Presentation is loading. Please wait.

Presentation is loading. Please wait.

Interventions for Clients with Cardiac Problems. Heart Failure Also called pump failure, general term for the inadequacy of the heart to pump blood throughout.

Similar presentations


Presentation on theme: "Interventions for Clients with Cardiac Problems. Heart Failure Also called pump failure, general term for the inadequacy of the heart to pump blood throughout."— Presentation transcript:

1 Interventions for Clients with Cardiac Problems

2 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

3 Compensatory Mechanisms Increased heart rate Increased heart rate Because cardiac output is the product of heart rate and stroke volume, an increase in heart rate results in an immediate increase in cardiac output. An increase in heart rate is limited in its ability to compensate for decreased cardiac output. If heart rate becomes too rapid, diastolic filling time is limited and cardiac output may start to fall. An increase in heart rate also significantly increases oxygen demand by the myocardium. If the heart is poorly perfused because of arteriosclerosis, heart failure may worsen Because cardiac output is the product of heart rate and stroke volume, an increase in heart rate results in an immediate increase in cardiac output. An increase in heart rate is limited in its ability to compensate for decreased cardiac output. If heart rate becomes too rapid, diastolic filling time is limited and cardiac output may start to fall. An increase in heart rate also significantly increases oxygen demand by the myocardium. If the heart is poorly perfused because of arteriosclerosis, heart failure may worsen Improved stroke volume Improved stroke volume Stroke volume is also improved by sympathetic stimulation. Sympathetic stimulation increases venous return to the heart, which further stretches the myocardial fibers. This increased stretch is referred to as preload. In accordance with Starling's law of the heart, increased myocardial stretch results in more forceful contraction, which increases stroke volume and cardiac output. After a critical point is reached, further volume and stretch reduce the force of contraction and cardiac output Stroke volume is also improved by sympathetic stimulation. Sympathetic stimulation increases venous return to the heart, which further stretches the myocardial fibers. This increased stretch is referred to as preload. In accordance with Starling's law of the heart, increased myocardial stretch results in more forceful contraction, which increases stroke volume and cardiac output. After a critical point is reached, further volume and stretch reduce the force of contraction and cardiac output

4 Compensatory Mechanisms Arterial vasoconstriction Arterial vasoconstriction Sympathetic stimulation also results in arterial vasoconstriction. Constriction of the arteries has the benefit of maintaining blood pressure and improving tissue perfusion in low-output states. However, constriction of the arteries increases afterload, the resistance against which the heart must pump. Afterload is the major determinant of myocardial oxygen requirements. As afterload increases, the left ventricle requires more energy to eject its contents, and stroke volume may decline Sympathetic stimulation also results in arterial vasoconstriction. Constriction of the arteries has the benefit of maintaining blood pressure and improving tissue perfusion in low-output states. However, constriction of the arteries increases afterload, the resistance against which the heart must pump. Afterload is the major determinant of myocardial oxygen requirements. As afterload increases, the left ventricle requires more energy to eject its contents, and stroke volume may decline Sodium and water retention Sodium and water retention Reduced blood flow to the kidneys, a common occurrence in low- output states, results in the activation of the renin-angiotensin- aldosterone mechanism. Vasoconstriction becomes more pronounced in response to angiotensin, and aldosterone secretion causes sodium and water retention. The volume of blood returning to the left ventricle is further increased by activation of this mechanism Reduced blood flow to the kidneys, a common occurrence in low- output states, results in the activation of the renin-angiotensin- aldosterone mechanism. Vasoconstriction becomes more pronounced in response to angiotensin, and aldosterone secretion causes sodium and water retention. The volume of blood returning to the left ventricle is further increased by activation of this mechanism

5 Compensatory Mechanisms Myocardial hypertrophy Myocardial hypertrophy Myocardial hypertrophy, with or without chamber dilation, is the final compensatory mechanism. The walls of the heart thicken to provide more muscle mass. This results in more forceful contractions, further increasing cardiac output. However, cardiac muscle may hypertrophy more rapidly than collateral circulation can provide adequate blood supply to the muscle. Often, a hypertrophied heart is slightly oxygen deprived Myocardial hypertrophy, with or without chamber dilation, is the final compensatory mechanism. The walls of the heart thicken to provide more muscle mass. This results in more forceful contractions, further increasing cardiac output. However, cardiac muscle may hypertrophy more rapidly than collateral circulation can provide adequate blood supply to the muscle. Often, a hypertrophied heart is slightly oxygen deprived

6 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.

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

8 Left-Sided Heart Failure (Continued) –Oliguria –Organ failure, especially renal failure –Death Assessment Assessment Palpation the precordium - increased heart size is common, with a displacement of the apical impulse to the left. Palpation the precordium - increased heart size is common, with a displacement of the apical impulse to the left. On auscultation, the nurse may hear a third heart sound (S3) gallop, an early diastolic filling sound indicating an increase in left ventricular pressure. A fourth heart sound (S4) can also occur; it is not a sign of failure but is a reflection of decreased ventricular compliance. On auscultation, the nurse may hear a third heart sound (S3) gallop, an early diastolic filling sound indicating an increase in left ventricular pressure. A fourth heart sound (S4) can also occur; it is not a sign of failure but is a reflection of decreased ventricular compliance. Crackles and wheezes may be present on auscultation of the lungs. Late inspiratory crackles and fine profuse crackles that repeat themselves from breath to breath and do not diminish with coughing indicate heart failure. Crackles usually develop in the bases and spread upward as the condition worsens. Wheezes indicate a narrowing of the bronchial lumen caused by engorged pulmonary vessels Crackles and wheezes may be present on auscultation of the lungs. Late inspiratory crackles and fine profuse crackles that repeat themselves from breath to breath and do not diminish with coughing indicate heart failure. Crackles usually develop in the bases and spread upward as the condition worsens. Wheezes indicate a narrowing of the bronchial lumen caused by engorged pulmonary vessels

9 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

10 Assessments Laboratory assessment Laboratory assessment Radiographic assessment Radiographic assessment Electrocardiography – may demonstrate ventricular hypertrophy, dysrhythmias, and any degree of myocardial ischemia, injury, or infarction Electrocardiography – may demonstrate ventricular hypertrophy, dysrhythmias, and any degree of myocardial ischemia, injury, or infarction Echocardiography - is useful in diagnosing cardiac valvular changes, pericardial effusion, chamber enlargement, and ventricular hypertrophy Echocardiography - is useful in diagnosing cardiac valvular changes, pericardial effusion, chamber enlargement, and ventricular hypertrophy Pulmonary artery catheters Pulmonary artery catheters

11 Impaired Gas Exchange Interventions include: Interventions include: –Ventilation assistance (promotion of the optimal spontaneous breathing pattern that maximizes oxygen and carbon dioxide exchange in the lungs) –Hemodynamic regulation (optimization of heart rate, preload, afterload, and contractility) –Energy management, diet therapy, drug therapy

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

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

14 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.

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

16 Interventions That Reduce Preload Diet therapy Diet therapy –Fluid, sodium restrictions Drug therapy Drug therapy –Diuretics –Venous vasodilators

17 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

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

19 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

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

21 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.

22 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)

23

24 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.

25 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)

26 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

27 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

28

29

30 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

31 Manifestations Clinical manifestations usually occur within 2 weeks of a bacteremia. Clinical manifestations usually occur within 2 weeks of a bacteremia. Assessment usually reveals a recurrent fever. Assessment usually reveals a recurrent fever. Most clients have temperatures from 37.2° to 39.4° C. Most clients have temperatures from 37.2° to 39.4° C. Many older adults remain afebrile. Many older adults remain afebrile. The severity of symptoms may depend on the virulence of the infecting organism The severity of symptoms may depend on the virulence of the infecting organism

32 Manifestations

33 Manifestations Fever associated with chills, night sweats, malaise and fatigue Fever associated with chills, night sweats, malaise and fatigue Anorexia and weight loss Anorexia and weight loss Cardiac murmur (newly developed or change in existing) Cardiac murmur (newly developed or change in existing) Development of heart failure Development of heart failure Evidence of systemic embolization Evidence of systemic embolization Petechiae Petechiae Splinter hemorrhages Splinter hemorrhages Osier's nodes Osier's nodes Janeway's lesions Janeway's lesions Splenic infarction Splenic infarction Neurologic changes Neurologic changes

34 Splinter hemorrhage lesions in endocarditis Janeway's lesions on the sole of the foot

35 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

36 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

37 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

38 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)

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

40 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

41 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

42 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

43 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

44

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


Download ppt "Interventions for Clients with Cardiac Problems. Heart Failure Also called pump failure, general term for the inadequacy of the heart to pump blood throughout."

Similar presentations


Ads by Google