Chapter 35

Cardio: Heart Failure

Heart Failure
Inability of the heart to pump a sufficient amount of blood to meet the
body’s needs.

Congestive Heart Failure

The accumulation of blood and fluid within the organs and tissues due
to decreased circulation (Dig. & Lasix).

The heart is a dual pump. (Right and Left Sides)

May have Left or Right side heart failure, or both.

Left side heart failure leads to ® side heart failure.
No matter left or right heart failure, you have decreased cardiac output.

With decreased cardiac output, mechanisms within the body help to increase
the cardiac output; this does more harm than good.

*Sympathetic Nervous System: Attempts to increase Cardiac Output & raise

BP by speeding and increasing the contractions (this requires
extra Oxygen to the myocardium-- and oxygen is not
available so the patient worsens).

* Blood Vessels: Constrict to raise BP but in turn it makes the heart work
harder because there is more peripheral resistance.

* Renin-angiotensin-aldosterone mechanism: (in response to low blood flow

to the kidney because of decreased cardiac output)--
Vasoconstriction, Sodium, & Water retention which increases the
workload of the heart against the peripheral vascular resistance & more
fluid to have to pump due to aldosterone saving sodium & water.
Review:
The kidneys release renin, which stimulates angiotensin I in the liver
which in turn is converted to angiotensin II in the lung by the ACE enzyme.
Angiotensin II is a potent vasoconstrictor which helps raise BP. It also
stimulates the adrenal cortex to release aldosterone which saves sodium and
water (because water ALWAYS follows salt). It increases fluid & pressure; and
excretes potassium.
Creates a problem b/c you have more fluid for the heart to pump.

* Cells: Switch from aerobic to anaerobic metabolism which increases lactic

acid, lowers pH, and causes metabolic acidosis.
CHF leads to metabolic acidosis.
Hint: IF it’s left it’s a lung if it’s right it’s anything else.

Left Sided Heart Failure

Conditions that may lead to left-sided heart failure:

1. High Blood Pressure

Increases the workload of the (L) ventricle and in the end the (L)
ventricle just gives out.
2. Clients post MI
Muscle doesn’t work as effectively and creates decreased cardiac
output. So the heart fails b/c it pump the blood d/t the amount of muscle
damage.
3. Inflammatory heart conditions
Affects the blood flow thru the heart which decreases cardiac output.
4. Hypervolemia/ rapid infusion of IV fluids
Fluid overload.
5. Tachycardia (hypoxemia)
Fluid accumulates in the lungs in the pulmonary capillary bed (This impairs
oxygen and carbon dioxide exchange).
Don’t give it time for ventricles to fill up and heart gives out. Fluid
backs up in the 1st place it comes to: which is the lungs. Oxygen doesn’t
travel well thru water, CO2 does. You have more chance of transferring CO2
than you do O2. When you have fluid in the lung- you do not get good O2
exchange. The more fluid you have in the lung, the less Oxygen you
exchange.
See Respiratory S/S

1. Extertional Dyspnea: (1st sign) Shortness of breath or dyspnea

during activity.
Ex: Short of breath going to bathroom.
2. Orthopnea: have to sit upright to breathe

3. Paroxysmal nocturnal dyspnea: Awakened by breathlessness due to

the recumbent positioning during sleep & secretions pool in
the lungs (increased venous return to the heart).
** PINK, FROTHY SPUTUM**
When you lay flat it decreases venous return to the heart. So more
fluid backs up into the lungs. That’s why a lot of CHF patients will come in
early in the morning. It’s due to the recumbent position when they sleep.
They’ve laid flat for a long time and all that fluid has accumulated in the
lungs while they’ve slept.
4. Hypoxia
Makes heart rate increase.
5. Crackles in the lung
Rales- will not clear with cough- “death rattle”
Diagnostic Findings:

1. Chest X-ray shows heart enlargement & fluid in the lungs.

Enlarged heart is compressing on the lung inhibiting full expansion.
2. Echocardiogram: shows ineffective pumping of the heart.
Shows heart wall and valve function.
3. ABG: Respiratory alkalosis early, then metabolic acidosis due to impaired
gas exchange.

4. Elevated BUN: (waste product) in the blood because of decreased renal

perfusion due to decreased cardiac output.
BUN is up because the BP is low, and you need so much BP for the kidneys to
filter.

Right-Sided Heart Failure

The major cause of ® sided heart failure is left sided heart failure.

Exception: MI’s that affect the ® ventricle can cause ® sided heart
failure.

Cor Pulmonale: Condition in which the heart is affected by lung

disease/damage.
PAP: Normal: 20-30 systolic/8-12 diastolic
Exerts increased pressure in the pulmonary artery (comparable to HTN
on the left side)
If PAP is increased, the ® ventricle will have to work harder to get the
blood thru the pulmonary artery b/c there is too much pressure on the other
side.® ventricle enlarges.
Cor Pulmonale means (in a nutshell) ® side failure d/t lung disease:
increased CO2 (vasoconstriction) Peripherial resistance increased: causes
edema Hepatomegaly.

**Lung disease increases carbon dioxide levels in the blood (COPD) and
causes Pulmonary Arterial Vasoconstriction which increases the force in
which the ® ventricle has to pump blood to the lungs-- results in an
enlargement of the ® ventricle (Pulmonary HTN due to vasoconstriction
of the pulmonary artery).
X-ray would show an enlarged ® ventricle.
When the ® ventricle fails, blood backs up in the venous system and you
systemic symptoms-- Peripheral symptoms:
® side heart failure exhibits urinary frequency d/t increased
urinary output.

1. Weight Gain: from edema (heart can no longer circulate the blood so the
body allows it to seep from the intravascular system into tissues to try to get
rid of some circulatory fluid volume. Daily weight!!!!

2. Pitting edema in the feet and ankles. Seems to disappear over night (while
lying flat). it actually redistributes the edema while sleeping. When up and
walking (gravity) you see edema again.

3. Ascites: Fluid in the abdomen.

4. Hepatomegaly: enlarged liver (fluid within the organ)
5. Jugular vein distension: (increased central venous pressure)
Rings may be tight on the fingers due to edema. Abdominal distension
may cause dyspnea, nausea, and vomiting.

Central venous pressure: pressure within the ® atrium. Normal level:

2-7mmHg or 4-10 cm H2O.
Stomach puts pressure on the diaphragm.

S-3 sound is an indication of heart failure in adults. (Ventricular gallop)

S-4 sound is called Atrial gallop: (HTN)
(go to the bathroom many times thru the night)

Diagnostic Findings:

1. Chest X-ray: ® ventricular enlargement.

2. Lung scan and pulmonary autobiography: confirms Cor Pulmonale.

3. Liver enzymes are elevated if ® side heart failure causes liver

abnormalities (Hepatomegaly).
LDH1, LDH2 : Can’t produce clotting factors.

Box 35-1 Estimating Central Venous Pressure

Measure while the client is lying at a 45 degree angle. At least 45 degrees!!

1.Ruler is spaced on the sternal angle & jugular vein distension is
measured by the height on the ruler (see illustration in
book).
2. Add 5 cm to the ruler measurement.

In ® ventricular heart failure, CVP is more than 12 cm of water.

Medical Management of CHF

Goal is to reduce the workload of the heart & improve cardiac output.

1. Limited Activity
Bed rest (maybe with bathroom privileges)
2. Drugs--
Digoxin: given to slow the heart rate and increase the strength
of myocardial contractions.
Lasix
Sedatives (for dyspnea & anxiety)
Aspirin or anticoagulants to prevent thrombi from decreased
circulation.
3. Low sodium diet: Water follows salt--so the more sodium you eat the
more fluid you hold.

Devices used in the treatment of CHF:

Know what it does & what it’s used for
 1. Intra-aortic balloon pump: Increases cardiac output; placed in
aortic arch and connected to a matching synchronized with a ventricular
contraction; inflates during diastole; deflates during systole.

Helps to keep blood going forward so it doesn’t back up. Placed in

aorta inflates during diastole.

2.* (L) Ventricular Blood Pump (Hemopump): Increases cardiac

output; motorized device inserted into the (L) ventricle; pumps blood not
ejected from the (L) ventricle into the descending aorta.
Pumps blood from the left ventricle to the descending aorta.

3. * (L) Ventricular assist Device: increases cardiac output using a

cannula that reroutes blood from the (L) atrium into the aorta (may be used
in client’s awaiting heart transplants).
You are trying to assist the ventricle by removing blood from the left
atria, so it don’t have to go to the ventricle. Takes some of the blood from left
atria and puts it directly into the aorta, bypassing the left ventricle.

Surgical Management

1. Heart Transplants: Adults < 55y; must be transplanted within 6 hours;

Give Sandimmune (action: decreases immune
response) to decrease chance of rejection (EKG
changes= rejection); reverse isolation (suture chambers
in place).
Monitor for infection : WBC increased, Fever (really high); reverse isolation

2. Cardiomyoplasty: Use patient’s back muscle (Latissimus Dorsi

“swimmer‘s muscle“) Wraps it around the heart (ventricles); uses electrical
stimulator to trigger muscle contractions.

Nursing Management

1. Daily weight (same scale, same time), I/O records

2. Digitalization: 1mg over a 24h period. Digoxin then given ONCE daily of
doses 0.125mg or 0.25mg. Has occurred when the heart is receiving
maximum benefits (increased cardiac output); Hold Digoxin if pulse < 60 or
>120 in an adult; < 80 in a child; <100 in an infant.
* Monitor KCL levels; normal level is 3.5-5.3; Hypokalemia (Low KCL)
increases the risk of Digitalis toxicity.
Lasix causes loss of fluid, sodium and potassium.
3. Monitor edema
4. V/S
5. Administer prescribed medications
6. Semi-Fowler’s position to ease breathing
7. Oxygen; report O2 Sat. < 90%
8. Peripheral pulses (edema) if you can’t feel one d/t edema use a Doppler.
9. Elevate Extremities promotes venous return to the heart.
10. No anti-embolic hose (TEDS) pushes blood out of the superficial veins
back into the deeper veins to return to the heart.
11. Assess breath sounds/color of sputum/respiratory rate (when assessing
for (L) side)

12. Monitor lab-- Potassium for diuretics (encourage KCL foods such as
potatoes, OJ, bananas, prunes, raisins)
Potassium-Sparing Diuretics
1. Aldactone
2. Midamor
3. Dyrenum
* Salt Substitutes are high in potassium.
Lasix is classified as a loop diuretic--it depletes potassium.
Mannatol is classified as an osmotic diuretic-- used for head trauma.
Client and Family Teaching

13. Notify MD if 2lb. Weight gain (1 liter of fluid) (weigh every day)
14. Rest periods between activity.
15. Teach Client to take their pulse and blood pressure.
16. Take medication as prescribed.
17. Notify physician if pulse is <60 or >120.

Pulmonary Edema

Compication of left ventricle failure

Fluid accumulates in the lungs; impaired gas exchange; it is an acute

emergency-- may lead to cardiac or respiratory arrest.

S/s
(See left sided heart failure--respiratory S/S)

Diagnostic Findings
Chest X-ray shows pulmonary infiltration
ABG: severe hypoxemia/hypercapnia (high CO2)

Medical Management

1. Digoxin: increases cardiac output

Lasix: decreases circulating volume
Morphine to decrease anxiety/relieve respiratory symptoms (slows
respirations).
Dobutamine: Increases myocardial contraction.

2. Oxygen (via mask)/? Mechanical ventilation?/CPAP

3. VAD
IABP (balloon pump)
Nursing Management

1. IV Access Line

2. Oxygen/ Pulse Ox

3. Suction as needed (PRN)

4. Assess V/S heart rate/rhythm/breath sounds

5. F/C to help assess response to diuretics, and I/O but the best way is daily
weight.

6. HOB elevated

7. If intubated, establish a method of communication (*see nursing

management for CHF).

Add on Notes from Lecture:

*Valsava: bear down and hold breath (Vagal Stimulation) to decrease BP &
Pulse

*Back pain for dissecting or rupturing aneurism (nausea)

* Cardiopulmonary machine (heart/lung machine) used in open heart surgery!

*Does work of the heart & lungs while the heart is stopped (pumps
blood & oxygenates the blood?)
* After cardiac surgery (if they open your chest) it’s normal to have
Hemoglobin In urine. It has to do with the amount of time the heart is
stopped and the machine isn’t as effective as the heart and lungs
and where the machine outside the body it may damage some cells and you
get rid of the hemoglobin in the urine.
* Swanz-Ganz catheter measures CVP
* Give Lasix in the morning, if they have a catheter, can be given anytime.
* Annulosplasty: Repair--tighten valves in fibrous ring (mitral valve)
* Valvuloplasty: Repair-- Balloon opens/stretches the valve (Mitral Valve)
* Commisserotomy: Stick finger in to open valve to stretch it (Mitral Valve)
* No pillows behind the knees (popliteal area) Decreases circulation,
Increases chance for clots formations by pooling blood.
*Arterial clots: S/S: Pain, cold, & pale (keep dependent (down)).
*Weight is the best way to determine fluid volume in the body
* BP and Oliguria: you have to have so much BP for the kidneys to function
correctly.
* Echocardiogram: Wall & Valve Functioning
Depolarization: Sodium goes into the cell & potassium comes out.
Repolarization: Potassium goes into the cell & sodium comes out.