Caring for Patients With Cardiac Disorders

Learning Outcomes Compare and contrast the causes, pathophysiology, effects, and manifestations of common cardiac disorders. Safely administer drugs commonly prescribed for patients with heart disease. Provide individualized and evidence-based nursing care for patients undergoing invasive procedures or surgery of the heart. Use clinical judgment and the nursing process to conduct focused assessments, contribute to care planning, and provide individualized nursing care for patients with disorders of the heart.

Learning Outcomes Provide and reinforce appropriate teaching for patients with heart disorders and their families, taking patient values, expressed needs, and preferences into consideration. Use electronic resources for planning and documenting nursing care for patients with heart disorders.

Disorders of Cardiac Function

Heart Failure Inability of heart to function as pump Results from any condition that causes: Impaired contractions Increased workload of the heart Leading causes Hypertension CHD with myocardial ischemia and MI

Pathophysiology Cardiac output drops Compensatory mechanisms activated Sympathetic nervous system stimulated Arteries and veins constrict Venous return increases to the heart Increase in preload

Pathophysiology Renin–angiotensin–aldosterone system activated Salt and water retention Heart chambers dilate Ventricular hypertrophy Reduced cardiac reserve Classified as left-sided or right-sided

Pathophysiology Left-sided heart failure Manifestations Pulmonary congestion Reduced cardiac output Fatigue, activity intolerance Dyspnea on exertion (DOE) Orthopnea Acute pulmonary edema

Pathophysiology Right-sided heart failure Manifestations Fatigue Activity intolerance Jugular vein distention (JVD) Peripheral edema Anorexia, nausea Abdominal distention

Pathophysiology Right-sided heart failure Biventricular failure Manifestations Ascites Liver/spleen enlarged and tender Biventricular failure Paroxysmal nocturnal dyspnea (PND) Acute and chronic failure Multisystemic effects

Manifestations of Heart Failure

Collaborative Care Diagnostic tests Cardiac hormones, atrial natriuretic factor, and brain natriuretic peptide Serum electrolytes Chest x-ray Echocardiogram ECG

Collaborative Care Hemodynamic monitoring Assess cardiovascular function Multilumen catheter inserted through central vein in right side of the heart Pulmonary artery used to measure central venous pressure, pulmonary artery pressures, and cardiac output Arterial blood pressure measured using a peripheral arterial line

The nurse observes tracings of a patient’s hemodynamic pressures The nurse observes tracings of a patient’s hemodynamic pressures. The upper screen in the background shows (from top): heart rate (green); arterial blood pressure (red and yellow); central venous pressure (CVP, light blue); blood oxygen (dark blue); respiration rate (white). (Source: James King-Holmes / Science Source.)

Collaborative Care Medications ACE inhibitors ARBs (angiotensin II receptor blockers) Diuretics Inotropic medications Vasodilators

Collaborative Care Medications Morphine sulfate Digitalis Pulmonary edema treatment Digitalis Positive inotropic effect on heart Narrow therapeutic index Easy digitalis toxicity

Collaborative Care Diet and activity Implanted devices Low-sodium diet Bed rest during acute phase Activity gradually increased Implanted devices Implantable cardiac defibrillator (ICD) Biventricular pacemaker

Collaborative Care Surgery Heart transplant Dynamic cardiomyoplasty Infection and rejection main concerns Immunosuppressive drugs Dynamic cardiomyoplasty Skeletal muscle graft around heart to support myocardium No real success

Nursing Care Prioritizing nursing care Health promotion Assessing Oxygen demand Reduce workload of heart Health promotion Measures to prevent CHD Assessing Frequent, careful assessment

Assessment: Patients with Heart Failure

Nursing Care Identifying potential complications Acute pulmonary edema Liver, kidney failure Mental status changes Diagnosing, planning, and implementing Decreased cardiac output Heart and breath sounds Mental status

Nursing Care Diagnosing, planning, and implementing Decreased cardiac output Urinary output (UOP) Oxygen Medications Rest Quiet

Nursing Care Diagnosing, planning, and implementing Excess fluid volume Panic I&O Daily weights Fowler's position Diuretics/medications Fluid restriction

Nursing Care Diagnosing, planning, and implementing Activity intolerance VS Rest periods Assist with care Progressive activity plan Small, frequent meals

Nursing Care Documenting Continuity of care Note any changes Note patient's response to treatment Continuity of care Chronic, progressive nature Lifestyle changes Exercise parameters Referrals to home health agencies

Inflammatory Cardiac Disorders

Rheumatic Fever and Rheumatic Heart Disease Pathophysiology Streptococcal bacteria Carditis Valves swollen and red Scarring of valves In RHD, scarring leads to valve stenosis and regurgitation.

Rheumatic Fever and Rheumatic Heart Disease Manifestations Fever Migratory joint pain and inflammation Rash on trunk or extremities Chest pain/discomfort Tachycardia SOB Heart sound changes Muscle spasms

Rheumatic Fever and Rheumatic Heart Disease Collaborative care Laboratory testing WBC, ESR elevated C-reactive protein Rapid antigen test for group A Streptococcus Antistreptolysin-O titer Cardiac enzymes Echocardiogram

Rheumatic Fever and Rheumatic Heart Disease Collaborative care Treat primary infection, manifestations Prevent complications and recurrences Antibiotics Medications Aspirin Ibuprofen Steroids

Nursing Care Prioritizing nursing care Health promotion Assessing Supportive care Health promotion Prompt treatment of streptococcal throat infections Assessing Recent sore throat or "strep throat" Chest pain SOB

Nursing Care Assessing Identifying potential complications Fatigue Weakness Fever Joint pain Rash Identifying potential complications Decreasing activity tolerance or change in heart sounds

Nursing Care Diagnosing, planning, and implementing Acute pain Report increased chest pain Administer medications as prescribed Warm, moist compresses prn

Nursing Care Diagnosing, planning, and implementing Activity intolerance Reduce stress on the heart Diversional activities Monitor activity intolerance

Nursing Care Evaluating Documenting Continuity of care Degree of pain VS Response to activity Documenting Any symptoms, changes Continuity of care Importance of antibiotics

Infective Endocarditis Inflammation of endocardium Usually affects patients with underlying heart disease Acute Staphylococcus aureus Subacute Streptococcus viridans

Pathophysiology Bacteria enter body and settle in mitral valve. Normal valve closure prevented Regurgitation of blood Heart murmurs Onset can be sudden or gradual.

Manifestations and Complications Elevated temperature Flu-like Cough SOB Joint pain Petechiae Splinter hemorrhages Heart failure or stroke

Collaborative Care No definitive tests Prevention Medications Surgery Teach risks of IV drug use Preventative antibiotics if indicated Medications Antibiotics Surgery Replace damaged valves

Indications for Antibiotic Prophylaxis to Prevent Endocarditis

Nursing Care Prioritizing nursing care Health promotion Treat infection process. Maintain heart function. Health promotion Teach prevention. Advise patients at high risk to avoid body piercing.

Nursing Care Assessing Risk factors Recent surgery or dental work IV drug use Current S/S VS Heart and breath sounds

Nursing Care Diagnosing, planning, and implementing Hyperthermia Risk for ineffective tissue perfusion Review of system Managing nursing care Vital signs, I&O, and hygiene

Nursing Care Evaluating Documenting Continuity of care Reduction in symptoms Documenting Subjective, objective assessments Continuity of care Education and support through course Importance of reporting unusual manifestations

Myocarditis Inflammatory disorder of heart Causes include: Infection Immunity Radiation Poisons Drugs Burns

Myocarditis Manifestations Nursing care Asymptomatic or fever, fatigue, malaise, dyspnea Heart failure manifestations Nursing care Decrease myocardial work Explain all procedures, tests to decrease anxiety

Pericarditis Pathophysiology Manifestations Damaged pericardial tissue Fluid and exudates in pericardial space Manifestations Chest pain, sharp Pericardial friction rub Fever

Pericarditis Complications Pericardial effusion Cardiac tamponade Abnormal collection of fluid between pericardial layers Cardiac tamponade Fatal if untreated Paradoxical pulse

Pericarditis Collaborative care Self-limiting and will resolve Ecocardiography, CT, MRI Acetominophen, NSAIDs Pericardiocentesis Large (16- to 18-gauge) needle inserted into pericardial sac to remove fluid May be done as an emergency procedure for cardiac tamponade

Nursing Care Prioritizing nursing care Acute pain Pain scale NSAIDs Calm/quiet environment Ineffective breathing pattern Respiratory rate Incentive spirometer Oxygen

Nursing Care Risk for decreased cardiac output VS Heart sounds Prepare for pericardiocentesis as necessary

Nursing Care Continuity of care Stay on medications Medication teaching Fluid intake Activity restrictions

Disorders of Cardiac Structure

Valvular Heart Disease Rheumatic heart disease most common cause Endocarditis After MI Congenital heart defects Changes in structures with normal aging

Pathophysiology and Manifestations Mitral stenosis Valve leaflets fuse. Dyspnea on exertion (DOE) Palpable thrill Mitral regurgitation Valves do not close. "Cooing" or "seagull-like"

Pathophysiology and Manifestations Mitral valve prolapse Unknown cause but may relate to inherited collagen defect Young women aged 14–30 Aortic stenosis Idiopathic, congenital, or RHD Left ventricle hypertrophies. At risk for sudden cardiac death

Pathophysiology and Manifestations Aortic regurgitation Aortic valve fails to close completely. Mild-to-moderate Palpitations when lying flat Angina

Mitral stenosis.

Mitral regurgitation.

Aortic stenosis.

Aortic regurgitation.

Characteristics of Common Heart Murmurs

Collaborative Care Diagnosis Percutaneous balloon valvuloplasty Echocardiogram Cardiac catheterization Medication (prophylactic) Percutaneous balloon valvuloplasty Nursing care similar to that for the patient with percutaneous coronary revascularization

Collaborative Care Surgery Valvuloplasty Resection Valve replacement

Balloon valvuloplasty Balloon valvuloplasty. The balloon catheter is positioned across the stenosed valve. The balloon is then inflated to increase the size of the valve opening.

Nursing Care Prioritizing nursing care Decreased cardiac output VS Hemodynamic measures Cardiac output every 8 hours I&O Daily weights Fluid restriction

Nursing Care Prioritizing nursing care Decreased cardiac output Elevate HOB Oxygen Medications Activity intolerance VS Gradually increase activity Assist as needed

Nursing Care Managing nursing care Continuity of care As appropriate Prevent rheumatic fever Explain all tests and procedures Diet Medications Rest Evaluate for edema

Cardiomyopathy Group of disorders that affect filling and output Often lead to heart failure Cause often unknown Categorized by effects on heart Dilated Hypertrophic Restrictive

Classifications and Characteristics of Cardiomyopathy

Cardiomyopathy Medical management Positive inotropic agents Digoxin Sympathomimetic agents Dopamine Notify health care provider of abdominal pain, rash, or burning.

Cardiomyopathy Medical management ACE inhibitors Diuretics Vasotec, Prinivil Change position slowly. Report bruising or weight gain. Diuretics Abdominal pain, jaundice Electrolyte imbalances Blood pressure changes

Cardiomyopathy Treatment Focus on self-care measures and education. Minimize heart failure Treat dysrhythmias Prevent sudden cardiac death Surgery Cardiac transplant for dilated form Resection for hypertrophic form Focus on self-care measures and education.