Question

Oxygenation, Perfusion, fluid and electrolytes are concepts reflect normal physiological mechanism occurring inside the human body which may be affected by the pathological conditions and at the same time can lead to new pathological one.

Fluid and electrolytes concept and apply it on heart failure disease showing the following:

1. Introduction about the selected concept(s)
2. Brief introduction about heart failure
3. Focus on the physiological changes on the selected concept(s) associated with heart failure in relation to:

1. Clinical S & S
2. Diagnostic measures
3. Management (medical, surgical & nursing management).

Answer 1

Heart failure

Inability of the heart to pump adequate amount of blood to the systemic circulation in order to meet the metabolic needs of the body.The heart failure generally classified as:

1. left sided heart failure: It occures when left ventricle fails to contract effectively to maintain cardiac output. Results backflow of blood in to pulmonary system through left atrium and pulmonary vein.Increased pulmonary pressure causes trnsudation into interstitial tissues of the lungs with resultant pulmonary.congestion.

Usually due to myocardial infarction, hypertension, ACS, left side valvular diseases- aortic valve and myotic valve stenosis or regurgitation.

2. right sided heart failure Weakened right ventricle is unable to pump adequate amount of blood into pulmonary system: systemic venous congestion develop due to decreased venous returm. subsequently dependent edema occur.

3. high output failure Versus low output

high output: when metabolic needs of the body is exceeds the normal cardiac oputput. Here demand is more than suppy. conditions are A.V fistula, hyperthyroidism, anaemia and pregnancy.

low outputfailure occur when there is outflow obstruction present , cardiomyopathy, pulmonary artery stenosis. When cardiac output is decreased pressure will increase inside of the chamber, gradually size of the ventricle will increase and cause pump failure.

clinical signs and symptoms

left side failure are first evident in pulmonary system causing pulmonary edema

dyspnoea, orthopnea, Paroxismal nocturnal dyspnoea, tiredness,weakness, non productive cough, tachycardia, bronchial wheezing, crackles, ventricle gallopS3, peripheral cyanosis, Chyne-Strokes respiration, decreased PO2, increased PCo2, shifting of point of maximum impulse.

Right sided failure

Anorexia, nausia, abdominal pain, dependent pitting edema, ankle edema is usually a first sign, jugular vein distention, bounding pulses, hepatomegaly, cold and clammy extremities, oliguria and increased CVP, ascitis.

Diagnostic studies: B-type natriuretic peptide - elevateed >100 pg/ml- enzyme released when myocardium overstreached

• Echocardiography- to assess ventricular function and ejection fraction, wall motion, valvular function, wall thickness
• Coronary angiogram: to find coronary artery block
• Chest Xray- reveals cardiomegaly and pulmonary congestion / edema
• ECG - reveals signs of ACS, Cardiomegaly
• Cardiac catheterization - to measure CVP, Pulmonary artey pressure, Pulmonary cappillary  wedge pressure and cardiac ouput status
• Serum elctrolytes( Na+, K+, HCo3, Cl-), hemoglobin, Blood urea nitrogen, TSH, CBC, creatinine and troponine .
• ABG analysis-to reveal status of Po2, PCo2, HCo3 and oxygen saturation.

Medical Management-

• Diuretics- to reduce fluid overload and reduce cardiac workload by reducing preload. (frusemide, spirinolactone)
• Morphine- to reduce anxiety and dyspnoea
• Inotropics- Dopamine, Dobutamin, milrinone to increase cardiac contractility
• angiotensin -converting enzyme inhibitors- to reduce BP by decreasing peripheral resistance ( Enalapril, Captopril
• Angitensin receptor blockers- Blocks angiotensin receptor1 on the herat, periphera vessels and kidney.Losartan, telmisartan
• Vasodialators- Nitroglycerin, Hydralazine
• cardiac glycosides- Digoxin- To increase force of contraction and cardiac output, decrease HR, increase renal blood flow.
• Beta blockers- cardiac selective drugs - Carvedol, Metoprolol, Bisoprolol
• Antiarrythmic drugs to treat arrythmias
• Blood transpusion, iron supplements to correct hemoglobin
• Thyroid hormone replacement- if hypothyroidism present( Levothyroxin)
• Antithyroid drugs for hyperthyroidism

Non pharmacological management-

• Intra-aortic ballon pump therapy-Device is used  to augment blood circulation to the vital organs.
• External devices- Univentricular and Bi-ventricular assistive devices- Electronic devices for assisting left or right or both ventricle functions.
• Surgical management:
• ventriculoplasty
• Valvular correction or replacement surgeries.
• Cardiac transplantation in end stage failure
• Artificial/ Mechanical heart

Nursing management

1. maintain adequate ventilation and pulmonary perfusion

- Administer oxygen via mask, nasal cannula, CPAP

- Provide smi-fowler's or Fowler's position

-Analyse ABG/ check saturation using pulseoxymetry

- Assess for breath sounds, air entry, use of  accessary muscles.

- Administer Diuretics , if pulmonary congestion or extreme peripheral edema present.

- Support with mechanical ventilation, if failure/ insufficiency occur.

Increase cardiac output

• Administer ionotropics, cardiac glycosides
• Monitor ECG, hemodyanamic status and vital signs
• Administer vasodialators
• Measure intake and output and CVP

Manage edema/ fluid overload

• Administer diuretics as ordered
• Check weight daily, peripheral edema, abdominal distension
• measure intake and output
• restrict fluid intake as ordered
• Check serum electrolytes
• Provide sodium restricted diet
• Paracentesis if asciris is severe
• Provide skin care , change posotion every two hourly.

Provide physical and emotional rest

• complete bed rest with minimal activity is recommended during acute stage
• gradually increase activity level as per patient's tolerance capacity
• Asses anxiety and provide counselling and psychological support

Provide client teaching and discharge planning about

• diet- restrict sodium intake 2gm/day, small and frequent meals/day, restrict fluid intake if ordered.
• self monitoring of weight gain- report pedal edema, cough with dyspnea, PND, and weght gain 1-2 kg in 2 days
• Medication regimen
• Avoid strenuous activities because overactivity demands more cardiac ouput.
• Do exercise in aerobic place
• Plan resting period
• Avoid pottassium rich food if the patient is on pottassium sparing diuretics( spirinolactone).because hyperkalemia may occur.