Heart Failure

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Heart Failure

• CHAPTER 34

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Heart Failure Pg 516

• Inability of heart to pump enough blood to meet
  metabolic needs
• Term congestive heart failure describes
  accumulation of blood and fluid within organs and
  tissues due to impaired circulation

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Heart Failure

• Because the heart is a double pump, it is
  possible to have either side fail
• Left sided-left ventricle-usually acute
• Right sided-right ventricle-usually chronic

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Pathophysiology Pg 518

• Regardless of the etiology, when one of the
  ventricles fails to pump effectively, the amount
  of blood entering the atria remains the same but
  ventriclular output is diminished.
• Vascular system becomes overloaded with fluid and
  cardiac output is reduced

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Heart Failure

• When cardiac output is low, the sympathetic
  nervous system raises heart rate and increases
  the force of myocardial contraction to try to get
  more blood into circulation
• This increases oxygen demand (the amt of O2 the
  heart itself needs to perform its work) and makes
  the condition worse
• Blood vessels constrict to raise BP and this
  makes it harder for the heart to pump

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Heart Failure S/S
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Compensatory Mechanisms

• Renin is released by the kidney and activates
  angiotensin which causes vasoconstriction and
  increased BP
• Angiotensin stimulates adrenal gland to secrete
  aldosterone which causes Na and water to be
  retained. This makes it worse as the heart has to
  pump more blood

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Pathophysiology Pg 518

• As cardiac output falls, cells deprived of oxygen
  switch from aerobic metabolism to anaerobic which
  will cause lactic acid and eventually metabolic
  acidosis. ?

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Left Sided Heart Failure Pg 518

• Produces respiratory distress
• If not controlled, pulmonary edema results
• Fluid accumulate in lungs when left ventricle
  fails, creating congestion in the pulmonary
  vascular bed (capillaries surrounding the alveoli
  of lungs)
• Fluid escapes from pulmonary capillaries into the
  alveoli, impairing gas exchange, waste products
  accumulate in the blood. The Pt then becomes
  hypoxic ( a state of insufficient O2 within the
  body)

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Pulmonary Edema

• Wing Pattern on X-Ray

• normal PE

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Pathophysiology

• High BP 2? arteriosclerosis atherosclerosis.
• Scar formation post MI
• Hypervolemia r/t renal failure or rapid infusion
  of IV fluids
• Prolonged cardiac infections or inflammatory
  heart conditions
• Tachycardia r/t hyperthyroidism hypoxemia

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Signs and Symptoms

• Unusual fatigue during activity
• exertional dyspnea (effort to breath when active)
  is 1st symptom
• Orthopnea (inability to breathe unless sitting
  upright)
• Paroxysmal nocturnal dyspnea (awakened by
  breathlessness)--use several pillows or sleep in
  recliner

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Signs and Symptoms

• Rapid or irregular pulse
• Unless cardiac output is extremely low, the BP is
  high
• Cough, hemoptysis (blood streaked sputum)
• Moist crackles
• Ua output is diminished
• Restlessness and confusion accompany severe
  hypooxia

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Left Ventricular Failure Table 34-2 Pg 519

• Fatigue
• paroxysmal nocturnal dyspnea
• orthopnea, hypoxia
• crackles, cyanosis
• S3 heart sound
• cough with pink frothy sputum
• elevated pulmonary capillary wedge pressure

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Right-sided Heart Failure pg 518

• When the right pump fails, there is congestion of
  blood within the venous vascular system.
• The major cause is left-sided failure.

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Right Sided Patho

• MI that affect the Rt Ventricle can also cause
  Right ventricular failure.
• Pts with chronic respiratory disorders tend to
  develop right-sided failure first due to cor
  pulmonale. ?

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Patho

• Cor pulmonaleheart (cor) is affected by lung
  damage (pulmonale).
• Pulmonary disease impairs oxygen-CO2 exchange in
  alveoli leading to ? CO2 in the blood.
• Pulmonary arterial vasoconstriction occurs

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Patho

• Prolonged pulmonary arterial vasoconstriction
  causes pulmonary hypertension (? pressure in the
  pulmonary arterial system)
• Right ventricle forced to pump against high
  pressures and failure occurs

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Patho

• When the right ventricle fails to empty
  completely, blood is trapped in the venous
  vascular system.
• Eventually, the fluid is forced to move into the
  cells interstitial spaces of other organs
  tissues of the body.

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Signs and Symptoms

• Gradual unexplained weight gain due to fluid
  retention
• Dependent pitting edema in feet and ankles,sacral
  area
• Distended abdomen( ascites), liver enlarged
  (hepatomegaly)
• Jugular vein distention
• Dyspnea, anorexia, nausea, flatulence

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Rt sided S/S Table 34-2 pg 519

• Weakness
• ascites
• weight gain
• nausea, vomiting
• arrhythmias
• elevated central venous pressure
• jugular vein distention

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Medical Treatment of Both Rt Lt Heart
Failure

• Reduce workload of the heart
• low na diet, fluids may be restricted
• sedatives or tranquilizers to relieve anxiety and
  dyspnea

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Significance of BNP Levels

• Box 34-2
• BNP brain natriuretic peptidethis protein is
  stored primarily in the ventricular myocardium.
  BNP is released when ventricular diastolic
  pressure rises. BNP levels are elevated in
  ventricular hypertrophy, severe HTN, and CHF
• gt 100 suggests HF is present

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MUGA pg. 520

• MUGA multigated acquisition scan measures a
  decrease in the ejection fraction. A MUGA is
  more accurate than an echocardiogram for
  measuring HF.

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Drug Therapy Pg 522

• Drugs in table 34-2 pg 522 look at on your own.
• Because poor circulated blood leads to the
  formation of thrombi and emboli, a daily aspirin,
  dipyridamole (Persantine), or an oral
  anticoagulant is prescribed.

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Intra-aortic balloon Pump

• If acute left ventricular failure amd cardiogenic
  shock a balloon pump is inserted into left
  femoral and threaded up to descending aortic
  arch.
• Connected to a machine that is synchronized with
  ventricular contraction.
• Balloon inflates during diastole and deflates
  during systole so supplements the contraction

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Intra-aortic Balloon Pump
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Surgical management

• Adults ? 55 yrs of age are candidates for a heart
  transplant when medical treatment is
  unsuccessful.

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Nursing Care PG 525

• Give meds with caution as dangerous
• digitalis given in large amounts when beginning
  tx (digitalization) and then maintenance dosage
  given
• Monitor heart rate and report signs of
  toxicity--loss of appetite, N/V,rapid, slow or
  irregular heart rate or sudden disturbances of
  color vision

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Nursing Management

• Monitor electrolytes, especially with diuretics.
• Hypokalemia increases risk for digitalis toxicity
• Monitor magnesium levels as low magnesium can
  cause arrhythmias

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Assessment

• Assess for dyspnea, moist lung sounds,
  tachycardia, hypotension, distended neck veins,
  peripheral edema, reduced urine output, lethargy
  and confusion

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Important Information

• Nursing Interventions page 526 527

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Potassium Foods

• Important to monitor potassium levels if on
  diuretics.
• See Box 34-3 on pg 527 Potassium-Rich Foods

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Pulmonary Edema Pg 527

• Is the fluid accumulation in the lungs that
  interferes with gas exchange in the alveoli.
• Pulmonary edema represents an acute emergency.

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Pulmonary Edema

• Cardiac arrhythmias cardiac or respiratory
  arrest are complications of pulmonary edema.

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Pathophysiology

• Is a complication of left ventricular failure.
• Noncardiogenic pulmonary edema, sometimes
  referred to as adult respiratory distress
  syndrome (ARDS), also occurs when there is an
  alteration in the pulmonary capillary membrane
  from a pulmonary embolism, infections, or blast
  injuries.

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Pathophysiology

• When the etiology is cardiogenic, the left
  ventricle becomes incapable of maintaining
  sufficient output of blood with each contraction.
• The right ventricle, however, continues to pump
  blood toward the lungs.
• The pulmonary capillaries the alveoli become
  engorged with blood.

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Pathophysiology

• The lungs can rapidly fill with fluid, and acute
  respiratory distress develops.
• As CO2 accumulates, respiratory rate depth
  increase.
• Without treatment, hyperventilation becomes
  insufficient in preventing respiratory acidosis,
  which is then followed by metabolic acidosis.

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Signs Symptoms

• Sudden dyspnea, wheezing, orthopnea,
  restlessness, cough (pink, frothy sputum),
  cyanosis, tachycardia and severe apprehension
• Respirations sound moist or gurgling, cardiac
  output is decreased and wedge pressures increased

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Signs Symptoms

• While the body responds with arterial
  vasoconstriction, an adequate BP may be
  temporarily sustained however, the client
  eventually becomes hypotensive peripheral
  pulses disappear.

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Medical Management pg 528

• Every effort is made to relieve lung congestion
  as quickly as possible because pulmonary edema
  can be fatal.
• Meds that improve myocardial contractility and
  decrease preload.
• Supplemental O2 or mechanical ventilation

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Drug Therapy

• Inotropic agents, such as Dobutamine or digitalis
  given to improve force of contractions
• To ? myocardial O2 consumption, drugs that ?
  venous return to the heart (diuretics)
• Those that promote vasodilation, (nitrates or
  calcium channel blockers) are ordered.

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Drug Therapy

• Morphine relieves anxiety and slows the
  respiratory rate.
• Morphine also promotes muscle relaxation
  reduces the work of breathing.
• Oxygen to facilitate gas exchange

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Nursing Management pg 528

• IV line stat
• O2 pulse oximeter to measure oxygenation.
• Suction airway prn
• Assess HR, rhythm, BP frequently.
• Foley for strict IO

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FYI Terms To Remember

• Inotrope a substance which affects myocardial
  contractility
• A Positive inotrope ? force of contraction
• A negative inotrope ? force of contraction
• Chronotrope a substance which affects the HR
• A Positive chronotrope ? heart rate
• A Negative chronotrope ? heart rate

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FYI Terms

• Preloadthe pressure/volume in the left ventricle
  at the end of diastole.
• Afterloadthe pressure or resistance against
  which the heart must pump
• Agonista drug or substance that produces a
  predictable response (stimulates action)
• Antagonistan agent that exerts an opposite
  action to another (blocks actions)

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Your Thinking like A Nurse!!!