Sunday, March 15, 2009

CARING FOR CLIENTS WITH HEART FAILURE

MEDICAL SURGICAL


CARING FOR CLIENTS WITH HEART FAILURE



HEART FAILURE




The heart is a double pump. The right side pumps
deoxygenated blood to the lungs to be oxygenated. The left side pumps that
oxygenated blood into the systemic circulation . If either one of the sides
doesn’t work properly it will effect systemic circulation.


Heart failure is the inability of the heart to
pump a sufficient amount of blood to meet the body’s metabolic needs.


Congestive heart failure (CHF) is the
accumulation of blood and fluid within organs & tissues due to impaired
circulation




HEART FAILURE




Ejection fraction is an estimation of the heart’s efficiency as
a pump. It is a measurement of the % of blood that the left ventricle ejects
when it contracts


Normal is 55% or greater





CLASSIFICATION OF HEART FAILURE – table 34-1




ACUTE - a sudden change in the heart’s ability
to contract that can lead to life threatening symptoms and pulmonary edema


CHRONIC – occurs when some other chronic
condition gradually comprises the heart’s ability to pump effectively




Left and Right Sided Heart Failure




LEFT SIDED HEART FAILURE – when the left
ventricle does not eject blood into the aorta normally


RIGHT SIDED HEART FAILURE – when the right
ventricle fails to eject it’s total filling volume into the pulmonary
artery, causing congestion in the venous vascular system.
Most common
cause of right sided heart failure is left sided heart failure





Pathophysiology & Etiology




Inability of the heart muscle to contract forcefully because of
direct damage to the heart wall:


Acute MI


When the pumping chambers enlarge & weaken & are unable to
eject all the blood received


Cardiomyopathy


HTN




Diagnostic Findings




Left sided failure


cxr shows cardiac enlargement


echocardiogram shows enlarged left ventricle,
decreased ejection fraction


MUGA scan measures the ejection fraction more
accurately


Right sided failure: all show enlarged right
ventricle


cxr


echocardiogram


ECG




LEFT SIDED FAILURE




Decreased cardiac output


Blood backs up into the left atrium, & finally the pulmonary
vasculature causing impaired gas exchange


Causes: HTN, tachydysrhythmias, valvular disease,
cardiomyopathy & renal failure




RIGHT-SIDED FAILURE




Blood backs up into the right atrium, superior & inferior vena
cava, & then the venous vasculature


Causes: Most common cause is left-sided heart failure,
MI, respiratory diseases


cor pulmonale – when the heart is affected by lung disease such
as COPD, asthma & can lead to


pulmonary HTN – vasoconstriction in the arterial pulmonary
circulation




Compensatory Mechanisms




These mechanism usually make matters worse by increasing the
amount of blood the heart must pump & the resistance it must overcome from
arterial constriction




Assessment Findings:




Left-sided Failure



Hypoxemia which leads to:


exertional dyspnea


orthopnea


paroxysmal nocturnal dyspnea


hemoptysis




Assessment Findings:




Right-sided Failure



gradual wt gain from fluid retention


dependent pitting edema


ascites


hepatomegaly


jugular vein distention



enlarged right ventricle on chest xray




Medical Management




Focuses on reducing the workload of the heart and improving
cardiac output


Fluid restriction


Low Na+ diet


Drugs-see table 34-1


Digitalization – initially using large doses of digoxin
to build up therapeutic drug levels


diuretics


vasodilators




B-type Natriuretic Peptide - BNP




A cardioprotective neurohormone that functions to decrease BP
by increasing excretion of Na+ & H2O, promoting arterial dilation, &
counteracting renin, angiotension, & aldosterone


BNP is measured via a blood test to estimate how far advanced
the CHF is


See box 34-2




Medical Management




Cardiac Resynchronization Therapy (CRT) – used to restore
synchronization to the right & left ventricles via a pacemaker thereby
improving force of contraction & cardiac ejection fraction


Intra-aortic balloon pump (IABP) – fig 34-4 – a temporary
secondary circulatory pump




Surgical Management




Ventricular Assist Device (LVAD) – fig 34-5 – an auxiliary pump
that supplements the heart’s ability to eject blood. Used for those awaiting
heart transplants


Cardiomyoplasty – a surgical procedure in which the client’s
own chest muscle is grafted to the aorta & wrapped around the heart
augmenting the ineffective heart muscle contraction fig 34-6


Artificial Heart – used for adults < 55 who are waiting heart
transplant – usually temporary – fig 34-9


 




NURSING MANAGEMENT




Medication administration and teaching


Hx of symptoms


Baseline physical assessment


Daily wts



Accurate I & O


Watch electrolytes & other labs


Measure abdominal girth


See client & family teaching for Heart Failure
34-1


Nursing process – the client with CHF




PULMONARY EDEMA




Fluid accumulation in the lungs that interferes with gas
exchange


An acute emergency


S/S – sudden dyspnea, wheezing, orthopnea, restlessness, cough
often with pink, frothy sputum, cyanosis, tachycardia & severe apprehension,
moist, gurgly respirations




MEDICAL MANAGEMENT




DRUGS


Inatropic agents used to improve myocardial
contractility: dopamine, dobutamine, Inocor, or digitalis


To reduce venous return: diuretics & promote
vasodilation: nitrates, ACE inhibitors, calcium channel blockers


IV morphine to reduce anxiety


OXYGENATION usually by mask or if respiratory
failure occurs may be intubated & put on mechanical ventilator




Nursing Management




IV access


Medication administration


Pulse oximetry


V/S with cardiac monitoring


Foley catheter insertion for accurate monitoring of I&O


 




GENERAL NUTRITIONAL CONSIDERATIONS




Clients with severe heart failure may require Na+ restriction
to as little as 500-1000mg/day


Clients with mild heart failure may tolerate 3000mg Na+/day


Encourage weight loss in obese clients


Provide 5-6 small meals a day to reduce dyspnea & nausea
related to enlarged abdominal organs




GENERAL PHARMALOGICAL CONSIDERATIONS




Mild heart failure usually responds to thiazide diuretics such
as HCTZ or Hygroton


Severe heart failure usually requires loop diuretics such as
Lasix


For those who don’t respond to diuretics & digitalis ACE
inhibitors are used




GENERAL GERONTOLOGIC CONSIDERATIONS




Dyspnea on exertion is the earliest s/s of heart failure in the
elderly + change in mental status such as confusion


Older adults who take digitalis are at an increased risk for
toxicity due to reduced kidney function & decreased drug excretion



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