1. Case Study

2. What is Heart Failure?
Heart Failure is a condition that causes
the muscle in the heart wall to slowly
weaken and enlarge, which prevents the
heart from pumping enough blood to
your body.

3. Incidence and prevalence
• One of the most common reasons that people age
65 and older go to the hospital.
• HF affects about 5.1 million Americans
• One in NINE deaths in 2009 included HF as a
contributing cause

5. Incidence and prevalence
• Men more likely to die than women from HF (over
age of 55)
• 71% Men died over a 15 year period from HF
• 39% Women died over a 15 year period from HF

6. Healthcare Cost
• HF costs the nation $32 BILLION each year.
Includes health care costs, medications and
missed days of work.

7. Genetics?
• Genes for cardiomyopathies
• Genes for myocyte contractility
• Neurohumoral receptors

9. Heart Failure Video
• http://www.youtube.com/watch?v=GnpLm9fzYxU

10. Heart Failure BINGO
• Cross off “HEART” Bingo squares as you hear the HF signs or
symptoms
• FREE box in the middle HEART FAILURE
• When you get a row (up, down, across or horizontally) you have
to stand up and say “I have Heart Failure”
• You must then tell everyone your signs and symptoms of HF
• Questions?

21. J.M.’s Lab results
Patient
Normal results
Na: 136 mmol/L
135 - 148
K: 5.2 mmol/L
3.5 – 5
BUN: 15 mg/dl
7 – 18
Creatinine: 1.8 mg/dl
0.7 – 1.3
Glucose: 82 mg/dl
70 - 110
CI: 95 mmol/L
98 – 106
WBC: 4.4 thou/cmm
5 – 10
Hgb: 10.5 g/dl
13.5 – 17.5
Hct: 31.4%
40 – 54%
Platelets: 229 thou/cmm
150 - 350
Case Study Internal Care Clinic

22. Lab Value Note…
The hemoglobin and hematocrit levels might be
falsely decreased because of hemodilution of HF.

27. What other classes of meds could be prescribed?
• Inotrope (digoxin) - to increase cardiac contractility and CO
• Vasodilator (ACE inhibitor) – to increase organ perfusion and
coronary artery perfusion
• Beta Blockers – Help open up BV and slow down HR
• ARB – Prevents vasoconstriction from Angiotensin II keeping
the BP from rising

28. Banana vs. K Supplement
To get the same amount of K from a banana that
the supplement provides, he would have to eat a
banana that is 4 feet long!
The supplement
also comes in a
drink form.

29. Lifestyle Modifications
•
•
•
•
•
•
•
Gradually increase exercise
Minimize stress
Learn to take pulse
Avoid very hot or very cold environments
Report 2-5lb weight gain over 1-4 days
Take medications faithfully
Carefully monitor salt intake

30. BAD salty foods

31. A Registered Dietician
J.M. needs to be educated on the foods that are high in
sodium. He obviously does not understand that some foods
are high in sodium even without adding salt.
A RD can provide information and teach J.M. how to read
food labels, and make low-sodium food modifications.

34. Nursing Diagnoses
Activity Intolerance r/t fatigue, generalized
weakness, lack of adequate oxygenation aeb
client’s SOB climbing the stairs to his bedroom
and his need to lie down and rest (“put his feet
up”) at least an hour twice a day.

35. Activity Intolerance Interventions
• When appropriate, gradually increase activity.
• Monitor the client and report the client’s ability to tolerate activity: note
pulse rate, blood pressure, monitor pattern, dyspnea, use of accessory
muscles, and skin color before, during, and after the activity.
• Encourage routine low-level exercise periods such as a daily short walk or
chair exercises.
• Refer to medical social services as necessary to assist the family in adjusting
to major changes in pattern of living because of activity intolerance.

36. Nursing Diagnoses
Decreased Cardiac Output r/t impaired cardiac
function and altered heart rate aeb tachycardia,
(pulse of 105), orthopnea, prolonged capillary
refill, edema, and fatigue.

37. Decreased CO Interventions
• Monitor and report presence and degree of symptoms including dyspnea at rest
or with reduced exercise capacity, orthopnea, paroxysmal nocturnal dyspnea,
nocturnal cough, distended abdomen, fatigue, or weakness.
• Place client in semi-fowler’s or high fowler’s position with legs down or in a
position of comfort.
• Check blood pressure, pulse, and condition before administering cardiac
medications such as ACE inhibitors, ARBs, digoxin, and beta blockers.
• Encourage small, frequent, sodium-restricted, low saturated fat meals.

38. Nursing Diagnoses
Excess fluid volume r/t compromised regulatory
mechanism (weakened heart, ventricles,
decreased CO) aeb SOB, orthopnea, increased
pulmonary congestion, peripheral edema.

39. Excess FV Interventions
• Monitor daily weight for sudden increases; use same scale and type of clothing at
same time each day, preferably before breakfast.
• Administer prescribed diuretics as appropriate; check blood pressure before
administration to ensure it is adequate. If IV administration of a diuretic, note
and record the blood pressure and urine output following the dose.
• Teach about signs and symptoms of both excess and deficient fluid volume such
as darker urine and when to call the physician.

40. Community resources
• Caregiver Supporthttp://www.heart.org/HEARTORG/Conditions/HeartFailure
/PreventionTreatmentofHeartFailure/For-Heart-FailureCaregivers_UCM_306366_Article.jsp
• St. Vincent’s Mobile Health Outreach
Mobile health unit that delivers care to rural and indigent
areas (serves Clay, Duval, Nassau, Putnam, St. Johns and
Volusia counties)

41. Community resources
Online Support Groups
Mended Hearts-Heart Disease- http://mendedhearts.org/
Daily Strength-Heart Failurehttp://www.dailystrength.org/c/HeartFailure/support-group
Heart Failure Matters
http://www.heartfailurematters.org/EN/What-can-you-do/Supportgroups

42. NCLEX Question time!
An elderly client is being monitored for evidence of congestive heart
failure. To detect early signs of heart failure, the nurse would instruct the
certified nursing attendant (CNA) to do which of the following during care
of the patient?
a. Observe electrocardiogram readings and report deviations to the
nurse.
b. Assist the client with ambulation three times during the shift.
c. Monitor vital signs every 15 minutes and report each reading to
the nurse.
d. Accurately weigh the patient, and report and record the readings.

43. NCLEX Question time!
Which of the following drug classifications should the nurse question if
prescribed for a person with congested heart failure (CHF)?
a. Angiotensin-converting enzyme (ACE) inhibitor
b. Beta-adrenergic blocker
c. Alpha adrenergic antagonist
d. Rosiglitazone (Avandia)

44. NCLEX Question time!
A nurse in a medical unit is caring for a client with heart failure. The client
suddenly develops extreme dyspnea, tachycardia, and lung crackles and the
nurse suspects pulmonary edema. The nurse immediately asks another nurse
to contact the physician and prepares to implement which priority
inventions? Select all that apply.
a. Administering oxygen.
b. Inserting a foley catheter
c. Administering furosemide (Lasix)
d. Administering morphine sulfate intravenously.
e. Transporting the client to the coronary care unit.
f. Placing the client in a low fowler’s side-lying position.

45. NCLEX Question time!
One hour after administering IV furosemide (Lasix) to a client with
heart failure, a short burst of ventricular tachycardia appears on the
cardiac monitor. Which of the following electrolyte imbalances should
the nurse suspect?
a. Hypocalcemia
b. Hypermadnesemia
c. Hypokalemia
d. Hypernatremia

46. NCLEX Question time!
Which of the following symptoms is most commonly associated with
left-sided heart failure?
a. Hepatic engorgement
b. Arrhythmias
c. Crackles
d. Hypotension

47. NCLEX Question time!
Correct answer: D. Accurately weigh the patient, and
report and record the readings.
Rationale: Due to fluid accumulation, an expanded blood volume can
result when the heart fails. Body weight is a sensitive indicator of water
and sodium retention, which will manifest itself with edema, dyspnea –
especially nocturnal- and pedal edema. Patients should be instructed
about the need to perform daily weights upon discharge to monitor body
water. It is not within the role of the CNA to monitor ECG readings, and
ambulation is not an assessment. Vital signs every 15 minutes are not
necessary for this level of patient care.

48. NCLEX Question time!
Correct answer: D. Rosiglitazone (Avandia)
Rationale: Thiazolidinediones, like rosiglitazone (Avandia), are glucosereducing drugs that are prescribed for persons with type 2 diabetes
mellitus. ACE inhibitors, such as Lisinopril, are first-line drugs used to treat
CHF. Propranolol (Inderal), a beta blocker, has remained one of the most
widely used beta-blocking drugs. It blocks both beta1 and beta2 receptors
in various organs, resulting in reduction of heart rate and force of
contraction, and suppresses impulse conduction through the AV node, all
of which slows the progression of the disease process. Carvedilol (coreg)
is another beta-adrenergic blocker used to treat heart failure.

49. NCLEX Question time!
Correct answer : a, b, c, d
Administering oxygen, inserting a foley catheter, administering furosemide,
administering morphine sulfate intravenously.
Rationale: Pulmonary edema is a life-threatening event that can result from
severe heart failure. In pulmonary edema, the left ventricle fails to eject
sufficient blood, and pressure increases in the lungs because of the
accumulated blood. Oxygen is always prescribed, and the client is placed in a
high fowler’s position to ease the work of breathing. Furosemide, a rapid acting
diuretic, will eliminate accumulated fluid. A foley catheter is inserted to
measure output accurately. IV administered morphine sulfate reduces venous
return (preload), decreases anxiety, and reduces the work of breathing.
Transporting the client to the coronary care unit is not a priority intervention. In
fact, this may not be necessary at all if the client’s response to treatment is
successful.

50. NCLEX Question time!
Correct answer: c. Hypokalemia
Rationale: furosemide is a potassium-depleting diuretic that
can cause hypokalemia. In turn, hypokalemia increases
myocardial excitability, leading to ventricular tachycardia

51. NCLEX Question time!
Correct answer : c. Crackles
Rationale: Crackles in the lungs are a classic sign of left-sided heart
failure. These sounds are caused by fluid backing up into the pulmonary
system. Arrhythmias can be associated with both right and left-sided
heart failure. Left-sided heart failure causes hypertension secondary to
an increased workload on the system.

52. The foods that are killing us
http://www.ted.com/talks/dean_ornish_on_the_world_s_killer_diet.html

53. Thank you!