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body’s needs. Congestive Heart Failure The accumulation of blood and fluid within the organs and tissues due to decreased circulation (Dig. & Lasix). The heart is a dual pump. (Right and Left Sides) May have Left or Right side heart failure, or both. Left side heart failure leads to ® side heart failure. No matter left or right heart failure, you have decreased cardiac output. With decreased cardiac output, mechanisms within the body help to increase the cardiac output; this does more harm than good. *Sympathetic Nervous System: Attempts to increase Cardiac Output & raise BP by speeding and increasing the contractions (this requires extra Oxygen to the myocardium-- and oxygen is not available so the patient worsens). * Blood Vessels: Constrict to raise BP but in turn it makes the heart work harder because there is more peripheral resistance. * Renin-angiotensin-aldosterone mechanism: (in response to low blood flow to the kidney because of decreased cardiac output)-Vasoconstriction, Sodium, & Water retention which increases the workload of the heart against the peripheral vascular resistance & more fluid to have to pump due to aldosterone saving sodium & water. Review: The kidneys release renin, which stimulates angiotensin I in the liver which in turn is converted to angiotensin II in the lung by the ACE enzyme. Angiotensin II is a potent vasoconstrictor which helps raise BP. It also stimulates the adrenal cortex to release aldosterone which saves sodium and water (because water ALWAYS follows salt). It increases fluid & pressure; and excretes potassium. Creates a problem b/c you have more fluid for the heart to pump. * Cells: Switch from aerobic to anaerobic metabolism which increases lactic acid, lowers pH, and causes metabolic acidosis. CHF leads to metabolic acidosis.
Hint: IF it’s left it’s a lung if it’s right it’s anything else. Left Sided Heart Failure Conditions that may lead to left-sided heart failure: 1. High Blood Pressure Increases the workload of the (L) ventricle and in the end the (L) ventricle just gives out. 2. Clients post MI Muscle doesn’t work as effectively and creates decreased cardiac output. So the heart fails b/c it pump the blood d/t the amount of muscle damage. 3. Inflammatory heart conditions Affects the blood flow thru the heart which decreases cardiac output. 4. Hypervolemia/ rapid infusion of IV fluids Fluid overload. 5. Tachycardia (hypoxemia) Fluid accumulates in the lungs in the pulmonary capillary bed (This impairs oxygen and carbon dioxide exchange). Don’t give it time for ventricles to fill up and heart gives out. Fluid backs up in the 1st place it comes to: which is the lungs. Oxygen doesn’t travel well thru water, CO2 does. You have more chance of transferring CO2 than you do O2. When you have fluid in the lung- you do not get good O2 exchange. The more fluid you have in the lung, the less Oxygen you exchange. See Respiratory S/S 1. Extertional Dyspnea: (1st sign) Shortness of breath or dyspnea during activity. Ex: Short of breath going to bathroom. 2. Orthopnea: have to sit upright to breathe 3. Paroxysmal nocturnal dyspnea: Awakened by breathlessness due to the recumbent positioning during sleep & secretions pool in the lungs (increased venous return to the heart). ** PINK, FROTHY SPUTUM** When you lay flat it decreases venous return to the heart. So more fluid backs up into the lungs. That’s why a lot of CHF patients will come in early in the morning. It’s due to the recumbent position when they sleep. They’ve laid flat for a long time and all that fluid has accumulated in the lungs while they’ve slept. 4. Hypoxia Makes heart rate increase. 5. Crackles in the lung Rales- will not clear with cough- “death rattle” Diagnostic Findings: 1. Chest X-ray shows heart enlargement & fluid in the lungs. Enlarged heart is compressing on the lung inhibiting full expansion.
2. Echocardiogram: shows ineffective pumping of the heart. Shows heart wall and valve function. 3. ABG: Respiratory alkalosis early, then metabolic acidosis due to impaired gas exchange. 4. Elevated BUN: (waste product) in the blood because of decreased renal perfusion due to decreased cardiac output. BUN is up because the BP is low, and you need so much BP for the kidneys to filter. Right-Sided Heart Failure The major cause of ® sided heart failure is left sided heart failure. Exception: MI’s that affect the ® ventricle can cause ® sided heart failure. Cor Pulmonale: Condition in which the heart is affected by lung disease/damage. PAP: Normal: 20-30 systolic/8-12 diastolic Exerts increased pressure in the pulmonary artery (comparable to HTN on the left side) If PAP is increased, the ® ventricle will have to work harder to get the blood thru the pulmonary artery b/c there is too much pressure on the other side.® ventricle enlarges. Cor Pulmonale means (in a nutshell) ® side failure d/t lung disease: increased CO2 (vasoconstriction) Peripherial resistance increased: causes edema Hepatomegaly. **Lung disease increases carbon dioxide levels in the blood (COPD) and causes Pulmonary Arterial Vasoconstriction which increases the force in which the ® ventricle has to pump blood to the lungs-- results in an enlargement of the ® ventricle (Pulmonary HTN due to vasoconstriction of the pulmonary artery). X-ray would show an enlarged ® ventricle. When the ® ventricle fails, blood backs up in the venous system and you systemic symptoms-- Peripheral symptoms: ® side heart failure exhibits urinary frequency d/t increased urinary output. 1. Weight Gain: from edema (heart can no longer circulate the blood so the body allows it to seep from the intravascular system into tissues to try to get rid of some circulatory fluid volume. Daily weight!!!! 2. Pitting edema in the feet and ankles. Seems to disappear over night (while lying flat). it actually redistributes the edema while sleeping. When up and walking (gravity) you see edema again. 3. Ascites: Fluid in the abdomen.
4. Hepatomegaly: enlarged liver (fluid within the organ) 5. Jugular vein distension: (increased central venous pressure) Rings may be tight on the fingers due to edema. Abdominal distension may cause dyspnea, nausea, and vomiting. Central venous pressure: pressure within the ® atrium. Normal level: 2-7mmHg or 4-10 cm H2O. Stomach puts pressure on the diaphragm. S-3 sound is an indication of heart failure in adults. (Ventricular gallop) S-4 sound is called Atrial gallop: (HTN) (go to the bathroom many times thru the night) Diagnostic Findings: 1. Chest X-ray: ® ventricular enlargement. 2. Lung scan and pulmonary autobiography: confirms Cor Pulmonale. 3. Liver enzymes are elevated if ® side heart failure causes liver abnormalities (Hepatomegaly). LDH1, LDH2 : Can’t produce clotting factors. Box 35-1 Estimating Central Venous Pressure Measure while the client is lying at a 45 degree angle. At least 45 degrees!! 1.Ruler is spaced on the sternal angle & jugular vein distension is measured by the height on the ruler (see illustration in book). 2. Add 5 cm to the ruler measurement. In ® ventricular heart failure, CVP is more than 12 cm of water. Medical Management of CHF Goal is to reduce the workload of the heart & improve cardiac output. 1. Limited Activity Bed rest (maybe with bathroom privileges) 2. Drugs-Digoxin: given to slow the heart rate and increase the strength of myocardial contractions. Lasix Sedatives (for dyspnea & anxiety) Aspirin or anticoagulants to prevent thrombi from decreased circulation. 3. Low sodium diet: Water follows salt--so the more sodium you eat the more fluid you hold. Devices used in the treatment of CHF: Know what it does & what it’s used for
1. Intra-aortic balloon pump: Increases cardiac output; placed in aortic arch and connected to a matching synchronized with a ventricular contraction; inflates during diastole; deflates during systole. Helps to keep blood going forward so it doesn’t back up. Placed in aorta inflates during diastole. 2.* (L) Ventricular Blood Pump (Hemopump): Increases cardiac output; motorized device inserted into the (L) ventricle; pumps blood not ejected from the (L) ventricle into the descending aorta. Pumps blood from the left ventricle to the descending aorta. 3. * (L) Ventricular assist Device: increases cardiac output using a cannula that reroutes blood from the (L) atrium into the aorta (may be used in client’s awaiting heart transplants). You are trying to assist the ventricle by removing blood from the left atria, so it don’t have to go to the ventricle. Takes some of the blood from left atria and puts it directly into the aorta, bypassing the left ventricle. Surgical Management 1. Heart Transplants: Adults < 55y; must be transplanted within 6 hours; Give Sandimmune (action: decreases immune response) to decrease chance of rejection (EKG changes= rejection); reverse isolation (suture chambers in place). Monitor for infection : WBC increased, Fever (really high); reverse isolation 2. Cardiomyoplasty: Use patient’s back muscle (Latissimus Dorsi “swimmer‘s muscle“) Wraps it around the heart (ventricles); uses electrical stimulator to trigger muscle contractions. Nursing Management 1. Daily weight (same scale, same time), I/O records 2. Digitalization: 1mg over a 24h period. Digoxin then given ONCE daily of doses 0.125mg or 0.25mg. Has occurred when the heart is receiving maximum benefits (increased cardiac output); Hold Digoxin if pulse < 60 or >120 in an adult; < 80 in a child; <100 in an infant. * Monitor KCL levels; normal level is 3.5-5.3; Hypokalemia (Low KCL) increases the risk of Digitalis toxicity. Lasix causes loss of fluid, sodium and potassium. 3. Monitor edema 4. V/S 5. Administer prescribed medications 6. Semi-Fowler’s position to ease breathing 7. Oxygen; report O2 Sat. < 90% 8. Peripheral pulses (edema) if you can’t feel one d/t edema use a Doppler. 9. Elevate Extremities promotes venous return to the heart.
10. No anti-embolic hose (TEDS) pushes blood out of the superficial veins back into the deeper veins to return to the heart. 11. Assess breath sounds/color of sputum/respiratory rate (when assessing for (L) side) 12. Monitor lab-- Potassium for diuretics (encourage KCL foods such as potatoes, OJ, bananas, prunes, raisins) Potassium-Sparing Diuretics 1. Aldactone 2. Midamor 3. Dyrenum * Salt Substitutes are high in potassium. Lasix is classified as a loop diuretic--it depletes potassium. Mannatol is classified as an osmotic diuretic-- used for head trauma. Client and Family Teaching 13. 14. 15. 16. 17. Notify MD if 2lb. Weight gain (1 liter of fluid) (weigh every day) Rest periods between activity. Teach Client to take their pulse and blood pressure. Take medication as prescribed. Notify physician if pulse is <60 or >120.
Pulmonary Edema Compication of left ventricle failure Fluid accumulates in the lungs; impaired gas exchange; it is an acute emergency-- may lead to cardiac or respiratory arrest. S/s (See left sided heart failure--respiratory S/S) Diagnostic Findings Chest X-ray shows pulmonary infiltration ABG: severe hypoxemia/hypercapnia (high CO2) Medical Management 1. Digoxin: increases cardiac output Lasix: decreases circulating volume Morphine to decrease anxiety/relieve respiratory symptoms (slows respirations). Dobutamine: Increases myocardial contraction. 2. 3. Oxygen (via mask)/? Mechanical ventilation?/CPAP VAD IABP (balloon pump)
Nursing Management 1. IV Access Line 2. Oxygen/ Pulse Ox 3. Suction as needed (PRN) 4. Assess V/S heart rate/rhythm/breath sounds 5. F/C to help assess response to diuretics, and I/O but the best way is daily weight. 6. HOB elevated 7. If intubated, establish a method of communication (*see nursing management for CHF). Add on Notes from Lecture: *Valsava: bear down and hold breath (Vagal Stimulation) to decrease BP & Pulse *Back pain for dissecting or rupturing aneurism (nausea) * Cardiopulmonary machine (heart/lung machine) used in open heart surgery! *Does work of the heart & lungs while the heart is stopped (pumps blood & oxygenates the blood?) * After cardiac surgery (if they open your chest) it’s normal to have Hemoglobin In urine. It has to do with the amount of time the heart is stopped and the machine isn’t as effective as the heart and lungs and where the machine outside the body it may damage some cells and you get rid of the hemoglobin in the urine. * Swanz-Ganz catheter measures CVP * Give Lasix in the morning, if they have a catheter, can be given anytime. * Annulosplasty: Repair--tighten valves in fibrous ring (mitral valve) * Valvuloplasty: Repair-- Balloon opens/stretches the valve (Mitral Valve) * Commisserotomy: Stick finger in to open valve to stretch it (Mitral Valve) * No pillows behind the knees (popliteal area) Decreases circulation, Increases chance for clots formations by pooling blood. *Arterial clots: S/S: Pain, cold, & pale (keep dependent (down)). *Weight is the best way to determine fluid volume in the body * BP and Oliguria: you have to have so much BP for the kidneys to function correctly. * Echocardiogram: Wall & Valve Functioning Depolarization: Sodium goes into the cell & potassium comes out. Repolarization: Potassium goes into the cell & sodium comes out.