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Diseases Of The Heart 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 Etiology of Heart Failure • • • • • • CAD Systemic or pulmonary hypertension Cardiomyopathy Valvular disease Septal defects Myocarditis • • • • • Dysrhythmias Hypervolemia Metabolic disorders Autoimmune disorders Anemia in the elderly Pathophysiology Of Heart Failure • Decreased amount of blood ejected from ventricles • Stimulation of SNS - increases myocardial workload or O2 demand • Ventricular hypertrophy • Decreased renal perfusion • Activation of Renin-AngiotensinAldosterone System – Renin interacts with Angiotensinogen to produce Angiotensin I – Angiotensin I converts to Angiotensin II – Angiotensin II stimulates release of Aldosterone • 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 • Right ventricular failure usually follows left ventricular failure • Right ventricular failure can occur solely without left ventricular failure – cor pulmonale • Heart failure can affect systolic function or diastolic function Clinical Manifestations Of Left Ventricular Failure (LVF) • Dyspnea – Dyspnea on exertion (DOE) – Orthopnea – Paroxysmal nocturnal dyspnea (PND) • • • • Cough Crackles Hypoxia, cyanosis Tachycardia, palpitations • S3, S4, murmurs • • • • • • Weak, thready pulses Fatigue Pale, cool, clammy skin Restlessness, anxiety, confusion Nocturia, oliguria Decreased GFR, increased creatinine Clinical Manifestations of Right Ventricular Failure (RVF) • • • • • Elevated JVD Positive HJR Hepatomegaly, splenomegaly Ascites Anorexia, nausea, constipation • • • • • Sacral edema Peripheral edema Anasarca Weight gain Decreased activity tolerance Acute Pulmonary Edema • Life threatening situation • Large accumulation of fluid in lungs • Manifestations – Severe dyspnea, sense of suffocation – Cough, large amounts of frothy, blood tinged sputum – Wheezing and coarse crackles – Cyanosis New York Heart Association’s Functional Classification of Heart Disease • Class I – Ordinary activity does not cause symptoms • Class II – Slight limitation of ADLs • Class III – Comfortable at rest but any activity causes symptoms • Class IV – Symptoms at rest Diagnostic Findings With Heart Failure • • • • Echocardiogram with Doppler flow studies Chest x-ray ECG B-Type Natriuretic Peptide (BNP) • • • • BUN and creatinine T4 and TSH Liver function tests Stress testing or cardiac cath Objectives In Treating Heart Failure • Identify and eliminate the precipitating cause • Reduce the workload on the heart • Enhance patient and family coping with lifestyle changes Medical Management of Heart Failure • Exercise – Bed rest in upright position in acute and refractory stages – Regular exercise program • Oxygen therapy • Dietary restrictions – Sodium restriction – Fluid restriction • Cardiac resynchronization – biventricular pacing (Medtronic InSyn) • Mechanical assist devices • Transplantation Pharmacologic Management of Heart Failure • ACE inhibitors – Vasodilate – Promote diuresis – Drugs – Vasotec, Captopril, Zestril, • Angiotensin II Receptor Blockers (ARBs) – Prescribed when patient intolerant of ACE-I – Drugs – Diovan, Aticand • 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) • 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 conduction through AV node – 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 • Calcium channel blockers – Contraindicated with severe systolic dysfunction – Drugs – Norvasc, Cardizem, Procardia • 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, binds with Heparin – Side effects - hypotension, VT, HA, nausea – Incompatible with Heparin in same line Medical Management Of Pulmonary Edema • Sit patient in high Fowlers with legs and feet dependent • Oxygen • Morphine • Diuretics • Other meds as with heart failure Nursing Diagnoses For The Client With Heart Failure Nursing Interventions For The Client With Heart Failure • Monitor and manage potential complications – Assess cardiovascular status frequently • • • • Vital signs Heart sounds Degree of JVD & HJR All peripheral pulses – Assess respiratory status frequently • Lung sounds • Assess degree of dyspnea • Assess O2 sats – Assess renal status • I&O • BUN & Cr • Assess for nocturia • Assess GI system – HJR – Ascites – Appetite and constipation • Monitor fluid status closely – Daily weights – I&O – Peripheral and sacral edema • • • • • Reduce fatigue Promote activity tolerance Control anxiety Referrals Teach client and family Client and Family Teaching Related to Heart Failure • • • • Weigh daily 2-3 gm Na diet Fluid restrictions Meds and side effects • Signs and symptoms to report to physician – Weight gain – Loss of appetite – Syncopy or palpitations – Worsening SOB – Persistent cough 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 – viral myocarditis, toxins, alcohol, pregnancy, ischemia • 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 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. Also tx underlying cause Rheumatic Endocarditis • Results directly from group A betahemolytic strep • Can be prevented if strep infection treated early • Myocardium, valves and pericardium are affected – Contractility is decreased – Valve leaflets develop vegetative bodies • Clinical manifestations – Signs of rheumatic fever (fever, chills, sore throat) – Heart murmur, heart failure • Dx tests – Positive throat culture; ECHO; increased strep antibody titer • Tx – Prevention is best treatment – Bed rest and treat heart failure if present – Penicillin or mycin drugs (Cleocin, EES) if Penicillin allergy Infective Endocarditis • Infection of the endocardium and valves • Etiology – staph, strep, fungi • 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, Osler’s 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 • Tx - parenteral antibiotics for 6 wks (penicillin, vancomycin, gentamycin, ciprofloxacin) Myocarditis • Inflammation of myocardium results in degeneration and dilation • Thrombi form on endocardial lining (mural thrombi) • Etiology – viruses, parasites, bacteria, toxins, radiation • Clinical manifestations – asymptomatic or fever, fatigue, tachycardia, palpitations, dyspnea, symptoms of HF • Dx – endomyocardial biopsy, ECHO, chest x-ray, ECG, elevated cardiac enzymes • 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 • 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 Valvular Disorders • Stenosis – valve does not open completely • Regurgitation – valve does not close properly Mitral Valve Prolapse (MVP) • Portion of a leaflet balloons backward during systole • Valve may not remain closed and regurgitation can occur • Clinical manifestations – fatigue, dyspnea, chest pain, anxiety, dizziness, syncope, palpitations (atrial or ventricular dysrhythmias) • Dx – ECHO with Doppler flow studies • Tx – Beta blockers – Eliminate caffeine, alcohol, and smoking – Antibiotics prophylactically before and after invasive procedures Mitral Regurgitation or Mitral Insufficiency • Leaflets do not close properly and blood flows backward • Pressure increases in left atrium and blood backs up into lungs • Etiology - MI, heart enlargement, rheumatic endocarditis • Clinical manifestations – asymptomatic or symptoms of LVF, palpitations (atrial fib or PVCs), systolic murmur • 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, anticoagulation if atrial fib 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, dysrhythmias, DOE, systolic murmur, and possibly a thrill • Dx – ECHO, TEE, cardiac cath • Tx – Bed rest, aortic valve replacement (AVR), valvuloplasty, prophylactic antibiotics for invasive procedures Aortic Regurgitation or Aortic Insufficiency • Backflow of blood into LV from aorta during diastole • LV hypertropies and dilates • Competent mitral valve keeps blood from backing up into LA and lungs for a long time • Clinical manifestations – sensations of forceful heart beat especially in the head or neck, head bobbing, 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 • Commisurotomy – procedure to separate fused leaflets • Annuloplasty – repair of the valve annulus • Chordoplasty – repair of chordae tendineae Valve Replacement • Open heart procedure and requires heart lung bypass • Two types of valve prostheses – Mechanical valves • Ball-and-cage or disc design • More durable • Valves are susceptible to thromboemboli – Tissue grafts • Xenograft – porcine or bovine • Homograft (allograft) - from cadavar • Autograft (autologous) – use patient’s pulmonic valve Complications Related To Valve Replacement • • • • • • Hemorrhage Thromboembolism Infection Dysrhythmias Hemolysis of RBCs Heart failure Educational Needs of Client With Valve Replacement • Wound care, diet, meds, activity restrictions • Long term anticoagulant therapy if mechanical valve used • Prophylactic antibiotic therapy if mechanical valve used