Heart Failure-Chapter 35

Ride Sided HF

- Right ventricle cannot fully empty - The increased volume and pressure leads to systemic congestion

Cardiac Transplantation

- Still first choice for end stage - Specific criteria must be met - Not enough organs available to meet demand

Which of the following is a common side effect of Spironolactone? A. Renal failure B. Hyperkalemia C. Hypokalemia D. Dry cough

B

Cardiac Resynchronization (CRT)

- Biventricular Pacemaker - Electrical impulses stimulate chambers to contract simultaneously - Studies have proved clinical benefits - Can reverse remodeling, improve LV function and contractility

Discuss the compensatory mechanisms of HF

- Body tries to compensate the demands to increase cardiac output (CO) - This will usually work at first then actually makes it worse - Sympathetic Nervous System stimulation- --- Starlings Law-↑myocardial stretch = ↑ contraction strength --- More contractions ↑ SV and CO - Arterial Vasoconstriction- Maintains B/P, ↑ tissue perfusion, but increases resistance - Renin Angiotensin System Activation (RAAS)- From decreased blood flow to the kidneys activates Renin Angiotensin II → vasoconstriction→ aldosterone secretion → Na and H2O retention → ventricular remodeling (changes in the size and shape of the left ventricle) → contractile dysfunction - Myocardial Hypertrophy- Enlargement of - Results of RAAS

Primary Causes of HFrEF

- CAD with MI - Other diseases that cause LV enlargement - Other name -Systolic Dysfunction

Other treatments

- CPAP- obstructive sleep apnea --- Improves CO and EF-decrease preload and afterload, B/P and dysrhythmias - Stem Cell Therapy- studies ongoing at least 1 study improved EF and 6-minute walk test

Nutrition Assessment

- Cardiac Cachexia --- General physical wasting --- Poor prognosis-associated with a 50% mortality rate --- Higher hospital readmission rates --- About 15% of the heart failure population has cachexia, but about 50% of heart failure patients may be malnourished - Potential Causes: --- Hepatic Congestion o Gut edema and hepatic congestion can contribute to a feeling of fullness and nausea --- Neurohormonal Activation and Insulin Resistance - Interventions --- Screening --- Evidenced Based HF medications best treatment --- Diet-adequate calorie intake

Primary Causes of HFpEF

- Chronic HTN - Aortic Stenosis - Other name: Diastolic Dysfunction

Subcutaneous ICD

- Completely Subcutaneous - No lead inside the heart or vasculature - Delivers shock about 80 joules (twice as much because not in heart)

Understand vital patient teaching in collaboration with all members of the team

- Daily Weights --- same time each day (morning) --- call provider if weight puts them in the "yellow zone"- gain of 3 pound in 1 day or 5 pounds or more in a week --- "Teachable Moment"- morning weights in hospital - Medication adherence --- Do not to skip doses unless instructed --- Get refills before they run out of medicine or notify their provider if they are having difficulty paying for or obtaining their medicine before they run out --- If possible, ensure meds are in hand at discharge, or scripts have been faxed to the patient pharmacy --- "Teachable Moment"- administering diuretic - Symptom monitoring "red flags": --- Increased shortness of breath --- Weight gain of more than 3 pounds in 1 day or 5 pounds in one week --- Increased edema in their feet, ankles, legs or abdomen --- "Teachable Moment" - Diet Adherence- One of the biggest barriers! --- Research is changing on sodium intake and the value in HF --- Patients with congestion should limit salt intake-may help decrease congestion --- Great deal of "hidden salt" in processed food-avoid lunch meat, canned soups, canned vegetables, etc. --- "Teachable Moment" - Follow up appointments: --- A timely follow up appointment is a key concept of avoiding a readmission --- Evidence shows this appointment is best within 5-7 days, since many readmissions and symptom issues arise within 14 days of discharge --- Transitional Care Clinics --- HF Disease Center Clinics - Fluid Restriction as ordered --- May be asked to limit fluids (2000cc/day or 2 liters) --- Acute decompensated state --- Eating ice chips using smaller cups may help - Staying active - Stop Smoking - Avoid alcohol - Avoiding stress

Implantable Cardioverter Defibrillator (ICD)

- Detects life threatening arrhythmias- Sudden Cardiac Death (SCD) - Delivers shock about 40 joules

Identity laboratory and imaging testing

- Electrolyte imbalance may occur from complications of HF or as side effects of drug therapy, esp. diuretic therapy. Evaluations of a patient's serum electrolytes. - Any impairment of renal function resulting form inadequate perfusion cause elevated BUN and serum Cr and decreased creatinine clearance levels. - BNP (Brain natriuretic peptide) is used for diagnosing HF (diastolic HF) with acute dyspnea. - Basic Metabolic Panel (BMP)- drug therapy (diuretic) - Hemoglobin/ hematocrit tests should be performed to identify HF resulting from anemia. If patient has fluid volume excess, the hematocrit levels may be low as a result of hemodilution. - Urinalysis- proteinuria and high specific gravity - Microalbuminuria is an early indicator of decreased compliance of the heart and occurs before the BNP rises. - "early warning detector" - Chest X-rays can be helpful in diagnosing left ventricular failure. - Echocardiography is considered the best tool in diagnosing heart failure.-noninvasive technique. The test can also used to determine ejection fraction - Electrocardiogram (ECG) may show ventricular hypertrophy, dysrhythmias, and any degree of myocardial ischemia, injury, or infarction. However, it is not helpful in determining the presence or extent of HF.

Symptoms of Left Sided HF

- Forward flow to body poor-decreased CO - Blood backs up in pulmonary system --- Fatigue --- Dyspnea --- Decreased urine output --- Confusion --- Arrhythmias

Self Care/ Self Management-Barriers

- Health literacy - Non Adherence to plan - Cost of medications - Inadequate social support - Depression-chronic illness - Living alone - Cognitive Impairment

Explain the pathophysiology of HF

- Heart failure, sometimes referred to as pump failure, is a general term for the inability of the heart to work effectively as a pump. It results from a number of acute and chronic cardiovascular problems. - HF is common chronic health problem, with acute episodes often causing hospitalization. - Acute coronary disease and other structural or functional problems of the heart can lead to acute heart failure.

Treatment: Cardiac Devices

- Implantable Cardioverter Defibrillator (ICD) - Subcutaneous ICD - Cardiac Resynchronization (CRT) - External Defibrillator

hospice care

- Implemented at end of life - Prognosis <6 months - Offered when patient has poor response to medical or surgical therapy or declines further medical or surgical treatment

Cardiac Rehabilitation

- Important Nursing Assessments o Usually no palpable pulse- strength depends on the level of VAD assistance provided o Must use automatic B/P cuff-get Mean Arterial Pressure (MAP) ideal between 60-70 or Doppler

BNP (Brain natriuretic peptide)

- Increase in BNP, with history and symptoms of HF helps decipher if dyspnea related to lung issues or HF - Ventricles release in fluid overload - Renal patients may also have increased BNP - Level <100 unlikely HF >500 typically HF specific >900 severe HF >300-500 - gray area-use along with clinical picture and symptoms - Levels tend to be lower in obese patients and HFpEF - Levels elevated with MI and acute pulmonary embolism - Also affected by age, gender, and renal function.

Causes of Ride Sided HF

- LV Failure, right ventricular MI, pulmonary hypertension (↑ pressure pulmonary system) - Right Side failure without left side failure usually from --- COPD, Pulmonary hypertension and ARDS (Acute Respiratory Distress Syndrome)

HF with preserved EF (preserved ventricular function) HFpEF >40%

- Left ventricle can't relax during diastole. It is "stiff", so the ventricles cannot fill enough blood to meet body needs

Chronic Management

- Maintenance - Reduce myocardial remodeling - Exercise-Cardiac Rehab - Reduce stress - Reduce risk of injury - Transition care to the community - Share data with all providers

VAD-Ventricular Assist Device

- Mechanical pump implanted-works with patients own heart - LVAD and RVAD - Non-Eligibility- end stage kidney, chronic severe lung disease, clotting disorders, drug resistant infections- also smoking, obese will exclude patients - VAD can be short term "bridge to transplant" or long term "destination therapy" - Increased Quality of Life

Cardiac Rehabilitation

- Meta-analyses show that cardiac rehabilitation --- reduces mortality --- improves functional capacity, exercise duration and HRQOL --- reduces hospitalizations - Cardiac rehabilitation in heart failure patients to aid in patient self-care, symptom management, - quality of life and depression - As of 2014- HF Medicare approved diagnosis for cardiac rehab - must be stable, chronic, EF <35%, and NYHA II-IV despite optimal therapy for at least 6 weeks

Palliative Care

- Prevents or relieves suffering - Supports the best quality of life - Symptom management - Psychosocial/Spiritual support - Not just end of life care - Useful at any stage, but especially helpful at NYHA class III-IV

Acute Decompensated Episodes

- Rapid Onset of acute or worsening symptoms - Usually present with normal or high B/P with symptoms of congestion - Reduce fluid retention --- IV loop diuretics --- Monitor urine output-adjust dose --- Add combo diuretic therapy - Reduce myocardial workload - Improve ventricular pump performance - Supplement oxygen - Control dysrhythmias

Self-Management Behaviors:

- The chronic, progressive nature of HF requires: --- patient self-care or self-management to successfully manage the disease --- avoid costly hospital readmissions - Self-management behaviors in HF include monitoring "red flags" of the disease such as: - weight gain - edema - shortness of breath - monitoring sodium intake - attending follow up appointments - medication adherence - smoking cessation

Right Sided Nursing Assessment Findings

- The increased volume and pressure lead to issues with the venous system - Edema --- Jugular Venous distention- best way to estimate - Weight Gain- 4-7 liters of fluid is 10-15 pounds before pitting edema can occur - Nausea/Anorexia - Ascites- advanced HF-liver congestion - Diuresis- more at rest-peripheral tissue is more mobile at rest-awaken at night to void **R sided is many times a result of L sided failure, so your pt. may have many of these symptoms at the same time

HF with reduced EF (reduced ventricular function) HFrEF <40%

- The left ventricle can't contract strongly enough during systole to eject enough blood into the circulation to meet body needs

Surgical Management

- VAD-Ventricular Assist Device - Cardiac Rehabilitation - Cardiac Transplantation

Compare the treatments for HF

- cardiac devices - Cardiac Rehabilitation - surgical management - palliative - hospice care

S & S of Pulmonary edema

- crackles - dyspnea at rest - disorientation or acute confusion (especially in older adults as early symptom) - tachycardia - hypertension or hypotension - reduced urinary output - cough with frothy, pink-tinged sputum - premature ventricular contractions and other dysrhythmias - anxiety - restlessness - lethargy

The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of feet. 2. Thick white sputum and crackles that clear with cough. 3. The client sleeping with no pillow and eupnea. 4. Radial pulse rate of 90 and capillary refill time <3 seconds.

1 Rationale: The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status. 2. The client with CHF usually has pink frothy sputum and crackles that do not clear with coughing. 3. The client with CHF would report sleeping on at least two pillows, if not sleeping in an upright position, and labored breathing, not eupnea, which means normal breathing. 4. In a client diagnosed with heart failure, the apical pulse, not the radial pulse, is the best place to assess the cardiac status.

Left Sided (formally CHF)

1) HF with reduced EF (reduced ventricular function) HFrEF <40% 2) HF with preserved EF (preserved ventricular function) HFpEF >40%

The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? 1. The client diagnosed with myocardial infarction who has an audible S3 heart sound. 2. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. 4. The client with chronic renal failure who has an elevated creatinine level.

1. The client diagnosed with myocardial infarction who has an audible S3 heart sound. Rationale: An S3 heart sound indicates left ventricular failure, and the nurse must assess this client first because it is an emergency situation. 2. The nurse would expect a client with CHF to have sacral edema of 4+; the client with an S3 would be in a more life-threatening situation. 3. A pulse oximeter reading of greater than 93% is considered normal. 4. An elevated creatinine level is expected in a client diagnosed with chronic renal failure.

The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply. 1. Notify health-care provider of a weight gain of more than one (1) pound in a week. 2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct client to remove the saltshaker from the dinner table. 4. Encourage client to monitor urine output for change in color to become dark. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime.

2,3 Rationale: 2. The client should not take digoxin if the radial pulse is less than 60. 3. The client should be on a low-sodium diet to prevent water retention. 1. The client should notify the HCP of weight gain of more than two (2) or three (3) pounds in one (1) day. 4. The color of the urine should not change to a dark color; if anything, it might become lighter and the amount will increase with diuretics. 5. Instruct the client to take the diuretic in the morning to prevent nocturia.

The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? 1. Check the client for peripheral edema and make sure the client takes a diuretic early in the day. 2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. 3. Determine if the client has gained weight and instruct the client to keep the legs elevated. 4. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.

2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. Rationale: The most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium. 1. The client with peripheral edema will experience calf tightness but would not have leg cramping, which is the result of low potassium levels. The timing of the diuretic will not change the side effect of leg cramping resulting from low potassium levels. 3. Weight gain is monitored in clients with CHF, and elevating the legs would decrease peripheral edema by increasing the rate of return to the central circulation, but these interventions would not help with leg cramps. 4. Ambulating frequently and performing leg-stretching exercises will not be effective in alleviating the leg cramps.

The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP? 1. Assist the client to go down to the smoking area for a cigarette. 2. Transport the client to the intensive care unit via a stretcher. 3. Provide the client going home discharge-teaching instructions. 4. Help position the client who is having a portable x-ray done.

4. Help position the client who is having a portable x-ray done. Rationale: The UAP can assist the x-ray technician in positioning the client for the portable x-ray. This does not require judgment. 1. Allowing the UAP to take a client down to smoke is not cost effective and is not supportive of the medical treatment regimen that discourages smoking. 2. The client going to the ICU would be unstable, and the nurse should not delegate to a UAP any nursing task that involves an unstable client. 3. The nurse cannot delegate teaching.

The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. Measure intake and output. 2. Provide two (2)-g sodium diet. 3. Weigh client daily. 4. Plan for frequent rest periods.

4. Plan for frequent rest periods. Rationale: Scheduling activities and rest periods allows the client to participate in his or her own care and addresses the desired outcome. 1. Measuring the intake and output is an appropriate intervention to implement for a client with CHF, but it does not address getting the client to tolerate activity. 2. Dietary sodium is restricted in clients with CHF, but this is an intervention for decreasing fluid volume, not for increasing tolerance for activity. 3. Daily weighing monitors fluid volume status, not activity tolerance.

Which of the following patients are MOST at risk for developing heart failure? Select-all-that-apply: A. A 69 year old male with a history of alcohol abuse and is recovering from a myocardial infarction. B. A 55 year old female with a health history of asthma and hypoparathyroidism. C. A 30 year old male with a history of endocarditis and has severe mitral stenosis. D. A 45 year old female with lung cancer stage 2. E. A 58 year old female with uncontrolled hypertension and is being treated for influenza.

A,C,E Rationale: The answers to this question are option: A, C, E. These patients are at most risk for heart failure. Remember risks factor for developing heart failure include: remember the mnemonic FAILURE: Faulty heart valves ( Option C mitral stenosis in this case), Arrhythmias, Infarction (Option A), Lineage, Uncontrolled hypertension (Option E), Recreational drug usage, Evaders (Option E with influenza)

Select all the correct statements about educating the patient with heart failure: A. It is important patients with heart failure notify their physician if they gain more than 6 pounds in a day or 10 pounds in a week. B. Patients with heart failure should receive an annual influenza vaccine and be up-to-date with the pneumonia vaccine. C. Heart failure patients should limit sodium intake to 2-3 grams per day. D. Heart failure is exacerbated by illness, too much fluid or sodium intake, and arrhythmias. E. Patients with heart failure should limit exercise because of the risks.

B, C, D Rationale: Option A is wrong because heart failure patients should notify their doctor if they gain 2-3 pounds in a day or 5 pounds in a week, and option E is wrong because exercise is important for heart failure patients to help strengthen the heart muscle...so they should exercise as tolerated.

Select all the correct statements about the pharmacodynamics of Beta-blockers for the treatment of heart failure: A. These drugs produce a negative inotropic effect on the heart by increasing myocardial contraction. B. A side effect of these drugs include bradycardia. C. These drugs are most commonly prescribed for patients with heart failure who have COPD. D. Beta-blockers are prescribed with ACE or ARBs to treat heart failure.

B, D

Which of the following are NOT typical signs and symptoms of right-sided heart failure? Select-all-that-apply: A. Jugular venous distention B. Persistent cough C. Weight gain D. Crackles E. Nocturia F. Orthopnea

B, D, F Rational: Persistent cough, crackles (also called rales), and orthopnea are signs and symptoms of LEFT-sided heart failure...not right-sided heart failure.

A client is diagnosed with left-sided heart failure. Which assessment findings will the nurse expect the client to have? Select all that apply. A. Peripheral edema B. Crackles in both lungs C. Breathlessness D. Ascites E. Tachypnea

B,C,E Rationale: Clients with left-sided heart failure will exhibit symptoms such as fatigue, dyspnea or breathlessness, and crackles on auscultation of breath sounds. Peripheral edema and ascites are associated with right-sided heart failure.

An older adult taking digoxin and hydrochlorothiazide (HCTZ) for chronic heart failure is admitted to the emergency department (ED) with an apical pulse of 48. A family member states that the client has reported blurred vision and loss of appetite for 2 weeks. What is the nurse's first action? A. Call the ED physician immediately. B. Draw a serum digoxin level. C. Assess for signs of hypokalemia. D. Establish the client's airway.

B. Draw a serum digoxin level. Rationale: The clinical manifestations of digoxin toxicity are often vague and nonspecific and include anorexia, fatigue, blurred vision, and changes in mental status, especially in older adults. Older adults are more likely than other patients to become toxic because of decreased renal excretion.

A patient with left-sided heart failure is having difficulty breathing. Which of the following is the most appropriate nursing intervention? A. Encourage the patient to cough and deep breathe. B. Place the patient in Semi-Fowler's position. C. Assist the patient into High Fowler's position. D. Perform chest percussion therapy.

C. Assist the patient into High Fowler's position. Rationale: Due to the patient being in fluid overload (especially with left-sided heart failure...remember the lungs are majorly affected in this type of heart failure), it is most appropriate to place the patient in High Fowler's position to help make breathing easier.

A patient is being discharged home after hospitalization of left ventricular systolic dysfunction. As the nurse providing discharge teaching to the patient, which statement is NOT a correct statement about this condition? A. "Signs and symptoms of this type of heart failure can include: dyspnea, persistent cough, difficulty breathing while lying down, and weight gain." B. "It is important to monitor your daily weights, fluid and salt intake." C. "Left-sided heart failure can lead to right-sided heart failure, if left untreated." D. "This type of heart failure can build up pressure in the hepatic veins and cause them to become congested with fluid which leads to peripheral edema."

D. "This type of heart failure can build up pressure in the hepatic veins and cause them to become congested with fluid which leads to peripheral edema." Rational: This is a description of right-sided heart failure NOT left ventricular systolic dysfunction. Left-sided systolic dysfunction is where the left side of the heart is unable to CONTRACT efficiently which causes blood to back-up into the lungs...leading to pulmonary edema.

A client has been taking furosemide (Lasix) and valsartan (Diovan) for the past year. The hospital laboratory notifies the nurse that the client's serum potassium level is 6.2 mEq/L. What is the nurse's best action at this time? A. Assess the client's oxygen saturation level. B. Ask the laboratory to retest the potassium level. C. Give potassium as an IV infusion. D. Check the client's serum creatinine.

D. Check the client's serum creatinine. Rationale: Clients who are hyperkalemic (those with an elevated serum potassium level) may also be in renal failure. The client's serum creatinine should be reviewed to determine if it is greater than 1.8 mg/dL, at which time the health care provider should be notified before administering any supplemental potassium.

The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the paddles on the client's chest and before discharge, which intervention is a priority? A. Ensure that the client has been intubated B. Set the defibrillator to the "synchronize" mode C. Administer an Amiodarone bolus intravenously. D. Confirm that rhythm is actually ventricular fibrillation

D. Confirm that rhythm is actually ventricular fibrillation Rationale: Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated to be defibrillated. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize. Amiodarone may be given subsequently but is not required before defibrillation.

Left Sided Nursing Assessment Findings:

Left Sided HF- CO diminished - poor tissue perfusion, anaerobic metabolism and unusual fatigue - Dyspnea --- Exertion (DUE???) or at rest --- Orthopnea --- Paroxysmal nocturnal (PND) - Lung Sounds --- Crackles- do not diminish with cough with HF-fluid filled alveoli --- Wheezes- narrowing bronchial lumen-engorged pulmonary vessels - Cough- due to fluid filled alveoli and congestion --- Early on may only be at night and usually non productive --- Severe HF- pink, frothy pink tinged sputum-Pulmonary edema - Arrhythmias- irregular, tachycardia - S3 gallop- increased LV pressure - Decreased urine output --- Body trying to maintain fluid status - Activity-Fatigue-poor oxygenation --- Many limit their activities without realizing it

- External Defibrillator

Life Vest-The LifeVest™ is an external defibrillator worn by a patient at risk for sudden cardiac death. • It monitors the patient's heart continuously for a life-threatening arrhythmia • Used as a "bridge" to ICD placement o Currently, Medicare requires a 40-day waiting period following an MI before approval of ICD, other conditions (infected ICD may warrant a "bridge" as well) • The device alerts the patient prior to delivering a shock • If the patient becomes unconscious, the device releases a Blue™ gel over the therapy electrodes and delivers an electrical shock to restore normal rhythm.

Examine the role of nurse in impacting HF quality care

Patients who understand: - The treatment plan --- Monitor changes in signs and symptoms- "Red flags" --- Act on issues can avoid a readmission - Nurses play a major role in decreasing readmissions by helping patients understand "red flags" with education, --- Not just at discharge --- Use "teachable" moments throughout the stay - Ensuring care coordination with a multidisciplinary team begins on admission --- Patient barriers to self-management identified --- Plan to address barriers- financial, social support, transportation, etc. - Ensure evidenced based guidelines are followed: --- Ensure most recent LVEF documented in chart - Ensure Evidenced Based Medications are ordered during the stay and at discharge --- ACE/ARB/ARNI LVEF <40% --- May require a conversation with provider - F/U appointment scheduled within 3-7 days (ideal 3-5) - Self-Management Education - Smoking Cessation Counseling

True or False: Patients with left-sided diastolic dysfunction heart failure usually have a normal ejection fraction.

True Rationale: Patient with left-sided DIASTOLIC dysfunction heart failure normally have a normal ejection fraction. However, patients with left-sided SYSTOLIC dysfunction heart failure usually do not because the heart is unable to CONTRACT efficiently rather than fill properly as with diastolic dysfunction.