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what is HF?

  • HF occurs when the heart muscle is unable to pump effectively which causes inadequate cardiac output, myocardial hypertrophy, and pulmonary/systemic congestion
    • Heart is unable to maintain adequate circulation to meet tissue needs
    • It is the result of an acute or chronic cardiopulmonary problem, such as systemic HTN, MI, pulmonary HTN, dysrhythmias, valvular heart dz, pericarditis, or cardiomyopathy


New York Heart Assoc’s functional classification scale for HF

  • indicates the level of activity it takes to make the client symptomatic (client pain or shortness of breath)
    • Class I: no symptoms w/ activity
    • Class II: symptoms with ordinary exertion
    • Class III: displays symptoms with minimal exertion
    • Class IV: symptoms at rest


American College of Cardiology and AHA staging HF

  • A: high risk for developing HF
  • B: cardiac structural abnormalities or remodeling but no heart failure symptoms
  • C: current or prior symptoms of HF
  • D: refractory end stage HF


left sided heart failure

  • results in inadequate left ventricle (cardiac) output and consequently in inadequate tissue perfusion
    • Systolic heart (ventricular) failure: ejection fraction below 40%, pulmonary and systemic congestion
    • Diastolic heart (ventricular) failure: inadequate relaxation or “stiffening” prevents ventricular filling


right sided heart failure

  • results in inadequate right ventricle output and systemic venous congestion (peripheral edema)


health promotion and dz prevention for HF

  • Maintain exercise routine to remain physically active
  • Diet: low in sodium, fluid restrictions
  • Refrain from smoking
  • Follow med regimen


what are 2 risk factors for all types of heart failure?

  • SBP is elevated in older adults, putting them at risk for coronary artery dz and HF
  • Some meds inc the risk of HF or worsen manifestations in older adult clients


risk factors for left sided HF

  • HTN
  • Coronary artery dz, angina, MI
  • Valvular dz


risk factors for right sided HF

  • Left sided HF
  • Right ventricular MI
  • Pulmonary problems (COPD, pulmonary fibrosis)


risk factors for cardiomyopathy


  • Coronary artery dz
  • Infection or inflammation of the heart muscle
  • Various cancer tx
  • Prolonged alcohol use
  • Heredity


expected findings of left sided HF

  • Dyspnea, orthopnea (SOB while laying down), nocturnal dyspnea
  • Fatigue
  • Displaced apical pulse (hypertrophy)
  • S3 heart sound (gallop)
  • Pulmonary congestion (dyspnea, cough, bibasilar crackles)
  • Frothy sputum (can be blood tinged)
  • Altered mental status
  • Manifestations of organ failure, such as oliguria (dec in urine output)


expected findings of right sided HF

  • JVD
  • Ascending dependent edema (legs, ankles, sacrum)
  • Abdominal distention, ascites
  • Fatigue, weakness
  • Nausea and anorexia
  • Polyuria at rest (nocturnal)
  • Liver enlargement (hepatomegaly) and tenderness
  • Weight gain


what is cardiomyopathy?

what are the 4 types?

  • Blood circulation to the lungs is impaired when the cardiac pump is compromised
    • can lead to HF
  • 4 types:
    • dilated: most common
    • hypertrophic
    • Arrhythmogenic right ventricular

    • Restrictive


manifestations of cardiomyopathy

  • Fatigue, weakness
  • HF (left with dilated type & right with restrictive type)
  • Dysrhythmias (heart block)
  • S3 gallop
  • Cardiomegaly
  • Angina (hypertrophic type)


lab test for HF

  • Human B type Natriuretic peptides (hBNP)
    • In clients who have dyspnea, elevated hBNP confirms a diagnosis of HF rather than a problem originating in the respiratory system.  hBNP levels direct the aggressiveness of treatment interventions
      • Less than 100: no HF
      • 100-300: suggests HF is present
      • >300: mild HF
      • >600: moderate HF
      • >900: severe HF


what are the diagnostic procedures for HF?

  • hemodynamic monitoring
  • ultrasound
  • transesophageal echocardiography (TEE)
  • CXR
  • ECG, cardiac enzymes, electrolytes, and ABGs: use to assess factors contributing to HF and/or the impact of HF


explain hemodynamic monitoring to diagnose HF

  • HF generally results in inc central venous pressure (CVP), inc pulmonary wedge pressure (PAWP), inc pulmonary artery pressure (PAP), and dec CO
  • Mixed venous O2 sats (SvO2) are directly related to CO.
    • Drop in SvO2 indicates worsening cardiac function


explain ultrasound to diagnose HF

  • 2D or 3D
    • Left ventricular ejection fraction: volume of blood pumped from the left ventricle into the arteries upon each beat
      • Expected reference: 55-70%
    • Right ventricular ejection fraction: volume of blood pumped from the right ventricle to the lungs upon each beat
      • Expected reference: 45-60%


explain transesophageal echocardiography (TEE) to diagnose HF

  • Uses a transducer placed on the esophagus behind the heart to obtain a detailed view of cardiac structures
  • Nurse prepares client in same manner as upper endoscopy


explain CXR to diagnose HF

  • can reveal cardiomegaly and pleural effusions


nursing care involved with HF

  • Monitor daily weight and I&O
  • Assess for SOB and dyspnea on exertion
  • Administer O2
  • Monitor V/S and hemodynamic pressures
  • Put client in high Fowler’s
  • Check ABGs, electrolytes, SaO2, and CXR
  • Assess for signs of med toxicity
  • Encourage bed rest
  • Encourage energy conservation
  • Maintain dietary restrictions as prescribed (restricted fluid intake, restricted sodium intake)


what are the classes of meds used to tx HF?

  • diuretics
  • afterload reducing agents
  • inotropic agents
  • beta blockers
  • vasodilators
  • human B type natriuretic peptides
  • anticoagulants


diuretics to tx HF

  • use to decrease preload
  • Loop: furosemide, bumetanide
  • Thiazide: HCTZ
  • Potassium sparing diuretics: spironolactone
  • Nursing considerations:
    • Administer furosemide IV no faster than 20 mg/min
    • Loop and thiazide diuretics can cause hypokalemia, and potassium supplementation can be required
  • Client edu: teach clients taking loop or thiazide diuretics to ingest foods and drinks that are high in potassium to counter the effects of hypokalemia


afterload reducing agents to tx HF

  • help the heart pump more easily by altering the resistance to contraction
  • Contraindicated for clients who have renal deficiency
    • ACE inhibitors: enalapril, captopril
    • ARBs: losartan
    • CCBs: diltiazem, nifedipine
    • Phosphodiesterase 3 inhibitors: milrinone
  • Nursing considerations:
    • ACE inhibitors: first dose hypotension, angioedema, dec sense of taste, skin rash
    • Monitor for inc levels of potassium
  • Client edu: ACE Inhibitors
    • Teach client about dry cough
    • Notify provider if rash or dec sense of taste
    • Notify provider if swelling of face occurs
    • Remind client that BP needs to be monitored for 2 hours after initial dose


intropic agents to tx HF: meds, action, nursing considerations

  • digoxin, dopamine, dobutamine, milrinone
  • Used to inc contractility and thereby improve cardiac output
  • Nursing considerations:
    • For a client taking digoxin, take apical HR for 1 min, and hold if pulse is <60/min
    • watch for n/v
    • Dopamine, dobutamine, and milrinone are administered via IV.
    • Closely monitor ECG, BP, and urine output


inotropic agents to tx HF: client edu

  • If client self administering digoxin:
    • Count pulse for 1 min before taking, and if less than 60 or greater than 100, then hold
    • Take dose at same time each day
    • Do not take at same time as antacids-->separate other meds by 2 hours
    • Toxicity: fatigue, muscle weakness, confusion, and loss of appetite
    • Check digoxin and K levels regularly


beta blockers to tx HF

  • carvedilol and metoprolol
    • Can be used to improve the condition of the client who has sustained increased levels of sympathetic stimulation and catecholamines
      • Includes clients who have chronic HF
  • Nursing considerations:
    • Monitor BP, pulse, activity tolerance, and orthopnea
    • Check orthostatic BP readings
  • Client edu:
    • Instruct client to weigh daily
    • Advise client to regularly check BP


vasodilators to tx HF

  • nitroglycerin and isosorbide mononitrate
    • Prevent coronary artery vasospasm and reduce preload and afterload, decreasing myocardial O2 demand
  • Nursing considerations:
    • Given to tx angina and help control BP
    • Use cautiously with other anti HTN meds
    • Can cause orthostatic hypoTN
  • Client edu:
    • HA is common SE
    • Sit and lie down slowly


human B type natriuretic peptids (hBNPs) to tx HF

  • nesiritide
    • Used to treat acute HF by causing natriuresis (loss of Na and vasodilation)
    • Administered IV
  • Nursing considerations:
    • Can cause hypoTN, v tach, and bradycardia
    • BNP levels will inc on this med
    • Monitor ECG, BP
  • Client edu:
    • Client may be asymptomatic with a low BP
    • Remind client to sit and lie down slowly


anticoagulants to tx HF


  • warfarin
    • Use if pt has hx of thrombus formation
  • Nursing considerations:
    • Contraindications: active bleeding, PUD, hx of CVA, recent trauma
    • Monitor PT, aPTT, INR, CBC
  • Client edu:
    • Teach client risk for bruising and bleeding
    • Teach about getting blood monitored