Nusing Management of CHF (English) Symposia

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Nusing Management of CHF(English) Symposia presented at Hôpital Sacré Coeur in Milot, Haiti.

CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.

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Nusing Management of CHF (English) Symposia

  1. 1. Nursing Management of Patients with Cardiovascular Disease Part 1: Heart Failure Barbara Moloney DNPc, RN, CCRN
  2. 2. First Patient <ul><li>50-year-old man brought to the hospital by his family </li></ul><ul><li>His family says he has been feeling more and more short of breath over the last several days </li></ul>
  3. 3. Assessment <ul><li>Vital signs: </li></ul><ul><ul><li>Temperature – 37 O C </li></ul></ul><ul><ul><li>HR – 100, irregular </li></ul></ul><ul><ul><li>Respiratory rate 32 </li></ul></ul><ul><ul><li>Bp – 102/60 </li></ul></ul><ul><ul><li>Oxygen saturation 88% on room air Respiratory </li></ul></ul><ul><ul><li>Dyspnoec </li></ul></ul><ul><li>Neurological </li></ul><ul><ul><li>Oriented </li></ul></ul><ul><ul><li>Anxious </li></ul></ul><ul><li>Skin </li></ul><ul><ul><li>Cool, damp </li></ul></ul><ul><li>Jugular Venous Distention >3cm </li></ul>WHAT ARE YOUR CONCERNS? What would you like to do next?
  4. 4. <ul><li>Past medical history </li></ul><ul><ul><li>Rheumatic fever as a child </li></ul></ul><ul><ul><li>Rheumatic heart disease involving aortic and mitral valve </li></ul></ul><ul><ul><li>Dilated cardiomyopathy </li></ul></ul><ul><ul><li>Increasing problems with chest pressure and dyspnea over the last year </li></ul></ul><ul><ul><li>Medications prescribed: </li></ul></ul><ul><ul><ul><li>Furosemide 40 mg daily </li></ul></ul></ul><ul><ul><ul><li>Digoxin 0.125 mg every other day </li></ul></ul></ul>
  5. 5. Listen to his lungs
  6. 6. Assess the heart <ul><li>Palpate </li></ul><ul><ul><li>Point of maximum intensity should be 5 th intercostal space, mid-clavicular line </li></ul></ul><ul><ul><li>Displaced = enlarged heart </li></ul></ul>
  7. 7. Auscultating the heart <ul><li>A: Aortic valve: 2 nd intercostal space (ICS) right of sternum </li></ul><ul><li>P: Pulmonic valve: 2 nd ICS left of sternum ERB’s point: 3 rd ICS left of sternum </li></ul><ul><li>T: Tricuspid: 4 th ICS left of sternum </li></ul><ul><li>M: Mitral: 5 th ICS left of sternum </li></ul>
  8. 8. Listen to his heart
  9. 9. <ul><li>Abdomen </li></ul><ul><ul><li>Soft, flat </li></ul></ul><ul><ul><li>Bowel sounds normal </li></ul></ul><ul><li>Peripheral </li></ul><ul><ul><li>Pedal pulses present </li></ul></ul><ul><ul><li>Pitting Edema </li></ul></ul>
  10. 10. Review of the Heart <ul><li>Atria </li></ul><ul><li>Ventricles “ PUMPS ” </li></ul><ul><ul><li>RV pumps blood to lungs </li></ul></ul><ul><ul><li>LV pumps blood to body </li></ul></ul><ul><ul><li>Flow of Blood through heart </li></ul></ul>
  11. 11. Blood flow through the heart
  12. 12. Valves: Allow blood to flow in one direction <ul><li>Tricuspid & mitral </li></ul><ul><ul><li>Prevent regurgitation from ventricles into atria </li></ul></ul><ul><li>Pulmonic and Aortic valves </li></ul><ul><ul><li>Prevents blood from regurgitating into ventricle </li></ul></ul>
  13. 14. Assessing Heart Sounds
  14. 15. Review Murmurs <ul><li>Intensity </li></ul><ul><ul><li>Faint </li></ul></ul><ul><ul><li>Quit </li></ul></ul><ul><ul><li>Moderately loud </li></ul></ul><ul><ul><li>Loud </li></ul></ul><ul><ul><li>Very loud </li></ul></ul><ul><ul><li>Heard with stethoscope off chest </li></ul></ul><ul><li>Characteristics </li></ul><ul><ul><li>Location </li></ul></ul><ul><ul><li>Pitch </li></ul></ul><ul><ul><li>Timing </li></ul></ul><ul><ul><li>Loudness </li></ul></ul><ul><ul><li>Quality </li></ul></ul><ul><ul><li>Radiation </li></ul></ul><ul><ul><li>Variation </li></ul></ul>
  15. 16. Timing <ul><li>Systolic murmur </li></ul><ul><li>Occur during systole: when the ventricles are contracting </li></ul><ul><ul><li>Aortic Stenosis </li></ul></ul><ul><ul><li>Mitral regurgitation </li></ul></ul><ul><li>Diastolic murmur </li></ul><ul><ul><li>Occurs during diastole, when ventricles are filling </li></ul></ul>
  16. 17. <ul><li>Jugular Venous Distention </li></ul><ul><ul><li>Assess patient at 45 0 </li></ul></ul><ul><ul><li>Should be <3cm </li></ul></ul>
  17. 18. Analysis <ul><li>Your analysis </li></ul>
  18. 19. <ul><li>Medical diagnosis </li></ul><ul><ul><li>Left-sided heart failure secondary to valvular heart disease and cardiomyopathy </li></ul></ul><ul><ul><li>Right-sided heart failure </li></ul></ul><ul><ul><li>Chronic heart failure </li></ul></ul><ul><ul><li>Acute decompensated heart failure </li></ul></ul>
  19. 20. Review: Heart Failure <ul><li>Etiology </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Coronary Artery Disease </li></ul></ul><ul><ul><li>Cardiomyopathy </li></ul></ul><ul><ul><li>Valvular Heart Disease </li></ul></ul>
  20. 21. Heart Failure <ul><li>Left ventricular heart failure </li></ul><ul><li>Right ventricular heart failure </li></ul><ul><li>Biventricular Heart Failure </li></ul><ul><li>Acute decompensated heart failure </li></ul><ul><li>Chronic heart failure </li></ul><ul><li>Systolic Heart Failure </li></ul><ul><li>Diastolic Heart Failure </li></ul>
  21. 22. Left Ventricular Failure <ul><li>Left Ventricle can no longer pump enough blood to the systemic circulation </li></ul>http://www.heartfailure-europe.com/img/009333ed66ae8f1f9c77487008990cceimage001.jpg
  22. 23. <ul><li>Pressure rises in the LV, LA & pulmonary vasculature </li></ul><ul><li>Hydrostatic forces can cause intracellular fluid to accumulate in the pulmonary capillary bed, leading to pulmonary congestion </li></ul>
  23. 24. Left ventricular failure http://www.csufresno.edu/nursing/n140/studassign/studgif/chf8.gif
  24. 25. Left ventricular failure <ul><li>Signs and symptoms ( Signes et symptômes ) </li></ul><ul><ul><li>Restlessness and confusion </li></ul></ul><ul><ul><ul><li>Agitation et confusion </li></ul></ul></ul><ul><ul><li>Dyspnea ( Dyspnée ) </li></ul></ul><ul><ul><li>Cyanosis (Cyanose) </li></ul></ul><ul><ul><li>Cough ( Toux ) </li></ul></ul><ul><ul><li>Crackles ( Râles ) </li></ul></ul><ul><ul><li>Wheezes (rauque, respiration sifflante) </li></ul></ul><ul><ul><li>Blood-tinged sputum ( Crachat teint é de sang ) </li></ul></ul><ul><ul><li>Paroxysmal Nocturnal dyspnea ( Dyspnée nocturne paroxysmale ) </li></ul></ul>
  25. 26. Left ventricular failure Restless, Confused Orthopnea, Tachycardia, Cyanosis Dysponea on Exertion Paroxysmal Nocturnal Dyspnea Rales, Wheezes, Cough Blood Tinged sputum
  26. 27. Right Ventricular Failure <ul><li>Pressure increases on right side of the heart </li></ul><ul><li>Hydrostatic forces can cause intracellular fluid to accumulate in systemic venous circulation </li></ul>
  27. 28. Right Ventricular Failure <ul><li>Signs and symptoms </li></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>Jugular Venous distention </li></ul></ul><ul><ul><li>Dependent edema </li></ul></ul><ul><ul><li>Anorexia </li></ul></ul><ul><ul><li>Enlarged liver and Spleen </li></ul></ul><ul><ul><li>Ascites </li></ul></ul>
  28. 29. Right Ventricular failure Fatigue Anorexia Dependent edema Distended jugular veins Ascites enlarged liver & Spleen
  29. 30. Cardiomyopathy
  30. 31. Dilated Cardiomyopathy
  31. 32. Review: Valvular Heart Disease <ul><li>General: </li></ul><ul><ul><li>A cardiac dysfunction produced by structural and/or functional abnormalities of single or multiple cardiac valves </li></ul></ul><ul><li>Stenosis: valve doesn’t open all the way </li></ul><ul><li>Regurgitation: valve doesn’t close all the way </li></ul><ul><ul><li>Mitral Regurgitation </li></ul></ul><ul><ul><li>Aortic Stenosis </li></ul></ul>http://www.youtube.com/watch?v=XzjvV8UMEy4 http://www.youtube.com/watch?v=MJg257pyt4I
  32. 33. <ul><li>Collaborative Management </li></ul><ul><ul><li>Follow clinically </li></ul></ul><ul><ul><li>Follow with echocardiograms </li></ul></ul><ul><ul><li>Avoid infection </li></ul></ul><ul><ul><li>Manage symptoms of HF </li></ul></ul><ul><ul><li>May treat with repair or replacement </li></ul></ul>
  33. 34. Nursing Diagnoses <ul><li>Problem List </li></ul><ul><ul><li>Inadequate oxygenation </li></ul></ul><ul><ul><li>Excess fluid </li></ul></ul><ul><ul><li>Low cardiac output </li></ul></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Activity intolerance </li></ul></ul><ul><ul><li>Knowledge deficit </li></ul></ul>
  34. 35. Plan: Inadequate Oxygenation <ul><li>Goal: </li></ul><ul><ul><li>Maintain oxygenation sa turation >93% </li></ul></ul><ul><ul><li>Absence of respiratory distress </li></ul></ul><ul><li>Interventions </li></ul><ul><ul><ul><li>Nasal oxygen </li></ul></ul></ul><ul><ul><ul><li>Oxygen mask – i.e. non-rebreather </li></ul></ul></ul><ul><ul><ul><li>C onsider bipap </li></ul></ul></ul><ul><ul><ul><li>Prepare for intubation </li></ul></ul></ul>
  35. 36. Excess fluid <ul><li>Goal: Optimize fluid and electrolyte balance </li></ul><ul><ul><li>Absence of pulmonary congestion: clear lung sounds, clear chest x-ray </li></ul></ul><ul><ul><li>Absence of peripheral edema </li></ul></ul><ul><ul><li>Electrolytes within normal limits </li></ul></ul><ul><ul><li>Stable vital signs </li></ul></ul><ul><ul><li>Adequate urine output </li></ul></ul><ul><li>Interventions </li></ul><ul><ul><li>Strict I&O, calculate fluid balance, monitor electrolytes </li></ul></ul><ul><ul><li>Monitor lung sounds </li></ul></ul><ul><ul><li>Administer diuretics as ordered and assess effect </li></ul></ul>
  36. 37. Low Cardiac Output <ul><li>Goal </li></ul><ul><ul><li>Skin warm and dry with brisk capillary re-fill </li></ul></ul><ul><ul><li>Alert and oriented </li></ul></ul><ul><ul><li>Vital signs within normal limits </li></ul></ul><ul><ul><li>Urine output >30 mLs/hour </li></ul></ul><ul><ul><li>Absence of edema </li></ul></ul><ul><ul><li>Lungs clear </li></ul></ul><ul><li>Interventions: </li></ul><ul><ul><li>Continuous cardiac monitor; assess and treat dysrhythmias </li></ul></ul><ul><ul><li>Monitor VS, Capillary re-fill, edema, mental status ; lab values </li></ul></ul><ul><ul><li>Administer medications that increase cardiac output when ordered by physician (dopamine) </li></ul></ul>
  37. 38. <ul><li>Optimize pre-load and afterload </li></ul><ul><ul><li>Semi-fowlers position </li></ul></ul><ul><ul><li>Vasodilators (nitroglycerine) </li></ul></ul><ul><ul><li>ACE- inhibitors ( Lisinopril, Quinapril ) </li></ul></ul><ul><li>Decrease ventricular remodeling </li></ul><ul><ul><li>ACE-inhibitors </li></ul></ul><ul><ul><li>Beta-blockers (when hemodynamically stable) (metoprolol, atenolol) </li></ul></ul>
  38. 39. Anxiety <ul><li>Goal </li></ul><ul><ul><li>Reduce anxiety level </li></ul></ul><ul><li>Interventions </li></ul><ul><ul><li>Calm supportive environment </li></ul></ul><ul><ul><li>Medications - Morphine </li></ul></ul>
  39. 40. Activity Intolerance <ul><li>Goal </li></ul><ul><ul><li>Promote activity </li></ul></ul><ul><ul><li>Reduce fatigue </li></ul></ul><ul><li>Intervention </li></ul><ul><ul><li>Bed-rest during acute phase only </li></ul></ul><ul><ul><li>Space activities to allow for rest </li></ul></ul><ul><ul><li>Monitor heart rate, respiratory rate, and oxygen saturation with initial activity. </li></ul></ul><ul><ul><li>Avoid large meals - encourage frequent small meals </li></ul></ul><ul><ul><li>As patient recovers, initiate exercise regimen as tolerated. </li></ul></ul>
  40. 41. Knowledge Deficit <ul><li>Goal </li></ul><ul><li>Intervention </li></ul><ul><ul><li>Begin teaching as soon as patient is able to participate </li></ul></ul><ul><ul><li>Teach </li></ul></ul>
  41. 42. Evaluation <ul><li>Oxygenation </li></ul><ul><li>Diuresis </li></ul><ul><ul><li>Fluids </li></ul></ul><ul><ul><li>Electrolytes (K + ) </li></ul></ul><ul><li>Cardiac Output </li></ul><ul><li>Anxiety </li></ul><ul><li>Activity intolerance </li></ul><ul><li>Knowledge </li></ul>
  42. 43. Patient Education <ul><li>Review heart failure, diagnosis and treatment </li></ul><ul><li>Symptoms of Heart Failure </li></ul><ul><ul><li>Short of breath or wheezing </li></ul></ul><ul><ul><li>Difficulty breathing when lying down </li></ul></ul><ul><ul><li>Frequent dry cough </li></ul></ul><ul><ul><li>Feeling tired or weak </li></ul></ul><ul><ul><li>Weight gain of 3 or more pounds in 1 day or 5 pounds in more than 1 week </li></ul></ul><ul><ul><li>Swelling in feet, ankles, legs, or stomach </li></ul></ul>
  43. 44. <ul><li>Review of medications </li></ul><ul><ul><li>Ace inhibitors ( Lisinopril, Quinapril) </li></ul></ul><ul><ul><ul><li>Purpose: Helps heal the heart and lower the amount of water and salt you retain, will help you live longer </li></ul></ul></ul><ul><ul><ul><li>Side effects: Orthostatic hypotension </li></ul></ul></ul><ul><ul><li>Beta blockers (Metoprolol, Atenolol) </li></ul></ul><ul><ul><ul><li>Purpose: Helps heal the heart and help you live longer </li></ul></ul></ul><ul><ul><ul><li>Side effects: May decrease your heart rate </li></ul></ul></ul>
  44. 45. <ul><ul><li>Diuretics (furosemide) </li></ul></ul><ul><ul><ul><li>Purpose: Helps reduce fluid in your lungs, and swelling in feet, ankles, legs and stomach </li></ul></ul></ul><ul><ul><ul><li>Side effects: make you urinate more often. </li></ul></ul></ul><ul><ul><li>Digoxin </li></ul></ul><ul><ul><ul><li>Helps your heart pump better </li></ul></ul></ul><ul><ul><ul><li>Take as ordered (may be every other day) </li></ul></ul></ul><ul><ul><ul><li>Review side effects: blurred vision, slow heart- rate, </li></ul></ul></ul>
  45. 46. <ul><li>General Instructions </li></ul><ul><ul><li>Take medications as prescribed </li></ul></ul><ul><ul><li>Get some exercise (walking is great) but do not over-do it </li></ul></ul><ul><ul><li>Do not smoke, do not drink alcohol </li></ul></ul><ul><ul><li>Vaccines </li></ul></ul><ul><ul><li>Regular clinic appointments </li></ul></ul>
  46. 47. <ul><li>Diet Instructions </li></ul><ul><ul><li>Do not add salt to foods </li></ul></ul><ul><ul><li>Avoid foods with hidden salt (please help here) </li></ul></ul><ul><ul><li>Fluid restriction (if on one) </li></ul></ul>
  47. 48. <ul><li>When to seek medical help </li></ul><ul><ul><li>More short of breath than usual </li></ul></ul><ul><ul><li>Swelling in ankles, feet, or abdomen </li></ul></ul><ul><ul><li>Loss of appetite </li></ul></ul><ul><ul><li>Persistent cough </li></ul></ul><ul><ul><li>Restless sleeping: needing sleep upright or waking in the night suddenly short of breath </li></ul></ul><ul><ul><li>Weight gain of 3 pounds in 1 day or 5 pounds in 1 week </li></ul></ul>Dressler, D.K. (2010).

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