Med/Surg Unit # 2
What is heart failure?
An abnormal clinical syndrome involving impaired cardiac pumping and/or filling. HF is associated with numerous types of cardiovascular diseases, particularly long-standing hypertension, coronary artery disease, and myocardial infarction.
What are the risk factors for heart failure?
CAD and advancing age are the primary risk factors for HF. Other factors, such as hypertension, diabetes, cigarette smoking, obesity, and high serum cholesterol are also contributing factors.
What causes left-sided failure?
Results from left ventricular dysfunction, which prevents normal blood flow and causes blood to back up into the left atrium and into the pulmonary veins. The increased pulmonary pressure causes fluid extravasation from the pulmonary capillary bed into the interstitium and then the alveoli, which manifests as pulmonary congestion and edema.
What causes right-sided failure?
Causes a backup of blood into the right atrium and venous circulation. Venous congestion in the systemic circulation results in jugular vein distension, hepatomegaly, splenomegaly, vascular congestion of the GI tract, and peripheral edema. The primary cause is left-sided failure.
Right-sided heart failure signs
RV heaves, murmurs, JVD, peripheral edema, weight gain, increased HR, ascites, anasarca (massive generalized edema), and hepatomegaly
Right-sided heart failure symptoms
Fatigue, anxiety, depression, dependent-bilateral edema, RUQ pain, anorexia, GI bloating, and nausea.
Left-sided heart failure signs
LV heaves, pulsus aternans (alternating pulses: strong, weak), increased HR, PMI displaced inferiorly and posteriorly, poor O2 exchange, crackles, S3 and S4 heart sounds, pleural effusion, change in mental status, restlessness and confusion.
Left-sided heart failure symptoms
Weakness, fatigue, anxiety, depression, dyspnea, shallow resp up to 32-40/min, paroxysmal nocturnal dyspnea, orthopnea, dry hacking cough, nocturia, frothy, pink-tinged and sputum.
What system assessment is the priority for right-sided failure?
Peripheral vascular circulation:
Edema, facial edema, peripheral pulses, assess for presence, quality and equality of pulses, cap refill, JVD, skin color, and temp, vitals esp BP, daily weights, and distended abdomen.
What system assessment is the priority for left-sided?
Respiratory assessment:
Auscultate lung sounds, respiratory rate, document where, which side, what lobe, and when, mucus and sputum in interstitial space, JVD, shortness of breath, nasal flaring, use of accessory muscles, chest symmetry, skin color, temp, and additional vitals.
What are the treatment goals for heart failure?
Adequate tissue perfusion
Increased cardiac pump effectiveness
Energy conservation and management
Relief of pulmonary edema
What are class I-IV from the NYHA functional classification of heart disease?
Level of Impairment:
I-No symptom limitation with ordinary physical activity
II-Ordinary physical activity somewhat limited by dyspnea (e.g., long-distance walking, climbing two flights of stairs)
III-Exercise limited by dyspnea with moderate workload (e.g., short-distance walking, climbing one flight of stairs)
IV-Dyspnea at rest or with very little exertion
What are stages A-D from the ACC/AHA stages of heart failure?
A: High risk for developing heart failure
Hypertension, diabetes mellitus, CAD, family history of cardiomyopathy
B: Asymptomatic heart failure
Previous MI, LV dysfunction, valvular heart disease
C: Symptomatic heart failure
Structural heart disease, dyspnea and fatigue, impaired exercise tolerance
D: Refractory end-stage heart failure
Marked symptoms at rest despite maximal medical therapy
B-Type Natriuretic Peptide (BNP)
Released as part of the neurohormonal response to decreased CO
Normal: 0-99pg/ml
Creatinine phosphokinase (CPK)
Enzyme that gives the heart energy for movement
Normal CPK-MB 0-3 ng/mL
Troponin (TnL or T)
Enzyme that regulates the contraction of the cardiac muscle
Troponin I < 0.4-0.6ng/mL
What is the lifestyle treatment for HF?
2-g Sodium diet
Monitoring weight daily
2-L Fluid restriction
Monitoring blood pressure
Smoking cessation
Light aerobic exercise
Achieving ideal weight
Comply with medication regime
What are the medication goals for HF?
Decrease intravascular volume
Decrease overall workload on the heart
Improve Contractility
Decrease Anxiety
How are diuretics (Lasix, etc.) used to treat HF?
By decreasing venous return (pre-load), reduces the amount of volume returned to the LV during diastole. This increases left ventricular function, decreases pulmonary vascular pressures, and improves gas exchange.
How are vasodilators (Nitroglycerin) used to treat HF?
By reducing circulating volume by decreasing preload and also increases coronary artery circulation by dilating the coronary arteries.
How is morphine used to treat HF?
It reduces preload and afterload and is frequently used in the treatment of ADHF and pulmonary edema. It dilates both the pulmonary and systemic blood vessels, a goal in decreasing pulmonary pressures and improving the gas exchange
How are positive inotropes (digitalis) used to treat HF?
Increases myocardial contractility. Also increases myocardial oxygen consumption.
How are ACE inhibitors (pril's) used to treat HF?
Prevent conversion of angiotensin I to angiotensin II resulting in vasodilation, decrease endothelial disfunction.
How are angiotensin II receptor blockers (losartan, valsartan) used to treat HF?
Inhibit binding of angiotensin II to AT1 receptors resulting in vasodilation
How are beta-adrenergic blockers (lols) used to treat HF?
Inhibit sympathetic nervous stimulation of the heart, reduce heart rate, contractility, and blood pressure. Decrease afterload.
How are calcium channel blockers (Cardizem, calan) used to treat HF?
Prevent calcium entry into vascular smooth muscle cells and myocytes, coronary and peripheral vasodilation, reduce heart rate, contractility, and blood pressure.