Heart Failure

Marvick F. Galima RN

Objectives
At the end of discussion, the student will be able to: Master the concept of heart failure; the causes, signs and symptoms, medical and nursing management Elicit proper decision making with regards to proper intervention between and among different signs and symptoms manifested by their patient Prioritized interventions depending upon the immediate need of the patient Explain clearly the blood flow and blood supply of the heart Compare and contrast the right sided heart failure and left sided heart failure

Realized that nursing is an art!!!

Internal Anatomy of the Heart

Heart Functions
1. Generating blood pressure Required for blood flow through the blood vessels 2. Routing blood Two pumps, moving blood through the pulmonary and systemic circulations 3. Regulating blood supply Adjusts blood flow by changing the rate and force of heart contractions as needed

Blood Flow to the Heart

Blood Flow to the Heart

Myocardial Blood Flow

Heart Failure
It is an inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. Types of Heart Failure: A. Acute Heart failure B. Chronic heart failure

Systolic heart failure Diastolic heart failure

Physical Examination: Heart Sounds

Normal vs. abnormal Pathologic splitting of S2 Gallops Quadruple rhythm Clicks Pericardial friction rub Murmurs

Heart Failure
Causes: Coronary artery disease Cardiomyopathy Hypertension Valvular disease Diabetes mellitus Cardiac dysrhythmias Risk factors: Thyrotoxicosis Iron overload Hypoxia Severe anemia

Pathophysiology
Ischemic heart disease Myocardial infarction Valvular diseases Chronic hypertension

Myocardial dysfunction

Decrease Cardiac output Decrease Systemic blood pressure Decrease Perfusion to the kidneys

Activation of Increase sodium and water retention renin Vasoconstriction angiotensinaldosterone system

Activation of baroreceptor s

Left ventricle Aortic arc Carotid sinus

Activation of sympathetic nervous system

Increase catecholamine's (epinephrine & norepinephrine)

vasoconstrict ion

Increase afterload Increase blood pressure Increase heart rate

Release of ANP & BNP

Chronic increase workload of the
heart

Promotes vasodilation diuresis to decrease workload of the heart

Decrease contractility of the myocardial muscles Ventricular dilation and hypertrophy Abnormal proliferation of myocardial cells Decrease heart filling Decrease CO

Heart Failure: Clinical Manifestations

Left Sided Heart Failure Signs & symptoms: Dyspnea Orthopnea Paroxysmal nocturnal dyspnea Productive and nonproductive cough (frothy sputum) Crackles Decrease perfusion to the distant extremities Oliguria Altered digestion

Dizziness Lightheadedness Confusion Restlessness Anxiety Pale/ ashen skin Cool clammy skin Dysrhythmias Bradycardia Presence of S3 sound

Heart Failure: Clinical Manifestations

Right Sided Heart Failure
Signs & Symptoms: Edema on the lower & upper extremities Hepatomegaly Ascites Anorexia & nausea Weakness Weight gain Dysrhythmias Bradycardia

Diagnostic Findings
Echocardiogram Chest X-Ray Electrocardiogram Serum electrolytes Blood urea nitrogen Creatinine Thyroid stimulating hormone Complete Blood cell count B-type natriuretic peptide (increased)

Medical Management
A. Pharmacologic Therapy Angiotensin converting enzyme inhibitor (ACE-inhibitor); oral & IV - Benazepril - Quinapril - Ramipril - Enalapril - Captopril - Moexipril Side effects: - Hypotension - Hypovolemia - Hyperkalemia - Alteration in the renal function - Dry persistent cough

Medical Management
A. Pharmacologic Therapy Angiotensin II Receptor Blockers - Valsartan (Diovan) - Telmisartan - Irbesartan - Candesartan - Losartan Side effects: - Hyperkalemia - Hypotension - Renal dysfunctions

Medical Management
A. Pharmacologic Therapy Hydralazine and Isosorbide Dinitrate - Apresoline (Hydralazine) - Isordil - Dilatrate - Sorbitrate

Side effects: - GI upset - Headache - Dizziness - Hypotension

Medical Management
A. Pharmacologic Therapy Beta Blockers - Carvedilol - Atenolol - Metoprolol (Toprol, Lopressor) Side effects: - Dizziness - Hypotension - Bradycardia - Broncho - constriction

Medical Management
A. Pharmacologic Therapy Diuretics Thiazides (Benzthiazide, Chlorothiazide, Bendroflumethiazide) Loop diuretics (Furosemide, Bumetanide, Torsemide) Potassium sparing diuretics (Spironolactone, Amiloride, Aldactone)

Side effects: - Electrolyte imbalances - Symptomatic hypotension - Hyperuricemia - Ototoxicity

Medical Management
A. Pharmacologic Therapy Digitalis (Digoxin) Therapeutic level - .5 2.0 ng/ml Side effects: - Electrolyte imbalances - Symptomatic hypotension - Decrease heart rate - GI upset - Anorexia

Digoxin therapy
Nursing Consideration and actions: - Assess patients clinical response to Digoxin - Monitor the patient for factors that increase the risk of toxicity - Assess apical pulse before administering Digoxin. Do not give if the heart rate is below 60 bpm - Monitor for gastrointestinal side effects such as anorexia, vomiting, abdominal pain and distention - Monitor for neurologic effects such as headache, malaise, nightmare, forgetfulness, social withdrawal, depression, agitation, confusion, paranoia, hallucinations, decrease visual acuity, yellow or green halo around objects (especially lights) or snowy vision. - Teach the patient not to abruptly withdraw medications - If toxicity is severe, administer Digibind as ordered

Medical Management
A. Pharmacologic Therapy Calcium channel Blockers - Verapamil - Nifedipine

- Diltiazem - Amlodipine

Side effects: - Hypotension - Bradycardia - Dizziness - Headache

Medical Management
A. Pharmacologic Therapy Intravenous Infusions: Nesiritide promotes dilation of the arteries and veins and also suppresses the neurohormones responsible for fluid retention thus promoting diuresis. Milrinone a phosphodiesterase inhibitor that inhibit the release of calcium from the intracellular reservoirs and prevents the reuptake of extracellular calcium by the cells. This promotes vasodilation, resulting in decrease preload and afterload and reduces cardiac workload of the heart. Dobutamine a catecholamine that stimulate the beta 1 adrenergic receptors thus increasing cardiac contractility

Other medications and therapy

Anticoagulants Anti-anginal medications Non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided

Nutritional therapy (low sodium diet; 2-3 g/day) and avoidance of excessive amount of fluids Supplemental oxygen Surgical Management: Placement of implantable cardioverter defibrillator (ICD) Used of cardiac resynchronization therapy (CRT) Cardiac Transplantation last resort

Nursing Assessment
Administer medications and assessing the patients response to the pharmacologic regimen Assess fluid balance including intake and output Weigh the patient daily Assess pulmonary functions Assess degree of jugular venous distention Assess and evaluate the severity of the edema Monitor pulse rate and blood pressure Examine the integrity of the skin Assess for any signs and symptoms of fluid overload

Nursing Management
Promote activity tolerance by providing rest periods between activities Teach the patient to avoid performing physical activities outside in extreme hot, cold or humid weather Teach the patient to perform activity in a normal pace manner Teach the patient to perform activity 2 hours after eating Warn the patient to stop activities if there are symptoms manifested such as severe shortness of breath, chest pain and dizziness Emphasized to client cooling down activities is necessary after doing physical activities Small frequent feeding should be emphasized to clients If the patient is in the hospital, oxygen saturation level are monitored before, during and after an activity

Nursing Management
Diuretics should be administered early in the morning Assist the patient to maintain diet low in sodium content If the patient is receiving IV infusion, closely monitor the rate of the infusion Assist the patient to assume position that facilitates easy breathing Provide frequent changing of position as necessary Teach patient to avoid straining Lower anxiety level of the patient?

Complications of Heart Failure

Cardiogenic Shock it is the condition wherein the heart is incapable of providing blood supply to the circulation due to myocardial muscle loss of contractile power Thrombolembolism due to decrease mobility of the patient, this may lead to the development of intracardiac and intravascular thrombosis that may travel to circulation

Complications of Heart Failure

Pericardial Effusion and Cardiac Tamponade this is a condition wherein there is an excess accumulation of fluid in the pericardial sac thereby, compressing the heart muscle. The result will be decrease heart muscles contractility and decrease cardiac output.

Surgical Treatment
Treatment: Pericardiocentesis a procedure to remove excess pericardial fluid by inserting a needle in the pericardial sac thereby decreasing the pressure in the heart muscle and increasing heart filling and contraction

Pericardiotomy a portion of the pericardium is excised to permit the pericardial fluid to drain into the lymphatic system

Complications of Heart Failure

Cardiac arrest the condition occurs when the heart ceases to produce an effective pulse and circulate blood. Emergency management: Cardiopulmonary Resuscitation

Medications to be used: - Epinephrine (Adrenaline) - Vasopressin (Pitressine) - Atropine Sulfate - Sodium Bicarbonate - Magnesium

Nursing Diagnosis
Activity Intolerance Decreased Cardiac Output Ineffective tissue perfusion Excess Fluid Volume Fatigue Impaired Gas Exchange Ineffective Health Maintenance Fear Noncompliance

Review questions
Diltiazem (Cardizem) is classified as what type of medication? a. calcium channel blocker b. beta-adrenergic blocker c. ACE inhibitor d. inotropic drug

Review questions
The physician ordered Dopamine (Intropin) to a patient who has cardiac failure. The nurse knows that the effect of such medication is which of the following? a. decrease the oxygen demand of the heart b. increase cardiac output and stroke volume c. decrease the hearts workload d. decrease the circulating blood volume

Review questions
doctor prescribes digoxin (Lanoxin) twice a day until a therapeutic drug level is attained. When the nurse takes the patients apical pulse on the 3rd day, it was 52 bpm and the patient is complaining of nausea. The nurse should do which of the following? a. withhold the digoxin and notify the doctor b. withhold the digoxin and obtain a serum digoxin level c. administer the digoxin and medicate for nausea d. administer the digoxin and notify the doctor

Review questions
Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply. a. Ineffective tissue perfusion r/t decreased peripheral blood flow secondary to decreased cardiac output b. Activity intolerance r/t increase cardiac output c. Decreased cardiac output r/t structural and functional changes d. Impaired gas exchange r/t decreased sympathetic nervous system activity

Knowledge has to be improved, challenged, and increased constantly, or it vanishes. Peter Drucker

Thank You for Listening!!!