Learning Activity week 5 Congestive Heart Failure, Cerebrovascular Accidents, Cardiac Arrhythmias

How does hypertension lead to congestive heart failure? Hypertension is a major contributing factor for the development of HF. The risk of HF increases progressively with the severity of hypertension and systolic and diastolic hypertension equally predict risk. Pathology of Ventricular failure (Systolic heart failure) Systolic heart failure is the most common type of HF, results from an inability of the heart to pump blood. It is caused by a defect in the ability of the ventricles to contract (pump) or by increased afterload or mechanical abnormalities. The left ventricle loses its ability to generate enough blood pressure to eject blood forward through the high pressure aorta. The hallmark of systolic HF is a decrease in the left ventricular ejection fraction (the fraction or percentage of total amount of blood in the LV that is ejected during each ventricular contraction). Systolic HF is caused by impaired contractile function (e.g myocardial infarction) increased afterload (eg hypertension) cardiomyopathy, and mechanical abnormalities (eg valvular heart disease). Diastolic heart failure is an impaired ability of the ventricles to fill during diastole. Decreased filling of the ventricles will result in decreased stroke volume. Diastolic HF is characterized by high filling pressures and the resultant venous engorgement in both the pulmonary and the systemic vascular systems. The diagnosis of diastolic HF is made on the basis of the presence of pulmonary congestion, pulmonary hypertension, ventricular hypertrophy and a normal EF. Diastolic HF is usually the result of left ventricular hypertrophy from chronic systemic hypertension, aortic stenosis, or hypertrophic cardiomyopathy. Create a flowchart pattern to recognize the S&S of left sided and right sided heart failure. Left sided failure results from LV dysfunction, which causes blood to back up through the left atrium and into the pulmonary veins. The increased pulmonary pressure causes fluid extravasation from the pulmonary capillary bed into the interstitium and then the alveoli which is manifested as pulmonary congestion and edema. Right sided heart failure causes backward blood flow to the right atrium and venous circulation. Venous congestion in the systemic circulation results in peripheral edema, hepatomegaly, splenomegaly, vascular congestion of the gastrointestinal (GI) tract and jugular venous distention. Primary cause of right sided heart failure is left sided failure.

Clinical Manifestations of Heart Failure Right sided heart failure Signs RV heaves Murmurs Peripheral edema Weight gain Increased heart rate Edema of dependent body parts (sacrum, anterior tibias, pedal edema) Ascites Anasarca (massive generalized body edema) Jugular venous distension Hepatomegaly (liver enlargement) Right sided pleural effusion Symptoms Fatigue Dependent edema Right upper quadrant pain Anorexia and GI bloating Nausea Left sided heart failure LV heaves Cheyne-Stroke respirations Pulsus alternans (alternating pulses: strong, weak) Increased heart rate PMI displaced inferiorly and posteriorly (LV hypertrophy) ^ Pa02 slight ^PaC02 (poor 02 exchnage) Crackles (pulmonary edema) S3 and S4 heart sounds

Fatigue Dyspnea (shallow respirations up to 3240/min) Orthopnea (shortness of breath in recumbent position) Dry, hacking cough Pulmonary edema Nocturia Paroxysmal nocturnal dyspnea

What diagnostic test would help to determine the origin of heart failure? Diagnostic studies- Measures to assess the cause and degree of HF include a through history, physical examination, chest radiograph, electrocardiogram (ECG), laboratory data (cardiac enzymes, BNP, serum chemistries, liver function studies, thyroid function studies abd complete blood count (CBC), hemodynamic assessment, echocardiogram, stress testing and cardiac catheterization. Transient Ischemic Attack is a temporary focal loss of neurological function caused by ischemia of one of the vascular territories of the brain, lasting less than 24 hours and often lasting less than 15 minutes. Most TIA resolve within 3 hours. TIA¶s may be due to micro emboli that temporarily block the blood flow. TIA¶s are a warning sign of progressive cerebrovascular disease.

Thrombotic stroke, which is a result of thrombosis or narrowing of the blood vessel is the most common cause of stroke, accounting for 61% of strokes. Two thirds of thrombotic strokes are associated with hypertension or diabetes mellitus, both of which accelerate atherosclerosis. Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase. Embolic stroke occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel. Embolism is the second most common cause of stroke. Plaque breaks off from the endocardium and enters the circulation. The embolus travels upward to the cerebral circulation and lodges where a vessel narrows or bifurcates. Clinical Manifestations A stroke can have an effect on many body functions such as: Motor function- motor deficits are the most obvious effect of stroke. Motor defecits include impairment of mobility, respiratory function, swallowing, and speech, gag reflex, self care abilities. Symptoms are caused by the destruction of motor neurons in the pyramidal pathway. The characteristic motor deficits include loss of skilled voluntary movement (akinesia), impairment of integration of movements, alterations in muscle tone, and alterations in reflexes. Communication the left hemisphere is dominant for language skills in right handed persons and in most left handed persons. The client may experience aphasia (an abnormal neurological condition in which language function is disordered or absent because of an injury to certain areas of the cerebral cortex) when a stroke damages the dominant hemisphere of the brain. Affect clients may have difficulty controlling their emotions. Emotions responses may be exaggerated or unpredictable. Depression and feelings associated with changes in body image and loss of function can make this worse. Intellectual function both memory and judgement may be impaired as a result of stroke. A left brain stroke is more likely to result in memory problems related to language. Clients with left brain stroke are often very cautious in making judgments. The client with a right brain stroke tends to be impulsive and to move quickly. An example of behaviour with right brain stroke is the client who tries to rise quickly from the wheelchair without locking the wheels or raising the foot rests. The client with a left brain stroke would move slowly and cautiously from the wheelchair. Elimination when a stroke affects a hemisphere of the brain, the prognosis for normal bladder function is excellent. Partial sensation of the bladder filling remains and voluntary urination is present. Initially the client may experience frequency, urgency and incontinence. Clients are

frequently constipated due to immobility, weak abdominal muscles, dehydration and diminished response to defecation reflex.

Differentiate between left and right hemispheric strokes. Hemorrhagic strokes result from bleeding into the brain tissue itself or into the subarachnoid space or the ventricles (subarachnoid haemorrhage or intraventricular haemorrhage). Intracerebral hemorrhage is bleeding within the brain caused by a rupture of a vessel; it accounts for about 10% of all strokes. Hypertension is the most important cause of this type of hemorrhage. Haemorrhage commonly occurs during periods of activity symptoms include neurological deficits, headache, nausea vomiting and decreased level of consciousness. Subarachnoid Hemorrhage occurs when there is intracranial bleeding into the cerebrospinal fluid-filled space between the arachnoid and pia mater membranes on the surface of the brain. It is commonly caused by a rupture of a cerebral aneurysm. The characteristic presentation of a ruptured aneurysm is the sudden onset of a severe headache that is different from a previous headache and typically the ³worst headache of one¶s life´. Right brain damage (stroke on the right side of the brain) Paralyzed left side: hemiplegia Spatial perceptual deficits Tends to deny or minimize problems Rapid performance short attention span Impulsive safety problems Impaired judgement impaired time concepts Left brain damage Stroke on the left side of the brain paralyzed right side: hemiplegia Impaired speech- language aphasis Impaired right left discrimination Slow performance, catious Impaired comprehension related to language, math

Dyrhythmias occurs as the result of various abnormalities and disease states. Common causes of dysrhythmias are accessory pathways, conduction defects, congestive heart failure, myocardial infarction, hypertrophy of the cardiac muscle, myocardial cell degeneration. When assessing the cardiac rhythm, the nurse must make an accurate interpretation and immediately evaluate the consequences of the findings for the individual client. Assessment of the client hemodynamic response to any change in rhythm is essential since this information will guide the selection of therapeutic interventions.

When assessing a cardiac rhythm always assess the client first and then proceed with a systemic approach to interpreting the rhythm: Evaluate the rhytm (ventricular and atrial) Determine the rate (ventricular and atrial) Assess the presence and configuration of P waves Calculate the duration of the PR interval, Calculate the QRS duration, Calculate the QT interval Assess for ST or T wave changes or both, Interpret the rhythm What are some complications of atrial fibrillation? Explain why someone would take Coumadin if they have atrial fibrillation. Atrial fibrillation is total disorganization of atrial electrical activity due to multiple ectopic foci resulting in loss of effective atrial contraction. Atrial fibrillation usually occurs in the client with underlying heart disease , such as CAD, rheumatic heart disease, HF, hypertensive heart disease. Atrial fibrillation can often result in a decrease in CO because of ineffective atrial contraction or loss of atrial kick, a rapid ventricular response or both. Thrombi may form in the atria as a result of blood stasis. An embolized clot may develop and pass to the brain. The risk of stroke increases five folds with atrial fibrillation. If a client has been in atrial fibrillation for more than 48 hours, anticoagulation therapy with wafarin (Coumadin) is recommended for 3-4 weeks before any attempt at cardioversion and for 4-6 weeks after successful cardioversion. Arrhythmia treatments may include:
y y y y y y y

Lifestyle changes Medicine to prevent and control arrhythmias and to treat related conditions such as high blood pressure, coronary artery disease and heart failure Anticoagulant medication to reduce the risk of blood clots and stroke A pacemaker that uses batteries to help your heart beat more regularly Cardiac defibrillation and implanted cardioverter defibrillators (ICDs) Cardiac ablation Surgery

Treatment for Heart Failure include drug therapy such diuretics. These drugs are used in HF to mobilize edematous fluid, reduce pulmonary venous pressure and reduce preload. Diuretics act on the kidney by promoting excretion of sodium and water.

Angiotensin converting enzymes inhibitors ace inhibitors are useful in both systolic and diastolic heart failure and they are the first line therapy in treatment of HF. Examples of ace inhibitors are ramipril (altace) enalapril (vasotec). B-adrenergic blockers, inotropic drugs, cardiac glycosides and vasodilators drugs are all used in the treatment of HF. Nutritional therapy- diet education and weight management are critical to clients control of chronic HF. The edema of chronic HF is often treated by dietary restriction of sodium. Treatments for stroke TPA (tissue plasminogen activator) Thrombolytic drugs such as TPA are often called clot busters.TPA is a drug that can stop a stroke caused by a blood clot by breaking up the clot. TPA is short for tissue plasminogen activator and can only be given to patients who are having a stroke caused by a blood clot (ischemic stroke). It must be given within three hours of the onset of symptoms. Health Canada has approved tPA to be used within three hours from the time symptoms begin. However, emerging science is now showing that tPA could be effective up to 4 ½ hours afterward. As a result, the Canadian Stroke Strategy has issued new Canadian Best Practices Recommendations for Stroke Care, which have included this new treatment time. However, it will be up to the attending emergency doctors to determine when tPA may be administered or if it is appropriate to the situation. In some cases, tPA cannot be used and other drugs are required. Surgery In some cases, surgery may be required to repair damage after a stroke or to prevent a stroke from occurring. Surgery may be performed to remove blood that has pooled in the brain after a hemorrhagic stroke, to repair broken blood vessels, or to remove plaque from inside the carotid artery.

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