1. Chapter 29 Management of Patients With Complications From Heart Disease

2. Heart Failure (HF)
A clinical syndrome resulting from structural or functional cardiac disorders that impair the ability of the ventricles to fill or eject blood
In the past, HF was often referred to as congestive heart failure (CHF), because many patients experience pulmonary or peripheral congestion with edema
HF is recognized as a clinical syndrome characterized by signs and symptoms of fluid overload or inadequate tissue perfusion

3. Heart Failure (HF)
The term heart failure indicates myocardial disease, in which there is a problem with the contraction of the heart (systolic failure) or filling of the heart (diastolic failure)
Some cases are reversible depending on the cause
Most HF is a chronic, progressive condition managed with lifestyle changes and medications

4. Chronic HF The incidence of HF increases with age
Approximately 6 million people in the United States have HF, and 870,000 new cases are diagnosed each year
Most common in people older than 75 years
Most common reason for hospitalization of people older than 65 years and is the second most common reason for visits to a physician's office
Approximately 25% of patients discharged after treatment for HF are readmitted to the hospital within 30 days

5. Pathophysiology of Heart Failure

6. Clinical Manifestations
Right Sided
Left Sided
Viscera and peripheral congestion
Jugular venous distention (JVD)
Dependent edema
Hepatomegaly
Ascites
Weight gain
Pulmonary congestion, crackles
S3 or “ventricular gallop”
Dyspnea on exertion (DOE)
Low O2 sat
Dry, nonproductive cough initially
Oliguria

7. Medications
Angiotensin-converting enzyme (ACE) inhibitors: vasodilation; diuresis; decreases afterload; monitor for hypotension, hyperkalemia, and altered renal function; cough
Angiotensin II receptor blockers: prescribed as an alternative to ACE inhibitors; work similarly
Hydralazine and isosorbide dinitrate: alternative to ACE inhibitors
Beta-blockers: prescribed in addition to ACE inhibitors; may be several weeks before effects seen; use with caution in patients with asthma

8. Medications (cont.)
Diuretics: decreases fluid volume, monitor serum electrolytes
Digitalis: improves contractility, monitor for digitalis toxicity especially if patient is hypokalemic
IV medications: indicated for hospitalized patients admitted for acute decompensated HF
Milrinone: decreases preload and afterload; causes hypotension and increased risk of dysrhythmias
Dobutamine: used for patients with left ventricular dysfunction; increases cardiac contractility and renal perfusion

9. Gerontologic Considerations
May present with atypical signs and symptoms such as fatigue, weakness, and somnolence
Decreased renal function can make older patients resistant to diuretics and more sensitive to changes in volume
Administration of diuretics to older men requires nursing surveillance for bladder distention caused by urethral obstruction from an enlarged prostate gland

10. Question
Which classification of medications play a pivotal role in the management of HF caused by systolic dysfunction?
ACE inhibitors
Beta-blockers
Diuretics
Digitalis

11. Answer
ACE inhibitors
ACE inhibitors play a pivotal role in the management of HF caused by systolic dysfunction. Beta-blockers have been found to reduce mortality and morbidity in patients with NYHA class II or III HF by reducing the adverse effects from the constant stimulation of the sympathetic nervous system. Diuretics are prescribed to reduce excess extracellular fluid by increasing the rate of urine produced in patients with signs and symptoms of fluid overload. Digitalis increases the force of myocardial contraction and slows conduction through the atrioventricular node

12. Nursing Process: The Care of the Patient With Heart Failure—Assessment
Focus
Effectiveness of therapy
Patient’s self-management
S&S if increased HF
Emotional or psychosocial response
Health history PE
Mental status; lung sounds: crackles and wheezes; heart sounds: S3; fluid status or signs of fluid overload; daily weight and I&O; assess responses to medications

13. Nursing Process: The Care of the Patient With Heart Failure—Diagnoses
Activity intolerance related to decreased CO
Excess fluid volume related to the HF syndrome
Anxiety-related symptoms related to complexity of the therapeutic regimen
Powerlessness related to chronic illness and hospitalizations
Ineffective family therapeutic regimen management

14. Collaborative Problems and Potential Complications
Hypotension, poor perfusion, and cardiogenic shock (see Chapter 14)
Dysrhythmias (see Chapter 26)
Thromboembolism (see Chapter 30)
Pericardial effusion and cardiac tamponade

15. Nursing Process: The Care of the Patient With Heart Failure—Planning
Goals
Promote activity and reduce fatigue
Relieving fluid overload symptoms
Decrease anxiety or increase the patient’s ability to manage anxiety
Encourage the patient to verbalize his or her ability to make decisions and influence outcomes
Educate the patient and family about management of the therapeutic regimen

16. Activity Intolerance Bed rest for acute exacerbations
Encourage regular physical activity; 30 to 45 minutes daily
Exercise training
Pacing of activities
Wait 2 hours after eating for physical activity
Avoid activities in extreme hot, cold, or humid weather
Modify activities to conserve energy
Positioning; elevation of the head of bed to facilitate breathing and rest, support of arms

17. Fluid Volume Excess Assessment for symptoms of fluid overload
Daily weight
I&O
Diuretic therapy; timing of meds
Fluid intake; fluid restriction
Maintenance of sodium restriction

18. Patient Education Medications
Diet: low-sodium diet and fluid restriction
Monitoring for signs of excess fluid, hypotension, and symptoms of disease exacerbation, including daily weight
Exercise and activity program
Stress management
Prevention of infection
Know how and when to contact health care provider
Include family in education

19. Question
What evaluation most illustrates that the patient with HF has met outcomes for the nursing diagnosis “Activity intolerance related to decreased CO?”
Exhibits decreased peripheral edema
Maintains heart rate, blood pressure, respiratory rate, and pulse oximetry within the targeted range
Avoids situations that produce stress
Performs and records daily weights

20. Answer
Maintains heart rate, blood pressure, respiratory rate, and pulse oximetry within the targeted range
Rationale: Patients with HF who exhibit stable VS shows that they have been able to adjust and plan activities to include rest and allow their bodies to adjust. A decrease in peripheral edema illustrates a reduction of fluid, avoiding situations that produce stress shows a move toward decreasing anxiety, and performing and recording daily weights shows adherence to the therapeutic regimen

21. End of Life Considerations
HF is a chronic and often progressive condition
Need to consider issues related to the end of life
When palliative or hospice care should be considered

22. Pulmonary Edema Acute event results in LV failure
As LV begins to fail, blood backs up into the pulmonary circulation, causing pulmonary interstitial edema
Results in hypoxemia, often severe
Clinical manifestations: restlessness, anxiety, dyspnea, cool and clammy skin, cyanosis, weak and rapid pulse, cough, lung congestion (moist, noisy respirations), increased sputum production (sputum may be frothy and blood tinged), decreased level of consciousness

23. Management of Pulmonary Edema
Easier to prevent than to treat
Early recognition: monitor lung sounds and for signs of decreased activity tolerance and increased fluid retention
Minimize exertion and stress
Oxygen; nonrebreather
Medications
Diuretics (furosemide), vasodilators (nitroglycerin)

24. Nursing Management of Pulmonary Edema
Positioning the patient to promote circulation
Positioned upright with legs dangling
Providing psychological support
Reassure patient and provide anticipatory care
Monitoring medications
I&O

25. Cardiogenic Shock
A life-threatening condition with a high mortality rate
Decreased CO leads to inadequate tissue perfusion and initiation of shock syndrome
Clinical manifestations: symptoms of HF, shock state, and hypoxia

26. Management of Cardiogenic Shock
Correct underlying problem
Reducing preload and afterload to decrease cardiac workload
Improving oxygenation, and restoring tissue perfusion
Monitor hemodynamic parameters, monitor fluid status, and adjust medications and therapies based on the assessment data

27. Management of Cardiogenic Shock (cont.)
Medications
Diuretics, positive inotropic agents, and vasopressors
Circulatory assist devices
Intra-aortic balloon pump (IABP)

28. Thromboembolism
Decreased mobility and decreased circulation increase the risk for thromboembolism in patient with cardiac disorders, including those with HF
Pulmonary embolism: blood clot from the legs moves to obstruct the pulmonary vessels
S&S: dyspnea, pleuritic chest pain, tachypnea, cough
Treatment: anticoag therapy
Unfractionated heparin, low--molecular-weight heparin, fondaparinux (Arixtra), or rivaroxaban (Xarelto)

29. Pulmonary Emboli

30. Pericardial Effusion and Cardiac Tamponade
Pericardial effusion is the accumulation of fluid in the pericardial sac
Cardiac tamponade is the restriction of heart function because of this fluid, resulting in decreased venous return and decreased CO
Clinical manifestations: ill-defined chest pain or fullness, pulsus paradoxus, engorged neck veins, labile or low BP, shortness of breath
Cardinal signs of cardiac tamponade: falling systolic BP, narrowing pulse pressure, rising venous pressure, distant heart sounds

31. Assessment Findings in Cardiac Tamponade

32. Medical Management Pericardiocentesis
Puncture of the pericardial sac to aspirate pericardial fluid
Pericardiotomy
Under general anesthesia, a portion of the pericardium is excised to permit the exudative pericardial fluid to drain into the lymphatic system

33. Sudden Cardiac Death or Cardiac Arrest
Emergency management: cardiopulmonary resuscitation
A: airway
B: breathing
C: circulation
D: defibrillation for VT and VF

34. Question
What is the most reliable sign of cardiac arrest in an adult and child?
Decrease in blood pressure
Absence of brachial pulse
Absence of breathing
Absence of carotid pulse

35. Answer Absence of carotid pulse
Rationale: The most reliable sign of cardiac arrest is the absence of a pulse. In an adult or child, the carotid pulse is assessed. In an infant, the brachial pulse is assessed