Heart Failure

What is left sided HF systolic dysfunction?

When the left ventricle can not effective pump blood out of the heart The left ventricle (LV) in systolic failure loses its ability to generate enough pressure to eject blood forward through the aorta. Over time, the LV becomes dilated and hypertrophied. It is caused by impaired contractile function (e.g., MI), increased afterload (e.g., hypertension), cardiomyopathy, and mechanical abnormalities (e.g., valvular heart disease).

What is HF?

condition in which the heart cannot pump enough blood into circulation to meet the body's needs •Affects >5 million people •Most rapidly increasing form of Cardiovascular Disease •Increases dramatically with aging process •Most common reason for hospital admission in adults >65

What is left sided HF Diastolic Dysfunction?

when the left ventricle can not effective pump blood out of the heart

How do the following cause left sided HF systolic dysfunction?

•HTN- increases afterload (the force heart has to contract to eject blood), from increased blood pressure, makes heart work harder to contract sufficiently •CAD- myocardial ischemia to infarction to the Left coronary artery (LMCA- left main coronary artery), decreased oxygen needed for left ventricle to function •DILATED CARDIOMYOPATHY- when the heart muscle wall in the left ventricle enlarges (stretches and thins out) leading to weak contractions •VALVULAR HEART DISEASE- Aortic valve stenosis stiffens and causes some resistance for left ventricle to pump out blood, makes heart work harder

What is acute HF?

sudden decrease in cardiac function as a result: •Myocardial Infarction •Congenital heart defects •Hypertensive crisis •Massive pulmonary embolus •Hypermetabolic states: sepsis, hyperthyroidism, pregnancy

AHA HF S/S chart

(look at picture)

What are some diagnostic studies for HF?

*CXR- see if heart is enlarged and pulmonary edema EKG- abnormal electrical activity causing HF *Echocardiogram- can evaluate how well the heart contracts, EF and heart valves. Can also have a type called Stress Echo. (combo between stress test and echo) Labs -ANP/*BNP- atrial natriuretic peptides (ANP) / beta natriuretic peptides (BNP)- proteins that are released from the heart when it is stretched. Decreased cardiac output decreases renal perfusion which stimulates the RAS system to vasoconstrict and reabsorb Na and water. This increases volume and pressure in the heart causing it to stretch. Patients who present in the ER with dyspnea can have B-type Natriuretic Peptide (BNP) blood test drawn to help determine if the SOB is due to heart failure or a respiratory condition BNP hormone that is released by heart muscle in response to changes in blood volume and increases in HF Serum BNP levels are used as an assessment of heart failure. Women > 60 years old may have elevated levels. Not to be used as a sole indicator for HF. Normal range IS BNP 0.5-30 pg/mL: •BNP levels below 100 indicate no heart failure. •BNP levels of 100-300 suggest heart failure is present. •BNP levels above 300 indicate mild heart failure. •BNP levels above 600 indicate moderate heart failure. •BNP levels above 900 indicate severe heart failure -Electrolytes- checks heart function (Potassium, Calcium and Magnesium) for cause of HF -UA- detects kidney problems which can have similar S&S), kidney problems can cause HTN which can lead to HF -Liver function- detect liver problems (which can have similar S&S) -Thyroid function- detect thyroid problems (which can have similar S&S), Thyroid hormone also effects HR and BP -ABG- detect respiratory status associated with HF S&S

What are some medications for HF?

*First line drugs for HF: ACE INHIBITORS or ARBS's- helps dilate vessels which decreases amount of work the heart has to do, relieves dyspnea and fatigue BETA BLOCKERS- helps decrease the amount of work the heart has to do VASODILATORS - opens or dilates blood vessels, hydralazine (Apresoline), isosorbide (Isordil), isosorbide & Hydralazine (Bidil) DIURETEICS- decrease excess fluid volume MORPHINE- decreases myocardial oxygen demand of the heart, relieves chest pain POSITIVE INOTROPES - Enhance the strength/force of the contraction, which increases cardiac output, slows heart rate down Meds: Digoxin (IVP, PO), milrinone (Primacor) IV and Dobutamine (IV) •Side Effects of Digoxin: Bradycardia •Interventions: Asses Apical pulse for 1 min before giving-hold if <60. Monitor K+, Ca & Mg levels, (hypokalemia can precipitate toxicity even when serum digitalis levels are in normal range) Assess levels of digoxin (norm 0.5-2ng/ml) •Digitalis levels Therapeutic levels: 0.8 - 2 ng/ml •Treatment for Digoxin toxicity: Withhold digitalis, Antidote: Digoxin immune FAB (Digibind) Digitalis Toxicity: •Early symptoms; N/V, anorexia •Visual disturbances; Diplopia, blurred vision, yellow, green or white halos, Arrhythmias

S/S of left-sided HF?

-DYSPNEA Orthopnea- difficulty breathing when laying down Nocturnal - sudden difficulty breathing during sleep. Paroxysmal Nocturnal Dyspnea- sudden shortness of breath during sleep. Dyspnea is a common manifestation of chronic HF. It is caused by increased pulmonary pressures secondary to interstitial and alveolar edema. Dyspnea can occur with mild exertion or at rest. Orthopnea often accompanies dyspnea. Most people go to sleep laying down, Patient with HF may sit up in recliner or sleep with head elevated with pillows in the bed. -TACHYCARDIA- early clinical sign of HF. One of the body's first mechanisms to compensate for a failing ventricle is to increase the HR. Because of reduced cardiac output, the SNS is activated, which increases HR. *However, this response may be blocked or reduced in patients taking beta-blocker drugs. -PULMONARY CONGESTION (EDEMA) •Cough •Crackles •Frothy sputum- increased blood in the lungs of tissue Breath sounds will reveal crackles (caused by fluid in the alveoli of the lungs) that do not cleared by coughing. In addition, red blood cells also leak into the lungs having the classic sign of pink frothy sputum. In both conditions there will be diminished gas exchange resulting in ↑SOB and ↓O2 sats. -ALTERED MENTAL STATUS - decreased oxygenation blood to the brain Cerebral circulation may be reduced with chronic HF secondary to decreased cardiac output. The patient or caregiver may report unusual behavior, including restlessness, confusion, and decreased attention span or memory. This may also be secondary to poor gas exchange and worsening HF. It is often seen in the late stages of HF. •KIDNEY FAILURE- reduced oxygenated blood flow to the kidneys, this activates the RAS systems (makes the body think there is not enough fluid in the body, so retains fluid, leading to more blood in the heart, increasing preload (amount of blood left ventricle fills up with before contracting) •FATIGUE- overall result of difficulty breathing for decreased oxygen and increased congested, overworked heart

What are some risk factors for HF?

ALTERED STRUCTURE & FUNCTION- affects normal function of the heart: •Advanced Age: older persons are more likely a decline in function, longer "wear and tear" of the body, •HTN: increase size of left ventricular muscle making the heart work harder to pump blood throughout the body •Congenital heart defects: structures of heart (defective vessels, hole in heart, leaky valves) •Valvular heart disease: when heart valves don't open and close properly •Cardiomyopathy- disease of the heart that enlarges or stiffens the heart muscle walls •Dysrhythmias: abnormal electrical activity WEAKENS OR DAMAGES - impact on heart muscle: •Heart attack: leads tissue necrosis of the heart muscle •Coronary artery disease: narrowed arteries may limit your heart muscles supply of oxygen-rich blood •Sleep apnea: Lows blood oxygen levels during periods of sleep, decreased perfusion to heart muscle •Viruses: viral infections attack on heart muscle. LIFESTYLE •Alcohol use: Drinking too much alcohol can weaken heart muscle and lead to heart failure. •Tobacco use: Using tobacco can increase your risk of heart failure. SPECIFIC CONDITIONS- risk that are already present that can contribute to other HF risks •Obesity: leads to higher risks of developing CAD •Diabetes: increases the risks of having HTN and CAD

How do the following conditions cause right-sided HF?

CAUSES •Primarily by Left-sided HF- pulmonary congestion and increased pressure in the blood vessels of the lung (pulmonary hypertension). Eventually, chronic pulmonary hypertension (increased right ventricular afterload) results in right-sided hypertrophy and HF. •Chronic Lung diseases- that increase pulmonary pressure •. Cor pulmonale- disorder of the lung (latin: pulmonale) cause dysfunction in the heart (latin: cor) leading to right ventricular dilation (ex. PE) or hypertrophy (ex. COPD)

What are other s/s of HF (Chest pain & Skin changes)?

CHEST PAIN HF can precipitate chest pain (angina) due to decreased coronary artery perfusion from decreased cardiac output and increased myocardial work. Chest pain may accompany either acute HF -sudden worsening of s/s of HF, includes dyspnea, leg or feet swelling, & fatigue or chronic HF. SKIN CHANGES Because tissue capillary oxygen extraction is increased in a person with chronic HF, the skin may appear dusky to cyanosis in severe cases. Often the lower extremities are shiny and swollen, with diminished or absent hair growth. Chronic swelling may result in pigment changes. This causes the skin to appear brown or brawny in areas covering the ankles and lower legs similar venous ulcers seen in chronic venous insufficiency

What are the most common diagnostic tests for HF?

CXR, Echo and BNP EKG and Electrolytes are also commonly taken to see if the abnormalities they detect cause the heart failure

What can HF be caused by?

Caused by ineffective heart function (either or both): •Systolic dysfunction: inability of heart to contract or pump effectively •Diastolic dysfunction: inability of heart to relax or fill effectively •

What is chronic HF?

Chronic HF- progressive deterioration of heart muscle from following conditions: •CAD •Hypertension •Diabetes •Valvular Disorders •Cardiomyopathy •Sleep Apnea.

What are some non-pharmacological treatments for HF?

Decreased blood flow to the body and heart from heart failure can lead to the heart abnormal heart rhythms that can be deadly. TREATMENTS: ICD- Implantable Cardiac Defibrillator- electronic device, place in chest wall and connected to heart by wires -Sends small shock to heart muscle if heart beat gets out of abnormal rhythm. -Client will feel a shock, which is uncomfortable. *Anyone touching patient at time will not get shocked too, may feel light contractions" -Watch the video: https://www.youtube.com/watch?v=-cjExcU0R8U CRT- Cardiac Resynchronization Therapy (Biventricular Pacing), electronic device (pacemaker), usually placed in chest wall and connected to heart by wires -Sends electrical pulses to the heart muscle which are not painful to client -Helps the right and left ventricles to contract/relax at the same time, increasing better perfusion -Watch the video: https://www.youtube.com/watch?v=FAGno7PZaQs CRT-D- electronic device that have a CRT and ICD LVAD- Left Ventricular Assist Device- mechanical pump attached to left ventricle and aorta -Does not replace the heart, just assist in getting blood to the aorta and rest of body -Watch the video: https://www.youtube.com/watch?v=U8rCoDiRaxY SURGERIES Coronary Artery Bypass Graft (CABG)- restores blood flow to artery that helps ventricles contract by rerouting the blood around the blockages with a graft Valve Surgery- fixes the mitral and aortic valves so they can work properly

What is EF (Ejection Fraction)?

Ejection Fraction- amount of blood the left ventricle pumps out in one cardiac cycle, reflects how well body is perfused •Left ventricle usually fills up with 100 ml •How much is injected when contracting divided by 100 = ejection fraction ex. Heart fills up with 100 ml, ejects 50 ml = 0.5 or 50% EF •Normal EF=50 -70%, <40% indicates heart failure from systolic dysfunction, the lower the number, the worst the heart failure

What can HF lead to?

HF can lead to the following results: •decreased cardiac output •decreased tissue perfusion

Answer the following questions with the correct stage of HF?

HF failure can be a progressive, worsening condition that can worsen over time and reflected in how one functions. Often use client's activity level as way to determine client's functional level. QUESTIONS: Which stage/lass would you give client who answered yes to the following questions? - -With your risk for HF, are you able to walk from one room to anther without getting short of breath? A/ I -With your diagnosis and treatments for HF, do you have shortness of breath when sitting, standing that becomes more severe when walking? D / IV - -With your diagnosis of HF, do you have shortness of breath when walking from one room to another but not at rest ? B / II - -With your diagnosis of HF and treatments, do you have moderate shortness of breath when walking from one room to another and mild at rest? C / III

S/S of right-sided HF?

JVD- can see a bulging external jugular vein, primarily when HOB is at 45 degrees and head turned to the side DEPENDENT EDEMA- from excess blood/fluid by gravity, mainly in the legs, ankle and sacrum, can be pitting edema (grade 1+ to 4+) ASCITES- from excess blood/fluid in the abdominal region, can cause abdominal distension, can even leak out through skin in severe cases ANOREXIA/NAUSEA- from blood is being moved away from the digestive system causing abnormal GI function HEPATOMEGALY- from excess blood/flood in hepatic veins, decreasing blood drainage from the liver NOCTURIA- increased urination at night caused by decreased cardiac output that will impaired renal perfusion and decreased urinary output during the day. However, when the person lies down at night, fluid moves from the interstitial spaces back into the circulatory system. In addition, cardiac workload is decreased at night while resting. These combined effects result in increased renal blood flow and diuresis. The patient may complain of having to void frequently throughout the night. Patient may void 6 -7 times per night WEIGHT GAIN- rapid increase in fluid volume Patient weights are extremely important in patients with HF as they can change significantly as a result of fluid volume. Retention of fluid results in increased weight and provides an indication that the patients heart failure is worsening. During discharge teaching patients should be taught the importance of weighing themselves daily and notify the health care provider about an increase of 3 pounds in 2 days or 3 to 5 pounds in a week FATIGUE/WEAKNESS- from excess fluid/blood in the body, feeling of body heaviness *Some clients can have both LEFT SIDED HF and RIGHT SIDED HF called Biventricular Heart Failure (usually caused Left-Sided HF)

Description of LV Diastolic Dysfunction?

LV (Left Ventricle) Diastolic Dysfunction -stiff heart muscle can't relax normally -less blood fill the ventricle

Difference between LV Diastolic Dysfunction and LV Systolic Dysfunction?

LV (Left Ventricle) Diastolic Dysfunction -reduced volume LV (Left Ventricle) Systolic Dysfunction -dilated ventricle (ex. Dilated Cardiomyopathy)

What can HF be called and be described as?

Sometimes called Congested Heart Failure (CHF), more recently and commonly called just Heart Failure (HF) Can be described as someone having a heart muscle that is weak, damaged, stressed or stiff

What are some patient education?

The Heart Failure Society of America (HFSA) developed the acronym, FACES (fatigue, limitation of activities, chest congestion/cough, edema, and shortness of breath) to help educate patients on identifying HF symptoms through self assessments. • Fatigue- overworked heart, dyspnea and decreased oxygenation, excess fluid Q- Do I feel extremely tired or have any weakness? Activities are limited- not able to normal daily activities, decline in ability to walk, self care, without getting SOB Q- Am I still able to do my normal daily activities without getting short of breath? Chest congestion/cough- from pulmonary edema, cough up clear frothy sputum, blood tinged, may say they feel fluid in chest Q- Do I have any chest pain, cough or congestion? Edema- excess fluid in body, primarily lower extremities but can include, upper extremities, abdomen, sacrum, periorbital (around eyes) and face Q- Do I have any swelling anywhere in my body or sudden weigh gain Shortness of breath- at rest and walking/moving Q- Do I have any shortness of breath when laying down, sitting, standing or walking

How do the following cause left sided HF diastolic dysfunction?

•HYPERTROPHIC CM- becomes thick leading to less space available to fill up blood, also more muscle means more need for 02 and less space for coronaries to dilate leading to weak contractions •RESTRICTIVE CM- becomes very ridged leading to the inability to stretch (ex. Think about filling up a water balloon, it's ability stretch allows it to hold more water) •HTN- increase systemic blood pressure can cause the heart to work harder to push blood through the aorta (ex. think about what happens when you weigh lift- those muscle gets larger). To compensate, the heart muscle becomes thicker and larger muscle means less space for ventricle to fill up *EF can present to be normal when there is actual low amount of blood being pump out (ex. A smaller ventricle fills up with only 50 ml and pumps out on 25ml = 0.5 or 50%EF Very important to diagnosed between systolic and diastolic dysfunction.

What are some nursing interventions for HF?

•Positions •Bedrest for fatigue, prevent risk due to decreased mobility (skin, VTE prophylaxis) •HOB elevated for dyspnea and cough •Elevate legs for edema • •Diet •Low sodium to prevent fluid retention •Heart Healthy- maintain appropriate electrolytes and prevent further complications •Fluid Restriction- prevent excess fluid volume, may be no more than 2 liters per day • •Monitor •Daily weights- see if weight is increasing rapidly (same time, same scale, say way- ex. naked?) •Intake & output- monitor fluid status Input should equal Output ( negative output- fluid volume deficit, positive deficit- fluid volume negative) •Urinate if necessary- if strict I & O and incontinent • •Organize activities •Allowing for frequent rest periods •Cluster care- attempt to do many activities at one time but short interval, still need to do hourly rounds

What is right-sided HF?

•Right-sided HF occurs when the right ventricle (RV) fails to contract effectively. •Right-sided HF causes a backup of blood into the right atrium and venous circulation. •Venous congestion in the systemic circulation results in jugular venous distention, hepatomegaly, splenomegaly, vascular congestion of the gastrointestinal (GI) tract, and peripheral edema.

What is Left-Sided HF?

•The most common form of HF •Results from left ventricular dysfunction, prevents normal, forward blood flow and causes blood to back up into the left atrium and pulmonary veins. •increased pulmonary pressure causes fluid leakage from the pulmonary capillary bed into the lung tissue and alveoli. •manifests as pulmonary congestion and edema.