Nur 342

Unit II
Management of Patients
with Complications from
Heart Disease

Cardiac Hemodynamics
Cardiac Output= HR X SV
Stroke Volume- amount of blood
pumped by ventricle with each
contraction
Preload is amount of myocardial
stretch just before systole

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Cardiac Hemodynamics
(cont.)
Afterload is amount of resistance
to the ejection of blood from
ventricle
Contractility is the force of
contraction related to number and
status of myocardial cells

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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.
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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.

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Noninvasive Assessment of
Cardiac Hemodynamics
Right ventricular preload may be
estimated by jugular venous
distention
Mean arterial blood pressure is rough
indicator of left ventricular afterload
Activity tolerance may be indicator
of overall cardiac functioning

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Invasive Assessment of
Cardiac
Hemodynamics
Thermodilution
measures CO

Thermistor records the

temperature before and after the
ejection of fluid from RV to PA
Change in temperature is inversely
related to CO
Afterload and contractility are
calculated the same time as CO
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Lumens of Pulmonary
Artery Catheter

Proximal Port: RA CVP readings

Distal Tip: PA readings
Balloon Inflated at tip: PA wedge pressure
readings normally between 4.5-13 mm Hg;
critically ill may need higher LV filling
pressures to maintain CO = PCWP 18mm
Hg; correlates with mean left ventricular
end-diastolic pressure.
Thermistor port: used to calculate CO
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Placement of PA Line

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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 HF 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 HF is a progressive, lifelong disorder
managed with lifestyle changes and medications.
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Heart Failure

Chronic heart failure managed based

upon type, severity, and cause
Diastolic heart failure
Systolic heart failure
Assessment of Ejection Fraction (EF)
performed to assist in diagnosis
NYHA Classification of Heart Failure:
Class I-Class IV
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Classification of Heart Failure

NYHA and ACC/AHA Classification of
HF
NYHA classification of HF

Classification I, II, III, IV

ACC/AHA classification of HF

Stages A, B, C, D

Treatment guidelines are in place for each

stage.
See pp. 796-797, Tables 29-1 & 29-2
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Pathophysiology

Systolic HF: Low COSNSepinephrine &

norepinephrine as compensatory mechanism;
decreased renal perfusionrenin release by
kidney angiotensin I &II
(vasoconstriction)aldosteroneNa & Water
retention worsen the problem as leads to
increased volume (preload) & increased
afterload which increase workload of heart
ventricular dilatation & ventricular
hypertrophymyocardial ischemiavicious
cycle of HF.
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Pathophysiology of HF

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Etiology

CAD: atherosclerosis of coronary

arteries is primary cause of HF
Cardiomyopathy
Hypertension
Valvular disorders
Dysrhythmias e.g. atrial fibrillation
Overstretching of myocardial fibers
of ventricle
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Assessment Heart Failure

Right-sided failure

Left-sided failure

RV cannot eject sufficient amounts of blood, and

blood backs up in the venous system. This resuts
in peripheral edema, hepatomegaly, ascites,
anorexia, nausea, weakness, and weight gain.
LV cannot pump blood effectively to the systemic
circulation. Pulmonary venous pressures increase,
resulting in pulmonary congestion with dyspnea,
cough, crackles, and impaired oxygen exchange.

Chronic HF is frequently biventricular.

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Assessment: Congestion

Dyspnea, orthopnea, PND, cough,

pulmonary crackles that do not
clear with cough, weight gain
(rapid), dependent edema,
abdominal bloating or discomfort,
ascites, JVD, sleep disturbance
(anxiety or air hunger), fatigue

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Assessment: Poor
Perfusion/Low Cardiac
Decreased exercise tolerance, muscle
Output
wasting or weakness, anorexia or

nausea, unexplained weight loss,

lightheadedness or dizzinesss,
unexplained confusion or altered
mental status, resting tachycardia,
daytime oliguria with recumbent
nocturia, cool or vasoconstricted
extremities, pallor or cyanosis
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Left-Sided Heart Failure

Pulmonary congestion occurs
when left ventricle cannot
pump well
Dyspnea upon exertion (DOE),
orthopnea, and paroxysmal
nocturnal dyspnea (PND)
Oliguria

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Right-Sided Heart
Failure

Congestion of viscera and peripheral

tissues when right ventricle fails
Jugular vein distention
Dependent edema
Hepatomegaly
Ascites
Weakness, anorexia, and nausea
Weight gain
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Assessment & Diagnostic

Findings

Physical findings as described

Echocardiogram: Ejection Fraction
CXR
EKG
Blood work: Electrolytes, BUN/Cr,
B-type Natriuretic Peptide (BNP),
CBC, TSH, UA
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Medical Management

Eliminate or reduce contributing factors

Reduce workload of heart by reducing afterload and preload;
Optimize all therapeutic regimens.
Prevent exacerbations of HF.
Medications are routinely prescribed for HF.
Pharmacologic Therapy
ACE inhibitors and ARBs
Hydralazine and isosorbide dinitrate
Beta-blockers
Diuretics
Digitalis
Anticoagulants
Low Sodium Diet
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Medical Management (Cont.)

Eliminate or reduce contributing factors

Reduce workload of heart by reducing afterload
and preload
Pharmacologic Therapy

ACE inhibitors and ARBs

Hydralazine and isosorbide dinitrate
Beta-blockers
Diuretics
Digitalis
Anticoagulants

Low Sodium Diet

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Medical Management (Cont.)

Eliminate or reduce contributing factors

Reduce workload of heart by reducing afterload
and preload
Pharmacologic Therapy

ACE inhibitors and ARBs

Hydralazine and isosorbide dinitrate
Beta-blockers
Diuretics
Digitalis
Anticoagulants

Low Sodium Diet

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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

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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.
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Nursing Process: The Care of the

Patient with HF: Assessment

Health history
Sleep and activity
Knowledge and coping
Physical exam

Mental status
Vital signs, BP
Lung sounds: crackles and wheezes
Heart sounds: S3
Fluid status/signs of fluid overload; JVD (RV failure)

Daily weight and I&O; edema

Peripheral pulses; skin color and temperature

Assess responses to medications
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Nursing Process: The Care

of the Patient with HF:
Activity intolerance and fatigue r/t
Diagnosis
decreased CO

Excess fluid volume r/t HF syndrome

Anxiety r/t complexity of therapeutic
regimen
Powerlessness r/t chronic illness and
hospitalizations
Ineffective family therapeutic regimen
management
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Collaborative Problems/Potential
Complications

Hypotension, poor perfusion,

cardiogenic shock
Dysrhythmias
Thromboembolism
Pericardial effusion and cardiac
tamponade

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Nursing Process: The Care

of the Patient with HF:
Goals may include promoting activity
Planning

and reducing fatigue, relieving fluid

overload symptoms, decreasing
anxiety or increasing the patients
ability to manage anxiety,
encouraging the patient to make
decisions and influence outcomes,
teaching the patient about the selfcare program.
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Promoting Activity
Tolerance

Bed rest for acute exacerbations

Encourage regular physical activity; 30-45
minutes daily
Exercise training
Pacing of activities
Wait 2 hours after eating before doing physical
activity.
Avoid activities in extremely hot, cold, or humid
weather.
Modify activities to conserve energy.
Positioning; elevation of HOB to facilitate
breathing and rest, support of arms
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Managing Fluid Volume

Assessment for symptoms of fluid overload

Daily weight
I&O
Diuretic therapy; timing of meds;Chart 29-2,
Administering and Monitoring Diuretic
Therapy
Fluid intake; fluid restriction
Maintenance of sodium restriction: Health
Promotion: Facts about sodium; Chart 29-5,
p. 807

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

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Pulmonary Edema
Acute event in which the LV cannot handle an
overload of blood volume. Pressure increases in
pulmonary vasculature, causing fluid to move out of
the pulmonary capillaries and into the interstitial
spaces 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 LOC

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Management of Pulmonary
Edema

Prevention
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

Diuretic (furosemide)
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Nursing Management
Positioning
Psychological Support
Monitoring medications

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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 HF, shock state, and hypoxia
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Management of
Cardiogenic Shock

Correct underlying problem

Circulatory assist devices

Intra-aortic balloon pump (IABP)

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Pathophysiology of
Cardiogenic Shock

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The Intra-Aortic Balloon

Pump

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Thromboembolism

Decreased mobility and decreased circulation

increase the risk for thromboembolism in
patients with cardiac disorders, including
those with HF.
Pulmonary embolism: blood clot from the legs
moves to obstruct the pulmonary vessels

The most common thromboembolic problem with

HF
Prevention
Treatment
Anticoagulant therapy
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Pulmonary Emboli

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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
See Figure 29-6, p. 814
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Signs & Symptoms of

Cardiac Tamponade

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Medical Management

Pericardiocentesis
Pericardiotomy

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Cardiac Arrest

Cardiac arrest occurs when heart

ceases to produce effective pulse and
blood circulation
Pulseless electrical activity (PEA)
Emergency Management is CPR

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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
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Answer
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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Sudden Cardiac
Death/Cardiac Arrest

See steps in Emergency

Assessment and Management of
CPR: p. 815
Maintaining airway and breathing
Debrillation
ACLS

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Chin Lift & Bag-Mask

Technique during CPR

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Medications Used in CPR

Epinephrine
Vasopressin
Norepinephrine
Dopamine
Atropine
Amiodarone
Sodium Bicarbonate
Magnesium
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