Test #2 Heart Failure

Front 1

Heart Failure?

Back 1

clinical syndrome (not a disease) involving impaired pumping function of ventricles

Front 2

Cardiac output?

Back 2

blood pumped by heart/min
- stroke vol (amt of blood pumped per beat) x heart rate

Front 3

Starling's Rule?

Back 3

- sees the heart muscle as elastic band
- the force of contraction of ventricles is directly proportional to the initial stretch on the L ventricle

Front 4

PND? Paroxyl Nocturnal Dyspnea?

Back 4

At night when lying down, body fluids are redistributed which inc the intrathoracic vol which inc the preload; pt becomes short of breath and pt has to get up to feel better
- 1st indication of L heart failure

Front 5

Orthopnea?

Back 5

breathing difficulty at rest

Front 6

Afterload?

Back 6

aka SVR (Systemic Vascular Resistance)
- resistance against which L ventricle has to pump blood

Front 7

Preload?

Back 7

Blood volume left in L ventricle at end of diastole

Front 8

PCWP?

Back 8

Pulmonary Capillary Wedge Pressure- reflects the LV end-diastole pressure (as long as mitral valve is normal)
- normal is 8-12 dynes
- measured with Swan-Gans catheter (3 ports) - very rarely used due to complications

Front 9

CVP?

Back 9

Central Venous Pressure - measures pressure in R atrium via Vena Cava
- normal is 0-10 dynes

Front 10

LVEDP/LVEDV?

Back 10

- LV end-diastole pressure
- LV end-diastole vol
- these reflect PCWP

Front 11

- HF is most common cause of hospitalization
- more common in men than women
- AA have higher incidence of HF & develop HF at earlier age
- AA experience more ACEI related angioedema
- Asians have extremely high risk for ACEI- related cough
T or F

Back 11

T

Front 12

- HF can have acute or insidious onset
- Sympathetic Nervous System causes inc HR, inc BP, and inc Force of contraction which together causes inc 02 demand on failing heart and becomes viscous cycle which hastens heart failure
T or F

Back 12

T

Front 13

Neurohumoral system (?)
- because dec cardiac output leads to dec renal perfusion, it activates RASS system which leads to vasoconstriction compounded by Na & water retention which increases preload to a failing heart
T or F

Back 13

T

Front 14

So what does heart do to compensate for all this?
- secretes nitro euritic peptides secreted from R atrium and ventricle & often referred to as:
- ANP: Atrial Nitrouric Peptide
- BNP: Brain or Beta Nitrouric Peptide
- whenever atria get stretched, they release ANP
- whenever Ventricles get stretched, release BNP
- ANP & BNP counteract sypathetic NS & RASS effects by inc Na & water excretion
-there is a synthetic BNP given IV to treat HF
- T or F

Back 14

T

Front 15

___ leads to R ventricular failure due to inc pulmonary HTN

Back 15

COPD. How?
- 1st leads to RV hypertrophy, & RV & RA enlargement
- Eventually will lead to RHF called Cor Pulmonale

Front 16

Cor Pulmonale?

Back 16

RHF due to pulmonary causes

Front 17

Multi-valve disease ie mitral regurgitation, aortic stenosis, etc leads to multi-chamber enlargement (could cause large, pear-shaped heart). T or F

Back 17

T

Front 18

3 types of Heart Failure?

Back 18

- L-sided failure - most common HF
- R-sided failure
Bi ventricular failure (both sides)

Front 19

With LHF , see changes in ___

Back 19

pulmonary circ
- blood backs up in pulmonary circ since if LV fails, blood backs up into LA; if LA fails, blood backs up into pulmonary veins which increas hydrostatic pressure and fluid oozes out into alveoli; pt has SOB and rales
- LHF can lead to RHF and BVF (bi-ventricular failure)

Front 20

With RHF, see changes in ____

Back 20

systemic circ on venous side due to venous engorgement

Front 21

HF classified as either caused by ____ dysfunction or by ____ dysfunction

Back 21

- systolic dysfunction (most common cause of HF) ; inability of LV to pump blood
- diastolic dysfunction: no problem w force of contraction, but inability of ventricle to relax and have enough diastolic volume; ejection fraction is normal

Front 22

hallmark of systolic dysfunction?

Back 22

always have dec Ejection Fraction

Front 23

NYHA ?
Has 4 classes of HF. These are most commonly used; more so than the ACC (American College of Cardiology) and the AHA (American Heart Association)

Back 23

NY Heart Assoc
- Class 1: no physical limitations
- Class 2: slight limitation
- Class 3 & 4: pts are candidates for heart transplants or LVAD (LV Assistive Device)
- Stage 4- symptomatic even at rest; can't perform ADLs

Front 24

Earliest sign of chronic LHF?

Back 24

Fatigue

Front 25

Other signs of LHF?

Back 25

- cough, worse at night (paroxyl Nocturnal Dyspnea)
- dizziness due to dec BP and dec cardiac output
- cool skin since not enough blood flowing to keep skin warm
- confusion & restlessness due to hypoxia causing dec cerebral perfusion

Front 26

Assessment findings for LHF?

Back 26

- Tachypnea- inc resp
- Tachycardia- inc HR
- Weak, thready pulse
- low 02 sat
- auscultate S3 & S4 Gallop
- displaced PMI - because of LV hypertrophy - normally PMI is in 5th L intercostal space along mid clav line
- also hear crackles, rales
& wheezes

Front 27

To hear rales, need to auscultate at bases of lungs
- Rales in morning are normal since pt is lying down; make pt cough, if rales disappear, then position-dependent rales
- however, rales due to LHF or PE will not disappear after coughing. T or F

Back 27

T

Front 28

Perform BNP test when pt presents w SOB; 2 systems will cause SOB: resp & cardiac
- BNP test will determine if pt that's SOB have COPD with acute exacerbation of CHF or pneumonia?
- if BNP is elevated, treat with Lasix for CHF
- if BNP is normal, give antibiotic for pneumonia

Back 28

T

Front 29

Pulmonary edema as seen on Xray has _____ appearance.

Back 29

Batwing

Front 30

Flash Pulmonary Edema?

Back 30

happens in elderly pts post-op due to getting too much fluid.

Front 31

RHF never causes ____ .
But LVF can lead to RHF.

Back 31

LHF

Front 32

Many symptoms of RHF are similar except for a few that are very specific;
1) Nausea
2) Swelling/edema in feet
3) Abdominal pain
4) JVD
5) HJR
6) Hepatic Spleno megaly
7) Pleural effusion
8) Ascites & Anasarca

Back 32

1) since all veins are connected to portal system & inferior vena cava; when blood backs up it backs up into gastric veins
2) if sitting; if lying down,then edema of sacrum
3)esp RUQ due to liver getting enlarged which stretches the capsule which has many nerve endings
4) Jugular Vein Distension with bed at 45' angle (JVD normal in flat position)
5) Hepatic Jugular Reflex: press on liver & JVD bumps up because your pushing all blood up into inferior vena cava
7) fluid in lungs due to inc hydrostatic pressure
8) fluid in peritoneal cavity and fluid accumulates in every part of body (severe generalized edema)

Front 33

Starting IV in RHF patients is very easy. Why?

Back 33

Due to inc venous pressure (hydrostatic pressure)

Front 34

Assessing for heart failure:
1) Cardiovascular?
2) Respiratory?
3) Neurological?
4) Gastrointestinal?
5) Renal?

Back 34

In general, does pt look pale, cool skin, may have circum-oral cyanosis; dependent edema of feet or sacrum
1) Tachy, auscultate murmurs, gallops, JVD, displaced PMI
2) tachypnea, if LHF, pt will have crackles or moist rales, wheezing, pink frothy sputum
3) restless, confusion, dec attention span
4) nausea, abd distension, ascites, RUQ pain, enlarged liver & spleen
5) dec urinary output

Front 35

Goal for managing HF?

Back 35

minimize workload on heart

Front 36

Specifics for managing HF?

Back 36

1) Give oxygen
2) strict I & O
3) weigh daily if CHF; any wt gain of 3 lbs/wk, no good
4) fluid restriction- never leave pitcher of water at bedside
5) sodium restricted diet
6) flu & pneumonia vaccine assessment - required with CHF pts since dev pneumonia inc chance of death since heart is already weak

Front 37

Specific diet for CHF?

Back 37

- eliminate all foods high in Na: canned goods, pizza , V8
- substitute potassium chloride for sodium; watch for pts in renal failure, can go into hyperkalemia easily
- try DASH diet ( Dietary Approach to Stop Hypertension)

Front 38

High doses of Lasix can cause ____ which is usually manifested as tinnitus and deafness (sometimes irreversible)

Back 38

autotoxicity

Front 39

Lasix aka _____ is a ____ diuretic

Back 39

Furosemide; loop diuretic

Front 40

3 kinds of diuretics?

Back 40

1) Thiazide diuretics - most common
2) Loop diuretics
3) Potassium-sparing Diuretics

Front 41

For cardiac pts, keep potassium >____ to prevent arrythmias, even though low end of normal range is 3.5

Back 41

4.0 mg/dl

Front 42

ACEI delays progression of HF. T or F

Back 42

T

Front 43

Side effects of ACEI?

Back 43

chronic cough, angioedema, elevated BUN & creatinine levels

Front 44

Using Beta-Blockers for CHF is a dble-edged sword. Why?

Back 44

Because Beta -blockers dec 02 demand on heart at same time as they dec force of contraction (neg inotrope); in pts with heart failure, you're dec force of contraction for a heart that's already failing

Front 45

You should never stop using Beta-blockers abruptly, but should taper off. Why?

Back 45

Biggest problem is hypotension, so taper off rather than stop abruptly

Front 46

Nitrates dec ____ more than ____

Back 46

preload; afterload

Front 47

major side effect of Hydralazine (non-nitrate) is lupus-like syndrome. T or F

Back 47

T

Front 48

Nitroprusside (Nipride) is given IV and decreases both preload and afterload equally.
Should not be used more than 24 hrs, since could lead to cyanide poisoining T or F

Back 48

T

Front 49

How do Beta-Blockers work?

Back 49

- negative inotrope: dec force of contraction and so dec 02 demand on heart

Front 50

How do Beta adrenergic agonists work?

Back 50

Positive inotrope: inc force of contraction; no effect on HR, good for pts w CHF
Ex: Dobutamine

Front 51

How do cardiac glycosides work?

Back 51

positive inotrope: inc force of contraction
negative chronotrope: slows heart rate
very narrow therapeutic index; dose must be adjusted in pts w renal failure since excreted thru kidneys
- most common side effects: loss of appetite, N&V, multiple atrial tachycardia (sign of toxicity)

Front 52

What's LVAD & what is it used for?

Back 52

Left Ventricular Assisted Device
- used for pts on heart transplant lists; helps support failing heart

Front 53

ICD's? Use for?

Back 53

Internal Cardiac Defibrillator; esp for pts with CHF related to arrythmias such as V-tach

Front 54

Nursing mgmt for heart failure pts?

Back 54

- Check daily wt; Maintain strict I & Os
- Watch fluid intake; don't allow family members to bring fluids
- maintain low sodium diet
- monitor electrolytes esp Magnesium & Potassium, since hypomagnesia & hypokalemia can cause arrythmias.
- Monitor for arythmias - A-Fib, V-Tach, PVCs

Front 55

Pt & family teaching for HF?

Back 55

- encourage flu & pneumonia vaccines
- should have return home diet plan; read labels
- do not stop taking meds w/o talking to doc;
- report wt gain of 3 lbs in 1 wk
- Ongoing monitor BP. HR
- Important to continue DVT prophylaxsis for sluggish blood

Front 56

What do written discharge instructions need to include to be considered "Best Practices?"

Back 56

1) activity level
2) diet
3) meds
4) follow up appt
5) wt monitoring
6) symptom mgmt- esp what systems pt and/or family

Front 57

For Best Practices, LV function must be addressed before discharge? T or F

Back 57

T

Front 58

For Best Practices, Pt w known systolic function with EF<40% will be prescribed ACEI or ARBS if not contraindicated. T or F

Back 58

T

Front 59

Pts who are smokers will be given smoking cessation advice/counseling. T or F

Back 59

T

Front 60

Name 4 Nursing Dx for HF?

Back 60

- Activity intolerance r/t HF
- Fluid vol excess r/t
- Impaired gas exchange r/t
- knowledge deficit r/t