Handout - Cardiac - Heart Failure (3)-1.rtf - 1 Cardiac...

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Unformatted text preview: 1 Cardiac: Heart Failure (HF) Nursing 2106 – Adult I Heart Failure (HF): • General term for cardiac dysfunction that results in the…. –Inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients • Complaints of reduced exercise tolerance, dyspnea, fatigue, fluid retention, diminished quality of life, shortened life expectancy Prevalence & Outcomes: • 5.1 Million Americans –AHA estimates 600,000 new cases each year –10 in every 1000 older adults –Most common reason for hospital admission in adults older than 65 years –2nd most common reason for visit to physician's office • Outcomes –Mortality 56% - 69% at 5 years –“Worse than some forms of cancer” Causes & Manifestations of HF: Heart Failure: Etiology and Pathophysiology: • • Primary risk factors: –Coronary artery disease (CAD) –Advancing age Contributing risk factors: –Hypertension –Diabetes –Tobacco use –Obesity –High serum cholesterol Cultural and Ethnic Health Disparities : • African Americans have a higher incidence of HF, develop HF at an earlier age, and experience higher mortality rates related to HF than whites. • African Americans experience more ACE inhibitor-related angioedema than whites. • Isosorbide dinitrate and hydralazine (BiDil) are used for the treatment of HF in African Americans; this copackaged drug is only approved for use in this ethnic group. • Asians have an extremely high risk (50%) for ACE inhibitor-related cough. 2 Ejection Fraction (EF): • The percentage of total ventricular filling volume that is ejected during each ventricular contraction • Normal = 60 - 70% of ventricular volume Systolic Heart Failure: • Inability of the heart to pump… –Impaired ventricular contraction (MI) –Increased afterload (hypertension, cardiomyopathy, valvular heart disease • Hallmark EF < 40% • LV becomes dilated and hypertrophied Diastolic Heart Failure: • Inability of the ventricles to relax and fill during diastole –Stiff or noncompliant ventricles –Chronic hypertension, aortic stenosis, hypertrophic cardiomyopathy –Normal EF • More common in older adults, women, obesity • Can occur singly or with systolic HF Mixed Systolic and Diastolic Failure: • Seen in dilated cardiomyopathy • Usually extremely low EF –< 35% • Biventricular failure • Poor filling and emptying capacity • High pulmonary pressures Isolated RV Diastolic Failure: • Less common • May be caused by pulmonary disease, or RV infarction (MI) • Causes ↓ RV emptying, resulting in a low LV filling pressure and ↓ CO Regardless of type of HF… • Low systemic arterial BP • Low CO • Poor renal perfusion • Poor exercise tolerance • Ventricular dysrhythmias So, the body must try to compensate for the ↓ CO… • Sympathetic nervous system activation • Neurohormonal responses • Ventricular dilation • Ventricular hypertrophy Cardiac Output: 3 • • • CO = HR X SV Factor for heart rate –Autonomic nervous system Factors for stroke volume (SV) –Preload –Afterload –Contractility Sympathetic Nervous System: • First mechanism triggered • Least effective • SNS activation ↑ catecholamines (epinephrine and norepinephrine) ↑ HR, ↑ myocardial contractility, and peripheral vasoconstriction – This initially increase CO – However, over time makes things worse need for more myocardium oxygen (increases workload of the heart) Neurohormonal Response: • ↓ Blood flow to the kidneys causing activation of the RAAS – Vasoconstriction – Sodium and water retention • ↓ Cerebral perfusion posterior pituitary secretes antidiuretic hormone (ADH) – Water retention • ↑ Endothelin – Vasoconstriction • Pro-inflammatory cytokines released by cardiac myocytes (TNF and IL-1) – Cardiac hypertrophy, contractile dysfunction, and myocyte cell death Ventricular Dilation: • Dilation is an enlargement of the chambers of the heart… –Muscle fibers stretched in response to the volume of blood in the heart at the end of diastole –Initially helps ↑ CO, but…Frank- Starling law Ventricular Hypertrophy: • An increase in the muscle mass and cardiac wall thickness in response to overwork and strain –Occurs slowly over time –Usually follows chronic dilation • Initially helps to ↑ CO, CO, but… Counterregulatory Mechanisms: • Natriuretic peptides –ANP –BNP • Nitric oxide (NO) Cardiac Compensation vs. Decompensation: • Compensation 4 –Compensatory mechanisms succeed in maintaining and adequate CO • Decompensation –Compensatory mechanisms can no longer maintain adequate CO and inadequate tissue perfusion results Types of Heart Failure: • Systolic or diastolic • Left or right • Acute or chronic Left-Sided Heart Failure: • Most common form of HF • Results from LV dysfunction prevents normal blood flow … –Backs up to left atrium pulmonary veins pulmonary capillary bed lung interstitium, then alveoli • Manifests as pulmonary congestion and edema Right-Sided Heart Failure: • Causes backup of blood into the right atrium and venous circulation • JVD, hepatomegaly, splenomegaly, vascular congestion of GI tract, peripheral edema • Primary cause: Left-sided failure • Other causes: Cor pulmonale, right ventricular infarction Diagnostic Findings: • Chest x-ray • Clinical manifestations • BNP • EF Acute Decompensated HF (ADHF): Pulmonary Edema: • Acute, life-threatening • Lung alveoli become filled with serosanguineous fluid • Most common cause: LV failure secondary to CAD • Early clinical signs: Mild ↑ in RR, ↓ O2, restlessness • Clinical manifestations: – Anxious; pale; possibly cyanotic; skin cold and clammy; severe dyspnea; use of accessory muscles; RR > 30 breaths/minute; orthopnea; may be wheezing and coughing; production of frothy, blood-tinged sputum; crackles, wheezes, and rhonchi; tachycardia; BP may be elevated or decreased; worsening of ABGS ( ↓ O2, ↑ CO2, progressive acidemia); S3 and S4 heart sounds; Clinical Manifestations: • Decreased cerebral oxygenation… –Restless and anxious –As condition worsens confusion, stuporous • “Drowning in own secretions”… –S.O.B. , suffocation • Breathing rapid, noisy, & moist sounding –Hands cold & moist 5 –Nail beds cyanotic; skin ashen (gray) –Incessant coughing (pink frothy sputum) Prevention: • Recognize in the early stages… –Auscultate lung fields & heart sounds –Monitor RR along with other vital signs –Monitor mental status or change in behavior –Monitor pulse ox –Monitor JVD; edema; weight; SOB; fatigue; dry, hacking cough –Decreased activity tolerance may be an early indicator • Early stage… –Place in upright position with feet & legs dependent –Eliminate overexertion & minimize stress –Re-examination of the treatment regimen Medical Management: • Oxygen –To relieve hypoxemia & dyspnea –Could progress to intubation & mechanical ventilation –Monitor pulse oxy and/or ABGS –Also, have patient sit upright • Morphine –IV in small doses 2 – 5 mg –Direct arteriolar and venous vasodilation –Reduces anxiety, some sedation –Watch for nausea and vomiting • Diuretics –IV furosemide 40 – 80 mg • Various intravenous medications… –Nitrates (IV, SL, patch) –Sodium nitroprusside IV • Possible thiocyanate toxicity with prolonged use or in renal dysfunction –IV digoxin, dobutamine, dopamine, milrinone, nesiritide Clinical Manifestations: Chronic HF: • Fatigue –Activity intolerance • Dyspnea –PND (paroxysmal nocturnal dyspnea) –Orthopnea –Cough –Crackles • Tachycardia • Edema • Nocturia • Skin changes • Behavioral changes • Chest pain 6 • Weight changes –Fluid retention –Anorexia, nausea (ascites, hepatomegaly, renal failure) • Inadequate tissue perfusion FACES: • F = Fatigue • A = limitation of Activities • C = Congestion/cough • E = Edema • S = Shortness of breath Edema: • Dependent body (peripheral edema) –Ankles –Sacral and scrotal areas –Pitting edema • Liver (hepatomegaly) • Abdominal cavity (ascites) • Lungs (pulmonary edema and pleural effusion) Exacerbated HF: • Development of dependent edema or a sudden weight gain of 3 lb in 2 days Complications of HF: • Pleural effusion • Dysrhythmias • Left ventricular thrombus • Hepatomegaly • Renal failure • Pulmonary edema Heart Failure: Complications: • Pleural effusion • Atrial fibrillation (most common dysrhythmia) –Loss of the atrial contraction (kick) can reduce CO by 10% to 20% –Promotes thrombus/embolus formation increasing risk for stroke –Treatment may include cardioversion, antidysrhythmics, and/or anticoagulants • High risk of fatal dysrhythmias (e.g., sudden cardiac death, ventricular tachycardia) with HF and an EF <35% • Hepatomegaly –Liver nodules become congested with venous blood leads to impaired liver function –Fibrosis and cirrhosis can develop over time • Renal failure – ↓ Perfusion to the kidneys can lead to insufficiency or failure 7 Heart Failure: Classification Systems : • New York Heart Association (NYHA) Functional Classification of HF –Classes I to IV –Based on the person's tolerance to physical activity • ACC/AHA Stages of HF –Stages A to D –From risk for HF to advanced HF –Disease progression and treatment strategies New York Heart Association (NYHA) Classification of HF: I II III IV ACC/AHA Stages of HF: A B C D Heart Failure: Nursing and Collaborative Management: • Four core measures in the acute management of HF –Joint Commission on Accreditation of Healthcare Organizations (JACHO) Four Core Measures: • Written discharge instructions or educational material must be given to include all of following: –Activity level, diet, discharge medications, follow-up appointment, weight monitoring, and symptom management • LV function must be documented • EF < 40% will be prescribed ACE-I or ARB –As long as no contraindication • Smokers or current smokers in last 12 months smoking cessation advice or counseling during the hospital Acute Decompensated Heart Failure (ADHF): • Covered more in NURS 230 Main Goals for Chronic HF: • Treat underlying cause and contributing factors 8 –Hypertension, CAD, valvular disorders, dysrhythmias • • • • • • Maximize CO Provide treatment to alleviate symptoms Improve ventricular function Improve quality of life Preserve target organ function Improve mortality and morbidity risks Collaborative Care: Chronic HF: • Treatment of underlying cause • Oxygen therapy at 2 – 6 L/min by nasal cannula –Pulse ox and/or ABGs • Rest-activity periods • Drug therapy • Daily weights • Sodium-restricted diet • Possible fluid restriction • Home health nursing care (telehealth monitoring) • Cardiac rehabilitation • Circulatory assist devices (ventricular assist device) • Cardiac resynchronization (biventricular pacing) therapy with internal cardioverter-defibrillator • Cardiac transplantation • Palliative and end-of-life care Drug Therapy: • Refer to handout The nurse should not… • Make a decision to withhold an antihypertensive medication based on a BP reading only!!!! –Written criteria versus no written criteria –How do you tell if the patient has adequate cardiac perfusion or not? –What has been the trend of previous blood pressure readings? –When in doubt, hold the med, and call the physician. DO NOT HOLD AND GO ABOUT YOUR MERRY BUSINESS WITHOUT CALLING THE MD!!!! HF Readmissions to Hospital: • Two most common reasons –Poor adherence to a low-sodium diet –Failure to take prescribed medications IV Continuous Drips: • Formula Nutritional Therapy: 9 • • • • A low-sodium (2.5 grams) –For more severe HF 500mg – 1000 mg Avoid excessive amounts of fluid –Possible fluid restriction –To deal with thirst: Ice chips, gum, hard candy, ice pops –Weigh daily to monitor for fluid retention DASH diet Foods High in Sodium: • Major source salt –¼ tsp of salt 590 mg –¼ tsp of Tony Chachere’s 310 mg • Canned or processed foods –Bacon, hot dogs, ham, sardines –Canned vegetables, soups • Cheese, milk, bread –Slice of bread 110 mg sodium • Baking soda 1/8 tsp 150 mg • Baking powder ¼ tsp 120 mg –Cup of milk 125 mg –Cheese 1 oz 170 mg • Watch over the counter meds & salt substitute • Read food labels for “sodium”… –Sodium alginate (improves food texture) –Sodium benzoate (acts as a preservative) Hyponatremia: • Apprehension, weakness, fatigue, malaise, headache, muscle cramps and twitching; rapid, thready pulse • Lethargic progression to unresponsive –Possible tremors and seizures • Lab value < 135 mEq/L Hypokalemia: • Weak pulse, faint heart sounds, hypotension, muscle flabbiness, diminished deep tendon reflexes, & generalized weakness –EKG shows a flattened T wave, ST-segment depression, and U-wave elevation –Ventricular fibrillation, respiratory paralysis & cardiac arrest • Lab value < 3.5 mEq/L • Digitalis toxicity dangerous dysrhythmias • Low levels can indicate hypomagnesemia adds to the risk for dysrhythmias Hyperkalemia: • Risk of cardiac arrest –EKG shows flattened P waves, a prolonged PR interval, a wide QRS complex, tall tented T waves, and ST-segment depression • Lab value > 5.0 mEq/L 10 • Weakness, malaise, nausea, diarrhea, colicky pain, muscle irritability progressing to flaccid paralysis, oliguria, and bradycardia Foods High in Potassium: • Dried apricots, bananas, beets, figs, orange or tomato juice, peaches, and prunes, potatoes, raisins, spinach, squash, and watermelon • Grapefruit (fresh and juice) is a good source of potassium, but has serious drugfood interactions Nursing Process: • Assessment • Nursing Diagnoses –Decreased cardiac output r/t impaired cardiac function –Activity intolerance r/t imbalance between oxygen supply & demand due to decreased CO –Excess fluid volume r/t excess fluid or sodium intake & retention of fluid due to HF –Decreased cardiac output r/t impaired cardiac function –Impaired gas exchange r/t fluid in alveoli –Anxiety r/t breathlessness & restlessness from inadequate oxygenation –Powerlessness r/t inability to perform role responsibilities due to chronic illness & hospitalizations –Knowledge deficit r/t lack of knowledge regarding treatment plan, medications –Risk of impaired skin integrity r/t decreased activity, edema Nursing Care Plan: • Patient with Heart Failure –NCP 35-1, pp 780 – 781 Nursing Management: • Administer medications & monitor therapeutic and detrimental effects… –I & O –Daily weight (3 lbs over 2 days or a 3 – 5 lb in one week) –Auscultate lung sounds at least daily –Monitor for JVD, dependent edema, & other symptoms of fluid overload –Monitor vital signs, signs of dehydration, activity tolerance • Monitor and manage complications… • Hypokalemia or hyperkalemia –Hypomagnesemia and hyponatremia –Monitor for digitalis toxicity • Teaching • Reduction of anxiety Teaching: • Medications –Counting pulse • • • Maintain low-sodium diet Perform & record daily weights Engage in routine physical activity 11 –Balance with rest periods –Watch for orthostatic hypotension • • • • • • Recognize symptoms that indicate worsening HF Sign & symptoms of hypokalemia and hyperkalemia –Foods high in potassium Avoid excess fluids Preventing infection with influenza & pneumococcal immunizations Relaxation techniques Avoid tobacco and Keep appointments with doctor When to Call the Doctor: • Weight gain… –2-3 lbs in one day or 5 lbs in one week • Loss of appetite • Unusual SOB with activity • Swelling of ankles, feet, or abdomen • Persistent cough • Development of restless sleep –Increase in # pillows used –Having to sit up to sleep Case Study: Ongoing Research: 12 Questions? 10/10/14; 10/16. BN ...
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