Congestive Heart Failure

advertisement

Coronary Heart Disease

(CHD)

Leading cause of death in U.S.

Narrowing coronary arteries

Atherosclerosis

Angina Pectoris -

Pathophysiology

Obstructed coronary artery

Increased myocardial oxygen demand

Lactic acid release

Leads to pain

Three types

Stable

Unstable

Prinzmetal’s: is a syndrome typically consisting of angina

(cardiac chest pain) at rest that occurs in cycles. It is caused by vasospasm , a narrowing of the coronary arteries caused by contraction of the smooth muscle tissue in the vessel walls rather than directly by atherosclerosis

Angina Pectoris -

Manifestations

Chest pain

Radiates

Onset with exercise, etc.

Relieved by rest, nitroglycerin (NTG)

SOB, pallor, fear

Acute Coronary Syndrome

Condition that includes:

Unstable angina

Acute myocardial ischemia with or without muscle damage

Associated with coronary artery stenosis and atherosclerotic plaque

Acute Myocardial Infarction

(AMI)

Pathophysiology

Occluded coronary artery stops blood flow to part of cardiac muscle

Cellular death

Tissue necrosis

Description—heart area affected

Classification

AMI Manifestations

Chest pain

Radiates to shoulder, neck, jaw, arms

Lasts longer than 15–20 minutes

Not relieved with NTG

Sense of impending doom

SOB

Diaphoresis

Nausea and vomiting

AMI Manifestations

(continued)

Manifestations in women and elderly

May be atypical

Upper abdominal pain

No chest pain but other symptoms

AMI Complications

Related to size and location of infarct

Dysrhythmias

Pump failure

Cardiogenic shock

Pericarditis

Cardiac Dysrhythmias

Pathophysiology

Due to altered formation of impulses or altered conduction of the impulse through the heart

Ectopic beats

Heart block

Reentry phenomenon

Classified to the site of impulse formation or the site and degree of conduction block

Types of Cardiac

Dysrhythmias (continued)

PVCs

Ventricular tachycardia

Ventricular fibrillation

AV conduction blocks

First degree

Second degree

Third degree

Types of Cardiac

Dysrhythmias

• Supraventricular

• Sinus tachycardia

• Sinus bradycardia

• PAC

• Atrial flutter

• Atrial fibrillation

• Junctional

• Ventricular dysrhythmias

ECG Changes in Angina

Pectoris vs. Myocardial

Infection

04/11/2009

Congestive Heart Failure

Dr Ibraheem Bashayreh, RN,PhD

15

Normal heart function

Heart failure

04/11/2009

16

Congestive Heart Failure

Definition

Impaired cardiac pumping such that heart is unable to pump adequate amount of blood to meet metabolic needs

Not a disease but a “ syndrome

Associated with long-standing HTN and

CAD

17

04/11/2009

Factors Affecting Cardiac Output

Preload

Cardiac Output

CO

= Heart Rate X

Stroke Volume

SV

Afterload Contractility

SV: the

volume

beat

04/11/2009 of blood pumped from one ventricle of the heart with each

18

Factors Affecting Cardiac Output

• Heart Rate

– In general, the higher the heart rate, the lower the cardiac

• E.g. HR x Systolic Volume (SV) = CO

» 60/min x 80 ml = 4800 ml/min (4.8 L/min)

» 70/min x 80 ml = 5600 ml/min (5.6 L/min)

– But only up to a point. With excessively high heart rates, diastolic filling time begins to fall, thus causing stroke volume and thus CO to fall

19

04/11/2009

Heart Rate

60/min

80/min

100/min

130/min

150/min

04/11/2009

Stroke Volume

80 ml

80/ml

80/ml

50/ml

40/ml

Cardiac Output

4.8 L/min

6.4 L/min

8.0 L/min

6.5 L/min

6.0 L/min

20

Factors Affecting Cardiac Output

Preload

The volume of blood/amount of fiber stretch in the ventricles at the end of diastole (i.e., before the next contraction)

21

04/11/2009

Factors Affecting Cardiac Output

• Preload increases with:

Fluid volume increases

Vasoconstriction (“squeezes” blood from vascular system into heart)

• Preload decreases with

• Fluid volume losses

• Vasodilation (able to “hold” more blood, therefore less returning toheart)

22

04/11/2009

Factors Affecting Cardiac Output

• Starling’s Law

– Describes the relationship between preload and cardiac output

– The greater the heart muscle fibers are stretched (b/c of increases in volume), the greater their subsequent force of contraction – but only up to a point. Beyond that point, fibers get over-stretched and the force of contraction is reduced

• Excessive preload = excessive stretch → reduced contraction → reduced SV/CO

23

04/11/2009

Factors Affecting Cardiac Output

Afterload

– The resistance against which the ventricle must pump. Excessive afterload = difficult to pump blood → reduced CO/SV

– Afterload increased with

:

• Hypertension

• Vasoconstriction

– Afterload decreased with:

• Vasodilation

24

04/11/2009

Factors Affecting Cardiac Output

Contractility

– Ability of the heart muscle to contract; relates to the strength of contraction.

25

04/11/2009

Factors Affecting Cardiac Output

• Contractility decreased with:

– infarcted tissue – no contractile strength

– ischemic tissue – reduced contractile strength.

– Electrolyte/acid-base imbalance

– Negative inotropes (medications that decrease contractility, such as beta blockers).

• Contractility increased with:

– Sympathetic stimulation (effects of epinephrine)

– Positive inotropes (medications that increase contractility, such as digoxin, sympathomimmetics)

04/11/2009

26

Pathophysiology of CHF

• Pump fails → decreased stroke volume /CO.

• Compensatory mechanisms kick in to increase CO

– SNS stimulation → release of epinephrine/norepinephrine

• Increase HR

• Increase contractility

• Peripheral vasoconstriction (increases afterload)

– Myocardial hypertrophy: walls of heart thicken to provide more muscle mass → stronger contractions

27

04/11/2009

Pathophysiology of CHF

Hormonal response: ↓’d renal perfusion interpreted by juxtaglomerular apparatus as hypovolemia. Thus:

Kidneys release renin, which stimulates conversion of antiotensin I → angiotensin

II, which causes:

Aldosterone release → Na retention and water retention (via ADH secretion)

Peripheral vasoconstriction

04/11/2009

28

Pathophysiology of CHF

• Compensatory mechanisms may restore

CO to near-normal.

• But, if excessive the compensatory mechanisms can worsen heart failure because . . .

04/11/2009

29

Pathophysiology of CHF

Vasoconstriction: ↑’s the resistance against which heart has to pump (i.e., ↑’s afterload), and may therefore ↓ CO

Na and water retention: ↑’s fluid volume, which

↑’s preload. If too much “stretch” (d/t too much fluid) → ↓ strength of contraction and ↓’s CO

Excessive tachycardia → ↓’d diastolic filling time → ↓’d ventricular filling → ↓’d SV and CO

30

04/11/2009

Congestive Heart Failure

Risk Factors

CAD

Age

HTN

Obesity

Cigarette smoking

Diabetes mellitus

High cholesterol

31

Underlying causes/risk factors

Ischemic heart disease

(CAD)

• hypertension

• myocardial infarction

(MI)

• valvular heart disease

• congenital heart disease

• dilated cardiomyopathy

04/11/2009

Heart failure

32

Congestive Heart Failure

Types of Congestive Heart Failure

Left-sided failure

Most common form

Blood backs up through the left atrium into the pulmonary veins

Pulmonary congestion and edema

Eventually leads to biventricular failure

33

04/11/2009

Congestive Heart Failure

Types of Congestive Heart Failure

Left-sided failure

Most common cause:

HTN

Cardiomyopathy

Valvular disorders

CAD (myocardial infarction)

04/11/2009

34

Congestive Heart Failure

Types of Congestive Heart Failure

Right-sided failure

Results from diseased right ventricle

Blood backs up into right atrium and venous circulation

Causes

LVF

Cor pulmonale: failure of the right side of the heart brought on by long-term high blood pressure in the pulmonary arteries and right ventricle of the heart

04/11/2009

35

RV infarction

Congestive Heart Failure

Types of Congestive Heart Failure

Right-sided failure

Venous congestion

Peripheral edema

Hepatomegaly

Splenomegaly

Jugular venous distension

36

04/11/2009

Congestive Heart Failure

Types of Congestive Heart Failure

Right-sided failure

Primary cause is left-sided failure

Cor pulmonale

RV dilation and hypertrophy caused by pulmonary pathology

37

04/11/2009

Acute Congestive Heart Failure

Clinical Manifestations

Pulmonary edema (what will you hear?)

Agitation

Pale or cyanotic

Cold, clammy skin

Severe dyspnea

Tachypnea

Pink, frothy sputum

38

04/11/2009

Chronic Congestive Heart Failure

Clinical Manifestations

Fatigue

Dyspnea

Paroxysmal nocturnal dyspnea (PND)

Tachycardia

Edema – (lung, liver, abdomen, legs)

Nocturia

39

04/11/2009

Chronic Congestive Heart Failure

Clinical Manifestations

Behavioral changes

Restlessness, confusion,

attention span

Chest pain

(d/t

CO and ↑ myocardial work)

Weight changes

Skin changes

(r/t fluid retention)

Dusky appearance

40

04/11/2009

Congestive Heart Failure

Classification

Based on the person’s tolerance to physical activity

Class 1 : No limitation of physical activity

Class 2 : Slight limitation

Class 3 : Marked limitation

Class 4 : Inability to carry on any physical activity without discomfort

41

04/11/2009

Congestive Heart Failure

Diagnostic Studies

Primary goal is to determine underlying cause

Physical exam

Chest x-ray

ECG

Hemodynamic assessment

04/11/2009

42

Congestive Heart Failure

Diagnostic Studies

Primary goal is to determine underlying cause

Echocardiogram

(Uses ultrasound to visualize myocardial structures and movement, calculate EF)

Cardiac catheterization

43

04/11/2009

Acute Congestive Heart Failure

Nursing and Collaborative

Management

Primary goal is to improve LV function by:

Decreasing intravascular volume

Decreasing venous return

Decreasing afterload

Improving gas exchange and oxygenation

Improving cardiac function

Reducing anxiety

04/11/2009

44

Acute Congestive Heart Failure

Nursing and Collaborative

Management

Decreasing intravascular volume

Improves LV function by reducing venous return

Loop diuretic: drug of choice

Reduces preload

High Fowler’s position

45

04/11/2009

Acute Congestive Heart Failure

Nursing and Collaborative

Management

Decreasing afterload

Drug therapy:

vasodilation,

Angiotensin-converting enzyme

(

ACE) inhibitors

Decreases pulmonary congestion

46

04/11/2009

Acute Congestive Heart Failure

Nursing and Collaborative

Management

Improving cardiac function

Positive inotropes

Improving gas exchange and oxygenation

Administer oxygen, sometimes intubate and ventilate

Reducing anxiety

Morphine

04/11/2009

47

Chronic Congestive Heart Failure

Collaborative Care

Treat underlying cause

Maximize CO

Alleviate symptoms

48

04/11/2009

Chronic Congestive Heart Failure

Collaborative Care

Oxygen treatment

Rest

Biventricular pacing

Cardiac transplantation

49

04/11/2009

Chronic Congestive Heart Failure

Drug Therapy

ACE inhibitors

Diuretics

Inotropic drugs : drugs that influence the force of contraction of cardiac muscle

Vasodilators

-Adrenergic blockers

50

04/11/2009

Chronic Congestive Heart Failure

Nutritional Therapy

Fluid restrictions not commonly prescribed

Sodium restriction

2 g sodium diet

Daily weights

Same time each day

Wearing same type of clothing

51

04/11/2009

Chronic Congestive Heart Failure

Nursing Management

Nursing Assessment

Past health history

Medications

Functional health problems

Cold, diaphoretic skin

52

04/11/2009

Chronic Congestive Heart Failure

Nursing Management

Nursing Assessment

Tachypnea

Tachycardia

Crackles

Abdominal distension

Restlessness

53

04/11/2009

Chronic Congestive Heart Failure

Nursing Management

Nursing Diagnoses

Activity intolerance

Excess fluid volume

Disturbed sleep pattern

Impaired gas exchange

Anxiety

54

04/11/2009

Chronic Congestive Heart Failure

Nursing Management

Planning

Overall goals:

Peripheral edema

Shortness of breath

Exercise tolerance

Drug compliance

No complications

55

04/11/2009

Chronic Congestive Heart Failure

Nursing Management

Nursing Implementation

Acute intervention

Establishment of quality of life goals

Symptom management

Conservation of physical/emotional energy

Support systems are essential

56

04/11/2009

What is Blood Pressure?

• The force of blood against the wall of the arteries.

• Systolic- as the heart beats

• Diastolic - as the heart relaxes

• Written as systolic over diastolic.

• Normal Blood pressure is less than 130 mm

Hg systolic and less than 85 mm Hg diastolic .

04/11/2009

57

High Blood Pressure

• A consistent blood pressure of 140/90 mm

Hg or higher is considered high blood pressure.

• It increases chance for heart disease, kidney disease, and for having a stroke.

• 1 out of 4 Americans have High Bp.

• Has no warning signs or symptoms.

58

04/11/2009

Why is High Blood Pressure

Important?

• Makes the Heart work too hard.

• Makes the walls of arteries hard.

• Increases risk for heart disease and stroke.

• Can cause heart failure, kidney disease, and blindness.

59

04/11/2009

How Does It Effect the Body?

The Brain

• High blood pressure is the most important risk factor for stroke.

• Can cause a break in a weakened blood vessel which then bleeds in the brain.

04/11/2009

60

The Heart

• High Blood Pressure is a major risk factor for heart attack.

• Is the number one risk factor for Congestive

Heart Failure.

61

04/11/2009

The Kidneys

• Kidneys act as filters to rid the body of wastes.

• High blood pressure can narrow and thicken the blood vessels.

• Waste builds up in the blood, can result in kidney damage.

62

04/11/2009

The Eyes

• Can eventually cause blood vessels to break and bleed in the eye.

• Can result in blurred vision or even blindness.

63

04/11/2009

The Arteries

• Causes arteries to harden.

• This in turn causes the kidneys and heart to work harder.

• Contributes to a number of problems.

64

04/11/2009

What causes High Blood

Pressure?

• Causes vary

• Narrowing of the arteries

• Greater than normal volume of blood

• Heart beating faster or more forcefully than it should

• Another medical problem

• The exact cause is not known.

65

04/11/2009

Who can develop High Blood

Pressure?

• Anyone, but it is more common in:

• African Americans- get it earlier and more often then Caucasians.

• As we get older. 60% of Americans over

60 have hypertension.

• Overweight, family history

• High normal bp:135-139/85-89 mm Hg.

66

04/11/2009

Detection

• Dr.’s will diagnose a person with 2 or more readings of 140/90mm Hg or higher taken on more than one occasion.

• White-Coat Hypertension

• Measured using a spygmomameter.

67

04/11/2009

Tips for Having your blood pressure taken.

• Don’t drink coffee or smoke cigarettes for

30 minutes before.

• Before test sit for five minutes with back supported and feet flat on the ground. Test your arm on a table even with your heart.

• Wear short sleeves so your arm is exposed.

68

04/11/2009

Tips for having blood pressure taken.

• Go to the bathroom before test. A full bladder can affect bp reading.

• Get 2 readings and average the two of them.

• Ask the Dr. or nurse to tell you the result in numbers.

69

04/11/2009

Categories of High Blood

Pressure

• Ages 18 Years and Older)

• Blood Pressure Level (mm Hg)

• Category Systolic Diastolic

• Optimal** < 120 < 80

• Normal < 130 < 85

• High Normal 130–139 85–89

04/11/2009

70

Categories of High Blood

Pressure

High Blood Pressure

Stage 1

Stage 2

Stage 3

140–159 /90–99

160–179 /100–109

180 /110

04/11/2009

71

Preventing Hypertension

Adopt a healthy lifestyle by:

• Following a healthy eating pattern.

• Maintaining a healthy weight.

• Being Physically Active.

• Limiting Alcohol.

• Quitting Smoking.

04/11/2009

72

DASH diet

• Dietary Approaches to Stop Hypertension.

• Was an 11 week trial.

• Differences from the food pyramid:

• an increase of 1 daily serving of veggies.

• and increase of 1-2 servings of fruit.

• inclusion of 4-5 servings of nuts,seeds, and beans.

73

04/11/2009

Tips for Reducing Sodium

• Buy fresh, plain frozen or canned “no added salt” veggies.

• Use fresh poultry, lean meat, and fish.

• Use herbs, spices, and salt-free seasonings at the table and while cooking.

• Choose convenience foods low in salt.

• Rinse canned foods to reduce sodium.

74

04/11/2009

Maintain Healthy Weight

• Blood pressure rises as weight rises.

• Obesity is also a risk factor for heart disease.

• Even a 10# weight loss can reduce blood pressure.

04/11/2009

75

Be Physically Active

• Helps lower blood pressure and lose/ maintain weight.

• 30 minutes of moderate level activity on most days of week. Can even break it up into 10 minute sessions.

• Use stairs instead of elevator, get off bus 2 stops early, Park your car at the far end of the lot and walk!

76

04/11/2009

Limit Alcohol Intake

Alcohol raises blood pressure and can harm liver, brain, and heart

77

04/11/2009

Quit Smoking

• Injures blood vessel walls

• Speeds up process of hardening of the arteries.

04/11/2009

78

Other Treatment

• If Lifestyle Modification is not working, blood pressure medication may be needed, there are several types:

• Diuretics-work on the kidney to remove access water and fluid from body to lower bp.

• Beta blockers-reduce impulses to the heart and blood vessels.

79

04/11/2009

Other Treatment

• ACE inhibitors- cause blood vessels to relax and blood to flow freely.

• Angiotensin antagonists- work the same as

ACE inhibitors.

• Calcium Channel Blockers- causes the blood vessel to relax and widen.

• Alpha Blocker- blocks an impulse to the heart causing blood to flow more freely.

80

04/11/2009

Other Treatment

• Alpha-beta blockers- work the same as beta blockers, also slow the heart down.

• Nervous system inhibitors- slow nerve impulses to the heart.

• Vasodilators- cause blood vessel to widen, allowing blood to flow more freely.

81

04/11/2009

Conclusion

• Hypertension is a very controllable disease, with drastic consequences if left uncontrolled.

82

04/11/2009

Download