Chf

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Congestive Heart Failure

(Kozier, “Nursing Management: Heart Failure and Cardiomyopathy,” chp.34)

L Del Balso

Heart Anatomy Preload Contractility Afterload CO

L Del Balso

Congestive Heart Failure Definition • Abnormal condition involving impaired cardiac pumping.

• CHF is not a disease. • Ventricular dysfunction caused by cardiac and non-cardiac dysfunctions. L Del Balso

Definition (Cont’d) • Cardiac diseases: long-standing hypertension coronary artery disease (CAD) • Characteristics: ventricular dysfunction ↓ exercise tolerance ↓ quality of life shortened life expectancy L Del Balso

Definition (Cont’d) • incidence for men = women • High rate of mortality and morbidity • 1 in 100>65yrs

L Del Balso

ETIOLOGY & RISK FACTORS – – – – – –

CAD Age Hypertension Obesity, high cholesterol level Smoking DM

– African American descent

L Del Balso

Manifestation of Ventricular Failure • low BP, • low CO • poor renal perfusion, • poor exercise tolerance, • ventricular arrhythmias

L Del Balso

PATHOPHYSIOLOGY • CO depends on: – Preload – Afterload – Myocardial contractility – Heart rate

L Del Balso

Compensatory Mechanisms 1. Ventricular dilatation 2. Ventricular hypertrophy- in chronic

CHF

3. Sympathetic nervous system stimulation 4. Neurohormonal responses: >Kidneys: angiotensin aldosterone >Brain: antidiuretic hormone (ADH) L Del Balso

Types of CHF • One-sided failure eventually leads to biventricular failure – –

Left sided failure Right sided failure

L Del Balso

Left Sided Failure – Most common form (LV dysfunction) – Blood backs up through the LA into the pulmonary veins Pulmonary congestion and edema – Causes: HTN, CAD, rheumatic heart disease (streptococcus L Del Balso

Lt Sided Failure Symptoms • dyspnea, orthopnea & paroxysmal

nocturnal dyspnea • adventitious sounds: crackles at bases of lungs --- throughout lungs • moist, hacking productive cough w/frothy sputum • restlessness & anxiety, fatigue • Nocturia L Del Balso

Right Sided Failure – Backward flow to the RA and venous circulation – Results from diseased RV – Leads to venous congestion in systemic circulation peripheral edema, etc.. – Causes: Lt sided failure, Cor Pulmonale, Rt ventr. infarction L Del Balso

Rt sided Failure Symptoms • jugular vein distention • ascities: hepatomegaly • Anorexia, nausea, GI bloating • weight gain • Dependant edema • Peripheral edema • fatigue L Del Balso

Acute CHF • Manifestation: Pulmonary edema. • Cause: Lt ventricular failure secondary to CAD • Symptoms: -Pale or cyanotic, Cold, clammy skinsecondary to vasoconstriction from sympathetic nervous system response -Agitation -Severe dyspnea-use of accessory muscles, orthopnea -Tachypnea , wheezing, crackles, coughing -Nocturia L Del Balso L Del Balso

CHRONIC CHF • Fatigue. • Dyspnea, orthopnea (key symptom) • • • • • • •

-Paroxysmal nocturnal dyspnea Dry hacking cough. Tachycardia- (compensatory mechanism) Edema-pitting edema, dependant edema (sacral edema). Sudden weight gain Nocturia (6-7 x/night) Skin changes Behavioral changes L Del Balso

Complications of CHF 1. Pleural effusion: collection of fluid in pleural space. 2. Arrhythmias: alteration normal electrical pathway. 3. Left ventricular thrombus: enlarged LV and decrease CO can increase chance of clot. 4. Hepatomegaly (RV failure) L Del Balso

CLASSIFICATION OF CHF by the NY Heart Association

– Class 1: No limitation of physical activity – Class 2: Slight limitation

L Del Balso

CLASSIFICATION (cont’d) – Class 3: Marked limitation – Class 4: Inability to carry on any physical activity without discomfort

L Del Balso

Diagnostic Studies • Primary goal is to determine

underlying cause – Physical exam – Chest x-ray – ECG – Hemodynamic assessment L Del Balso

Diagnostic studies (cont’d) – Echocardiogram-measures ejection fraction. – Stress testing – Cardiac catheterization – Ejection fraction (EF)

L Del Balso

Collaborative Care • Treat underlying cause • Maximize CO • Alleviate symptoms

L Del Balso

Drug Therapy Goal: improve symptoms, minimize side effects of treatment, prevent morbidity and prolong survival

• ACE inhibitors • Diuretics ∀β-Adrenergic blockers • Inotropics agents • Vasodilators L Del Balso

ACE Inhibitors Enalapril & Capoten

• Action: -Block production of

angiotensin II decrease aldosterone -Dilate arterioles and veins, decrease SVR, afterload and increase CO. • Adverse effects -hypotension - hyperkalemia L Del Balso

DIURETICS • Action: -Reduce blood volume and decrease

preload

-Mobilize edematous fluid -Decrease venous pressure and afterload -Decrease pulmonary edema, peripheral edema, cardiac dilation L Del Balso

Diuretics (cont’d) 3 Types: • Thiazide-Hydrochlorothiazide: tubule

Inhibit Na/H2O resorption of distal

2. Loop Diuretics- Lasix

severe

-Acts on ascending loop of Henle -Na, CL, H2O excretion. -SE: hypokalemia, ototoxicity, hypotension. L Del Balso

DIURETICS (cont’d) 3. K sparing diuretics: Spironolactone (aldactone)

>Improves survival of CHF pts by blocking effects of aldosterone in heart. >Excretion of Na,H2O

L Del Balso

Beta Adrenergic Carvedilol, Metoprolol, Bisoprolol • Action: -Blocks the sympathetic nervous system (high HR) -improve L ventricular ejection fraction, increase exercise tolerance, slow progression of CHF, • Adverse effects: fluid retention from worsening CHF, fatigue, hypotension, bradycardia, MI

L Del Balso

INOTROPIC AGENTS 1.DIGOXIN(LANOXIN) • cardiac glycoside, anti-arrthymic (digitalis) • used CHF & arrthymias • functions in 2 ways: – increases force of myocardial contractility – slows conduction from AV node  slows HR  ventricular emptying >inhibits K Intracellular levels uptake >increase intracellular Na, Ca--L Del Balso increase contractility .

Digoxin (cont’d) • NRSG: – take AP for full minute – note rate & rhythm (if AP < 60, HOLD) – monitor K+ levels – educate client & family to assess pulse for rhythm & rate – educate & monitor for signs of digoxin toxicity *(sign of toxicity??)*

L Del Balso

Digoxin (cont’d) • SE: -Therapeutic range: 1.54 +/- 0.5 mmol /L -First sign is arrthymia -anorexia, N & V, malaise (mild) -vision disturbances: “yellow” -changes in HR & rhythm through palpation, auscultation or on ECG -monitor K+ levels: hypokalemia may predispose to toxicity L Del Balso

INOTROPIC AGENTS 2.sympathomimetics: • • •

Dopamine Dobutamine Hydralazine (APRESOLINE)

 Increases CO and renal blood flow.

L Del Balso

INOTROPIC AGENTS (cont’d) 3.Phosphodiesterase inhibitor • Inamarinone lactate(INOCOR): -increases contractility (increasing ca entry) -Vasodilator, increases CO and decreases afterload (lower BP)

L Del Balso

Vasodilators • Sodium Nitrate: (Nitroprusside) -IV vasodilator for pulmonary edema • Nitrates: -decrease preload -beneficial in MI: increase vasodilatation of arteries L Del Balso

POTENTIAL COMPLICATIONS • Electrolyte imbalances due to use of diuretics & digoxin • Hypokalemia: (low K+)

– weakens cardiac contractions – leads to digoxin toxicity – Signs of hypokalemia: weak pulse, hypotension, muscle flabbiness, generalized weakness & diminished deep tendon reflexes

• K supplements(K-Dur) if not on ACE

inhibitor or K sparing diuretics. Give with meals.

L Del Balso

POTENTIAL COMPLICATIONS (cont’d)

• Hyponatremia: low Na+ – due to prolonged diuretic therapy – signs: apprehension, weakness, fatigue, muscle cramps & twitching, rapid, thready pulse

L Del Balso

Nutritional Therapy for CHF • Fluid restrictions not commonly prescribed only for severe CHF • Na restriction in order to decrease circulating volume and decrease workload of heart – 2 g sodium diet for mild CHF – 500-1000mg for severe CHF • Daily weights L Del Balso

Nursing and Collaborative Management - Goal: Improve LV function by: - Action demands: – Decreasing intravascular volume – Decreasing venous return – Decreasing afterload – Improving gas exchange and oxygenation L Del Balso

Nursing and Collaborative Management (Cont’d) Action demands: – Improving cardiac function – Reducing anxiety – Promote skin integrity – Promote activity tolerance – Provide client & family education: self care at home L Del Balso

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