Transcript Smeltzer Textbook of Medical Surgical Nursing

Chapter 29
Management of Patients With
Complications From Heart
Disease
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Heart Failure (HF)
• 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 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.
• Most HF is a progressive, lifelong disorder managed with
lifestyle changes and medications.
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Pathophysiology of Heart Failure
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Clinical Manifestations
Right Sided
• Viscera and peripheral
congestion
Left Sided
• Pulmonary congestion,
crackles
• Jugular venous
distention (JVD)
• S3 or “ventricular gallop”
• Dependent edema
• Dyspnea on exertion
(DOE)
• Hepatomegaly
• Orthopnea
• Ascites
• Dry, nonproductive
cough initially
• Weight gain
• Oliguria
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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
– Relieve 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; 30–45 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 HOB 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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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
alternate 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’d)
• 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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Pulmonary Edema
• Acute event in which the LV cannot handle an overload of
blood volume. Pressure increases in the pulmonary
vasculature, causing fluid movement 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
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Management of Pulmonary Edema
• Prevent
• 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
– Diuretics (furosemide), vasodilators (nitroglycerin)
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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
• Treated in an ICU
• Assess cardiac rhythm, monitor hemodynamic
parameters, monitor fluid status, and adjust medications
and therapies based on the assessment data
• 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.
– The most common thromboembolic problem with HF
– Prevention
– Treatment
– Anticoagulant therapy
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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
• Pericardiotomy
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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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