Chapter 35: Nursing Management: Heart Failure Etiology and Pathophysiology · Heart failure (HF) is an abnormal clinical syndrome involving impaired cardiac pumping and/or filling. · HF is characterized by ventricular dysfunction, reduced exercise t olerance, diminished quality of life, and shortened life expectancy. · Risk factors include coronary artery disease (CAD) and advancing age. Hypertension, diabetes, cigarette smoking, obesity, and high serum cholesterol also contribute to the development of HF. · Heart failure is classified as systolic or diastolic failure. o Systolic failure results from an inability of the heart to pump blood effectively . o Diastolic failure is an impaired ability of the ventricles to relax and fill during diastole. Clinical Manifestations : Acute Decompensated Heart Failure a nd Chronic Heart Failure · HF can have an abrupt onset as with acute myocardial infarction or it can be an insidious process resulting from slow, progressive changes. · Compensatory mechanisms are activated to maintain adequate cardiac output ( CO ) . S everal counter regulatory processes are activated, including the production of hormones from the heart muscle to promote vasodilation. · Cardiac compensation occurs when compensatory mechanisms succeed in maintaining an adequate CO that is needed for tissue perfusion. · Cardiac decompensation occurs when these mechanisms can no longer maintain adequate CO and inadequate tissue perfusion results. · Over time, ventricular remodeling, dilation , and hypertrophy develop and lead to chronic HF. · The most common form of HF is left-sided failure from left ventricular dysfunction. Blood backs up into the left atrium and into the pulmonary veins , causing pulmonary congestion and edema. · Acute decompensated heart failure (ADHF) typically manifests as pulmonary edema , an acute, life-threatening situation. · Clinical manifestations of chronic HF depend on the patient’s age and the underlying type and extent of heart disease. Common symptoms include fatigue, cough, dyspnea, tachycardia, edema, and limitations of usual activities of daily living ( ADLs ) . · Pleural effusion, atrial fibrillation, thrombus formation, renal insufficiency, and hepatomegaly are all com plications of HF. Diagnostic Studies · To determine the underlying etiology of HF, a thorough history, physical examination, chest x-ray, electrocardiogram (ECG), laboratory data ( e.g., cardiac enzymes , b-type natriuretic peptide [ BNP ] , serum chemistries, liver function studies, thyroid f unction studies, complete blood count), hemodynamic assessment, echocardiogram, stress testing and cardiac catheterization may be done . Collaborative Care: Acute Decompensated Heart Failure · The goals of therapy for ADHF are to improve patient symptoms, reverse ventricular remodeling, improve quality of life, and decrease mortality and morbidity. · Treatment strategies should include the following: o Decreasing intravascular volume with the use of diuretics or ultrafiltration , o Decreasing venous return (preload) to reduce the amount of volume returned to the left ventricle ( LV ) during diastole. o Decreasing afterload (the resistance against which the LV must pump) to improve CO and decrease pulmonary congestion. o Gas exchange is improved by the administration of intravenous ( IV ) morphine sulfate and supplemental oxygen. o Inotropic therapy and hemodynamic monitoring may be needed in patients who do not respond to conventional pharmacotherap y. o Reduction of anxiety is an important nursing function, since anxiety may increase the sympathetic nervous system ( SNS ) response and further increase myocardial workload. Collaborative Care: Chronic Heart Failure · The main goal in the treatment of chronic HF is to treat the underlying cause and contributing factors, maximize CO, provide treatment to alleviate symptoms, improve ventricular function, improve quality of life, preserve target organ function, and improv e mortality and morbidity. · Administration of oxygen improves saturation and assists greatly in meeting tissue oxygen needs and helps relieve dyspnea and fatigue. · Physical and emotional rest allows the patient to conserve energy and decreases the need f or additional oxygen. The degree of rest recommended depends on the severity of HF. · Nonpharmacologic therapies , including c a rdiac resynchronization therapy, b iventricular pacing, in traaortic balloon pump , and v entricular assist devices , are an integral part of the management of HF patients. · Drug therapy is a critical part of the care of patients with HF: o Diuretics are used in HF to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload. o Vasodilator drugs have been s hown to improve survival in HF by increasing venous capacity, improving EF through improved ventricular contraction, slowing the process of ventricular dysfunction, and decreasing heart size . o Angiotensin-converting enzyme ( ACE ) inhibitors are the primary drug of choice in chronic HF patients with systolic dysfunction . o Angiotensin II receptor blockers may be used in patients who are ACE inhibitor intolerant. o - Adrene r gic blockers in combination with ACE inhibitors and diuretics have improved survival of patients with HF. o Digitalis glycosides remain the mainstay in the treatment of HF; however, they have not been shown to prolong life. · Diet education and weight management are critical to the patient’s control of chronic HF. o The edema of chronic HF is often treated by dietary restriction of sodium. o Fluid restrictions are not commonly prescribed for the patient with mild to moderate HF. I n moderate to severe HF , fluid restrictions are usually implemented. o Patients should weigh themselves daily . If a patient experiences a weight gain of 3 lb over 2 days or 3 to 5 lb over a week, the primary care provider should be called. NURSING MANAGEMENT: HEART FAILURE · The overall goals for the patient with H F include a decrease in symptoms, an increase in exercise tolerance, compliance with the medical regimen, and no complications related to HF. · Treatment or control of underlying heart disease is key to preventing episodes of ADHF. · Nursing care of the p atient with ADHF revolves around the nursing diagnoses of decreased CO , impaired gas exchange, excess fluid volume, and activity intolerance. Ambulatory and Home Care · Effective h ome health nursing can prevent or limit hospitalizations of the HF patient. · Preventive care should focus on slowing the progression of the disease. Teaching must include information on medications, diet , and exercise regimens. · Important nursing responsibilities in the care of a patient with HF include (1) teaching the patient about the physiologic changes that have occurred, (2) assisting the patient to adapt to both the physiologic and psychologic changes, and (3) integrating the patient and the patient’s family or support system in the overall care plan. o Many patients with HF are at high risk for anxiety and depression . o Patients should be taught to evaluate the action of the prescribed drugs and to recognize the manifestations of drug toxicity. § Patients should be taught how to take their pulse rate and to know under w hat circumstances drugs, especially digitalis and -adrenergic blockers, should be withheld and a health care provider consulted. § It may be appropriate to instruct patients in home BP monitoring . § Patients should be taught the symptoms of hypo kalemia and hyperkalemia if diuretics that deplete or spare potassium are being taken. o The physical therapist, occupational therapist , or you should instruct the patient in energy-conserving and energy-efficient behaviors after an evaluation of daily activities has been done. § An exercise training program or cardiac rehabilitation program improves symptoms. § Sometimes an activity that the patient enjoys may need to be eliminated. § The physical environment may require modification in situations in which there is an increased cardiac workload demand . · Goals for patients with end - stage HF include reducing the number of exacerbations that require hospitalization and maintaining comfort. CARDIAC TRANSPLANTATION · Cardiac transplantation , the transfer of a heart from one person to another, is used to treat a variety of terminal or end-stage heart conditions . · Once a patient meets the criteria for cardiac transplantation, a complete physical exam ination and diagnostic work - up is completed. Once accepted as a transplant candidate, the patient is placed on a transplant list. o Stable patients wait at home and receive ongoing medical care. o Unstable patients may require hospitaliza tion for more intensive therapy, including the use of assistive devices that serve as a bridge to transplantation. · Key complications after transplantation include acute rejection, risk for sudden cardiac death, infection, and cardiac transplant vasculopathy. o Life-time immunosuppression plus corticosteroids are necessary . o Endomyocardial biopsies are typically used to detect rejection. · Nursing management throughout the posttransplant period focuses on promoti ng patient adaptation to the transplant process, monitoring cardiac function, managing lifestyle changes, and providing ongoing teaching of the patient and family.