Cardiovascular III: Heart Failure

Tuesday, January 17, 2012 10:47 AM

Cardiac Hemodynamics Nursing Process: The Care of the Patient with HF: Assessment 1. Health history 2. Sleep and activity 3. Knowledge and coping 4. Physical exam a. Mental status b. Lung sounds: crackles and wheezes c. Heart sounds: murmurs d. Fluid status/signs of fluid overload i. Daily weight and I&O 5. Assess responses to medications CO = HR X SV Contractility Preload: amount of blood present in the ventricles just before systole Afterload: resistance of ventricle to pump against to get the blood out Stroke volume is amount of blood pumped out of ventricle with each contraction Normal ejection fraction: 55%-65% of ventricular volume Nursing Process: The Care of the Patient with HF: Diagnosis 1. Activity intolerance and fatigue 2. Excess fluid volume 3. Anxiety 4. Powerlessness 5. Noncompliance Collaborative Problems/Potential Complications 1. Cardiogenic shock 2. Dysrhythmias 3. Thromboembolism 4. Pericardial effusion and cardiac tamponade Nursing Process: The Care of the Patient with HF: Planning 1. Goals may include promoting activity and reducing fatigue, relieving fluid overload symptoms, decreasing anxiety or increasing the patients ability to manage anxiety, encouraging the patient to make decisions and influence outcomes, teaching the patient about the self-care program. Activity Intolerance 1. Bed rest for acute exacerbations 2. Encourage regular physical activity; 30-45 minutes daily 3. Exercise training 4. Pacing of activities 5. Wait 2 hours after eating before doing physical activity. 6. Avoid activities in extremely hot, cold, or humid weather. 7. Modify activities to conserve energy. 8. Positioning; elevation of HOB to facilitate breathing and rest, support of arms Fluid Volume Excess 1. Assessment for symptoms of fluid overload 2. Daily weight 3. I&O 4. Diuretic therapy; timing of meds 5. Fluid intake; fluid restriction 6. Maintenance of sodium restriction See Chart 30-4 Patient Teaching 1. Medications 2. Diet: low-sodium diet and fluid restriction 3. Monitoring for signs of excess fluid, hypotension, and symptoms of disease exacerbation, including daily weight 4. Exercise and activity program 5. Stress management 6. Prevention of infection 7. Know how and when to contact health care provider 8. Include family in teaching

Heart Failure 1. The inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients 2. A syndrome characterized by fluid overload or inadequate tissue perfusion 3. The term HF indicates myocardial disease, in which there is a problem with the contraction of the heart (systolic heart failure: weakened heart muscle) or filling of the heart (diastolic failure: stiff and non-compliant heart muscle, makes it difficult for ventricle to fill up). 4. Some cases are reversible. 5. Most HF is a progressive, lifelong disorder managed with lifestyle changes and medications. Clinical Manifestations (See Chart 30-1) 1. Right-sided failure (Venous) a. RV cannot eject sufficient amounts of blood, and blood backs up in the venous system. This results in peripheral edema - jugular vein distention, hepatomegaly, ascites, anorexia, nausea, weakness, and weight gain. 2. Left-sided failure (Lungs) a. LV cannot pump blood effectively to the systemic circulation. Pulmonary venous pressures increase, resulting in pulmonary congestion with dyspnea, cough, crackles, and impaired oxygen exchange. 3. Chronic HF is frequently biventricular.

Classification of Heart Failure 1. NYHA classification of HF (table 30-1) a. Classification I, II, III, IV (the more the level increase, the more symptoms they have) i. Class III: person has marked limitation to ADL's, feels comfortable at rest but less then normal activity will cause symptoms 2. ACC/AHA classification of HF a. Stages A, B, C, D 3. Treatment guidelines are in place for each stage. 4. Lab value: BNP >100 pg/mL
Medical Management of HF 1. Eliminate or reduce etiologic or contributory factors. 2. Reduce the workload of the heart by reducing afterload and preload. 3. Optimize all therapeutic regimens. 4. Prevent exacerbations of HF. 5. Medications are routinely prescribed for HF. 6. Lifestyle change Medications 1. Angiotensin-converting enzyme inhibitors (given a low dose for diastolic heart failure) 2. Angiotensin II receptor blockers 3. Beta-blockers 4. Diuretics 5. Digitalis (digoxin level 0.5-2ng/mL) 6. Anticoagulants 7. Right sided heart failure can cause peripheral edema, give diuretics a. Thiazide, Loop, Potassium-sparing diuretics

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Cardiovascular III: Heart Failure

Wednesday, January 18, 2012 12:03 AM

Pulmonary Edema 1. Acute event in which the LV cannot handle an overload of blood volume. Pressure increases in the pulmonary vasculature, causing fluid to move out of the pulmonary capillaries and into the interstitial space of the lungs and alveoli. 2. Results in hypoxemia 3. 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 Management of Pulmonary Edema 1. Prevention 2. Early recognition: monitor lung sounds and for signs of decreased activity tolerance and increased fluid retention 3. Place patient upright and dangle legs. 4. Minimize exertion and stress. 5. Oxygen 6. Medications a. Morphine b. Diuretic (furosemide): promotes excretion of sodium and water from the kidneys i. Lasix causes rapid diuretic effects, vasodilation, pooling of blood in blood vessels reducing amount of blood returning to heart Cardiogenic Shock 1. A life-threatening condition with a high mortality rate 2. Decreased CO leads to inadequate tissue perfusion and initiation of shock syndrome. 3. Clinical manifestations: symptoms of HF, shock state, and hypoxia Pathophysiology of Cardiogenic Shock (Signs & symptoms is a cycle)

Thromboembolism 1. Decreased mobility and decreased circulation increase the risk for thromboembolism in patients with cardiac disorders, including those with HF. a. Very common in A-Fib patients-can develop clots from the blood pooling in atrium 2. Pulmonary embolism: blood clot from the legs moves to obstruct the pulmonary vessels a. The most common thromboembolic problem with HF b. Prevention and treatment i. Anticoagulant therapy, Thrombolytics therapy ii. Prevent pt. from having DVT and pulmonary emboli 1) SCDs, TED hose
Pulmonary Emboli

Pericardial Effusion and Cardiac Tamponade 1. Pericardial effusion is the accumulation of fluid in the pericardial sac. 2. Cardiac tamponade is the restriction of heart function due to this fluid, resulting in decreased venous return and decreased CO. 3. Clinical manifestations: ill-defined chest pain or fullness, pulsus parodoxus, engorged neck veins, labile or low BP, shortness of breath 4. Cardinal signs of cardiac tamponade: falling systolic BP, narrowing pulse pressure, rising venous pressure, distant heart sounds - See Chart 30-6 Assessing for Cardiac Tamponade

Management of Cardiogenic Shock 1. Correct underlying problem 2. Reduce any further demand on heart 3. Restore tissue perfusion 4. Improve oxygenation 5. Medications a. Diuretics: reduce workload on heart b. Vasodilator: can decrease B/P c. Positive inotropic agents (ex. dopamine, dobutrex): can lead to tachycardia d. Vasopressors 6. Circulatory assist devices a. Intra-aortic balloon pump (IABP) Some drugs that are used, you would need to know the patients weight. IV Flow Rate Ordered by kg per min Dosage Calculations pg. 435-436 Set it up: Prescribed rate X wt(kg) X 60min = Concentration 1 1hr Example: Order is for Natrecor 0.01 mcg/kg/min. The concentration is 1.5mg in 250 ml of D5W. The patient weighs 162 pounds. What rate would the nurse start the Natrecor drip via the infusion pump? - 0.01 mcg/kg/min X 73.64 X 60 min = 1.5 mg/250ml 1 1hr - 0.00001mg X kg min X 250ml 1.5mg X X 73.64 kg X 60 min 1 X 1hr = 7.36

Medical Management 1. Pericardiocentesis 2. http://www.operationalmedicine.org/Videos/Pericardiocentesis.htm 3. Pericardiotomy

Sudden Cardiac Death/Cardiac Arrest 1. Emergency management: cardiopulmonary resuscitation a. A- airway b. B- breathing c. C- circulation (chest compression) d. D- defibrillation for VT and VF Digoxin: positive inotropic (gives a strong contraction) but slows heart rate down Signs of Toxicity: anorexia, N&V, HA, blurred vision, green-yellow halos, confusion, delirium Signs and symptoms of Increase pericardial fluids Elevated pressure in cardiac chambers Decrease venous return Ventricle can't distend and can't fill Decrease cardiac output.

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