Heart failure
The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure?
Dyspnea on exertion
The diagnosis of heart failure is usually confirmed by which of the following?
Echocardiogram
The nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump?
Echocardiogram
The nursing instructor is discussing heart failure with their clinical group. The instructor talks about heart failure in terms of a decreasing ejection fraction of the heart. What diagnostic test is used to measure the ejection fraction of the heart?
Echocardiogram
A patient with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, bradycardia, and muffled heart sounds. The senior nursing student recognizes these symptoms occur when
Excess pericardial fluid compresses the heart and prevents adequate diastolic filling
You are caring for a client with suspected right-sided heart failure. What would you know that clients with suspected right-sided heart failure may experience?
Gradual unexplained weight gain
How should the pt be positioned to assess for juglar vein distention
Have the pt lay supine, raise the head of the bed to a 45 degree angle and have them turn their head to the left
Cardiac Output= ___ x ____
Heart RateStroke Volume
A nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect
Heart failure
A nurse is discussing cardiac hemodynamics with a nursing student and explains the concept of afterload. The student asks what medical conditions might cause increased afterload. The nurse correctly answers which of the following?
Hypertension and aortic valve stenosis
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when he makes which statement?
"I sleep on three pillows each night."
Nitrates
-A venous vasodilator-Prescribed for pt with HF who has persistent dyspnea-Monitor pt blood pressure when starting nitrate therapy or increasing dose-Pt may report headache, but assure the pt that they will develop a tolerance to this effect and that it will cease or diminish.→They can take tylenol if they need it
Digoxin
-AKA Lanoxin-A cardiac glycoside-For chronic heart failure w/sinus rhythm and atrial fibrillation-Competes with K to stimulate the heart-Alleviates symptoms of heart failure, but does not prolong life (It actually shortens the life of women)-Benefits:a) Increased contractilityb) Reduced heart ratec) Slowing of conduction through the atrioventricular noded) Inhibition of sympathetic activity while enhancing parasympathetic activity
Diuretics considerations
-Added when diet and fluid restrictions have not been effective in managing HF symptoms-First line drug of choice in older adults with HF and fluid overload-Loop, thiazide, and k sparing are used depending on severity
Nursing interventions for pt who is taking ACE inhibitors or ARBs
-Assess for hyperkalemia, orthostatic hypotension, acute confusion, poor peripheral perfusion, and reduced urine output-Monitor serum K, and creatinine levels to determine renal dysfunction-Monitor BP q1hr for several hours after the initial dose and each time the dose is increased→Immediately report systolic BP <90→→If this occurs, place pt flat to increase cerebral perfusion
Signs of digoxin toxicity
-Bradycardia-Loss of P wave-Anorexia-Fatigue-Blurred Vision-Changes in mental status-Hypokalemia-Angina
Nursing considerations for ACE inhibitors and ARBs
-Can be used alone in treatment of heart failure, but they are usually given in combination with a beta blocker and a diuretic-If cough develops bc of ACE, medication should be discontinued and pt should be started on ARB-Teach pt to move slowly when changing positions-Caution to pt taking K supplements or K sparing diuretics-Should not be given to pt with systolic BP <100-Caution to pt w/Na level <135
What happens Renin-Angiontensin System is activated
-Caused when there is a decreased in blood flow to the kidneys-It will increase the blood volume, pressure, and venous return. The increased venous return will increase the ventricular filling and stroke volume-Angiotensin II will→Cause constriction of renal blood vessels to decrease blood flow to the kidneys, reducing urine production→Cause constriction of the systemic arterioles and veins to increase venous and arterial pressure→Stimulate the release of aldosterone,-Aldosterone will work on the kidneys to→Increase reabsorption of Na and water into blood circulation to increase blood volume and pressure
Indications of left sided heart failure:
-Decreased tissue perfusion due to poor cardiac output-Pulmonary congestion from increased pressure in the pulmonary vessels
ARBs
-Effects are similar to those of ACE inhibitors-Main clinical difference is that ARBs do not increase levels of kinins, so their effects on cardiac remodeling are less favorable than ACE-ARBs are usually used when pt is intolerant of ACE inhibitors (usually noted by the cough)
Nursing interventions following an acute episode of heart failure
-Encourage pt to verbalize feelings about lifestyle changes required as a result of hf-Assist client in identifying precipitating risk factors of HF and methods of eliminating the risks-Instruct pt about prescribed medication regimen-Instruct pt to notify HCP if pt cannot take meds b/c of illness-Advise to avoid otc meds-Instruct pt to avoid large amounts of caffeine (often found in tea, coke, chocolate, and coffee)-Teach pt about low Na, low fat, and low cholesterol diet-Provide pt with list of K rich foods b/c diuretics can cause hypokalemia-Advise pt to spread fluid intake throughout the day. Pt can suck on hard candy to reduce thirst
Diuretic teaching points
-Encourage to take them in the morning-Get weight each morning at the same time.
Examples of thiazide diuretics
-Hydrochlorothiazide-Metolazone/Zaroxolyn
Typical causes of left sided heart failure are
-Hypertension-Coronary artery disease-Valvular disease involving the mitral or aortic valve
Adverse effects of ACE inhibitors
-Hypotension-Hyperkalemia-Nagging, dry cough-Angioedema
A new client has been admitted with right-sided heart failure. The nurse knows to look for which of the following assessment findings when assessing this client?
Jugular venous distention
Examples of loop diuretics
Lasix Bumex
The clinical manifestations of cardiogenic shock reflect the pathophysiology of heart failure (HF). By applying this correlation, the nurse notes that the degree of shock is proportional to which of the following?
Left ventricular function
In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure?
Leg edema
A client is in the early stage of heart failure. During this time, which compensatory mechanism occurs?
Low blood pressure triggers the baroreceptors to increase sympathetic nervous system
Which of the following is the hallmark of heart failure?
Low ejection fraction (EF)
Which of the following medications is a human brain natriuretic peptide (BNP) preparation?
Natrecor
The nurse does an assessment on a patient who is admitted with a diagnosis of right-sided heart failure. The nurse knows that a significant sign is which of the following?
Pitting edema
Drugs that Enhance Contractility Double check this slide
Positive Inotropes-Digoxin-Calcium channel blockers-Beta-adrenergic agonists (Dobutamine)Beta Blockers
A physician orders digoxin (Lanoxin) for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity?
Potassium level of 2.8 mEq/L
A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which of the following assessment findings for this client?
Pulmonary congestion
A hospitalized client with heart failure puts on the call light and makes the following statement: "I've become very short of breath, and I've been coughing up this pink frothy sputum." The nurse immediately suspects which of the following complications?
Pulmonary edema
Overall, right sided heart failure is usually the result of
Pulmonary problems like COPD
Heart Sounds
S1-Heard as the atrioventricular valves close-Heard loudest at the apexS2-Heard when the semilunar valves close-Heard lodes at the base of the heartS3-Heard if ventricular wall compliance is decreased and structures in the ventricular wall vibrate-May occur in conditions like heart failure or valvular regurgitation-Often the first sign of heart failureS4-Heard on atrial systole if resistance to ventricular filling is present-Causes include cardiac hypertrophy, disease, or injury to the wall-Not a sign of heart failure, it is a reflection of decreased ventricular compliance
Following a left anterior myocardial infarction, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure?
Increased pulmonary artery diastolic pressure
Draw backs to the renin-angiotensin system
-If the venous pressure becomes too high, edema of the lungs and/or periphery-If the increase in cardiac output is insufficient to maintain adequate kidney function, renal retention of water will continue to progress, which will result in more fluid accumulation, causing severe cardiac, pulmonary, and peripheral edema-This will increase the preload and after load-Angiotensin II contributes to ventricular remodeling, resulting in dysfunction of the myocyte contraction
Interventions for beta blockers
-Monitor pt for bradycardia or hypotension after the first dose-Daily weight-Assess pt weekly for changes in BP, pulse, activity tolerance, and orthopnea
Beta blocker considerations
-Must be started off slowly in pt with HF-Approved for chronic HF treatment-Pt in an acute HF episode should not be started on this medication-Resting heart rate should be between 55-60 with mild increases for exercise
Loop diuretic considerations
-Older pt are at increased risk of dehydration, monitor for:→Acute confusion→Decreased Urine→Dizziness-They will be at risk for falls-Prefered over thiazides when cardiac output is greatly reduced-Can cause severe hypotension-Causes profound diuresis
Indications of right sided heart failure:
-Peripheral edema-Juglar vein distension
Nonsurgical interventions to improve cardiac output generally rely on ___ measures, and their goal is to:
-Pharmacological-To improve stroke volume by reducing after load, reducing preload, and improve cardiac muscle contractility
Considerations for thiazide diuretics
-Preferred by pt because it does not cause feelings of dehydration like loops do, and because of the gradual onset of diuresis-Acts a lot like loop diuretics, just do a lower degree-Monitor for s/s of hypokalemia (depressed reflexes, generalized weakness, irregular heart beat)
Causes of right sided heart failure:
-Prolonged, untreated left ventricular failure-Right ventricular myocardial infarction-Pulmonary hypertension
Pt education for heart transplant
-Pt will be on lifetime immunosupressive therapy-Caution pt to change position slowly to prevent orthostatic hypotension
What are the compensatory mechanisms of insufficient cardiac output
-Stimulation of the Sympathetic nervous system-Renin-Angiotensin System activation-Chemical responses (BNP)-Myocardial hypertrophy
What happens in systolic left sided heart failure
-There will be in increase in preload and after load→Preload is increased b/c of decreased constriction→Afterload is increased because of increased peripheral resistance-The ejection fraction drops from normal (50-70%) to < 40%→As this decreases, tissue perfusion is decreased and blood accumulates in the pulmonary vessels
Medications that reduce afterload
-These medications are arterial vasodilators that will will relax the arterioles, effectively reducing the resistance to left ventricular ejection (aka afterload)-ACE inhibitors and ARBs→One or the other is always given, however ACE inhibitors are usually the first choice-Human B-type Natriuretic Peptides
ACE inhibitors
-These meds prevent the conversion of angiotensin I to angiotensin II, thus decreasing the release of aldosterone-They increase kinin levels, so they have a favorable effect on cardiac remodeling-Causes:a) Arteriolar dilation which will reduce afterload, increases stroke volume and cardiac output→Improves blood flow in the kidney, which will promote excretion of Na and waterb) Venous dilation which will reduce venous pressure. This will reduce pulmonary congestion, peripheral edema, preload, and cardiac dilationc) Supression of aldosterone release increases the release of Na and water, while retaining K≈
Myocardial Hypertrophy
-This is an enlargement of the myocardium-The walls of the heart thicken, increasing muscle mass to provide more forceful contractions
Drawbacks to the stimulation of the sympathetic nervous system
-This significantly increases the rate at which the heart consumes oxygen. If the heart has poor perfusion due to arteriosclerosis, HF may worsen-It stimulates increased venous return, thus it stretches the vessel walls. There is a point in which the the muscle fibers stretch so much because of increased volume that force of contraction and cardiac output is decreased-Excessive heart rate can reduce ventricular filling
What happens when the body stimulates the sympathetic nervous system in response to decreased cardiac output
-When the body senses decreased pressure, it stimulates the sympathetic nerve fibers to release norepinephrine in order to:→Increase heart rate→Increase atrial and ventricular contractility→Increase blood pressure by increasing peripheral vasoconstriction
Chemical responses to to heart failure
-When the pt is having fluid overload due to heart failure, B-type natriuretic peptide (BNP) is produced to increase the loss of Na in the renal tubules-Decreased blood flow and perfusion to the brain because of low cardiac output causes the pituitary gland to release ADH/vasopressin to stimulate fluid retention
Diastolic left sided heart failure vs. systolic left sided heart failure
-With diastolic, ejection fraction is >40%, vs. < 40% with systolic
How should the nurse assess for left sided heart failure
1. Assess activity tolerance by:1a) Asking whether the pt can perform normal ADLs or climb flights of stairs without fatigue or dyspnea→Many pt with HF experience weakness or fatigue w/activity or have a feeling of heaviness in their arms or legs→If the pt has dyspnea, when and how did it develop?→If the pt has orthopnea (dyspnea when lying flat), ask how many pillows are used to sleep or whether the pt sleeps in an upright position in a bed, recliner, etc.1b) Ask the pt to perform simultaneous arm and leg work→Example would be walking while carrying grocery bags1c) Ask pt identify his/her most strenuous activity→Many people unconsciously limit their activities in response to fatigue or dyspnea and may not realize how limited they have become2. Assess chest comfort-Aside from chest pain, pt may have palpitations, skipped, beats, or fast heartbeat3. Does the pt have a cough?-In early stages of HF, pt may describe cough as irritating, and nocturnal and is usually nonproductive-HF becomes severe if he or she may begin expectorating frothy, pink tinged sputum4. Assess whether the pt is oriented to person, place, and time5. Auscultate heart6. Auscultate the lungs for crackles and wheezing-Crackles indicate HF-Wheezing indicates Pulmonary congestion
How should the nurse assess for right sided heart failure
1. Does the pt have dependent edema?-Ambulatory pt commonly has edema in the ankles and legs-Pt on bed rest may have edema on the sacrum-Pt may notice that their shoes fit more tightly or their shoes or socks leave indentations on their swollen feet2. Do they have weight gain?-Remember, edema is an unreliable indicator or HF, weight is the most reliable indicator of fluid gain and loss3. Do they have frequent diuresis at night?4. Do they have increased thirst?5. Assess the neck veins for distention6. Measure abdominal girth
What are the priority problems for pt with heart failure?
1. Impaired gas exchange2. Decreased cardiac output3. Fatigue/weakness4. Potential for pulmonary edema
It is important for the nurse to gather pt information in regards to the following when assessing pt with cardiovascular problems
1. Medical History of:-Hypertension-Angina-MI-Rheumatic heart disease-Valvular disorders2. Ask pt about their perception of their:-Activity tolerance-Breathing pattern-Sleeping pattern-Urinary patter-Fluid volume status-Knowledge about HF
What imaging assessments are used for HF
A) Chest x-rays→Useful in diagnosing left ventricular failure because the heart will be enlargedB) Echocardiogram→Considered the best tool for diagnosing heart failure→Can be used to diagnose valvular changes, pericardial effusion, chamber enlargement, ventricular hypertrophy, and to determine ejection fraction
Normal levels for (A) Creatinine, (B) BUN, (C) BNP
A) Creatinine-0.6 to 1.3mg/dL-High levels of creatinine indicate that kidneys are not performing wellB) BUN-7 to 20mg/dL-High levels indicate that the kidneys are not working wellC) BNP-Levels less than 100 indicate no heart failure-Levels 100-300 indicate possible heart failure-300+ indicates mild heart failure-600+ indicates moderate heart failure-900+ indicate severe heart failureLevels increase as heart failure worsen, and decrease as the heart stablizes
Clinical manifestations of left sided heart failure
A) Decreased cardiac output that can lead to→Fatigue→Oliguria during the day (nocturia at night)→Angina→Dizziness→Cool extremities→Weak peripheral pulsesB) Pulmonary congestion→Hacking cough that gets worse at night→Dyspnea/breathlessness→Crackles or wheezes in lungs→Frothy, pink tinged sputum→S3/S4 gallop→Tachypnea
Drug interactions w/digoxin
A) Diuretics-Thiazide and loop diuretics promote the loss of K, increasing the risk of digoxin induced dysrhythmias.B) ACE and ARBs-These meds can increase K levels, so they can reduce the response to digoxinC) Antacids-Antacids will decrease the absorption or digoxin, so pt will need increased digoxin dose
What labs are important to monitor in HF
A) ElectrolytesB) Kidney tests→Any renal impairment as a result from inadequate perfusion causes elevated BUN and serum creatinine, and creatinine clearance levels decreaseC) Hematocrit and Hemoglobin→To identify if HF is a result of anemia→Hematocrit may be low if pt has fluid volume excessD) BNP→Particularly used with diastolic HF in pt with dyspnea. Increased BNP is a result of HF w/dyspnea, vs w/lung dysfunctionE) Urinalysis→HF will show up with proteinuria and high specific gravityF) ABGs
Postop care for heart transplant pt:
A) Strict aseptic technique and hand washing because pt is immunosuppressed and at increased risk for infectionB) Monitor for signs of heart rejection, such as:-Hypotension-Dysrhythmias-Weakness/fatigue-Dizziness-SOB-Abdominal bloating-Fluid gain-Decreased ejection fractionC) Monitor for bleeding into the pericardial sac for potential tamponade
Interventions to reduce preload
A)Nutrition Therapy→Na intake restriction→Eliminate table salt, ham, bacon, pickles from diet→Avoid milk and milk products, and use a few canned or prepared foods as possibleB) Weigh pt daily, using same scale every morning before breakfastC) Drug Therapy→Diuretics→Morphine sulfate is given to pt w/acute HF to reduce anxiety, decrease preload and afterload, slow respirations, and reduce pain associated w/MI→Nitrates
A total artificial heart (TAH) is an electrically powered pump that circulates blood into the pulmonary artery and the aorta, thus replacing the functions of both the right and left ventricles. What makes it different from an LVAD?
An LVAD only supports a failing left ventricle.
A patient has been experiencing increasing shortness of breath and fatigue. The physician has ordered a diagnostic test in order to determine what type of heart failure the patient is having. What diagnostic test does the nurse anticipate being ordered?
An echocardiogram
When are interventions to reduce preload appropriate?
Appropriate when HF is accompanied by congestion with total body Na and water overload
A client with left-sided heart failure is in danger of impaired renal perfusion. How would the nurse assess this client for impaired renal perfusion?
Assess for elevated blood urea nitrogen levels.
A patient arrives at the ED with an exacerbation of left-sided heart failure and complains of shortness of breath. Which of the following is the priority nursing intervention?
Assess oxygen saturation level
Which of the following is a key diagnostic laboratory test for heart failure?
B-type natriuretic peptide
Which of the following is a key diagnostic indicator of heart failure?
BNP
A nurse taking care of a patient recently admitted to the ICU observes the patient coughing up large amounts of pink, frothy sputum. Auscultation of the lungs reveals course crackles to lower lobes bilaterally. Based on this assessment, the nurse recognizes this patient is developing which of the following problems?
Decompensated heart failure with pulmonary edema
Which of the following body system responses correlates with systolic heart failure (HF)?
Decrease in renal perfusion
What is the primary underlying disorder of pulmonary edema?
Decreased left ventricular pumping
Which of the following medications reverses digitalis toxicity?
Digoxin immune FAB (Digibind)
Which drug is most commonly used to treat cardiogenic shock?
Dopamine (Intropin)
The nurse identifies which of the following symptoms as a manifestation of right-sided heart failure (HF)?
Congestion in the peripheral tissues
Left sided heart failure is aka
Congestive heart failure
Frequently, what is the earliest symptom of left-sided heart failure?
Dyspnea on exertion
Clinical manifestations of right sided heart failure
Systemic Congestion-Jugular vein distention-Polyuria at night-Weight gain-Dependent edema (legs and sacrum), peripheral edema (Swollen hands & fingers)-Distended abdomen-Hepatomegaly→Can cause anorexia and nausea→Can cause ascites if liver congestion is severe-Hepatojugular reflux-Increased BP due to fluid volume excess or decreased BP due to pump failure
Which of the following is a manifestation of right-sided heart failure?
Systemic venous congestion
The nurse is administering nitroglycerin, which he knows decreases preload as well as afterload. Preload refers to which of the following?
The amount of blood presented to the ventricles just before systole
Afterload is:
The amount of resistance the heart faces to pump the blood-As afterload increases, the amount of energy the left ventricle needs to pump the blood is increase
Ascites
The build up of fluid in the space between the lining of the abdomen and the abdominal organs
A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?
The client says his rings have become tight and are difficult to remove.
A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?
The development of left-sided heart failure
Systolic left sided heart failure is a condition in which:
The heart cannot contract forcefully enough during systole to eject adequate amounts of blood into circulation
Diastolic left sided heart failure is a condition in which:
The left ventricle cannot adequately relax during diastole. This "stiffens" the heart and prevents the ventricle from filling with enough blood for heart to pump out.-The ejection fraction will be >40%, however, the ventricle becomes less compliant over time because more pressure is needed to move the same amount of volume
Ejection fraction is:
The percent of blood ejected from the heart during systoles
Right sided heart failure is a condition in which:
The right ventricle cannot completely empty, causing fluid to to be retained and venous pressure to increase
Examples of ACE inhibitors
They end in "-pril"-Lisinopril/Zestril, Prinivil-Enalapril/Vasotec-Captopril/Capoten-Quinapril/Accupril
Examples of ARBs
They end in "-sartan"-Losartan/Cozaar-Candesartan/Atacand-Valsartan/Diovan
Which of the following is a classic sign of cardiogenic shock?
Tissue hypoperfusion
When focusing on improving cardiac output, the goal is:
To have increased cardiac output by improving stroke volume, and heart rate.
The physician writes orders for a patient to receive an angiotensin II receptor blocker for treatment of heart failure. What medication does the nurse administer?
Valsartan (Diovan)
