NURS 5263 Introduction to Chronic Heart Failure

Janet L. Harris BSN, RN Denise Winiarski MSN, RN

Cheryl Holcomb BSN, RN Kay Hewitt BSN, RN

Student Resources

Brunner, L. S., Suddarth, D. S., & Smeltzer, S. C. (2008). Brunner & Suddarth's textbook of medical-surgical nursing (11th ed.). Philadelphia: Lippincott Williams & Wilkins.– Chapter 26: Assessment of Cardiovascular Function– Chapter 30: Management of Patients with

Complications from Heart Disease

Objectives

• Explain normal and abnormal pathophysiology of the heart in relation to chronic heart failure.

• Differentiate between left and right sided heart failure.

• Discuss current medical treatments for patients with heart failure.

• Discuss common teaching principles related to heart failure.

• Utilize the nursing process as a framework for care in patients with heart failure.

• Demonstrate competent and compassionate nursing care for the heart failure patient.

Stroke Volume

• The amount of blood pumped by the ventricles per beat.

• Average resting SV is 60-80 ml (2 Ounces) per beat.

Cardiac Output

• CO – the amount of blood pumped by the heart in 1 minute.

• Normal CO = 5 Liters per min• CO = Heart rate X stroke volume• The entire blood volume passes through

the heart every minute

Starling’s Law of the Heart

• The greater the stretch of the myocardial fibers, the stronger the force of the contraction.

Inotropic effect

• Positive inotropic effect – increase stroke volume by increasing the force of contraction without stretching the fibers.– Digitalis

• Negative Inotropic Effect – decrease in contraction

Congestive Heart Failure

• Heart is unable to pump adequate amount of blood to meet metabolic needs

• CHF describes the accumulation of blood and fluid in organs and tissues from impaired circulation.

http://www.cdc.gov/dhdsp/library/fs_heart_failure.htm

HF Video

Preload

• The amount of blood presented to the ventricles just before systole.

• Blood volume - stretches cardiac muscle fibers

• Ventricular compliance – the elasticity or amount of give when blood enters ventricle.– Ventricular hypertrophy = decreased

ventricular compliance

Afterload

• The amount of resistance to the ejection of blood from the ventricle.

• Resistance caused by tension in aorta and systemic vessels.

Contractility

• The force of contraction• Catecholamines – released by SNS,

increases contractility and stroke volume• MI = myocardial cell damage = decreased

contractility = HF

Test Your Knowledge

Stroke Volume of the heart is determined by:

a. The degree of cardiac muscle strength.b. The intrinsic contractility of the cardiac

muscle.c. The pressure gradient against which the

muscle ejects blood during contraction.d. All of the above

Heart Failure

• The inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients

Compensatory Mechanisms:• Ventricular dilation– Muscle fibers stretch.. Increase contractile force– Increases cardiac output / blood pressure– Eventually inadequate

…overstretched/overstrained• Ventricular hypertrophy– Increase in muscle mass– Hypertrophic muscle has POOR contractility

• Increased SNS stimulation• First mechanism triggered• LEAST EFFECTIVE mechanism• Increased workload causes increased

demand for O2

Chronic Heart Failure

Pathology of Ventricular Failure:oSystolic

failure

Chronic Heart Failure

Diastolic failureHeart muscle that

doesn’t relax properly between beats. This is called diastolic heart failure.

Chronic Heart Failure • Risk Factors:– *HYPERTENSION– Diabetes– Cigarette smoking– Obesity– High cholesterol level

What conditions might contribute to HF?

Slide 119

• Hypertension• Tachydysrhythmias• Valvular disease• Cardiomyopathy• Renal failure

Hypertension, tachydysrhythmias, valvular disease, cardiomyopathy, and renal failure reduce C/O by:

1.

2.

3.

Chronic Heart Failure

Types of CHF:• Usually manifested by biventricular

failure• One ventricle may precede the other• Prolonged strain …. causes remaining

side to fail

Left-Sided Heart Failure

• Results from LV dysfunction

• Blood backs up into LEFT atrium

• Pulmonary congestion and edema

Left Sided CHF

• What are the Signs & Symptoms?

S & S Left Sided HF

– Pulmonary symptoms– Cough, may have frothy sputum– SOB– Orthopnea– Crackles on auscultation– Tachycardia– Extra Heart Sound - S3

S3 Heart Sound Audio

Lung Sounds – Crackles Audio

Pulmonary Edema

Acute Pulmonary Edema• Pulmonary edema :

Severe dyspnea, orthopnea

• Tachycardia, pallor• Blood tinged frothy

sputum• Wheezing, crackles• Bubbling respirations• Acute anxiety,

apprehension, restlessness

• Diaphoresis cold clammy skin

• Cyanosis• Nasal faring• Use of accessory muscles• Tachypnea• Hypocapnia evidenced by

muscle cramps, weakness, dizziness

Right-Sided Failure

• What is #1 Cause? • Results from diseased right

ventricle• Blood backs up into right atrium and venous circulationS & S:

S & S Right Sided Failure

• Peripheral edema• Hepatomegaly• Splenomegaly• Vascular congestion in GI tract• Jugular venous distention• ABD distention (ascites) from portal

hypertension

Cor Pulmonale

Test Your Knowledge

When collecting subjective data, the nurse could expect that the client who is developing left-sided congestive heart failure would describe having:

a. to sleep in a reclining chair b. intolerance for fatty foods c. tight fitting shoes d. to urinate frequently

Test Your Knowledge

All of the following are clinical manifestations of right-sided heart failure except:

a. Hepatomegalyb. Jugular vein distentionc. Ascitesd. Orthopnea

Ejection Fraction

The percentage of blood the LV ejects when it contracts

• Normal = 55% - 65%• Mild reduction = 45-55%• Moderately reduced =

35-45%• Severely reduced = < 35%

BNP• Brain (B-Type) Natriuretic Peptide• Helps regulate BP and fluid volume• Secreted from the ventricles in response

to increased preload• Used to diagnose and monitor HF• > 51.2 pg/mL = mild HF• > 1000 pg/mL = severe HF

Managementof CHF and Pulmonary Edema

• Reduce the heart’s workload

• Improve cardiac output

How do we do that?

Drug Therapy for Chronic HF

Goals: • Identification of TYPE of HF and

underlying cause• Correction of Na+ and water

retention• Reduction of cardiac workload• Improvement of cardiac

contractility

Drug Categories for Treating CHF

Drug Categories for Treating HF • Standard TX:

– Diuretics– ACE inhibitors– Beta Blockers

• Other drugs used:– Cardiac Glycosides (Positive inotropic drugs) [Digoxin]– Vasodilator drugs [Nitroprusside]– Nonglycoside inotropic Agents (Dobutrex)

• See Brunner pgs 952-956

Review HF Medication Therapy Handout

Test Your Knowledge

A client admitted with heart failure who is taking a thiazide diuretic has been ordered to receive furosemide (Lasix). What side effect of these medications should the nurse be alert for?

a. Hypertension b. Headache c. Bradycardia d. Arrhythmias

Test Your KnowledgeThe treatment of cardiac failure is directed

at:a. Decreasing oxygen needs of the heartb. Increasing CO by strengthening muscle

contraction and decreasing PVRc. Reducing the amount of circulating

blood volumed. All of the above

Test Your Knowledge

The physiologic effect of an angiotensin converting enzyme inhibitor in the management of congestive heart failure includes which of the following: (Mark all that apply)

a. Decrease peripheral vascular resistance (PVR) b. Decrease in heart rate c. Increase myocardial contractility d. Decrease in afterload

Nursing Diagnoses for HF

• Name some Nursing Diagnoses for HF

Nursing Interventions for Patient with HF

Test Your Knowledge

If a client with left sided heart failure experiences paroxysmal nocturnal dyspnea, which one of the following would be most appropriate to add to the plan of care?

a. Place the client on an alternating pressure mattress b. Use several pillows to support the head and thorax c. Administer oxygen per nasal cannula at bedtime d. Cough forcefully to expectorate accumulated

secretions

NYHA Heart Classification System ACC/AHA Staging System

Class I — Mild• No limitation of activity• No symptoms with normal activity

Stage A• No structural abnormality of the heart• No symptoms of HF

Class II — Mild• Slight limitation of activity• Comfortable with rest or mild exertion

Stage B• Structural abnormality of the heart• No symptoms of HF

Class III — Moderate• Marked limitation of activity• Comfortable only at rest

Stage C• Structural abnormality of the heart• Some symptoms of HF

Class IV — Severe• Complete rest is required; confined to bed or chair• Any activity brings discomfort; symptoms occur at rest

Stage D• Structural abnormality of the heart• Symptoms of HF that do not respond well to normal treatment

NYHA = New York Heart Association AHA = American Heart AssociationACC = American College of Cardiology

Resources

• Lehne, R.A., Pharmacology For Nursing Care, 7th Edition, 2010, Elsevier

• Brunner, L. S., Suddarth, D. S., & Smeltzer, S. C. (2008). Brunner & Suddarth's textbook of medical-surgical nursing (11th ed.). Philadelphia: Lippincott Williams & Wilkins.