SIXTH EDITION

Nursing Care of
Patients with Cardiac
Disorders

Copyright © 2015, © 2011, © 2008 by Pearson Education, Inc.

All Rights Reserved
  Disorder of cardiac function
 Causes

The Patient  Impaired myocardial contraction

 Structural cardiac disorders
with Heart  Acute excess demands placed on the
Failure myocardium
 Hypertension
 Coronary heart disease
  Incidence, prevalence, and risk
factors

The Patient  More than 6.6 million people in U.S.

 Rapid rise in prevalence after age 65
with Heart  Mortality rate higher in African

Failure Americans than Whites

 Ischemic heart disease leading risk
factor
  Physiology review
 Cardiac output (CO)
 Cardiac reserve

The Patient  Heart rate

with Heart  Stroke volume

 Preload
Failure  Afterload
 Contractility
 Ejection fraction (EF)
  Pathophysiology
 Primary compensatory mechanisms
 Frank-Starling mechanism

The Patient  Neuroendocrine responses

 Myocardial hypertrophy

with Heart  Ventricular remodeling

Failure  Ventricular hypertrophy

 Chronic distention exhausts atrial
stores of atrial natriuretic factor
(ANF).
  Classifications and manifestations

The Patient
 Systolic versus diastolic failure
 Systolic when ventricle fails to eject a

with Heart sufficient blood volume into arterial

system

Failure  Diastolic when heart cannot completely

relax in diastole
  Classifications and manifestations
 Left-sided versus right-sided failure
The Patient  Coronary heart disease, hypertension
common causes of left-sided
with Heart  Orthopnea

Failure  Conditions that restrict blood flow to

lungs often cause of right-sided
 Pulmonary disease
  Classifications and manifestations
 Low- versus high-output failure
 Patients with coronary heart disease,

The Patient hypertension, cardiomyopathy, other

primary cardiac disorders

with Heart  Acute versus chronic heart failure

Failure  Acute is result of myocardial injury.

 Chronic is progressive deterioration
due to cardiomyopathies, valvular
disease, or coronary heart disease.
  Classifications and manifestations
 Other manifestations
The Patient  Weight gain

with Heart  Edema

 Nocturia
Failure  Paroxysmal nocturnal dyspnea (PND)
 S3 and an S4 gallop
  Complications
 Congestive hepatomegaly

The Patient  Splenomegaly

with Heart  Impaired liver function

 Myocardial distention
Failure  Cardiogenic shock
 Acute pulmonary edema
  Diagnosis
 Atrial natriuretic factor (ANF) and
Brain natriuretic peptide (BNP)
Interprofessio  Serum electrolytes

nal Care  Urinalysis

 Liver function tests
 Thyroid function tests
  Diagnosis
 Arterial blood gases (ABGs)
 Chest x-ray
Interprofession  Electrocardiography
al Care  Echocardiography with Doppler flow
studies
 Radionuclide imaging
  Hemodynamic monitoring
 Intra-arterial pressure monitoring
Interprofessio  Venous pressure monitoring
nal Care  Pulmonary artery pressure
monitoring
  Hemodynamic parameters
 Heart rate
 Arterial blood pressure
Hemodynami  Central venous or right atrial
cs pressure
 Pulmonary pressure
 Cardiac output
Figure 31–3
A
hemodynamic
monitoring
setup.
 Figure 31–4
Inflation of the
balloon on the
flow-directed
catheter allows
it to be carried
through the
pulmonic valve
into the
pulmonary
artery.
 Figure 31–5
Typical waveforms
seen when
measuring A,
pulmonary artery
pressure, and B,
pulmonary wedge
pressure.
  Medications
 ACE inhibitors
 Angiotensin II receptor blockers

Interprofessio  Beta blockers

 Diuretics
nal Care  Inotropic medications
 Direct vasodilators
 Antidysrhythmic drugs
  Nutrition and activity
 Sodium-restricted diet
 Exercise to reduce intolerance
 Other treatments
Interprofessio  Circulatory assistance
nal Care  Cardiac transplantation
 Other procedures
 Cardiomyoplasty
 Ventricular reduction surgery
  Complementary therapies
 Hawthorn
 Nutritional supplements

Interprofessio  End-of-life care

nal Care  Honest discussion with family about

anticipated course of disease
 Discuss advance directives
 Severe dyspnea common
  Diagnoses, outcomes, and
interventions
 Decreased Cardiac Output
 Excess Fluid Volume
 Activity Intolerance
Nursing Care  Deficient Knowledge: Low-Sodium
Diet

 Continuity of care
 Active participation by patient, family
 Provide referrals
  Systemic inflammatory disease
The Patient  Abnormal immune response to
with pharyngeal infection by group A
beta-hemolytic streptococci
Rheumatic
Fever and  Incidence, prevalence, and risk
factors
Rheumatic  Rare in the U.S.
Heart Disease  Peaks between ages 5–15
  Incidence, prevalence, and risk
The Patient factors
with  Risk factors
Rheumatic  Crowded living conditions

Fever and
 Malnutrition
 Immunodeficiency
Rheumatic  Poor access to health care

Heart Disease  Genetic factors

  Pathophysiology
The Patient  Not totally understood

with  Abnormal immune response

 Carditis
Rheumatic  Aschoff bodies develop in cardiac
Fever and tissues.

Rheumatic  Rheumatic heart disease (RHD)

Heart Disease
 Stenosis
 Regurgitation
  Manifestations

The Patient  Fever

 Migratory joint pain
with  Erythema marginatum
Rheumatic  Neurologic symptoms
Fever and  Chest pain

Rheumatic  Tachycardia
 Pericardial friction rub
Heart Disease  S3 or S4 or heart murmur
  Diagnosis
 Complete blood count (CBC) and

Interprofessio erythrocyte sedimentation rate (ESR)

 C-reactive protein (CRP)
nal Care  Antistreptolysin (ASO) titer
 Throat culture
  Medications
 Antibiotics

Interprofessio  Penicillin
 Erythromycin, clindamycin
nal Care  Anti-inflammatory drugs
 Corticosteroids
  Diagnoses, outcomes, and
interventions
 Acute Pain
 Activity Intolerance

Nursing Care  Continuity of care

 Acute care
 Preventing further tissue damage
 Referral for home health services,
household assistance as indicated
 The Patient  Inflammation of the endocardium
with Infective  Infection by a pathogen
Endocarditis
  Pathophysiology
 Risk factors
 Previous heart damage
The Patient  Intravenous drug use

with Infective  Invasive catheters

 Dental health
Endocarditis  Recent heart surgery
 Mechanical or tissue valve replacement
(prosthetic valve endocarditis)
Figure 31–7
A vegetative
lesion of
bacterial
endocarditis.
Source: M.
English/Custo
m Medical
Stock Photo,
Inc.
  Pathophysiology
The Patient  Classifications
with Infective  Acute infective endocarditis

Endocarditis  Subacute infective endocarditis

  Manifestations
 Flulike symptoms
 Arthralgias
The Patient  Cough, dyspnea
with Infective  Heart murmurs

Endocarditis  Anorexia, abdominal pain

 Splenomegaly
 Petechiae, splinter hemorrhages
  Complications
 May affect any organ system
The Patient  Lungs

with Infective  Brain

 Kidneys
Endocarditis  Skin and mucous membranes
 Heart failure, abscess, aneurism
  Diagnosis
 Blood cultures
 Echocardiography
 Serologic immune testing
Interprofessio  CBC

nal Care  ESR

 Serum creatinine
 Chest x-ray
 Electrocardiogram
  Medications
 Prolonged course of antibiotics
 Eradicate the infecting organism
 Surgery
Interprofessio  Purpose
nal Care  Replace severely damaged valves
 Remove vegetations at risk for
embolism
 Remove a valve that does not respond
to antibiotic therapy
  Diagnoses, outcomes, and
interventions
 Risk for Imbalanced Body
Temperature
 Risk for Ineffective Tissue Perfusion

Nursing Care
 Ineffective Health Maintenance
 Continuity of care
 Education on infective endocarditis
from the AHA
 Home health or home intravenous
therapy services
  Inflammation of the heart muscle
 Causes
The Patient  Infectious processes
with  Immunologic response

Myocarditis  Effects of radiation, toxins, or drugs

 Bacterial myocarditis
  Incidence and risk factors
 More common in men
 Alteration of immune response

The Patient  Advanced age

with  Malnutrition
 Alcohol use
Myocarditis  Immunosuppression
 Exposure to radiation
 Stress
  Pathophysiology
 Cells damaged by an inflammatory

The Patient process that causes local or diffuse

swelling and damage
with  Autoimmune injury

Myocarditis  Extent of damage to cardiac muscle

ultimately determines long-term
outcome of disease.
  Manifestations
The Patient  May be asymptomatic

with  Fever
 Fatigue, general malaise
Myocarditis  Dyspnea
  Manifestations
 Palpitations
The Patient  Arthralgias
with  Sore throat

Myocarditis  Abnormal heart sounds

 Chest pain
  Diagnosis

Interprofessio  Electrocardiography
 Cardiac markers
nal Care  Endomyocardial biopsy
  Medications
 Antibiotics and antiviral therapy, if
infection

Interprofessio  Immunosuppressive therapy

 ACE inhibitors and other drugs
nal Care  Digitalis used with caution
 Antidysrhythmic agents
 Anticoagulants
  Diagnoses, outcomes, and
interventions
 Activity Intolerance

Nursing Care  Decreased Cardiac Output

 Fatigue
 Anxiety
 Excess Fluid Volume
  Inflammation of the pericardium
 May be primary or secondary
The Patient disorder

with  Categories

Pericarditis
 Acute pericarditis
 Postmyocardial infarction pericarditis
 Postcardiotomy pericarditis
  Pathophysiology
 Inflammatory response after
The Patient pericardial tissue damage

with  Exudate formed

 Fibrinous or serofibrinous
Pericarditis  Fibrosis, scarring may restrict cardiac
function.
  Manifestations
 Chest pain
 Pericardial friction rub
The Patient  Fever

with  Complications
Pericarditis  Pericardial effusion
 Cardiac tamponade
 Chronic constrictive pericarditis
 Figure 31–8 Cardiac
tamponade. Note increased
volume in the right ventricle
during inspiration in both the
normal heart and the heart
affected by a pericardial
effusion. In tamponade, fluid
in the pericardial sac and the
distended right ventricle
restrict filling of the left
ventricle and, consequently,
cardiac output.
  Diagnosis
 CBC
 Cardiac enzymes
 Electrocardiography
Interprofessio  Echocardiography
nal Care  Hemodynamic monitoring
 Chest x-ray
 Computed tomography (CT scan) or
magnetic resonance imaging (MRI)
  Medications
 Determined by manifestations
 Aspirin and acetaminophen

Interprofessio
 NSAIDs
 Corticosteroids
nal Care  Pericardiocentesis
 Surgery
 Partial or total pericardiectomy
Figure 31–9
Constrictive
pericarditis.
  Diagnoses, outcomes, and
interventions
 Acute Pain
Nursing Care  Ineffective Breathing Pattern
 Risk for Decreased Cardiac Output
 Activity Intolerance
  Interferes with blood flow to and
from the heart
The Patient  Acquired disorders can result from
with Valvular acute or chronic conditions.
Heart  Infective endocartidis

Disease  Rheumatic heart disease

 Most common cause
  Atrioventricular (AV) valves
 Mitral (bicuspid) on left
 Tricuspid on right

Physiology  "Lub"
 Semilunar valves
Review  Aortic valve
 Pulmonic valve
 "Dub”
  Types of disorders
 Stenosis
 Regurgitation
 "Insufficient" or "incompetent" valves

Pathophysiolo  Hemodynamic changes both in front

gy of and behind affected valve
 Cardiac output falls as
compensatory mechanisms become
less effective.
  Mitral stenosis
 Manifestations
 Dyspnea on exertion (DOE), cough

Pathophysiolo  Women may be asymptomatic until

pregnancy.

gy  Complications
 Thrombi that embolize to brain,
coronary arteries, kidneys, spleen,
extremities
  Mitral regurgitation
 Manifestations
 Murmur usually loud, high pitched,
rumbling, holostolic

Pathophysiolo  Cooing or gull-like

gy  Mitral valve prolapse (MVP)

 Manifestations and complications
 High-pitched late systolic murmur
 Tachydysrhythmias
  Aortic stenosis
 Course and manifestations
 Harsh systolic murmur
 Pulmonary hypertension, right
Pathophysiolo ventricular failure late in the disease

gy  Aortic regurgitation
 Manifestations
 May be asymptomatic for many years
even when severe
  Tricuspid valve disorders
 Tricuspid stenosis
 Tricuspid regurgitation

Pathophysiology  Pulmonic valve disorders

 Pulmonic stenosis
 Pulmonic regurgitation
Figure 31–10
Valvular heart
disorders. A,
Stenosis of a
heart valve. B,
An
incompetent or
regurgitant
heart valve.
 Figure 31–11 Mitral
stenosis. Narrowing of the
mitral valve orifice (1)
reduces blood volume to left
ventricle (2), which reduces
cardiac output (3). Rising
pressure in the left atrium (4)
causes left atrial hypertrophy
and pulmonary congestion.
Increased pressure in the
pulmonary vessels (5) causes
hypertrophy of the right
ventricle and right atrium.
 Figure 31–12 Mitral
regurgitation. The mitral valve
closes incompletely (1), allowing
blood to regurgitate during systole
from the left ventricle to the left
atrium (2). Cardiac output falls; to
compensate, the left ventricle
hypertrophies (3). Rising left atrial
pressure (4) causes left atrial
hypertrophy and pulmonary
congestion. Elevated pulmonary
artery pressure (5) causes slight
enlargement of the right ventricle.
 Figure 31–13 Mitral
valve prolapse. Excess
tissue in the valve leaflets
(1) and elongated cordae
tendineae (2) impair
mitral valve closure
during systole. Some
ventricular blood
regurgitates into the left
atrium (3).
 Figure 31–14 Aortic stenosis.
The narrowed aortic valve orifice
(1) decreases the left ventricular
ejection fraction during systole (2)
and cardiac output (3). The left
ventricle hypertrophies (4).
Incomplete emptying of the left
atrium (5) causes backward
pressure through pulmonary veins
and pulmonary hypertension.
Elevated pulmonary artery
pressure (6) causes right
ventricular strain.
 Figure 31–15 Aortic
regurgitation. The cusps of
the aortic valve widen and fail
to close during diastole (1).
Blood regurgitates from the
aorta into the left ventricle (2)
increasing left ventricular
volume and decreasing
cardiac output (3). The left
ventricle dilates and
hypertrophies (4) in response
to the increase in blood
volume and workload.
  Diagnosis
 Echocardiography

Interprofessio  Chest x-ray

 Electrocardiography
nal Care  Cardiac catheterization
 Exercise testing
  Medications
 Diuretics, ACE inhibitors, vasodilators
 Digitalis, if heart failure

Interprofessio  Small doses of beta blockers

nal Care  Anticoagulant therapy, if atrial

fibrillation
 Prophylactic antibiotics prior to any
dental work or surgery
  Percutaneous balloon valvotomy
 Treatment of choice for symptomatic
mitral valve stenosis

Interprofessio  Surgery

nal Care  Reconstructive surgery

 General term, valvuloplasty
 Open commissurotomy
 Annuloplasty
  Surgery
 Valve replacement

Interprofessio
 Three factors determine outcome
 Heart function at time of surgery

nal Care  Intraoperative, postoperative care

 Characteristics, durability of
replacement valve
 Figure 31–16
Balloon valvotomy.
The balloon catheter is
guided into position
straddling the
stenosed valve. The
balloon is then inflated
to increase the size of
the valve opening.
  Diagnoses, outcomes, and
interventions
 Decreased Cardiac Output
Nursing Care  Activity Intolerance
 Risk for Infection
 Ineffective Protection
 The Patient  Disorders that affect the heart
muscle
with  Both systolic and diastolic functions
Cardiomyopa  Primary or secondary in origin
thy
  Dilated cardiomyopathy
 Most common type
 Cause unknown but likely result from
Pathophysiolo toxins, metabolic conditions, infection

gy  Manifestations and course

 Gradual, with dysrhythmia
 Prognosis grim
  Hypertrophic cardiomyopathy
 Decreased compliance of left
ventricle

Pathophysiolo  Manifestations and course

 Increased oxygen demand causes
gy increased ventricular contractility
 Probably cause of 36% of young
athletes who die suddenly
 Dyspnea, angina, syncope
  Restrictive cardiomyopathy
 Rigid ventricular walls impair diastolic
filling.
Pathophysiolo  Manifestations and course
gy  Dyspea on exertion, exercise
intolerance
 Poor prognosis
  Diagnosis
 Echocardiography

Interprofessio  Electrocardiography and ambulatory

ECG monitoring
nal Care  Chest x-ray
 Hemodynamic studies
  Diagnosis
 Radionuclear scans
Interprofessio  Cardiac catheterization and coronary
nal Care angiography
 Myocardial biopsy
  Medications
 ACE inhibitors
 Vasodilators
Interprofessio  Digitalis

nal Care  Beta blockers

 Anticoagulants
 Antidysrhythmics
  Surgery
 Cardiac transplant
 Ventricular assist devices
Interprofessio  Removal of excess muscle
nal Care  Dual-chamber pacemakers
 Implantable cardioverter-
defibrillators
  Diagnoses, outcomes, and
interventions
 Decreased Cardiac Output
 Fatigue
Nursing Care  Ineffective Breathing Pattern
 Fear
 Ineffective Role Performance
 Anticipatory Grieving