Congestive Heart Failure

Heart failure:

Structural or functional cardiac disorders so that the heart is unable to pump enough blood to meet the body’s metabolic demands or needs. Impaired contraction or filling of the heart may cause pulmonary or systemic congestion.

Systolic HF:

Also called heart failure w/reduced ejection fraction. Results in fluid volume overload, increased cardiac workload, and vasodilation and diuresis (ANP/BNP).

Diastolic HF:

Increased workload causes dilation of heart chambers and thickening of muscle. Heart muscle becomes fibrotic leading to HF.

S/S of HF:

Dyspnea, fatigue, and fluid retention. Other signs are based on the affected ventricle. Some patients have S/S of both.

Left-sided HF:

Left ventricle cannot pump effectively to the aorta, blood volume and pressure is built up in the left atrium decreasing flow to pulmonary veins (lungs).

Left-sided HF cardio/resp manifestations:

Pulmonary congestion including dyspnea, cough, crackles, low O2, and S3 may be heard. Other S/S: nocturnal dyspnea, orthopnea, cough (non-prod at first then prod with pink or tan sputum), crackles do not clear w/coughing.

Left-sided HF bodily manifestations:

Decreased urine output, renal perfusion pressure falls, decreased GI perfusion (poor digestion), decreased brain perfusion (dizziness, lightheaded, confusion, anxiety), pale and ashen skin that feels cool and clammy, palpitations (increased HR), weak peripheral pulses, easily fatigued upon activity.

Right-sided HF:

Cannot eject blood effectively and cannot accommodate all the blood that normally returns from venous circulation. Increased venous pressure -> jugular venous distension and increased capillary hydrostatic pressure though the venous system.

Right-sided HF manifestations:

Dependent edema (worse when standing/sitting, progresses up the legs unless elevated), hepatomegaly (venous engorgement of liver causing impairment), ascites, weight gain due to fluid retention, sacral edema for bedrest patients., GI distress due to liver impairment, weakness due to decreased cardiac output.

Congestive HF:

Left ventricle fails, increasing fluid pressure in the lungs, causing right-sided damage. Right side loses pumping power causing blood to back up into the venous system. May progress to pulmonary edema.

Pulmonary edema:

Acute event caused by a breakdown of compensatory mechanisms. Left ventricle fails -> blood backs up into pulmonary circulations -> pulmonary interstitial edema. Can occur quickly.

Pulmonary edema S/S:

Restless, anxious, sudden onset of breathlessness, tachypneic w/ low O2, cyanosis, tachycardia and JVD, incessant coughing w/foamy sputum, and progressive confusion.

Immediate treatment for pulmonary edema:

Sit up in high fowlers, dependent leg position, apply non-rebreather, advance to bipap, then intubation.

Assessment of suspected HF:

Focuses on ventricular function, use ECHO to determine EF and confirm diagnosis, chest x-ray and 12-lead EKG, labs (electrolytes, BUN, creatinine, LFTs, TSH, CBC, BNP, and routine urinalysis.

Elevated BNP indicates:

High cardiac filling pressure, progressive rising suggests acute exacerbation.

Ejection fraction:

A measurement of ventricular contractility, percentage of the end-diastole blood volume that is ejected w/each heartbeat. Should be 55-65%.

Medical management for HF:

Based on the stage of HF, treatment options vary. Focuses on education on S/S recognition, lifestyle changes, and pharmacology.

Pharmacologic therapy for HFrEF:

Includes a diuretic, angiotensin system blocker, and beta blocker.

Pharmacologic PO therapy:

Diuretics, angiotensin system blockers, beta-blockers, and digitalis.

Pharmacologic IV therapy:

Dopamine, dobutamine, milrinone, and vasodilators.

Adjunct therapies for HF:

Nutritional therapy (low sodium <2g/day, omega-3), supplemental oxygen (continuous or intermittent), manage sleep disorders (CPAP), surgical interventions (ICD, CRT, ultrafiltration, cardiac transplant).

Nursing interventions for HF:

Promote activity tolerance (avoid inactivity, allow rest periods, plan energy-consuming activities for peak energy periods), manage fluid volume (give diuretics in morning, educate on reading food labels, positioning, accurate I/O, assess for skin breakdown), control anxiety, minimize powerlessness, and assist in managing health.