Valvular Heart Disorders: Nursing Management

Heart Failure #1

• Cardiovascular disease is the primary cause of death in the United States.
• Heart disease is often a chronic and progressive condition linked with co-morbidities like heart failure.
• Heart failure (HF) arises from structural or functional cardiac disorders affecting the ventricle's ability to fill or eject blood. The heart becomes unable to pump enough blood to meet metabolic demands

Heart Failure #2

• Heart failure indicates myocardial disease, disrupting the contraction of the heart (systolic dysfunction) or filling of the heart (diastolic dysfunction), which can lead to pulmonary or systemic congestion.
• Some HF cases are reversible, depending on the root cause.
• Most HF is a chronic condition, managed through lifestyle changes and medications.

Chronic Heart Failure

• The occurrence of HF rises with age.
• Approximately 6 million individuals in the United States have HF, with 870,000 new cases each year.
• HF is the most frequent cause for hospitalization in individuals over 65 years and the second most common reason for provider's office visits.
• About 20% of HF patients are readmitted to the hospital within 30 days after discharge and almost 50% within 6 months.

Pathophysiology of Heart Failure

• Myocardial dysfunction can occur due to ischemic heart disease, hyperthyroidism, myocardial infarction, valve disease, alcohol/cocaine abuse, and hypertension.
• Several compensatory mechanisms are activated including:
  • Activation of baroreceptors
  • Stimulation of vasomotor regulatory centers in the medulla
  • Activation of sympathetic nervous system
  • Renin-angiotensin-aldosterone system activation.
• This leads to vasoconstriction, increased afterload, increased blood pressure and heart rate potentially causing ventricular remodeling

Clinical Manifestations of Heart Failure

Right Sided Heart Failure

• Viscera and peripheral congestion
• Jugular venous distention (JVD)
• Dependent edema
• Hepatomegaly
• Ascites
• Weight gain

Left Sided Heart Failure

• Pulmonary congestion, crackles
• S3 or "ventricular gallop"
• Dyspnea on exertion (DOE)
• Low O₂ sat
• Dry, nonproductive cough initially.
• Oliguria

Medical Management of the Patient with Heart Failure

• Medical management depends on the severity of the patient’s condition, comorbidities, and cause.
• Treatments include:
  • Oral and IV Medications
  • Lifestyle modifications
  • Supplemental O₂
  • Surgical interventions like ICD and heart transplant
• Comprehensive education is to be provided to patient and family

Medications Used to Treat HF #1:

• Diuretics decrease fluid volume, monitor serum electrolytes.
• Angiotensin-converting enzyme(ACE) inhibitors can be used for vasodilation, diuresis, and decreased afterload. Watch for hypotension, hyperkalemia, altered renal function, and cough.
• Angiotensin II receptor blockers can be prescribed as an alternative to ACE inhibitors; they work similarly.
• Beta-blockers can be prescribed with ACE inhibitors; effects may take weeks to be seen. Use with caution in patients with asthma.

Medications Used to Treat HF #2

• Ivabradine is used to decrease SA node conduction, so monitor for decreased HR and BP.
• Hydralazine and isosorbide dinitrate: alternative to ACE inhibitors; observe for decreased BP.
• Digitalis improves contractility but watch out for digitalis toxicity, especially if the patient is hypokalemic.

Medications Used to Treat HF #3

• IV medications: for hospitalized patients with acute decompensated HF.
  • Dopamine: vasopressor to increase BP and myocardial contractility; adjunct with loop diuretics
  • Dobutamine: used for patients with left ventricular dysfunction; increases cardiac contractility and renal perfusion
  • Milrinone: decreases preload and afterload; causes hypotension and increased risk of dysrhythmias.
  • Vasodilators: IV nitro, nitroprusside, nesiritide enhance symptom relief.

Gerontologic Considerations of Heart Failure

• Older people might show signs and symptoms such as fatigue, weakness, and sleepiness.
• Reduced kidney function can make older patients resistant to diuretics and more sensitive to volume changes.
• When giving diuretics to older men, nurses watch for bladder distention from urethral obstruction due to an enlarged prostate.

Assessment of the Patient with Heart Failure

• Focus on:
  • Effectiveness of therapy
  • Patient's self-management
  • S&S of increased HF
  • Emotional or psychosocial response
• Take Health history
• PE:
  • Mental status
  • Lung sounds (crackles and wheezes);
  • Heart sounds (S3)
  • Fluid status (signs of fluid overload)
  • Daily weight and I&O
  • Responses to medications

Collaborative Problems and Potential Complications of Heart Failure

• Pulmonary Edema
• Hypotension, poor perfusion, and cardiogenic shock
• Arrhythmias
• Thromboembolism
• Pericardial effusion

Planning and Goals for the Patient With Heart Failure

• Promote activity and reduce fatigue
• Relieve fluid overload symptoms
• Decrease anxiety or increase the patient's ability to manage anxiety
• Encourage the patient to verbalize his or her ability to make decisions and influence outcomes
• Educate the patient and family about management of the therapeutic regimen

Nursing Interventions for the Patient with Heart Failure #1

• Promote activity tolerance:
  • Bed rest for acute exacerbations
  • Regular physical activity, aim for 30 minutes daily
  • Exercise training.
  • Pacing of activities; wait 2 hours after eating for physical activity
  • Avoid activities in extreme hot, cold, or humid weather
  • Modify activities to conserve energy
  • Elevate the head of bed to facilitate breathing and rest, support arms

Nursing Interventions for the Patient with Heart Failure #2

• Manage fluid volume:
  • Assess symptoms of fluid overload
  • Daily weight
  • I&O
  • Diuretic therapy; timing
  • Fluid intake; fluid restriction.
  • Maintain sodium restrictions.

Patient Education for the Patient with Heart Failure

• Medications
• Diet: low-sodium diet and fluid restriction
• Monitor 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 education

Pulmonary Edema

• Pulmonary edema is an acute event reflecting a breakdown of physiologic compensatory mechanisms.
• As left ventricle (LV) begins to fail, blood backs up into the pulmonary circulation, causing pulmonary interstitial edema.
• Results in hypoxemia, often severe.
• Clinical manifestations: restlessness, anxiety, tachypnea, dyspnea, cool and clammy skin, cyanosis, weak and rapid pulse, cough, lung congestion (moist, noisy respirations), increased sputum production (may be frothy and blood-tinged), and decreased level of consciousness.

Management of Pulmonary Edema

• Easier to prevent than to treat
• Early recognition: Monitor lung sounds and watch out for signs of decreased activity tolerance and fluid retention
• Minimize exertion and stress
• Oxygen via nonrebreather mask
• Medications:
  • Diuretics (furosemide)
  • Vasodilators (nitroglycerin)

Nursing Interventions for the Patient with Pulmonary Edema

• Positioning the patient to promote circulation
  • Positioned upright with legs dangling
• Providing psychological support
  • Reassure patient and provide anticipatory care
• Monitoring medications
  • Monitor I&O

End-of-Life Considerations

• HF is a chronic and often progressive condition
  • Need to consider issues related to end of life
  • Consider palliative/hospice care needs

Cardiogenic Shock

• A life-threatening condition with a high mortality rate.
• Decreased CO leads to inadequate tissue perfusion and initiation of shock syndrome
• Commonly occurs following acute MI when a large area of myocardium becomes ischemic and hypokinetic
• Can occur as a result of end-stage HF, cardiac tamponade, pulmonary embolism (PE), cardiomyopathy, and arrhythmias

Thromboembolism

• Cardiovascular disorder patients are at risk for arterial and venous thromboemboli (VTE).
• Decreased mobility and circulation increase the risk for VTE in patients with cardiac disorders, including those with HF.
• Intracardiac thrombi form in patients with atrial fibrillation because the atria do not contract forcefully, increasing thrombus formation.
• Pulmonary embolism: A blood clot from the legs moves to obstruct pulmonary vessels.

Pericardial Effusion and Cardiac Tamponade

• Pericardial effusion involves fluid accumulation in the pericardial sac.
• Cardiac tamponade is the restriction of heart function because of this fluid, which causes decreased venous return and CO.
• Clinical manifestations: ill-defined chest pain or fullness, pulsus paradoxus, engorged neck veins, labile or low BP, and shortness of breath.
• Cardinal signs of cardiac tamponade: falling systolic BP, narrowing pulse pressure, rising venous pressure, and distant heart sounds.

Medical Management of Pericardial Effusion and Cardiac Tamponade

• Pericardiocentesis
  • Puncture of the pericardial sac to aspirate pericardial fluid
• Pericardiotomy
  • Under general anesthesia, a portion of the pericardium is excised to permit the exudative pericardial fluid to drain into the lymphatic system

Sudden Cardiac Death or Cardiac Arrest

• Emergency management: cardiopulmonary resuscitation
  • A: airway
  • B: breathing
  • C: circulation
  • D: defibrillation for VT and VF