Week 1: Heart Failure

What are the 4 main problems for a patient with heart failure?

Problem with preload, afterload, myocardial contractility, and/ or heart rate

What is Heart Failure?

The inability of the heart to provide sufficient blood to meet the oxygen demands of the body (low CO)

Why is low cardiac output a problem?

Leads to decreased tissue perfusion, impaired gas exchange, fluid volume imbalance, and decreased functional ability

What is preload?

Initial stretching of the heart muscle when it is filling before contraction; volume of blood in ventricles at the end of diastole (relax and fill)

What is the relationship between blood volume and preload?

Direct relationship; when blood volume increases, preload increases and vice versa

What is Afterload?

Resistance the heart muscle has to overcome to pump to the rest of the body during systole (cxt and empty)

What is myocardial contractility?

The ability for the heart muscle to contract (not related to blood volume)

How can heart rate cause heart failure?

When the HR is too fast or too slow for an extended period of time, it can cause damage

What are normal/expected ejection fraction values?

55-70%

What ejection fraction values indicate heart failure?

<40%

What is the formula for ejection fraction?

Stroke Volume/ End-Diastolic Volume

What is stroke volume?

Amount of blood ejected from the ventricle during contraction

What is end-diastolic volume?

Amount of blood in the ventricle right before ejection

What are the pathophysiology steps of heart failure?

There is a myocardial injury which decreases heart function, then there is compensation and remodeling of the heart

What is L. sided heart failure?

Excess of blood on the left side of the heart that backs up into the lungs which causes pulmonary congestion and edema

What causes L. sided HF?

Inability to empty adequately during cxt, fill adequately during rest periods, or both

What are manifestations of L sided HF?

Increased HR (compensation attempt), poor o2 exchange, increased PaCO2, crackles, pleural effusion, LOC changes, restlessness, shallow/fast respirations, dry cough, frothy/pink tinged sputum due to allveoli damage, S3 and S4 heart sounds, weakness, fatigue, anxiety, dyspnea, paroxysmal nocturnal dyspnea (sudden SOB that awakes someone from sleep), orthopnea (SOB when flat on back), nocturia

What is right sided heart failure?

When right ventricle does not pump effectively, fluid backs up into the venous system which causes movement of fluid into the tissues

What is the most common cause of right sided HF?

Left sided heart failure because it causes the right side to have to work harder to push blood to the pulmonary system due to back up

What are manifestations of right sided HF?

Increased HR, murmurs, juglar vein distention, edema, weight gain, ascites, generalized body edema, hepatomegaly, fatigue, anxiety, RUQ pain, anorexia, GI bloating, nausea

What is Cor Pulmonale?

Enlargement of the right side of the heart as a result of pulmonary hypertension (common in COPD pts)

How is Cor Pulmonale and R sided HF different?

Right sided HF that results from L sided HF is separate fromo Cor Pulmonale

What is Chronic HF?

Periods of acutely and or slowly worsening cardiac function over time, often the consequence of damage caused by other cardiac events; diagnosed in outpatient setting

What is Acute decompensated HF?

A life-threatening condition requiring acute interventions and therapies, typically present with SOB due to excess fluid caused by cardiac overload; diagnosed in inpatient setting

How do we diagnose HF?

H&P, EKG, BNP and ProBNP, CXR, Echo

How does BNP and ProBNP help diagnose HF?

Helps distinguish HF from other sources of dyspnea

What is a BNP value that would indicate HF?

>400

What is the relationship between BNP levels and s/s?

The higher the BNP value, the more symptomatic a patient is

What does treatment for chronic HF look like?

Treatment of underlying cause, O2 thearpy at 2-6L via NC, rest-activity periods (reduces o2 demand), daily weights (measures fluid volume status), sodium-restricted diet, medications, LVAD, heart transplant

What are types of medications used for chronic HF?

ACE inhibitors, ARBs, Beta blockers, diuretics (removes extra fluid), nitrates (coronary vasodilator), Digoxin, spironolactone

How is Digoxin used for HF?

Negative chronotype (slows down HR), positive inotrope (increases contractility); narrow therapeutic index and digitoxicity is a concern

How is spironolactone used for HF?

Suppresses sodium/water retention to help offload the left ventricle; must watch closely for hyperkalemia and worsening kidney failure

What are nursing considerations for digoxin?

Monitor serum K+ levels, monitor for s/s of toxicity, take apical pulse for 1 FULL minute prior to administering (hold if pulse lower than 60bpm), monitor cardiac rhythm; antidote for toxicity is Digoxin immune Fab (digibind) IV

What are s/s of digitoxicity?

Bradycardia, headache, dizziness, confusion, nausea, blurry and yellow vision

What is a Left Ventricular Assist Device (LVAD)?

Used to by time until patient can have transplant or destination therapy

What are nursing implications for LVADs?

BP cannot be read (ues doppler), Heart sounds cannot be heart just humming sound, do not start CPR unless youare sure it is off, family teaching

What does treatment look like for acute decompensated heart failure?

Treat underlying cause, monitor vs/I&Os hourly, continuous EKG, monitor ABG results, High fowlers position with feet dangling at bedside, O2 by mask, daily weights, drug therapy

What types of medications are used for acute decompensated heart failure?

Meds that decrease volume and afterload; diuretics, vasodilators, morphine, positive inotropes (ex. digoxin- increases cxt)