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• Cardiac output is the amount of blood pumped out of the left ventricle after each contraction, calculated by stroke volume (SV) multiplied by heart rate (HR).
• Preload refers to the volume of blood in the ventricles at the end of diastole, also known as end-diastolic pressure.
• Afterload is the resistance the left ventricle must overcome to circulate blood.
• Increased afterload leads to increased cardiac workload.

Preload and Afterload

• Preload is the volume of blood in the ventricles at the end of diastole (end diastolic pressure).
• Conditions that increase preload include hypervolemia, regurgitation of cardiac valves, and heart failure.
• Afterload is the resistance the left ventricle must overcome to circulate blood.
• Conditions that increase afterload include hypertension and vasoconstriction.
• Increased afterload leads to increased cardiac workload.

Heart Failure Pathophysiology

• Heart failure is a syndrome characterized by fluid overload or inadequate tissue perfusion, indicating myocardial disease.
• This myocardial disease is related to an issue with the heart's contraction (systolic failure) or filling (diastolic failure).
• The left ventricle failing to effectively pump blood to the aorta and systemic circulation, or the right ventricle being unable to accommodate blood volume from venous circulation.
• Complications may include pleural effusion (anemia), dysrhythmias, hepatomegaly, cardiorenal syndrome, and anemia.

Right-Sided Heart Failure

• Signs of right ventricular heaves, increased heart rate, ascites, anasarca, edema (e.g., pedal, scrotal), hepatomegaly, JVD, murmurs, and weight gain.
• Symptoms include anorexia, GI bloating, anxiety, depression, fatigue, nausea, and RUQ pain.

Left-Sided Heart Failure

• Signs include left ventricular heaves, increased heart rate, S3 and S4 heart sounds, increased PaO2 (with slight increased PaCO2), confusion, restlessness, dry hacking cough, crackles (pulmonary edema), pleural effusion, PMI displaced inferiorly and left midclavicular line (LV hypertrophy), pulsus alternans, and shallow respirations.
• Symptoms include anxiety, depression, dyspnea, fatigue, weakness, nocturia, orthopnea, and paroxysmal nocturnal dyspnea.

Heart Failure: Assessment, Interventions, and Medications

• Signs/Symptoms: Shortness of breath (SOB) at rest, fatigue, pallor, dyspnea, peripheral edema, tachycardia, edema, changes in urine output, skin changes (pallor, dusky cyanosis, shiny with edema), mental status changes, chest pain, weight changes, orthopnea, nausea, palpitations.
• Diagnostic Testing: Elevated BNP (Normal <100), echocardiogram for low ejection fraction (EF) (Normal 55-70%).
• Defined as the heart's inability to pump sufficient blood to meet tissue needs for oxygen and nutrients.
• Nursing Interventions: Assessment and evaluation of labs, gathering history, monitoring intake/output and electrolytes, telemetry, fall precautions, ventilatory support, and O2 therapy.
• Education includes diet therapy (low sodium or fluid restriction), activity program (cardiac rehab), drug therapy, health promotion (daily weights), rest, and ongoing monitoring.
• Medications: Diuretics (Furosemide): Monitor blood pressure due to potential drops, ensure repletion of potassium and magnesium before starting.

Clinical Manifestations of Heart Failure

• Fatigue
• Dyspnea
• Cough
• Tachycardia
• Palpitations
• Edema
• Changes in urine output
• Skin changes
• Mental status and behavior changes
• Sleep problems
• Chest pain
• Weight changes

Complications of Heart Failure

• Pleural effusion
• Dysrhythmias
• Hepatomegaly
• Cardiorenal syndrome
• Anemia

Cardiomyopathy: Assessment, Treatment, and Interventions

• Symptoms include dyspnea, fatigue, angina, murmurs (S3, S4), and dysrhythmias.
• Primary cardiomyopathy idiopathic, involving only the heart muscle.
• Secondary cardiomyopathy results from other diseases like cancer, muscular dystrophy, or sarcoidosis.
• Medical treatment options are surgical repair and heart transplant.
• Diagnostics include chest X-rays (cardiomegaly), ECG (low EF), and elevated BNP.
• Nursing interventions include educating on symptom management, medication adherence, balancing activity and rest, recognizing HF signs (SOB, weight gain), CPR education, cardiac rehab, VAD, and implantable cardioverter-defibrillator (ICD) for lethal arrhythmias.
• Prescribed medications include Beta-Blockers, Antidysrhythmics, ACE inhibitors, Calcium channel blockers, Diuretics, Anticoagulants, and Nitrates (for angina).

Types of Cardiomyopathy

• Dilated: The most common, with diffuse inflammation and rapid of heart fibers leading to impaired systolic function.
  • All 4 chambers are enlarged, decreasing contractility and cardiac output.
• Restrictive: Right ventricular walls cannot stretch during filling, leading to right heart failure and decreased stroke volume and cardiac output.
• Hypertrophic: Genetic, causing asymmetric left ventricular hypertrophy without dilation; typically diagnosed in active young athletes; impairs diastolic filling and stretch.
  • Progressive thickening of the ventricular muscle, decreasing cardiac output.

Assessment Findings in Cardiomyopathy

• All symptoms include Dyspnea, fatigue, angina, syncope, dysrhythmias, S3/S4.

Priority Assessments

• Auscultate heart and lung sounds, H&P, neuro assessment

Diagnostic Testing

• EKG (dilated heart walls and EF 30%), BNP (elevated), Chest x-ray (see if cardiomegaly is present)

Abnormal Findings and Goals for ICDs

• Expected abnormal findings include JVD, N/V, weight loss, bloating, pallor, thready weak pulses, dry cough, palpitations, and decreased appetite.
• Goal: Optimize level of function; grave prognosis.
• Implantable Cardioverter Defibrillator (ICD) indications:
  • Those who have survived sudden cardiac death.
  • Lethal dysrhythmias.
  • High risk for lethal dysrhythmias (Patients with HF)
• The lead system is inserted via the subclavian vein into the endocardium and is battery powered.

Patient Education topics for ICDs

• Magnets
• Travel considerations
• Medic Alert bracelet
• CPR
• "Interrogation."

Hypertension (HTN) Overview

• Risk factors: Smoking, age, diabetes, ethnicity, sodium intake and stress.
• Manifestations (often silent): Fatigue, dizziness, palpitations, angina, and dyspnea.
• HTN can result in an increase in cardiac output (CO), systemic vascular resistance (SVR), or both.
• Primary HTN has no identifiable cause.
• Secondary HTN is caused by a specific condition.
• Assessment of HTN includes checking GFR, BUN, creatinine lab values, and 12-lead EKG.
• Nursing interventions: Gather history and physical data, educate on complications (stroke, vision loss, kidney disease, sexual dysfunction, HF), monitor blood pressure, nutrition therapy (limit saturated fats, trans fats, red meat), exercise (walking 30 minutes moderate exercise), limit alcohol consumption, and manage stress.
• Side effect: orthostatic hypotension, change & notify for side effects

Blood Pressure Classifications

• Normal: Systolic <120 and Diastolic <80
• Elevated: Systolic 120-129 and Diastolic <80
• HTN, stage 1: Systolic 130-139 or Diastolic 80-89
• HTN, stage 2: Systolic ≥140 or Diastolic ≥90
• SVR is the force opposing the blood movement within the blood vessels.
  • The radius of small arteries and arterioles is significant factor determining SVR, as narrowing arteries increases resistance to blood flow.

Hypertensive Crisis

• Signs/Symptoms: Headache, blurred vision, vomiting, confusion, nosebleeds, bounding pulse, chest pain.
• 180/120+
• Normal MAP: 70-100
• Labs: troponin, CMP, ECG and BP
• Treatment includes surgeries and procedures.
• Monitor Blood pressure with ECG, Auscultate cardiac and respiratory sound, insert IV antihypertensives, O2 as prescribed.
• Antihypertensives are with the goal to Decrease MAP by no more than 20-25% and caution Bedrest with cardiac, lung, neuro, renal assessment.

Hypertensive Crisis Assessment and Interventions

• MAP is used to evaluate therapy and should be decreased by no more than 20-25% or to 110-115 mmHg.
• Confirm that medications are effective through bed rest, cardiac, lung, neuro, and renal assessments.

Causes of Hypertensive Crisis

• Acute aortic dissection
• Drug use (cocaine, amphetamines)
• Exacerbation of chronic hypertension
• Head injury
• Monoamine oxidase inhibitors taken with tyramine-containing foods
• Pheochromocytoma
• Preeclampsia, eclampsia
• Rebound hypertension (from abrupt withdrawal of some antihypertensive drugs)

Assessment Findings in Hypertensive Crisis

• Systolic BP >180mmHg and/or diastolic BP >120mmHg
• Blurred vision
• Chest pain
• Confusion
• Dyspnea
• Headache
• Nausea/vomiting
• Nosebleeds
• Seizures

Interventions for Hypertensive Crisis

• Obtain baseline vital signs, including O2 saturation
• Start continuous BP and ECG monitoring
• Auscultate heart and breath sounds
• Insert IV
• Administer IV antihypertensives
• Obtain baseline blood work
• Give O2 per agency protocol

Ongoing care

• Monitor vital signs, LOC, heart and breath sounds, neurologic function, heart rhythm, and O2 saturation.
• Titrate drugs according to MAP or SBP as ordered.
• Assess and record responses to drugs.
• Measure urine output hourly.
• Maintain bed rest.
• Provide reassurance and emotional support to patient and caregiver.
• Explain all interventions to patient
• Understand the potential side effects