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1 Congestive Heart Failure & Valvular Disease Keith Rischer RN, MA, CEN.

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Presentation on theme: "1 Congestive Heart Failure & Valvular Disease Keith Rischer RN, MA, CEN."— Presentation transcript:

1 1 Congestive Heart Failure & Valvular Disease Keith Rischer RN, MA, CEN

2 2 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

3 Introduction 3 Definition of CHF Etiology HTN MI Left sided vs. Right sided Rt sided COPD Systolic vs. Diastolic Ejection Fraction 50-70% normal

4 4 Cardiac Output CO = Stroke volume x heart rate SV ( 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

5 5 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

6 6 Definitions Inotropic state/contractility Afterload: Force of resistance that the LV must generate to open aortic valve Correlates w/SBP Correlates w/SBP Diastole Muscle fibers lengthen, the heart dilates, and cavities fill with blood

7 Patho: Starlings Law of the Heart 7 Maximum efficency of CO achieved when myocardium stretched appx 2 ½ times length Maximum efficency of CO achieved when myocardium stretched appx 2 ½ times length Think rubber band Think rubber band CO decreased with lower preload/filling pressures or too high CO decreased with lower preload/filling pressures or too high

8 8 Compensatory Mechanisms in CHF Increased Sympathetic Nervous System Stimulation Renin-angiotensin system activation Natriuretic peptides BNP Ventricular hypertrophy

9 Acute Pulmonary Edema: 9 Elevated capillary pressure within the lungs fluid pushed from circulating blood to interstitial tissues then to the alveoli, bronchioles, and bronchi

10 10 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

11 11 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

12 12 Diagnostic Assessment Chest x-ray Cardiac Enlargement 12 lead EKG Echocardiogram assess ejection fraction Labs BNP Liver enzymes…AST, ALT Creatinine/GFR

13 13 Acute Left Failure/Pulmonary Edema: Collaborative Management: O2 treatment Drug Treatment Diuretics Vasodilators-NTG MS Digitalis Semi- Fowlers position Frequent Heart and Lung Assessment Dietary Restrictions Planned rest periods Weigh daily Report to MD immediately: persisting productive cough; dyspnea; pedal edema; restlessness

14 14 Drug therapy: Diuretics ACE Inhibitors Beta Blockers Calcium Channel Blockers Nitroglycerine Positive Inotropic agents Digitalis Beta Adrenergic Stimulator Dopamine,Dobutamine.

15 15 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

16 16 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

17 17 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

18 18 Calcium Channel Blockers Amlodipine, Diltiazem, Nifedipine Mechanism 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 2 nd or 3 rd degree heart block Concurrent use w/b-blockers incr risk of CHF

19 19 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, tachycardia HA, hypotension, tachycardiaHydralazine arterial vasodilator arterial vasodilator

20 20 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

21 Valvular Heart Disease:Mitral Valve 21 Mitral Stenosis Patho Mitral Regurgitation Patho Mitral Valve Prolapse Patho

22 22 Valvular Heart Disease:Aortic Valve Aortic Stenosis Patho Causes Congenital Atheroclerosis Calcification Aortic Regurgitation (Insufficiency) Patho

23 23 Treatment Valvular Disease Non-surgical Management Diuretics Beta blockers Digoxin Antibiotics Before any invasives Coumadin-if artificial valve Surgical Management Balloon Valvuloplasty Open heart

24 24 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

25 25 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

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