Download Heart Failure By Kimberly Napper

1 Heart Failure
Heart Failure by Kimberly Napper
Congestive Heart Failure
Caused by conditions that require the heart muscle to work hard
Failure of one side of heart leads to failure of the other side due to reciprocal changes
Presenting symptoms may vary
Impaired myocardial function
Pulmonary congestion
Systemic venous congestion
Manifestations of Congestive Heart Failure
Tachypnea
Tachycardia (at rest)
Dyspnea
Retractions
Activity Intolerance (poor feeding in infants)
Enlarged liver
Enlarged heart on CXR (& on EKG)
↑pulmonary blood flow on CXR
Left-sided Heart Failure if difficult to pump blood into systemic circulation
↑ pressure develops in left atrium & pulmonary veins
→ pulmonary hypertension & pulmonary edema
Right–sided Heart Failure if difficult to pump blood into pulmonary circulation
↑ pressure develops in right atrium & venous system
→ hepatomegaly,
jugular vein distension (JVD), & peripheral edema
Which of the following symptoms should the nurse recognize as indicative of left-sided heart failure?
dependent edema
bilateral crackles (with Pulmonary Edema on CXR)
liver enlargement
jugular vein distension
2 Heart Failure
??? Which nursing assessment would support the complication of right-sided heart failure?
A.
B.
C.
D.
Increasing respiratory difficulty with exertion.
Cough productive of a large amount of thick yellow mucus.
Peripheral edema and anorexia.
Twitching of extremities.
Right –sided Heart Failure
Peripheral Edema
Jugular vein distension
Cardiac Performance: 4 primary determinants
Contractility -pumping ability/strength
Preload- depends on the volume of venous return to the heart
Afterload-the pressure against which the left ventricle ejects its content
Heart rate- helps maintain adequate cardiac output
Cardiac Output = Stroke Volume X Heart Rate
Stroke Volume- What volume of blood (in liters) is pumped each time the heart beats
How much volume heart holds vs. how much empties with each beat is the ejection fraction (% pumped out)
Heart Rate- How many times the heart empties each minute = rate
Beats/min= heart rate
systole = heart emptying
Things that reduce cardiac output
Decreased stroke volume
Hypovolemia
Blood loss (hemorrhage)
Dehydration (severe)
Burns
Decreased venous return
Sepsis, Shock
Congestive heart failure or cardiomyopathy → decreased ejection fraction
If stroke volume goes down, heart rate must go up to maintain cardiac output! Compensation!
Decreased heart rate: Medications that slow heart rate (example: Digoxin), Heart block (rhythm problem)
If heart rate goes down, stroke volume must go up to maintain cardiac output! Compensation!
Congestive Heart Failure= Condition in which heart cannot pump enough blood to meet metabolic needs
3 Heart Failure
Leads to congestion/edema
Pulmonary
Peripheral
Left-sided heart failure
Pulmonary congestion
Dyspnea on exertion or at rest
Orthopnea
Adventitious breath sounds (crackles)
Cough, dry
In pulmonary edema, frothy pink sputum (danger sign!!)
Right-sided heart failure
Peripheral/dependent edema
Hepatomegaly
JVD (jugular vein distension)
Anorexia/nausea
Weakness
Weight gain
Congestive Heart Failure Diagnosis
CXR
ECG
Routine lab work (blood & urine)
**BNP (B-type natriuretic peptide)
A key diagnostic indicator; Elevation signals high cardiac filling pressures
Echocardiogram
Left ventricular function
**Ejection fraction
Chest X-ray (CXR)
http://www.heartfailure.org/eng_site/treatinghf_doc_op_ang.asp
http://www.heartfailure.org/eng_site/treatinghf_doc_op_ang.asp
4 Heart Failure
Congestive Heart Failure Management
Diet
Fluid restriction
Sodium restriction
Daily weight
Activity
CHF Management:
Treat symptoms; include oxygen, if needed
Treat/modify underlying factors
Monitor symptoms
Monitor contributing factors
CHF Management:
M edication
A ctivity
W eight (daily!!)
D iet (low sodium, fluid restricted)
S ymptoms (report promptly!)
https://intermountainhealthcare.org/xp/public/lds/aboutus/news/article68.xml
Congestive Heart Failure (CHF) Medications:
Antihypertensives
ACE Inhibitors
Beta Blockers
Calcium Channel Blockers
Caution in heart failure!
Cardiac Glycosides
Digoxin
Diuretics
K sparing
K depleting
(Potassium Supplements)- do not treat CHF prevent hypokalemia side effects
5 Heart Failure
CHF Management: Activity
Avoid bedrest
Exercise as tolerated
Regular schedule of activity
Gradually increase endurance
CHF Management:
Weigh Daily
Have client record daily weight at home
Report increases promptly
Diet
Sodium restricted to 2 – 3 grams/day
Fluid restriction to optimize volume status
Watch for food/drug interactions
Licorice: ACE inhibitors, Digoxin, diuretics, aspirin
Grapefruit: Statins & calcium channel blockers
CHF Management: Symptoms to monitor (List symptoms- Brunner discusses the physical exam)
Congestive Heart Failure Treatment Goals
↓ afterload by vasodilation (ACE inhibitors)
↑ cardiac contractility (glycoside: Lanoxin)
↓ preload by removing excess fluid & sodium (diuretics: Lasix & thiazides)
↓ cardiac demands (rest & homeostasis)
Improve tissue oxygenation & ↓ oxygen consumption (O2 administration)
6 Heart Failure
Angiotensin Converting Enzyme (ACE) Inhibitors
Lower blood pressure by decreasing the formation of a potent vasoconstrictor
Common adverse drug reactions include: hypotension, cough, hyperkalaemia, headache, dizziness, fatigue,
nausea, renal impairment
Captopril (Capoten®) often used in pediatric population
Vasotec (enalapril), Prinivil, Zestril (lisinopril), Lotensin (benazepril), Monopril (fosinopril), Altace (ramipril),
Accupril (quinapril), Aceon (perindopril), Mavik (trandolapril), Univasc (moexipril)
???? The most appropriate nursing action before administration of captopril (Capoten) would be to check the client’s:
A.
B.
C.
D.
apical pulse for 60 seconds.
blood pressure.
urine output.
temperature.
Angiotensin II receptor blockers (ARBs) are “sartens”.
block the action of angiotensin II by preventing angiotensin II from binding to angiotensin II receptors on blood
vessels. As a result, blood vessels enlarge (dilate) and blood pressure is reduced
Calcium Channel Blockers… “dipines”, verapamil, diltiazem
slow heart rate by blocking the number of electrical impulses that cause the heart muscle to contract (& pump
blood).
lower B/P by relaxing the muscle tissue in the blood vessels. This makes it easier for blood to flow through the
vessels.
may be used to treat diastolic heart failure (difficulty filling with blood)
If heart beats slower, it has more time to fill between each heartbeat.
May also help heart muscle relax, which can help with filling of blood.
usually are not used for systolic heart failure, in which the heart has a hard time pumping out blood.
Beta-blockers…”lols”
work by slowing the heart rate, which allows the left ventricle to fill more completely.
may slow the progression of systolic heart failure.
may also help open or widen blood vessels in the body. (↓ B/P)
may be used together with other medicines that are usually used to treat heart failure, such as angiotensinconverting enzyme (ACE) inhibitors or diuretics.
may be used to treat diastolic heart failure by slowing the heart rate, which allows more time for the heart to fill
with blood.
This allows the left ventricle to fill more completely and increases the volume of blood that the heart
pumps with each heartbeat (ejection fraction). Then, the heart can pump more blood with each
heartbeat.
7 Heart Failure
Cardiac glycosides: Digoxin (Lanoxin)
Inhibit the Na+/K+ pump →
↑ sodium ions in the myocytes →
↑ calcium ions →
↑ amount of Ca++ ions available for contraction of the heart muscle →
improves cardiac output and reduces distention of the heart
IV with “loading dose”
Serum levels for safety & efficacy
PO for maintenance
Check apical pulse before administering
<90 – 110 beats/min in infants
< 70 beats/min in older children
S/S toxicity
Nausea
Vomiting
Anorexia
Bradycardia
Dysrhythmias
??? In addition to the digitalis levels, it would also be necessary for the nurse to periodically evaluate which lab values on
a client who has been digitalized?
A.
B.
C.
D.
Creatinine levels
Serum potassium
Urine potassium and sodium
Blood urea nitrogen and glucose
8 Heart Failure
Diuretics
Furosemide (Lasix) (potassium depleting)
po, IV
works by blocking the absorption of salt and fluid in the ascending loop of Henle, causing a profound
increase in urine output (diuresis)
can cause lowering of blood potassium, sodium, and magnesium levels, which can lead to heart rhythm
abnormalities, especially in patients already taking digoxin (Lanoxin)
Thiazides (potassium depleting)
a group of drugs that block reabsorption of sodium in the distal tubules of the kidneys
used as diuretics primarily in the treatment of hypertension
po Hydrochlorothiazide (HCTZ) often used
Cause loss of potassium (hypokalemia)
May combine with ACE inhibitors, which cause hyperkalemia, to balance potassium
Potassium Sparing Diuretics
Spironolactone
??? Which of the following areas of assessment would the nurse monitor to determine the effectiveness of a diuretic?
A.
B.
C.
D.
heart rate
blood pressure
urine output
breath sounds
Intake & Output = Great indicator of Cardiac output
(“No pump, no pee”)
Fluid volume status
Look at color of urine (water → tea)
Urine specific gravity (1.003 to 1.035)
Diagnostic Tests
Chest X-ray
Electrocardiogram
Echocardiogram
Cardiac Catheterization
Blood work
BNP (brain natriuretic peptide)
9 Heart Failure
Chest X-ray (CXR)
a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues,
bones, and organs onto film
CXR: Increased pulmonary blood flow supports diagnosis of CHF (Congestive Heart Failure) (left side)
KUB (kidney, ureter, & bladder) x-ray: Hepatomegaly (enlarged liver) goes with right sided heart failure
Electrocardiogram (ECG or EKG)
A test that records the electrical activity of the heart
Shows abnormal rhythms (arrhythmias or dysrhythmias)
Can detect heart muscle stress
Echocardiogram (Echo)
A procedure that evaluates the structure and function of the heart by using sound waves recorded on an
electronic sensor
Produces a moving picture of the heart and heart valves
Can show the pattern of blood flow through the septal openings & determine how large the openings are & how
much blood is passing through them
***Ejection Fraction
Percentage of blood that's pumped out of a filled ventricle with each heartbeat
Usually measured in the left ventricle (LV)
55 % or higher is considered normal
Can be measured with imaging techniques
Cardiac catheterization
%
A long thin tube (catheter) is inserted into an artery or vein in the groin, neck or arm and threaded into the heart
Contrast dye may be used for imaging
Used to diagnose and treat cardiovascular conditions
Diagnostic tests, such as ejection fraction
Treatments, such as coronary angioplasty
Magnetic resonance imaging (MRI)
Computerized tomography (CT)
Nuclear medicine scan
10 Heart Failure
***B-type Natriuretic Peptide (BNP) (blood test)
a hormone produced by the heart & released in response to changes in pressure within the heart
↑ BNP when heart failure develops or worsens
BNP (and NT-proBNP) levels should ↓ with drug therapies for heart failure
For example: ACE inhibitors, beta blockers, and diuretics
Reference values are dependent on many factors
Age
Gender
Test method
Results can have different meanings in different labs.
Significance of Blood Levels
< 100 pg/mL indicate no heart failure.
100-300 pg/mL suggest heart failure is present.
> 300 pg/mL indicate mild heart failure.
> 600 pg/mL indicate moderate heart failure.
> 900 pg/mL indicate severe heart failure.