Care of Patients with Cardiac Problems Chapter 37 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

2  Also called pump failure; inability of heart to work effectively as a pump Heart Failure

3  Major types:  Left-sided  Right-sided  High-output Heart Failure (cont’d)

4  Formerly known as congestive heart failure  Typical causes—hypertensive, coronary artery, valvular disease  Not all cases involve fluid accumulation  Two types: systolic and diastolic Left-Sided Heart Failure

5  Causes—left ventricular failure, right ventricular MI, pulmonary hypertension  Right ventricle cannot empty completely  Increased volume and pressure in venous system and peripheral edema Right-Sided Heart Failure

6  Cardiac output remains normal or above normal  Caused by increased metabolic needs of hyperkinetic conditions:  Septicemia  Anemia  Hyperthyroidism High-Output Failure

7  When cardiac output insufficient to meet body’s demands, these mechanisms operate to increase cardiac output:  Major types:  Sympathetic nervous system stimulation  Other renin-angiotensin system activation  Chemical responses (BNP)  Myocardial hypertrophy Compensatory Mechanisms

8  Systemic hypertension cause of heart failure in most cases  About one third of patients experiencing MI also develop HF  Structural heart changes (e.g., valvular dysfunction) cause pressure or volume overload on heart Etiology

9  Clinical manifestations:  Weakness  Fatigue  Dizziness  Acute confusion (low flow)  Pulmonary congestion  Breathlessness  Oliguria Left-Sided Heart Failure

10 Proportional Pulse Pressure

11  Clinical manifestations:  Jugular vein distention  Increased abdominal girth  Dependent edema  Hepatomegaly  Hepatojugular reflux  Ascites  Weight most reliable indicator of fluid gain/loss Right-Sided Heart Failure

12  Laboratory:  Electrolytes  Hemoglobin and hematocrit  B-type natriuretic peptide (BNP)  Urinalysis (proteinuria/high specific gravity)  ABGs Assessment of Right-Sided Heart Failure

13  Imaging:  CXR  Echocardiography (best diagnostic tool)  ECG  Pulmonary artery catheter Assessment of Right-Sided Heart Failure (cont’d)

14  PA catheter allows for assessment of cardiac function and fluid volume  PAP/PAWP elevated with left heart failure Hemodynamic Monitoring

15  Priority problems:  Impaired gas exchange  Decreased cardiac output  Fatigue/weakness  Potential for pulmonary edema Analysis of Right-Sided HF

16  Promoting oxygenation and gas exchange  Ventilation assistance  Monitor respiratory rate every 1-4 hr  Auscultate breath sounds every 4-8 hr  Position in high Fowler’s if patient dyspneic  Maintain oxygen saturation of 90% Improving Gas Exchange

17  Improved/increased cardiac pump effectiveness  Hemodynamic regulation Improving Cardiac Output

18  ACE inhibitors  ARB  Human B-type natriuretic peptides Drugs Used to Reduce Afterload

19  Nutrition therapy  Drug therapy  Diuretics  Venous vasodilators Interventions that Reduce Preload

20  Digoxin  Inotropic drugs  Beta-adrenergic blockers Drugs that Enhance Contractility

21  Morphine sulfate  Diuretics  Loop  Thiazide Drug Therapy

22  Cardiac glycoside  Increases contractility  Reduces heart rate (HR)  Slows conduction through atrioventricular node  Inhibits sympathetic activity Digoxin

23  CPAP  CRT  Gene therapy Other Nonsurgical Options

24  Heart transplantation  VADs  Other surgical therapies:  Heart reduction  Endoventricular circular patch cardioplasty  Acorn cardiac support device  Myosplint Surgical Management

25 Heart Transplantation

26  Rest for energy management  Basic leg exercises  Slow ambulation Decreasing Fatigue & Weakness

27  Assess for early signs (e.g., crackles in bases)  Dyspnea at rest, disorientation, confusion  High Fowler’s position Preventing or Managing Pulmonary Edema

28  Oxygen therapy  Nitroglycerin  Rapid-acting diuretics  IV morphine sulfate  Continual assessment Preventing or Managing Pulmonary Edema (cont’d)

29  Home care management  Teaching for self-management  Health care resources Community-Based Care

30  Rapid weight gain  Decrease in exercise tolerance  Cold symptoms  Excessive awakening at night to urinate  Development of dyspnea/angina at rest  Increased edema in feet, ankles, hands Indications for Worsening or Recurrent Heart Failure

31  Mitral stenosis  Mitral regurgitation (insufficiency)  Mitral valve prolapse  Aortic stenosis  Aortic regurgitation (insufficiency) Valvular Heart Disease

32  Sudden illness or slowly developing symptoms over many years  Ask about attacks of rheumatic fever, infective endocarditis; ask about possibility of IV drug abuse  Chest x-ray, ECG, stress test Assessment

33  Rest  Drug therapy  Diuretics  Beta blockers  Digoxin  Oxygen  Nitrates  Vasodilators  Anticoagulants Nonsurgical Management

34  Reparative procedures  Balloon valvuloplasty  Direct or open commissurotomy  Mitral valve annuloplasty  Replacement procedures Surgical Management

35 Heart Valves

36  Home care management  Teaching for self-management  Health care resources Community-Based Care

37  Microbial infection involving the endocardium  Those at high risk:  IV drug abusers  Valve replacement recipients  People who have had systemic infections  People with structural cardiac defects Infective Endocarditis

38  Possible ports of entry  Oral cavity  Skin rash  Lesion/abscess  Infection  Surgery or invasive procedure Infective Endocarditis (cont’d)

39  Murmur  Heart failure  Arterial embolization  Splenic infarction Manifestations of Endocarditis

40  Neurologic changes  Petechiae  Splinter hemorrhages Manifestations of Endocarditis (cont’d)

41  Positive blood cultures  New regurgitant murmur  Evidence of endocardial involvement by echocardiography Diagnostic Assessment

42  Antimicrobials  Activities balanced with adequate rest Nonsurgical Management

43  Removal of infected valve  Repair or removal of congenital shunts  Repair of injured valves and chordae tendineae  Draining of abscesses in heart or elsewhere Surgical Management

44  Inflammation/alteration of pericardium  Dressler’s syndrome  Post-pericardiotomy syndrome  Chronic constrictive pericarditis Pericarditis

45 Pericarditis (cont’d)

46  Substernal precordial pain radiating to left side of neck, shoulder, or back  Grating, oppressive pain, aggravated by breathing, coughing, swallowing Assessment of Pericarditis

47  Pain worsened by supine position; relieved by sitting up and leaning forward  Pericardial friction rub Assessment of Pericarditis (cont’d)

48  Pain management  NSAIDs  Antibiotics for bacterial form  Pericardiectomy Interventions

49  Puts patient at risk for cardiac tamponade  Cardiac tamponade findings:  JVD  Paradoxical pulse  Decreased CO  Muffled heart sounds  Circulatory collapse Pericardial Effusion

50  Cardiac tamponade is an extreme emergency!  Increased fluid volume  Hemodynamic monitoring  Pericardiocentesis  Pericardial window  Pericardiectomy Acute Cardiac Tamponade: Emergency Care

51 Pericardiocentesis

52  Sensitivity response from upper respiratory tract infection with group A beta-hemolytic streptococci  Inflammation in all layers of heart  Formation of Aschoff bodies  Impaired contractile function of myocardium, thickening of pericardium, valvular damage Rheumatic Carditis

53  Tachycardia  Cardiomegaly  New or changed murmur Clinical Manifestations

54  Pericardial friction rub  Precordial pain  Changes in ECG  Indications of heart failure  Existing streptococcal infection Clinical Manifestations (cont’d)

55  Subacute or chronic disease of cardiac muscle  Dilated cardiomyopathy  Hypertrophic cardiomyopathy  Restrictive cardiomyopathy  Arrhythmogenic right ventricular cardiomyopathy Cardiomyopathy

56  Drug therapy  Diuretics  Vasodilating agents  Cardiac glycosides  Implantable cardiac defibrillators  Toxin exposure avoidance  Alcohol avoidance Nonsurgical Management

57  Depends on cardiomyopathy type  Most common:  Ventriculomyomectomy  Percutaneous alcohol septal ablation  Heart transplantation Surgical Management

58 A 51-year-old Hispanic man came to the hospital 2 days ago for recurrent exacerbation of heart failure. He weighs 237 lbs and is 5’ 8” tall. He has IV access in his left forearm and is on oxygen at 2 L per nasal cannula. When you assess the patient, he is sitting on the side of the bed and appears to be short of breath. He tells you that he has just returned from the bathroom. He is sweating and his nasal cannula is laying on the bedside table. Which action should you take first? A. Replace the oxygen. B. Take his vital signs. C. Call the Rapid Response Team. D. Sit him up in a bedside chair.

59 Fifteen minutes after the oxygen is replaced and he has rested, the patient denies being short of breath. You obtain an oxygen saturation and it is 96%. Based on this result, what should you do next? A. Call the provider as soon as possible. B. Continue the assessment because 96% is acceptable. C. Increase the oxygen level to 5 L per nasal cannula. D. Encourage the patient to take some deep breaths. (cont’d)

60 After assessing the patient, you document the following:  Jugular venous distention  2+ edema in feet and ankles  Swollen hands and fingers  Distended abdomen  Bibasilar crackles on auscultation  Productive cough with pink-tinged sputum What is your best interpretation of these findings? A. Right-sided heart failure B. Left-sided heart failure C. Biventricular failure D. Class IV heart failure (cont’d)

61 During morning care, the patient develops shortness of breath, fatigue, and tachycardia. 1. What is your interpretation of these findings? 2. What interventions would you begin at this time? (cont’d)

62 During the evening shift, the patient has a bedside echocardiogram which reveals an ejection fraction of 30%. Based on this finding, which medications might the provider order? (Select all that apply.) A. Lisinopril (Zestril) 5 mg PO daily B. Ibuprofen (Advil) 200 PO mg twice daily C. Multivitamin 1 PO each day D. Furosemide (Lasix) 20 mg IV push daily E. Digoxin (Lanoxin) 0.25 mg PO daily (cont’d)

63 Audience Response System Questions Chapter 37

64 Which cardiovascular disease results in the highest number of hospital admissions in the United States? A.Mitral valve disease B.Infective endocarditis C.Heart failure D.Rheumatic carditis Question 1

65 Which symptom most likely suggests the heart transplant patient may be experiencing signs of organ rejection? A.Fever B.Hypertension C.Weight gain D.Tachycardia Question 2

66 The nurse expects to see what outcome in a patient who is taking a beta blocker for mild heart failure? A.Improved activity tolerance B.Increased myocardial contractility C.Increased myocardial oxygen consumption D.Improved urinary output Question 3