Heart Failure

Beryl Ben C. Mergal, RN, MSN

Integration of Faith and Learning

Hebrews 3: 18 Today, if you

hear His voice, do not harden
your hearts.
Rev 3: 20 If any man hear My
voice and open the door, I will
come in.

Hearts Basic Function

Basic function of the heart???

- TO PUMP BLOOD!!!
The hearts ability to pump
blood is measured by what???
- CARDIAC OUTPUT

Ejection Fraction
Ejection Fraction (EF) is the fraction of blood
ejected by the ventricle relative to its filled
volume (end-diastolic volume).

=
=

EF is a measure of the ability of the heart to

eject blood.
EF is normally about 0.55-0.65 (55%-65%)

Heart Failure
The inability of the
heart to pump enough
blood to meet the
bodys metabolic
demands

Heart Failure

Conditions Associated W/ Heart

Failure
1. ABNORMAL VOLUME LOAD

Aortic regurgitation
Mitral regurgitation
Tricuspid regurgitation
Left-to-right shunts
Secondary hypervolemia

Conditions Associated W/ Heart

Failure
2. ABNORMAL PRESSURE LOAD

Aortic stenosis
Coarctation of the aorta
HPN
Pulmonary emboli
Pulmonic valve stenosis
Lung congestion

Conditions Associated W/ Heart

Failure
3. Myocardial Abnormalities

Cardiomyopathy
Myocarditis
CHD/IHD/CAD
Infarction Arrhythmias
Toxic disorders(alcohol, cocaine)
Cardiac depressants

Conditions Associated W/ Heart

Failure
4. Filling Disorders

Mitral stenosis
Tricuspid stenosis
Cardiac tamponade
Restrictive pericarditis
Restrictive cardiomyopathy

Conditions Associated W/ Heart

Failure
5. Increased Metabolic Demands

Anemia
Hyperthyroidism
Fever, infection

2 Basic Effects of Heart Failure

1. Forward Effect

2. Backward Effect

Decreased Cardiac
output

Back up Congestion

Pathophysiology

Causes of the Histological

Features
Myocardial ischemia
Myocardial infarction
Hemodynamic
overload

Course of CHF
UNDERLYING CONDITION/S

START OF HISTOLOGICAL CHANGES

Myocardial Contractility
Cardiac Output

COMPENSATORY
MECHANISMS(to #1)

BLOOD &/or PRESSURE

in CHAMBER
CHAMBER DILATION or
HYPERTROPHY (to #2)

SNS STIMULATION
Course of CHF
1. Vasoconstriction,
preload LV afterload
2. HR & BP
3. myocardial
contractility

MAINTAIN CO
FOR A TIME

RENIN SECRETION
Angiotensin II =
vasoconstriction
Aldosterone =
Na & H2O
retention

HEART WORKLOAD
= O2 DEMAND

Left Ventricle
Weakens (to #2)

Further Myocardial Contractility

Further
Cardiac Output

Blood Back up in
Pulmonary Circulation

FORWARD EFFECTS

BACKWARD EFFECTS

Pulmonary
Congestion

RIGHT SIDE HF

Left-Sided Heart Failure

BACKWARD EFFECTS
Dyspnea
Orthopnea
as blood is redistributed fr the legs to the central
circulation when pt lies down
Paroxysmal Nocturnal Dyspnea (PND)
edema fluid accumulated is reabsorbed into the
circulation at night, causing fluid overload &
pulmonary congestion

Left-Sided Heart Failure

Backward Effects

Crackles
Cough w/ pink frothy sputum
Tachypnea
Increased PCWP(>13mmHg)
Increased PAP(>15mmHg)
Xray: lung congestion
Echocardiography: EF <50%
S3
Pulse deficit

Left-Sided Heart Failure

Forward Effects
Etiology: decreased CO
HEART
Tachycardia
increased or decreased BP
BRAIN
Decreased LOC
Irritability /agitation
Dizziness/syncope/fainting

Left-Sided Heart Failure

Forward Effects
MUSCULO
Easy fatigability
Fatigue/weakness
KIDNEYS
Decreased UO
INTEGUMENTARY
Pallor/cyanosis
Prolonged capillary refill
Decreased O2 saturation

Left-Side Heart Failure

Right-Sided Heart Failure

Backward Effects
> 8mmHg CVP (NR: 0-8mmHg)
>3cm Jugular vein pressure
Hepatomegaly (RUQ pain)
Ascites, AG
Anorexia, fullness, nausea
Peripheral Edema

Right-Sided Heart Failure

Backward Effects
Weight gain of 3 lbs in 24hrs
Nocturia as edema fluid from dependent
tissues is reabsorbed while in supine
Positive hepatojugular reflux
S3

Right-Sided Heart Failure

Forward Effects
Etiology: decreased CO
HEART
Tachycardia
increased or decreased BP
BRAIN
Decreased LOC
Irritability /agitation
Dizziness/syncope/fainting

Right-Sided Heart Failure

Forward Effects
MUSCULO
Easy fatigability
Fatigue/weakness
KIDNEYS
Decreased UO
INTEGUMENTARY
Pallor/cyanosis
Prolonged capillary refill
Decreased O2 saturation

Right-Sided Heart Failure

Types of Heart Failure

1. LVF vs RVF fluid fills the

chambers behind it
2. Acute vs. Chronic
Acute - abrupt onset as in MI
Chronic gradual
3. Diastolic vs. Systolic

Diagnostic Tests
1.
2.
3.
4.

ABG analysis
Chest xray
Echocardiography
Electrocardiography

Priority Nursing Diagnosis

Decreased cardiac output
Ineffective breathing pattern
Impaired gas exchange
Fluid volume excess
Activity intolerance
Fatigue

Collaborative Management
1.

2.

Improve Ventricular Pump Performance

Oxygen
Digoxin cardiac glycoside
Inotropes dopamine, dobutamine
Reduce myocardial workload
Reduce preload
- Diuretics reduce fluid vol overload & venous
return

Collaborative Management
3. Reduce afterload

Vasodilators Hydralazine, Isosorbide Dinitrate

ACE inhibitors suppress RAAS (e.g. captopril)
Beta-adrenergic antagonist or beta-blockers

4. Reduce fluid retention

Control sodium and water

5. Potassium supplements
6. Reduce stress and risk of injury
7. Rest promote diuresis, slow HR

Nursing Management
Goal: To reduce respiratory
distress.

Monitor respiratory status

Administer oxygen therapy as ordered.
Maintain on high-fowlers position
Monitor ABG
Assess for breath sounds
Monitor hemodynamic parameters

Nursing Management
Goal : To decrease cardiac demands and
improve cardiac function.
1. Provide physical and emotional rest.
a. Constantly assess level of anxiety.
b. Maintain bedrest and limit activity.
c. Maintain quiet and relaxed ent
2. Provide supplemental oxygen as prescribed.
3. Increase cardiac output.
a. Administer digitalis & vasodilators as ordered
b. Monitor ECG and hemodynamics.
d. Monitor v/s.

Nursing Management
Goal: To reduce/eliminate edema and
decrease circulating volume
Assess peripheral edema & JVP
Administer diuretics as ordered,
Daily weights, if client gains 3 lbs or more per day
- signs of fluid retention.
Take accurate I & O and record.
Measure AG.
Monitor electrolyte levels.
Monitor CVP and Swan-Ganz readings.
Provide sodium-restricted diet as ordered

Congestive Heart Failure

Best position: high fowlers position
Goal: to DECREASE venous return to prevent
further congestion

Digitalis Therapy
Digitalis
(+) inotropic

(-) chronotropic

Contraindicated if:
C.O.
<60 bpm

>120 bpm
T.P. in kidney

U.O. (potentiate HYPO

kalemia)

Signs of Digitalis Toxicity

Normal .5 2meq/L

Early (BANDAV)
B bradycardia
A anorexia
N nausea
D diarrhea
A abdominal pain
V vomiting

Late
Halo vision &Orange /
green vision
common to elderly
Dysrhythmia fatal
In males: gynecomastia,
decreased libido and
impotence

Nursing Responsibilities in
Digitalis Therapy
Monitor serum potassium (Normal 3.5-5.5
mEq/L) hypokalemia enhances
digitalis toxicity
Examples: Lanoxin (Digoxin), Crystodigin
(Digitoxin), Lanatoside (Cedilanid C)

Diuretics
To get rid of accumulated fluids.
Examples of Diuretics:
1. Thiazides

2.

Chlorthiazide (Diuril)
Hyrochlorthiazide (Esixdrix
Hyrdodiuril)

Loop Diuretics

3.

Furosemide (Lasix)
Bumetamide (Burmex)

Potassium-sparing

Spironolactone (Aldactone)
Triamterene (Dyrenium)

NYHA Classification of HF

NYHA Classification of HF