Nursing School Week by Week

Heart Failure

December 03, 2021 Melanie Season 2 Episode 7
Nursing School Week by Week
Heart Failure
Show Notes Transcript

Even as nursing students in clinicals, we see so many patients affected by heart failure. This is definitely a biggie, and one you need to know. Today I'm breaking it down, and hitting the highlights of what you need to know as a nursing student about heart failure.

Picmonic has some great resources to help you remember Heart Failure during test time. Click this link to check out Picmonic for free, or to get 20% off a subscription: https://www.picmonic.com/viphookup/nursingschoolweekbyweekLIK21

So, what is heart failure? Well, it is NOT when the heart stops. That would be cardiac arrest. Heart failure is when the heart isn’t pumping enough blood for your body. And this is either because the heart ventricle isn’t able to fill up all the way, or it’s too weak to pump the blood out once it’s filled up. The main cause of heart failure is hypertension over a long period of time, but it could also be caused by a heart attack that causes part of the heart muscle to die, or a problem with the valves of the heart. There are other causes as well, but you’re probably not gonna be tested on that, so, moving on. 

Alright, so if the heart is not pumping as much blood out, that means what essential thing is not getting to the tissues? That’s right, oxygen. And when there’s not enough oxygen circulating throughout your body, there’s one organ that is gonna notice right away. She’s kind of a spoiled little diva, this one. She’s the kidney. And the kidneys are going to sense this lack of oxygen, but interpret it as low blood pressure. So they’re gonna do what they can to increase the blood pressure. What’s one of the main ways we increase blood pressure? By increasing the blood volume. And if you’ll remember back to your anatomy class, the kidneys increase the blood volume by activating the Renin Angiotensin Aldosterone system and this is gonna make the body retain fluids. The kidneys think they’re helping, but they’re really just making things worse, because now the patient is fluid overloaded. So, when you think of heart failure, that starts with an H and an F. I want you to think “high fluids”. HF, Heart Failure equals “high fluids”. 

There are two types of heart failure you need to know. Left-sided and right-sided. Left-sided is the most common and this happens when there’s something wrong with the left ventricle. And remember, this means either the ventricle isn’t filling up all the way during diastole, or it isn’t getting all the blood out with that systolic contraction. Either way, it means the blood is gonna back up into the lungs. Because think about how the blood flows through the heart. The unoxygenated blood goes into the right side of the heart, then is pumped to the lungs where it exchanges CO2 for yummy oxygen and then it goes to the left side of the heart to be pumped up through the aorta and out to the whole body. So, if the left ventricle isn’t able to send that blood along that it just got from the lungs, then that blood is gonna back up into the lungs. So I want you to think of the L in Left Sided heart failure like the L for Lungs. Left-sided heart failure equals Lungs, cause we’re gonna see a lot of pulmonary symptoms with left sided heart failure.

The three main signs and symptoms to remember for Left-sided heart failure are: Crackles in the lungs, pink frothy sputum, and orthopnea, which is shortness of breath when lying down flat. So these patients will often tell you they have to prop themselves up on multiple pillows to sleep at night, or they may even sleep in a recliner because it helps them breathe. 

The other type of heart failure, Right-sided heart failure is when the right ventricle isn’t contracting effectively. And it’s easy to remember what kinds of signs and symptoms you’re gonna see with right-sided heart failure if you think about where the blood is coming from that goes into the right atrium. It’s coming from

Hey you guys! Welcome back to the Nursing School Week by Week Podcast. I’m your host, Melanie, and today we’re talking about heart failure. But real quick, I just gotta say how excited I am right now because the Podcast has been listed by Feedspot as one of the top 10 nursing school podcasts on the web! And that is so cool. It’s things like that, and reading all of your reviews that keep me going with this. In fact, I’m talking about heart failure today because you guys requested it.

Alright, so what is heart failure? Well, it is NOT when the heart stops. That would be cardiac arrest. Heart failure is when the heart isn’t pumping enough blood for your body. And this is either because the heart ventricle isn’t able to fill up all the way, or it’s too weak to pump the blood out once it’s filled up. The main cause of heart failure is hypertension over a long period of time, but it could also be caused by a heart attack that causes part of the heart muscle to die, or a problem with the valves of the heart. There are other causes as well, but you’re probably not gonna be tested on that, so, moving on. 

Alright, so if the heart is not pumping as much blood out, that means what essential thing is not getting to the tissues? That’s right, oxygen. And when there’s not enough oxygen circulating throughout your body, there’s one organ that is gonna notice right away. She’s kind of a spoiled little diva, this one. She’s the kidney. And the kidneys are going to sense this lack of oxygen, but interpret it as low blood pressure. So they’re gonna do what they can to increase the blood pressure. What’s one of the main ways we increase blood pressure? By increasing the blood volume. And if you’ll remember back to your anatomy class, the kidneys increase the blood volume by activating the Renin Angiotensin Aldosterone system and this is gonna make the body retain fluids. The kidneys think they’re helping, but they’re really just making things worse, because now the patient is fluid overloaded. So, when you think of heart failure, that starts with an H and an F. I want you to think “high fluids”. HF, Heart Failure equals “high fluids”. 

There are two types of heart failure you need to know. Left-sided and right-sided. Left-sided is the most common and this happens when there’s something wrong with the left ventricle. And remember, this means either the ventricle isn’t filling up all the way during diastole, or it isn’t getting all the blood out with that systolic contraction. Either way, it means the blood is gonna back up into the lungs. Because think about how the blood flows through the heart. The unoxygenated blood goes into the right side of the heart, then is pumped to the lungs where it exchanges CO2 for yummy oxygen and then it goes to the left side of the heart to be pumped up through the aorta and out to the whole body. So, if the left ventricle isn’t able to send that blood along that it just got from the lungs, then that blood is gonna back up into the lungs. So I want you to think of the L in Left Sided heart failure like the L for Lungs. Left-sided heart failure equals Lungs, cause we’re gonna see a lot of pulmonary symptoms with left sided heart failure.

The three main signs and symptoms to remember for Left-sided heart failure are: Crackles in the lungs, pink frothy sputum, and orthopnea, which is shortness of breath when lying down flat. So these patients will often tell you they have to prop themselves up on multiple pillows to sleep at night, or they may even sleep in a recliner because it helps them breathe. 

The other type of heart failure, Right-sided heart failure is when the right ventricle isn’t contracting effectively. And it’s easy to remember what kinds of signs and symptoms you’re gonna see with right-sided heart failure if you think about where the blood is coming from that goes into the right atrium. It’s coming from the inferior and superior vena cava, which gets blood from all over the body. So, if the right ventricle isn’t pumping the blood along to the lungs, then it’s going to back up throughout the whole body and we’re gonna see a lot of edema. So just like you think Left-sided heart failure equals Lungs, I want you to think Right-sided heart failure equals the Rest of the body. So, Left-sided equals lungs, and Right-sided equals the Rest of the body. 

The four signs you need to remember for Right-sided heart failure are: #1: Peripheral edema (so, swelling of the hands and feet), #2, Jugular vein distention, or JVD. This is when you have the patient turn their head to the side a bit and look for a bulging neck vein. The #3 sign is Ascites, or fluid buildup in the abdomen, and #4 is weight gain. So once again, the 4 signs you need to know for right-sided heart failure are peripheral edema, JVD, ascites, and weight gain. And as far as the weight gain goes, anything over 3 lbs gained in 1 day, or 5 lbs in a week is indicative of right-sided heart failure. 

So, beyond a physical assessment of the patient, how do we know they are in heart failure? There are three diagnostic tests we use to tell. The echocardiogram, hemodynamic monitoring, and the b-type natriuretic peptide, or BNP. The echocardiogram uses sound waves to make an image of the heart and it also gives us the ejection fraction of the heart. The ejection fraction is the percentage of blood that’s pumped out with each contraction. A normal healthy heart will have an ejection fraction, or EF of 55-70%. But the ejection fraction for someone with heart failure will be 40% or less. So, let’s say poor Bob has an ejection fraction of 35%. This means that only 35% of the blood being filled in his left ventricle is actually being pumped out. The second diagnostic test, hemodynamic monitoring, uses a catheter that’s placed in a vessel that directly measures the pressures, including the central venous pressure, or the blood pressure in the vena cava. A normal CVP, or central venous pressure is between 2-8. Anything over eight is indicative of heart failure or fluid retention. 

The last diagnostic test for heart failure is the BNP, or b-type natriuretic peptide. BNP is a hormone that’s released by the heart ventricles when they’re being stretched open. The more the heart is stretched and the harder it’s having to work, the more BNP will be found in the blood. A BNP of anything over 100 is abnormal. 100-600 is mild, 600-900 is moderate, and anything over 900 is severe heart failure. 

So, how do we treat heart failure? What can we do for these patients? We’re going to treat heart failure with medications and diet restrictions. One 1st line medication is diuretics. These patients are fluid overloaded because their kidneys have activated that Renin Angiotensin Aldosterone system which is causing them to hold onto any fluids they get. So the doctor’s gonna order diuretics, such as furosemide to help the kidneys release that water. But remember, with loop and thiazide diuretics, these will also cause the body to get rid of potassium, so we’re gonna need to keep a close eye on the patient’s potassium levels to make sure they don’t become hypokalemic. This is why you may see the doctor order a potassium-sparing diuretic, such as Spironolactone along with a loop or thiazide diuretic, in order to balance out that potassium level, and keep it within a normal range of 3.5-5.

Another 1st line treatment is ACE inhibitors, and are often prescribed with beta blockers. ACE inhibitors end in “pril”, like Lisinopril and they block the conversion of angiotensin 1 to angiotensin 2, so they’re gonna to stop the body from retaining fluids by blocking the Renin Angiotensin Aldosterone system. One side effect to remember with ACE inhibitors, is they can sometimes cause a dry nagging cough, in which case, the patient would probably be switched to an ARB, or Angiotensin II receptor blocker. These end in “sartan”, like Losartan.

So, the main medications prescribed for heart failure are: diuretics, ACE inhibitors, ARBS, and Beta blockers. Digoxin used to be prescribed a lot because it makes the heart contraction stronger, but we don’t see it as much anymore because the drug level can build up in the blood, especially if the patient has low potassium, and have toxic effects. Just remember, “digoxin is a toxin.” Also, know the normal digoxin level is 0.5-2.0, so anything over 2.0 is considered digoxin toxicity. If the patient does have digoxin toxicity, they may get vision changes, and see yellowish-green halos. As the nurse, you would hold the next dose of digoxin, notify the provider, and expect to be giving the antidote, Digibind.

Most of you probably use Picmonic, and they have a really good story and picture to help you remember these medications as part of their “Heart Failure Interventions” picmonic. I’m gonna play just a little clip of it here for you.

Once you look at the picture that goes along with that picmonic, it’ll make more sense to you. If you don’t have Picmonic, you should definitely check it out, and I’ll put a link in the show notes so you can save 20%.

Alright, What are some nursing interventions that we can do for our patients with heart failure? This is where the majority of your test questions are going to come from, so listen up. We can raise the head of their bed to 45 degrees, or high Fowler’s position. Remember, these patients often have orthopnea, or shortness of breath when they’re lying down, but it goes away if they can stay in an upright position, so keep the head of the bed at a 45 degree angle.  We can give them supplemental oxygen if their oxygen saturation drops below 90%, as long as there’s a doctor’s order for it.  We can have them wear compression stockings and elevate their legs on pillows in order to decrease some of the swelling in their feet. Also, because their feet are swollen, and because of the medications they’re on, we want to implement fall precautions and have them change positions slowly because they may have orthostatic hypotension, and we don’t want them passing out on us. They’re probably going to have a Foley catheter in because the diuretics are making them pee like crazy and they don’t have the energy to be getting up to go to the bathroom every 20 minutes. So we need to make sure we’re doing peri care and keeping the Foley line clean, as well as keeping the drainage bag below the level of the bladder to prevent an infection.

Remember, when we think of heart failure, we’re thinking High Fluids. Heart failure, High Fluids. So we’re gonna restrict their fluid intake and their sodium intake. We limit their sodium, or salt intake because where sodium goes, water follows, and we do not want them retaining any more water. So we’re gonna limit their fluids to 2 liters a day, and their sodium to 2 grams a day. 2 grams of sodium is not much. We need to make sure the patient isn’t eating packaged foods, since most packaged and canned foods are high in sodium. So, no chips, cans of soup, or salad dressing. Also, no over the counter medications, like cold medicine, TUMS, or NSAIDS, since these have sodium in them as well.

We’re also going to weigh these patients daily, every morning on the same scale to make sure they’re losing weight, not gaining it. And remember, we get worried if they gain more than 3 lbs in a day, or 5 lbs in a week.

We’re also going to keep a close eye on their labs, specifically their potassium level, their BNP, or b-type natriuretic peptide, and their digoxin level, if they’re on digoxin. We want to see the potassium level between 3.5-5; for the BNP, we want to make sure it’s not increasing; and the digoxin level needs to stay under 2.0.

And then finally, we want to assess, assess, assess. We’re assessing the patient with heart failure for any worsening symptoms. Can we hear more crackles when we auscultate their lungs? Do they have worsening pitting edema in their legs? Is their abdominal girth larger around? Is their blood pressure or heart rate going up? Any of these things would be bad and might indicate a need for a change to their treatment plan.

Alright, you guys. That’s about all you need to know about heart failure. I hope you go forth and rock your tests, and if you think of a topic you’d like me to talk about over the holiday break, you can let me know by writing it in as a review on Apple podcasts, Spotify, or whatever podcast provider you use. Alright, have a great week, and I’ll talk to you soon.