Chapter 29 Management of Patients With Heart Disease Complications PDF

Chapter 29 Management of Patients With Complications From Heart Disease Dr. Mohammed H  Heart Failure (HF) The inability of the heart to pump enough blood to meet the needs of the tissues for oxygen and nutrients A syndrome characterized by fluid overload or i...

Chapter 29 Management of Patients With Complications From Heart Disease Dr. Mohammed H  Heart Failure (HF) The inability of the heart to pump enough blood to meet the needs of the tissues for oxygen and nutrients A syndrome characterized by fluid overload or inadequate tissue perfusion The term heart failure indicates myocardial disease, in which there is a problem with the contraction of the heart (systolic failure) or filling of the heart (diastolic failure). Some cases are reversible. Most HF is a progressive, lifelong disorder managed with lifestyle changes and medications. Pathophysiology of Heart Failure  Clinical Manifestations Right Sided Left Sided Viscera and Pulmonary peripheral congestion, crackles congestion S3 or “ventricular Jugular venous gallop” distention (JVD) Dyspnea on exertion Dependent edema (DOE) Hepatomegaly Orthopnea Ascites Dry, nonproductive Weight gain cough initially Oliguria  Nursing Process: The Care of the Patient With Heart Failure—Assessment Focus Effectiveness of therapy Patient’s self-management S&S if increased HF Emotional or psychosocial response Health history Physical exam. Mental status; lung sounds: crackles and wheezes; heart sounds: S3; fluid status or signs of fluid overload; daily weight and I&O; assess responses to medications Nursing Process: The Care of the Patient With Heart Failure—Diagnoses Activity intolerance related to decreased CO Excess fluid volume related to the HF syndrome Anxiety-related symptoms related to complexity of the therapeutic regimen Powerlessness related to chronic illness and hospitalizations Ineffective family therapeutic regimen management Collaborative Problems and Potential Complications Hypotension, poor perfusion, and cardiogenic shock Dysrhythmias Thromboembolism Pericardial effusion and cardiac tamponade Nursing Process: The Care of the Patient With Heart Failure— Planning Goals 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  Activity Intolerance Bed rest for acute exacerbations Encourage regular physical activity; 30–45 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 Positioning; elevation of the HOB to facilitate breathing and rest, support of arms  Fluid Volume Excess Assessment for symptoms of fluid overload Daily weight I&O Diuretic therapy; timing of meds Fluid intake; fluid restriction Maintenance of sodium restriction  Patient Education Medications Diet: low-sodium diet and fluid restriction Monitoring 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 Question What evaluation most illustrates that the patient with HF has met outcomes for the nursing diagnosis “Activity intolerance related to decreased CO?” A. Exhibits decreased peripheral edema B. Maintains heart rate, blood pressure, respiratory rate, and pulse oximetry within the targeted range C. Avoids situations that produce stress D. Performs and records daily weights Answer B. Maintains heart rate, blood pressure, respiratory rate, and pulse oximetry within the targeted range Rationale: Patients with HF who exhibit stable VS shows that they have been able to adjust and plan activities to include rest and allow their bodies to adjust. A decrease in peripheral edema illustrates a reduction of fluid, avoiding situations that produce stress shows a move toward decreasing anxiety, and performing and recording daily weights shows adherence to the therapeutic regimen. Medications Angiotensin-converting enzyme (ACE) inhibitors: vasodilation; diuresis; decreases afterload; monitor for hypotension, hyperkalemia, and altered renal function; cough Angiotensin II receptor blockers: prescribed as an alternate to ACE inhibitors; work similarly Hydralazine and isosorbide dinitrate: alternative to ACE inhibitors Beta-blockers: prescribed in addition to ACE inhibitors; may be several weeks before effects seen; use with caution in patients with asthma  Medications (cont’d) Diuretics: decreases fluid volume, monitor serum electrolytes Digitalis: improves contractility, monitor for digitalis toxicity especially if patient is hypokalemic IV medications: indicated for hospitalized patients admitted for acute decompensated HF Milrinone: decreases preload and afterload; causes hypotension and increased risk of dysrhythmias Dobutamine: used for patients with left ventricular dysfunction; increases cardiac contractility and renal perfusion Gerontologic Considerations May present with atypical signs and symptoms such as fatigue, weakness, and somnolence Decreased renal function can make older patients resistant to diuretics and more sensitive to changes in volume Administration of diuretics to older men requires nursing surveillance for bladder distention caused by urethral obstruction from an enlarged prostate gland  Answer Which classification of medications play a pivotal role in the management of HF caused by systolic dysfunction? A. ACE inhibitors B. Beta-blockers C. Diuretics D. Digitalis A. ACE inhibitors ACE inhibitors play a pivotal role in the management of HF caused by systolic dysfunction. Beta-blockers have been found to reduce mortality and morbidity in patients with NYHA class II or III HF by reducing the adverse effects from the constant stimulation of the sympathetic nervous system. Diuretics are prescribed to reduce excess extracellular fluid by increasing the rate of urine produced in patients with signs and symptoms of fluid overload. Digitalis increases the force of myocardial contraction and slows conduction through the atrioventricular node.  Pulmonary Edema Acute event in which the LV cannot handle an overload of blood volume. Pressure increases in the pulmonary vasculature, causing fluid movement out of the pulmonary capillaries and into the interstitial space of the lungs and alveoli. Results in hypoxemia Clinical manifestations: restlessness, anxiety, dyspnea, cool and clammy skin, cyanosis, weak and rapid pulse, cough, lung congestion (moist, noisy respirations), increased sputum production (sputum may be frothy and blood tinged), decreased level of consciousness Management of Pulmonary Edema Early recognition: monitor lung sounds and for signs of decreased activity tolerance and increased fluid retention Place patient upright and dangle legs Minimize exertion and stress Oxygen Medications Diuretics (furosemide), vasodilators (nitroglycerin)  Cardiogenic Shock A life-threatening condition with a high mortality rate Decreased CO leads to inadequate tissue perfusion and initiation of shock syndrome. Clinical manifestations: symptoms of HF, shock state, and hypoxia Management Correct underlying problem Treated in an ICU Assess cardiac rhythm, monitor hemodynamic parameters, monitor fluid status, and adjust medications and therapies based on the assessment data Medications Diuretics, positive inotropic agents and vasopressors Circulatory assist devices Intra-aortic balloon pump (IABP)  Thromboembolism Decreased mobility and decreased circulation increase the risk for thromboembolism in patient with cardiac disorders, including those with HF. Pulmonary embolism: blood clot from the legs moves to obstruct the pulmonary vessels. The most common thromboembolic problem with HF Prevention Treatment Anticoagulant therapy Pulmonary Emboli Pericardial Effusion and Cardiac Tamponade Pericardial effusion is the accumulation of fluid in the pericardial sac. Cardiac tamponade is the restriction of heart function because of this fluid, resulting in decreased venous return and decreased CO. Pericardial Effusion and Cardiac Tamponade Clinical manifestations: ill-defined chest pain or fullness, pulsus paradoxus, engorged neck veins, labile or low BP, shortness of breath Cardinal signs of cardiac tamponade: falling systolic BP, narrowing pulse pressure, rising venous pressure, distant heart sounds. Management Pericardiocentesis Pericardiotomy  Sudden Cardiac Death or Cardiac Arrest Emergency management: cardiopulmonary resuscitation A: airway B: breathing C: circulation D: defibrillation for VT and VF Answer What is the most reliable sign of cardiac arrest in an adult and child? A. Decrease in blood pressure B. Absence of brachial pulse C. Absence of breathing D. Absence of carotid pulse D. Absence of carotid pulse Rationale: The most reliable sign of cardiac arrest is the absence of a pulse. In an adult or child, the carotid pulse is assessed. In an infant, the brachial pulse is assessed.