Ppt chapter29 hf1

Chapter 29
Management of Patients With
Complications From Heart
Disease

Copyright © 2018 Wolters Kluwer · All Rights Reserved
Learning objectives
Identify the etiology, pathophysiology, and clinical
manifestations of heart failure
Describe management of patients with heart failure
Use the nursing process as a framework for care of
patients with heart failure
Develop an education plan for patients with heart failure
Identify the etiology, pathophysiology, and clinical
manifestations of pulmonary edema
Describe the medical and nursing management of
patients with pulmonary edema
Describe the medical and nursing management of
patients with complications from heart disease

Heart Failure (HF) #1
A clinical syndrome resulting from structural or functional
cardiac disorders that impair the ability of the ventricles
to fill or eject blood
In the past, HF was often referred to as congestive
heart failure (CHF), because many patients experience
pulmonary or peripheral congestion with edema
HF is recognized as a clinical syndrome characterized by
signs and symptoms of fluid overload or inadequate
tissue perfusion

Heart Failure (HF) #2
The term heart failure indicates myocardial disease, in
which there is a problem with the contraction of the heart
(systolic failure) or filling of the heart (diastolic failure)
Some cases are reversible depending on the cause
Most HF is a chronic, progressive condition managed with
lifestyle changes and medications

Chronic HF
The incidence of HF increases with age
Approximately 6 million people in the United States have
HF, and 870,000 new cases are diagnosed each year
Most common in people older than 75 years
Most common reason for hospitalization of people older
than 65 years and is the second most common reason for
visits to a physician's office
Approximately 25% of patients discharged after treatment
for HF are readmitted to the hospital within 30 days
https://www.youtube.com/watch?v=2aiRpr5UCZs

Causes of heart failure
Primary causes
o Hypertension
o CAD, including MI
o Rheumatic heart disease
o Congenital heart defects
o Pulmonary hypertension
o Cardiomyopathy
o Hyperthyroidism
o Valvular disorders
o Myocarditis
Precipitating causes
o Anemia
o Infection
o Thyrotoxicosis
o Hypothyroidism
o Dysrhythmias
o Bacterial endocarditis
o Obstructive sleep apnea
o Pulmonary embolism
o Paget’s disease
o Nutritional deficiencies
o Hypervolemia

Pathophysiology of Heart Failure

Heart Failure
Complex clinical syndrome resulting in insufficient blood
supply/oxygen to tissues and organs
o Involves diastolic or systolic dysfunction
o Ejection fraction (EF) is amount of blood pumped by
LV with each heart beat

What is ejection fraction (EF)?
Calculated by 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 ejected
Normal EF is 55-65% of ventricular volume
What diagnostic tool is utilized to diagnose heart failure?

Risk Factors
Primary risk factors
o Hypertension
 Modifiable risk factor
 Properly treated and managed, incidence of HF can
be reduced by 50%
o CAD
Co-morbidities contribute to development of HF

Types of heart failure
 DIASTOLIC HEART
FAILURE
 Normal EF
 Heart failure with preserved
EF
 One third of all heart failure
patients have diastolic heart
failure
 SYSTOLIC HEART
FAILURE
 Reduced EF
 Heart failure with reduced EF
 One third of all heart failure
patients have systolic heart
failure
 MIXED Heart failure includes
both systolic and diastolic
heart failure

Classification of Heart Failure
Left-sided HF
o Most common form of HF
o Results from inability of LV to
 Empty adequately during systole
 Fill adequately during diastole
o Further classified as
 Systolic
 Diastolic
 Mixed systolic and diastolic

Left-Sided Heart Failure
Blood backs up into left atrium and pulmonary veins
Increased pulmonary pressure causes fluid leakage →→
pulmonary congestion and edema

Pathophysiology
Mixed Heart Failure
Mixed systolic and diastolic failure
o Seen in disease states such as dilated
cardiomyopathy (DCM)
o Poor EFs (<35%)
o High pulmonary pressures
o Biventricular failure
 Both ventricles may be dilated and have poor
filling and emptying capacity

Pathophysiology
Right-Sided Heart Failure
RV fails to pump effectively
Fluid backs up in venous system
Fluid moves into tissues and organs
Left-sided HF is most common cause
o Other causes include RV infarction, PE, and cor
pulmonale (RV dilation and hypertrophy)

Pathophysiology
Heart Failure in General
Ventricular failure leads to:
o Low blood pressure (BP)
o Low CO
o Poor renal perfusion
Abrupt or subtle onset
Compensatory mechanisms mobilized to maintain
adequate CO

Compensatory Mechanisms
Ventricular remodeling
o Continuous activation of neuro-hormonal responses
(RAAS and SNS)
o Hypertrophy of ventricular myocytes
o Ventricles larger but less effective in pumping
o Can cause life-threatening dysrhythmias and sudden
cardiac death

Dilation
o Enlargement/thinning of chambers of heart that
occurs when pressure in left ventricle is elevated
o Initially effective
o Eventually, becomes inadequate and CO decreases
due to loss of elasticity

Dilated Heart Chambers

Hypertrophy
o Increase in muscle mass and cardiac wall thickness
o Initially effective
o Over time leads to poor contractility, increased O2
needs, poor coronary artery circulation, and risk for
ventricular dysrhythmias

Hypertrophied Heart Chambers
Fig. 35-1. A, Dilated heart chambers. B, Hypertrophied heart chambers.

Dilated and Hypertrophied
Heart Chambers
Fig. 35-1. A, Dilated heart chambers. B, Hypertrophied heart chambers.

Clinical manifestations of heart failure
 CONGESTION
 Dyspnea
 Orthopnea
 Paroxysmal nocturnal dyspnea
 Cough
 Pulmonary crackles
 Weight gain
 Dependent edema
 Abdominal bloating or
discomfort
 Ascites
 Jugular venous distension
 Sleep disturbance
 Fatigue
 POOR PERFUSION/LOW
CARDIAC OUTPUT
 Decreased exercise tolerance
 Muscle wasting or weakness
 Anorexia or nausea
 Unexplained weight loss
 Unexplained confusion or
altered mental status
 Resting tachycardia
 Daytime oliguria with
recumbent nocturia
 Cool or vasoconstricted
extremities
 Pallor or cyanosis

Clinical Manifestations
Right Sided
Viscera and peripheral
congestion
Jugular venous
distention (JVD)
Dependent edema
Hepatomegaly
Ascites
Weight gain
Left Sided
Pulmonary congestion,
crackles
S3 or “ventricular gallop”
Dyspnea on exertion
(DOE)
Low O2 sat
Dry, nonproductive
cough initially
Oliguria

Pulmonary Edema
Anxious, pale,
cyanotic
Cool and clammy
skin
Dyspnea
Orthopnea
Tachypnea
Use of accessory
muscles
Cough with
frothy, blood-
tinged sputum
Crackles and
wheezes
Tachycardia
Hypotension or
hypertension
Abnormal S3 or
S4

Complications
Pleural effusion
Dysrhythmias – atrial and ventricular
Left ventricular thrombus
Hepatomegaly
Renal failure

Diagnostic Studies
Determine and treat underlying cause
Echocardiogram
o Provides information on EF, heart valves and
heart chambers
ECG, chest x-ray, 6-minute walk test, exercise stress
test, heart cardiac catheterization
BNP levels

Acute Phase
Nursing Interventions
High Fowler’s position
Supplemental oxygen
BIPAP or Intubation if unstable
Continuous monitoring and assessment
o VS, O2 saturation, urinary output
Hemodynamic monitoring if unstable

Medical management of heart failure
 Improvement of cardiac
function with optimal
pharmacologic management
 Reduction of symptoms and
improvement in functional
status
 Stabilization of patient
condition and decrease the
risk of hospitalization
 Delay the progression of
disease and extend life
expectancy
 Promotion of a lifestyle
conducive to cardiac health
 Treatment varies according
to severity of disease
 Includes; oral or IV
medications, major lifestyle
changes, O2, surgical
interventions such as
implantation of devices and
cardiac transplantation
 Requires intensive teaching
and counseling and
participation from patient
and family

Medication Management
Diuretics
o Decrease volume overload (preload)
 Loop diuretics - Furosemide (Lasix)
Vasodilators
o Reduce circulating blood volume and improve
coronary artery circulation
 IV nitroglycerin
 Sodium nitroprusside
 Nesiritide (Natrecor)

Drug Therapy
Morphine
o Reduces preload and afterload
o Relieves dyspnea and anxiety
Positive inotropes
o β-agonists dobutamine
o Phosphodiesterase inhibitor (milrinone)

Pharmacologic therapy
 ACE inhibitors
 Angiotensin receptor
blockers
 Hydralazine and isosorbide
dinitrate
 Beta blockers
 Diuretics
 Digitalis
 IV infusions of milrinone,
dobutamine
 Other therapies include
nutritional therapy,
supplemental oxygen,
cardiac resynchronization
therapy, ultrafiltration,
LVADs and cardiac
transplantation

Goals of Care
Treat the underlying cause and contributing factors
Maximize CO
Reduce symptoms
Improve ventricular function
Improve quality of life
Preserve target organ function
Improve mortality and morbidity

Nursing Intervention
Monitor respiratory status
Administer oxygen therapy
Semi-Fowler’s position
Monitor hemodynamic status
Daily weights
I and O
Administer prescribed drugs
Monitor edema

 Fluid restriction not generally required
 If required, < 2L/day
o Ice chips, gum, hard candy, ice pops to help thirst
 Daily weights important
o Same time, same clothing each day
 Weight gain of 3 lb (1.4 kg) over 2 days or a 3- to 5-lb (2.3
kg) gain over a week should be reported to HCP
Nutritional Therapy

Medications #1
Angiotensin-converting enzyme (ACE) inhibitors:
vasodilation; diuresis; decreases afterload; monitor for
hypotension, hyperkalemia, and altered renal function;
cough
Angiotensin II receptor blockers: prescribed as an
alternative to ACE inhibitors; Prevent vasoconstriction
Hydralazine and isosorbide dinitrate: alternative to ACE
inhibitors
Beta-blockers: prescribed in addition to ACE inhibitors;
may be several weeks before effects seen; use with
caution in patients with asthma

 Diuretics
o Reduce edema, pulmonary venous pressure, and
preload
o Promote sodium and water excretion
o Loop diuretics
o Thiazide diuretics
o Monitor potassium levels (hypokalemia)
Medication Management

Medications #2
Digitalis: improves contractility, monitor for digitalis
toxicity especially if patient is hypokalemic
IV medications: indicated for hospitalized patients
admitted for acute decompensated HF
o Milrinone: decreases preload and afterload; causes
hypotension and increased risk of dysrhythmias
o Dobutamine: used for patients with left ventricular
dysfunction; increases cardiac contractility and renal
perfusion

Gerontologic Considerations
May present with atypical signs and symptoms such as
fatigue, weakness, and somnolence
Decreased renal function can make older patients
resistant to diuretics and more sensitive to changes in
volume
Administration of diuretics to older men requires nursing
surveillance for bladder distention caused by urethral
obstruction from an enlarged prostate gland

Classification of heart
failure
New York Heart Association
(NYHA) functional guidelines
reflect exercise
American College of Cardiology
(ACC) guidelines based on
identified disease and
progression

Nursing Process: The Care of the Patient
With Heart Failure—Assessment
Focus
o Effectiveness of therapy
o Patient’s self-management
o S&S if increased HF
o Emotional or psychosocial response
Health history
PE
o Mental status; lung sounds: crackles and wheezes;
heart sounds: S3; fluid status or signs of fluid
overload; daily weight and I&O; assess responses
to medications

With Heart Failure—Diagnoses
Activity intolerance related to decreased CO
Excess fluid volume related to the HF syndrome
Anxiety-related symptoms related to complexity of the
therapeutic regimen
Powerlessness related to chronic illness and
hospitalizations
Ineffective family therapeutic regimen management

Collaborative Problems and Potential
Complications
Hypotension, poor perfusion, and cardiogenic shock (see
Chapter 14)
Dysrhythmias (see Chapter 26)
Thromboembolism (see Chapter 30)
Pericardial effusion and cardiac tamponade

With Heart Failure—Planning
Goals
o Promote activity and reduce fatigue
o Relieving fluid overload symptoms
o Decrease anxiety or increase the patient’s ability to
manage anxiety
o Encourage the patient to verbalize his or her ability
to make decisions and influence outcomes
o Educate the patient and family about management of
the therapeutic regimen

Activity Intolerance
Bed rest for acute exacerbations
Encourage regular physical activity; 30 to 45 minutes
daily
Exercise training
Pacing of activities
Wait 2 hours after eating for physical activity
Avoid activities in extreme hot, cold, or humid weather
Modify activities to conserve energy
Positioning; elevation of the head of bed to facilitate
breathing and rest, support of arms

Fluid Volume Excess
Assessment for symptoms of fluid overload
Daily weight
I&O
Diuretic therapy; timing of meds
Fluid intake; fluid restriction
Maintenance of sodium restriction

Patient Education
Medications
Diet: low-sodium diet and fluid restriction
Monitoring for signs of excess fluid, hypotension, and
symptoms of disease exacerbation, including daily weight
Exercise and activity program
Stress management
Prevention of infection
Know how and when to contact health care provider
Include family in education

End of Life Considerations
HF is a chronic and often progressive condition
o Need to consider issues related to the end of life
o When palliative or hospice care should be considered

Pulmonary Edema
Acute event results in LV failure
As LV begins to fail, blood backs up into the pulmonary
circulation, causing pulmonary interstitial edema
Results in hypoxemia, often severe
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
Easier to prevent than to treat
Early recognition: monitor lung sounds and for signs of
decreased activity tolerance and increased fluid retention
Minimize exertion and stress
Oxygen; nonrebreather
Medications
o Diuretics (furosemide), vasodilators (nitroglycerin)

Nursing Management of Pulmonary
Edema
Positioning the patient to promote circulation
o Positioned upright with legs dangling
Providing psychological support
o Reassure patient and provide anticipatory care
Monitoring medications
o I&O

Thromboembolism
Decreased mobility and decreased circulation increase
the risk for thromboembolism in patient with cardiac
disorders, including those with HF
Pulmonary embolism: blood clot from the legs moves to
obstruct the pulmonary vessels
S&S: dyspnea, pleuritic chest pain, tachypnea, cough
Treatment: anticoag therapy
o Unfractionated heparin, low--molecular-weight
heparin, fondaparinux (Arixtra), or rivaroxaban
(Xarelto)

Pericardial Effusion and Cardiac
Tamponade
Pericardial effusion is the accumulation of fluid in the
pericardial sac
Cardiac tamponade is the restriction of heart function
because of this fluid, resulting in decreased venous
return and decreased CO
Clinical manifestations: ill-defined chest pain or fullness,
pulsus paradoxus, engorged neck veins, labile or low BP,
shortness of breath
Cardinal signs of cardiac tamponade: falling systolic BP,
narrowing pulse pressure, rising venous pressure, distant
heart sounds

Assessment Findings in Cardiac
Tamponade

Medical Management
Pericardiocentesis
o Puncture of the pericardial sac to aspirate
pericardial fluid
Pericardiotomy
o Under general anesthesia, a portion of the
pericardium is excised to permit the exudative
pericardial fluid to drain into the lymphatic
system

Sudden Cardiac Death or Cardiac Arrest
Emergency management: cardiopulmonary resuscitation
A: airway
B: breathing
C: circulation
D: defibrillation for VT and VF

Ppt chapter29 hf1

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