Perfusion: Heart Failure

Question 1

Heart Failure: Defined

Answer 1

The inability of the heart to work effectively as a pump

Question 2

Heart Failure: Pathophysiology

Answer 2

Chronic; acute episodes; life threatening if not adequately treated or if pt does not respond to treatment

Question 3

Types of Heart Failure

Answer 3

Left-sided, right-sided, and high-output failure; Most begin with left-sided failure and progresses to both sides

Question 4

Causes of Left sided HF

Answer 4

Hypertension, coronary artery disease, valvular disease; decreased tissue perfusion from poor cardiac output and pulmonary congestion from increased pressure in the pulmonary vessels indicate left-ventricular failure

Question 5

Left-sided HF: systolic heart failure path

Answer 5

Heart cannot contract forcefully enough during systole to eject adequate amounts of blood into the circulation; preload increases with decreased contractility; afterload increases as a result of peripheral resistance

Question 6

Systolic heart failure: ejection fraction

Answer 6

Normal: 50-70%; EF drops down to below 40% with ventricular dilation; tissue perfusion diminishes and blood accumulates in the pulmonary vessels; EF

Question 7

Left-sided HF: diastolic heart failure path

Answer 7

Left ventricle cannot relax adequately during diastole; stiffening prevents ventricle from filling with sufficient blood to ensure an adequate cardiac output

Question 8

Systolic dysfunction manifestations

Answer 8

Inadequate tissue perfusion, pulmonary and systemic congestion

Question 9

Diastolic dysfunction manifestations

Answer 9

Inadequate tissue perfusion, pulmonary and systemic congestion

Question 10

Causes of right-sided HF

Answer 10

Left ventricular failure, right ventricular myocardial infarction, or pulmonary hypertension

Question 11

Right-sided HF path

Answer 11

Right ventricle cannot empty completely; increased volume and pressure develop in venous system and peripheral edema occurs

Question 12

High-output HF causes

Answer 12

Increased metabolic needs or hyperkinetic conditions, ie: septicemia, high fever, anemia, and hyperthyroidism

Question 13

High-output HF path

Answer 13

Cardiac output remains normal or above normal

Question 14

Compensatory mechanisms for HF

Answer 14

Stimulation of the sympathetic nervous system, renin-angiotensin system activation, other chemical responses, and myocardial hypertrophy; may initially increase cardiac output but eventually have a damaging effect on pump function

Question 15

Stimulation of the sympathetic nervous system

Answer 15

Most immediate compensatory mechanism; increases HR and BP from vasoconstriction

Question 16

Renin-Angiotensin system activation

Answer 16

Reduced blood flow to the kidneys activates RAS; vasoconstriction becomes more pronounced; preload and afterload increase

Question 17

Other chemical responses

Answer 17

Immune response r/t MI; increased B-type natriuretic peptide produced and released by ventricles; vasopressin which worsens HF; endothelin secreted when heart muscles are stretched to increase peripheral resistance and hypertension

Question 18

Myocardial hypertrophy

Answer 18

enlargement of the myocardium; walls of the heart thicken; produces more forceful contractions; increases cardiac output; my hypertrophy d/t slight oxygen deprived state

Question 19

HF general assessment

Answer 19

Medical hx, perception of activity tolerance, breathing pattern, sleeping pattern urinary pattern, fluid volume status, and knowledge of HF

Question 20

Left-sided HF assessment

Answer 20

Activity tolerance; simultaneous leg and arm work; identify most strenuous activity in the past week; chest discomfort, palpitations, skipped beats, fast heartbeat; cough; frothy pink-tinged sputum; dyspnea (exertional, orthopnea, paroxysmal nocturnal)

Question 21

Right-sided HF assessment

Answer 21

Peripheral edema; weight gain; nausea; anorexia (liver engorgement); ascites; increased abdominal girth; diuresis at rest; nutritional hx; fluid intake (may have excessive thirst d/t sodium retention

Question 22

Left-sided HF manifestations

Answer 22

Fatigue, weakness, oliguria during the day, angina, confusion, restlessness, dizziness, tachycardia, palpitations, pallor, weak peripheral pulses, cool extremities, hacking cough (worse at night), dyspnea, breathlessness, crackles or wheezes in lungs, frothy pink tinged sputum, tachypnea, S3/S4 summation gallop

Question 23

Right-sided HF manifestations

Answer 23

JVD, enlarged liver and spleen, anorexia and nausea, dependent edema, distended abdomen, swollen hands and fingers, polyuria at night, weight gain, increased BP (excess volume) or decreased BP (failure)

Question 24

Psychosocial assessment HF

Answer 24

Anxiety, frustration and depression are common; ask about usual methods of coping and if there is hx of mental health issues; social involvement

Question 25

Lab assessment HF

Answer 25

Serum electrolytes, BUN/Creatinine, Hgb/Hct, B-type natriuretic peptide, urinalysis, arterial blood gasses; microalbuminuria is early warning of decreased heart compliance

Question 26

Imaging assessment HF

Answer 26

Chest x-rays (enlarged heart), echocardiogram (best tool; detects cardiac valvular changes pericardial effusion, chamber enlargement, and ventricular hypertrophy), radionuclide studies (can indicate the presence and cause of HF)

Question 27

Other diagnostic assessments HF

Answer 27

Electrocardiogram (may show ventricular hypertrophy, dysrhythmias, and myocardial ischemia, injury, or infarction), invasive hemodynamic monitoring (direct assessment of cardiac function and can confirm the diagnosis and guide the management)

Question 28

Serum electrolytes for HF

Answer 28

Evaluates for electrolyte imbalance (Na, K, Mg, Ca, Cl)

Question 29

BUN/Creatinine for HF

Answer 29

Elevated BUN and decreased creatinine in renal function impairment

Question 30

Hgb/Hct for HF

Answer 30

Identifies if HF is result of anemia; may be low in fluid volume excess as result of hemodilution

Question 31

BNP for HF

Answer 31

Increased in HF differentiates between dyspnea of HF or lung dysfunction

Question 32

Urinalysis for HF

Answer 32

Proteinuria, high specific gravity, microalbuminuria (early indicator)

Question 33

Arterial blood gas for HF

Answer 33

Hypoxemia (fluid filled alveoli), resp alk (hyperventilation), resp acid (CO2 retention), Met acid (accumulation of lactic acid)

Question 34

Priority problems for pts with heart failure

Answer 34

Impaired gas exchange, decreased cardiac output, fatigue and weakness, potential for pulmonary edema

Question 35

HF gas exchange interventions

Answer 35

Ventilation assistance, monitor resp rate, rhythm, and quality every 1-4 hrs, ascultate breath sounds every 4-8 hrs

Question 36

HF cardiac output interventions

Answer 36

ACE inhibitors, ARBs, diuretics, Human B-type natriuretic peptides, nitrates inotropics (beta-adrenergic agonists, phosphodiesterase inhibitors, calcium sensitiers, digoxin), Beta-adrenergic blockers, surgical and non-surgical management

Question 37

ACE inhibitors and ARBs for HF

Answer 37

Reduces afterload by reversing some of the inappropriate vasoconstriction (reduces the number of sacks on the donkey's wagon); ACE is first line but can cause a nagging dry cough; suppresses the RAS resulting in arterial dilation and increased stroke volume; ARBs decrease arterial resistance and arterial dilation; both block aldosterone to decrease fluid overload; monitor for hyperkalemia, orthostatic hypotension, acute confusion, serum potassium and creatinine

Question 38

Human B-type natriuretic peptides for HF

Answer 38

Reduces afterload; lowers pulmonary capillary wedge pressure; improves glomerular filtration; bolus for 60 sec and continuous for up to 48 hrs; monitor BP and pulse; give through separate infusion line; expect increase in BNP after admin

Question 39

Nutrition therapy for HF

Answer 39

Reduces preload; decrease the workload of the heart by reducing sodium and water retention; weigh daily; 1 kg gain or loss equals 1 L of retained or lost fluid

Question 40

Diruetics for HF

Answer 40

Reduces preload (reduces the number of sacks on the donkey's wagon); enhances renal excretion of sodium and water; monitor/prevent hyperkalemia (generalized weakness, depressed reflexes, irregular heart rate)

Question 41

Nitrates for HF

Answer 41

Reduces preload; venous vasodilators; for pts with persistent dyspnea; returns venous vasculature to a more normal capacity; decreases the volume of blood returning to the heart; improves left ventricular function; may be administered IV, oral, or topical; monitor BP; HA will go away; prevent tolerance by using 12 out of 24 hrs

Question 42

Digoxin for HF

Answer 42

Enhances contractility (the carrot place in front of the donkey to make him move); reduces exacerbations and hospitalizations when added to regimen of ACE inhibitors, ARBs, beta blockers, and diuretics; may increase mortality d/t drug toxicity; eliminated by renal excretion

Question 43

Digoxin toxicity

Answer 43

Anorexia, fatigue, blurred vision, changes in mental status, dysrhythmias (esp PVCs), bradycardia, loss of P wave; report irregular rhythm in pt with normally regular rhythm and vice versa; monitor serum digoxin and potassium

Question 44

Beta-adrenergic agonists for HF

Answer 44

Used for short-term treatment; improves cardiac contractility

Question 45

Beta-adrenergic blockers for HF

Answer 45

Enhances contractility (limits the donkey's speed, saving energy); must be started slowly; monitor for bradycardia or hypotension after first dose; weigh daily; report worsening symptoms of HF; gradually increases drug dose if HF worsens; pt evaluated weekly; resting HR should remain between 55 and 60 and increase slightly with exercise

Question 46

Continuous positive airway pressure (CPAP) for HF

Answer 46

Improves cardiac output and ejection fraction; decreases afterload and preload, BP, and dysrhythmias

Question 47

Cardiac resynchronization therapy for HF

Answer 47

Permanent pacemaker alone or with an implantable cardioverter/defibrillator; causes more synchronous ventricular contractions to improve EF, CO, and MAP; Indicated for pt with EF of less than 35%

Question 48

Heart transplantation for HF

Answer 48

Ultimate choice for end-stage HF

Question 49

Ventricular assist devices (VAD) for HF

Answer 49

Mechanical pump is implanted to work with the pts own heart; used short term while awaiting heart transplantation or long term;

Question 50

Heart reduction surgery/Partial left ventriculectomy (PLV) for HF

Answer 50

Removal of triangle-shaped section of the weakened heart in the left lateral ventricle to reduce the ventricle's diameter and decrease wall tension

Question 51

Endoventricular circular patch cardioplasty for HF

Answer 51

Removal of portions of the cardiac septum and left ventricular wall and graft a circular patch into the opening; provides a more normal shape to the left ventricle to improve the hearts EF and CO

Question 52

Acorn cardiac support device for HF

Answer 52

Polyester mesh jacket that is placed over the ventricles to provide support and avoid overstretching the myocardial muscle

Question 53

Myosplint for HF

Answer 53

Electrical stimulation of several tension pads on the outside of the ventricle changes it to a more normal shape to improve function

Question 54

Decreasing fatigue and weakness interventions for HF

Answer 54

Physical and emotional rest for energy management; up in chair on hospital day 1, ambulation day 2 (check BP, pulse, and O2 sat before and after); activity intolerance includes dyspnea, fatigue, chest pain, and BP or HR change of more than 20; if pt rates exertion more than 12 (1-20 scale) have pt slow down; PT steadily increases until pt is ambulating 200-400 ft several times/day

Question 55

Prevention/Management of pulmonary edema interventions for HF

Answer 55

Monitor for acute pulmonary edema; often admitted to CCU; administer NTG if systolic BP>100 to decrease afterload and preload; Give Lasix IVP over 1-2 minutes; if pt BP is stable, IV morphine may be prescribed to reduce venous return, decrease anxiety, and reduce work of breathing; monitor RR and BP

Question 56

S/S of Pulmonary edema

Answer 56

Crackles, dyspnea at rest, disorientation, acute confusion, tachycardia, hypertension or hypotension, reduced urinary output, cough with frothy pink-tinged sputum, premature ventricular contractions and other dysrhythmias, anxiety, restlessness, lethargy

Question 57

Activity patient teaching for HF

Answer 57

Lifestyle adjustments (dietary, activity, drug therapy); verbalize fears and concerns; assist in exploring coping skills; health teaching; activity schedule; regular exercise regimen; not to overdo it; if chest pain and dyspnea develop during exercise, slow down; keep diary of time and duration of each exercise session, and HR and symptoms that occur

Question 58

Indications of worsening or recurrent HF

Answer 58

rapid weight gain (3 lbs in 1 wk or 1-2 lbs overnight), decrease in exercise tolerance lasting 2-3 days; cold symptoms lasting more than 3-5 days; excessive nighttime urination; dyspnea or angina at rest or worsening angina; increased swelling in the feet, ankles, or hands

Question 59

Drug therapy teaching for HF

Answer 59

Provide variety of methods of instruction; teach how to count pulse; take diuretics in the morning; weight each day at same time; if taking ACEIs or ARBs move slowly when changing positions; report dizziness, light-headedness, and cough; Monitor serum K and renal function every few months for diuretics and ACEIs or ARBs; teach K rich foods

Question 60

Nutrition therapy teaching for HF

Answer 60

Sodium restriction (3 g for mild-mod, 2 g for severe)

Question 61

Collaboration for HF

Answer 61

Case management, physical therapy, occupational therapy, cardiac rehab

Question 62

Flow of electricity in the heart

Answer 62

SA node - AV node - Ventricles

Question 63

Premature ventricular contractions (PVCs)

Answer 63

Do not need intervention unless it progresses

Question 64

Ventricular tachycardia (V-tach)

Answer 64

Check pulse; call code; shockable; epinephrine

Question 65

Asystole

Answer 65

Assess pt; start CPR; un-shockable

Question 66

Sinus bradycardia

Answer 66

Check if pt is symptomatic; get fluid on board; administer atropine

Question 67

Ventricular fibrillation (V-fib)

Answer 67

Assess pt; call code; shockable

Question 68

Premature atrial contractions (PACs)

Answer 68

(look this up)

Question 69

Cardiac output

Answer 69

Volume of blood pumped per minute by each ventricle of the heart; equal to the stroke volume (SV) x HR

Question 70

Stroke volume

Answer 70

Volume of blood pumped from each ventricle in a single heartbeat

Question 71

Ejection fraction

Answer 71

Amount of blood in the heart compared to the amount of blood pumped out; should be between 50-70%; less than 40% is considered reduced

Question 72

Paroxysmal nocturnal dyspnea interventions

Answer 72

Check on pt several hrs after bed and assist the pt to sit upright and dangle feet when dyspnea occurs