Week 5 Heart Failure (HF) Flashcards
1
Q
what is HF?
A
an abnormal condition involving impaired cardiac pumping
2
Q
HF (aka ___) is not a ____ but a “___”
A
CHF
disease
syndrome
3
Q
HF is associated with what 2 chronic disorders?
A
long-standing HTN & CAD
4
Q
How does HF results?
A
Results from the heart’s inability to pump amt of oxygenated blood needed to meet metabolic requirements of body
5
Q
What are the 2 US statistics regarding HF?
A
- Affects >5 million people
2. Most common reason for hospitalization in adults older than 65
6
Q
About how many people in the United States have heart failure?
A
5.7 million people
7
Q
One in ___ in 2009 included heart failure as contributing cause.
A
9 deaths
8
Q
About ___ of people who develop heart failure die within __ years of diagnosis.
A
half
5
9
Q
Heart failure costs the nation an estimated ___ each year. This total includes the cost of ___, ___ heart failure, and ____.
A
$30 billion
health care services
medications to treat
missed days of work
10
Q
Which part of the US has the highest death rates of HF from 2011 to 2013?
A
middle region, near Texas, (“bible belt”)
11
Q
What are the 5 HF risk factors?
A
- CAD and its risk factors
- age
- htn
- high cholesterol
- African American descent
12
Q
How is CAD and its risk factors, risk factors for HF?
A
smoking, obesity, and sedentary lifestyle
13
Q
How is age a risk factor of HF?
A
HF is most common reason for hospitalization of pts greater than 65 y/o.
14
Q
How is htn a risk factor of HF?
A
- to compensate for increase bp, the heart muscle thickens.
- over time, the force of heart muscle contraction weakens preventing normal filling of heart with blood.
15
Q
How is African American descent a risk factor of HF?
A
- their race is related to the higher incidence of htn and dm.
- have a 30% higher mortality rate.
16
Q
what is the etiology of HF?
A
may be caused by an interference with normal mechanisms regulating cardiac output
17
Q
formula of CO?
A
CO = HR X SV
amt of blood pumped from LV with each contraction
18
Q
CO is influenced by what 5 things?
A
- Preload: volume of blood in ventricle at end of diastole
- afterload: force ventricle must develop to eject blood into circulatory system
- myocardial contractility
- heart rate
- metabolic state of individual.
19
Q
Pathophysiology of Systolic Heart Failure: (5)
A
- Most common cause of CHF: MI - Heart wall weakens from extra workload
- “Squeeze” of ventricles is issue
- LV loses ability to generate enough pressure to eject blood forward
- -Difficulty emptying
- -The hallmark is a ↓ LV ejection fraction - Ejection fraction of 50 – 75% is considered normal
- With L side failure it usually falls below 40%
20
Q
Pathophysiology of Diastolic Heart Failure: (5)
A
- Impaired ability of ventricles to fill during diastole: Commonly caused by HTN
- Inability to fill & relax LV is issue
- Usually result of LV hypertrophy
- Pulmonary congestion
- Normal ejection fraction
21
Q
One compensatory mechanism of HF is?
A
Compensatory mechanisms are activated to maintain adequate CO
22
Q
How does our bodies maintain adequate CO? what changes? (3)
A
- Sympathetic nervous system (SNS) activation
- Neurohormonal responses: Low CO causes a decrease in cerebral perfusion pressure
–Antidiuretic hormone (ADH) is secreted and causes increased water reabsorption in the renal tubules leading to water retention and increased blood volume - Neurohormonal responses: Kidneys release renin
–Renin converts angiotensinogen to angiotensin I
Angiotensin I is converted to angiotensin II by a converting enzyme made in the lungs
23
Q
What is one consequence of compensatory mechanism?
A
Ventricular dilation: Enlargement of the chambers of the heart that occurs when pressure in the left ventricle is elevated
- -Initially an adaptive mechanism
- -Eventually this mechanism becomes inadequate and CO decreases
- -Ventricular Hypertrophy: Increase in the muscle mass and cardiac wall thickness in response to chronic dilation; heart muscle
- -Ventricular Remodeling
24
Q
What is another consequence of compensatory mechanism?
A
it is known as the Counter-regulatory processes
- Natriuretic Peptides (hormones):
- –Released in response to increases in atrial volume and ventricular pressure
- -Promote venous and arterial vasodilation, reducing preload and afterload
- Atrial natriuretic peptide (ANP) = ↑ diuresis
- Brain natriuretic peptide (BNP) (secreted by ventricles) – a measure of the “stretch” of heart tissues
25
what is preload?
volume coming into ventricles (end diastolic pressure)
26
Preload is increased in... (2)
1. Hypervolemia
| 2. regurgitation of cardiac values
27
what is after load?
resistance- left ventricle must overcome to circulate blood
28
After load is increased in... (2)
1. hypertension
| 2. vasoconstriction
29
What happen to after load and cardiac workload in HF?
Increased after load
| increased cardiac workload
30
What is the pathophysiology of Ventricular Failure?
Mixed Systolic and Diastolic Failure
- -Seen in cardiomyopathy
- -Biventricular failure
- -Pts have extremely poor ejection fractions
31
What is the compensatory mechanism of Ventricular Failure? (4)
1. Ventricular dilation
- --Initial adaptive mechanism to ↑ CO then becomes inadequate → can no longer contract
2. Ventricular hypertrophy (remodeling)
3. Increased SNS stimulation
4. Neurohormonal responses
32
Name 2 things about Left-sided failure.
1. Most common form
2. Blood backs up through left atrium into pulmonary veins
- --Pulmonary congestion & edema
33
Name 2 things about Right-sided failure.
1. Backflow to right atrium & venous circulation
| 2. Results from diseased right ventricle
34
___ ___ failure eventually leads to ____ failure
One-sided
| biventricular
35
What are some signs and symptoms of Left-sided heart failure?
1. paroxysmal nocturnal dyspnea
2. elevated pulmonary capillary wedge pressure
2. cough
4. crackles
5. wheezes
6. blood tinged sputum
7. restlessness
8. confusion
9. orthopnea
10. tachycardia
11. exertional dyspnea
12. cyanosis.
36
what are some signs and symptoms of Right-sided heart failure?
1. fatigue
2. increased peripheral venous pressure
3. ascites
4. enlarged liver and spleen
5. distended jugular veins
6. anorexia and complaints of GI distress
7. swelling in hands and fingers
8. dependent edema.
37
what is the Clinical Manifestations of Acute HF /Congestive Heart Failure? (2)
1. Pulmonary edema
| 2. low cardiac output
38
What are the signs and symptoms of Pulmonary edema?
1. Agitation
2. Pale or cyanotic
3. Cold, clammy skin
4. Severe dyspnea, crackles, cough (hacking, productive, dry), “frothy” secretions
5. Tachypnea
6. Tachycardia
39
What are the signs and symptoms of low cardiac output?
Think “head-to-toe” assessment & abnormal heart sounds (e.g., S3, S4, murmur)
40
What are other clinical manifestations of HF?
1. fatigue
2. Dyspnea (PND – paroxysmal nocturnal dyspnea) or SOB
3. tachycardia
4. heart murmur, S3, S4
5. heaves/lift
6. edema/anasarca
7. nocturia
8. chest pain
9. weight changes
10. skin changes
11. many pts suffer from sleep obstructive apnea
12. behavior changes
41
Explain fatigue of HF:
Earliest symptoms, after activities which are normally not tiring
--Related to decreased CO
42
```
Explain Dyspnea (PND – paroxysmal nocturnal dyspnea) or SOB
of HF: (2)
```
1. Cause by alveolar edema
2. PND – reabsorption from dependent areas when patient is sleeping
Pt c/o suffocation feelings
43
Explain tachycardia of HF:
Compensatory mechanism from SNS
44
explain heaves or lift of HF:
3rd to 5th intercostal spaces using ball of your hand
45
explain edema or anasarca of HF
in the legs, liver and abdomen
46
explain nocturne of HF:
related to recumbent position, increase renal blood flow
47
Explain chest pain of HF:
- related to decreased coronary perfusion from decreased CO and increased work of heart
- can be anginal pain
48
explain weight changes of HF:
multifactoral
49
explain skin changes of HF:
dusky appearance
50
explain behavioral changes of HF:
restlessness, confusion, decreased attention span, some impaired cognition and sleepiness
51
What’s the normal ejection fraction (EF)?
55 to 70%
52
what's HFNEF?
HF with a normal ejection fraction. Same as HFpEF
53
What's HFpEF?
HF with preserved ejection fraction. Left ventricular ejection fraction (LVEF) is normal (formerly diastolic HF)
54
What's HFREF?
HF with reduced ejection fraction
55
New York Heart Association
| Heart Failure Symptom Classification System: level of impairment of NYHA Class I
no symptom liitatio with ordinary physical activity
56
New York Heart Association
| Heart Failure Symptom Classification System: level of impairment of NYHA Class II
ordinary physical activity somewhat limited by dyspnea (i.e., long distance walking, climbing 2 flights of stairs)
57
New York Heart Association
| Heart Failure Symptom Classification System: level of impairment of NYHA Class III
exercise limited by dyspnea at mild work loads (i.e., short distance walking, climbing one flight of stairs)
58
New York Heart Association
| Heart Failure Symptom Classification System: level of impairment of NYHA Class IV
dyspnea at rest or with very little exertion
59
ACC/AHA Classification of Chronic Heart Failure: Description of stage A:
aka high risk for developing heart failure.
| description: hypertenion, dm, CAD, family history of cardiomyopathy
60
ACC/AHA Classification of Chronic Heart Failure: Description of stage B:
aka asymptomatic heart failure
| description: previous MI, LV dysfunction, valvular heart disease
61
ACC/AHA Classification of Chronic Heart Failure: Description of stage C:
aka symptomatic heart failure
| description: structural heart disease, dyspnea and fatigue, impaired exercise tolerance
62
ACC/AHA Classification of Chronic Heart Failure: Description of stage D:
aka refractory end-stage heart failure
| description: marked symptoms at rest despite maximal medical therapy
63
What are some Diagnostic Studies of HF? (11)
1. Primary goal to determine underlying cause
2. History & physical exam
3. ABGs, serum chemistries, LFTs (acute)
4. Chest X ray
5. 12-Lead ECG
6. Hemodynamic assessment/monitoring
- -PCWP
- ---Indirect measure of left atrial pressure
- -CVP
- ---Used to make estimates of circulatory function
7. Echocardiogram (determines LVEF)
8. Stress testing (chronic)
9. Nuclear imaging studies
10. Cardiac catheterization
11. Laboratory tests; CBC, BMP, HBA1C, Lipid profile, thyroid levels, cardiac enzymes and B type natriuretic peptide level (BNP)
64
BNP and Heart Failure: cardiac hormone:
- Secreted by ventricular myocytes in response to wall stretch
- Normal 400 – CHF 95% probable
- Factors affecting BNP levels
65
BNP and Heart Failure: plasma concentrations reflect what?
- Plasma concentrations reflect severity of heart failure
- - In decompensated heart failure, BNP rises
- - As heart failure is treated, BNP will lower
66
BNP and Heart Failure:
| BNP:
Good marker for differentiating between pulmonary and cardiac causes of dyspnea
67
Dysrhythmias and Heart Failure: what is dysrhythmias?
A ventricular ejection fraction below 30% and the presence of New York Heart Association (NYHA) class III or IV heart failure are strongly associated with ventricular dysrhythmias and an increased risk for death.
68
What are the Nursing &
| Collaborative Management of acute HF?
- -Primary goal is to improve LV function by:
- --↓ intravascular volume
- --↓ preload (venous return)
- --↓ afterload (systemic vascular resistance)
- --Improving gas exchange and oxygenation
- --Improving cardiac function
- --Reducing anxiety
69
what are the nursing and collaborative management for acute HF? (3)
1. decreased intravascular volume
2. decreased venous return (preload)
3. decreased afterload
70
Describe decreased intravascular volume (2)
1. increased LV function by decreasing venous return
| 2. use loop diuretic: drug of choice: lasix (Furosemide) or Bumex (Bumetanide)
71
describe decreased venous return (preload) (2)
1. reduce the amount of volume returned to the heart:
- --Lasix (Furosemide) or Bumex (Bumetanide)
- --nitroglycerin, morphine
2. high flowler's position
72
describe decreased afterload (6)
1. decreased pulmonary congestion
2. IV nitroprusside (Nipride)- potent vasodilator
3. nesiritide (Natrecor)-both afterload and preload reducer.
4. Improving gas exchange & oxygenation
- -↓ pulmonary congestion
- -IV Morphine
- -Administer oxygen
- -Possible intubation
5. Improving cardiac function
- -Digitalis – AKA digoxin (Lanoxin)
- -Newer inotropics e.g., PDE III inhibitor: Milrinone (Primacor)
- -Dobutamine
- -Hemodynamic monitoring
6. ↓ anxiety
7. Continuity of care
- -Morphine (acute phase/pulmonary edema)
- -IV inotropic drugs
- -Vasodilators
- -ACE inhibitors
8. For severely compromised cardiac function (e.g., manifestation of shock)
- -Intra-aortic Balloon Pump (IABP)
- -Mechanical Hearts
- -Ventricular Assist Devices (VAD)
- -heart transplant
73
What is an implanted cardiac resynchronization device?
An implanted cardiac resynchronization device is a medical device used in cardiac resynchronization therapy (CRT). It resynchronizes the contractions of the heart’s ventricles by sending tiny electrical impulses to the heart muscle, which can help the heart pump blood throughout the body more efficiently.
74
What is a ventricular assist device?
A ventricular assist device (VAD) is an electromechanical circulatory device that is used to partially or completely replace the function of a failing heart. LVAD is short term while waiting for transplant.
75
What is an artificial heart?
An artificial heart is a device that replaces the heart. Artificial hearts are typically used to bridge the time to heart transplantation, or to permanently replace the heart in case heart transplantation is impossible.
76
What are some Drug Therapy for Chronic HF? (8)
1. ACE Inhibitors
2. Angiotensin-II Receptor Blockers (ARB)
3. Inotropic drugs
- --Digoxin
- --Phosphodiesterase (PDE) 3 inhibitor
4. Vasodilators (Nitro)
5. Beta Blockers
6. Diuretics - Natrecor (Nesiritide)
7. Anticoagulants (e. g., Warfarin)
8. Antidysrhythmic drugs (Ca Channel Blockers)
77
Digoxin: Drug Interactions
What can Increase serum digoxin levels?
- Quinidine, verapamil, flecainide
- Erythromycin, clarithromycin
- Amiodarone
- -Significantly ↑↑ digoxin levels
- -Must ↓ digoxin dose by 50%!!!!
- Thiazide & loop diuretics
- -↑ risk dig toxicity due to ↓ K+ levels
78
Digoxin: Drug Interactions
What can Decrease digoxin absorption?
Antacids
79
Herbs Interacting with Digoxin: (6)
1. Ginseng – falsely ↑ dig level
2. St. John’s Wort – ↓ absorption, ↓ serum level
3. Hawthorn – ↑ effect of dig
4. Aloe – ↑ potassium loss
5. Ma-Huang –↑ risk of dig toxic
6. Licorice – potentiates effect of dig
80
What is a PDE3 inhibitor?
A PDE3 inhibitor is a drug which inhibits the action of the phosphodiesterase enzyme PDE3 (PDE3 is clinically significant because of its role in regulating heart muscle and vascular smooth muscle contractility and platelet aggregation) ie: milrinone
81
What are the Nursing and
| Collaborative Management for Chronic HF? (8)
1. Treat underlying cause
2. Maximize (optimize) cardiac output
3. Alleviate symptoms
4. Rest
5. Biventricular pacing (Generic: Cardiac Resynchronization Therapy or CRT)
6. Oxygen treatment
7. Mechanical hearts
8. Heart transplantation
82
What are the Drug Therapy
| for Chronic HF? (8)
1. ACE Inhibitors
2. Angiotensin-II Receptor Blockers (ARB)
3. Inotropic drugs
- --Digoxin
- --PDE III inhibitor
4. Vasodilators
5. Beta Blockers
6. Diuretics
7. Anticoagulants (e.g.,Warfarin)
8. Antidysrhythmic drugs
83
Describe Atrial fibrillation: (3)
1. Atrial fibrillation (most common dysrhythmia) - Loss of the atrial contraction (kick) can reduce CO by 10% to 20%
2. Promotes thrombus/embolus formation, increasing risk for stroke
3. Treatment may include cardioversion, antidysrhythmics, and/or anticoagulants
84
What are some HF Complications? (7)
1. Pleural effusion
2. Arrhythmia (AF most common)
3. Stroke (CHA2DS2-VASc Score
4. Hepatomegaly/cirrhosis
5. Renal insufficiency/failure
6. GI distress
7. Cardiomyopathy
85
What is the Nutrition Therapy for Chronic HF? (4)
1. Fluid restrictions not commonly prescribed
2. Sodium restriction
1. 5 gm sodium diet (AHA, 2010)
3. Daily weights
- -Same time each day, wearing same type of clothing
- -Weight gain of 3 lbs. (1.4 kg) over 2 days or a 3 to 5 lbs. (2.3 kg) gain over a week should be reported to health care provider
4. Teach patients on how to read food labels
86
What are some Discharge Teaching for pts with Chronic HF? (6)
MAWDS
1. Medications
2. Activity
3. Weight
4. Diet
5. Symptoms
6. Follow-up Appointment
87
What are some Nursing Assessments for Chronic HF? (4)
1. Past health history
2. Medications
3. Functional health problems
4. Objective symptoms: cold, diaphoretic skin, tachypnea, tachycardia, crackles, abdominal distention/pain (feel bloated), restlessness
88
What are some Nursing Diagnoses for Chronic HF?
1. Activity intolerance (remember NYHA functional Class)
2. Excess fluid volume
3. Disturbed sleep pattern
4. Impaired gas exchange
5. Anxiety
89
What are some Plannings or
| Overall Goals for chronic HF? (5)
1. ↓ peripheral edema
2. ↓ SOB
3. ↑ exercise tolerance
4. Compliance with medications, diet, clinic appointments
5. No complications
90
What are some Acute Interventions for Chronic HF? (4)
- Establishment of quality of life goals
- Symptom management
- Conservation of physical/emotional energy
- Support system
91
What are some Ambulatory and home care Teaching for Chronic HF? (7)
1. Psychological changes
2. Exercise-saving behaviors
3. Medications
4. Diet
5. Relaxation techniques
6. Support groups (as needed)
7. Social services referral as needed
92
What should the nurse Evaluate on a pt with Chronic HF?
1. Tissue perfusion
2. Respiratory status
3. Sleep
4. Fluid balance
5. Activity intolerance
6. Anxiety control
7. Knowledge: Disease process
8. Support system
93
Hypertesnion is due to...
LV damages: LV hypertrophy, so increasing O2 demand bc more muscle there.
94
Preload: volume of blood in ventricle at end of diastole...
Think VOLUME!
95
Afterload: force ventricle must develop to eject blood into circulatory system...
Think SYSTEMATIC VASCULAR RESISTANCE
96
CO influenced by Metabolic state of individual...
Think EXAMPLE: FEVER, AND INCREASED HR
97
systolic failure:
heart is not contracting
98
diastolic failure:
ventricle is not relaxing, clood can't be filled into the ventricles.
99
ADH is not as great as RAAS, why?
only H2O reabsorption so will make heart super congested with H2O.
100
Natriuretic Peptides (hormones) promote venous and arterial vasodilation, reducing preload and afterload where?
Esp in the renal area!
101
Brain Natriuretic Peptide (BNP) is a biomarker of?
biomarker of CHF!
102
Right-sided heart failure is...
esp in COPD pulmonary hypertension
103
S3 heart sound:
1. heart sound for gallop due to turbulence in the mitral valve
2. marker of acute congestion
104
Tachycardia as the compensatory mechanism from SNS is
counter productive bc it decreases ventricle filling
105
S4 heart sound
related to MI
106
what is anasarca?
generalized edema
107
weight changes of HF clinical manifestations is due to?
weight gain due to fluid retenion and meds' side effects.
108
skin changes of HF clinical manifestations: dusky appearance is
dusk= darker "sunset"
109
Many HF patients suffer from sleep obstructive apnea bc
due to weight gain, think obese people
110
CHF affect ___ severely.
ADL
111
BNP is ...
the main biomarker of HF!
112
Chest Xray of HF patients will show:
infiltrate
113
Echocardiogram can check what 3 things on a HF patient?
1. the size of the heart
2. thrombus
3. ejection fraction
114
Cardiac hormone is secreted by ventricular myocytes in response to wall stretch, if it is 500 or more, what does it indicate?
CHF!!
115
Diuretic use can help decrease venous return (preload) how?
by decreasing volume to decreasing workload.
116
what are the Lasix side effects?
hypokalemia, hyponatremia, hypotension, could lead to hearing loss too (if long term use ) by drying out the fluid in the ear!
117
Nitroglycerin can help HF. how?
it can pull fluid to the peripheral to redistribute; decreasing venous return (preload).
118
Antacids should...
not be taken with other meds.
119
morphine is used to ...
decreasing preload
120
ACE inhibitors are used to...
decreasing afterload
121
Patients with CHF have a ...
these pts are at higher risk for pneumonia.
122
weight gain ...
could indicate volume retention
123
1. A patient with a history of chronic heart failure is hospitalized with severe dyspnea and a dry, hacking cough. She has pitting edema in both ankles, and her vital signs are BP 170/100, P 92, and R 28. The nurse recognizes that the patient’s symptoms indicate
1. the venous return to the heart is impaired, causing a decrease in cardiac output.
2. impaired emptying of both the right and left ventricles, with low forward blood flow.
3. the right side of the heart is failing to pump enough blood to the lungs to provide systemic oxygenation.
4. the myocardium is not receiving enough blood supply through the coronary arteries to meet its oxygen demand.
discuss with me!
124
2. A patient with left-sided heart failure has oxygen at 4 L/min per nasal cannula, furosemide (Lasix) 40 mg po daily, spironolactone (Aldactone) 25 mg po daily, and enalapril (Vasotec) 5 mg po bid. Which of the following actions is most important for the nurse to carry out?
1. Draw a blood sample for arterial blood gases
2. Measure intake and output
3. Assess skin turgor
4. Auscultate lung sounds
discuss with me.
125
3. A patient with chronic heart failure who is taking digoxin (Lanoxin) 0.25 mg po daily with furosemide (Lasix) 60 mg po daily develops nausea and vomiting. The home care nurse should
1. instruct the patient to increase intake of high-potassium foods.
2. notify the health care provider.
3. perform a dipstick urine test for protein.
4. ask the patient to weigh each morning and call the nurse in 3 days.
discuss with me!
126
Heart failure happens when the heart ___ pump enough ___ and ____ to ____ other _____ in your body. Heart failure is a _____ condition, but it _____ mean that the heart has ____ beating.
```
cannot
blood
oxygen
support
organs
serious
does not
stopped
```
127
Deaths from Heart Failure Vary by ____
Geography
128
Diseases that ____ your heart also ___ your risk for heart failure. Some of these diseases include: (3)
```
damage
increase
1. Coronary heart disease (the most common type of heart disease) and heart attacks.
2. High blood pressure
3. Diabetes
```
129
_____ behaviors can also ____ your risk for heart failure, especially for people who have unhealthy behaviors include: (4)
```
Unhealthy
increase
1. Smoking tobacco.
2. Eating foods high in fat, cholesterol, and sodium.
3. Not getting enough physical activity.
4. Being obese
```
