Nursing care of clients with disorders of cardiac function part I

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Nursing care of clients with disorders of cardiac function part I: Heart failure

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Nursing care of clients with disorders of cardiac function part I

  1. 1. NURSING CARE OFCLIENTS WITH DISORDERSOF CARDIAC FUNCTIONMaria Carmela L. Domocmat, RN, MSN
  2. 2. Heart Failure2 heart is unable to pump enough blood to meet the metabolic needs of the body at rest or during exercise not a disease itself; group of manifestations related to inadequate pump performance Maria Carmela L. Domocmat 8/13/2012
  3. 3. 3 More than 287,000 people die yearly of heart failure 40% of patients admitted to the hospital with the condition die or are readmitted within 1 year. estimated annual cost for the management of heart failure in 2006 was $29.6 billion dollars. Maria Carmela L. Domocmat 8/13/2012
  4. 4. 4 Maria Carmela L. Domocmat 8/13/2012
  5. 5. Heart Failure5 Congestive Heart Failure.flv Congestive Heart Failure2.mp4 Maria Carmela L. Domocmat 8/13/2012
  6. 6. Etiology6 conditions that can lead to Other conditions that may the development of heart contribute to the failure development and severity coronary artery disease of heart failure include: cardiomyopathy increased metabolic rate hypertension iron overload valvular heart disease hypoxia severe anemia electrolyte abnormalities cardiac dysrhythmias diabetes Maria Carmela L. Domocmat 8/13/2012
  7. 7. 7 Maria Carmela L. Domocmat 8/13/2012
  8. 8. Cause and effect8 Coronary artery disease Atherosclerosis of the coronary arteries is the primary cause of heart failure found in more than 60% of patients with the condition. Hypoxia and acidosis lead to ischemia, which causes an MI that leads to heart muscle necrosis, myocardial cell death, and loss of contractility. The extent of the MI correlates with the severity of the heart failure. Maria Carmela L. Domocmat 8/13/2012
  9. 9. Cause and effect9 cardiomyopathy A disease of the myocardium, there are three types of cardiomyopathy: dilated, hypertrophic, and restrictive Heart failure due to cardiomyopathy usually becomes chronic and progressive; however, both may resolve if the cause, such as alcohol use, is removed. Maria Carmela L. Domocmat 8/13/2012
  10. 10. 10 Maria Carmela L. Domocmat 8/13/2012
  11. 11. Cause and effect11 Cardiomyopathy dilated cardiomyopathy The most common type may result from an unknown cause (idiopathic), an inflammatory process such as myocarditis, or alcohol abuse; it causes diffuse cellular necrosis and fibrosis, leading to decreased contractility (systolic failure). Hypertrophic and restrictive cardiomyopathy lead to decreased distensibility and ventricular filling (diastolic failure). Maria Carmela L. Domocmat 8/13/2012
  12. 12. Cause and effect12 Hypertension Systemic or pulmonary hypertension increases the hearts workload, leading to hypertrophy of its muscle fibers. This hypertrophy may impair the hearts ability to fill properly during diastole, and the hypertrophied ventricle may eventually fail Maria Carmela L. Domocmat 8/13/2012
  13. 13. 13 Maria Carmela L. Domocmat 8/13/2012
  14. 14. Cause and effect14 valvular heart disease The valves ensure that blood flows in one direction. In valvular disorders, blood has an increasing difficulty moving forward, increasing pressure within the heart and cardiac workload and leading to heart failure. Degenerative aortic stenosis and chronic aortic and mitral regurgitation are often the culprits. Maria Carmela L. Domocmat 8/13/2012
  15. 15. Etiology15 1. Systolic dysfunction a. decreased contractility b. increased after load 2. Diastolic Dysfunction a. abnormalities in active relaxation b. abnormalities in passive relaxation Maria Carmela L. Domocmat 8/13/2012
  16. 16. Etiology: Systolic dysfunction16 a. decreased b. increased after load contractility MI disease states that Valvular heart disease increase either the HPN systolic pressure(HPN, cardiomyopathies aortic stenosis) or chamber radius(dilated cardiomyopathies) increase after load unless wall thickness increases proportionately Maria Carmela L. Domocmat 8/13/2012
  17. 17. Etiology: Diastolic Dysfunction17 1. abnormalities in active relaxation MI Ventricular hypertrophy 2. abnormalities in passive relaxation increased ventricular stiffness leading to increase filling pressure Concentric hypertrophy HPN Hypertrophic growth of a hollow organ without overall enlargement, in which the walls of the organ are Maria Carmela L. Domocmat 8/13/2012 thickened and its capacity or volume is diminished.
  18. 18. Conditions that Precipitate18 Heart Failure 1. Dysrhythmias especially tachycardia 2. Sepsis 3. Anemia 4. Thyroid disorders 5. Pulmonary embolism 6. Thiamine deficiency 7. Medication dose changes 8. Physical or emotional stress 9. Endo, Myo and Pericarditis 10. Fluid retention from medication or salt intake Maria Carmela L. Domocmat 8/13/2012
  19. 19. Classification of Heart Failure19 1. Acute versus Chronic Heart Failure 2. Left versus Right Ventricular Failure 3. Backward versus Forward Failure 4. High versus Low Output Failure 5. Systolic versus Diastolic Failure Maria Carmela L. Domocmat 8/13/2012
  20. 20. Acute versus chronic heart20 failure acute heart failure an emergency situation in which a patient who was completely asymptomatic before the onset of heart failure decompensates when theres an acute injury to the heart, such as a myocardial infarction (MI), impairing its ability to function chronic heart failure a long-term syndrome in which the patient experiences persistent signs and symptoms over an extended period of time, likely as a result of a preexisting cardiac condition. Maria Carmela L. Domocmat 8/13/2012
  21. 21. Classification of Heart Failure21 1. Acute versus Chronic Heart Failure 2. Left versus Right Ventricular Failure 3. Backward versus Forward Failure 4. High versus Low Output Failure 5. Systolic versus Diastolic Failure Maria Carmela L. Domocmat 8/13/2012
  22. 22. Left versus Right ventricular22 failure left-sided heart failure inability of the left ventricle to pump enough blood, causing fluid to back up into the lungs right-sided heart failure the inefficient pumping of the right side of the heart, causing congestion or fluid buildup in the abdomen, legs, and feet Maria Carmela L. Domocmat 8/13/2012
  23. 23. Pathophysiology of LSHF23 Maria Carmela L. Domocmat 8/13/2012
  24. 24. MI, HPN, Valvular Disorders Reduced myocardial contractility, Increased cardiac workload, Decreased diastolic filing, Obstruction of left atrial emptying Increased left atrial pressure Left sided heart failure Blood dams back into the Decrease stroke volume24 pulmonary capillary bed Maria Carmela L. Domocmat 8/13/2012
  25. 25. Blood dams back into the pulmonary capillary bed Pressure of blood into the pulmonary capillary bed increases Fluid shifts into the intraalveolar and interalveolar spaces Signs and symptoms of left sided heart failure25 Maria Carmela L. Domocmat 8/13/2012
  26. 26. Decreased stroke volume Decreased tissue perfusion Increased Cellular Decreased blood flow to kidneys hypoxia RAAS stimulation Vasoconstriction and reabsorption of Na and water Increased ECF volume Increased total blood volume; Increase26 Maria Carmela L. Domocmat 8/13/2012 Bp systemic
  27. 27. Pathophysiology of RSHF27 Maria Carmela L. Domocmat 8/13/2012
  28. 28. LSHF, PE, RV infarction, CHD Reduced myocardial contractility, Increased cardiac workload, Decreased diastolic filing, Obstruction of left atrial emptying Increased atrial pressure Right sided HF Blood dams back from RV to RA28 Signs and Symptoms Domocmat 8/13/2012 Maria Carmela L. of RSHF
  29. 29. left-sided heart failure (LSHF)29 Signs and symptoms are Clubbing of fingers related to pulmonary restlessness and anxiety congestion and include: fatigue and weakness dyspnea Anorexia Wheezing ( Cardiac asthma) Hypokalemia (increased unexplained cough levels of aldosterone) pulmonary crackles polycythemia low oxygen saturation levels reduced urine output third heart sound (S3) altered digestion dizziness and light- Elevated PAP, PCWP, LVEDP headedness confusion Maria Carmela L. Domocmat 8/13/2012
  30. 30. LSHF30 Dyspnea -Most frequent symptom - Vascular congestion Cheyne-stokes respiration Cough Frothy, blood tinged - fluid in the lung irritates the lung mucosa Orthopnea Dyspnea on recumbency -increase blood returning to heart when recumbent Maria Carmela L. Domocmat 8/13/2012
  31. 31. 31 Cheyne – Stokes Respiration is an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in apnea Maria Carmela L. Domocmat 8/13/2012
  32. 32. Paroxysmal nocturnal dyspnea Sudden dyspnea that awakens patients from sleep -subsides after 5-20 minutes Cardiomegaly Dilatation of the left ventricle in an effort to augment ventricular contraction S3 Ventricular gallop-single most reliable sign of LVF -due rapid filling of left ventricle due to inc.left atrial pressure and non compliance of LV Cerebral Decrease cardiac output hypoxia,fatigue,muscular weakness Nocturia During the day blood is diverted into the skeletal musculature at night cardiac output is shifted toward the kidney and diuresis ensues32 Maria Carmela L. Domocmat 8/13/2012
  33. 33. 33 Maria Carmela L. Domocmat 8/13/2012
  34. 34. 34 Normal Chest X-ray Cardiomegaly Maria Carmela L. Domocmat 8/13/2012
  35. 35. 35 Maria Carmela L. Domocmat 8/13/2012
  36. 36. 36 Maria Carmela L. Domocmat 8/13/2012
  37. 37. 37 Maria Carmela L. Domocmat 8/13/2012
  38. 38. Right-sided heart failure38 Peripheral edema Prominent at the end of the day Hepatomegaly Chronic passive congestion of the liver Abdominal pain Stretching of Glisson’s capsule Cardiac cirrhosis Jaundice,ascites Jugular vein distention Increase right sided pressure Ascites accumulation of fluid in the peritoneal cavity Maria Carmela L. Domocmat 8/13/2012
  39. 39. 39 Leg varicosities Elevated CVP reading Internal hemorrhoids Anorexia Nausea Weight gain Weakness Maria Carmela L. Domocmat 8/13/2012
  40. 40. Hepatomegaly40 Maria Carmela L. Domocmat 8/13/2012
  41. 41. Splenomegaly41 Maria Carmela L. Domocmat 8/13/2012
  42. 42. Cardiac Cirrhosis42 •An extensive fibrotic reaction occurring within the liver as a result of prolonged congestive heart failure. •Also called pseudocirrhosis. Maria Carmela L. Domocmat 8/13/2012
  43. 43. 43 Maria Carmela L. Domocmat 8/13/2012
  44. 44. Leg varicosities44 Maria Carmela L. Domocmat 8/13/2012
  45. 45. Internal hemorrhoids45 Maria Carmela L. Domocmat 8/13/2012
  46. 46. Abdominal pain46 Maria Carmela L. Domocmat 8/13/2012
  47. 47. Jugular vein distention47 See video in physical assessment by mosby, siedel 6th ed Maria Carmela L. Domocmat 8/13/2012
  48. 48. Classification of Heart Failure48 1. Acute versus Chronic Heart Failure 2. Left versus Right Ventricular Failure 3. Backward versus Forward Failure 4. High versus Low Output Failure 5. Systolic versus Diastolic Failure Maria Carmela L. Domocmat 8/13/2012
  49. 49. Backward versus Forward49 Failure Backward failure venous congestion arising from the damming of blood behind the failing chamber increase hydrostatic pressure resulting into pulmonary edema or peripheral edema Forward failure decreased CO causes decreased organ perfusion Maria Carmela L. Domocmat 8/13/2012
  50. 50. Decrease CO decreased blood to vital organs mental confusion muscular weakness renal retention of sodium/water50 Maria Carmela L. Domocmat 8/13/2012
  51. 51. Classification of Heart Failure51 1. Acute versus Chronic Heart Failure 2. Left versus Right Ventricular Failure 3. Backward versus Forward Failure 4. High versus Low Output Failure 5. Systolic versus Diastolic Failure Maria Carmela L. Domocmat 8/13/2012
  52. 52. High versus Low output failure52 High output failure – a condition causes the heart to work harder to meet metabolic demands of the body ex. Sepsis, anemia, thyrotoxicosis , pregnancy Low output - heart unable to pump blood out of the left ventricle to meet demand of the body ex. RHD, cardiomegaly Maria Carmela L. Domocmat 8/13/2012
  53. 53. Classification of Heart Failure53 1. Acute versus Chronic Heart Failure 2. Left versus Right Ventricular Failure 3. Backward versus Forward Failure 4. High versus Low Output Failure 5. Systolic versus Diastolic Failure Maria Carmela L. Domocmat 8/13/2012
  54. 54. Systolic versus Diastolic54 Failure systolic heart failure (pumping problem) the inability of the heart to contract enough to provide blood flow forward causes problems with contraction and ejection of blood diastolic heart failure (filling problem) the inability of the left ventricle to relax normally, resulting in fluid backing up into the lungs Diastolic failure leads to problems with heart relaxation and filling with blood Maria Carmela L. Domocmat 8/13/2012
  55. 55. 55 Maria Carmela L. Domocmat 8/13/2012
  56. 56. Framingham Criteria for CHF56 Major Criteria Minor Criteria PND Hepatomegaly NVE Extremity edema Rales Night cough Cardiomegaly DOB on exertion Acute pul.edema Pleural effusion S3 gallop Dec.vital capacity Inc.venous pressure >16cm H20 Tachycardia >120bpm + hepatojugular reflux Maria Carmela L. Domocmat 8/13/2012
  57. 57. 57 hepatojugular reflux distention of the jugular vein induced by applying manual pressure over the liver; it suggests insufficiency of the right heart. Hepatojugular Reflux.flv hepatojugular reflux sign.flv Maria Carmela L. Domocmat 8/13/2012
  58. 58. 58 Diagnostics Maria Carmela L. Domocmat 8/13/2012
  59. 59. Diagnostics59 1. ECG 2. CXR 3. 2Decho- EF > 55% 4. ABG’s -early CHF- metabolic acidosis 5. Liver enzymes 6. BUN / Creatinine Maria Carmela L. Domocmat 8/13/2012
  60. 60. Diagnostics60 brain natriuretic peptide (BNP) a hormone secreted by the heart at high levels when its injured or overworked. One of the most specific for heart failure complete blood cell count complete metabolic panel (electrolytes, creatinine, glucose, and liver function studies), urinalysis To determine the cause of heart failure include thyroid function tests, a fasting lipid profile, and testing for offending drug levels. Maria Carmela L. Domocmat 8/13/2012
  61. 61. Diagnostics61 echocardiogram, or echo chest X-ray ECG cardiac stress test cardiac catheterization (angiogram), cardiac computed tomography scan or magnetic resonance imaging, radionuclide ventriculography ambulatory ECG monitoring (Holter monitor) pulmonary function tests a heart biopsy exercise testing such as the 6-minute walk. Maria Carmela L. Domocmat 8/13/2012
  62. 62. Diagnostics: Echocardiogram62 One of the most important diagnostic tools for heart failure Not only is this an important assessment tool when the patient presents for the first time with heart failure, but it can also provide information periodically on the improvement of his hearts function Echocardiography is a type of cardiac ultrasound that involves pulsed and continuous Doppler waves. An echo provides an accurate assessment of left ventricular function while also determining whether a patient has systolic or diastolic dysfunction. The number most frequently quoted from the echo is the ejection fraction (EF). EF is the measurement of how effectively the heart is pumping blood. A normal EF is greater than 55%. That means with every cardiac cycle more than 55% of the blood is being pumped out of the ventricle. Maria Carmela L. Domocmat 8/13/2012
  63. 63. Diagnostics63 CXR evaluate the size of the patients heart and the basic heart structures and to determine the amount of fluid buildup in his lung fields. ECG examine the electrical activity of the heart. Maria Carmela L. Domocmat 8/13/2012
  64. 64. 64 Classification systems Maria Carmela L. Domocmat 8/13/2012
  65. 65. Classification systems 65 After all the data are obtained, determine the cause and classification of the patients heart failure and the appropriate treatment plan. two well-accepted classification systems used to describe heart failure, focusing on either structural abnormalities or symptoms: 1. the American College of Cardiology/American Heart Association stages of heart failure (ACC/AHA) 2. the New York Heart Association (NYHA) functional classificationshttp://www.hearthealthywomen.org/cardiovascular- Maria Carmela L. Domocmat 8/13/2012disease/heart-failure/heart-failure-2.html
  66. 66. American College of Cardiology/American Heart Association stages of heart failure 66 focuses on the progression and worsening of the condition over time. moves forward from one stage to the next based on the progression of the disease. helps doctors identify people who are at high risk for heart failure but dont have the condition yet ( Stage A), those with heart damage but no symptoms of heart failure ( Stage B), and those with heart damage and with symptoms of heart failure (Stages C and D). helps doctors prevent heart failure in those at risk and complements the New York Heart Association (NYHA) classification system, which gauges the severity of symptoms in people who are at stages C and D of the AHA/ACC system.http://www.hearthealthywomen.org/cardiovascular- Maria Carmela L. Domocmat 8/13/2012disease/heart-failure/heart-failure-2.html
  67. 67. AHA/ACC Heart Failure Stages67 Stage Description People at high risk for developing heart failure but who do A not have heart failure or damage to the heart People with damage to the heart but who have never had B symptoms of heart failure; for example, those who have had heart attack People with heart failure symptoms caused by damage to C the heart, including shortness of breath, tiredness, inability to exercise People who have advanced heart failure and severe D symptoms difficult to manage with standard treatmenthttp://www.hearthealthywomen.org/cardiovascular- Maria Carmela L. Domocmat 8/13/2012disease/heart-failure/heart-failure-2.html
  68. 68. Algorithm of the stages in the development of heart failure, with recommended therapy for patients by stage. (ACE = angiotensin- converting enzyme; ARB = angiotensin-II receptorhttp://www.aafp.org/afp/2010/0301/p654.html blocker.) http://www.hearthealthywomen.org/68 Maria Carmela L. Domocmat 8/13/2012 cardiovascular-disease/heart- failure/heart-failure-2.html
  69. 69. The New York Heart Association 69 (NYHA) Classification System used to classify symptoms of heart disease, including heart failure. Symptoms are graded based on how much they limit your functional capacity Unlike the AHA/ACC staging system, the NYHA class often can shift from one level to another; for example, if you respond well to treatment and your symptoms improve, your NYHA class can go down. If you dont respond well and your symptoms continue to worsen, your NYHA class can go up.http://www.hearthealthywomen.org/cardiovascular- Maria Carmela L. Domocmat 8/13/2012disease/heart-failure/heart-failure-2.html
  70. 70. NYHA Heart Failure Classification70 Class Description No limitation of physical activity - ordinary physical activity 1 (Mild) doesnt cause tiredness, heart palpitations, or shortness of breath Slight limitation of physical activity; 2 (Mild) comfortable at rest, but ordinary physical activity results in tiredness, heart palpitations, or shortness of breath Marked or noticeable limitations of physical activity; 3 (Moderate) comfortable at rest, but less than ordinary physical activity causes tiredness, heart palpitations, or shortness of breath Severe limitation of physical activity; unable to carry out any physical activity without discomfort. 4 (Severe) Symptoms also present at rest. If any physical activity is undertaken, discomfort increases. Maria Carmela L. Domocmat 8/13/2012
  71. 71. 71 Medical Management Maria Carmela L. Domocmat 8/13/2012
  72. 72. Medical Management72 4 D’s (Basic) 1. Digitalis 2. Diuretics 3. vasoDilators 4. Diet Maria Carmela L. Domocmat 8/13/2012
  73. 73. Digitalis73 Major therapy in HF Positive inotropic, negative chronotropic and inotropic, dromotropic effects Assess HR before giving the drug Monitor serum potassium levels Assess for S/Sx of digitalis toxicity Maria Carmela L. Domocmat 8/13/2012
  74. 74. 74 Digoxin can be used in patients with heart failure and atrial fibrillation to slow conduction through the atrioventricular node, which increases left ventricular function and results in increased diuresis, and to increase the force of myocardial contraction. It may also be added to existing therapy for a patient with NYHA Class II, III, or IV heart failure and an EF of less than 40% whos receiving optimal doses of an ACE inhibitor or ARB, beta-blocker, and aldosterone antagonist. Maria Carmela L. Domocmat 8/13/2012
  75. 75. Symptoms of Digitalis Toxicity GI Anorexia, nausea, vomiting, diarrhea CNC Headache, fatigue, lethargy CVS Bradycardia. Dysrhythmias Ophthalmologic Flickering flashes of light * Toxicity may be treated with gastric lavage, activated charcoal or digoxin-Fab fragment75 ( Digibind ) which is theCarmela L. Domocmat 8/13/2012 Maria antidote
  76. 76. 76 Inotropes Dopamine Dobutamine affecting the force of muscular contractions; commonly applied to drugs that increase contractility of cardiac muscle, e.g. digitalis 8/13/2012 Maria Carmela L. Domocmat glycosides.
  77. 77. Diuretic Therapy77 To decrease cardiac workload by reducing circulating volume and thereby reduce preload used as symptom relief agents and are recommended for patients who have clinical signs of congestion. Maria Carmela L. Domocmat 8/13/2012
  78. 78. Diuretic Therapy78 Assess for signs of hypokalemia especially when administering thiazides and loop diuretics Give potassium supplements or food rich in potassium Give diuretics in the morning Maria Carmela L. Domocmat 8/13/2012
  79. 79. 79 Aldosterone antagonist added to pharmacologic therapy if EF is less than 35% and adequate ACE inhibitor therapy. are approved for NYHA Classes III and IV and must be used cautiously, acknowledging renal function and potassium level. been shown to decrease hospital admissions for heart failure and also increase survival when added to existing therapy. Maria Carmela L. Domocmat 8/13/2012
  80. 80. VasoDilators80 To decrease afterload by decreasing resistance to ventricular emptying Example ACE inhibitors – first line Nitroprusside Hydralazine Maria Carmela L. Domocmat 8/13/2012
  81. 81. 81 The foundation of heart failure treatment is the ACE inhibitor. Unless contraindicated, EF of less than 40% should receive an ACE inhibitor has been shown to improve ventricular function and patient well-being, reduce hospitalization, and increase survival. If intolerant to ACE inhibitor, an ARB should be initiated. Maria Carmela L. Domocmat 8/13/2012
  82. 82. 82 beta-blockers Unless contraindicated or not tolerated, should be started for every HF patient with an EF of less than 40% due to the mortality benefit Maria Carmela L. Domocmat 8/13/2012
  83. 83. 83 Hydralazine/ isosorbide may be added as an alternative to an ACE inhibitor or ARB if the patient is intolerant to both drugs or it may be added to existing therapy if symptoms continue to progress. Maria Carmela L. Domocmat 8/13/2012
  84. 84. 84 Nursing Management Maria Carmela L. Domocmat 8/13/2012
  85. 85. Nursing Management85 1. Providing oxygenation 2. Promote rest and activity 3. Facilitating fluid balance 4. Provide skin care 5. Promote nutrition 6. Promote elimination 7. Manage acute pulmonary edema 8. Phlebotomy 9. Administer medications and assess the patients response to them Maria Carmela L. Domocmat 8/13/2012
  86. 86. Nursing Management86 Providing oxygenation O2 at 2-6 L/min as ordered Evaluate ABG’s Semi fowler’s position Maria Carmela L. Domocmat 8/13/2012
  87. 87. Nursing Management87 Promote rest and activity Bed rest or limit activity during acute phase Activities should progress through dangling, sitting up in a chair and then walking in increased distances under close supervision Assess for signs of activity intolerance such as dyspnea, fatigue, and increased PR Maria Carmela L. Domocmat 8/13/2012
  88. 88. Nursing Management88 Facilitating fluid balance assess fluid balance with a goal of optimizing fluid volume limit sodium intake ( no added salt) Limit fluid to < 1.2 L/day Diuretics I and O, V/S, weight weigh the patient daily at the same time on the same scale, usually in the morning after the patient urinates (a 2- to 3-pound [0.9- to 1.4-kg] gain in a day or a 5- pound [2.3 kg] gain in a week indicates trouble) Dry phlebotomy Maria Carmela L. Domocmat 8/13/2012
  89. 89. Nursing Management89 auscultate lung sounds to detect an increase or decrease in pulmonary crackles determine the degree of jugular vein distension identify and evaluate the severity of edema monitor the patients pulse rate and BP and check for postural hypotension due to dehydration examine skin turgor and mucous membranes for signs of dehydration assess for symptoms of fluid overload. Maria Carmela L. Domocmat 8/13/2012
  90. 90. Nursing Management90 Provide skin care Edematous skin is poorly nourished and susceptible to pressure sores Frequent change in position Assess sacral area regularly Egg crate mattress Maria Carmela L. Domocmat 8/13/2012
  91. 91. Nursing Management91 Promote nutrition Bland, low calorie, low-residue with vitamin supplement during the acute phase Small frequent feedings Maria Carmela L. Domocmat 8/13/2012
  92. 92. Nursing Management92 Promote elimination Advise to avoid straining at defecation which involves Valsalva’s manuever. It increases cardiac workload. Laxatives as ordered Bedside commode Maria Carmela L. Domocmat 8/13/2012
  93. 93. Nursing Management93 If acute pulmonary edema occurs in the client with CHF, the following are the appropriate management: High fowler’s position Morphine sulfate IV push as ordered to allay anxiety and reduces preload and afterload O2 per nasal canula or face mask Aminophylline to relieve bronchospasm Rapid digitalization Diuretics Vasodilators Dopamine/Dobutamine Monitor serum potassium Maria Carmela L. Domocmat 8/13/2012
  94. 94. Nursing Management94 Phlebotomy Dry phlebotomy or rotating tourniquets intends to allow pooling of blood in the lower extremities, thereby reducing preload Occlude 3 extremities at a time Rotate tourniquets clockwise every 15 minutes Each extremity is occluded for a maximum of 45 minutes If Bp compression cuff is used as tourniquet inflate up to slightly above diatolic pressure (10-40). This allows occlusion of venous return but arterial pressure remains Maria Carmela L. Domocmat 8/13/2012
  95. 95. Nursing Management95 Perform neurovascular check distal to the tourniquet application: Skin color Skin temperature Presence of pulse Presence of numbness or tingling If tourniquet application is too tight, tissue ischemia may occur Assess for signs and symptoms of thrombosis and embolism Remove tourniquet one at a time every 15 minutes Maria Carmela L. Domocmat 8/13/2012
  96. 96. Nursing Management96 Administer medications and assess the patients response to them Maria Carmela L. Domocmat 8/13/2012
  97. 97. 97 Devices and surgical management Maria Carmela L. Domocmat 8/13/2012
  98. 98. Devices and surgical management98 1. Biventricular pacing 2. Implantable cardioverter defibrillator (ICD) 3. Ventricular assist device, or artificial heart 4. Heart transplantation Maria Carmela L. Domocmat 8/13/2012
  99. 99. Biventricular pacing99 Aka: cardiac resynchronization therapy recommended for NYHA Class III or Class IV with a QRS prolongation of greater than 120 ms who continue to experience symptoms despite adequate pharmacologic therapy. Maria Carmela L. Domocmat 8/13/2012
  100. 100. 100 Maria Carmela L. Domocmat 8/13/2012
  101. 101. 101 Maria Carmela L. Domocmat 8/13/2012
  102. 102. 102 Implantable cardioverter defibrillator (ICD) placed to prevent sudden cardiac death caused by symptomatic and asymptomatic arrhythmias, which are seen frequently in patients with heart failure a primary prevention to reduce mortality for patients with an EF of less than 35% a secondary prevention for patients who survived a ventricular tachycardic event. Maria Carmela L. Domocmat 8/13/2012
  103. 103. 103 Maria Carmela L. Domocmat 8/13/2012
  104. 104. 104 Maria Carmela L. Domocmat 8/13/2012
  105. 105. Implantable cardioverter defibrillator105 (ICD) Implantable Cardioverter Defibrillator (ICD).flv Automated Implantable Cardiac Defibrillator.flv Maria Carmela L. Domocmat 8/13/2012
  106. 106. Left ventricular assist devices and106 artificial hearts Approved for both bridge-to-transplant and destination therapy are gaining more popularity as technology advances. Devices that are implanted under the skin have been developed that help monitor the patients fluid status and then transmit the data back to the healthcare provider, which is helpful in monitoring patients remotely. These devices will hopefully prove to reduce hospitalizations for heart failure in the future. Maria Carmela L. Domocmat 8/13/2012
  107. 107. Ventricular assistive device107 G:E CARMELA G:E CARMELA video downloadsvideos cardi video downloadsvideos cardi Video presentation Video presentation from Mayo clinic on how it works Maria Carmela L. Domocmat 8/13/2012
  108. 108. G:E CARMELA G:E CARMELA video downloadsvideos cardi video downloadsvideos cardi Artificial heart Artificial heart transplant at OR transplant Breakthrough Artificial Heart Transplant Surgery108 Maria Carmela L. Domocmat 8/13/2012
  109. 109. Heart transplantation or109 Cardiac transplant Because the prognosis for patients with heart failure is so poor, the option continues to be a viable choice. When reached point of end-stage heart failure, transplantation is commonly addressed. Theres a very detailed, complex process by which the patient qualifies for transplantation; therefore, it may not be an option for every patient. Maria Carmela L. Domocmat 8/13/2012
  110. 110. Managing the stages of heart failure110 The American College of Cardiology/American Heart Association 2005 guideline update classifies heart failure into four stages and makes specific recommendations for each. Maria Carmela L. Domocmat 8/13/2012
  111. 111. Stage A111 identifies patients at high risk for heart failure because of conditions such as hypertension, diabetes, and obesity. Treat each comorbidity according to current evidence-based guidelines. Maria Carmela L. Domocmat 8/13/2012
  112. 112. Stage B112 includes patients with structural heart disease, such as left ventricular remodeling, left ventricular hypertrophy, or previous MI, but no symptoms. Provide all appropriate therapies in Stage A. Focus on slowing the progression of ventricular remodeling and delaying the onset of heart failure symptoms. Strongly recommended in appropriate patients: Treat with ACE inhibitors or beta-blockers unless contraindicated; these drugs delay the onset of symptoms and decrease the risk of death and hospitalization. Maria Carmela L. Domocmat 8/13/2012
  113. 113. Stage C113 includes patients with past or current heart failure symptoms associated with structural heart disease such as advanced ventricular remodeling. Use appropriate treatments for Stages A and B. Modify fluid and dietary intake. Use additional drug therapies, such as diuretics, aldosterone inhibitors, and ARBs in patients who cant tolerate ACE inhibitors, digoxin, and vasodilators. Treat with nonpharmacologic measures such as biventricular pacing, an ICD, and valve or revascularization surgery. Avoid drugs known to cause adverse reactions in symptomatic patients, including nonsteroidal anti-inflammatory drugs, most antiarrhythmics, and calcium channel blockers. Administer anticoagulation therapy to patients with a history of previous embolic event, paroxysmal or persistent atrial fibrillation, familial dilated cardiomyopathy, and underlying disorders that may increase the risk of thromboembolism. Maria Carmela L. Domocmat 8/13/2012
  114. 114. Stage D114 includes patients with refractory advanced heart failure having symptoms at rest or with minimal exertion and frequently requiring intervention in the acute setting because of clinical deterioration. Improve cardiac performance. Facilitate diuresis. Promote clinical stability. Achieving these goals may require I.V. diuretics, inotropic support (milrinone, dobutamine, or dopamine), or vasodilators (nitroprusside, nitroglycerin, or nesiritide). As heart failure progresses, many patients can no longer tolerate ACE inhibitors and beta-blockers due to renal dysfunction and hypotension and may need supportive therapy to sustain life (a left ventricular assist device, continuous I.V. inotropic therapy, experimental surgery or drugs, or a heart transplant) or end-of-life or hospice care. Maria Carmela L. Domocmat 8/13/2012
  115. 115. 115 Lifestyle management Maria Carmela L. Domocmat 8/13/2012
  116. 116. 116 Maria Carmela L. Domocmat 8/13/2012
  117. 117. Lifestyle management117 As a nurse, the most important piece of heart failure management is helping your patients understand the lifestyle modifications that are necessary when living with this disease. Nurses must help patients learn how to change their lives to benefit their health. Maria Carmela L. Domocmat 8/13/2012
  118. 118. Lifestyle management118 first step - stress the importance of adherence to the treatment regimen. must follow through with taking medications coming to follow-up appointments. Data have shown that 20% to 60% of patients with heart failure dont adhere to their prescribed treatment plan. You play an important role in educating your patients on this topic. Maria Carmela L. Domocmat 8/13/2012
  119. 119. Lifestyle management: Educate119 Symptom recognition (what to do if symptoms worsen) Follow-up appointments Activity: (Physical activity, Sexual activity) Diet and nutrition, Fluid intake Medications Weight monitoring, Weight loss Alcohol cessation, Smoking cessation Pregnancy Maria Carmela L. Domocmat 8/13/2012
  120. 120. 120 Maria Carmela L. Domocmat 8/13/2012
  121. 121. 121 By empowering the patient to embrace self- management, you can make the difference in your patients prognosis Maria Carmela L. Domocmat 8/13/2012
  122. 122. Discharge122 an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) at discharge when left ventricular EF is less than 40%, indicating systolic dysfunction an anticoagulant if the patient has chronic or recurrent atrial fibrillation optional beta-blocker therapy at discharge for stabilized patients with left ventricular systolic dysfunction without contraindications. Maria Carmela L. Domocmat 8/13/2012
  123. 123. Discharge123 seasonal influenza immunization pneumococcal immunization Maria Carmela L. Domocmat 8/13/2012
  124. 124. Quiz124 Maria Carmela L. Domocmat 8/13/2012
  125. 125. 125 1. A chest X-ray of a person with heart failure will show: A. Cardiomegaly B. Black Lungs C. Decreased heart size D. Actlectasis Maria Carmela L. Domocmat 8/13/2012
  126. 126. 126 2. All of the following medications are used to treat heart failure except? A. Digoxin B. Metoprolol C. Lopressor D. Baclofen Maria Carmela L. Domocmat 8/13/2012
  127. 127. 127 3. A nurse is taking care of a patient with CHF, the patient weighed 87.4 kg on 11/03/09. The patients weight on 11/04/09 is 90.3. What is the nurse’s primary intervention? A. Document weight as normal B. Notify MD C. Have patient ambulate the hall 3 times D. Administer lasix without order Maria Carmela L. Domocmat 8/13/2012
  128. 128. 128 4. Referring to heart failure, pulmonary congestion is caused by? A. Right sided heart failure B. Left sided heart failure C. Wheezing D. Atelectasis Maria Carmela L. Domocmat 8/13/2012

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