Heart failure exam 5

What is enhanced external counterpulsation (EECP) and a ventricular assist device (VAD)?

devices on legs that pulsate to improve symptoms of HF. therapy multiple times a week to be effective

How is SHF diagnosied? (4)

echocardiogram BNP levels EKG Chest X ray

What are preload enhancers and reducers?

enhancers: fluids reducers: diuretics

Afterload enhancers and reducers?

enhancers: vasoconstrictors (dopamine, leviphed) reducers: vasodilators

What are the 6 respiratory complications of HF?

pulmonary edema, pneumonia, cardiac asthma, pleural effusion, cheyne-stokes respiration, respiratory acidosis

pulmonary is more _____ edema is more _____

pulmonary//left edema//right

What is the hallmark finding of Systolic heart failure ?

reduced EF ejection fraction

BNP levels above 900 pg/mL indicate

severe heart failure

what do calcium channel blockers and beta blockers do?

slows everything down gives time for ventricles to fill

HF compensation- hormonal response

(Release renin leads to sodium retention & peripheral vasoconstriction & ADH secretion, increased blood volume) atrial natriuretic factor.

• What are the considerations when planning care for a patient with HF?

-Activity intolerance related to fatigue -Sleep pattern disturbance related to nocturnal dyspnea and nocturia. -Fluid volume excess related to pump failure & fluid retention. -Risk for impaired skin integrity related to edema or immobility. -Impaired gas exchange related to increased preload, mechanical failure, or immobility. -Anxiety related to dyspnea or perceived threat of death. -Ineffective management of therapeutic regimen related to lack of knowledge regarding....

What are the nursing interventions for HF?

-Administer prescribed medications -Assess lung and heart sounds -Assess for EKG changes -Monitor I&O -Daily weights -Monitor labs (electrolytes, BNP and renal function) -Monitor vitals (postural hypotension) -Monitor for changes in LOC -Monitor O2 saturation -Monitor ascites/edema

What 4 drugs are used for DHF?

-CCB -BBB -ARBS -ACE1

what does natrecore do?

-Decreases plasma levels of norepinephrine and aldosterone; indicating that it blunts activation of SNS & RAAS in client's with heart failure. -Improves pulmonary pressures, Urine output

What are 6 risk factors for heart failure?

-Hypertension -Atherosclerotic disease -Diabetes -Obesity & insulin resistance -Patients using cardiotoxins -Family history of cardiomyopathy -Metabolic syndrome (abdominal adiposity, hyertriglyceridemia, low HDL, HT, fasting hyperglycemia) ****side effects of myocardial infarction

Describe the vicious cycle of heart failure? Three steps

-LV Dysfunction causes Decreased cardiac output -Decreased Blood Pressure and Decreased Renal perfusion -Stimulates the Release of renin, Which allows conversion of Angiotensin to Angiotensin II. Angiotensin II stimulates Aldosterone secretion which causes retention of Na+ and Water, increasing filling pressure

What are the CLINICAL MANISFESTATIONS OF LHF?

-Pulmonary congestion and decreased CO -Fatigue -Dizziness and syncope -Dyspnea, SOB, Cough, orthopnea, cyanosis, -crackles, wheezes -Cheyne-Stokes respirations, Crackles, poor oxygen exchange -LV heaves, S3 & S4, displac- -ed PMI (LVH) -Increased HR, Pulsus alternans

What 5 things happen when contractility is decreased in SHF?

-SV falls -Ventricular end diastolic volume (VEDV) is increased -This causes dilation of the heart and increased preload -Increase in afterload is commonly related to increase in PVR d/t HTN -With increased afterload there is resistance to LV emptying and more work load on the ventricle. Which responds with hypertrophy of the myocardium. large ventricle that doesn't contract well at all

• What are the patient education guidelines for HF? How much Na, and H2O?

-Two gram sodium diet -Monitoring weight daily -Two liter fluid restriction -Monitoring blood pressure -Medications -Smoking cessation -Light aerobic exercise (Cardiac Rehabilitation) -Knowing whom to call -Achieving ideal weight -Follow-up visits

four examples of increased cardiac workload in HF what is the main one?

-Valvular heart disease -Anemias -Congenital heart defects *Hypertension

four examples of acute noncardiac conditions in HF

-Volume overload -Hyperthyroidism -Fever, infection -Massive pulmonary embolus

What are the clinical indications of heart failure in general? (What do you anticipate seeing with HF)?

-Weight gain -Edema -Nocturia -PND paroxysmal nocturnal dyspnea -Dyspnea at rest or with activity -Crackles -S3,S4, -Dysrhythmias -Pleural effusion

Which Class/ Drugs Should be Avoided in Acute Heart Failure and SHF?

-calcium channel blockers ex) diltiazem (cardizem) and verapamil

four examples of impaired myocardial contraction in HF what is the main one?

-coronary heart disease -cardiomyopathy -rheumatic fever -infective endocarditis

What are the three symptoms of DHF?

-dyspnea on exertion -fatigue -evidence of pulmonary edema (crackles, pleural effusions)

What are the four causes of high output failure?

-hyperthyroidism -infection -anemia -pregnancy

What are the compensatory mechanisms of HF? (There are 4)

-increased SNS stimulation -ventricular dilation -ventricular hypertrophy -hormonal response

HF compensation -SNS stimulation -what increases? -this results in what three things?

-increased epinephrine & norepinephrine results in: -increased HR and contractility -increased myocardial oxygen need & workload -vasoconstriction and increased venous return to the heart

What are symptoms of RV failure? (righted sided failure)

-peripheral edema -ascites -heptosplenomeglay

What are the 5 items that interfere with CO?

-preload -afterload -myocardial contractility -heart rate -metabolic state of client Alterations in these factors may lead to decreased ventricular function ...HF

BNP levels above 600 pg/mL indicate

moderate heart failure

What is the treatment for DHF aimed at?

Aimed at improving ventricular relaxation, and prolonging diastolic filling times to reduce diastolic pressures.

• WHAT ARE THE SYMPTOMS OF DIGOXIN TOXICTY?

Anorexia, fatigue, blurred vision, and changes in mental status, dysrhythmias (PVC)

Why do you monitor for angina when a patient is on dig for HF?

Any drug that increases the workload of a failing heart also will increase O2 requirements. Monitor for angina.

What is the BNP?

B-type natriuretic peptide (BNP)- molecular marker that is unequivocally associated with congestive heart failure. -Plays a key role in volume homeostatis, producing balanced vasodilatation, positive neurohumeral changes (¯endothelin & aldosterone levels) and diuresis and natriuresis

what do ace inhibitors and ARBS do?

Block conversion of angiotensin I to angiotensin II, preventing vasoconstriction and increases afterload

Left heart failure is commonly referred to as can be further categorized as:

CHF congestive heart failure Left heart failure can be further categorized as systolic (SHF) and diastolic failure (DHF).

What can cause RV failure?

Can result from left heart failure when an increase in LVFP is reflected back into pulmonary circulation.

How is DHF diagnosied?

Echocardiogram demonstrates a normal EF with poor ventricular filling

What is high output failure?

Hypermetabolic states require increased cardiac output to maintain tissue oxygenation and perfusion.

systolic ventricular failure -what is it? -characteristics

Impaired emptying ¯muscle ability to contract or pump resulting in inability to move blood forward ¯Ejection Fraction -Pulmonary pressures -Caused by loss of myocardial cell (ischemia or infarction) cardiomyopathy or inflammation

Diastolic ventricular failure -what is it? -6 symptoms?

Impaired filling and relaxation -SOB -tachypnea -crackles if LV is affected -distended neck veins -liver enlargement -anorexia and nausea if RV is affected

class 4 CHF

Inability to carry on with any activity without having symptoms. May have s/s at rest

What is the cause/etiology if HF?

Interference with normal mechanisms regulating cardiac output (CO)

Isolated DHF is defined as?

Isolated DHF is defined as pulmonary congestion despite a normal SV and CO.

DHF is more common in what sex?

It is the cause of 40-50% of left heart failure and is more common in women.

RV failure occurs secondary to??

LV failure or various types of lung diseases

class 3 CHF

More severe limitations, usually comfortable at rest, have s/s with usual activity

class 1 chf

No limitation on physical activity, physical activity results in no symptoms

What is a normal BNP? levels reflect severity of what?

levels less than 100 are normal. They reflect the severity of heart failure

class 2 CHF

Slight limitation on physical activity, no s/s at rest but possible with ordinary physical activity

What is the goals of HF management?

Slow the progression reduce cardiac workload improve cardiac function control fluid retention.

What are the symptoms of SHF? What are these due to?

Symptoms are a result of pulmonary congestion and inadequate perfusion of systemic circulation. -Dyspnea -cough of frothy sputum -fatigue -decreased UO -edema -cyanosis -pleural effusions -rales, -S3 gallop.

What is heart failure? Understanding this definition, what kind of symptoms will be seen?

The heart is unable to pump an adequate amount of blood to meet the metabolic needs of the tissues. impaired ability of ventricle to fill or eject blood Symptoms of hypoperfusion will be seen

What are the 4 GI/GU complications of HF?

malnutrition, ascites, liver dysfunction, renal involvement

what is afterload

The ventricular pressure at the end of systole (resistance/pressure against the ejection of blood) increased with hypertension and vasoconstriction

What are the metabolic complications of HF?

metabolic acidosis

How is SHF treated? what is treatment aimed at?

Treatment is aimed at interrupting the worsening cycle of decreased contractility and increased preload and afterload. -ACE-I, BBB, Diuretics -ARBS -Aldosterone Blockers

How do you diagnosis HF?

determine underlying etiology and assess degree of HF, echo, BNP (b-type natriuretic peptide). CXR, electrolytes, UA, BUN, ECG.

• What are the discharge instructions for a patient with HF? How much weight can they gain?

Worsening Heart Failure -Rapid weight gain (3 lb/wk or 1-2 lb overnight) -↓exercise tolerance lasting 2-3 days -Excessive awakening @night to urinate -Development of dyspnea or angina at rest or worsening angina -↑swelling in feet, ankles or hands

What are the 5 cardiac complications of HF?

angina, dysrhythmias, sudden cardiac death, cardiogenic shock, LV thrombosis

• What do you monitor prior to giving dig?

apical pulse

If RV failure occurs in the absence of LV failure, what causes it?

caused by hypoxic lung disease: COPD, cystic fibrosis, ARDS. These disorders result in an increase in RV afterload.

BNP levels above 300 pg/mL indicate

mild heart failure

BNP levels of 100-300 pg/mL suggest

heart failure is present

what position should a patient with acute HF be in?

high fowlers with elevated legs

Why do we monitor renal function?

hypoperfsuion, kidneys will have decreased blood flow increasing creatine and BNP

what is a common side effect of natracore?

hypotension

HF compensation- ventricular hypertrophy

increased contractile force, poor contractility

HF compensation- Ventricular dilation

increased contraction, overstrained leading to ventricular remodeling

What is the most common type of HF?

left ventricle (LV)

• What is the medical management of HF?

nACE inhibitors and beta blockers for all heart failure patients if they can tolerate it. nDiuretics are needed in most patients to manage fluid retention. nDigoxin is reserved for patients with signs and symptoms of heart failure. nAldosterone blockers improve survival and prevent hospitalizations. nHydralazine plus a nitrate may be added to ACE and a beta-blocker for additional symptomatic benefit. n nC-PAP will increase intra thoracic pressure, giving a boost to ventricular contractility, thereby, reducing the afterload in acute HF.

• Why does the RV dilate and fail?

nAs pressure in the pulmonary circulation rises, the resistance to the RV emptying increases. The RV is poorly prepared to compensate for this increased afterload and will dilate and fail

What is the general patient population with DHF?

ngenerally an elderly female with underlying CAD, HTN, DM or valvular disease.

BNP levels below 100 pg/mL indicate

no heart failure

When does DHF occur?

occurs when the ventricle can not fill properly because it can not relax or because the wall is too thick/rigid. A low left ventricular end diastolic volume (LVEDV), results in in increased left ventricular end diastolic pressure (LVEDP). This pressure is reflected back into pulmonary circulation and will result in pulmonary edema.

what is ejection fraction? What is normal? What is concern?

percentage of blood ejected from the heart during contraction. Thus, creating an inability for the heart to generate an adequate CO to perfuse the vital tissue. (normal 50-70%, below 40% is abnormal)

DHF is described as?

preserves systolic function (normal EF)

what is stroke volume?

the amount of blood pumped by the left ventricle per beat

the end diastolic filling volume is directly related to

the degree of stretch of the myocardial muscle of the ventricles (the basis of the Frank-Starling Law of the Heart)

What are the integumentary complications of HF?

tissue breakdown

What is preload

volume of blood in ventricles at end of diastole End-diastolic filling volume (EDV) at the beginning of systole (contraction).

with SNS stimulation there is an increase in preload due to ____________ increase in afterload due to ____________

with SNS stimulation there is an increase in preload due to the water and sodium retention increase in afterload due to the vasoconstriction

increased afterload gives you and increased ___

workload

Can DHF occur with SHF?

yes