1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 20: Heart Failure

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Heart Failure

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Compensatory Mechanisms in Heart Failure See Figure 20-2.

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Severity of Heart Failure Changes in neurological status Respiratory status –Can patient speak in complete sentences? –Presence of dyspnea on exertion and at rest, crackles, Cheyne-Stokes respirations –Orthopnea –Paroxysmal nocturnal dyspnea Chest pain or discomfort

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Laboratory Studies Used in Evaluation of Heart Failure BNP and NT: pro-BNP test - diagnose and grade severity of heart failure Cardiac biomarkers (CK, CK-MB, Troponin) CBC Thyroid function tests Renal profile Liver function tests Lipid panel

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Medications Used in the Treatment of Chronic Heart Failure ACE inhibitors and ACE II blockers –Main drug used in treatment –Start low, go slow –Monitor serum creatinine and potassium –Watch for angioedema; stop drug immediately –Cough is annoying but harmless

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Medications Used in Treatment of Acute Exacerbation of Heart Failure Inodilators: dobutamine, milrinone Monitor for ventricular dysrhythmias and tachycardia Start low, go slow Beta-blockers help prevent tachycardia Dopamine Higher doses increase afterload; monitor BP, urine output Give only in a central line

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Nesiritide is a BNP approved by the FDA for its ability to do which of the following? A. Reduce preload B. Act as a vasodilator C. Control blood pressure D. Increase renal perfusion

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

21. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

22. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

23. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

24. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

25. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Home Care: Heart Failure

26. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.”

27. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.