1. Care of Patients with Cardiac Problems Chapter 37 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

2. Learning Outcomes 1. Provide the patient with heart failure (HF) and the family information on discharge to home, hospice, or other community-based setting. 2. Identify community resources for patients with cardiac problems and their families. 3. Teach patients about actions to maintain health and prevent worsening HF. 4. Explain the pathophysiology of HF.

3. 5. Compare and contrast left-sided and right-sided HF. 6. Identify priority problems for patients with HF. 7. Explain how common drug therapies improve cardiac output and prevent worsening of HF. 8. Monitor the laboratory values for patients with cardiac problems. 9. Plan nursing interventions to improve the patient's cardiovascular status when needed.

4. 10. Provide emergency care for patients experiencing life-threatening complications, such as cardiac tamponade and pulmonary edema. 11. Compare and contrast common valvular disorders. 12. Differentiate between common cardiac inflammations and infections—endocarditis, pericarditis, and rheumatic carditis. 13. Differentiate patients with various types of cardiomyopathy.

5. **Heart Failure** Valvular Heart Disease Mitral Stenosis Mitral Regurgitation (Insufficiency) Mitral Valve Prolapse Aortic Stenosis Aortic Regurgitation (Insufficiency) Inflammation and Infections Infective Endocarditis Pericarditis Rheumatic Carditis Cardiomyopathy

6. Also called pump failure; inability of heart to work effectively as a pump What can lead to heart failure? Acute coronary disease Structural problem Functional problem SeeTABLE 37-1 COMMON CAUSES AND RISK FACTORS FOR HEART FAILURE Heart Failure

7. Left-sided (usually starts here) AKA as _________ Systolic heart failure Diastolic heart failure Right-sided High-output Major Types of Heart Failure

8. Not all cases involve fluid accumulation Systolic Versus Diastolic HF Left-Sided Heart Failure

9. Right ventricle cannot empty completely Increased volume and pressure in venous system and peripheral edema Right-Sided Heart Failure

10. Cardiac output remains normal or above normal Caused by increased metabolic needs of hyperkinetic conditions: Septicemia Anemia Hyperthyroidism High-Output Failure

11. When cardiac output insufficient to meet body’s demands, these mechanisms operate to increase cardiac output: Sympathetic nervous system stimulation Renin-angiotensin system activation Myocardial hypertrophy Compensatory Mechanisms

12. Systemic hypertension cause of heart failure in most cases About one third of patients experiencing MI also develop HF Structural heart changes (e.g., valvular dysfunction) cause pressure or volume overload on heart Etiology

13. Chart 37-1 Key Features Of Left-Sided Heart Failure Chart 37-2 Key Features Of Right-Sided Heart Failure S+S Assessment: Heart Failure

14. Psychosocial Assessment: Heart Failure Hope is a major indicator of well-being for patients with HF. Those who are hopeful tend to feel better and are more socially involved. Ask patients about their daily activities and how often they interact with the significant people in their life to help determine patient and family coping strategies.

15. Electrolytes Hemoglobin and hematocrit B-type natriuretic peptide (BNP) Urinalysis (proteinuria/high specific gravity) ABGs Lab Assessment: Heart Failure

16. Chest x-ray Echocardiography (best diagnostic tool) ECG Invasive hemodynamic monitoring Diagnostic Assessment: Heart Failure

17. Impaired Gas Exchange related to ventilation/ perfusion imbalance Decreased Cardiac Output related to altered contractility, preload, and afterload Fatigue and weakness related to hypoxemia Potential for pulmonary edema related to left-sided HF Nursing Diagnosis: Heart Failure

18. Drugs That Reduce Afterload Afterload= resistance to the left ventricular ejection Afterload is decreased by relaxing arterioles by using arterial vasodilator drugs like ACE inhibitors and ARBs

19. ACE inhibitors- Angiotensin-converting enzyme (ACE) inhibitors help relax blood vessels. ACE inhibitors prevent an enzyme in your body from producing angiotensin II, a substance in your body that affects your cardiovascular system by narrowing your blood vessels and releasing hormones that can raise your blood pressure. Enalapril (Vasotec) http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/ace- inhibitors/art-20047480 ACE inhibitors- Angiotensin-converting enzyme inhibitors

20. ARB- Angiotensin II receptor blockers ARB- Angiotensin II receptor blockers help relax your blood vessels, which lowers your blood pressure and makes it easier for your heart to pump blood. Angiotensin II is a natural substance in your body that * narrows your blood vessels * releases a hormone that increases the amount of sodium and water in your body, which can lead to increased blood pressure * thickens and stiffens the walls of your blood vessels and heart Valsartan (Diovan) Losartan (Cozaar) http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/angiotensin-ii-receptor- blockers/art-20045009

21. Preload [pre´lōd] the volume of blood in the ventricle at the end of diastole. Nutrition therapy Possible sodium restriction Possible fluid restriction Drug therapy Morphine Diuretics- Furosemide (Lasix) Venous vasodilators- Nitrates like Isorbide (Imdur) http://medical-dictionary.thefreedictionary.com/preload Interventions that Reduce Preload

22. Cardiac glycoside Digoxin (Lanoxin) Beta-adrenergic blockers (AKA Beta Blockers) Carvedilol (Coreg) Metoprolol (Lopressor) Drugs that Enhance Contractility

23. Increases contractility Reduces heart rate (HR) Slows conduction through atrioventricular node Inhibits sympathetic activity Enhances parasympathetic activity Potential Benefits of Digoxin (Dig)

24. Heart transplantation VADs= Ventricular Assist Device Other surgical therapies: Heart reduction Endoventricular circular patch cardioplasty Acorn cardiac support device Myosplint Surgical Management

25. Heart Transplantation

26. Pulmonary edema= left ventricle fails to eject enough blood and therefore the pressure increases in the lungs Assess for Crackles, Dyspnea at rest, Disorientation, Tachycardia High Fowler’s position Preventing or Managing Pulmonary Edema

27. Oxygen therapy Nitroglycerin Rapid-acting diuretics IV morphine sulfate Continual assessment Preventing or Managing Pulmonary Edema (cont’d)

28. Evaluation So did your interventions work? How do you know? What could you do differently next time (if anything)?

29. Home care management Teaching for self-management TABLE 37-4 HEART FAILURE SELF- MANAGEMENT HEALTH TEACHING Health care resources Community-Based Care

30. Valvular Heart Disease Mitral Stenosis Mitral Regurgitation (Insufficiency) Mitral Valve Prolapse Aortic Stenosis Aortic Regurgitation (Insufficiency)

31. Mitral Stenosis In mitral stenosis, the valve leaflets fuse and become stiff and the chordae tendineae contract and shorten. The valve opening narrows, preventing normal blood flow from the left atrium to the left ventricle. As a result of these changes, left atrial pressure rises, the left atrium dilates, pulmonary artery pressures increase, and the right ventricle hypertrophies.

32. Mitral Regurgitation (Insufficiency) The fibrotic and calcific changes occurring in mitral regurgitation (insufficiency) prevent the mitral valve from closing completely during systole. Incomplete closure of the valve allows the backflow of blood into the left atrium when the left ventricle contracts (Ray, 2010).

33. Mitral Valve Prolapse Occurs because the valvular leaflets enlarge and prolapse into the left atrium during systole. This abnormality is usually benign but may progress to pronounced mitral regurgitation.

34. Aortic Stenosis: the aortic valve orifice narrows and obstructs left ventricular outflow during systole. Aortic Regurgitation (Insufficiency): the aortic valve leaflets do not close properly during diastole and the annulus (the valve ring that attaches to the leaflets) may be dilated, loose, or deformed. This allows flow of blood from the aorta back into the left ventricle during diastole.

35. Home care management Teaching for self-management Chart 37-7 Patient and Family Education: Preparing for Self- Management Valvular Heart Disease Health care resources Community-Based Care

36. Inflammation and Infections Infective Endocarditis Pericarditis Rheumatic Carditis

37. Infective Endocarditis (previously called bacterial endocarditis) is a microbial infection (e.g., viruses, bacteria, fungi) of the endocardium. The most common infective organism is Streptococcus viridans or Staphylococcus aureus. Heart failure is the most common complication of infective endocarditis. Arterial embolization is a major complication in up to half of patients with infective endocarditis.

38. Antimicrobials 4-6 weeks of IV Activities balanced with adequate rest Aseptic technique to protect the patient Assess for heart failure Nonsurgical Management

39. Removal of infected valve Repair or removal of congenital shunts Repair of injured valves and chordae tendineae Draining of abscesses in heart or elsewhere Surgical Management

40. Pericarditis Inflammation or alteration of the pericardium (membranous sac that encloses the heart.) Interventions Pain management NSAIDs Antibiotics for bacterial form Pericardiectomy Chart 37-9

41. Pericarditis (cont’d)

42. Cardiac Tamponade= small volumes (20-50 mL) of fluid accumulate rapidly in the pericardium and cause a sudden decrease in cardiac output. S+S Jugular venous distention Paradoxical pulse, also known as pulsus paradoxus (systolic blood pressure 10 mm Hg or more higher on expiration than on inspiration) Decreased heart rate, dyspnea, and fatigue Muffled heart sounds Hypotension Acute Cardiac Tamponade: Emergency Care

43. Acute Cardiac Tamponade: Interventions Increased fluid volume Hemodynamic monitoring Pericardiocentesis Pericardial window Pericardiectomy

44. Pericardiocentesis

45. Sensitivity response from upper respiratory tract infection with group A beta-hemolytic streptococci Inflammation in all layers of heart Formation of Aschoff bodies (small nodules that turn into scar tissue) Impaired contractile function of myocardium, thickening of pericardium, valvular damage Rheumatic Carditis

46. Subacute or chronic disease of cardiac muscle 4 categories based on structure and function Dilated cardiomyopathy Hypertrophic cardiomyopathy Restrictive cardiomyopathy Arrhythmogenic right ventricular cardiomyopathy Cardiomyopathy

47. Dilated cardiomyopathy Fibrosis of myocardium and endocardium Dilated chambers Hypertrophic cardiomyopathy Hypertrophy of all walls Hypertrophy of septum Relatively small chamber size

48. Restrictive cardiomyopathy Stiff ventricles that restrict filling during diastole Arrhythmogenic right ventricular cardiomyopathy Replacement of myocardial tissue with fibrous and fatty tissue

49. Drug therapy to increase cardiac output Diuretics like…. Vasodilating agents like…. Cardiac glycosides like…. Toxin (like ETOH) exposure avoidance Nonsurgical Management

50. Depends on cardiomyopathy type Most common: Ventriculomyomectomy Percutaneous alcohol septal ablation Heart transplantation Surgical Management

51. A 51-year-old Hispanic man came to the hospital 2 days ago for recurrent exacerbation of heart failure. He weighs 237 lbs and is 5’ 8” tall. He has IV access in his left forearm and is on oxygen at 2 L per nasal cannula. When you assess the patient, he is sitting on the side of the bed and appears to be short of breath. He tells you that he has just returned from the bathroom. He is sweating and his nasal cannula is laying on the bedside table. Which action should you take first? A. Replace the oxygen. B. Take his vital signs. C. Call the Rapid Response Team. D. Sit him up in a bedside chair.

52. ANS: A The patient has exerted himself in ambulating to and from the bathroom. He also has been without supplemental oxygen. The first action should be to replace his nasal cannula. He has a history of heart failure and will often require supplemental oxygen. Taking his vital signs can be done once his oxygen is restored. If he wants to sit up, he should be positioned in bed, not in a bedside chair. Calling the Rapid Response Team is not necessary.

53. Fifteen minutes after the oxygen is replaced and he has rested, the patient denies being short of breath. You obtain an oxygen saturation and it is 96%. Based on this result, what should you do next? A. Call the provider as soon as possible. B. Continue the assessment because 96% is acceptable. C. Increase the oxygen level to 5 L per nasal cannula. D. Encourage the patient to take some deep breaths. (cont’d)

54. ANS: B Once the patient’s oxygen is replaced, he denies shortness of breath. The supplemental oxygen and a period of rest resulted in his oxygen saturation being 96%, which is acceptable. The oxygen should not be increased, nor does he need to take deep breaths because the patient’s SaO 2 is normal and he is not short of breath.

55. After assessing the patient, you document the following: Jugular venous distention 2+ edema in feet and ankles Swollen hands and fingers Distended abdomen Bibasilar crackles on auscultation Productive cough with pink-tinged sputum What is your best interpretation of these findings? A. Right-sided heart failure B. Left-sided heart failure C. Biventricular failure D. Class IV heart failure (cont’d)

56. ANS: C The patient has key features of both right-sided and left-sided heart failure.

57. During morning care, the patient develops shortness of breath, fatigue, and tachycardia. 1. What is your interpretation of these findings? 2. What interventions would you begin at this time? (cont’d)

58. 1.The patient has developed activity intolerance from too much exertion. 2.Energy management – provide physical and emotional rest; arrange nursing care to provide periods of rest; provide assistance with any care the patient is unable to complete for himself; observe and document the patient’s response to activity; as the patient improves, consult with a physical therapist; gradually increase activity based on the patient’s responses.

59. During the evening shift, the patient has a bedside echocardiogram which reveals an ejection fraction of 30%. Based on this finding, which medications might the provider order? (Select all that apply.) A. Lisinopril (Zestril) 5 mg PO daily B. Ibuprofen (Advil) 200 PO mg twice daily C. Multivitamin 1 PO each day D. Furosemide (Lasix) 20 mg IV push daily E. Digoxin (Lanoxin) 0.25 mg PO daily (cont’d)

60. ANS: A, D, E Commonly prescribed drug classes for patients with heart failure include ACE inhibitors (lisinopril), diuretics (furosemide), nitrates (digoxin), human B-type natriuretic peptides, inotropics, and beta-adrenergic blockers.

61. Which cardiovascular disease results in the highest number of hospital admissions in the United States? A.Mitral valve disease B.Infective endocarditis C.Heart failure D.Rheumatic carditis Question 1

62. Answer: C Rationale: According to the American Heart Association, heart failure affects nearly 5.7 million Americans of all ages and is responsible for more hospitalizations than all forms of cancer combined. It is the number one cause for hospitalizations among Medicare patients. With improvement in survival of acute MIs and a population that continues to age, heart failure will continue to increase in prominence as a major health problem in the United States. ( Source: Accessed August 2, 2011, from http://emedicine.medscape.com/article/163062- overview#a0156)

63. Which symptom most likely suggests the heart transplant patient may be experiencing signs of organ rejection? A.Fever B.Hypertension C.Weight gain D.Tachycardia Question 2

64. Answer: C Rationale: Clinical manifestations of heart transplant rejection include shortness of breath, fatigue, fluid gain (edema, increased weight), abdominal bloating, new bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction (late sign).

65. The nurse expects to see what outcome in a patient who is taking a beta blocker for mild heart failure? A.Improved activity tolerance B.Increased myocardial contractility C.Increased myocardial oxygen consumption D.Improved urinary output Question 3

66. Answer: A Rationale: Beta-blocker therapy for mild and moderate heart failure can lead to improvement in symptoms, including improved activity tolerance and less orthopnea.