Management of Patients with Heart Disease PDF

Management of Patients with Complications from Heart Disease Chapter 25 page 793 Objectives Recognize the etiology, pathophysiology, and clinical manifestations of the different categories of heart failure Describe the medical management, including recommended pharmacologic tr...

Management of Patients with Complications from Heart Disease Chapter 25 page 793 Objectives Recognize the etiology, pathophysiology, and clinical manifestations of the different categories of heart failure Describe the medical management, including recommended pharmacologic treatments for patients with heart failure Use the nursing process as a framework for care of the patient with heart failure Identify additional heart disease disorders and medical and nursing management of patients with complications from heart disease Heart Failure Clinical syndrome where heart is unable to pump enough blood to meet body’s needs Myocardial disease with systolic dysfunction (contraction) or diastolic dysfunction (filling) Chronic and progressive ○ Can be managed by lifestyle changes or medications Patients who are over 65 y/o have a higher risk of hospitalization and hospital and readmission Risk Factors African Americans and Latinos Age (over 60 y/o) Gender (men more likely than women) Major cardiac disorders Diabetes Cigarette smoking Obesity Metabolic Syndrome CAD, cardiomyopathy, poorly managed cholesterol Types of Heart Failure Dysfunction typically occurs before the patient experiences symptoms (edema, SOB, fatigue) Systolic Heart Failure: ○ Most common form of HF Diastolic Heart Failure Systolic Heart Failure Decreased blood flow ejected from ventricle Baroreceptors sense this and stimulate release of epinephrine in order to increase the HR to pump more blood Vasoconstriction occurs Kidneys will release renin (plasma protein that converts angiotensinogen to angiotensin I in the lungs Angiotensin-converting enzyme (ACE) converts angiotensin I-angiotensin II These lead to increased preload and afterload Cardiac chambers will release Atrial Natriuretic Peptide (ANP) and B-type Natriuretic Peptide (BNP) to vasodilate Systolic Heart Failure Cont Ventricular Dilation ○ Increased workload=decreased contractility ○ Myocardial stretching occurs and increases the size of the ventricle Ventricular Hypertrophy: ○ Abnormal changes in the structure/function of myocardial cells (ventricular remodeling) ○ Happens under the influence of neurohormones (angiotensin II) ○ Enlarged myocardial cells become dysfunctional and stimulate early apoptosis Diastolic Heart Failure Preserved Ejection fraction Stiff ventricle will not fill Leading to decrease CO (cardiac output) Makes the heart work harder to pump Signs and Symptoms of Heart Failure Congestion: ○ Dyspnea ○ Orthopnea ○ Paroxysmal nocturnal dyspnea ○ Cough ○ Pulmonary crackles ○ Rapid weight gain ○ Dependent edema ○ Abdominal bloating ○ Ascites ○ JVD ○ Fatigue Signs and Symptoms of Heart Failure cont Poor perfusion/low cardiac output ○ Decreased exercise tolerance ○ Muscle wasting/weakness ○ Anorexia or nausea ○ Unexplained weight loss ○ Lightheaded or dizziness ○ Unexplained confusion or altered mental status ○ Resting tachycardia ○ Daytime oliguria ○ Cool, vasoconstricted extremities ○ Pale or cyanotic Left Sided Heart Failure Left ventricular failure ○ Inability of the left ventricle to fill or eject blood to the body S/S: ○ Pulmonary congestion ○ Dyspnea ○ Cough ○ Crackles ○ Low O2 sat ○ Orthopnea (cannot lie flat) ○ Paroxysmal nocturnal dyspnea (sudden dyspnea) Left-Sided Heart Failure Symptoms Explained Orthopnea: patient unable to lie flat and may require multiple pillows when sleeping Paroxysmal orthopnea: fluid accumulated in the extremities during the day is reabsorbed when the patient lies down ○ Impaired left ventricle cannot eject fluid to body and fluid becomes backed up ○ Alveoli cannot gas exchange Cough: pink or tan sputum indicates decompensated HF and pulmonary edema Decreased Cardiac Output (CO): low perfusion to organs, stimulation of catecholamines, fatigue Right-Sided HF Right ventricular failures leads to congestion in the peripheral tissue and viscera Due to inability to accommodate the blood returning to the heart from venous circulation Increased JVD due to pressure in the venous system Hepatomegaly (enlargement of the liver) and Ascites Weight gain Pitting edema Anorexia Left-Sided Heart Failure Right-Sided Heart Failure Congestive Heart Failure Results from left-sided heart failure Blood backs up and also impacts the right side of the heart S/S: swelling of extremities, GI tract, and liver; JVD Pulmonary Edema: caused by left ventricular failure ○ Patient will be deprived of O2 to the brain ○ Restless ○ Anxious ○ Sense of suffocation ○ Tachycardia ○ Emergent Ejection Fraction Determines degree of heart failure as it measures ventricular contractility and percentage of end-diastolic volume that is ejected with each heartbeat Expected: 55%-65% Heart Failure with Reduced EF: systolic HF, left ventricle loses ability to contract, EF less than 40% Heart Failure with Preserved Ejection Fraction: diastolic heart failure, left ventricle function is greater or equal to than 50% but loses its ability to relax due to stiffness Heart Failure with Midrange ejection fraction: EF 40-49% Tests for Congestive Heart Failure Echocardiogram Chest x-ray 12-lead EKG Electrolytes BUN/Creatinine Liver function TSH BNP (KEY diagnostic indicator) CBC Urinalysis Heart Failure Classification (NY American Heart Assoc.) I: no limitation of physical activity. Ordinary activity does not cause fatigue, palpitation or dyspnea II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity causes fatigue, palpitation, or dyspnea III: Marked limitation of physical activity, comfortable at rest, but less than ordinary activity causes fatigue, palpitations, or dyspnea IV: Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If physical activity is undertaken, discomfort is increased Treatment for Classes of HF see table 25-2 pg 799 Stage A: patients at high risk for developing left ventricular dysfunction but without structural heart disease or symptoms of HF ○ Characteristics: HTN, atherosclerosis, diabetes, metabolic syndrome ○ Treatment: lifestyle modification, control HTN, diabetes, and obesity Stage B: Patients with left ventricular dysfunction or structural heart disease who have not developed symptoms of HF ○ Characteristics: history of MI, left ventricular hypertrophy, low ejection fraction ○ Lifestyle modifications plus ACE/ARB, BB, statin Treatment for Heart Failure Cont. Stage C: Patients with left ventricular dysfunction or structural heart disease with current or prior symptoms of heart disease ○ Characteristics: SOB, fatigue, decreased exercise intolerance ○ Treatment: same as A and B plus diuretics, aldosterone antagonist, sodium restriction, implantable defibrillator, cardiac resynchronization therapy Stage D: patients with refractory end-stage HF requiring special interventions ○ Characteristics: symptoms despite maximal medication therapy, recurrent hospitalizations ○ Treatment: implement stages A, B, and C plus fluid restriction, end-of-life, inotropes, cardiac transplant, mechanical support IV Infusions for HF Patients Used when all other treatments have failed Patients are usually admitted to the ICU for monitoring These drugs have a profound impact on BP Examples: Dopamine, Debutamone, Milrinone, Vasodilators Adrenergic Antagonists Examples: Dobutamine, Dopamine, Epinephrine, Norepinephrine Dobutamine: ○ Increase myocardial force and cardiac output Dopamine: ○ Increases BP and cardiac output through positive inotropic action which increases renal blood flow ○ Good for patients in renal failure Epinephrine: ○ Used as emergency to increase cardiac stimulation during cardiac arrest Norepinephrine: ○ Stimulates heart during cardiac arrest increases BP in hypotension and shock Side effects: dysrhythmias, tachycardia, restlessness, urinary incontinence Nursing Implications: VS, lung sounds, urinary output Direct-Acting Arterial Vasodilators Relax smooth muscle of blood vessels with vasodilation BP drops and sodium and water are retained leading to peripheral edema ○ May need to administer diuretics with this medication Helps promote blood flow to brain and kidneys Side effects: hypotension, edema, dizziness, HEADACHE, nasal congestion Nursing Interventions: monitor BP, if taking nitroprusside monitor cyanide levels for toxicity Examples: Nitroglycerin, Sodium Nitroprusside Miscellaneous Vasodilators Similar to B-type natriuretic peptide (BNP) that allows for vasodilation of arteries and veins Used for treatment of decompensated heart failure Side effects: hypotension, confusion, dizziness, dysrhythmias Interventions: administer via continuous IV, monitor BP, cardiac rhythm, urine output and body weight, monitor for improvement of HF symptoms Example: Nesiritide Adjunct Therapy Blood pressure medication: ○ Target BP should be less than 130/80 ○ Helps decrease risk of morbid progression Iron Replacement: ○ Anemia can be seen in patients who have HF ○ Caused by reduced exercise capacity Anticoagulation therapy: ○ Prevents clots especially in patients who have Afib Antiarrhythmic Drugs: ○ Amiodarone or evaluation for ICD (Implantable Cardioverter Defibrillator) Statins Medications to AVOID: ○ NSAIDs (ibuprofen) ○ Renal effects Non-Medication Adjunct Therapy Nutritional therapy: ○ Low- salt diet ○ Fluid restriction Supplemental Oxygen: ○ May only be needed during periods of activity Management of Sleep Disorders: ○ Over half of HF patients have OSA ○ Sleep study should be performed ○ CPAP will help with sleep quality Procedures for Patients in HF PCI or CABG ○ If underlying cause is CAD ICD: ○ Indicated when EF is less than 35% ○ Prevents sudden cardiac death Cardiac Resynchronization Therapy (CRT): ○ Used to treat electrical conduction defects and synchronize ventricular contractions Ultrafiltration: ○ Filters blood at the bedside ○ For patients who do not respond to diuretic therapy Heart Transplantation Procedures ICD: https://www.youtube.com/watch?v=hxTxROuUj4g Cardiac Resynchronization Therapy (CRT): https://www.youtube.com/watch?v=WjMYY443Egk Nursing Interventions Promoting activity tolerance: ○ Lack of exercise worsens condition Managing Fluid Volume: ○ Diet ○ Auscultation of lung sounds Controlling Anxiety Minimizing Powerlessness Assisting patients and families to effectively manage health Monitor and manage complications Complications from Heart Disease Cardiogenic Shock: ○ From inadequate tissue perfusion ○ Life-threatening condition with high mortality rate Thromboembolism: ○ Risk factor for patients who have afib and are immobile ○ Atria do not contract forcefully which leads to slow and turbulent blood flow Pericardial Effusion and Cardiac Tamponade ○ Greater than 20 mL of fluid surrounding the heart Cardiac Arrest Clinical Manifestation of Cardiac Tamponade Acute Tamponade: ○ Sudden chest pain, tachypnea, dyspnea, and JVD Hypotension for both Tamponade and Effusion Subacute Pericardial Effusion: ○ Less dramatic ○ Occurs over time Pulsus Paradoxus: systolic BP that is lower during inhalation (10mmhg difference) EKG: tachycardia Chest X-ray: enlarged silhouette Normal vs Abnormal X-ray of Heart Treatment of Pericardial Fluid Pericardiocentesis: ○ Catheter is inserted and drains the pericardial fluid ○ Patient feels instant relief ○ https://www.youtube.com/watch?v=0nGrujklpHY Pericardiotomy: ○ For recurrent pericardial effusions ○ Portion of pericardium is removed to help with drainage Cardiac Arrest Heart is unable to pump and circulate blood Usually associated with V-Fib Pulseless Electrical activity: electrical activity is present on EKG but no contractions are present S/S: consciousness, pulse, and BP are lost immediately, pupils dilate and seizures occur ○ Irreversible brain damage is possible with each minute that passes Ventricular Fibrillation Pulseless Electrical Activity (PEA) Emergency Assessment 1) Quick Recognition 2) Activation of Emergency Response 3) Performance of High-Quality CPR: must be done on a firm surface and compressions are done at a rate of 100 compressions/minute a) Complete recoil must be done in between compressions b) Allows for cardiac refilling c) Switch providers for a break 4) Rapid cardiac analysis and defibrillation within 2 minutes https://www.youtube.com/watch?v=BTkM9CDQjc4 Medications for Cardiac Arrest Epinephrine: improves perfusion and myocardial contractility, given when there is no pulse ○ 1 mg q 3-5 mins IV push followed by 20 mL saline Norepinephrine: increases BP given for hypotension and shock ○ 0.1-0.5 mcg/kg/min as IV infusion in central line Dopamine: given to increase BP in shock ○ 5-10 mcg/kg/ min as IV in central line Atropine: increases SA node automaticity and AV conduction, given to bradycardic patients ○ 0.5 mg IV push Medication for Cardiac Arrest Cont Amiodarone: acts on sodium-potassium and calcium channels to prolong action potential-treats pulseless VT and VF unresponsive to shock ○ 300 mg IV Sodium Bicarbonate: corrects metabolic acidosis ○ 1 mEq/kg IV Magnesium Sulfate: promotes adequate functioning of cellular sodium- potassium pump ○ 1-2 g diluted in 10mL D5W over 5-20 mins References Hinkle, J., Cheever, K., & Overbaugh, K. (2022). Medical-surgical nursing (15th ed) Wolters Kluwer. Silvestri, L., & Silvestri, A. (2023). Comprehensive review for the NCLEX-RN examination (9th ed). Elsevier Inc.