Heart failure

  1. Mr Wright’s admission states that he has heart failure (congestive cardiac failure). Clearly define heart failure. What organs and which body systems are affected by this disorder?

Heart failure is medical condition where cardiac output of the heart is reduced (Huether, McCance, Brashers & Rote 2012, p.623), and as a result, insufficient blood, or in other words, oxygen and nutrients can be pumped to meet the body’s needs. This also causes increased diastolic filling pressure of the left ventricle and increased pulmonary capillaries pressures. The cardiac tissues may respond by stretching to hold more blood or by becoming stiff and thickened. This temporarily helps keep the blood moving, but over time, the heart muscle walls eventually weaken and become contract less efficiently (Better Health Channel 2013). Heart failure, when happens to the left side of the heart, is commonly called congestive cardiac failure.

As the heart supplies blood to allow functioning of body tissues, all body systems would be affected by heart failure. In particular, the normal functions of the cardiovascular system, respiratory system and urinary system in the body would be impacted greatly, hence vital body organs such as the heart, lungs and kidneys would not be able to function optimally.

  1. Give a brief overview of the normal function of the body systems affected by this disorder.

Cardiovascular system

  • Delivers oxygen, nutrients and hormones to body tissues via the blood
  • Carries away body waste such as carbon dioxide, urea and bilirubin
  • Sustain a reasonably high blood pressure to allow blood perfusion to body tissues in the extremities and to maintain organ function, such as filtration in the glomerulus.

(Marieb 2012, p.392)

Respiratory system

  • Facilitate the movement of air into the lungs while filtering, humidifying and warming it
  • Allow oxygen and carbon dioxide exchange in the alveoli

(Marieb 2012, p. 436)

Urinary system

  • Kidneys maintain the purity and consistencies of the body internal fluid by filtration of blood
  • Regulating the blood’s volume, pressure by secreting enzymes and pH by ensuring acid-base balance
  • Allow excretion of wastes and excessive ions while retaining sufficient solutes, nutrients and water.
  • Produce erythropoietin to stimulate red blood cell production in the bone marrow
  • Kidney cells also convert vitamin D to its active form
  • Urinary bladder provide temporary storage reservoirs for urine

(Marieb 2012, p.534)

Digestive system

  • A passageway for food to enter the body from the mouth
  • Breaks down ingested food into particles that are small enough to be absorbed into the body to provide nutrients and building blocks for body cells
  • Hydrochloric acid (HCl) secreted in the stomach provides nonspecific protection against bacteria
  • Control absorption of water to maintain normal blood volume

(Marieb 2012, p.506)

Lymphatic system

  • Returns leaked plasma to the blood vessels
  • Immune cells in the lymph ensure cleansing of bacteria and foreign particles

(Marieb 2012, p.398)

Endocrine system

  • Regulate homeostasis by releasing body hormones that are crucial for growth and development, metabolism and reproduction

(Marieb 2012, p.308)

Nervous system

  • Conducts electrical signals to other body parts to maintain body control
  • Regulate sensation, coordination, emotional response, mobility and hormones stimulation

(Marieb 2012, p. 226)

  1. Define the signs and symptoms of heart failure, and explain why these signs and symptoms occur.
  • Swollen ankles or legs (oedema) (American Heart Association 2014)
  • As blood flow out of the heart slows, blood returning to the heart accumulates in the veins, causing fluid build-up and increased pressure in the capillaries. This in turn forces fluid to leak out of the vessels and accumulate in the tissues, hence causing oedema. The kidneys are also less able to secrete sodium and water, worsening fluid retention in the tissues.
  • Angina

    • As cardiac output decreases, blood perfusion to the tissues supplied by the coronary arteries reduce as well, hence less oxygen is delivered to the cardiac tissues, which causes angina symptoms.
  • Weight gain (Healthline 2012)
  • Fluid build-up in the body tissues would increase body weight, hence it is important for patients with heart failure to weight themselves often.
  • Shortness of breath during rest, exercise, or while lying flat (American Heart Association 2014)
  • Blood “backs up” in the pulmonary vein as blood is not pumped out of the heart efficiently. This increases pressure in the capillaries, causing fluids to leak out into the lungs, resulting in shortness of breath.
  • Fatigue/tiredness (American Heart Association 2014)
  • Fatigue occurs as body tissues do not receive sufficient oxygen and nutrients, hence energy production is reduced. The body also diverts blood away from less vital organs, for example muscles in the limbs, which causes weakness.
  • Loss of appetite/nausea (American Heart Association 2014)

    • Inadequate blood supply to the digestive system, resulting in reduced production of digestive enzymes, reduced absorption and muscle contraction.
  • Persistent cough that can cause blood-tinged sputum or wheezing (American Heart Association 2014)
  • Fluid builds up in the lungs causing shortness of breath, which causes reflex coughing in the body in attempt to obtain more air.
  • Confusion or impaired thinking (American Heart Association 2014)
  • Changing levels of electrolytes in the blood such as sodium can cause confusion.
  • Rapid or irregular heart rate (American Heart Association 2014)
  • The heart beats faster in order to maintain normal cardiac output, in the long term, this would lead to arrhythmia.
  • Rapid breathing (Healthline 2012)

    • The body compensates for shortness of breath by increasing respiratory rate
  • Cyanosis (Healthline 2012)

    • Cyanosis is a condition where the skin turns blue/purple due to lack of oxygen. This often occurs in body extremities as blood supply to these areas decrease as a result of heart failure.
  • Fainting (Healthline 2012)

    • Insufficient blood supply to the brain cells as a result of heart failure will result in fainting
  • Nocturia (MedicineNet onhealth 2014)

    • When patients lie down, fluids accumulated in the extremities returns to the heart easier, consequently increase blood perfusion to the kidneys, which in turn result in increased filtration and excretion.
  • Swollen abdomen/ abdominal pain

    • Fluid accumulation in the abdominal area and possible liver enlargement can impact on sensory nerves causing abdominal pain
  • Disturbed sleep pattern/sleep apnoea (MedicineNet onhealth 2014)

    • Nocturia, shortness of breath and coughing can contribute to disturbed sleeping patterns
  • Liver enlargement

    • Reduced blood return to the heart also results in accumulation of blood in the hepatic vein and liver, affecting the hepatocytes and contributing to liver enlargement
  • Palpitations

    • The heart beats faster in order to maintain normal cardiac output, especially when the body’s oxygen demand increases, resulting in palpitations.
  • Pale, clammy skin

    • Blood perfusion to the skin is reduced, hence cells in the skin layers do not grow and function optimally
  • Heart grows larger (UCSF Medical Centre)

    • In order to compensate for the reduced cardiac output, the cardiac cells grow in size so stronger contractions can take place, causing the heart to grow larger. The heart chambers also enlarge and stretch so they can hold a larger volume of blood.
  • Blood vessels narrow (UCSF Medical Centre)
  • Reduced blood return to the heart results in less blood flow through the veins, which causes decreased blood pressure in these vessels. To compensate for this, veins start becoming narrower to maintain the pressure.
  • Blood flow is diverted (UCSF Medical Centre)
  • When the blood supply is no longer able to meet all of the body’s needs, it is diverted away from less crucial areas such as the limbs, and instead channelled to the vital organs including the heart and brain. In turn, physical activity becomes more difficult as heart failure progresses.
  • Constipation

    • Reduced blood supply to the smooth muscles in the intestines reduce contraction and overall motility resulting in constipation
  1. List the information taken on his admission that demonstrates these signs and symptoms.
  • Cyanosis – blue/purple discolouration of skin indicates inadequate oxygen supply to the extremities
  • Dyspnoea – shortness of breath indicates fluid accumulation in lungs
  • Low oxygen saturation level – fluid accumulation impairs gas exchange in the lungs
  • Hypotensive – reduced cardiac output causes low blood pressure
  • High pulse rate – tachycardia occurs to compensate for reduced cardiac output
  • Increased respiratory rate – to compensate for reduced oxygen levels in the tissues
  • Ulcer – Reduced blood supply to lower limbs contribute to impaired wound healing
  • Loss of appetite – Reduced blood flow to digestive system
  • Constipation – Reduced blood supply to smooth muscles in GI tract
  • Confusion – Imbalance in body electrolytes e.g. sodium and potassium
  1. Do you think his diabetes is related to his leg ulcer and amputated left toe? Explain.

Yes, I think that his diabetes is related to his leg ulcer and amputated left toe as poorly controlled diabetes causes peripheral neuropathy (nerve damage) (National Diabetes Information Clearinghouse NDIC 2013) and peripheral vascular disease (impaired circulation causing cell ischemia).

Over time, high blood sugar levels in the blood causes nerve damage in the body, which may be asymptomatic initially. These damaged nerves cannot transmit messages to the brain effectively, hence causing loss of feeling particularly in the body extremities.

On the other hand, adequate blood supply is vital to facilitate wound healing and to resolve underlying infections. In poorly controlled diabetes, blood flow is impaired, thus tissues do not receive sufficient nutrients to repair themselves. There is also an increased risk of infection (due to inadequate white blood cells to fight off bacteria/foreign matter), which can turn into an ulcer if not taken care of. The tissues can also become necrotic after prolong period of inadequate blood supply and amputation may be required.

This is likely to have happened to Mr Wright, being unaware of a wound that he had due to sensory loss, the wound gradually worsen as blood flow was impaired. The wound slowly progresses to an ulcer, and eventually had to be amputated.

  1. One of the medications he is taking is Lasix. What is the action of Lasix? Which body systems are affected by it? Explain why you think Mr. Wright is ordered Lasix. (Your answer need only be brief.)

Lasix is the trade name of frusemide, which is a loop diuretic. It inhibits the reabsorption of sodium and chloride ions in the ascending limb of the loop of Henle, which accounts for retention of approximately 20% of filtered sodium in the kidney. (Australian Medicines Handbook 2012) As water follows sodium and chloride ions, reducing reabsorption of these ions also reduces water retention. Therefore, the main systems that are affected by frusemide is the cardiovascular system and the urinary system. In Mr Wright’s situation, congestive cardiac failure results in fluid retention in the lungs and legs. Frusemide has been to assist the body in getting rid of excessive fluids through the excretion in the urine. This would improve his oedema symptoms as well as shortness of breath.

  1. List three conditions in Mr. Wright’s relevant medical history that are commonly associated with ageing.
  • Type 2 Diabetes – pancreatic islet slowly deteriorate causing reduced insulin production, cell receptors might also be less sensitive to insulin, hence increasing blood glucose level
  • Arthritis – as the body ages, cartilage in the joints gradually wear out causing pain during movement
  • Glaucoma – increased pressure in the eyes due to inefficient clearing of aqueous humour
  1. Using Mr. Wright’s admission history and assessment, list the factors that may impact on his safety whilst in hospital and when he returns home.
  • Mr Wright claim that he has very blurry vision after using his drops. As he might not be able to see clearly, he is more likely to fall if there are obstacles in his home.
  • Mr Wright’s history of asthma and low oxygen saturation means that he can have asthma attack at any time especially during exertion or after long distance of walk. The feeling of out of air and panic can increase the risk of falling.
  • Mr Wright’s blood pressure is lower than normal, which can contribute to orthostatic hypotension and dizziness, further increasing his falling risk.
  • Mr Wright has an ulcer on his lower left leg, which is prone to further infection if not taken care of properly. Infection causes pain, redness, swelling and dead tissue which can affect his stability while moving.
  • Mr Wright has Type 2 diabetes which means he has to constantly monitor his blood glucose level. It can be quite dangerous if he becomes hypoglycemic, as he may experience dizziness or even fainting.
  • Mr Wright is orientated but slipping into confusion. This puts him in greater danger during his daily activities. Confusion can also lead to medication misadventure, which can have disastrous impact.
  • Mr Wright is currently on multiple medications. The common adverse effects of medications are nausea and dizziness, which therefore increase his falling risk.
  • The fact that Mr Wright has to walk with walking aid suggests that he is not steady on his feet, thus he is more prone to fall.
  • Mr Wright is experiencing chronic pain due to his arthritis on his left hip. The pain that he is undergoing can increase the risk of fall as well, especially when he gets out from the bed, when the affected site can be stiff and painful.
  1. What other health professionals will be involved in his care and what services can they provide for Mr. Wright.
  1. Podiatrist
  • Deal with the prevention, diagnosis and management of foot problems
  • Carry out regular checks to determine patient’s feet health
  • Provide necessary foot care for Mr Wright due to his diabetes (i.e manicure and pedicure)
  1. Dietician
  • Provide expert nutrition and dietary advice by translating scientific information into practical advice in diets.
  • Work out a suitable diet plan for Mr Wright to manage his condition while ensuring sufficient nutrition.
  1. Cardiologist
  • Develop a management plan to suit his heart condition and diabetes
  • Monitoring for any symptoms that suggest worsening of his condition
  1. Nurses
  • Assist in managing Mr Wright’s condition during his stay in the hospital, develop a care plan to assist in the recovery of functions and prevent deterioration of his condition
  • Help in managing Mr Wright’s asthma condition, regular spirometry check up to monitor his lung function
  • Educate Mr Wright about lifestyle changes in order to maintain good health.
  • Access Mr Wright’s ulcer and provide proper wound care such as choice of wound dressing to control the amount of exudate and promote wound healing
  1. Occupational therapist
  • Helping Mr Wright to regain or enhance his daily life after discharge
  • Assessing and modifying Mr Wright’s home and community to improve his functional independence as well as to reduce falling risks
  • Educating Mr Wright in the use of home health equipment to assist function
  1. Physiotherapist
  • Access Mr Wright’s movement and assisting him to overcome movement disorders
  • Assisting in management of his chronic pain
  1. Pharmacist
  • Manage his medications and provision of Webster-pak and medical advice
  1. Social worker
  • Provide everyday care that is needed by Mr Wright after discharge, for example bathing, meals, shopping, transportation and social support
  1. Ophthalmologist
  • Management and monitoring of his glaucoma
  1. Dentist
  • Provide dental care to Mr Wright, make sure that all his teeth and gums are healthy. This is because the teeth share the same artery as the heart, infection in the teeth can spread to the heart.
  1. List the nursing documentation you would expect to be used in the care of Mr Wright.
  • Fluid balance chart
  • Bladder chart
  • Bowel chart
  • Diabetic management chart
  • History assessment
  • Neurovascular observation chart
  • Pain assessment
  • Nursing wound assessment and dressing regime
  • Weight chart
  • Medication chart
  • Falls risk assessment tool
  • Patient admission form
  • Progress notes
  • Pressure area observation/care plan
  • Individual care plan
  • Observations graphic chart

References

  1. Huether, SE, McCance, KL., Brashers, VL. & Rote, NS 2012, Understanding pathology, 5th edn, Elsevier Mosby, Missouri.
  2. Better Health Channel 2013, Congestive heart failure (CHF), viewed 5th September 2014,

http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Congestive_heart_failure_(CHF)>

  1. Marieb , EN 2012, Essentials of Human Anatomy and Physiology, 10th edn, Pearson Education, San Francisco.
  2. MedicineNet onhealth 2014, Congestive Heart Failure, viewed 5th September 2014, http://www.onhealth.com/congestive_heart_failure/page3.htm#what_are_the_symptoms_of_congestive_heart_failure>.

  3. Healthline 2012, Congestive Health Failure (CHF), viewed 6th September 2014, http://www.healthline.com/health/congestive-heart-failure#Overview1>.

  4. UCSF Medical Centre, Heart Failure Signs and Symptoms, viewed 3 September 2014, http://www.ucsfhealth.org/conditions/heart_failure/signs_and_symptoms.html>.

  5. National Diabetes Information Clearinghouse (NDIC) 2013, Diabetic Neuropathies: The Nerve Damage of Diabetes, viewed 6th September 2014, http://diabetes.niddk.nih.gov/dm/pubs/neuropathies/>.

    1. Mr Wright’s admission states that he has heart failure (congestive cardiac failure). Clearly define heart failure. What organs and which body systems are affected by this disorder?

    Heart failure is medical condition where cardiac output of the heart is reduced (Huether, McCance, Brashers & Rote 2012, p.623), and as a result, insufficient blood, or in other words, oxygen and nutrients can be pumped to meet the body’s needs. This also causes increased diastolic filling pressure of the left ventricle and increased pulmonary capillaries pressures. The cardiac tissues may respond by stretching to hold more blood or by becoming stiff and thickened. This temporarily helps keep the blood moving, but over time, the heart muscle walls eventually weaken and become contract less efficiently (Better Health Channel 2013). Heart failure, when happens to the left side of the heart, is commonly called congestive cardiac failure.

    As the heart supplies blood to allow functioning of body tissues, all body systems would be affected by heart failure. In particular, the normal functions of the cardiovascular system, respiratory system and urinary system in the body would be impacted greatly, hence vital body organs such as the heart, lungs and kidneys would not be able to function optimally.

    1. Give a brief overview of the normal function of the body systems affected by this disorder.

    Cardiovascular system

    • Delivers oxygen, nutrients and hormones to body tissues via the blood
    • Carries away body waste such as carbon dioxide, urea and bilirubin
    • Sustain a reasonably high blood pressure to allow blood perfusion to body tissues in the extremities and to maintain organ function, such as filtration in the glomerulus.

    (Marieb 2012, p.392)

    Respiratory system

    • Facilitate the movement of air into the lungs while filtering, humidifying and warming it
    • Allow oxygen and carbon dioxide exchange in the alveoli

    (Marieb 2012, p. 436)

    Urinary system

    • Kidneys maintain the purity and consistencies of the body internal fluid by filtration of blood
    • Regulating the blood’s volume, pressure by secreting enzymes and pH by ensuring acid-base balance
    • Allow excretion of wastes and excessive ions while retaining sufficient solutes, nutrients and water.
    • Produce erythropoietin to stimulate red blood cell production in the bone marrow
    • Kidney cells also convert vitamin D to its active form
    • Urinary bladder provide temporary storage reservoirs for urine

    (Marieb 2012, p.534)

    Digestive system

    • A passageway for food to enter the body from the mouth
    • Breaks down ingested food into particles that are small enough to be absorbed into the body to provide nutrients and building blocks for body cells
    • Hydrochloric acid (HCl) secreted in the stomach provides nonspecific protection against bacteria
    • Control absorption of water to maintain normal blood volume

    (Marieb 2012, p.506)

    Lymphatic system

    • Returns leaked plasma to the blood vessels
    • Immune cells in the lymph ensure cleansing of bacteria and foreign particles

    (Marieb 2012, p.398)

    Endocrine system

    • Regulate homeostasis by releasing body hormones that are crucial for growth and development, metabolism and reproduction

    (Marieb 2012, p.308)

    Nervous system

    • Conducts electrical signals to other body parts to maintain body control
    • Regulate sensation, coordination, emotional response, mobility and hormones stimulation

    (Marieb 2012, p. 226)

    1. Define the signs and symptoms of heart failure, and explain why these signs and symptoms occur.
    • Swollen ankles or legs (oedema) (American Heart Association 2014)
    • As blood flow out of the heart slows, blood returning to the heart accumulates in the veins, causing fluid build-up and increased pressure in the capillaries. This in turn forces fluid to leak out of the vessels and accumulate in the tissues, hence causing oedema. The kidneys are also less able to secrete sodium and water, worsening fluid retention in the tissues.
    • Angina

      • As cardiac output decreases, blood perfusion to the tissues supplied by the coronary arteries reduce as well, hence less oxygen is delivered to the cardiac tissues, which causes angina symptoms.
    • Weight gain (Healthline 2012)
    • Fluid build-up in the body tissues would increase body weight, hence it is important for patients with heart failure to weight themselves often.
    • Shortness of breath during rest, exercise, or while lying flat (American Heart Association 2014)
    • Blood “backs up” in the pulmonary vein as blood is not pumped out of the heart efficiently. This increases pressure in the capillaries, causing fluids to leak out into the lungs, resulting in shortness of breath.
    • Fatigue/tiredness (American Heart Association 2014)
    • Fatigue occurs as body tissues do not receive sufficient oxygen and nutrients, hence energy production is reduced. The body also diverts blood away from less vital organs, for example muscles in the limbs, which causes weakness.
    • Loss of appetite/nausea (American Heart Association 2014)

      • Inadequate blood supply to the digestive system, resulting in reduced production of digestive enzymes, reduced absorption and muscle contraction.
    • Persistent cough that can cause blood-tinged sputum or wheezing (American Heart Association 2014)
    • Fluid builds up in the lungs causing shortness of breath, which causes reflex coughing in the body in attempt to obtain more air.
    • Confusion or impaired thinking (American Heart Association 2014)
    • Changing levels of electrolytes in the blood such as sodium can cause confusion.
    • Rapid or irregular heart rate (American Heart Association 2014)
    • The heart beats faster in order to maintain normal cardiac output, in the long term, this would lead to arrhythmia.
    • Rapid breathing (Healthline 2012)

      • The body compensates for shortness of breath by increasing respiratory rate
    • Cyanosis (Healthline 2012)

      • Cyanosis is a condition where the skin turns blue/purple due to lack of oxygen. This often occurs in body extremities as blood supply to these areas decrease as a result of heart failure.
    • Fainting (Healthline 2012)

      • Insufficient blood supply to the brain cells as a result of heart failure will result in fainting
    • Nocturia (MedicineNet onhealth 2014)

      • When patients lie down, fluids accumulated in the extremities returns to the heart easier, consequently increase blood perfusion to the kidneys, which in turn result in increased filtration and excretion.
    • Swollen abdomen/ abdominal pain

      • Fluid accumulation in the abdominal area and possible liver enlargement can impact on sensory nerves causing abdominal pain
    • Disturbed sleep pattern/sleep apnoea (MedicineNet onhealth 2014)

      • Nocturia, shortness of breath and coughing can contribute to disturbed sleeping patterns
    • Liver enlargement

      • Reduced blood return to the heart also results in accumulation of blood in the hepatic vein and liver, affecting the hepatocytes and contributing to liver enlargement
    • Palpitations

      • The heart beats faster in order to maintain normal cardiac output, especially when the body’s oxygen demand increases, resulting in palpitations.
    • Pale, clammy skin

      • Blood perfusion to the skin is reduced, hence cells in the skin layers do not grow and function optimally
    • Heart grows larger (UCSF Medical Centre)

      • In order to compensate for the reduced cardiac output, the cardiac cells grow in size so stronger contractions can take place, causing the heart to grow larger. The heart chambers also enlarge and stretch so they can hold a larger volume of blood.
    • Blood vessels narrow (UCSF Medical Centre)
    • Reduced blood return to the heart results in less blood flow through the veins, which causes decreased blood pressure in these vessels. To compensate for this, veins start becoming narrower to maintain the pressure.
    • Blood flow is diverted (UCSF Medical Centre)
    • When the blood supply is no longer able to meet all of the body’s needs, it is diverted away from less crucial areas such as the limbs, and instead channelled to the vital organs including the heart and brain. In turn, physical activity becomes more difficult as heart failure progresses.
    • Constipation

      • Reduced blood supply to the smooth muscles in the intestines reduce contraction and overall motility resulting in constipation
    1. List the information taken on his admission that demonstrates these signs and symptoms.
    • Cyanosis – blue/purple discolouration of skin indicates inadequate oxygen supply to the extremities
    • Dyspnoea – shortness of breath indicates fluid accumulation in lungs
    • Low oxygen saturation level – fluid accumulation impairs gas exchange in the lungs
    • Hypotensive – reduced cardiac output causes low blood pressure
    • High pulse rate – tachycardia occurs to compensate for reduced cardiac output
    • Increased respiratory rate – to compensate for reduced oxygen levels in the tissues
    • Ulcer – Reduced blood supply to lower limbs contribute to impaired wound healing
    • Loss of appetite – Reduced blood flow to digestive system
    • Constipation – Reduced blood supply to smooth muscles in GI tract
    • Confusion – Imbalance in body electrolytes e.g. sodium and potassium
    1. Do you think his diabetes is related to his leg ulcer and amputated left toe? Explain.

    Yes, I think that his diabetes is related to his leg ulcer and amputated left toe as poorly controlled diabetes causes peripheral neuropathy (nerve damage) (National Diabetes Information Clearinghouse NDIC 2013) and peripheral vascular disease (impaired circulation causing cell ischemia).

    Over time, high blood sugar levels in the blood causes nerve damage in the body, which may be asymptomatic initially. These damaged nerves cannot transmit messages to the brain effectively, hence causing loss of feeling particularly in the body extremities.

    On the other hand, adequate blood supply is vital to facilitate wound healing and to resolve underlying infections. In poorly controlled diabetes, blood flow is impaired, thus tissues do not receive sufficient nutrients to repair themselves. There is also an increased risk of infection (due to inadequate white blood cells to fight off bacteria/foreign matter), which can turn into an ulcer if not taken care of. The tissues can also become necrotic after prolong period of inadequate blood supply and amputation may be required.

    This is likely to have happened to Mr Wright, being unaware of a wound that he had due to sensory loss, the wound gradually worsen as blood flow was impaired. The wound slowly progresses to an ulcer, and eventually had to be amputated.

    1. One of the medications he is taking is Lasix. What is the action of Lasix? Which body systems are affected by it? Explain why you think Mr. Wright is ordered Lasix. (Your answer need only be brief.)

    Lasix is the trade name of frusemide, which is a loop diuretic. It inhibits the reabsorption of sodium and chloride ions in the ascending limb of the loop of Henle, which accounts for retention of approximately 20% of filtered sodium in the kidney. (Australian Medicines Handbook 2012) As water follows sodium and chloride ions, reducing reabsorption of these ions also reduces water retention. Therefore, the main systems that are affected by frusemide is the cardiovascular system and the urinary system. In Mr Wright’s situation, congestive cardiac failure results in fluid retention in the lungs and legs. Frusemide has been to assist the body in getting rid of excessive fluids through the excretion in the urine. This would improve his oedema symptoms as well as shortness of breath.

    1. List three conditions in Mr. Wright’s relevant medical history that are commonly associated with ageing.
    • Type 2 Diabetes – pancreatic islet slowly deteriorate causing reduced insulin production, cell receptors might also be less sensitive to insulin, hence increasing blood glucose level
    • Arthritis – as the body ages, cartilage in the joints gradually wear out causing pain during movement
    • Glaucoma – increased pressure in the eyes due to inefficient clearing of aqueous humour
    1. Using Mr. Wright’s admission history and assessment, list the factors that may impact on his safety whilst in hospital and when he returns home.
    • Mr Wright claim that he has very blurry vision after using his drops. As he might not be able to see clearly, he is more likely to fall if there are obstacles in his home.
    • Mr Wright’s history of asthma and low oxygen saturation means that he can have asthma attack at any time especially during exertion or after long distance of walk. The feeling of out of air and panic can increase the risk of falling.
    • Mr Wright’s blood pressure is lower than normal, which can contribute to orthostatic hypotension and dizziness, further increasing his falling risk.
    • Mr Wright has an ulcer on his lower left leg, which is prone to further infection if not taken care of properly. Infection causes pain, redness, swelling and dead tissue which can affect his stability while moving.
    • Mr Wright has Type 2 diabetes which means he has to constantly monitor his blood glucose level. It can be quite dangerous if he becomes hypoglycemic, as he may experience dizziness or even fainting.
    • Mr Wright is orientated but slipping into confusion. This puts him in greater danger during his daily activities. Confusion can also lead to medication misadventure, which can have disastrous impact.
    • Mr Wright is currently on multiple medications. The common adverse effects of medications are nausea and dizziness, which therefore increase his falling risk.
    • The fact that Mr Wright has to walk with walking aid suggests that he is not steady on his feet, thus he is more prone to fall.
    • Mr Wright is experiencing chronic pain due to his arthritis on his left hip. The pain that he is undergoing can increase the risk of fall as well, especially when he gets out from the bed, when the affected site can be stiff and painful.
    1. What other health professionals will be involved in his care and what services can they provide for Mr. Wright.
    1. Podiatrist
    • Deal with the prevention, diagnosis and management of foot problems
    • Carry out regular checks to determine patient’s feet health
    • Provide necessary foot care for Mr Wright due to his diabetes (i.e manicure and pedicure)
    1. Dietician
    • Provide expert nutrition and dietary advice by translating scientific information into practical advice in diets.
    • Work out a suitable diet plan for Mr Wright to manage his condition while ensuring sufficient nutrition.
    1. Cardiologist
    • Develop a management plan to suit his heart condition and diabetes
    • Monitoring for any symptoms that suggest worsening of his condition
    1. Nurses
    • Assist in managing Mr Wright’s condition during his stay in the hospital, develop a care plan to assist in the recovery of functions and prevent deterioration of his condition
    • Help in managing Mr Wright’s asthma condition, regular spirometry check up to monitor his lung function
    • Educate Mr Wright about lifestyle changes in order to maintain good health.
    • Access Mr Wright’s ulcer and provide proper wound care such as choice of wound dressing to control the amount of exudate and promote wound healing
    1. Occupational therapist
    • Helping Mr Wright to regain or enhance his daily life after discharge
    • Assessing and modifying Mr Wright’s home and community to improve his functional independence as well as to reduce falling risks
    • Educating Mr Wright in the use of home health equipment to assist function
    1. Physiotherapist
    • Access Mr Wright’s movement and assisting him to overcome movement disorders
    • Assisting in management of his chronic pain
    1. Pharmacist
    • Manage his medications and provision of Webster-pak and medical advice
    1. Social worker
    • Provide everyday care that is needed by Mr Wright after discharge, for example bathing, meals, shopping, transportation and social support
    1. Ophthalmologist
    • Management and monitoring of his glaucoma
    1. Dentist
    • Provide dental care to Mr Wright, make sure that all his teeth and gums are healthy. This is because the teeth share the same artery as the heart, infection in the teeth can spread to the heart.
    1. List the nursing documentation you would expect to be used in the care of Mr Wright.
    • Fluid balance chart
    • Bladder chart
    • Bowel chart
    • Diabetic management chart
    • History assessment
    • Neurovascular observation chart
    • Pain assessment
    • Nursing wound assessment and dressing regime
    • Weight chart
    • Medication chart
    • Falls risk assessment tool
    • Patient admission form
    • Progress notes
    • Pressure area observation/care plan
    • Individual care plan
    • Observations graphic chart

    References

    1. Huether, SE, McCance, KL., Brashers, VL. & Rote, NS 2012, Understanding pathology, 5th edn, Elsevier Mosby, Missouri.
    2. Better Health Channel 2013, Congestive heart failure (CHF), viewed 5th September 2014,

    http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Congestive_heart_failure_(CHF)>

    1. Marieb , EN 2012, Essentials of Human Anatomy and Physiology, 10th edn, Pearson Education, San Francisco.
    2. MedicineNet onhealth 2014, Congestive Heart Failure, viewed 5th September 2014, http://www.onhealth.com/congestive_heart_failure/page3.htm#what_are_the_symptoms_of_congestive_heart_failure>.

    3. Healthline 2012, Congestive Health Failure (CHF), viewed 6th September 2014, http://www.healthline.com/health/congestive-heart-failure#Overview1>.

    4. UCSF Medical Centre, Heart Failure Signs and Symptoms, viewed 3 September 2014, http://www.ucsfhealth.org/conditions/heart_failure/signs_and_symptoms.html>.

    5. National Diabetes Information Clearinghouse (NDIC) 2013, Diabetic Neuropathies: The Nerve Damage of Diabetes, viewed 6th September 2014, http://diabetes.niddk.nih.gov/dm/pubs/neuropathies/>.

    6. Australian Medicines Handbook 2012, Australian Medicines handbook Pty Ltd, Adelaide, pp.233-235.

Heart Failure

  • February 26, 2021/

Mrs. Santos is a retired school teacher who has been experiencing dyspnea for the past few weeks, along with cough. At night, she has difficulty of sleeping at night because of shortness of breath. When she visited her physician, she was diagnosed with heart failure stage 2.   

Description


Heart failure, also known as congestive heart failure, is recognized as a clinical syndrome characterized by signs and symptoms of fluid overload or of inadequate tissue perfusion.

  • Heart failure is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients.
  • The term heart failure indicates myocardial disease in which there is a problem with contraction of the heart (systolic dysfunction) or filling of the heart (diastolic dysfunction) that may or may not cause pulmonary or systemic congestion.
  • Heart failure is most often a progressive, life-long condition that is managed with lifestyle changes and medications to prevent episodes of acute decompensated heart failure.

Classification


Heart failure is classified into two types: left-sided heart failure and right-sided heart failure.

Left-Sided Heart Failure

  • Left-sided heart failure or left ventricular failure have different manifestations with right-sided heart failure.
  • Pulmonary congestion occurs when the left ventricle cannot effectively pump blood out of the ventricle into the aorta and the systemic circulation.
  • Pulmonary venous blood volume and pressure increase, forcing fluid from the pulmonary capillaries into the pulmonary tissues and alveoli, causing pulmonary interstitial edema and impaired gas exchange.

Right-Sided Heart Failure

  • When the right ventricle fails, congestion in the peripheral tissues and the viscera predominates.
  • The right side of the heart cannot eject blood and cannot accommodate all the blood that normally returns to it from the venous circulation.
  • Increased venous pressure leads to JVD and increased capillary hydrostatic pressure throughout the venous system.

The American College of Cardiology and American Heart Association have classifications of heart failure.

  • Stage A. Patients at high risk for developing left ventricular dysfunction but without structural heart disease or symptoms of heart failure.
  • Stage B. Patients with left ventricular dysfunction or structural heart disease that has not developed symptoms of heart failure.
  • Stage C. Patients with left ventricular dysfunction or structural heart disease with current or prior symptoms of heart failure.
  • Stage D. Patients with refractory end-stage heart failure requiring specialized interventions.

Pathophysiology


Heart failure results from a variety of cardiovascular conditions, including chronic hypertension, coronary artery disease, and valvular disease.

  • As HF develops, the body activates neurohormonal compensatory mechanisms.
  • Systolic HF results in decreased blood volume being ejected from the ventricle.
  • The sympathetic nervous system is then stimulated to release epinephrine and norepinephrine.
  • Decrease in renal perfusion causes renin release, and then promotes the formation of angiotensin I.
  • Angiotensin I is converted to angiotensin II by ACE which constricts the blood vessels and stimulates aldosterone release that causes sodium and fluid retention.
  • There is a reduction in the contractility of the muscle fibers of the heart as the workload increases.
  • Compensation. The heart compensates for the increased workload by increasing the thickness of the heart muscle.

Schematic Diagram

Below is a schematic diagram to help you visualize the pathophysiology of Heart Failure:

[scribd id=134403937 key=key-2d697c63oihfvjjl2t32 mode=scroll]

Statistics


Just like coronary artery disease, the incidence of HF increases with age.

  • More than 5 million people in the United States have HF.
  • There are 550, 000 cases of HF diagnosed each year according to the American Heart Association.
  • HF is most common among people older than 75 years of age.
  • HF is now considered epidemic in the United States.
  • HF is the most common reason for hospitalization of people older than 65 years of age.
  • It is also the second most common reason for visits to the physician’s office.
  • The estimated economic burden caused by HF is more than $33 billion annually in direct and indirect costs and is still expected to increase.

Incidences


Heart failure can affect both women and men, although the mortality is higher among women.

  • There are also racial differences; at all ages death rates are higher in African American than in non-Hispanic whites.
  • Heart failure is primarily a disease of older adults, affecting 6% to 10% of those older than 65.
  • It is also the leading cause of hospitalization in older people.

Causes


Systemic diseases are usually one of the most common causes of heart failure.

  • Coronary artery disease. Atherosclerosis of the coronary arteries is the primary cause of HF, and coronary artery disease is found in more than 60% of the patients with HF.
  • Ischemia. Ischemia deprives heart cells of oxygen and leads to acidosis from the accumulation of lactic acid.
  • Cardiomyopathy. HF due to cardiomyopathy is usually chronic and progressive.
  • Systemic or pulmonary hypertension. Increase in afterload results from hypertension, which increases the workload of the heart and leads to hypertrophy of myocardial muscle fibers.
  • Valvular heart disease. Blood has increasing difficulty moving forward, increasing pressure within the heart and increasing cardiac workload.

Clinical Manifestations


The clinical manifestations produced y the different types of HF are similar and therefore do not assist in differentiating the types of HF. The signs and symptoms can be related to the ventricle affected.

from Cardiovascular Mnemonics

Left-sided HF

  • Dyspnea or shortness of breath may be precipitated by minimal to moderate activity.
  • Cough. The cough associated with left ventricular failure is initially dry and nonproductive.
  • Pulmonary crackles. Bibasilar crackles are detected earlier and as it worsens, crackles can be auscultated across all lung fields.
  • Low oxygen saturation levels. Oxygen saturation may decrease because of increased pulmonary pressures.

    Right-Sided Heart Failure Manifestations: “AW HEAD”
    from Cardiovascular Mnemonics.

Right-sided HF

  • Enlargement of the liver result from venous engorgement of the liver.
  • Accumulation of fluid in the peritoneal cavity may increase pressure on the stomach and intestines and cause gastrointestinal distress.
  • Loss of appetite results from venous engorgement and venous stasis within the abdominal organs.

Prevention


Prevention of heart failure mainly lies in lifestyle management.

  • Healthy diet. Avoiding intake of fatty and salty foods greatly improves the cardiovascular health of an individual.
  • Engaging in cardiovascular exercises thrice a week could keep the cardiovascular system up and running smoothly.
  • Smoking cessation. Nicotine causes vasoconstriction that increases the pressure along the vessels.

Complications


Many potential problems associated with HF therapy relate to the use of diuretics.

  • Hypokalemia. Excessive and repeated dieresis can lead to hypokalemia.
  • Hyperkalemia. Hyperkalemia may occur with the use of ACE inhibitors, ARBs, or spironolactone.
  • Prolonged diuretic therapy might lead to hyponatremia and result in disorientation, fatigue, apprehension, weakness, and muscle cramps.
  • Dehydration and hypotension. Volume depletion from excessive fluid loss may lead to dehydration and hypotension.

Assessment and Diagnostic Findings


HF may go undetected until the patient presents with signs and symptoms of pulmonary and peripheral edema.

  • ECG: Ventricular or atrial hypertrophy, axis deviation, ischemia, and damage patterns may be present. Dysrhythmias, e.g., tachycardia, atrial fibrillation, conduction delays, especially left bundle branch block, frequent premature ventricular contractions (PVCs) may be present. Persistent ST-T segment abnormalities and decreased QRS amplitude may be present.
  • Chest x-ray: May show enlarged cardiac shadow, reflecting chamber dilation/hypertrophy, or changes in blood vessels, reflecting increased pulmonary pressure. Abnormal contour, e.g., bulging of left cardiac border, may suggest ventricular aneurysm.
  • Sonograms (echocardiography, Doppler and transesophageal echocardiography): May reveal enlarged chamber dimensions, alterations in valvular function/structure, the degrees of ventricular dilation and dysfunction.
  • Heart scan (multigated acquisition [MUGA]): Measures cardiac volume during both systole and diastole, measures ejection fraction, and estimates wall motion.
  • Exercise or pharmacological stress myocardial perfusion (e.g., Persantine or Thallium scan):Determines presence of myocardial ischemia and wall motion abnormalities.
  • Positron emission tomography (PET) scan: Sensitive test for evaluation of myocardial ischemia/detecting viable myocardium.
  • Cardiac catheterization: Abnormal pressures are indicative and help differentiate right- versus left-sided heart failure, as well as valve stenosis or insufficiency. Also assesses patency of coronary arteries. Contrast injected into the ventricles reveals abnormal size and ejection fraction/altered contractility. Transvenous endomyocardial biopsy may be useful in some patients to determine the underlying disorder, such as myocarditis or amyloidosis.
  • Liver enzymes: Elevated in liver congestion/failure.
  • Digoxin and other cardiac drug levels: Determine therapeutic range and correlate with patient response.
  • Bleeding and clotting times: Determine therapeutic range; identify those at risk for excessive clot formation.
  • Electrolytes: May be altered because of fluid shifts/decreased renal function, diuretic therapy.
  • Pulse oximetry: Oxygen saturation may be low, especially when acute HF is imposed on chronic obstructive pulmonary disease (COPD) or chronic HF.
  • Arterial blood gases (ABGs): Left ventricular failure is characterized by mild respiratory alkalosis (early) or hypoxemia with an increased Pco2 (late).
  • BUN/creatinine: Elevated BUN suggests decreased renal perfusion. Elevation of both BUN and creatinine is indicative of renal failure.
  • Serum albumin/transferrin: May be decreased as a result of reduced protein intake or reduced protein synthesis in congested liver.
  • Complete blood count (CBC): May reveal anemia, polycythemia, or dilutional changes indicating water retention. Levels of white blood cells (WBCs) may be elevated, reflecting recent/acute MI, pericarditis, or other inflammatory or infectious states.
  • ESR: May be elevated, indicating acute inflammatory reaction.
  • Thyroid studies: Increased thyroid activity suggests thyroid hyperactivity as precipitator of HF.

Medical Management


The overall goals of management of HF are to relieve patient symptoms, to improve functional status and quality of life, and to extend survival.

Management of Heart Failure: “DAD BOND CLASH”
from Cardiovascular Care Nursing Mnemonics.

Pharmacologic Therapy

  • ACE Inhibitors. ACE inhibitors slow the progression of HF, improve exercise tolerance, decrease the number of hospitalizations for HF, and promote vasodilation and diuresis by decreasing afterload and preload.
  • Angiotensin II Receptor Blockers. ARBs block the conversion of angiotensin I at the angiotensin II receptor and cause decreased blood pressure, decreased systemic vascular resistance, and improved cardiac output.
  • Beta Blockers. Beta blockers reduce the adverse effects from the constant stimulation of the sympathetic nervous system.
  • Diuretics. Diuretics are prescribed to remove excess extracellular fluid by increasing the rate of urine produced in patients with signs and symptoms of fluid overload.
  • Calcium Channel Blockers. CCBs cause vasodilation, reducing systemic vascular resistance but contraindicated in patients with systolic HF.

Nutritional Therapy

  • Sodium restriction. A low sodium diet of 2 to 3g/day reduces fluid retention and the symptoms of peripheral and pulmonary congestion, and decrease the amount of circulating blood volume, which decreases myocardial work.
  • Patient compliance. Patient compliance is important because dietary indiscretions may result in severe exacerbations of HF requiring hospitalizations.

Additional Therapy

  • Supplemental Oxygen. The need for supplemental oxygen is based on the degree of pulmonary congestion and resulting hypoxia.
  • Cardiac Resynchronization Therapy. CRT involves the use of a biventricular pacemaker to treat electrical conduction defects.
  • Ultrafiltration. Ultrafiltration is an alternative intervention for patients with severe fluid overload.
  • Cardiac Transplant. For some patients with end-stage heart failure, cardiac transplant is the only option for long term survival.

Nursing Management


Despite advances in the treatment of HF, morbidity and mortality remains high. Nurses have a major impact on outcomes for patients with HF.

Nursing Assessment

The nursing assessment for the patient with HF focuses on observing for the effectiveness of therapy and for the patient’s ability to understand and implement self-management strategies.

Health History

  • Assess the signs and symptoms such as dyspnea, shortness of breath, fatigue, and edema.
  • Assess for sleep disturbances, especially sleep suddenly interrupted by shortness of breath.
  • Explore the patient’s understanding of HF, self management strategies, and the ability and willingness to adhere to those strategies.

Physical Examination

  • Auscultate the lungs for presence of crackles and wheezes.
  • Auscultate the heart for the presence of an S3 heart sound.
  • Assess JVD for presence of distention.
  • Evaluate the sensorium and level of consciousness.
  • Assess the dependent parts of the patient’s body for perfusion and edema.
  • Assess the liver for hepatojugular reflux.
  • Measure the urinary output carefully to establish a baseline against which to assess the effectiveness of diuretic therapy.
  • Weigh the patient daily in the hospital or at home.

Diagnosis

Based on the assessment data, major nursing diagnoses for the patient with HF include the following:

  • Activity intolerance related to decrease CO.
  • Excess fluid volume related to the HF syndrome.
  • Anxiety related to breathlessness from inadequate oxygenation.
  • Powerlessness related to chronic illness and hospitalizations.
  • Ineffective therapeutic regimen management related to lack of knowledge.

Planning & Goals

Main Article: 16+ Heart Failure Nursing Care Plans

The care plan necessary for HF focuses on:

  • Promoting physical activities.
  • Reducing fatigue.
  • Relieving fluid overload symptoms.
  • Decreasing anxiety.
  • Increasing the patient’s ability to manage anxiety.
  • Encouraging the patient to verbalize his or her ability to make decisions and influence outcome.
  • Teaching the patient about self-care program.

Nursing Interventions

Nursing interventions for a patient with HF focuses on management of the patient’s activities and fluid intake.

  • Promoting activity tolerance. A total of 30 minutes of physical activity every day should be encouraged, and the nurse and the physician should collaborate to develop a schedule that promotes pacing and prioritization of activities.
  • Managing fluid volume. The patient’s fluid status should be monitored closely, auscultating the lungs, monitoring daily body weight, and assisting the patient to adhere to a low sodium diet.
  • Controlling anxiety. When the patient exhibits anxiety, the nurse should promote physical comfort and provide psychological support, and begin teaching ways to control anxiety and avoid anxiety-provoking situations.
  • Minimizing powerlessness. Encourage the patient to verbalize their concerns and provide the patient with decision-making opportunities.

Nursing Priorities

  1. Improve myocardial contractility/systemic perfusion.
  2. Reduce fluid volume overload.
  3. Prevent complications.
  4. Provide information about disease/prognosis, therapy needs, and prevention of recurrences.

Evaluation

For the expected patient outcomes, the following are evaluated:

  • Demonstration of tolerance for increased activity.
  • Maintenance of fluid balance.
  • Less anxiety.
  • Decides soundly regarding care and treatment.
  • Adherence to self-care regimen.

Discharge and Home Care Guidelines

The nurse should provide education and involve the patient in the therapeutic regimen.

  • Patient education. Teach the patient and their families about medication management, low-sodium diets, activity and exercise recommendations, smoking cessation, and learning to recognize the signs and symptoms of worsening HF.
  • Encourage the patient and their families to ask questions so that information can be clarified and understanding enhanced.

Discharge Goals

  • Cardiac output adequate for individual needs.
  • Complications prevented/resolved.
  • Optimum level of activity/functioning attained.
  • Disease process/prognosis and therapeutic regimen understood.
  • Plan in place to meet needs after discharge.

Documentation Guidelines

The following data should be documented appropriately:

  • Assessment findings
  • I&O fluid balance
  • Degree o f fluid retention
  • Results of laboratory tests and diagnostic studies.
  • Response to interventions, teachings, and actions performed.
  • Attainment or progress toward desired outcomes.

Practice Quiz: Heart Failure


Let’s test what you’ve learned from this study guide with this 5-item quiz for heart failure.

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Practice Quiz: Heart Failure

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1. The most frequent cause of hospitalization for people older than 75 years old is:

A. Angina pectoris
B. Heart failure
C. Hypertension
D. Pulmonary edema

2. The primary cause of heart failure is:

A. Arterial hypertension
B. Coronary atherosclerosis
C. Myocardial dysfunction
D. Valvular dysfunction

3. The dominant function in cardiac failure is:

A. Ascites
B. Hepatomegaly
C. Inadequate tissue perfusion
D. Nocturia

4. On assessment, the nurse knows that a patient who reports no symptoms of heart failure at rest but is symptomatic with increased physical activity would have a heart failure classification of:

A. Stage I
B. Stage II
C. Stage III
D. Stage IV

5. The diagnosis of heart failure is usually confirmed by:

A. Chest x-ray
B. Echocardiogram
C. Electrocardiogram
D. Ventriculogram

Answers and Rationale


1. Answer: B. Heart failure

  • B: Heart failure is the most frequent cause of hospitalization for people older than 75 years old.
  • A: Angina pectoris also occurs among people more than 75 years of age but it is not the most frequent cause of hospitalization.
  • C: Hypertension also occurs among people more than 75 years of age but it is not the most frequent cause of hospitalization.
  • D: Pulmonary edema also occurs among people more than 75 years of age but it is not the most frequent cause of hospitalization.

2. Answer: B. Coronary atherosclerosis

  • B: Coronary atherosclerosis is the primary cause of heart failure.
  • A: Arterial hypertension is not the primary cause of heart failure.
  • C: Myocardial dysfunction is not a cause of heart failure.
  • D: Valvular dysfunction is not the primary cause of heart failure.

3. Answer C. Inadequate tissue perfusion

  • C: Inadequate tissue perfusion is the dominant function as low oxygenation occurs because of this.
  • A: Ascites may occur in cardiac failure but is not considered as a dominant function.
  • B: Hepatomegaly is present in heart failure but not a dominant function.
  • D: Nocturia is not present in heart failure.

4. Answer: A. Stage I

  • A: Stage I refer to a patient who reports no symptoms of heart failure at rest but becomes symptomatic with increased physical activity.
  • B: Stage II refers to a patient who reports presence of symptoms with increased physical activities.
  • C: Stage III refers to a patient who reports presence of symptoms with minimal physical activity.
  • D: Stage IV refers to a patient who reports presence of symptoms even during at rest. 

5. Answer: B: Echocardiogram

  • B: An echocardiogram is usually performed to confirm the diagnosis of HF, and identify the underlying cause.
  • A: Chest x-ray findings are also basis of the diagnosis of HF, but it is not the confirmatory diagnostic test.
  • C: ECG is obtained to assist in the diagnosis.
  • D: Ventriculogram is not a part of the diagnostic tests for HF.

See Also


Posts related to Heart Failure:

  • Myocardial Infarction and Heart Failure NCLEX Practice Quiz (70 Items)
  • 16+ Heart Failure Nursing Care Plans
  • 7 Myocardial Infarction (Heart Attack) Nursing Care Plans

Heart Failure

  • October 14, 2020/

Mrs. Santos is a retired school teacher who has been experiencing dyspnea for the past few weeks, along with cough. At night, she has difficulty of sleeping at night because of shortness of breath. When she visited her physician, she was diagnosed with heart failure stage 2.   

Description


Heart failure, also known as congestive heart failure, is recognized as a clinical syndrome characterized by signs and symptoms of fluid overload or of inadequate tissue perfusion.

  • Heart failure is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients.
  • The term heart failure indicates myocardial disease in which there is a problem with contraction of the heart (systolic dysfunction) or filling of the heart (diastolic dysfunction) that may or may not cause pulmonary or systemic congestion.
  • Heart failure is most often a progressive, life-long condition that is managed with lifestyle changes and medications to prevent episodes of acute decompensated heart failure.

Classification


Heart failure is classified into two types: left-sided heart failure and right-sided heart failure.

Left-Sided Heart Failure

  • Left-sided heart failure or left ventricular failure have different manifestations with right-sided heart failure.
  • Pulmonary congestion occurs when the left ventricle cannot effectively pump blood out of the ventricle into the aorta and the systemic circulation.
  • Pulmonary venous blood volume and pressure increase, forcing fluid from the pulmonary capillaries into the pulmonary tissues and alveoli, causing pulmonary interstitial edema and impaired gas exchange.

Right-Sided Heart Failure

  • When the right ventricle fails, congestion in the peripheral tissues and the viscera predominates.
  • The right side of the heart cannot eject blood and cannot accommodate all the blood that normally returns to it from the venous circulation.
  • Increased venous pressure leads to JVD and increased capillary hydrostatic pressure throughout the venous system.

The American College of Cardiology and American Heart Association have classifications of heart failure.

  • Stage A. Patients at high risk for developing left ventricular dysfunction but without structural heart disease or symptoms of heart failure.
  • Stage B. Patients with left ventricular dysfunction or structural heart disease that has not developed symptoms of heart failure.
  • Stage C. Patients with left ventricular dysfunction or structural heart disease with current or prior symptoms of heart failure.
  • Stage D. Patients with refractory end-stage heart failure requiring specialized interventions.

Pathophysiology


Heart failure results from a variety of cardiovascular conditions, including chronic hypertension, coronary artery disease, and valvular disease.

  • As HF develops, the body activates neurohormonal compensatory mechanisms.
  • Systolic HF results in decreased blood volume being ejected from the ventricle.
  • The sympathetic nervous system is then stimulated to release epinephrine and norepinephrine.
  • Decrease in renal perfusion causes renin release, and then promotes the formation of angiotensin I.
  • Angiotensin I is converted to angiotensin II by ACE which constricts the blood vessels and stimulates aldosterone release that causes sodium and fluid retention.
  • There is a reduction in the contractility of the muscle fibers of the heart as the workload increases.
  • Compensation. The heart compensates for the increased workload by increasing the thickness of the heart muscle.

Schematic Diagram

Below is a schematic diagram to help you visualize the pathophysiology of Heart Failure:

[scribd id=134403937 key=key-2d697c63oihfvjjl2t32 mode=scroll]

Statistics


Just like coronary artery disease, the incidence of HF increases with age.

  • More than 5 million people in the United States have HF.
  • There are 550, 000 cases of HF diagnosed each year according to the American Heart Association.
  • HF is most common among people older than 75 years of age.
  • HF is now considered epidemic in the United States.
  • HF is the most common reason for hospitalization of people older than 65 years of age.
  • It is also the second most common reason for visits to the physician’s office.
  • The estimated economic burden caused by HF is more than $33 billion annually in direct and indirect costs and is still expected to increase.

Incidences


Heart failure can affect both women and men, although the mortality is higher among women.

  • There are also racial differences; at all ages death rates are higher in African American than in non-Hispanic whites.
  • Heart failure is primarily a disease of older adults, affecting 6% to 10% of those older than 65.
  • It is also the leading cause of hospitalization in older people.

Causes


Systemic diseases are usually one of the most common causes of heart failure.

  • Coronary artery disease. Atherosclerosis of the coronary arteries is the primary cause of HF, and coronary artery disease is found in more than 60% of the patients with HF.
  • Ischemia. Ischemia deprives heart cells of oxygen and leads to acidosis from the accumulation of lactic acid.
  • Cardiomyopathy. HF due to cardiomyopathy is usually chronic and progressive.
  • Systemic or pulmonary hypertension. Increase in afterload results from hypertension, which increases the workload of the heart and leads to hypertrophy of myocardial muscle fibers.
  • Valvular heart disease. Blood has increasing difficulty moving forward, increasing pressure within the heart and increasing cardiac workload.

Clinical Manifestations


The clinical manifestations produced y the different types of HF are similar and therefore do not assist in differentiating the types of HF. The signs and symptoms can be related to the ventricle affected.

Left-Sided Heart Failure: “DO CHAP”
from Cardiovascular Mnemonics

Left-sided HF

  • Dyspnea or shortness of breath may be precipitated by minimal to moderate activity.
  • Cough. The cough associated with left ventricular failure is initially dry and nonproductive.
  • Pulmonary crackles. Bibasilar crackles are detected earlier and as it worsens, crackles can be auscultated across all lung fields.
  • Low oxygen saturation levels. Oxygen saturation may decrease because of increased pulmonary pressures.
    Right-Sided Heart Failure Manifestations: “AW HEAD”
    from Cardiovascular Mnemonics.

Right-sided HF

  • Enlargement of the liver result from venous engorgement of the liver.
  • Accumulation of fluid in the peritoneal cavity may increase pressure on the stomach and intestines and cause gastrointestinal distress.
  • Loss of appetite results from venous engorgement and venous stasis within the abdominal organs.

Prevention


Prevention of heart failure mainly lies in lifestyle management.

  • Healthy diet. Avoiding intake of fatty and salty foods greatly improves the cardiovascular health of an individual.
  • Engaging in cardiovascular exercises thrice a week could keep the cardiovascular system up and running smoothly.
  • Smoking cessation. Nicotine causes vasoconstriction that increases the pressure along the vessels.

Complications


Many potential problems associated with HF therapy relate to the use of diuretics.

  • Hypokalemia. Excessive and repeated dieresis can lead to hypokalemia.
  • Hyperkalemia. Hyperkalemia may occur with the use of ACE inhibitors, ARBs, or spironolactone.
  • Prolonged diuretic therapy might lead to hyponatremia and result in disorientation, fatigue, apprehension, weakness, and muscle cramps.
  • Dehydration and hypotension. Volume depletion from excessive fluid loss may lead to dehydration and hypotension.

Assessment and Diagnostic Findings


HF may go undetected until the patient presents with signs and symptoms of pulmonary and peripheral edema.

  • ECG: Ventricular or atrial hypertrophy, axis deviation, ischemia, and damage patterns may be present. Dysrhythmias, e.g., tachycardia, atrial fibrillation, conduction delays, especially left bundle branch block, frequent premature ventricular contractions (PVCs) may be present. Persistent ST-T segment abnormalities and decreased QRS amplitude may be present.
  • Chest x-ray: May show enlarged cardiac shadow, reflecting chamber dilation/hypertrophy, or changes in blood vessels, reflecting increased pulmonary pressure. Abnormal contour, e.g., bulging of left cardiac border, may suggest ventricular aneurysm.
  • Sonograms (echocardiography, Doppler and transesophageal echocardiography): May reveal enlarged chamber dimensions, alterations in valvular function/structure, the degrees of ventricular dilation and dysfunction.
  • Heart scan (multigated acquisition [MUGA]): Measures cardiac volume during both systole and diastole, measures ejection fraction, and estimates wall motion.
  • Exercise or pharmacological stress myocardial perfusion (e.g., Persantine or Thallium scan):Determines presence of myocardial ischemia and wall motion abnormalities.
  • Positron emission tomography (PET) scan: Sensitive test for evaluation of myocardial ischemia/detecting viable myocardium.
  • Cardiac catheterization: Abnormal pressures are indicative and help differentiate right- versus left-sided heart failure, as well as valve stenosis or insufficiency. Also assesses patency of coronary arteries. Contrast injected into the ventricles reveals abnormal size and ejection fraction/altered contractility. Transvenous endomyocardial biopsy may be useful in some patients to determine the underlying disorder, such as myocarditis or amyloidosis.
  • Liver enzymes: Elevated in liver congestion/failure.
  • Digoxin and other cardiac drug levels: Determine therapeutic range and correlate with patient response.
  • Bleeding and clotting times: Determine therapeutic range; identify those at risk for excessive clot formation.
  • Electrolytes: May be altered because of fluid shifts/decreased renal function, diuretic therapy.
  • Pulse oximetry: Oxygen saturation may be low, especially when acute HF is imposed on chronic obstructive pulmonary disease (COPD) or chronic HF.
  • Arterial blood gases (ABGs): Left ventricular failure is characterized by mild respiratory alkalosis (early) or hypoxemia with an increased Pco2 (late).
  • BUN/creatinine: Elevated BUN suggests decreased renal perfusion. Elevation of both BUN and creatinine is indicative of renal failure.
  • Serum albumin/transferrin: May be decreased as a result of reduced protein intake or reduced protein synthesis in congested liver.
  • Complete blood count (CBC): May reveal anemia, polycythemia, or dilutional changes indicating water retention. Levels of white blood cells (WBCs) may be elevated, reflecting recent/acute MI, pericarditis, or other inflammatory or infectious states.
  • ESR: May be elevated, indicating acute inflammatory reaction.
  • Thyroid studies: Increased thyroid activity suggests thyroid hyperactivity as precipitator of HF.

Medical Management


The overall goals of management of HF are to relieve patient symptoms, to improve functional status and quality of life, and to extend survival.

Management of Heart Failure: “DAD BOND CLASH”
from Cardiovascular Care Nursing Mnemonics.

Pharmacologic Therapy

  • ACE Inhibitors. ACE inhibitors slow the progression of HF, improve exercise tolerance, decrease the number of hospitalizations for HF, and promote vasodilation and diuresis by decreasing afterload and preload.
  • Angiotensin II Receptor Blockers. ARBs block the conversion of angiotensin I at the angiotensin II receptor and cause decreased blood pressure, decreased systemic vascular resistance, and improved cardiac output.
  • Beta Blockers. Beta blockers reduce the adverse effects from the constant stimulation of the sympathetic nervous system.
  • Diuretics. Diuretics are prescribed to remove excess extracellular fluid by increasing the rate of urine produced in patients with signs and symptoms of fluid overload.
  • Calcium Channel Blockers. CCBs cause vasodilation, reducing systemic vascular resistance but contraindicated in patients with systolic HF.

Nutritional Therapy

  • Sodium restriction. A low sodium diet of 2 to 3g/day reduces fluid retention and the symptoms of peripheral and pulmonary congestion, and decrease the amount of circulating blood volume, which decreases myocardial work.
  • Patient compliance. Patient compliance is important because dietary indiscretions may result in severe exacerbations of HF requiring hospitalizations.

Additional Therapy

  • Supplemental Oxygen. The need for supplemental oxygen is based on the degree of pulmonary congestion and resulting hypoxia.
  • Cardiac Resynchronization Therapy. CRT involves the use of a biventricular pacemaker to treat electrical conduction defects.
  • Ultrafiltration. Ultrafiltration is an alternative intervention for patients with severe fluid overload.
  • Cardiac Transplant. For some patients with end-stage heart failure, cardiac transplant is the only option for long term survival.

Nursing Management


Despite advances in the treatment of HF, morbidity and mortality remains high. Nurses have a major impact on outcomes for patients with HF.

Nursing Assessment

The nursing assessment for the patient with HF focuses on observing for the effectiveness of therapy and for the patient’s ability to understand and implement self-management strategies.

Health History

  • Assess the signs and symptoms such as dyspnea, shortness of breath, fatigue, and edema.
  • Assess for sleep disturbances, especially sleep suddenly interrupted by shortness of breath.
  • Explore the patient’s understanding of HF, self management strategies, and the ability and willingness to adhere to those strategies.

Physical Examination

  • Auscultate the lungs for presence of crackles and wheezes.
  • Auscultate the heart for the presence of an S3 heart sound.
  • Assess JVD for presence of distention.
  • Evaluate the sensorium and level of consciousness.
  • Assess the dependent parts of the patient’s body for perfusion and edema.
  • Assess the liver for hepatojugular reflux.
  • Measure the urinary output carefully to establish a baseline against which to assess the effectiveness of diuretic therapy.
  • Weigh the patient daily in the hospital or at home.

Diagnosis

Based on the assessment data, major nursing diagnoses for the patient with HF include the following:

Planning & Goals

Main Article: 16+ Heart Failure Nursing Care Plans

The care plan necessary for HF focuses on:

  • Promoting physical activities.
  • Reducing fatigue.
  • Relieving fluid overload symptoms.
  • Decreasing anxiety.
  • Increasing the patient’s ability to manage anxiety.
  • Encouraging the patient to verbalize his or her ability to make decisions and influence outcome.
  • Teaching the patient about self-care program.

Nursing Interventions

Nursing interventions for a patient with HF focuses on management of the patient’s activities and fluid intake.

  • Promoting activity tolerance. A total of 30 minutes of physical activity every day should be encouraged, and the nurse and the physician should collaborate to develop a schedule that promotes pacing and prioritization of activities.
  • Managing fluid volume. The patient’s fluid status should be monitored closely, auscultating the lungs, monitoring daily body weight, and assisting the patient to adhere to a low sodium diet.
  • Controlling anxiety. When the patient exhibits anxiety, the nurse should promote physical comfort and provide psychological support, and begin teaching ways to control anxiety and avoid anxiety-provoking situations.
  • Minimizing powerlessness. Encourage the patient to verbalize their concerns and provide the patient with decision-making opportunities.

Nursing Priorities

  1. Improve myocardial contractility/systemic perfusion.
  2. Reduce fluid volume overload.
  3. Prevent complications.
  4. Provide information about disease/prognosis, therapy needs, and prevention of recurrences.

Evaluation

For the expected patient outcomes, the following are evaluated:

  • Demonstration of tolerance for increased activity.
  • Maintenance of fluid balance.
  • Less anxiety.
  • Decides soundly regarding care and treatment.
  • Adherence to self-care regimen.

Discharge and Home Care Guidelines

The nurse should provide education and involve the patient in the therapeutic regimen.

  • Patient education. Teach the patient and their families about medication management, low-sodium diets, activity and exercise recommendations, smoking cessation, and learning to recognize the signs and symptoms of worsening HF.
  • Encourage the patient and their families to ask questions so that information can be clarified and understanding enhanced.

Discharge Goals

  • Cardiac output adequate for individual needs.
  • Complications prevented/resolved.
  • Optimum level of activity/functioning attained.
  • Disease process/prognosis and therapeutic regimen understood.
  • Plan in place to meet needs after discharge.

Documentation Guidelines

The following data should be documented appropriately:

  • Assessment findings
  • I&O fluid balance
  • Degree o f fluid retention
  • Results of laboratory tests and diagnostic studies.
  • Response to interventions, teachings, and actions performed.
  • Attainment or progress toward desired outcomes.

Practice Quiz: Heart Failure


Let’s test what you’ve learned from this study guide with this 5-item quiz for heart failure.

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Practice Quiz: Heart Failure

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1. The most frequent cause of hospitalization for people older than 75 years old is:

A. Angina pectoris
B. Heart failure
C. Hypertension
D. Pulmonary edema

2. The primary cause of heart failure is:

A. Arterial hypertension
B. Coronary atherosclerosis
C. Myocardial dysfunction
D. Valvular dysfunction

3. The dominant function in cardiac failure is:

A. Ascites
B. Hepatomegaly
C. Inadequate tissue perfusion
D. Nocturia

4. On assessment, the nurse knows that a patient who reports no symptoms of heart failure at rest but is symptomatic with increased physical activity would have a heart failure classification of:

A. Stage I
B. Stage II
C. Stage III
D. Stage IV

5. The diagnosis of heart failure is usually confirmed by:

A. Chest x-ray
B. Echocardiogram
C. Electrocardiogram
D. Ventriculogram

Answers and Rationale


1. Answer: B. Heart failure

  • B: Heart failure is the most frequent cause of hospitalization for people older than 75 years old.
  • A: Angina pectoris also occurs among people more than 75 years of age but it is not the most frequent cause of hospitalization.
  • C: Hypertension also occurs among people more than 75 years of age but it is not the most frequent cause of hospitalization.
  • D: Pulmonary edema also occurs among people more than 75 years of age but it is not the most frequent cause of hospitalization.

2. Answer: B. Coronary atherosclerosis

  • B: Coronary atherosclerosis is the primary cause of heart failure.
  • A: Arterial hypertension is not the primary cause of heart failure.
  • C: Myocardial dysfunction is not a cause of heart failure.
  • D: Valvular dysfunction is not the primary cause of heart failure.

3. Answer C. Inadequate tissue perfusion

  • C: Inadequate tissue perfusion is the dominant function as low oxygenation occurs because of this.
  • A: Ascites may occur in cardiac failure but is not considered as a dominant function.
  • B: Hepatomegaly is present in heart failure but not a dominant function.
  • D: Nocturia is not present in heart failure.

4. Answer: A. Stage I

  • A: Stage I refer to a patient who reports no symptoms of heart failure at rest but becomes symptomatic with increased physical activity.
  • B: Stage II refers to a patient who reports presence of symptoms with increased physical activities.
  • C: Stage III refers to a patient who reports presence of symptoms with minimal physical activity.
  • D: Stage IV refers to a patient who reports presence of symptoms even during at rest. 

5. Answer: B: Echocardiogram

  • B: An echocardiogram is usually performed to confirm the diagnosis of HF, and identify the underlying cause.
  • A: Chest x-ray findings are also basis of the diagnosis of HF, but it is not the confirmatory diagnostic test.
  • C: ECG is obtained to assist in the diagnosis.
  • D: Ventriculogram is not a part of the diagnostic tests for HF.

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