Congestive heart failure

CHF Heart Failure: failure of the cardiac muscle to pump blood to meet the body’s metabolic needs

CHF is a complication that can result from problems such as cardiomyopathy, valvular heart disease, endocarditis, Acute MI

Left-sided failure pulmonary congestion dyspnea, Paroxysmal nocturnal dyspnea
Pulmonary edema, rales (crackles) cough  blood-tinged, frothy sputum restlessness tachycardia
S-3 gallop orthopnea pleural effusion
Cheyne-Stokes respirations
Decreased renal function  elevated BUN
Changes in mental status
Fatigue, muscle weakness

Right-sided failure (cor pulmonale) enlarged organs
Dependent edema (ankle, lower extremities)
Edema
Weight gain
Distended neck vein
Liver enlargement and abdominal pain
Anorexia, nausea, bloating
Anxiety, fear, depression
Ascites

THINK:
Systolic: heart can’t contract and eject
Diastolic: ventricles can’t relax and fill
Plan/ Implementation
1. Administer cardiac glycosides
a. Digitalis (e.g., digoxin)— fundamental drug in the treatment of heart failure, especially when associated with low cardiac output b. Two categories of dosages
1) Digitalizing or loading dose— aimed at administering the drug in divided dosages over a period of 24 hours until an “optimum” cardiac effect is reached
2) Maintenance dose— patient placed on this dose after digitalization; smaller in amount and designed to replace the digitalis lost by excretion while maintaining “optimal” cardiac functioning 2. Administer angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs)– decrease afterload and improve myocardial contractility
3. Administer diuretics— thiazide diuretics, carbonic anhydrase inhibitors, aldosterone antagonists, loop diuretics
4. Administer vasodilators– decrease afterload and improve contractility
5. Administer morphine– decrease afterload
6. Administer inotropic agents– improve cardiac contractility
7. Administer Human B– type natriuretic peptides– vasodilates
8. Administer beta-adrenergic blockers– decrease myocardial oxygen demand
9. Diet
a. Restricted sodium diet
1) Normal intake: 6-15 g/ day
2) No table salt: 1.6-2.8 g/ day
3) No salt: 1.2-1.4 g/ day
4) Strict low-sodium diet: 0.2-1 g/ day A. Low calorie, supplemented with vitamins— promotes weight loss, thereby reducing the workload of the heart B.. Bland, low residue— avoids discomfort from gastric distention and heartburn C. Small, frequent feedings to avoid gastric distention, flatulence, and heartburn

10. Record I and O
11. Weigh daily
12. Oxygen therapy and continuous positive airway pressure (CPAP)
13. Teach about disease process, medications, energy management

A. Digitalis® (Lanoxin®, Digoxin)
 -used with atrial fibrillation;
 may increase workload
 increasing contraction
 decreasing heart rate
 when the heart rate is slowed this gives the ventricles more time to fill with blood
 increase cardiac output
 increase kidney perfusion
- Always diurese heart failure pts.....they can't handle volume
 -digitalizing dose
- loading dose
 -normal dig level= 0.5 - 2  2 is toxic
 *How do you know the Digoxin is working? Heart rate slows *S/Sx of toxicity?
 early: Anxiety, Nausea, Vomiting
 late: arrhythmias vision changes *Before administering do what? AP pulse *Monitor electrolytes
 -all electrolyte levels must remain normal,
 but K+ is the one that causes the most trouble
  K + dig = toxicity
 know that really any imbalance in electrolytes can cause toxicity
B. Diuretics (Lasix®, HCTZ®, Bumex®, Diazide®)
Administer diuretics— thiazide diuretics, carbonic anhydrase inhibitors, aldosterone antagonists, loop diuretics .
 Decreases preload – which  volume
 Aldactone may be given to decrease aldosterone levels
 give diuretics? In early morning
C. ACE inhibitor and/ or a Beta Blocker Administer angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs)– decrease afterload and improve myocardial contractility -Examples of ACE inhibitor include: (Vasotec®(enalapril), Monopril ® (fosinopril), Capoten ® (captopril) -Examples of Beta Blockers include: (Inderal® (propranolol), Lopressor® (which is Toprol XL® or metoprolol), Tenormin® (atenolol), Coreg® (carvedilol))
Low Na Diet
 -decreases preload
 -watch salt substitutes salt substitutes can contain a lot of K
 -canned/processed foods, & OTC’s can contain a lot of sodium Miscellaneous
 -elevate head of bed -l0”blocks under the head of the bed
 -weigh daily (report gain of 2-3 lbs)
 -report s/sx of recurring failure
DX:
Swan Ganz catheter
 (is a type of central line that measures pressures inside the heart)
 -Helps to determine the cause of decreased cardiac output
 -Killer complications: air embolus, pulmonary infarction
A-line
 *Measures BP continuously on a monitor
 *NEVER use an A-line as an IV site, you may draw blood from an A-Line, but do not administer medication via the A-Line
 * You do have to be careful with an A-line because if you do not have the connections on your pressure tubing secured properly then the blood will move up in the tubing or if you do not have the stopcocks in the proper position your patient could bleed out.

ABG’s
 *Allen’s test – a check for more circulation
 **Apply pressure to clients ulnar and radial arteries at the same time, ask client to open and close hand, hand should blanch, release the pressure from the ulnar artery while continuing to compress the radial artery and assess the color in the extremity distal to the pressure point—pinkness should return within 6 seconds (indicating the ulnar artery is sufficient to provide hand with adequate circulation if radial artery is occluded with a-line) o *Check distal circulation while in place -The 5- Ps: -Pulselessness, -Pallor, -Pain, -Paresthesia, -Paralysis
BNP: B-type natriuretic peptide
 *secreted by ventricular tissues in the heart when ventricular volumes and pressures in the heart are increased;
 sensitive indicator; can be positive for CHF when the CXR does not indicate a problem
 * If your patient is on Natrecor®, you will need to turn it off for 2 hours prior to drawing your BNP because it will give you a false high CXR (enlarged heart, pulmonary infiltrates)