Heart Failure

1. Heart Failure Dr. Belal Hijji, RN, PhD September 26-October 03, 2011

2. Learning Outcomes At the end of this lecture, students will be able to: Define HF, recognise its classifications, causes and risk factors, and identify its clinical manifestations. Describe the pharmacologic, nutritional, and other additional therapies for HF. Discuss the nursing management of a patient with HF.

3. Definition of HF Heart failure is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients.

4. Causes of HF Chronic hypertension, coronary artery disease, and valvular disease result in HF; diabetes mellitus is also a risk factor. Atherosclerosis (areteriosclerosis and fatty deposits) of the coronary arteries is the main cause of HF.

5. New York Heart Association Classification of HF

6. Clinical Manifestations • The signs and symptoms of HF can be related to which ventricle is affected. Left-sided heart failure causes different manifestations than right-sided heart failure.

7. Clinical Manifestations of Left-Sided Heart Failure • Pulmonary congestion occurs when the left ventricle cannot effectively pump blood into the aorta and the systemic circulation. • The blood volume and pressure increase in the left atruim, which decreases blood flow from the pulmonary vessels. Pulmonary venous volume and pressure increase, forcing fluid from pulmonary capillaries into the pulmonary tissues and alveoli, causing pulmonary edema and impaired gas exchange. • The clinical manifestations of pulmonary congestion include dyspnea, cough, crackles and low oxygen saturation .

8. Clinical Manifestations of Right-Sided Heart Failure • The right side of the heart cannot eject blood and cannot accommodate all the blood returning to it from the venous circulation. • As a result, congestion occurs in the peripheral tissues and the viscera. • Increased venous pressure leads to jugular venous distention (JVD) and increased capillary hydrostatic pressure throughout the venous system. • Clinical manifestations include edema of lower extremities, hepatomegaly, ascites, anorexia & nausea, and weight gain.

9. Pharmacologic Therapy of HF • Angiotensin-Converting Enzyme (ACE) Inhibitors: These include lisinopril and captopril; they decrease BP, relieve signs and symptoms of HF and reduce morbidity and mortality. Nurses should observe the patient for hypotension, increased serum potassium, and worsening renal function. • Beta blockers: these include metoprolol and atenolol . They decrease signs and symptoms of HF and improve exercise capacity. Nurses should observe the patient for decrease HR, symptomatic hypotension, and fatigue. • Diuretics: such as Frusemide (lasix) which decreases fluid volume overload and decreases signs and symptoms of HF. Nurses should observe for electrolyte imbalance, hypotension and monitor I & O and daily weight. • Digitalis: such as digoxin improves contractlity and decreases signs and symptoms of HF. Nurses should observe for bradycardia.

10. Nutritional Therapy of HF • Low sodium diet. • Avoidance of excessive fluid intake. Additional Therapy of HF • Supplemental oxygen: The need for oxygen on the degree of pulmonary congestion and resulting hypoxia. Some patients would need oxygen administration only during periods of activity.

11. Nursing Management of a Patient With HF • Assessment: • Observe for effectiveness of therapy and for the patient’s ability to understand and implement self-management strategies. • Record and report immediately signs and symptoms of pulmonary and systemic fluid overload. • Health History • Ask about dyspnea, SOB, fatigue, edema, and sleep interruption. • Ask about the number of pillows needed for sleep, ADLs, and activities that cause fatigue. • Explore the patient’s understanding of HF, self-management strategies, and ability and willingness to adhere to them.

12. Nursing Management of a Patient With HF • Physical examination • Auscultate the lungs for crackles and wheezes. • Document the rate and depth of respirations. • Auscultate the heart for S3, a signs indicating that the heart is beginning to fail. • Document heart rate and rhythm. • Assess jugular vein distension (JVD). A distension greater than 3 cm above the sternal angle is considered abnormal. • Assess level of consciousness. As the volume of blood ejected by the heart decreases, so does the amount of oxygen transported to the brain. • Assess the patient for perfusion and edema. Signs of decreased peripheral perfusion include cool, pale, or cyanotic skin. • Measure I & O and record weight daily.

13. Nursing Management of a Patient With HF A man with congestive heart failure and marked jugular venous distension. External jugular vein marked by an arrow.

14. Nursing Diagnoses: • Activity intolerance and fatigue related to decreased cardiac output. • Excess fluid volume related to HF. • Anxiety related to breathlessness from inadequate oxygenation. • Ineffective therapeutic regimen management related to lack of knowledge.

15. Planning and Goals: • Promoting activity and reducing fatigue. • Relieving fluid overload symptoms. • Decreasing anxiety. • Teaching the patient self-care. • Nursing Interventions: • Promoting activity tolerance • Avoid prolonged bed rest as it increases the risk for pressure ulcer, venous thrombosis, and pulmonary embolism. • Encourage a total of 30 minutes of physical activity daily. • Develop a schedule of exercise that promotes pacing and priortisation of activities. • Avoid having two successive significant energy-consuming activities.

16. Nursing Interventions (continued…): • Managing fluid volume • Administer diuretics early in the morning, so that diuresis does not interfere with the patient’s nighttime rest. • Monitor fluid status closely. • Auscultate lungs. • Monitor daily body weight. • Encourage low-salt diet. • Monitor the amount of fluid if IVF is prescribed for the patient. • Position the patient with head of bed elevated or in sitting in a comfortable armchair to facilitate breathing. These positions reduce venous return to heart; alleviate pulmonary congestion; and minimise pressure on the diaphragm.

17. Nursing Interventions (continued…): • Teaching the patient self-care • The nurse educate the patient to promote understanding and adherence to the therapeutic plan. A knowledgeable patient who recognises that HF can be successfully managed with life style changes and medications can lessen the recurrences of acute HF, decrease hospitalisation, and increase life expectancy. • Therefore, nurses educate patients and their families about medications management, low-sodium diets, exercises, smoking cessation, and signs and symptoms of worsening HF. • Nurses should encourage patients to ask questions so that information can be clarified and understanding enhanced. • Nurses should also inform the patients that healthcare providers are available for their help and support.

18. Nursing Interventions (continued…): • Controlling anxiety • Restlessness and anxiety may be present in patients with HF due to inadequate oxygenation. These symptoms tend to be intensive at night and may interfere with sleep. • Emotional stress stimulates the sympathetic nervous system causing vasoconstriction, elevated arterial pressure, increased heart rate, and increased cardiac workload. • When the patient is anxious, the nurse should promote physical comfort and provide psychological support. Oxygen may need to be administered to diminish the work of breathing and to increase the patient’s comfort. • The nurse should also begin teaching the patient ways to control and avoid anxiety through using relaxation techniques.

19. Evaluation: • The patient demonstrates tolerance for increased activity • Describes adaptive methods for usual activities. • Schedules activities to conserve energy and reduce fatigue and dyspnea. • Maintains vital signs within normal range. • Evaluation (Continued……): • The patient maintains fluid balance • Shows decreased peripheral and sacral edema. • Demonstrate methods for preventing edema.

20. Evaluation (continued): • The patient has less anxiety • Avoids situations that cause stress. • Sleeps comfortably at night. • Reports decreased stress and anxiety. • Evaluation (continued…): • The patient adheres to self-care regimen • Maintains daily record of weight. • Ensures that his salt intake is not more than 2-3 grams daily. • Takes medications as ordered. • Reports any unusual symptoms.