1. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins UNIT 5 Cardiac Conditions FNP:ACTIVITY-EXERCISE PATTERN REQUIRED READINGS: Smeltzer: Chapters 26-32 Do Case Studies from Critical Thinking Book Before Class!Do Case Studies from Critical Thinking Book Before Class! 1st CS on pg:49 Angina 2nd CS on pg:27 Coronary Artery Disease 3rd CS on pg:89 Congestive Heart Failure

2. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 The term HF indicates myocardial disease, in which there is a problem with the contraction of the heart (systolic failure) or filling of the heart (diastolic failure). Some cases are reversible. Most HF is a progressive, lifelong disorder managed with lifestyle changes and medications.

3. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Pathophysiology of HF

4. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following is a primary cause of chronic heart failure? a.Atherosclerosis b.Valvular dysfunction c.Hypertension d.Cardiomyopathy

5. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Manifestations (See Chart 30-1) Right-sided failure –RV cannot eject sufficient amounts of blood, and blood backs up in the venous system. This resuts in perpheral 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, resulting in pulmonary congestion with dyspnea, cough, crackles, and impaired oxygen exchange. Chronic HF is frequently biventricular.

6. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Classification of Heart Failure NYHA classification of HF –Classification I, II, III, IV ACC/AHA classification of HF –Stages A, B, C, D Treatment guidelines are in place for each stage.

7. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Medical Management of HF Eliminate or reduce etiologic or contributory factors. Reduce the workload of the heart by reducing afterload and preload. Optimize all therapeutic regimens. Prevent exacerbations of HF. Medications are routinely prescribed for HF.

8. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Medications Angiotensin-converting enzyme inhibitors Angiotensin II receptor blockers Beta-blockers Diuretics Digitalis Other medications

9. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Tell whether the following statement is true or false. Digoxin immune FAB (Digibind) may be given to treat severe digoxin toxicity.

10. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: The Care of the Patient with HF: Assessment Health history Sleep and activity Knowledge and coping Physical exam –Mental status –Lung sounds: crackles and wheezes –Heart sounds: S 3 –Fluid status/signs of fluid overload Daily weight and I&O Assess responses to medications

11. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: The Care of the Patient with HF: Diagnosis Activity intolerance and fatigue Excess fluid volume Anxiety Powerlessness Noncompliance

12. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Collaborative Problems/Potential Complications Cardiogenic shock Dysrhythmias Thromboembolism Pericardial effusion and cardiac tamponade

13. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: The Care of the Patient with HF: 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.

14. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Activity Intolerance Bed rest for acute exacerbations Encourage regular physical activity; 30-45 minutes daily Exercise training Pacing of activities Wait 2 hours after eating before doing physical activity. Avoid activities in extremely hot, cold, or humid weather. Modify activities to conserve energy. Positioning; elevation of HOB to facilitate breathing and rest, support of arms

15. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Fluid Volume Excess Assessment for symptoms of fluid overload Daily weight I&O Diuretic therapy; timing of meds Fluid intake; fluid restriction Maintenance of sodium restriction See Chart 30-4

16. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

17. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question All of the following are clinical manifestations of right-sided heart failure except: a.Hepatomegaly b.Jugular vein distention c.Ascites d.Orthopnea

18. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Pulmonary Edema Acute event in which the LV cannot handle an overload of blood volume. Pressure increases in the pulmonary vasculature, causing fluid to move out of the pulmonary capillaries and into the interstitial space of the lungs and alveoli. Results in hypoxemia Clinical manifestations: restlessness, anxiety, dyspnea, cool and clammy skin, cyanosis, weak and rapid pulse, cough, lung congestion (moist, noisy respirations), increased sputum production (sputum may be frothy and blood-tinged), decreased level of consciousness

19. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Management of Pulmonary Edema Prevention Early recognition: monitor lung sounds and for signs of decreased activity tolerance and increased fluid retention Place patient upright and dangle legs. Minimize exertion and stress. Oxygen Medications –Morphine –Diuretic (furosemide)

20. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Cardiogenic Shock A life-threatening condition with a high mortality rate Decreased CO leads to inadequate tissue perfusion and initiation of shock syndrome. Clinical manifestations: symptoms of HF, shock state, and hypoxia

21. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Pathophysiology of Cardiogenic Shock

22. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Management of Cardiogenic Shock Correct underlying problem Medications –Diuretics –Positive inotropic agents and vasopressors Circulatory assist devices –Intra-aortic balloon pump (IABP)

23. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Intra-Aortic Balloon Pump

24. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Thromboembolism Decreased mobility and decreased circulation increase the risk for thromboembolism in patients with cardiac disorders, including those with HF. Pulmonary embolism: blood clot from the legs moves to obstruct the pulmonary vessels –The most common thromboembolic problem with HF –Prevention –Treatment –Anticoagulant therapy

25. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Pulmonary Emboli

26. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Pericardial Effusion and Cardiac Tamponade Pericardial effusion is the accumulation of fluid in the pericardial sac. Cardiac tamponade is the restriction of heart function due to this fluid, resulting in decreased venous return and decreased CO. Clinical manifestations: ill-defined chest pain or fullness, pulsus parodoxus, engorged neck veins, labile or low BP, shortness of breath Cardinal signs of cardiac tamponade: falling systolic BP, narrowing pulse pressure, rising venous pressure, distant heart sounds See Chart 30-6

27. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessing for Cardiac Tamponade

28. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Medical Management Pericardiocentesis Pericardiotomy

29. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Sudden Cardiac Death/Cardiac Arrest Emergency management: cardiopulmonary resuscitation A- airway B- breathing C- circulation D- defibrillation for VT and VF

30. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Tell whether the following statement is true or false. The most reliable sign of cardiac arrest is absence of breath sounds.