Chapter 29

Management of Patients With

Complications From Heart Disease
Heart Failure (HF)

• A clinical syndrome resulting from structural or functional

cardiac disorders that impair the ability of the ventricles
to fill or eject blood
• In the past, HF was often referred to as congestive
heart failure (CHF), because many patients experience
pulmonary or peripheral congestion with edema
• HF is recognized as a clinical syndrome characterized by
signs and symptoms of fluid overload or inadequate
tissue perfusion

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Heart Failure (HF)

• The term heart failure 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 depending on the cause
• Most HF is a chronic, progressive condition managed with
lifestyle changes and medications

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Chronic HF

• The incidence of HF increases with age

• Approximately 6 million people in the United States have
HF, and 870,000 new cases are diagnosed each year
• Most common in people older than 75 years
• Most common reason for hospitalization of people older
than 65 years and is the second most common reason for
visits to a physician's office
• Approximately 25% of patients discharged after
treatment for HF are readmitted to the hospital within 30
days

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Pathophysiology of Heart Failure

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Clinical Manifestations

Right Sided Left Sided

• Viscera and peripheral • Pulmonary congestion,
congestion crackles
• Jugular venous • S3 or “ventricular gallop”
distention (JVD)
• Dyspnea on exertion
• Dependent edema (DOE)
• Hepatomegaly • Low O2 sat
• Ascites • Dry, nonproductive
• Weight gain cough initially
• Oliguria

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Medications

• Angiotensin-converting enzyme (ACE) inhibitors:

vasodilation; diuresis; decreases afterload; monitor for
hypotension, hyperkalemia, and altered renal function;
cough
• Angiotensin II receptor blockers: prescribed as an
alternative to ACE inhibitors; work similarly
• Hydralazine and isosorbide dinitrate: alternative to ACE
inhibitors
• Beta-blockers: prescribed in addition to ACE inhibitors;
may be several weeks before effects seen; use with
caution in patients with asthma

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Medications (cont.)

• Diuretics: decreases fluid volume, monitor serum

electrolytes
• Digitalis: improves contractility, monitor for digitalis
toxicity especially if patient is hypokalemic
• IV medications: indicated for hospitalized patients
admitted for acute decompensated HF
– Milrinone: decreases preload and afterload; causes
hypotension and increased risk of dysrhythmias
– Dobutamine: used for patients with left ventricular
dysfunction; increases cardiac contractility and renal
perfusion

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Gerontologic Considerations

• May present with atypical signs and symptoms such as

fatigue, weakness, and somnolence
• Decreased renal function can make older patients
resistant to diuretics and more sensitive to changes in
volume
• Administration of diuretics to older men requires nursing
surveillance for bladder distention caused by urethral
obstruction from an enlarged prostate gland

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Question

Which classification of medications play a pivotal role in the

management of HF caused by systolic dysfunction?
A.ACE inhibitors
B.Beta-blockers
C.Diuretics
D.Digitalis

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Answer

A. ACE inhibitors
ACE inhibitors play a pivotal role in the management of HF
caused by systolic dysfunction. Beta-blockers have been
found to reduce mortality and morbidity in patients with
NYHA class II or III HF by reducing the adverse effects
from the constant stimulation of the sympathetic nervous
system. Diuretics are prescribed to reduce excess
extracellular fluid by increasing the rate of urine
produced in patients with signs and symptoms of fluid
overload. Digitalis increases the force of myocardial
contraction and slows conduction through the
atrioventricular node

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Nursing Process: The Care of the Patient
With Heart Failure—Assessment

• Focus
– Effectiveness of therapy
– Patient’s self-management
– S&S if increased HF
– Emotional or psychosocial response
• Health history
• PE
– Mental status; lung sounds: crackles and wheezes; heart
sounds: S3; fluid status or signs of fluid overload; daily
weight and I&O; assess responses to medications

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Nursing Process: The Care of the Patient
With Heart Failure—Diagnoses

• Activity intolerance related to decreased CO

• Excess fluid volume related to the HF syndrome
• Anxiety-related symptoms related to complexity of the
therapeutic regimen
• Powerlessness related to chronic illness and
hospitalizations
• Ineffective family therapeutic regimen management

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Collaborative Problems and Potential
Complications

• Hypotension, poor perfusion, and cardiogenic shock (see

Chapter 14)
• Dysrhythmias (see Chapter 26)
• Thromboembolism (see Chapter 30)
• Pericardial effusion and cardiac tamponade

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Nursing Process: The Care of the Patient
With Heart Failure—Planning

• Goals
– Promote activity and reduce fatigue
– Relieving fluid overload symptoms
– Decrease anxiety or increase the patient’s ability to
manage anxiety
– Encourage the patient to verbalize his or her ability
to make decisions and influence outcomes
– Educate the patient and family about management of
the therapeutic regimen

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Activity Intolerance

• Bed rest for acute exacerbations

• Encourage regular physical activity; 30 to 45 minutes daily
• Exercise training
• Pacing of activities
• Wait 2 hours after eating for physical activity
• Avoid activities in extreme hot, cold, or humid weather
• Modify activities to conserve energy
• Positioning; elevation of the head of bed to facilitate
breathing and rest, support of arms

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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

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Patient Education

• 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 education

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Question

What evaluation most illustrates that the patient with HF has

met outcomes for the nursing diagnosis “Activity intolerance
related to decreased CO?”
A.Exhibits decreased peripheral edema
B.Maintains heart rate, blood pressure, respiratory rate, and
pulse oximetry within the targeted range
C.Avoids situations that produce stress
D.Performs and records daily weights

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Answer

B. Maintains heart rate, blood pressure, respiratory rate,

and pulse oximetry within the targeted range

Rationale: Patients with HF who exhibit stable VS shows

that they have been able to adjust and plan activities to
include rest and allow their bodies to adjust. A decrease
in peripheral edema illustrates a reduction of fluid,
avoiding situations that produce stress shows a move
toward decreasing anxiety, and performing and
recording daily weights shows adherence to the
therapeutic regimen

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End of Life Considerations

• HF is a chronic and often progressive condition

– Need to consider issues related to the end of life
– When palliative or hospice care should be considered

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Pulmonary Edema

• Acute event results in LV failure

• As LV begins to fail, blood backs up into the pulmonary
circulation, causing pulmonary interstitial edema
• Results in hypoxemia, often severe
• 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

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Management of Pulmonary Edema

• Easier to prevent than to treat

• Early recognition: monitor lung sounds and for signs of
decreased activity tolerance and increased fluid retention
• Minimize exertion and stress
• Oxygen; nonrebreather
• Medications
– Diuretics (furosemide), vasodilators (nitroglycerin)

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Nursing Management of Pulmonary Edema

• Positioning the patient to promote circulation

– Positioned upright with legs dangling
• Providing psychological support
– Reassure patient and provide anticipatory care
• Monitoring medications
– I&O

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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

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Management of Cardiogenic Shock

• Correct underlying problem

• Reducing preload and afterload to decrease cardiac
workload
• Improving oxygenation, and restoring tissue perfusion
• Monitor hemodynamic parameters, monitor fluid status,
and adjust medications and therapies based on the
assessment data

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Management of Cardiogenic Shock (cont.)

• Medications
– Diuretics, positive inotropic agents, and vasopressors
• Circulatory assist devices
– Intra-aortic balloon pump (IABP)

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Thromboembolism

• Decreased mobility and decreased circulation increase

the risk for thromboembolism in patient with cardiac
disorders, including those with HF
• Pulmonary embolism: blood clot from the legs moves to
obstruct the pulmonary vessels
• S&S: dyspnea, pleuritic chest pain, tachypnea, cough
• Treatment: anticoag therapy
– Unfractionated heparin, low--molecular-weight
heparin, fondaparinux (Arixtra), or rivaroxaban
(Xarelto)

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Pulmonary Emboli

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Pericardial Effusion and Cardiac
Tamponade

• Pericardial effusion is the accumulation of fluid in the pericardial

sac
• Cardiac tamponade is the restriction of heart function because of
this fluid, resulting in decreased venous return and decreased CO
• Clinical manifestations: ill-defined chest pain or fullness, pulsus
paradoxus, 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

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Assessment Findings in Cardiac
Tamponade

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 Medical Management

• Pericardiocentesis
– Puncture of the pericardial sac to aspirate pericardial
fluid
• Pericardiotomy
– Under general anesthesia, a portion of the pericardium
is excised to permit the exudative pericardial fluid to
drain into the lymphatic system

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Sudden Cardiac Death or Cardiac Arrest

• Emergency management: cardiopulmonary resuscitation

• A: airway
• B: breathing
• C: circulation
• D: defibrillation for VT and VF

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Question

What is the most reliable sign of cardiac arrest in an adult

and child?
A.Decrease in blood pressure
B.Absence of brachial pulse
C.Absence of breathing
D.Absence of carotid pulse

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Answer

D. Absence of carotid pulse

Rationale: The most reliable sign of cardiac arrest is the

absence of a pulse. In an adult or child, the carotid pulse
is assessed. In an infant, the brachial pulse is assessed

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