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• Chapter 20:

Heart Failure
• Heart Failure
• New York Heart Association (NYHA) Functional Classification
• Measures the effect that symptoms (fatigue and dyspnea) of heart failure have on physical activities:
– Class I: No limitation of activities
– Class II: Slight limitation of activities, no symptoms at rest
– Class III: Marked limitation of activities, symptoms at rest
– Class IV: Not able to do any activities without symptoms; symptoms at rest
• The ACC/AHA Guidelines for Stages of Heart Failure
• Four stages enhance the NYHA Functional Classification system
• Used to outline the prevention, diagnosis, clinical management, and prognosis of patients with heart
failure
• Only stages C and D correlate with the NYHA Functional Classification system
• Compensatory Mechanisms in Heart Failure

See Figure 20-2.

• Assessment of Severity of Heart Failure
• Changes in neurological status
• Respiratory status
– Can patient speak in complete sentences?
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– Presence of dyspnea on exertion and at rest, crackles, Cheyne-Stokes respirations

– Orthopnea
– Paroxysmal nocturnal dyspnea
• Chest pain or discomfort
• Chronic Heart Failure
• Left-Sided Heart Failure
• Crackles
• Orthopnea
• Nocturia and coughing at nighttime
• S3, S4
• Right-Sided Heart Failure
• Dependent edema, weight gain, JVD
• Hepatomegaly, hepatojugular reflex, ascites
• Right upper quadrant pain
• Decreased appetite, bloating
• Possible Cardiac Auscultation Findings in Patients With Heart Failure
• S3: warning of imminent or worsening heart failure
• Summation gallop
• Mitral regurgitation murmur
• Tricuspid regurgitation murmur
• Laboratory Studies Used in Evaluation of Heart Failure
• BNP and NT: pro-BNP test - diagnose and grade severity of heart failure
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• Cardiac biomarkers (CK, CK-MB, Troponin)

• CBC
• Thyroid function tests
• Renal profile
• Liver function tests
• Lipid panel
• Question
In the client with heart failure secondary to dilated cardiomyopathy, a PAWP of ____ results in a(n) __
cardiac output and a(n) ___ in renal insufficiency.
A. 20 mm Hg; decreased; increase
B. 8 to 12 mm Hg; increased; decrease
C. 8 to 12 mm Hg; decreased; increase
D. 20 mm Hg; decreased; decrease
• Answer
C. 8 to 12 mm Hg; decreased; increase
Rationale: If the client was diuresed and had a normal PAWP (8 to 12 mm Hg), it would result in a decreased
cardiac output and an increase in renal insufficiency because the client needs a higher PAWP for ventricular
filling because of the dilated cardiomyopathy.
• Medications Used in the Treatment of Chronic Heart Failure
• ACE inhibitors and ACE II blockers
– Main drug used in treatment
– Start low, go slow
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– Monitor serum creatinine and potassium

– Watch for angioedema; stop drug immediately
– Cough is annoying but harmless
• Medications Used in the Treatment of Chronic Heart Failure (cont.)
• Hydralazine and nitrates: given together when patient cannot take ACE inhibitors/blockers
– Monitor for tachycardia, headache, hypotension
• Digoxin: blockade of norepinephrine
– Improves exercise tolerance and improves symptoms of heart failure
– Decreased dose in renal insufficiency or if taking amiodarone
– Keep blood level at 1.0 ng/mL
– Medications Used in the Treatment of Chronic Heart Failure (cont.)
• Diuretics
– ACE inhibitors and beta-blockers provide maximum therapeutic effect when patient is
euvolemic
– Educate patient on need to follow sodium restriction and weigh self daily
• Beta-blockers
– Use as long-term treatment with stable patients
– Improve exercise tolerance and ejection fraction
• Medications Used in Treatment of Acute Exacerbation of Heart Failure
Inodilators: dobutamine, milrinone
• Monitor for ventricular dysrhythmias and tachycardia
• Start low, go slow
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• Beta-blockers help prevent tachycardia

Dopamine
• Higher doses increase afterload; monitor BP, urine output
• Give only in a central line
• Medications Used in Treatment of Acute Exacerbation of Heart Failure (cont.)
Nitroprusside
• Avoid high doses or prolonged use; cyanide level increases. Monitor cyanide level if used >24 hours.
• Monitor for cyanide toxicity (tinnitus, visual blurring, mental status changes); antidote is sodium
thiosulfate.
• Monitor BP continuously via arterial line.
• Wrap bottle in aluminum foil.
• Medications Used in Treatment of Acute Exacerbation of Heart Failure (cont.)
Nesiritide
• If hypotension occurs, decrease dose or discontinue and give IV fluids, and place in supine position.
• Bolus must be given from prepared IV bag.
– See package insert for dosage formulas.
Hydralazine
• Give IVP over 3 to 5 minutes.
• Monitor pulse, BP every 15 min x4, then every hour x2.
• Question
Nesiritide is a BNP approved by the FDA for its ability to do which of the following?
A. Reduce preload
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B. Act as a vasodilator
C. Control blood pressure
D. Increase renal perfusion
• Answer
B. Act as a vasodilator
Rationale: Nesiritide is a BNP approved by the FDA for its ability to vasodilate (reduce afterload). Caution
should be used if the systolic blood pressure is <90 mm Hg. The medication does not increase renal perfusion,
improve diuresis, or decrease preload. Dopamine is the drug that can be used to increase renal perfusion and
improve diuresis. Nitrates can be used to reduce preload. Nesiritide is very expensive and is not used to
control blood pressure. Hydralazine is used for blood pressure control and helps reduce afterload.
• Strategies to Manage Heart Failure to Decrease Incidence of Rehospitalization
• Educate client on sodium restriction and importance of label reading.
• Explain why the client should avoid alcohol.
• Explain how walking 15 to 20 minutes/day will improve energy level.
• Explain importance of taking daily weights and taking prompt action to resolve fluid retention.
• Educate on a system to ensure medications are taken and recorded.
• Oxygenation/Ventilation Outcomes
• Hgb 10 g/dL or greater
• Pulse oximetry 90% or greater
• No dyspnea at rest
• NYHA class at baseline or better
• BNP within normal range
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• Circulation/Perfusion Outcomes
• Cardiac index >2.0
• Weight at baseline or better
• Urine output >30 mL/hr
• Mental status at baseline
• Vital signs normal
• Peripheral pulses intact
• Fluid/Electrolyte Outcomes
• Baseline BUN and serum creatinine and GFR
• Electrolytes within normal range
• Baseline weight or better
• No edema present
• No ascites present
• Mucous membranes moist and intact
• Teaching/Discharge Planning Outcomes
• Adequate verbal understanding of care and follow-up
– States ways to meet sodium restriction
– States process to weigh self daily to ensure accuracy
– States what to do if weight is 3 to 5 lb over baseline
– States will abstain from smoking and alcohol
– States realistic plan for exercise
– States plan to ensure medication compliance
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• Home Care: Heart Failure

• Question
The nurse is teaching a group of patients with chronic heart failure about home management. Which statement
during class discussion warrants further teaching?
A. “Drinking a glass of wine every day will decrease my risk of coronary artery disease.”
B. “I will walk for 25 minutes every day.”
C. “I will watch food labels for hidden salt.”
D. “I will weigh myself every day and act fast if I gain 2 pounds.”
• Answer
A. “Drinking a glass of wine every day will decrease my risk of coronary artery disease.”
Rationale: Alcohol is a cardiac depressant, and although wine has been linked to a decreased risk for CAD, it
has deleterious effects on the heart with systolic dysfunction.