[Exam 1] Chapter 29: Management of Patients with Complications from Heart Diseases (Page 818-833) Flashcards
What is heart failure?
Clinical syndrome resulting from structural or functional cardiac disorders that impair the ability of the ventricles to fill or eject blood
HF used to be referred as
congestive heart failure
Now, HF is recognized as a clinical lsyndrome characterized by signs and symptoms of
fluid overload or inadequate tissue perfusion.
Occurs when heart cannot generate CO sufficient to meet bodys demands.
HF is chronic, progressive condition that is managed with lifestyle changes and medications to prevent episodes of
acute decompensated heart failure, characterized by increased symptoms, decreased CO, and low perfusion
Two major types of HF are identified by
assessment of left ventricular function, usually echo-cardiogram
Most common type of HF is
alteration in ventricular contraction called systolic heart failure, which is characterized by weakened heart muscle
Second most common type of HF is
diastolic heart failure, which is cahracterized by a stiff and noncompliant heart muscle making it difficult for the ventricle to fill
How is EF calculated?
Subtracting the amount of blood present in the left ventricle at the end of systole from the amount present at the end of diastole and calculating the percentage of blood that is ejected
Normal EF is
55-65% of ventricular volume
EF is normal in what Hf?
Diastolic, known as heart failure with preversed EF
what is Heart Failure Class I
No limitation of physication
Ordinary activity does not cause undue fatigue
What is Heart Failure Class II
Slight limitation of physical activity
Comfortable at rest, but oridinary activity causes fatigue
What is Heart Failure Class III
Marked limitation of physical activity
Comfortable at rest, but less than ordinary activity causes fatigue
What is Heart Failure Class IV
Unable to carry out any physical activity
Symptoms of cardiac insufficiency at rest
What can cause Myocardial dysfunction and HF?
Coronary Artery Disease
Hypertension
Cardiomyopathy
Valvular Disorders
What is the primary cause of HF?
Atherosclerosis of the coronary arteries and coronary artery disease is found in the majority of patients with HF
Ischemia causes myocardial dysfunction because
it deprives heart cells of oxygen and causes cellular damage
What does MI cause?
focal heart muscle necrosis
death of myocardial cells
loss of contractility
What does sytemic or pulmonary hypertension do to the body?
Increases afterload, which increases cardiac workload and leads to hypertrophy of myocardial muscle fibers
What does sustained hypertension do?
Eventually leads to changes that impair the hearts ability to fill properly during diastole, and hypertrophied ventricles may dilate and fail
What is Cardiomyopathy?
Disease of the myocardium. Various types lead to HF and dysrhythmias.
Most common type of cardiomyopathy?
Dilated cardiomyopathy which causes diffuse myocyte necrosis and fibrosis and commonly leads to progressive HF
Dilated Cardiomyopathy can result from
an inflammatory process such as myocarditis or from a cytotoxic agent.
Criteria for Stage A HF?
Patients at high risk for developing left ventricular dysfunction but without structural heart disease
Treatment for Stage A HF
Heart healthy lifestyle
RF control of hypertension, lipids, diabetes, obesity
Criteria for Stage B HF?
Patients with left ventricular dysfunction or structural heart disease who have not developed symptoms of HF
Treatment for Stage B HF
Implement Stage A
Ace Inhibitor
Beta Blocker
Statins
Criteria for Stage C HF
Patients with left ventricular dysfunction or structural heart disease with current or prior symptoms of heart disease
Treatment for Stage C HF
Stage A/B
Diuretics
Aldosterone Antagonist
Sodium Restriction
Implantable Defribilator
Criteria for STage D HF
Patients with refractory end-stage HF requiring specialized interventions
Treatment for Stage D HF
A,B,C
Fluid restriction
End-of-life care
Extraoridnary measures
Inotropes
Cardiac Transplantion
Valvular heart disease is also a cause of HF. With Vascular dysfunction it becomes difficult to
move the blood forward, increasing pressure within the heart and increasing cardiac workload, leading to HF
What does cardiorenal syndrome describe?
How dysfunction in one of these systems leads to dysfunction in the other, resulting in increased morbidity and mortality
Significant myocardial dysfunction usually occurs before the patient experiences signs and symptoms of HF such a
shortness of breath, edema, or fatigue
As HF develops, body activtes what to fight back?
Neurohormonal comensatory mechanisms which represent bodys attempt to cope with the HF.
Systolic HF results blood doing what?
Decreased blood ejected from the ventricle
Sensed by baroreceptors. Sympathetic nervous sytem is then stimulated to release epinephrine and norepinephrine.
Purpose is to increase HR and contractility but has multiple negative effcts
Negative effects of epinephrine and norepinephrine cause what to the body?
Vasocontriction in the skin, GI Tract, Kidneys
Causes release of REnin to release Angiotensin II to increase blood pressure. Leads to fluid volume overload
When the cardiac chambers are overdistended, what is released?
ANP and BNP
Promote vasodilation and diuresis.
As the hearts worklkoad increases, contractility of the myocardial muscle fibers…
decreases
This results in an increase in end-diastolic blood volume in teh ventricle , stretching the myocardial muscle and increasing size of ventricles
Heart compensates for increased workload by
increasing the thickness of the heart muscle but leads to abnormal changes known as ventricular remodeling
Signs and Symptoms of HF related to
congestion and poor perfusion and the ventricle that is mosst affected
Left sided heart failure causes different manifesttions than
right-sided heart failure
Left-Sided Heart Failure: Pulmonary congestion occurs when
left ventricle cannot effectively pump blood out of the ventricle into the aorta and the systemic circulation
Increased volume increase pressure which decreases blood flow
Left-Sided Heart Failure: The blood volume and pressure build up in left atrium, decreasing
flow through the pulmonary veins into the left atrium . Pulmonary venous blood volume and pressure increase in the lungs, forcing fluid into pulmonary capilaries into pulmonary tissue and alveoli causing edema and impaired gas exchange
Left-Sided Heart Failure: Clinical manifestations of Pulmonary Congestion include
dyspnea, cough, pulmonary crackles, and low oxygen saturation levels
Left-Sided Heart Failure: Pulmonary Congestion and Heart Sounds
You may be able to hear S3
Left-Sided Heart Failure: With minimal to moderate activity, what may happen?
Dyspnea or shortness of breath
Left-Sided Heart Failure: Difficulty with Orthopnea, which is
difficulty breathing when lying flat.
Use pillows to prop themselves up in bed.
Left-Sided Heart Failure: SOme patients have Paroxysmal Noctural Dyspnea (PND) which is when
some patients have sudden attacks of dyspnea at night
Left-Sided Heart Failure: Problem with fluid that accumulates during the day and is reabsorbed at night?
LV cannot eject the increased circulating blood volume, the pressure in the pulmonary circulation increases , shifting fluid into the alveoli. Thus cannot exchange oxygen and CO2
Left-Sided Heart Failure: Cough with this is usually
Dry and nonproductive. Most complain of dry hacking cough that may be mislabed as asthma. Pink frothy sputum indicated acute decompensated HF with pulmonary edem
Left-Sided Heart Failure: Lung sounds
As it progresses, the crackles can be ausculted throughout the lung fields
Left-Sided Heart Failure: Amount of blood ejected from left ventricle decreases, leading to
inadequate tissue perfusion
Left-Sided Heart Failure: With a reduced CO and catecholamines decreases blood flow to the kidneys , urine output
drops.
Renal perfusion pressure falls nd RAAS is stimulated to increase blood pressure and intravascular volume.
Left-Sided Heart Failure: AS HF progresses, decreased output from left ventricle may cause other symptoms such ass
Decreased GI Perfusion
Decreased brain perfusion causes dizziness, lightheadness, confusion, restlessness, and anxiety due to decreased oxygen
Left-Sided Heart Failure: Decrease in SV causes the sympathetic nervous system to
increase the heart rate, often causing the patient to complain of palpitaitons
Right-Sided Heart Failure: When the right ventricle fails, congestion in the peripheral tissues and the viscera
predominates
Right-Sided Heart Failure: Peripheral tissues and viscerea predominates because
right side of the heart cannot eject blood effectively and cannot accommodate all of the blood that normally returns to it from the venous circulation
Right-Sided Heart Failure: Increased venous pressure leads to
jugular venous distention and increased capillary hydrostatic pressure throughout the venous system
Right-Sided Heart Failure: Systemic clinical manifestations include
edema of the lower extremities, hepatomegaly, ascites (accumulation of fluid in the perioneal cavity) and weight gain due to retention of fluid
Right-Sided Heart Failure: Edema usually affects
the feet and ankles and worsens when the patient stands or sits for a long period . Edema may decrease when patients elevate the legs
Right-Sided Heart Failure: Edema can progress to
The legs and thighs and eventually into the external genitalia and lower trunk
Right-Sided Heart Failure: Ascites evidenced by
increased abdominal girth and may accompany lower ody edema
Right-Sided Heart Failure: Sacral edema common on those who are on
bed rest, because sacral area is dependent
Right-Sided Heart Failure: Pitting edema is obvious after retention of how much fluid?
10 lb (4.5 L)
Right-Sided Heart Failure: Hepatomeagaly and tenderness in right upper quadrant result from
venous engorgement of the liver.. May interefere with ability to function.
May force fluid into abdominal cavity
Right-Sided Heart Failure: What else can come from venous engorgement?
Anorexia, Nausea, or Abdominal Pain
HF may go undeteced until patient presents with
signs of pulmonary and peripheral edem a
HF may also occur with other diseases, such as
kidney injury and COPD
What is an essential part of the initial diagnostic workup?
Assessment of ventricular function. Echocardiogram is usually performed to determine EF, identify anatomic feaures such as structural abnormalities
HF information may be obtained noninvasively by
radionuclide ventriculography or invasively by ventriculography
Lab Studies for HF?
Serum Electrolytes BUN Creatinine Liver Function Tests TSH CBC BNP
What lab is a key diagnostic indicator of HF?
BNP
High levels are a sign of high cardiac filling pressure and can aid in diagnosis and managmenet of HF
Medical Management: Goal of management of HF is to
relieve patient symptoms, to improve functional status and quality of life
What drugs are prescribed for HF?
ACE Inhibitors
Beta-Blockers
Diuretics
Angiotensin-Converting Enzyme Inhibitor: What do they relieve and help?
Relieve the signs and symptoms of HF especially in those with a left ventricular EF less than 35%.
Angiotensin-Converting Enzyme Inhibitor: What do these accomplish?
Slow progression of HF, improve exercise tolerance and decrease number of hospitalizations
Angiotensin-Converting Enzyme Inhibitor: What do they promote?/
Vasodilation adn diuresis , ultimately decreasing afterload and preload
Angiotensin-Converting Enzyme Inhibitor: Vasodilation reduces resistance to
left ventricular ejection of blood, dimishing the hearts workload and improve ventricular emptying .
Angiotensin-Converting Enzyme Inhibitor: Decrease the secretion of
aldosterone, a hormone that causes kidneys to retain sodium adn water. Also promote excretion of sodium and fluid thereby reduing left ventricular filling presure
Angiotensin-Converting Enzyme Inhibitor: First medication prescribed for patients with
mild failure
Angiotensin-Converting Enzyme Inhibitor: Dosage?
Started on low dose that is gradually increased until optimal dose is achieved and patient is hemodynamically stable
Angiotensin-Converting Enzyme Inhibitor: Monitored for
hypotension, hyperkalemia , and alterations in renal function. Because they retain potassium, you don’t need potassium supplements
Angiotensin-Converting Enzyme Inhibitor: Other adverse effects include
dry, persistent cough that may not respond to cough suppressants
Angiotensin Receptor Blockers: Difference between this and ACE inhibitors?
ACE inhibitors block conversion of angtiotensin I to angiotensin II, ARBs block the vasoconstricting eftcts of angiotensin II at the angiotensin II receptors
Hydralazine and Isosorbide Dinitrate: This commincation is another alternative for those who cannot take
ACE inhibitors
Hydralazine and Isosorbide Dinitrate: Nitrates cause
venous dilation, which reduces the amount of blood return to the heart and lowers preload
Hydralazine and Isosorbide Dinitrate: Hydralazine lowers
systemic vascular resistance and left ventricular afterload.
Hydralazine and Isosorbide Dinitrate: May be more effective for what population?
Africa Americans who do not respond to ACE Inhibitors
Beta Blockers: These are considerd to be a
first-line therapy and are routinely prescribed in addition to ACE inhibitors
Beta Blockers: They block the adverse effects of
sympathetic nervous ystem
Beta Blockers: Effect on body?
RElax blood vessels, lower blood pressure, decrease afterload, and decrease cardiac workload.
Impove functional status and reduce mortality and morbidity in patients with HF
Beta Blockers: Recommended for patients with
aymptomatic systolic dysfunction , such as those with decreased EF.
Beta Blockers: Therapeutic Effects may not be seen for
several weeks or even months
Beta Blockers: Side effects?
Dizziness, hypotension, bradycardia, fatigue, and depresion
Beta Blockers: Side effects most common in what time frame?
Initial few weeks of treatment . Because of that, started at low doses
Beta Blockers: Since they can cause bronchiole constriction, drugs used in caution for those with
caution in patients with a history of bronchospastic diseases such as uncontroleld asthma
Diuretics: Prescribed to remove excess
extracellular fluid by increasing rate of urine produced in patients with signs of fluid overload. Use smallest dose possible
Diuretics: Which ones may be prescribed for someone with HF?
Loop, thiazide, and aldosterone blocking
Diuretics: Loop diuretics inhibit
sodium and chloride reabsorption mainly in the ascending loop of Henle.
Diuretics: HF patients with severe volume overload treated with what first?
Loop diuretic.
Diuretics: Thiazide diuretics inhibit
sodium and chloride reabsorption in the early distal tubules.
Diuretics: What must be monitored in those taking loop and tiazide diuretics
Potassium levels, because they both increase pottasium excretion
Diuretics: Need for diureitcs canbe decreased if
patient avoids excessive fluid intake and adhere to low sodium diet
Diuretics: What do Aldosterone Antagonists do?
They are potassium-sparing diuretics that block the effects of aldosterone in the distal tubule and collecting duct. REduce mortality in in patients with moderate to severe HF
Diuretics: Whats monitored with Aldosterone Antagonists?
Serum creatinine and potassium levels. Not prescribed for those with elevated creatinine
Diuretics: When would loop diuretics be administered by IV
for exacerbations of HF when rapid diuresis is necessary
Digitalis : What does this do?
Increases the force of myocardial contraction and slows conduction through the atrioventricular node. Improves contractility , increasing left ventricular output.
Digitalis : Effective in
decreasing the symptoms of HF and preventing hospitiliazation
Digitalis : Key concern with this is
toxicity
Digitalis : clinical manifestations of toxicity include
Anorexia, Nausea, Visual Disturbances, Confusion, And Bradycardia
Digitalis : What is monitored here?
Serum potassium because digoxin enhanced in presence of hypokalemia and digitalis toxicity may occur
Intravenous Infusions: What do they do?
Increase the force of myocardial contractions and may be indicated for hospitalized patients with acute decompensated HF
Intravenous Infusions: This is used for those who do not respond to
routine pharmacologic therapy and are reserved for patients with severe ventrircular dysfunction
Intravenous Infusions: Requirements for this??
Admission to ICU and may also have hemodynamic monitoring with pulmonary artery catheter
Intravenous Infusions: Who would be candiate to have this at home?
End-stage HF who cannot be weaned.
Milrinone: What is this?
Phosphodiesterase inhibitor that leads to an increase in intracellular calcium within myocardial cells, increasing their contractility
Milrinone: Agent promotes
vasodilation resulting in decreased preload and afterload and reduced cardiac workload
Milrinone: Administered IV to patients with
severe HF, including those waiting for heart transplant
Milrinone: What is monitored?
Blood pressure because drug can cause vasodilation
Milrinone: Major side effects are
hypotension and increased ventricular dysrhythmias.
Dobutamine (IV) : Given to those with
significant left ventricular dysfunction and hypoperfusion.
Dobutamine (IV) : Major action?
Increases the heart rate and can precipitate ectopic beats and tachydysrhythmias
What is done for patients with predominant diastolic HF?
Hypertension and ischemic heart disease are evaluated and treated . They do not tolerate tachycardiai because it does not alow time for ventricular filling . Patients given beta blockers to control tachycardia
When would anticoagulants be prescribed?
When the patient has a history of atrial fibrillation or thromboembolic event.
NSAIDS should be avoided because
they decrease renal perfusion especially in oldere adults
Nutritional Therapy for HF?
Following a low sodium and avoiding excessive fluid intake
Nutritional Therapy: Purpose of sodium restriction is to
decrease the amount of circulating blood volume, which decreaes myocardial work which reduces fluid retention
Other Interventions: If patient with HF has other underlying heart diseases, what may be considered?
coronary artery bypass surgery may be considered
Other Interventions: Patients with HF who do not improve with standard ttherapy, may benefit from
cardiac resynchronization therapy, which invovles use of biventricular pacemaker to treat electrical conduction defects
Other Interventions: Prolonged QRS duration indicates
a left bundle branch block, which is a type of delayed conduction seen in those with HF
Other Interventions: Why would a pacing device be used in CRT?
Leads placed on left ventricular cardiac vein, right ventricle, and right atrium can synchronize the contractions of right and left ventricals to improve CO, optimize myocardial energy consumption and reduce mitral regurgitation
Other Interventions: What is Ulrafiltration?
Alternative intervention for patients with severe fluid overload. Reserved for those with severe HF who are resistant to diureti ctherapy
Other Interventions: How is Ultrafiltration performed?
Dual lumen central iv catheter is placed and patients blood is circulated through small bedside filtrtion machine
Other Interventions: Whats monitored in Ultrafiltration?
Patients output of filtration fluid, blood pressure, and hemoglobin
Nursing Process - Assessment: Focuses on
observing for effectiveness of therapy and fo rthe aptients ability to understand and implement self-management strategies.
Nursing Process - Assessment , Health History: Focuses on
signs and symptoms of HF, such as dyspnea, fatigue, and edema
Nursing Process - Assessment , Physical Examination: Observed for
REstlessness and anxiety that might suggest hypoxia from pulmonary congestion. LOC and RR also assessed.
Nursing Process - Assessment , Physical Examination: Blood pressure carefully evaluated because
HF patients may present with hypotension or hypertension
Nursing Process - Assessment , Physical Examination: Patient is ausculated for
S3 heart sound, which is an early sign that increased blood voume fills the ventricle with each beat
Nursing Process - Assessment , Physical Examination: Abdomen examined for
tenderness and hepatomegaly
Nursing Process - Assessment , Physical Examination: Patient asked to breathe normally while manual pressure is appleid over right upper quadrant. What is monitored for?
neck vein distention
Nursing Process - Diagnosis: Potential complications include
Hypotension
Dysrhythmias
Thromboembolism
Pericardial Effusion
Nursing Process - Planning: Major goals for patient are
promiting activity and reduciing fatigue, relieving fluid overload symptoms, decreasing anxiety and increasing patients ability to manage anxiety
Nursing Process - Nursing Interventions, Promoting Activity Tolerance: Reduced physical activity leads to
Physical deconditioning that worsens te patients symptoms and exercises tolerance
Nursing Process - Nursing Interventions, Promoting Activity Tolerance: Inacitivty risks include
pressure ulcers and venous thromboembolism
Nursing Process - Nursing Interventions, Promoting Activity Tolerance: Exercise has many favorable effects for HF patient, including
increased functional capcity, decreased dyspnea, and improved quality of life
Nursing Process - Nursing Interventions, Promoting Activity Tolerance: Referal to what may be recommended for newly diagnosed with HF
cardiac rehabilitation
Nursing Process - Nursing Interventions, Managing Fluid Volume: Those with severe HF may receieve
IV diuretic therapy
Nursing Process - Nursing Interventions, Managing Fluid Volume: Those with less severe symptoms are typally prescribed
oral diuretics
Should be given in morning so that diuresis does not interefere with nightitme rest
Nursing Process - Nursing Interventions, Managing Fluid Volume: Fluid status is monitred closely by
ausculating the lungs, monitoring daily body weight and assisting the patient to adhere to low sodium diet
Nursing Process - Nursing Interventions, Managing Fluid Volume: Teaching the patient about being positioned upright does what to the body?
Preload is reduced
Pulmonary congestion reduced
Pressure on diaphragm redued
Nursing Process - Nursing Interventions, Controlling Anxiety: What does the nurse do when patient experineces anxiety?
Nurse takes steps to promote physical comfort, and provides psychological support.
Nursing Process - Nursing Interventions, Minimizing Powerlessness: Contributing factors to this include
Lack of knowledge and lack of opportunity to make decisions, particularly if health care providers or family member sod not encourage the patient to participate in the treatment
Nursing Process - Nursing Interventions, Assisting Patients and Family To Effectively Manage Health: What has shown to increase effectiveness of a discharge plan?
Comprehensive, Patient Centered Instructions
Scheduling PAtient Follow Up Visits within 7 days
Follow up by telephone 3 days after
Nursing Process - Nursing Interventions, Monitoring and Managing Potential Complications: Because HF is a complex and progressive condition, pateints are at risk for many complications include
acute decompensated HF
Pulmonary Edema
Kidney Injury
Life threatening dysrhythmias
Nursing Process - Nursing Interventions, Monitoring and Managing Potential Complications: Excesive and repeated diuresis can lead to
hypokalemia . with signs indicating dysrhythmias, hypotension, muscle weakness, and generalized weakness
Nursing Process - Nursing Interventions, Monitoring and Managing Potential Complications: In patients receiving digoxin, hypokalemia can lead to
digitalis toxicity which increases likelihood of dangerous dysrhythmias
Nursing Process - Nursing Interventions, Monitoring and Managing Potential Complications: Hypokalemias may occur especially with use of
ACE Imhibtors, ARBs, or spironolactone
Nursing Process - Nursing Interventions, Monitoring and Managing Potential Complications: Prolonged diuretic therapy may produce
hyponatremia which can result is disorientation
Nursing Process - Nursing Interventions, Monitoring and Managing Potential Complications: Volume depletion from excessive fluid may lead to
dehydration and hypotension . Also ACE Inhibitors and beta blockers
