Heart Failure

1. Heart Failure Assessments, Interventions and Outcomes

2. Psychosocial Assessment • Query patient about recent stressors • Ask patient to rate current stress level • Ask patient to describe any significant recent life change Hope is a major determinant of well being.

3. Lab Assessment • Serum electrolytes • BUN, Creatinine, Creatinine Clearance • Urinalysis • H&H • ABG’s • BNP

4. Radiographic Assessment • Chest X-ray

5. Other Diagnostic Tests • ECG • Ventricular hypertrophy, dysrhythmias, myocardial ishemia, injury, infarction • Echo • Cardiac valvular changes, pericardial effusion, chamber enlargement, ventricular hypertrophy • Radionuclide studies • Can indicate presence and cause of heart failure • MUGA scan • Provide information about Left ventricular ejection fraction and velocityPulmonary Artery Catheter

6. Other Diagnostic Tests (cont.) • Pulmonary Artery Catheter • Right Atrial Pressure • increased in Right Ventricular Failure • Normal or increased in Left Ventricular Failure • Pulmonary Artery Pressure and Pulmonary Artery Wedge Pressure (PAWP) elevated in Left sided failure

7. Nursing Diagnoses • Impaired Gas Exchange related to inadequate cardiac pump function • Decreased Cardiac Output related to a reduction in stroke volume as a result of mechanical malfunctions • Activity Intolerance related to an imbalance between oxygen supply and demand, fatigue, or an electrolyte imbalance

8. Primary Collaborative Problem • Potential for Pulmonary Edema

9. Additional Nursing Diagnoses • Ineffective Therapeutic Regimen Management • Ineffective Coping • Acute Confusion • Impaired Physical Mobility • Potential for Pneumonia • Potential for Dysrhythmias • Potential for Renal Dysfunction secondary to decreased renal perfusion

10. Impaired Gas Exchange Expected Outcome: Client with heart failure is expected to have: • Normal rate, rhythm and depth of respirations • Oxygen saturation within normal limits • No dyspnea at rest

11. Impaired Gas Exchange Interventions: • Should be aimed at promoting optimal spontaneous breathing pattern that maximizes oxygen and maintains normal CO2 levels in the lungs • Auscultate breath sounds and monitor respiratory rate, rhythm and character every 1-4 hours • Titrate supplemental oxygen to maintain Oxygen saturation at 92% or greater • Position patient to facilitate breathing • Reposition with coughing and deep breathing exercises at a minimum of every 2 hours

12. Decreased Cardiac Output Expected Outcome: Client with heart failure is expected to resume and maintain an adequate cardiac output, as indicated by: • Heart rate in expected range • Cardiac Index in expected range • No dysrhythmia • No abnormal heart sounds • Strong peripheral pulses

13. Decreased Cardiac Output Interventions: • Purpose of care is to optimize afterload, preload, and contractility • Treatment is aimed at optimizing stroke volume and heart rate • Reducing afterload • Reducing preload • Improving cardiac muscle contractility

14. Reducing Afterload • Relax arterioles through arterial vasodilation to reduce the resistance to left ventricular ejection • ACE inhibitors • Captopril (Capoten), Enalapril maleate (Vasotec) • Suppress renin-angiotensin-aldosterone system • Patients that are at a risk of hypotension must have BP monitored closely after initiation of ACE inhibitor therapy or with dose changes • Physician/Provider should describe BP parameters for management • Must monitor serum potassium, creatinine, and development of cough

15. Reducing Preload • Decrease volume and pressure in Left ventricle and optimize ventricular muscle stretch and contraction • Diet therapy: • Sodium restriction • Fluid volume restrictions • Drug therapy • Diuretics • Venous Vasodilators

16. Drugs: Diuretics • Loop • Furosemide, Torsemide, Ethacrynic Acid • Most effective for treating fluid volume overload • Thiazide • Self-limiting • Don’t cause excessive diuresis and dehydration • Potassium sparing Must monitor serum potassium levels May need potassium supplements Monitor daily weight

17. Drugs: Venous Vasodilators • May be added to drug regimen for patient with heart failure and persistent dyspnea • Nitrates • Isosorbide dinitrate (Isordil) • Nitroglycerin (Nitrodur) • Cardiac Glycosides • Digoxin • Digitoxin • Beta Blockers • Carvedilol (Coreg)

18. Drugs: Venous Dilators • Nitrates primarily cause venous dilation, but arteriolar vasodilation also occurs • Must monitor BP when initiating therapy or increasing dosage • Instruct patients that initial headache will cease or diminish with continued therapy • To decrease risk of tolerance development– provide a 12 hour nitrate free period

19. Enhancing Contractitliy • Digitalis Therapy • Preferred drug for increasing contractility • Digoxin is beneficial for clients in NSR or AF with heart failure • In combination with ACE inhibitor and diuretics, Digoxin increases functional capacity • Benefits: increased contractility, reduction in heart rate, slowing of conduction through AV node, inhibition of sympathetic activity while increasing parasympathetic activity. May also have a mild diuretic effect

20. Digoxin Considerations • Absorbed erratically from gi tract • Antacids interfered with absorption • Must monitor apical pulse before administration • Older clients are much more susceptible to digitalis toxicity

21. Digitalis Toxicity • Increased automaticity • PVC’s • Report development or dysrhythmias to MD • Symptoms: • Anorexia, fatigue, and mental status changes • Resting heart rate <60 or >100 should be reported to MD • Monitor serum digoxin and potassium levels. • Angina (secondary to increased workload and O2 needs)

22. Beta-Adrenergic Blockers • Action is not completely known • Can initiate therapy after ACE inhibitor and diuretic doses stable for 2 weeks • Carvedilol, metoprolol, and bisoprolol are often used. • Initial dose is low and patient is monitored in hospital or office to detect bradycardia or hypotension.

23. Considerations for Beta-Blockers • Instruct about daily weight • Dose can be adjusted upward with weekly evaluation for changes in BP, pulse, activity tolerance or orthopnea • Resting heart rate should remain between 55 and 60 with slight increase with activity • Benefits are not seen immediately, they accrue over a period of time.

24. Activity Intolerance Expected Outcome: Client with heart failure is expected to: • Perform ADL’s • Walk at least two blocks without experiencing dyspnea or excessive fatigue • Have energy restored after rest • Perform usual routine

25. Activity Intolerance Interventions • Aimed at regulating energy, preventing fatigue, and optimizing function • Energy Management • Monitor and document physiologic response to activity • With increasing activity monitor: B/P, pulse, oxygen saturation • Observe for and treat signs of activity intolerance: • Dyspnea, fatigue, and chest pain • Increase activity as tolerated

26. Additional Interventions • Nonsurgical: • CPAP • Cardiac Resynchronization therapy • Gene therapy • Surgical • LVAD • Partial L Ventriculectomy • Endoventricular circular patch • Acorn cardiac support device • myosplint

27. Potential for Pulmonary Edema Expected Outcome: Client with heart failure is expected to be free of pulmonary edema. Collaborative Care: • Monitor for acute pulmonary edema • Administer meds as ordered (Lasix IV) • IV Morphine Sulfate • Drugs to reduce venous return (preload), anxiety, & work of breathing • Administer O2 • Position to facilitate breathing (High Fowlers) • Accurate I&O, foley required • May require Bipap or Mechanical Ventilation and advanced cardiac drug therapy

28. Health Teaching • Activity Schedule • Indications of worsening heart failure • Rapid weight gain (3 lbs in a week) • Decreased activity tolerance for 2-3 days • Cough lasting more than 3-5 days • Excessive awakening at night to void • Development of dyspnea or angina at rest or worsening angina • Drug therapy • See Chart 35-7, p.711 re: digoxin • Diet therapy • Advance directives