Heart Failure (Left and Right)

Aug 26, 2023

Heart Failure (Left and Right)

This video discusses left- and right-sided heart failure. It covers pathophysiology, signs and symptoms, risk factors, diagnostic tests, treatment options, medications and complications of heart failure. For a more detailed discussion of cardiac output, cardiac medications, RAAS, BNP and fluid volume regulation, please refer to the other videos on my channel Nursing School Explained.

You may also find these other videos helpful:
Fluid volume Excess:
   • Fluid Volume Excess/Overload (FVE)

Cirrhosis:
   • Cirrhosis

Cardiac medications:
   • Cardiac medications (Nitroglycerin, M…

Cardiac Output (CO = HR x SV):
   • Cardiac Output (CO = HR x SV)

Content

3.1 -> Hello and welcome to Nursing School Explained.

6.97 -> Today's topic is heart failure. So let's take a look at the basic physiology

11.299 -> first. So I've drawn out a little diagram of the heart and lungs here. So we have

17.24 -> the right atrium, right ventricle, left atrium, left ventricle, lungs in blue, then

23.269 -> we have the superior and inferior vena cava bringing the blood

27.65 -> back to the heart. We have the pulmonary vasculature going to the lungs, and then

32.87 -> the aorta leaving the heart. And I'm a big fan of knowing the

40.309 -> physiology of how the system is supposed to function. That way, if something goes

46.91 -> wrong, you can really refer back to and say, well I know it's supposed to

51.32 -> function this way, now if this is going on, what kind of signs and symptoms am I

56.51 -> going to see this patient? So first of all the normal blood flow through the heart.

61.539 -> Remember: the blood comes back into the right atrium from the peripheral

66.11 -> vasculature, flows through the right ventricle, goes out to the lungs, returns

71.45 -> back in the left atrium, goes to the left ventricle and goes back out into the

76.159 -> body. Now when the heart fails, so the heart is not able to pump

82.54 -> efficiently, then we have right or left-sided heart failure. So either one

88.72 -> of these two sides can fail. Now the most common heart failure is left-sided heart

94.03 -> failure and the most common cause for that is hypertension.

98.47 -> So basically when there is an increased blood volume in the patient system, the

105.19 -> heart has to pump extra hard to pump all that fluid around so if the blood

110.5 -> pressure is elevated it takes some extra force off that left ventricle to create

116.14 -> the cardiac output and after a while that heart muscle will wear out and it'll

121.99 -> lead to heart failure. So now if you think about it, if that left ventricle is

127 -> not working, the blood is going to back up to where it came from

132.1 -> which, means the lungs. And so the patients' complaints will be mostly

137.1 -> shortness of breath or I also wrote down orthopnea and orthopnea basically

142.87 -> means shortness of breath with activity, they might have some chest pain, they

147.94 -> might feel fatigued, they might have some nocturia, they will definitely have some

152.92 -> weight gain because they're retaining all that fluid, they might have

156.73 -> paroxysmal nocturnal dyspnea (PND) and I wrote in parentheses here pillows. So

164.56 -> that means when the patient is sleeping at night typically we

168.77 -> sleep flat, but because there's so much workload now on the heart when the

173.48 -> patient is flat because all the fluids are at the same plane that in order for

177.74 -> the patient to get some relief they need to elevate the head of the bed and

181.94 -> usually they prop themselves with extra pillows because they can breathe easier

186.68 -> when they sleep when they sleep sitting upright. And the term for that is

190.91 -> paroxysmal nocturnal dyspnea. And when the patient tells you I'm using three

196.58 -> pillows at night to sleep that's usually a warning sign that there's something

200.72 -> going on with heart failure when the fluid is backing up into the lungs and

205.19 -> the patient might have left-sided heart failure. And then also pink frothy

210.38 -> sputum is another thing that we need to watch out for and that's more in the

214.73 -> later stages. So if there's so much congestion now in the lungs because the

218.78 -> heart is not pumping the fluid through the body efficiently and it backs up

223.58 -> into the lungs, it can cause pulmonary edema and then the lungs get congested

228.47 -> and the way that the body tries to get rid of that extra fluid from the lungs

233.6 -> is by sputum production and there will be a little bit of bleeding in there which

240.553 -> is why that sputum production will be pink and frothy. Now for right-sided heart failure, it is usually,

245.209 -> most commonly caused by left-sided heart failures. So there's

249.859 -> something going on with this left ventricle, the fluid backs up into the lungs, eventually

255.17 -> it'll get so bad that the lungs get so congested and then fluid is backing up

259.669 -> all the way to the right ventricle. excuse me, and we'll have all the signs and

264.44 -> symptoms of right-sided heart failure. Now another cause of right-sided heart

271.19 -> failure is some pulmonary pathology. So that can be pulmonary hypertension,

275.78 -> aspbestosis, any of the things that stem directly from the lungs that could

281.36 -> cause some lung congestion and then the lungs are not really perfusing and that

287.33 -> fluid is backing up into the right side of the heart.

289.88 -> So symptoms of right-sided heart failure, basically the fluid will back up and it

295.61 -> will get back into the systemic circulation so symptoms will be

299.99 -> peripheral edema, very typical patient will be complaining of lower extremity edema.

305.36 -> Ascites, so now if the right side of the heart is not

310.699 -> working and the blood is backing up into the peripheral circulation, there could be

316.52 -> fluid sitting, being pushed out by the principle of basically osmosis and the

323.57 -> oncotic pressure so that there's extra fluid collecting in the abdomen and now

328.55 -> they'll have ascites. They can also have hepatosplenomegaly because again if the

335 -> fluid is being backed up, the organs that sit in that

339.41 -> inferior vena cava that come up the organs are the liver and the spleen so

345.89 -> if the fluid is backing up it might back it up into the liver and spleen making

350.09 -> them enlarged and hepatosplenomegaly basically just means enlarged liver and

355.43 -> spleen. And then the patient can also have JVD, jugular venous distention,

361.27 -> because again if that right side of the heart is not pumping efficiently, fluid

366.38 -> is going to back up and you will see that in their jugular veins. Now risk

373.31 -> factors for developing heart failure are pretty self-explanatory if we know what

380.18 -> causes them, which is hypertension and this is a chronic condition that will

385.22 -> over time just wear out that heart muscle and lead to heart failure.

389.38 -> Coronary artery disease so again if the heart muscle doesn't get

393.44 -> perfused efficiently it will can lead to heart failure. Myocardial infarctions,

398.51 -> that's an acute cause of heart failure if there is a part of the heart muscle

404.39 -> that is now has not been perfused and it's infarcted which basically means the

409.58 -> cells have died, then of course that heart muscle, that part of that heart

413.69 -> muscle, will not be able to contract efficiently and therefore it'll lead

418.43 -> to heart failure. And then also cardiomyopathy and there's a variety of

423.02 -> different cardiomyopathies, which basically means disease of the heart

427.48 -> muscle. And you can look into those and see what causes those but those are also

432.85 -> common causes of heart failure. Now that if we look into diagnostic studies so

438.56 -> what are we going to want to know in a patient with heart failure? So diagnostic

443.18 -> studies will definitely be an EKG because we want to see how the heart, the

448.43 -> conduction system is working, we want to look at an echocardiogram to get more

453.14 -> information about the chambers, the heart chamber sizes, the heart valves and also

458.51 -> the ejection fraction, which is basically the percentage and a measure of how well

464.6 -> that left ventricle is contracting. Patients may also undergo a stress test,

469.97 -> where they either run on a treadmill or chemically-induced

476.03 -> have they have a tachycardia and then they'll see if they produce symptoms.

479.96 -> Patients certainly, if it's because of coronary artery disease they can have an

486.2 -> angiogram, which basically means a cardiac catheterization to visualize the

491.15 -> inside of the coronary arteries and see what's going on in there. And then for

495.919 -> labs so we're definitely gonna want to know a complete metabolic panel

501.13 -> including electrolytes, kidney and liver function as well as a complete blood

505.79 -> count to see their level of their platelets, their Hemoglobin and hematocrit

511.61 -> and that a BNP. So BNP stands for b-type natriuretic peptide and that is a

521.45 -> chemical marker that the heart gives off if it's under constant stretch. It's

526.85 -> basically a cry for help and it's telling the body: what's going on? I have

532.61 -> all this volume that I have to deal with and I'm being stretched to the max. Help me

538.16 -> get rid of some of this fluid! And BNP and the RAAS have an inverse

544.67 -> relationship. So if you need to review those please go back to the video about

549.2 -> RAAS where I go into the details of how these two relate to one another. But BNP

554.089 -> is a very simple lab test that we can draw and then depending on the elevation

560 -> of the level in BNP we can determine how bad the heart failure is. Now

566.12 -> complications: heart thought you can lead to poor effusion so if the left-sided

570.95 -> heart failure gets so bad that all that fluid is backing up into the lungs, we're

575.63 -> having this pink frothy sputum and the fluid, the lungs can handle that fluid,

582.079 -> it's being pushed out into the pleural space then

586.72 -> fluid will be accumulating around the lining of the lungs definitely causing

591.04 -> shortness of breath. And the treatment for pleural effusion is a thoracentesis,where

595.72 -> basically a needle is inserted and that fluid is drained out with all these

600.759 -> other treatments that we're going to be talking about here in a moment. Another

604.629 -> complication is dysrhythmias because the heart chambers get enlarged because

608.769 -> they have to pump around this increased fluid volume and that puts the

615.129 -> patient at risk for atrial fibrillation and we know that atrial

619.12 -> relation is a risk factor for stroke because the blood kind of gets

623.439 -> swooshed around in the atria and then the clots can break off causing a stroke or

627.73 -> maybe DVT or other clots in the system. It can lead to hepatomegaly and

633.069 -> eventually liver failure but like I discussed before, the right from the

637.899 -> right ventricle it backs up into the systemic circulation and then into the

642.339 -> liver and the spleen and this can lead to some liver impairment and elevation

647.8 -> in liver enzymes. And then it can also lead to renal failure because now that

653.11 -> cardiac muscle cannot contract the way that it's supposed to and the kidneys

659.68 -> don't get the perfusion that they need, which makes them not work properly and

664.42 -> it can lead to renal failure. Now how do we treat patients with heart failure? So

671.62 -> I wrote down here in black the treatment and then in green the pathophysiology so

676.93 -> that you can understand why are we doing these things. ACE inhibitors are number one

682.7 -> treatment for heart failure and I wrote in parenthesis also angiotensin receptor

687.38 -> blockers. Both of those pertain to the RAAS system. In heart failure there's

694.37 -> decreased cardiac output again because that heart muscle has been stretched for

698.21 -> so long that it's not pumping efficiently, which leads to renal

702.17 -> perfusion we just discussed that, which activates the RAAS because now the

706.46 -> kidney says: hello, I need more blood volume, give me something that I can work

711.32 -> with so I can increase my perfusion! Which then leads to the activation of

716.56 -> renin, angiotensin 1 and aldosterone and that leads to increased blood pressure

721.91 -> and fluid retention. So that's the normal mechanism that will happen. But in a

726.95 -> heart failure patient we do not want to increase the blood pressure and we do

730.55 -> not want to increase the fluid retention because the heart is diseased

735.32 -> and we already have the problem with that fluid volume excess. So by using an

740.75 -> ACE inhibitor and blockin the RAAS system we are lowering the patient's

745.49 -> blood pressure and we are lowering the fluid retention. We'll help them excrete

750.32 -> some of that extra fluid and that's why ACE inhibitors are such a powerful

755.03 -> medication to help in the treatment of patients with heart failure. Now number 2

760.31 -> beta blockers. Beta blockers when there is cardio, a decrease in cardiac output

766.01 -> but the pathophysiology is decreased cardiac output because the heart is not

770.3 -> working properly, it'll lead to catecholamine release. So that activates the

775.34 -> sympathetic the system. The whole system will say:

778.52 -> hello I'm not getting enough blood flow, give me some blood that I can work with!

782.72 -> Every organ will say: give me some blood flow so I can do the function that I

787.85 -> need to do. And the sympathetic nervous system will vasoconstrict in order to

793.85 -> bring up the blood pressure and the blood volume to these organs, which will

798.35 -> increase the heart rate and the blood pressure. But again in a deceased heart

802.7 -> when there's heart failure present we do not want to put more workload on the

806.78 -> heart by increasing the heart rate and we certainly do not need more volume in the

811.91 -> system while increasing blood pressure, which is why beta blockers are so

816.29 -> efficient in decreasing the heart rate and the blood pressure and therefore

820.79 -> they help us treat that heart failure. Now digoxin is a cardiac glycoside and

827.75 -> if you watch the other video that I have on preload, afterload and contractility

832.19 -> it discusses Digoxin in a little bit more detail but there is the

836.03 -> Frank Starling law, which basically means when that heart muscle wears out it it

842.06 -> can now, the cardiac fibers cannot contract efficiently to produce that

847.01 -> cardiac output and the force of contraction therefore after a while,

851.65 -> because of this prolonged hypertension, then force of contraction goes down. Now

857.9 -> Digoxin helps the patient by increasing the force of contraction so

862.43 -> it's a positive inotrope that will help the cardiac muscles contract

866.27 -> more efficiently and help produce the cardiac output of that weakened heart so

871.7 -> every blood or every organ and cell in the body can get perfused. Diuretics: usually in

880.86 -> a patient with hypertension will lead to fluid volume excess. So when there's a

886.95 -> high sodium diet, most likely that's cause, high sodium diet, water

893.28 -> follows sodium, which means fluid volume excess, which increases the

898.53 -> afterload. And the after load is the amount of force that the left ventricle

905.73 -> has to overcome to produce a cardiac output, to really perfuse all the blood

912.27 -> tissues but again when we're already having heart failure we don't want any

917.7 -> more fluid, we're already having a problem with fluids in the lungs and

922.02 -> periphery, so we need to decrease the fluid volume and diuretics helped us to

927.93 -> do that. Diuretics helped us get rid of some of that extra

931.41 -> fluid that the patient has our board, therefore lowering the blood pressure

935.01 -> and lowering the workload on the heart. And then there's another treatment

940.32 -> called LVAD, left ventricular assist device, and that's usually for patients

946.23 -> with long-standing heart failure, who have maybe do not respond to treatments anymore and

952.37 -> it's a device that gets implanted into the patient's chest or abdominal cavity

957.74 -> that helps with the contraction, it's kind of like their last resort kind of a

962.36 -> treatment and a very specialized treatment. And then the other one is

965.72 -> heart transplant so if that heart muscle is not working at all, it's completely

969.74 -> given out then a heart transplant would be another option. Now when it comes to

974.72 -> nursing care, what is it that we need to do for these patients that we're dealing

977.99 -> with with heart failure. Number one: control their blood pressure

983.63 -> because we know heart failure is caused by hypertension that's the number one

988.88 -> cause of left-sided heart failure and eventually if we don't get it under

992.9 -> control it will lead to right-sided heart failure. So blood pressure control

997.55 -> is super important. When the patient is at the hospital, they have all this extra

1002.11 -> fluid that they are pumping around and we're given them medications to decrease

1006.97 -> the fluid or to help them with the cardiac output, certainly we're gonna

1011.05 -> have to measure the intake and output and their daily weight to see if they're

1015.7 -> retaining fluid. We have to administer all these medications and know all the

1022.36 -> nursing care that pertains to those, we have to sometimes the patient about

1027.37 -> cardiac rehab, specifically if it is after an MI.

1032.14 -> And exercising is very important but certainly a very specialized regimen

1037.42 -> will be put together for the patients so that they don't overdo it. Flu and

1042.25 -> pneumonia vaccination is very important because this is a chronic condition and

1046.66 -> anything that stresses the patients' system such as flu or pneumonia, so an

1052.39 -> infection, can lead to significant complications in these patients. And then

1056.92 -> definitely low sodium diet, which kind of goes along with the blood pressure

1060.82 -> control, so along with medication, exercise we want to emphasize a proper

1066.85 -> diet for these patients. Now part of a nurses job is always to do patient

1072.31 -> education to keep them from having complications. So here are certain

1076.66 -> things that we definitely need to include when we educate our patients

1080.26 -> about how to manage themselves with heart failure. So in red I've written down

1084.73 -> here report weight gain three pounds in two days or three to five pounds in one

1089.83 -> week. Because the heart is not pumping efficiently, which will lead to all this

1094.66 -> fluid backing up, and certainly it can be measured by the patient's weight. So just

1100.03 -> like we want to monitor the patient's daily weight while they're at

1103.09 -> the hospital we want to teach them about measuring their weight at home and that

1109 -> should be the same scale, about the same time of day, with the same amount of

1112.81 -> clothing so they can keep track of their fluid volume status.

1117.26 -> And then we want to educate them to report any of the signs and symptoms to

1122.96 -> see if they are getting worse so those include report shortness of breath,

1128 -> paroxysmal nocturnal dyspnea, that's the one where the patient sits up with extra

1132.98 -> pillows, sleeps with extra pillows elevated, increase in peripheral edema and

1138.56 -> that sometimes just means that their watch, their rings or their socks are

1141.92 -> getting a little bit tighter, if they're having a cough certainly because the

1146.99 -> fluid can be backing up into the lungs, they can have pink frothy sputum leading

1151.34 -> to pulmonary edema. Also if they feel dizzy, if they have an episode of

1156.14 -> syncope, so fainting or any kind of nausea with abdominal distension, again

1161.33 -> because that means that the fluid is backing up into the abdominal cavity and

1165.62 -> the heart is not pumping the fluids efficiently. So I hope this video has

1171.05 -> helped you review this basic concept, I hope this video has helped you review

1176.78 -> the concept of heart failure and all its facets. If you haven't already watched

1182.11 -> please go back to the videos of cardiac output and the different medications

1187.94 -> where I discuss the nursing care and side effects of certain medications, as well

1192.56 -> as the basic principle of RAAS, where the relationship between the RAAS and the

1199.82 -> BNP in the control of blood pressure and fluid volume are discussed in more

1204.47 -> detail. Thank you for watching Nursing School Explained, I will see you

1208.85 -> next time.

Source: https://www.youtube.com/watch?v=vcAlhEmvQqA