Week 13: HF, PVD, Carditis Flashcards
Cardiac Infection / Carditis
Infectious Processes Involving the Heart
Involves various layers - endocardial, myocardial, and pericardial
Various etiologies
Layers of the Heart in to out
Endocardium, Myocardium (Muscle Middle), Epicardium
Pericarditis
Inflammation of the pericardial sac
can be primary or secondary - due to surgery or medical causes
s/s of Pericarditis
constant subclavicular chest pain - worse with turning or lying flat
pain improved with leaning forward or sitting position
friction rub - grating, creaking sound with each heartbeat
Increased WBC, Temp, ESR, and CRP
What could it mean if a patient is in too much pain to sit back during assessment in semi-fowlers
if they cannot sit forward it may indicate pericarditis
Nursing Care for Pericarditis
Bed rest if s/s decrease CO until fever is normalized, chest pain and friction rub gone
Morphine, Corticosteroids, NSAIDs, Meds
Observe for s&s of cardiac tamponade - pericardiocentesis
Endocarditis
life threatenining inflammation of the inner lining of your heart’s chambers and valves (endocardium)
Where does the infection for endocarditis come from
bacteria, fungi, or other microorganisms from another part of the body such as the mouth, limb abscess, or lung infection that spreads through the bloodstream and attaches to damaged areas in the heart (it loves attaching to valves)
If endocarditis is not treated quickly what can happen
it can damage or destroy the heart valves
Treatments for Endocarditis
IV antibiotics long term (6+ weeks) and sometimes surgery
What are some risk factors for endocarditis
poor dental hygiene
cardiac disease (prior)
COVID-19
IV drug user
central line access
Important Nursing Care Considerations for Endocarditis Tx
Stabilize the patient depending on the stage
Carry out the provider’s orders to find the source (cultures, monitor labs, radiology exam)
Monitor cardiorespiratory status
Monitor for S&S of sepsis
administer ordered IV antibiotics for some time
Holistic/Wrap around care (social work, substance abuse providers, other specialists)
LISTEN WITHOUT BEING JUDMENTAL
5 Cardiac Valvular Disorders
Mitral Valve Prolapse
Mitral Regurgitation
Mitral Stenosis
Aortic Regurgitation
Aortic Stenosis
Diagnostic Testing for Valvular Disorders
2D Echocardiogram
Cardiac Catheterization
MRI
CT Scan
Valve Disease: Prolapse
Portion of the valve leaflets protrude into the atrium during systole
so, the valve wont stay closed during systole
S/S and Characteristics of Valve Prolapse
few symptoms
seen in young women
fatigue
palpitations
SOB
lightheadedness
Valve Disease: Incompetence
the valve wont stay closed durign systole
cannot close when blood is pumping
s/s and characteristics of valve incompetence
few symptoms
seen in young women
fatigue
SOB
palpitations
lightheadedness
(Similar to prolapse)
Valve Disease: Stenosis
Obstruction of blood flow
Valve does not open completely during systole
improper opening
S/S of Valve Stenosis
fatigue d/t lowered CO
SOB
cough and hemoptysis
weak, irregular pulse
murmur
CHF
Valve Disease: Regurgitation
valve does not close tightly
allows blood to flow backward into the heart
some people may NOT need tx
improper closing
S/S and Characteristics of Valve Regurgitation
SOB
fatigue
lightheadedness
rapid fluttering heartbeat
What may more serious valve regurgitation cases need
medications like diuretics and blood thinners, or surgery
Types of Replacement Valves
Mechanical Valves
Tissue (Biologic) Valves
Mechanical Valves
Heart valves that do not deteriorate or become infected easily
Thrombogenic and require life long anticoagulation therapy (Coumadin)
Tissue (Biologic) Valves
Xenograft, Homograft, and Autograft
Xenograft
Tissue Valve / Heterograft
Pig or Cow Valve Transplant
Homograft
Tissue Valve / Allograft
Human Valve Transplant
Autograft
Tissue valve
Patient’s own valve transplant
Nursing Management Considerations for Valvular Disorders
prophylactic antibiotics (esp. for dental procedures)
anticoagulants - lifelong therapy post-mechanical valve replacement
cardiovascular follow-up
education!!!
Balloon Valvuloplasty
A less invasive surgery for valvular stenosis
It opens the valve and vessel up to be more functional with an inflated balloon
Surgical Valvuloplasty
For Incompetent Valves - Valve Incompetence
Closing the Valve basically
Self Concept Factors r/t to Cardiac Infections and Valve Disorders
Fear
Addiction / Lifestyle Choices
Guilt/Shame (over choices and addictions)
Physical Care of Self
Beliefs about Self
Congestive Heart Failure (CHF)
Impaired cardiac pumping, vasoconstriction and fluid retention
an inability of the heart to pump sufficient blood to meet the body’s needs
RIGHT OR LEFT SIDED
Is CHF a disease
Not a disease, but is associated with other problems - CAD (60%), HTN, MI, Valvular Dysfunction, cardiomyopathy
What are the majro risk factors for CHF
Advancing Age and CAD
Contributing Factors for CHF
1 Advancing Age and CAD
HTN
DM
Tobacco
Obesity
High Serum Cholesterol
What may patients exhibit with CHF
ventricular dysfunction
reduced exercise tolerance
diminished QOL
self concept issues
shortened life expectancy
Why is CHF increasing in incidence
due to improved survival after CV events AND increasing aging population
CHF is a major reason for admission in elderly patients - comorbidities are causing this
How many people ahve CHF
5 million
What is the most common reason for admission in adults >65 yo
CHF
CHF is associated with …
high morbidity, mortality, and economic cost
What are the disparities in CHF for Asian Americans
higher risk of ACE inhibitor related cough
lower rates of CHF
What are the disparities in CHF for AA and Hispanic Americans
Higher incidence, higher mortality & develops at an earlier age than caucasians
experience more ACE inhibitor related angioedema
How does CHF differ in Men compared to Women
Men experience more systolic dysfunction
Better response to ACE Inhibitor therapy (less mortality)
How does CHF differ in Women compared to Men
Experience more disatolic dysfunction
Higher risk of ACE cough
More frequently experience a major depression
May be a hormonal thing that explains why ACE response is worse in women
Clinical Picture of Left Sided Heart Failure
Nocturnal Dyspnea
Cough
Crackles
Wheezes
Blood Tinged Sputum
Restlessness and Confusion
Orthopnea
Tachycardia
Exertional Dyspnea
Cyanosis
Hypoxia causes much of this
in Left Sided Ventricular Failure what causes the pulmonary congestion
the LV not emptying
What would a left sided ventricular failure CXR show
CXR would show fluffy infiltrates: fluid in alveoli
What sort of things are auscultated in L Sided Ventricular Failure
Lung sounds - crackles
S/S of Pulmonary Decompensation from Left Sided Ventricular Failure
Pulsus Alternans
Increased HR
S3 > S4 Heart Sounds
Pleural Effusion
Mental Status Changes - restlessness, confusion
Weakness and fatigue
anxiety and depression
shallow respirations
paroxysmal noctural dyspnea
orthopnea
dry hacking cough
nocturia
mental status changes - hypoxia
Clinical Picture of Right Sided Heart Failure
Fatigue
Increased Peripheral Venous Pressure
Ascites
Enlarged Liver and Spleen
Distended Jugular Veins
Anorexia and Complaints of GI Distress
Swelling in Hands and Fingers
Dependent Edema (trunk or torso area)
What does right ventricular failure cause
backup of blood into the venous systemic circulation
Right sided heart failure may be caused by …
pulmonary heart disease
valve disease
disease of myocardium
S/S of Right Sided Ventricular Failure
Edema - legs, scrotum, sacrum
Dependent, bilateral pitting edema
Weight gain
poor tissue perfusion
fatigue
anxiety
Right upper quadrant pain
liver enorgement and failure
anorexia, GI bloating
ascites, anasarca
hepatomegaly
nausea
weakness
NYHA Classification
Classifications of Heart Failure from I, II, III, and IV
Treatment guidelines are in place for each stage
Stage I HF
no symptoms with normal physical activity
normal functional status
Stage II HF
mild symptoms with normal physical activity
comfortable at rest
slight limitation of functional status
Stage III HF
moderate symptoms with less than normal physical activity
comfortable only at rest
marked limitation of functional status
Stage IV HF
severe symptoms with features of HF with minimal physical activity even at rest
severe limitation of functional status
Commong HF Symptoms
fatigue
palpitations
chest pain
dyspnea
syncope
BNP
B Type Natreutic Hormone - cardiac hormone released by monocytes in ventricles and plays a big role in hemostasis in volume control
Has a significant role in HF diagnosis
Elevated BNP of _____ pg/mL is highly sensitive and specific for dx of HF
> 100 pg/mL
What reflects the severity of heart failure diagnostically
the plasma concentration of BNP
What are some other labs to look at for HF diagnosis
lipid profile
coagulation profile
CBC
CRP
Electrolytes
Hemodynamic Monitoring
Measures the pressure in the chambers of the heart using invasive equipment and continuous monitoring
Needs specialized nursing educatio
Used in acute HF
What sort of catheters may be used for hemodynamic monitoring? What are both capable of?
CVC - central venous catheter
Swan Ganz Catheter (PA Catheter)
*Both are capable of measuring pressures in portions of the right heart: CVP (right atrium or superior vena cava) and PA (Pulmonary artery pressure)
Nursing Interventions for Chronic Heart Failure related to Activity
avoid activities in extreme hot, cold, or humid weather
modify activities to conserve energy
positioning: elevation of the HOB to facilitate breahting and rest, support of arms
monitor VS wiht activity
cardiac rehabilitation
bed rest for acute exacerbations
encourage regular physical activity - 30-45 minutes a day
exercise training
pacing of activities (give more time to complete)
wait 2 hours after eating for physical activity
Nursing Interventions for Chronic Herat Failure related to Fluid Volume Excess
assessment for symptoms of fluid overload
daily weight
I&O
diuretic therapy; timing of meds
fluid intake/resuscitation
maintenance of sodium restriction
positioning - may elevate legs if no respiratory compromise, otherwise legs down
Nursing Interventions: Patient Education Topics for Chronic HF
Diet
Stress Management
Prevention of infection
know how and when to conact health care provider
include family in teaching
before the body gets to CHF - prevention teaching
What is the diet like with chronic heart failure
small frequent meals
bland low residue diet
edema may “cover malnutrition” - know this and make the patient aware
Zone Management Tool
Education tool for patients with chronic heart failure
It is a tool of green, yellow, red that tells what to do when experiencing certain symptoms
Green Zone S/S and What to do (Zone Management)
You have: no SOB, weight gain more than 3 pounds a day, swelling of fett, ankles, legs, or stomach, and no chest pain
What to do: Keep up the good work, take your medicine, eat a low salt diet, weight daily
Yellow Zone S/S and What to Do (Zone Management)
You have: weight gain of 3 poounds in 1 day or 5 pounds in one week, SOB, swelling, feeling more tired, dizziness, new or unusual cough, hard to breath lying down - need to sleep sitting in a chair
what to do: Call the doctor or nurse
Red Zone S/S and What to Do (Zone Management)
You have: Hard time breathing, struggling to breathe even at rest, chest pain or discomfort, feeling faint
What to do: CALL 911 OR Get help, go to the ER
Common medications for CHF
ACE inhibitors
ARB receptor blockers
Nitrates
Beta Blockers
Diuretics
Digitalis
Calcium channel blockers
Aquapheresis
Simple Ultrafiltration of fluids being pulled from a CHF patient that occurs over 2-12 hours
It is controlled with sodium and water intake and output
automated - no clinically significant impact onf lyte balance, BP, or HR
Almost like a CHF Dialysis
see video on blackboard
Complications of Heart Failure
thromboembolism
pulmonary edema
cardiogenic shock
pericardial effusion and cardiac tamponade
sudden cardiac death / cardiac arrest
resp compromise complications are the most serious due to quick death
Ways to Prevent PE Early - Nursing Interventions
monitor lung sounds
assess for decreased activity tolerance
assess for increased fluid retention
long term anticoagulation medication
Nursing Interventions for PE
HIGH FOWLERS POSITIONE AND DANGLE LEGS
O2, VS, assess LOC
indwelling catheter
assess ABGs and lab values
administer ordered meds: vasodilators, analgesics, diuretics, inotropics, bronchodilators
monitor for pink frothy sputum from coughing
3 Important Nursing interventions for Cardiogenic Shock
correct underlying problem
medications
circulatory assist devices
What underlying problems cause cardiogenic shock
Rhythm problems the most common reason:
MI
CHF
Tamponade
Dysrhythmias
Medications for Cardiogenic Shock
Diuretics
Positive inotropic agents and vasopressors
What sort of circulatory assist devices are used in cardiogenic shock
intra-aortic balloon pump (IABP)
extracorporeal membrane oxygenation (ECMO)
IABP
intra aortic balloon pump
improves heart flow and improves heart flow to vessels
decreases workload of the heart with an 85-90% occlussive balloon blocking the aorta
ECMO
veno arterial (VA) extracorporeal membrane oxygenation (ECMO)
Blood is pulled from a vein, sent through the ECMO machine where it is oxygenated and then sent back to the body via an artery
Like dialysis but specific to cardiac system
Nursing Interventions for Pericardial Effusion and Cardiac Tamponase
monitoring pericardiocentesis and pericardiotomy sites
Monitoring cardiorespiratory and hemodynamic status
monitor chest tube
Your client has been diagnosed with CHF. What discharge teaching will you provide?
Weigh self daily at the same time and before breakdast
take your pulse before taking digoxin
take your diuretic in the morning
notify MD if you gain 2-3 pounds in a day
notify MD if you gain 5 pounds in a week
Your patient notices yellow rings around the lights in her room. You suspect what?
Digoxin Toxicity
Your patient’s potassium level is 3.2 this morning. She is also on Digoxin and Lasix. You will do what interventions?
hold both and get order for K+ (should be 3.6-5.2)
Your patient’s digoxin level comes back as 0.4 ng/mL, you know this level is ___?
low
3 Types of Peripheral Vascular Disease (PVD)
Aterial
Venous
HTN
Arterial
oxygen carrying vessel damage/occlusion
ARTERIES FEED THE TOES
Venous
portal for transport to the heart
VEINS PULL BACK TO OUR NOSE
Hypertension
vessel damage
force of blood icnreased causing higher pressure
Function fo the Vascular System
Blood and nutrients to organs
O2 for aerobic metabolism
Collection fo waste products to ecretory organs
Movement and return of immune system components
The perfusion of the vascular system depends on…
the heart, the main pump
if the heart fails what happens to the vascular system
the adequacy to supply of the vascular systme fails
What are some local and systemic vessel regulators
trauma
histamine
muscle metabolites
heat
cold
nervous system
hormones
Risk Factors for Vascular Compromise
hypercholesterolemia
hyperlipidemia
HTN
obesity
smoking
diabetes
sedentary life
genetics
What happens if the flow rate of the vessels decreases?
decreased flow = decreased O2 to tissue = causes ischemia and malnutrition
How do the arteries change with metabolic needs?
Increased need = arterial dilation
Decreased need = arterial constriction
What happens when vessel function is impaired?
Cells are malnourished
Arterial - no O2 or nutrients
Venous - system clogged with wastes and excess fluid
Chronic function impairment will lead to arterial and/or venous fysfunction
Symptoms fo Venous Insufficiency
Varicose Veins
Darkened Hard or Leathery Skin
Swelling
Pain and Heaviness
Leg Cramps or Spasms
Restless Leg Syndrome
Itchy Skin
What do veins do
return deoxygenated blood to the heart
have thinner less muscular walls
flow is controlled by valves - when the valves are incompetent they cannot push or pull blood back up to the central circulation
Manifestations of Venous Compromise (Venous Ulcers)
“Gaiter Region” - most common area
Skin Brown, Scaly, Hard
Copious Serous Exudate - common
Wound bed tissue range red granulation to fibrinous tissue to necrosis
Commonly have cellulitis
May lead to lymphedema
Increased venous stasis and edema
What do Venous Ulcers Look like?
Hemosiderin Staining
Brown Colored Skin
Weeping Tissue
Interventions for Venous Insufficiency
Walking
Combo Exercise and Rest
Elevate legs too/Elevation
Compression/Pressure Stockings
Infection Control and topical Antiinfectives
Debride large non healing wounds
Skin grafting
Improve mobility
Adequate nutrition
COMPRESSION COMPRESSION COMPRESSION!
What is the ideal exercise for venous insuffiencies ?
Walking - done in a progressive fashion
Particularly in arterial disease what should be a guide to activity?
Pain - it signals decreased O2
Exercise UNTIL pain
Increases collateral circulation and muscle activity helps move the fluid around
What is important in venous sufficiency that you should not do if there is also arterial insufficiency
compression
Arterial Ulcers
Extremely Painful and often infected limb threatening ischemia ulcers
Treatment is difficult and outcomes are unpredictable - because of poor circulation
Where are arterial ulcers typically found
on or between the toes
on the upper surface of the foot over the metatarsal heads
What results in arterial ulcers
decreased blood supply
Arterial Ulcer Limbs may be …
cool to the touch
What do arterial ullcers look like?
Punched Out Infected Ulcers
Can be necrotic
Usually a defined circular lesion on the feet
What is the major symptom of arterial insuffieincy
Intermittent Claudication
Intermittent Claudication
Pain - sharp, stabbing, decreases with rest, and dependent position often occurs at night
Pain in the lower legs from arterial insufficiency
Can be aching with mild cramping along with the pain
More comfortable at rest and dependent position -arterial insufficiency poorly tolerates activity
Diagnostics for Arterial Disease
doppler studies
angiography
ankle brachial indexes (doppler)
treadmill testing
Interventions for Arterial Insufficiency
LOWER feet and raise head - because of deficit of blood in extremities
RAISE feet and lower head - to reverse pooling of deoxygenated blood in extremities
Avoid standing still for extended periods of time
Control pain
Surgical Management Modalities for Arterial Insufficiencies
Vascular Grafting - bypass grafting
Surgical revascularization is required in advanced cases - esp if problem with ulcer healing (Endarterectomy)
Why should some arterial insufficiency patients NOT exercise
Increases in metabolic demand - stopping exercise to prevent infection in central circulation
If they have increased metabolic demand there can be / worsening of leg ulcers, cellulitis, gangrene, acute thrombotic occlusion or condition
Patient Education for Arterial Ulcers
Do NOT cross legs
No constriction/compression
Warmth-avoid cold
STOP Nicotine! (jagged marks in arteries causing occlusion)
Nutrition - esp Vitamin B and C
Avoid injury
Good hygiene
Foot care - shoes, inspection
Adequate Fluids
Emotions! - stimulated SNS
Deep Vein Thrombosis (DVT)
a blood clot (thrombus) forms in one or more of the deep veins in the body
Interventions for Prevention of DVTs
Hospitalized pts at risk:
TEDS SCDS Heparin SC Lovenox SC Maintain Mobility ROM Isometrics NSAIDS
Treatment for Existing DVT
elevate legs
Do NOT cross legs
heat application
anticoagulants - IV heparin (APTT, PTT, INR) and Coumadin (PT and INR)
Thrombolysis with t-Pa
Embolectomy
Insertion of venous filter (prevent movement to the chest)
Medications and Substances that cause Vasoconstriction and can worsen DVT
Licorice
Nicotine
Caffiene
Chewing Tobacco
Amphetamines
Abdominal Aortic Aneurysm (AAA)
an enlargement of the aorta, the main blood vessel that delivers blood to the body, at the level of the abdomen
serious medical problem - classified by shape and location
Can rupture and be fatal
Cause of AAA
atherosclerotic disease
Risk Factors for AAA
HTN, Smoking, Genetics
S/S of AAA
HTN
Back pain with AAA
Bruit or thrill
Abdominal Mass
Throbbing or beating feeling in abdomen
Diagnostics for AAA
CT Scan
Ultrasound
Cardiac Catheterization
Treatment for AAA
Surgical Repair and Resection - graft or stent
Monitor
Self Concept Aspects for Patients with Vascular Disorders
fear of the unknown, limb threatening
motivation - why bother - may be tired of condition
tired of a chronic disease
may be fighting addiction - nicotine
financial affects self concept
physical limitations
does the patient buy into the plan, if not why ?
Patient Education topics for Vascular Disorders
exercise within limits of pain
when to seek medical attention
how to control precipitating factors: DM, Smoking, Sedentary lifestyle, Diet, Stress
*Think about hwo to get them to buy into change
