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163 Cards in this Set
- Front
- Back
|
(def)
an abnormal clinical condition involving impaired cardiac pumping |
Heart Failure
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In heart failure, the heart is unable to produce an adequate CO to meet what?
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metabolic needs
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What are the 2 characteristic pathophysiological changes that result in heart failure (cause it)?
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- vasoconstriction
- fluid retention |
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Heart Failure is associated with numerous types of cardiovascular diseases. List 3 that are particularly implicated in the development of HF.
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1. long-standing hypertension
2. CAD 3. MI |
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Heart Failure is characterized by what 4 things?
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- ventricular dysfunction
- reduced exercise tolerance - diminished quality of life - shortened life expectancy |
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What are 2 reasons for the increase in the incidences of HF in the population?
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1. improved survival after cardiovascular events
2. increase in aging population |
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True/False:
The incidence of HR is greater in men vs. women. |
False- incidence are similar
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What is the most common reason for hospital admission in adults older than 65?
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HF
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What are the 2 primary risk factors for HF?
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CAD and advancing age
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While CAD and advancing age are the primary risk factors for HF, what are 5 other factors that are major contributors in the development of HF?
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- hypertension
- diabetes - cigarette smoking - obesity - high serum cholesterol |
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Hypertension increases the risk for HF how much?
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threefold
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Can diabetes alone predispose a person to HF?
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Yes, it is a risk factor regardless of the presence of concomitant CAD or hypertension
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Is diabetes more likely to predispose men or women to HF?
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women
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List examples of chronic causes of heart failure. (9)
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- CAD
- HTN - Rheumatic heart disease - Congenital heart disease - Cor Pulmonale - Cardiomyopathy - Anemia - Bacterial endocarditis - Valvular disorders |
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List examples of acute causes of heart failure. (8)
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- acute MI
- dysrhythmias - pulmonary emboli - thyrotoxicosis - hypertensive crisis - rupture of papillary muscle - ventricular septal defect - myocarditis |
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What ethnic group has a higher incidence of HF, develops HF at an earlier age, and experiences higher rates of mortality?
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african americans
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How does anemia contribute to the development of HF?
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decrease oxygen carrying capacity increases cardiac output to meet demands
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How does infection contribute to the development of HF?
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increased oxygen demands of tissues leads to increased CO
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How do dysrhythmias contribute to the development of HF?
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may decrease cardiac output, but increase workload and O2 requirements of the myocardium
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How does pulmonary disease contribute to the development of HF?
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an increase in pulmonary pressure exerts pressure on the RV, leading to RV hypertrophy and failure
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HF may be caused by any interference with the normal mechanisms regulating CO. CO depends on what 5 things?
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1. preload
2. afterload 3. myocardial contractility 4. HR 5. metabolic state of the individual |
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Heart failure is classified as _______ or _______ failure (or dysfunction).
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systolic or diastolic
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Of systolic or diastolic failure, which is the most common cause?
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systolic
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_____ _______ results from an inability of the heart to pump blood.
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systolic failure
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Systolic failure is a defect in what?
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the ability of the ventricles to contract (pump)
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What happens to the LV in systolic failure? What happens if this continues long term?
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- it loses its ability to generate enough pressure to eject blood forward through the aorta;
- over time, the LV becomes thinwalled, dilated, and hypertrophied |
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What is the hallmark of systolic dysfunction?
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a decrease in LV "ejection fraction"
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What is a normal ejection fraction?
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greater than 55% of the ventricular volume
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What are 4 causes of systolic failure?
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- impaired contractile function (ex. MI)
- increased afterload (ex. HTN) - cardiomyopathy - mechanical abnormalities (valvular heart disease) |
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What is diastolic failure?
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an impaired ability of the ventricles to relax and fill during diastole
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In diastolic failure, decreased filling of the ventricles will result in what?
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decreased stroke volume and CO
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Diastolic failure is characterized by high filling pressures due to what?
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stiff or non-compliant ventricles
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Diastolic failure will result in venous engorgement where?
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in both the pulmonary and systemic vascular systems
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Diastolic failure is usually the result of left ventricular hypertrophy from what 3 things?
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1. chronic systemic hypertension
2. aortic stenosis 3. hypertrophic cardiomyopathy |
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Isolated right ventricular diastolic failure is less common. It results from what?
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pulmonary hypertention
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What is the result of isolated right ventricular diastolic failure?
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- reduced right ventricular failure results in low LV filling pressure and reduced CO
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Systolic and Diastolic failure of mixed origin is seen in diseased states such as what?
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dilated cardiomyopathy (poor systolic function with dilated LV walls that are unable to relax.
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Regardless of the type of ventricular failure, the patient with any type will have what 3 symptoms?
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- Low arterial BP
- Low CO - poor renal perfusion |
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What are the 4 main compensatory mechanisms that are seen in HF as an attempt to maintain adequate CO?
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1. SNS activation
2. neurohormonal responses 3. ventricular dilation 4. ventricular hypertrophy |
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What is often the 1st compensatory mechanism triggered in low CO states?
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SNS activation
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What compensatory mechanism for low CO states is the least effective?
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SNS activation
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How does the SNS respond to low CO? What reaction does this have on the body?
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- release of catecholamines, which increases HR, increases myocardial contractility, and peripherally vasoconstricts
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Although the SNS compensatory mechanisms initially improve CO, over time what happens?
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- they become detrimental by increasing the need for O2 and over-work the already failing heart. The peripheral vasoconstriction may increase CO, but it is sending additional volume to an already stressed heart.
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As CO falls, blood flow to the kidneys decrease. How do the kidneys respond?
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by activating the RAAS
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What does Angiotensin II do? (2)
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- triggers the release of aldosterone (sodium and water retention)
- vasoconstricts peripherally |
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Low CO causes a decrease in cerebral perfusion pressure. What compensatory mechanisms reacts when this occurs?
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posterior pituitary releases ADH (retains water in the kidneys)
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Overall, the RAAS activation and ADH activation have what effect on the patient in heart failure?
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blood volume is increased in a person who is already volume overloaded
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What is endothelin? What does it do?
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hormone produced by the endothelial cells; arterial vasoconstriction and increases cardiac contractility and hypertrophy
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What are 2 cytokines released by the heart that cause cardiac hypertrophy, contractile dysfunction, and myocyte cell death?
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- tumor necrosis factor
- interleukin-I |
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The activation of the SNS in conjunction with the neurohormonal response result in what 3 problems r/t HF?
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1. increase in cardiac workload
2. myocardial dysfunction 3. ventricular remodeling |
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(def)
an enlargement of the chambers of the heart that occurs when pressure in the heart chambers is elevated over time |
Dilation
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While dilation initially leads to increased CO and maintainance of arterial BP and perfusion, it becomes inadequate why?
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b/c the elastic elements of the muscle fibers are overstretched and can no longer effectively contract
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(def)
an increase in the muscle mass and cardiac wall thickness in response to overwork and strain |
hypertrophy
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While hypertrophic heart tissue leads to an increase in CO and maintenance of tissue perfusion, it has what 4 specific problems?
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1. poor contractility
2. requires more O2 3. poor coronary artery circulation 4. prone to dysrhythmias |
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What are 3 counterregulatory mechanisms that try to balance the effects of regulatory actions (such as sympathetic or neurohormonal response)?
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- ANP
- BNP - Nitric oxide |
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What are the benefits of natriuretic peptides? (3)
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- promote venous and arterial vasodilation
- endothelin and aldosterone antagonists - block RAAS |
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How does Nitric oxide work?
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relaxes arterial smooth muscle (vasodilation/decreased afterload)
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When does cardiac compensation occur?
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when compensatory mechnisms succeed in maintaining adequate CO
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When does cardiac decompensation occur?
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when compensatory mechanisms can no longer maintain adequate CO and inadequate tissue perfusion results
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While HF is usually manifested by biventricular failure, one side is more common than the other. Which side is it?
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Left-side
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In left sided HF, the blood backs up where? What problems does this cause?
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backs up into the left atrium and into the pulmonary veins; leads to pulmonary congestion and edema
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In right sided HF, blood backs up where? What problems does this cause?
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backs up into the right atrium and venous circulation; results in jugular venous distention, hepatomegaly, splenomegaly, vascular congestion of the GI, and peripheral edema
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Regardless of etiology, acute decompensated heart failure typically manifests as what?
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pulmonary edema
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the most common cause of pulmonary edema is what?
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Acute left ventricular failure secondary to CAD
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The early stage of acute decompensated heart failure typically manifests how?
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mild increase in respiratory rate and a decrease in PaO2
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If pulmonary venous pressure continues to increase in ADHF, the increase causes more fluid to move into the interstitial space than the lymphatics can drain. This results in what?
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Interstitial Edema
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As pulmonary edema increases and interstitial edema occurs, what happens to the patient's symptoms?
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they become tachypnic
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What happens to ABGs in pulmonary edema?
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PaCo2 is increased and PaO2 is decreased, resulting in respiratory acidosis
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What are the clinical manifestations of pulmonary edema?
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- anxiety
- pale (possibly cyanotic) - cold, clammy skin - severe dypsnea and tachypnea/orthopnea - possible wheezing, coughing - frothy, blood-tinged sputum - crackles, wheezes, rhonchi - rapid HR |
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What is one of the earliest symptoms of chronic HF?
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fatigue
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Why is dyspnea seen in chronic HF?
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b/c of increased pulmonary pressure secondary to interstitial/alveolar edema
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What is paroxysmal nocturnal dyspnea?
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difficulty breathing when asleep due to the reabsorption of fluid from dependent body areas when the patient is recumbent
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True/False:
A dry, hacking cough may be the first clinical symptom of HF. |
True, because there are increased pulmonary pressures
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Is tachycardia an early or late sign of HF?
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early, it is one of the body's first mechanisms to compensate for a failing ventricle
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True/False:
Edema is a rare sign of HF. |
False- Edema is a common sign, and may occur in dependent areas, liver (hepatomegaly), lungs, or abdomen
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For a patient with HF, the development of dependent edema or a sudden weight gain of more than 3 lb in 2 days is often indicative of what?
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exacerbated HF
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Why is nocturia seen in HF patients?
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although HF patients have impaired renal perfusion and decreased output, when they lie down at night the fluid moves back into circulation
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Because tissue oxygen extraction is increased in people with chronic HF, their skin may appear what color? What other changes may occur in the skin?
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color may be dusky
- skin may be cool and damp, lower extremities are shiny and swollen with diminished hair growth, and chronic swelling may result in pigment changes (appear brown/brawny in areas covering the ankles and lower legs) |
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Why are behavioral changes sometimes seen in HF?
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b/c of decreased cerebral perfusion; this may cause unusual behavior, such as restlessness, confusion, and decreased attention span or memory
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Does chest pain ever accompany HF?
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yes, decreased coronary perfusion r/t poor cardiac output can cause angina-type pain
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For many HF patient's, a weight gain indicates what?
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fluid retention/edematous condition
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In heart failure, pleural effusion results from what?
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increasing pressure in the pleural capilaries
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Why are dysrhythmias often seen in HF?
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HF causes enlargement of the heart which leads to an alteration in the normal electrical pathway
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Atrial fibrillations can promote the development of what?
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thrombus formation within the atria
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Patients with atrial fibrillations are often treated with what methods?
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cardioversion, antidysrhythmics and/or anticoagulants
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Patient's with HF and EF less than 35% have a high risk of what? (2)
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-severe hepatomegaly
-fatal dysrhythmias |
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What happens to the liver if hepatomegaly occurs?
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liver cells dies, fibrosis occurs, and cirrhosis can develop
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What are the 5 goals of therapy for both ADHF and chronic HF?
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1. decrease symptoms
2. reverse ventricular remodeling 3. improve quality of life 4. decrease mortality/mobidity 5. improve LV functioning |
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What is the purpose of using diuretics in HF?
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to decrease intravascular volume
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Are diuretics ever prescribed alone in HF?
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Not usually, alone they can trigger compensatory mechanisms in the body; normally they are started after vasodilator therapy
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What is ultrafiltration?
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an alternative to diuretics, this is a filtration method achieved through hemodialysis (but without hemodynamic instability)
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What are ways to decrease preload?
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- place patient in high fowlers
- IV nitroglycerin |
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What assessment should be made when titrating IV nitroglycerin?
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BP every 5-10 minutes
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What is IV sodium nitroprusside (Nipride), and what is it used for.
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a potent vasodilator (that reduces preload and afterload)
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IV sodium nitroprusside (Nipride) is the drug of choice for what?
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patient with ADHF and pulmonary edema
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What are 2 problems seen with IV sodium nitroprusside (Nipride)?
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- hypotension
- thiocyanate toxicity |
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What assessment should be made prior to the administration and during the administration of IV sodium nitroprusside (Nitrate)?
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BP before, and BP every 5-10 minutes during
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What are some of the benefits is using morphine sulfate in the treatment of ADHF and pulmonary edema?
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- decreases preload/afterload
- dilates both pulmonary and systemic blood vessels ** - reduces anxiety - may assist in reducing dyspnea |
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What are 4 methods of improving gas exchange and oxygenation in HF patients?
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- IV morphine sulfate (decreases O2 demands)
- O2 administration - noninvasive ventilator support (BiPAP) - intubation/mechanical ventilation |
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When the use of diuretics, morphine, and vadodilators are not enough and the person becomes hemodynamically unstable, the use of what drug class therapy may be warranted?
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positive inotropic agent (specifically, Digitalis)
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What is the purpose of a pulmonary artery catheter in HF?
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- to measure CO, pulmonary artery pressure, and pulmonary artery wedge pressure
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Digitalis improves ____ ________ functioning.
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left ventricular
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Why is digitalis not recommended for the initial treatment of ADHF?
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- narrow therapeutic index
- requires a loading dose and time to achieve improvement |
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Beta adrenergic agonists are typically reserved for what?
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short term use in severe ADHF and cardiogenic shock
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If administering Dopamine, what should you be alert to?
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- extravasation with tissue sloughing may occur with IV administration
- monitor IV site for signs of necrosis - High dosages may cause dysrhythmias |
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Inocor and Primacor, 2 phosphodiesterase inhibitors, have what effect in HF?
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- increase Myocardial contractility
- promote peripheral vasoconstrictor |
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When administering morphine, you should monitor what?
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respiratory rate - although morphine-induced respiratory depression is rare
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What is biventricular pacing? Why is it used in HF?
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the use of pacemakers to pace one or two chambers of the heart; this increases left ventricular performance and CO
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What is cardiac resynchronization therapy?
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coordinating the right and left ventricle through biventricular pacing
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Cardiac transplantation if one form of treatment for ADHF, however it is likely an option for only a small number of patients. For those who are waiting, what are some methods used to sustain their heart while they wait?
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- intraaortic balloon pump (very limiting to patient)
- ventricular assist devices (effective long-term care for up to 2 years) |
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What are the 3 goals of diuretic therapy in the treatment of HF?
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- mobilized edamatous fluid
- reduce pulmonary venous pressure - reduce preload |
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What are some benefits of Thiazide diuretics?
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- convient
- safe - low cost - effective |
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Thiazide diuretics are particularly useful in treating what?
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- edema secondary to HF
- controlling HTN |
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What are the 3 goals of diuretic therapy in the treatment of HF?
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- mobilized edamatous fluid
- reduce pulmonary venous pressure - reduce preload |
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What must the nurse be aware of when administering Loop diuretics (lasix, bumex)? (3)
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- they are potassium wasting
- can be ototoxic - sulfa-allergies |
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What is aldactone?
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a potassium-sparing diuretic
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Aldactone appears to add to the benefits of what other drug class?
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ACE inhibitors
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What should you be alert to when administering aldactone?
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- assess for hyperkalemia
- use cautiously in patients taking digoxin (hyperkalemia reduces digoxin therapy) - instruct patients to avoid foods high in potassium |
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What are the 5 goals of vasodilator therapy in the treatment of HF?
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- increase venous capacity
- improve EF - slowing the process of ventricular dysfunction - decreasing heart size - avoiding stimulation of negative compensatory mechanisms |
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Captopril, enalapril, and benazepril are all examples of what drug class?
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ACE Inhibitors
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What drug class is used as a first-line drug in the treatment of chronic HF?
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ACE Inhibitors
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What action does ACE inhibitors have on the body?
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- BP decreases
- increased tissue perfusion - increased CO due to less resistance - diuresis due to the suppression of aldosterone |
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What are 4 major side effects of ACE inhibitors?
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- symptomatic hypotension
- intractable cough - hyperkalemia - angioedema (edema in face/airways) |
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What should be monitored regularly when a patient is on an ACE inhibitor?
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BP and renal function
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In high doses, ACE inhibitors can cause what major problem?
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renal insufficiency
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What is the major hemodynamic effect of nitrates?
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decrease preload
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Nitrates are particularly beneficial as treatment of MI why?
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b/c they vasodilate the coronary arteries
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Why aren't nitrates often used in HF?
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nitrate tolerance can develop
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What are 2 major side effects of nitrates?
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- headaches
- erectile dysfunction |
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Nitrates and Viagra are contraindicated. Why?
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profound hypotension could occur
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Carvedilol and metoproplol are examples of what drug class?
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B-adrenergic blocker
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How do B-adrenergic blockers work?
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- directly block the negative effects of the SNS
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Are B-adrenergic blockers prescribed alone for HF?
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No, they are recommended with use in combination with other therapies (ACE inhibitors, digitalis, etc.)
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What are the major side effects of B-adrenergic blockers?
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- edema
- worsening of HF - hypotension - fatigue - bradycardia |
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What specific information should the nurse know about carvedilol? (3)
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- overdose can lead to profound bradycardia, hypotension, bronchospasm, and cardiogenic shock
- assess BP and pulse before administering abrupt w/d may lead to sweating, palpitations, and headache |
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What benefit does digoxin, a digitalis glycoside, have on HF?
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- increases the force of cardiac contraction
- decreases conduction speed to slow the HR |
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What are early symptoms of digitalis toxicity?
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anorexia, nausea, vomiting, and yellow vision
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Are dysrhythmias an early or late indicator of digitalis toxicity?
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late
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What is one of the most common causes of digitalis toxicity?
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hypokalemia
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Both hypo- and hyperkalemia precipitate the development of what?
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dysrhythmias
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A person taking digoxin who has liver and kidney disease is more prone to what? why?
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- more prone to dig toxicity b/c the preparations are metabolized by these organs
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What is the usual treatment for dig toxicity?
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withholding the drug until the symptoms subside
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What is given in the case of life-threatening dig toxicity?
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Digoxin immune Fab (ovine) (Digibind)
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B-adrenergic agonists are typically used in __________ (short-term/long-term) treatment of HF?
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short term
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Patients who are unable to tolerate ACE inhibitors are prescribed what?
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ARBs
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Losartan and Valsartan are examples of what drug class?
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ARBs
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True/False:
Although the mechanism of action between ACE inhibitors and ARBs are different, the outcome is essentially the same. |
True
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Do ARBs or ACE inhibitors have fewer side effects?
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ARBs
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What is BiDil?
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a combination drug containing isosorbide dinitrate and dydralazine; it is only approved for use in AA; mechanism of action is unknown
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Nutritionally, how is the edema of chronic HF treated?
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Dietary restriction of sodium
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What diet is effective as a first-line therapy for many individuals with isolated hypertension, and is now commonly used in HF patients with or w/o hypertension?
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DASH diet
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What is the recommended sodium intake for a person with mild HF?
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2.5 g
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For severe HF, sodium intake may be limited to what?
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500-1000 mg
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What type of foods are high in sodium? (5)
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- milk
- cheese - bread - cereals - canned goods |
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When are fluid restrictions usually implemented for HF patients?
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Moderate to severe HF and renal insufficiency
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What is the best way for a patient to monitor fluid retention?
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daily weights
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If a patient experiences a weight gain of ___ lbs over 2 days or a ___to ____ gain over a week, the primary care provider should be called.
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3 lbs over 2 days
3-5 lbs over a week |
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For a person with valvular disease, what should be done before HF develops?
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valve replacement
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For a person with CAD, what should be done before HF develops?
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Coronary revascularization procedures
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Hyperlipidemic states in persons with CAD should be managed with what 3 things?
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diet, exercise, and medication
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HF is a chronic illness for most. As a nurse, what are 3 things you should do to enhance the patient's knowledge and emotional state?
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1. teach the patient about the changes that have occurred
2. assist the patient to adapt to both physiologic and psychologic changes 3. intergrating family or support system in entire plan |
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True/False:
Patients with HF are usually required to take medication for the rest of their life. |
True
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What important information should you teach a patient who is on a drug like digitalis or B-adrenergic blockers?
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teach them to take pulse rate and w/h and contact PCP if pulse is under 50
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