management of patient with complication from heart disease

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 30
Management of Patients With
Complications From Heart
Disease

Cardiac Hemodynamics
• CO = SV × HR
• Preload
• Afterload
• Contractility

Question
Is the following statement True or False?
Heart failure is the inability of the heart to pump sufficient
blood to meet the needs of the tissues for oxygen and
nutrients.

Answer
True
Heart failure is the inability of the heart to pump sufficient
blood to meet the needs of the tissues for oxygen and
nutrients.

Heart Failure
• The inability of the heart to pump sufficient blood to
meet the needs of the tissues for oxygen and nutrients.
• A syndrome characterized by fluid overload or inadequate
tissue perfusion.
• 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.
• Most heart failure is a progressive, lifelong disorder
managed with lifestyle changes and medications.

Pathophysiology of Heart Failure

Clinical Manifestations
• Right-sided failure
– RV cannot eject sufficient amounts of blood and
blood backs up in the venous system. This resuts in
perpheral edema, hepatomegaly, ascites, anorexia,
nausea, weakness, and weight gain.
• Left-sided failure
– LV cannot pump blood effectively to the systemic
circulation. Pulmonary venous pressures increase and
result in pulmonary congestion with dyspnea, cough,
crackles, and impaired oxygen exchange.
• Chronic heart failure is frequently biventricular.

Classification of Heart Failure
• NYHA classification of heart failure
– Classification I , II, III, IV
• ACC/AHA classification of heart failure
– Stages A, B, C, D
• Treatment guidelines are in place for each stage

Medical Management of Heart Failure
• Eliminate or reduce etiologic or contributory factors.
• Reduce the workload of the heart by reducing afterload
and preload.
• Optimize all therapeutic regimens.
• Prevent exacerbations of heart failure.
• Medications are routinely prescribed for heart failure.

Medications
• Angiotensin: converting enzyme inhibitors
• Angiotensin II receptor blockers
• Beta-blockers
• Diuretics
• Digitalis
• Other medications

Question
Which classification of medications play a pivotal role in the
management of heart failure due to systolic dysfunction?
A.Angiotensin converting enzyme inhibitors
B.Beta blockers
C.Diuretics
D.Digitalis

Answer
A
Angiotensin converting enzyme inhibitors play a pivotal role
in the management of Heart Failure due to systolic
dysfunction. Beta blockers have been found to reduce
mortality and morbidity in patients with NYHA class II or
III heart failure by reducing the adverse effects from the
constant stimulation of the sympathetic nervous system.
Diuretics are prescribed to reduce excess extracellular
fluid by increasing the rate of urine produced in patients
with signs and symptoms of fluid overload. Digitalis
increases the force of myocardial contraction and slows
conduction through the atrioventricular node.

Nursing Process: The Care of the Patient
with Heart Failure—Assessment
• Health history
• Sleep and activity
• Knowledge and coping
• Physical exam
– Mental status
– Lung sounds: crackles and wheezes
– Heart sounds: S3
– Fluid status/signs of fluid overload
• Daily weight and I&O
• Assess responses to medications

with Heart Failure—Diagnoses
• Activity intolerance and fatigue
• Excess fluid volume
• Anxiety
• Powerlessness
• Noncompliance

Collaborative Problems/Potential
Complications
• Cardiogenic shock
• Dysrhythmias
• Thromboembolism
• Pericardial effusion and cardiac tamponade

with Heart Failure—Planning
• Goals may include promoting activity and reducing
fatigue, relieving fluid overload symptoms, decreasing
anxiety or increasing the patient’s ability to manage
anxiety, encouraging the patient to make decisions and
influence outcomes, teaching the patient about the self-
care program.

Activity Intolerance
• Bed rest for acute exacerbations
• Encourage regular physical activity; 30–45 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 HOB 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 Teaching
• 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 teaching

Question
Is the following statement True or False?
Hyperkalemia may occur especially with the use of ACE
inhibitors, angiotensin II receptor blockers, and
spironolactone.

Answer
True
Hyperkalemia may occur especially with the use of ACE
inhibitors, angiotensin II receptor blockers, and
spironolactone.

Pulmonary Edema
• Acute event in which the LV cannot handle an overload of
blood volume. Pressure increases in the pulmonary
vasculature, causing fluid movement out of the
pulmonary capillaries and into the interstitial space of the
lungs and alveoli.
• Results in hypoxemia.
• 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
• Prevent
• Early recognition: monitor lung sounds and for signs of
decreased activity tolerance and increased fluid retention
• Place patient upright and dangle legs
• Minimize exertion and stress
• Oxygen
• Medications
– Morphine
– Diuretic: furosemide

Cardiogenic Shock
• A life-threatening condition with a high mortality rate
• Decreased CO leads to inadequate tissue perfusion and
initiation of shock syndrome.
• Clinical manifestations: symptoms of heart failure, shock
state, and hypoxia

Management of Cardiogenic Shock
• Correct underlying problem
• Medications
– Diuretics
– Positive inotropic agents and vasopressors
• Circulatory assist devices
– Intra-aortic balloon pump (IABP)

Intra-Aortic Balloon Pump

Thromboembolism
• Decreased mobility and decreased circulation increase
the risk for thromboembolism in patient with cardiac
disorders including those with Heart Failure.
• Pulmonary embolism: blood clot from the legs moves to
obstruct the pulmonary vessels.
– The most common thromboembolic problem with
heart failure
– Prevention
– Treatment
– Anticoagulant therapy

Pulmonary Emboli

Pericardial Effusion and Cardiac
Tamponade
• Pericardial effusion is the accumulation of fluid in the
pericardial sac.
• Cardiac tamponade is the restriction of heart function due
to this fluid resulting in decreased venous return and
decreased CO.
• Clinical manifestations: ill-defined chest pain or fullness,
pulsus parodoxus, 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.

Medical Management
• Pericardiocentesis
• Pericardiotomy

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

Question
What is the most reliable sign of cardiac arrest in an adult
and child?
A.Blood pressure
B.Brachial pulse
C.Breathing
D.Carotid pulse

Answer
D
The most reliable sign of cardiac arrest is the absence of a
pulse. In an adult or child, the carotid pulse is assessed.
In an infant, the brachial pulse is assessed.

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