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