Chapter 30 Management of Patients With Complications From Heart Disease

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. (insufficient CO) HF is a progressive, life-long condition that is managed with lifestyle changes and medications to prevent episodes of acute decompensated heart failure. The term heart failure indicates myocardial disease, in which there is a problem with the contraction of the heart (systolic failure) or filling of the heart (diastolic failure).

The EF is normal in diastolic HF but severely reduced in systolic HF. systolic heart failure (alteration in ventricular contraction and a weakened heart muscle.) Diastolic heart failure, (a stiff and noncompliant heart muscle, making it difficult for the ventricle to fill). ejection fraction (EF) is performed to assist in determining the type of HF. The EF is normal in diastolic HF but severely reduced in systolic HF.

Classification of Heart Failure NYHA (NEW YORK HEART ASSOCIATION) classification of heart failure Classification I , II, III, IV ACC/AHA (AMERICAN COLLEGE OF CARDIOLOGY AND AMERICAN HEART) ASSOCIATION classification of heart failure Stages A, B, C, D Treatment guidelines are in place for each stage

Pathophysiology of Heart Failure

Clinical Manifestations

Clinical Manifestations Right-sided failure RV cannot eject sufficient amounts of blood and blood backs up in the venous system. This results in JVD and increased capillary hydrostatic pressure, peripheral 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 and result in pulmonary congestion with dyspnea, nocturia, cough, crackles, and impaired oxygen exchange. Chronic heart failure is frequently biventricular.

Assessment and Diagnostic Findings HF may go undetected until the patient presents with signs and symptoms of pulmonary and peripheral edema. Assessment of ventricular function is an essential part of the initial diagnostic workup. An echocardiogram is usually performed to confirm the diagnosis of HF,

-2determine the EF, which helps identify the type and severity of HF. ECG CxR Serum electrolytes (BNP level) radionuclide ventriculography invasively ventriculography

Medical Management of Heart Failure depend on the type, severity, and cause of HF The overall goals of management of HF are to relieve patient symptoms, to improve functional status and quality of life, and to extend survival. Eliminate or reduce etiologic or contributory factors. Reduce the workload of the heart by reducing afterload and preload. Optimize all therapeutic regimens. Promote a lifestyle conducive to cardiac health Prevent episodes of acute decompensated HF

oral and IV medications, major lifestyle changes, supplemental oxygen, Implantation of assistive devices, and surgical approaches, including cardiac transplantation. provide comprehensive education and counseling restriction of dietary sodium; avoidance of excessive fluid intake, alcohol, and smoking; weight reduction and regular exercise recognize signs and symptoms

Medications Angiotensin: converting enzyme inhibitors and Angiotensin II receptor blockers Decrease BP and decrease afterload Relieves signs and symptoms of HF Prevents progression of HF Hydralazine and Isosorbide Dinitrate cause venous dilation

Medications Beta-blockers Diuretics Decrease fluid volume overload Decrease S&S of HF Digitalis Improves contractility Other medications

Nutritional Therapy A low-sodium (2 to 3 g/day) diet and avoidance of drinking excessive amounts of fluid Supplemental Oxygen

Nursing Process: The Care of the Patient with Heart Failure—Assessment Health history and Assess responses to medications Sleep and activity Knowledge and coping Physical exam Mental status Lung sounds: crackles and wheezes Heart sounds: Fluid status/signs of fluid overload (JVD and assess for hepatojugular reflux) Daily weight and I&O assesses dependent parts of the patient’s body for perfusion and edema.

Nursing Process: The Care of the Patient with Heart Failure—Diagnoses Activity intolerance and fatigue Excess fluid volume Anxiety Powerlessness Noncompliance

Collaborative Problems/Potential Complications Cardiogenic shock Dysrhythmias Thromboembolism Pericardial effusion and cardiac tamponade Hypotension, poor perfusion, and cardiogenic shock

Nursing Process: The Care of the Patient with Heart Failure—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 self-care program.

Activity Intolerance Encourage regular physical activity; 30–45 minutes daily Exercise training (increasing functional capacity and decreasing dyspnea.) Wait 2 hours after eating for physical activity Avoid activities in extreme hot, cold, or humid weather Modify activities to conserve energy Stop the activity if severe shortness of breath, pain, or dizziness develops. short-term and long-term goals can be developed to gradually increase the intensity, duration, and frequency of activity. Bed rest for acute exacerbations

Fluid Volume Excess Assessment for symptoms of fluid overload Auscultating the lungs, monitoring daily body weight, and assisting the patient to adhere to a low-sodium diet and fluid restriction I&O patient is positioned or taught how to assume a position that facilitates breathing. Frequent changes of position, positioning to avoid pressure, and leg exercises

Minimizing Powerlessness Controlling Anxiety Oxygen promote physical comfort and provide psychological support use relaxation techniques to control anxious feelings. Minimizing Powerlessness lack of knowledge and lack of opportunities to make decisions influence the direction of their lives and the outcomes of treatment. .

Monitoring and Managing Potential Complications Hypokalemia Hyperkalemia Hyponatremia dehydration and hypotension. increased serum creatinine and hyperuricemia

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