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Congestive Heart Failure Management

Katie Anderson Nursing English

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Medication Therapy
- Wolters Kluwer Clinical Drug Information. (2018). Lexicomp online. Retrieved February 16, 2018, from https://online-lexi-com.eztest.ocls.ca/lco/action/home?siteid=1
  - Angiotensin Converting Enzyme (ACE) Inhibitors
    - Produce vasodilation (reduction in BP) by inhibiting formation of angiotensin II
    - Monitor For: hypotension, cough, hyperkalemia, deteriorating renal function, neutropenia (captopril)
    - Symptom Management: BP, tissue perfusion, cardiac workload, increased activity tolerance
  - Calcium Channel Blockers (CCB)
    - Produce vasodialtion by Inhibiting uptake of the calcium ion in smooth muscle (cardiac & peripheral)
    - Monitor For: Increase in chest pain, hypotension, peripheral edema, may reduce coronary perfusion
    - Symptom Management: BP, tissue perfusion, cardiac workload, increased activity tolerance
  - Nitrates
    - By relaxing the smooth muscle, vasodilation occurs promoting oxygen supply to the tissues
    - Monitor For: hypotension, dizziness, abdominal pain, weakness, dyspnea
    - Symptom Management: BP, tissue perfusion, cardiac workload, increased activity tolerance
  - Angiotensin Receptor Neprilysin Inhibitor (ARNI)
    - Inhibits Neprilysin resulting in the increase of BNP and bradykinin allowing for vasodilation
    - Monitor For: Orthostatic hypotension, dizziness, falls, cough, hyperkalemia, hypercreatinemia
    - Symptom Management: BP, tissue perfusion, cardiac workload, increased activity tolerance
  - Mineralocorticoid Receptor Antagonists (MRA)
    - Competitive binding at the aldosterone dependent sodium potassium exchange site in the kidney
    - Monitor For: Gynacomastia, ED, hepatotoxicity, increased BUN, lethargy, hyponatremia
    - Symptom Management: BP, tissue perfusion, cardiac workload, increased activity tolerance, potassium sparing properties
  - Cardiac Glycosides
    - Increase intracellular sodium and availability of calcium ions, results in improved contractility increasing cardiac output
      - Dougherty, C. M. (1985). The nursing diagnosis of decreased cardiac output. The Nursing clinics of North America, 20(4), 787-799.
        Symptom Management: Arrhythmia, increased tissue perfusion, decrease in fatigue, increased activity tolerance, decreased anxiety
    - Monitor For: HR <60bpm, bradycardia, atrial tachycardia, 1st/2nd/3rd degree heart block, dizziness, nausea, vomiting, mental disturbances, headache
    - Lab Values: Ensure therapeutic levels are within range to ensure optimal treatment impact
  - Beta Blockers
    - Block the effects of epinephrine, resulting in a decrease in contractility and heart rate decreasing blood pressure
    - Monitor for: bradycardia, heart failure, chest pain, confusion, ED, constipation, lethargy
    - Symptom Management: BP, tissue perfusion, cardiac workload, increased activity tolerance
  - Angiotensin II Receptor Blockers (ARBs)
    - Monitor For: hypotension, hyperkalemia, hyperglycemia, hypercreatinemia, anxiety, parathesia
    - Blocks the action of Angiotensin II, resulting in vasodialtion and hypotension
    - Symptom Management: BP, tissue perfusion, cardiac workload, increased activity tolerance
  - Diuretics
    - Block the reabsorption of sodium, increasing urine output, assisting in decreasing blood pressure
    - Monitor For: Hypokalemia, hypotension, hyperglycemia, headache, dizziness, restlessness
    - Symptom Management: Hypertension, hyperkalemia, dyspnea, ascites, fatigue, improved appetite, decreased peripheral edema (adventitious sounds), cough, increased activity tolerance
  - Opiods (Palliative)
    - Inhibit neurotransmitter release, resulting in ananalgesic effect
    - Monitor for : Increased drowsiness, respiratory depression, headache, constipation, nausea, vomiting
    - Symptom Management: Decreased WOB and pain
Nutrition
- Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Camera, I. (3rd ed.). (2014). Medical- Surgical Nursing in Canada. Toronto, Canada: Elsevier.
  - Diet
    - Low Sodium
      - <1.5-2.0g
      - Reduces hypertension
      - Reduces fluid retention
      - Avoid processed foods
    - Low Cholesterol
      - Decreases hypertension
      - Meats low in saturated fats
      - Decrease risk of MI and plaque formation
      - Fresh fruits and vegetables
    - Avoid alcohol
    - Restrict fluid intake
      - 1.5-2.0 L
      - Reduce fluid retention
        Signs & Symptoms
        SOB
        Edema
        Crackles
        Restlessness
        Anxiety
        Change in LOC
        Weight gain
        Ascites
        Interventions
        Monitor urine output
        Indicates fluid retention
        Assess need for indwelling catheter
        Congestive Heart Failure (CHF) Nursing Care Plan & Management. (2017, July). Retrieved March 03, 2018, from https://www.rnpedia.com/nursing-notes/medical -surgical-nursing-notes/congestive-heart-failure-chf/
        Auscultate lung sounds Q2h
        Assess sputum production Q2h
        monitor VS Q4h
        Assess for JVD
        Monitor edema
        Peripheral
        Ascites
        Reposition Q2h; Assist into high-fowlers
        Decrease stress on heart & lungs
        Q24h weight
        1kg = 2L of fluid
        Gain of 2+ lbs maintained over 48+ hrs indicates retention
        Monitor Lab Results
        K+
        3.5-5.0 mmol/L
        High: Acute or chronic renal failure, Addison's disease, dehydration, diabetic ketosis, excessive dietary/IV intake, massive tissue destruction, metabolic acidosis
        Low: Burns, Cushing's syndrome, deficient dietary or IV intake, diarrhea (severe), diuretic therapy, GI fistula, insulin administration, pyloric obstruction, starvation, vomiting
        Element in resting membrane potential of neurons, maintenance of cardiac rhythms, conduction of nerve impulses and smooth muscle contraction
        Na+
        Low: Addison's disease, decreased sodium intake in dietary or IV intake, diabetic ketoacidosis, diuretic therapy, excessive loss from GI tract, excessive perspiration, water intoxication
        High: Corticosteroid therapy, dehydration, impaired renal function, increased sodium intake in diet/IV, primary aldosteronism
        135-145 mmol/L
        Impacts the intra and extracellular fluid balance, nerve impulses, and the acid-base balance
        Creatinine
        High: Anemia, leukemia, muscular atrophy, salmonellosis
        7.1-17.7 mmol/day
        Low: Renal disease
        Byproduct of muscle breakdown (creatinine phosphate) excreted through the kidneys
        Brain Natriuretic Peptide
        High: Congestive heart failure, MI, hypertension, cor pulmonale
        A peptide which causes natriuresis, reducing fluid retention
        <100 ng/L
        Troponin
        Contractile proteins released following an MI, sampling often done in conjunction with CK-MB and ECGs.
        <0.5mcg/L is negative for myocardial injury, >2.3mcg/L indicates myocardial injury
        High: Cardiac muscle damage, (MI, myocarditis or pericarditis), chronic renal failure, multiorgan failure, severe heart failure
        BUN
        High: Burns, dehydration, GI bleeds, increase in protein catabolism (fever, stress), renal disease, shock, urinary tract infection
        Low: Fluid overload, malnutrition, severe liver damage, SIADH
        Determines the kidneys' ability to properly excrete waste
        3.6-7.1 mmol/L
        ABG
        Indicate balance or imbalance in the oxygen, carbon dioxide, and pH levels within the blood
        Metabolic alkalosis; ineffective bicarbonate excretion through the kidneys with elevated pH
        Respiratory Alkalosis: ineffective alveolar ventilation leading to a decreased partial pressure ( PaCO2)
        Urso, C., Brucculeri, S., & Caimi, G. (2015). Acid–base and electrolyte abnormalities in heart failure: pathophysiology and implications. Heart Failure Reviews, 20(4), 493–503. http://doi.org/10.1007/s10741-015-9482-y
        Most commonly metabolic or respiratory alkalosis impacts patients in heart failure, however they can experience any form or combination of blood gas imbalances
        pH (7.35-7.45) PCO2 (34-45) PO2 (83-108) HCO3 (21-28)
        Monitor LOC
    - High Calorie
      - Facilitate metabolic needs
Education
- American Heart Association. (2018). (n.d). Classes of Heart Failure. Retrieved March 03, 2018, from http.//www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeart Failure/Classes-of-Heart-Failure_UCM_306328_Article.jsp#.WpBeEyMZPR0
  - NYHA Scale
    - NYHA Class 1: No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath).
    - NYHA Class 2: Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).
    - NYHA Class 3: Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea.
    - NYHA Class 4: Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.
- Cardiac Care Network. (2014). Strategy for community management of heart failure in Ontario. Retrieved February 16, 2018, from http://www.ccn.on.ca/ccn_public/uploadfiles/files/ Strategy_for_Community_Mgmt_in_HF_in_ON.pdf
  - Patient Supports
    - Linkages to outpatient services through the hospital and in the community to ensure care integration and connection across the system
      - Support for collaborative care with patient and family to recognize changes in condition and promote independent self-care
    - Interdisciplinary teams to promote holistic care
    - In Home Suppport
      - CHF patients often need home care support
        CCAC facilitates care services
        Nursing
        Heart failure specialist
        Health teaching
        Disease process
        Medication management/ compliance
        information about community resources
        PSW
        Assist with ADLs
        Social work
        Family and patient supports
        Physio/OT
        Assist with exercise techniques
        Teach energy conservation techniques
        Palliative care
        Comfort measures
        Family meetings
        Pharmacy
        Medication changes
        Dosettes
        Speech language pathology
        Swallowing tests
        Dietary
        High calorie
        low sodium
        Fluid restriction
    - LTC
      - Care management
        Medication
        Dietary
        Rehab
        Patient care needs/ADLs
    - Cardiac Rehabilitation
      - nutrition counselling
      - Smoking cessation
      - Stress management
      - Exercise classes
Exercise & Mobility
- Respiratory
  - Hammond, M. D., Bauer, K. A., Sharp, J. T., & Rocha, R. D. (1990). Respiratory muscle strength in congestive heart failure. Chest, 98(5), 1091-1094.
    - Reduced strength and endurance of muscle tissue resulting in respiratory failure
      - Adventitious Sounds
      - Pleural edema
      - Promote deep breathing and coughing
        Expell phlegm
    - Respiratory muscle weakness
      - Increased WOB
      - Fatigue
    - Decreased perfusion to respiratory tissues
      - Increased oxygen demands
- Energy Management
  - Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Camera, I. (3rd ed.). (2014). Medical- Surgical Nursing in Canada. Toronto, Canada: Elsevier.
    - Encourage alternating periods of rest and activity
      - Teach self-care techniques to minimize energy consumption
        Reduce energy consumption and O2 demands
        Pace yourself and take breaks
      - Promote relaxing activities to provide distraction
        Decreases HR and BP, reducing stress on the heart
    - Encourage clients to have meals up in the chair
      - Prevention of DVT
      - Pressure Ulcer Prevention
    - Monitor Response to Activity
      - Vital signs
      - Helps to determine activity tolerance

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Description: Nursing Mind Map on Congestive Heart Failure Management, created by Katie Anderson on 04/03/2018.
Created by: Katie Anderson
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Congestive Heart Failure Management

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