CARE OF PATIENTS WITH HEART FAILURE Flashcards by Kelsey Klipfel

Leading cause of hospital admissions for patients over 65 - affects many
Require lot follow-up care
Major cause of disability and death
Readmission an important quality measurement in acute care - readmitted often - core measure to provide edu
CMS core measure
Aka Pump failure-chronic inability of heart to work effectively as a pump
Heart not able to maintain adequate cardiac output to meet the metabolic needs of the body
Acute episodes lands them in hospital
Types
Most heart failure begins with failure of the left ventricle and progresses to failure of both ventricles; possible one fail by itself for short period of time

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Heart failure discharge education

CMS core measure

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Left-sided heart failure
Right-sided heart failure
High-output failure

Types HF

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Right ventricle can not empty/pump effectively
Causes:

Right sided HF

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Left ventricular failure
Right ventricular MI (myocardial infarction)
Pulmonary hypertension
Chronic lung disease

Causes:- Right sided HF

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Systemic Congestion
Jugular (neck vein) distention (JVD) - seen often
Enlarged liver and spleen
Anorexia and nausea
Dependent edema (legs and sacrum) - 4+ pitting edema in LE
Distended abdomen
Swollen hands and fingers
Polyuria at night
Weight gain - weigh daily; no more than 2 lb/daily or 5 lb/week: is an issue
Increased blood pressure (from excess volume)
Decreased blood pressure (from failure)

Symptoms of right sided HF

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Decreased tissue perfusion from poor cardiac output and pulmonary congestion from increased pressure in pulmonary vessels
Systolic Heart Failure
Dystolic Heart Failure
Common Causes:

Left sided HF

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Heart can not contract forcefully enough to eject adequate blood
HF with reduced EF: normally 50-70%; <40% = HF

Systolic Heart Failure - Left sided HF

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Ventricle can not relax adequately during diastole preventing adequate filling of blood - not enough blood to be pumped out
HF with preserved LV func

Dystolic Heart Failure - Left sided HF

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Hypertension
Coronary artery disease
Valvular disease

Common Causes:- Left sided HF

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Pulmonary congestion - alveoli fill with fluid
Decreased cardiac output

Symptoms of left sided HF

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Hacking cough, worse at night
Dyspnea - at rest, exertion, orthopnea
Crackles/wheezes in lungs
Pink, frothy sputum - lifethreating pulm edema; severe HF
Tachypnea
S3/S4 gallop: S3: increase in LV diastolic pressure and means not able to work as well - first sign of HF; S4: not sign of HF but sign decreased ventricular compliance

Pulmonary congestion - alveoli fill with fluid - Symptoms of left sided HF

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Fatigue and weakness - affects ADLS
Oliguria during day (not much urine at night)/Nocturia at night
Angina
Confusion and restlessness
Dizziness - lack volume to body
Pallor and cool extremities
Weak peripheral pulses
Tachycardia

Decreased cardiac output - Symptoms of left sided HF

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Not as common as right/left HF (CO remains below norm)
Occurs when cardiac output remains normal or above normal but there are increased metabolic needs or hyperkinetic conditions
Causes:
Not as common as the other two types

High output HF

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Septicemia
High fever
Anemia
Hyperthyroidism

Causes: - High output HF

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When cardiac output is insufficient to meet the demands of the body, are compensatory mechanisms that try work to improve cardiac output - might initially but do have damaging effect on heart
Initially increase cardiac output but eventually have a damaging effect of pump function
All the compensatory mechanisms contribute to increased oxygen needs of the myocardium
Eventually the heart can not keep up with the demands - damaging effect eventually
Then clinical manifestations of HF occur

Compensatory mechanisms

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Sympathetic nervous system stimulation
Renin-angiotensin-aldosterone system (RAAS) activated as well
Other chemical responses
Myocardial hypertrophy

When cardiac output is insufficient to meet the demands of the body, are compensatory mechanisms that try work to improve cardiac output - might initially but do have damaging effect on heart

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Increases HR and blood pressure - increase blood flow
Results from tissue hypoxia - stimulation adrenergic receptors
CO initially increased but limited esp if heart poorly perfused because of aterosclerosis - may worsen because of this

Sympathetic nervous system stimulation

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Causes vasoconstriction and retention of Na and water - fluid volume up - get blood out to body

Renin-angiotensin-aldosterone system (RAAS) activated as well

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Immune response causes ventricular remodeling
Endothelin (secreted by endothelin cells as stretched and released because stretch on cardiac muscle) causes vasoconstriction - increases PVR and BP; HF worsens
Vasopressin causes vasocostriction - increase CO

Other chemical responses

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Thicken of heart walls to increase muscle mass and lead to more forceful contractions
Helps as first; thicker - not as much stretch

Myocardial hypertrophy

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Monitor diagnostics closely
Lab assessment
Imaging

Diagnostic assessment - HF

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Electrolytes
BUN and creatinine
Hemoglobin and hematocrit
Urinalysis
ABG’s –
BNP (B-type natriuretic peptide)

Lab assessment

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Abnormalities from complications of HF or side effects of drug therapy
Esp with diuretics

Electrolytes

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Inadequate perfusion of kidneys can result in impairment and elevated levels Monitor kidney func - blood not pumped effectively kidneys affected

BUN and creatinine

Could be result/low secondary to hemodilution HF resulting from anemia?

Hemoglobin and hematocrit

Possible proteinuria and high specific gravity Microalbuminuria - early indicator of decreased compliance of the heart and occurs before the BNP rises

Urinalysis

Evaluates for hypoxemia Decrease in gas exchange secondary due to fluid filled alveoli when left sided HF with dyspnea/exertion

ABG’s –

Will be elevated and used for diagnosing HF (diastolic HF and acute dyspnea) Response to left/right ventricular dysfunc Higher levels - HF likely cause BNP is produced and released by the ventricles when the patient has fluid overload becuase of HF (left/right sided ventricular dysfunc) Natriuretic peptides are neurohormones that promote vasodilation and diuresis through sodium loss in the renal tubules Therapy can lower levels Patients with renal disease and age may also have elevated levels

BNP (B-type natriuretic peptide)

Chest x-ray Echocardiography (ultrasound of the heart)

Imaging

Cardiomegaly (enlarged heart) may be present - hypertrophy of left side of heart Look at for Pleural effusions with biventricular failure Look at for LV failure

Chest x-ray

Best tool in diagnosing HF Measures chamber size, ejection fraction and flow How advance, EF measurement; understanding how pat is Noninvasive

Echocardiography (ultrasound of the heart)

Start with ABCs Impaired gas exchange related to ventilation/perfusion imbalance - want increase gas exchange Decreased cardiac output related to altered contractility, preload, and afterload - want adequate perfusion Fatigue related to hypoxemia - affects ADLs Potential for pulmonary edema - not want develop (HF pats at high risk for this)

Priority probs - HF

Oxygen Monitor respirations and lung sounds - not labored/accessory muscles/abnormal sounds If dyspnea present, high-Fowler’s position Reposition, cough and deep breathe at least every 2 hours Drug Therapy Nutrition therapy Fluid restriction Weigh daily Monitor and record intake and output closely Provide periods of uninterrupted rest Assess the patient’s response to increased activity - see if good activity and able get back to baseline prior to exacerbation of HF

Nursing interventions - HF

Keep oxygen saturations 90% or greater - monitor O2 levels closely

Oxygen

Maximizes chest expansion and improves oxygenation

If dyspnea present, high-Fowler’s position

Up and moving Improve oxygenation and prevent atelectasis

Reposition, cough and deep breathe at least every 2 hours

Goal: To improve stroke volume Will reduce afterload, reduce preload, and improve cardiac muscle contractility

Drug Therapy

Encourage with pats Goal to reduce sodium and water retention - not get edema Reduce sodium intake (can be as low as 2 gram/day) - KEY

Nutrition therapy

Range from 2 Liters to 3 Liters per day

Fluid restriction

Encourage this; keep record Most reliable indicator of fluid gain or loss 1 kg of weight gain or loss equals 1 liter of retained or lost fluid

Weigh daily

Continuous positive airway pressure (CPAP) – Cardiac resynchronization therapy (CRT) – Gene Therapy -

Non surgical options: HF

improves obstructive sleep apnea and supports cardiac output and ejection fraction - decreases afterload, preload, BP, dysrhythmias

Continuous positive airway pressure (CPAP) –

uses a permanent pacemaker alone or in combination with an implantable cardioverter-defibrillator (ICD); aka biventricular pacemaker; more synchronous venous contractions - improves EF and CO causing contractility to improve

Cardiac resynchronization therapy (CRT) –

end-stage HF who cannot have heart transplant; replaces norm genes with norm/modified genes by series of injections of growth factors into LV; improve exercise tolerance and repair cardiac cells

Gene Therapy -

Heart transplantation Ventricular Assistive Devices (VAD)

surgical options: HF

Ultimate choice for end-stage HF

Heart transplantation

Mechanical pump is implanted to work with patient’s heart to improve function Debilitating end-stage HF and sent home on drug therapy and improves lives of pats and sent to hospice; short-term while waiting for transplant/long-term

Ventricular Assistive Devices (VAD)

Arterial vasodilators reduce the resistance to left ventricular ejection (afterload) and improve cardiac output - reverse excessive vasoconstriction Suppress RAAS Angiotensin-converting enzyme (ACE) inhibitors Angiotensin-receptor blockers (ARBs) Human B-type Natriuretic Peptides (hBNPs)

Drugs to reduce afterload

Enalapril (Vasotec) Fisinopril (Monopril) -pril

Angiotensin-converting enzyme (ACE) inhibitors

Valsartan (Diovan) Irbesartan (Avapro) Losartan (Cozaar) -sartan Both more effective in Euro Americans/African Americans Start slowly esp in volume depleted pats ACE inhibitors are the first-line drug of choice Monitor for:

Angiotensin-receptor blockers (ARBs)

May cause dry cough - AE; nagging

ACE inhibitors are the first-line drug of choice

Orthostatic hypotension Acute confusion Poor peripheral perfusion Reduced urine output in patients with low systolic BP Serum Potassium and creatinine levels - renal dysfunc?

Monitor for: - ACE, ARBs

Used to treat acute HF Drug Causes loss of sodium and vasodilation Nesiritide (Natrecor) Monitor BP and pulse - sig decreases in BP Serum BNP will increase after administration - expected Bolus followed by continuous infusion up to 48 hrs Give in dedicated line - not compatible with most meds

Human B-type Natriuretic Peptides (hBNPs)

Reduce preload by decreasing volume and pressure in the left ventricle, increasing ventricular muscle stretch and contraction Diuretics Venous vasodilators (nitrates) Morphine sulfate

Drugs to reduce preload

First-line drug of choice in older adults with HF and fluid overloaded pats Enhance renal excretion of sodium and water Monitor for dehydration - get rid fluid Monitor potassium levels - often on K replacement protocol If creatinine level is greater than 1.8 mg/dL, notify health care provider before administering supplemental potassium - eye on labwork Loop excretes K Loop - Furosemide (Lasix) Loop - Torsemide (Demadex) Loop - Bumetanide (Bumex) Thiazide – Hydrochlorothiazide (HCTZ); Metolazone (Zaroxolyn); not excrete K; not want get too high Potassium-sparing – Spironolactone (Aldactone); not excrete K; not want get too high

Diuretics

For HF patients that have persistent dyspnea Returns venous vasculature to more norm capacity; decrease volume blood returning to heart and improve LV func May be administered IV, orally, topically - acute HF pats Monitor BP when starting/increasing because vasodilation can cause Headache is common but the patient will develop a tolerance to this side effect - go away/diminish

Venous vasodilators (nitrates)

Reduces venous return Given in acute heart failure to reduce anxiety Decreases preload and afterload Slows respirations and reduces the pain associated with a myocardial infarction (MI)

Morphine sulfate

Digoxin (Lanoxin) Inotropic drugs Beta-adrenergic blockers

Drugs to improve contractility

Provides symptomatic benefits for patients in chronic HF: Reduce HR; Increase contractility; slows conduction through AV node - decreases dyspnea and improves func activity in pats Added to ACEs/ARBs/diuretics does reduce exacerbations HF and hospitalizations Inconsistent absorption in GI tract - drugs interfere with absorption (including antacids) Eliminated by renal excretion - if have renal disease consider Maintain lower dose for older pats Monitor for digoxin toxicity (s/s: anorexia, fatigue, blurred vision, changes in mental status, dysrhythmias: PVCs); hypokolemia can potentiate toxicity and closely monitor older pats HR and rhythm for no changes

Digoxin (Lanoxin)

IV route and continuous drips Increase force cardiac contraction Dobutamine (Dobutrex): used for short-term treatment of acute episodes of HF Milrinone (Primacor) - vasodilator; acute episodes HF; can go if adv HF; go home with central line Levosimendan (Simdax) - HF pats at risk MI; short half-life; never pause these influces

Inotropic drugs

Start slowly Not used in patients with acute HF Blocks the sympathetic stimulation Monitor closely so not have bradycardia, hypotension; benefits mild to mod disease pats: EF, decrease hospitalizations, decreases orthopnea, increases activity tolerance Increase contracility -lol Carvedilol (Coreg) Metoprolol succinate (Toprol XL) Bisoprolol (Zebeta)

Beta-adrenergic blockers

Diet Activity schedule Drug therapy - afford meds, AE, requirements what take before Discharge instructions Resources and equipment needs VERY IMPORTANT TO DECREASE READMISSIONS need appt before leaving; home support; pamphlets, books; support groups; any activity assistance: walker/canes

Patient teaching for HF

Sodium restriction and fluid restriction Why imp

Diet

Notify any of the following symptoms to health care provider - know when notify HCP

Discharge instructions

Rapid weight gain (3 lbs in a week or 1-2 lb overnight) - weigh daily Decrease in exercise tolerance lasting 2 to 3 days Cold symptoms (cough) lasting more than 3-5 days Excessive awakening at night to urinate Development of dyspnea or angina at rest or worsening angina Increased swelling in the feet, ankles, or hands

Notify any of the following symptoms to health care provider - know when notify HCP

CARE OF PATIENTS WITH HEART FAILURE Flashcards

(66 cards)