 and welcome to nursing school explained. Today's topic is heart failure. So let's take a look at the basic physiology first. So I've drawn out a little diagram of the heart and lungs here. So we have the right atrium, right ventricle, left atrium, left ventricle, lungs in blue. Then we have the superior and inferior vena cava bringing the blood back to the heart. We have the pulmonary vasculature going to the lungs and then the aorta leaving the heart. And I'm a big fan of knowing the physiology of how the system is supposed to function. That way, if something goes wrong, you can really refer back to and say, well, I know it's supposed to function this way. Now, if this is going on, what kind of signs and symptoms am I going to see in this patient? So first of all, the normal blood flow through the heart. Remember, the blood comes back into the right atrium from the peripheral vasculature, flows through the right ventricle, goes out to the lungs, returns back in the left atrium, goes to the left ventricle and goes back out into the body. Now, when the heart fails, so the heart is not able to pump efficiently, then we have right or left-sided heart failure. So either one of these two sides can fail. Now, the most common heart failure is left-sided heart failure. And the most common cause for that is hypertension. So basically, when there's an increased blood volume in the patient system, the heart has to pump extra hard to pump all that fluid around. So if the blood pressure is elevated, it takes some extra force off that left ventricle to create the cardiac output. And after a while, that heart muscle will wear out and it'll lead to heart failure. So now if we think about it, if that left ventricle is not working, the blood is going to back up to where it came from, which means the lungs. And so the patient's complaints will be mostly shortness of breath or I also wrote down orthopnea. And orthopnea basically means shortness of breath with activity. They might have some chest pain. They might feel fatigued. They might have some nocturia. They will definitely have some weight gain because they're retaining all that fluid. They might have paroxysmal nocturnal dyspnea, PND. And I wrote in parentheses here pillows. So that means when the patient is sleeping at night, typically we sleep flat, but because there's so much workload now on the heart when the patient is flat, because all the fluids are at the same plane that in order for the patient to get some relief, they need to elevate the head of the bed. And usually they prop themselves with extra pillows, because they can breathe easier when they sleep up when they sleep sitting upright. And the term for that is paroxysmal nocturnal dyspnea. And when the patient tells you I'm using three pillows at night to sleep, that's usually a warning sign that there's something going on with heart failure, when a fluid is backing up into the lungs and the patient might have left side heart failure. And then also pink frothy sputum is another thing that we need to watch out for. And that's more in the later stages. So if there's so much congestion now in the lungs, because the heart is not pumping the fluid through the body efficiently and it backs up into the lungs, it can cause pulmonary edema. And then the lungs get congested. And the way that the body tries to get rid of that extra fluid from the lungs is by sputum production. And there will be a little bit of bleeding in there, which is why that sputum will be pink and frothy. Now for right-sided heart failure is usually most commonly caused by left-sided heart failure. So if there's something going on with this ventricle, the fluid backs up into the lungs, eventually it'll get so bad that the lungs get so congested and then fluid is backing up all the way to the right ventricle. Excuse me, it will have all the signs and symptoms of right-sided heart failure. Now another cause of right-sided heart failure is some pulmonary pathology. So that can be pulmonary hypertension, asbestosis, any of the things that stem directly from the lungs that could cause some lung congestion and then the lungs are not really profusing and that fluid is backing up into the right side of the heart. So symptoms of right-sided heart failure, basically the fluid will back up and it'll get back into the systemic circulation. So symptoms will be peripheral edema, very typical patient while complaining of lower, complaining of lower extremity edema. Asidease, so now if the right side of the heart is not working and the blood is backing up into the peripheral circulation, there could be fluid sitting being pushed out by the principle of basically osmosis and the oncotic pressure so that there's extra fluid collecting in the abdomen and now they'll have asidease. They can also have hepatosplenomegaly because again, if the fluid is being backed up, the organs that sit in that inferior vena cava that come up, the organs are the liver and the spleen. So if the fluid is backing up, it might back it up into the liver and spleen, making that enlarged and hepatosplenomegaly basically just means enlarged liver and spleen and then the patient can also have JVD, jugular venous distention because again, if that right side of the heart is not pumping efficiently, fluid is going to back up and you will see that in their jugular veins. Now risk factors for developing heart failure are pretty self-explanatory if we know what causes them, which is hypertension and this is a chronic condition that will over time just wear out that heart muscle and lead to heart failure. Coronary artery disease, so again if the heart muscle doesn't get profused efficiently, it can lead to heart failure. Myocardial infarction, that's an acute cause of heart failure. If there is a part of the heart muscle that is now has not been profused and it's infarcted, which basically means the cells have died, then of course that heart muscle, that part of that heart muscle will not be able to contract efficiently and therefore it'll lead to heart failure. And then also cardiomyopathy, and there's a variety of different cardiomyopathies which basically means disease of the heart muscle and you can look into those and see what causes those but those are also common causes of heart failure. Now then if we look into diagnostic studies, so what are we going to want to know in a patient with heart failure? So diagnostic studies will definitely be an EKG because we want to see how the heart, the conduction system is working. We want to look at an echocardiogram to get more information about the chamber, the heart chamber sizes, the heart valves, and also the ejection fraction which is basically the percentage and a measure of how well that left ventricle is contracting. Patient might also undergo a stress test where they either run on a treadmill or chemically induced, they have a tachycardia and then they'll see if they produce symptoms. Patient certainly if it's because of coronary artery disease they can have an angiogram which basically means a cardiocatheterization to visualize the inside of the coronary arteries and see what's going on in there. And then for labs, so we're definitely going to want to know a complete metabolic panel including electrolytes, kidneys, liver function, as well as a complete blood count to see the level of their platelets, their hemoglobin hematocrit, and then a BNP. So BNP stands for B type natriuretic peptide and that is a chemical marker that the heart gives off if it's on a constant stretch. It's basically a cry for help and it's telling the body what's going on. I have all this volume that I have to deal with and being stretched to the max help me get rid of some of this fluid and BNP and the RAS have an inverse relationship so if you need to review those please go back to the video about RAS where I go into the details of how these two relate to one another but BNP is a very simple lab test that we can draw and then depending of the elevation of the level in BNP we can determine how bad the heart failure is. Now complications, heart failure can lead to pleural effusion so if that left-sided heart failure gets so bad that all that fluid is backing up into the lungs we have in the spink frothy sputum and the fluid the lungs can handle that fluid it's being pushed out into the pleural space then the fluid will be accumulating around the lining of the lungs definitely causing shortness of breath and the treatment for pleural effusion is a thoracentesis where basically a needle is inserted and that fluid is drained out with all these other treatments that we're going to be talking about here in a moment. Another complication is dysrhythmias because the heart chambers get enlarged because they have to pump around this increased fluid volume and that puts the patient at risk for atrial fibrillation and we know that atrial fibrillation is a risk factor for stroke because the blood kind of gets swooped around in the atria and then the clots can break off causing a stroke or maybe DVT or other clots in the system. It can lead to hepatomegaly and eventually liver failure but like I discussed before the right from the right ventricle it backs up into the systemic circulation and then into the liver and the spleen and this can lead to some liver impairment and elevation in liver enzymes and then it can also lead to renal failure because now that cardiac muscle cannot contract the way that it's supposed to and the kidneys don't get the perfusion that they need which makes them not work properly and it can lead to renal failure. Now how do we treat patients with heart failure? So I wrote down here in black the treatment and then in green the pathophysiology so that you can understand why are we doing these things. Ace inhibitors are the number one treatment for heart failure and I wrote in parentheses also angiotensin receptor blockers. Both of those pertain to the RAS system and in heart failure there's decreased cardiac output again because that heart muscle has been stretched for so long that it's not pumping efficiently which leads to renal perfusion which has discussed that which activates the RAS because now the kidney says hello I need more blood volume give me something that I can work with so I can increase my perfusion which then leads to the activation of renin angiotensin 1 and aldosterone and that leads to increased blood pressure and fluid retention so that's the normal mechanism that will happen but in a heart failure patient we do not want to increase the blood pressure and we do not want to increase the increase the fluid retention because of the hardest disease and we already have the problem with that fluid volume excess. So by using an ace inhibitor and blocking the RAS system we're lowering the patient's blood pressure and we're lowering their fluid retention we help them excrete some of that extra fluid and that's why ace inhibitors are such a powerful medication to help in the treatment of patients with heart failure. Now number two beta blockers beta blockers when there is cardio a decreased cardiac output but the pathophysiology is decreased cardiac output because the heart is not working properly it'll lead to catecholamine release so that activates the parasympathetic nervous system the whole system will say hello I'm not getting enough blood flow give me some blood that I can work with every organ will say give me some blood flows that I can do the function that I need to do and the sympathetic nervous system will basically constrict in order to bring up the blood pressure and the blood volume to these organs which will increase the heart rate and the blood pressure but again in a diseased heart when having this heart failure present we do not want to put more workload on the heart by increasing the heart rate and we certainly do not need more volume in the system or increase in blood pressure which is why beta blockers are so efficient in decreasing the heart rate and the blood pressure and therefore they help us treat that heart failure. Now digoxin is a cardiac glycoside and if you watched the other video that I have on preload afterload and contractility it discusses the joxin a little bit more detail but there's that Frank Starling law which basically it means when that heart muscle wears out it it cannot the cardiac fibers cannot contract efficiently to produce that cardiac output and the force of contraction therefore after a while because of this prolonged hypertension the force of contraction goes down. Now the joxin helps the patient but increasing the force of contraction so it's a positive ionotrope that will help the cardiac muscles contract more efficiently and help produce the cardiac output of that weak and hard so every blood or every organ in the cell and the body can get perfused. Diuretics usually in a patient with hypertension will lead to fluid volume excess so when there's a high sodium diet most likely that's the cause high sodium diet sodium water follows sodium which means fluid volume excess which increases the afterload and the afterload is the amount of force that the left ventricle has to overcome to produce a cardiac output to really perfuse all the blood tissues but again when we're already having heart failure we don't want any more fluid we're already having a problem with fluids in the lungs and in the periphery so we need to decrease the fluid volume and diuretics help us to do that so diuretics help us get rid of some of that extra fluid that the patient has on board therefore lowering the blood pressure and lowering the workload on the heart and then there's another treatment called L-BAD left ventricular assist device and that's usually for patients with long-standing heart failure who have maybe do not respond to treatments anymore and it's a device that gets implanted into the patient's chest or abdominal cavity that helps with the contraction it's kind of like a last resort kind of a treatment and a very specialized treatment and then the other one is heart transplant so if that heart muscle is not working at all it's completely given out and the heart transplant would be another option now when it comes to nursing care what is it that we need to do for these patients that we're dealing with with heart pressure heart failure number one control their blood pressure because we know heart failure is caused by hypertension there's the number one cause of left-sided heart failure and eventually if we don't get it under control it will lead to right-sided heart failure so blood pressure control is super important when the patients at the hospital they have all this extra fluid that they are pumping around and we're giving them medications to decrease their fluid or to help them with the cardiac output certainly we're going to have to measure the intake and output and their daily weight to see if they're retaining fluid we have to administer all these medications and know all the nursing care that pertains to those we have to sometimes the patient will go to cardiac rehab specifically if it is after an MI and exercising is very important but certainly a very specialized regimen will be put together for the patients so that they don't overdo it flu and pneumonia vaccination is very important because this is a chronic condition and anything that stresses the patient's system such as fluid pneumonia so an infection can lead to significant complications in these patients and then definitely low sodium diet which kind of goes along with the blood pressure control so along with medication exercise we want to emphasize the proper diet for these patients now part of a nurse's job is always to do patient education to keep them from having complications so here are certain things that we definitely need to include when we educate our patients about how to manage themselves with heart failure so in red I've written down here report weight gain three pounds in two days or three to five pounds in one week because the heart is not pumping efficiently which will lead to all this fluid backing up and certainly it can be measured by the patient's weight so just like we want to monitor the patient's daily weight while they're at the hospital we want to teach them about measuring their weight at home and that should be the same scale about the same time of day with the same amount of clothing so they can keep track of their fluid volume status and then we want to educate them to report any of the signs and symptoms to see if they're getting worse so those include report shortness of breath paroxysmal nocturnal dyspnea that's the one where the patient sits up with extra pillows sleeps with extra pillows elevated increasing peripheral edema and that sometimes just means that their water their rings or their socks are getting a little bit tighter if they're having a cough certainly because the fluid can be backing up into the lungs they can have pink frothy sputum leading to pulmonary edema also if they feel dizzy if they have this episode of syncope so fainting or any kind of nausea with abdominal distention again because that means that the fluid is backing up into the abdominal cavity and the heart is not pumping the fluids efficiently so i hope this video has helped you review this basic concept of i hope this video has helped you review the concept of heart failure and all its facets if you haven't already watched please go back to the videos of cardiac output and the different medications where discussed the nursing care and side effects of certain medications as well as the basic principle of RAS where the relationship between the RAS and the B and P in the control of blood pressure and fluid volume are discussed in more detail thank you for watching nursing school explained i will see you next time