Professional Documents
Culture Documents
Heart Failure
Heart failure is a clinical syndrome Heart is unable to pump sufficient blood to meet the needs of the tissues Heart failure is the number 1 DRG for hospitalization in people over 65 years
Cultural Considerations
Higher prevalence in African Americans and Native Americans Directly related to the higher incidence and prevalence of HTN and DM Exacerbated by lack of access to health care
Effects of Aging
Decreased compliance Decreased response to SNS stimulation Decreased ability of heart to increase CO with exercise Increased incidence of dysrhythmias
Vascular volume and venous return increase which increase blood volume and pressure in the heart Release of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) Failure of compensatory mechanisms occurs Blood backs up from LV into LA and pulmonary venous system Blood backs up into the RV, RA and systemic venous system
Blood backs up in left atrium and pulmonary veins Increased hydrostatic pressure forces fluid out of pulmonary capillaries into alveoli and interstitial spaces Right ventricle dilates due to increased pulmonary pressures (pulmonary HTN) Engorgement of venous system extends backwards into systemic veins and organs
If left ventricular failure occurs, ususlly right ventricular failure will follow Right ventricular failure can occur solely without left ventricular failure cor pulmonale Heart failure can affect systolic function or diastolic function
Weak, thready pulses Fatigue, decreased exercise tolerance Pale, cool, clammy skin Restlessness, anxiety, confusion Nocturia Edema and weight gain
BUN and creatinine T4 and TSH Liver function tests Stress testing or cardiac cath
Transplantation
Beta1 Blockers
Decrease cytotoxic effects of constant stimulation of SNS Decrease workload by decreasing heart rate Drugs - Coreg, Lopressor, Atenolol
Vasodilators
Cause venous dilation Cause arterial dilation Drugs Nitrates ie. Isordil (isosorbide) and other meds ie. Apresoline (hydralazine); BiDil ( isosorbide & hydralazine combination)
Diuretics
Control Na and H2O retention Three types
Potassium sparing Aldactone (spironalactone), Inspra (eplerenone) Loop diuretics Lasix (furosemide), Demadex (torsemide) Thiazide diuretics Zaroxolyn (metolazone), HCTZ (hydrochlorazide)
Monitor for hypotension, lyte imbalances and dehydration, worsening renal failure
Cardiac glycosides
Increase force of myocardial contraction and slow electrical conduction Drugs Lanoxin (digoxin), Primacor, Inocor Precautions with Lanoxin administration
Decreased renal function slows elimination Will need to decrease dose with certain meds ie. amiodarone, erythromycin, quinidine Usual dose 0.125 mg to 0.5 mg (PO,IV,IM)
Lanoxin toxicity Therapeutic level 0.5-2.0 ng/mL Symptoms anorexia, N/V, fatigue, H/A, yellow or green halos, new dysrhythmias Reversal hold dose or administer Digibind (digoxin immune FAB) Nursing considerations for Lanoxin administration Assess heart rate for 1 min Give after breakfast Monitor for hypokalemia
Natrecor (nesiritide)
Indicated for the IV treatment of clients with acutely decompensated congestive heart failure with dyspnea at rest Manufactured from E-coli Effects - dilates veins and arteries, suppresses Aldosterone Administration - IV bolus, then drip for 48 hrs Contraindications - systolic pressure <90mm Hg Side effects - hypotension, VT, HA, nausea Incompatible with Heparin in same line
Assess GI system
HJR Ascites Appetite and constipation
Reduce fatigue Promote activity tolerance Control anxiety Assess for depression Referrals Teach client and family
Pneumococcal and flu vaccines recommended Stop smoking, no ETOH Signs and symptoms to report to physician
Weight gain Loss of appetite Syncopy or palpitations Worsening SOB Persistent cough Increasing fatigue
Web Sites
Heart Failure Society of America www.hfsa.org Heart Failure Online www.heartfailure.org Heart Failure Treatment Guidelines from the AHA/ACC www.acc.org AHA www.hearthub.org
Expected Outcomes
Maintains or improves cardiac function Maintains or increases activity tolerance Adheres to self-care program Absence of complications
Cardiomyopathy
Disease of the myocardium which affects its function Three major types of cardiomyopathy
Dilated - DCM Hypertropic - HCM Restrictive
Dilated Cardiomyopathy
Contractility decreases and ventricles dilate. Affects systolic function. Etiology ischemia, viral myocarditis, toxins, alcohol, pregnancy
Clinical manifestations same as with LVF Dx tests ECHO, endomyocardial biopsy, ECG, chest x-ray, blood chemistries Tx same as with LVF; tx dysrhythmias; heart transplant
Hypertropic Cardiomyopathy
Myocardium increases in size and mass Reduces inner cavity of ventricles and ventricles take longer to relax and fill. Affects diastolic function Etiology genetic, HTN, and hypoparathyroidism
Appears most often in young adults Clinical manifestations sudden cardiac death; dyspnea, palpitations, dizziness Dx tests radionuclide scans, ECHO, chest x-ray, ECG Tx Beta blockers and Ca channel blockers. Avoid meds that decrease preload (diuretics) or increase contractility (Lanoxin). Tx dysrhythmias - may insert ICD
Restrictive Cardiomyopathy
Ventricle walls are rigid and do not stretch normally during filling. Cardiac output decreases. Affects diastolic function. Etiology - Amylodiosis, Sarcoidosis
Clinical manifestations fatigue, activity intolerance, dyspnea and other symptoms of LVF Dx tests same as other cardiomyopathies Tx similar to hypertropic cardiomyopathy; tx dysrhythmias and tx underlying cause
Rheumatic Endocarditis
Results directly from group A beta-hemolytic strep Can be prevented if strep infection treated early Myocardium, valves and pericardium are affected
Contractility is decreased Valve leaflets develop vegetative bodies which can embolize
Clinical manifestations
Signs of rheumatic fever (fever, rash, migratory joint pain) Signs of carditis Signs of heart failure
Dx tests Positive throat culture; elevated ESR, CBC, ECHO, ASO positive Tx
Prevention is best treatment Limited activity, treat heart failure if present Penicillin or mycin drugs (clindamycin, erythromycin) if Penicillin allergy NSAIDS for joint pain
Infective Endocarditis
Infection of the endocardium and valves Etiology staph, strep, fungi, entrococcci Increased risk in patients with valve disorders and IV drug abusers
Clinical manifestations malaise, intermittent fever and chills, night sweats, Roth spots, splinter hemorrhages in nails, Janeway lesions, Oslers nodes, murmur, HF, stroke, pulmonary embolus
Dx blood cultures, CBC, transesophageal ECHO (TEE) Prevent in patients with valve disorders with prophylactic antibiotics before and after invasive procedures (Amoxicillin, Duricef, Cleocin) Tx - parenteral antibiotics for 6 wks (Penicillin, EES, Clindamycin, Vancomycin)
Myocarditis
Inflammation of myocardium results in degeneration and dilation Thrombi form on endocardial lining (mural thrombi) Etiology viruses, mumps, parasites, bacteria, toxins, radiation
Clinical manifestations asymptomatic or fever, fatigue, tachycardia, palpitations, dyspnea, symptoms of HF Dx ECHO, endomyocardial biopsy, chest xray, ECG, elevated cardiac biomarkers
Tx
Tx underlying cause Bed rest Tx heart failure Anti-inflammatory or immunosuppressive medications
Pericarditis
Inflammation of the pericardial sac Fibrinous adhesions or exudate can form in pericardial sac Etiology viruses, bacteria, fungi, myocardial injury, collagen diseases, drug reaction, radiation, neoplasms, ESRD
Clinical manifestations chest pain, pericardial friction rub, fever, chills, dyspnea Dx ECG changes, elevated ESR and possibly WBC, enzymes negative,ECHO Tx
Tx cause NSAIDS, analgesics, steroids
Complications of Pericarditis
Pericardial effusion Cardiac tamponade signs and symptoms Pulsus paradoxus Muffled heart sounds Tachycardia Narrow pulse pressure Distended neck veins Drop in BP Chronic constrictive pericarditis
Valvular Disorders
Stenosis valve does not open completely Regurgitation valve does not close properly
Dx ECHO with Doppler flow , TEE, cardiac cath Tx tx LVF, mitral valve replacement (MVR) or valvuloplasty Prophylactic antibiotics for invasive procedures
Mitral Stenosis
Leaflets are thickened and contracted Flow of blood from left atrium into left ventricle is obstructed Left atrium dilates and hypertropies Blood backs up into lungs and eventually the right side of heart
Clinical manifestations Diastolic murmur, fatigue, dyspnea, hemoptyosis, cough, crackles, atrial fib Dx ECHO, cardiac cath Tx tx LVF, valvuloplasty or MVR, anticoagulants if AF persists
Aortic Stenosis
Narrowing of aortic valve orifice or calcification of leaflets LV hypertrophies, dilates, and contractility eventually decreases Blood backs up into lungs and right heart
Clinical manifestations angina, dizziness or syncope, DOE, narrowed pulse pressure, dysrhythmias, systolic murmur, and possibly a thrill Dx ECHO, TEE, cardiac cath Tx Bed rest, aortic valve replacement (AVR), valvuloplasty, prophylactic antibiotics for invasive procedures
Clinical manifestations sensations of forceful heart beat especially in the head and neck, head bobbing (Mussets sign), marked visible carotid pulsations, water-hammer pulse, widened pulse pressure, diastolic murmur, fatigue, DOE, signs of heart failure Dx ECHO, TEE, cardiac cath Tx AVR or valvuloplasty, prophylactic antibiotics
Valvuloplasty
Valve Replacement
Open heart procedure requiring heart lung bypass
Classic approach Minimally invasive robtic approach