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Heart Failure
Inability of heart to pump blood out as rapidly as it enters Often referred to as congestive heart failure (CHF)

Heart Failure
Also called pump failure Left-sided heart failure Right-sided heart failure High-output failure

Pathophysiology

Congestive Heart Failure

Congestion of pulmonary or systemic circulation (backward failure) Reduced output to body tissues (forward failure

Etiology
Heart failure is caused by systemic hypertension in 75% of cases. About one third of clients experiencing myocardial infarction also develop heart failure. Structural heart changes, such as valvular dysfunction, cause pressure or volume overload on the heart.

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Etiology
A syndrome of Pulmonary and/ or Systemic congestion due to C.O Heart is unable to pump enough blood to meet tissues O2 requirements Pulmonary pressure fluid in alveoli (PULMONARY EDEMA) Systemic pressure fluid in tissues (PERIPHERAL EDEMA)
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Causes
Diffuse coronary artery disease Myocardial ischemia Myocardial infarction Valvular heart disease Acute Hypertensive Crisis Chronic Hypertension Idiopathic Causes
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Compensatory Mechanisms
Sympathetic nervous system stimulation Renin-angiotensin system activation Myocardial hypertrophy

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Location
Heart failure classified according to location of ventricular failure One ventricle may fail independently of another, but failure in one will impact on the other.

L sided failure- pulmonary congestion R sided failure- peripheral congestion

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Right-sided Heart Failure

Right ventricle fails as effective pump Right ventricle cannot eject blood returning through vena cava Blood backs up into systemic circulation Increased pressure in systemic capillaries forces fluid out of capillaries into interstitial spaces Tissue edema occurs
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Right Heart Failure Causes

Left sided Heart Failure Chronic hypertension COPD Pulmonary embolism Right ventricular infarction

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Right-Sided Heart Failure

Manifestations include:
Distended neck veins, increased abdominal girth Hepatomegaly (liver engorgement) Hepatojugular reflux Ascites Dependent edema Weight: the most reliable indicator of fluid gain or loss
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(R) SIDED HF
Blood BACKS UP into venous circulation. High oncotic pressure pushes fluids into tissues. CLINICAL SIGNS: CVP SUDDEN WT. GAIN JVD DEPENDENT EDEMA FATIGUE LIVER CONGESTION LETHARGY ASCITES ORTHOPNEA ANOREXIA
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Assessments
Laboratory assessment- electrolytes Radiographic assessment Electrocardiography Echocardiography Pulmonary artery catheters
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Nursing Assessments
O2 Saturation Vital Signs Heart Rhythm Lung Sounds Level of dyspnea Serum Electrolytes Daily weights Changes in LOC I & O Coping ability of pt and family Signs of drug toxicity
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GOAL
Nursing Dx Enhance O2 supply Work of heart by promoting contractility Interventions: 1. Adequate ventilation 2. Maintain cardiac function 3. Promote rest 4. Medication
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Nursing Intervention
1. ADEQUATE VENTILATION Monitor respirations, breath sounds Administer O2 Position- high-Fowlers

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Nursing Intervention
2. MAINTAIN CARDIAC FUNCTION Monitor heart sounds Pulmonary Artery Catheter Measurements CVP Pulmonary Artery Pressure Pulmonary Capillary Wedge Pressure

Cardiac Output
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Nursing Intervention
3. Promote rest until patient is stable strain on heart BR promotes cardiac efficiency Elevate legs to enhance venous return

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Nursing Intervention
4. OTHERS Monitor LOC Assess edema Provide adequate nutrition Provide emotional support Maintain diet restrictions as prescribed (Na and fluid)
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Nursing Intervention
5. Medication Improve myocardial muscle function Restore C.O. & SV Reduce cardiac demands

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Medications
Fluid load, Preload, Afterload
ACE inhibitors & Diuretics

Improve contractility Digoxin

Dobutamine Workload of the heart

Blockers
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Drugs That Enhance Contractility

Digitalis
Digitalis toxicity includes anorexia, fatigue, muscle weakness, changes in mental status. Monitor heart rate for 1 full minute. Hold for <60 Monitor electrolytes Take same time each day

Other inotropic drugs including dobutamine, dopamine Beta-adrenergic blockers

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Improve contractility Inotropic agents

Digoxin: cardiac glycoside force of myocardial contraction & slows HR ( C.O. venous pressure, diuresis) Narrow therapeutic range:
Monitor for toxicity
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AFTER LOAD REDUCING AGENTS

ACE inhibitors-enalapril (Vasotec) captopril (Capoten) Beta-blockers- carvedilol (Coreg) metoprolol (Lopressor XL) Angiotensin receptor II blockers losartan (Cozaar) Nitrates- preload and afterload
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Diuretic Therapy
Increases excretion of Na+/H2O/K Sites of action differ Result in varying degrees of lyte imbalance Categories: Loop, Thiazide, K+-sparing
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Nursing Interventions
DIURETIC THERAPY- give early in day Monitor WT. Assess for edema Strict I&O Monitor electrolytes Nutrition = Low Na+ diet, K + supplements
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Loop Diuretics
MORE POTENT ACTION furosemide (LASIX) bumetamide (BUMEX) PO/ IV

ACTION: at loop of Henle, K+ loss, Na+/Clexcretion ADVERSE EFFECTS: orthostatic hypotension, may digitalis toxicity, hypokalemia Health Teaching: K rich foods, oral K, S&S hypokalemia
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Thiazide Diuretics
Useful for maintenance HCTZ (Hydrochlorothiazide) Action: excretion of Na+/Cl- & H2O Adverse effects: orthostatic hypotension, may digitalis toxicity
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+ K

Sparing Diuretics

Maintenance therapy conserves K+, has a gradual diuretic effect Spironolactone (Aldactone) Action: blocks reabsorption of Na+/ClAdverse effects: Hyperkalemia
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Left-Sided Heart Failure

Left ventricle fails as effective pump Left ventricle cannot eject blood delivered from right heart through pulmonary circulation Blood backs up into pulmonary circulation Left-Sided Heart Failure Increase pressure in pulmonary capillaries forces blood serum out of capillaries into interstitial spaces and alveoli Increase respiratory work and decrease gas exchange occur
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Left-Sided Heart Failure

Manifestations include:
Weakness Fatigue Dizziness Confusion Pulmonary congestion Shortness of breath Oliguria Organ failure, especially renal failure Death

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Pulmonary Edema
Rapid fluid accumulation in lung spaces that has leaked from engorged pulmonary capillaries Etiology most common cause is sudden deterioration of LV function

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Potential for Acute Pulmonary Edema due to Left Sided HF

Interventions include:
Assess for early signs, such as crackles in the lung bases, dyspnea at rest, tachycardia, disorientation, and confusion. Rapid-acting diuretics are prescribed, such as Lasix or Bumex. IV morphine sulfate Oxygen and/or intubation Strictly monitor fluid intake and output. 40

(L) SIDED HF
Tissue hypoxia occurs because heart is unable to efficiently pump blood CLINICAL SIGNS of pulmonary congestion: Dyspnea Orthopnea Cough WT. gain Fatigue Anxiety/ restless

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Crackles Cardiomegaly HR BP

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Nursing Interventions
Administer O2 to relieve hypoxia & dyspnea CPAP Assess breath sounds and monitor respirations Pulmonary Artery Catheter Hi fowlers position Urinary catheterization

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Aminophylline
Bronchodilator given to relieve wheeze/ bronchospasms that may occur

Monitor closely for adverse effects: GI upset, nervousness, HR, H/A, tremors

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Cardiogenic Shock
Occurs with extensive LV injury perfusion to vital organs Degree of shock, directly relates to level of ventricular failure Diminished cardiac output leading to impaired tissue perfusion. Most extreme form of pump failure
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Cardiogenic Shock
Significant reduction in SV & CO causes drop in pressure & poor tissue perfusion a/r/o LV MI Clinical signs: BP, pulse, peripheral pulses confusion/ agitation (cerebral hypoxia) cold/ clammy skin urine output Resp distress Chest pain
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Treatment
Hemodynamic monitoring Reduce demand on the heart Improve oxygenation Improve tissue perfusion Intra-aortic balloon pump Inotropic Meds to BP, workload Correct underlying pathophysiology
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Laboratory Tests
CBC (Complete Blood Count) This test measures the quality and number of red blood cells, white blood cells, hemoglobin (the oxygen carrier), and platelets in your blood. A CBC test can diagnose anemia, which may be a marker of advanced heart failure.
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Normal CBC Test Results Normal Range

White Blood Cell- 4,500 to 11,000 per mcL3 or 4.5 to 11.0 x 109 per L Red Blood Cell- 5.4 million per mcL3 or 4.2 to 5.4 x 1012 per L Hematocrit- 37% to 47% or 0.37 to 0.47 volume fractionHemoglobin-12 to 16 g/dL or 7.4 to 9.9 mmol/L

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Serum Electrolytes
This test measures the amount of different electrolytes (molecules that carry an electric charge) in the blood, including sodium, potassium, chlorate, and bicarbonate. Abnormal levels of electrolytes can be caused by heart failure, kidney problems, or other conditions.
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Kidney and Liver Function Tests

A BUN (Blood Urea Nitrogen) test is used to determine how well the kidneys are working by measuring the amount of urea nitrogen in the blood. Blood urea nitrogen is a waste product that is filtered out of the blood by the kidneys: high levels of BUN indicate the kidneys are not working properly. An BUN level of more than 21 mg/dL is considered elevated, although the exact cutoff varies between laboratories.
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 This can be caused by heart failure when the heart is not strong enough to pump sufficient blood to the kidneys, or by dehydration (caused by too much diuretic medication). A serum creatinine test measures the amount of creatinine in the blood, another waste product that is filtered out of the blood by the kidneys.

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 High levels of creatinine in the blood may be a sign of kidney problems resulting in fluid buildup. Normal value ranges from 0.5 to 1.1 mg/dL (milligrams per deciliter) or 44 to 97 mcmol/L (micromoles per liter).
Liver function tests measure the levels of enzymes produced by the liver. They are used to check how well the liver is working. In heart failure enzyme levels may be high if fluid is backing up into your liver.
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BNP Test
This test measures the amount of BNP (B-type natriuretic peptides) in your blood. BNP are proteins released by the overworked heart into the bloodstream when the heart cells stretch in response to added strain. High levels of BNP may be a sign of heart failure.

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 A BNP test is useful for diagnosing or ruling out heart failure in patients with shortness of breath. It is also used to assess the effectiveness of heart failure therapy: if BNP levels drop, it means the treatment is working. The BNP test should not be used as the only test to confirm or rule out heart failure.

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Lipid Panel (Cholesterol Tests)

A Lipid Panel measures the fatty substances (lipids) in your blood, including your total cholesterol, LDL (bad) cholesterol, HDL (good) cholesterol, and triglyceride levels. Excess cholesterol that circulates in the blood can stick to the walls of arteries. Over time, this fatty plaque buildup narrows the arteries, causing coronary artery disease, a major risk factor for heart failure.
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Urinalysis
This test examines how well kidneys are working by measuring any physical or chemical changes in urine, such as color, clarity, and the presence of certain compounds. Kidneys filter your blood and get rid of the waste and extra water as urine, so urine from normal kidneys should not include protein, sugar, blood cells, or bacteria or other parasites.
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 Poor kidney function may be caused by a lack of blood supply to the kidneys caused by heart failure, and your kidney function can affect your heart failure symptoms and how your body regulates your blood pressure and responds to certain medications

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Angioplasty
Also known as Percutaneous Coronary Interventions [PCI], Balloon Angioplasty and Coronary Artery Balloon Dilation. What the Procedure Does Special tubing with an attached deflated balloon is threaded up to the coronary arteries. The balloon Is inflated to widen blocked areas where blood flow to the heart muscle has been reduced or cutoff.
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 Often combined with implantation of a stent to help prop the artery open and decrease the chance of another blockage. Considered less invasive because the body is not cut open. Lasts from 30 minutes to several hours. Often requires an overnight hospital stay.

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 Reason for the Procedure Greatly increases blood flow through the blocked artery. Decreases chest pain (angina). Increases ability for physical activity. Reduces risk of a heart attack. Can also be used to open neck and brain arteries to help prevent stroke.
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Bypass Surgery
(Also known as CABG or "cabbage," Coronary Artery Bypass Graft and Open-Heart Surgery) What the Procedure Does Treats blocked heart arteries by creating new passages for blood to flow to your heart muscle. It works by taking arteries or veins from other parts of your body called grafts and using them to reroute the blood around the clogged artery
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A patient may undergo one, two, three or more bypass grafts, depending on how many coronary arteries are blocked. Requires several days in the hospital.

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 Reason for the Procedure One of the most common and effective procedures to manage blockage of blood to the heart muscle. Improves the supply of blood and oxygen to the heart. Relieves chest pain (angina). Reduces risk of heart attack. Improves ability for physical activity.
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Artificial Heart Valve Surgery

(Also known as Heart Valve Replacement Surgery) What the Procedure Does Replaces an abnormal or diseased heart valve with a healthy one. Reason for the Procedure Restores function of the heart valves.
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Stent Procedure
What the Procedure Does A stent is a wire mesh tube used to prop open an artery during angioplasty (View an animation of a stent). The stent stays in the artery permanently. Reason for the Procedure Holds the artery open. Improves blood flow to the heart muscle. Relieves chest pain (angina).
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Heart Transplant
What the Procedure Does Removes a diseased heart and replaces it with a healthy human heart when a heart is irreversibly damaged. Uses hearts from organ donation. Reason for the Procedure Recognized as a proven procedure to restore heart health in appropriately selected patients
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Health Teachings
In order to prevent the progression of this disease, your patient must follow his/her doctor's advice and make necessary lifestyle changes such as: Stop Smoking Smoking is directly related to an increased risk of heart attack and its complications.
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 Lower high blood cholesterol A high-fat diet can contribute to increased fat in the blood. Follow a low-fat, low-cholesterol eating plan. When proper eating does not control cholesterol levels, medication is prescribed. Control high blood pressure High blood pressure can damage the lining of your coronary arteries and lead to coronary artery disease. A healthy diet, exercise, medications and controlling sodium in the diet can help control high blood pressure.
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 Maintain tight diabetes control If the patient has diabetes, it is important to control high blood sugar through diet, exercise, and medications. Follow a regular exercise plan A regular exercise program helps to regain or maintain energy level, lower cholesterol, manage weight, control diabetes and relieve stress. Check with a doctor first before beginning an exercise program.
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 Achieve and maintain your ideal body weight When patient is overweight, the heart has to do more work, and he/she is at increased risk of high blood pressure, high cholesterol levels and diabetes. A healthy diet and exercise program aimed at weight loss can help improve his/her health.

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 Control Stress and Anger Uncontrolled stress or anger is linked to increased coronary artery disease risk. Learn skills such as time management, relaxation, or yoga to help lower your stress levels.

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Question
The nurse is awaiting the arrival of a client from the ER who is being admitted with a LVMI. The nurse should be alert for which S&S of left-sided heart failure? A. Jugular vein distention B. Hepatomegaly C. Dyspnea D. Crackles E. Tachycardia
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Question
Harvey is a 76-year-old man being followed up by his nurse practitioner for congestive heart failure (CHF). Which assessment finding would be typically found in an older adult? A. Orthostatic hypotension in conjunction with drug therapy for CHF B. Clearing of crackles immediately after medication treatment C. Auscultation of crackles D. Digitalis toxicity
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Question
Carlos is prescribed digoxin after having open heart surgery and postoperative atrial fibrillation. Which statement, if made by the client, demonstrates the need for further teaching regarding his digoxin medication? A. I should notify my doctor if my pulse is less than 60 or more than 100 beats/min. B. I need to keep my laboratory appointments. C. I should not take my digoxin at the same time as antacids or laxatives. D. If I forget to take my digoxin one day, I can double up on the dose the next day 75

Question
Mrs. Clark is an 83-year-old woman admitted with symptoms of heart failure. Her nurse, after performing the assessment, tries to decipher between right- and left-sided heart failure. Which symptoms below are consistent with left-sided heart failure? A.Weight gain, jugular distention, and distended abdomen B.Fatigue, weakness, and palpitations C.Agitation, blood tinged, frothy sputum, dyspnea D.Anorexia and nausea, distended abdomen, and enlarged liver
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