Nursing Care of Clients With Disorders of Cardiac Function (HF)

7/31/2019 Nursing Care of Clients With Disorders of Cardiac Function (HF)

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NURSING CARE OF

CLIENTS WITH DISORDERSOF CARDIAC FUNCTION

Maria Carmela L. Domocmat, RN, MSN


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Heart FailureHeart Failure heart is unable to pump

enough blood to meet themetabolic needs of thebody at rest or duringexercise

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not a disease itself; groupof manifestations relatedto inadequate pump

performance

Maria Carmela L. Domocmat 8/13/2012


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More than 287,000 people die yearly of heart

failure 40% of patients admitted to the hospital with the

condition die or are readmitted within 1 ear.

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estimated annual cost for the management of heart

failure in 2006 was $29.6 billion dollars.



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Heart FailureHeart Failure5

Congestive Heart Failure.flv Congestive Heart Failure2.mp4



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Etiology conditions that can lead to

the development of heartfailure

coronary artery disease

cardiomyopathy

Other conditions that maycontribute to thedevelopment and severityof heart failure include:

increased metabolic rate

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hypertension valvular heart disease

iron overload hypoxia

severe anemia

electrolyte abnormalities cardiac dysrhythmias

diabetes



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Cause and effect Coronary artery disease

Atherosclerosis of the coronary arteries is the primarycause of heart failure

found in more than 60% of patients with the condition.

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Hypoxia and acidosis lead to ischemia, which causes anMI that leads to heart muscle necrosis, myocardial cell

death, and loss of contractility. The extent of the MI

correlates with the severity of the heart failure.



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Cause and effect cardiomyopathy

A disease of the myocardium, there are three types ofcardiomyopathy: dilated, hypertrophic, and restrictive

Heart failure due to cardiom o ath usuall

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becomes chronic and progressive; however, bothmay resolve if the cause, such as alcohol use, is

removed.



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Cause and effect Cardiomyopathy

dilated cardiomyopathy The most common type

may result from an unknown cause (idiopathic), an

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inflammatory process such as myocarditis, or alcohol abuse; it causes diffuse cellular necrosis and fibrosis, leading to

decreased contractility (systolic failure).

Hypertrophic and restrictive cardiomyopathy

lead to decreased distensibility and ventricular filling

(diastolic failure).



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Cause and effectHypertension

Systemic or pulmonary hypertension increases theheart's workload, leading to hypertrophy of its muscle

fibers.

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This hypertrophy may impair the heart's ability to fillproperly during diastole, and the hypertrophied

ventricle may eventually fail



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Cause and effect

valvular heart disease

The valves ensure that blood flows in one direction. In valvular disorders, blood has an increasing difficulty

moving forward, increasing pressure within the heart

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and cardiac workload and leading to heart failure. Degenerative aortic stenosis and chronic aortic and

mitral regurgitation are often the culprits.



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Etiology1. Systolic dysfunction

a. decreased contractility

b. increased after load

2. Diastolic D sfunction

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a. abnormalities in active relaxation

b. abnormalities in passive relaxation



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Etiology:Etiology: Systolic dysfunction

a. decreasedcontractility

MI Valvular heart disease HPN cardiom o athies

b. increased after load

disease states thatincrease either thesystolic pressure(HPN,aortic stenosis)

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or chamberradius(dilatedcardiomyopathies)increase after load

unless wall thicknessincreasesproportionately



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Etiology:Etiology: Diastolic Dysfunction

1. abnormalities in active relaxation MI

Ventricular hypertrophy

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2. abnormalities in passive relaxation increased ventricular stiffness leading to increase filling

pressure

Concentric hypertrophy

HPN

Hypertrophic growth of a hollow organ without overall

enlargement, in which the walls of the organ arethickened and its capacity or volume is diminished.



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Conditions that PrecipitateConditions that Precipitate

Heart FailureHeart Failure1. Dysrhythmias especially tachycardia1. Dysrhythmias especially tachycardia

2. Sepsis2. Sepsis3. Anemia3. Anemia

4. Thyroid disorders4. Thyroid disorders

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. u. u

6. Thiamine deficiency6. Thiamine deficiency

7. Medication dose changes7. Medication dose changes

8. Physical or emotional stress8. Physical or emotional stress

9. Endo,9. Endo, MyoMyo andand PericarditisPericarditis

10. Fluid retention from medication or salt intake10. Fluid retention from medication or salt intake



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Classification of Heart Failure

1. Acute versus Chronic Heart Failure

2. Left versus Right Ventricular Failure3. Backward versus Forward Failure

4. High versus Low Output Failure

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5. Systolic versus Diastolic Failure



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Acute versus chronic heart

failure acute heart failure

an emergency situation in which a patient who wascompletely asymptomatic before the onset of heartfailure decompensates when there's an acute injury to

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impairing its ability to function chronic heart failure

a long-term syndrome in which the patient experiences

persistent signs and symptoms over an extended periodof time, likely as a result of a preexisting cardiaccondition.



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2. Left versus Right Ventricular Failure3. Backward versus Forward Failure


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Left versus Right ventricular

failure left-sided heart failure

inability of the left ventricle to pump enough blood,causing fluid to back up into the lungs

ri ht-sided heart failure

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the inefficient pumping of the right side of the heart,causing congestion or fluid buildup in the abdomen,

legs, and feet



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Pathophysiology ofPathophysiology of LSHFLSHF23



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Blood dams back into the

pulmonary capillary bed

Pressure of blood into the pulmonary

capillary bed increases

Fluid shifts into the intraalveolar

Signs and symptoms of left sided

heart failure



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Decreased stroke volume

Decreased tissue perfusionDecreased tissue perfusion

Decreased blood flow to kidneysDecreased blood flow to kidneys

RAAS stimulationRAAS stimulation

Increased CellularIncreased Cellular

hypoxiahypoxia

Vasoconstriction and reabsorption ofVasoconstriction and reabsorption of

Na and waterNa and water

Increased ECF volumeIncreased ECF volume

Increased total blood volume; IncreaseIncreased total blood volume; Increase

systemic Bpsystemic BpMaria Carmela L. Domocmat 8/13/201226


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Pathophysiology ofPathophysiology of RSHFRSHF27



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LSHF, PE, RV infarction, CHD

Reduced myocardial contractility, Increased cardiac

workload, Decreased diastolic filing, Obstruction of left

atrial emptying

Increased atrial pressure

Right sided HF

Blood dams back from

RV to RA

Signs and Symptoms of RSHFMaria Carmela L. Domocmat 8/13/201228


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left-sided heart failure (LSHF)

Signs and symptoms arerelated to pulmonarycongestion and include: dyspnea

Wheezing ( Cardiac asthma)

Clubbing of fingers

restlessness and anxiety

fatigue and weakness

Anorexia

H okalemia increased

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unexplained cough pulmonary crackles

low oxygen saturation levels

third heart sound (S3)

dizziness and light-headedness

confusion

levels of aldosterone) polycythemia

reduced urine output

altered digestion

Elevated PAP, PCWP, LVEDP



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LSHF

Dyspnea -Most frequent symptom

- Vascular congestion

Cheyne-stokes respiration

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Cough Frothy, blood tinged- fluid in the lung irritates the

lung mucosa

Orthopnea Dyspnea on recumbency

-increase blood returning to

heart when recumbent



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Cheyne Stokes Respiration

is an abnormal pattern of breathing

characterized by progressively deeper and

sometimes faster breathing, followed by a

gradual decrease that results in apneaMaria Carmela L. Domocmat 8/13/2012


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Paroxysmal nocturnal dyspnea Sudden dyspnea that awakens patients from

sleep-subsides after 5-20 minutes

Cardiomegaly Dilatation of the left ventricle in an effort to

augment ventricular contraction

S3 Ventricular gallop-single most reliable sign of

LVF

-due ra id fillin of left ventricle due to inc.left

atrial pressure and non compliance of LV

Cerebral

hypoxia,fatigue,muscular

weakness

Decrease cardiac output

Nocturia During the day blood is diverted into the

skeletal musculature at night cardiac output is

shifted toward the kidney and diuresis ensues



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Normal ChestNormal Chest XX--rayray CardiomegalyCardiomegaly

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Right-sided heart failure

Peripheral edema Prominent at the end of the day

Hepatomegaly Chronic passive congestion of theliver

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Cardiac cirrhosis Jaundice,ascites

Jugular vein distention Increase right sided pressure

Ascites accumulation of fluid in theperitoneal cavity



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Leg varicosities

Elevated CVP reading Internal hemorrhoids

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norex a

Nausea

Weight gain

Weakness



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Splenomegaly41



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CardiacCardiac CirrhosisCirrhosis42

An extensive fibrotic reaction occurring within the liver as a result of prolonged congestive

heart failure.

Also calledpseudocirrhosis

. Maria Carmela L. Domocmat 8/13/2012


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Leg varicosities44



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Internal hemorrhoids45



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Abdominal painAbdominal pain


l d


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Jugular vein distention

See video in physical assessment by mosby, siedel

6th ed

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Cl ifi i f il


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2.

Left versus Right Ventricular Failure3. Backward versus Forward Failure


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Backward versus Forward


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Backward versus Forward

Failure Backward failure

venous congestion arising from the damming of blood behindthe failing chamber

increase hydrostatic pressure resulting into pulmonary

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e ema or per p era e ema

Forward failure

decreased CO causes decreased organ perfusion



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Decrease CO

decreased blood to vital organs

muscular weaknessrenal retention of sodium/water


Cl ifi ti f H t F il


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2. Left versus Right Ventricular Failure

3. Backward versus Forward Failure


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Hi h L t t f ilHi h L t t f il


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High versus Low output failureHigh versus Low output failure

High output failureHigh output failure a condition causes the heart toa condition causes the heart towork harder to meet metabolic demands of the bodywork harder to meet metabolic demands of the body

ex. Sepsis, anemia, thyrotoxicosis ,ex. Sepsis, anemia, thyrotoxicosis ,pregnancypregnancy

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Low outputLow output -- heart unable to pump blood out of theheart unable to pump blood out of theleft ventricle to meet demand of the bodyleft ventricle to meet demand of the body

ex. RHD,ex. RHD, cardiomegalycardiomegaly




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2. Left versus Right Ventricular Failure

3. Backward versus Forward Failure


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Systolic versus DiastolicSystolic versus Diastolic


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yy

FailureFailure systolic heart failure (pumping problem)

the inability of the heart to contract enough to provideblood flow forward

causes problems with contraction and ejection of blood

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diastolic heart failure (filling problem) the inability of the left ventricle to relax normally, resulting

in fluid backing up into the lungs

Diastolic failure leads to problems with heart relaxation and

filling with blood



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Framingham Criteria forFramingham Criteria for CHFCHF


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Major CriteriaMajor Criteria Minor CriteriaMinor Criteria

PND HepatomegalyNVE Extremity edema

Rales Ni ht cou h

Framingham Criteria forFramingham Criteria for CHFCHF56

Cardiomegaly DOB on exertionAcute pul.edema Pleural effusion

S3 gallop Dec.vital capacity

Inc.venous pressure >16cm H20 Tachycardia >120bpm+ hepatojugular reflux



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hepatojugular reflux distention of the jugular vein

induced by applying manual pressure over the liver;it suggests insufficiency of the right heart.

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Hepatojugular Reflux.flv hepatojugular reflux sign.flv



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Diagnostics58


Diagnostics


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Diagnostics

1. ECG

2. CXR3. 2Decho- EF > 55%

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4. - ar y - m a o a o

5. Liver enzymes

6. BUN / Creatinine


Diagnostics


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Diagnostics

brain natriuretic peptide (BNP) a hormone secreted by the heart at high levels when it's

injured or overworked. One of the most specific for heart failure

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complete metabolic panel (electrolytes, creatinine,glucose, and liver function studies),

urinalysis

To determine the cause of heart failure includethyroid function tests, a fasting lipid profile, andtesting for offending drug levels.


Diagnostics


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Diagnostics

echocardiogram, or echo

chest X-ray

ECG cardiac stress test

cardiac catheterization (angiogram),

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cardiac computed tomography scan or magnetic resonance

imaging, radionuclide ventriculography

ambulatory ECG monitoring (Holter monitor)

pulmonary function tests

a heart biopsy

exercise testing such as the 6-minute walk.


Diagnostics: Echocardiogram


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Diagnostics: Echocardiogram

One of the most important diagnostic tools for heart failure

Not only is this an important assessment tool when the patient

presents for the first time with heart failure, but it can also provideinformation periodically on the improvement of his heart's function

Echocardiography is a type of cardiac ultrasound that involvespulsed and continuous Doppler waves.

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An echo provides an accurate assessment of left ventricular function

while also determining whether a patient has systolic or diastolicdysfunction.

The number most frequently quoted from the echo is the ejectionfraction (EF). EF is the measurement of how effectively the heart is

pumping blood. A normal EF is greater than 55%. That means withevery cardiac cycle more than 55% of the blood is being pumpedout of the ventricle.


Diagnostics


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Diagnostics

CXR

evaluate the size of the patient's heart and the basicheart structures

and to determine the amount of fluid buildu in his lun

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fields. ECG

examine the electrical activity of the heart.



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Classification systems64


Classification systems


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Classification systems

After all the data are obtained, determine thecause and classification of the patient's heartfailure and the appropriate treatment plan.

two well-accepted classification systems used to

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describe heart failure, focusing on either structuralabnormalities or symptoms:1. the American College of Cardiology/American Heart

Association stages of heart failure (ACC/AHA)

2. the New York Heart Association (NYHA) functionalclassifications

http://www.hearthealthywomen.org/cardiovascular-disease/heart-failure/heart-failure-2.html Maria Carmela L. Domocmat 8/13/2012

American College of Cardiology/American


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Heart Association stages of heart failure focuses on the progression and worsening of the condition over time.

moves forward from one stage to the next based on the progression

of the disease. helps doctors identify people who are at high risk for heart failure

but don't have the condition yet ( Stage A), those with heart damagebut no symptoms of heart failure ( Stage B), and those with heart

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damage and with symptoms of heart failure (Stages C and D).

helps doctors prevent heart failure in those at risk and complementsthe New York Heart Association (NYHA) classification system, whichgauges the severity of symptoms in people who are at stages C andD of the AHA/ACC system.


AHA/ACC Heart Failure Stages


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AHA/ACC Heart Failure Stages

Stage Description

A People at high risk for developing heart failure but who donot have heart failure or damage to the heart

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B

symptoms of heart failure; for example, those who have had

heart attack

CPeople with heart failure symptoms caused by damage to

the heart, including shortness of breath, tiredness, inability to

exercise

DPeople who have advanced heart failure and severe

symptoms difficult to manage with standard treatment

http://www.hearthealthywomen.org/cardiovascular-disease/heart-failure/heart-failure-2.html


Algorithm of the stages in

the development of heart

failure, with


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301/p654.h

tml

recommended therapy

for patients by stage.(ACE = angiotensin-

converting enzyme; ARB

= angiotensin-II receptor

blocker.)

ht

tp://www.aafp.org/afp/201

0/

http://www.hearthealthywomen.org/

cardiovascular-disease/heart-failure/heart-failure-2.htmlMaria Carmela L. Domocmat 8/13/201268

The New York Heart Association


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(NYHA) Classification System used to classify symptoms of heart disease,

including heart failure.

Symptoms are graded based on how much theylimit your functional capacity

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Unlike the AHA/ACC staging system, the NYHAclass often can shift from one level to another; forexample, if you respond well to treatment and yoursymptoms improve, your NYHA class can go down. If

you don't respond well and your symptoms continueto worsen, your NYHA class can go up.


NYHA Heart Failure Classification


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Class Description

1 (Mild)

No limitation of physical activity - ordinary physical activity

doesn't cause tiredness, heart palpitations, or shortness of

breath

2 (Mild)

Slight limitation of physical activity;

comfortable at rest, but ordinary physical activity results in

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tire ness, eart pa pitations, or s ortness o reat

3 (Moderate)

Marked or noticeable limitations of physical activity;

comfortable at rest, but less than ordinary physical activity

causes tiredness, heart palpitations, or shortness of breath

4 (Severe)

Severe limitation of physical activity;

unable to carry out any physical activity without discomfort.

Symptoms also present at rest. If any physical activity is

undertaken, discomfort increases.Maria Carmela L. Domocmat 8/13/2012


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Medical Management71


Medical ManagementMedical Management


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gg

4 Ds (Basic)4 Ds (Basic)

1.1. DigitalisDigitalis

2.2. DiureticsDiuretics

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..

4.4. DietDiet


Digitalis


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g

Major therapy in HF

PositivePositive inotropicinotropic, negative, negative chronotropicchronotropic andanddromotropicdromotropic effectseffects

Assess HR before ivin the dru

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Monitor serum potassium levels Assess for S/Sx of digitalis toxicity



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Digoxin can be used in patients with heart failureand atrial fibrillation to slow conduction through

the atrioventricular node, which increases leftventricular function and results in increased

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ures s, an o ncrease e orce o myocar a

contraction. It may also be added to existingtherapy for a patient with NYHA Class II, III, or IVheart failure and an EF of less than 40% who's

receiving optimal doses of an ACE inhibitor orARB, beta-blocker, and aldosterone antagonist.


Symptoms of Digitalis Toxicity


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GI Anorexia, nausea,vomiting, diarrhea

CNC Headache, fatigue,lethargy

CVS Brad cardia.

DysrhythmiasOphthalmologic Flickering flashes

of light

* Toxicity may be treated with gastric lavage,activated charcoal or digoxin-Fab fragment( Digibind ) which is the antidoteMaria Carmela L. Domocmat 8/13/2012

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Inotropes

DopamineDobutamine

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affecting the force of muscular contractions; commonly applied to

drugs that increase contractility of cardiac muscle, e.g. digitalisl cosides.



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Diuretic Therapy


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Assess for signs of hypokalemia especially whenadministering thiazides and loop diuretics

Give potassium supplements or food rich in potassium

Give diuretics in the morning

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Aldosterone antagonist

added to pharmacologic therapy if EF is less than 35%and adequate ACE inhibitor therapy.

are a roved for NYHA Classes III and IV and must

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be used cautiously, acknowledging renal functionand potassium level.

been shown to decrease hospital admissions for

heart failure and also increase survival whenadded to existing therapy.


VasoDilators


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To decrease afterload by decreasing resistance to

ventricular emptying

Example

ACE inhibitors first line

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NitroprussideHydralazine



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The foundation of heart failure treatment is the ACE

inhibitor.

Unless contraindicated, EF of less than 40% should

receive an ACE inhibitor

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has been shown to improve ventricular function andpatient well-being, reduce hospitalization, and

increase survival.

If intolerant to ACE inhibitor, an ARB should beinitiated.



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beta-blockers

Unless contraindicated or not tolerated, should be started for every HF patient with an EF

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Hydralazine/ isosorbide may be added as an

alternative to an ACE inhibitor or ARB if the

patient is intolerant to both drugs or it may be

t xi tin th r i m t m ntin

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to progress.



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Nursing Management84


Nursing Management


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1. Providing oxygenation2. Promote rest and activity3. Facilitating fluid balance4. Provide skin care

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5. romote nutrition6. Promote elimination7. Manage acute pulmonary edema8. Phlebotomy9. Administer medications and assess the

patient's response to them


Nursing Management


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Providing oxygenation O2 at 2-6 L/min as orderedEvaluate ABGsSemi fowlers osition

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Nursing Management


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Promote rest and activityBed rest or limit activity during acute phaseActivities should ro ress throu h dan lin

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sitting up in a chair and then walking inincreased distances under close supervision

Assess for signs of activity intolerance such asdyspnea, fatigue, and increased PR


Nursing ManagementNursing Management


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Facilitating fluid balance assess fluid balance with a goal of optimizing fluid

volume limit sodium intake ( no added salt)

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Nursing Care of Clients With Disorders of Cardiac Function (HF)

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