Kristin Hinkle

NSC 386

Heart Failure

Heart Failure NSC 386 What is Heart Failure? Heart cannot pump blood to the body. Not a disease- lifelong process that must be manages; lifestyle changes etc. Pts. can be diagnosed chronic heart failure with acute exasperations (attacks) Inability of the heart to pump and/or fill Leads to: CO Inadequate tissue perfusion Impaired organ function Associated with: CAD and HTN After a MI- from muscle damage Valvular disease A lot go into renal & hepatic failure Atrial fibrillation- lose kick=stasis- working harder but not as effectively so it can lead to heart failure. (A fib can cause or be caused by HF) Heart Failure- Major Health Problem Most common reason for hospital admission in adults >65 y/o- rates of re-admission to hospital is . @ are re-admitted within 6 months! Economic burden In-hospital mean LOS= 6.5 days spend in hospital HF has a poor prognosis- @ 1/3 of diagnosed HF pts. will die within 1 year of diagnosis! Etiology of Heart Failure Risk Factors: CAD (#1 most common cause), advanced age, HTN, DM, cigarette smoking, obesity Heart Failure is caused by an interference with CO CO depends on: 1. Preload (volume) 2. Afterload (pressure/resistance) 3. Stroke volume 4. Heart rate Pathophysiology of Heart Failure 1. Systolic Failure: more common PUMP problem Caused by impaired contractility or increased afterload Hallmark of systolic failure= low ejection fraction (EF) Normal EF = 55-65% EF with heart failure < 40% EF is % of blood is ejected from heart with each cardiac contraction Ejection Fraction-(photo)- can be determined from echocardiogram; Heart failure is a structural problem with the heart so it cant pump as well= its EF Ejection Fraction Video

Formatted: Font: Not Bold

Formatted

Formatted: Numbered + Level: 1 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1"

Formatted: Font: Bold

Formatted

Kristin Hinkle

NSC 386

Heart Failure

Pathophysiology of Heart Failure cont 2. Diastolic Failure- less common FILLING problem-ventricles cannot relax enough to fill Caused by chronic HTN (left ventricular hypertrophy) or cardiomyopathy Results in: SV and CO Will see a backup of blood in the pulmonary and systemic systems 3. Mixed Systolic and Diastolic Failure- very poor quality of life A PUMPING and FILLING problem Will see biventricular failure- both right and left are effected- cant pump or fill properly EF will be very low and BP will be low usually < 35% Often seen with cardiomyopathy Heart Failure- Compensatory Mechanisms In order to compensate for the decrease in CO associated with heart failure, we will see 1. Ventricular dilation 2. Ventricular hypertrophy 3. Activation of the SNS 4. Neurohormonal responses Heart Failure- Compensatory Mechanisms 1. Ventricular Dilation usually in left ventricle Result of high pressures in the heart over time Muscle fibers stretch to increase contractile force Over time, muscle fibers become overstretched = Poor contractility (think Starlings lawonce its overstretched, overtime it looses its stretch Heart Failure- Compensatory Mechanisms (cont.) 2. Ventricular Hypertrophy - increase in cardiac wall thickness- muscle gets bigger from working so hard then its not as effective - usually follows chronic dilation - initially, will see, improved CO but over time, CO will decrease Heart Failure- Compensatory Mechanisms (cont.) 3. Activation of the SNS 1st mechanism activated, but least effective - Epinephrine and Norepinephrine released = - see, vasoconstriction which increases the SVR (systemic vascular resistance)(afterload) - leads to an increased workload on the heart Heart Failure- Compensatory Mechanisms (cont.) 4. Neurohormal Response -kidneys Renin- Angiotensin- Aldosterone System (RAAS) CO to kidneys = kidneys release renin = conversion of angiotensin I to angiotensin II (a potent vasoconstrictor) ( afterload) = release of aldosterone = Na++ and H2O retention ( preload) = fluid overload less blood to kidneys- they try to compensate by fluid volume to BP Heart Failure- Compensatory Mechanisms (cont.) 2

Formatted: No bullets or numbering Formatted: Font: Bold

Formatted: Font: Bold

Formatted: Font: Bold Formatted: Font: Bold

Formatted: Font: Bold

Formatted: Font: Bold Formatted: Superscript

Formatted: Font: Bold

Kristin Hinkle

NSC 386

Heart Failure

4. Neurohormonal Response (cont.) Release of ADH (due to decrease in cerebral perfusion pressure)-body holds on to fluids Leads to an increase in H2O reabsorption = Preload Compensatory responses are more damaging overtime, making an already damaged heart work even harder Ventricular Remodeling result of compensatory mechanisms Because of: Hypertrophy of ventricles = EF Large, spherical chambers Often seen in the left ventricle- enlarged- starts to look like a football! Less effective pump! Ventricular remodeling is a risk factor for ventricular dysrhythmias & sudden cardiac death Heart Failure- Counter Regulatory Mechanisms Brain Natriuretic Pepide (BNP) Produced by the heart Secreted in response to increased pressure in the ventricles Leads to: 1. vasodilation- to combat afterload 2. diuresis & naturesis excreting extra sodium(helps with preload ) 3. Blockage of the RAAS- Renin-Angiotensin Aldosterone System- blockage that preload and afterload Types of Heart Failure Left-sided Heart Failure will see respiratory problems; more common than right pressure means heart has to work harder Caused by: Left ventricular dysfunction Backup of blood into the L atrium-then backs up into the lungs S/S: pulmonary edema and congestion- fluid moves into alveolar spaces; symptoms become more severe with more fluid accumulation SOA Wheezing Crackles Moist cough Cyanosis Chest Congestion-photo white in the xray, is fluid in the lungs

Formatted: Font: Not Bold

Formatted: Font: Bold

Formatted: Font: Bold

Formatted: List Paragraph, Bulleted + Level: 1 + Aligned at: 1.5" + Indent at: 1.75"

Normal Chest X-ray:

Pulmonary Congestion:

Types of Heart Failure (cont.) 3

Kristin Hinkle

NSC 386

Heart Failure
Formatted: Font: Bold

Right-sided Heart Failure- common in COPD pts. Caused by: Right ventricular dysfunction Backup of blood into R atrium Often a result of left- sided HF or cor pulmonale (result of pulmonary disease) S/S: systemic edema 1. JVD 2. Peripheral edema 3. Vascular congestion of GI tract (ascites) 4. Hepatomegaly enlarged liver ( liver enzymes)

Jugular Venous Distention-photo

Peripheral Edema- photo

pitting edema

Ascites- photo Right vs. Left Sided Heart Failure Right Sided HF R ventricle pump failure = back-up congestion in peripheral tissue & organs Increased venous pressure = JVD, peripheral edema, ascites, hepatomegaly Left Sided HF L ventricle pump failure = back-up congestion in lungs Increased pulmonary pressure = fluid forced from pulmonary capillaries into pulmonary tissues and alveoli = pulmonary edema Acute Decompensated Heart Failure probably have a Dx of HF; may have eaten a salty meal Due to acute L ventricular failure Manifests as: pulmonary edema- alveoli become flooded in bases of lungs Acute Decompensated Heart Failure requires immediate action! Signs and Symptoms: Anxious & restless Pale- may have cyanotic nail beds Cool, clammy skin from CNS vasoconstriction Severe dyspnea RR > 30 breaths/min Wheezing, crackles, or rhonchi Cough with frothy, pink sputum- BAD sign! ABGs: low PaO2 and high PaCO2- bad gas exchange- alveoli cant exchange so they cant get rid of CO2 or get in O2= respiratory acidosis Chronic Heart Failure 4

Formatted: Font: Not Bold

Formatted: Font: Not Bold

Kristin Hinkle

NSC 386

Heart Failure
Formatted: Underline

Progressive worsening of ventricular function Often see symptoms of biventricular failure (left & right failure) Acronym FACES Fatigue Limitation of Activities Chest Congestion Edema Shortness of breath Chronic Heart Failure Symptoms 1. Fatigue- due to a decrease in oxygen to the tissues, tired all the time; dont sleep well; one of the earliest signs of heart failure 2. Dyspnea- seen with mild exertion, but as it progresses, it can be seen while lying in bed Orthropnea- SOA when pt. lies down; a lot will sleep with many pillows Paroxysmal Nocturnal Dyspnea (PND)- result of reabsorption of fluid when the pt. is lying down; wake up with a panicky drowning feeling Pre-load goes at night because they are lying down 3. Tachycardia- early onset symptom of HF; from reduced cardiac output 4. EdemaR-sided = peripheral edema, hepatomegaly, ascites L-sided = pulmonary edema 5. Nocturia- when pt. lies down Fluid reabsorption when pt. lies down = renal blood flow= diuresis 6. Skin Changes- r/t poor oxygenation in tissues; dusky appearance, cool & damp lower extremities: shiny & swollen, brownish pigment 7. Behavioral Changes- restless, confused, anxiety 8. Chest Pain- typically relieved by Nitroglycerin 9. Weight changes- initial weight gain from fluid; later, may see a loss- from not eating well-may still look big from the edema Complications of Heart Failure Renal Failure Decrease in renal perfusion BUN & Creatinine, Urine output Left Ventricular Thrombus- stasis of blood in Lt. ventricle Enlarged LV and decreased CO= higher risk for thrombus formations Pleural Effusion (collection of fluid) Fluid accumulation in pleural space- drain them or diuresis them Complications of Heart Failure (cont.) Dysrhythmias Result of stretching of the heart chambers

Formatted

Formatted

Often see- Atrial fibrillation- seen in 1/3 of pts. with heart failure Hepatomegaly- seen with RV failure; leads to impaired liver function- see changes in liver enzymes American Heart Association Stages of Heart Failure 5

Kristin Hinkle

NSC 386

Heart Failure

Stage A Pt. at high risk for HF, but no symptoms or structural changes of the heart -Treatment: lifestyle changes Stage B Pt. has structural heart disease, but has not shown symptoms Treatment: lifestyle changes, possible meds Stage C Pt. has prior or current symptoms of HF along with underlying structural heart disease Treatment: lifestyle changes, possible meds, possible ICD Stage D Pt. has refractory (treatment doesnt work) HF and needs specialized interventions (Treatment: same measures as above, plus end of life care, heart transplant, experimental drugs) Diagnostic Studies Goal= determine the underlying cause- lung disease? CAD? History and Physical- do they have HTN, CAP, Rt or Lt. side failure? Chest X-ray- look for white out; pulmonary congestion; cardiomyopathy Echocardiogram Will see a low ejection fraction (EF) <40% Normal EF = 55-65% BNP (nml = 0-100 pg/mL) BNP 100-500 pg/mL= HF probable BNP >500 pg/mL= HF highly probable Chronic BNP levels = around 550 pg/ml Acute BNP levels = 1500+ pg/ml Nursing Care in Acute Decompensated Heart Failure (ADHF) Case Study - Mr. Miller, age 74, presents to the ED today with acute onset of dyspnea. Crackles are audible throughout both lung fields and his O2 sat is 88% on RA. Hi wife mentioned that he has been c/o increasing SOB over the past few days, inability to sleep at night (he uses 2 pillows), getting up numerous times a night to urinate, his socks are too tight and he can only wear his house shoes. Symptoms: peripheral edema (rt side), crackles (lt. side), Biventricular HF?, urinating frequently at night, sleeping with 2 pillows, O2 -88% Priority: get O2 up! What is his position? Is he lying down? Sit him Up! Give oxygen, get labs- BNP, ABG, Creatinine- get before diuresing, get fluid off. Medical Hx- previous Dx? Compliant with meds? Lifestyle compliance? What has he been eating or drinking? Nursing Care in Acute Decompensated Heart Failure (ADHF) This is Mr. Millers 3rd admission in the past 6 months. He lives with his wife who has beginning stages of dementia. He states he often forgets to take his medicine. He and his wife eat lots of frozen dinners. He c/o fatigue during the day and has difficulty walking to his driveway to get his daily newspaper. He has gained 12 pounds since his last admission 2 months ago. Acute Heart Failure- Collaborative and Nursing Care (cont.) 6

Formatted: Underline

Formatted: Underline

Formatted: Underline

Formatted: Underline

Formatted: Underline Formatted: Underline Formatted: Underline Formatted: Underline Formatted: Underline Formatted: Underline

Kristin Hinkle

NSC 386

Heart Failure
Formatted: Underline Formatted

Improve Gas Exchange and Oxygenation- TOP PRIORITY 1. High fowlers position- 90* 2. Supplemental oxygen- start with NC, 2-4L 3. Morphone0 decrease anxiety= decreased O2 demand, so RR, overall workload of heart and lungs Acute Heart Failure- Collaborative and Nursing Care (cont.) Decrease Intravascular Volume/ Reduce Preload fluid volume 1. High Fowlers position with legs dangling or horizontal in bed 2. Loop Diuretics (Lasix) given IV- rapid acting nsg: watch K+ levels, monitor I&O, auscultate breath sounds, check pt. weight 3. Vasodilators (Nitroglycerin- NTG) Nsg: watch for hypotension- check every 15 minutes Acute Heart Failure- Collaborative and Nursing Care (cont.) Decrease Afterload NTG Nipride (STRONG vasodilator) given in ICU Improved cardiac contraction= CO and pulmonary congestion Nsg: watch for hypotension, thiocynate toxicity Nesiritide (Natercor)- synthetic BNP Arterial and venous vasodilator Provides diuresis and sodium excretion Nsg: must be on an IV pump, watch for hypotension ACE Inhibitors: -pril blocks RAAS- Renin-Angiotensin Aldosterone System (keeps this from retaining fluids) Acute Heart Failure- Collaborative and Nursing Care (cont.) Improve Cardiac Function Inotropic Therapy- if pt. has NOT responded to vasiodialators or diuretics For SHORT TERM management of acute HF Increases myocardial contractility Digoxin- PO, IV push Dobutamine continuous IV infusion Nursing Care in Chronic Heart Failure Mr. Miller loses 18 pounds while in the hospital. He states he can breathe much easier now, his regular shoes fit comfortably, and he is ready for DC home. Educate: meds, diet, lifestyle changes Core/Performance (minimum standards) Measures for Heart Failure These measures must be documented with every admission: 1. Left Ventricular Function Assessment Ejection Fraction-from echocardiogram 2. ACE Inhibitor or ARB (Angiotensin Receptor Blocker) for EF <40% 3. Discharge Instructions: 1. Activity level 2. Diet / fluid intake 3. Actions when symptoms worsen 7

Formatted: Underline

Formatted

Formatted Formatted: Underline Formatted: Font: Bold

Formatted: Font: Bold Formatted: Font: Bold

Formatted: Font: Bold Formatted: Indent: First line: 0.5", No bullets or numbering Formatted: Indent: Left: 0", Hanging: 1", No bullets or numbering Formatted: Underline Formatted

Formatted Formatted: Underline

Kristin Hinkle

NSC 386

Heart Failure

4. Daily weights 5. Follow up appointments 6. Medications Chronic Heart Failure- Collaborative and Nursing Care Goals for treatment of Chronic HF: 1. Treat the underlying cause 2. Maximize CO 3. Symptom management 4. Improve quality of life and decrease mortality rates 5. Preserve target organ function Chronic Heart Failure- Collaborative and Nursing Care (cont.) Oxygen Therapy Activity Balance of rest and activity For stable chronic HF- Stage A & B pts.- start slowly, then increase a few minutes each day (like 5 min/day of walking) Teach pts. how to check their HR and RR Chronic Heart Failure- Collaborative and Nursing Care (cont.) Drug Therapy Diuretics Thiazide diuretics preferred for chronic HF Lasix for acute ACE Inhibitors Block the RAAS system Vasodilators- nitrates For patients who can not tolerate ACE Inhibitors Chronic Heart Failure- Collaborative and Nursing Care (cont.) Nutritional Therapy 2-4g is normal recommendation (healthy) Sodium restriction- Americans average @ 7-15g/day Should be limited to < 2g per day Avoid canned or processed foods Encourage fresh fruits and vegetables No table salt! Fluid Restriction For patients with Class C & D Heart Failure Should be < 2 liters per day Give ice, gum, lemon flavored things, hard candy to help with thirst Chronic Heart Failure- Collaborative and Nursing Care (cont.) Daily Weights/Monitor Fluid Balance How do we teach our patients to weigh themselves? Same time, same clothing, same scale, morning is best before breakfast Weight gain of 3 lbs over 2 days or 3-5 lbs over a week = contact MD in weight is an earlier indication of fluid retention than edema How do we assess fluid balance? 1. Ankle swelling 2. Abdominal swelling 3. Orthopnea- SOA when lying flat 8

Formatted: Underline

Formatted: Font: Bold

Formatted: Numbered + Level: 1 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 1.25" + Indent at: 1.5"

Kristin Hinkle

NSC 386

Heart Failure

4. Paroxysmal Nocturnal Dyspnea 5. Weight Gain Chronic Heart Failure- Collaborative and Nursing Care (cont.) Limit Alcohol/ Smoking Cessation Avoid Herbal Therapy and NSAIDS (ibuprofen, Alieve, Motrin) can lead to sodium and water retension Education about s/s of Acute Decompensation- SOA, swelling Chronic Heart Failure- Collaborative and Nursing Care (cont.) Address Psychosocial Issues Depression- high rates Stress/Anxiety Sexual Dysfunction Class A & B can use Viagra (as long as not on nitrates), Class C & D cannot Nursing Diagnoses for Chronic Heart Failure Activity intolerance r/t fatigue Excess fluid volume r/t cardiac dysfunction Impaired gas exchange e/t alveolar-capillary membrane changes Anxiety r/t dyspnea & fear of death Decreased cardiac output r/t altered contractility & stroke volume Knowledge deficit r/t . Advanced/End Stage Heart Failure- Class D Biventricular Pacing Coordinates R and L ventricular contractility, which improves LV function and CO Implantable Cardioverter Defibrillator- for ventricular dysrhythmias Cardiac Transplantation

Formatted: Underline

Formatted: List Paragraph, Bulleted + Level: 1 + Aligned at: 0.25" + Indent at: 0.5"

Formatted: Font: Not Bold