Tachycardia occurs because the heart is under distress and trying to compensate.
Other signs: edema, anemia.
Complications of Heart Failure
Liver and spleen enlargement.
Pleural effusions: fluid entering the lungs.
Thrombosis, MI.
Cardiogenic shock: body in shock due to heart failure, similar to septic shock.
BNP (B-Type Natriuretic Peptide) Testing
BNP is the gold standard for heart failure diagnosis.
Monitoring BNP levels is similar to monitoring troponin levels during a heart attack.
Troponin levels rise to a peak during a heart attack, then trend down as the event ends and recovery begins.
In heart failure, BNP is monitored serially (at intervals).
Daily BNP monitoring helps assess the effectiveness of treatments like Lasix or torsomide (diuretics).
When diuretics are effective, fluid is removed, and BNP levels should trend down.
A rising BNP indicates worsening heart failure, prompting a review of interventions, I&O, net balance, restrictions, and diuretic dosages.
High BNP on admission that trends down indicates effective treatment.
A sudden increase in BNP, like in flash pulmonary edema, requires identifying what was missed or could have been done better in the treatment plan, such as diuretic dosages or fluid output.
BUN and Creatinine Testing
BUN and creatinine levels provide information about kidney function.
BUN levels indicate fluid balance.
High BUN suggests dehydration.
Low BUN suggests overhydration.
Importance of Lab Monitoring
Lab results provide crucial information about a patient's status and the effectiveness of interventions.
Lab monitoring can reveal issues such as electrolyte imbalances or kidney problems due to excessive diuretic use.
Dehydration can harm the kidneys, as they need fluid to function properly.
Analogy: Kidneys are like a car engine needing oil (fluid) to function; without it, they get damaged while still trying to filter.
Over-diuresis can lead to kidney injury.
Additional Labs
Liver function tests: Assess liver function, as the liver also filters.
Thyroid function tests, ferritin: Screen for other conditions that may exacerbate heart failure symptoms.
Thyroid issues (hyperthyroidism) can affect heart rate, worsening CHF.
Low iron levels can cause shortness of breath, exacerbating CHF symptoms.
It's important to view the body holistically and consider all factors affecting heart function.
Echocardiograms
Electrocardiograms, exercise stress testing, and sleep studies.
Sleep Studies and Sleep Apnea
Sleep studies diagnose sleep apnea, which is common in CHF patients.
Untreated sleep apnea impairs compensation during CHF exacerbation due to lack of reserve.
Sleep apnea causes right heart strain because the heart compensates for lack of oxygen during the night.
This leads to hypertrophy and increased heart strain, so addressing sleep apnea is crucial.
Goals of Heart Failure Management
Identify underlying causes.
Increase the strength of heart contraction.
Maintain water and sodium balance.
Decrease the heart's workload.
Oxygen as Medication
Oxygen is a medication that can be administered in emergencies without an immediate order, but an order is still required.
Titration orders allow nurses to adjust oxygen levels within prescribed parameters.
Ivabradine: decreases heart rate to allow the heart to fill more completely.
Slower heart rate increases blood volume and oxygenation to organs.
Anticoagulants: prevent clot formation due to compromised pumping mechanism and conditions like cardiomyopathy or atrial fibrillation (A-fib).
Activity
Encourage appropriate exercise.
Teach time management to optimize energy levels.
Help patients structure their day to align activities with their energy levels, which may fluctuate with medication schedules.
Breaking up activities into smaller segments can help manage fatigue.
Sodium and Weight Control
Patients should notify their physician if they gain 5 pounds in a week or 2-3 pounds overnight.
Teach patients to monitor their weight daily in the morning before eating, wearing similar clothing, and using the same scale.
Implantable Devices
Pacemakers and defibrillators may be necessary.
Defibrillators are indicated for patients at high risk of arrhythmia, often when the ejection fraction is below 35%.
Left Ventricular Assist Device (LVAD)
An LVAD is a device that assists the left ventricle, acting as a bridge to heart transplantation.
It is not a cure but helps maintain patients until a heart transplant is available.
LVAD patients require specialized care, and hospitals have dedicated LVAD nurses.
Balloon Pump
A balloon pump is used in the ICU for patients in cardiogenic shock.
It is inserted into the groin and inflates/deflates to support the heart during the cardiac cycle.
Surgical Interventions
Coronary artery bypass grafting (CABG).
Valve replacement.
Ventricular reconstruction.
Nursing Diagnoses
Impaired gas exchange: due to edema in alveoli from left heart failure.
Decreased cardiac output.
Pain: CHF-related edema is extremely painful.
Anxiety: due to difficulty breathing.
Excess fluid volume.
Nursing Interventions
Oxygen administration.
Rest and activity management.
Positioning: Elevate the head of the bed to facilitate breathing.
Fluid Management: Strict I&O monitoring is crucial.
Reduce oxygen consumption by providing rest periods and assistance with activities.
Medication administration and teaching: Educate patients about their medications and potential side effects.
Low-sodium diet and weight control: Refer to a nutritionist.
Coping support: Assess their support network and living situation including if they have stairs without an elevator, who will help get to appointments, etc.
Patient Scenario
A 72-year-old patient with a history of heart failure is admitted to the ER.
Reports running out of diuretics and difficulty breathing with bilateral ankle swelling.
Assessment includes dyspnea on exertion, low oxygen saturation, crackles in lower lobes, and edema.
Immediate actions: administer oxygen, order diuretics, and obtain lab work.
If after administering diuretics, if the patient reports muscle cramps and abnormal heart rhythm, it could mean hypokalemia.
You would want to check vital signs first.
Labs needs to be done quickly.
Cardiac Transplants
An option for end-stage heart failure when no other treatments are effective.
Strict selection criteria due to limited availability of donor hearts.
Patients require lifelong immunosuppressive therapy to prevent rejection of the transplanted heart.
Complications of Transplant
Rejection: The body recognizes the transplanted organ as foreign and attacks it.
Infections: Immunosuppressive therapy increases the risk of infections.
Increase in malignancies: Immunosuppressive medications can increase the risk of cancer.
Side effects of anti-rejection medications: Can be a reason some patients don't fully adhere to their medication regimen.
Review Questions
What is a classic symptom of acute heart failure?
Pink frothy sputum
What happens to blood flow in left sided heart failure?
Blood backs up from the left ventricle.
What lab test is most important for heart failure?
BNP
What do you need after getting a heart transplant?
Lifelong anti rejection medication
Increased malignancy risk
What happens in right sided heart failure?
Edema
Jugular vein distention
Peripheral edema
Abdomen is big one.
Name some medications needed to treat heart failure.