Heart Failure Karen Ruffin RN, MSN Ed.

Incidence and Prevalence of Heart Failure Leading cause of death in the US More than 5 million Americans are living with heart failure, and 550,000 new cases are diagnosed each year. About 250,000 people a year die from heart disease. That means more than 680 Americans a day die from it!!!!!!!! Women have a poorer survival rate then men

Basic Needs: Oxygenation Two body systems that work together to meet this basic need. 3

Oxygenation Oxygen is required to sustain life, primary basic human need The cardiac & respiratory systems function to supply the body’s oxygen demands Cardiopulmonary physiology involves delivery of deoxygenated blood to the right side of the heart & to the pulmonary system When we think about basic needs this is at the top of the list. If you cant find a bathroom you will find a place to go but you will continue to live. If your heart does not work or you are not breathing you are not able to sustain life. 4

What are the 3 concepts in oxygenation? Ventilation Perfusion Diffusion

What are the 2 mechanisms that drive the function of the heart? Electrical/conduction Mechanical/pump

What are they???? What is Heart Failure? Heart cannot pump enough blood to meet the metabolic demands of the body. Results from changes in the systolic or diastolic function of the ventricles There are many causes????? What are they???? Diabetes Mellitus, cigarette smoking, obesity, high serum cholesterol, hypertension, MI, CAD Hypertensive HD Rheumatic Heart Dis Congenital Heart Dis Cor pulmonale Cardiomyopathy Anemia Bacterial endocarditis Valvular disorders Acute MI Dysrhythmias Pulmonary emboli Thyrotixicosis Hypertensive crisis Rupture of papillary muscle VSD Myocarditis http://www.americanheart.org/presenter

Types of Heart Failure Left Sided Right sided Systolic Diastolic

Left Sided Heart Failure Most Common LV dysfunction causes blood to back up through the left atrium and into the pulmonary system. Common causes of left heart failure are: HTN, CAD, mitral and/or aortic valve disease, decreased tissue perfusion.

What does that patient look like?????

Right Sided Heart Failure Most common cause is left sided heart failure. Other causes MI or pulmonary HTN RV dysfunction causes the blood to back up in the right atrium and then the venous circulation.

What does that patient look like?????

Systolic Failure Defect in ventricular contraction Left Ventricle loses ability to generate enough pressure to eject blood forward through the high pressure aorta – Decreased ejection fraction Afterload – hypertension, cardiomyopathy, and valvular heart disease

Diastolic Failure Impaired ability of ventricles to fill Decreased filling = decreased stroke volume Which + decreased WHAT? Pulmonary congestion, pulmonary hypertension, with normal ejection fraction

Heart Failure

Diagnostic Studies Goal: Assess the cause & degree of failure History and Physical Exam B-Type Natriuretic Peptide level (BNP). elevated in acute and chronic heart failure useful in following the response to treatment of congestive heart failure. ABGs, Serum chemistries, LFTs Chest x-ray EKG Echocardiogram Nuclear imaging studies Cardiac catheterization Hemodynamic monitoring

Lets Compare!!!!

Classification of Heart Failure Class 1 – No limitation of physical activity Class 2 – Slight limitation – fatigue, dyspnea, palpitations Class 3 – marked limitation. Comfortable at rest; ordinary activities cause symptoms Class 4 – Inability to carry out any physical activity without symptoms – Pain/discomfort at rest

Management and Outcome Measures Use of ß-blockers at discharge and during admission. Use of aspirin at discharge and during admission. Timely and appropriate acute reperfusion (thrombolysis or primary angioplasty). The use of angiotensin-converting enzyme (ACE) inhibitors for patients with depressed left ventricular systolic function. Similarly, a minority of patients with AMI are potential candidates for this care process,

Management and Outcome Measures The proportion of patients eligible for smoking-cessation counseling is relatively small, and ascertainment can be difficult, given the variability in documentation as well as practice. Diet and exercise counseling Cholesterol status assessment and management.

Congestive Heart Failure Medical Treatment Goals Decreasing Intravascular Volume Decreasing Venous Return Decreases preload – decreases the volume to the left ventricle during diastole Med: Diuretics – Lasix (furosemide) Decreasing Afterload Decrease systemic vascular resistance CO increases Pulmonary congestion decreases Meds: Nitroglycerine (NTG); Morphine; Calcium Channel Blockers

Congestive Heart Failure Medical Treatment Goals Improving Gas Exchange & Oxygenation Supplemental oxygen Morphine Severe cases – intubation / ventilation Improving Cardiac Function Increase cardiac contractility without increasing cardiac oxygen consumption Hemodynamic Monitoring: pulmonary artery pressure; pulmonary artery wedge pressure (14-18mmg HG) Inotropic Meds: Digoxin Inotropic meds used with hemodynamic monitoring: Dobutamine Inodilators: (inotropic & vasodilator): Milrinone

Congestive Heart Failure Medical Treatment Goals Reducing Anxiety Sedative action of IV Morphine Complication: respiratory depression Determine & Treat Underlying Cause Systolic or Diastolic failure Aggressive drug therapy

So what medical complications do you think can occur??????? Pleural effusion Dysrhythmias Left ventricular thrombus Hepatomegaly – impaired liver function Acute Pulmonary Edema

What basic needs are being effected? Why and how?

Nursing Care for the Patient with Heart Failure What will you assess???? What are some potential nursing diagnosis????? What are your goals for those diagnosis???? What are your interventions????? How will you evaluate your goals????? Assess: Assess: Hemodynamic status – VS, PO, CVP, PAP, PAWP, response to medication cardiac rhythm, LOC, energy level; labs Nx Dx Activity intolerance r/t fatigue secondary to cardiac insufficiency Excess fluid volume r/t cardiac failure Disturbed sleep pattern r/t nocturnal dyspnea Impaired gas exchange r/t increased preload and afterload Anxiety r/t dyspnea / fear of death Knowledge deficit r/t disease process Nsg Action: Administer medications, oxygen, supportive treatment, community referral & home preparation Pt/Family Education: Lifestyle modification, Medication

Case Study A 74-year-old woman is admitted to the hospital with heart failure. She had been growing progressively weaker and has ankle edema, dyspnea on exertion, and three-pillow orthopnea. On admission, she is severely dyspneic and can answer questions only with one-word phrases. She is diaphoretic and has central cyanosis, with a heart rate of 132 beats/min, and blood pressure 98/70. She is extremely anxious.

Case Study 1. Because this client cannot breath or talk easily, prioritize the immediate nursing assessments and intervetions upon admission. 2. Considering the process of congestive heart failure, explain the symptoms she is having. 3.Based on assessment, identify nursing diagnoses for this client. 4. What diagnostic studies do you anticipate being ordered and why?

Case Study 5. The physician orders the following items for this client. (Start an IV, then give dobutamine 3 mcg/kg/min IV; Furosemide (Lasix) 40 mg IV stat; Digoxin 0.5 mg IV stat, then 0.125mg PO every 6 hours for three doses, with ECG before doses 3 and 4; Morphine 2 mg IV stat and then 2 mg IV every 1 to 2 hours prn; Oxygen to maintain O2 sat >94%; Schedule for an echocardiogram; Low Na, Fat, Cardiac diet; Weigh daily and monitor input and output) Explain the rationale for these medications and treatments. Would you ask for any other ORDERDS and why?