narrated CHF for class spr 2011

Chapter 37:

Chapter 37 Care of Patients with Cardiac Problems

Heart Failure:

Heart Failure Also called pump failure, general term for the inability of the heart to work effectively as a pump Left-sided heart failure Right-sided heart failure High-output failure Biventricular eventually occurs, usually with left causing right.

Cardiac Output Key Terms:

Cardiac Output Key Terms Stroke volume Ejection fraction Preload Afterload Contractility

Adaptive And Compensatory Mechanisms:

Adaptive And Compensatory Mechanisms Frank Starling Mechanism Sympathetic Nervous system 4

Adaptive And Compensatory Mechanisms:

Adaptive And Compensatory Mechanisms Neurohumeral influences Renin- angiotension -aldosterone mechanism Natriuretic peptides Vasoactive substances Myocardial hypertrophy and remodeling Initially contributes to compensated heart failure Hypertrophy occurs slowly in chronic CHF as the muscle mass and cardiac wall thicken in response to overwork and strain. Heart has poor contractility. 5

Compensatory Mech.:

6 Compensatory Mech. Dilation occurs when pressure in the heart is elevated over time. Chambers enlarge, muscle fibers stretch and increase contractile force. Eventually the fibers are overstretched and strained.

Renin Angiotension Mechanism:

Renin Angiotension Mechanism 7

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Natriuretic Peptides ANP BNP CNP 8

Etiology :

Etiology Heart failure is caused by systemic hypertension in 75% of cases. About one third of patients experiencing myocardial infarction also develop heart failure. Structural heart changes, such as valvular dysfunction, cause pressure or volume overload on the heart. 9

Risk Factors/Etiology Cont. :

10 Risk Factors/Etiology Cont. CAD, age, DM, cigarette smoking, obesity, high cholesterol Etiology can be anything that causes decreased CO by alteration of preload, afterload , contractility, HR , or metabolic state. There may be underlying disease or precipitating causes. Ex. MI

Left-Sided Heart Failure:

Left-Sided Heart Failure Typical causes—hypertensive, coronary artery, valvular disease Formerly known as congestive heart failure Two types of left-sided heart failure: Systolic heart failure Diastolic heart failure

Systolic heart failure:

Systolic heart failure Systolic heart failure is the result of a pumping problem ( systolic dysfunction ), caused by the ventricle losing its ability to contract normally because the heart muscle has become weak. When this happens, the heart can't pump with enough force and not enough blood is pushed into the circulation. 12

Pathophysiology:

Pathophysiology 1. systolic failure – inability of the heart to pump blood. Most common. Causes : MI HTN valvular heart disease < ejection fraction ( e.f .) is hallmark 13

Diastolic Heart Failure:

Diastolic Heart Failure diastolic heart failure is the result of a filling problem ( diastolic dysfunction ), caused by the ventricle losing its ability to relax normally because the heart muscle has become stiff. When this happens, the heart can't fill with enough blood, resulting in too little blood being pumped back out into the circulation. Diastolic heart failure is more common in women than men 14

Pathophysiology:

15 Pathophysiology Diastolic failure Impaired ability of ventricles to fill during diastole causing <SV Characterized by venous engorgement in pulmonary and systemic systems and normal EF Usually results from LVH from chronic HTN, aortic stenosis , or dilated cardiomyopathy (DCM). Commonly seen in older adult d/t myocardial fibrosis & HTN

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MIXED : Usually d/t cardiac myopathy , poor ejection fraction, and Biventricular failure. 16

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Left-sided failure results from LV dysfunction & blood backs up into pulmonary veins > fluid extravasation > congestion & edema. More common. 18

Congestive Heart Failure:

19 Congestive Heart Failure . -- Definition: A condition in which heart unable to pump an adequate amount of blood to meet body demands. Affects 5 mil. In USA. --Characterized by left ventricular dysfunction, activity intolerance, decreased quality of life, and shortened life expectancy. -- Dramatic ^ with age & most common reason for hosp. adm > 65. -- Other primary risk factor: CAD .

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Left-Sided Heart Failure:

Left-Sided Heart Failure Manifestations include: Weakness Fatigue Dizziness Confusion Pulmonary congestion Breathlessness Oliguria

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Right-sided failure results from diseased RV and causes backward blood flow > right atrium & venous circulation > peripheral edema, organomegaly , vascular congestion of GI tract, & JVD. pulmonary hypertension , COPD, hypertension , obesity, tricuspid or pulmonary stenosis ). 23

Right-Sided Heart Failure:

Right-Sided Heart Failure Typical causes —left ventricular failure right ventricular MI pulmonary hypertension Right ventricle not able to empty completely Increased volume and pressure in the venous system and peripheral edema

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Right-Sided Heart Failure:

Right-Sided Heart Failure Manifestations include: Distended neck veins, increased abdominal girth Hepatomegaly (liver engorgement) Hepatojugular reflux Ascites Dependent edema Weight—the most reliable indicator of fluid gain or loss

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29 A man with congestive heart failure a

Right sided failure:

Right sided failure 30

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High-Output Failure:

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

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Pathophysiology:

Pathophysiology 1. systolic failure – inability of the heart to pump blood. Most common. Causes : MI HTN valvular heart disease < ejection fraction ( e.f .) is hallmark 35

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2. Diastolic failure - impaired ability of ventricles to fill. 3. Mixed failure – mixed origin. 36

Pathophysiology:

37 Pathophysiology Diastolic failure (20% of patients): Impaired ability of ventricles to fill during diastole causing <SV Characterized by venous engorgement in pulmonary and systemic systems and normal EF Usually results from LVH from chronic HTN, aortic stenosis , or dilated cardiomyopathy (DCM). Commonly seen in older adult d/t myocardial fibrosis & HTN

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MIXED : Usually d/t cardiac myopathy , poor ejection fraction, and Biventricular failure. 38

Resulting Clinical Picture::

39 Resulting Clinical Picture: Low system arterial B/P Low cardiac output (CO) Poor renal perfusion Poor exercise tolerance Ventricular arrhythmias are common.

Clin. Manifest. & CX:

40 Clin. Manifest. & CX Chronic CHF s/s depend on age, cause: Dry hacking cough may be 1 st sign. Fatigue common early sx d/t lack of cardiac reserve. Dyspnea, first with mild exertion, later at rest. PND may occur. Tachycardia (may also be 1 st sign) Edema is common peripherally and in liver, as ascites, lungs, etc.

Chronic CHF Clinical Manifestations:

41 Chronic CHF Clinical Manifestations Nocturia (d/t increased blood flow to kidneys when lie down). Skin changes: dusky, LE cool, shiny and swollen with decreased hair and possible pigment changes Behavioral changes d/t less cerebral blood flow Chest pain d/t less coronary perfusion d/t decreased CO Weight changes

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Clin. Manifest. & CX:

43 Clin. Manifest. & CX Acute CHF manifested as acute pulmonary edema , usually from CAD and present clinically very ill with ( p. 1039 ): Restlessness Agitation/Anxiety Pallor Cyanosis possibly Clammy, cool skin Severe dyspnea with uses of accessory muscles, wheezing, blood tinged sputum, crackles, rhonchi Tachycardia and ^B/P, RR > 30, orthopnea

Complications CHF:

44 Complications CHF Pleural effusion d/t ^pressure in capillaries. Arrhythmias – ½ experience SCD! Atrial fibrillation is common. LV thrombus d/t enlarged LV and poor CO Hepatomegaly (>fibrosis > cirrhosis possibly)

Diagnosing CHF:

45 Diagnosing CHF Physical examination CXR ECG Echo/hemodynamic assessment/stress test Cardiac catheterization BNP P.832 Labs: ABGs, serum chemistries, liver & renal profiles Nuclear imaging studies

Collab. Mgmt. Chr. CHF:

46 Collab. Mgmt. Chr. CHF Treat underlying cause!! Goals are to decrease intravascular volume, decrease venous return (preload), decrease afterload , improve gas exchange and oxygenation, increase CO, & reduce anxiety. Nutrition Low Sodium Diet

Surgical Management:

Surgical Management Heart transplantation Ventricular assist devices Other surgical therapies: Partial left ventriculectomy Endoventricular circular patch Acorn cardiac support device Myosplint

Pharmacology :

48 Pharmacology ACE Inhibitors – beneficial @ all states of CHF, syst. & diast . (p. 831-832). 1 st line tx e.g. Capoten ( captopril ), Lotensin ( benazapril ), Vasotec ( enalapril ) Lower levels of angiotensin II, a potent vasoconstrictor B-Adrenergic Blockers – improve survival rate. Used in combo with others. Examples: Co- reg ( carvedilol ) & Toprol XL ( metoprolol ). (p.)832

Pharmacotherapeutics:

49 Pharmacotherapeutics Diuretics mobilize fluid, reduce pulmonary venous pressure, and reduce preload. A thiazide often first tried d/t low cost & effectiveness: HCTZ, Diuril Loop diuretics: Lasix , Bumex Potassium sparing : triamterene , spironolactone p. 831

Pharmacotherapeutics:

50 Pharmacotherapeutics Digitalis preparations: do not seem to reduce mortality, but reduce hospitalizations & symptoms Increase force or strength of contractions ( inotropic action) Decrease conduction and slow HR CO increases d/t ^SV from improved contractility Manifestations of Toxicity

Pharmacotherapeutics:

51 Pharmacotherapeutics Vasodilators improve survival in overt heart failure Nitrates act directly on smooth muscle of vessel wall and decrease preload and particularly benefit patient if myocardial ischemia also present. Na. Nitroprusside (ed.) acute pulm ed.

BiDil:

52 BiDil BiDil - a fixed dose combination of 2 vasodilators : Hydralazine and Isosorbide Used for African Americans Reduces symptoms, decreases hospitalizations and prolongs life in this population Dose 1 to 2 tabs 3x/day SE: headache, hypotension

Nursing Management:

53 Nursing Management Impaired Gas Exchange Decreased Cardiac output Fear Activity Intolerance

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Nursing Diagnosis Decreased Cardiac Output:

55 Nursing Diagnosis Decreased Cardiac Output Definition: state in which individual experiences a decreased amount of blood pumped by heart, resulting in compromised cardiac function. Major defining characteristics : low B/P, usually increased P & R, restlessness, cyanosis, dyspnea, angina, arrhythmias, oliguria ( <30cc/h), fatigue, dizziness, edema, crackles, JVD, cool/moist skin, decreased capillary refill, weak pulse. ( LATE signs )

Decreased CO:

56 Decreased CO Goals : (examples) Patient will remain hemodynamically stable AEB ______, ________, ______, etc. Patient will have B/P ____, P ____, etc. Patient will have UO ^30 cc/hr Patient will have W & D skin or clear lungs, etc. etc. (ALL WITH DATES)

Decreased CO:

57 Decreased CO Interventions: Assess for (monitor) the defining characteristics * Administer oxygen as ordered * Administer prescribed medications Maintain high-Fowler’s Encourage rest EVALUATION : any improvement noted, do you need to do more, were goals met?

Implementation of POC for Chronic Cardiac:

58 Implementation of POC for Chronic Cardiac Prioritize ND and interventions according to ABCs. Prioritization for acute SOB – be familiar with MD orders (individual/standing and hospital protocols): Oxygen, Positioning, BRest ABGs (or sat with pulse ox) V/S and lung assessment

Evaluation of POC for Chronic Cardiac:

59 Evaluation of POC for Chronic Cardiac CAD, angina, and CHF do not go away although they may improve. NCP rarely terminated but modified as condition/needs change. If patient has adapted to these conditions and is living productively, the POC is working!

Think about it….:

60 Think about it…. Joan is scheduled for a card catherization w/ coronary angiography. Prior to the test, the Rn informs her A. a catheter will be inserted into a vein in the arm or leg and advanced to the heart B. ECG monitoring will be required fro 24 hrs. following the test to detect arrhythmias C. Complications include puncture of the ventricles, blood embolism, catheter breaking

Answer:

61 Answer A catheter will be inserted into a vein in the arm or leg and advanced to the heart C. Complications include puncture of the ventricles, blood embolism, catheter breaking

Think about it….:

62 Think about it…. Dr. Kelsey orders serum troponin levels in a pt w/ a poss. MI. The RN explains this test as A. measures the amt of myoglobin released in from damaged myocardial cells B. Is diagnostic for myocardial damage only when used in combo w/ CK-MB isoenzymes C. is the most specific indicator for myocardial damage available