often described as
- Left Sided Heart Failure (Left Ventricular HF)
- Right Sided Heart Failure (Right Ventricular HF) - Many Common Symptoms – Advanced cases of HF present nearly identical symptoms
General Symptoms of Heart Failure?
1.Pale, cyanotic skin because of decreased perfusion to the extremities
- Dependent edema because of increased venous pressure
- Referred to as Pitting Edema - Decreased activity tolerance
- Confusion, altered mental status
general symptoms of Cardiovascular?
- Apical impulse, enlarged and left lateral displacement because of cardiac enlargement (cardiomyopathy)
- Third Heart Sound
- Murmurs if valvular dysfunction
- Tachycardia
- Increased and pronounced Jugular Vein Distention (JVD)
general symptoms of Cerebrovascular?
Lightheadedness
Dizziness
Confusion
general symptoms of Gastrointestinal?
Nausea and Anorexia
Enlarged Liver
Ascites
general symptoms of Renal?
Decreased urinary frequency during the day
Nocturia
general symptoms of Respiratory?
Dyspnea on Exertion (DOE) Orthopnea Paroxsysmal nocturnal dyspnea Bilateral crackles that do not resolve with cough Cough on exertion or when supine
What is Left Sided Heart Failure?
- The left ventricle fails as an effective pump
- The left ventricle cannot eject blood delivered from the right side of the heart through pulmonary circulation
- Blood backs up into pulmonary circulation
- The increased pressure in pulmonary capillaries forces fluid out of the capillaries and into the interstitial spaces and alveoli
- Result: Increased respiratory work and decreased gas exchange
sign and symptoms of Left Sided Heart Failure?
Since Left sided heart failure results in fluid backing up into the lungs, the signs and symptoms most associated with Left sided HF are: DOE Paroxysmal nocturnal dyspnea Orthopnea Generalized Weakness Non-Productive Cough with Pink Frothy Sputum Labored Breathing; tachypnea Tachycardia Crackles and pronounced wheezing
What is Right Sided Heart Failure?
- The Right Ventricle fails as an effective pump
- The Right Ventricle Cannot eject blood returning through the vena cava
- Blood backs up into systemic circulation
- The increased pressure in the systemic capillaries forces fluid out of the capillaries into interstitial spaces
- Tissue Edema occurs
- The most common cause of right sided HF is left sided HF
sign and symptoms of Right Sided Heart Failure?
The signs & symptoms associated wit Right sided HF are, therefore:
- Tachycardia
- Jugular vein Distention
- Pedal, Lower extremity and sacral edema
- hepatomegaly; ascites
- splenomegaly
- Anasarca
- **The classic triad of symptoms associated with R sided HF are: JVD, Hypotension and CLEAR lungs ***
Assessment and Diagnostic of Heart Failure?
*Many physical signs of HF are also S & S of other illnesses
*Further assessment is necessary – mostly to rule out other causes
-Echocardiogram can confirm the dx of HF
-Chest X-Ray
-Ejection Fraction determines R or L sided HF
ECG Helps Determine underlying Cause of the -HF
- Laboratory Studies
- BUN
- Creatinine
- TSH
- B-Type natriuretic peptide (BNP) – high levels associated with high cardiac filling pressure
- Urinalysis
- CBC
Diagnostic Studies:
- Exercise testing (Cardiac Stress Test)
- Cardiac Catheterization – can help determine if CAD and/or cardiac ischemia are causing the HF
- Ventricular Function Testing
- The results of the test studies will help -determine the course of treatment
Medical Management of Heart Failure?
The Goals of Medical Management is based on the type , severity and cause of HF
- Relieve the symptoms
- Improve Functional Status
- Improve Quality of Life
- Eliminate or reduce etiological factors
- Reduce the workload of the heart by reducing afterload and preload
- Optimize all therapeutic regimens
- Prevent exacerbations of HF
Treatment options of Heart Failure?
Treatment Options: Oral and IV Pharmacological Treatment 1. Angiotensin Converting Enzyme (ACE) Inhibitors 2. Angiotensin II Receptor Blockers 3. Beta Blockers 4. Diuretics 5. Digitalis 6. Vasodilators
What is ACE Inhibitors?
- Used in Systolic HF
- Slow the Progression of HF
- Improve Exercise Tolerance
- Promote Vasodilation and diuresis by decreasing afterload and preload, reducing workload of the heart
- Decrease secretion of aldosterone
- Stimulate the kidneys to excrete sodium & fluid
What is Angiotensin II Receptor Blockers?
- Decreases Blood Pressure
- Decreases Systemic Vascular Resistance
- Works by blocking the effect of Angiotensin II
- Usually prescribed if Patient Cannot take ACE inhibitors
What is Hydralazine & Isosorbide?
- Given together when patient cannot tolerate ACE Inhibitors
- Hydralazine lowers systemic vascular resistance and left ventricle afterload
- Isorbide dinitrate causes venous dilation
What is Beta Blockers?
- Usually prescribed in addition to ACE Inhibitors, diuretics and digitalis
- Reduces the adverse effects of the constant stimulation of the SNS
- Need to be monitored closely – side effects can include exacerbation of the HF symptoms
What is Diuretics?
Prescribed to remove excess extracellular fluid by increasing the rate of urine produced in patients with signs and symptoms of fluid overload
-Most Common: Furosemide (Lasix)
What id Digitalis (Digoxin)?
- Used in patients with systolic HF, Atrial Fibrillation and atrial flutter
- Increases the force of myocardial contractions
- Slows cardiac conduction through the AV node (slows ventricular rate)
- Increases cardiac output by enhancing the force of ventricular contraction
- Promotes diuresis by increasing cardiac output
Digoxin Toxicity
- Therapeutic level usually 0.5-2.0 ng/ml
- Digoxin Toxicity is a serious complication
- Diagnosis of toxicity based on patient’s clinical symptoms:
- Anorexia, nausea, vomiting
- Fatigue, depression, malaise
- Changes in HR or rhythm, onset of irregular rhythm
- ECG changes - Reversal: Digibind- binds with the digoxin and makes it unavailable for use in the body at receptor sites
Nursing Considerations: Digoxin medication
Monitor for signs of toxicity
- **Before administering digoxin, standard nursing practice: assess apical heart rate. Do not give if HR is less than 60 or irregular HR
- -Hold the Digoxin &Notify MD if HR < 60 or Irregular
Nursing Interventions: Pt. With Heart Failure?
- Administer prescribed medications and monitor the patient’s response to treatment
- Supplemental Oxygen per orders
- Assess Fluid balance
- Strict Input and Output
- Dependent Edema
- Daily Weights
- ——Same time of day on the same scale after urinating
Danger Sign: A weight gain or 2-3 lbs in a DAY or a 5 lb gain in a week
- Auscultate lung sounds
- —Monitor all aspects of pulmonary status - Monitor for JVD
- Monitor pulse rate and pressure
- Blood Pressure
- —Monitor for Hypotension - Monitor for Digoxin Toxicity
- Monitor for dehydration too
- —Turgor
- —Mucous Membranes
The Nursing Process: Patient With Heart Failure?
Assess Diagnose Plan Intervention Evaluate
Assessment?
*Assessment focuses on S & S of HF Dyspnea SOB (Shortness of Breath) DOE (Dyspnea on Exertion) Dependent Edema Urine Output and Daily Weights Paroxysmal Dyspnea ----How many Pillows do they need to sleep comfortably?
Diagnosis?
- Excess Fluid Volume R/T Excess Sodium -Intake, HF Syndrome
- Activity Intolerance and Fatigue R/T HF
- Ineffective Breathing Pattern R/T Dyspnea, pulmonary congestion
- Anxiety R/T Breathlessness
- Knowledge Deficit R/T Medications, HF syndrome, Diet
Planning and Goals?
Major goals:
- Relieve fluid overload
- Promoting Activity/Reducing Fatigue
- Promote Compliance
- ——Patient Education
- Reduce Anxiety
Interventions?
Include Patient Teaching:
Diet – Low sodium Daily Weights Compliance with Medications Compliance with Lab work Report symptoms Physical Activity Guidelines
Evaluation?
- Outcomes may include:
- Demonstrates tolerance for increased activity
- Maintains fluid balance
- Is Less Anxious
- Adheres to self-care regimen
- ——Dietary restrictions – Low sodium diet
- ——Medications
- ——Fluid balance monitoring
*Sleeps comfortably at night
No shortness of breath
