Chapter 25 Management of Patients with Complications from Heart Disease
Worksheet for Heart Failure Lecture /readings
Page 794
What is heart failure?
a clinical syndrome resulting from structural or functional cardiac disorders so that the heart is
unable to pump enough blood to meet the body’s metabolic demands or needs
List the Clinical Manifestations page 795
Right sided page 797 (a lot of fluid retention)
JVD
Congestive hepatomegaly
Ascites- fluid in abdomen from laying supine
Peripheral edema- from ambulating/standing
Sacral edema- also from laying?
Left sided aka congestive HF (think lungs)
Dyspnea/ orthopnea
cough
Pulm crackles
Low o2 sat lvl
Extra heart sounds S3 “ventricular gallop”
nocturia
What should the nurse focus on?
Promoting comfort and managing the signs and symptoms
Chart 25-1 assessment :
Chapter 25 Management of Patients with Complications from Heart Disease
Pulmonary Edema
Define Pulmonary Edema : fluid in the lungs
sometimes referred to as acute decompensated heart failure.
When the left ventricle begins to fail, blood backs up into the pulmonary circulation, causing
pulmonary interstitial edema
What will you observe in your assessment ?
restlessness and anxiety
Breathlessness and sense of suffocation
Tachypnea and low O2 sat lvl
Cyanosis
Hands may be cold and clammy
Tachycardia
Pt may become progressively confused
What diagnostic findings will be done and reviewed ?
Table 25-1 NYHA classification on HF – this is a way to put a level on how much the HF is
affecting the patient
Classification
Signs and symtpoms
No limitation of physical activity
I
Ordinary activity does not cause undue fatigue,
palpitation, or dyspnea
Slight limitation of physical activity
Comfortable at rest, but ordinary physical activity
causes fatigue, palpitation, or dyspnea
Marked limitation of physical activity
Comfortable at rest, but less than ordinary
activity causes fatigue, palpitation, or dyspnea.
Unable to carry out any physical activity without
discomfort
Symptoms of cardiac insufficiency at rest
If any physical activity is undertaken, discomfort
is increased.
II
III
IV
Table 25-2 ACC/AHA classification of HF
Classification
Criteria
Stage A
Patients at high risk for
developing left
ventricular
dysfunction but
without structural
heart disease or
symptoms of HF
Patient
characteristics
Treatment
recommendations for
appropriate patients
Hypertension
Atherosclerotic disease
Diabetes
Metabolic syndrome
Heart healthy lifestyle
Risk factor control of
hypertension, lipids,
diabetes, obesity
Chapter 25 Management of Patients with Complications from Heart Disease
Stage B
Stage C
Stage D
Patients with left
ventricular dysfunction
or structural heart
disease who have not
developed symptoms
of HF
History of myocardial
infarction
Left ventricular
hypertrophy
Low ejection fraction
Implement stage A
recommendations,
plus:
Patients with left
ventricular dysfunction
or structural heart
disease with current or
prior symptoms of
heart disease
Shortness of breath
Fatigue
Decreased exercise
tolerance
Implement stage A and
B recommendations,
plus:
Patients with
refractory end-stage
HF requiring
specialized
interventions
Symptoms despite
maximal medical
therapy
Recurrent
hospitalizations
Implement stage A, B,
and C
recommendations,
plus:
•ACE inhibitor, or ARB,
or ARNI for low EF
or history of MI
•Beta-blocker
•Statin
•Diuretics
•Aldosterone
antagonist
•Sodium restriction
•Implantable
defibrillator
•Cardiac
resynchronization
therapy
•Fluid restriction
•End-of-life care
•Extraordinary
measures:
•Inotropes
•Cardiac
transplantation
•Mechanical support
Medical mangment
What are the goals ? page 799
 Improvement of cardiac function with optimal pharmacologic management
 Reduction of symptoms and improvement of functional status
 Stabilization of patient condition and lowering of the risk of hospitalization
 Delay of the progression of HF and extension of life expectancy
 Promotion of a lifestyle conducive to cardiac health
Pharmacologic therapy
Table 25-3
Chapter 25 Management of Patients with Complications from Heart Disease
Medication
Diuretics
Loop diuretics
Therapeutic effects
Key nursing considerations
↓ Fluid volume overload
↓ Signs and symptoms of HF
Observe for electrolyte
abnormalities, renal
dysfunction, diuretic resistance,
and ↓ BP. Carefully monitor I&O
and daily weight
Improves HF symptoms in
advanced HF
Observe for ↑ serum K+, ↓ serum
Na+
↓ BP and ↓ afterload
Relieves signs and symptoms of
HF
Prevents progression of HF
↓ BP and ↓ afterload
Relieves signs and symptoms of
HF
Observe for symptomatic ↓ BP, ↑
serum K+, cough, and worsening
renal function.
↓ BP and ↓ afterload
↓ Fluid volume overload
↓ Signs and symptoms of HF
Prevents progression of HF
Dilates blood vessels and ↓
afterload
↓ Signs and symptoms of HF
Improves exercise capacity
Observe for symptomatic ↓ BP, ↑
serum K+, cough, dizziness, and
renal failure.
Ivabradine
Decreases rate of conduction
through the SA node
Hydralazine-isosorbide
dinitrate
Digitalis
Digoxin
Dilates blood vessels
↓ BP and ↓ afterload
Observe for ↓ heart rate,
symptomatic ↓ BP, dizziness,
and fatigue.
Observe for symptomatic ↓ BP
furosemide
Thiazide diuretics:
metolazone
hydrochlorothiazide
Aldosterone antagonists
Angiotensin system blockers
ACE Inhibitors
Lisinopril
enalapril
ARB’s
Volsartan
losartan
ARNI
Beta-adrenergic-blocking
agents ( beta blockers )
Improves cardiac contractility
↓ Signs and symptoms of HF
Observe for symptomatic ↓ BP, ↑
serum K+, and worsening renal
function
Observe for ↓ heart rate,
symptomatic ↓ BP, dizziness,
and fatigue
Observe for ↓ heart rate and
digitalis toxicity.
Chart 25-2 administering and monitoring diuretic therapy page 800
Chapter 25 Management of Patients with Complications from Heart Disease
IV infusions page 802
These maybe indicated for hospitalized patients with pulmonary edema .
What do inotropes do? (dopamine, dobutamine, milrinone)
They increase the force of myocardial contraction
They are used for pt who do not respond to pharmacologic therapy and are reserved for patients
with severe ventricular dysfunction, low blood pressure, or impaired perfusion and evidence of
significantly depressed CO, with or without congestion
Adjunct medications for heart failure – page 803
Anticoagulant for pt with history of a-fib or thromboembolic events
Antiarrhythmic drugs such as amiodarone may be prescribed for patients with arrhythmias, along
with an evaluation for device therapy with an implantable cardioverter defibrillator
Meds to manage hyperlipidemia such as statins
Avoid NSAIDS
Look at details about hypertension and anemia and anticoagulants
-If pt hypertensive -> take prescribed hypertensive med -> target BP should be less than 130/80
->improves morbidity in pt who are symptomatic with both HFrEF and HFpEF
-iron deficiency appears to be associated with reduced exercise capacity -> erythropoietinstimulating agents such as darbepoetin alfa are not recommended in pt with both HF and
anemia -> risk of thromboembolic events
Adjunct therapies for heart failure
Chapter 25 Management of Patients with Complications from Heart Disease
nutritional therapy, supplemental oxygen, management of sleep disorders, and procedural or
surgical interventions
Nutrition
Low sodium (no more than 2g/ day)
Avoid excessive fluid intake
Vitamins and antioxidants are not recommended
Omega-3 polyunsaturated fatty acid supplement is recommended for pt with HFrEF or HFpEF
Oxygen
Some pt will require O2 only during periods of activity to prevent hypoxia
Management of sleep disorders
Sleep apnea (central or obstructive) -> continuous positive air pressure (CPAP)
Procedural & surgical interventions – not tested on this – it is covered in complex adults in
senior one .
Nursing process
Video on page 805 is a good resource
Assessment
Observing effectivesness of therapy
Pt education for S/S of worsening HF
Pt emotional response to diagnosis
Health history
Focus on S/S such dyspnea, fatigue, and edema
Sleep disturbances -> ask numbers of pillows needed to sleep
Edema, abdominal symptoms, altered mental status, activities of daily living, and activity that
causes fatigue
Assess pt understanding of HF, self care management and ability to adhere to those strategies
Physical exam
Observation of restlessness and anxiety may suggest hypoxia
Lvl of consciousness
Respiration rate and depth
Wheezing
BP, heart rate and rhythm, peripheral pulse
JVD (while pt sit at 45 degree angle)
Skin (feel cool or appear cyanotic), lower leg for edema
Chapter 25 Management of Patients with Complications from Heart Disease
Abdomen for hepatomegaly
Oliguria or anuria
Weight daily (hospital and at home) -> if gain 2-3 lb in a day or 5 lb in a week this may indicate
worsening of HF
What are some goals a nurse should have when caring for a patient with heart failure ?
promoting activity and reducing fatigue
relieving fluid overload symptoms,
decreasing anxiety or increasing the patient’s ability to manage anxiety,
encouraging the patient to verbalize their ability to make decisions and influence outcomes
educating the patient and family about health management
Plan of Care
Activity intolerance related to decreased CO
PROMOTING ACTIVITY TOLERANCE
Daily walking (promote pacing and prioritization of activities)
Avoid performing physical activities outside in extreme hot, cold, or humid weather.
Wait 2 h after eating a meal before performing the physical activity.
Ensure that you can talk during the physical activity; if you cannot do so, decrease the intensity
of activity.
Stop the activity if severe shortness of breath, pain, or dizziness develops.
(Hypervolemia )Excess fluid volume related to the HF syndrome
MANAGING FLUID VOLUME
Diuretics
Low sodium diet (avoid canned, processes and convenience foods)
Monitor fluid intake and weight
Use pillows or reclinner
Anxiety-related symptoms related to complexity of the therapeutic regimen
CONTROLLING ANXIETY
When pt is experiencing anxiety -> nurse should promote physical comfort and provide
psychological support
Use recliner
O2 may be administer
Assess the need of family caregivers and provide support to them
Educate pt and family about techniques for controlling anxiety and anxiety provoking situation
Relaxation techniques
Quality and Safety Nursing Alert
When patients with HF are delirious, confused, or anxious, restraints should be avoided. Restraints are
likely to be resisted, and resistance inevitably increases the cardiac workload.
Chapter 25 Management of Patients with Complications from Heart Disease
Powerlessness related to chronic illness and hospitalizations
MINIMIZING POWERLESSNESS
Include pt in treatment plan -> help pt recognize their choices
Taking time to actively listen to pt and encourage them to express their concerns and ask
questions
Provide pt with decision making opportunities
Provide encouragement
(pt needs to be screened for depression)
Ineffective family therapeutic regimen management
ASSISTING PATIENTS AND FAMILY TO EFFECTIVELY MANAGE HEALTH
Education, discharge plans to prevent hospital readmission and increase pt quality of life
Managing personal health
Providing pt with comprehensive, pt centered instruction, schedule foloow-up visits with PCP
7days of discharge
MONITORING AND MANAGING POTENTIAL COMPLICATIONS
Pulmonary edema
Asses pt airway and breathing to determine severity of resp distress
Asses VS
Pulse OX, cardiac monitor, and IV access
Lab test ( BUN, ABG, CR, CBC, BNP, serum troponin) C-xray or ultrasound of lungs
Give O2 to relieve hypoxemia and dyspnea
Vasodilators S/A IV nitroglycerin or nitroprusside
Furosemide -> monitor for S/S of hypokalemia
PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE (page 831)
Take a look at this too- What does the nurse need to teach the patient about home
management?
Long-term care of the feet and legs is of prime importance in the prevention of trauma,
ulceration, and gangrene.
DONOT READ PAGE 811 CARDEGENIC SHOCK , PERICARDIAL EFFUSION AND CARDIAC
TAMPONADE , CARDIAC ARREST
WE COVERED THROMBOEMBOLISM IN VASCUALAR