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Medical 6-MS38-Heart failure


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Heart failure or pump failure is a general term for?
inadequacy of heart to pump blood throughout body
Heart failure causes insufficient perfusion of body tissues with?
vital nutrients and oxygen
What are 3 major types of heart failure?
high-output failure
Most heart failures begin with which side?
left ventricle...and then progresses to both ventricles
What causes left-sided heart (ventricular) failure? (4)
coronary artery disease
aortic valvular disease
mitral valvular disease
What indicates LEFT ventricular failure?
decreased tissue perfusion from poor CARDIAC output and
pulmonary congestion from increased pressure in PULMONARY vessels

(so what's LEFT (CHeF) is a NEGATIVE heart and a POSITIVE pulmonary)
Left-sided heart failure was formerly referred to as?
CHF which can be categorized into acute or chronic and mild to severe
What 2 subtypes can CHF be divided into?
diastolic heart failure
systolic heart failure
What is another term for systolic heart failure?
systolic ventricular dysfunction
Systolic heart failure results when?
the heart is unable to CONTRACT forcefully enough during SYSTOLE to EJECT adequate amounts of blood into circulation
In the case of systolic heart failure, PRELOAD INCREASES with _______ contractility.

DECREASED, and AFTERLOAD INCREASES as a result of _______ peripheral resistance because of hypertension.
What is ejection fraction?
the percentage of blood ejected from the heart during systole
In the case of systolic heart failure, the ejection fraction drops from a normal of 50% to 70% to what percentage?
below 40%
A consequence of decreased ejection fraction is?

tissue perfusion diminishes and blood accumulates where?
Symptoms of systolic dysfunction are?
inadequate tissue perfusion
pulmonary and systemic
Another term for diastolic heart failure is?
diastolic ventricular function
What occurs in diastolic heart failure?

normal...diastolic failure represents about what percentage of all heart failures?

MI....symptoms are similar to systolic dysfunction which are?
left ventricle is unable to relax adequately during diastole...this prevents the ventricle from filling with sufficient blood to ensure an adequate cardiac output; however the ejection fraction may remain?

20% to 40%...and it occurs more frequently in elders and in women following what heart condition?

inadequate tissue perfusion or pulmonary and systemic congestion
Heart failure may be caused by systemic hypertension in what percentage of cases?
What percentage of MI patients develop HF?
one third
Heart failure can be caused by infective?
What kind of stenosis also causes heart failure?

causes presssure or volume overload on the heart
aortic stenosis
pulmonic stenosis
why is this?
What's the best way to enhance contractility?
combination of:
glycosides (digitalis, digoxin)
ACE inhibitors
beta blockers
What should patient be aware of when taking ACE inhibitors?
move slowly to avoid
check potassium levels q3mos
What electrolyte needs to be checked when taking diuretics?
Left-sided heart failure (CHF) may be caused by?
substance abuse
congenital defects
cardiac infections
hyperkinetic conditions
valvular disease involving
mitral and aortic valve
Left-sided heart, ventricular failure, or CHF may be divided into two subtypes?
systolic heart failure
diastolic heart failure
Systolic heart failure and diastolic heart failure are indicated by these 2 DOMINATE causes?
decreased tissue perfusion
from poor cardiac output
pulmonary congestion from
increased pressure in
pulmonary vessels
Pulmonary edeme is evidenced by?
pink frothy sputum
Define afterload?
resistance against which the heart must pump
Define -megaly?
elargement of a specified body part
Define myocardial hypertrophy?
with or without chamber dilation..the final compensatory mechanism...heart walls thicken and become more muscular...however heart muscle is using up oxygen faster than it's being heart muscle is slightly deprived of oxygen...this can ultimately cause a form of heart failure
Define diastolic heart failure (diastolic ventricular function)?
occurs when the left ventricle is unable to relax adequately during diastole...inadequate relaxation or "stiffening" prevents the ventricle from filling with sufficient blood to ensure an adequate cardiac output; however, the ejection fraction may remain near normal
What causes right-sided heart failure?
left ventricular failure
right ventricular MI
pulmonary hypertension
What happens with right-sided heart failure?


systemic venous congestion develops with what type of edema?
right ventricle is unable to EMPTY completely...what happens to the volume and pressure in the systemic veins?

What pulmonary problems can cause RIGHT-SIDED heart failure ONLY?
chronic obstructive pulmonary
cystic fibrosis
acute respiratory distress
syndrome (ARDS)
What happens with high-output failure?

septicemia (fever)
can occur when cardiac output remains normal or above normal...unlike left- and right-sided heart failure, which are typically low-output states...caused by increased metabolic needs or hyperkinetic conditions...what are some of these conditions?
When cardiac output is insufficient to meet the demands of the body, what kicks in?
compensatory mechanisms...strive to increase cardiac output initially, but overall if continued for a length of time, can hav a damaging effect on pump function
What are 4 compensatory mechanisms?
SNS stimulation
Renin-angiotensin system
activation (RAS)
other neurohumoral responses
myocardial hypertrophy
An increase in HR results in an immediate increase in?
cardiac output
An increase in HR is limited in its ability to compensate for ______ cardiac output?
If heart rate becomes too rapid, diastolic filling time is limited and ______ _____ may start to decline?
cardiac output
An increase in HR also significantly _______ oxygen demand by the myocardium
If heart rate is poorly perfused because of arteriosclerosis, heart failure may ______?
Stroke volume is also IMPROVED by?
sympathetic stimulation
Sympathetic stimulation _______ venous return to the heart, which _______ myocardial fibers, causing dilation

What does Starling's Law of the Heart say?

SV and CO...however, after a critical point is reached within cardiac muscle, further volume and stretch will ________ force of contraction and CO
increased myocardial stretch results in more forceful contraction and what does that increase?

Sympathetic stimulation also results in arterial?
Constriction of the arteries has the benefit of maintaining ______ _______
and improving tissue perfusion in low-output states; however constriction of arteries INCREASES _______


as afterload increases, the left vent
blood pressure

afterload...afterload is the major determinant of ________ oxygen requirements

stroke volume
Reduced blood flow to kidneys, a common occurrence in low-output states, results in activation of the?
renin-angiotensin system (RAS)
Vasoconstriction becomes more pronounced in response to ________ ____

sodium and water retention...preload and afterload increase, angiotensin II contributes to?
angiotensin II and aldosterone secretion causes?

ventricular remodeling which results in progressive myocyte contractile dysfunction over time
What is the neurohumoral response?

posterior pituitary gland to secrete vasopressin (ADH or antidiuretic hormone)

the hormone causes vasoconstriction and fluid retention which does what to HF?
Following MI, heart muscle cell injury causes IMMUNE response...BNP released by ventricles, increases to counterbalance RAS, and DECREASES preload...low CO causes DECREASED cerebral perfusion...this activates what part of the brain to secrete what hormone?

worsens it
Long-term NSAID use such as ibuprofen (Motrin) can cause what condition with elders?

arthritic pain and inflammation...what other drugs causes fluid and sodium retention?
fluid and sodium retention...why are the elders taking these drugs?

thiazolidinediones (TZDs)
ex: pioglitazone (Actos)
which is used for diabetes
What are 8 common causes of heart failure?
substance abuse
valvular disease
congenital defects
cardiac infections and
hyperkinetic conditions
What are manifestations of left-sided heart failure with decreased cardiac output?
decreased cardiac output:
oliguria during day
tachycardia, palpitations
weak peripheral pulses
cool extremities
What are manifestations of left-sided heart failure with pulmonary congestion?
hacking cough, worse at night
crackles or wheezes in lungs
frothy, pink-tinged sputum
S3 and S4 summation gallop
Key features of right-sided heart failure with systemic congestion include?
jugular (neck vein)
enlarged liver and spleen
dependent edema (legs and
distended abdomen
swollen hands and fingers
polyuria at night
weight gain
increased blood pressure (from excess volume) or decreased blood pressure (from failure)
Fatigue in left-sided heart failure may be reported as?
a feeling of heaviness in arms and legs...can patient perform leg and arm work simultaneously? Many patients have limited their movement unconsciously.
What kind of chest discomfort might a patient with left-sided heart failure report?
skipped beats
fast heartbeat
In left sided heart failure, as the amount of blood ejected from the left ventricle diminishes, what builds up in pulmonary venous system?

alveoli and pulmonary congestion...this results in COUGHING!!!which is an early manifestation of HF
hydrostatic pressure...this results in fluid-filled?
How does the patient describe the cough that goes with HF?
usually nonproductive
As HF becomes very severe, the patient may begin expectorating frothy, pink-tinged sputum which is a sign of?
pulmonary edema
What breathing condition may develop from rising pulmonary venous pressure and pulmonary congestion?
The patient may describe dyspnea as?
"trouble in catching my
"difficulty in breathing"
Define orthopnea?
dyspnea at rest in recumbent (lying flat) position; indicative of left sided heart failure...patient may be using pillows to prop himself up in chair or bed to help relieve symptoms...ask about the use of pillows
Define paroxysmal nocturnal dyspnea?

left-sided heart failure

what usually relieves this condition?
sudden awakening with a feeling of breathlessness 2 to 5 hours after falling asleep; indicative of?

sitting upright
dangling feet
In right-sided heart failure, what signs occur?
systemic congestion
retained fluid
venous pressure increases
edema develops lower legs
and ascends to thighs
and abdominal wall...
ask clients if shoes fit more tightly or if shoes and socks leave indentations...swollen fingers around rings...weight gain
How much may an adult retain before pitting edema occurs?
4 to 7 L of fluid
GI complaints of nause and anorexia may be a direct consequence of?
liver engorgement resulting from fluid retention
In advanced HF, what may develop from pronounced liver congestion?
increased abdominal girth
Another finding related to fluid retention is ______ at rest.
diuresis...fluid in peripheral tissue is mobilized and excreted, and client describes frequent awakening at night to urinate
Fluid intake increases with HF. Patients with HF may take in how much excessive fluid because of sodium retention?
4000 to 5000 mL
What is oliguria?
scant urine output
How can the nurse detect signs of left-sided heart failure?

premature atrial contractions
premature ventricular
contractions (PVCs)
atrial fibrillation (AF)

#2 monitor patient's
respiratory rate,
#1 take apical pulse for a full
minute...check for an
irregular rhythm...most
common irregularities for
HF are?

20 breaths/min

#3 determine whether the client is oriented to person, place, or time

#4 palpate what?

left side...S3 and S4 gallop may be heard

#5 What sounds might be heard on auscultation of lungs?
What are crackles produced by?

dependent areas of lungs...crackles usually develop in the _______
intra-alveolar fluid and are often first noted where?

bases and spread UPWARD as condition worsens...
What do wheezes indicate?
a narrowing of the bronchial lumen caused by engorged pulmonary vessels
To assess for right-sided heart failure?
assess neck veins for
measure abdominal girth?
hepatojugular reflux?
abdominal fluid (can reach
volumes of more than 10L)?
What psychosocial problem is common with HF?
anxiety (dyspnea increases it)
What imbalance may occur from complications of HF or as side effects of drug therapy, esp diuretic therapy?
Which serum electrolytes should be regularly monitored with HF?
With HF, any impairment of renal function resulting from inadequate perfusion causes a change in which studies?
BUN increases
serum creatinine increases
creatinine clearance levels
urinalysis may reveal
proteinuria and high
specific gravity
H&H should be performed to
identify HF resulting from
If the client has fluid
volume excess, the
hematocrit levels may
appear low as a result of
increased BNP
ABGs reveal hypoxia
What do ABGs reveal?

oxygen does not diffuse easily through fluid-filled alveoli...
hypoxia or low oxygen level...why is this?
In HF, respiratory alkalosis may occur because of?
In HF, respiratory acidosis may occur because of?
carbon dioxide retention
In HF, metabolic acidosis may occur because of?
an accumulation of lactic acid
Heart failure may be caused or aggravated by hypothyroidism or hyperthyroidism in which age group? (page 755, box)
elderly (lecture says hyperthyroidism only)
What is looked for on CXR when diagnosing left ventricular failure?
enlarged heart (cardiomegaly), representing hypertrophy or dilation

pleural effusions (possibly due to biventricular failure)
An ECG is helpful in determining presence or extent of HF, true or false?
If not HF, what does ECG reveal?
ventricular hypertrophy
any degree of myocardial
ischemia, injury,
A priority nursing diagnosis for HF is?

Impaired Gas Exchange related to?
ventilation perfusion imbalance

(assist with ventilation in the way of high or semi Fowlers position, deep breathing exercises, pulse oximetry)
A priority nursing diagnosis for HF is?

Decreased Cardiac Output related to?
altered contractility, preload, and afterload
A priority nursing diagnosis for HF is?

Activity intolerance related to?
an imbalance between oxygen supply and demand
The primary collaborative problem is Potential for?
Pulmonary Edema
Planning for Impaired Gas Exchange?

pulmonary artery pressure
respiratory function
respiratory rate
ABGs and pH
oxygen saturation
Client with HF is expected to have adquate pulmonary tissue perfusion...what are 5 indicators of this?
A nursing diagnosis of Impaired Gas Exchange requires ventilation assistance. How is this accomplished?
monitor respiratory rate,
rhythm and quality every
1 to 4 hours and auscultate
breath sounds...
titrate amount of
supplemental oxygen
delivered to client to
maintain oxygen saturation
at 92% or greater
How should patient be positioned if experiencing respiratory difficulty?

every 2 hours...deep breathing exercises every 2 hours can help improve oxygenation and prevent what condition?
high Fowlers position with pillows under each arm to maximize chest expansion and improve oxygenation...reposition the pillows how often?

What are VENTILATION ASSISTANCE intervention activities for clients with heart failure?
monitor respiratory and
oxygenation status
initiate and maintain
supplemental oxygen, as
position to alleviate dyspnea
auscultate breath sounds,
noting areas of decreased
or absent ventilation and
presence of adventitious
position to minimize
respiratory efforts
ex: elevate head of bed
and provide overbed
table for patient to
lean on
monitor effects of position
change on oxygenation
What are HEMODYNAMIC REGULATION intervention activities for clients with heart failure?
monitor and document heart
rate, rhythm, pulses
monitor peripheral pulses,
capillary refill, and
temp and color of
monitor pulmonary capillary/
pulmonary artery wedge
pressure and central venous
/right atrial pressure, if
administer vasodilator and/or
vasoconstrictor medication
as appropriate
administer positive inotropic
/contractility meds
maintain fluid balance by
administering IV fluids or
diuretics, as appropriate
monitor intake/output, urine
output, and client weight,
as appropriate
monitor electrolyte levels
auscultate heart sounds
What is the purpose of hemodynamic regulation?
optimize heart rate
<preload (reduce)
<afterload (reduce)
What are ENERGY MANAGEMENT intervention activities for client with heart failure?
monitor cardiorespiratory
response to activity
ex: tachycardia
other dysrhythmias
hemodynamic pressures
respiratory rate
determine client's physical
encourage alternate rest and
activity periods
arrange physical activities
to reduce competition for
oxygen supply to vital body
ex: avoid activity
immediately after
encourage physical activity
ex: ambulation or
performance of
activities of daily
living, consistent
with client's energy
monitor client's oxygen
ex: pulse rate
cardiac rhythm
respiratory rate
teach client and significant
other techniques of self-
care that will minimize
oxygen consumption
ex: self-monitoring and
pacing techniques for
performance of
activities of daily
What is the purpose of energy management?
regulate energy used to treat or prevent fatigue and optimize function
Different methods of heart failure assessments include?
pulmonary artery catheters
Explain pulmonary artery catheter assessment?

normal or elevated right atrial pressure....elevated pulmonary artery pressure and elevated pulmonary artery wedge pressure...and this is because?
allows for assessment of cardiac function and volume status in ACUTELY ill patients...what are the results if it's LEFT ventricular failure?

volumes and pressures are increased in left ventricle
Indicators for nursing diagnosis of Decreased Cardiac Output include? (5)
systolic and diastolic blood pressure
apical pulse rate
ejection fraction
peripheral pulses
skin color
urine output
cognitive status
Commonly used drug classifications for clients with heart failure?
enzyme (ACE) inhibitors
(a drug that reduces
Postassium sparing

<Human B-type natriuretic


Beta-adrenergic agonists
Phosphodiesterase inhibitor
Calcium sensitizers

Beta-adrenergic blockers
Nursing interventions for nursing diagnosis of Decreased Cardiac Output include?
try to optimize:
cardiac output
stroke volume (preload,
afterload, contractility) heart rate
What is stroke volume determined by?
determined by:
Nonsurgical management for nursing diagnosis of Decreased Cardiac Output relies mainly on?
variety of meds..if unsuccessful, then proceed to other nonsurgical methods
Hemodynamic regulation of nursing diagnosis of Decreased Cardiac Output includes?
improve stroke volume by
reducing afterload
reducing preload
improving cardiac
How do drugs that reduce AFTERLOAD affect system?
relaxes arterioles which reduces resistance to left ventricular ejection (afterload) and improves CO...these drugs don't cause EXCESSIVE vasodilation but reverse some of the inappropriate or excessive VASOCONSTRICTION common in heart failure
A trial of ACE inhibitors (arterial vasodilators)should be given to patients with even MILD?
heart failure
What do ACE inhibitors do to arteries?
Examples of ACE inhibitors (arterial vasodilators)?
enalapril (Vasotec)
fosinopril (Monopril)
captopril (Capoten)
<What kind of diet is recommended for heart failure to reduce preload?

low sodium
reduced or no salt diet

check with doctor about using salt substitute because some of them have a lot of?>
<About 25% of heart failure admissions are due to excessive?
sodium intake
<What do some salt substitutes have in them that may adversely affect a heart failure recommended diet?
<When are diuretics used with heart failure patients?

they reduce blood volume and decrease preload>
<when diet and fluid restrictions are not effective>
and what do diuretics do?
<What kind of diuretics are there for HF patients?
<loop diuretics
ex: Lasix...effective
at reducing fluid
volume, esp in
acute heart failure..
<Because Lasix is such a potent diuretic, what adverse effect can it have on a HF patient who's primary goal with diuretics is to lose fluid?
<How do thiazide diuretics
treat HF patients?
reduces fluid volume...are self-limiting which means when edema goes away, thiazides quit there is much less chance of dehydration, unlike with loop diuretics (Lasix)

an example of a thiazide? Hydrodiuril>
<As heart failure progresses, they can possibly develop a diuretic resistance and this can be treated by?
giving a combination of a loop and thiazide diuretic>
<What needs to be monitored when a patient is on a diuretic?
<monitor heart rate for dysrhythmias>
<Aldactone is a _______-______ diuretic that can be used to decrease fluid volume in HF patients.
<So when administering diuretics, what are some lab tests that need to be run?
<Drugs that enhance the contractility of the heart?

change in mental status
(so monitor apical heart rate and watch electrolytes)
<digitalis (...but toxicity is a problem...strengthens the heart muscle and it slows the contractions down too...some of the toxicity signs are?
<Coreg and Lopressor are beta blockers that?
<lower blood pressure...beta blockers are reserved for later use after the ACE inhibitors and diuretics have been stabilized for 2 weeks and THEN start beta adrenergic blockers...monitor them for hypotension and bradycardia
<Other nonsurgical options is the CPAP which is the continuous positive airway pressure...what is this?
<mechanically keeps airway open...helps decrease preload and afterload...decreases blood pressure and relieves dysrhythmias
<What is cardiac resynchronization therapy?
<Gene therapy as a nonsurgical option for HF?
trying it on patients that have end-stage heart failure and people that are not a candidate for heart transplant which is ultimate therapy if other measures don't work...replaces damaged genes with normal genes by a series of injection of growth facter into left's under research as of now>
<What are interventions for activity intolerance?
<avoid stress
sit up esp. for meals
monitor vital signs, O2 sat, electrolytes...
monitor dyspnea to find out how tired patient is actually getting when performing activities...are they having chest pain with activity?
watch diet
if there's a raise of 20 in systolic blood pressure or in the pulse, this indicates activity is too stressful for them...decrease activity>
<Text book has an exertion scale of 1-20...anything about what number is too much exertions?
What are some interdisciplinary interventions?>
<leg exercises
help them with distance
walking...increase it

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