Nursing Management of Patients with Cardiovascular Disease

Part 1: Heart Failure

Barbara Moloney DNPc, RN, CCRN

First Patient 50-year-old man

brought to the hospital by his family

His family says he has been feeling more and more short of breath over the last several days

Assessment Vital signs:

Temperature – 37O C HR – 100, irregular Respiratory rate 32 Bp – 102/60 Oxygen saturation 88% on

room air Respiratory Dyspnoec

Neurological Oriented Anxious

Skin Cool, damp

Jugular Venous Distention >3cm

WHAT ARE YOUR CONCERNS?

What would you like to do next?

Past medical history Rheumatic fever as a child Rheumatic heart disease involving aortic and mitral valve Dilated cardiomyopathy Increasing problems with chest pressure and dyspnea over

the last year Medications prescribed:

Furosemide 40 mg daily Digoxin 0.125 mg every other day

Listen to his lungs

Assess the heart

Palpate Point of

maximum intensity should be 5th intercostal space, mid-clavicular line

Displaced = enlarged heart

Auscultating the heart

A: Aortic valve: 2nd intercostal space (ICS) right of sternum

P: Pulmonic valve: 2nd ICS left of sternum ERB’s point: 3rd ICS left of sternum

T: Tricuspid: 4th ICS left of sternum

M: Mitral: 5th ICS left of sternum

Listen to his heart

Abdomen Soft, flat Bowel sounds normal

Peripheral Pedal pulses present Pitting Edema

Review of the Heart

Atria Ventricles

“PUMPS” RV pumps

blood to lungs LV pumps

blood to body Flow of Blood

through heart

Blood flow through the heart

Valves: Allow blood to flow in one direction

Tricuspid & mitral Prevent

regurgitation from ventricles into atria

Pulmonic and Aortic valves Prevents blood

from regurgitating into ventricle

Assessing Heart Sounds

Review Murmurs

Intensity1. Faint2. Quit3. Moderately loud4. Loud5. Very loud6. Heard with stethoscope

off chest

Characteristics Location Pitch Timing Loudness Quality Radiation Variation

Timing

Systolic murmur Occur during systole:

when the ventricles are contracting Aortic Stenosis Mitral regurgitation

Diastolic murmur Occurs during diastole,

when ventricles are filling

Jugular Venous Distention Assess patient at 450

Should be <3cm

Analysis Your analysis

Medical diagnosis Left-sided heart failure

secondary to valvular heart disease and cardiomyopathy

Right-sided heart failure Chronic heart failure Acute decompensated heart

failure

Review: Heart Failure Etiology

Hypertension Coronary Artery Disease Cardiomyopathy Valvular Heart Disease

Heart Failure

Left ventricular heart Left ventricular heart failurefailure

Right ventricular heart Right ventricular heart failurefailure

Biventricular Heart Biventricular Heart FailureFailure

Acute decompensated Acute decompensated heart failure heart failure

Chronic heart failureChronic heart failure

Systolic Heart Systolic Heart FailureFailure

Diastolic Heart Diastolic Heart FailureFailure

Left Ventricular Failure

Left Ventricle can no Left Ventricle can no longer pump enough blood longer pump enough blood to the systemic circulationto the systemic circulation

http://www.heartfailure-europe.com/img/009333ed66ae8f1f9c77487008990cceimage001.jpg

Pressure rises in the LV, Pressure rises in the LV, LA & pulmonary LA & pulmonary vasculaturevasculature

Hydrostatic forces can Hydrostatic forces can cause intracellular fluid to cause intracellular fluid to accumulate in the accumulate in the pulmonary capillary bed, pulmonary capillary bed, leading to pulmonary leading to pulmonary congestioncongestion

Left ventricular failure

http://www.csufresno.edu/nursing/n140/studassign/studgif/chf8.gif

Left ventricular failure

Signs and symptoms (Signs and symptoms (Signes et symptômesSignes et symptômes) ) Restlessness and confusionRestlessness and confusion

Agitation et confusion Agitation et confusion

Dyspnea (Dyspnea (DyspnéeDyspnée)) Cyanosis (Cyanose)Cyanosis (Cyanose) Cough Cough ((TouxToux )) Crackles (Crackles (RâlesRâles)) Wheezes (rauque, respiration sifflante)Wheezes (rauque, respiration sifflante) Blood-tinged sputum (Blood-tinged sputum (Crachat teintCrachat teinté é de sangde sang)) Paroxysmal Nocturnal dyspnea (Paroxysmal Nocturnal dyspnea (Dyspnée nocturne paroxysmale )Dyspnée nocturne paroxysmale )

Left ventricular failure Restless, Confused

Orthopnea, Tachycardia, Cyanosis

Dysponea on Exertion

Paroxysmal Nocturnal Dyspnea

Rales, Wheezes, Cough

Blood Tinged sputum

Right Ventricular Failure

Pressure increases Pressure increases on right side of the on right side of the heartheart

Hydrostatic forces can Hydrostatic forces can cause intracellular fluid cause intracellular fluid to accumulate in to accumulate in systemic venous systemic venous circulationcirculation

Right Ventricular Failure Signs and symptomsSigns and symptoms

FatigueFatigue Jugular Venous distentionJugular Venous distention Dependent edemaDependent edema AnorexiaAnorexia Enlarged liver and SpleenEnlarged liver and Spleen AscitesAscites

Right Ventricular failure

Fatigue

Anorexia

Dependent edemaDependent edema

Distended jugular veins

Ascites enlarged liver & Spleen

Cardiomyopathy

Dilated Cardiomyopathy

Review: Valvular Heart Disease General:

A cardiac dysfunction produced by structural and/or functional abnormalities of single or multiple cardiac valves

Stenosis: valve doesn’t open all the way Regurgitation: valve doesn’t close all the way

Mitral Regurgitation Aortic Stenosis

http://www.youtube.com/watch?v=XzjvV8UMEy4

http://www.youtube.com/watch?v=MJg257pyt4I

Collaborative Management Follow clinically Follow with echocardiograms Avoid infection Manage symptoms of HF May treat with repair or replacement

Nursing Diagnoses Problem List

Inadequate oxygenation Excess fluid Low cardiac output Anxiety Activity intolerance Knowledge deficit

Plan: Inadequate Oxygenation

Goal: Goal: Maintain oxygenation saMaintain oxygenation saturation >93%turation >93% Absence of respiratory distressAbsence of respiratory distress

InterventionsInterventions Nasal oxygen Nasal oxygen Oxygen mask – i.e. non-rebreatherOxygen mask – i.e. non-rebreather CConsider bipaponsider bipap Prepare for intubationPrepare for intubation

Excess fluid Goal: Optimize fluid and electrolyte balance

Absence of pulmonary congestion: clear lung sounds, clear chest x-ray

Absence of peripheral edema Electrolytes within normal limits Stable vital signs Adequate urine output

Interventions Strict I&O, calculate fluid balance, monitor electrolytes Monitor lung sounds Administer diuretics as ordered and assess effect

Low Cardiac Output Goal

Skin warm and dry with brisk capillary re-fill Alert and oriented Vital signs within normal limits Urine output >30 mLs/hour Absence of edema Lungs clear

Interventions: Continuous cardiac monitor; assess and treat dysrhythmias Monitor VS, Capillary re-fill, edema, mental status ; lab values Administer medications that increase cardiac output when ordered by

physician (dopamine)

Optimize pre-load and afterload Semi-fowlers position Vasodilators (nitroglycerine)

ACE- inhibitors (Lisinopril, Quinapril)

Decrease ventricular remodeling ACE-inhibitors Beta-blockers (when hemodynamically stable)

(metoprolol, atenolol)

Anxiety Goal

Reduce anxiety level

Interventions Calm supportive environment Medications - Morphine

Activity Intolerance Goal

Promote activity Reduce fatigue

Intervention Bed-rest during acute phase only Space activities to allow for rest Monitor heart rate, respiratory rate, and oxygen saturation

with initial activity. Avoid large meals - encourage frequent small meals As patient recovers, initiate exercise regimen as tolerated.

Knowledge Deficit Goal Intervention

Begin teaching as soon as patient is able to participate

Teach

Evaluation Oxygenation Diuresis

Fluids Electrolytes (K+)

Cardiac Output Anxiety Activity intolerance Knowledge

Patient Education Review heart failure, diagnosis and treatment Symptoms of Heart Failure

Short of breath or wheezing Difficulty breathing when lying down Frequent dry cough Feeling tired or weak Weight gain of 3 or more pounds in 1 day or 5

pounds in more than 1 week Swelling in feet, ankles, legs, or stomach

Review of medications Ace inhibitors (Lisinopril, Quinapril)

Purpose: Helps heal the heart and lower the amount of water and salt you retain, will help you live longer

Side effects: Orthostatic hypotension

Beta blockers (Metoprolol, Atenolol) Purpose: Helps heal the heart and help you live longer Side effects: May decrease your heart rate

Diuretics (furosemide) Purpose: Helps reduce fluid in your lungs, and swelling in feet,

ankles, legs and stomach Side effects: make you urinate more often.

Digoxin Helps your heart pump better Take as ordered (may be every other day) Review side effects: blurred vision, slow heart- rate,

General Instructions Take medications as prescribed Get some exercise (walking is great) but do not

over-do it Do not smoke, do not drink alcohol Vaccines Regular clinic appointments

Diet Instructions Do not add salt to foods Avoid foods with hidden salt (please help here) Fluid restriction (if on one)

When to seek medical help More short of breath than usual Swelling in ankles, feet, or abdomen Loss of appetite Persistent cough Restless sleeping: needing sleep upright or

waking in the night suddenly short of breath Weight gain of 3 pounds in 1 day or 5 pounds in

1 week

Dressler, D.K. (2010).