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