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Heart Failure (HF) Pathophysiology

• Heart failure is the inability of the heart to provide sufficient output to meet the body's demands.
• A variety of disorders can lead to low or high output failure.
• Key issues include increased sympathetic nervous system activity, ADH secretion from the brain, cardiac dilation, and hypertrophy.
• Pulmonary and systemic venous congestion are significant consequences.
• Neurohormonal responses worsen HF.
• Sodium and water retention increase preload.

Risk Factors/Etiology

• Primary risk factors for heart failure include hypertension and CAD.
• If hypertension is aggressively treated and managed, the incidence of HF can be reduced by 50%.
• Co-morbidities contribute to the development of HF.
• Etiology of HF involves any interference with mechanisms regulating cardiac output (CO).
• Primary causes are conditions that directly damage the heart.
• Precipitating causes are conditions that increase the workload of the heart.

Classification

• Left-Sided Heart Failure
• Most common form.
• Results from inability of the left ventricle to:
• Empty adequately during systole.
• Fill adequately during diastole.
• Blood backs up into the left atrium (LA).
• Increased pulmonary hydrostatic pressure causes fluid leakage from the pulmonary capillary bed into the interstitium and then the alveoli.
• This results in pulmonary congestion and edema.
• Right-Sided Heart Failure
• The RV does not pump effectively.
• Fluid backs up in the venous system.
• This results in peripheral edema, JVD, and ascites.
• Left-sided HF is the most common cause.
• Other causes include RV infarction, PE, and cor pulmonale (RV dilation and hypertrophy).
• Further classified:
• HFrEF (systolic HF): reduced ejection fraction.
• HFpEF (diastolic HF): preserved ejection fraction (problem with relaxation/refilling).
• Or combination of the two.

Heart Failure

• HFrEF (Systolic Failure)
• It is the Inability to pump blood effectively.
• Impaired contractile function.
• Increased Afterload.
• Mechanical abnormalities.
• Decreased LV ejection fraction (LVEF).
• HFpEF (Diastolic HF)
• Inability of the ventricles to relax and fill during the diastole, resulting in decreased SV and CO.
• Result of left ventricular hypertrophy from HTN.
• Hypertension, older age, female, diabetes, obesity. Diagnosis based on:
• Symptoms of HF
• Normal LVEF
• LV diastolic dysfunction

Chronic Heart Failure Clinical Manifestations

• General Symptoms: Fatigue.
• Respiratory Symptoms: Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and cough.
• Cardiovascular Symptoms: Tachycardia can develop.
• Systemic Symptoms: Edema, palpitations, and skin changes.
• Neurological symptoms can occur, as can mental and behavioral changes along with sleep disturbances.
• Other symptoms: Chest pain and weight changes indicate related health shifts.

Labs & Diagnostics

• Diagnostics
• Echocardiogram provides the fluid overload/damage.
• Information on LVEF
• Heart Valves
• Presence of Effusion/Thrombus
• ECG, chest x-ray, ambulatory heart monitors, stress test, MRI, and cardiac catheterization are used.
• BNP levels indicate if there is damage.
• Elevated BNP indicates fluid overload.
• Diuretics are indicated with increased fluid.

Interprofessional Care

• Main Treatment Goals
• Treating the underlying cause and contributing factors.
• Maximize CO through ventricular function.
• Improving quality of life is also key.
• Preserving the function of target organs.
• Oxygen Therapy
• Relieves dyspnea and fatigue.
• Physical and Emotional Rest
• Conserving energy and decreasing oxygen needs.
• Structured Exercise Program
• Cardiac rehabilitation is associated with better outcomes.
• 30min workouts are recommended 3x/week.

Interprofessional Care

• Nutritional Therapy
• Low sodium diet of processed foods, canned foods and little to no red meats
• A 2g/day diet is recommended.
• Cultural background should be considered when individual recommendations are given.
• Dietary guidelines are found on AHA websites.
• Fluid restriction depends on if patients are in stage D or IV HF.
• A weight gain of 3lbs in 2 days, or a 3-5lbs gain over a week should be reported immediately/a diuretic will be issued.

Drug Therapy

• RAAS Inhibitors
• ACE Inhibitors (-pril).
• ↓ BP and Afterload
• Angiotensin II Receptor Blockers
• Use ARBs if dry cough.
• Allergic, ethnic background.
• Neprilysin-Angiotensin Receptor Inhibitors
• Aldosterone Antagonists (Spironolactone)
• Monitor K+.
• Vasodilators (Reduce preload and afterload).
• ↓ workload
• Nitrates
• Positive Inotropic Agents
• Increase contractility which improves CO
• Digitalis
• Dig Toxicity (GI)
• Diuretics Furosemide (Thiazide, ↓K+, ↓Mg+)
• Reducing Edema
• Pulmonary Venous Pressure
• Preload
• Promoting Sodium and Water Excretion
• Loop Diuretics
• Thiazide Diuretics
• Monitor Potassium Levels (Hypokalemia)

Nursing Management

• Nursing Implementation focuses on Health promotion and basic principles of care
• Health Promotion involves Communication and joint decision making with patient, caregiver and interprofessional team.
• Aggressively identify risk factors for HF to prevent or slow disease progression.
• Basic Principles of Care should entail that HF is progressive, and goals are made with quality of life goals in mind.
• Symptom management also depends on adherence to self management protocols.
• Nurses should address factors like Etiologies, and Conditions, and to provide support when patients feel stressed.
• Nursing, also focuses on positioning, Respiratory and hemodynamic status and administration of care.
• Respiratory status and oxygen therapy are priority.
• Semi-Fowler's position and monitor hemodynamic status is encouraged.
• Daily weights and I/O should also me monitored, as well medicated prescriptions (especially for edema)

Nursing Management

• Alternate Rest With Activity; Provide Diversionary Activities.
• Monitor Response to activity and collaborate with OT/PT.
• Reduce Anxiety and evaluate support system
• Patient signs and the symptoms of worsening HF and therapeutic intervention in care.
• Telehealth and remote monitoring technology can help avoid acute incidents.

Nursing management

• Ensure the following actions for Drug Therapy are implemented:
• Basic mechanism of action to take
• Signs of drug toxicity (check apical pulse for 1 minute).
• How to take pulse for a full minute, Home BP monitoring.
• Signs and symptoms of hypokalemia and hyperkalemia.
• Exercise training
• Individualize for the client and teach the importance of rest.
• Conserve energy and manage the environment to make a lower strain situation.
• Consult with PT/OT.

Nursing management

• Evaluation/Expected:
• Maintain adequate ventilation; ensure the body is supplied with enough blood.
• Reduce/Remove edema from the body, and balance energy with a good exercise regiment.

Cardiomyopathy

• Presentation
• The conditions below reflect on the anatomy and structure of the heart, and often lead to heart failure

Dilated Cardiomyopathy

• Most common type in 25-40% HF cases
• Infectious myocarditis and/or consistent alcohol/drug use
• Patient Manifestations
• Decreased Exercise/Rest Capacities
• Orthopnea is increasingly prevalent
• Dry Coughs w/ Edema
• Weak Peripheral Pulses

Dilated Cardiomyopathy

• Dx. Studies:
• Doppler Echocardiography
• CXR
• ECG, BNP/Catheterization (endomyocardial biopsy)
• Interprofessional/Nursing Care:
• Nitrates, B-Blockers, and Antidysrhythmics help regulate abnormal rhythms.
• ACE Inhibitors and Diuretics are vital to patient care.
• Digitalis/ Nutritional Therapy is required.
• Be prepared to teach the patient how to administer CPR.

Hypertrophic Cardiomyopathy

• Diagnosed in athletic adults
• Genetic, Aortic causes
• Massive ventricular hypertrophy
• forceful contraction/impaired relaxation is common Signs can be asymptomatic

Restrictive Cardiomyopathy

• Rare Heart Disease
• Causes: Amyloidosis and Cancer
• Fatigue/Intolerance are likely a manifestation of the issue.
• Dyspnea/Stiffening are signs of heart difficulties.
• Nurse should provide information about heart transplant and reducing strenuous work.

Valvular Heart Disease

• The heart has two atrioventricular valves (mitral/tricuspid) and two semilunar valves (aortic/pulmonic).
• Types are determined by: which valve is affected and the type of dysfunction (stenosis/regurgitation)

Valvular Heart Disease

• Mitral Valve Stenosis is often common.
• It is a stiff valve caused by heart disease.
• Contractions develop and decreased blood flow.
• There is risk of Atrial Fribillation.

Mitral Valve Regurgitation

• To have a Normal Valve it is important to maintain
• Intact/Clear leaflets of: the mitral annulus and Chordae tendineae.
• It should also maintain Papillary muscles. Damage can be caused by Rheumatic/Ischemic Muscle Difficulties.
• Incomplete Valve Closure
• Backward Flow of Blood
• Acute/Chronic Valve Closure
• Pulmonary Edema is dangerous w/ ventricular hypertrophy.

Mitral Valve Regurgitation

• Specific symptoms related to clinical manifestations
• Thread Peripheral Pulses
• Asymptomatic for years.
• Chronic Clinical Manifestations: Weakness/Fatigue
• Progress w/ Othopnea and murmurs

Mitral Valve Prolapse

• Abnormality of leaflets and papillary muscles.
• Leaflets Prolapse during Systole
• Benign in nature w/ certain treatments + closing procedures
• Not a confirmed process (it may be genetic)
• Most Asymptomatic issues

Mitral valve prolapse.

• Dysrhythmias can cause palpitations/lightheadedness/syncope.
• You are able to treat symptoms with beta Blockers,
• If MR is present please provide Prophylaxis

Aortic valve stenosis

• Aortic valve stenosis (AS) is a congenital condition often found in childhood/young adulthood, or may be degenerative/rheumatic.
• Obstruction of blood flow from the left ventricle to the aorta can occur.
• It can lead to decreased tissue perfusion, pulmonary hypertension, and HF.
• It has a poor prognosis if left untreated.
• Clinical Manifestations:
• Syncope
• Angina
• Exertional dyspnea
• Auscultatory findings: There can be a normal-soft S1, and an absent S2.
• Use nitroglycerin cautiously.
• It can reduce preload and BP, but it can worsen chest pain

Aortic Valve Regurgitation

• Acute AR: IE, Trauma, Life threat
• Backward flow from ascending Aorta can lead to ventricular dilation and hypertrophy. Clinical manifestations of ACUTE AR
• Severe dyspnea
• Chest pain
• Hypotension
• Life Threathing issue

Aortic valve regurgitation

• Clinical Chronic AR: years of heart problems Exertion/Angina -Murmur and High Pulse to the heart -If you have High pulse please elevate the heart beat.

Labs & Diagnostics

• Patient History is key
• Physical Examination information
• EGC Data should be gathered. Heart catheterization may be required.

Interprofessional Care

• Maintain an open airway
• Provide Prophylactic antibiotics to avoid heart issues

Interprofessional care

• Consider surgical valve repair.

Surgical Valve Repair

• Use an Aorta Valve if it is required
• Biologic Tissue
• Bovine, Porcine, Human.

Nursing Management

• Impaired Outputs mean higher Fluid Imbalances/Lower activity
• Improve activity tolerance, but promote exercise

Nursing management

• Individualize rest with gentle exercise.
• Followup should be made to treat cardiac health.

Nursing Management

• Maintain adequate fluids/ balance of blood and the functions of those things.

Peripheral Artery Disease (PAD)

• Thickening of the artery walls/narrowing of arteries
• Symptomatic people at age 60-80 suffer (earlier for Diabetics)
• PAD affects 8.5 million in United States per year
• Atherosclerosis is the main cause (gradual thickening of cholesterol/lipids).
• The Exact cause is unknown but damage to tissue occurs.

Pathogenesis of Atherosclerosis

• Chronic Endothelial Injury
• Hypertension, tobacco use, hyperlipidemia, elevated homocysteine levels, diabetes, infections, and toxins
• Cause Damaged endothelium
• Fatty Streak
• Lipids Accumulate and migrates into smooth muscle cells
• Fibrous Plaque
• Collagen covers the fatty streak. Vessel lumen is narrowed. Blood flow is reduced/Fissures can develop
• Complicated Lesion
• Plaque Rupture
• Thrombus Formation - Furthermore, Narrows or Causes total occlusion of vessel

Risk Factors

• Risk Factors Involve
• Diabetics
• Atherosclerosis
• Tobacco Use
• High Cholesterol
• Risks increase in PAD, atherosclerosis/arteries of certain sections.
• Symptoms occurs when arteries are 60 - 75% blocked.

Clinical Manifestations

• Walking Around Can Damage Health; but may result in reduced intermittent claudication
• Sores/Numbness or limited blood flow can be common
• Changes to the patient's lifestyle are needed to prevent further pain

Assessment Findings

It may be necessary to check a full analysis of someone to assure health.

• The lack of circulation can be deadly

Diagnostic Studies

• Diagnostic studies such as Ankle-Brachial Index (ABI) have been used to see effects.
• Doppler and resonance tools are used for testing or evaluation of a situation.

Complications

• Prolonged Ischemia leads to: -Skin Atrophy. Muscle and wound Infections etc
• Amputation may Occur --With little effective blood circulation and severe inflammation. -Infections can spread/be uncontrolled

Interprofessional Care

• There are multiple drug and care efforts used to fight this.
• Cilostazol + Walking exercises/antiplatelets

Interprofessional Care

• Atherectomy has been used with various tip implements such diamond/cutting tips
• PTA and bypass surgery will lead to the growth of health tissue.

Nursing Management

• Poor tissue perfusion can cause a number of issues for the patient due to a lack of adequate tissue and oxygen intake.
• Exercise and healthy skin are essential parts of these stages.

Nursing Management

• Patients should quit smoking tobacco.
• Check the Skin and shoes to avoid feet issues.
• There should be effective pain management to allow for proper healing.

Nursing Management

• Be aware of the patients' condition and check them after they leave the care of a hospital.
• Compression and skin checks will tell you a great deal about the patient.
• Avoid prolonged stress on joints and have a solid plan on how to work these conditions.

Thromboagniitis Obliteans

• Thromboangiitis Obliteans
• Nonatherosclerotic, segmental, recurrent. inflammatory disorder Most common in men who are younger than 45 years old, that have CVD risk factors like tobacco abuse.
• Intermitted Claudication and changes to hands (color/temp).
• Treatment should involve ceasing any consumption of any material which can lead to cancer.

Raynaud's Phenomenon

• Raynaud Phenomenon
  • Vasoplastic disorder
  • Finger + Toes are easily hurt More common in women
• White/coldness/ red skin areas
• Triggers can Include Weather & Temperature
• Patient safety includes prevention efforts and education of effects.

Chronic Venous Insufficiency (CVI)

• Prolonged venous hypertension
• Sitting in One spot for period of time/Obesity/Pregnancy
• Skin in the region is hard+ Thick
• Bounding Pulses

CVI-Interprofessional and Nursing Care

• The main forms of dealing.
• IPC and Stockings/Wound + Skin care are extremely potent for issues.
• Be sure to eat healthy + give your body a good amount of vitamins and such.

Peripheral Venous Disease: Nursing Process

• Cues (ASSES)/ SOLUTIONS (PLAN)/ ACTIONS (TAKE)/ outcomes (Evaluate)
• Find wounds, pains or signs of infection and treat them

Hypertension (HTN)

_ The slides below will show the key points about hypertension and how it affects people!_

Overview

• High Blood Pressure in People with Pre-existing Condition.
• Causes 23.7% of deaths in United States.
• Risks: Stroke MI/Renal Failure.

General Data

• More common in older, more stressed women to the heart.
• Hypertension more effective to control in people in younger populations

Normal Regulation of BP

• BP is a force between walls and vessels
• Systemic factors determine internal pressure

Classification of HTN

Etiology Of HTN

Primary:

• elevated blood pressure/unknown cause
• high cholesterol in some forms
• genetic reasons Secondary:
• sudden development
• endocrine complications, pregnancy induced

Risk Factors

• Risk Factor Age can influence Blood Pressue

Complifications

Eye -Aortic Nicking and narrowing are all linked Heart -Coronary problems are linked Brain -Brain tissue may be damaged Kidney -Serum damage -Peripheral Vascular is likely -Damage Vessels Indicate the effects

Diagnostic Studies

• Diagnostic Studies: Lab to identify health problems.
• Blood in test, and Ambulatory levels can test if there are heart problems.
• Ambulatory Blood Pressure (ABPM) Non invasive; helps in some test.

Interprofessional Care

• Maintain low HP and cholesterol content.
• Get active and improve your health.

Interprofessional Care

• Focus on a Low Diet of 2300MG a day.
• Avoid food with high salt content.
• Eat health foods without much fats.

Interprofessional Care

• Reduce/Cease all Tobacco
• Reduce high levels of stress
• Drink less soda and alcohol

Interprofessional Care Notes

• Vasodilators that reduce constrictions will be effective to provide more long term control.

Nursing Management Notes

• It's recommended to know the patient's history for a faster recovery and diagnosis to improve any given patient's life.

Nursing Management

• BP reading tests: -Take in both arms, note differences -Use your upper arm or do something such as measure someone's forearm with 200HG. -You perform multiple tests at a time.

Nursing Recommendations - Community

• give verbal recommendations to take less drugs.
• suggest community outreach

Notes on Management

• Take Drugs as prescribed
• Check Diet
• Home BP is important (Monitor+Record)

Nursing Management

• Patient Health may result