Download CHF slide show 2016

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
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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?
1.
2.
3.
4.
dependent edema
bilateral crackles
liver enlargement
jugular vein distension
Pulmonary Edema on CXR
http://medicalpicturesinfo.com/pulmonary-edema/
5.7
Which nursing assessment would support the complication
of right-sided heart failure?
1. Increasing respiratory difficulty with
exertion.
2. Cough productive of a large amount of thick
yellow mucus.
3. Peripheral edema and anorexia.
4. Twitching of extremities.
Right –sided Heart Failure
Peripheral Edema
http://en.wikipedia.org/wiki/File:Combinpedal.jpg
Jugular vein distension
Cardiac Performance
4 primary determinants
Contractility
Afterload

 the pressure against
which the left ventricle
ejects its content
pumping
ability/strength
Preload

depends on the
volume of venous
return to the heart
Heart rate
 helps maintain adequate
cardiac output
Cardiac Output =
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
An average resting cardiac output would be 5.6 L/min for a human male and 4.9 L/min for a female
Things that reduce cardiac output
Decreased stroke volume
Hypovolemia
• Blood loss (hemorrhage)
• Dehydration (severe)
– Burns
Decreased heart rate
• Medications that slow heart
rate (example: Digoxin)
• Heart block (rhythm problem)
• 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!
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
• Leads to congestion/edema
– Pulmonary
– Peripheral
Congestive Heart Failure
• 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
Congestive Heart Failure
• Right-sided heart failure
– Peripheral/dependent edema
– Hepatomegaly
– JVD (jugular vein distension)
– Anorexia/nausea
– Weakness
– Weight gain
Congestive Heart Failure
Diagnosis
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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
Echocardiogram
http://www.heartfailure.org/eng_site/treatinghf_doc_op_ang.asp
Congestive Heart Failure Management
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Diet
Fluid restriction
Sodium restriction
Daily weight
Activity
Medications
CHF Management
• Treat symptoms
– include oxygen, if needed
• Treat/modify underlying factors
• Monitor symptoms
• Monitor contributing factors
CHF Management
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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 systolic heart failure!
– Cardiac Glycosides
• digoxin
Congestive Heart Failure (CHF)
Medications
– Diuretics
• K sparing
• K depleting
– (Potassium Supplements)• do not treat CHF
• prevent hypokalemia side effects
CHF Management:
Activity
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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
CHF Management:
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)
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
ACE Inhibitors
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Capoten (captopril)
Vasotec (enalapril)
Prinivil, Zestril (lisinopril)
Lotensin (benazepril)
Monopril (fosinopril)
Altace (ramipril)
Accupril (quinapril)
Aceon (perindopril)
Mavik (trandolapril)
Univasc (moexipril)
9.46
1.
2.
3.
4.
The most appropriate nursing action before
administration of captopril (Capoten) would be to
check the client’s:
apical pulse for 60 seconds.
blood pressure.
urine output.
temperature.
Angiotensin II receptor blockers (ARBs)
Generic Name
Brand Name
Angiotensin II
candesartan
eprosartan
irbesartan
losartan
olmesartan
telmisartan
valsartan
Atacand
Teveten
Avapro
Cozaar
Benicar
Micardis
Diovan
http://www.webmd.com/heart-disease/angiotensin-ii-receptor-blockers-arbs
Calcium Channel Blockers…
• 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.
Calcium Channel Blockers
Generic Name
Brand Name
amlodipine
Norvasc
diltiazem
Cardizem, Dilacor,
Taztia, Tiazac
Ca
felodipine
nifedipine
Procardia
nisoldipine
Sular
verapamil
Calan, Verelan
++
http://www.webmd.com/heart-disease/heart-failure/heart-failure-treatment
Beta-blockers…
• 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 angiotensin-converting 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.
Beta-blockers
β1, β2
Generic Name
Brand Name
bisoprolol
Zebeta
carvedilol
Coreg
metoprolol
Lopressor
http://www.webmd.com/heart-disease/heart-failure/beta-blockers-for-heart-failure
Cardiac glycosides
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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
• Digoxin (Lanoxin) commonly used
Digoxin (Cardiac glycoside)
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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
Digoxin (Lanoxin)= digitalis
Digoxin (Cardiac glycoside)
• S/S toxicity
– Nausea
– Vomiting
– Anorexia
– Bradycardia
– Dysrhythmias
– Visual disturbances
9.27
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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?
Creatinine levels
Serum potassium
Urine potassium and sodium
Blood urea nitrogen and glucose
Diuretics
• Furosemide (Lasix)
– 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)
+
Diuretics
• Thiazides
– 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
– Important side effect:
• May lead to high levels of potassium,
especially in patients with kidney problems.
– If not treated, very high potassium
levels can be fatal.
» No salt substitutes (Contains
potassium!)
»Assess for S/S ↓ K :
• slow/irregular heartbeat, muscle
weakness.
Which of the following areas of assessment
would the nurse monitor to determine the
effectiveness of a diuretic?
1.
2.
3.
4.
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
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Chest X-ray
Electrocardiogram
Echocardiogram
Cardiac Catheterization
Blood work
–BNP (brain natriuretic peptide)
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
http://www.crkirk.com/thumbnail/common/vsd.htm
Congestive Heart Failure
http://www.med-ed.virginia.edu/courses/rad/cxr/pathology2Bchest.html
Normal KUB (kidney, ureter, & bladder)
http://pediatricimaging.wikispaces.com/file/view/anand-ibd-kub.jpg/124653157/350x427/anand-ibd-kub.jpg
Hepatomegaly
http://openi.nlm.nih.gov/detailedresult.php?img=2768249_ymj-50-713-g001&req=4
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
Echocardiogram
Echocardiogram
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
– Echocardiogram
– Cardiac catheterization
– Magnetic resonance imaging (MRI)
– Computerized tomography (CT)
– Nuclear medicine scan
%
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
Cardiac Catheterization
http://www.yalemedicalgroup.org/stw/images/125490.jpg
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.
B-type Natriuretic Peptide (BNP) (blood test)
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.
http://my.clevelandclinic.org/heart/diagnostics-testing/laboratory-tests/b-type-natriuretic-peptide-bnp-bloodtest.aspx