NRSG 250: Exam 2 - HF and Cardiomyopathy

What is heart failure?

heart cannot pump enough blood to meet body’s needs

What is the patho of HF?

1. heart structure damange & impaired function

2. decreased cardiac output

3. Compensatory mechanisms (RAAS + SNS)

4. fluid retention

5. pulmonary & systemic congestion

6. HF symptoms

Who is mostly hospitalized for HR?

adults >65 years

What are the direct causes of HF?

1. Coronary artery disease & HTN!!!!!!!

2. cardiomyipathy

3. valvular disease

4. MI

What are the risk factors for HF?

1. obesity

2. DM & metabolic syndrome

3. smoking

4. HLD

5. family hx

6. ETOH abuse

What are the manifestations of HF?

1. SOB while walking

2. difficulty climbing stairs

3. fatigue during ADLs

4. sleep disruption

5. anxiety, depression, & social isolation

What is the nursing focus for HF?

1. energy conservation & activity pacing

2. qualify of life

3. I&Os

What pt teaching is needed for HF?

1. Monitor weights, edema, & dyspnea

2. Low sodium diet & fluid restrictionm

3. Take meds as prescribed & do not d/c abruptly

4. report weight gain >2-3 lb/day or >5 lb/week

What are the classifications of HF?

By pump:

• systolic HF

• diastolic HF

• mixed

By location:

• left-sided HF

• right-sided HF

• biventricular HF

What are the other names for systolic & diastolic HF?

systolic = HFrEF

diastolic = HFpEF

What is systolic HF?

ventricle fills but cannot effectively eject bloodWhat

What is the patho of systolic HF?

1. damanged myocardium

2. weak contraction → poor pumping

3. decreased left ventricular EF <40-50% (systolic dysfunction)

4. decreased cardiac output

5. fatigue, weakness, exercise intolerance

What are the risk factors of systolic HF?

1. CAD & MI

2. dilated cardiomyopathy

3. long-standing HTN

4. valvular disease

What is diastolic HF?

ventricle squeezes normally (LVEF > or = 50%) but cannot fill adequately

What is the patho of diastolic HF?

1. chronic HTN / LV hypertrophy

2. stiff ventricle w/ prolonged relaxation

3. poor filling

4. increased filling pressure in LV (diastolic dysfunction)

5. pulmonary congestion

What are the risk factor for diastolic HF?

1. HTN

2. obesity

3. DM

4. aging

5. afib

What are the key differences between systolic & diastolic HF?

Systolic:

1. can’t squeeze

2. weak ventricle

3. reduced EF (<40%)

4. impaired contraction

5. dilated ventricle common

6. volume overload

Diastolic:

1. can’t fill

2. stiff ventricle

3. preserved EF (> or = 50%)

4. impaired relaxation

5. hypertrophy common

6. pressure overload

What is left-sided HF?

weak left ventricle causes impaired pumping

What is the patho of left-sided HF?

1. weak LV → impaired pumping

2. reduced cardio ouput

3. blood backs up into lungs

4. pulmonary congestion

5. dyspnea, crackles, orthopnea

What are the risk factor for left-sided HF?

1. HTN

2. CAD

3. valvular disease

What are the manifestations of left-sided HF?

Pulmonary congestion

1. exertional dyspnea

2. orthopnea

3. paroxysmal nocturnal dyspnea (PND)

4. crackles

5. pulmonary edema

What is right-sided HF?

RV cannot empty

What is the patho of right-sided HF?

1. RV fails → cannot empty

2. blood backs up

3. systemic venous congestion

4. fluid retention

5. edema, JVD, ascites

What are the risk factors for right-sided HF?

1. left-sided HF!!!!!! = most cases occur secondary to left-sided HF

2. pulmonary HTN

3. RV MI

What are the 3 general effects of rt-sided HF?

1. venous congestion

2. fluid retention

3. GI symptoms

What are the manifestations of right-sided HF regarding venous congestion?

1. JVD

2. hepatomegaly & splenomegaly

What are the manifestations of right-sided HF regarding fluid retention?

1. peripheral edema

2. increased abd. girth & ascites

3. weight gain

What are the manifestations of right-sided HF regarding the GI?

1. early satiety

2. nausea

3. poor appetite

What is the most reliable indicator of fluid gain/loss?

weight gain

What is biventricular HF?

both sides of the heart are failing

What does each failing side of the heart do to the body?

Left HF → pulmonary congestion

Right HF → systemic congestion

What are the manifestations of biventricular HF?

1. severe fatigue

2. exercise intolerance

3. fluid overload

4. frequent hospitalizations

What are the risk factors for biventricular HF?

most pts w/ advanced HF eventually develop biventricular failure

What is high-output HF?

the heart pumps normally, but the body demands more than it can deliver

What are the risk factors for high-output HF?

1. severe anemia

2. hyperthyroidism

3. sepsis

4. high fever

What is the patho of high-output HF?

1. increased metabolic demand

2. heart pumps more blood

3. eventually cannot keep up

4. HF symptoms

* problem is not weak heart, it is excessive demand!!!

How does the body immediately compensate for HF d/t decreased caridac output?

1. SNS activation

2. increased HR

3. increased contractility

4. vasoconstriction

How does the body long-term compensate for HF d/t decreased cardiac output?

1. RAAS activation

2. sodium retention

3. water retention

4. increased preload

How does the compensation mechanisms affect the body?

initially helpful = maintains BP and improves perfusion;

eventually harmful = fluid overload, increased workload → worsening HF!!!

How does HF progress and what does it lead to?

1. chronic stress on heart → HF

2. SNS + RAAS Activation

3. increased work

4. ventricular remodeling

5. progressive HF

leads to structural changes = progressive decline in cardiac function

• ventricular enlargement

• myocardial hypertrophy

• fibrosis

What are the symptoms in the early stages of HF?

1. symptoms are controlled

2. occasional exacerbations

What are the symptoms in the early stages of HF?

1. increasing dyspnea

2. activity limitations

= more frequent admissions

What happens in the advanced stages of HF?

1. symptoms at rest

2. frequent hospitalizations

3. advanced therapies

4. left ventricle assist device (LVAD)

5. transplant

6. palliative care

What are the stages of HF according to ACC/AHA?

Stage A: High risk of heart failure; no structural abnormalities or symptoms

Stage B: Asymptomatic with structural heart disease

Stage C: Symptomatic with structural heart disease

Stage D: End-stage heart failure

What are the stages of HF according to the HY Heart Association?

Class I: Patient has no symptoms

Class II: Patient has symptoms with ordinary exertion

Class III: Patient has symptoms with less than ordinary exertion.

Class IV: Patient has symptoms at rest

What are some cues to recognize for HF during an assessment?

Hx:

• CAD

• HTN

• previous HF admission

Subjective findings:

• increasing SOB

• difficulty sleeping flat

• weight gain of at least 5 lb/week

Objective findings:

• crackles

• O2 sat 89%

• bilateral LE edema

• JVD

Diagnostic findings:

• increased BNP

• CXR = pulmonary congestion

• ECG = EF 30%

What analysis can we make on HF cues to make a hypothesis?

Analyze Cues:

1. Weight gain → Fluid retention

2. Crackles → Pulmonary congestion

3. Edema → Volume overload

4. Low O2 saturation → Impaired gas exchange

5. Elevated BNP → Ventricular stretch

Priority hypothesis: Acute exacerbation of heart failure with fluid overload

Priority problem: impaired oxygenation

What are the nursing priorities for HF?

1. monitor oxygenation and perfusion

   • BP

   • HR

   • cardiac output indicators

   • mental status

2. monitor fluid status

   • daily weights

   • I&Os

   • edema

   • lung sounds

3. monitor rhythm

   • dysrhythmias

   • cardiac monitor changes

What are some interventions for HF?

• High Fowler's position

1. Administer oxygen

2. Monitor respiratory status

3. Administer prescribed diuretics (i.e.

4. Strict I&O

5. Daily weights

* The first intervention should be oxygen!!!!!

What is the evaluation for HF?

Desired Outcome:

• Improved oxygenation

• Reduced congestion

• Reduced fluid overload

• Improved breathing

Evidence:

• SpO2 increased

• Crackles decrease

• Weight decreases

• Less dyspnea

What treatment can be used to reduce fluid overload in HF?

1. diuretics

2. sodium restriction

3. fluid management

What tx can be used to improve cardiac output in HF?

1. ACE inhibitors / ARBs / ARNI

2. beta blockers

3. hydralazine + isosorbide dinitrate

What tx can be used to prevent the progression and remodeling of HF?

1. control BP

2. smoking cessation

3. weight management

4. physical activity

5. ETOH moderation

What are some end-stage HF therapies?

Device therapy:

1. ICD = prevents sudden cardiac death

2. cardiac resynchronization therapy (CRT/biventricular pacemaker) = imrpoves ventricular coordination

3. LVAD = mechanical pump that pumps blood in chest to do work of weak LV

4. heart transplant

What teaching can we provide for HF?

Acute HF:

1. fowler’s position

2. vital signs/oxygen

3. diuretics

Long-term HF:

1. medications

2. activity

3. weight

4. diet

5. symptoms

What are the 7 key interventions for HF?

1. LV systolic heart function assessment (ECG)

2. ACE inhibitor of ARB at discharge for CHF pts w/ systolic dysfunction (LVEF <40%)

3. Anticoagulant at discharge for CHF pts w/ chronic afib

4. influenza immunization

5. pneumococcal immunization

6. smoking cessation counseling

7. discharge instructions that address:

   • activity level

   • diet

   • discharge meds

   • follow-up appts

   • weight monitoring

   • worsening symptoms

What is cardiomyopathy?

subacute or chronic disease of the cardiac muscle, and the cause may be unknown

Types:

• dilated

• hypertrophic

• restrictive

• arrhythmogenic right ventricular

What is dilated cardiomyopathy (DCM)?

chronic disease-causing ventricular dilation and impaired systolic function leading to:

• decreased myocardial contractility

• reduced cardiac output

• progressive HF

Which is the most common cardiomyopathy worldwide?

dilated cardiomyopathy (DCM)

What are the risk factors for DCM?

1. ischemic heart disease

2. viral myocarditis

3. alcohol abuse

4. cocaine/methamphetamine use

   • genetic disorders

What is the patho of DCM?

1. myocardial injury

2. myocyte (muscle cell) fibrosis & remodeling

3. ventricular dilation

4. reduced contractility

5. decreased cardiac output

6. HF symptoms

What are the manifestations of DCM?

1. blood stasis → thombus formation

2. neurohormonal (SNS, RAAS, etc.) activation → worsens remodeling

3. reduced EF <40% is common

4. insidious onset → may b asymptomatic for years

5. classic symptoms of Lft-sided and/or Rt-sided HF

Additional findings:

6. S3 heart sound

7. mitral/tricuspid regurgitation

8. dysrhythmias

9. thromboembolic events

What is the management for DCM?

1. prevention → identify precipitating factors

2. prevent HF by controlling progression of structural dysfunction

3. treat like HF

   • ionotropics

   • diuretics

   • antidysrhthmics

   • rest

   • assess for fluid overload

What is the tx for end-stage DCM?

advanced HF strategies

1. permanent mechanical assist devices = ICD

2. heart transplant

What is hypertrophic obstructive cardiomyopathy (HCM)?

genetic cardiac muscle disorder that causes a thick heart w/ a small chamber

• septal hypertrophy

• usually autosomal dominant

• leading cause of sudden cardiac death in young athletes

What is the patho of HCM?

1. genetic mutation

2. septal hypertrophy

3. stiff LV (fibrotic infiltrations)

4. poor ventricular filling (diastolic dysfunction)

5. decreased cardiac output

6. dyspnea, syncope, chest pain (worsens w/ exercise)

7. high risk of sudden cardiac death

What are the manifestations of HCM?

1. dyspnea ← poor filling & congestion

2. chest pain ← increased O2 demand

3. syncope ← decreased cardiac output

4. palpitations ← dysrhythmias

5. fatigue ← reduced perfusion

* first symptom is sudden cardiac death!!!!

What tx is used for HCM?

Medication:

• beta blockers

• calcium channel blockers

• antiarhythmics

Other:

• ICD placement

• septal mycetomy

• alcohol septal ablation

• Echocardiogram (required to diagnose, but not part of routine sports physical)

• genetic testing of close family members

What nursing interventions are used for HCM?

1. encourage hydration

2. monitor cardiac rhythms

3. avoid overexertion

4. medication teaching

What pt teaching is needed for HCM?

1. stay hydrated

2. take meds as prescribed

3. attend follow-up appts

4. encourage family screening

5. avoid dehydration, high-intensity activities, & skipping

What is restrictive cardiomyopathy (RCM)?

rarest cardiomyopathy w/ poor prognosis characterized by endocardial scarring causing:

• stiff ventricles (one or both)

  • dilated atria w/ high filling pressure

What are the risk factors for RCM?

1. infiltrative disorders = amyloidosis, sarcoidosis, hemochromatosis

2. fibrotic disorders = radiation therapy, CT disease, endomyocardial fibrosis

What is the patho of RCM?

1. fibrosis or infiltraiton

2. stiff ventricles

3. poor ventricular filling

4. reduced stroke volume

5. decreased cardiac output

6. HF symptoms (possible rapid onset)

What are the manifestations of RCM?

1. Left-sided HF S/S:

   • dyspnea & orthopnea

   • fatigue

   • exercise intolerance

2. Right-sided HF S/S:

   • peripheral edema

   • JVD

   • hepatomegaly

   • ascites

3. Decreased cardiac output S/S:

   • fatigue/weakness

   • dizziness, syncope

   • angina

Assessment findings:

• S3 heart sound

• palpitations

What is used for tx of RCM?

Medication:

• beta blockers

• calcium channel blockers

• diuretics

• anticoagulation if afib & dysrhythmia

Treat underlying cause:

• amyloidosis, hemochromatosis, and sarcoidosis

What nursing interventions are used for RCM?

1. monitor fluid status & daily weights

2. assess for worsening HF

3. monitor O2

4. med adherence

5. low-sodium diet

6. energy conservation strategies

What is arrhythmogenic right ventricular cardiomyopathy (ARVC)?

rare genetic heart condition characterized by replacement of right ventricular heart muscle with fatty or fibrous tissue

• scarred RV = electrical problems

• teens and YA

• major cause of sudden cardiac death in young athletes

What is the patho of ARVC?

1. genetic mutation

2. RV muscle loss

3. fat & fibrous replacement

4. abnormal electrical conduction

5. ventricular dysrhythmias

6. syncope or sudden cardiac death

What are the manifestations of ARVC?

1. dysrhythmia S/S:

   • palpitations

   • lightheadedness

   • syncope/near-syncope

2. HF S/S:

   • Left-sided = fatigue, dyspnea

   • Right sided = JVD, hepatomegaly, peripheral edema

* sudden cardiac death may be first symptom!!!!

What is used for the tx of ARVC?

Medication:

• beta blockers

• antiarrhythmics

Other:

• ICD

• heart transplant

What nursing interventions are used for ARVC?

1. monitor cardiac rhythm

2. assess for syncope & fall precautions

3. med adherence

4. activity restrictions

5. ICD education

6. family screening