MANAGEMENT OF PATIENTS

WITH COMPLICATIONS FROM

HEART DISEASE
IAN VAN V. SUMAGAYSAY, MAN, RN
College Of Nursing
West Visayas State University
Learning Objectives:
1. Describe the management of patients with chronic heart
failure.
2. Use the nursing process as a framework for care of patients
with heart failure.
3. Describe the management of patients with acute heart
failure.
4. Develop teaching plans for patients with heart failure.
5. Describe the management of patients with cardiogenic
shock.
6. Describe the management of patients with thromboembolic
episodes, pericardial effusion and cardiac tamponade, and
myocardial rupture.
7. Demonstrate the techniques of cardiopulmonary
resuscitation.
HEART FAILURE
HEART FAILURE
• Also known as Congestive Heart Failure (CHF)

• This refers to the inability of the heart to pump an adequate

supply of blood to meet the metabolic needs of the body
• A syndrome of systemic or pulmonary circulatory congestion
caused by decreased myocardial contractility resulting to
inadequate cardiac output to meet oxygen demands
Common types:
a. Left-sided heart failure (Respiratory)
b. Right-sided heart failure (Circulatory)
Etiology:
• Decreased myocardial contractility due to CAD, MI,
cardiomyopathy
• Valvular heart disease, hypertensive heart disease,
dysrhythmias, cor pulmonale, pericardial tamponade,
pericarditis, other systemic conditions
HEART FAILURE
Pathophysiology:
• Systolic HF: Decreased amount of blood from the
ventricle – stimulates sympathetic nervous system –
release of epinephrine and norepinephrine – further heart
muscle damage – decreased renal perfusion – Renin
secretion – Angiotensin I production – ACE in the lumen
– Angiotensin II – causes vasoconstriction and
aldosterone production – fluid retention – increases
heart’s workload – ventricular hypertrophy without
capillary blood supply – myocardial ischemia
• Diastolic HF: Increased workload – cardiac hypertrophy –
decreased blood in the ventricles – causes decreased
cardiac output
HEART FAILURE
HEART FAILURE
HEART FAILURE
HEART FAILURE
HEART FAILURE
Signs and Symptoms:
General:
Pale, cyanotic skin (with decreased perfusion to
extremities)
Dependent edema (with increased venous pressure)
Deceased activity tolerance

Cardiovascular:
Apical impulse, enlarged and left lateral displacement
(with cardiac enlargement)
Third heart sound (S3)
Murmurs (with valvular dysfunction)
Tachycardia
Increased jugular venous distention (JVD)
HEART FAILURE
Cerebrovascular:
Lightheadness
Dizziness
Confusion

Gastrointestinal:
Nausea and anorexia
Enlarged, pulsatile liver
Ascites
Hepatojugular test, increased (with
increased right ventricular
filling pressure)
HEART FAILURE
Renal:
Decreased urinary frequency during the day
Nocturia

Respiratory:
Dyspnea on exertion
Orthopnea
Paroxysmal nocturnal dyspnea
Bilateral crackles that do not clear with cough
HEART FAILURE
New York Heart Association’s Classification of Heart
Failure:
a. Class I: ordinary physical activity does not cause chest
pain and fatigue, no pulmonary congestion,
asymptomatic, no limitations in the activity of daily
living (ADL’s) (Good Prognosis)
b. Class II: Slight limitation in ADL’s, no symptoms at rest,
positive symptoms in increased activities (Good
Prognosis)
c. Class III: marked limitations in ADL’s, comfortable at
rest but symptoms present in less than ordinary
activities (Fair Prognosis)
d. Class IV: symptoms are present at rest (Fair
Prognosis)
LEFT SIDED
HEART FAILURE
LEFT SIDED HEART FAILURE

• Left ventricular damage usually due to MI,

hypertension, ischemic heart disease, aortic
valve disease or mitral stenosis
• Left ventricular damage causes blood to
back up through the atrium into the
pulmonary veins which results to pulmonary
congestion
• Diminished blood flow will result to
decreased blood flow to the brain, kidneys
and other tissues
LEFT SIDED HEART FAILURE
Pathophysiology:
• Left ventricular failure→ pump failure→
back up of blood into the pulmonary veins
→ increased pulmonary capillary pressure
→ pulmonary congestion
• Left ventricular failure → decreased
cardiac output → decreased perfusion to
the brain, kidney and other tissues →
oliguria, dizziness
LEFT SIDED HEART FAILURE
Predisposing Factors
1. 90% is mitral valve stenosis due to
a. RHD – inflammation of mitral valve due to
invasion of Group A beta-hemolytic
streptococcus
- Formation of aschoff bodies in the mitral
valve
- Common among children (throat infection)
- ASO Titer (Anti streptolysin O titer)
- Penicillin
- Aspirin
b. Aging
LEFT SIDED HEART FAILURE
Predisposing Factors:
2. Myocardial Infarction
3. Ischemic heart disease
4. Hypertension
5. Aortic valve stenosis
LEFT SIDED HEART FAILURE
Signs and Symptoms
1. Dyspnea
2. Paroxysmal nocturnal dyspnea – client
awakened at night due to DOB (sudden attacks
of Orthopnea at night)
3. Orthopnea – use 2 – 3 pillows when sleeping or
place in high fowlers
4. Productive cough with blood tinged sputum
(severe pulmonary edema)
5. Frothy salivation
LEFT SIDED HEART FAILURE
Signs and Symptoms
6. Cyanosis
7. Rales/Crackles (bi-basilar lobes that do not
clear w/ coughing)
8. Bronchial wheezing
9. Pulsus Alternans – weak pulse followed by
strong bounding pulse
10. PMI is displaced laterally due to cardiomegaly
LEFT SIDED HEART FAILURE
Signs and Symptoms
11. There is anorexia and generalized body
malaise
12. S3 – ventricular gallop
13. Oliguria – blood flow to the kidney decreases,
causing decreased perfusion and reduce urine
output. (Daytime)
14. Nocturia – sleeping cardiac workload
decreased, improving renal perfusion, which then
leads to frequent urination at
Night.
LEFT SIDED HEART FAILURE

Left-Sided Heart Failure (CHOP):

C- Cough
H- Hemoptysis
O- Orthopnea
P- Pulmonary Congestion (crackles/ rales)
LEFT SIDED HEART FAILURE
LEFT SIDED HEART FAILURE
Diagnostic Procedure
1. Chest x-ray – reveals cardiomegaly
2. PAP (pulmonary arterial pressure) –
measures pressure in right ventricle or
cardiac status
PCWP (pulmonary capillary wedge
pressure) – measures end systolic and
dyastolic pressure
- both are increased
- done by cardiac catheterization
(insertion of swan ganz catheter)
LEFT SIDED HEART FAILURE
Diagnostic Procedure
3. Echocardiography – enlarged heart
chamber (cardiomyopathy), dependent on
extent of heart failure
4. ABG – reveals PO2 is decreased
(hypoxemia), PCO2 is increased
(respiratory acidosis)
LEFT SIDED HEART FAILURE
Diagnostic tests:
• Chest X-ray: cardiac hypertrophy,
vascular congestion
• 2D echocardiography: increased size
of cardiac chamber
• ECG: cardiac hypertrophy
• ABG: decreased PaO2; increased
PaCO2
• Pulse oximeter: decreased SaO2
• Pulse arterial pressure (PAP) and
Pulmonary capillary wedge pressure
(PCWP): increased
LEFT SIDED HEART FAILURE
LEFT SIDED HEART FAILURE
LEFT SIDED HEART FAILURE
RIGHT SIDED
HEART FAILURE
RIGHT SIDED HEART FAILURE

• Weakened right ventricle is unable to

pump blood into the pulmonary system;
systemic venous congestion occurs as
pressure builds up
• Caused by left sided heart failure, right
ventricular infarction, atherosclerotic
heart disease, COPD, pulmonic
stenosis, pulmonary embolism
RIGHT SIDED HEART FAILURE

Pathophysiology:
• Right ventricular failure → blood
pooling in the venous circulation →
increased hydrostatic pressure →
peripheral edema
• Right ventricular failure → blood
pooling → venous congestion in the
kidney, liver and GIT
RIGHT SIDED HEART FAILURE
Predisposing Factors
1. Tricuspid valve stenosis
2. Pulmonary embolism
3. Related to COPD
4. Pulmonic valve stenosis
5. Left sided heart failure
RIGHT SIDED HEART FAILURE
Signs and Symptoms (venous
congestion)
1. Neck/jugular vein distension
2. Pitting edema (lower extremities)
3. Ascites
4. Weight gain
5. Hepatosplenomegaly
6. Jaundice
7. Pruritus (albumin)
8. Anorexia
9. Esophageal varices
RIGHT SIDED HEART FAILURE
Right-Sided Heart Failure (HEAD):
H- Hepatomegaly
E- Edema (Bipedal)
A- Ascites
D- Distended Neck Vein
RIGHT SIDED HEART FAILURE
RIGHT SIDED HEART FAILURE
RIGHT SIDED HEART FAILURE
Diagnostic Procedures
1. Chest x-ray – reveals
cardiomegaly
2. Central venous pressure (CVP)
- Measure pressure in right atrium (4
– 10 cm of water)
- CVP fluid status measure
- If CVP is less than 4 cm of water
hypovolemic shock
- Do the fluid challenge (increase IV
flow rate)
RIGHT SIDED HEART FAILURE
- If CVP is more than 10 cm of water
hypervolemic shock
- Administer loop diuretics as ordered
- When reading CVP patient should
be flat on bed
- Upon insertion place client in
Trendelenburg position to promote
ventricular filling and prevent
pulmonary embolism
RIGHT SIDED HEART FAILURE
3. Echocardiography – reveals
enlarged heart chambers
(cardiomyopathy)

4. Liver enzymes – SGPT and SGOT is

increased
RIGHT SIDED HEART FAILURE
Goal: increase cardiac contractility thereby
increasing cardiac output (3 – 6 L/min)
1. Enforce CBR
2. Administer medications as ordered
a. Cardiac glycosides
b. Dilated cardiomyopathy
- Digoxin (Lanoxin) (increases cardiac
contraction but lowers the pulse rate)
- Increase force of cardiac contraction
- If heart rate is decreased do not give
RIGHT SIDED HEART FAILURE
b. Loop Diuretics
- Lasix (Furosemide) peak 1-2 hrs, duration 6-8
hrs (monitor for hyperkalemia)
c. Bronchodilators aminophylline
d. Narcotic analgesics
- Morphine Sulfate
e. Vasodilators
- Nitroglycerine
f. Anti Arrhythmic
- Lidocaine (Xylocane)
RIGHT SIDED HEART FAILURE
3. Administer oxygen inhalation with high inflow, 3
– 4 L/min, delivered via nasal cannula
4. High fowler‘s position
5. Monitor strictly vital signs, intake and output and
ECG tracing
6. Measure abdominal girth daily and notify
physician
7. Provide a dietary intake of low sodium,
cholesterol and caffeine
8. Provide meticulous skin care
RIGHT SIDED HEART FAILURE
9. Assist in bloodless phlebotomy – rotating tourniquet,
rotated clockwise every 15 minutes to promote decrease
venous return
10. Provide client health teaching and discharge planning
a. Prevent complications
- Arrhythmia
- Shock
- Right ventricular hypertrophy
- MI
- Thrombophlebitis
b. Dietary modification
c. Strict compliance to medications
MANAGEMENT OF
HEART FAILURE
HEART FAILURE
Goal of Treatment:
• Eliminate or reduce any etiologic
contributory factors
• Reduce workload of the heart by
decreasing preloads and afterloads
HEART FAILURE
Medical Management:
• Sodium and fluid restriction; weight
reduction; less than 2-3g of sodium per
day
• Avoidance of alcohol and smoking
• Oxygen therapy depending on the
client’s condition
• PTCA, CABG, Pacemakers, Valvular
Replacement
HEART FAILURE

Pharmacology:
Major types of drugs used to treat CHF:
a. Inotropic – affects cardiac contractility
b. Chronotropic – affects heart rate
c. Dromotropic – affects conduction velocity of
the AV node and rate of electrical impulses
in the heart
HEART FAILURE
• Vasodilators: decreases blood pressure with
pooling of blood in the veins; decreases preload
and after load
• ACE inhibitors: decreases after load; decreases
blood volume
• ARB: lowers blood pressure and systemic
vascular resistance
• Diuretics
• Beta stimulators: increases myocardial
contraction (positive inotropic effect)
• Beta blockers: decreases myocardial contraction
HEART FAILURE
• Cardiotonic drugs: increases myocardial
contractility
• Hydralazine: lowers systemic vascular
resistance, decreases left ventricular
afterload
• Isosorbide Dinitrate: vasodilation, decreases
preload
• Digitalis: increases myocardial contraction,
improves contractility
• Anti-coagulants
• Calcium Channel Blockers
HEART FAILURE
HEART FAILURE
HEART FAILURE
Nursing intervention:
1. Monitor and assess client’s respiratory
status, provide ventilation, ABG, vital
signs, weight monitoring, MIO
2. Increase cardiac output: VS, ECG
3. Provide rest
4. Prevent complications such as
hypokalemia and hypomagnesemia
5. Reduce/eliminate edema
6. Skin care
7. Low salt diet
ACUTE HEART FAILURE
(PULMONARY EDEMA)
ACUTE HEART FAILURE

• Condition of rapid fluid accumulation in the

extravascular lung spaces
• Medical emergency that usually results from
left sided heart failure
• Capillary pressure within the lungs is too
much. Fluid pours from the blood into the
alveoli, bronchi and bronchioles
ACUTE HEART FAILURE
Etiology:
• MI, LSCHF, circulatory overload, smoke
inhalation or embolism, pulmonary infections,
CVA, head trauma, substance abuse
Pathophysiology:
• Pulmonary capillaries become filled with blood
→ increase in hydrostatic pressure →
capillaries cannot hold the hydrostatic pressure
→ fluid leaks out to the adjacent alveoli → fluid
in the lungs → atelectasis → severe hypoxia
ACUTE HEART FAILURE
Etiology:
• MI, LSCHF, circulatory overload, smoke
inhalation or embolism, pulmonary infections,
CVA, head trauma, substance abuse
Pathophysiology:
• Pulmonary capillaries become filled with blood
→ increase in hydrostatic pressure →
capillaries cannot hold the hydrostatic pressure
→ fluid leaks out to the adjacent alveoli → fluid
in the lungs → atelectasis → severe hypoxia
ACUTE HEART FAILURE

Clinical Manifestations:
• Restlessness, Fear, Anxiety
• DOB, Dyspnea
• Cyanotic nailbeds
• Ashen skin
• Cold and moist hands
• Incessant coughing
• Depressed O2 sat
• Frothy, Blood-tinged Sputum
• Tachycardia
• Elevated CVP
ACUTE HEART FAILURE

Diagnostic Tests:
• Chest X-ray: vascular congestion of the lung
fields(butterfly appearance)
• CVP and PCWP: elevated
• ABG: decreased PaO2 and increased PaCO2
• Pulse oximetry: decreased SaO2
Goal of Medical Management:
• Improvement of ventricular function
• Increase respiratory exchange
ACUTE HEART FAILURE

Medical Management:
• Oxygenation – Positive End Expiratory Pressure
(PEEP)
Pharmacology:
• Morphine sulfate(2-5mg): induce vasodilation
• Cardiac glycoside: digitalis to increase cardiac
output
• Diuretics: furosemide, excretion of sodium and
water
• Aminophylline: relieve bronchospasm and
increase output
• Vasodilators: nitroglycerin; dilate vessels
ACUTE HEART FAILURE
Pharmacology:
• Dobutamine: beta-adrenergic receptor stimulant,
increases cardiac contractility and heart rate, to
be administered after/with digitalis, beta-blockers
or calcium channel blockers
• Milrinone: decreases cardiac pre load and after
load by delaying the release of calcium from
intracellular reservoir
• Nesiritide: causes vasodilation and suppresses
neurohormones (renin, aldosterone,
norepinephrine)
ACUTE HEART FAILURE

Nursing Intervention:
1. Monitor VS and hemodynamics
2. Provide ventilation; intubation; high concentration
O2 (40-60%)
3. MIO
4. Positioning
5. Health teaching
6. Diet: low sodium, low cholesterol, potassium rich
7. Rotating tourniquets, phlebotomy
EMERGENCY
MANAGEMENT:
CARDIOPULMONARY
RESUSCITATION
CARDIOPULMONARY RESUSCITATION
Resuscitation consists of the following steps:

1. Airway: maintaining an open airway

2. Breathing: providing artificial ventilation by
rescue breathing
3. Circulation: promoting artificial circulation
by external cardiac compression
4. Defibrillation: restoring the heartbeat
CARDIOPULMONARY RESUSCITATION
CARDIOPULMONARY RESUSCITATION