Академический Документы
Профессиональный Документы
Культура Документы
com
I. Pathophysiology
a. Remodeling of the myocardium (as a structural response to
injury) changes the heart from an efficient football shape
to an inefficient basketball shape, making coordinated
contractility difficult.
i. Ventricular dilation (systolic dysfunction) results in poor
contractility and inadequate emptying of chamber.
ii. Ventricular stiffening (diastolic dysfunction) impairs
ability of chamber to relax and receive and eject blood.
b. Failure of the left and/or right chambers of the heart results
in insufficient output to meet metabolic needs of organ and
tissues.
c. Cardiac-related elevation of pulmonary or systemic venous
pressures leads to organ congestion.
d. Backward heart failure (HF): passive engorgement of the
veins caused by elevated systemic venous pressure or a
“backward” rise in pressure proximal to the failing cardiac
chambers (right ventricular failure)
e. Forward HF: decreased cardiac output with reduced forward
flow into the aorta, systemic circulation (inadequate renal
blood flow leads to sodium and water retention), and increasing
pulmonary venous pressure results in fluid accumulation
in alveoli (left ventricular failure)
f. Myocardial muscle dysfunction associated with left ventricular
hypertrophy (LVH) causes decreased cardiac output, activating
neurohormones.
g. Elevated circulating or tissue levels of neurohormones,
norepinephrine, angiotensin II, aldosterone, endothelin,
vasopressin, and cytokines, causes sodium retention and
peripheral vasoconstriction, increasing hemodynamic
stresses on the ventricle.
II. Classification
a. New York Heart Association Functional Classification
System for HF (9th ed, 1994)
i. Class I—normal physical activity is not limited by
symptoms.
ii. Class II—ordinary physical activity results in fatigue,
dyspnea, or other symptoms.
iii. Class III—marked limitation in normal physical
activity
iv. Class IV—symptoms at rest or with any physical
activity
b. American College of Cardiology/American Heart
Association (ACC/AHA) 2005 Guidelines include specific
recommendations for each stage (Hunt et al, 2005).
i. Stage A—high risk for HF associated with such conditions
as hypertension, diabetes, and obesity. Treatment is
focused on comorbidity.
ii. Stage B—presence of structural heart disease, such as
left ventricular remodeling, LVH, or previous myocardial
infarction (MI), but is asymptomatic. Treatment is
focused on retarding the progression of ventricular
remodeling and delaying the onset of HF symptoms.
iii. Stage C—clients with past or current HF symptoms
associated with structural heart disease, such as
advanced ventricular remodeling. Treatment is focused
on modifying fluid and dietary intake and drug therapies
as well as nonpharmacological measures, such as
biventricular pacing and valvular or revascularization
surgery.
iv. Stage D—refractory advanced HF symptoms at rest or
with minimal exertion and frequently requiring intervention
in the acute setting. Treatment is focused on promoting
clinical stability including supportive therapy to sustain
life, such as left ventricular assist device, continuous
intravenous (IV) inotropic therapy, experimental surgery
or drugs, a heart transplant, or end-of-life or hospice care.
III. Etiology
a. Multifactoral
i. Complex clinical syndrome resulting from any structural
or functional cardiac disorder that impairs the ability of
the ventricle to fill with or eject blood (ACC/AHA 2005
Guidelines; see Hunt et al, 2005).
ii. Risk factors and comorbidities—hypertension; obesity;
diabetes; coronary artery disease (CAD); peripheral and
cerebrovascular disease; valvular heart disease with onset
of atrial fibrillation (AF); sleep disorders such as sleep
apnea; history of exposure to cardiotoxins, for example,
chemotherapy, alcohol, and cocaine; family history of
cardiomyopathy
IV. Statistics
a. High morbidity and mortality, particularly in clients with
New York Heart Association Class IV symptoms (Hunt et
al, 2005)
b. Morbidity: 5.2 million Americans have HF. (National
Heart, Lung and Blood Institute [NHLBI], 2007)
i. Approximately 550,000 new cases reported annually
(Centers for Disease Control and Prevention [CDC],
2006b).
ii. 1.1 million hospitalizations reported annually (CDC,
2006b).
c. Mortality: 287,000 deaths reported annually (CDC, 2006b).
d. Cost: $29.6 billion spent in 2006, making HF the most
common reason for hospitalization of Medicare clients
(CDC, 2006b).
Care Setting
Although generally managed at the community level, an
in-client stay may be required for periodic exacerbation of
failure or development of complications.
Nursing Priorities
1. Improve myocardial contractility and systemic perfusion.
2. Reduce fluid volume overload.
3. Prevent complications.
4. Provide information about disease and prognosis, therapy
needs, and prevention of recurrences.
Discharge Goals
1. Cardiac output adequate for individual needs.
2. Complications prevented or resolved.
3. Optimum level of activity and functioning attained.
4. Disease process, prognosis, and therapeutic regimen
understood.
5. Plan in place to meet needs after discharge.
May be related to
Altered myocardial contractility, inotropic changes
Alterations in rate, rhythm, electrical conduction
Structural changes, such as valvular defects and ventricular aneurysm
Possibly evidenced by
Increased heart rate (tachycardia), dysrhythmias, ECG changes
Changes in BP (hypotension, hypertension)
Extra heart sounds (S3, S4)
Decreased urine output
Diminished peripheral pulses
Cool, ashen skin and diaphoresis
Orthopnea, crackles, JVD, liver engorgement, edema
Chest pain
Desired Outcomes/Evaluation Criteria—Client Will
Cardiac Pump Effectiveness
Display vital signs within acceptable limits, dysrhythmias absent or controlled, and no
symptoms of failure, for example,
hemodynamic parameters within acceptable limits and urinary output adequate.
Report decreased episodes of dyspnea and angina.
Cardiac Disease Self-Management
Participate in activities that reduce cardiac workload.
ACTIONS/INTERVENTIONS
Hemodynamic Regulation
Independent
Auscultate apical pulse; assess heart rate, rhythm, and document
dysrhythmia if telemetry available.
Note heart sounds.
Palpate peripheral pulses.
Monitor BP.
Inspect skin for pallor and cyanosis.
Monitor urine output, noting decreasing output and dark or
concentrated urine.
Note changes in sensorium, for example, lethargy, confusion,
disorientation, anxiety, and depression.
Encourage rest, semirecumbent in bed or chair. Assist with
physical care, as indicated.
Provide quiet environment, explain medical and nursing management,
help client avoid stressful situations, listen and
respond to expressions of feelings or fears.
Provide bedside commode. Have client avoid activities eliciting
a vasovagal response, for instance, straining during defecation
and holding breath during position changes.
Elevate legs, avoiding pressure under knee. Encourage active
and passive exercises. Increase ambulation and activity as
tolerated.
Check for calf tenderness; diminished pedal pulse; and
swelling, local redness, or pallor of extremity.
Withhold digoxin, as indicated, and notify physician if marked
changes occur in cardiac rate or rhythm or signs of digoxin
toxicity occur.
Collaborative
Administer supplemental oxygen, as indicated.
Administer medications, as indicated, for example:
Loop diuretics, such as furosemide (Lasix), ethacrynic acid
(Edecrin), and bumetanide (Bumex); thiazide and thiazidelike
diuretics, such as hydrocholorothiazide (HydroDiuril)
and metolazone (Zaroxolyn)
ACE inhibitors, such as benazepril (Lotensin), captopril
(Capoten), lisinopril (Prinivil), enalapril (Vasotec),
quinapril (Accupril), ramipril (Altace), and moexipril
(Univasc)
ARBs (also known as angiotensin II receptor antagonists),
such as candesartan (Atacand), losartan (Cozaar),
eprosartan (Teveten), ibesartan (Avapro), and valsartan
(Diovan)
Vasodilators, such as nitrates (Nitro-Dur, Isordil); arteriodilators
such as hydralazine (Apresoline); combination
drugs, such as prazosin (Minipress) and nesiritide
(Natrecor)
-adrenergic receptor antagonists (also called beta blockers),
such as carvedilol (Coreg), bisoprolol (Zebeta), and metoprolol
(Lopressor)
Digoxin (Lanoxin)
Inotropic agents, such as amrinone (Inocor), milrinone
(Primacor), and vesnarinone (Arkin-Z)
Aldosterone antagonist, such as eplerenone (Inspra)
Morphine sulfate
Anti-anxiety agents and sedatives
Anticoagulants, such as low-dose heparin and warfarin
(Coumadin)
Administer IV solutions, restricting total amount, as indicated.
Avoid saline solutions.
Monitor and replace electrolytes, as indicated.
Monitor serial ECG and chest x-ray changes.
Measure cardiac output and other functional parameters, as
indicated.
Prepare for insertion and maintain pacemaker or
pacemaker/defibrillator, if indicated.
Prepare for surgery, such as valve replacement, angioplasty,
coronary artery bypass grafting (CABG), as indicated:
Cardiomyoplasty
Transmyocardial revascularization
Assist with and maintain mechanical circulatory support
system, such as intra-aortic balloon pump (IABP) or leftventricular
assist device (LVAD), when indicated.
RATIONALE