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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.