Download Heart Failure

HEART
FAILURE
NUR240
Lecture 4
R. Kolk, revised 11/09 J. Borrero
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Heart Failure
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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.
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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:
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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
Orthopnea
Cough
WT. gain
Fatigue
Anxiety/ restless
S3
Cardiomegaly
Crackles
 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
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O2 Saturation
Vital Signs
Heart Rhythm
Lung Sounds
Level of dyspnea
Serum Electrolytes
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Daily weights
Changes in LOC
I&O
Coping ability of pt
and family
• Signs of drug toxicity
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JCAHO Core Measures for HF
Every 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
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Monitor respirations, breath sounds
Administer O2
Position- high-Fowlers
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Interventions
2. MAINTAIN CARDIAC FUNCTION
• Monitor heart sounds
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Pulmonary Artery Catheter
Measurements
CVP
Pulmonary Artery Pressure
Pulmonary Capillary Wedge Pressure
Cardiac 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
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Assess edema
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Provide adequate nutrition
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Provide emotional support
Maintain diet restrictions as
prescribed (Na and fluid)
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MEDICATION
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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
MEDICATIONS
•  Fluid load,  Preload,  Afterload
ACE inhibitors & Diuretics
• Improve contractility
Digoxin
Dobutamine
•  Workload of the heart
“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)
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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/min
3. Calculate the dosage flow rate in mL/min
Dosage on hand = Dosage desired/min
Amt solution on hand X amt desired/ min
4. 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 pump2.Dopamine 800 mg/ 500 mL D5W to infuse
at 4 mcg/kg/min.
Weight- 190 lbs.
Flow rate on pump27
Afterload Reducing Agents
• ACE inhibitors-enalapril (Vasotec)
captopril (Capoten)
• Beta-blockers- carvedilol (Coreg)
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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 DIURETICS
MORE POTENT   ACTION
furosemide
(LASIX)
bumetamide
(BUMEX)
PO/ IV
ACTION: at loop of Henle,  K+ loss,
Na+/Cl- excretion
ADVERSE 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
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K+ Sparing Diuretics
Maintenance therapy – conserves K+, has
a gradual diuretic effect
Spironolactone (Aldactone)
Action: blocks reabsorption of Na+/ClAdverse effects: Hyperkalemia
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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
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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.
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Clinical signs
•  LV diastolic pressure   pulmonary
pressure
• Lungs become “stiff” due to fluid buildup,
resulting in hypoxia
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 _________________
 _________________
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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
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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
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Cardiogenic Shock
• Occurs with extensive LV injury  
perfusion to vital organs
• Degree of shock, directly relates to
level of ventricular failure
• Results in:
 ______________ ______________
______________  ______________
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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
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Treatment
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Hemodynamic monitoring
Reduce demand on the heart
Improve oxygenation
Improve tissue perfusion
Intra-aortic balloon pump
Inotropic Meds to  BP,  workload
Correct underlying pathophysiology
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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 distention
B. Hepatomegaly
C. Dyspnea
D. Crackles
E. Tachycardia
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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
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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
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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 leftsided 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
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NCLEX TIME
Provide the rationale Therapy
for each of the
O2
following therapies: Diuretics
Rationale
Bedrest
Inotropic agents
Vasodilators
Fluid restriction
Sodium
restriction
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