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Congestive Heart Failure &

Valvular Disease

Keith Rischer RN, MA, CEN

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Todays Objectives…

Review essential cardiac patho concepts Compare and contrast left-sided heart failure to right Describe special considerations for older adults with

heart failure Discuss the prevention of complications for patients

with heart failure Prioritize nursing care for clients with heart failure Identify common nursing diagnoses and collaborative

problems for patients with heart failure Evaluate the effects of interventions for reducing

preload and afterload through pharmacological management

Compare and contrast common valvular disorders

Introduction

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Definition of CHF Etiology

HTN MI

Left sided vs. Right sided Rt sided

COPD

Systolic vs. Diastolic Ejection Fraction

50-70% normal

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Cardiac OutputCardiac Output

CO = Stroke volume x heart rateSV (80cc) x HR (80)= 6400cc (6.4

lpm)

• Daily pumps 1800 gallonsDaily pumps 1800 gallons• 657,000 gallons every year657,000 gallons every year• Over 80 year lifetime:Over 80 year lifetime:

• 52,560,000 gallons52,560,000 gallons

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Definitions

Pre-load primarily venous blood return to

RA Right and left side of heart filling

pressure (atria>ventricles) Pressure/Stretch in ventricles

end diastole Stroke volume

Amount of blood ejected from the ventricle with each contraction

Systole Contraction; myocardium are

tightening and shortening

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Definitions

Inotropic state/contractility

Afterload: Force of resistance that Force of resistance that

the LV must generate to the LV must generate to open aortic valveopen aortic valve

Correlates w/SBPCorrelates w/SBP Diastole

Muscle fibers lengthen, the heart dilates, and cavities fill with blood

Patho: Patho: Starling’s Law of the HeartStarling’s Law of the Heart

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Maximum efficency of CO achieved when Maximum efficency of CO achieved when myocardium stretched appx 2 ½ times lengthmyocardium stretched appx 2 ½ times length

Think rubber bandThink rubber band CO decreased with lower preload/filling CO decreased with lower preload/filling

pressures or too highpressures or too high

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Compensatory Mechanisms in CHF

Increased Sympathetic Nervous System Stimulation

Renin-angiotensin system activation

Natriuretic peptides BNP

Ventricular hypertrophy

Acute Pulmonary Edema:

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Elevated capillary pressure within the lungs fluid pushed from circulating blood to interstitial tissues then to the alveoli, bronchioles, and bronchi

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Nursing Assessment:Left Failure

Dyspnea Cough Bilateral crackles Orthopnea PND Pulmonary Edema S3 (ken-tuck-ee) confusion fatigue and muscular weakness nocturia increase retention of sodium and water due to lowered

glomerular filtration edema

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Nursing Assessment: Right Failure

Dependent edema – early sign symmetric pitting edema Bedrest-sacral edema anasarca- late sign of CHF

Ascites Anorexia, nausea and bloating Cyanosis of nail beds Anxious, frightened, depressed Weight gain >2# daily

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Diagnostic Assessment

Chest x-ray Cardiac Enlargement

12 lead EKG Echocardiogram

assess ejection fraction

Labs BNP Liver enzymes…AST,

ALT Creatinine/GFR

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Acute Left Failure/Pulmonary Edema: Collaborative Management:

O2 treatment Drug Treatment

Diuretics Vasodilators-NTG MS Digitalis

Semi- Fowler’s position Frequent Heart and Lung Assessment Dietary Restrictions Planned rest periods Weigh daily Report to MD immediately:

persisting productive cough; dyspnea; pedal edema; restlessness

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Drug therapy:

Diuretics ACE Inhibitors Beta Blockers Calcium Channel Blockers Nitroglycerine Positive Inotropic agents

Digitalis

Beta Adrenergic Stimulator Dopamine,Dobutamine

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Pharmacologic: Diuretics

Mechanism of Action: Thiazides, Loop,

Potassium Sparing S/E:

fluid and electrolyte imbalances

CNS effects GI effects

Nursing Considerations:

Monitor for orthostatic hypotension

Hypokalemia

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Angiotensin Converting Enzyme (ACE) Inhibitors

Mechanism of Action S/E:

Hypotension cough Hyperkalemia…esp w/CHF, CKD, DM Angioedema

Facial/laryngeal swelling

Nursing considerations: Do not use with potassium sparing diuretic Metabolized by liver-excreted by kidneys

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Adrenergic Inhibitors:Beta Blockers

Mechanism of Action Recommended for initial drug therapy of

uncomplicated HTN (along with diuretic) S/E:

Orthostatic hypotension bradycardia bronchospasm

Nursing considerations: monitor pulse regularly

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Calcium Channel Blockers

Amlodipine, Diltiazem, NifedipineMechanism of Action:

S/E: Nausea H/A Peripheral edema

Nursing considerations: use with caution in patients with heart failure Orthostatic changes contraindicated in patients with 2nd or 3rd degree heart block Concurrent use w/b-blockers incr risk of CHF

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Vasodilators

Mechanism of Action-NTG

• Vasodilater-predominant on venous system by relaxing smooth muscles of vessels

• Dilates coronary arteries/improves collateral flow

• Up to 20% normal coronaries…30-40% pre/post stenosis

• Decreases LVEDP…why?

• Decreases O2 needs myocardium

Side effects

• HA, hypotension, tachycardiaHA, hypotension, tachycardia

HydralazineHydralazine

• arterial vasodilatorarterial vasodilator

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Priority Nursing Diagnosis

Impaired Gas exchange r/t ventilation perfusion imbalance

Decreased Cardiac Output r/t altered contractility, preload and afterload

Activity Intolerance r/t imbalance between O2 supply and demand

Knowledge Deficit Activity schedule Recognizing worsening heart failure Medications Diet therapy

Valvular Heart Disease:Mitral Valve

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Mitral Stenosis Patho

Mitral Regurgitation Patho

Mitral Valve Prolapse Patho

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Valvular Heart Disease:Aortic Valve

Aortic Stenosis Patho Causes

Congenital Atheroclerosis Calcification

Aortic Regurgitation (Insufficiency) Patho

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Treatment Valvular Disease

Non-surgical Management Diuretics Beta blockers Digoxin Antibiotics

Before any invasives Coumadin-if artificial valve

Surgical Management Balloon Valvuloplasty Open heart

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Pericarditis

Patho Open heart AMI

Assessment findings Friction rub CP w/insp CP relieves sitting up Global ST elevation

Complications Pericardial effusion Cardiac tamponade

pericardiocentesis

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Endocarditis Patho Etiology

Valve replacement Structural cardiac defects Invasive procedures

Clinical Manifestations New murmur Heart failure Embolic

Diagnosis Transesophageal Echo + blood cultures

Interventions IV abx Surgical