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Disorders Of The Heart

Terri Slifer Lynch, MSN, RN, BC, CNE

Heart Failure
Heart failure is a clinical syndrome Heart is unable to pump sufficient blood to meet the needs of the tissues Heart failure is the number 1 DRG for hospitalization in people over 65 years

Cultural Considerations
Higher prevalence in African Americans and Native Americans Directly related to the higher incidence and prevalence of HTN and DM Exacerbated by lack of access to health care

Etiology of Heart Failure


CAD Cardiomyopathy Systemic or pulmonary hypertension Valvular disease Septal defects Myocarditis Dysrhythmias Hypervolemia Metabolic disorders Autoimmune disorders Anemia in the elderly Cardiotoxic substances

Effects of Aging
Decreased compliance Decreased response to SNS stimulation Decreased ability of heart to increase CO with exercise Increased incidence of dysrhythmias

Pathophysiology Of Heart Failure


Decreased amount of blood ejected from ventricles Stimulation of SNS occurs causing tachycardia, vasoconstriction and increased contractility Increased contractility and venous return lead to ventricular hypertrophy Activation of Renin-Angiotensin-Aldosterone System

Vascular volume and venous return increase which increase blood volume and pressure in the heart Release of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) Failure of compensatory mechanisms occurs Blood backs up from LV into LA and pulmonary venous system Blood backs up into the RV, RA and systemic venous system

Blood backs up in left atrium and pulmonary veins Increased hydrostatic pressure forces fluid out of pulmonary capillaries into alveoli and interstitial spaces Right ventricle dilates due to increased pulmonary pressures (pulmonary HTN) Engorgement of venous system extends backwards into systemic veins and organs

If left ventricular failure occurs, ususlly right ventricular failure will follow Right ventricular failure can occur solely without left ventricular failure cor pulmonale Heart failure can affect systolic function or diastolic function

Clinical Manifestations Of Left Ventricular Failure (LVF)


Dyspnea
Dyspnea on exertion (DOE) Orthopnea Paroxysmal nocturnal dyspnea (PND)

Cough Crackles Hypoxia, cyanosis Tachycardia, palpitations

S3, S4, murmurs

Weak, thready pulses Fatigue, decreased exercise tolerance Pale, cool, clammy skin Restlessness, anxiety, confusion Nocturia Edema and weight gain

Clinical Manifestations of Right Ventricular Failure (RVF)


Elevated JVD Positive HJR Hepatomegaly, splenomegaly Ascites Anorexia, nausea, constipation Sacral edema Peripheral edema

Acute Pulmonary Edema


Life threatening situation Large accumulation of fluid in lungs Manifestations
Severe dyspnea, sense of suffocation, orthopnea Cough, large amounts of frothy, blood tinged sputum Wheezing and coarse crackles Cyanosis Cool, clammy, diaphoretic skin

New York Heart Associations Functional Classification of Heart Disease


Class I Ordinary activity does not cause symptoms Class II Slight limitation of ADLs Class III Comfortable at rest but any activity causes symptoms Class IV Symptoms at rest

ACC/AHA Staging System


Stage A No structural abnormality of the heart No symptoms of HF Stage B Structural abnormality of the heart No symptoms of HF Stage C Structural abnormality of the heart Some symptoms of HF Stage D Structural abnormality of the heart Symptoms of HF that do not respond well to normal treatment

Diagnostic Findings With Heart Failure


Echocardiogram with Doppler flow studies Chest x-ray ECG B-Type Natriuretic Peptide (BNP)

BUN and creatinine T4 and TSH Liver function tests Stress testing or cardiac cath

Objectives In Treating Heart Failure


Identify and eliminate the precipitating cause Reduce the workload on the heart Enhance patient and family coping with lifestyle changes

Medical Management of Heart Failure


Exercise
Bed rest in upright position in acute and refractory stages Regular exercise program

Oxygen therapy Dietary restrictions


Sodium restriction Fluid restriction

Cardiac resynchronization (CRT) biventricular pacing (Medtronic InSyn)

Mechanical assist devices


VAD Artificial heart

Transplantation

Pharmacologic Management of Heart Failure


ACE inhibitors
Vasodilate Promote diuresis Drugs Vasotec, Captopril, Zestril,

Angiotensin II Receptor Blockers (ARBs)


Prescribed when patient intolerant of ACE-I Drugs Diovan, Aticand

Beta1 Blockers
Decrease cytotoxic effects of constant stimulation of SNS Decrease workload by decreasing heart rate Drugs - Coreg, Lopressor, Atenolol

Vasodilators
Cause venous dilation Cause arterial dilation Drugs Nitrates ie. Isordil (isosorbide) and other meds ie. Apresoline (hydralazine); BiDil ( isosorbide & hydralazine combination)

Diuretics
Control Na and H2O retention Three types
Potassium sparing Aldactone (spironalactone), Inspra (eplerenone) Loop diuretics Lasix (furosemide), Demadex (torsemide) Thiazide diuretics Zaroxolyn (metolazone), HCTZ (hydrochlorazide)

Monitor for hypotension, lyte imbalances and dehydration, worsening renal failure

Cardiac glycosides
Increase force of myocardial contraction and slow electrical conduction Drugs Lanoxin (digoxin), Primacor, Inocor Precautions with Lanoxin administration
Decreased renal function slows elimination Will need to decrease dose with certain meds ie. amiodarone, erythromycin, quinidine Usual dose 0.125 mg to 0.5 mg (PO,IV,IM)

Lanoxin toxicity Therapeutic level 0.5-2.0 ng/mL Symptoms anorexia, N/V, fatigue, H/A, yellow or green halos, new dysrhythmias Reversal hold dose or administer Digibind (digoxin immune FAB) Nursing considerations for Lanoxin administration Assess heart rate for 1 min Give after breakfast Monitor for hypokalemia

Calcium channel blockers


Contraindicated with severe systolic dysfunction Drugs Norvasc, Cardizem, Procardia

Natrecor (nesiritide)
Indicated for the IV treatment of clients with acutely decompensated congestive heart failure with dyspnea at rest Manufactured from E-coli Effects - dilates veins and arteries, suppresses Aldosterone Administration - IV bolus, then drip for 48 hrs Contraindications - systolic pressure <90mm Hg Side effects - hypotension, VT, HA, nausea Incompatible with Heparin in same line

Medical Management Of Pulmonary Edema


Sit patient in high Fowlers with legs and feet dependent Oxygen Morphine Diuretics Foley Other meds as with heart failure

Nursing Diagnoses For The Client With Heart Failure

Nursing Interventions For The Client With Heart Failure


Monitor and manage potential complications
Assess cardiovascular status frequently
Vital signs Heart sounds Degree of JVD & HJR All peripheral pulses

Assess respiratory status frequently


Lung sounds Assess degree of dyspnea Assess O2 sats

Assess renal status


I&O BUN & Cr Assess for nocturia

Assess GI system
HJR Ascites Appetite and constipation

Monitor fluid status closely


Daily weights I&O Peripheral and sacral edema

Reduce fatigue Promote activity tolerance Control anxiety Assess for depression Referrals Teach client and family

Client and Family Teaching Related to Heart Failure


Weigh daily 2-3 gm Na diet Fluid restrictions Meds and side effects

Pneumococcal and flu vaccines recommended Stop smoking, no ETOH Signs and symptoms to report to physician
Weight gain Loss of appetite Syncopy or palpitations Worsening SOB Persistent cough Increasing fatigue

Web Sites
Heart Failure Society of America www.hfsa.org Heart Failure Online www.heartfailure.org Heart Failure Treatment Guidelines from the AHA/ACC www.acc.org AHA www.hearthub.org

Expected Outcomes
Maintains or improves cardiac function Maintains or increases activity tolerance Adheres to self-care program Absence of complications

Cardiomyopathy
Disease of the myocardium which affects its function Three major types of cardiomyopathy
Dilated - DCM Hypertropic - HCM Restrictive

Dilated Cardiomyopathy
Contractility decreases and ventricles dilate. Affects systolic function. Etiology ischemia, viral myocarditis, toxins, alcohol, pregnancy

Clinical manifestations same as with LVF Dx tests ECHO, endomyocardial biopsy, ECG, chest x-ray, blood chemistries Tx same as with LVF; tx dysrhythmias; heart transplant

Hypertropic Cardiomyopathy
Myocardium increases in size and mass Reduces inner cavity of ventricles and ventricles take longer to relax and fill. Affects diastolic function Etiology genetic, HTN, and hypoparathyroidism

Appears most often in young adults Clinical manifestations sudden cardiac death; dyspnea, palpitations, dizziness Dx tests radionuclide scans, ECHO, chest x-ray, ECG Tx Beta blockers and Ca channel blockers. Avoid meds that decrease preload (diuretics) or increase contractility (Lanoxin). Tx dysrhythmias - may insert ICD

Restrictive Cardiomyopathy
Ventricle walls are rigid and do not stretch normally during filling. Cardiac output decreases. Affects diastolic function. Etiology - Amylodiosis, Sarcoidosis

Clinical manifestations fatigue, activity intolerance, dyspnea and other symptoms of LVF Dx tests same as other cardiomyopathies Tx similar to hypertropic cardiomyopathy; tx dysrhythmias and tx underlying cause

Rheumatic Endocarditis
Results directly from group A beta-hemolytic strep Can be prevented if strep infection treated early Myocardium, valves and pericardium are affected
Contractility is decreased Valve leaflets develop vegetative bodies which can embolize

Clinical manifestations
Signs of rheumatic fever (fever, rash, migratory joint pain) Signs of carditis Signs of heart failure

Dx tests Positive throat culture; elevated ESR, CBC, ECHO, ASO positive Tx
Prevention is best treatment Limited activity, treat heart failure if present Penicillin or mycin drugs (clindamycin, erythromycin) if Penicillin allergy NSAIDS for joint pain

Infective Endocarditis
Infection of the endocardium and valves Etiology staph, strep, fungi, entrococcci Increased risk in patients with valve disorders and IV drug abusers

Clinical manifestations malaise, intermittent fever and chills, night sweats, Roth spots, splinter hemorrhages in nails, Janeway lesions, Oslers nodes, murmur, HF, stroke, pulmonary embolus

Dx blood cultures, CBC, transesophageal ECHO (TEE) Prevent in patients with valve disorders with prophylactic antibiotics before and after invasive procedures (Amoxicillin, Duricef, Cleocin) Tx - parenteral antibiotics for 6 wks (Penicillin, EES, Clindamycin, Vancomycin)

Myocarditis
Inflammation of myocardium results in degeneration and dilation Thrombi form on endocardial lining (mural thrombi) Etiology viruses, mumps, parasites, bacteria, toxins, radiation

Clinical manifestations asymptomatic or fever, fatigue, tachycardia, palpitations, dyspnea, symptoms of HF Dx ECHO, endomyocardial biopsy, chest xray, ECG, elevated cardiac biomarkers

Tx
Tx underlying cause Bed rest Tx heart failure Anti-inflammatory or immunosuppressive medications

Pericarditis
Inflammation of the pericardial sac Fibrinous adhesions or exudate can form in pericardial sac Etiology viruses, bacteria, fungi, myocardial injury, collagen diseases, drug reaction, radiation, neoplasms, ESRD

Clinical manifestations chest pain, pericardial friction rub, fever, chills, dyspnea Dx ECG changes, elevated ESR and possibly WBC, enzymes negative,ECHO Tx
Tx cause NSAIDS, analgesics, steroids

Complications of Pericarditis
Pericardial effusion Cardiac tamponade signs and symptoms Pulsus paradoxus Muffled heart sounds Tachycardia Narrow pulse pressure Distended neck veins Drop in BP Chronic constrictive pericarditis

Treatment of Complications of Pericarditis


Pericardiocentesis Pericardiectomy

Valvular Disorders

Stenosis valve does not open completely Regurgitation valve does not close properly

Mitral Valve Prolapse (MVP)


Portion of a leaflet balloons backward during systole Valve may not remain closed and regurgitation can occur Clinical manifestations fatigue, dyspnea, chest pain, anxiety, dizziness, syncope, palpitations (atrial or ventricular dysrhythmias)

Dx ECHO with Doppler flow studies Tx


Beta blockers Eliminate caffeine, alcohol, and smoking

Mitral Regurgitation or Mitral Insufficiency


Leaflets do not close properly and blood leaks backward Pressure increases in left atrium and blood backs up into lungs Etiology - MI, heart enlargement, rheumatic endocarditis Clinical manifestations asymptomatic or symptoms of LVF, palpitations (atrial fib or PVCs), systolic murmur

Dx ECHO with Doppler flow , TEE, cardiac cath Tx tx LVF, mitral valve replacement (MVR) or valvuloplasty Prophylactic antibiotics for invasive procedures

Mitral Stenosis
Leaflets are thickened and contracted Flow of blood from left atrium into left ventricle is obstructed Left atrium dilates and hypertropies Blood backs up into lungs and eventually the right side of heart

Clinical manifestations Diastolic murmur, fatigue, dyspnea, hemoptyosis, cough, crackles, atrial fib Dx ECHO, cardiac cath Tx tx LVF, valvuloplasty or MVR, anticoagulants if AF persists

Aortic Stenosis
Narrowing of aortic valve orifice or calcification of leaflets LV hypertrophies, dilates, and contractility eventually decreases Blood backs up into lungs and right heart

Clinical manifestations angina, dizziness or syncope, DOE, narrowed pulse pressure, dysrhythmias, systolic murmur, and possibly a thrill Dx ECHO, TEE, cardiac cath Tx Bed rest, aortic valve replacement (AVR), valvuloplasty, prophylactic antibiotics for invasive procedures

Aortic Regurgitation or Aortic Insufficiency


Backflow of blood into LV from aorta during diastole Increased blood volume in LV causes LV to contract more forcefully and hypertropy Blood backs up into LA and lungs

Clinical manifestations sensations of forceful heart beat especially in the head and neck, head bobbing (Mussets sign), marked visible carotid pulsations, water-hammer pulse, widened pulse pressure, diastolic murmur, fatigue, DOE, signs of heart failure Dx ECHO, TEE, cardiac cath Tx AVR or valvuloplasty, prophylactic antibiotics

Valvuloplasty

Commisurotomy procedure to separate fused leaflets

Annuloplasty repair of the valve annulus

Chordoplasty repair of chordae tendineae

Valve Replacement
Open heart procedure requiring heart lung bypass
Classic approach Minimally invasive robtic approach

Patients age, contraindications to anticoagulants and underlying cause are considered

Two types of valve prostheses


Mechanical valves
Ball-and-cage or disc design More durable Valves are susceptible to thromboemboli

Biologic tissue grafts


Xenograft porcine or bovine Homograft (allograft) - from human pericardial tissue Autograft (autologous) use patients pulmonic valve

Complications Related To Valve Replacement


Hemorrhage Thromboembolism Infection Dysrhythmias Hemolysis of RBCs Heart failure

Educational Needs of Client With Valve Replacement


Wound care, diet, meds, activity restrictions Long term anticoagulant therapy if mechanical valve used Prophylactic antibiotic therapy if mechanical valve used