Management of Patients with Complications from Heart Disease

CARDIAC HEMODYNAMICS

Basic function of the heart: to pump blood Measured by CO: HR x SV SV: amount of blood pumped out of the ventricle with each contraction HR: primarily controlled by the ANS Determinants of SV

PRELOAD AFTERLOAD CONTRACTILITY

Precise measurement of these factors requires hemodynamic monitoring

PRELOAD

Is the amount of blood presented to the ventricle just before systole Increases pressure in the ventricle ---> stretching the ventricular wall (by blood to produce optimal recoil & forceful ejection of blood) ---> too little or too much muscle fiber stretch decreases the volume of blood ejected

PRELOAD
Major Determinants of PRELOAD Venous return of blood to the heart creating the volume of the blood entering the ventricle during diastole Ventricular compliance: the elasticity or amount of give when blood enters the ventricle

Decrease elasticity due to thickening of the muscles (hypertrophic cardiomyopathy) Increased fibrotic tissue within the ventricle (MI)

AFTERLOAD

The amount of resistance to the ejection of blood from the ventricle To eject blood: the ventricle must overcome the resistance caused by tension in the aorta and systemic vessels Inversely related to SV An increase in afterload causes the ventricle to work harder and may decrease the amount of blood ejected DETERMINANTS The diameter and distensibility of the great vessels (aorta / PA) Competence of the semilunar valves Significant vasoconstriction, HTN, or a narrowed valvular opening from stenosis ----> resistance (afterload) increases

CONTRACTILITY

The force of contraction is related to the status of the myocardium Increase contractility and SV Catecholamines released by sympathetic stimulation during exercise Administration of positive inotropic medications MI: necrosis and fibrosis of the myocardial cells

NONINVASIVE ASSESSMENT OF CARDIAC HEMODYNAMICS

RV PRELOAD:

estimated by measuring the jugular venous distention (JVD) Mean Arterial Blood Pressure

LV AFTERLOAD:

OVERALL CARDIAC FUNCTIONING:

Activity Tolerance

INVASIVE ASSESSMENT OF CARDIAC HEMODYNAMICS

CENTRAL VENOUS CATHETERS

PULMONARY ARTERY CATHETER

Intacardiac pressures PAP CO

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.

ETIOLOGY

Coronary artery disease Cardiomyopathy Hypertension Valvular disorders Primary cause of HF

atherosclerosis of the coronary arteries (60%)

CLINICAL MANIFESTATIONS

GENERAL

Fatigue Decreased activity tolerance Dependent edema Weight gain Third heart sound (S3) Apical impulse enlarged with left lateral displacement Pallor and cyanosis Jugular venous distention (JVD)

CARDIOVASCULAR

CLINICAL MANIFESTATIONS

RESPIRATORY

Dyspnea on exertion Pulmonary crackles that do not clear with cough Orthopnea Paroxysmal nocturnal dyspnea (PND) Cough on exertion or when supine

CLINICAL MANIFESTATIONS

CEREBROVASCULAR

Unexplained confusion or altered mental status Lightheadedness Oliguria and decreased frequency during the day Nocturial Anorexia and nausea Enlarged liver Ascites Hepatojugular reflux

RENAL

GASTROINTESTINAL

Clinical Manifestations

Right-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.

Left-sided failure

Chronic HF is frequently biventricular.

CLINICAL MANIFESTATIONS

LEFT-SIDED HEART FAILURE

Dyspnea Cough Pulmonary crackles Low oxygen saturation levels S3 or ventricular gallop Orthopnea PND Nocturia

CLINICAL MANIFESTATIONS

RIGHT-SIDED HEART FAILURE JVD Edema Hepatomegaly Ascites Anorexia and nausea

Classification of Heart Failure

NYHA classification of HF

Classification I, II, III, IV Stages A, B, C, D

ACC/AHA classification of HF

Treatment guidelines are in place for each stage.

NYHA CLASSIFICATION OF HEART FAILURE

CLASS
I

SIGNS & SYMPTOMS

PROGNOSIS

Ordinary physical activity does not cause undue GOOD fatigue, dyspnea, palpitations, or chest pain No pulmonary congestion or peripheral hypotension Patient is considered asymptomatic Usually no limitations of ADLs Slight limitation on ADLs GOOD Patient reports no symptoms at rest but increased physical activity will cause symptoms Basilar crackles and S3 murmur may be detected

II

NYHA CLASSIFICATION OF HEART FAILURE

CLASSIFICATION SIGNS & SYMPTOMS PROGNOSIS

III

Marked limitation on ADL Patient feels comfortable at rest but less than ordinary activity will cause symptoms Symptoms of cardiac insufficiency at rest

FAIR

IV

POOR

ACC / AHA CLASSIFICATION OF HF

CLASSIFICATION STAGE A CRITERIA Patients at high risk for developing left ventricular dysfunction but without structural heart disease or symptoms of heart failure Patients with left ventricular dysfunction or structural heart disease who have not developed symptoms of heart failure Patients with left ventricular dysfunction or structural heart disease with current or prior symptoms of heart failure Patients with refractory end-stage heart failure requiring specialized interventions

STAGE B

STAGE C

STAGE D

ASSESSMENT & DIAGNOSTIC FINDINGS

Echocardiogram CXR ECG Serum Electrolytes BUN Creatinine

ASSESSMENT & DIAGNOSTIC FINDINGS

TSH CBC BNP Urinalysis Cardiac Stress Testing or Cardiac Catheterization

Medical Management of HF

Eliminate or reduce etiologic or contributory factors. Reduce the workload of the heart by reducing afterload and preload. Optimize pharmacologic and other therapeutic regimens. Prevent exacerbations of HF. Medications are routinely prescribed for HF. Promote a lifestyle conducive to cardiac health

PHARMACOLOGIC THERAPY

Angiotensin-converting enzyme inhibitors Angiotensin II receptor blockers Hydralazine and Isosorbide Dinitrate Beta-blockers Diuretics Digitalis Calcium Channel Blockers Intravenous Infusions Other medications

ACE INHIBITOR

Slow the progression of HF Improve exercise tolerance Decrease the number of hospitalizations for HF Form: oral, IV

ACE INHIBITOR

Promote vasodilation and diuresis by decreasing afterload and preload -----> decrease the workload of the heart Vasodilation reduces resistance to left ventricular ejection of blood -----> diminish the hearts workload and improving ventricular emptying Promoting diuresis: decrease the secretion of aldosterone (hormone causing kidneys to retain sodium & water) Stimulate the kidneys to excrete Na & H20 (retaining K) -----> reducing left ventricular filling pressure & decreasing pulmonary congestion

ACE INHIBITOR

THERAPEUTIC EFFECTS

Dec BP and afterload Relieve signs and symptoms of HF Prevents progression of HF Hypotension Hypovolemia Hyperkalemia Hyponatremia Alterations in Renal Function

KEY NURSING CONSIDERATION

ACE INHIBITOR

Lisinopril (Prinivil, Zestril) Benazepril (Lotensin) Captopril (Capoten) Enalapril/Enalaprilat (Vasotec) Fosinopril (Monopril) Moexipril (Univasc) Perindopril (Aceon) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik)

ANGIOTENSIN II RECEPTOR BLOCKERS

ARBs have similar hemodynamic effects with ACEI

Dec BP and afterload Dec SVR Improved CO Relieves signs and symptoms of HF Prevents progression of HF Similar with ACEI

KEY NURSING CONSIDERATION

ARBs

Valsartan (Diovan) Candesartan (Atacand) Eprosartan (Teveten) Irbesartan (Avapro) Telmisartan (Micardis) Losartan (Cozaar)

HYDRALAZINE & ISOSORBIDE DINITRATE

Alternative therapy for patients who cant take ACEI Nitrates:

Venous dilation -----> reduces the amount of blood return to the heart -----> lowers PRELOAD Lowers SVR and left ventricular AFTERLOAD

Hydralazine:

Combination recommended in HF Guidelines

BETA-ADRENERGIC BLOCKING AGENTS BETA BLOCKERS

Dilates blood vessels and dec afterload Dec signs and symptoms of HF Improves exercise capacity KEY NURSING CONSIDERATION

Dizziness Fatigue Hypotension Bradycardia

BETA BLOCKERS

Metoprolol (Lopressor, Toprol) Atenolol (Tenormin) Carvedilol (Coreg)

DIURETICS

To remove excess extracellular fluid -----> increasing the rate of urine produced Dec fluid volume overload Dec signs and symptoms of HF KEY NURSING CONSIDERATIONS

Electrolyte abnormalities Renal dysfunction Diuretic resistance Dec BP Monitor I&O Daily weight

DIURETICS

LOOP

Furosemide (Lasix) Metolazone (Zaroxolyn) Hydrochlorothiazide (HCTZ) Spironolactone (Aldactone)

THIAZIDE

ALDOSTERONE ANTAGONIST

DIGITALIS

Increases the force of myocardial contraction Slows conduction through the AV node Improves contractility, increasing LV output --> enhances diuretics KEY CONCERN: DIGITALIS TOXICITY DIGOXIN (Lanoxin)

DIGOXIN USE & TOXICITY IN HF

Therapeutic Level: 0.5 2.0 mg/mL Preparations:

Tablets: 0.125, 0.25, 0.5 mg (Lanoxin) Capsules: 0.05, 0.1, 0.2 mg (Lanoxicaps) Elixir: 0.05 mg/mL (Lanoxin Pediatric Elixir) Injection: 0.25 mg/mL, 0.1 mg/mL (Lanoxin)

DIGOXIN TOXICITY Early

Anorexia Nausea & vomiting Fatigue Depression Malaise

Changes in HR or rhythm; onset of irregular rhythm ECG changes indicating ventricular dysrhythmias, atrial tachycardia with block, junctional tachycardia, ventricular tachycardia

REVERSAL OF TOXICITY

Holding the medication Monitor serum digoxin level

Severe toxicity: DIGOXIN IMMUNE FAB (Digibind)

NURSING CONSIDERATIONS & ACTIONS FOR DIGITALIS THERAPY

Assess the patients clinical response to therapy through evaluation of relief of symptoms

Dyspnea Orthopnea Crackles Hepatomegaly Peripheral edema

MONITOR THE PATIENT FOR FACTORS THAT INCREASE THE RISK OF TOXICITY

Hypokalemia Use of medications that may enhance the effects of digoxin Impaired renal function
STANDARD PRACTICE: ASSESS FOR APICAL HR!!!

Before administration

Monitor for GI side effects Monitor for Neurologic side effects

CALCIUM CHANNEL BLOCKERS

Vasodilation Reduction of SVR KEY NURSING CONSIDERATION Hypotension Drowsiness or dizziness

CALCIUM CHANNEL BLOCKERS

Dihydropyridines

Amlodipine (Norvasc) Felodipine (Plendil) Verapamil (Calan0 Nifedipine (Procardia) Diltiazem (Cardizem)

First Gen Ca Channel

INTRAVENOUS INFUSIONS

NESIRITIDE (Natrecor)

32 amino acid recombinant technology BNP Binds to vascular smooth muscle and endothelial cells ---> dilation of arteries and veins Suppression of neurohormones responsible for fluid retention ---> diuresis END RESULT

preload and afterload unloader inc SV

MILRINONE (Primacor)

A phosphodiesterase inhibitor delaying the release of Calcium from intracellular reservoirs ---> prevents uptake of extracellular Calcium by the cells ---> vasodilation ---> decreased PRELOAD & AFTERLOAD ---> REDUCED CARDIAC WORKLOAD Hypotension GI dysfunction Increased ventricular dysrhythmias

KEY CONSIDERATION

DOBUTAMINE (Dobutrex)

Stimulates the beta-1-adrenergic receptors ---> increase cardiac contractility Increases the heart rate Precipitate ectopic beats Tachydysrhythmias

KEY CONSIDERATION

OTHER MEDICATIONS FOR HF

Anticoagulants Statins

Nutritional Therapy Additional Therapy

Supplemental Oxygen Other Interventions

CAD: coronary artery revascularization DYSRHYTHMIAS: ICD No Improvement with Standard Therapy: CRT Severe Fluid Overload: ULTRAFILTRATION End Stage HF: CARDIAC TRANSPLANTATION

GERONTOLOGIC CONSIDERATIONS

Age-related changes increasing frequency of HF

Inc SBP Inc ventricular wall thickness Inc myocardial fibrosis

Elderly may present with atypical signs & symptoms

Fatigue Weakness Somnolence

GERONTOLOGIC CONSIDERATIONS

Decreased Renal Function

Resistant to diuretics More sensitive to changes in volume Requires nursing surveillance for bladder distention

Diuretics in elderly men

Nursing Process: The Care of the Patient with HF: Assessment

Health history Signs and Symptoms of HF Sleep and activity Knowledge and coping Physical exam Mental status JVD Hepatojugular Reflux Lung sounds: crackles and wheezes Heart sounds: S3 Fluid status/signs of fluid overload Daily weight and I&O Assess responses to medications

Nursing Process: The Care of the Patient with HF: Diagnosis

Activity intolerance and fatigue Excess fluid volume Anxiety Powerlessness Ineffective therapeutic regimen (Noncompliance)

Collaborative Problems/Potential Complications

Hypotension, Poor Perfusion, Cardiogenic shock Dysrhythmias Thromboembolism Pericardial effusion and cardiac tamponade

Nursing Process: The Care of the Patient with HF: Planning

Goals may include: promoting activity 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 self-care program.

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

Managing Fluid Volume

Assessment for symptoms of fluid overload Daily weight I&O Diuretic therapy; timing of meds Fluid intake; fluid restriction Maintenance of sodium restriction See Chart 30-4

Controlling Anxiety

With difficulty maintaining adequate oxygenation Restless and anxious Overwhelmed by breathlessness Interfere with sleep Emotional Stress ---> stimulates SNS Oxygen administration during an acute event Promote physical comfort Provide psychological support Identify factors contributing to anxiety How to use relaxation techniques to control anxious feelings

Minimizing Powerlessness

Assess factors contributing to a sense of powerlessness

Lack of knowledge Lack of opportunities to make decisions

Taking time to listen actively to patients Provide the patient with decision-making opportunities Provide encouragement

Monitoring and Managing Potential Complications

Excessive and repeated diuresis

Hypokalemia

Hyperkalemia Hyponatremia Dehydration and hypotension Increased serum creatinine and hyperuricemia

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

CONTINUING CARE

Home health care HF clinic Telehealth management

END-OF-LIFE CONSIDERATIONS

EVALUATION

EXPECTED PATIENT OUTCOMES

Demonstrates tolerance for increased activity

Describes adaptive methods for usual activities Schedules activities to conserve energy and reduce fatigue and dyspnea Maintains HR, BP, RR, and pulse oximetry within the targeted range Exhibits decreased peripheral and sacral edema Demonstrates methods for preventing edema

Maintains Fluid Balance

EVALUATION

EXPECTED PATIENT OUTCOMES

Is less anxious

Avoids situations that produce stress Sleeps comfortably at night Reports decreased stress and anxiety Denies symptoms of depression

Makes sound decisions regarding care and treatment

Demonstrates ability to influence outcomes

EVALUATION

EXPECTED PATIENT OUTCOMES

Adheres to self-care regimen

Performs and records daily weights Ensures dietary intake includes no more than 2 to 3 g of sodium per day Takes medications as prescribed Reports any unusual symptoms or side effects

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

Pulmonary Emboli

Umbrella Filter

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

Assessing for Cardiac Tamponade

Medical Management

Pericardiocentesis Pericardiotomy

END
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