Heart Failure - Pulmonary Edema

How does O2 therapy help Heart Failure patients?

*improves ventilation* impaired by congestion and sluggish circulation in lungs

How do Diuretics help with Heart Failure?

*reduce excess fluid* - working on preload When using Lasix, you lose Potassium (K) b/c you pee it out so monitor *hypokalemia*

Diagnostic Tests for CHF (8)

1. Chest x-ray - fluid presence 2. Electrocardiography (ECG) - enlarged heart from the stretch over time 3. Exercise stress testing 4. Cardiac catheterization - how well it's ejecting 5. ABGs 6. LFTs 7. Serum Electrolytes and Enzymes (Na, Mg, K, BUN, creatinine) 8. BNP - Brain Natriuretic Peptide 100 less picograms - no HF 700 and above = severe HF

What is the Pitting Edema scale?

0+ = *NO* pitting edema 1+ = *2 mm* deep, disappears *RAPIDLY* *MILD* 2+ = *4 mm* deep, disappears in *10 to 15 secs* *MODERATE* 3+ = *6 mm* deep, may last more than *1 min* *MODERATELY SEVERE* 4+ = *8 mm* deep, may last more than *2 mins* *SEVERE*

The degree (severity) of pitting edema is based on what? (2)

1. *DEPTH* of tissue depression and 2. *TIME* it takes for indentation to *DISAPPEARS.*

Causes of CHF include: (6)

1. Congenital defects Diseases of the heart & blood vessels: 2. Atherosclerosis/Arteriosclerosis 3. Myocardial Infarction (MI) 4. Diabetes Mellitus (DM) -high sugars root of all evils b/c it hardens the arteries ** 5. Hypertension (HTN) 6. Valvular heart disease

Left Ventricular Failure is often affected by (2)

1. Coronary Atherosclerosis 2. HTN - that's why it is so important to have well maintained BP

S/s of Left Ventricular Failure

1. Decreased Cardiac Output 2. Pulmonary Congestion First signs = r/t decreased CO [cardiac output] (low bp, increased hr, decreased UOP [urinary output]) Second signs = r/t pulm congestion (crackles, sob [shortness of breath], increased resp. effort, frothy sputum, wheezing)

Describe the Renin-Angiotensin-Aldosterone System (RAAS)

*Renin* from *kidneys* activates *Angiotensin I* formation *Angiotensin Converting Enzyme (ACE)* converts *Angiotensin I* to *Angiotensin II* Angiotensin II is a *potent vasoconstrictor* *Angiotensin II* induces secretion of *Aldosterone* from the *Adrenal Gland* *Aldosterone* causes retention of *Sodium and Water* "Water follows Salt" This *INCREASES* Blood Pressure

How do Nitrates help with Heart Failure?

*VASODILATOR* - dilates arteries decreasing vascular resistance

What are 3 Nursing Diagnoses r/t (related to) Heart Failure?

*1. DECREASED CARDIAC OUTPUT 2. ANXIETY 3. ACTIVITY INTOLERANCE*

S/S of Left Heart Failure (10)

*1. Paroxysmal (sudden) Nocturnal Dyspnea* 2. Elevated Pulmonary Capillary Wedge Pressure 3. Pulmonary Congestion: *Cough,* *Crackles - moist crackles and popping upon auscultation of lungs,* Wheezes, *Blood-Tinged Sputum,* Tachypnea 4. Restlessness 5. Confusion *6. Orthopnea* 7. Tachycardia *8. EXERTIONAL Dyspnea* 9. Fatigue 10. Cyanosis

What is a 1+ Edema?

*2 mm* deep, disappears *RAPIDLY* *MILD*

What is a 2+ Edema?

*4 mm* deep, disappears in *10 to 15 secs* *MODERATE*

What is a 3+ Edema?

*6 mm* deep, may last more than *1 min* (1-2 mins) *MODERATELY SEVERE*

What is a 4+ Edema?

*8 mm* deep, may last more than *2 mins* (2-5 mins) *SEVERE*

What is a 0+ Edema?

*NO* pitting edema

Clinical Manifestations of Heart Failure (3)

1. Decreased cardiac output. 2. Left ventricular failure. 3. Right sided failure. Symptoms of either left or right sided heart failure may appear first leading to failure of both sides. Regardless of the etiology, when one ventricle or the other fails to pump effectively, the fluid entering the atria remains the same but ventricular output is diminished.

Drug Therapies used for Heart Failure

1. Digitalis Preparations (cardiac glycosides) 2. Nitrates 3. ACE Inhibitors 4. Diuretics

S/s of Right Ventricular Failure (12)

1. Fatigue 2. Increased Peripheral Venous Pressure 3. Ascites (Fluid in the abdominal cavity) "abdominal edema" : flatulence, anorexia, nausea, abdominal distention 4. Enlarged Liver and Spleen 5. May be secondary to Chronic Pulmonary Problems 6. JVD = Jugular Vein Distention 7. Anorexia & Complaints of GI Distress 8. Swelling in Hands & Fingers 9. Dependent, Pitting Edema 10. Nocturia 11. Organ dysfunction - b/c of edema 12. Weight gain - greater than 10 pounds

Nursing Diagnoses r/t Pulmonary Edema (3)

1. Fluid volume excess 2. Impaired Gas Exchange 3. Anxiety

Medical Management for Pulmonary Edema

1. High Fowler's to promote lung expansion 2. Morphine (10-15mg) titrate IV - morphine will slow resp rate so be cautious b/c they already have trouble breathing 3. Oxygen 40-60 (100)% 4. Nitroglycerin SL 5. Diuretics - works on *preload* 6. Inotropic agents - works on *contractility* 7. Nitroprusside (nitropress) - *potent vasodilator*

Focus on what Nursing Interventions for Pulmonary Edema? (2)

1. Improving *OXYGENATION* AND 2. Improving *CARDIAC OUTPUT* - Administering *oxygen* effectively - Place patient in upright position with *lower extremities lower than heart to decrease venous return* - b/c there's already too much. - Monitor ABG's - Assess pulmonary status often

How do Digitalis Preparations (cardiac glycosides) help with Heart Failure?

1. Increase contractile force of ventricles and 2. Slows heart rate *IMPROVES CONTRACTILITY*

What effects do catecholamines have on the heart/circulatory System?

1. Increased BP (HTN) 2. Tachycardia 3. Vasoconstriction of peripheral arteries All of the above result in MORE WORKLOAD for the heart and increased myocardial o2 consumption.

Conditions that *Increase* Cardiac Output (CO): (5)

1. Infection. - b/c heart rate goes up 2. Stress.- b/c heart rate goes up 3. Hyperthyroidism. 4. Pregnancy. - b/c of significant change in blood volume 5. Anemia.

Causes of Congestive Heart Failure (CHF) include factors that either:

1. Interfere with *blood supply* to heart muscle - MI and/or 2) Increase in *workload* to pump blood

Diagnostic Tests for Pulmonary Edema

1. Physical examination (S/S) 2. Chest X-Ray - to see fluid accumulation 3. ABG sampling - to check gas exchange (may reveal respiratory acidosis or alkalosis).

HF revolves around 3 things

1. Preload 2. Contractility 3. Afterload

S/S of Pulmonary Edema (6)

1. Restlessness, vague uneasiness 2. Agitation, disorientation 3. Diaphoresis, Severe dyspnea, Tachypnea, Tachycardia, Cold Extremities 4. pallor or cyanosis - b/c of decreased O2 *5. COUGH - produces large amt of blood tinged frothy sputum* 6. wheezes, crackles wheezes - high-pitched, continuous, musical, squeaky crackles - sounds like salt added to a hot pan

Nursing Interventions for Nursing Diagnosis of Fluid Volume Excess (3)

1. Strict *I&O's* 2. *Weigh* pt daily (important to weigh patient at the same time q day) 3. Assess pt for *edema* - increased risk for skin breakdown

What is one of the most classic S/S of *RIGHT* sided heart failure?

1. Weight gain: greater than 10 pounds of extra fluid must be retained before edema becomes noticeable. 2. Jugular vein distension

How does Morphine help with Pulmonary Edema? (4)

1. decrease pt's *anxiety* 2. *dilate* pulmonary blood vessels 3. slow *respirations* 4. reduce *venous return* - b/c it's already backed up

1L of fluid = __ kg or __ lbs

1L of fluid = 1kg or 2.2 lbs Wt. gain of 2.2 lbs = 1L of body fluid May not notice edema until 10 lbs. or more fluid is retained

What would edema that is 6mm deep and persists for 1-2 minutes be classified as?

3+

Edema may not be not be noticeable until pt gains more than 10 pounds = __ liters of fluid

5 liters

HF is the most common diagnosis for the hospitalized patient older than __ years of age.

65

When giving Digitalis preparations (cardiac glycosides), make sure you check for _____ ____ being administering the med

APICAL PULSE. SSG Wilhight will chew you up if you do not.

What is Pulmonary Edema?

Accumulation of *EXTRAVASCULAR* fluid in the *INTERSTITIAL SPACE* of the lungs and alveoli

Why does Left Sided Heart Failure cause Pulmonary Edema?

Because blood from the LEFT side backs up into the LUNGS "regurgitation" b/c of the ineffective left side of the heart

Right Ventricular Failure backs up into the ___

body systemic, body, organs, especially on the right side - like the liver ... usually hepatomegaly happens and you can feel the liver by the last rib because of this

Heart Failure was called what before?

CHF (Congestive Heart Failure) because inefficient circulation leads to the "congestion" of organs. Many patients suffer pulmonary or systemic congestion along with Heart Failure. But it is not used anymore because not all patients experience congestion with Heart Failure.

Heart Failure is also known as

Cardiac Insufficiency

Another name for Right Ventricular Failure

Cor Pulmonale

Decreased Cardiac Output = ______ Blood Flow to the kidneys = _____ urine

Decreased CO = Decreased blood to kidneys = Decreased urine

What happens in the compensatory mechanism during HF?

Decreased Cardiac Output (blood from the heart) = Decreased Blood Pressure = Decreased Renal Perfusion = Kidney thinks it needs to get more blood so it can produce more urine = Kidney releases Renin starts RAAS system

Hepatomegaly

Enlargement of the Liver

What are catecholamines?

Epinephrine and Norepinephrine - hormones of the sympathetic nervous system that produces toxic, negative effects on the failing heart and circulatory system.

Nursing Diagnoses of Fluid Volume Excess is related to what?

Fluid accumulation in pulmonary vessels

When assessing Subjective Data on a Heart Failure pt, what things should you focus on?

Focus on 1. symptoms, 2. precipitating, and 3. relieving factors notice any: 1. dyspnea, 2. orthopnea, 3. and cough Are the pt's ADL's affected?

When assessing Objective Data on a Heart Failure pt, what things should you focus on?

Focus on physical assessment: Decreased Blood Flow to Kidneys = Decreased *Cardiac Output* on the 1. cerebral and 2. renal perfusion check for Right sided failure too if pt has Left sided failure Oxygen deficit in tissues results in cyanosis and general debilitation Physical symptoms and impaired physical function causes psychosocial stress. Note presence of: 1. respiratory distress, 2. number of pillows used to assist comfortable breathing in bed (orthopnea), 3. edema (site degree of pitting) ; 4. abdominal distention due to ascites, 5. weight gain, 6. abnormal heart or lung sound (gallops/murmurs), 7. activity intolerance, 8. JVD 9. Oliguria

Why do patients with Pulmonary Edema produce Frothy, Blood-Tinged Sputum?

Frothy Sputum is produced from *AIR* mixing with *FLUID* in the alveoli It becomes pink and Blood-tinged from the cells *bursting* into the alveoli.

What is the goal of Medical Management for Heart Failure?

Goal is to *reduce workload and improve its pumping ability*

HF stands for

Heart Failure

Inability of the heart to adequately pump blood

Heart Failure - inability to perfuse tissues

continues to be one of the leading causes of death today in the United States.

Heart disease

What is a pitting edema?

If you press down on the tissue and the depression does not fill almost immediately, pitting edema is present

What causes Left Ventricular Failure?

Increased pressure in left side of the heart backs up into the lungs Lungs accumulate fluid Increased capillary permeability leads to *Pulmonary Edema and Lungs Pleural Effusion* b/c fluid leaks out

Pitting Edema is a sign of fluid in what fluid compartment of the body?

Interstitial

If Left Ventricular Failure is left untreated, what could happen?

It could progress to Right Sided Failure - b/c fluid backing up from lungs, now right side has to work harder to pump it out to the lungs, so now backing up into the right

How do crackles sound like?

It sounds like hair being rubbed together.

Which ventricle is most often affected by coronary atherosclerosis and HTN?

LEFT ventricle

For Medical Management of Heart Failure, how would you decrease the myocardial workload demand?

LIMIT PATIENT'S ACTIVITY

Heart Failure patients should be on what kind of diet?

LOW SODIUM diet with Fluid Restriction to help with Edema

What causes Pulmonary Edema?

Left Sided Heart Failure

inability of left ventricle to effectively pump

Left Ventricular Failure

Right Ventricular Failure most often caused by what?

Left-sided Failure and can also be from lung problems such as: 1. Chronic Pulmonary disease - smoked for many years, has COPD 2. Pulmonary Hypertension

What is Oliguria?

Little urine

Supplemental Oxygen devices *reminder*

Nasal Cannula: 2-6L/min -> approx. 25 - 45% O2 Concentration Simple Face Mask: 5-8L/min -> approx. 40 - 60% Partial Rebreather Mask: 6-10L/min -> approx. 60 - 90 % Non-rebreather Mask: 10-15L/min -> approx. 95 - 100% Venturi Mask: Specific concentration of 24 - 40% or 50% at 3 - 8L/min

What procedure may be required to relieve ascites?

Paracentesis

Preload vs Contractility vs Afterload

Preload- coming back to heart Contractility - heart muscle pumping Afterload - what heart has to pump against going out of the heart

What are some Classic Clinical Manifestations of Pulmonary Edema? (3)

Pt will exhibit signs of 1. *RESPIRATORY DISTRESS.* 2. *FROTHY SPUTUM* 3. *BLOOD TINGED SPUTUM*

Pitting Edema is a sign of which sided ventricular failure?

RIGHT - b/c it backs up into the body

What's worse, Respiratory Distress or Respiratory Failure?

Respiratory Failure Respiratory Distress may progress to Respiratory Failure without prompt medical treatment

Inability of right ventricle to effectively pump

Right Ventricular Failure - the right ventricle enlarges due to high blood pressure in the pulmonary arteries usually caused by *chronic lung disease*

Educate HF patient not to drink tomato juice because it is high in what?

Sodium (Na) water follow salt = edema = heart will have to work harder b/c of increased blood volume

What is Cardiac Output?

Stroke Volume x Heart Rate Amount of blood ejected from the heart

How does infection contribute to Heart failure?

The body's *metabolic demands are increased to fight the infection* thereby increasing myocardium demand. = will make heart work harder

How do you check for edema?

To check for edema, press down on the tissue for several seconds and lift the finger and watch for dent

Why is the left ventricle most often affected by coronary atherosclerosis and HTN?

because it is the one that pumps out blood to the body therefore it requires to exert more force that is why HF usually begins there.

Can HF develop after an MI?

Yes, it can be from: 1. prolonged HTN 2. Diabetes Mellitus 3. Valvular or Inflammatory Heart Disease

Recent thinking of how Heart Failure should be viewed as

as a NEUROHORMONAL problem that results from *chronic* release of catecholamines (Epinephrine and Norepinephrine). - oversecretion from adrenal glands = constant vasoconstriction-harder for heart to pump against, heart gets tired overtime

Assessing for Pulmonary Edema is the same with

assessing Heart Failure

When pt has edema, their legs feel

clumsy, heavy, and tired

Fluid accumulation in the lungs = _______ gas exchange

decreased

What does Orthopnea mean?

difficulty breathing while laying flat abnormal condition where patient must sit or stand to breath comfortably (better lung expansion) esp if obese

What is Dependent Edema?

edema of ankles when patient is standing or sitting. May shift to sacral region when pt is in the prone position. can also happen in the scrotum or labial area in females.

How do ACE Inhibitors help with Heart Failure?

improves *CARDIAC OUTPUT*

During Right Sided Heart Failure, the Right ventricle is unable to pump blood to the lungs because of what?

increased pulmonary pressures

What is Myocardial Myopathy?

large heart not pumping effectively

Pulmonary Edema is an *acute, extensive, life threatening* complication of ___-sided heart failure

left

left sided heart failure backs up into the ____

lungs

Right Ventricular Failure results in fluid accumulation in *systemic* circulation causing poor _____ ______.

venous return causing problems such as: *1. organ congestion 2. peripheral edema* -b/c patients retain sodium which worsens edema -water follows sodium

Nursing Diagnosis of *Cardiac Output* for Heart Failure is related to what?

r/t Cardiac Insufficiency

Nursing Diagnosis of *Activity Intolerance* for Heart Failure is related to what?

r/t Extreme Fatigue

Nursing Diagnosis of *Anxiety* for Heart Failure is related to what?

r/t: 1. Health Status 2. Lifestyle Changes 3. Fear of Death

If left ventricular failure is left untreated, what can happen?

right ventricular failure - it can occur separately from left ventricular failure but it is usually the consequence of the left side being untreated.

What is Nocturnal paroxsymal dyspnea?

sudden awakening from sleep caused by shortness of breath

*Severe* HF might need what?

transplant

What is Pitting Edema?

when pressure is applied, the pressure area becomes indented After pressure is released, indentation disappears over time