1. Heart Failure

2. Objectives Describe congestive heart failure Explain the pathophysiology of congestive heart failure Describe nursing interventions in caring for clients with congestive heart failure

3. Heart Failure Definition- Inability of the heart to fill with blood and/or pump blood, sufficiently. Caused by structural or function abnormality (i.e. cardiomyopathy, valve disorders etc.)

4. Heart Failure No longer termed “congestive heart failure” – Many pts. do not experience pulmonary or systemic congestion  Now identified as a “neurohormonal” problem that progresses due to chronic release of catecholamines (epi- and norepi-) which produce negative effects on a failing heart

5. Heart Failure May results in any or all of the following: – Intravascular fluid volume overload – Intrastitial fluid volume overload – An inability to meet the demands of the body

6. Types of Heart Failure Right Heart Failure Left Heart Failure Key aspects of heart failure include: – Weakened heart contractions – Increase in blood volume and congestion – Decreased cardiac output

7. Causes of Heart Failure Age CAD HTN Valve Disease Congenital Heart Disease Cardiomyopathy Endocarditis Myocarditis COPD

8. NYHeartAsso Classification of Heart Failure Class I: no limitation is experienced in any activities; there are no symptoms from ordinary activities. Class II: slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion. Class III: marked limitation of any activity; the patient is comfortable only at rest. Class IV: any physical activity brings on discomfort and symptoms occur at rest.

9. Right-Sided Heart Failure The Right Ventricle is unable to fill with a sufficient amount of venous blood AND/OR The Right Ventricle is unable to effectively pump blood forward to the pulmonary circulation

10. Right-Sided Heart Failure Causes: – ↑ pressure of blood backing up from a failing Left ventricle – Pulmonary Hypertension Primary (idiopathic) Secondary (caused by another pathology) – If related to COPD: COR Pulmonale – Pulmonary or Tricuspid Valve disease

11. Right-Sided Heart Failure Causes (cont.) – Preexisting left sided heart failure – Myocardial changes – Body fluid overload – Rhythm Disturbances

12. Right-Sided Heart Failure Signs & Symptoms are related to: Peripheral Congestion Low cardiac output L/R Ventricular Failure  See p. 334 Box 8-3

13. Cor Pulmonale COPD increases pressure in the Pulmonary Arteries. Over time the increased pressure on the Right Ventricle causes it to dilate and/or hypertrophy. The inability of the RV to eject all of its volume forward causes blood to back up into the Right Atrium and the veins  peripheral edema – Special note: 1 liter fluid = 1 kg (2.2 lbs) – Wt. gain of 2.2 lbs = 1 liter body fluid gain

14. Left-Sided Heart Failure The Left Ventricle is unable to fill with a sufficient amount of blood AND/OR The LV is unable to effectively pump blood out to the rest of the body

15. Left-Sided Heart Failure Causes: – Hypertension (peripheral arteries) – Aortic and Mitral Valve disease, – Aortic coarctation – Myocardial Changes – Rhythm Disturbances

16. Left-Sided Heart Failure Signs & Symptoms are related to: *Decreased Cardiac Output *Pulmonary Congestion: Pulmonary edema Pleural Effusion

17. Heart Failure Nursing Assessment – Subjective Data: pt. c/o: Dyspnea Orthopnea Cough Paroxysmal nocturnal dyspnea Fatigue Anxiety Weight gain

18. Heart Failure Nursing Assessment – Objective Data: Clinical manifestations: Observed respiratory distress Number of pillows pt is requiring Edema Abdominal distension, ascitis Weight gain Adventitious breath sounds Abnormal heart sounds Jugular vein distension Activity intolerance Oliguria Cyanosis General debilitation

19. Heart Failure Diagnostic Tests – CXR – EKG – Echo – Cardiac Catheterization – Multiple-gated acquisition scanning MUGA – Lab tests

20. Heart Failure Medical Management – Goals: Increase cardiac efficiency Lower oxygen requirements Provide oxygen Treat edema and pulmonary congestion – Medications – Prognosis is good with treatment

21. MEDICATIONS Diuretics – Thiazides (HCTZ) – Loop Diuretics (Lasix) Digoxin Ace Inhibitors (possibly ARB’s) Beta Blockers – Coreg

22. MEDICATIONS Positive Inotropes – Dobutamine infusion Vasodilators – Nitrates – Hydralazine

23. Digoxin Onset of action 2-6 hours, half-life 2-4 days Action: – Strengthens the force and efficiency of cardiac contraction – Slows heart rate – Increases circulation, effecting diuresis Therapeutic Levels – Normal serum dig level range 0.5- 2 ng/mL

24. Digoxin Side Effects – Bradycardia – Hypokalemia leads to: Toxicity- N/V, Visual disturbances, confusion, severe bradycardia, tachycardic dysrhythmias Antidote – Digibind (Digoxin immune Fab) Duration 2-6 hours

25. Nursing Interventions Goals – Prevent disease progression – Prevent complications – Patient & family education including end-of-life decisions