Exam 22 - Heart Failure and Pulmonary Edema

• Heart failure, or cardiac insufficiency, involves circulatory congestion due to the heart's inability to pump effectively and meet the body's metabolic needs, but it doesn't mean the heart has stopped or is about to stop.
• Weakening of the heart's pumping ability leads to blood and fluid backup into the lungs (pulmonary edema), fluid buildup in the feet, ankles, and legs (peripheral edema), tiredness, and shortness of breath (decreased oxygen supply).
• This condition is considered a neurohormonal problem, with the chronic release of catecholamine (epinephrine and norepinephrine) producing toxic effects.

Causes of Congestive Heart Failure

• Congenital defects, such as aortic stenosis
• Diseases directly affecting the heart and blood vessels like atherosclerosis, arteriosclerosis, myocardial infarction, diabetes mellitus, hypertension, valvular heart disease, and inflammatory heart disease
• Conditions increasing cardiac workload include infection, stress, hyperthyroidism, anemia, and fluid replacement therapy

Clinical Manifestations of Heart Failure

• General symptoms: decreased cardiac output, fatigue, anginal pain, anxiety, oliguria, decreased gastrointestinal motility, pale cool skin, weight gain, and restlessness
• Symptoms of right or left-sided heart failure may appear first, leading to failure of both sides
• When one ventricle fails, fluid entering the atria remains the same, but ventricular output is diminished
• As the vascular system becomes overloaded with fluid, cardiac output is reduced

Left Ventricular Failure

• Inability of the left ventricle to pump enough oxygenated blood to meet the demand of body tissues
• Early signs/symptoms: decreased cardiac output, blood diverted to heart and brain, pale cool skin, cyanosis, anxiety, and restlessness
• Pulmonary congestion: increased pressure in the left side of the heart backs up to the pulmonary veins, resulting in lungs filling with fluid, increased capillary permeability, pulmonary edema, pleural effusions, dyspnea (especially with exertion), orthopnea, pulmonary crackles, wheezing, pink frothy sputum, and cough
• Often resulting from coronary atherosclerosis and hypertension

Right Ventricular Failure

• Inability of the right ventricle to pump effectively due to increased pressure in the pulmonary circulation
• Causes include left-sided heart failure, chronic pulmonary disease (cor pulmonale), or pulmonary hypertension
• Leads to accumulation of fluid (edema) in extremities due to backflow of venous blood
• Edema occurs in dependent areas such as the sacrum and lower extremities, progressing to pitting edema, thighs, genitalia, and lower trunk
• Noticeable weight gain occurs after retaining more than 10 pounds of fluid (2.2 lbs ≈ 1 Liter of fluid)
• Blood backs up into body organs (liver, GI tract), causing liver congestion, impaired function, ascites, decreased GI motility, anorexia, nausea, abdominal distention, and jugular vein distension

Assessment of Heart Failure

• Subjective Data considerations: focus on symptoms of increased activity intolerance, increasing edema, and weight gain, as well as precipitating and relief factors, and the impact on activities of daily living
• Objective Data considerations: complete physical assessment focusing on how heart failure affects all organs
  • Cerebral impacts: anxiety, restlessness, confusion
  • Renal perfusion: oliguria, abnormal I&O, BUN, and creatinine levels
  • Peripheral edema: dependent edema, pitting edema, daily weights
  • GI Congestion: decreased GI motility, N/V, ascites, abdominal distention, and anorexia
  • Jugular Vein Distension (JVD)

Diagnosis of Congestive Heart Failure

• Diagnosis based on presenting signs and symptoms and patient history
• Confirmation through non-invasive and invasive diagnostic tests

Diagnostic/Laboratory Tests for Congestive Heart Failure

• Chest x-ray detects an enlarged heart, fluid accumulation in the lungs, and pleural effusion
• Electrocardiography (ECG) rules out myocardial infarction or cardiac dysrhythmias
• Echocardiography determines valvular disease, heart disease, pericardial fluid, and ejection fraction:
  • Normal ejection fraction is 50%-70%
  • Moderate heart failure ranges from 40-50%
  • Severe heart failure is less than 40%
• Exercise stress testing determines activity tolerance and the extent of ischemic cardiovascular disease
• Cardiac catheterization identifies cardiac abnormalities and cardiovascular disease
• Pulmonary artery catheterization assesses right vs. left function/pressures
• Laboratory tests:
  • Serum electrolytes (Na, Ca, Mg, K) are necessary for muscle contraction
  • Elevated Na, BUN, and creatinine indicate kidneys are not functioning well
  • Liver Function Tests show liver enzyme values slightly elevated due to congestion in the liver or decreased cardiac output
  • BNP (B-type natriuretic peptide) is released by the heart muscle when the walls are stretched, with a normal level less than 100pg/ml

Medical Management of Heart Failure

• Goal: reduce the workload of the heart and improve pumping ability
• Drug Therapy: digoxin and vasodilators increase cardiac efficiency, decrease workload, and increase cardiac output
• Therapeutic management includes lowering the oxygen requirements of the body system:
  • Elevate the HOB to 45 degrees or have the patient sit in an orthopneic position to reduce myocardial oxygen demand and decrease circulating volume returning to the heart Decreasing oxygen requirement through rest and anxiety management
• Reduce edema and pulmonary congestion with diuretics, a sodium-restricted diet, and fluid restriction:
  • Weighing the patient daily helps determine if the patient is retaining fluid
• A biventricular pacemaker can improve symptoms and function, improve quality of life, and decrease hospitalizations
• Implanted cardioverter-defibrillators can decrease the risk of sudden cardiac death

Nursing Interventions for Heart Failure

• Aimed to prevent disease progression and complications
• Monitor vital signs for changes and note any signs of respiratory distress or pulmonary edema
• Auscultate lungs for crackles or wheezes, also noting cough and if it is productive (pink frothy sputum = pulmonary edema)
• Provide oxygenation with a nasal cannula or positioning
• Monitor for signs and symptoms of Right vs. Left Heart Failure
• Monitor urinary output and note edema
• Elevate the patient's legs to help decrease edema
• Monitor abdominal girth and daily weights as indicators of fluid retention
• Provide meticulous skin care and use prophylactic measures to prevent skin breakdown in patients with severe edema
• Assist in maintaining an adequate nutritional intake while observing sodium and fluid restrictions
• Restful sleep may be possible only in the sitting position or with extra pillows
• Activity intolerance is accompanied by extreme fatigue and anxiety, which increases the work of the heart
• Assess the patient for depression and explain that depression is readily treatable with several approaches
• Patient teaching is paramount and should include monitoring for signs and symptoms of worsening Heart Failure (HF)

Pulmonary Edema

• Accumulation of extravascular fluid in the lungs and alveoli primarily caused by heart failure
• Acute, extensive, life-threatening complication of left-sided heart failure
• Involves fluid from the left side of the heart backing up into the pulmonary vasculature, resulting in fluid accumulation in the interstitial lung space and alveoli, decreasing gas exchange
• Clinical Manifestations include Severe respiratory distress
  • Frothy sputum from air mixing with fluid in the alveoli
  • Blood tinged from blood cells bursting in the alveoli

Assessment of Pulmonary Edema

• Subjective feelings of vague uneasiness, restlessness, agitation
• Objective indications: disorientation, diaphoresis, severe dyspnea, tachypnea, tachycardia, pallor and cyanosis, cough (productive with pink frothy sputum), audible wheezes, crackles, and cold extremities

Diagnostic Tests for Pulmonary Edema

• Based on physical examinations (s/s) and supported by chest radiograph and arterial blood gas analysis

Medical Management of Pulmonary Edema

• Requires simultaneous treatment to promote oxygenation, improve cardiac output, and reduce pulmonary congestion
  • Place the patient in high Fowler's position to promote lung expansion and oxygenation
  • Administer Morphine Sulfate 10-15 mg titrated IV to decrease the patient's anxiety, slow respirations, reduce venous return, and dilate pulmonary blood vessels
  • Administer Oxygen 40-60% via a nonrebreather face mask, progressing to intubation as needed
  • Place a Foley catheter
  • Give Medications: Diuretics, Inotropic agents, Vasodilators

Nursing Priorities/Plan of Care for Pulmonary Edema

• Improving oxygenation and decreasing excess fluid to cardiac output
  • Administer oxygen effectively
  • Place the patient in an upright position with lower extremities lower than the heart to decrease venous return
  • Assess pulmonary status often for signs of hypoxia
• Providing emotional support and explaining procedures to help calm the patient
• Promoting decrease in fluid volume
  • Administer medications to decrease fluid volume, increase heart contractility, and decrease peripheral vascular resistance
  • Measure intake and output carefully to track fluid balance and ensure diuretics are effective
  • Weigh the patient at the same time each day with the same clothes and bed sheets to track fluid loss or gain
  • Assess for edema in all dependent areas to ensure a decrease in edema or degree of pitting
  • Monitor serum electrolyte levels, due to diuretics
  • Monitor digoxin levels to prevent toxicity
  • Monitor renal and liver function to ensure medications are processed properly
• Monitor BP, HR, and EKG during medication administration
• Provide Patient Teaching: Explain the rationale for medication and the need for frequent monitoring