Interventions for Clients with Cardiac Problems

Heart Failure Also called pump failure, general term for the inadequacy of the heart to pump blood throughout the body; causes insufficient perfusion of body tissue with vital nutrients and oxygen Also called pump failure, general term for the inadequacy of the heart to pump blood throughout the body; causes insufficient perfusion of body tissue with vital nutrients and oxygen Left-sided heart failure Left-sided heart failure Right-sided heart failure Right-sided heart failure High-output failure High-output failure

Compensatory Mechanisms Sympathetic nervous system stimulation Sympathetic nervous system stimulation Renin-angiotensin system activation Renin-angiotensin system activation Other neurohumoral responses Other neurohumoral responses Myocardial hypertrophy Myocardial hypertrophy

Etiology Heart failure is caused by systemic hypertension in 75% of cases. Heart failure is caused by systemic hypertension in 75% of cases. About one third of clients experiencing myocardial infarction also develop heart failure. About one third of clients experiencing myocardial infarction also develop heart failure. Structural heart changes, such as valvular dysfunction, cause pressure or volume overload on the heart. Structural heart changes, such as valvular dysfunction, cause pressure or volume overload on the heart.

Left-Sided Heart Failure Manifestations include: Manifestations include: –Weakness –Fatigue –Dizziness –Confusion –Pulmonary congestion –Shortness of breath (Continued)

Left-Sided Heart Failure (Continued) –Oliguria –Organ failure, especially renal failure –Death Assess blood pressure, mental status, breath sounds Assess blood pressure, mental status, breath sounds

Right-Sided Heart Failure Manifestations include: Manifestations include: –Distended neck veins, increased abdominal girth –Hepatomegaly (liver engorgement) –Hepatojugular reflux –Ascites –Dependent edema –Weight: the most reliable indicator of fluid gain or loss

Assessments Laboratory assessment Laboratory assessment Radiographic assessment Radiographic assessment Electrocardiography Electrocardiography Echocardiography Echocardiography Pulmonary artery catheters Pulmonary artery catheters

Impaired Gas Exchange Interventions include: Interventions include: –Ventilation assistance –Hemodynamic regulation –Energy management, diet therapy, drug therapy

Decreased Cardiac Output Interventions include: Interventions include: –Optimization of cardiac output: stroke volume (determined by preload, afterload, and contractility) and heart rate (Continued)

Decreased Cardiac Output (Continued) –Drug therapy including: Angiotensin-converting enzyme Angiotensin-converting enzyme ACE inhibitors ACE inhibitors Diuretics Diuretics Human B-type natriuretic peptides Human B-type natriuretic peptides Nitrates Nitrates Inotropics Inotropics Beta-adrenergic blockers Beta-adrenergic blockers

Hemodynamic Regulation Interventions include: Interventions include: –Reduce afterload. –Reduce preload. –Improve cardiac muscle contractility. –Administer drugs as prescribed. –Monitor for therapeutic and adverse effects. –Teach client and family drug therapy.

Drugs That Reduce Afterload Angiotensin-converting enzyme (ACE) inhibitors Angiotensin-converting enzyme (ACE) inhibitors Human B-type natriuretic peptides Human B-type natriuretic peptides

Interventions That Reduce Preload Diet therapy Diet therapy Drug therapy Drug therapy –Diuretics –Venous vasodilators

Drugs That Enhance Contractility Digitalis Digitalis –Digitalis toxicity includes anorexia, fatigue, changes in mental status. –Monitor heart rate and electrolytes. Other inotropic drugs including dobutamine, milrinone, and levosimendan Other inotropic drugs including dobutamine, milrinone, and levosimendan Beta-adrenergic blockers Beta-adrenergic blockers

Other Nonsurgical Options Continuous positive airway pressure Continuous positive airway pressure Cardiac resynchronization therapy Cardiac resynchronization therapy Investigative gene therapy Investigative gene therapy

Surgical Management Newer surgical therapies include the following: Newer surgical therapies include the following: –Partial left ventriculectomy –Endoventricular circular patch –Acorn cardiac support device –Myosplint

Activity Intolerance Interventions include: Interventions include: –Ventilation assistance –Hemodynamic regulation –Energy management –Interdisciplinary interventions, which regulate energy to prevent fatigue and optimize function

Potential for Pulmonary Edema Interventions include: Interventions include: –Assess for early signs, such as crackles in the lung bases, dyspnea at rest, disorientation, and confusion. –Rapid-acting diuretics are prescribed, such as Lasix or Bumex. –Oxygen is always used. –Strictly monitor fluid intake and output.

Valvular Heart Disease Mitral stenosis Mitral stenosis Mitral regurgitation (insufficiency) Mitral regurgitation (insufficiency) Mitral valve prolapse Mitral valve prolapse Aortic stenosis Aortic stenosis Aortic regurgitation (insufficiency) Aortic regurgitation (insufficiency)

Assessment Client may become suddenly ill or slowly develop symptoms over many years. Client may become suddenly ill or slowly develop symptoms over many years. Question client about attacks of rheumatic fever, infective endocarditis, and possibility of IV drug abuse. Question client about attacks of rheumatic fever, infective endocarditis, and possibility of IV drug abuse. Obtain chest x-ray, echocardiogram, and exercise tolerance test. Obtain chest x-ray, echocardiogram, and exercise tolerance test.

Common Nursing Diagnoses Decreased Cardiac Output related to altered stroke volume Decreased Cardiac Output related to altered stroke volume Impaired Gas Exchange related to ventilation perfusion imbalance Impaired Gas Exchange related to ventilation perfusion imbalance Activity Intolerance related to inability of the heart to meet metabolic demands during activity Activity Intolerance related to inability of the heart to meet metabolic demands during activity Acute Pain related to physiologic injury agent (hypoxia) Acute Pain related to physiologic injury agent (hypoxia)

Nonsurgical Management Drug therapy, including diuretics, beta blockers, digoxin, oxygen, and sometimes nitrates Drug therapy, including diuretics, beta blockers, digoxin, oxygen, and sometimes nitrates Prophylactic antibiotic Prophylactic antibiotic Management of atrial fibrillation, cardioversion Management of atrial fibrillation, cardioversion Anticoagulant Anticoagulant Rest with limited activity Rest with limited activity

Surgical Management Reparative procedures Reparative procedures Balloon valvuloplasty Balloon valvuloplasty Direct, or open, commissurotomy Direct, or open, commissurotomy Mitral valve annuloplasty Mitral valve annuloplasty Replacement procedures Replacement procedures

Infective Endocarditis Microbial infection involving the endocardium Microbial infection involving the endocardium Occurs primarily with IV drug abuse, valvular replacements, systemic infections, or structural cardiac defects Occurs primarily with IV drug abuse, valvular replacements, systemic infections, or structural cardiac defects Possible ports of entry: mouth, skin rash, lesion, abscess, infections, surgery, or invasive procedures including IV line placement Possible ports of entry: mouth, skin rash, lesion, abscess, infections, surgery, or invasive procedures including IV line placement

Manifestations Murmur Murmur Heart failure Heart failure Arterial embolization Arterial embolization Splenic infarction Splenic infarction Neurologic changes Neurologic changes Petechiae (pinpoint red spots) Petechiae (pinpoint red spots) Splinter hemorrhages Splinter hemorrhages

Interventions Antimicrobials Antimicrobials Rest, balanced with activity Rest, balanced with activity Supportive therapy for heart failure Supportive therapy for heart failure Anticoagulants Anticoagulants Surgical management Surgical management

Pericarditis Inflammation or alteration of the pericardium, the membranous sac that encloses the heart Inflammation or alteration of the pericardium, the membranous sac that encloses the heart Dressler’s syndrome Dressler’s syndrome Postpericardiotomy syndrome Postpericardiotomy syndrome Chronic constrictive pericarditis Chronic constrictive pericarditis

Assessment Substernal precordial pain radiating to left side of the neck, shoulder, or back Substernal precordial pain radiating to left side of the neck, shoulder, or back Grating, oppressive pain, aggravated by breathing, coughing, swallowing Grating, oppressive pain, aggravated by breathing, coughing, swallowing Pain worsened by the supine position; relieved when the client sits up and leans forward Pain worsened by the supine position; relieved when the client sits up and leans forward Pericardial friction rub Pericardial friction rub

Interventions Hospitalization for diagnostic evaluation, observation for complications, and symptom relief Hospitalization for diagnostic evaluation, observation for complications, and symptom relief Nonsteroidal anti-inflammatory drugs Nonsteroidal anti-inflammatory drugs Corticosteroid therapy Corticosteroid therapy Comfortable position, usually sitting Comfortable position, usually sitting Pericardial drainage Pericardial drainage(Continued)

Interventions (Continued) Chronic pericarditis: radiation or chemotherapy Chronic pericarditis: radiation or chemotherapy Uremic pericarditis: dialysis Uremic pericarditis: dialysis Pericardiectomy Pericardiectomy

Emergency Care of Cardiac Tamponade Cardiac tamponade—an extreme emergency Cardiac tamponade—an extreme emergency Increased fluid volume Increased fluid volume Hemodynamic monitoring Hemodynamic monitoring Pericardiocentesis Pericardiocentesis Pericardial window Pericardial window Pericardiectomy Pericardiectomy

Rheumatic Carditis Sensitivity response that develops following an upper respiratory tract infection with group A beta- hemolytic streptococci Sensitivity response that develops following an upper respiratory tract infection with group A beta- hemolytic streptococci Inflammation in all layers of the heart Inflammation in all layers of the heart Impaired contractile function of the myocardium, thickening of the pericardium, and valvular damage Impaired contractile function of the myocardium, thickening of the pericardium, and valvular damage

Clinical Manifestations Tachycardia Tachycardia Cardiomegaly Cardiomegaly New or changed murmur New or changed murmur Pericardial friction rub Pericardial friction rub Precordial pain Precordial pain Changes in electrocardiogram Changes in electrocardiogram Indications of heart failure Indications of heart failure Existing streptococcal infection Existing streptococcal infection

Cardiomyopathy Subacute or chronic disease of cardiac muscle Subacute or chronic disease of cardiac muscle Dilated cardiomyopathy Dilated cardiomyopathy Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy Restrictive cardiomyopathy Restrictive cardiomyopathy

Interventions Nonsurgical management Nonsurgical management Surgical management Surgical management –Cardiomyoplasty –Heart transplantation