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