Download Congestive Heart Failure

Coronary Heart Disease
(CHD)
• Leading cause of death in U.S.
• Narrowing coronary arteries
– Atherosclerosis
Angina Pectoris Pathophysiology
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Obstructed coronary artery
Increased myocardial oxygen demand
Lactic acid release
Leads to pain
Three types
– Stable
– Unstable
– Prinzmetal’s: is a syndrome typically consisting of angina
(cardiac chest pain) at rest that occurs in cycles. It is caused by
vasospasm, a narrowing of the coronary arteries caused by
contraction of the smooth muscle tissue in the vessel walls
rather than directly by atherosclerosis
Angina Pectoris Manifestations
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Chest pain
Radiates
Onset with exercise, etc.
Relieved by rest, nitroglycerin (NTG)
SOB, pallor, fear
Acute Coronary Syndrome
• Condition that includes:
– Unstable angina
– Acute myocardial ischemia with or without
muscle damage
• Associated with coronary artery stenosis
and atherosclerotic plaque
Acute Myocardial Infarction
(AMI)
• Pathophysiology
– Occluded coronary artery stops blood flow
to part of cardiac muscle
– Cellular death
– Tissue necrosis
– Description—heart area affected
– Classification
AMI Manifestations
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Chest pain
Radiates to shoulder, neck, jaw, arms
Lasts longer than 15–20 minutes
Not relieved with NTG
Sense of impending doom
SOB
Diaphoresis
Nausea and vomiting
AMI Manifestations
(continued)
• Manifestations in women and elderly
– May be atypical
– Upper abdominal pain
– No chest pain but other symptoms
AMI Complications
• Related to size and location of infarct
• Dysrhythmias
• Pump failure
– Cardiogenic shock
• Pericarditis
Cardiac Dysrhythmias
• Pathophysiology
– Due to altered formation of impulses or
altered conduction of the impulse through
the heart
– Ectopic beats
– Heart block
– Reentry phenomenon
– Classified to the site of impulse formation or
the site and degree of conduction block
Types of Cardiac
Dysrhythmias (continued)
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PVCs
Ventricular tachycardia
Ventricular fibrillation
AV conduction blocks
– First degree
– Second degree
– Third degree
Types of Cardiac
Dysrhythmias
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Supraventricular
Sinus tachycardia
Sinus bradycardia
PAC
Atrial flutter
Atrial fibrillation
Junctional
Ventricular dysrhythmias
ECG Changes in Angina
Pectoris vs. Myocardial
Infection
Congestive Heart Failure
Dr Ibraheem Bashayreh, RN,PhD
04/11/2009
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Heart failure
Normal heart function
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Congestive Heart Failure
Definition
• Impaired cardiac pumping such that
heart is unable to pump adequate amount
of blood to meet metabolic needs
• Not a disease but a “syndrome”
• Associated with long-standing HTN and
CAD
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Factors Affecting Cardiac Output
Preload
Cardiac Output
=
CO
Heart Rate
X
Afterload
Stroke Volume
SV
Contractility
SV: the volume of blood pumped from one ventricle of the heart with each
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beat 04/11/2009
Factors Affecting Cardiac Output
• Heart Rate
– In general, the higher the heart rate, the lower
the cardiac
• E.g. HR x Systolic Volume (SV) = CO
» 60/min x 80 ml = 4800 ml/min (4.8 L/min)
» 70/min x 80 ml = 5600 ml/min (5.6 L/min)
– But only up to a point. With excessively high
heart rates, diastolic filling time begins to fall,
thus causing stroke volume and thus CO to fall
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Heart Rate
Stroke Volume
Cardiac Output
60/min
80 ml
4.8 L/min
80/min
80/ml
6.4 L/min
100/min
80/ml
8.0 L/min
130/min
50/ml
6.5 L/min
150/min
40/ml
6.0 L/min
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Factors Affecting Cardiac Output
• Preload
– The volume of blood/amount of fiber stretch
in the ventricles at the end of diastole (i.e.,
before the next contraction)
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Factors Affecting Cardiac Output
• Preload increases with:
• Fluid volume increases
• Vasoconstriction (“squeezes” blood from
vascular system into heart)
• Preload decreases with
• Fluid volume losses
• Vasodilation (able to “hold” more blood, therefore
less returning toheart)
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Factors Affecting Cardiac Output
• Starling’s Law
– Describes the relationship between preload and cardiac
output
– The greater the heart muscle fibers are stretched (b/c of
increases in volume), the greater their subsequent force
of contraction – but only up to a point. Beyond that
point, fibers get over-stretched and the force of
contraction is reduced
• Excessive preload = excessive stretch → reduced
contraction → reduced SV/CO
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Factors Affecting Cardiac Output
• Afterload
– The resistance against which the ventricle must
pump. Excessive afterload = difficult to pump
blood → reduced CO/SV
– Afterload increased with:
• Hypertension
• Vasoconstriction
– Afterload decreased with:
• Vasodilation
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Factors Affecting Cardiac Output
• Contractility
– Ability of the heart muscle to contract; relates
to the strength of contraction.
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Factors Affecting Cardiac Output
• Contractility decreased with:
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infarcted tissue – no contractile strength
ischemic tissue – reduced contractile strength.
Electrolyte/acid-base imbalance
Negative inotropes (medications that decrease
contractility, such as beta blockers).
• Contractility increased with:
– Sympathetic stimulation (effects of epinephrine)
– Positive inotropes (medications that increase
contractility, such as digoxin, sympathomimmetics)
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Pathophysiology of CHF
• Pump fails → decreased stroke volume /CO.
• Compensatory mechanisms kick in to increase CO
– SNS stimulation → release of epinephrine/norepinephrine
• Increase HR
• Increase contractility
• Peripheral vasoconstriction (increases afterload)
– Myocardial hypertrophy: walls of heart thicken to
provide more muscle mass → stronger contractions
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Pathophysiology of CHF
– Hormonal response: ↓’d renal perfusion
interpreted by juxtaglomerular apparatus as
hypovolemia. Thus:
• Kidneys release renin, which stimulates
conversion of antiotensin I → angiotensin
II, which causes:
– Aldosterone release → Na retention and
water retention (via ADH secretion)
– Peripheral vasoconstriction
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Pathophysiology of CHF
• Compensatory mechanisms may restore
CO to near-normal.
• But, if excessive the compensatory
mechanisms can worsen heart failure
because . . .
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Pathophysiology of CHF
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Vasoconstriction: ↑’s the resistance against
which heart has to pump (i.e., ↑’s afterload), and
may therefore ↓ CO
•
Na and water retention: ↑’s fluid volume, which
↑’s preload. If too much “stretch” (d/t too much
fluid) → ↓ strength of contraction and ↓’s CO
•
Excessive tachycardia → ↓’d diastolic filling
time → ↓’d ventricular filling → ↓’d SV and CO
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Congestive Heart Failure
Risk Factors
• CAD
• Age
• HTN
• Obesity
• Cigarette smoking
• Diabetes mellitus
• High cholesterol
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• African descent
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Heart failure
Underlying causes/risk factors
• Ischemic heart disease (CAD)
• hypertension
• myocardial infarction (MI)
• valvular heart disease
• congenital heart disease
• dilated cardiomyopathy
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Congestive Heart Failure
Types of Congestive Heart Failure
• Left-sided failure
– Most common form
– Blood backs up through the left atrium
into the pulmonary veins
• Pulmonary congestion and edema
– Eventually leads to biventricular failure
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Congestive Heart Failure
Types of Congestive Heart Failure
• Left-sided failure
– Most common cause:
• HTN
• Cardiomyopathy
• Valvular disorders
• CAD (myocardial infarction)
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Congestive Heart Failure
Types of Congestive Heart Failure
• Right-sided failure
– Results from diseased right ventricle
– Blood backs up into right atrium and venous
circulation
– Causes
• LVF
• Cor pulmonale: failure of the right side of the heart brought on
by long-term high blood pressure in the pulmonary arteries and right
ventricle of the heart
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• RV infarction
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Congestive Heart Failure
Types of Congestive Heart Failure
• Right-sided failure
– Venous congestion
• Peripheral edema
• Hepatomegaly
• Splenomegaly
• Jugular venous distension
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Congestive Heart Failure
Types of Congestive Heart Failure
• Right-sided failure
– Primary cause is left-sided failure
– Cor pulmonale
• RV dilation and hypertrophy caused
by pulmonary pathology
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Acute Congestive Heart Failure
Clinical Manifestations
• Pulmonary edema (what will you hear?)
– Agitation
– Pale or cyanotic
– Cold, clammy skin
– Severe dyspnea
– Tachypnea
– Pink, frothy sputum
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Chronic Congestive Heart Failure
Clinical Manifestations
• Fatigue
• Dyspnea
– Paroxysmal nocturnal dyspnea (PND)
• Tachycardia
• Edema – (lung, liver, abdomen, legs)
• Nocturia
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Chronic Congestive Heart Failure
Clinical Manifestations
• Behavioral changes
– Restlessness, confusion,  attention span
• Chest pain (d/t  CO and ↑ myocardial work)
• Weight changes (r/t fluid retention)
• Skin changes
– Dusky appearance
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Congestive Heart Failure
Classification
• Based on the person’s tolerance to physical
activity
– Class 1: No limitation of physical activity
– Class 2: Slight limitation
– Class 3: Marked limitation
– Class 4: Inability to carry on any physical
activity without discomfort
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Congestive Heart Failure
Diagnostic Studies
• Primary goal is to determine underlying
cause
– Physical exam
– Chest x-ray
– ECG
– Hemodynamic assessment
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Congestive Heart Failure
Diagnostic Studies
• Primary goal is to determine underlying
cause
– Echocardiogram (Uses ultrasound to visualize
myocardial structures and movement, calculate EF)
– Cardiac catheterization
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Acute Congestive Heart Failure
Nursing and Collaborative
Management
• Primary goal is to improve LV function by:
– Decreasing intravascular volume
– Decreasing venous return
– Decreasing afterload
– Improving gas exchange and oxygenation
– Improving cardiac function
– Reducing anxiety
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Acute Congestive Heart Failure
Nursing and Collaborative
Management
• Decreasing intravascular volume
– Improves LV function by reducing
venous return
– Loop diuretic: drug of choice
– Reduces preload
– High Fowler’s position
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Acute Congestive Heart Failure
Nursing and Collaborative
Management
• Decreasing afterload
– Drug therapy:
• vasodilation, Angiotensin-converting enzyme
(ACE) inhibitors
– Decreases pulmonary congestion
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Acute Congestive Heart Failure
Nursing and Collaborative
Management
• Improving cardiac function
– Positive inotropes
• Improving gas exchange and oxygenation
– Administer oxygen, sometimes intubate and
ventilate
• Reducing anxiety
– Morphine
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Chronic Congestive Heart Failure
Collaborative Care
• Treat underlying cause
• Maximize CO
• Alleviate symptoms
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Chronic Congestive Heart Failure
Collaborative Care
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Oxygen treatment
Rest
Biventricular pacing
Cardiac transplantation
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Chronic Congestive Heart Failure
Drug Therapy
• ACE inhibitors
• Diuretics
• Inotropic drugs : drugs that influence the
force of contraction of cardiac muscle
• Vasodilators
• -Adrenergic blockers
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Chronic Congestive Heart Failure
Nutritional Therapy
• Fluid restrictions not commonly prescribed
• Sodium restriction
– 2 g sodium diet
• Daily weights
– Same time each day
– Wearing same type of clothing
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Chronic Congestive Heart Failure
Nursing Management
Nursing Assessment
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Past health history
Medications
Functional health problems
Cold, diaphoretic skin
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Chronic Congestive Heart Failure
Nursing Management
Nursing Assessment
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Tachypnea
Tachycardia
Crackles
Abdominal distension
Restlessness
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Chronic Congestive Heart Failure
Nursing Management
Nursing Diagnoses
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Activity intolerance
Excess fluid volume
Disturbed sleep pattern
Impaired gas exchange
Anxiety
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Chronic Congestive Heart Failure
Nursing Management
Planning
• Overall goals:
–  Peripheral edema
–  Shortness of breath
–  Exercise tolerance
– Drug compliance
– No complications
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Chronic Congestive Heart Failure
Nursing Management
Nursing Implementation
• Acute intervention
– Establishment of quality of life goals
– Symptom management
– Conservation of physical/emotional energy
– Support systems are essential
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What is Blood Pressure?
• The force of blood against the wall of the
arteries.
• Systolic- as the heart beats
• Diastolic - as the heart relaxes
• Written as systolic over diastolic.
• Normal Blood pressure is less than 130 mm
Hg systolic and less than 85 mm Hg
diastolic.
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High Blood Pressure
• A consistent blood pressure of 140/90 mm
Hg or higher is considered high blood
pressure.
• It increases chance for heart disease, kidney
disease, and for having a stroke.
• 1 out of 4 Americans have High Bp.
• Has no warning signs or symptoms.
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Why is High Blood Pressure
Important?
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Makes the Heart work too hard.
Makes the walls of arteries hard.
Increases risk for heart disease and stroke.
Can cause heart failure, kidney disease, and
blindness.
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How Does It Effect the Body?
The Brain
• High blood pressure is the most important
risk factor for stroke.
• Can cause a break in a weakened blood
vessel which then bleeds in the brain.
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The Heart
• High Blood Pressure is a major risk factor
for heart attack.
• Is the number one risk factor for Congestive
Heart Failure.
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The Kidneys
• Kidneys act as filters to rid the body of
wastes.
• High blood pressure can narrow and thicken
the blood vessels.
• Waste builds up in the blood, can result in
kidney damage.
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The Eyes
• Can eventually cause blood vessels to break
and bleed in the eye.
• Can result in blurred vision or even
blindness.
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The Arteries
• Causes arteries to harden.
• This in turn causes the kidneys and heart to
work harder.
• Contributes to a number of problems.
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What causes High Blood
Pressure?
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Causes vary
Narrowing of the arteries
Greater than normal volume of blood
Heart beating faster or more forcefully than
it should
• Another medical problem
• The exact cause is not known.
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Who can develop High Blood
Pressure?
• Anyone, but it is more common in:
• African Americans- get it earlier and more
often then Caucasians.
• As we get older. 60% of Americans over
60 have hypertension.
• Overweight, family history
• High normal bp:135-139/85-89 mm Hg.
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Detection
• Dr.’s will diagnose a person with 2 or more
readings of 140/90mm Hg or higher taken
on more than one occasion.
• White-Coat Hypertension
• Measured using a spygmomameter.
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Tips for Having your blood
pressure taken.
• Don’t drink coffee or smoke cigarettes for
30 minutes before.
• Before test sit for five minutes with back
supported and feet flat on the ground. Test
your arm on a table even with your heart.
• Wear short sleeves so your arm is exposed.
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Tips for having blood pressure
taken.
• Go to the bathroom before test. A full
bladder can affect bp reading.
• Get 2 readings and average the two of them.
• Ask the Dr. or nurse to tell you the result in
numbers.
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Categories of High Blood
Pressure
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Ages 18 Years and Older)
Blood Pressure Level (mm Hg)
Category Systolic Diastolic
Optimal** < 120 < 80
Normal < 130 < 85
High Normal 130–139 85–89
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Categories of High Blood
Pressure
High Blood Pressure
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Stage 1
Stage 2
Stage 3
140–159 /90–99
160–179 /100–109
180 /110
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Preventing Hypertension
Adopt a healthy lifestyle by:
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Following a healthy eating pattern.
Maintaining a healthy weight.
Being Physically Active.
Limiting Alcohol.
Quitting Smoking.
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DASH diet
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Dietary Approaches to Stop Hypertension.
Was an 11 week trial.
Differences from the food pyramid:
an increase of 1 daily serving of veggies.
and increase of 1-2 servings of fruit.
inclusion of 4-5 servings of nuts,seeds, and
beans.
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Tips for Reducing Sodium
• Buy fresh, plain frozen or canned “no added
salt” veggies.
• Use fresh poultry, lean meat, and fish.
• Use herbs, spices, and salt-free seasonings
at the table and while cooking.
• Choose convenience foods low in salt.
• Rinse canned foods to reduce sodium.
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Maintain Healthy Weight
• Blood pressure rises as weight rises.
• Obesity is also a risk factor for heart
disease.
• Even a 10# weight loss can reduce blood
pressure.
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Be Physically Active
• Helps lower blood pressure and lose/
maintain weight.
• 30 minutes of moderate level activity on
most days of week. Can even break it up
into 10 minute sessions.
• Use stairs instead of elevator, get off bus 2
stops early, Park your car at the far end of
the lot and walk!
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Limit Alcohol Intake
Alcohol raises blood pressure and can harm
liver, brain, and heart
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Quit Smoking
• Injures blood vessel walls
• Speeds up process of hardening of the
arteries.
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Other Treatment
• If Lifestyle Modification is not working,
blood pressure medication may be needed,
there are several types:
• Diuretics-work on the kidney to remove
access water and fluid from body to lower
bp.
• Beta blockers-reduce impulses to the heart
and blood vessels.
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Other Treatment
• ACE inhibitors- cause blood vessels to relax
and blood to flow freely.
• Angiotensin antagonists- work the same as
ACE inhibitors.
• Calcium Channel Blockers- causes the
blood vessel to relax and widen.
• Alpha Blocker- blocks an impulse to the
heart causing blood to flow more freely.
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Other Treatment
• Alpha-beta blockers- work the same as beta
blockers, also slow the heart down.
• Nervous system inhibitors- slow nerve
impulses to the heart.
• Vasodilators- cause blood vessel to widen,
allowing blood to flow more freely.
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Conclusion
• Hypertension is a very controllable disease,
with drastic consequences if left
uncontrolled.
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