ATI Chapter 32: Heart Failure and Pulmonary Edema

Intropic agents

*DIGOXIN*, dopamine, doutamine, and milrinone, are used to increase contractility and thereby improve cardiac output - Nursing Considerations * for a client taking digoxin, take the apical heart rate for 1 min. Hold the medication if apical pulse is less than 60/min, and notify the provider * observe the client for nausea and vomiting * Dopamine, dobutamine, and milrinone are administered via IV. The ECG, blood pressure, and urine output must be closely monitored - Client education (for those taking digoxin) * Teach clients how to count pulse for 1 min before taking the medication. If the pulse rate is irregular or the pulse rate is outside of the limitations set by the provider (usually less than 60/min or greater than 100/min), instruct the client to hold the dose and contact the provider * take the digoxin dose at the same time each day * do not take digoxin at the same time as antacids. Separate the two medications by at least 2 hr * report signs of TOXICITY, including FATIGUE, MUSCLE WEAKNESS, CONFUSION, and LOSS OF APPETITE * regularly have digoxin and potassium levels checked

Pulmonary Edema: medications

- *RAPID-ACTING DIURETICS*: such as furosemide and bumetanide, promote FLUID EXCRETION - *MORPHINE*: decreases sympathetic nervous system response and anxiety and PROMOTES MILD VASODILATION - *VASODILATORS*: nitroglycerin, sodium nitroprusside; DECREASED PRELOAD and AFTERLOAD - *INOTROPIC AGENTS*: such as digoxin and dobutamine, IMPROVE CARDIAC OUTPUT - *ANTIHYPERTENSIVE*: such as ACE inhibitors and beta-blockers, DECREASED AFTERLOAD

Pulmonary Edema Assessment: Risk factors

- Acute MI - Fluid volume overload - Hypertension - Valvular heart disease - Postpneumonectomy - Post evacuation of pleural effusion - Acute respiratory failure - Left-sided heart failure - high altitude exposure of deep-sea diving - Trauma - Sepsis - Drug Overdose

Interprofessional care

- CARDIOLOGY and PULMONARY -services should be consulted to manage heart failure - RESPIRATORY services should be consulted for inhalers, breathing treatment, and suctioning for airway management - CARDIAC REHABILITATION services can be consulted if the client has prolonged weakness and needs assistance with increasing level of activity - NUTRITIONAL services can be consulted for diet modification to promote low-sodium, and low-saturated fat food choices

Left-sided Failure: Expected findings 9

- Dyspnea, orthopnea (shortness of breath while lying down), nocturnal dyspnea - Fatigue - displaced apical pulse (hypertrophy) - S3 heart sound (gallop)(early diastole) - pulmonary congestion (dyspnea, cough, bibasilar crackles) - frothy sputum (can be blood-tinged) - altered mental status - Manifestations of organ failure, such as oliguria (decrease in urine output) -Nocturia

Diagnostic procedures: ECG, cardiac enzymes, electrolytes, and ABGs

- Electrocardiogram (ECG), cardiac enzymes, electrolytes, and ABGs are used to assess factors contributing to heart failure and/or the impact of heart failure

Pulmonary Edema Assessment: Expected findings

- anxiety - inability to sleep - persistent cough with pink, frothy sputum (CARDINAL SIGNS) - tachypnea, dyspnea, and orthopnea - hypoxemia (SaO2 expected reference range greater than 95%) - cyanosis - crackles - tachycaria - reduced urine output - confusion, stupor - S3 heart sound (gallop) - Increased pulmonary artery occlusion pressure

Diagnostic procedures: Hemodynamic monitoring

- heart failure generally results in increased central venous pressure (CVP), increased pulmonary wedge pressure (PAWP), increased pulmonary artery pressure (PAP), and decreased cardiac output (CO) - Mixed venous oxygen to saturation (SvO2) is directly related to cardiac output. a drop in SvO2 indicates worsening cardiac function

Right-sided failure: expected findings 8

- jugular vein distention - Ascending dependent edema (legs, ankles, sacrum) - Abdominal distention, ascites - fatigue, weakness - nausea and anorexia - Polyuria at rest (nocturia) - liver enlargement (hepatomegaly) and tenderness - weight gain

Health promotion and disease prevention

- maintain an exercise routine to remain physically active, and consult with the provider before starting any exercise regimen - Consume a diet low in sodium, along with fluid restrictions, and consult with the provider regarding diet specifications - Refrain from smoking - Follow medication regimen, and follow up with the provider as needed

Health Promotion and Disease prevention

- maintain an exercise routine to remain physically active, and consult with the provider before starting any exercise regimen - consume a diet low in sodium along with fluid restrictions, and consult with the provider regarding diet specifications - Refrain from smoking - Follow medication regimen, and follow up with the provider as needed

Pulmonary Edema: Nursing care

- monitor VS every 15 minutes until stable - monitor intake and output - monitor hemodynamic status (pulmonary wedge pressures, cardiac output) - Check ABGs, electrolytes (especially potassium if on diuretics), SaO2, and chest x-ray findings - maintain a patent airway. suction as needed - position the client in high-fowler's position with feet and legs dependent or sitting on the side of the bed to decrease preload - Administer oxygen using a high-flow using a face mask or nonrebreather mask. Bilevel positive airway pressure or intubation/ventilation can become necessary. Be prepared to intervene quickly - restrict fluid intake (slow or discontinue infusing IV fluids) - Monitor hourly urine output. Watch for intake greater than output or hourly urine less than 30 mL/hr

Nursing Care

- monitor daily weight and I&O - assess for shortness of breath and dyspnea on exertion - administer oxygen as prescribed - monitor VS and hemodynamic pressures - position the client to maximize ventilation (high-Fowler's) - Check ABGs, electrolytes (especially potassium if on diuretics), SaO2, and chest x-ray findings - Assess for signs of medication toxicity (digoxin toxicity) - encourage bed rest until the client is stable - Encourage energy conservation by assisting with care and ADLs - Maintain dietary restrictions are prescribed (restricted fluid intake, restricted sodium intake) - provide emotional support to the client and family

Heart failure

- occurs when the heart muscle is unable to pump effectively, resulting in inadequate cardiac output, myocardial hypertrophy, and pulmonary/systemic congestion. - it is the result of an acute or chronic cardiopulmonary problem, such as systemic hypertension, myocardial infarction (MI), pulmonary hypertension, dysrhythmias, valvular heart disease, pericarditis, or cardiomyopathy - pulmonary edema is a severe, life-threatening accumulation of fluid in the alveoli and interstitial spaces of the lung that can result from severe heart failure

Pulmonary Edema: client education

- provide emotional support for the client and family - instruct the client on effective breathing techniques - instruct the client on medications - stress the importance of continuing to take medications even if the client is feeling better - teach common adverse effects of medications, and reasons to contact the provider - follow instructions for reasons to contact provider - instruct the client on a low-sodium diet and fluid restriction - the client should measure weight daily at the same time. Notify the provider of a gain of more than 2 lb in 1 day or 5 lb in 1 week - report swelling of feet or ankles or any shortness of breath or angina

Assessment: Risk factors

- systolic blood pressure is elevated in older adults, putting them at risk for coronary artery disease and heart failure - some medications can increase the risk of heart failure or worsen manifestations in older adult clients

American College of Cardiology and American Heart Association staging heart failure

American College of Cardiology and American Heart Association developed evidence-based guidelines for staging and managing heart failure in comparison with NYHA system - A: high risk for developing heart failure - B: Cardiac structural abnormalities or remodeling but no heart failure symptoms - C: Current or prior symptoms of heart failure - D: Refractory end-stage heart failure

High-output heart failure

An uncommon form of heart failure; cardiac output is normal or above normal

Cardiomyopathy (leading to heart failure): expected findings

Blood circulation to the lungs is impaired when the cardiac pump is compromised - FOUR TYPES * dilated (most common) * Hypertrophic * Arrhythmogenic right ventricular * Restrictive - MANIFESTATIONS * fatigue, weakness * heart failure (left with dilated type, right with restrictive type) * Dysrhythmias (heart block) * S3 gallop * Cardiomegaly (enlarged heart), more severe with dilated type * Angina (hypertrophic type)

Pulmonary Edema

Cardiogenic factors are the most common cause of pulmonary edema. It is a complication of various heart and lung diseases and usually occurs from increased pulmonary vascular pressure secondary to serve cardiac dysfunction

Noncardiac Pulmonary Edema

can occur due to barbiturate or opiate overdose, inhalation of irritating gases, rapid administration of IV fluids, and after a pneumonectomy evacuation of pleural effusion.

Low-output heart failure

Heart failure can occur on either side of the heart - Left-sided (ventricular) failure: results in inadequate left ventricle (cardiac) output and consequently in inadequate tissue perfusion * Systolic heart (ventricular) failure: ejection fraction below 40%, pulmonary and systemic congestion * Diastolic heart (ventricular) failure: inadequate relaxation or "stiffening" prevents ventricular filling - Right-sided (ventricular) failure: results in inadequate right ventricle output and systemic venous congestion (peripheral edema)

Afterload-reducing agents

Help the heart pump more easily by altering the resistance to contraction. These are contraindicated for clients who have RENAL DEFICIENCY - ANGIOTENSION-CONVERTING ENZYME (ACE) INHIBITORS: such as enalaPRIL and captoPRIL - ANGIOTENSION RECEPTOR II BLOCKERS: such as losartan - CALCIUM CHANNEL BLOCKERS: such as *diltiazem* and nifedipine - PHOSPHODIESTERASE-3 INHIBITORS: such as milrinone NURSING CONSIDERATIONS - monitor clients taking ACE inhibitors for hypotension following the initial dose - ACE inhibitors can cause angioedema (swelling of the tongue and throat), decreased sense of taste, or skin rash - Monitor for increased levels of potassium CLIENT EDUCATION -ACE INHIBITORS - inform the client that this medication can cause dry cough - notify the provider if the client observes a rash or has a decreased sense of taste - notify the provider if swelling of the face or extremities occurs - remind the client that blood pressure needs to be monitored for 2 hours after the initial dose to detect hypotension

Laboratory tests

Human B-type natriuretic peptides (hBNP): in clients with dyspnea, elevated hBNP confirms a diagnosis of heart failure rather than a problem originating in the respiratory system. hBNP levels direct the aggressiveness of treatment interventions - less than 100pg/mL indicates no heart failure - 100 to 300 pg/mL suggests heart failure is present - greater than 300 pg/mL indicates mild heart failure - greater than 600 pg/mL indicates moderate heart failure - greater than 900 pg/mL indicates severe heart failure

Vasodilators

Nitroglycerin and isosorbide mononitrate prevent coronary artery vasospasm and reduce preload and afterload, decreasing myocardial oxygen demand - NURSING CONSIDERATIONS * vasodilators are given to treat angina and help control blood pressure * use cautiously with other anti-hypertensive medications * vasodilators can cause orthostatic hypotension - CLIENT EDUCATION * remind the client that a headache is a common side effect of this medication * encourage the client to sit and lie down slowly

Diagnostic procedures: Chest X-ray

a chest x-ray can reveal cardiomegaly and pleural effusions.

Complications: Acute pulmonary edema

a life-threatening medical emergency - effective interventions should result in diuresis (carefully monitor output), reduction in respiratory distress, improved lung sounds, and adequate oxygenation. - *EXPECTED FINDINGS*: anxiety, tachycardia, acute respiratory distress, dyspnea at rest, change in level of consciousness, and an ascending fluid level within the lungs (crackles, cough productive of frothy, blood-tinged sputum) - *NURSING ACTIONS*: ▪prompt response to this emergency includes the following: -> positioning the client in high-fowler's position -> administration of oxygen, positive airway pressure, and/or intubation and mechanical ventilation -> IV morphine (to decrease activity, respiratory distress, and decrease venous return) ▪ IV administration of rapid-acting loop diuretics, such as furosemide. Administer prescribed medications to improve cardiac output. ▪teach the client about measures to improve tolerance to activity, such as alternating periods of activity with periods of rest.

Therapeutic procedures: Ventricular assist device (VAD)

a mechanical pump that assists a heart that is too weak to pump blood through the body. It is used in clients who are eligible for heart transplants or who have severe end-stage heart failure and are not candidates for heart transplants. ▪ Heart transplantation is the treatment of choice for clients who have severe dilated cardiomyopathy ▪ contradictions to ventricular assist devices surgery includes severe chronic lung disease, and stage kidney disease, clotting disorders, and infections unresponsive to antibiotic therapy. - NURSING ACTIONS * prepare the client for the procedure (NPO status and informed consent) * monitor postoperatively: VS, SaO2, incision drainage, and pain management

New York's Heart Association's functional classification scale

chest pain , shortness of breath - Class 1: client exhibits no symptoms with activity - Class 2: Client has symptoms with ordinary exertion - Class 3: Client displays symptoms with minimal exertion - Class 4: Client has symptoms at rest

Neurogenic Pulmonary Edema

develops following a head injury

Human B-type natriuretic peptides

hBNPs, such as nesiritide, are used to treat acute heart failre by causing natriuresis (loss of sodium and vasodilation). they are administered IV - NURSING CONSIDERATIONS * hBNPs can cause hypotension, as well as a number of cardiac effects, including ventricular tachycardia and bradycardia * BNP levels will increase while on this medication * monitor ECG, blood pressure, and other parameters - CLIENT EDUCATION * the client can be asymptomatic with a low blood pressure(lower BP without warning) * remind the client to sit and lie down slowly

Medications

herbal medications can stimulate the cardiovascular system. obtain a list of herbal supplements the client takes, and advise the client of potential contraindications

Older adults: pulmonary edema

increased risk for pulmonary edema occurs related to decreased cardiac output and heart failure - increased risk for fluid and electrolyte imbalances occurs when the older adult client receives treatment with diuretics - For older adults, IV infusions must be administered at a slower rate to prevent circulatory overload

Beta-adrenergic blockers (beta-blockers)

medications such as carvedilol and metoprolol can be used to improve the condition of the client who has sustained increased levels of sympathetic stimulation and catecholamines. This includes clients who have chronic heart failure - Nursing considerations * monitor blood pressure, pulse, activity tolerance, and orthopnea(Discomfort when breathing while lying down flat; common in people with some types of heart or lung conditions.) * check orthostatic blood pressure readings - Client education * weigh daily * check blood pressure * tell the client to follow the provider's instructions for increasing medication dosage

Diuretics

used to decrease the preload - *LOOP DIURETICS*: such as furosemide and bumetanide - *THIAZIDE DIURETICS*: such as hydrochlorrthiazide - *POTASSIUM-SPARING DIURETICS*: such as spironolactone Nursing considerations - administer FUROSEMIDE IV no faster than 20mg/min - loop and thiazide diuretics can cause hypokalemia, and potassium supplementation can be required *CLIENT EDUCATION*: teach clients taking loop or thiazide diuretics to ingest foods and drinks that are high in potassium to counter the effects of hypokalemia

Complications: Pericardial tamponade aka cardiac tamponade

result from fluid accumulation in the pericardial sac - EXPECTED FINDINGS: include hypotension, jugular venous distention, muffled heart sounds, and PARADOXICAL PULSE (variance of 10 mm Hg or more in SYSTOLIC blood pressure between expiration and inspiration) - DIAGNOSTIC PROCEDURES: hemodynamic monitoring will reveal intracardiac and pulmonary artery pressures similar and elevated (plateau pressures) - NURSING ACTIONS * notify the provider immediately * administer IV fluids to combat hypotension as prescribed while monitoring for fluid overload * obtain a chest x-ray or echocardiogram to confirm diagnosis * prepare the client for pericardioventesis (informed consent, gather materials, administer medications as appropriate) * Monitor hemodynamic pressures as they normalize * monitor heart rhythm; changes indicate improper positioning of the needle * monitor for re-occurrence of findings after the procedure

Expected findings for heart failure

the presence of other chronic illnesses (lung disease, kidney failure) can mask the presence of heart failure in older adult clients

Complications: cardiogenic shock

this is a serious complication of pump failure that occurs commonly following an MI and injury to greater than 40% of the LEFT ventricle - EXPECTED FINDINGS: include tachycardia, hypotension, inadequate urinary output, altered level of consciousness, respiratory distress (crackles, tachypnea), cool, clammy skin, decreased peripheral pulses, and chest pain - NURSING ACTIONS * monitor breath sounds. Assess for crackles or wheezing * monitor heart sounds * administration of oxygen, intubation, and ventilation can be required * administer IV morphine, diuretics, and/or nitroglycerin to decrease preload. Administer IV vasopressors and/or positive inotropes to increase cardiac output and maintain organ perfusion * provide continuous hemodynamic monitoring(measures the blood pressure inside the veins, heart, and arteries. It also measures blood flow and how much oxygen is in the blood. It is a way to see how well the heart is working.)

Diagnostic procedures: Ultrasound

two-dimensional or three-dimensional ultrasound (also called cardiac ultrasound or echocardiogram) is used to measure the systolic and diastolic functioning of the heart. - Left ventricular ejection fraction: the volume of blood pumped from the left ventricle into the arteries upon each beat. Expected reference range is 55% to 70% - Right ventricular ejection fraction: the volume of blood pumped from the right ventricle to the lungs upon each beat. Expected reference range is 45% to 60%

Diagnostic procedures: Transesophageal echocardiography (TEE)

uses a transducer placed in the esophagus behind the heart to obtain a detailed view of cardiac structures. The nurse prepares the client for a TEE in the same manner as for an upper endoscopy

Anticoagulants

warfarin; prescribed if the client has a history of thrombus formation - NURSING CONSIDERATIONS: * assess for contraindications: active bleeding, peptic ulcer disease, history of cerebrovascular accident, and recent trauma * monitor bleeding time: PT, aPTT, INR, and CBC - CLIENT EDUCATION * remind the client of the risk for bruising and bleeding while on this medication * instruct the client to have blood monitored routinely to check bleeding times

Therapeutic procedures: heart transplantation

~ Heart transplantation is a possible option for clients who have end-stage heart failure. Immunosuppressant therapy is required post-transplantation to prevent rejection ~ Eligibility for transplantation depends on several factors, including life expectancy, age, psychosocial status, and absence of drug and alcohol use disorders - NURSING ACTIONS * prepare the client for the procedure (NPO status and informed consent). Lab reports and results of diagnostic testing should be available as prescribed * monitor postoperatively : VS, SaO2, incision drainage, and pain management * monitor for complications. Organ transplant recipients are at risk for infection, thrombosis, and rejection - CLIENT EDUCATION * take medications as prescribed * take diuretics in the early morning and early afternoon * maintain fluid and sodium restriction: a dietary consult can be useful * increase dietary intake of potassium (cantaloupe or bananas) if the client is taking potassium-losing diuretics, such as loop and thiazide diuretics * Check weight daily at the same time, and notify the provider for a weight gain of 2lb in 24 hours or 5 lbs in a week. follow-up visits with the provider * get vaccinations (pneumococcal and yearly influenza vaccines)