Heart Failure Cardiomyopathy

Key points Heart failure is the inability of the heart to maintain adequate circulation to meet tissue needs for oxygen and nutrients. Heart failure occurs when the heart muscle is unable to pump effectively, leading to: inadequate cardiac output, myocardial hypertrophy, and pulmonary/systemic congestion. Heart failure is the result of an acute or chronic cardiopulmonary problem, such as systemic HTN,MI, pulmonary HTN, dysrhythmias, valvular heart disease, pericarditis, and cardiomyopathy.

Key points Severity of heart failure is classified according to indicating how little, or how much, activity it takes to make the client symptomatic (chest pain, shortness-of-breath). Class I: Client exhibits no symptoms with activity. Class II: Client has symptoms with ordinary exertion. Class III: Client displays symptoms with minimal exertion. Class IV: Client has symptoms at rest.

Cardiomyopathy is a change in the structure of cardiac muscle fibers that causes impaired cardiac function leading to heart failure. Blood circulation is impaired to the lungs or body when the cardiac pump is compromised. There are three main types: Dilated – decreased contractility and increased ventricular filling pressures. Hypertrophic – increased thickness of ventricular and/or septal muscles. Restrictive – ventricles become rigid and lose their compliance.

Low output heart failure can initially occur on either the left or right side of the heart. Left-sided heart (ventricular) failure results in inadequate left ventricle output and consequently in inadequate tissue perfusion. Forms include: Systolic heart (ventricular) failure (ejection fraction below 40%, pulmonary and systemic congestion). Diastolic heart (ventricular) failure (inadequate relaxation or “stiffening” prevents ventricular filling).

Right-sided heart (ventricular) failure results in inadequate right ventricle output and systemic venous congestion (for example, peripheral edema). An uncommon form of heart failure is high- output failure, in which cardiac output is normal or above normal.

Risk Factors/Causes: Lt-Sided Heart Failure Hypertension Coronary artery disease, (AP, MI) Valvular disease (mitral and aortic) Risk Factors: Rt-Sided Heart Failure Left-sided heart (ventricular) failure Right ventricular myocardial infarction Pulmonary problems (COPD, ARDS)

Risk Factors/Causes: Risk Factors/Causes: High-Output Heart Failure Increased metabolic needs Septicemia (fever) Anemia Hyperthyroidism Risk Factors/Causes: Cardiomyopathy Coronary artery disease Infection or inflammation of the heart muscle Various cancer treatments Prolonged alcohol abuse Heredity Diagnostic Procedures and N

Diagnostic Procedures and Nursing Interventions Human B-type Natriuretic Peptides (BNP): Elevated in heart failure. Used to differentiate dyspnea related to heart failure versus respiratory problem BNP levels below 100 pg/mL indicate no heart failure; BNP levels of 100 to 300 pg/mL suggest heart failure is present; severe heart failure. Hemodynamic Monitoring: Increased central venous pressure (CVP), increased pulmonary artery pressure (PAP), decreased cardiac output (CO)

Diagnostic Procedures and Nursing Interventions Ultrasound (also called cardiac ultrasound or echocardiogram) to measure both systolic and diastolic function of the heart. Left ventricular ejection fraction (LVEF): The volume of blood pumped from the left ventricle into the arteries upon each beat. Normal is 55 to 70%. Right ventricular ejection fraction (RVEF): The volume of blood pumped from the right ventricle to the lungs upon each beat. Normal is 45 to 60%. Chest x-ray can reveal cardiomegaly and pleural effusions. Electrocardiogram (ECG), cardiac enzymes, electrolytes, and arterial blood gases: Assess factors contributing to heart failure and/or the impact of heart failure.

Therapeutic Procedures and Nursing Interventions A ventricular assist device (VAD) is a mechanical pump that assists a heart that is too weak to pump blood through the body. Heart transplantation is the treatment of choice for clients with severe dilated cardiomyopathy. Heart transplantation is a possible option for clients with end-stage heart failure. Immunosuppressant therapy is required post transplantation to prevent rejection.

Assessments Monitor for signs and symptoms. Left-sided failure Dyspnea, orthopnea, nocturnal dyspnea Fatigue Displaced apical pulse (hypertrophy) S3 heart sound (gallop) Pulmonary congestion (dyspnea, cough, bibasilar crackles) Frothy sputum (may be blood-tinged) Altered mental status Symptoms of organ failure, such as oliguria Hemodynamic findings: CVP/right atrial pressure (normal = 1 to 8 mm Hg): Normal or elevated PAP (normal = 15 to 26 mm Hg/5 to 15 mm Hg): Elevated PAWP (normal = 4 to 12 mm Hg): Elevated CO (normal = 4 to 7 L/min): Decreased

Assessments Right-sided failure Jugular vein distention Ascending dependent edema (legs, ankles, sacrum) Abdominal distention, ascites Fatigue, weakness Nausea and anorexia Polyuria at rest (for example, nocturnal) Liver enlargement (hepatomegaly) and tenderness Weight gain Hemodynamic findings CVP/right atrial pressure (normal = 1 to 8 mm Hg): Elevated

Heart failure (left with dilated type, right with restrictive type) Cardiomyopathy Fatigue, weakness Heart failure (left with dilated type, right with restrictive type) Dysrhythmias (for example, heart block) S3 gallop Cardiomegaly

Assess/Monitor Oxygen saturation Vital signs Heart rhythm Lung sounds for crackles, wheezes Level of dyspnea upon exertion Serum electrolytes (especially potassium if receiving diuretics) Daily weight Changes in level of consciousness Intake and output For signs of drug toxicity Coping ability of client and family

NANDA Nursing Diagnoses Impaired gas exchange Decreased cardiac output Activity intolerance Excess fluid volume Ineffective tissue perfusion (cerebral) Risk for ineffective tissue perfusion (renal)

Nursing Interventions If a client is experiencing respiratory distress, place the client in high-Fowler’s position and administer oxygen as prescribed. Encourage bed rest until the client is stable. Encourage energy conservation by assisting with care and activities of daily living. Maintain dietary restrictions as prescribed (restricted fluid intake, restricted sodium intake). Administer medications as prescribed. Diuretics: To decrease preload Loop diuretics, such as furosemide (Lasix), bumetanide (Bumex) Thiazide diuretics, such as hydrochlorothiazide (HydroDIURIL) Potassium-sparing diuretics, such as spironolactone (Aldactone) Teach the client taking loop or thiazide diuretics to ingest foods and drinks that are high in potassium to counter hypokalemia effect. Potassium supplementation may be required. Administer IV furosemide (Lasix) no faster than 20 mg/min.

Nursing Interventions Afterload-Reducing Agents Angiotensin converting enzyme (ACE) inhibitors, such as captopril (Capoten); monitor for initial dose hypotension. Beta-blockers, such as carvedilol (Coreg), metoprolol (Lopressor XL) Angiotensin receptor II blockers, such as losartan (Cozaar) Inotropic agents, such as digoxin (Lanoxin), dopamine, dobutamine (Dobutrex), milrinone (Primacor): To increase contractility and thereby improve cardiac output Vasodilators, such as nitrates: To decrease preload and afterload

Nursing Interventions Human B-Type Natriuretic Peptides (hBNP), such as nesiritide (Natrecor): To treat acute heart failure by causing natriuresis (loss of sodium and vasodilation) Anticoagulants, such as warfarin (Coumadin), heparin, clopidogrel: To prevent thrombus formation (risk associated with congestion/stasis and associated atrial fibrillation) Teach clients who are self-administering digoxin (Lanoxin) to: Count pulse for one full minute before taking the medication. If the pulse is abnormal the dose and to contact the primary care provider. Take digoxin (Lanoxin) dose at same time each day (for example, 0900). Do not take digoxin at the same time as antacids. Separate by 2 hr. Report signs of toxicity, including fatigue, muscle weakness, confusion, and loss of appetite. Regularly have digoxin and potassium levels checked.

Nursing Interventions Provide emotional support to the client and family. Client Education Take medications as prescribed. Take diuretics in early morning and early afternoon. Maintain fluid and sodium restriction – a dietary consult may be useful. Increase dietary intake of potassium (cantaloupe, bananas) if taking potassium-losing diuretics such as loop diuretics and thiazide diuretics. Weigh self daily at the same time and notify the primary care provider for weight gain of 1Kg in 24 hr or 2.5 Kgs in 1 week. Schedule regular follow-ups with the primary care provider. Get vaccinations (pneumococcal vaccine and yearly influenza vaccine).

Complications and Nursing Implications Acute pulmonary edema is a life-threatening medical emergency; (anxiety, tachycardia, acute respiratory distress, dyspnea at rest, change in level of consciousness, and an ascending fluid level within lungs (crackles, cough productive of frothy, blood-tinged sputum). Prompt response to this emergency includes: Positioning the client in high-Fowler’s position. Administration of oxygen, positive airway pressure, and/or intubation and mechanical ventilation.