03.03 Heart (Cardiac) Failure Therapeutic Management

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Overview

Therapies for Heart Failure are primarily focused on decreasing volume overload, relieving the stress on the heart, and improving the heart’s ability to pump effectively. In other words, decreasing preload and afterload and increasing contractility.

Nursing Points

General

  1. Assess for modifiable risk factors
    1. CAD, HLD, HTN, DM, Obesity
    2. Diet & Exercise
  2. Causes – severity of risk?
    1. Valve disorders, Hx of MI

Therapeutic Management

Goal to decrease workload on heart while still increasing cardiac output
Pharmacological:

  1. Decrease Preload
    1. Diuretics
      1. Prevent water retention
      2. Furosemide
      3. Bumetanide
      4. Spironolactone
    2. ACE Inhibitors
      1. Block RAAS
      2. Captopri
      3. Lisinopril
  2. Decrease Afterload
    1. ACE Inhibitors
      1. Block RAAS
      2. Captopri
      3. Lisinopril
    2. Angiotensin Receptor Blockers (ARBs)
      1. Block RAAS
      2. Losartan
      3. Valsartan
    3. Vasodilators – for acute exacerbation
      1. Relax smooth muscle, vasodilation
      2. Hydralazine
      3. Isosorbide Dinitrate
  3. Increase Contractility
    1. Cardiac Glycoside
      1. Positive Inotrope
      2. Digoxin
    2. Sympathomimetic
      1. Positive Inotrope
      2. Dobutamine

Surgical:

  1. CABG/PCI – revascularization
  2. Pacemaker / Internal Cardioverter Defibrillator (ICD)
    1. Hx of arrhythmias
    2. EF <25%
  3. Left Ventricular Assist Device (LVAD) –
    1. ↑ cardiac output
    2. Bridge to transplant
  4. Heart Transplant

Nursing Care

  1. Perfusion
    1. Assess peripheral perfusion (skin, pulses, cap refill, edema)
    2. Assess VS
    3. Admin BP meds
  2. Fluid & Electrolyte Balance
    1. Admin diuretics
    2. Strict I&O
    3. Elevate Legs
    4. Na & H2O restriction
    5. Monitor electrolytes
  3. Oxygenation
    1. Head of Bed > 45°
    2. Monitor SpO2
    3. Admin O2 PRN
  4. Functional Ability
    1. Fatigue
      1. Frequent rest periods
      2. Cluster care
    2. Activity Intolerance
      1. Oxygen during activity
  5. Comfort
    1. Chest Pain
      1. PQRST
      2. Meds PRN
      3. 12-Lead EKG
    2. Positioning
      1. HOB > 45°
      2. Elevate Legs

Patient Education

  1. Diet / Lifestyle Changes
    1. Low Sodium Diet
      1. Avoid processed foods / lunch meats
      2. Salt subs = Potassium Chloride
        1. Caution in Renal Failure
    2. Fluid Restriction – <2L/day
    3. Exercise
      1. 30 min, 5 days/wk
      2. Follow Cardiologist Instructions
      3. Activity Tolerance?
    4. No smoking, caffeine, or alcohol
  2. Monitoring
    1. Daily Weights
      1. Same – clothes, scale, time
    2. Monitor BP
    3. Monitor for Edema
  3. Medication Instructions
    1. Med Changes
    2. New meds
    3. Orthostatic Hypotension – stand slowly
    4. S/S med toxicity or intolerance
    5. Bleeding precautions PRN
  4. Call HCP
    1. Weight gain — 2 lbs / day or 5 lbs / wk
    2. Crushing CP
    3. Severe SOB
    4. Severe Edema

Reference Links

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Video Transcript

So now we’re going to talk about the therapeutic management and nursing care of patients with heart failure.

We said before that you’re going to see heart failure a lot in clinical practice. I personally don’t think it gets enough stress or importance in the public. The reality is the mortality rate is higher than some cancers! So it’s important that you know how to care for these patients!

Now we’re not going to talk in much detail about the medical management because I want to focus on nursing care, but what I want you to see here is that the general goal for medical management of heart failure is to reduce the stress on the heart and still be able to increase the cardiac output. The three things were going to try to do are to decrease preload, decrease afterload, and increase contractility. This will help take some of the congestion load off of the heart, reduce the force that has to push against, and make that contraction effort a little bit stronger.

Now, there are quite a few drugs and even surgical procedures we can use to accomplish this goal. You can check out the outline in this lesson or the pharmacology course for more details! But for now, let’s zoom in on just the most important things for you to know.

For decreasing preload, the best option is diuretics – remember when you think preload it’s that volume stretching out the heart muscle – so we need to get rid of some of that volume! Furosemide is the most common diuretic we use – it will get rid of volume and ease some of that stretch on the heart. Just make sure you have a potty plan because they’re gonna make a LOT of urine.

For decreasing afterload, we’ll look at ACE inhibitors. This is part of breaking that RAAS cycle of death I was talking about in the last lesson – it can also help relieve some of the volume overload, but the big thing it does is allow for vasodilation! This helps to decrease the afterload so the heart doesn’t have to push against such high pressure. The big caution here is orthostatic hypotension, so keep an eye out for that and stand your patients up slowly.

Then for increasing contractility, the number one drug class we see is cardiac glycosides – the best example is Digoxin. It helps increase the force of contraction on the heart and slows it down. So instead of a fast weak pump, we have a slow strong deliberate pump. It makes it much more efficient. Just make sure you’re checking the patient’s apical pulse for a full minute prior to giving Digoxin and don’t give it if it’s less than 60 bpm, because it will slow it down.

When it comes to nursing care we can categorize our interventions based on Concepts, then we just implement what’s applicable to our individual patient. Some of the main concepts are perfusion, fluid and electrolyte balance, elimination, comfort, functional ability, and oxygenation. These are relatively self-explanatory, but, let’s look at each of these concepts individually and figure out what the most important thing is that we need to do for them as the nurse.

First is perfusion. We know that this patient has significant perfusion issues considering their heart isn’t pumping correctly. So what are our most important assessments? Well, peripheral perfusion, right? We assess things like skin color, temperature, pulses, capillary refill, etc. Since it’s perfusion, we can also assess their Vital Signs. We’ll also be giving blood pressure medications as ordered. Always be looking for any changes in the signs of poor perfusion, that may be the first indicator you have that the patient is getting worse.

Let’s talk fluid & electrolytes. We know these patients tend to be volume overloaded because of the congestion within their heart, but also the kidneys are trying to compensate by retaining more water. We will maintain strict intake and output measurements, as well as a strict sodium and water restriction to keep it from getting worse. Their legs will have that dependent peripheral edema, so we want to make sure to elevate their legs. We will also perform daily weights – same time, same scale, same clothes. We do this because we know that 1 kg of body weight is equivalent to 1 L of fluid retained. Getting a daily weight can show us if they’re retaining more fluid. And then, we will be giving diuretics, too. Keep in mind when you’re giving patients diuretics that you need a potty plan. Make sure their call light is in reach, maybe have a bedside commode next to their bed. For male patients, I always recommend having two urinals available for them because they will make quite a bit of urine in a short amount of time.

When it comes to heart failure patients, oxygenation is a huge issue. Lungs that are full of fluid don’t oxygenate well. So we need to listen to their lungs, monitor their O2 sats and give supplemental oxygen as needed. We can also raise the head of the bed to help them breathe a bit easier. When you think of oxygenation issues in heart failure patients, I want you to also consider functional ability. Functional ability just refers to the patient’s ability to perform daily tasks and to take care of themselves. Since these patients tend to have a lot of difficulty breathing and are usually quite fatigued, they tend to find it harder to do the normal day-to-day tasks. We need to encourage them to take frequent rest periods, eat multiple smaller meals throughout the day, and utilize any breathing exercises as necessary to relieve their shortness of breath.

When it comes to heart failure patients, oxygenation is a huge issue. Lungs that are full of fluid don’t oxygenate well. So we need to listen to their lungs, monitor their O2 sats and give supplemental oxygen as needed. We can also raise the head of the bed to help them breathe a bit easier. When you think of oxygenation issues in heart failure patients, I want you to also consider functional ability. Functional ability just refers to the patient’s ability to perform daily tasks and to take care of themselves. Since these patients tend to have a lot of difficulty breathing and are usually quite fatigued, they tend to find it harder to do the normal day-to-day tasks. We need to encourage them to take frequent rest periods, eat multiple smaller meals throughout the day, and utilize any breathing exercises as necessary to relieve their shortness of breath.

Heart failure patients have a lot of things to remember and look out for, we need to make sure they understand their discharge teaching. You can refer to the outline in this lesson for a detailed list, but let’s review really quickly the most important things these patients need to know. They will have to make diet and lifestyle changes, the most significant of which being a low sodium diet. They will need to do some self monitoring, especially daily weights. Again, it should be done at the same time, on the same scale, and in the same clothes. They will need medication instructions, specifically what meds to stop, instructions for new medications, and any precautions they should take. Then, they need to know what to report to their provider. That would be chest pain, sudden severe shortness of breath, or significant weight gain. That’s more than 2 lbs in a day or more than 5 lbs in a week. Remember – one kg of body weight is equivalent to 1 L of fluids – so if they gained 2 lbs in a day, they’ve actually gained an entire Liter of fluid! That’s why it’s so important that they weigh daily and report it.

So let’s quickly recap what we learned about therapeutic management of heart failure patients. Remember that the overall goal of medical management is to decrease preload, decrease afterload, and increase contractility, so that we can improve cardiac output. The main medications we use for that are diuretics, ACE inhibitors, and drugs like Digoxin. When it comes to nursing care, keep the concepts in mind that apply to heart failure and choose interventions that are appropriate to your patient. And of course always include patient education as one of your priorities for heart failure patients. They have a lot of responsibility so we need to make sure they’re empowered.

I hope this helps you to see the big picture for heart failure patients. Be sure to check out the case study attached to this lesson to see what this would look like in a patient who is experiencing a heart failure exacerbation. These case studies are great ways to learn how to think critically about what your patients might need.

We love you guys, go out and be your best selves today. And as always, happy nursing!

Read more

  • Question 1 of 10

A patient with heart failure has a new prescription for digoxin (Lanoxin). The nurse is giving this patient more information. What should be included as part of teaching this patient about digoxin? Select all that apply.

  • Question 2 of 10

A patient with heart failure is being treated for exacerbation of symptoms. The physician has ordered a dose of milrinone to be given IV. Which best describes a property of this type of medication?

  • Question 3 of 10

A patient with acute decompensated heart failure has been prescribed intravenous diuretic medications to control fluid and congestion. Which nursing intervention would the nurse need to perform in order to best monitor fluid and electrolyte balance in this patient?

  • Question 4 of 10

A nurse is discussing dietary intake for a patient with symptomatic heart failure. Which of the following foods should the nurse tell the patient to avoid?

  • Question 5 of 10

A patient with heart failure has a new prescription for furosemide. Which information would the nurse include as part of teaching this patient about Lasix? Select all that apply.

  • Question 6 of 10

A client has been admitted to the cardiac unit with exacerbation of heart failure symptoms. The nurse has given him a nursing diagnosis of decreased cardiac output related to heart failure, as evidenced by a poor ejection fraction, weakness, edema, and decreased urinary output. Which of the following nursing interventions is the most appropriate in this situation?

  • Question 7 of 10

The nurse is caring for a client with a history of congestive heart failure (CHF). While reviewing his medications with the nurse, the client asks for help identifying which medication is for CHF. The nurse knows that which of the following medication is used to treat this condition?

  • Question 8 of 10

A patient who is in the cardiac unit and who suffers from heart failure has been given a dose of enalapril IV. What effect should most likely occur after administration of this drug?

  • Question 9 of 10

The nurse is caring for a client taking lisinopril. The nurse knows that this medication works by doing which of the following? Select all that apply.

  • Question 10 of 10

The nurse is caring for a client with a cardiac diet ordered. This client should choose foods that are low in which of the following? Select all that apply.