Module 8 Heart Failure W24 PDF

Care of the Patient with: Heart Failure NUPD 701: Week 8  Preload: amount of blood in the ventricle before contraction  EDV end diastolic volume  Afterload: pressure required to open the valve – think of opening a door that someone is trying to hold closed...

Care of the Patient with: Heart Failure NUPD 701: Week 8  Preload: amount of blood in the ventricle before contraction  EDV end diastolic volume  Afterload: pressure required to open the valve – think of opening a door that someone is trying to hold closed A Quick  Stroke volume: volume of blood pumped out of the heart with each contraction – dependent on – ( per beat) Reminder –  preload/after/contraction key terms  Cardiac Output: the amount of blood the heart pumps in 1 minute, dependent on  Heart rate, Contractility, Preload & Afterload Heart Failure – let’s hear from an expert   An abnormal clinical syndrome which involves impaired cardiac pumping and/or filling  Ventricle has an impaired ability to fill or eject blood  Characterized by:  ventricular dysfunction  reduced exercise tolerance Heart Failure  diminished quality of life & shortened life expectancy  Mortality is high  Risk factors are numerous  What are they?  Consider manifestations  Acute Heart Failure & Chronic Heart Failure 4 By the end of our lecture be sure you can answer the following: What lifestyle changes are required What dietary changes are required Purpose of certain medications (think of the triad) *** need to know REVIEW 6  REVIEW HF may be caused by interference with the normal mechanism regulating cardiac output (CO) What can impact CO depends on: Metabolic Cardiac Preload Afterload Myocardial contractility Heart rate state of the individual Output Any alteration in these factors can lead to decreased ventricular function and the resultant manifestations of HF Heart Failure Challenge Game 7   Systolic HF: The left ventricle can’t contract vigorously, indicating a pumping problem Types of Heart  Diastolic HF: The left Failure ventricle can’t relax or fill fully, indicating a filling problem (also referred to as HF with preserved EF) Types of Heart Failure Left-sided HF:  Results from LV dysfunction causing blood to back up through the left atrium and into the pulmonary veins  Increased pulmonary pressure causes movement of fluid into the interstitium, and then into the aveoli Types of Heart Failure Right-sided HF:  Causes backward blood flow into the right atrium and venous circulation  Venous congestion in the systemic circulation results in peripheral edema, hepatomegaly, splenomegaly, vascular congestion of gastrointestinal tract, and jugular venous distention  Primary cause of RSF is LSF  May also be caused by right ventricular infarction  Classification of HF Cl No limitation of physical activity. Ordinary physical activity as does not cause fatigue, dyspnea, palpitations, or angina pain Classification is s based on the 1 Slight limitation of physical activity. No symptoms at rest. Cl person’s as Ordinary physical activity results in fatigue, dyspnea, palpitations, or angina pain tolerance to s physical activity 2 Marked limitation of physical activity. Usually comfortable at Cl as rest. Ordinary physical activity causes fatigue, dyspnea, palpitations, or anginal pain s 3 Inability to carry on any physical activity without discomfort. Cl Symptoms of cardiac insufficiency or of angina may be as present even at rest. If any physical activity is undertaken, s discomfort is increased 4 Clinical Manifestations***  Manifestations of HF depends on the type of heart failure, the ventricle involved, and underlying cause  Impaired tissue perfusion, pulmonary congestion, and edema dominate the picture of left ventricular failure  Systemic venous congestion and peripheral edema are associated with right ventricular failure   Hacking cough, worse Pulmonary Congestion Decreased Cardiac Output at night  Fatigue  Dyspnea/  Weakness breathlessness Clinical Manifestations:  Oliguria during day; nocturia  Crackles or wheezes in  Angina Left Sided Heart lungs  Confusion, restlessness Failure  Frothy, pink-tinged  Dizziness  Tachycardia, palpitations sputum L – left & lungs  Tachypnea  Pallor  Weak peripheral pulses  Cool extremities  Systemic Congestion:  Jugular (neck vein) distention  Increased BP (from excessive volume) OR Clinical decreased BP (from failure)  Enlarged liver & spleen Manifestatio  Anorexia and nausea ( due to edema and ns: Right compression of vesical organs)  Distended abdomen Sided Heart  Weight gain Failure  Dependent edema (legs & sacrum)  Swollen hands and fingers  Polyuria at night Clinical Manifestations of HF Heart Failure Complications  Pleural effusion  Dysrhythmias – Atrial Fibrillation is most common  Loss of atrial kick can reduce CO by 20%  Promotes thrombus/embolus formation – risk stroke  Hepatomegaly/Ascites  Fibrosis and cirrhosis can develop over time  Can store up to 10 L  Renal insufficiency or failure  Cardiogenic shock *Consider each and what you would assess/monitor  Goal of therapy : Improve left ventricular function by  Decreasing intravascular volume  Decrease fluid intake (fluid restriction) and no sodium  Decreasing venous return (preload) Goal of  Lasix  Decreasing afterload Manageme  ACE inhibitor ( angioedema, cough, increased potassium) nt: Acute HF  Beta blocker  Prevents RAAS system  Reduce pulmonary congestion  Position patient  Improving gas exchange and oxygenation  Increasing cardiac output  Reducing anxiety 19   Treat underlying cause  High fowler’s position  Oxygen ? O2 sat  Cardiac & hemodynamic monitoring  Weight Manageme  Drug treatment: diuretics, morphine, vasodilators, nt: Acute HF inhibitors of RAAS, Beta-blockers, anti-dysrhythmic drugs  Cardioversion  Endotracheal intubation & mechanical ventilation  Circulatory assistive devices  Main goal is to treat underlying cause and contributing factors:  Maximize cardiac output & reduce cardiac workload Goal of  Improve myocardial contractility Manageme  Provide treatment to alleviate symptoms nt: Chronic HF  Manage arrhythmias, hypertension, CAD  Physical and emotional rest 21  Nutritional therapy:  Mild HF: 2g Na diet; severe HF: 1g Na diet  Dietitian  Consider sociocultural factors Nutritional  DASH diet Manageme  Fluid restriction (1.5-2L/day): may or may not be required nt: Chronic HF  Daily weights important: same time, same clothing each day  Eg. Weight gain of 3 lb (1.4 kg) over 2 days or a 3- to 5-lb (2.3 kg) gain over a week: report to health care provider  General therapeutic objectives for drug management of chronic CHF include:  Identification of the type of CHF and underlying causes  Correction of sodium and water retention and volume overload  Reduction of cardiac workload Medical  Improving myocardial contractility  Control of precipitating factors Manageme Drugs: nt: Chronic  Diuretics – reducing sodium/fluid retention  ACE-Inhibitors – reduces afterload, side effects HF  Beta-adrenergic blockers (metoprolol) – reduces afterload, improves contractility, decreased risk of arrythmias  Inotropic drugs – vasodilators (nitrates)-> increase risk of arrythmia , beta-adrenergic agonists (dopamine), digitalis (cardiac glycosides eg. digoxin)-> help with contractility , phosphodiesterase inhibitors (milrinone)  diesterase inhibitors – enhances calcium entry into the cell and improves myocardial contractility, increase CO & reduce arterial pressure (decrease afterload) Nursing Assessment  Subjective  Objective Symptoms Nursing Diagnosis  Decreased cardiac output  Activity intolerance  Excess fluid volume  Ineffective breathing pattern  Impaired gas exchange  Anxiety  Deficient knowledge  Fear Can you identify other possible nursing diagnoses?  Overall goals for a patient with HF:  Decreased peripheral edema  Decreased SOB  Increased exercise tolerance  Adherence to drug regimen Planning  No complications related to HF Nursing Interventions:  Teaching: individual & family  Exercise promotion  Discharge planning   Cardiac pump effectiveness  Energy conservation Outcomes  Vital sign status  Knowledge: illness care and self-care management   Treatment of underlying heart disease Nursing  Coronary revascularization Implementati  Treatment of hypertension, CAD on:  Smoking cessation Health  Yearly vaccinations: influenza, pneumococcal promotion  Preventive care: slow progression of disease  Diet, medication, exercise regimen  Decreased cardiac output:  Recognize primary characteristics of decreased cardiac Nursing output: fatigue, dyspnea, edema, orthopnea, paroxysmal nocturnal dyspnea, weight gain, hepatomegaly, jugular venous distention, Intervention palpitations, lung crackles, coughing, clammy skin, skin color changes s: Acute  During acute events, client is placed on short-term bed rest or maintains activity level that does not compromise cardiac output  Monitor pulse oximetry and administer oxygen prn  Monitor VS at rest and during activity  Review lab results and hemodynamic monitoring results*** See Ackley text with corresponding Nursing Diagnosis   Fluid restriction: keep accurate intake & output  Teach relaxation and ROM exercises  Apply graduated compression stockings  Serve small, frequent, sodium-restricted, low saturated fat meals Nursing  Fluid restriction (as indicated) Intervention  Plan frequent rest periods alternate with activity s  Exercise  Elevate legs when sitting  Self management tools: daily weight, drug regimen, exercise plans  Activity Intolerance:  Provide O2 as needed  Practice deep breathing exercises  Teach energy saving techniques Nursing  Prevent interruptions at night Intervention  Monitor progression of activity s  Offer 4-6 meals a day What nursing interventions can you identify based on other nursing diagnosis discussed?   Refer to cardiac rehabilitation program for education & monitored exercise  Facilitate recommended weekly exercise (30-40min, 3-5x Nursing per week, aerobic activity & resistance training  Health teaching Intervention  Assist patient to adapt to physiological & psychological s: Chronic changes  Integrate patient & family or support system into overall care plan  Energy-saving/efficient behaviors What are some psychosocial nursing interventions/considerations can you identify?