Heart Failure

Question 1

Heart Failure

• An abnormal condition involving impaired cardiac pumping/filling
• Heart is unable to produce an adequate cardiac output (CO) to meet metabolic needs

Answer 1

• Progressive disease is characterized by myocardial cell dysfunction
• Inability of the heart to pump enough CO to meet the demands of the body
• Prevalence is high and it’s increasing; we’re living longer and are eating diets that’re full of unhealthy synthetic products & preservatives

Question 2

Epidemiology - HF Risk Factors

• CAD
• HTN producing LVH
• DM, hyperlipidemia
• Sedentary lifestyle
• Obesity
• Excessive alcohol use, smoking, high sodium dietary intake

Question 3

?

Diastolic HF occurs as a result of __ __

Answer 3

filling failure

Question 4

?

Systolic HF occurs as a result of __ __

Answer 4

pump failure

Question 5

?

Refers to the inability of the ventricles to relax & thereby fill the chambers appropriately

Answer 5

Diastolic

Question 6

?

Refers to the action of contraction in the ventricles or the lower chambers (emptying)

Ventricles don’t have enough systemic vascular resistance (SVR) to exert sufficient pressure & eject the blood to the body in an optimal manner to perfuse the body effectively

Answer 6

Systolic

Question 7

HF classification is based solely on measurement of ejection fraction (EF); is the % of blood that’s ejected from the ventricle w/each contraction

> Normal 55-70%; around 45% - indicates HF

Answer 7

Question 8

HF - Pathophysiology

Characterized by
> Ventricular dysfunction
> Reduced exercise tolerance
> Diminished quality of life
> Shortened life expectancy

Answer 8

Compensatory Mechanisms

• SNS
• Renin-Angiotensin-Aldosterone
• Natriuretic peptides (BNP)

Question 9

SNS is activated first; you see increased HR, contractility of the heart, & peripheral vasoconstriction (why we check pedal pulses & assess the heart)

Mechanisms then start to fail as heart cannot keep up w/workload & need for O2

Question 10

Kidneys act by activating the __ __ __ __. Begins ok, but then retention of fluid to maintain volume & eventually strains the overworked heart w/volume & workload

Answer 10

renin-angiotensin-aldosterone system

Question 11

A neurohormonal mechanism is the body’s release of ___

Answer 11

BNP (brain natriuretic peptide)

Question 12

• Overstretching of the heart causes this peptide to be released in r/t inc pressure & volume
• Results in natural diuresis as well as dilation of veins & arteries
• These decrease __ and __ & therefore workload of the heart

Answer 12

preload; afterload

Question 13

BNP

• Lab can draw BNP levels and if they’re elevated, then that’s a clear indication of HF
• Pts can be given a BNP rx that mimics the effects of the body’s natural BNP neurohormonal mechanism

Question 14

___ can be released w/even a minor cardiac muscle stretch

Answer 14

ANP (so we look at BNP if there’s a question of HF)

Question 15

Management

• Heavily dependent on hx & physical assessment as sx’s nonspecific
• Lab testing
  > cardiac enzymes, serum electrolytes, CBC, UA, fasting lipid profile, LFT’s,
• Rx’s

Answer 15

Complications

• Pulmonary edema

Question 16

• Goals of HF management are manipulation of the critical components of CO (preload, afterload, contractility) and control of the compensatory mechanisms

Question 17

?

Is an acute complication of HF characterized by rapid accumulation of fluid in interstitial & alveolar spaces of the lung, resulting from elevated filling pressures within the heart

Answer 17

Pulmonary edema

Question 18

?

• Most common type
• Results from LVD
  > HTN, CAD, cardiomyopathy
  > Back up of blood into the left atrium & pulmonary veins
• Pulmonary congestion
• Edema

Answer 18

Left HF

Question 19

?

Occurs as back up of blood into right atrium and venous systemic circulation

Answer 19

Right HF

Question 20

HF: Where’s the backflow?

Right or Left?

• Backup of blood into the right atrium and venous systemic circulation

Answer 20

Right

Question 21

Left - most common type

• Results from LVD (HTN, CAD, cardiomyopathy)
• Backup of blood into the left atrium and pulmonary veins
  > Pulmonary congestion
  > Edema

Answer 21

Remember: Left / Lungs (Left-sided HF classically is when the fluid is built up in the lungs)

Question 22

HF Sx’s - ?

• SOB, dyspnea, fatigue
• Crackles in lung auscultation
• Poor color, weak pulses, cool extremities

Answer 22

LEFT

Question 23

?

• Jugular vein distention (JVD)
• Generalized dependent edema
• Hepatomegaly
• Ascites

Answer 23

Right

Question 24

• Left-sided HF can eventually cause right-sided HF & then sx’s can be less clear
• Severe exacerbations of HF, pt may present w/hypotension, cool extremities, decreased or no urine output, & poor or declining mentation

Question 25

? If this is left untreated, treatment is delayed, or the HF progresses, it can rapidly decline into an acute decompensated state such as severe __ __

Answer 25

Pulmonary edema

Question 26

* Other complications of HF can be pleural effusions, afib (which can cause thrombus/embolus formation & inc pts risk for stroke), fatal dysrhythmias, severe hepatomegaly, renal insufficiency or failure

Answer 26

* As pulmonary edema progresses, it inhibits O2 & CO2 exchange @ the alveolar-capillary interface

Question 27

* Orthopnea * Dyspnea, tachypnea * Use of accessory muscles * Cyanosis * Cool & clammy skin

Answer 27

* Cough w/frothy, blood-tinged sputum * Crackles, wheezes, rhonchi * Tachycardia * Hypo- or HTN

Question 28

Flash Pulmonary Edema ! Fast & sudden * Pt is usually anxious, pale, & possibly cyanotic * Skin is clammy & cold from vasoconstriction caused by stimulation of SNS

Question 29

Diagnostic Studies | Primary goal: *Determine & treat underlying cause* * History & PE * Cxr * Lab studies (e.g., cardiac enzymes, BNP, electrolytes, CBC, UA, lipids) * Hemodynamic assessment

Answer 29

* Echo * Nuclear imaging/stress testing * Cardiac cath * Ejection fraction (MUGA scans)

Question 30

BNP Below __ pg/mL indicates no HF Levels between __ and __ pg/mL suggest HF is present Level above __ pg/mL indicates mild HF

Answer 30

100 100-300 300

Question 31

Level above __ pg/mL indicates moderate HF Level above __ pg/mL indicates severe HF

Answer 31

600 900

Question 32

Electrolytes - Assess K+ as diuretics might deplete - Look at BUN as inadequate blood flow to the kidneys may impair kidney function - H/H in anemia that could result in decreased CO

Answer 32

! Be aware of any National Hospital Quality Measures (6 core measures) 1. Beta-blocker @ discharge 2. Follow-up within 7 days >d/c 3. Record of care transmitted to the next level of care within 7 days of d/c 4. Documentation of advance care planning (adv dir) w/an HCP 5. Documentation of adv dir within the medical record 6. F/u d/c eval of pt status & treatment adherence within 72 hrs of d/c (can occur by phone, scheduled OV, or home visit)

Question 33

Classification Systems * New York Heart Association **Functional** Classification of HF: Classes I to IV > Patients may progress up & back to any of the classifications @ any time during their dz, depending on treatment & response

Answer 33

* ACC/AHA Stages of HF: Stages A to D > A pt can't go backward in these stages

Question 34

Class ? No symptoms w/physical activity such as dyspnea or CP

Answer 34

Class I

Question 35

Class ? Marked limitation w/physical activity but comfortable @ rest

Answer 35

Class III

Question 36

Class ? Severe limitation & distress w/physical activity or at rest

Answer 36

Class IV

Question 37

Class ? Mild sx's w/ordinary activities

Answer 37

Class II

Question 38

Stage ? Refractory HF eligible for heart transplant, inotropic and/or mechanical support

Answer 38

D

Question 39

Stage ? Asymptomatic w/LVH and/or impaired LV function

Answer 39

B

Question 40

Stage ? Pt's w/risk factors but no LV impairment

Answer 40

A

Question 41

Stage ? Current or past sx's of HF

Answer 41

C

Question 42

Overall objective is to increase CO by effecting the SV (preload, afterload, & contractility) ***"UNLOADFAST"*** * Morphine is also used as it decreases preload & anxiety

Question 43

"UNLOADFAST"

Answer 43

Question 44

Improve Cardiac Output: Preload, Afterload, Contractility Reduce ___ * Nutrition therapy * Drug therapy > Diuretics > Venous vasodilators

Answer 44

Preload

Question 45

Reduce Afterload * Drugs > __ > __ > __

Answer 45

ACE inhibitors ARB Human BNP

Question 46

Drugs: Enhance Contractility * Inotropic drugs > ___ * Beta adrenergic blockers (usually short-term)

Answer 46

Digoxin

Question 47

Treatments: Non-pharmacological * Noninvasive ventilatory support (BIPAP) * Cardiac resynchronization therapy (CRT) or biventricular pacing * Cardiac transplantation

Answer 47

* Intra-aortic balloon pump (IABP) therapy * Ventricular assist devices (VADs) * AICD - automatic internal cardiac defibrillator * Heart transplantation - depending on the cause

Question 48

Nursing Management - HF Nursing Diagnoses * Activity intolerance * Fluid volume excess * Anxiety * Deficient knowledge

Answer 48

Evaluation * Respiratory status * Fluid balance * Activity tolerance * Anxiety control * Knowledge of disease process