Download Understanding Heart Failure

Understanding
Heart Failure
By Damon Cottrell, RN, ACNS-BC, CCNS, CCRN,
CEN, MS; Cynthia Bither, RN, ANP, ACNP, MSN;
Renee Garnes-Spence, RN, PCCN, MSN; and Michelle
Jones, RN, ANP, ACNP, MSN
LPN2009, March/April 2009
2.3 ANCC contact hours
Online: www.lpnjournal.com
© 2009 by Lippincott Williams & Wilkins. All world rights reserved.
What is heart failure?
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Progressive disease
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Affects heart’s ability to pump effectively
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Can’t supply sufficient blood and oxygen to the
body’s tissues
Heart failure
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Usually caused by injury to myocardium
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Injury results in dilation or hypertrophy of one or
both ventricles, called “remodeling”
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Cardiac output and blood pressure drop
Causes of heart failure
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Aortic regurgitation
Aortic stenosis
Cardiomyopathy
Coronary artery
disease
Myocardial infarction
Renal artery stenosis
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Volume overload
Dysrhythmias (atrial
fibrillation)
HIV
Hypertension
Hyperthyroidism
Medications
Causes of heart failure
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May be acute or chronic
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Patients usually exhibit signs of shortness of
breath, tiredness, swelling of feet, ankles,
abdomen
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May see jugular venous distention and hear a
third heart sound
Signs and symptoms
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Dyspnea
Orthopnea
Paroxysmal nocturnal
dyspnea
Weakness/fatigue
Confusion
Headache
Insomnia
Tachycardia
Third heart sound
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Rales
Edema
Jaundice
Alternating weak and
strong pulse
Cool, cold, or pale
extremities
Jugular venous distention
Cyanosis
Diagnosing heart failure
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History and physical: provide clues about
patient’s physical status
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ECG looks for dysrhythmias
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Echocardiography provides information about
function and heart size
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Lab tests: electrolytes, thyroid studies, BUN, BNP
Classes and stages
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Heart failure is divided into classifications based
on specific pathophysiology
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Helps guide best treatments
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Heart failure is also broken down into stages
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Treatment of stages is aimed at stabilizing
patient’s condition and delaying progression
New York Heart Association
Classification of Heart Failure
Classification I
 Ordinary physical activity doesn’t cause undue
fatigue, dyspnea, palpitations, or chest pain
 No pulmonary congestion or peripheral
hypotension
 Patient is considered asymptomatic
 Usually no limitations of ADLs
 Prognosis: Good
New York Heart Association
Classification of Heart Failure
Classification II
 Slight limitation on ADLs
 Patient reports no symptoms at rest but
increased physical activity will cause symptoms
 Basilar crackles and S3 murmur may be detected
 Prognosis: Good
New York Heart Association
Classification of Heart Failure
Classification II
 Marked limitations on ADLs
 Patient feels comfortable at rest but less than
ordinary activity will cause symptoms
 Prognosis: Fair
Classification IV
 Symptoms of cardiac insufficiency at rest
 Prognosis: Poor
The four stages of heart failure
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Stage A: Patient at high risk of developing left
ventricular dysfunction
Stage B: Patients with left ventricular
dysfunction who haven’t developed symptoms
Stage C: Patients with left ventricular
dysfunction with current or prior symptoms
Stage D: Patients with refractory end-stage
heart failure
Treating heart failure
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Primary treatment: lifestyle modifications
- restrict dietary sodium
- smoking cessation
- weight reduction (if indicated)
- regular exercise
Treating heart failure
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Medications
- given to block hormones that circulate in
excess when heart becomes weak
- reverse changes in heart’s muscle that occur
over time
- first-line drugs given include angiotensinconverting enzyme (ACE) inhibitors, angiotensin
receptor blockers (ARBs), beta-blockers
Medications
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Most often recommended beta-blockers are
bisoprolol (Concor) and carvedilol (Coreg)
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Best chance of cardiac recovery with higher
doses to reduce heart workload and lower BP
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Evidence of lower mortality and fewer adverse
reactions
Diuretics
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Used mainly for symptom relief
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Bumetanide (Bumex) and furosemide in low
doses are preferred
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Spironolactone (Aldactone) for advanced patients
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African-Americans and patients with with renal
failure may be given BiDil
Diuretics used to treat heart
failure
Thiazide diuretics
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Bendroflumethiazide
(Naturetin)
Benzthiazide (Exna)
Chlorothiazide (Diuril)
Chlorthalidone (Hygroton)
Hydrochlorothiazide
(HydroDIURIL, Esidrix,
Oretic)
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Hydroflumethiazide
(Diucardin, Saluron)
Methyclothiazide (Enduron)
Metolazone (Zaroxolyn,
Mykrox)
Polythiazide (Renese)
Quinethazone (Hydromox)
Trichlormethiazide
(Metahydrin, Naqua)
Diuretics used to treat heart
failure
Loop diuretics
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Bumetanide (Bumex)
Ethacrynic acid (Edecrin)
Furosemide (Lasix)
Torsemide (Demadex)
Potassium-sparing
diuretics
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Amiloride (Midamor)
Spironolactone
(Aldactone)
Triamterene (Dyrenium)
Pacing
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Many patients have delayed time interval
between contraction of right and left ventricles
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Synchronized biventricular pacing uses a third
lead to pace ventricles simultaneously
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Improves cardiac output
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Nursing care: monitoring patient post procedure,
elevation of head of bed, pain medication
Ventricular assist device
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Supports right, left, or both ventricles
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Used for patients awaiting transplant (“bridge to
transplant”)
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Used as treatment (“destination therapy”)
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“Bridge to recovery” allows heart time to recover
from remodeling; device is then removed
Nursing care of patients with a
ventricular assist device
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Assessment and prevention of infection at
“driveline site” (patient’s abdomen)
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Assess nutritional and functional status
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Assess pump function and troubleshoot alarms
Monitoring patient
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Vital signs
Lab results
Renal function
Nutritional status
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Presence of infection
or bleeding
Effectiveness of
anticoagulation
Monitor pump
parameters
Cardiac transplantation
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Treatment option for end-stage heart failure
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Approx. 2,500 procedures in U.S. each year
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1- and 3-year survival rates 85.6% and 79.5%
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Rigorous screening of candidates
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Patient put on united organ sharing list
Cardiac transplantation
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Major postoperative difference in these patients
is need for chronotropic (heart rate) support
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Immunosuppressive drug therapy to prevent
rejection
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Consists of three types of drugs: calcineurin
inhibitors, corticosteroids, antimetabolites
Nursing care of transplant
patients
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Education on signs and symptoms of infection
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Education on signs and symptoms of rejection
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Nutrition counseling (well-balanced, low-fat diet)
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Review follow-up visits
Nursing management/interventions
for patients with heart failure
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Administering medications and assessing
patient response
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Assessing fluid balance, intake, and output with
goal of optimizing balance
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Daily weights
Nursing management/interventions
for patients with heart failure
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Assessing jugular venous distention
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Auscultating lung and heart sounds
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Identifying dependent edema
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Monitoring pulse, BP
Nursing management/interventions
for patients with heart failure
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Checking for postural hypotension
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Examining skin turgor for signs of dehydration
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Assessing for symptoms of fluid overload
Potential complications of HF
therapy
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Hypokalemia: low potassium; signs include
dysrhythmias, weak muscles; can cause heart
muscle weakness
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Hyperkalemia: abnormally high serum
potassium, especially when taking ACEs, ARBs,
or spironolactone
Potential complications of HF
therapy
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Hyponatremia: deficiency of serum sodium
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Hyperuricemia: excessive uric acid in blood
Patient teaching
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Teach patients rationale for medications (doses,
times, adverse reactions)
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Teach patient to limit fluid to 2 liters per day
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Teach patient to follow a low-sodium diet
Patient teaching
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Teach patient to weight himself daily and to
notify healthcare provider of an increase in
weight of 3 lbs or more
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Address patient’s psychological needs