Transcript Heart Failure

Heart Failure
Dr. Belal Hijji, RN, PhD
September 26-October 03, 2011
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.
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.
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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.
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New York Heart Association Classification of HF
Classification
I
II
III
IV
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Signs and symptoms
Prognosis
Ordinary physical activity does not cause
undue fatigue, dyspnea, palpitation, or
chest pain. Patient is considered
asymptomatic. Usually no limitations of
ADLs.
Slight limitation on ADLs. No symptoms at
rest, increased physical activity will cause
symptoms. Basilar crackles and S3 may be
present
Marked limitation on ADLs. Patient is
comfortable at rest but minimal activity
will cause symptoms.
Symptoms of cardiac insufficiency at rest
Good
Good
Fair
Poor
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.
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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 .
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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.
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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.
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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.
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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, selfmanagement strategies, and ability and willingness to
adhere to them.
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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.
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Nursing Management of a Patient With HF
A man with congestive heart failure and marked jugular venous distension.
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External
jugular vein marked by an arrow.
• 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.
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• 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.
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• 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.
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• 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.
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• 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.
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• 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.
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• 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
•
•
•
•
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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.