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ELECTIVE II Acute/ Critical Care Nursing

Submitted by: Abdulcadil, Fatima Jane R. Booc, Jerome Anthony Cruz, Jame Rae Esic, Claire P. Lapuhapo, Kenneth B.

Submitted to: Prof. Maricor R. Gaan, RN

Anatomy and Physiology of the Heart


Heart- is a hollow muscular organ, located in thorax between 2 lungs; 4 chambers; 4 valves; 2 atria (atrium) & 2 ventricles; 2 separate pumps (R & L sides); Right side receives blood from the body and sends it to the lungs (pulmonary); Left side receives blood from lungs and sends it to the body (systemic). The heart lies between the lungs in a region called the mediastinum. You can also see that the heart is wrapped by some membranes that also hold the heart in its position relative to the diaphragm and lungs. Position of Heart Pumps

The Pericardium- The pericardium is the set of membranes around the heart. It is actually composed of three layers of membranes. visceral pericardium - the innermost parietal pericardium - the middle fibrous pericardium - the outer one is the extra one, and is tough.

o Pericardial Cavity- tiny space between the visceral pericardium and the parietal pericardium. Layers of the Heart

Chambers of the Heart

Valves of the Heart - 4 valves; One way flow; Leaky valve = heart murmur; 2 atrioventricular valves (Left AV valve- bicuspid or mitral and Right AV valve- tricuspid); 2 semilunar valves (Pulmonic semilunar valve and Aortic semilunar valve).

Atrioventricular Valves: 1. Right AV valve Between right atrium and right ventricle Also called the tricuspid valve because it has three cusps . Cusps close when right ventricle contracts, preventing blood from going back up into the right atrium 2. Left AV valve Between the left atrium and the left ventricle Also called the bicuspid valve because it only has two cusps Also called the mitral valve Cusps close when left ventricle contracts, preventing blood from back up into the left atrium Semilunar Valves 1. Pulmonary semilunar valve- When right ventricle contracts, blood is forced through this valve to enter pulmonary trunk. 2. Aortic semilunar valve- When a left ventricle contract, blood is forced through this valve to enter the aorta.

Cardiac Conduction System- The cardiac conduction system generates and transmits impulses that stimulate contraction of the myocardium. Under normal circumstances, the conduction system first stimulates the contraction of the atria and then the ventricles.

Electrophysiologic Properties of the Heart 1. Excitability- The ability of the heart to depolarize in response to a stimulus. Once stimulated, the whole heart muscle contracts. It is influenced by hormones, electrolytes, nutrition, oxygen supply, medications, infection, and nerve characteristics. 2. Automaticity/Rhythmicity- The ability of cardiac cells to initiate an impulse spontaneously and repetitively, without external neurohormonal control. 3. Conductivity- The ability of the heart muscle fibers to propagate electrical impulses along and across cell membranes. Cardiac Cycle- refers to the events of one complete heart beat. The length of the cardiac cycle is usually about 0.8 sec. Systole (contraction of the muscle)- there is ventricular pumping, the chambers of the heart become smaller as the blood is ejected. Occur secondary to depolarization of cells. Diastole (relaxation of the muscle)- there is ventricular filling, the heart chambers fill with blood in preparation for subsequent ejection.

Cardiac Output Volume of blood ejected per minute- Each ventricle ejects approximately 70mL of blood/ beat Averages between 4-8L/min CO = Stroke volume X heart rate =70 ml X 60 beats/min =4,200 ml/min

Stroke Volume- Is determined by three factors Preload, after load, and Contractility

Preload- Degree of stretch of myocardial fiber; determined by the volume of blood in left ventricle (LV) at end of diastole; Increased volume increased preload- increased cardiac output (CO); Decreased volume decreased preload decreased cardiac output (CO) Frank- Starling Law - the critical factor controlling stroke volume is how much the cardiac muscle cells are stretched just before the contract. The more they are stretched, the stronger the contraction will be. The important factor stretching the heart muscles is the venous return. Factors Which Increase Preload IV fluids Blood Vasoconstriction Factors Which Decrease Preload Diuretics Dehydration Hemorrhage Vasodilation

Contractility- Force generated by the myocardium when it contracts inotropic property. Ejection fraction (EF) - percentage of LV end-diastolic volume that is ejected with each contraction Autonomic Nervous System (ANS) Regulation of Cardiovascular System Heart rate chronotropic effect Contractility inotropic effect Conduction velocity at AV node dromotropic effect Afterload - vascular resistance arterial vasoconstriction and dilation Preload venous constriction and dilation

Subdivisions of ANS Parasympathetic acetylcholine produces inhibitory response Sympathetic catecholamines stimulate Increase heart rate Beta 1 receptors Dilate smooth muscles Beta 2 receptors Vasoconstrict vessels Alpha receptors

Heart Failure
Definition Heart failure, sometimes known as congestive heart failure (CHF), occurs when your heart muscle doesn't pump blood as well as it should. Conditions such as narrowed arteries in your heart (coronary artery disease) or high blood pressure gradually leave your heart too weak or stiff to fill and pump efficiently. Not all conditions that lead to heart failure can be reversed, but treatments can improve the signs and symptoms of heart failure and help you live longer. Lifestyle changes, such as exercising, reducing salt in your diet, managing stress and especially losing weight, can improve your quality of life. The best way to prevent heart failure is to control conditions that cause heart failure, such as coronary artery disease, high blood pressure, diabetes or obesity. Pathophysiology Heart Failure, or congestive heart failure (CHF) is a physiologic state in which the heart cannot pump enough blood to meet the metabolic needs of the body. Heart failure results from changes in systolic or diastolic function of left ventricle. The heart fails when, because of intrinsic disease or structural defects, it cannot handle a normal blood volume or, in the absence of disease, cannot tolerate a sudden expansion in blood volume. Heart failure is not a disease itself; instead, the term refers to a clinical syndrome characterized by manifestations of volume overload, inadequate tissue perfusion, and poor exercise tolerance. Whatever the cause, pump failure results in hypo-perfusion of tissue, followed by pulmonary and systemic venous congestion. Because heart failure causes vascular congestion, it is often called congestive heart failure, although most cardiac specialist no longer use this term. Symptoms Heart failure can be ongoing (chronic) or your condition may start suddenly (acute). Shortness of breath (dyspnea) when you exert yourself or when you lie down Fatigue and weakness Swelling (edema) in your legs, ankles and feet Rapid or irregular heartbeat Reduced ability to exercise Persistent cough or wheezing with white or pink blood-tinged phlegm Increased need to urinate at night Causes Heart failure often develops after other conditions have damaged or weakened your heart. Over time, the heart can no longer keep up with the normal demands placed on it to pump blood to the rest of your body. The main pumping chambers of your heart (the ventricles) may become stiff and not fill properly between beats. Also, your heart muscle may weaken, and Swelling of your abdomen (ascites) Sudden weight gain from fluid retention Lack of appetite and nausea Difficulty concentrating or decreased alertness Sudden, severe shortness of breath and coughing up pink, foamy mucus Elevated blood pressure Chest pain, if your heart failure is caused by a heart attack

the ventricles stretch (dilate) to the point that the heart can't pump blood efficiently throughout your body. Heart failure can involve the left side, right side or both sides of your heart. Typically, heart failure begins with the left side specifically the left ventricle, your heart's main pumping chamber. Type of heart failure Left-sided heart failure Right-sided heart failure Systolic heart failure Diastolic heart failure (also called heart failure with normal ejection fraction)

Description Fluid may back up in your lungs, causing shortness of breath. Fluid may back up into your abdomen, legs and feet, causing swelling. The left ventricle can't contract vigorously, indicating a pumping problem. The left ventricle can't relax or fill fully, indicating a filling problem.

Coronary artery disease and heart attack. Coronary artery disease is the most common form of heart disease and the most common cause of heart failure. Over time, arteries that supply blood to your heart muscle narrow from a buildup of fatty deposits, a process called atherosclerosis.

High blood pressure (hypertension) Blood pressure is the force of blood pumped by your heart through your arteries. If your blood pressure is high, your heart has to work harder than it should to circulate blood throughout your body.

Faulty heart valves The valves of your heart keep blood flowing in the proper direction through the heart. A damaged valve, due to a heart defect, coronary artery disease or heart infection, forces your heart to work harder to keep blood flowing as it should.

Damage to the heart muscle (cardiomyopathy) Some of the many causes of heart muscle damage (cardiomyopathy) include infections, alcohol abuse, and the toxic effect of drugs such as cocaine or some drugs used for chemotherapy.

Myocarditis Myocarditis is an inflammation of the heart muscle. It's most commonly caused by a virus and can lead to left-sided heart failure.

Heart defects you're born with (congenital heart defects) If your heart and its chambers or valves haven't formed correctly, the healthy parts of your heart have to work harder to pump blood through your heart, which in turn may lead to heart failure.

Abnormal heart rhythms (heart arrhythmias) Abnormal heart rhythms may cause your heart to beat too fast. This creates extra work for your heart. Over time, your heart may weaken, leading to heart failure. A slow heartbeat may prevent your heart from getting enough blood out to the body and may also lead to heart failure.

Risk factors High blood pressure Coronary artery disease Heart attack Diabetes Some diabetes medications Sleep apnea Congenital heart defects Viruses Alcohol use Irregular heartbeats

Complications Kidney damage or failure. Heart failure can reduce the blood flow to your kidneys, which can eventually cause kidney failure if left untreated. Kidney damage from heart failure can require dialysis for treatment. Heart valve problems. The valves of your heart, which keep blood flowing in the proper direction through your heart, may not function properly if your heart is enlarged, or if the pressure in your heart is very high due to heart failure. Liver damage. Heart failure can lead to a buildup of fluid that puts too much pressure on the liver. This fluid backup can lead to scarring, which makes it more difficult for your liver to function properly. Stroke. Because blood flow through the heart is slower in heart failure than in a normal heart, it's more likely you'll develop blood clots, which can increase your risk of having a stroke.

Tests and diagnosis Blood tests. Your doctor may take a sample of your blood to check your kidney and thyroid function and to look for indicators of other diseases that affect the heart. A blood test to check for a chemical called N-terminal pro-B-type natriuretic peptide (NTproBNP) can help in diagnosing heart failure. Chest X-ray. In heart failure, your heart may appear enlarged and fluid buildup may be visible in your lungs. Your doctor can also use an X-ray to diagnose conditions other than heart failure that may explain your signs and symptoms. Electrocardiogram (ECG). This test records the electrical activity of your heart through electrodes attached to your skin. Impulses are recorded as waves and displayed on a monitor or printed on paper. This test helps your doctor diagnose heart rhythm problems and damage to your heart from a heart attack that may be underlying heart failure. Echocardiogram. An important test for diagnosing heart failure is the echocardiogram. An echocardiogram helps distinguish systolic heart failure from diastolic heart failure in which the heart is stiff and can't fill properly.

Ejection fraction. Your ejection fraction is measured during an echocardiogram and can also be measured by nuclear medicine tests, cardiac catheterization and cardiac MRI. An ejection fraction is an important measurement of how well your heart is pumping and is used to help classify heart failure and guide treatment. Stress test. Stress tests measure how your heart and blood vessels respond to exertion. You may walk on a treadmill or pedal a stationary bike while attached to an ECG machine. Cardiac computerized tomography (CT) scan or magnetic resonance imaging (MRI). In a cardiac CT scan, you lie on a table inside a doughnut-shaped machine. An X-ray tube inside the machine rotates around your body and collects images of your heart and chest. In a cardiac MRI, you lie on a table inside a long tube-like machine that produces a magnetic field. Coronary catheterization (angiogram). In this test, a thin, flexible tube (catheter) is inserted into a blood vessel at your groin or in your arm and guided through the aorta into your coronary arteries. A dye injected through the catheter makes the arteries supplying your heart visible on an X-ray. Myocardial biopsy. In this test, your doctor inserts a small flexible biopsy cord into a vein in your neck or groin, and small pieces of the heart muscle are taken. This test is performed to diagnose certain types of heart muscle diseases that cause heart failure. Classifying heart failure Results of these tests help doctors determine the cause of your signs and symptoms and develop a program to treat your heart. To determine the best course of treatment, doctors may classify heart failure using two scales: New York Heart Association scale. This symptom-based scale classifies heart failure in categories from one to four. American College of Cardiology /American Heart Association guidelines. This stagebased classification system uses letters A to D.

Possible Nursing Diagnosis 1. Fluid Volume Excess Goals:

Body weight will remain within normal limits Electrolyte levels will be within normal limits Will demonstrate adequate knowledge concerning medical condition. Will maintain optimal fluid balance Will verbalize less dyspnea and be more comfortable.

Interventions: Administer Oxygen as ordered

Assess for symptoms such as dizziness, weakness/fatigue, nausea/vomiting, confusion, sweatiness, cyanosis. Notify physician as appropriate. Assess for presence of edema Check breath sounds and assess for labored breathing. Check Vital Signs Keep head of bed elevated

Monitor fluid intake, restrict sodium intake as ordered. Monitor Lab work; K+, NA, BUN, Creatinine Observe for signs and symptoms of malnutrition, Do not force resident to eat. Offer small frequent feedings. Assess food preferences. Weigh patient daily

2. (Potential for) Decreased cardiac output Goal:

Will maintain optimal cardiac output aeb vital signs within acceptable limits, no s/sx of decreased cardiac output.

Interventions: Administer medications as ordered by MD and check for side effects.

Assess and document breath sounds such as dyspnea, cough, extended expiration, wheezing. Assess and document heart sounds, apical heart rate, presence of any abnormal heart sounds. Check for symptoms related to decreased cardiac output, such as chest pain, dyspnea, orthopnea, dependent edema, JVD, fluid overload. Discourage smoking. Discuss avoiding allergens when possible. Encourage activity as tolerated, rest as needed. Encourage proper posture (stand/sit upright, elevate head as needed) to optimize air exchange and comfort. Monitor breathing pattern; include rate, rhythm, depth, pursed lips, nasal flaring and fatigue. Obtain lab/diagnostic work as ordered and report results to MD.

3. Potential for fluid volume overload. Goals: Will be free from s/sx or complications related to fluid overload. Interventions: Administer diuretics as ordered and monitor for side effects.

Encourage adequate fluid intake within fluid restrictions as ordered by MD Ensure that snacks and beverages offered at activities comply with all ordered diet and fluid restrictions. Monitor fluid intake and record Monitor for s/sx of fluid overload (edema, shortness of breath, dyspnea, jugular vein distention, bounding pulses) and report to MD

4. Potential for decreased endurance due to decreased cardiac output Intervention: Allow for periods of rest between activities Determine factors that contribute to intolerance (ie sleep disturbance)

Encourage patient to conserve energy If applicable, discourage smoking.


Monitor food intake to ensure that activity is supported. Monitor vital signs during activities. Slowly increase activity level. Continue to monitor vital signs.

Treatments and drugs Medications Doctors usually treat heart failure with a combination of medications. Depending on your symptoms, you might take one or more of these drugs. They include: o Angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitors are a type of vasodilator, a drug that widens blood vessels to lower blood pressure, improve blood flow and decrease the workload on the heart. Examples include enalapril (Vasotec), lisinopril (Prinivil, Zestril) and captopril (Capoten). o Angiotensin II receptor blockers. These drugs, which include losartan (Cozaar) and valsartan (Diovan), have many of the same benefits as ACE inhibitors. They may be an alternative for people who can't tolerate ACE inhibitors. o Digoxin (Lanoxin). This drug, also referred to as digitalis, increases the strength of your heart muscle contractions. It also tends to slow the heartbeat. Digoxin reduces heart failure symptoms in systolic heart failure. o Beta blockers. This class of drugs not only slows your heart rate and reduces blood pressure but also limits or reverses some of the damage to your heart if you have systolic heart failure. Examples include carvedilol (Coreg), metoprolol (Lopressor) and bisoprolol (Zebeta). o Diuretics. Often called water pills, diuretics make you urinate more frequently and keep fluid from collecting in your body. Diuretics, such as furosemide (Lasix), also decrease fluid in your lungs, so you can breathe more easily. o Aldosterone antagonists. These drugs include spironolactone (Aldactone) and eplerenone (Inspra). They are potassium-sparing diuretics but also have additional properties that may reverse scarring of the heart and help people with severe systolic heart failure live longer. o Inotropes. These are intravenous medications used in severe heart failure patients to improve heart pumping function and maintain blood pressure.

Surgery and medical devices o Coronary bypass surgery. If severely blocked arteries are contributing to your heart failure, your doctor may recommend coronary artery bypass surgery. In this procedure, blood vessels from your leg, arm or chest bypass a blocked artery in your heart to allow blood to flow through your heart more freely. o Heart valve repair or replacement. If a faulty heart valve causes your heart failure, your doctor may recommend repairing or replacing the valve. The

surgeon can modify the original valve (valvuloplasty) to eliminate backward blood flow. Surgeons can also repair the valve by reconnecting valve leaflets or by removing excess valve tissue so that the leaflets can close tightly. Sometimes repairing the valve includes tightening or replacing the ring around the valve (annuloplasty). o Implantable cardioverter-defibrillators (ICDs). An ICD is a device similar to a pacemaker. It's implanted under the skin in your chest with wires leading through your veins and into your heart. o Heart pumps (left ventricular assist devices, or LVADs). These mechanical devices are implanted into the abdomen or chest and attached to a weakened heart to help it pump. o Heart transplant. Some people have such severe heart failure that surgery or medications don't help. They may need to have their diseased heart replaced with a healthy donor heart.

Lifestyle and home remedies o Stop smoking. Smoking damages your blood vessels, raises blood pressure, reduces the amount of oxygen in your blood and makes your heart beat faster. o Weigh yourself daily o Restrict salt in your diet. Too much sodium contributes to water retention, which makes your heart work harder and causes shortness of breath and swollen legs, ankles and feet. o Maintain a healthy weight. If you're overweight, your dietitian will help you work toward your ideal weight. Even losing a small amount of weight can help. o Limit fats and cholesterol. In addition to avoiding high-sodium foods, limit the amount of saturated fat, trans fat and cholesterol in your diet. o Limit alcohol and fluids. Your doctor likely will recommend that you don't drink alcohol if you have heart failure, since it can interact with your medication, weaken your heart muscle and increase your risk of abnormal heart rhythms. o Be active. Moderate aerobic activity helps keep the rest of your body healthy and conditioned, reducing the demands on your heart muscle. o Reduce stress. When you're anxious or upset, your heart beats faster, you breathe more heavily and your blood pressure often goes up. o Sleep easy. If you're having shortness of breath, especially at night, sleep with your head propped up at a 45-degree angle using a pillow or a wedge.


Prevention Not smoking Controlling certain conditions, such as high blood pressure, high cholesterol and diabetes. Nursing Responsibilities Place the patient inn Fowlers position and give supplemental oxygen, as ordered. Organize all activities to provide maximum rest periods. To prevent deep vein thrombosis due to vascular congestion, assist the patient with range-of-motion exercises. Weigh the patient daily to help detect fluid retention and observe for peripheral edema. Assess the patients vital signs for increased respiratory and heart rates and for narrowing pulse pressure and mental status. Frequently monitor blood urea nitrogen and serum creatinine, potassium, sodium, chloride, and magnesium levels. Watch for calf pain and tenderness. Advise the patient to avoid foods high in sodium content. Stress the need for regular medical check up and periodic blood tests to monitor drug levels. Stress the importance of taking medications exactly as prescribed. Tell the patient to notify the doctor if his pulse rate is usually irregular or less than 60 beats/min. Staying physically active Eating healthy foods Maintaining a healthy weight Reducing and managing stress