This document discusses hypertension, including its definition, classification, causes, types (primary and secondary), diagnosis, management through lifestyle changes and medications, complications, and heart failure. Hypertension is defined as blood pressure over 140/90 mmHg. Its causes include lifestyle factors like stress, diet, obesity, and genetics. Treatment involves lifestyle modifications like diet changes and exercise, as well as medications that lower blood pressure such as diuretics, ACE inhibitors, and calcium channel blockers. Complications of uncontrolled hypertension include heart disease, stroke, kidney disease, and cognitive impairment.

1. Nursing management of patient
with hypertension and
congestive cardiac failure

2. Hypertension- definition
 Hypertension is defined by the Seventh
Report of the Joint National Committee on
Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC 7) as a
systolic blood pressure greater than 140 mm
Hg and a diastolic pressure greater than 90
mm Hg based on the average of two or more
accurate blood pressure measurements taken
during two or more contacts w i t h a health
care provider.

3. Classification
 Blood
pressure(mmhg)
Classsification Systolic Diastolic
Normal 119 or lower 79 or lower
Prehypertension 120-139 80-89
Stage1
hypertenson
140-159 90-99
Stage2
hypertension
160 0r higher 100 or higher

4. Causes
 In general the major causes of hypertension
are the following:
 Hectic and stress filled life style
 Unhealthy food habits
 Obesity
 Excessive consumption of liquors
 Smoking
 Over consumption of tea/coffee
 Insufficient rest and sleep
 Metabolic disorders

5. Contd……
 Hardening of the arteries
 Excessive use of pain killers and other strong
medicines
 Genetic disorders
 Over consumption of oily food and fast food
 High salt intake
 Emotional and Physical stress
 Family history of hypertension

6. Secondary causes
 Sleep apnoea
 Drug-induced or drug-related
 Chronic kidney disease
 Primary aldosteronism
 Renovascular disease
 Chronic steroid therapy and Cushing syndrome
 Phaeochromocytoma
 Acromegaly
 Thyroid or parathyroid disease
 Coarctation of the aorta
 Takayasu Arteritis


7. Primary hypertension
 Primary (essential) hypertension is the most
common form of hypertension, accounting for
90–95% of all cases of hypertension. Numerous
common genetic variants with small effects on
blood pressure have been identified as well as
several environmental factors influence blood
pressure. Insulin resistance, which is common in
obesity and is a component of syndrome X (or
the metabolic syndrome), is also thought to
contribute to hypertension

8. Secondary hypertension
 Secondary hypertension results from an
identifiable cause. Renal disease is the most
common secondary cause of hypertension.
Hypertension can also be caused by
endocrine conditions, such as Cushing's
syndrome, hyperthyroidism, hypothyroidism,
acromegaly, Conn's syndrome or
hyperaldosteronism, hyperparathyroidism
and pheochromocytoma.

9. Resistant hypertension
 Resistant hypertension is defined as
hypertension that remains above goal blood
pressure in spite of concurrent use of three
antihypertensive agents belonging to
different antihypertensive drug classes

10. Hypertensive crisis
 Severely elevated blood pressure (equal to or
greater than a systolic 180 or diastolic of 110 —
sometime termed malignant or accelerated
hypertension) is referred to as a "hypertensive
crisis.People with blood pressures in this range
may have no symptoms, but are more likely to
report headaches (22% of cases) and dizziness
than the general population.Other symptoms
accompanying a hypertensive crisis may include
visual deterioration or breathlessness due to
heart failure or a general feeling of malaise due
to renal failure.

11. Malignant hypertension
 A "hypertensive emergency", previously
"malignant hypertension", is diagnosed when
there is evidence of direct damage to one or
more organs as a result of the severely elevated
blood pressure. This may include hypertensive
encephalopathy, caused by brain swelling and
dysfunction, and characterized by headaches
and an altered level of consciousness (confusion
or drowsiness). Retinal papilloedema and/or
fundal hemorrhages and exudates are another
sign of target organ damage. Chest pain may
indicate heart muscle damage

12. Pathophysiology
Etiological factors

sed periphral resistance

 sed venous compliance
sed venous return

cardiac preload

Diastolic dysfunction

13. Signs and symptoms.
 Headaches - Headaches may be experienced due to elevation in blood
pressure. Sometimes morning headaches can also be due to
hypertension.
 Dizziness - Dizziness is often experience by people with high blood
pressure. However dizziness cannot always be treated as a symptom of
hypertension. If dizziness is experienced it is always wise to consult a
medical practitioner.
 Heart pain
 Palpitations
 Nosebleeds - Nosebleeds without particular reason might be a symptom
of high blood pressure. It is better to check the blood pressure in such
cases.
 Difficulty in breathing
 Tinnitus (ringing or buzzing in the ears)
 Blurred Vision
 Frequent urination

14.  On physical examination, hypertension may be
suspected on the basis of the presence of hypertensive
retinopathy detected by examination of the optic fundus
found in the back of the eye using ophthalmoscopy

15. Diagnosis
 History and physical examination
 laboratoryTests
 Renal
 Microscopic urinalysis, proteinuria, BUN and/or creatinine

 Endocrine
 Serum sodium, potassium, calcium, TSH

 Metabolic
 Fasting blood glucose, HDL, LDL, and total cholesterol, triglycerides
 Hematocrit

16. Others
Electrocardiogram
Echo cardiography

17. Prevention
 maintain normal body weight for adults (e.g. body mass
index 20–25 kg/m2)
 reduce dietary sodium intake to <100 mmol/ day (<6 g of
sodium chloride or <2.4 g of sodium per day)
 engage in regular aerobic physical activity such as brisk
walking (≥30 min per day, most days of the week)
 limit alcohol consumption to no more than 3 units/day in
men and no more than 2 units/day in women
 consume a diet rich in fruit and vegetables (e.g. at least five
portions per day);
 Effective lifestyle modification may lower blood pressure

18. Management
 Me d i c a l M a n a g e m e n t
 Lifestyle modifications
 Medications

19. Adopt DASH (Dietary Approaches
to Stop Hypertension
 Eating more fruits, vegetables, and low-fat dairy
foods
 Cutting back on foods that are high in saturated
fat, cholesterol, and trans fats
 Eating more whole grain products, fish, poultry,
and nuts
 Eating less red meat (especially processed
meats) and sweets
 Eating foods that are rich in magnesium,
potassium, and calcium

20. Other modifications
 Maintain normal body weight (body mass
index 18.5-24.9 kg/nF).

 Physical activity
 Reduce dietary sodium intake to no more 2,4
g sodium or 6 g sodium chloride.
 Engage in regular aerobic physical activity
such 4-9 mm Hg as brisk walking (at least 30
minutes per day, most days of the week

21.  Different programs aimed to reduce
psychological stress such a biofeedback,
relaxation or meditation are advertised to
reduce hypertension

22. Medications
 Several classes of medications, collectively
referred to as antihypertensive drugs, are
currently available for treating hypertension..
.One or more of these blood pressure medicines
are often used to treat high blood pressure:
 Diuretics are also called water pills. They help
your kidneys remove some salt (sodium) from
your body. As a result, your blood vessels don't
have to hold as much fluid and your blood
pressure goes down.

23.  Beta-blockers make the heart beat at a slower rate
and with less force.
 Angiotensin-converting enzyme inhibitors (also
called ACE inhibitors) relax your blood vessels,
which lowers your blood pressure.
 . Angiotensin II receptor blockers (also called
ARBs) work in about the same way as
angiotensin-converting enzyme inhibitors

24. .
 Calcium channel blockers relax blood vessels by
stopping calcium from entering cells.
Blood pressure medicines that are not used as
often include:
 Alpha-blockers help relax your blood vessels,
which lowers your blood pressure.
 Centrally acting drugs signal your brain and
nervous system to relax your blood vessels.
 Vasodilators signal the muscles in the walls of
blood vessels to relax.

25.  Renin inhibitors, a newer type of medicine for
treating high blood pressure, act by relaxing your
blood vessels
 Renin inhibitors work, as the name would suggest,
by inhibiting the activity of renin, the enzyme largely
responsible for angiotensin II levels. In clinical trials,
renin inhibitors have proven effective in not only
lowering blood pressure, but also keeping blood
pressure levels steadier throughout the day.One
renin inhibitor, aliskiren (Tekturna), was approved by
the FDA in 2007. Other drugs in this class are in
development

26. Complications of
hypertension
 Hypertension is the most important
preventable risk factor for premature death.
 Ischemic heart disease
 Strokes
 Peripheral vascular disease,
 Other cardiovascular diseases
 , Including heart failure, aortic aneurysms,
diffuse atherosclerosis, and
pulmonaryembolism

27.  Hypertension is also a risk factor for cognitive
impairment and dementia, and chronic
kidney disease. Other complications include
hypertensive retinopathy and hypertensive
nephropathy.
 Bleeding from the aorta

28. Researches
 Sesame and rice bran oil can treat high blood
pressure and cholesterol, study showSignificant
blood pressure, cholesterol level reductions
Yoga benefits high blood pressure through
promoting relaxation of the mind and body.
Practicing yoga helps decrease the negative
impacts of stress, including tension, shallow
breathing and elevated heart rate. It also
improves physical strength and flexibility, plus
may assist with weight loss

29. Heart failure
 Heart failure is an illness in which the
pumping action of the heart becomes less
and less powerful. When this happens, blood
does not move efficiently through the
circulatory system and starts to back up,
increasing the pressure in the blood vessels
and forcing fluid from the blood vessels into
body tissues

30. Incidence
 Heart failure affects 2% of the adult
population. In the United States, nearly four
million people have heart failure. Each year
about 550,000 new cases are diagnosed. The
condition is more common among African
Americans than Caucasians.
 Heart failure affects 1% of people age 50
years or older, about 5% of those age 75 years
or older, and 25% of those age 85 years or
older.

31. Left-sided failure
 When the left side of the heart (left ventricle)
starts to fail, fluid collects in the lungs
(pulmonary edema). This extra fluid in the
lungs (pulmonary congestion) makes it more
difficult for the airways to expand as a person
inhales. Breathing becomes more difficult
and the person may feel short of breath,
particularly with activity or when lying down

32. Right-sided failure
 When the right side of the heart (right
ventricle) starts to fail, fluid begins to collect
in the feet and lower legs. Puffy leg swelling
(edema) is a sign of right heart failure,
especially if the edema is pitting edema.

33. Biventricular failure
 Dullness of the lung fields to finger
percussion and reduced breath sounds at the
bases of the lung may suggest the
development of a pleural effusion .Though it
can occur in isolated left- or right-sided heart
failure, it is more common in biventricular
failure because pleural veins drain both into
the systemic and pulmonary venous system.
When unilateral, effusions are often right
sided.

34. Systolic heart failure
 This condition occurs when the pumping
action of the heart is reduced or weakened. A
common clinical measurement is ejection
fraction (EF).. Systolic heart failure is
diagnosed when the ejection fraction has
significantly decreased below the threshold
of 55%.

35. Diastolic heart failure
 This condition occurs when the heart can
contract normally but is stiff, or less compliant,
when it is relaxing and filling with blood. The
heart is unable to fill with blood properly, which
produces backup into the lungs and heart failure
symptoms. Diastolic heart failure is more
common in patients older than 75 years of age,
especially in patients with high blood pressure,
and it is also more common in women. In
diastolic heart failure, the ejection fraction is
normal or increased.

36. Causes
 Congestive heart failure (CHF) is a syndrome
that can be brought about by several
causes,or a combination of several problems,
including the following:
 Weakened heart muscle (cardiomyopathy)
 Damaged heart valves
 Blocked blood vessels supplying the heart
muscle which may lead to a heart attack (This
is known as ischemic cardiomyopathy.

37. Contd………..
 Toxic exposures, such as alcohol or cocaine
 Infections, commonly viruses, which for
unknown reasons affect the heart in only
certain individuals
 High blood pressure that results in thickening
of the heart muscle (left ventricular
hypertrophy)
 Congenital heart diseases
 Certain genetic diseases involving the heart

38. Risk Factors
Some of the most common risk factors for heart
failure include:
 Age
 Hypertension
 Physical inactivity
 Diabetes
 Obesity
 Smoking
 Metabolic syndrome
 Family history of heart failure

39. Contd………….
 Enlargement of the left ventricle
 Some types of valvular heart disease, including
infection
 Coronary artery disease
 High cholesterol and triglycerides
 Excessive alcohol consumption
 Prior heart attack
 Certain exposures, such as to radiation and some
types of chemotherapy
 Infection of the heart muscle (usually viral)

41. . Cardiac compensatory mechanisms
 1.tachycardia
 2.ventricular dilation-Starling’s law
 3.myocardial hypertrophy
 Hypoxia leads to dec. contractility

42.  B. Homeostatic Compensatory mechanisms
 Sympathetic Nervous System
 1. Vascular system- norepinephrine- vasoconstriction
 2. Kidneys
 A. Dec. CO and B/P
 B. Aldosterone release > Na and H2O retention
 3. Liver- stores venous volume (ascites, Hepatomegaly-
Counter-regulatory-
 Inc. Na > release of ADH (diuretics)
 *Release of atrial natriuretic factor > Na and H20
excretion, prevents severe cardiac decompensation

43.  Compensatory mechanisms- activated to
maintain adequate CO
 Neurohormonal responses: Endothelin -
stimulated by ADH, catecholamines, and
angiotensin II >
 Arterial vasoconstriction
 Inc. in cardiac contractility
 Hypertrophy

44. Cntd……………..
 **Counter regulatory processes
 Natriuretic peptides: atrial natriuretic
peptide (ANP) and b-type natriuretic peptide
 Released in response to inc. in atrial volume
and ventricular pressure
 Promote venous and arterial vasodilation,
reduce preload and afterload
 Prolonged HF > depletion of these factors

45.  Counter regulatory processes
 Natriuretic peptides- endothelin and aldosterone
antagonists
 Enhance diuresis
 Block effects of the RAAS
 Natriuretic peptides- inhibit development of
cardiac hypertrophy; may have antiinflammatory
effects

46. Pathophysiology-
Structural Changes with HF
 Dec. contractility
 Inc. preload (volume)
 Inc. afterload (resistance)
 **Ventricular remodeling
 Ventricular hypertrophy
 Ventricular dilation

47. Ventricular remodeling

48. Symptoms and Signs
 Left sided heart failure
 Common respiratory signs are tachypnea
 and increased work of breathing (non-specific
signs of respiratory distress).
 Backward failure of the left ventricle causes
congestion of the pulmonary vasculature,
 dyspnea (shortness of breath) on exertion and in
severe cases, dyspnea at rest. orthopnea, occurs.
It is often measured in the number of pillows
required to lie comfortably.

49.  "Cardiac asthma" or wheezing
 paroxysmal nocturnal dyspnea
Rales or crackles suggestive of pulmonary edema
 Cyanosis which suggests severe hypoxemia, is a
late sign of extremely severe pulmonary edema

50.  gallop rhythm may be heard as a marker of
increased blood flow, or increased intra-cardiac
pressure
 Heart murmurs
 Due to reduced systemic circulation,
dizziness, confusion and cool extremities at
rest can occur.

51. Right heart failure
 Physical examination may reveal pitting
peripheral edema, ascites,
and hepatomegaly
 Increased jugular venous pressure
 If the right ventricular pressure is increased,
aparasternal heave may be present,
signifying the compensatory increase in
contraction strength.

52.  Backward failure of the right ventricle leads
to congestion of systemic capillaries
 peripheral edema or anasarca
 Sacral edema in lying patients
 Nocturia
 Hepatomegaly
 Significant liver congestion may result in
impaired liver function, and jaundice and
even coagulopathy

53. What is present in this extremity, common to right sided HF?

54. What does this
show?

55. Symptoms

56. Diagnostic measures
 Imaging
 Echocardiography is commonly used to support a
clinical diagnosis of heart failure. This modality
uses ultrasound to determine the stroke volume ,
the end-diastolic volume , and the SV in
proportion to the EDV, a value known as
the ejection fraction (EF Normally, the EF should
be between 50% and 70%; in systolic heart failure,
it drops below 40%. Echocardiography can also
identify valvular heart disease and assess the state
of the pericardium.

57. Transesophageal
echocardiogram
TEE

58. But

59.  Chest X-rays are frequently used to aid in the
diagnosis of CHF. In the compensated patient,
this may show cardiomegaly ), quantified as
the cardiothoracic ratio (proportion of the heart
size to the chest). In left ventricular failure, there
may be evidence of vascular redistribution
("upper lobe blood diversion" or
"cephalization"), Kerley lines, cuffing of the areas
around thebronchi, and interstitial edema.

60. X ray finding

62.  Electrophysiology
 An electrocardiogram (ECG/EKG) may be
used to identify arrhythmias, ischemic heart
disease, right and left ventricular
hypertrophy, and presence of conduction
delay or abnormalities (e.g. left bundle
branch block). Although these findings are
not specific to the diagnosis of heart failure a
normal ECG virtually excludes left ventricular
systolic dysfunction

63. Left bundle branch block

64.  Others
 comparing BNP and N-terminal pro-BNP (NTproBNP) in the
diagnosis of heart failure, BNP is a better indicator for heart
failure and left ventricular systolic dysfunction.
 Angiography
 Heart failure may be the result of coronary artery
disease, and its prognosis depends in part on the
ability of the coronary arteries to supply blood to
the myocardium.As a result, coronary
catheterization may be used to identify possibilities
for revascularisation through percutaneous coronary
intervention or bypass surgery

65. Classification
 There are many different ways to categorize
heart failure, including the side of the heart
involved (left heart failure versus right heart
failure).
 whether the abnormality is due to
insufficient contraction (systolic dysfunction),
or due to insufficient relaxation of the heart
(diastolic dysfunction), or to both.

66. NYHA –functional
classification
 Functional classification generally relies on the New York
Heart Association functional classification. The classes (I-IV)
are:
 Class I: no limitation is experienced in any activities; there
are no symptoms from ordinary activities.
 Class II: slight, mild limitation of activity; the patient is
comfortable at rest or with mild exertion.
 Class III: marked limitation of any activity; the patient is
comfortable only at rest.
 Class IV: any physical activity brings on discomfort and
symptoms occur at rest.
 This score documents severity of symptoms, and can be
used to assess response to treatmen

67. ACC- stages of heart faiure
 American College of Cardiology/American Heart
Association working group introduced four stages of heart
failure:
 Stage A: Patients at high risk for developing HF in the future but
no functional or structural heart disorder.
 Stage B: a structural heart disorder but no symptoms at any
stage.
 Stage C: previous or current symptoms of heart failure in the
context of an underlying structural heart problem, but managed
with medical treatment.
 Stage D: advanced disease requiring hospital-based support, a
heart transplant or palliative care.
 The ACC staging system is useful in that Stage A encompasses
"pre-heart failure" — a stage where intervention with treatment
can presumably prevent progression to overt symptoms.

69. Algorithm
 There are various algorithms for the diagnosis of
heart failure. For example, the algorithm used by
the Framingham Heart Study adds together
criteria mainly from physical examination.
 Framingham criteria
 By the Framingham criteria, diagnosis of
congestive heart failure requires the
simultaneous presence of at least 2 of the
following major criteria or 1 major criterion in
conjunction with 2 of the following minor criteria

70. Framingham criteria
 Major criteria:
 Cardiomegaly on chest radiography
 S3 gallop (a third heart sound)
 Acute pulmonary edema
 Paroxysmal nocturnal dyspnea
 Crackles on lung auscultation
 Central venous pressure of more than 16 cm H2O at the
right atrium
 Jugular vein distension
 Positive abdominojugular test
 Weight loss of more than 4.5 kg in 5 days in response to
treatment

71.  Minorcriteria
 Tachycardia of more than 120 beats per minute
 Nocturnal cough
 Dyspnea on ordinary exertion
 Pleural effusion
 Decrease in vital capacity by one third from maximum recorded
 Hepatomegaly
 Bilateral ankle edema
 Minor criteria are acceptable only if they can not be attributed to
another medical condition such as pulmonary hypertension,
chronic lung disease, cirrhosis, ascites, or the nephrotic
syndrome. The Framingham Heart Study criteria are 100%
sensitive and 78% specific for identifying persons with definite
congestive heart failure.

72. Congestive Heart Failure
Treatment
 Lifestyle modifications
 Elevate the feet and legs if they are swollen.
 Eat a reduced-salt diet.
 Weigh in every morning before breakfast and
record it in a diary that can be shown to a health
care provider.
 Avoid the following:
 Not taking prescribed medications
 Smoking
 Alcohol (up to one drink per day is usually fine)

73.  Excessive emotional stress and/or depression (seek
professional help)
 avoid high altitude :breathing is more difficult
because of the lower level of oxygen in the
atmosphere; pressurized cabin air travel is usually
fine
 Stay active
 Exercise; consult your doctor to determine a safe
workout routine.
 If you are overweight, lose weight.
 Reduce cholesterol
 Get enough sleep

74.  Supplemental oxygen
 Oxygen therapy may become necessary as
heart failure progresses. The need is based on
the degree of pulmonary congestion and
resulting hypoxia. Some patients require
supplemental oxygen only during activity

75. Medications
 Diuretics (water pills):
Diuretics cause the kidneys to remove excess
salt and accompanying water from the
bloodstream, thereby reducing the amount
of blood volume in circulation.
 Diuretics commonly used in heart failure
include furosemide (Lasix), bumetanide
(Bumex), hydrochlorothiazide (
spironolactone (Aldactone), eplerenone ,
triamterene, torsemide, or metolazone

76.  Digoxin (Lanoxin): Digoxin is a mild inotrope
and, in some cases, is beneficial as an add-on
therapy to ACE inhibitors and beta-blockers.
It is the most common form of digitalis.
Digoxin can reduce heart failure symptoms
and hospitalizations, but it does not prolong
life.
 Digoxin is mainly used as an antiarrhythmic
to control the rate of the heart in atrial
fibrillation and flutter

77.  Vasodilators: These medications enlarge the
small arteries or arterioles, which relieve the
systolic workload of the left ventricle.
 ACE inhibitors are the most widely used
vasodilators for congestive heart failure. They
block the production of angiotensin II, which is
abnormally high in congestive heart failure. Some
common examples of ACE inhibitors are captopril,
enalapril. Lisino pril

78.  Angiotensin II receptor blockers (ARBs) work by
preventing the effect of angiotensin II at the tissue level.
Examples of ARB medications include olmesartan ,
losartan (Cozaar),
 Nitrates are venous vasodilators that include isosorbide
mononitrate (Imdur) and isosorbide dinitrate (Isordil).
They are commonly used in combination with an arterial
vasodilator, such as hydralazine
 Nitroglycerin is a nitrate preparation that is administered
to treat acute chest pain, or angina.
 Hydralazine (Apresoline) is a smooth muscle arterial
vasodilator that may be used for congestive heart failure.

79.  Beta-blockers: These drugs slow down the
heart rate, lower blood pressure, and have a
direct effect on the heart muscle to lessen the
workload of the heart. Specific beta-blockers,
such as carvedilol and long-acting
metoprolol , have been shown to decrease
symptoms, hospitalization due to congestive
heart failure, and deaths.

80.  Inotropes: IV inotropes are stimulants, such
as dobutamine and milrinone which increase
the pumping ability of the heart. These are
used as a temporary support of a very weak
left ventricle that is not responding to
standard congestive heart failure therapy.
Commonly used inotropes are dobutamine
(Dobutex) and milrinone (Primacor).
Phenylephrine may be used when a patient is
suffering with severe low blood pressure.

81. Congestive Heart Failure
Interventions
 Angioplasty: This is an alternative to coronary
bypass surgery for some people whose heart
failure is caused by coronary artery disease and
may be compounded by heart damage or a
previous heart attack
 Pacemaker: This device controls the rate of the
heartbeat. A pacemaker may keep the heart
from going too slow, increasing heart rate when
the heart is not increasing enough with activity.
It also helps sustain regular rates when the heart
is not beating in a coordinated way

82.  Implantable Cardioverter Defibrillator
(ICD): This device returns the heart to a
normal rhythm by pacing or delivering an
electrical shock, with a life-threatening
arrhythmia.
 ICDs are indicated for ischemic or
nonischemic cardiomyopathy patients with
slight or marked physical limitations and low
left ventricular ejection fractions (<30% to
35%),

83. CRT-Cardiac
Resynchronization Therapy
HOW IT WORKS:
Standard implanted pacemakers -
equipped with two wires (or "leads")
conduct pacing signals to specific regions
of heart (usually at positions A and C).
Biventricular pacing devices have added a
third lead (to position B) that is designed
to conduct signals directly into the left
ventricle. Combination of all three lead >
synchronized pumping of ventricles, inc.
efficiency of each beat and pumping more
blood on the whole.

84.  Temporary Cardiac Support: An intra-aortic
balloon pump is used as a temporary
support of left ventricle function, such as
in a large heart attack, waiting for the
heart to recover

85. Surgical management
 Left ventricle assist device (LVAD): This
device is surgically implanted to mechanically
bypass the left ventricle. It can be used as a
“bridge to transplant” until a heart transplant
is available.
 Alternatively, LVADs are also being used as
“destination therapy” in patients who are not
eligible for a transplant, but only at approved
specialized medical centers.

86. LVAD

87.  Total artificial heart (TAH): For patients with
severe, end-stage heart failure.
 These devices are most commonly used as a
temporary bridge to heart transplantation, but
can be used as destination therapy in patients
who are not eligible for a transplant and have a
high chance of mortality within 30 days.
 This technique is constantly improving, but is still
limited to specialized centers and is considered
experimental at this time.

89. complications
 Pleural effusion
 Atrial fibrillation (most common
dysrhythmia)
 Loss of atrial contraction (kick) -reduce CO by
10% to 20%
 Promotes thrombus/embolus formation inc. risk
for stroke
 Treatment may include cardioversion,
antidysrhythmics, and/or anticoagulants

90. Complications
 High risk of fatal dysrhythmias (e.g., sudden
cardiac death, ventricular tachycardia) with HF
and an EF <35%
 HF lead to severe hepatomegaly, especially with
RV failure
Fibrosis and cirrhosis - develop over time
 Renal insufficiency or failure

91. Prognosis
 Prognosis in heart failure can be assessed in
multiple ways including clinical prediction rules
and cardiopulmonary exercise testing. Clinical
prediction rules use a composite of clinical
factors such as lab tests and blood pressure to
estimate prognosis
 ADHERE Tree rule indicates that patients
with blood urea nitrogen < 43 mg/dl and systolic
blood pressure at least 115 mm Hg have less than
10% chance of inpatient death or complications

92. Contd………..
 cardiopulmonary exercise testing (CPX
testing). CPX testing is usually required prior to
heart transplantation as an indicator of
prognosis. Cardiopulmonary exercise testing
involves measurement of exhaled oxygen and
carbon dioxide during exercise. The peak oxygen
consumption (VO2 max) is used as an indicator
of prognosis. As a general rule, a VO2 max less
than 12–14 cc/kg/min indicates a poor survival
and suggests that the patient may be a
candidate for a heart transplant. Patients with a
VO2 max<10 cc/kg/min have clearly poorer
prognosis

93. Nursing Assessment
 History
 Physical examination
 Vital signs
 PA readings
 Urine output

94. Nursing diagnoses
 Decreased cardiac output
 Activity intolerance
 Fluid volume excess
 Impaired gas exchange
 Anxiety
 Deficient knowledge

95. Decreased cardiac output
 Plan frequent rest periods
 Monitor VS and O2 sat at rest and during activity
 Take apical pulse
 Review lab results and hemodynamic monitoring
results
 Fluid restriction- keep accurate I and O
 Elevate legs when sitting
 Teach relaxation and ROM exercises

96.  Activity Intolerance
 Provide O2 as needed
 practice deep breathing
exercises
 teach energy saving
techniques
 prevent interruptions at
night
 monitor progression of
activity
 offer 4-6 meals a day
 Fluid Volume Excess
 Give diuretics and
provide BSC
 Teach side effects of
meds
 Teach fluid restriction
 Teach low sodium diet
 Monitor I and O and
daily weights
 Position in semi or
high fowlers
 Listen to BS frequently

97. Knowledge deficit
 Low Na diet
 Fluid restriction
 Daily weight
 When to call Dr.
 Medications

98. Nursing Management
 Health Promotion
 Treatment or control of underlying heart disease
key to preventing HF and episodes of ADHF (e.g.,
valve replacement, control of hypertension)
 Antidysrhythmic agents or pacemakers for
patients with serious dysrhythmias or conduction
disturbances
 Flu and pneumonia vaccinations