Understanding Heart Failure
By Damon Cottrell, RN, ACNS-BC, CCNS, CCRN, CEN, MS; Cynthia Bither, RN, ANP, ACNP, MSN; Renee Garnes-Spence, RN, PCCN, MSN; and Michelle Jones, RN, ANP, ACNP, MSN
LPN2009, March/April 2009
2.3 ANCC contact hours
Online: www.lpnjournal.com
© 2009 by Lippincott Williams & Wilkins. All world rights reserved.
What is heart failure?
Progressive disease
Affects heart’s ability to pump effectively
Can’t supply sufficient blood and oxygen to the body’s tissues
Heart failure
Usually caused by injury to myocardium
Injury results in dilation or hypertrophy of one or both ventricles, called “remodeling”
Cardiac output and blood pressure drop
Causes of heart failure
Aortic regurgitation Aortic stenosis Cardiomyopathy Coronary artery
disease Myocardial infarction Renal artery stenosis
Volume overload Dysrhythmias (atrial
fibrillation) HIV Hypertension Hyperthyroidism Medications
Causes of heart failure
May be acute or chronic
Patients usually exhibit signs of shortness of breath, tiredness, swelling of feet, ankles, abdomen
May see jugular venous distention and hear a third heart sound
Signs and symptoms
Dyspnea Orthopnea Paroxysmal nocturnal
dyspnea Weakness/fatigue Confusion Headache Insomnia Tachycardia Third heart sound
Rales Edema Jaundice Alternating weak and
strong pulse Cool, cold, or pale
extremities Jugular venous distention Cyanosis
Diagnosing heart failure History and physical: provide clues about patient’s
physical status
ECG looks for dysrhythmias
Echocardiography provides information about function and heart size
Lab tests: electrolytes, thyroid studies, BUN, BNP
Classes and stages
Heart failure is divided into classifications based on specific pathophysiology
Helps guide best treatments
Heart failure is also broken down into stages
Treatment of stages is aimed at stabilizing patient’s condition and delaying progression
New York Heart Association Classification of Heart Failure
Classification I Ordinary physical activity doesn’t cause undue
fatigue, dyspnea, palpitations, or chest pain No pulmonary congestion or peripheral
hypotension Patient is considered asymptomatic Usually no limitations of ADLs Prognosis: Good
New York Heart Association Classification of Heart Failure
Classification II Slight limitation on ADLs Patient reports no symptoms at rest but
increased physical activity will cause symptoms Basilar crackles and S3 murmur may be detected Prognosis: Good
New York Heart Association Classification of Heart FailureClassification II Marked limitations on ADLs Patient feels comfortable at rest but less than ordinary
activity will cause symptoms Prognosis: Fair
Classification IV Symptoms of cardiac insufficiency at rest Prognosis: Poor
The four stages of heart failure
Stage A: Patient at high risk of developing left ventricular dysfunction
Stage B: Patients with left ventricular dysfunction who haven’t developed symptoms
Stage C: Patients with left ventricular dysfunction with current or prior symptoms
Stage D: Patients with refractory end-stage heart failure
Treating heart failure
Primary treatment: lifestyle modifications
- restrict dietary sodium
- smoking cessation
- weight reduction (if indicated)
- regular exercise
Treating heart failure
Medications
- given to block hormones that circulate in excess when heart becomes weak
- reverse changes in heart’s muscle that occur over time
- first-line drugs given include angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta-blockers
Medications
Most often recommended beta-blockers are bisoprolol (Concor) and carvedilol (Coreg)
Best chance of cardiac recovery with higher doses to reduce heart workload and lower BP
Evidence of lower mortality and fewer adverse reactions
Diuretics
Used mainly for symptom relief
Bumetanide (Bumex) and furosemide in low doses are preferred
Spironolactone (Aldactone) for advanced patients
African-Americans and patients with with renal failure may be given BiDil
Diuretics used to treat heart failureThiazide diuretics Bendroflumethiazide
(Naturetin) Benzthiazide (Exna) Chlorothiazide (Diuril) Chlorthalidone (Hygroton) Hydrochlorothiazide
(HydroDIURIL, Esidrix, Oretic)
Hydroflumethiazide (Diucardin, Saluron)
Methyclothiazide (Enduron) Metolazone (Zaroxolyn,
Mykrox) Polythiazide (Renese) Quinethazone (Hydromox) Trichlormethiazide
(Metahydrin, Naqua)
Diuretics used to treat heart failureLoop diuretics Bumetanide (Bumex) Ethacrynic acid (Edecrin) Furosemide (Lasix) Torsemide (Demadex)
Potassium-sparing diuretics
Amiloride (Midamor) Spironolactone
(Aldactone) Triamterene (Dyrenium)
Pacing Many patients have delayed time interval between
contraction of right and left ventricles
Synchronized biventricular pacing uses a third lead to pace ventricles simultaneously
Improves cardiac output
Nursing care: monitoring patient post procedure, elevation of head of bed, pain medication
Ventricular assist device Supports right, left, or both ventricles
Used for patients awaiting transplant (“bridge to transplant”)
Used as treatment (“destination therapy”)
“Bridge to recovery” allows heart time to recover from remodeling; device is then removed
Nursing care of patients with a ventricular assist device Assessment and prevention of infection at
“driveline site” (patient’s abdomen)
Assess nutritional and functional status
Assess pump function and troubleshoot alarms
Monitoring patient
Vital signs Lab results Renal function Nutritional status
Presence of infection or bleeding
Effectiveness of anticoagulation
Monitor pump parameters
Cardiac transplantation
Treatment option for end-stage heart failure
Approx. 2,500 procedures in U.S. each year
1- and 3-year survival rates 85.6% and 79.5%
Rigorous screening of candidates
Patient put on united organ sharing list
Cardiac transplantation
Major postoperative difference in these patients is need for chronotropic (heart rate) support
Immunosuppressive drug therapy to prevent rejection
Consists of three types of drugs: calcineurin inhibitors, corticosteroids, antimetabolites
Nursing care of transplant patients Education on signs and symptoms of infection
Education on signs and symptoms of rejection
Nutrition counseling (well-balanced, low-fat diet)
Review follow-up visits
Nursing management/interventions for patients with heart failure Administering medications and assessing patient
response
Assessing fluid balance, intake, and output with goal of optimizing balance
Daily weights
Nursing management/interventions for patients with heart failure Assessing jugular venous distention
Auscultating lung and heart sounds
Identifying dependent edema
Monitoring pulse, BP
Nursing management/interventions for patients with heart failure Checking for postural hypotension
Examining skin turgor for signs of dehydration
Assessing for symptoms of fluid overload
Potential complications of HF therapy Hypokalemia: low potassium; signs include
dysrhythmias, weak muscles; can cause heart muscle weakness
Hyperkalemia: abnormally high serum potassium, especially when taking ACEs, ARBs, or spironolactone
Potential complications of HF therapy Hyponatremia: deficiency of serum sodium
Hyperuricemia: excessive uric acid in blood
Patient teaching
Teach patients rationale for medications (doses, times, adverse reactions)
Teach patient to limit fluid to 2 liters per day
Teach patient to follow a low-sodium diet
Patient teaching
Teach patient to weight himself daily and to notify healthcare provider of an increase in weight of 3 lbs or more
Address patient’s psychological needs
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