Chapter 29

Management of Patients With

Complications From Heart
Disease

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Heart Failure (HF)

The inability of the heart to pump sufficient 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).
Heart failure is only reversible if caused by underlying
condition, such as anemia or infection.
Most HF is a progressive, lifelong disorder managed with
lifestyle changes and medications.
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Pathophysiology of Heart Failure

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Clinical Manifestations
Right Sided

Left Sided

Viscera and peripheral

congestion

Pulmonary congestion,
crackles

Jugular venous
distention (JVD)

S3 or ventricular gallop

Dependent edema

Dyspnea on exertion
(DOE)

Hepatomegaly

Orthopnea

Ascites

Dry, nonproductive
cough initially

Weight gain

Oliguria
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Nursing Process: The Care of the Patient

With Heart FailureAssessment
Focus
Effectiveness of therapy
Patients self-management
S&S if increased HF
Emotional or psychosocial response
Health history
PE
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
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Nursing Process: The Care of the Patient

With Heart FailureDiagnoses
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

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Collaborative Problems and Potential

Complications
Hypotension, poor perfusion, and cardiogenic shock (see
Chapter 14)
Dysrhythmias (see Chapter 26)
Thromboembolism (see Chapter 30)
Pericardial effusion and cardiac tamponade

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient

With Heart FailurePlanning
Goals
Promote activity and reduce fatigue
Relieve fluid overload symptoms
Decrease anxiety or increase the patients 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
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Activity Intolerance
Bed rest for acute exacerbations
Encourage regular physical activity; 3045 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
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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

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

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
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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

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

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.
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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
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Medications (contd)
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
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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

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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
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Management of Pulmonary Edema

Prevent
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)

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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

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Management of Cardiogenic Shock

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)
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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
Anticoagulant therapy

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Pulmonary Emboli

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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.
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

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Assessment Findings in Cardiac

Tamponade

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Medical Management
Pericardiocentesis-Fluid is removed from punctur in
pericardial sac.
Pericardiotomy-Opening is cut in the pericardium to allow
fluid to flow into lymphatic system.

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Sudden Cardiac Death or Cardiac Arrest

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

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Question
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

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
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.

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins