NURS291-Disorders of the Heart

8/2/2019 NURS291-Disorders of the Heart

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Disorders Of The Heart

Terri Slifer Lynch,

MSN, RN, BC, CNE


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Heart Failure

Heart failure is aclinical syndrome

Heart is unable to

pump sufficient bloodto meet the needs ofthe tissues

Heart failure is the

number 1 DRG forhospitalization inpeople over 65 years


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Cultural Considerations

Higher prevalence in African Americans and

Native Americans

Directly related to the higher incidence and

prevalence of HTN and DM

Exacerbated by lack of access to health care


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Etiology of Heart Failure

CAD

Cardiomyopathy

Systemic or pulmonary

hypertension

Valvular disease

Septal defects

Myocarditis

Dysrhythmias

Hypervolemia

Metabolic disorders

Autoimmune disorders

Anemia in the elderly

Cardiotoxic substances


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Effects of Aging

Decreased compliance

Decreased response to

SNS stimulation

Decreased ability ofheart to increase CO

with exercise

Increased incidence ofdysrhythmias


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Pathophysiology Of Heart Failure

Decreased amount of blood ejected fromventricles

Stimulation of SNS occurs causing tachycardia,vasoconstriction and increased contractility

Increased contractility and venous return lead toventricular hypertrophy

Activation of Renin-Angiotensin-AldosteroneSystem


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Vascular volume and venous return increase which

increase blood volume and pressure in the heart

Release of atrial natriuretic peptide (ANP) and brainnatriuretic peptide (BNP)

Failure of compensatory mechanisms occurs

Blood backs up from LV into LA and pulmonaryvenous system

Blood backs up into the RV, RA and systemic venous

system


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Blood backs up in left atrium and pulmonary veins

Increased hydrostatic pressure forces fluid out ofpulmonary 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


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If left ventricular failure occurs, ususlly right

ventricular failure will follow

Right ventricular failure can occur solely

without left ventricular failure cor

pulmonale

Heart failure can affect systolic function or

diastolic function


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Clinical Manifestations Of Left

Ventricular Failure (LVF)

Dyspnea

Dyspnea on exertion (DOE)

Orthopnea

Paroxysmal nocturnal dyspnea (PND)

Cough

Crackles

Hypoxia, cyanosis Tachycardia, palpitations


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S3, S4, murmurs

Weak, thready pulses

Fatigue, decreased exercise tolerance Pale, cool, clammy skin

Restlessness, anxiety, confusion

Nocturia

Edema and weight gain


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Clinical Manifestations of Right

Ventricular Failure (RVF)

Elevated JVD

Positive HJR Hepatomegaly, splenomegaly

Ascites

Anorexia, nausea, constipation Sacral edema

Peripheral edema


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Acute Pulmonary Edema

Life threatening situation

Large accumulation of fluid in lungs

Manifestations Severe dyspnea, sense of suffocation, orthopnea

Cough, large amounts of frothy, blood tinged sputum

Wheezing and coarse crackles

Cyanosis

Cool, clammy, diaphoretic skin


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New York Heart Associations

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


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ACC/AHA Staging System

Stage A No structural abnormality of the heart No symptoms of HF

Stage B Structural abnormality of the heart No symptoms of HF

Stage C Structural abnormality of the heart

Some symptoms of HF Stage D

Structural abnormality of the heart Symptoms of HF that do not respond well to normal

treatment


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Diagnostic Findings With Heart Failure

Echocardiogram with Doppler flow studies

Chest x-ray

ECG B-Type Natriuretic Peptide (BNP)


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BUN and creatinine

T4 and TSH

Liver function tests

Stress testing or cardiac cath
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Objectives In Treating Heart Failure

Identify and eliminate the precipitating cause

Reduce the workload on the heart

Enhance patient and family coping withlifestyle changes
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Medical Management of Heart Failure

Exercise

Bed rest in upright position in acute and refractorystages

Regular exercise program

Oxygen therapy

Dietary restrictions

Sodium restriction Fluid restriction
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Cardiac

resynchronization

(CRT) biventricular

pacing (Medtronic

InSyn)


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Mechanical assist

devices VAD

Artificial heart

Transplantation
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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
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Beta1 Blockers

Decrease cytotoxic effects of constant stimulation

of SNS

Decrease workload by decreasing heart rate

Drugs - Coreg, Lopressor, Atenolol
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Vasodilators

Cause venous dilation

Cause arterial dilation

Drugs Nitrates ie. Isordil (isosorbide) and other

meds ie. Apresoline (hydralazine); BiDil (

isosorbide & hydralazine combination)
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Diuretics

Control Na and H2O retention

Three types Potassium sparingAldactone (spironalactone),

Inspra (eplerenone)

Loop diuretics Lasix (furosemide), Demadex

(torsemide) Thiazide diuretics Zaroxolyn (metolazone), HCTZ

(hydrochlorazide)

Monitor for hypotension, lyte imbalances and

dehydration, worsening renal failure
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Cardiac glycosides

Increase force of myocardial contraction and

slow electrical conduction

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)
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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
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Calcium channel blockers

Contraindicated with severe systolic dysfunction

Drugs Norvasc, Cardizem, Procardia


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Natrecor (nesiritide)

Indicated for the IV treatment of clients with

acutely decompensated congestive heartfailure 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


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Medical Management Of

Pulmonary Edema

Sit patient in high Fowlers with legs and feet

dependent

Oxygen

Morphine

Diuretics

Foley Other meds as with heart failure
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Nursing Diagnoses For The Client

With Heart Failure
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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
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Assess respiratory status frequently

Lung sounds

Assess degree of dyspnea

Assess O2 sats

Assess renal status

I&O

BUN & Cr Assess for nocturia
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Assess GI system

HJR

Ascites

Appetite and constipation

Monitor fluid status closely

Daily weights

I&O Peripheral and sacral edema
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Reduce fatigue

Promote activity tolerance

Control anxiety Assess for depression

Referrals

Teach client and family

li d il hi l d
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Client and Family Teaching Related

to Heart Failure

Weigh daily

2-3 gm Na diet

Fluid restrictions

Meds and side effects
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Pneumococcal and flu vaccines recommended

Stop smoking, no ETOH

Signs and symptoms to report to physician Weight gain

Loss of appetite

Syncopy or palpitations

Worsening SOB Persistent cough

Increasing fatigue
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Web Sites

Heart Failure Society of America www.hfsa.org

Heart Failure Online www.heartfailure.org

Heart Failure Treatment Guidelines from the

AHA/ACC www.acc.org

AHA www.hearthub.org
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Expected Outcomes

Maintains or improves cardiac function

Maintains or increases activity tolerance

Adheres to self-care program

Absence of complications


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Cardiomyopathy

Disease of the myocardium which affects its

function

Three major types of cardiomyopathy

Dilated - DCM

Hypertropic - HCM

Restrictive


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Dilated Cardiomyopathy

Contractility decreasesand ventricles dilate.

Affects systolic function. Etiology ischemia, viral

myocarditis, toxins,alcohol, pregnancy


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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


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Hypertropic Cardiomyopathy

Myocardium increases in

size and mass

Reduces inner cavity ofventricles and ventricles

take longer to relax and

fill. Affects diastolic

function

Etiology genetic, HTN,

and hypoparathyroidism


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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. Avoidmeds that decrease preload (diuretics) or increasecontractility (Lanoxin). Tx dysrhythmias - mayinsert ICD


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Restrictive Cardiomyopathy

Ventricle walls arerigid and do notstretch normallyduring filling. Cardiacoutput decreases.Affects diastolicfunction.

Etiology - Amylodiosis,Sarcoidosis


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Clinical manifestations fatigue, activity intolerance,dyspnea and other symptoms of LVF

Dx tests same as other cardiomyopathies

Tx similar to hypertropic cardiomyopathy; txdysrhythmias and tx underlying cause


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Rheumatic Endocarditis

Results directly from group A beta-hemolytic strep

Can be prevented if strep infection treated early

Myocardium, valves and pericardium are affected

Contractility is decreased

Valve leaflets develop vegetative bodies which can

embolize


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Clinical manifestations Signs of rheumatic fever (fever, rash, migratory joint

pain)

Signs of carditis

Signs of heart failure

Dx tests Positive throat culture; elevated ESR,CBC, ECHO, ASO positive

Tx Prevention is best treatment Limited activity, treat heart failure if present

Penicillin or mycin drugs (clindamycin, erythromycin) ifPenicillin allergy

NSAIDS for joint pain


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Infective Endocarditis

Infection of theendocardium andvalves

Etiology staph,strep, fungi,entrococcci

Increased risk inpatients with valvedisorders and IV drugabusers


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Clinical manifestations malaise,intermittent fever and

chills, night sweats,Roth spots, splinterhemorrhages in nails,Janeway lesions,Oslers nodes,murmur, HF, stroke,pulmonary embolus


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Dx blood cultures, CBC, transesophagealECHO (TEE)

Prevent in patients with valve disorders with

prophylactic antibiotics before and afterinvasive procedures (Amoxicillin, Duricef,Cleocin)

Tx - parenteral antibiotics for 6 wks (Penicillin,EES, Clindamycin, Vancomycin)


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Myocarditis

Inflammation of myocardium results in

degeneration and dilation

Thrombi form on endocardial lining (mural

thrombi)

Etiology viruses, mumps, parasites, bacteria,

toxins, radiation


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Clinical manifestations asymptomatic or

fever, fatigue, tachycardia, palpitations,

dyspnea, symptoms of HF

Dx ECHO, endomyocardial biopsy, chest x-ray, ECG, elevated cardiac biomarkers


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Tx

Tx underlying cause

Bed rest

Tx heart failure

Anti-inflammatory or immunosuppressive

medications


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Pericarditis

Inflammation of thepericardial sac

Fibrinous adhesions or

exudate can form inpericardial sac

Etiology viruses,bacteria, fungi,

myocardial injury,collagen diseases, drugreaction, radiation,neoplasms, ESRD


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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


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Complications of Pericarditis

Pericardial effusion

Cardiac tamponadesigns and symptoms

Pulsus paradoxus

Muffled heart sounds

Tachycardia

Narrow pulse pressure

Distended neck veins

Drop in BP

Chronic constrictivepericarditis

Treatment of Complications of


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Treatment of Complications of

Pericarditis

Pericardiocentesis

Pericardiectomy


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Valvular Disorders

Stenosis valve does not open completely

Regurgitation valve does not close properly


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Mitral Valve Prolapse (MVP)

Portion of a leaflet balloons backward duringsystole

Valve may not remain closed and regurgitation

can occur Clinical manifestations fatigue, dyspnea,

chest pain, anxiety, dizziness, syncope,palpitations (atrial or ventriculardysrhythmias)


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Dx ECHO with Doppler flow studies

Tx

Beta blockers

Eliminate caffeine, alcohol, and smoking

Mitral Regurgitation or Mitral


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Mitral Regurgitation or Mitral

Insufficiency

Leaflets do not close properly and blood

leaks backward

Pressure increases in left atrium and bloodbacks up into lungs

Etiology - MI, heart enlargement, rheumatic

endocarditis Clinical manifestations asymptomatic or

symptoms of LVF, palpitations (atrial fib or

PVCs), systolic murmur


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Dx ECHO withDoppler flow , TEE,cardiac cath

Tx tx LVF, mitralvalve replacement(MVR) orvalvuloplasty

Prophylacticantibiotics forinvasive procedures


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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


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Clinical manifestations Diastolic murmur,

fatigue, dyspnea, hemoptyosis, cough,

crackles, atrial fib

Dx ECHO, cardiac cath

Tx tx LVF, valvuloplasty or MVR,

anticoagulants if AF persists


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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


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Clinical manifestations angina, dizziness orsyncope, DOE, narrowed pulse pressure,dysrhythmias, systolic murmur, and possibly a

thrill Dx ECHO, TEE, cardiac cath

Tx Bed rest, aortic valve replacement (AVR),valvuloplasty, prophylactic antibiotics forinvasive procedures

Aortic Regurgitation or Aortic


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Aortic Regurgitation or Aortic

Insufficiency

Backflow of blood into LV from aorta during

diastole

Increased blood volume in LV causes LV to

contract more forcefully and hypertropy

Blood backs up into LA and lungs


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Clinical manifestations sensations of forceful heartbeat especially in the head and neck, head bobbing

(Mussets sign), 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


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Valvuloplasty

Commisurotomy

procedure to separatefused leaflets


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Annuloplasty repair of the valve annulus


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Chordoplastyrepairof chordae tendineae

V l R l


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Valve Replacement

Open heart procedure requiring heart lung

bypass

Classic approach

Minimally invasive robtic approach

Patients age, contraindications to

anticoagulants and underlying cause are

considered


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Two types of valve

prostheses

Mechanical valves

Ball-and-cage or disc

design

More durable

Valves are susceptible

to thromboemboli


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Biologic tissue grafts

Xenograft porcine or

bovine

Homograft (allograft) - fromhuman pericardial tissue

Autograft (autologous)

use patients pulmonic valve

Complications Related To Valve
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p

Replacement

Hemorrhage

Thromboembolism

Infection

Dysrhythmias

Hemolysis of RBCs

Heart failure

Educational Needs of Client With
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Valve Replacement

Wound care, diet, meds, activity restrictions

Long term anticoagulant therapy if mechanical

valve used

Prophylactic antibiotic therapy if mechanical

valve used
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Documents

NURS291-Disorders of the Heart