HeartFailureeducationforMDandnurse060209文档格式.docx

1、 Care for the Hospitalized Patient with Heart Failure What nurses and physician need to know for a good patient care outcome 1. Heart Failure Symptoms: Ask the patient about their symptoms and INFORM the physician of any new or worsening HF symptoms （do not assume the physician is aware that the pat

2、ient is experiencing new or worsening symptoms）.2. Symptoms of left sided heart failure （congestion on the left side）: Orthopnea/PND: Is the patient waking at night with difficulty breathing or does the patient have difficulty falling asleep due to “anxiety”? Does the patient describe nighttime symp

3、toms of “drowning”, “smothering”, insomnia, or having a dry cough at night? These c/os are often times equivalent symptoms for paroxysmal nocturnal dyspnea （PND） due to shift of water from periphery to lungs at night. DOE: Is the patient experiencing worsening dyspnea on exertion （DOE） and if so, wh

4、en did it start? Is the patient experiencing worsening exercise tolerance （feeling more tired or fatigued with any activity）when was this worsening exercise tolerance first noticed? Worsening exercise tolerance （DOE） may indicate worsening cardiac output and heart function. Orthostatic Dizziness: Do

5、es patient report dizziness when in vertical position? Orthostatic dizziness suggests intravascular depletion from overdiuresis, sepsis or very low cardiac output.3. Symptoms of right sided heart failure （congestion on the right side）: Poor appetite, early satiety: Is patient experiencing a worsenin

6、g of appetite? Assess if the patient can eat a complete meal without feeling full or nauseated. Pay attention if the patient is having epigastric pain or fullness before finishing a meal and which is clearly aggravated by meals associated with an increase in their abdominal girth （ascites）. The abov

7、e symptoms are often due to liver and stomach congestion from heart failure. These symptoms are especially present in patients with advanced heart failure who require chronic diuretic use. Do not be fooled if there is minimal evidence of peripheral edema in presence of right sided heart failure with

8、 volume overload. Decreased urine output: Pay attention to the effectiveness of the diuretic regimen. Are they having the same effect as when initially dosed （causing similar amount of urine output as before）? When there is stomach and liver congestion, medication absorbtion decreases, especially fo

9、r furosemide and hydralazine and reduces their effectiveness and patients will complain they dont work anymore. Lower extremity Edema （LEE）: Any lower extremity swelling? In order to quantify edema see below.4. Important information about the patients outpatient HF care prior to admission: Who is th

10、e physician who manages their heart failure; when was last time they saw him/her? Who is their “helper” or coach at home? Studies have shown that patients who have a coach at home to help implement the therapy and dietary instructions do much better than the ones who dont. If the patient does not ha

11、ve a “helper” or “coach”, who is their main support and is this person able to provide support at this time? Home Medications prior to admission? Are they taking them routinely? When was patient first diagnosed with HF and how frequently do they require hospitalizations/ER visits? Are there barriers

12、 to HF treatments （financial, social, perception of illness, cognitive impairment）? Salt restriction （do they eat out, etc）, do they know how to read labels? Prior Tests/Therapies: Did they have a recent stress test, cardiac catheterization, pacemaker/defibrillator and if so when was last time they

13、received a shock. Who is following their pacemaker/ICD and what type of device do they have （Medtronic, etc）.5. Other illnesses （co-morbid disorders） that can decompensate heart failure and affect/complicate its treatment in hospital: Any signs of infection （URI, UTI, etc）. Any joint aches, swelling

14、? （GOUT attacks which always occur 1-2 weeks after a recent increase in diuretics use）.o Either inflammation （gout） or infections will cause inappropriate vasodilatation of periphery with vasoconstriction in the kidneys, which will decompensate their heart failure and often us prevent from treating

15、it （need to hold diuretics and vasodilators until UTI/gout resolves）. Any diarrhea （causes lost of K and Mg and triggers arrhythmias and shocks from ICD） or constipation （alters the absorbtion of vitamin K and therefore response to warfarin）. Headache （most common side effect from nitrates） and dizz

16、iness （most common side effect from hydralazine）.6. Physical exam of the patient admitted with acutely decompensated heart failure （ADHF）:Vital Signso Ideally, every patient admitted with ADHF should have orthostatic BP and pulse performed/documented on admission. If orthostatic hypotension is prese

17、nt, the patient likely has intravascular depletion or is septic and often requires withholding of diuretics. o Document systolic, diastolic and mean arterial pressure （MAP）. Note: An ideal MAP is 65-70 mm Hg （this corresponds to an SVR of 900-1000） in those patients admitted with acute CHF. The puls

18、e pressure （PP） is difference between systolic and diastolic BP divided by systolic BP. o SBP reflects more the stroke volume and therefore cardiac output and will decrease as cardiac output diminishes. Typically, even in prior hypertensive patients, the systolic BP will go down in advanced heart fa

19、ilure because of low EF. For example a BP of 110/90 is actually severe hypertension for these patients because high MAP reflects severe peripheral vasoconstriction （if they had normal EF, SBP wouldve been 200 mm Hg!） and this is often interpreted wrongly by MDs as hypotension and lead to inappropria

20、te withholding of vasodilators! Often these patients will become hypertensive again outpatient, 2-3 months after they are placed on appropriate drugs to improve their EF.o DBP reflects more the peripheral vascular tone and will increase with vasoconstriction （high systemic vascular resistance （SVR）

21、and will decrease with vasodilatation （high SVR）. Therefore, a small PP equals low cardiac output while a high PP equals normal or high cardiac output which strongly suggests systemic inflammation （gout） or sepsis （UTI, etc）. Any diastolic 70 mm Hg is abnormal high in patients with ADHF （patient is

22、vasoconstricted and needs vasodilators）, the same any diastolic 70 mm Hg; this is inappropriately high for a patient with acutely decompensate heart failure and volume overload. If the patient is cold （vasoconstricted） and wet （edema, volume overload） o A） If the pulse pressure is normal （SBP-DBP25%

23、 of SBP but less then 50%）, then patient needs vasodilators first （to vasodilate and increase cardiac output） and then diuretics.o B） If the pulse pressure is low （PP70 mm Hg and patient has good renal function. However if renal function worsens （renal hypoperfusion due to low cardiac output and ren

24、al vasoconstriction） and patient is still symptomatic with congestion （still needs diuretics） then may benefit from adding/switching to an inotrop before administering diuretics. If the MAP is 50% （example BP 90/40 mm Hg） there is most likely concomitant sepsis （UTI, etc） or other inflammatory expla

25、nation （such as gout or SIRS=systemic inflammatory response syndrome） which inappropriately vasodilates the periphery （low SVR） and vasoconstricts the kidney often with worsening renal function. The vasodilators and diuretics need to be withhold because will aggravate renal function. On contrary, on

26、e needs to increase MAP to 65-70 mm Hg to shift the blood back from periphery to main organs to improve their perfusion. Occasionally, patient need to be transferred to ICU/CCU to receive low dose pressors （norepinephrine 2-5 mcg/min） to raise the MAP and improve renal perfusion while we are treatin

27、g the underlying inflammatory/septic condition）. B） And the patient is warm and dry, then check orthostatics to confirm that patient is intravascular depleted. This confirms true overdiuresis and we need to stop diuretics and vasodilators and give 2 liters of water- ideally orally. If patient is per

28、sistent hypotensive one may replete fluid with iv 500-1000 ml of NS over 2-4 hours （avoid NS which gives to much salt and will always cause next day inappropriate volume expansion due to excessive sodium load and patient recurring CHF）. C） And the patient is cold and wet- then likely patient has sev

29、erely reduced cardiac output due to both inappropriate vasoconstriction and low EF. The treatment will be to first start an inotrope （dobutamine 5 mcg/kg/min） and check again BP in 30 min. If indeed that is the case, usually the MAP will increase65 mm Hg and then we can also add the vasodilators （ag

30、ain, we need to do this before giving diuretics）. D） And the patient is cold and dry （lies flat without being SOB and no evidence of peripheral and central edema）, - patient may be intravascular depleted from overdiuresis and may need inotropes （severely reduced cardiac output）. If that is the case, administration of 500 ml of 1/2NS over 1 hour should increase the MAP65 mm Hg. If the MAP is still less then 65 mm Hg the patient needs inotropes too and may ben