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UNIT
5
Cardiac Conditions
FNP:ACTIVITY-EXERCISE PATTERN
REQUIRED READINGS:
Smeltzer: Chapters 26-32
•Do Case Studies from Critical Thinking Book Before
Class!
1st CS on pg:49 Angina
2nd CS on pg:27 Coronary Artery Disease
3rd CS on pg:89 Congestive Heart Failure
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Heart Failure
• 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 HF 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.
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Pathophysiology of HF
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Question
Which of the following is a primary cause of chronic heart
failure?
a. Atherosclerosis
b. Valvular dysfunction
c. Hypertension
d. Cardiomyopathy
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Clinical Manifestations (See Chart 30-1)
• Right-sided failure
– RV cannot eject sufficient amounts of blood, and
blood backs up in the venous system. This resuts in
perpheral edema, hepatomegaly, ascites, anorexia,
nausea, weakness, and weight gain.
• Left-sided failure
– LV cannot pump blood effectively to the systemic
circulation. Pulmonary venous pressures increase,
resulting in pulmonary congestion with dyspnea,
cough, crackles, and impaired oxygen exchange.
• Chronic HF is frequently biventricular.
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Classification of Heart Failure
• NYHA classification of HF
– Classification I, II, III, IV
• ACC/AHA classification of HF
– Stages A, B, C, D
• Treatment guidelines are in place for each stage.
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Medical Management of HF
• Eliminate or reduce etiologic or contributory factors.
• Reduce the workload of the heart by reducing afterload
and preload.
• Optimize all therapeutic regimens.
• Prevent exacerbations of HF.
• Medications are routinely prescribed for HF.
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Medications
• Angiotensin-converting enzyme inhibitors
• Angiotensin II receptor blockers
• Beta-blockers
• Diuretics
• Digitalis
• Other medications
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Question
Tell whether the following statement is true or false.
Digoxin immune FAB (Digibind) may be given to treat
severe digoxin toxicity.
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Nursing Process: The Care of the Patient
with HF: Assessment
• Health history
• Sleep and activity
• Knowledge and coping
• Physical exam
– Mental status
– Lung sounds: crackles and wheezes
– Heart sounds: S3
– Fluid status/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 HF: Diagnosis
• Activity intolerance and fatigue
• Excess fluid volume
• Anxiety
• Powerlessness
• Noncompliance
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Collaborative Problems/Potential
Complications
• Cardiogenic shock
• Dysrhythmias
• Thromboembolism
• Pericardial effusion and cardiac tamponade
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Nursing Process: The Care of the Patient
with HF: Planning
• Goals may include promoting activity and reducing
fatigue, relieving fluid overload symptoms, decreasing
anxiety or increasing the patient’s ability to manage
anxiety, encouraging the patient to make decisions and
influence outcomes, teaching the patient about the selfcare program.
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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 before doing physical activity.
• Avoid activities in extremely hot, cold, or humid weather.
• Modify activities to conserve energy.
• Positioning; elevation of 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
See Chart 30-4
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Patient Teaching
• 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 teaching
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Question
All of the following are clinical manifestations of right-sided
heart failure except:
a. Hepatomegaly
b. Jugular vein distention
c. Ascites
d. Orthopnea
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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 to move 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
• Prevention
• 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
– Morphine
– Diuretic (furosemide)
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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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Pathophysiology of Cardiogenic Shock
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Management of Cardiogenic Shock
• Correct underlying problem
• Medications
– Diuretics
– Positive inotropic agents and vasopressors
• Circulatory assist devices
– Intra-aortic balloon pump (IABP)
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Intra-Aortic Balloon Pump
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Thromboembolism
• Decreased mobility and decreased circulation increase
the risk for thromboembolism in patients 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
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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
due to this fluid, resulting in decreased venous return
and decreased CO.
• Clinical manifestations: ill-defined chest pain or fullness,
pulsus parodoxus, 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
See Chart 30-6
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Assessing for Cardiac Tamponade
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Medical Management
• Pericardiocentesis
• Pericardiotomy
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Sudden Cardiac Death/Cardiac Arrest
• Emergency management: cardiopulmonary resuscitation
• A- airway
• B- breathing
• C- circulation
• D- defibrillation for VT and VF
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Question
Tell whether the following statement is true or false.
The most reliable sign of cardiac arrest is absence of
breath sounds.
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