Heart Failure

Cool. Hey, if you're new to tutoring, oh, my name is chance. Brian's got the right idea. And tell me where you're at, where you're from, where you are in your nursing journey. Um, Steve, you're supposed to take an the inklings pretty quick. Have you done that yet? I thought you were supposed to schedule it. I thought you were pretty close. All right. Give everybody just like one more minute or do some strange sharing. Today we're going to go over heart failure. This is a, uh, I have not done this one. Um, typically Nicole does this one. Ah, still working through view. Have you done the same clicks? How many? How? Tell me some classes have you done, cause I think you could do it. I don't doubt a couple. Gail. Gail's ready for the end client getting ready. I am. Cool guys. Let's get started.
Okay.
Um, if you haven't been to, uh, any of the tutoring sessions before, this is a laid back type of atmosphere. This is something that we enjoy doing. Uh, it gives us the opportunity to hang out with you guys into your questions, go through some basic stuff. Um, and try to drive things home that, uh, are really important for you guys to understand in terms of nursing care and the inclax um, that way because that's what the intellect is, right? It's, it's a culmination of everything that you've done over your nursing program. That's what your professors prepared you for. That's what we try to prepare you for so that whenever you walk out on the floor, not only can you pass boards, but you can go out and you can go take care of those patients. So I'm going to actually screen share and we're going to do, we're going to run through some stuff. So today we're dealing with heart failure. So the first thing we're gonna do, let's get this screen going. Shaved screen too. Everybody should be able to see my screen. If you cannot see my screen, let me know.
But you guys should be able to see my screen and hear me talk to me. Walk through this. So use the dual part teller. So let's come over here and cool. Oh, hard. Tell your let's think about what's going on with heart failure. Well, the first thing we have to recognize is the heart of the pump. And we're talking about the circulatory system. We're dealing with a right and a left side. So this is a left side change. Bring College real quick. Cool. This is the right side, right side. It's oxygenated blood. Left side has oxygen in your blood, right? So the deoxygenated blood comes into the right side, goes up, goes to the lungs, oxygen, carbon dioxides let off, they pick up a tube, comes back to the left, cause up to the body and delivers it. The scapula or butt beds and comes back.
So there's essentially two sides of the heart rate. So there's a right and left side. So left the way that is the easiest way to remember which side of the body that the blood is going to. His left is for lungs, right? Is the rest. Rest of the body. Right? So the left, um, is a, and this is talking about heart failure specifically, um, and the areas that are affected. So when you have left sided heart failure, the left side or the lungs are affected. Um, whereas when you have the right side or heart photo, the rest of the body is affected. So let's get into kind of why that happens. So the first one, am I, so this is actually a picture of a myocardial infarction, right? So myocardial infarction, that's infarction. Okay? Are according to [inaudible],
yeah,
happens, right? So you've got this blood vessel. This is a, um, the actually this is the Zune and picture of the Ledcor in art coronary artery, which is actually happening right here. What happened is you have an occlusion. This is supposed to be delivering oxygenated blood to the, uh, to that heart muscle. Well, what happens when we have decreased perfusion?
Okay?
You ended up getting what in the heart? What happens when you have decreased profusion to myocardial or the cardiac myocytes. And, um, in the case of Ami, what happens to that tissue? You guys tell me in the chat dies, right? You'll get that tissue necrosis. So unlike, um, a lot of other awesome parts of our body, the cardiac monocytes can't regenerate. So you'll get that tissue necrosis. And when you get the tissue necrosis, um, you'll actually get that, um, the decreased ability for the heart to utilize its pumping ability, right? So it's like a weakened muscle. So Suez decreased strength. So over time, oops, I'm going gonna remind me later. Cool. Um, over time, what ends up happening is you'll get, uh, one sec for me.
Um, what happens over time is that you'll get, uh, the, the weakened heart tries to beat harder will becomes there's, you still can't beat it, get any more strength from anywhere else. So what ends up happening is you, uh, you had this increased afterload and an increased afterload on that we can heart, especially on the left side, causes the increased stretch. The heart becomes weaker, it stretches out, and you'll get the left side heart failure. So now let's think about hypertension. This is another reason that you're going to get heart failure, is that increased workload on the heart. So think of the, um, the cardiovascular system as a plumbing system. So there are several variables, uh, if you have, if you know anything about plumbing. So let's say you've got a pump and you have a certain amount of fluid that needs to be pumped through, uh, the, um, certain amount of pump fluid that needs to be pumped into the system.
And then you have a pipe size, right? So imagine if your, your fluid, your fluid amount stays the same. Let's say you're, you're kicking out six liters a minute and your pipe, let's say you got a half inch pipe. Well, and that's what the pump is regulated for. Let's say the pump says, okay, cool. We can pump six liters a minute in a normal velocity, uh, which we, which we call a stroke volume and cardiac output. Uh, and we're going to go through a half inch pipe. Well, imagine if we take that same thing and we're going to change this instead of a half inch pipe road or a quarter inch pipe. So this is what's interesting is you have the same amount of volume that's being pushed through this pipe. So if we know anything about physics is that you have the same amount of volume and how we smaller space, the pressure is going to go up.
So you have this increase in pressure. Well, if the volume can't actually go anywhere, guess what happens? Everything goes backwards. So now you're putting extra stress on the pond. So same thing that happens here, which is what is, that's essentially what afterload is, is after load is increased systemic vascular resistance, would you call as VR? And that increased us. VR actually causes a harder workload on the heart. That's the afterload. So then the last thing that that causes it is you have valvular disorders. You have to do two types. You've got regurge regurgitation and you've got stenosis.
So the way that I try to remember these as Sonos is a narrowing. So if you have a narrow, so imagine, uh, imagine your valves being like a funnel. So if you ha this is your valve and Mitral Macho, my cousin, a order pulmonic whatever, and you have the fluid going and it's trying to go through this valve, what ends up happening is you have this stenosis and it's actually narrowed. So it actually can't allow the fluid, the fluid kind of trickled, the blood kind of trickles in. So what ends up happening is all the fluid that's behind this going this way ends up getting blocked up. So if this is like let's say the right side, you're going to end up getting right sided heart failure cause you're getting this increased volume in that area. So the other one that you're going to get is regurgitation, which is backflow.
That's what regurge is. So think of the, also think of the valves as like a door. So the door opens and closes, opens and closes. Um, when blood rushes in, um, it opens in the, when the door closes, um, and the, and the, uh, the chamber contracts, what happens to that door closes? Um, so here's your valve. Blood comes in and all of a sudden you get to increase pressure at door closes and it keeps it from going backwards. Well, imagine for a second, if you've got a broken door, so now you've got a door like this, but then it doesn't quite close, you're gonna actually get backflow. So then you've got that back pressure. So you've got, you've got your sis, your systemic vascular resistance, and that's pushing that fluid back. And so that's also gonna Cause, um, cause heart failure because you have these increases, basically the pump is not working properly. So that's why all of these things happen. So the kidneys play into it. Well, can use, are responsible. Actually, I'm going to have you guys, so tell me what the kidneys are responsible here for here. You're telling me what's going on when we're talking about heart failure,
the idea behind the kidneys is that we want to maintain this concept of homeostasis. When we're talking about fluid volume, you want to stay euvolemic.
So Brian, don't think about, um, okay, so the kidneys have several functions, right? So the kidneys are responsible for filtering. But there's one other really important concept. They're responsible for the Renin Angiotensin aldosterone system and they are responsible for maintaining blood pressure. So, right, so we're dealing with the excretion of sodium, the retention of water. We're talking about a couple of things. So what, here's what happens. So let's say you have a patient that's in heart failure. We're going to follow the training. I can do this a couple of times just in state. You guys get it right? So you have a patient in a heart failure. Well, what's happening is you have this over typically heart failure. Patients are um, hyperbulemic.
Actually I'm going to hit this from a different angle. We're going to go a different angle here. There's a couple different ways we're gonna do this, but this is, so think about it like this. So heart failure patients, we're going to talk about perfusion cause this is more likely. So in heart failure, you have decreased perfusion to the kidneys. So what happens with the kidneys? Well, the kidney say, Hey, well I need to whole, I'm, there's a couple of different ways we can compensate. We have decreased profusion. We need to increase intravascular volume, intra vascular volume. How does it do this? Well, it decreases water excretion by doing this, holding on a more water. So there's an increase in the anti decorator cone. So when that happens, you have an increase in intra vascular volume. So if you have this increase in intravascular volume, think about the rest of the body.
Well now you've got this heart that already can't keep up with the six liters a minute that it's supposed to. And it also, and we're adding more volume, you're actually exacerbating the problem. The other thing that the kidneys do is they vasoconstrict. So remember we've got the half inch pipe. Oh, it goes, hey, we need to increase profusion. One of the ways that we can increase perfusion is by causing vasoconstriction because the kidneys think that the body's not constricting enough to get enough profusion. So you have your compensatory mechanisms. So if you have decreased heart rate, um, and it's all related to stroke volume and Sophia that decrease stroke volume and you know, that decreased cardiac output, what happens is we're not getting enough perfusion and so we have to figure out a way to do that. So we either have to increase the heart rate, which is where the system, um, the SNS comes in, sympathetic nervous system comes in and says, hey, we need to increase the heart rate. And the other thing we're going to have to do is we're going to have to increase the [inaudible], uh, the basic, stricter properties of the blood vessels. So they go at it again, you've got heart failure. So heart failure equals decreased perfusion. If there's not enough, if there's not enough profusion to the kidneys, the kidneys kick in saying we need to do three things, increase water, increase blood pressure, and increase heart rate because that's what they're going to do. The problem is, is the heart that is already failing cannot keep up.
Okay.
All right, so let's talk about diagnostics, but when we talk about diagnostics for these types of, uh, in order to diagnose a patient with heart failure, you, we're gonna look at basically three things. We're going to take a look at something called BMP, which is brain nature, Reddick peptide.
And what BMP does is inside the ventricles, draw my heart here for a second. So wait, I draw heart. Looks like a skull, right? So here's the ventricle. This is the Septum. This is the other ventricle. Well, what happens is you have this increase in here and the change of color, CPS, you guys can see a little bit better. So here you're going to have this increase in stretch. So in a normal heart, what happens is, so let's say you have more volume coming in, right? So we've got this increased volume. What happens is the ventricles detect that there's increased volume because there's more than tricolor stretch. So what happens is when this happens, there's an increase in BNP production. When that B in p m is increased, what happens is it tells the kidneys, because it's a peptide that talks about nature [inaudible], which is, this is sodium and your Riddick urine,
sorry, can't spell their name or your ISAs, which means we want to kick out fluid, right? That's the goal. So what happens is, okay, so the heart goes, we've got this extra volume, we got to get rid of it. And the way that this is triggered is through this BMP release. So there's ventricular swelling. So are this been trickle and stretching Hutchen say so when it's been the metrical stretch, BMP is released that BNP tells the kidneys to kick out sodium and when it does waterfall the sodium and it goes out in urine, therefore it decreases that intravascular volume. And when it decreased the intravascular volume, it equals a better workload, right? Or or more manageable workload for the heart. That's what they're going for with the BMP. So the way we do, the way we look at this in terms of a diagnostic perspective is we say, Hey, what?
What value is this? So less than a hundred is actually ideal. Peter Grams per mil is the way it is in the United States. So let's not a hundred picograms per mil is normal. Okay? That's, we don't expect anybody that is not in any sort of significant heart failure or heart disease or any sort of ventricular sweat chain. Maybe somebody who's hyperkalemia. You can sometimes see BP increases in hyperkalemic patients. Um, because you've got the increased stretch, but you're not going to typically see anything greater than a hundred. If you got a patient that's symptomatic for, um, you had a patient is symptomatic for the, uh, for heart failure, then you got to figure out how bad, right? So 100 to 300 is mild, greater than 300 is monitored. So you can be like three to 500 and that's modern. But anything grid of the 900, we're going to say that this patient's severe.
Okay? That's what we're looking for in these. We want to know how badness is. The most I've ever seen is the patient is about 4,500 and they were in pretty significant, um, some pretty significant heart failure. The other thing, we just look at this thing called Echo cardiography. And so the way we, it's, it's basic. This is basically, I mean, or I'm running out of room, I'm doing so much writing. Hold on one second. Alright, so with this, this is an ultrasound of the heart. So cardiac ultrasound. This is essentially what it is. So when we do, when we have, uh, when we get an order for it or the ultrasound tech comes to do echo, what they're looking for are a couple of things. They're looking, first off, they're looking for a, a foul rhythm disorder cause you're not going to be able to see that on a CT very well.
Um, you can hear it. You can also say it. Um, but you can also, uh, if there's a suspicion of it, then they use echo to confirm it. Because if a patient has a really high BNP and they're symptomatic, they have to figure out why it's happening because whatever, um, whatever direction they decided to go in terms of treatment, whether it's a surgical intervention, you have to make sure they're doing the right surgery. So this is what they do. So then they also look at something called injection fraction who can tell me what a normal injection fraction is. And while you guys are typing in your answers, can you explain what it is? An injection fraction is the amount of blood and a percentage is injected with each contraction. There's a normal value and then there are certain than our certain lower values that we can get concerned about. Then we'll talk about that here in a little bit more. But just what do you guys think of when you, in terms of a percentage, what you think a normal, I'm a normal injection fraction. Is anybody care to guess? [inaudible] so normal is about 50 to 60
okay.
And where are we actually start to worry is about 25% and I'll explain that here in just a second. But that's the 50 to 60 every time the ventricles a squeeze, we expect 50 to 60% of that blood to be ejected out of the heart because we know that there's going to be some refilling where we know there's going to be sun that slipped over. We don't because essentially if all that were to go out the sides, the ventricle ventricular walls won't touch. The last thing we want to look at is radiology, right? So we want to take an x rate, we want to look for things. These are for your symptomatic patients.
And then so we are looking for pulmonary and we're looking for that fluid on the lungs. We're looking for that back up on the left side. See if there's a problem. Yeah. The thing we're looking for is cardiomegaly. So this is that enlarged heart. So let me see if I can draw a picture here. So this is my patient and here's the sternal wall. And then here are rhythms, right? So for a patient that, let's see if I can draw about the right size. So normal heart sets, oh my goodness. As I'm drawing slow as get all freaked out. So somewhere like that. I see. So that's about a normal patient size. I've seen patients where they get like this where that the heart is just in like ink. Almost that whole left side is giant cardiacs a little bit. So that's what they're looking for.
That's the other thing. They want to see how much of that that um, in terms of size, in reference to this, to the patients, like the resting cage is taken up by the heart. That means if that basically that heart is stretched out over time. So I want you guys to tell me what you think this, we're going to get into a little bit of some nursing stuff. So signs and symptoms of right side and heart failure. Do you have a patient that has a right sided heart failure? I want you guys to start telling me what you think you're going to see for that patient. Uh, so tell me like maybe the complaints that they have or, uh, things that you've seen. Okay, so we've got it. Let's write them down. So you've got an edema.
Okay.
A Sophia says specifically lower extremity. Agila. Okay, cool. Brian says shortness of breath. Let's see, what else do we have? Anybody else? Oh, JVD. Increased JVD. There's another one. Wheezing. Tamila says wheezing, increased heart rate.
Anybody else? Alright. Tiredness. Oh, that's a good one. There we go. So here, let me, let me show you the one. So let's go over these real quick. You guys said Edema, shortness of breath, increased JVD, wheezy, increased heart rate, lethargy, ISO tresses that increased weight. And there's another one. That one's really important. So I'll tell you which ones I am for sure on and I'll explain which ones I um, we need to discuss a little bit more. So the Dema exactly. We're expecting that edema, especially that low and or that low extremity edema. The other one you want to look for here is assignees. You're going to have some of that backup and that portal hypertension system. And you can get some societies from that. Basically, it's, it's backing up, uh, right above the point of the liver. And you're going to get that, uh, you're going to end up getting that, um, that the leaking out of that fluid from the liver into the abdominal cavity.
So you'll see a citation patients soreness of breath, that's another one. Increased JVD. Remember that's on the right side. That's you've got the, um, you've got basically, uh, an increased preload and you've got so much fluid on their right side that it can't get to the, it's not being ejected out to the lungs. It's getting there so that then you're going to have that lethargy and then you're going to have that weight gain. So these things kind of tie back in. Now, wheezing, you're not typically gonna get. Um, and we'll talk about that here. Wheezing. Now remember what wheezing is, right? So wheezing is a bronchospasm.
Um, and with a bronchospasm, we have a narrowing of the passageways of the, uh, of the, of the airway, right? So there are only 10, there are only a few things that are going to cause a bronchospasm, an allergic reaction or asthma. So this is going to be something you're not going to typically see, like a wheezing. You can't get what you're going to hear. Um, in terms of, uh, you're gonna hear more lung associated stuff and you're gonna hear it with the left side and we'll talk about that here in a second. But wheezing is a very, very particular sound. Um, but any sort of lung sounds you're going to hear like, um, basically fluid or there's going to be coughing. So basically let's, let's jump to the left side so I can explain this just a little bit better or I can, I can flush this out just a little bit more. So let's talk about last time for a sec. Brian mentions left side of heart failure. You can hear the lungs and the right, let's say left side of the heart failure. You can hear in the lungs, right question. And so
I'm assuming that's a question. So let's talk about, well Brian, before I get to that, okay, so let's talk about left side and heart failure. Tell me some symptoms that you guys see in left, left second heart failure. Okay. Blue says in Tema some shortness of breath. Yeah, I'm gonna. I'm gonna write these down. We'll go through them wheezing. Oh my goodness. You guys are going crazy. Fatigue, weight loss, crackles. I'm going to write something down here. Adventitious. Let me sounds.
Okay.
Oh, there it is.
Yeah.
Hello. [inaudible]. That's that pink frothy sputum. Alright, so let's go with each, right. So shortness of breath. We may have some shortness of breath. And the reason we're going to get shortness of breath is because remember we've got, so let's think about the heart, right? So you've got the right side goes in and goes to the lungs and you've got the increased pressure, your pressure starting to build throughout and it's going into the left side. And here's the left side. Here's the right side as it goes. If this cannot push the, the blood out of the, out of the heart to the body through the aorta, because there's an increased afterload, what's going to happen is it's going to back up. You're going to get that pulmonary congestion is what you're going to get. So when we say shortness of breath, we have to be more specific. What is short? So are they, is my patient something called doe? How many of you guys have seen that abbreviation?
Anybody see the abbreviation doe? So vue stands for a dismia on exertion. And what it means, yeah, Chris has exertional dyspnea. And what it means is every time they start to become more active, what happens is if body can't keep up because they have a higher need for oxygen. And so they basically become short of breath. It's more associated with like most of the times, uh, like right side. Cause you'll get that, um, that activity and tolerance. But when we're talking about left side, it, it's going to become shortness of breath because you're going to get things like chronicles, an adventitious lung sounds because you're getting that buildup of fluid. It's the old, the reason they're short of breath. This there shortness of breath here comes from um, poor perfusion, the shortness of breath on left side. It is actually because of pulmonary congestion, right?
So if I've got a patient that's got pulmonary congestion, that means there's fluid in those lungs. And that's a totally reason why my patients aren't getting that oxygen exchange when it comes from the right side. And it has to do with the fact that I can't get blood to the lungs to pick up oxygen. All right, cool. So what else? So we also said, oh, weight loss, not really. You're still gonna have a wait name for a lot of these patients. Um, because you're just gonna have this just increased, uh, this, uh, not a great ability to get the fluid out where it needs to go, but typically, so think about it. You're going to have more lung associated stuff with the left side. Remember, left lungs,
okay.
In right arrest.
That's where, that's where this thing comes in. So I want you loss of appetite, of course. So they're not going to feel like eating. They can feel like they've got, um, especially in rights and his right second heart failure. You can also have patients that because of the increased abdominal pressure from maybe assignees, they're not gonna want to eat. So, uh, Brian says tripod Pasha, you're going to get more of that with like chronic. Um, it's like CLP, dears. You're going to get that from patients that have like commonary, uh, chronic pulmonary disease versus now getting thoracic extension may help, but it may also not depending on their, um, the, their amount of, uh, congestion that they have. The other thing that you're also going to see is you can see decrease per, I think somebody said this, so O'Brien said low, low blood pressure and upper extremities.
So how do we manage or how do we determine what that is? We're gonna actually go say decreased pulses. Like th th you could have a patient like let's say they're happy, they have exacerbating left sided from one day to a next. You can actually have like two plus puzzles on one day and then you can open one plus the post is on the next day. So you have the decreased policies. You have that decreased renal perfusion, that's another one. Um, yes, so some patients, chronic patients are chronic heart failure. Patients will say, okay, trouble breathing. So they've got that orthopnea. Corrina says that where they got to use two or three pillows. So when you're doing your full, uh, your patient workup, changing your, your comprehensive health histories, we need you to say, hey, you have trouble sleeping at night. You wake up a lot. If you do, are you using pillows? You use one polar coming pillows. Do you use to sleep? Um, do you sometimes, like I've know patients have had to sit in a chair. Um, so on the left side, yes. Remember? So when the left side and you get that left sided heart failure, you say you have decreased, decreased fluid out of the body. So if we have decreased fluid out of the body, that means we have decreased profusion
okay
to the kidneys. If that happens, you're going to have that, that urine output dropping. But it gets a little bit tricky because you know that your patient needs some intravascular volume. So how do you do that? So let's take about, I think with managements next one. And so let's talk about management. Well, there's basically three avenues that we can go when I'm over talking about it. So we have to do two things. You've got your preload, which is stretch, and you have afterload, which is resistance.
That's how I want you to think of them, right? Payload, his bedroom, my heart. This is fluid coming in and it's how much stretch we can get and how much, uh, how much of a squeeze you can get out. And then also you have the afterload is systemic vascular resistance. So what do we do when we're talking about medications? There's a couple of different ways we can do it. The first thing we have to do is reduce the afterload and every patient is going to be a little bit different. You can't, you know, say these are all of the same, uh, you can't treat all your heart failure patients the same way because they could have like, you know, a primary left side heart failure with a mild right started heart failure. But because their primary left side is, uh, a bigger issue, that means that they have to, they have to treat their patients a little bit more aggressively with left side and versus right side and depending on what's going on.
So let's talk about that. So you've got [inaudible] and a decrease resistance. So how do we do that? Well, if we have increased resistance, we want to base it only, and this is where your blood pressure medications come in, or your arms, your ace inhibitors. That's what we're gonna do. What's one of the things we're going to do? Second thing we're going to do is we're going to reduce the preload. How do we do that? Well, we sometimes we can use, um, and we'll talk about that in a second. We can help the heart squeeze a little bit better. But the thing we want to do is we want to reduce the amount of work. So we want, we can remember what we've got. We've got the, let's say we've got the pump, we've got the volume, we've got the pipe, we've got a quarter inch pipe. First thing we have to do is go to a half inch pipe.
Okay. Then by going into a half inch pipe, we're going to help her knees the volume. Well, maybe instead of going six liters a minute and let's say there's six liters in the whole circuit, well let's take that down to five. We're going to drain out, oops, we're gonna drain that so that, so instead they're going six liters a minute and say, well it's rated for six liters a minute, but we're actually gonna put in five so it can actually go every minute. So now we've got this idea, we want to reduce the volume. That's where that preload comes in. So we're going to do that through diuretics. Direct are gonna help both right and left side. So it's going to, that's the other thing it's going to do this. When you're using a diuretics, pay attention to your k. You always want to pay attention to that potassium cause some are potassium-sparing sometimes or some are potassium wasting.
So if you have a potassium wasting diuretics, which is most of the times going to be your lasix and patients are on Lasix, you need to make sure that they're getting a supplement adequately without potassium. The other thing we can do is improve contractions. These are called, did, your option is called an inotrope. What that does is it helps to squeeze. So every time it squeezes, it'll um, it squeezes harder so it improves that contractility. So in some acute we can use something called sympathomimetics. So [inaudible] mean so you can be able to do a [inaudible] mean drip [inaudible]. So the beauty mean drip. There you go. So that's what we're doing. So then you have your different types of surgical intervention. So that's what we're doing from a medication standpoint and we've got our surgical interventions. So we can do something called a cabbage. Oh my goodness.
Yes.
Um, we can do with cabinets which in a coronary artery bypass graft, which we all call, uh, which we call a cabbage or bypass. And what we're going to do here is we're going to try to re perfuse, we're going to try to reprove fuse that, um, that damaged tissue we're going to try and do is as much as possible. And so we're gonna do that as quickly as possible. Sometimes we can do stents in the meantime to try to improve that. But then we're also gonna do a cabbage. The other thing is a pacemaker or an ICD, um, or Combo. So, um, internal cardiac defibrillators, what stain ICD stands for, so that's going to be able to shock them. Now the reason we say we talked about injection fraction a few minutes ago is because anything less than 25% has an increased probability of lethal ever written is there you go.
So letha written in is so any, any patient that maybe had an MRI and they realize that their ETF has only like 25% or less, you're going to see them most of the time get an ICD. And it's because they have a significantly higher likelihood of um, getting going into d v-fib or Vitac at home and it's undetected and patients end up dying and they're not, they're not necessarily like having another MRI, they just go onto these lethal arrhythmias because it shows it doesn't totally up. Then you also have some, they call it all bad, which is a left ventricular assist device. And what that is is it goes in and it helps to pump out that increase, that cardiac output. And this is just a bridge, right? So this is this something that the providers are going to do for patients until they can get them heart transplant. Obviously you have to meet all those criteria for it. So talk about when you're in nursing, when you're taking care of a heart failure patients. Tell me some things that you are going to do from the standpoint of the nurse to take care of that patient. What is your responsibility in this?
Yes,
you guys tell me your I'm, I'm your heart failure patient. All right, cool. So we're going to check eyes and nose. Cool. Eyes, nose daily. Wayne, what else?
[inaudible]
cool. Ranch of vital signs and instead of bed, these are all things you can do. Raising had a bed wouldn't, would help a patient
if they're exacerbating. Like if you're maybe in a step down. Check K we're going to do lights, right? Diet modification. What does diet, I want to, I want to stop for a second. So we've got diet modification. What does that mean? What does diet modification? Okay, so Brian says both sending you what else? Uh, hurting health and heart healthy diet. So credit guy. Oh, I can't spell today. Cordy cool. What else? Brian? Brian's on it. Decrease calories. Do you think that you guys could maybe do a referral? Cool. Where are we going to refer to you? Rd. Yeah.
I trust that you guys know your nutrition back and forth. Um, I think that when we talk about diet modifications, there are some things that we can do that are, what would you really hope our patients in terms of, hey, we need to check your sodium. Maybe you're on a 1500 mil restriction diet. Maybe you on a, um, maybe we need to reduce shirt your calories. But the thing is, is it falls kind of outside of our scope of practice to be, um, it's a tree. It's a fine line to walk. Um, oftentimes, even though I've feel like I have a pretty strong background in nutrition, um, if I'm just having a kind of a candid conversation with a patient, I will. But if I'm doing something in terms of educating my mind, my patient, I want to make sure that they're really prepared and I'm going to go for that referral.
I don't have a nutritionist come in and make sure that we're on the right calories because if I tell them, oh, hey, we need to reduce your calories by 15% and they're not even counting the count the calories correctly, like that's where that comes in. So always kind of default to, if you can tailor for, for an rd, then great. But in terms of diet modification, I wouldn't do diet, diet modification per, uh, in registered Dietitian. That's how I would approach it. Um, anything else that we can do for, uh, patients with heart failure? There's one exercise.
Um, and I'm going to put a caveat with this one. Um, per MD or our per provider. That's what I'm going to say. Because you want to make sure that if you have a patient who's got, um, if you've got a patient who's got like an f of 15, they may not be a candidate for, um, they may not be a candidate for exercise. And does exercise mean, is exercise walking one to two times a week? Is it going to the gym and lifting weights? Is it signing up for an iron man? You know, there's, we have to be a little bit more precise. So one of the things I would definitely do is say, hey, you know, you talked to your, you know, whoever your provider is, hey, I'm about to district as patient, what are the gaps, what are the Diet and exercise recommendations? And then you go from there. Um, let's see. Smoking cessation, always smoking cessation. Perfect. There's one that I haven't seen yet and I'm trying to see if you guys are going to pick up on it. [inaudible] I'm going to start writing it.
[inaudible]
medication compliance. I'm going to make sure that my patient understands that when I discharge them, that they totally understand why it's important to check medications or why it's important for them to stay on their medications, what medications they have, make sure they've got the right doses, make sure they've got the right pharmacy, make sure they understand what every medication does. Um, and what things that they should come back to the emergency room for these. I mean there's, there's a ton of education that goes with this. So you have to make sure that you have a good understanding of what those medications that you're instructing your patient to take. And also to make sure that they understand why they're taking. So that's kind of heart failure in a nutshell. Let me go back to this.
Alright guys. So I want you to tell me, do you have any questions kind of about her vote or, I know sometimes we have different, uh, instructors come on and talk to you about different types of things. And so this was fun to get to that help you guys out with this because I know that Cole Nicole loves doing heart failure. Um, she's not, um, doing it right now. So I got to jump in here and help you guys out. So what questions do you guys have about her failure or maybe some things, some other questions that you may have
[inaudible]
if you have any, if you don't, that is totally okay.
[inaudible]
all right guys. Absolutely. Perfect. All right, so for left side,
Henrietta asks, so for left side, is it weight gain or weight loss? You're typically going to see weight gain across the board. Um, you can have appetite loss, but you're still going to have, um, you are still going to have that increased because most patients, even though they don't, um, eat a lot, they still don't buy a Reese as well. So you're going to have a lot, like Brian says, a lot of fluid retention. So you may not see, um, you're not going to see weight loss. In most cases. You're going to see either a patient that stays at their weight or they'll slowly gain. But for patients that, for the general rule of thumb is you're gonna have weight gain for, um, your heart failure patients. And Corrina says that ETF, uh, it says only 50 to 60 old, about 50 to 60 is normal and anything less than 25%, they usually put an ICD in because there's that higher likelihood of those lethal or lethal arrhythmias. So da tutoring. So if you're totally off topic, but I need da tutoring. So then what is da tutoring?
[inaudible]
oh, dimensional analysis. Oh, okay. Um, absolutely. We can figure that out. I know I need to mention analysis a, it's, it's a tough one. Um,
[inaudible]
no, you're good. Let me see something.
[inaudible]
let me try one thing real quick since I'm here. We'll throw an extra one in here for you guys.
[inaudible]
I'll do a quick dimensional analysis one. I'll show. I'll give you like a brief. Um, I'll show you how I do [inaudible] analysis and then you can tell me if it helps. One thing, let me pull this back up.
[inaudible].
That's great. Okay, cool.
[inaudible]
okay. Did you go back to share my screen? All right, cool. Here we go.
[inaudible]
alright, so the keys, the keys to doing dimensional analysis, right? So this is how I do it and I'll fucking get my line. Oh, it's gonna start out like this. I make my brackets. So let's say, let me think of something. Let's say you have to give a, I'm just thinking here. Uh, let's say you have to give a 75 milligrams of the solution that comes. Um, okay, let's do this. You have to give 75 milligrams per kilogram to a patient that your dose and it comes in a concentration of a 10 milligrams per mil. Okay? Um, you want to know how many mils you need to give your patient. Okay, so let's start out right? And let's say our patient weighs a 50. Gonna make me pull up my calculator too. Alright, here we go. Did you, okay, so you've got a 50 kilogram patient.
That's what, you know, start with what you know here. Um, then what I like to do is I will find out the next appropriate, like a unit so that my units, um, this so that my units cancel out. And when I say 75 milligrams per kilogram, don't get lost in the kilogram because it's per one kilogram. So if I want my kilograms to cancel out, I'm gonna say one kilogram is here and I'm gonna put 75 here, 75 milligrams. So now what's happened, what's happened now is, um, my kilograms have canceled out. So now I'm left with 75 milligrams, right? So this is going, I've taken care of that, that thing that I have to worry about. So now what am I left with? Because I still want to know mills, right? I still haven't gotten the mills yet. So now I, if I calculated this, uh, I would know the dose that I need in milligrams, which is what that gives me.
So then I've got 75 milligrams, so now I'm gonna make my units cancel out. Well, this is Mary. This is 10 milligrams per one mil. So if I say 10 milligrams and I put the 10 milligrams here and I go one mil, thank goodness, doing like rainbow colors. Cool. All right, so these things don't matter. I'm here cause I'm going to be done. Okay, so my milligrams cancel that. Right? I want to know how many mils I'm still giving my patient. Correct. So now all I do is multiply straight across and this, because then this just becomes like a fraction. So 50 times 75 times one divided by one times 10 so this gives me 50 times 75 gives me 37 50 Oh oh my goodness. I don't know why I didn't here. Let's try this again. 37 50 over 10 divided by 10 I'm going to give 375 mils because all I knew it was multiple across. So I think what I've done better had been a hundred and a mil milligrams per mil.
Yeah, that's so that's how that works. And so what do we always do? No matter what I'm doing is I say, okay, what do I know and whatever. I know I'm going to plug in here and then at the end I just want the last unit, whatever box I have to have that last unit. Is it milligrams? Is it milligrams per minute or whatever it is. So like milligrams for a minute is a little bit different. So what you need to do is make sure that when you cancel out that you're going to have milligrams on one side and minute on the other. That's all you're doing.
Okay.
You're welcome. Yeah, Sophia, it's always just, it literally is what do I know on a plugin? What I know you are very, very few times you're going to have something in this box usually when I started, but it's like I got this one thing, I know this one thing, so I can sell my units out and it gives me this one other thing and then I keep going. So that's how, that's how it goes. All right guys, I'm actually going to head out, I know this is going a little bit long today, but, um, share my screen again or here we go. Cool. Alright guys, hope you had fun. Um, this was a lot of fun to do this and get back into some of this other stuff, but that's how the dimensional analysis works. That's how heart failure works. So you guys have a good one. Awesome. Perfect. Alright, you guys have a great day. Happy Nursing.