Heart FailureKaren Ruffin RN, MSN Ed.

Incidence and Prevalence of Heart Failure

• Leading cause of death in the US• More than 5 million Americans are living with

heart failure, and 550,000 new cases are diagnosed each year.

• About 250,000 people a year die from heart disease.

• That means more than 680 Americans a day die from it!!!!!!!!

• Women have a poorer survival rate then men

Basic Needs: Oxygenation

OxygenationOxygenation• Oxygen is required to sustain life, primary Oxygen is required to sustain life, primary

basic human needbasic human need• The cardiac & respiratory systems function to The cardiac & respiratory systems function to

supply the body’s oxygen demandssupply the body’s oxygen demands• Cardiopulmonary physiology involves delivery Cardiopulmonary physiology involves delivery

of deoxygenated blood to the right side of the of deoxygenated blood to the right side of the heart & to the pulmonary systemheart & to the pulmonary system

What are the 3 concepts in oxygenation?

• Ventilation

• Perfusion

• Diffusion

What are the 2 mechanisms that drive the function of the heart?

• Electrical/conduction • Mechanical/pump

What is Heart Failure?

• Heart cannot pump enough blood to meet the metabolic demands of the body.

• Results from changes in the systolic or diastolic function of the ventricles

• There are many causes?????

What are they????http://www.americanheart.org/presenter

Types of Heart Failure

• Left Sided

• Right sided

• Systolic

• Diastolic

Left Sided Heart Failure

• Most Common

• LV dysfunction causes blood to back up through the left atrium and into the pulmonary system.

• Common causes of left heart failure are:

HTN, CAD, mitral and/or aortic valve disease, decreased tissue perfusion.

What does that patient look like?????

Right Sided Heart Failure

• Most common cause is left sided heart failure.

• Other causes MI or pulmonary HTN

• RV dysfunction causes the blood to back up in the right atrium and then the venous circulation.

What does that patient look like?????

Systolic Failure

• Defect in ventricular contraction

• Left Ventricle loses ability to generate enough pressure to eject blood forward through the high pressure aorta – Decreased ejection fraction

• Afterload – hypertension, cardiomyopathy, and valvular heart disease

Diastolic Failure

• Impaired ability of ventricles to fill

• Decreased filling = decreased stroke volume Which + decreased WHAT?

• Pulmonary congestion, pulmonary hypertension, with normal ejection fraction

Heart Failure

Diagnostic Studies• Goal: Assess the cause & degree of failure

• History and Physical Exam

• B-Type Natriuretic Peptide level (BNP).

– elevated in acute and chronic heart failure

– useful in following the response to treatment of congestive heart failure.

• ABGs, Serum chemistries, LFTs

• Chest x-ray

• EKG

• Echocardiogram

• Nuclear imaging studies

• Cardiac catheterization

• Hemodynamic monitoring

Lets Compare!!!!

Classification of Heart Failure

• Class 1 – No limitation of physical activity

• Class 2 – Slight limitation – fatigue, dyspnea, palpitations

• Class 3 – marked limitation. Comfortable at rest; ordinary activities cause symptoms

• Class 4 – Inability to carry out any physical activity without symptoms –

Pain/discomfort at rest

Management and Outcome Measures

• Use of ß-blockers at discharge and during admission.

•Use of aspirin at discharge and during admission.

•Timely and appropriate acute reperfusion (thrombolysis or primary angioplasty).

•The use of angiotensin-converting enzyme (ACE) inhibitors for patients with depressed left ventricular systolic function. Similarly, a minority of patients with AMI are potential candidates for this care process,

Management and Outcome Measures

• The proportion of patients eligible for smoking-cessation counseling is relatively

small, and ascertainment can be difficult, given the variability in documentation as well as practice.

• Diet and exercise counseling

• Cholesterol status assessment and management.

Congestive Heart FailureMedical Treatment Goals

• Decreasing Intravascular Volume– Decreasing Venous Return

• Decreases preload – decreases the volume to the left ventricle during diastole

• Med: Diuretics – Lasix (furosemide)

• Decreasing Afterload– Decrease systemic vascular resistance

• CO increases • Pulmonary congestion decreases• Meds: Nitroglycerine (NTG); Morphine; Calcium Channel

Blockers

Congestive Heart FailureMedical Treatment Goals

• Improving Gas Exchange & Oxygenation– Supplemental oxygen– Morphine

• Severe cases – intubation / ventilation

• Improving Cardiac Function– Increase cardiac contractility without increasing cardiac oxygen

consumption– Hemodynamic Monitoring:

• pulmonary artery pressure; pulmonary artery wedge pressure (14-18mmg HG)

– Inotropic Meds: Digoxin• Inotropic meds used with hemodynamic monitoring:

– Dobutamine– Inodilators: (inotropic & vasodilator): Milrinone

Congestive Heart FailureMedical Treatment Goals

• Reducing Anxiety– Sedative action of IV Morphine

• Complication: respiratory depression

• Determine & Treat Underlying Cause– Systolic or Diastolic failure– Aggressive drug therapy

So what medical complications do

you think can occur???????

What basic needs are being effected?

Why and how?

Nursing Care for the Patient with Heart Failure

• What will you assess????

• What are some potential nursing diagnosis?????

• What are your goals for those diagnosis????

• What are your interventions?????

• How will you evaluate your goals?????

Case Study

• A 74-year-old woman is admitted to the hospital with heart failure. She had been growing progressively weaker and has ankle edema, dyspnea on exertion, and three-pillow orthopnea. On admission, she is severely dyspneic and can answer questions only with one-word phrases. She is diaphoretic and has central cyanosis, with a heart rate of 132 beats/min, and blood pressure 98/70. She is extremely anxious.

Case Study

• 1. Because this client cannot breath or talk easily, prioritize the immediate nursing assessments and intervetions upon admission.

• 2. Considering the process of congestive heart failure, explain the symptoms she is having.

• 3.Based on assessment, identify nursing diagnoses for this client.

• 4. What diagnostic studies do you anticipate being ordered and why?

Case Study

• 5. The physician orders the following items for this client. (Start an IV, then give dobutamine 3 mcg/kg/min IV; Furosemide (Lasix) 40 mg IV stat; Digoxin 0.5 mg IV stat, then 0.125mg PO every 6 hours for three doses, with ECG before doses 3 and 4; Morphine 2 mg IV stat and then 2 mg IV every 1 to 2 hours prn; Oxygen to maintain O2 sat >94%; Schedule for an echocardiogram; Low Na, Fat, Cardiac diet; Weigh daily and monitor input and output) Explain the rationale for these medications and treatments. Would you ask for any other ORDERDS and why?