NCLEX Review: Nursing Care of Patients with Heart Failure

Key Terms in Heart Failure Nursing

• Afterload: The force the left ventricle must exert to eject blood into the aorta.
• Cor Pulmonale: Right ventricular hypertrophy caused by disorders of the lung.
• Cyanosis: Bluish discoloration of the skin and mucous membranes due to insufficient oxygen.
• Exertional Dyspnea: Shortness of breath that is triggered with an increase in activity.
• Hepatomegaly: Enlargement of the liver.
• Orthopnea: Shortness of breath that increases when lying flat.
• Paroxysmal Nocturnal Dyspnea: Sudden shortness of breath after lying flat for a period of time.
• Perfusion: The passage of fluid through the circulatory or lymphatic system to an organ or a tissue.
• Peripheral Vascular Resistance: Resistance in the blood vessels that affects afterload and the force needed to open the aortic valve.
• Preload: The amount of ventricular stretch at the end of diastole.
• Pulmonary Edema: Fluid congestion within the lung alveoli.
• Splenomegaly: Enlargement of the spleen.

Core Concepts in Heart Failure Nursing

• Caring involves providing compassionate and holistic care to patients with heart failure.
• Collaboration is essential with other healthcare professionals to optimize patient outcomes.
• Comfort measures can alleviate symptoms and improve the patient's quality of life.
• Maintaining fluid and electrolyte balance is crucial to prevent complications.
• Ensuring adequate oxygenation is a primary goal of nursing care.
• Promoting perfusion helps maintain adequate blood flow to vital organs.
• Teaching and learning strategies will empower patients and families to manage their condition.

Heart Failure Overview

• Heart failure (HF) is a clinical syndrome affecting perfusion that arises due to the ventricle's inability to fill or pump enough blood.
• HF leads to dyspnea, fatigue, and fluid volume overload, which reduces the quality and length of life.
• Causes include coronary artery disease, myocardial infarction, cardiomyopathy, heart valve problems, and hypertension (HTN).
• Any heart problem has the potential to cause HF.
• In older adults, cardiac ischemia is the most common cause.
• HF can develop rapidly (acute), such as with cardiogenic shock and pulmonary edema, or over time (chronic) due to disorders like HTN or pulmonary disease.
• HF incidence is rising due to an aging population and improved treatments leading to better survival rates.
• An estimated 6.2 million Americans have HF, with a million new cases each year.
• Black females have the highest incidence, prevalence, and mortality.
• In 2017, HF was the main reason for hospital admissions in older adults.
• Readmission rates are highest for those previously hospitalized for HF

Understanding Congestive Heart Failure

• Congestive HF is an older term for HF but is less accurate as not all HF patients experience volume overload.
• Heart consists of two pumping systems: the right and left sides each require balanced function.
• Effective cardiac function requires each ventricle to pump out equal amounts of blood over time to maintain balance.
• If the amount of blood returning to the heart exceeds what either ventricle can manage, the heart's effectiveness as a pump is compromised.

Heart Failure and Dysfunction

• Systolic dysfunction refers to a contractile problem where the ventricle cannot generate enough force.
• Diastolic dysfunction is a problem with the ability of the ventricle to relax and fill.
• Mixed dysfunction involves both systolic and diastolic defects.

Right and Left Sided Heart Failure

• Conditions causing HF may affect either or both pumping systems, leading to right-sided, left-sided, or biventricular HF.
• The left ventricle typically weakens first because of its workload ejecting blood against aortic resistance.
• Failure of one side of the heart usually leads to the failure of the other because the right and left sides function together.

Recognizing the Effects of Heart Failure

• To understand the effects of HF, follow the backward flow of blood path from each ventricle.
• Identifying the specific signs and symptoms aids in understanding whether heart failure is left-sided or right-sided.

The Vicious Cycle of Heart Failure

• Dyspnea (shortness of breath) results from pulmonary congestion that impairs gas exchange, leading to short, rapid respirations as a compensatory mechanism.
• Exertional dyspnea refers to shortness of breath that increases with activity.
• Orthopnea is dyspnea that increases when lying flat due to fluid shifting from the lower extremities back to the heart.
• Paroxysmal Nocturnal Dyspnea occurs as a sudden reaction in the night from excess fluid in the lungs.
• A chronic, dry cough is frequent due to increased irritation of the lung mucosa from increased pulmonary congestion that occurs when gravity releases fluid in the legs that returns to the heart and lungs.
• Crackles and wheezes indicate fluid buildup in the alveoli or bronchiolar constriction from increased fluid.
• Tachycardia is triggered by low cardiac output, causing the sympathetic nervous system to increase heart rate which results in a decreased ability for the heart to effectively pump.

Left-Sided Heart Failure: Understanding Afterload and Resistance

• Afterload refers to the force the left ventricle generates to eject blood through the aortic valve.
• Peripheral vascular resistance describes the pressure within the aorta and arteries, which affects the force needed to open the aortic valve.
• Hypertension (HTN) is a leading cause of left-sided HF, as it increases pressure in the arteries, making the left ventricle work harder.

Consequences of Left-Sided Heart Failure: Pulmonary Pressure and Edema

• The blood backs up from the left ventricle to the left atrium and lungs, causing pulmonary pressure to increase.
• The increasing pulmonary pressure causes fluid to move into the interstitium and the alveoli.
• Alveolar edema reduces gas exchange, leading to shortness of breath and cyanosis from decreased oxygenation, resulting in acute pulmonary edema.
• Acute pulmonary edema requires immediate medical treatment, as alveolar edema is serious.

Primary Effects of Left Ventricular Workload

• Aortic stenosis increases volume to pump due to restricted blood outflow.
• Cardiomyopathy increases workload due to impaired contractility.
• Coarctation of the aorta restricts outflow and increases resistance due to narrowing.
• Hypertension increases resistance due to elevated pressure.
• Heart muscle infection increases workload from damaged myocardium.
• Myocardial Infarction increases workload from impaired contractility.
• Mitral Regurgitation increases volume to pump due to backward blood flow.

Right-Sided Heart Failure: Causes and Effects

• Conditions causing right-sided HF increase the work of the right ventricle by increasing contractile force or requiring pumping of excess blood volume (preload).
• A major cause is left-sided HF, which increases pulmonary pressure.
• The right ventricle weakens over time from continually pumping against increased fluid and pressure, which is referred to as Hypertrophy.
• Cor Pulmonale is hypertrophy (increased muscle mass) or right ventricle failure from lung disorders.
• With right ventricle failure, blood backs up into systemic vessels, increasing right atrial and systemic venous blood volume, causing jugular vein distention.
• Peripheral tissue edema and abdominal organ distention may occur.
• GI tract upset, anorexia, abdominal pain, or nausea can occur.
• Blood pools in hepatic veins as right-sided failure progresses: congestion (hepatomegaly), impaired liver function, and pain in the right upper quadrant.
• Systemic venous congestion also leads to spleen distension (splenomegaly).

Impact of Low Cardiac Output

• A reduction in oxygen delivered to the tissues result in; fatigue, dyspnea, altered mental status, and cyanosis.

Compensatory Mechanisms in Heart Failure

• The sympathetic nervous system releases epinephrine and norepinephrine to increase heart rate.
• The kidneys activate the renin-angiotensin-aldosterone system to save water, while antidiuretic hormone is released from the pituitary to conserve water.
• The heart enlarges its chambers (dilation) and increases muscle mass (hypertrophy) to respond to the increased workload by the Frank-Starling Phenomenon.

Word Building

• Cor Pulmonale refers to heart and lung.
• Hepatomegaly refers to mega and large liver.
• Splenomegaly refers to mega and large spleen.

Pulmonary Edema (Acute Heart Failure): Pathophysiology and Symptoms

• Pulmonary edema is a life-threatening condition that can occur with myocardial infarction or severe heart stress.
• Pressure rises in lung vessels, causing fluid to move into interstitial spaces and then into alveoli, which reduces gas exchange and oxygen levels.
• Pink, frothy sputum is a classic symptom caused by lung congestion and increased pressure.
• One may find anxiety, restlessness, clammy skin, coughing, crackles and wheezes, and rapid respirations with accessory muscle use.

Diagnostic Tests and Therapeutic Measures for Pulmonary Edema

• Diagnostic tests include arterial blood gases (ABGs), chest x-ray, electrocardiogram (ECG), and hemodynamic monitoring.
• Therapeutic measures include oxygen, positioning in Fowler or semi-Fowler position, bedrest, and medications (diuretics, inotropic agents, vasodilators).

Nursing Care

• Critically ill and anxiety-ridden patients often require treatment in the intensive care unit. An important area for nursing care is psychosocial support.

Chronic Heart Failure: Symptoms and Management

• Fatigue and weakness, earliest symptoms of HF, worsen during the day with activity, occurring from reduced oxygen to tissues.
• Nurse-led interventions (brain exercises, education, self-care schedules, problem-solving training, and association techniques) can improve HF knowledge, IADLs, self-care, and quality of life.

Treatment Goals for Patients

• Improve pumping ability, reduce the symptoms, and decrease mortality.
• Improve the underlying cause of heart failure.
• Increase heart contractions.
• Maintain water and sodium optimization.
• Decrease workload.

Noninvasive Therapeutic Measures: Optimizing Oxygenation and Breathing

• Administer oxygen therapy guide by ABG values in patients with severe heart failure: high concentrations of oxygen or mechanical ventilation may be necessary.
• The semi-fowler position allows venous return while further allowing the lungs to expand with greater ease. This reduces the venous return.
• Activity tolerance depends on HF severity; severe symptoms require bedrest, while stable HF benefits from regular exercise like walking.

Noninvasive Therapeutic Measures: Dietary and Weight Control

• Restrict dietary sodium to decrease fluid retention.
• Maintain a healthy weight to improve overall cardiac function.
• The patient and the health care provider should discuss the use of salt since it often substitutes potassium in place of sodium.
• A dietitian can develop a meal plan for low sodium diets if needed.

Noninvasive Therapeutic Measures: Monitoring

• In severe HF, malnutrition is a concern, and weight gain from fluid retention can mask weight loss from anorexia.
• Monitor food intake, and account for the weight from fluid intake.
• Avoid failure to recognize!

Pharmacological Treatment Overview

• ACE inhibitors help with hypertension and reduce workload. You may want to take at night to lower BP.
• ARBs help if a cough develops from ACE inhibitors.
• Beta-adrenergic blockers help with sudden death or help reduce sympathetic nervous output.
• ARN inhibit blood volume and help with cardiac workload.
• Diuretics help decrease fluid overload.
• Inotropes can help with atrial fibrillation and are recommended to slow electrical currents.
• Spironolactone blocks impacts of aldosterone which results in sodium and water levels to be carefully monitored with potassium.

Medications

• ACE Inhibitors (captopril, benazepril, enalapril, fosinopril, lisinopril) help with hypertension and afterload and should also be given prior to meals. A common side effect is a cough.
• ARBs (candesartan, irbesartan, losartan, valsartan) are an alternative if ACE inhibitors cannot be tolerated. Rise slowing to avoid dizziness. Report side effects like swelling.
• ARNis (valsartan/sacubitril) are contraindicated with ACE inhibitors and require you to report swelling and cough.
• Beta Blockers (bisoprolol, carvedilol, metoprolol) require a daily pulse check and BP biweekly.
• Loop Diuretics (furosemide, torsemide, bumetanide) are potassium wasting and can cause nocturia.
• Potassium-sparing Diuretics (spironolactone) require no potassium administration. Teaching includes reporting hyperkalemia.
• Thiazide Diurectics (chlorothiazide, hydrochlorothiazide, metolazone) are potassium wasting and also overload-reducing agents.
• HCN Channel Blockers (ivabradine) require you to avoid grapefruit and report visual side effects.
• Use cardiac glycosides (digoxin) only for atrial fibrillation and to take an apical pulse for 1 minute. Report anorexia and visual side effects.
• Vasodilators (isosorbide dinitrate, hydralazine, nitroglycerin) may initially cause headache. Older patients are more susceptible to toxicity and also require specific administration times with specific parameters.

Cue Recognition in Heart Failure Patients

• For patients on vasodilators, the patient can be dizzy and lightheaded from low BP. Have the patient sit back down and take BP.
• For patients that are experiencing HF and pulmonary edema, monitor lung sounds and identify findings.

Home Management of Patients With Oxygen Therapy

• Oxygen management is often used for those with heart failure and requires special monitoring.
• Have patients report low blood pressure.
• Implement Telehealth to have patients alert the agency of signs of exacerbations such as 2 pound weight gain.
• Do not put a blood draw directly on ice! It could cause a false elevation in the potassium levels.
• Long oxygen tubing allows for movement at home, but for safety be sure to avoid kinking.
• Be sure to give small instructions to help patients recall written and video material.
• Make sure patients know to have the lowest sodium in the diet as possible.
• Be sure to have patients list foods with high sodium.

Cardiac Transplantation

• Heart transplants are for end stage diseases
• A multi-organ transport is used to keep a heart beating via a human-like organ system.
• Hearts are transported either with heterotopic and orthotopic ways.

Postoperative Cardiac Transplant Patient

• The safety of the patient must be assessed, from their ability to move to bed height.
• Monitor temperatures every four hours since immunosuppression can increase the risk of infection.
• The nurse records for complications, hemodynamic control, and ventilation.
• Monitor labs including ABG, CBC, electrolytes and coagulation to ensure cardiac contractility.

Cardiac Rehabilitation

• Focus is provided to limit pain. Opioids are splinted on the entire chest. Reinforce education so that all family and staff is on board.

Cardiac Transplant Statistics

• Heart rejection is the major cause of death!
• A biopsy is the way to check rejection and also a newer blood test.

Clinical Judgement

• With ACE inhibitors, kidney and potassium levels need to be monitored. The plan should also include a dietician and the need to explain the low sodium diet.