CHF: 220 test II
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7 primary risk factors for CHF?
- 1. CAD
- 2. advanced age
- 3. HTN
- 4. DM
- 5. smoking
- 6. obesity
- 7. high serum cholesterol
Culture/Ethnic disparities in CHF & its Tx?
- 1. AA high incidence, mortality, & develops at earlier age than in whites
- 2. AA have more ACE inhibitor angioedema
- 3. Asians have extremely high risk for ACE cough
Only medication approved specific for AA for CHF?
Primary causes of HF?
- 1. CAD including MI--> kills tissue --> HF
- 2. HTN & hypertensive crisis --> stretches heart tissue --> HF
- 3. rhumatic heart disease
- 4. congenital heart defects
- 5. pulmonary hypertension
- 6. cardiomyopathy: potpartum, substance abuse
- 7. hyperthyroidism
- 8. valvular disorders
- 9. myocarditis
3 primary precipitating causes of CHF?
- 1. anemia
- 2. infection
- 3. dysrhythmias
- 1. thyrotoxicosis
- 2. hypothyroidism
- 3. bacterial endocarditis
- 4. pulmonary disease
- 5. paget's disease
- 6. nutritional deficiencies
- 7. hypervolemia
What is hemodynamic monitoring?
What is it used for?
shows CO, SVR (vasoconstriction/dilation)
used to calculate CO, SVR, pulmonary art wdge pressure, SV, central venous pressure
What does pulmonary artery wedge pressure show?
function of L side of heart
Where is it & what does it show?
pulmonary artery catheter
sits in pulmonary artery & shows R-side pressure
How is central venous pressure measured?
What does it show?
can measure with a central line
shows fluid status (overload or dehydration) & gives info about why BP is decreased
Tx of decreased central venous pressure?
blood & fluids or if r/t heart not pumping can Tx with HF meds
volume coming back to heart
What occurs with preload in CHF?
it is increased
What meds are given for increased preload/CHF?
diuretics & vasodilators/BP meds
Nursing intervention that can decrease preload in CHF pt?
What AE can occur when placing central venous lines?
can go too far & hit ventricle --> arrhythmias
How would lasix affect preload?
How would vasodilation affect the preload?
3 goals of CHF Tx?
- 1. decrease preload
- 2. decrease afterload
- 3. increase CO
What effect does lasix have on SVR?
Should CHF pt legs be elevated?
no - will drown them
What is CO? What is normal CO?
volume of blood pumped by heart in one minute
What is SVR? What does it indicate?
systemic vascular resistance - afterload
What is central venous pressure?
What does central venous pressure indicate?
R atrial pressure
What hemodynamic devices are used to measure R atrial pressure/CVP?
What do they also indicate?
Schwann Ganz or pulmonary wedge
fluid status, increased CVP, volume overload or R ventricular failure, decreased CVP, hypovolemia
What is reflected by pulmonary wedge pressure?
L ventricle preload (measures pulmonary capillary pressure & R atrial pressure)
What is indicated by an elevated PAWP?
heart failure/fluid overload
Counterregulatory mechanisms that occur in HF?
natriuretic peptides (ANP & BNP) are released by heart muscle & promote vasodilation to reduce afterload & preload
What will occur with systolic failure?
no forward BF, decreased EF & BP
Causes of systolic failure?
- 1. MI
- 2. htn
- 3. cardiomyopathy
- 4. valvular heart disease
Hallmark of systolic failure?
ventricles do not fill during diastole --> decreased SV & CO
Swan-Ganz & pulmonary artery wedge are used to measure what?
CVP & R atrial pressure - shows functioning of the L side of the heart
Patho of diastolic failure?
high filling pressure in ventricles r/t noncompliance/stiffness --> venous engorgement in pulmonary & systemic systems --> pulmonary congestion, pulmonary HTN, ventricular hypertrophy, and normal EF
Cause of diastolic failure?
results from LV hypertrophy r/t chronic systemic HTN, aortic stenosis, or hypertrophic cardiomyopathy
How does dilation of the ventricles contribute to CHF?
Why does this occur?
muscles of heart stretch to increase CO & force of contractions --> enlarged heart will start to fail
What test can be used to distinguish CHF from lung problem?
elevated BNP indicates HF
What will happen to BNP with Tx of CHF?
How does hypertrophy of the ventricles contribute to heart failure?
How does SNS contribute to HF?
responds to decreased CO by releasing catecholemines (EPI & NE) to increase HR & contractility & vasoconstricts (increased preload) --> strains already failing heart
What is affected by L sided HF?
What diuretic cannot be given to CHF pt?
mannitol - pulls fluid from tissue into BV --> will stress overworked heart r/t increased BF
Important consideration with use of mannitol?
need IV filter
How does the neurohormonal response contribute to fluid retention during CHF?
decreased CO --> renin/angiotensin/aldosterone release --> retention of Na/water & vasoconstriction --> increased BP --> increased stress on heart
decreased CO also causes release of ADH
What type of CHF is usually seen first?
Patho of L-sided HF?
LV dysfunction --> blood backs up through L atrium into pulmonary veins --> increased pulmonary pressure --> fluid from pulmonary capillary bed shifts into interstitum & alveoli --> pulmonary congestion/edema
4 causes of L sided CHF?
CAD, HTN, cardiomyopathy, rheumatic heart disease
What may occur as a result of L sided CHF?
How may pulmonary congestion be monitored in L sided HF?
CXR will show decreased fluid in the lungs
R-sided failure patho?
backflow to R atrium & venous circulation --> venous congestion --> peripheral edema, hepatomegaly, splenomegaly, vascular congestion of GI, JVD
Med that may be given to increase BP & decrease peripheral edema in R sided HF?
5 causes of R sided HF?
- 1. L sided dysfunction
- 2. chronic pulmonary HTN/cor pulmonale
- 3. COPD
- 4. pulmonary emboli
- 5. MI
What occurs in ADHF/acute decompensated HF?
lung alveoli filled with fluid - manifests as pulmonary edema
12 S/S of acute decompensated HF? (ADHF)
- 1. agitation
- 2. pale
- 3. may be cyanotic
- 4. skin clammy & cold
- 5. dyspnea
- 6. RR >30
- 7. orthopnea: feel like drowning when lay flat
- 8. wheezing
- 9. frothy blood-tinged sputum
- 10. bubbling crackles
- 11. pulmonary edema
- 12. enlarged heart on CXR
- 13. paroxysmal nocturnal dyspnea
What usually occurs with chronic CHF?
- usually have biventricular failure
- 1. tachycardia
- 2. edema
- 3 nocturia
- 4. behavioral changes: r/t hypoxia
- 5. skin changes
- 6. weight changes
- 7. chest pain
- 8. fatigue
- 9. dyspnea
- 10. orthopnea: orthopnea X5 - sleep with 5 pillows
What could be 1st s/s of CHF exacerbation?
dry hacking cough
Why may anemia occur with HF?
poor nutrition, renal disease, or durg therapy (ACE)
dyspnea when in supine position
Paroxysmal nocturnal dyspnea?
pt wakes in panic with feelings of suffocation & has strong desire to sit up for relief
L or R sided HF cause skin open with seeping fluids?
Why may tachycardia not be evident in a pt with CHF?
if taking beta blockers
Where may edema occur with CHF?
peripheral, lungs, liver(hepatomegaly), dependent areas, abd cavity (ascites)
What is the cause of dyspnea with CHF?
increased pulmonary pressures
Why does pt with CHF have nocturia?
daytime UO is decreased by decreased CO & fluid in interstitial areas
at night fluid shifts back into BF
What skin changes occur with CHF?
- 1. dusky
- 2. cool & damp/diaphoretic
- 3. LE shiny & swollen with diminished or absent hair growth
- 4. pigment changes r/t chronic selling
- 5. brown or brawny ankles & lower legs
What behavioral changes may occur with CHF?
unusual behavior: restlessness, confusion, decreased att. span or memory
caused by decreased CO --> decreased BF to brain & hypoxia
Why may chest pain occur with CHF?
decreased CO --> decreased coronary circulation
Weight changes that occur with CHF?
may initially gain r/t fluid retention
eventually will lose weight b/c of anorexia & N: loss of muscle & fat
Why may pt muscle & fat loss with CHF go unnoticed?
may be masked by fluid retention & edema
5 complications of CHF?
- 1. pleural effusions
- 2. arrhythmias: high risk for fatal
- 3. L ventricular thrombus
- 4. hepatomegaly
- 5. renal failure
What causes pleural effusion r/t CHF?
Where effusion usually seen?
increase pressure in pleural capillaries --> fluid into pleural space
in R lower lobe
What is the cause of nearly 1/2 of sudden cardiac death in CHF?
What arrhythmias may occur with CHF?
tachyarrhythmias & afib
2 causes of arrhythmias with CHF?
low EF increases risk
lasix & other drugs that alter K
2 risks associated with low EF?
- 1. arrhythmias
- 2. formation of clots in L ventricle r/t blood pooling
How may clots be prevented with CHF?
may be on heparin
What may occur is thrombus forms in L ventricle r/t decreased EF & CHF?
can further decrease CO & can cause embolism
When is hepatomegaly most likely to occur with CHF?
What can it lead to?
more likely with R-sided failure
can lead to liver failure & cirrhosis
Why may renal failure occur with CHF?
decreased perfusion of the kidneys
Acronym to remeber s/s of CHF?
- Activity limitation
- Shortness of breath
How is CHF classified?
based on tolerance of physical activity
Class I CHF?
no limitation of activity
Class II CHF?
slight limitation of activity: no s/s at rest
ordinary activity causes fatigue, dyspnea, palpitations, or pain
Class III CHF?
marked limitation of activity: usually comfortable at rest & some s/s with activity
Class IV CHF?
inability to carry on anyphysical activity without discomfort
s/s of cardiac insufficiency or anigna may be present even at rest
Dx studies for HF?
- 1. physical exam
- 2. CXR
- 3. ECG
- 4. hemodynamic assessment
- 5. echo
- 6. cardiac cath
- 7. BNP
What may show on ECG for CHF?
may have BBB r/t enlarged heart
2 tests that will show EF for CHF?
Which is more accurate?
echo & cardiac cath
cath more accurate
Tx of acute decompensated HF?
- 1. high folwers
- 2. O2 by mask or BNC
- 3. BiPaP
- 4. ET & mechanical ventilation
- 5. cont ECG & pulse ox monitoring
- 6. hemodynamic monitoring
- 7. VS, UO at least q 1h
- 8. drug therapy
- 9. possible cardioversion (for afib, etc)
- 10. ultrafiltration
Meds used for acute decompensated HF?
- 1. diuretics
- 2. ACEs, ARBs, & aldosterone inhibitors
- 3. vasodilators: nipride, nitrates, B-type natriuretic peptides, hydralazine, isosorbide dinitrate, & bidil
- 4. Beta blockers
- 5. positive inotropes: dig, beta agonists: dopamine, dobutamine; phosphodiesterase inhibitors: inocor, primacor
- 6. antidysrhtyhmic drugs
- 7. anticoagulants
Tx goals for CHF?
- increase Co without increase work of heart
- 1. decrease intravascular volume
- 2. decrease venous return (preload)
- 3. decrease afterload
- 4. improve gas exchange
- 5. increase CO
- 6. decrease anxiety
Med that may be given for anxiety in CHF?
What finding can be used to distinguish b/t systolic and diastolic failure?
BNP levels correlate with what?
degree of L ventricular dysfunction
remove extracellular & intravascular fluid volume
4 core measures for heart failure?
What will occur if these are not done?
- 1. written discharge instructions or educational materials including: activity, d/c meds, follow-up, weight monitoring, & what to do if s/s worsen
- 2. L ventricular function is documented
- 3. pt EF<40% are prescribed ACE or ARB at discharge
- 4. current smokers are given smoking cessation advice
if not done: insurance won't pay
Tx of CHF?
- 1. O2 admin
- 2.biventricular pacing or cardiac resynchronization therapy
- 3. implantable cardioverter/defibrillator with CRT
- 4. mechanical options to sustain pt: intraaortic balloon pump, ventricualr assist devices (used as bridge to transplant)
- 5. Drugs: diuretics, ACE/ARB/aldosterone inhibitors, vasodilators, beta blockers, positive ionotropes,
- 6. nutrition: low Na diet & weight mgmt
Nursing interventions for CHF?
- 1. admin O2 & semi-fowlers & monitor ABG's & pulse ox
- 2. adequate rest to decrease O2 needs
- 3. monitor fluid status: weight, I&O
- 4. give ice chips, gum, hard candy, or popsicles for pt on fluid restrictions to decrease thirst
- 5. Teach: weight gain 2lb/day or 5lb/wk - need to call MD
- 6. Monitor electrolytes
- 7. monitor pulses & circulation to det CO
- 8. reduce anxiety to decrease SNS stimulation: benzos or morphine
2 psych issues that are common with CHF?
anxiety & depression
Effects of diuretics on CHF?
decrease venous return/preload, increase CO, & decrease pulmonary congestion --> increased gas exchange
Pt teaching for CHF?
- 1. low Na diet & lifestyle
- 2.should get vaccinations against flu & pneumonia
- 3.s/s of exacerbations
- 4. s/s of drug toxicity & how to take pulse & home BP monitoring
- 5. s/s of hypokalemia & hyperkalemia
First choice diuretics for HF?
3 AE of loop diuretics?
3 loop diuretic meds?
- 1. hypokalemia
- 2. ototoxicity
- 3. allergy in pt allergic to sulfa drugs
lasix, demadex, bumex
Effects of ACE inhibitors?
- 1. decrease hypertrophy
- 2. decrease BP
- 3. increase CO
- 4. increase diuresis
AE of ACE inhibitors/captopril?
- 1. hypotension
- 2. hyperkalemia
- 3. rebound hypertension if d/c
- 4. angioedema - can develop suddenly & may be life-threatening
Consideration with elderly & ACE?
Who may also have this issue?
decreased renal efficiency could cause increased drug levels
may also occur in renal failure
Aldosterone antagonist actions?
decrease Na & fluid retention - K sparing diuretics
spironolactone & inspra
4 AE/considerations with aldosterone antagonists/K sparing diuretics?
- 1. hyperkalemia
- 2. can decrease dig effects if hyperkalemia occurs
- 3. Teach pt to avoid high K foods: oranges, bananas, apricots
- 4 assess male pt for gynecomastia with long-term use
2 types of vasodilators used for CHF?
nitrates & bidil
AE of nitrates to watch for?
decreased BP - must monitor
Important consideration when giving IV nitrates?
adheres to plastic - must waste 50-100mL before running med
How may nitrates be used in pt who cannot tolerate ACE or ARBs?
may take nitrate combined with hydralazine
2 AE of nitrates?
- 1. tolerance
- 2. ED - ED meds are CI
combo of isosorbide dinitrate & hydralazine
for AA already being Tx with standard therapy
isosorbide - relaxes vessels & releases nitric oxide
hydralazine - relaxes arteries & decreases work of heart
Action of beta blockers?
block SNS stimulation on failing heart
2 reasons a pt with HF may have cough?
may be r/t HF or ACE inhibitor
Major AE of beta blockers?
- 1. edema
- 2. worsening HF
- 3. hypotension
- 4. fatigue
- 5. bradycardia
S/S of beta blocker OD?
extreme hypotension & bradycardia, bronchospasm, & cardiogenic shock
How to assess tolerance of beta blocker?
assess standing BP 1h after dose
3 AE that may occur with abrupt w/d of beta blockers?
sweating, palpitations, & HA
S/S of dig toxicity?
- GI: anorexia, NV
- Visual: blurred vision, yellow tinge, visual halos around dark objects
- CNS: fatigue, drowsiness, HA, depression
- CV: dysrhythmias, bradycardia, tachycardia, apical-radial pulse deficit, HF
What dysrhythmias may occur with dig toxicity?
afib, PVC, Vfib, heart block
Most common cause of dig toxicity?
K wasting diuretics & hypokalemia
What pt have increased risk for dig toxicity?
elderly, renal & liver dysfunction
What is the Tx of dig toxicity?
withhold the med and/or digibind
When may fluid restrictions be implemented for CHF?
moderate to severe HF & renal insufficiency
Pt postion that can decrease venous return?
high flowlers with feet dangling or horizontal - pools blood in extremeities & improves ventilation
Consideration if giving beta blocker with CHF?
should check CO & CHF exacerbation before giving beta blocker: any s/s of exacerbation or decreased CO --> should hold beta blocker
Why is it important to monitor BP in CHF pt?
if give too many BP meds and BP gets too low it cannot be increased with fluids
Med to decrease afterload?
nipride decreases afterload & preload
need to monitor BP
Consideration when giving nipride IV?
put in paper bag- light sensitive
2 effects of ACE inhibitors?
What med may be given with ACE inhibitors & why?
decrease afterload & SVR
may be given with thiazide diuretic b/c ACE holds K & thiazides get rid of it
2 EX of ARBs?
cozaar & diovan
What meds should be held during exacerbation of CHF?
beta blockers - will decrease CO too much
Interventions to improve gas exchange?
- 1. morphine - decreases O2 demand
- 2. sats decreased may need mask or nonrebreather
- 3. severe pulm edma may need vent
- 4. monitor ABG, pulse ox,
- 5. rest
- 6. may use BiPaP to deliver O2
Drug of choice for pt in pulmonary edema?
Interventions to improve cardiac function?
- 1. dig
- 2. dobutrex, inocor, primacor, natrecor - peripheral vasodilation
AE of meds that cause vasodilation in CHF?
dobutrex, inocor, primacor, natrecor
can die if stop taking these meds abruptly: when d/c must monitor for CHF exacerbation
Nursing care for chronic CHF?
- 1. ID underlying cause: HTN, valvular defects, etc
- 2. ventricular tachyarrhythmias - implantable cardioverter (ICD)
- 3. Swan-Ganz
- 4. intra-aortic balloon pumps (IABP) - balloon inflates during diastole so heart doesn't have to pump as hard to pump blood out during systole
- 5. ventricular assist devices (VAD) - longer-term support to wait for heart transplant
Does pt with VAD have a pulse?
may or may not have pulse
Complication of IABP?
- 1. if balloon moves can block aorta & BF to areas of body
- 2. dislodging plaque
- 3. aortic dissection
- 4. thrombocytopenia
- 5. infection
Complication of VAD?
sepsis & death
Major AE of nipride?
hypotension - monitor BP, cyanide poisoning after 48h
need to keep MAP>60
Monitoring of IABP?
pulses, UO, bowel sounds (ischemia & embolism)
CV checks, neuro, & hemodynamic assessments q15-60 minutes
Nursing care after IABP?
- 1. relatively immobile in sidelying or supine positions with HOB elevated <45 degrees
- 2. sedation, pain relief, skin care & comfort measures
- 3. weaning pt off of IABP
IABP causes increased risk for ___ & ____ especially.
clots & sepsis
Action of VAD?
augment or replace ventricular action when heart is failing and needs to recover or when waiting for transplant
Nutritional therapy for CHF?
- 1. low Na diet: mild CHF <2g, severe <500-1000mg
- 2. fluid restrictions with no more than 2L/day
- 3. daily weight before breakfast: gain of 3lb in 2 days or 3-5lb in a week: need to call
- 4. no alcohol- cardiotoxic
percentage of total ventricular volume ejected during each contraction
normal is >55% & usually is 65%
pulls off fluid but doesn't affect electrolytes
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