1. Heart Failure
Karen Ruffin RN, MSN Ed.

2. Incidence and Prevalence of Heart Failure
Leading cause of death in the US
More than 5 million Americans are living with heart failure, and 550,000 new cases are diagnosed each year.
About 250,000 people a year die from heart disease.
That means more than 680 Americans a day die from it!!!!!!!!
Women have a poorer survival rate then men

3. Basic Needs: Oxygenation
Two body systems that work together to meet this basic need. 3

4. Oxygenation
Oxygen is required to sustain life, primary basic human need
The cardiac & respiratory systems function to supply the body’s oxygen demands
Cardiopulmonary physiology involves delivery of deoxygenated blood to the right side of the heart & to the pulmonary system
When we think about basic needs this is at the top of the list. If you cant find a bathroom you will find a place to go but you will continue to live. If your heart does not work or you are not breathing you are not able to sustain life. 4

5. What are the 3 concepts in oxygenation?
Ventilation
Perfusion
Diffusion

6. What are the 2 mechanisms that drive the function of the heart?
Electrical/conduction
Mechanical/pump

8. What are they???? What is Heart Failure?
Heart cannot pump enough blood to meet the metabolic demands of the body.
Results from changes in the systolic or diastolic function of the ventricles
There are many causes?????
What are they????
Diabetes Mellitus, cigarette smoking, obesity, high serum cholesterol, hypertension, MI,
CAD
Hypertensive HD
Rheumatic Heart Dis
Congenital Heart Dis
Cor pulmonale
Cardiomyopathy
Anemia
Bacterial endocarditis
Valvular disorders
Acute MI
Dysrhythmias
Pulmonary emboli
Thyrotixicosis
Hypertensive crisis
Rupture of papillary muscle
VSD
Myocarditis

9. Types of Heart Failure
Left Sided
Right sided
Systolic
Diastolic

10. Left Sided Heart Failure
Most Common
LV dysfunction causes blood to back up through the left atrium and into the pulmonary system.
Common causes of left heart failure are:
HTN, CAD, mitral and/or aortic valve disease, decreased tissue perfusion.

11. What does that patient look like?????

12. Right Sided Heart Failure
Most common cause is left sided heart failure.
Other causes MI or pulmonary HTN
RV dysfunction causes the blood to back up in the right atrium and then the venous circulation.

13. What does that patient look like?????

14. Systolic Failure Defect in ventricular contraction
Left Ventricle loses ability to generate enough pressure to eject blood forward through the high pressure aorta – Decreased ejection fraction
Afterload – hypertension, cardiomyopathy, and valvular heart disease

15. Diastolic Failure Impaired ability of ventricles to fill
Decreased filling = decreased stroke volume Which + decreased WHAT?
Pulmonary congestion, pulmonary hypertension, with normal ejection fraction

16. Heart Failure

17. Diagnostic Studies Goal: Assess the cause & degree of failure
History and Physical Exam
B-Type Natriuretic Peptide level (BNP).
elevated in acute and chronic heart failure
useful in following the response to treatment of congestive heart failure.
ABGs, Serum chemistries, LFTs
Chest x-ray
EKG
Echocardiogram
Nuclear imaging studies
Cardiac catheterization
Hemodynamic monitoring

18. Lets Compare!!!!

19. Classification of Heart Failure
Class 1 – No limitation of physical activity
Class 2 – Slight limitation – fatigue, dyspnea, palpitations
Class 3 – marked limitation. Comfortable at rest; ordinary activities cause symptoms
Class 4 – Inability to carry out any physical activity without symptoms –
Pain/discomfort at rest

20. Management and Outcome Measures
Use of ß-blockers at discharge and during admission.
Use of aspirin at discharge and during admission.
Timely and appropriate acute reperfusion (thrombolysis or primary angioplasty).
The use of angiotensin-converting enzyme (ACE) inhibitors for patients with depressed left ventricular systolic function. Similarly, a minority of patients with AMI are potential candidates for this care process,

21. Management and Outcome Measures
The proportion of patients eligible for smoking-cessation counseling is relatively small, and ascertainment can be difficult, given the variability in documentation as well as practice.
Diet and exercise counseling
Cholesterol status assessment and management.

22. Congestive Heart Failure Medical Treatment Goals
Decreasing Intravascular Volume
Decreasing Venous Return
Decreases preload – decreases the volume to the left ventricle during diastole
Med: Diuretics – Lasix (furosemide)
Decreasing Afterload
Decrease systemic vascular resistance
CO increases
Pulmonary congestion decreases
Meds: Nitroglycerine (NTG); Morphine; Calcium Channel Blockers

23. Congestive Heart Failure Medical Treatment Goals
Improving Gas Exchange & Oxygenation
Supplemental oxygen
Morphine
Severe cases – intubation / ventilation
Improving Cardiac Function
Increase cardiac contractility without increasing cardiac oxygen consumption
Hemodynamic Monitoring:
pulmonary artery pressure; pulmonary artery wedge pressure (14-18mmg HG)
Inotropic Meds: Digoxin
Inotropic meds used with hemodynamic monitoring:
Dobutamine
Inodilators: (inotropic & vasodilator): Milrinone

24. Congestive Heart Failure Medical Treatment Goals
Reducing Anxiety
Sedative action of IV Morphine
Complication: respiratory depression
Determine & Treat Underlying Cause
Systolic or Diastolic failure
Aggressive drug therapy

25. So what medical complications do you think can occur???????
Pleural effusion
Dysrhythmias
Left ventricular thrombus
Hepatomegaly – impaired liver function
Acute Pulmonary Edema

26. What basic needs are being effected? Why and how?

28. Nursing Care for the Patient with Heart Failure
What will you assess????
What are some potential nursing diagnosis?????
What are your goals for those diagnosis????
What are your interventions?????
How will you evaluate your goals?????
Assess: Assess: Hemodynamic status – VS, PO, CVP, PAP, PAWP, response to medication
cardiac rhythm, LOC, energy level; labs
Nx Dx
Activity intolerance r/t fatigue secondary to cardiac insufficiency
Excess fluid volume r/t cardiac failure
Disturbed sleep pattern r/t nocturnal dyspnea
Impaired gas exchange r/t increased preload and afterload
Anxiety r/t dyspnea / fear of death
Knowledge deficit r/t disease process
Nsg Action: Administer medications, oxygen, supportive treatment, community referral & home preparation
Pt/Family Education: Lifestyle modification, Medication

29. Case Study
A 74-year-old woman is admitted to the hospital with heart failure. She had been growing progressively weaker and has ankle edema, dyspnea on exertion, and three-pillow orthopnea. On admission, she is severely dyspneic and can answer questions only with one-word phrases. She is diaphoretic and has central cyanosis, with a heart rate of 132 beats/min, and blood pressure 98/70. She is extremely anxious.

30. Case Study
1. Because this client cannot breath or talk easily, prioritize the immediate nursing assessments and intervetions upon admission.
2. Considering the process of congestive heart failure, explain the symptoms she is having.
3.Based on assessment, identify nursing diagnoses for this client.
4. What diagnostic studies do you anticipate being ordered and why?

31. Case Study
5. The physician orders the following items for this client. (Start an IV, then give dobutamine 3 mcg/kg/min IV; Furosemide (Lasix) 40 mg IV stat; Digoxin 0.5 mg IV stat, then 0.125mg PO every 6 hours for three doses, with ECG before doses 3 and 4; Morphine 2 mg IV stat and then 2 mg IV every 1 to 2 hours prn; Oxygen to maintain O2 sat >94%; Schedule for an echocardiogram; Low Na, Fat, Cardiac diet; Weigh daily and monitor input and output) Explain the rationale for these medications and treatments. Would you ask for any other ORDERDS and why?