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HEART FAILURE
NUR240
Lecture 4
1R. Kolk, revised 11/09 J. Borrero
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Heart Failure
• Also called pump failure
• Left-sided heart failure
• Right-sided heart failure
• High-output failure
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Etiology
• Heart failure is caused by systemic hypertension in 75% of cases.
• About one third of clients experiencing myocardial infarction also develop heart failure.
• Structural heart changes, such as valvular dysfunction, cause pressure or volume overload on the heart.
4
Etiology
• A syndrome of Pulmonary and/ or Systemic congestion due to C.O
• Heart is unable to pump enough blood to meet tissues O2 requirements
Pulmonary pressure fluid in alveoli (PULMONARY EDEMA)
Systemic pressure fluid in tissues(PERIPHERAL EDEMA)
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ETIOLOGY & RISK FACTORS
Cardiac pathology that changes heart’s performance
____________________________________________________________________________________
Risk Factors:
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Compensatory Mechanisms
• Sympathetic nervous system stimulation
• Renin-angiotensin system activation
• Myocardial hypertrophy
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LOCATION
Heart failure classified according to location of ventricular failure
One ventricle may fail independently of another, but failure in one will impact on the other.
L sided failure- pulmonary congestion
R sided failure- peripheral congestion
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Left-Sided Heart Failure
• Manifestations include:– Weakness– Fatigue– Dizziness– Confusion– Pulmonary congestion– Shortness of breath– Oliguria– Organ failure, especially renal failure– Death
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(L) SIDED HF
Tissue hypoxia occurs because heart is unable to efficiently pump blood
CLINICAL SIGNS of pulmonary congestion:Dyspnea OrthopneaCough WT. gainFatigue Anxiety/ restless
S3 CracklesCardiomegaly HR BP
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Right-Sided Heart Failure
• Manifestations include:– Distended neck veins, increased
abdominal girth– Hepatomegaly (liver engorgement)– Hepatojugular reflux– Ascites– Dependent edema– Weight: the most reliable indicator of fluid
gain or loss
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(R) SIDED HF
Blood “BACKS UP” into venous circulation. High oncotic pressure pushes fluids into tissues.
CLINICAL SIGNS:
CVP SUDDEN WT. GAIN
JVD DEPENDENT EDEMA
FATIGUE LIVER CONGESTION
LETHARGY ASCITES
ORTHOPNEA ANOREXIA
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Assessments
• Laboratory assessment- electrolytes,
• BNP- B type natriuretic peptide.
Normal =0
• Radiographic assessment
• Electrocardiography
• Echocardiography, TEE
• Pulmonary artery catheters
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Nursing Assessments
• O2 Saturation• Vital Signs• Heart Rhythm• Lung Sounds• Level of dyspnea• Serum Electrolytes
• Daily weights• Changes in LOC• I & O• Coping ability of pt
and family• Signs of drug toxicity
JCAHO Core Measures for HFEvery patient 100% of the time!
HF-1: Written discharge instructions
HF2: An evaluation of LVS function (Ejection fraction)
HF3: ACE or ARB for LVS function
HF4: Adult smoking cessation advice/counseling
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GOAL
Nursing Dx?
Enhance O2 supply
Work of heart by promoting contractility
Interventions:
1. Adequate ventilation
2. Maintain cardiac function
3. Promote rest
4. Other
5. Medication
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Nursing Interventions
1. ADEQUATE VENTILATION
• Monitor respirations, breath sounds
• Administer O2
• Position- high-Fowlers
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Interventions
2. MAINTAIN CARDIAC FUNCTION• Monitor heart sounds
• Pulmonary Artery Catheter Measurements
CVPPulmonary Artery PressurePulmonary Capillary Wedge
PressureCardiac Output
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Interventions
3. Promote rest until patient is stable
strain on heart
BR promotes cardiac efficiency
Elevate legs to enhance venous return
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Interventions
4. MISC.• Monitor LOC
• Assess edema
• Provide adequate nutrition
• Provide emotional support• Maintain diet restrictions as
prescribed (Na and fluid)
MEDICATION
5. Medication
• Improve myocardial muscle function
• Restore C.O. & SV
• Reduce cardiac demands
Natrecor (nesiritide)- Human B-type natriuretic peptide
causes natriuresis in acute HF
loss of Na and vasodilation
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MEDICATIONS
Fluid load, Preload, Afterload
• Improve contractility
Workload of the heart
ACE inhibitors & Diuretics
Digoxin
Dobutamine
“Blockers”
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Drugs That Enhance Contractility
• Digitalis– Digitalis toxicity includes anorexia, fatigue,
muscle weakness,changes in mental status.– Monitor heart rate for 1 full minute.Hold for <60– Monitor electrolytes– Take same time each day
• Other inotropic drugs including dobutamine, dopamine
• Beta-adrenergic blockers
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Improve contractility Inotropic agents
Digoxin: cardiac glycoside force of myocardial contraction &
slows HR( C.O. venous pressure, diuresis)
• Narrow therapeutic range:– Monitor for toxicity– Digitalization:
dobutamine, dopamine, milrinone (Primacor)
Advanced Calculations for IV Meds ordered/Kg/Minute
1. Convert to like units, such as mg to mcg or lb to kg
2. Calculate desired dosage per minute: mg/kg/min X kg = mg/min3. Calculate the dosage flow rate in mL/min Dosage on hand = Dosage desired/minAmt solution on hand X amt desired/ min4. Calculate the flow rate in mL/hour mL/min X 60 min/h = mL/hr
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Homework
1.Dobutamine 250mg / 250 mL D5W to infuse at 5 mcg/kg/min.
Weight- 80 kg
Flow rate on pump-
2.Dopamine 800 mg/ 500 mL D5W to infuse at 4 mcg/kg/min.
Weight- 190 lbs.
Flow rate on pump-27
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Afterload Reducing Agents
• ACE inhibitors-enalapril (Vasotec)
captopril (Capoten)
• Beta-blockers- carvedilol (Coreg)
• metoprolol (Lopressor XL)
• Angiotensin receptor II blockers
losartan (Cozaar)
• Nitrates- preload and afterload
•
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DIURETIC THERAPY
Increases excretion of Na+/H2O/K
Sites of action differ
Result in varying degrees of ‘lyte imbalance
Categories: Loop, Thiazide, K+-sparing
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NURSING INTERVENTIONS
DIURETIC THERAPY- give early in day
• Monitor WT.
• Assess for edema
• Strict I&O
• Monitor electrolytes
• Nutrition = Low Na+ diet,
K + supplements
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LOOP DIURETICSMORE POTENT ACTION
furosemide (LASIX)
bumetamide (BUMEX) PO/ IVACTION: at loop of Henle, K+ loss, Na+/Cl- excretionADVERSE EFFECTS: orthostatic hypotension, may digitalis toxicity, hypokalemia
Teach: K rich foods, po K, S&S hypokalemia
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THIAZIDE DIURETICS
Useful for maintenance
• HCTZ (Hydrochlorothiazide)
Action: excretion of Na+/Cl- & H2O
Adverse effects: orthostatic hypotension, may digitalis toxicity
33
K+ Sparing Diuretics
Maintenance therapy – conserves K+, has a gradual diuretic effect
Spironolactone (Aldactone)
Action: blocks reabsorption of Na+/Cl-
Adverse effects: Hyperkalemia
34
PULMONARY EDEMA
Rapid fluid accumulation in lung spaces that has leaked from engorged pulmonary capillaries
Etiology – most common cause is sudden deterioration of LV function
35
Potential for Acute Pulmonary Edema due to Left Sided HF
• Interventions include:– Assess for early signs, such as crackles in
the lung bases, dyspnea at rest, tachycardia, disorientation, and confusion.
– Rapid-acting diuretics are prescribed, such as Lasix or Bumex.
– IV morphine sulfate– Oxygen and/or intubation – Strictly monitor fluid intake and output.
36
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Clinical signs
LV diastolic pressure pulmonary pressure
• Lungs become “stiff” due to fluid buildup, resulting in hypoxia_____________________________________________________________________________________
38
Nursing Interventions
• Administer O2 to relieve hypoxia & dyspnea
• CPAP,PEEP
• Assess breath sounds and monitor respirations
• Pulmonary Artery Catheter
• Hi fowler’s position
• Urinary catheterization
39
Aminophylline
Bronchodilator given to relieve wheeze/ bronchospasms that may occur
IVPB loading dose, then IV continuous drip
Monitor closely for adverse effects: GI upset, nervousness, HR, H/A, tremors
40
Cardiogenic Shock
• Occurs with extensive LV injury perfusion to vital organs
• Degree of shock, directly relates to level of ventricular failure
• Results in: ______________ ____________________________ ______________
41
Cardiogenic Shock
Significant reduction in SV & CO causes drop in pressure & poor tissue perfusion a/r/o LV MI
• Clinical signs:– BP, pulse, peripheral pulses– confusion/ agitation (cerebral hypoxia)– cold/ clammy skin– urine output– Resp distress– Chest pain
42
Treatment
• Hemodynamic monitoring
• Reduce demand on the heart
• Improve oxygenation
• Improve tissue perfusion
• Intra-aortic balloon pump
• Inotropic Meds to BP, workload
• Correct underlying pathophysiology
43
NCLEX TIME
The nurse is awaiting the arrival of a client from the ER who is being admitted with a LVMI. The nurse should be alert for which S&S of left-sided heart failure?
A. Jugular vein distentionB. HepatomegalyC. DyspneaD. CracklesE. Tachycardia
44
NCLEX TIME
Harvey is a 76-year-old man being followed up by his nurse practitioner for congestive heart failure (CHF). Which assessment finding would be typically found in an older adult?
• A.Orthostatic hypotension in conjunction with drug therapy for CHF
• B.Clearing of crackles immediately after medication treatment
• C.Auscultation of crackles• D.Digitalis toxicity
45
NCLEX TIME
Carlos is prescribed digoxin after having open heart surgery and postoperative atrial fibrillation. Which statement, if made by the client, demonstrates the need for further teaching regarding his digoxin medication?
• A.“I should notify my doctor if my pulse is less than 60 or more than 100 beats/min.”
• B.“I need to keep my laboratory appointments.”• C.“I should not take my digoxin at the same time
as antacids or laxatives.”• D.“If I forget to take my digoxin one day, I can
double up on the dose the next day
46
NCLEX TIME
• Mrs. Clark is an 83-year-old woman admitted with symptoms of heart failure. Her nurse, after performing the assessment, tries to decipher between right- and left-sided heart failure. Which symptoms below are consistent with left-sided heart failure?
• A. Weight gain, jugular distention, and distended abdomen
• B. Fatigue, weakness, and palpitations• C. Agitation, blood tinged, frothy sputum, dyspnea• D. Anorexia and nausea, distended abdomen, and
enlarged liver
47
NCLEX TIME
Provide the rationale
for each of the
following therapies:
Therapy Rationale
O2
Diuretics
Bedrest
Inotropic agents
Vasodilators
Fluid restriction
Sodium restriction
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