Heart failure & pulmonary edema

Heart failure (HF) (4)

• Impaired cardiac pumping or filling

• When the heart cannot pump enough blood to the body

• Abrupt onset or slow, progressive

  • abrupt onset usually associated with MI

Heart failure is associated with: (3)

• CAD

• HTN

• MI

Heart failure risk factors: (4)

• DM

• Smoking

• Obesity

• Increased cholesterol

Heart failure cause (5)

Caused by interference with normal regulation of cardiac output (CO)

• Preload (volume of blood in ventricles before contraction)

• Afterload (resistance in which the ventricle pumps against)

• Myocardial contractility (ability of heart to contract)

• Heart rate

Ejection fraction (2)

• Heart’s ability to pump out blood to your body

• amount of blood pumped out over amount of blood in the chamber = percentage pumped out is the ejection fraction

  • amount of blood pumped out/amount of blood in the chamber = %

Types of heart failure

Left-sided and right-sided

Most common type of heart failure

Left-sided initially, then as the left side becomes dysfunctional then bilateral HF

Left-sided heart failure

• Left-ventricular dysfunction

• Blood backs up through left atrium

  • Pulmonary congestion and edema

Right-sided heart failure

Backward blood flow to right atrium and venous circulation

Heart failure clinical manifestations (10)

• Pulmonary edema

• Fatigue

• Dyspnea

• Tachycardia

• Edema

• Nocturia

• Skin changes

• Behavioral changes

• Chest pain (decreased perfusion)

• Weight changes

Dyspnea in HF

• Paroxysmal nocturnal dyspnea

  • When patient asleep

  • Reabsorption of fluid when patient is flat (want to elevate HOB)

  • Feelings of suffocation – wake in a panic

Edema in HF

Sudden weight gain = exacerbated HF

Nocturia in HF

Renal blood flow increases when laying down

Skin changes in HF (2)

• Dusky color

• Lower extremities swollen & shiny

Behavioral changes in HF

• Decreased oxygen and perfusion

• Restlessness, confusion

Weight changes in HF

• Fluid retention, so looks larger but

• Muscles are wasting so decreased muscle mass

Pulmonary edema (4)

• Life-threatening medical emergency

• Fluid in alveoli & interstitial spaces of lungs

• Interferes with gas exchange

• Most common cause – left-sided HF

Pulmonary edema S+S

• ↑RR, ↓PaO2, ↑HR

• SOB (accessory muscle use)

• Anxious, pale, cyanotic

• Orthopnea

• Wheezing, coughing

• Crackles, wheezes, rhonchi throughout lungs

• Blood-tinged sputum

Orthopnea

Shortness of breath when laying down, relieved by sitting or standing up

Rhonchi

Low pitched, snoring, gurgling sounds heard in the large airways during breathing, caused by mucus, secretions, fluid.

If you see blood-tinged sputum automatically think:

Pulmonary edema

How to treat pulmonary edema

Treat underlying cause

• oxygen, diuretics, BP meds

Complications of heart failure (5)

• Pleural effusion

• Dysrhythmias

• Left ventricular thrombus

• Hepatomegaly

• Renal failure

Pleural effusion (6)

• Fluid in pleural sac around lungs, restricts lungs from expanding all the way

• SOB, decreased breath sounds

• Trachea can deviate to opposite side of fluid

• Tx:

  • Thoracentesis (needle inserted and fluid is withdrawn)

  • Antibiotics if infection

Dysrhythmias and HF

Heart not working properly, working harder, getting bigger and thicker. Can disrupt electrical function

Left ventricular thrombus and HF

• Decreased cardiac output

• Increased risk of pooling

Hepatomegaly and HF

Fluid backs up into systemic circulation causing other organs (of a lower pressure) to enlarge, especially the liver

Renal failure and HF

• Decreased cardiac output

• Decreased perfusion to kidneys

• Causing kidneys to not work properly, can ultimately fail

Heart failure classification

• Class 1: no limitation of physical activity (early)

• Class 2: slight limitation of physical activity

• Class 3: marked limitation of physical activity

  • usually comfortable at rest

• Class 4: inability to carry on any physical activity without discomfort (advanced)

  • S+S at rest

Heart failure diagnostic studies (4)

• Echocardiography (ultrasound)

• BNP

• Chest X-ray (see enlargement of heart)

• ECG (can support dx)

BNP

• B-type natriuretic peptide

• When there’s increased volume in the heart, there’s increased pressure, BNP is released

• If pt is SOB should draw for BNP

  • If increased we look at the heart

Nursing management: Acute decompensated heart failure (12)

• ↓ Intravascular volume

  • Diuretics (IV then transitioned to oral)

• ↓ Venous return

  • High Fowler’s position (legs down low or sitting over side of bed)

  • Diuretics (both help with lung expansion)

• ↓ Afterload

  • Managing BP (so heart doesn’t have to pump against such increased resistance)

• ↑ Gas exchange

  • IV morphine (relax pt, decreases anxiety)

  • Oxygen (pulse oximetry)

• ↑Cardiac function

• ↓ Anxiety (morphine, Ativan)

Collaborative care: chronic heart failure (10)

• Multidisciplinary clinic

• O2 if <90%

• Self management: recognize S+S

• Exercise & activity

  • 30-45 mins, 3-5x week

  • cardiac rehab program

• Devices

• Cardiac transplantation

• Medication therapy

• Nutritional therapy

Chronic heart failure devices

• Pacemaker

• Implantable cardioverter-defibrillator (ICD)

• Ventricular assist device (VAD)

Pacemaker (3)

• Help regulate the heart beat with small evenly timed shocks

• Involves implanting electrodes into one or more of the hearts chambers

• Implanted generator

Implantable cardioverter-defibrillator (ICD) (2)

• Implanted defibrillator

• Capable of sensing a stopped heart and delivering an electric shock powerful enough to restart it

Chronic heart failure: medication therapy (6)

• Diuretics (Lasix)

• ACE Inhibitors (“prils”)

• Combination medication

  • ARB (Valsartan) + Neprilysin (Sacubitril)

• Beta blockers (“olol”)

• Mineralocorticoid receptor antagonists (Spironolactone)

• Inotropic drugs (dobutamine, milrinone)

Chronic heart failure: nutritional therapy (3)

• Sodium restriction (DASH diet)

• 1.5 - 2 L fluid/day

• Daily weight

  • Want weight to stay the same or decrease, an increase means something isn’t working

Nursing management: chronic heart failure (11)

• History & Physical

• Health Promotion (Treat & control underlying heart disease)

• O2 (nasal prongs when eating)

• Positioning (high fowlers)

• Intake/Output (s+s peripheral edema)

• Education

• ECG

• Administer medications & monitor lab values

• Nutrition

• Encourage rest/activity

• Support