Heart Failure, Fluids, and Diet Carolyn Scroggins, MSN, RN, GNP

Role of Potassium Disturbed K + metabolism r/t majority of clinical arrhythmias Disturbed K + metabolism r/t majority of clinical arrhythmias Na + & Ca ++ reverse K + -induced depression of conduction Na + & Ca ++ reverse K + -induced depression of conduction K + only electrolyte clinically significant anti-arrhythmic properties. K + only electrolyte clinically significant anti-arrhythmic properties.

Healthy Left Side Heart Healthy Left Side Heart Left heart receives blood as it returns from the lungs Left heart receives blood as it returns from the lungs Pumps blood into the aorta, main artery of the body. Pumps blood into the aorta, main artery of the body.aorta Then-- blood delivered via arteries to all organs, muscles & tissues. Then-- blood delivered via arteries to all organs, muscles & tissues.

Left Side Does the Hardest Work

What happens in Lt. Heart Failure LHF? Body holds extra fluid, blood backs up into the lungs: Body holds extra fluid, blood backs up into the lungs: 1. because left heart pumps blood away from heart to body organs. 2. During LHF, kidneys do not get enough blood, & are fooled into reacting as if body does not have enough blood. 3. Therefore, they hold on to salt & water to keep it in the blood rather than passing it out into the urine.Resulting: excess fluid builds up in the body, putting an additional strain on heart. 4. This strain makes pumping function of the left side of heart worse, causing less blood to get to the kidneys =vicious cycle.

Causes of Left-sided failure Heart Attack Heart Attack Chronic blockages of the heart arteries Chronic blockages of the heart arteries High Blood Pressure High Blood Pressure Leaking or narrow heart valves Leaking or narrow heart valves Heart muscle infections Heart muscle infections Acute MI & Cardiomyopathy Acute MI & Cardiomyopathy

Blocked Cardiac Arteries

Leaky Valve

Cardiomyopathy

Myocardial Infarction

What is this artery called?

Lt. Sided Heart Failure Symptoms dyspnea, orthopnea, crackles, wheezing, hypoxia, respiratory acidosis, cough (frothy sputum), cyanosis, palpitations, arrhythmias, elevated blood pressure dyspnea, orthopnea, crackles, wheezing, hypoxia, respiratory acidosis, cough (frothy sputum), cyanosis, palpitations, arrhythmias, elevated blood pressure dyspnea on exertion appears to be earliest symptom dyspnea on exertion appears to be earliest symptom complaints of paroxysmal nocturnal dyspnea (awakening from sleep with shortness of breath), or new-onset dyspnea on exertion should undergo evaluation for heart failure complaints of paroxysmal nocturnal dyspnea (awakening from sleep with shortness of breath), or new-onset dyspnea on exertion should undergo evaluation for heart failure

Shortness of Breath

Assessment for Fine Crackles

Left Heart Failure

Cyanosis R/T Lt. Sided Heart Failure

Difficulty Breathing R/T Lt. Sided Heart Failure

Medications for Lt. Sided Heart Failure DIURETICS DIURETICS ACE INHIBITORS ACE INHIBITORS BETA BLOCKERS BETA BLOCKERS DIGOXIN DIGOXIN

Why Meds are Used: Diuretics relieve pulmonary & peripheral edema. May also treat hypertension since they dilate blood vessels. Diuretics relieve pulmonary & peripheral edema. May also treat hypertension since they dilate blood vessels. Potential Side effects: dizziness, severe leg cramps, high blood sugar levels, high cholesterol levels (NURSES WATCH FOR THIS) Potential Side effects: dizziness, severe leg cramps, high blood sugar levels, high cholesterol levels (NURSES WATCH FOR THIS) Examples: Furosemide(Lasix,) Bumetanide(Bumex), Hydrochlorthiazide(HCTZ) Examples: Furosemide(Lasix,) Bumetanide(Bumex), Hydrochlorthiazide(HCTZ)

ACE Inhibitors Angiotensin Converting Enzyme (ACE) Inhibitors block Angiotensin II formation, Inhibitors block Angiotensin II formation, causes constriction of blood vessels. causes constriction of blood vessels. reduce strain on heart; relax smaller arteries & lower BP. reduce strain on heart; relax smaller arteries & lower BP. SE: dizziness. ACE inhibitors can prevent increases in heart size. SE: dizziness. ACE inhibitors can prevent increases in heart size. Potential Side effects: cough, dizziness, worsening of some types of kidney disease Potential Side effects: cough, dizziness, worsening of some types of kidney disease Examples: Lisinopril (Prinivil), Enalapril (Vasotec), Captopril (Capoten) Examples: Lisinopril (Prinivil), Enalapril (Vasotec), Captopril (Capoten)

Vasodilators Med group-- relax blood vessels & lower resistance against which the heart has to pump. Med group-- relax blood vessels & lower resistance against which the heart has to pump. Like ACE inhibitors or ARBs (Angiotensin Receptor Blockers) they can cause low blood pressure & dizziness. Like ACE inhibitors or ARBs (Angiotensin Receptor Blockers) they can cause low blood pressure & dizziness. Potential Side effects: hypotension, dizziness, tachycardia, headache (NOTE: THIS IS WHY NURSES TAKE BLOOD PRESSURE BEFORE ADMINISTRATION) Potential Side effects: hypotension, dizziness, tachycardia, headache (NOTE: THIS IS WHY NURSES TAKE BLOOD PRESSURE BEFORE ADMINISTRATION) Examples: Hydralazine, Isosorbide Dinitrate, Nitroglycerin Examples: Hydralazine, Isosorbide Dinitrate, Nitroglycerin

Beta Blockers Some sympathetic tone on the heart Some sympathetic tone on the heart beta-blockers reduce sympathetic influences that stimulate heart rate beta-blockers reduce sympathetic influences that stimulate heart rate beta-blockers--decrease heart rate, contractility, conduction velocity, & relaxation rate. beta-blockers--decrease heart rate, contractility, conduction velocity, & relaxation rate.

Beta Blockers Drugs block the heart cell response to catecholamines (norepinephrine, epinephrine) – Drugs block the heart cell response to catecholamines (norepinephrine, epinephrine) – 1. Catecholamines- responsible for CNS "fight or flight" response. Beta-Blockers may reduce heart’s energy needs, & over a long time may reduce heart size & improve heart function. Potential Side Effects: decreased ventricular function, slow heart rate, worsening of asthma symptoms. (NOTE: NURSES MUST TAKE APICAL PULSE) Potential Side Effects: decreased ventricular function, slow heart rate, worsening of asthma symptoms. (NOTE: NURSES MUST TAKE APICAL PULSE) Examples: Carvedilol (Coreg,), Metoprolol (Toprol XL ) Examples: Carvedilol (Coreg,), Metoprolol (Toprol XL )

side effects of beta blockers SE--beta-blockers r/t cardiac mechanisms & include: SE--beta-blockers r/t cardiac mechanisms & include: bradycardia bradycardia reduced exercise capacity reduced exercise capacity heart failure heart failure Hypotension Hypotension atrioventicular (AV) nodal conduction block. atrioventicular (AV) nodal conduction block. NOTE: (These side effects result from excessive blockade of normal sympathetic influences on the heart)

Beta Blockers/CCB When beta-blocker is given in conjunction with calcium-channel blockers (e.g., verapamil) = additive effects in producing electrical & mechanical depression. When beta-blocker is given in conjunction with calcium-channel blockers (e.g., verapamil) = additive effects in producing electrical & mechanical depression.calcium-channel blockerscalcium-channel blockers beta-blockers--contraindicated in heart failure patients. beta-blockers--contraindicated in heart failure patients. beta-blockers--contraindicated in pts. with bradycardia & partial AV block. beta-blockers--contraindicated in pts. with bradycardia & partial AV block.

Digitalis Increases strength of heart's contractions, reducing resistance in blood vessels. Increases strength of heart's contractions, reducing resistance in blood vessels. Decreases heart rate in heart failure patients & may decrease edema. Decreases heart rate in heart failure patients & may decrease edema. Potential Side effects: nausea & slow or fast heart beating Potential Side effects: nausea & slow or fast heart beating Examples: Digoxin (Lanoxin) Examples: Digoxin (Lanoxin)

Aldosterone Blockers Aldosterone-- adrenal hormone responds to decrease in renal blood flow & other factors in heart failure. Aldosterone-- adrenal hormone responds to decrease in renal blood flow & other factors in heart failure. May contribute to cardiac fibrosis. May contribute to cardiac fibrosis. Blockade of aldosterone effects may improve outcomes in advanced heart failure. Blockade of aldosterone effects may improve outcomes in advanced heart failure. Potential Side effects: fatigue, headache, low blood pressure, nausea Potential Side effects: fatigue, headache, low blood pressure, nausea Examples: Spironolactone( Aldactone ) Examples: Spironolactone( Aldactone )

Healthy Right Side Heart Right heart receives blood from veins. Right heart receives blood from veins. Blood is returning from organs & low in oxygen. Blood is returning from organs & low in oxygen. Right side heart pumps blood to the lungs, where it picks up oxygen & delivers throughout the body. Right side heart pumps blood to the lungs, where it picks up oxygen & delivers throughout the body. Right heart begins to fail, blood & fluid back up into abdomen, legs & ankles. Right heart begins to fail, blood & fluid back up into abdomen, legs & ankles. Tenderness in upper right abdomen. Tenderness in upper right abdomen. Loss of appetite, bloating, tired feeling. Loss of appetite, bloating, tired feeling.

Cause of Right Sided Heart Failure Left ventricle does not pump blood efficiently, Left ventricle does not pump blood efficiently, Leads to pressure buildup behind the left side of the heart Leads to pressure buildup behind the left side of the heart Eventually causes the right side of the heart to fail. Eventually causes the right side of the heart to fail.

Symptoms Rt. Heart Failure (cor pulmonale: rt.ventricle hypertrophy) dependent peripheral edema dependent peripheral edema hepatomegaly hepatomegaly splenomegaly splenomegaly jugular vein distention jugular vein distention ascites & kidney congested=decrease filtering ascites & kidney congested=decrease filtering weight gain weight gain arrhythmias, arrhythmias, nausea, vomiting, anorexia, nausea, vomiting, anorexia, fatigue, dizziness, syncope, weakness fatigue, dizziness, syncope, weakness

Dependent Edema

Pitting Edema Edema of ankles & feet-- common manifestation of right-sided heart failure. "Pitting" edema refers to the failure of the skin & soft tissue to immediately resume its normal contour upon release of pressure.

Ascites R/T Rt. Sided Heart Failure

Medications for Right-Sided Heart Failure Diuretics: Furosemide or bumetanide help moderate to severe symptoms. Diuretics: Furosemide or bumetanide help moderate to severe symptoms. Hydrochlorothiazide, chlorthalidone, and chlorothiazide used for mild symptoms. Hydrochlorothiazide, chlorthalidone, and chlorothiazide used for mild symptoms. Spironolactone, prevents salt retention & helps with severe heart failure. Spironolactone, prevents salt retention & helps with severe heart failure. ACE inhibitors, Angiotensin Receptor Blockers Beta-blockers (such as metoprolol or carvedilol) can help prevent death ACE inhibitors, Angiotensin Receptor Blockers Beta-blockers (such as metoprolol or carvedilol) can help prevent death Digitalis Digitalis NURSES NOTE: MEDICATIONS OFTEN INDICATE DEGREE OF HEART FAILURE

Anti-Anginal Medications Procardia (nifedipine)--Treats high blood pressure. migraine headaches, Raynaud's syndrome, cardiomyopathy, & congestive heart failure. Procardia (nifedipine)--Treats high blood pressure. migraine headaches, Raynaud's syndrome, cardiomyopathy, & congestive heart failure. calcium channel-blocker—relaxes blood vessels of the heart calcium channel-blocker—relaxes blood vessels of the heart

Calcium Channel Blockers Calcium channel blockers-- class of drugs that block entry of calcium into the muscle cells of heart & arteries. Calcium channel blockers-- class of drugs that block entry of calcium into the muscle cells of heart & arteries. The entry of calcium into these cells that causes heart to contract & arteries to narrow. By blocking the entry of calcium, CCBs decrease contraction of heart & dilate (widen) the arteries. The entry of calcium into these cells that causes heart to contract & arteries to narrow. By blocking the entry of calcium, CCBs decrease contraction of heart & dilate (widen) the arteries.

CALCIUM CHANNEL BOCKERS (CCB) By dilating arteries, CCBs reduce pressure in the arteries, making it easier for heart to pump blood, resulting in heart needing less oxygen. By dilating arteries, CCBs reduce pressure in the arteries, making it easier for heart to pump blood, resulting in heart needing less oxygen. By reducing heart's need for oxygen, CCBs relieve or prevent angina. By reducing heart's need for oxygen, CCBs relieve or prevent angina.

For what conditions are CCBs used? high blood pressure high blood pressurehigh blood pressurehigh blood pressure angina angina abnormal heart rhythms (e.g., atrial fibrillation). abnormal heart rhythms (e.g., atrial fibrillation).atrial fibrillationatrial fibrillation used after a heart attack, among pts who cannot tolerate beta-blocking drugs (high- risk for hypotension or bradycardia), have atrial fibrillation, or require treatment for angina. used after a heart attack, among pts who cannot tolerate beta-blocking drugs (high- risk for hypotension or bradycardia), have atrial fibrillation, or require treatment for angina.heart attackheart attack

HEALTH HEART DIETS CALORIE CONTROLLED CALORIE CONTROLLED LOW-CHOLESTEROL LOW-CHOLESTEROL FAT-RESTRICTED FAT-RESTRICTED SODIUM-RESTRICTED SODIUM-RESTRICTED Note pg. 311 DHO Book FOR DIETS Note pg. 311 DHO Book FOR DIETS FLUID RESTRICTIONS ACCORDING TO DAILY WEIGHT FLUID RESTRICTIONS ACCORDING TO DAILY WEIGHT

Enlarged Liver

Enlarged Spleen