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