Cardiac concepts and heart failure

hepatomegaly

enlarged liver, especially with right sided heart failure, the liver becomes congested with venous blood which impairs liver function and can lead to cirrhosis,

Preload

Affects SV volume of blood in the ventricles at the end of diastole before the next contraction This is the amnt of blood in the ventricle during diastole/ The biggest component to this is how stretched can those fibers in the heart become to allow the most blood to enter the heart before each contraction determined by the amnt of stretch on these fibers so can be increased or decreased by things like heart attack or hypobulimia

Diastole

Blood flows from region of high pressure to low pressure. This gradient is created by two major events. Diastole and systole. Relaxation of the myocardium allowing for filling of the ventricles is when the heart is relaxed and in its lowest pressure. This allows the venous blood to flow in from the vena cava into the right side of the heart and the o2 of the blood flow in from the lungs to the left side of the heart

Systole

Blood flows from region of high pressure to low pressure. This gradient is created by two major events. Diastole and systole. When heart is full it will rapidly increase the pressure inside the heart to force blood out of the ventricles to the body and lungs this is known as___. Once blood is ejected heart will relax and decrease its pressure allowing for diastole to start a new. •Contraction of the myocardium resulting in the ejection of blood from the ventricles contraction of the myocardium resulting in the rejection of blood from the venticles

Ongoing monitoring

FACE Fatigue: monitor for fatigue after usually activities, may be fatigued due to a decrease cardiac output or organ perfusion, so somethings not working if they are getting tired easily and more frequently Activity limitation: Congestion: look for those signs of cost and congestion if they have that fluid building up in their lungs. Edema: Edema if its dependent around the liver, abdomen and lungs, if they are bed bound look at there sacrum and scrotal areas on patients cause they collect fluid Shortness of breath: reabsorption of fluid when they're in a dependent body area, if u lay them flat and they cant breathe they'll wake in a panic, they'll feel like they are suffocating when, they want to get up they do not do well lying down. also confusion and poor sleep with elderly patients can be a sign of worstening conditions other sign symptom:Skin changesShiny swollen lower extremities Decrease or absent hair growth Chronic swelling leads to pigment changes so they can have dusky brownish colored skinBehavioral changes: if u are restless cause you cant sleep you can be confused, impaired memory or attention span cause all ur body is focusing on being able to breath Chest pain: especially with increased workload and if your cardiac output isn't appropriate from that decreased perfusionWeight changes: tell ur patients that they need to report a three pound change in two day so if they weigh themselves and if they have gained 3 pounds in two days they need to talk to their daughter or if they have gained 5 pounds in over a week important to follow up with health care provider and even follow up with their health care provider often because things can change day to day with these patients so close management is really important.

increased preload as a compensatory mechanisms

Increase preload is a consequence of reduced ejection fraction with a low ejection fraction the heart isn't able to pump out enough blood leading to decreased cardiac output. This means the kidneys aren't getting enough blood causing the renin aldosterone angiotension system and the sympatehteic nervous system to be activated this means the kidneys will retain na and h20 to increase blood volume which increases your preload. This enhances the ability of the myocardium to contract forcefully. Yout heart platueas at a certain point causisng more fluid rention than good contractions

Activity program

Increase their activity gradually, as long as it doesn't cause dyspnea Consider cardiac rehab Avoid extremes of heat and cold: cause more energy for ur body to regulate temp Plan rest periods after exertion (ADLs or exercis) Shorten working hours

Long term regulation of blood pressure

Long term regulation occurs when the renin-angiotensin aldosterone system created hormonal changes and the kidneys will start retaining sodium and water along with angiotensin 2 which is a vasoconstrictor

Treatment Goals

Maximize CO: Maximize cardiac output So that everything in the body is getting what it needs Preserve organ function: cause heart failure can affect your other organs Reduce symptoms improve ventricular function improve quality of life preserve organ function improve mortality and morbidity risks

Left sided heart failure symptoms

More common because the left ventricle is the stronger of the hearts two pump This may subsequently cause the right side to fail L side pumps blood out to the body therefore it receives blood from the lungs if it isn't pumping blood out to the body effectively that means it is backing up into the lungs. Think of a traffic jam. When one lane is closed it slows progression due to less space regardless of the malfunction whethter it s systolic or diastolic it leaves the heart unable to pump enough blood into the circulation to meet the bodies demands. An increase pressure in the heart causes blood to back up in the pulmonary circulation producing congestion in the lungs. It reduces cardiac output to the bodies organs and tissues however the first symptoms are often caused by fluid backup and impaired gas exchange in the lungs. First symptoms include: shortness of breath, rapid breathing, orthopnea, paramoxical nocturnal dyspene, attacks of sob and coughing that generally occur at night and sometimes crackling noises that can be heard in the lungs. Reduced cardiac output may cause general fatigue, abnormal heart sounds and murmurs that occur when heart is enlarged, when blood pressure in the heart is raised or when the heart valves are malfunctioning. In more severe cases of HF patients may experience other symptoms related to a lack of o2 in the organs and tissues such as cold clammy hands and feet, cyanosis which is the blue around the lips, weakness, dizziness, and fainting.

left side of heart

Oxygenated rich blood enters the heart from the lungs and goes out to the body thisside of the heart takes the oxygenated blood from the lungs and pumps it out to the body for use.

Afterload

Resistance to the ejection. This is effected mainly by the BP. Elevated BP ventricles need an increase resistance Resistance left ventrilce must overcome to circulate blood the peripheral resistance against which the workload of the myocardium, resulting in increased 02 demand. is affected by the size of the ventricle, wall tension and arterial bp. If blood pressure is elevated the ventricles need increased resistance they have to push harder to get through those vessels. Eventually this increased work on the heart will result in enlargement of the muscle tissue without an increase in cardiac output or the size of the chambers.

short term regulation of blood pressure

SNS and vascular endothelium One way it is regulated is by the sympathetic nervous system. When this is activated epinephrine is secreted and the heart rate will increase, peripheral vasoconstriction occurs, and renin is released from the kidneys this leads to an increased BP by increasing both the cardiac output and the systemic vascular resistance.

sympathetic nervous system activation

Sympathetic nervous system is first but least effective, this is when your baroreceptors respond to a decrease stroke volume causing your central nervous system to increase the HR, vasoconstrict blood vessels and shift blood to increase preload. This is an acute process good for volume depletion but over time is harmful since the increased of the failing hearts workload and need for co2. and your vasoconstriction increases preload your venous return in an already overloaded heart which worsens ventricular performance In heart failure a major problem with sns activation is that afterload on the left ventricle can increase significantly. A high afterload increases cardiac workload and may decrease stroke volume. Treatment of hypertension is important to improve cardiac function

cardiac output

The amount of blood pumped to the body depends on the bodies demand. volume of blood pumped by each venricle 1 minute it equals SV*HR normal in the body: is 4-6 L per min but can vary depending on the metabolic needs of the body will change based on the metabolic demands so how do we get more or less ____ when necessary? If you increase or decrease the HR then your ____ will follow. Stroke volume isn't as simple. There are 3 factors that affect.

BNP test

The biggest lab test to foucs on. Enzyme that is found in the ventricles of the heart so as the ventricle stretch and contract BNP is released into the vascular system. This test allows us to assess for fluid overload because of the higher the value the more stretch that is occurring in the ventricles. BNP is a hormone produced by the heart muscles that correlate positively with the degree of left ventricular failure. Can be higher with other conditions so u need to correlate it with an echocardiogram where you actually get to look at the heart

right side of heart

This side takes the deoxygenated blood from the body and pumps it out to the lungs to be oxygenated. oxygen poor blood enters the heart from the body and goes out to the lungs

Treating Congestive Heart Failure: UNLOAD FAST

Upright position Nitrates (decrease filling and systemic resistance, ^CO) Lasix Oxygen Ace inhibitors Digoxin Fluids (decrease) Afterload (decrease) Sodium (decrease) Test (dig level, ABG, potassium) u want to unload the pressure on the heart fast

right sided heart failure

Usually occurs as a result of left sided HFWhen the left side fails pressure increases in the right side. Over time this damages and weakens the right side of the heart which overtime decreases pumping power this causes blood to back up in the circulatory system supplying the rest of the body causing fluid retention in the limbs particualary in the libs, the legs, ankles and feet, abdomen or along the lvier. Many of the symptoms are related to fluid retention in the organs and tissues in particular congestion in peripheral caplillary beds cause swelling unger the skin, periphereal edema, that may move around due to force of gravity for ex ankles and feet may sweel when standing up and the back may may swell when lying down known as sacral edema. Periphereal edema in the legs may lead to nocturia this happens because fluid retained in the legs during the day flows down to the blood stream when a patient lies down and is processed into the urine in the kidneys while they sleep in more severe cases the edema caused by right sided heart failure may result in pitting peripheral edema, a swollen abdomen due to fluid retention in the space within the abdomincal cavity, also know as ascites, or liver enlargement due to lfluid retention around the lvier.

Mean Arterial Pressure (MAP)

When measuring BP in a heart failure patient u want to look at this The ___ is the average pressure with in the atrial system that is felt by the organs of the body. This means that at a certain number this is what is necessary to perfuse and maintain vital organs in the body. So a ___greater than 60mmg is normal to maintain and perfuse your body organs. Anything lower than 60 your tissues and organs can start becoming ischemic.

heart failure

a condition where the heart is unable to provide sufficient blood flow to meet metabolic needs. caused by any condition that damages or weakens the heart occurs in 2 ways in diastolic: you have siff and thick chambers so the heart cant fill. you have decreased cardiac output in systolic: stretched and thin chambers, heart cant pump. so you cant pump enough blood to meet the bodies demands So you cant pump enough blood to meet the bodies demands or u have decreased cardiac ouput this can be caused by any conditions that damages or weakens the heart reduicing its ability to pump bood efficiently such as heart attacks, high bp, coronary artery disease and even infections. can occur in 2 ways either the heart ventricles cant pump blood hard enough during systole called systolic heart failure. Or not enough blood fills the ventricles during diastole called diastolic heart failure

What do nurses do?

assessment Assess fluid balance Monitoring intake and output Looking for signs of signs of dehydration JVD Assessing respiratory status of patient Interventions: Daily weights: tell u if they have gained a lot of fluid in the last 24 hours or not, helps ensure the accuracy of interventions Elevate HOB: these patients don't breathe well when lying flat. Administer medication obtain vital signs patient education: so they can manage this when they are no longer In ur care apply oxygen PRN Drug therapy: learn about in separate lecture Some surgeries if heart failure gets really bad Think about adequate rest period inbetween activites Structuring exercises such as cardiac rehab

Patient teaching

dietary therapy activity program ongoing monitoring health promotion rest drug therapy Making sure patient know to get their annual flu vaccine, pneumonia vaccine and get re-vaccinated in five year a lot of HF patients are at increased risk for resp problems because of fluid in the lungs They need to reduce their other risk factors such as managing their blood pressure, quit smoking, lose weight Dietary therapy: really need to look at labels, NA content

Clinical Manifestations

clinical manifestations caused by failure of the left ventricle Anxious, pale, possibly cyanotic Skin clammy and cold Dyspnea and orthopnea, tachypnea Accessory muscle use Wheezing/crackles, coughing, frothy blood tinged sputum tachycardia pulmonary edema which is your alveoli filled with ur sangeuineous fluid BP may change depending on the severity Not all dependent edema results from heart failure, there other conditions that can cause edema and certain meds can cause. so just cause patient has edema u also want to make sure if they are a heart failure pt.

dietary therapy

examine labels to determine sodium content some laxatives, antacids and cough med contain sodium avoid adding salt to foods when cooking weigh yourself at the same time each day in AM, same scale, similar clothes Eat smaller, more frequent meals Water follows sodium So taking in a lot of excess sodium u are going to be retaining a lot of excess fluid.

sympathetic nervous system

fight or flight, has receptors for epinephrine and norepinephrine this increases the heart rate.

systemic vascular resistance

force opposing the movement of blood. On the left side of the heart the pressure that the left ventricle is pushing against When the blood vessels tighten or constrict the ___ increases which result in decreased stroke volume and decrease cardiac output this causes the heart to work harder increasing the oxygen demand. The opposite occurs when the blood vessels dilate.

diagnostic of heart failure

health history: Health care providers will likely start by taking a med history, reviewing symptoms and risk factors doing a physical assessment to check for signs of congestion or abnormal heart sounds blood test:CBC, BMP, BNP: Blood samples to test for kidneys liver and thyroid disease all of which may affect the heart function Chest Xray: Chest CT: EKG: ECHO: Stress test: A stress test using a tredmill or stationary bike to test how well the heart responds to exercises Coronary Angiogram: can reveal narrowed arteries and the strength of the pumping action of the left ventricles and the health of the heart valves Various image test that visualize the congestion of the lungs and the heart : MRI, Xray. Will show whether or not the heart is enlarged, if there is fluid buildup in the heart or lungs as well as help diagnose other heart problems including the cause of heart failure. Other useful test include ECG that test the electrical activity of the heart and can reveal abnormal heart rhythms and echocargiogram which is an ultrasound of the heart which can distinguish between systolic abnormal pumping and diastolic abnormal filling as well as indicate valve problems and other heart abnormalities and also provide the measure of the ejection fraction which can determine how well the heart is pumping and help guide therapy And a myocardial biopsy which can help diagnose heart muscle disease that could cause heart failure

factors affecting cardiac output

heart rate and stroke volume The _______ will change based on the metabolic demands so how do we get more or less when necessary? If you increase or decrease the HR then your _____ will follow.

stroke volume increasing HR

in order to increase HR the preload needs to increase, the contractility needs to increase and the afterload needs to decrease

Pleural effusions

increased pressure in the pulmonary capillaries leads to fluid leakage in the pleural space. You will see in chest xray it looks like they have a bunch of fluid in their lungs.

Contractility

increasing raises the stroke volume by increasing vascular emptying the amount of force generate by the myocardium the point the myocardial fibers are stretched the greater their force

myocardial cell growth

increasing the myocardial itself: this results in myocardial hypertrophy. Takes the longest to occur. So when the RAAS is activated the angiotensin also changes the heart muscle it will cause the heart growth pathways to activate. Initially this helps compensate for the acute loss of heart muscle after an MI but over time this creates a remodeling causing the ventricles to become stiff that doesn't allow the stretch needed during diastole

Systolic blood pressure

peak pressure exerted when heart contracts

Blood pressure

measure of the pressure exerted by blood against the walls of arteries affected by: systemic vascular resistance (SVR): force opposing the movement of blood Cardiac output we need Adequate BP to maintain tissue perfusion without increasing the demand on the heart

Regulation of BP

nervous/cardiovascular/renal/endocrine functions Short term mechanisms: SNS and vascular endothelium long term mechanisma: renal and hormonal processes

Diastolic heart failure

not a pumping problem A filling problem Thicker muscles more pumping power less filling space One of your compensatory mechanisms after a myocardial injury is to create thick muscles in order to increase pumping power most commonly as a result of high BP, or pushing against that increase pressure for long periods of time, the problem is these new thicker muscles now take up more space inside the ventricles which doesn't allow as much space for blood in the filling stages. The inability of the ventricles to relax and fill during diastole is which leads a normal ejection fraction but the decrease filling of the ventricles results in a decrease stroke volume and cardiac output Water bottle: this time you are using all the muscles you have to squeeze that water bottle. But this time the water bottle is only half way full so you cant get as much blood out because there isn't as much blood in there to begin with.

systolic heart failure

not pumping with enough force after cardiac cell death less muscle to pump the same amount of blood thin, weak heart muscle Hallmark sign: Decreased ejection fraction less than 45%. You left ventricle loses the ability to generate enough pressure to eject blood forward through the aortic its like taking a waterbottle and pinching it with a thumb and finger only. Not as much force so u arent getting out as much cardiac output out of the water bottle Typically occurs from Impaired contractility function, increased afterload which is your high BP and your hypertension patients, cardiomyopathy and alteration in the heart itself or even some valve disease of the heart

ejection fraction

percentage of end-diastolic blood volume that is ejected during systole Normal is 55-70% Heart failure <40 No matter how forceful the contraction the heart can never fully extract all the blood from the heart. This leads to the ejection fraction. Typically only used to measure the left ventricle. Basically it's a measurement of how well the heart is pumping the blood. A normal ____ does not mean a normal heart. It is commonly used to gauge the degree of damage to the left ventricle in heart failure patients The _____ provides info about the left ventricle during systole. If its 60% this means that 60% of the total amnt of blood in the left ventricle is pumped out with each heart beat. You can still have heart failure with a normal ____

Complications of heart failure

pleural effusion dysrhythmias: due to the enlargement of the heart muscle your normal electrical pathways can be altered left ventricular thrombus hepatomegaly renal failure: U can have problems with kidneys renal failure due to decreased perfusion of the kidneys so heart failure can lead to a lot of other compications Afib: common dysrhythmia these patient will have increase rick of thrombus formation and stroke

Factors affecting stroke volume

preload, contractility, afterload increasing preload and or afterload increasees the workload of the myocardium, resulting in increased 02 demand.

Heart rate

regulated by the autonomic nervous system-parasympathetic and sympathetic

dystolic blood pressure

residual pressure in arterial system during ventricular relaxation, or filling

parasympathetic nervous system

rest and digest slow the HR and is usually controlled by the Vagus nerve

treatment

treating the underlying cause: HTN Lipid disorders: high cholesterol Obesity DM Thyroid life style changes: modifying daily activties stop smoking weigh mangement healthy diet sodium restriction healthy diet sodium restriction stay active limit alcohol

compensatory mechanisms

when the heart fails to provide adequate cardiac output to meet perfusion demands. the body responds to low cardiac output to try and maintain blood pressure and cardiac output there are 3 mechanisms: sympathetic nervous system activation, increased preload, and myocardial hypertrophy n short term these mechanisms are helpful in restoring cardiac output toward normal levelsIn long term these are detrimental to cardiac structure and function much of the current management of heart failure is aimed at offsetting these harmful outcomes

Stroke volume

•: Volume ejected from the ventricle with each heart beat •Approximately 70mL