N250: Heart Failure
Categorize & justify cardiac medications used in HF
1) DECREASE PRELOAD: DIURETICS: decrease volume = decrease preload. SE: electrolyte imbalance. dehydration. hypotension. dizziness .....a) LOOP diuretics: furosemide, torsemide .......... MOA: inhibition of sodium & water resorption from loop of henge and DCT. Increase renal excretion of water, na+, cl-, mag, K+, ca+ .....b) THIAZIDE diuretics: HCTZ .......... MOA: on DCT, promoting na+, k+ & h2o excretion. vasodilator = decreases BP. 2) REDUCE AFTERLOAD: relax arterioles, vasodilators reduce resistance and improve CO. used when EF<40% .....a) ACE inhibitors (lisinopril) ..........MOA: A1 --/--> A2. Inhibiting RAAS causes overall decrease in BP. ..........SE: Angioedema. Cough. Electrolyte imbalance (low K+) .....b) ARB (valsartan) ..........MOA: block A2 at receptors. Causes vasodilation. reduces secretion of vasopressin & ALD = decreased BP. ..........SE: Dizziness, confusion, hypotension, blurry vision .....c) Beta Blockers (metoprolol) ..........MOA: inhibits B1 receptors. Decreases BP & HR .......... SE: Hypotension, orthostatic hypotension, bradycardia, masks hypoglycemia, ........... do not d/c abruptly. not for diabetics. 3) Enhance CONTRACTILITY (squeeze) .....a) Positive inotropes. increase strength of muscular contractions. Improve squeeze. - Digoxin (cardiac glycoside) = most common - Milrinone - Dobutamine (IV for acute HF in ICU)
Plan nursing care in the collaborative management of heart failure
Monitor daily I&O Assess for SOB Administer O2 prn Monitor VS and hemodynamic pressures position to maximize ventilation (high-fowler's) Check ABG's, electrolytes. (K+ if on diuretics) SaO2, CXR Med toxicity ---Dig (0.5-2) Encourage bed rest Encourage energy conservation Assist with ADL's Maintain dietary restrictions as prescribed Provide emotional support to client & family Cardiac rehab: exercise, diet, pacing activities Lifestyle modifications: alcohol, smoking Management of contributing conditions: - Weight reduction - HTN -Resp disease - Valvular disease -Ischemic heart disease (MI) -Infection -Thyroid disease -Palliative care
Identify and communicate significant assessment data that requires follow-up
BNP>100 EF normal: 4-8L CO normal: 50-70% CXR: enlarged heart, pulmonary edema Digoxin therapeutic range: 0.5-2 K+: 3.5-5.3 Na+ 135-145
Teach patients and families about self-administration of cardiac medications and the value of cardiac self-monitoring
DIURETICS: - hypokalemia. potassium supplement may be required. - teach to ingest foods high in K+ ACE: - angioedema, cough, hyperkalemia. - monitor k+. - report SE's - Monitor BP 2hrs after initial dose INOTROPIC AGENTS - Digoxin: .....Count pulsex1minute .....take at same time each day .....do not take with antacids .....report: fatigue, muscle weakness, confusion, loss of appetite .....labs: digoxin & K+ BETA BLOCKERS: - daily weights - check BP regularly
Consideration for older adults: NSAIDS
long-term use of NSAIDs for arthritis and other chronic pain can cause fluid and sodium retention. NSAIDs may cause peripheral vasoconstriction and increase the toxicity of diuretics and angiotensin-converting enzyme inhibitors (ACEIs).
Distinguish Right vs. Left HF
--RHF-- Systemic Congestion • Jugular (neck vein) distention • Enlarged liver and spleen • Anorexia and nausea • Dependent edema (legs and sacrum) • Distended abdomen • Swollen hands and fingers • Polyuria at night • Weight gain • Increased blood pressure (from excess volume) or decreased blood pressure (from failure) --LHF-- Decreased Cardiac Output • Fatigue • Weakness • Oliguria during the day (nocturia at night) • Angina • Confusion, restlessness • Dizziness • Tachycardia, palpitations • Pallor • Weak peripheral pulses • Cool extremities Pulmonary Congestion • Hacking cough, worse at night • Dyspnea/breathlessness • Crackles or wheezes in lungs • Frothy, pink-tinged sputum • Tachypnea • S3/S4 summation gallop
Classify ejection fraction values and their meanings
% of blood ejected from the heart (L. vent-->aorta) during systole normal = 50%-70%
Compare causes of HF
LOW OUTPUT HF: 1) Left Sided .....A) Systolic: Poor squeeze. EF <40% .....B) Diastolic: Stiffening. Prevents ventricular filling. 2) Right sided .....A) inadequate ventricular output--> peripheral edema ..........a) Caused by LHF, MI, pull HTN, chronic respiratory disease ..........b) R. vent cannot completely empty causing inadequate flow to lungs. HIGH OUTPUT HF: 1) Cardiac output > or = to normal .....caused from disease process: fever, sepsis, anemia, hyperthyroidism...
Describe HF core measure set
The Heart Failure Core Measure Set must be determined for hospitals accredited by The Joint Commission. These measures include that the patient with HF has: • Discharge instructions (including information on diet, activity, medications, weight monitoring, and planning for worsening symptoms) • Evaluation of left ventricular systolic function • An ACEI or ARB for left ventricular systolic dysfunction • Adult smoking-cessation advice/counseling (if appropriate) • Posthospitalization visit with the primary health care provider within 7 days of discharge
Provide patient centered care with patients in heart failure
To reduce hospitalizations of older adults with heart failure as the principal diagnosis: • For patients hospitalized for heart failure, collaborate with the case manager for discharge planning, including adequate support in the community. • Provide a continuing plan of care for patients and their families or other caregivers when the patient is discharged from the hospital. • If the patient is discharged to home, call to check that he or she has no impending signs and symptoms of heart failure (the case manager may make calls). • Teach the patient and family or other caregiver about when to call the health care provider for health changes so the patient can be treated at home. • Ensure that the interprofessional team provides the patient with follow-up care in the home or nursing home.
