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Care of Patients with Cardiac Problems
Chapter 37 Care of Patients with Cardiac Problems Cardiac stress test. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
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Heart Failure Also called pump failure; inability of heart to work effectively as a pump
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Heart Failure (cont’d)
Major types: Left-sided Right-sided High-output
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Left-Sided Heart Failure
Formerly known as congestive heart failure Typical causes—hypertensive, coronary artery, valvular disease Not all cases involve fluid accumulation Two types: systolic and diastolic
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Right-Sided Heart Failure
Causes—left ventricular failure, right ventricular MI, pulmonary hypertension Right ventricle cannot empty completely Increased volume and pressure in venous system and peripheral edema
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High-Output Failure Cardiac output remains normal or above normal
Caused by increased metabolic needs of hyperkinetic conditions: Septicemia Anemia Hyperthyroidism
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Compensatory Mechanisms
When cardiac output insufficient to meet body’s demands, these mechanisms operate to increase cardiac output: Major types: Sympathetic nervous system stimulation Other renin-angiotensin system activation Chemical responses (BNP) Myocardial hypertrophy
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Etiology 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
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Left-Sided Heart Failure
Clinical manifestations: Weakness Fatigue Dizziness Acute confusion (low flow) Pulmonary congestion Breathlessness Oliguria
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Proportional Pulse Pressure
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Right-Sided Heart Failure
Clinical manifestations: Jugular vein distention Increased abdominal girth Dependent edema Hepatomegaly Hepatojugular reflux Ascites Weight most reliable indicator of fluid gain/loss
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Assessment of Right-Sided Heart Failure
Laboratory: Electrolytes Hemoglobin and hematocrit B-type natriuretic peptide (BNP) Urinalysis (proteinuria/high specific gravity) ABGs
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Assessment of Right-Sided Heart Failure (cont’d)
Imaging: CXR Echocardiography (best diagnostic tool) ECG Pulmonary artery catheter
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Hemodynamic Monitoring
PA catheter allows for assessment of cardiac function and fluid volume PAP/PAWP elevated with left heart failure
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Analysis of Right-Sided HF
Priority problems: Impaired gas exchange Decreased cardiac output Fatigue/weakness Potential for pulmonary edema
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Improving Gas Exchange
Promoting oxygenation and gas exchange Ventilation assistance Monitor respiratory rate every 1-4 hr Auscultate breath sounds every 4-8 hr Position in high Fowler’s if patient dyspneic Maintain oxygen saturation of 90%
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Improving Cardiac Output
Improved/increased cardiac pump effectiveness Hemodynamic regulation
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Drugs Used to Reduce Afterload
ACE inhibitors ARB Human B-type natriuretic peptides
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Interventions that Reduce Preload
Nutrition therapy Drug therapy Diuretics Venous vasodilators
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Drugs that Enhance Contractility
Digoxin Inotropic drugs Beta-adrenergic blockers
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Drug Therapy Morphine sulfate Diuretics Loop Thiazide
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Digoxin Cardiac glycoside Increases contractility
Reduces heart rate (HR) Slows conduction through atrioventricular node Inhibits sympathetic activity
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Other Nonsurgical Options
CPAP CRT Gene therapy
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Surgical Management Heart transplantation VADs
Other surgical therapies: Heart reduction Endoventricular circular patch cardioplasty Acorn cardiac support device Myosplint
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Heart Transplantation
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Decreasing Fatigue & Weakness
Rest for energy management Basic leg exercises Slow ambulation
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Preventing or Managing Pulmonary Edema
Assess for early signs (e.g., crackles in bases) Dyspnea at rest, disorientation, confusion High Fowler’s position
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Preventing or Managing Pulmonary Edema (cont’d)
Oxygen therapy Nitroglycerin Rapid-acting diuretics IV morphine sulfate Continual assessment
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Community-Based Care Home care management Teaching for self-management
Health care resources
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Indications for Worsening or Recurrent Heart Failure
Rapid weight gain Decrease in exercise tolerance Cold symptoms Excessive awakening at night to urinate Development of dyspnea/angina at rest Increased edema in feet, ankles, hands
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Valvular Heart Disease
Mitral stenosis Mitral regurgitation (insufficiency) Mitral valve prolapse Aortic stenosis Aortic regurgitation (insufficiency)
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Assessment Sudden illness or slowly developing symptoms over many years Ask about attacks of rheumatic fever, infective endocarditis; ask about possibility of IV drug abuse Chest x-ray, ECG, stress test
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Nonsurgical Management
Rest Drug therapy Diuretics Beta blockers Digoxin Oxygen Nitrates Vasodilators Anticoagulants
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Surgical Management Reparative procedures Balloon valvuloplasty
Direct or open commissurotomy Mitral valve annuloplasty Replacement procedures
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Heart Valves Examples of biologic (tissue) heart valves. A, Freestyle, a stentless pig valve with no frame. B, Hancock II, a stented pig valve. C, Carpentier-Edwards pericardial bioprosthesis.
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Community-Based Care Home care management Teaching for self-management
Health care resources
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Infective Endocarditis
Microbial infection involving the endocardium Those at high risk: IV drug abusers Valve replacement recipients People who have had systemic infections People with structural cardiac defects
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Infective Endocarditis (cont’d)
Possible ports of entry Oral cavity Skin rash Lesion/abscess Infection Surgery or invasive procedure
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Manifestations of Endocarditis
Murmur Heart failure Arterial embolization Splenic infarction
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Manifestations of Endocarditis (cont’d)
Neurologic changes Petechiae Splinter hemorrhages
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Diagnostic Assessment
Positive blood cultures New regurgitant murmur Evidence of endocardial involvement by echocardiography
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Nonsurgical Management
Antimicrobials Activities balanced with adequate rest
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Surgical Management Removal of infected valve
Repair or removal of congenital shunts Repair of injured valves and chordae tendineae Draining of abscesses in heart or elsewhere
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Pericarditis Inflammation/alteration of pericardium
Dressler’s syndrome Post-pericardiotomy syndrome Chronic constrictive pericarditis
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Pericarditis (cont’d)
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Assessment of Pericarditis
Substernal precordial pain radiating to left side of neck, shoulder, or back Grating, oppressive pain, aggravated by breathing, coughing, swallowing
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Assessment of Pericarditis (cont’d)
Pain worsened by supine position; relieved by sitting up and leaning forward Pericardial friction rub
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Interventions Pain management Pericardiectomy NSAIDs
Antibiotics for bacterial form Pericardiectomy
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Pericardial Effusion Puts patient at risk for cardiac tamponade
Cardiac tamponade findings: JVD Paradoxical pulse Decreased CO Muffled heart sounds Circulatory collapse
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Acute Cardiac Tamponade: Emergency Care
Cardiac tamponade is an extreme emergency! Increased fluid volume Hemodynamic monitoring Pericardiocentesis Pericardial window Pericardiectomy
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Pericardiocentesis
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Rheumatic Carditis Sensitivity response from upper respiratory tract infection with group A beta-hemolytic streptococci Inflammation in all layers of heart Formation of Aschoff bodies Impaired contractile function of myocardium, thickening of pericardium, valvular damage
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Clinical Manifestations
Tachycardia Cardiomegaly New or changed murmur
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Clinical Manifestations (cont’d)
Pericardial friction rub Precordial pain Changes in ECG Indications of heart failure Existing streptococcal infection
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Cardiomyopathy Subacute or chronic disease of cardiac muscle
Dilated cardiomyopathy Hypertrophic cardiomyopathy Restrictive cardiomyopathy Arrhythmogenic right ventricular cardiomyopathy
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Nonsurgical Management
Drug therapy Diuretics Vasodilating agents Cardiac glycosides Implantable cardiac defibrillators Toxin exposure avoidance Alcohol avoidance
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Surgical Management Depends on cardiomyopathy type Most common:
Ventriculomyomectomy Percutaneous alcohol septal ablation Heart transplantation
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Which action should you take first? Replace the oxygen.
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? Replace the oxygen. Take his vital signs. Call the Rapid Response Team. Sit him up in a bedside chair. 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.
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(cont’d) 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? Call the provider as soon as possible. Continue the assessment because 96% is acceptable. Increase the oxygen level to 5 L per nasal cannula. Encourage the patient to take some deep breaths. 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 SaO2 is normal and he is not short of breath.
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(cont’d) 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? Right-sided heart failure Left-sided heart failure Biventricular failure Class IV heart failure ANS: C The patient has key features of both right-sided and left-sided heart failure.
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(cont’d) During morning care, the patient develops shortness of breath, fatigue, and tachycardia. What is your interpretation of these findings? What interventions would you begin at this time? The patient has developed activity intolerance from too much exertion. 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.
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(cont’d) 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.) Lisinopril (Zestril) 5 mg PO daily Ibuprofen (Advil) 200 PO mg twice daily Multivitamin 1 PO each day Furosemide (Lasix) 20 mg IV push daily Digoxin (Lanoxin) 0.25 mg PO daily 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.
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Audience Response System Questions
Chapter 37 Audience Response System Questions
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Question 1 Which cardiovascular disease results in the highest number of hospital admissions in the United States? Mitral valve disease Infective endocarditis Heart failure Rheumatic carditis 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
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Question 2 Which symptom most likely suggests the heart transplant patient may be experiencing signs of organ rejection? Fever Hypertension Weight gain Tachycardia 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).
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Question 3 The nurse expects to see what outcome in a patient who is taking a beta blocker for mild heart failure? Improved activity tolerance Increased myocardial contractility Increased myocardial oxygen consumption Improved urinary output 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.
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