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Us. Waleed AmeenHeart Failure

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at the end of this session students will be able to:Define HFUnderstand mechanism of controlling HF Symptoms.NYHA Classification of HF.List types of HFIdentify risk factors and causes of HFIllustrate the clinical manifestationsPredict complicationsProvide diagnostic tests for HF.Demonstrate appropriate nursing process

Learning Objectives

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Heart failure is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients.Definition

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The loss of a critical quantity of functioning myocardial cells after injury to the heart due to:Ischemic Heart Diseases Hypertension Idiopathic CardiomyopathyInfections (e.g., viral myocarditis)Toxins (e.g., alcohol or cytotoxic drugs) Valvular Diseases Prolonged Arrhythmias

Etiology of Heart Failure

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Classification of Heart FailureOnset:Acute heart failure Chronic heart failure Affected side of the heart: Left heart failure Right heart failureStages of heart failure severity:New York Heart Association American Heart Association/American College of Cardiology

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NYHA Classification of Functional CapacityDescriptionNYHA class IAsymptomaticNYHA class IISymptoms with moderate exertionNYHA class IIISymptoms with minimal exertionNYHA class IVSymptoms at rest

Table 1New Classification based on symptomsCorresponding NYHA classAsymptomaticNYHA class ISymptomaticNYHA class II/ IIISymptomatic with recent history of dyspnea at restNYHA class IIIBSymptomatic with dyspnea at rest.NYHA class IV

Table 2Heart Failure Classification

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Myocardial Disease / InjuryImpaired Ventricular PerformanceCardiac Output SNS HR Contractility Vasoconstriction

RAASVasoconstrictionNa/H2O RetentionCardiacWorkloadVentricular RemoldingDilation & HypertrophyVicious Cycleof Heart Failure

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The signs and symptoms of HF are most often described in terms of the effect on the ventricles.

Right sided heart failure (Right ventricular failure). Left-sided heart failure (left ventricular failure), causes different manifestations than right-sided heart failure (right ventricular failure). Clinical Manifestations

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SymptomsDyspnea on ExertionParoxysmal Nocturnal DyspneaTachycardiaCoughHemoptysisLeft-sided heart failure :

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Symptoms:Abdominal PainAnorexiaNauseaBloatingSwellingRight-sided heart failure

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2008 Heart Failure Society of America, Inc.What Are The Symptoms of Heart Failure?Think FACES...FatigueActivities limitedChest congestionEdema or ankle swellingShortness of breath

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Response to treatmentECGCXRECHO Angiography DIAGNOSIS

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Treatment

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Reduce the respiratory and cardiac workloadReduce agitation of patientInduce diuresis & vasodilatationReduce respiratory rateDecrease heart rateEstablish the cause and treat.

Goals of Treatment

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Therapy for heart failureMyocardial dysfunctionIncreased loadNeurohomonalactivationCardiomyocytedysfunctionCell deathHeart failure

Drug therapyDrug therapyGene therapyHeart transplantation

Cell transplantation

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Treatment Considerations Non-Pharmacologic

Diet:Salt restrictionFluid restrictionWeight loss Lipid control

AlcoholSmokingExerciseCardiac RehabPalliative ServicesSocial Support

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Pharmacologic Interventions

Good Evidence to use the following exist:

ACE-InhibitorsBeta BlockersSpironolactoneDiureticsDigoxin

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Angiotensin Converting Enzyme InhibitorsIndication: All HF patients with sDysfunction (symptomatic or not); [A]

Goal :Reduce morbidity & Mortality

Dose: Ideal dose controversial, start low and increase to common dose

Precautions: Baseline Serum K+ and Cr. at initiation of therapy required.Careful monitoring if sBP 25mg is rarely indicated.

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DiureticsIndication: to control fluid overload (Edema, Ascites, Wt gain)

Goal: Improve morbidity

Dose: - Usually Furosemide, start @ 20mg/d and incr/decr as needed - Diuretics can be stopped if fluid overload resolves.

Precautions: K+ wasting, typically given with KCl supplements, Monitor serum K+.

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ACE-Inhibitors

Evidence for Use: Systemic reviews & RTCs show that ACE-Inhibitors reduced ischemic events slow disease progression improve exercise capacity decrease hospitalization & mortality for heart failure compared with placebo.

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Diuretics, ACE InhibitorsReduce the number of sacks on the wagon

DigoxinIndication: HF + A.fib [A]Patients still symptomatic despite use of Diuretics, ACEI & b-Blockers. PRN use to control dyspnea at rest (existing or new onset) [A].

Goal: Improve morbidity

Dose: 0.125 0.25mg /d

Precautions:-Digoxin levels [when toxicity is suspected].-Pushed to backburner b/c of recent discovery that it can incr risk of death from any cause amongst women [not men] w/HF and decr LVEF.

Digoxin:Interaction: 1.Amiodarone- incr digoxin conc> decr A-V node conduction > HR. 2.Antacids- decr digoxin absorption [space out administration by 2hrs apart]3.B-Blocker- Carvedilol may incr digoxin4. Diltiazem / Verapamil (CCB)- decr digoxin absorption5. PPI- omeprazole- Incr conc

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Digitalis CompoundsLike the carrot placed in front of the donkey

Cardiac Resynchronization TherapyIncrease the donkeys (heart) efficiency

intractable heart failure patient becomes progressively refractory to therapy.cardiac dysrhythmias digitalis toxicity ( from decrease renal function).Pulmonary emboli, pneumoniaCardiogenic shock

Complications

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Nursing Process

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Nursing history:- 1.Family history of heart diseases2.Previous episodes of IHD 3.Dietary habits and salt intake4.Target organ diseases5. Sleep patterns.

Nursing assessment

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Auscultate heart rate and palpate peripheral pulsesAuscultate the chest for crackles and wheezingExamine the heart for enlargementDetermine mentation status by asking pt about memory, ability to concentrate

Physical examination

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Decreased cardiac output R\T impaired contractility & increase preload and after load. Goal : Maintaining adequate cardiac output.

Nursing diagnosis (1)

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place patient at physical & emotional rest to reduce work of heart.Observe for sign and symptoms of reducing tissue perfusion , cool temperature of skin, facial pallor, poor capillary refilling.Implementations

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Re-assure patient and familyMaintain patient in High Fowlers positionO2 100% via non re-breathable mask or CPAP.monitor O2 saturations.Attach to cardiac monitor, assess rhythm, rate.Cyclomorph (frequent small doses)Record ECG to identify &promptly treat cardiac cause.Implementations

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2. Activity intolerance (or risk for activity intolerance) related to imbalance between oxygen supply and demand because of decreased CO.

Goal : PROMOTING ACTIVITY TOLERANCENursing diagnosis (2)

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The schedule should alternate activities with periods of rest and avoid having two significant energy-consuming activities occur on the same day.Before undertaking physical activity, the patient should be given the following safety guidelines:Implementations

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Begin with a few minutes of warm-up activities.Avoid performing physical activities outside in extreme hot, cold, or humid weather.Ensure that you are able to talk during the physical activity; if you are unable to do so, decrease the intensity of activity.Wait 2 hours after eating a meal before performing the physical activity.Stop the activity if severe shortness of breath, pain, or dizziness develops.End with cool-down activities and a cool-down period.Implementations

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Heart Failure: Nursing Diagnoses Impaired gas exchange related to ventilation perfusion imbalance.

Ineffective (cardiopulmonary) tissue perfusion related to impaired arterial blood flow.

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Heart Failure: Nursing DiagnosesExcess fluid volume related to excess fluid or sodium intake and retention of fluid secondary to heart failure and its treatments.

Anxiety related to breathlessness and / or restlessness secondary to inadequate oxygenation.

Powerlessness related to inability to perform usual role responsibilities.

Knowledge deficit related to heart failure and its treatments.

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Nursing Management: Heat FailureNursing Considerations RespiratorySupplemental oxygen Good lung assessmentMonitoring Hemodynamic Monitoring Daily WeightsI & Os Laboratory Results i.e. electrolytes, BNP & digoxin levels Maintain Small frequent meals; low in salt Skin integrity

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Nursing Management: Heat FailureNursing considerations Cont.,Promote rest and avoid fatigue Assess for peripheral edema Client EducationMedications Lifestyle changesi.e. low-sodium diet & activity-rest balance Daily weights S/Sx of worsening heart failure to report Importance of follow-up care

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Continue standard heart failure medicationsMonitor of biochemistry and haematology profiles.Daily weight monitoring, before breakfast & after voiding.Daily intake / output chartSalt restrictionContinue education of patient and family member.MobilizationPreparation for discharge Two day ruleFollow up 7-10 days

Ward Management

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2 Day RuleSymptomatically stable and improved!!!!!Off all IV therapy for 2 daysStable oral therapy with no dose changes for 2 daysStable dry weight for 2 daysStability for Discharge

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Stable heart failure patients generally have low blood pressure!!!!!!ACE inhibitors and Beta blockers given to protect the heart muscle not to control BP!!!As a rule if patient is asymptomatic and has BP > 90/60 mmHg then regime can continue.Ensure that patient is not dehydrated. Check fluid intake, get patient to drink a glass of water and recheck BP in 30 mins Do not elevate end of bed!!!!!If still unsure check with medical team or Heart Failure.Never stop Heart Failure Meds!!!!

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Six signs of decompensaton Fatigue, Weight, Oedema, SOB, Nausea, Palpitations .Stable weight Significance of weight gainHow to report clinical deteriorationMedications & dosagesSalt restriction & fluid intakeAlcoholAppropriate lifestyle changes

What Heart Failure Patients MUST know!!!

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Any question?

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THANK YOU46

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(Medical dictionary definition of hypertension from KMLE Medical Dictionary retrieved on 07-04-1 Johnson JA, Turner ST (June 2009). "Hypertension pharmacogenomics: current status and future directions.". Current Opinion in Molecular Therapy 7 (3): 218-225. PMID 15977418.Up-to-date software program, 2010.Brunner , Medical-surgical nursing 11th edition.Shatzer, M. (2003). Using a BNP test to identify heart failure. Nursing, 33(1), 68.Svendsen, A., Arnold, J. M., & Parker, J. (2006). Caring for patients with heart failure. Canadian Nurse, 102(3), 14-17.

References

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