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Heart failure is the inability of the heart to pump sufficient blood to meet the
needs of the tissues for oxygen and nutrients.
The term heart failure indicates myocardial disease in which there is a problem
with contraction of the heart (systolic dysfunction) or filling of the
heart (diastolic dysfunction) that may or may not cause pulmonary or
systemic congestion.
Heart failure is most often a progressive, life-long condition that is managed with
lifestyle changes and medications to prevent episodes of acute
decompensated heart failure.
Classification
Heart failure is classified into two types: left-sided heart failure and right-sided heart
failure.
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When the right ventricle fails, congestion in the peripheral tissues and the
viscera predominates.
The right side of the heart cannot eject blood and cannot accommodate all the
blood that normally returns to it from the venous circulation.
Increased venous pressure leads to JVD and increased capillary hydrostatic
pressure throughout the venous system.
Stage A. Patients at high risk for developing left ventricular dysfunction but
without structural heart disease or symptoms of heart failure.
Stage B. Patients with left ventricular dysfunction or structural heart disease that
has not developed symptoms of heart failure.
Stage C. Patients with left ventricular dysfunction or structural heart disease
with current or prior symptoms of heart failure.
Stage D. Patients with refractory end-stage heart failure requiring specialized
interventions.
Pathophysiology
Systolic HF results in decreased blood volume being ejected from the ventricle.
The sympathetic nervous system is then stimulated to
release epinephrine and norepinephrine.
Decrease in renal perfusion causes renin release, and then promotes the
formation of angiotensin I.
Angiotensin I is converted to angiotensin II by ACE which constricts the blood
vessels and stimulates aldosterone release that causes sodium and fluid
retention.
There is a reduction in the contractility of the muscle fibers of the heart as the
workload increases.
Compensation. The heart compensates for the increased workload by
increasing the thickness of the heart muscle.
Schematic Diagram
Below is a schematic diagram to help you visualize the pathophysiology of Heart Failure:
Just like coronary artery disease, the incidence of HF increases with age.
There are 550, 000 cases of HF diagnosed each year according to the American
Heart Association.
HF is most common among people older than 75 years of age.
HF is now considered epidemic in the United States.
HF is the most common reason for hospitalization of people older than 65 years
of age.
It is also the second most common reason for visits to the physician’s office.
The estimated economic burden caused by HF is more than $33 billion annually
in direct and indirect costs and is still expected to increase.
Incidences
Heart failure can affect both women and men, although the mortality is higher among
women.
There are also racial differences; at all ages death rates are higher in African
American than in non-Hispanic whites.
Heart failure is primarily a disease of older adults, affecting 6% to 10% of those
older than 65.
It is also the leading cause of hospitalization in older people.
Causes
Systemic diseases are usually one of the most common causes of heart failure.
Clinical Manifestations
The clinical manifestations produced y the different types of HF are similar and
therefore do not assist in differentiating the types of HF. The signs and symptoms can
be related to the ventricle affected.
from Cardiovascular Mnemonics
Left-sided HF
Right-sided HF
Prevention
Healthy diet. Avoiding intake of fatty and salty foods greatly improves the
cardiovascular health of an individual.
Engaging in cardiovascular exercises thrice a week could keep
the cardiovascular system up and running smoothly.
Smoking cessation. Nicotine causes vasoconstriction that increases the
pressure along the vessels.
Complications
Many potential problems associated with HF therapy relate to the use of diuretics.
Hyperkalemia. Hyperkalemia may occur with the use of ACE inhibitors, ARBs, or
spironolactone.
Prolonged diuretic therapy might lead to hyponatremia and result in
disorientation, fatigue, apprehension, weakness, and muscle cramps.
Dehydration and hypotension. Volume depletion from excessive fluid loss may
lead to dehydration and hypotension.
HF may go undetected until the patient presents with signs and symptoms of
pulmonary and peripheral edema.
Medical Management
Pharmacologic Therapy
ACE Inhibitors. ACE inhibitors slow the progression of HF, improve exercise
tolerance, decrease the number of hospitalizations for HF, and
promote vasodilation and diuresis by decreasing afterload and preload.
Angiotensin II Receptor Blockers. ARBs block the conversion of angiotensin I
at the angiotensin II receptor and cause decreased blood pressure, decreased
systemic vascular resistance, and improved cardiac output.
Beta Blockers. Beta blockers reduce the adverse effects from the constant
stimulation of the sympathetic nervous system.
Diuretics. Diuretics are prescribed to remove excess extracellular fluid by
increasing the rate of urine produced in patients with signs and symptoms of
fluid overload.
Calcium Channel Blockers. CCBs cause vasodilation, reducing systemic
vascular resistance but contraindicated in patients with systolic HF.
Nutritional Therapy
Additional Therapy
Nursing Management
Despite advances in the treatment of HF, morbidity and mortality remains high. Nurses
have a major impact on outcomes for patients with HF.
Nursing Assessment
The nursing assessment for the patient with HF focuses on observing for the
effectiveness of therapy and for the patient’s ability to understand and implement self-
management strategies.
Health History
Assess the signs and symptoms such as dyspnea, shortness of breath, fatigue,
and edema.
Assess for sleep disturbances, especially sleep suddenly interrupted by
shortness of breath.
Explore the patient’s understanding of HF, self management strategies, and the
ability and willingness to adhere to those strategies.
Physical Examination
Diagnosis
Based on the assessment data, major nursing diagnoses for the patient with HF include
the following:
Reducing fatigue.
Relieving fluid overload symptoms.
Decreasing anxiety.
Increasing the patient’s ability to manage anxiety.
Encouraging the patient to verbalize his or her ability to make decisions and
influence outcome.
Teaching the patient about self-care program.
Nursing Interventions
Evaluation
The nurse should provide education and involve the patient in the therapeutic regimen.
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Discharge Goals
Complications prevented/resolved.
Optimum level of activity/functioning attained.
Disease process/prognosis and therapeutic regimen understood.
Plan in place to meet needs after discharge.
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