1. Timby/Smith: Introductory Medical-Surgical Nursing, 11/e
Chapter 28: Caring for Clients With Heart Failure

2. The Heart Cardiac Function
The heart is a double pump: right side pumps deoxygenated blood to the lungs for oxygenation, and the left side pumps oxygen-rich blood into the systemic circulation.
This process provides a continuous supply of oxygen and nutrients; cellular metabolism and mechanism to eliminate carbon dioxide (CO2)
Disturbances in one part of the heart, if severe or prolonged, eventually affect entire circulation.

3. Heart Failure
Heart failure: inability of the heart to pump sufficient blood to meet the body’s metabolic needs
Ejection fraction: estimate of the heart’s efficiency
Normal: ejects 55% or more of the blood that fills the left ventricle during diastole
Congestive heart failure (CHF): accumulation of blood and fluid in organs and tissues from impaired circulation

4. Heart Failure—(cont.) Types
Acute heart failure: sudden change in heart’s ability to contract; causes life-threatening symptoms and pulmonary edema
Chronic heart failure: heart’s ability to pump effectively is gradually compromised; impaired contractility remains prolonged
American Heart Association
Four stages: Stage A: no current symptoms but more risk factors (hypertension, diabetes); Stage D: advanced structural heart disease and marked symptoms at rest despite maximal medical therapy

5. Chronic Heart Failure
Class I (mild): ordinary physical activity does not cause fatigue, palpitations, or dyspnea; no limit of activity
Class II (mild): comfortable at rest; ordinary physical activity results in fatigue, heart palpitations, or dyspnea
Class III (moderate): marked limitation of physical activity; comfortable at rest; less than ordinary activity causes fatigue, heart palpitations
Class IV (severe): client is unable to carry out any physical activity without discomfort; symptoms of cardiac insufficiency occur at rest; discomfort is increased if any physical activity is undertaken

6. Heart Failure—(cont.)
Pathophysiology and Etiology: inability of the heart muscle to contract because of direct damage to the muscular wall
Left-sided heart failure
Causes: myocardial infarction (MI), cardiomyopathy, and hypertension
Right-sided heart failure
Causes: left-sided heart failure, chronic obstructive pulmonary disease (COPD)

7. Heart Failure—(cont.) Left-Sided Heart Failure
When left ventricle fails the heart, muscle cannot contract forcefully enough to expel blood into the systemic circulation.
Complications
Pulmonary vascular bed; fluid accumulates and creates congestion
Gas exchange is impaired, cells become hypoxic, CO2 accumulates in the blood
Hypertension, tachydysrhythmias, valvular disease, cardiomyopathy, renal failure; heart failure

8. Heart Failure—(cont.) Left-Sided Heart Failure—(cont.) Pathophysiology
Afterload: force that the ventricle must overcome to empty its diastolic volume; increases with arterial hypertension, aortic stenosis, pulmonary hypertension, or excessive blood volume from renal failure
Reduced ventricular ejection volume
Loss of elasticity in the muscle as a result of cardiomyopathy

9. Heart Failure—(cont.)
Right-sided heart failure: the right ventricle cannot forcefully contract and push the blood into the pulmonary artery
Complications
Congestion of blood and backflow accumulate first in the right ventricle, then in the right atrium, superior and inferior vena cavae, venous vasculature
Chronic respiratory disorders
Example: cor pulmonale, condition in which the heart (cor) is affected secondarily by lung damage (pulmonale)

10. Heart Failure—(cont.) Compensatory Mechanisms
Reduced cardiac output: hypotensive; low BP stimulates the sympathetic nervous system to release catecholamines to raise heart rate and BP
Increased force and contraction of heart maintains BP but increases myocardial oxygen demand.
Epinephrine causes blood vessels to constrict; body shunts more blood to vital organs of the brain and heart, decreasing supply to kidneys.
Ventricles secrete neurohormone β-type natriuretic peptide (BNP).

11. Heart Failure—(cont.) Assessment Findings
Left-sided heart failure: hypoxemia, unusual fatigue with activity, exertional dyspnea (first symptom), orthopnea, paroxysmal nocturnal dyspnea (sleep with several pillows in bed or in a chair), pulse rapid or irregular, BP elevated, cough, hemoptysis, moist crackles, urine output diminished
Acute left-sided heart failure: pulmonary edema; hypoxia, restlessness, confusion

12. Heart Failure—(cont.) Assessment Findings—(cont.)
Right-sided heart failure: gradual unexplained weight, dependent pitting edema, ascites, hepatomegaly, jugular vein distention
Enlarged abdominal organs: dyspnea
Fluid retention: rings, shoes, or clothing become tight
Accumulation of blood in abdominal organs: anorexia, nausea, and flatulence

13. Heart Failure—(cont.) Diagnostic Findings Left-sided heart failure
Chest radiography: cardiac enlargement and fluid accumulation in the lungs
Echocardiogram: size of left ventricle and ineffective pumping of heart
Multiple gated acquisition (MUGA) scan: measures a decrease in the ejection fraction
Arterial blood gas (ABG) analysis, serum sodium, blood urea nitrogen
Pulmonary artery catheter

14. Question
An elderly client has had a myocardial infarction of the right side of the heart. Which of the following signs should the nurse anticipate when assessing for heart failure? A) Nausea B) Heart murmur C) Crackles in lungs D) Edema in feet and legs

15. Answer
D) Edema in feet and legs Rationale: With right-sided heart failure, blood backs up in the systemic circulation, causing swelling of the lower extremities.

16. Heart Failure—(cont.) Diagnostic Findings—(cont.)
Right-sided heart failure
Chest radiograph
Electrocardiogram (ECG)
Echocardiography: right ventricular enlargement
Lung scan and pulmonary arteriography: cor- pulmonale
Liver enzymes

17. Heart Failure—(cont.)
Medical Management: reduce the heart’s workload, improve cardiac output
Interventions
Dietary modifications, low-sodium diet, fluid restriction, lifestyle changes; exercise, weight loss, cholesterol levels
Drug therapy
Digitalization
Acute heart failure or pulmonary edema: potent inotropic agent: dopamine (Intropin), dobutamine (Dobutrex)
Diuretic therapy: furosemide (Lasix)
Vasodilators, ACE inhibitor: captopril (Capoten), ramipril (Altace)

18. Heart Failure—(cont.) Medical Management—(cont.)
Cardiac resynchronization therapy (CRT): restores synchrony in contractions of the right and left ventricles
Used primarily for clients whose heart failure is caused by dilated cardiomyopathy
Intra-aortic balloon pump (IABP)
Temporary, secondary mechanical circulatory pump to supplement the ineffectual contraction of the left ventricle

19. Question
Which of the following client teaching points should be included in the discharge planning of a client who has a heart failure? Choose all that apply. A) Weigh yourself daily. B) Take your blood pressure before taking digoxin. C) Increase your carbohydrate intake. D) Take your diuretic early in the morning.

20. Answer
A) Weigh yourself daily. D) Take your diuretic early in the morning. Rationale: The client can assess any fluid retention by weighing daily. The client should also take the diuretic in the morning to decrease the chance of nocturia.

21. Heart Failure—(cont.) Surgical Treatment
Ventricular assist device (VAD)
Auxiliary heart pump that supplements the heart’s ability to eject blood; destination therapy, which is a mechanical circulatory support when there is no option for a heart transplant
Cardiomyoplasty (lastissimus dorsi) is grafted to the aorta and wrapped around the heart.
Electrical stimulator placed in subcutaneous pouch triggers skeletal muscle contraction.

22. Heart Failure—(cont.) Surgical Treatment—(cont.)
Surgical ventricular restoration (SVR)
Decreases the size of the heart to a near normal size and shape by removing dysfunctional heart muscle that does not contract properly
Total artificial heart (TAH): electrically powered pump that circulates blood into the pulmonary artery and the aorta
Replacing the functions of both right and left ventricles

23. Heart Failure—(cont.) Nursing Management
Medication teaching, lifestyle changes, diet restrictions
Hospital setting
Administer medications; monitor for therapeutic and adverse effects
Monitor for signs of excess fluid volume, evidence of electrolyte imbalance
Promote oxygenation, balance activity with rest
Support family members

24. Question
A client may be at risk for impaired gas exchange related to pulmonary congestion secondary to left ventricular dysfunction. A nursing intervention to assist client with maintaining adequate gas exchange includes all of the following, except: A) Maintaining client in a high-Fowler’s position B) Administering supplemental oxygen C) Limiting physical activity D) Providing foods and beverages that are a good source of potassium

25. Answer
D) Providing foods and beverages that are a good source of potassium Rationale: Dietary intake of foods and beverages that are rich in potassium affect serum potassium levels secondary to diuretic therapy and is not related to maintaining adequate gas exchange.

26. Cardiogenic Pulmonary Edema
Pathophysiology and Etiology: left ventricle incapable of maintaining sufficient blood output
Assessment Findings
Sudden dyspnea, wheezing, orthopnea, restlessness, cough (productive of pink, frothy sputum), cyanosis, tachycardia, severe apprehension, respirations sound moist or gurgling, hypotensive, peripheral pulses disappear
Diagnostic Findings
Chest radiographs; pulmonary infiltration; ABGs indicate hypoxemia, hypercapnia, and a pH below 7.35

27. Cardiogenic Pulmonary Edema—(cont.)
Medical Management
Supplemental oxygen or mechanical ventilation
Drug therapy: dopamine (Intropin), dobutamine (Dobutrex), digitalis, diuretics, nitrates, ACE inhibitors, calcium channel blockers, morphine
IABP, biventricular pacemaker, LVAD, cardiomyoplasty, artificial heart
Nursing Management: establishes an IV line immediately for medication administration, bedside ECG monitoring, pulse oximetry, automatic BP and pulse measurements, urinary catheter used to measure output, oxygenation, frequent mouth care