Transcript Diseases Of The Heart

Diseases Of The Heart
Heart Failure
• Heart failure is a
clinical syndrome
• Heart is unable to
pump sufficient
blood to meet the
needs of the tissues
• Heart failure is the
number 1 DRG for
hospitalization in
people over 65
years
Etiology of Heart Failure
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CAD
Systemic or pulmonary hypertension
Cardiomyopathy
Valvular disease
Septal defects
Myocarditis
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Dysrhythmias
Hypervolemia
Metabolic disorders
Autoimmune disorders
Anemia in the elderly
Pathophysiology Of Heart
Failure
• Decreased amount of blood ejected from
ventricles
• Stimulation of SNS - increases myocardial
workload or O2 demand
• Ventricular hypertrophy
• Decreased renal perfusion
• Activation of Renin-AngiotensinAldosterone System
– Renin interacts with Angiotensinogen to
produce Angiotensin I
– Angiotensin I converts to Angiotensin II
– Angiotensin II stimulates release of
Aldosterone
• Blood backs up in left atrium and pulmonary
veins
• Increased hydrostatic pressure forces fluid out
of pulmonary capillaries into alveoli and
interstitial spaces
• Right ventricle dilates due to increased
pulmonary pressures (pulmonary HTN)
• Engorgement of venous system extends
backwards into systemic veins and organs
• Right ventricular failure usually follows left
ventricular failure
• Right ventricular failure can occur solely
without left ventricular failure – cor
pulmonale
• Heart failure can affect systolic function or
diastolic function
Clinical Manifestations Of Left
Ventricular Failure (LVF)
• Dyspnea
– Dyspnea on exertion (DOE)
– Orthopnea
– Paroxysmal nocturnal dyspnea (PND)
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Cough
Crackles
Hypoxia, cyanosis
Tachycardia, palpitations
• S3, S4, murmurs
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Weak, thready pulses
Fatigue
Pale, cool, clammy skin
Restlessness, anxiety, confusion
Nocturia, oliguria
Decreased GFR, increased creatinine
Clinical Manifestations of Right
Ventricular Failure (RVF)
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Elevated JVD
Positive HJR
Hepatomegaly, splenomegaly
Ascites
Anorexia, nausea, constipation
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Sacral edema
Peripheral edema
Anasarca
Weight gain
Decreased activity tolerance
Acute Pulmonary Edema
• Life threatening situation
• Large accumulation of fluid in lungs
• Manifestations
– Severe dyspnea, sense of suffocation
– Cough, large amounts of frothy, blood tinged
sputum
– Wheezing and coarse crackles
– Cyanosis
New York Heart Association’s
Functional Classification of Heart Disease
• Class I – Ordinary activity does not cause
symptoms
• Class II – Slight limitation of ADLs
• Class III – Comfortable at rest but any
activity causes symptoms
• Class IV – Symptoms at rest
Diagnostic Findings With Heart
Failure
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Echocardiogram with Doppler flow studies
Chest x-ray
ECG
B-Type Natriuretic Peptide (BNP)
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BUN and creatinine
T4 and TSH
Liver function tests
Stress testing or cardiac cath
Objectives In Treating Heart
Failure
• Identify and eliminate the precipitating
cause
• Reduce the workload on the heart
• Enhance patient and family coping with
lifestyle changes
Medical Management of Heart
Failure
• Exercise
– Bed rest in upright position in acute and
refractory stages
– Regular exercise program
• Oxygen therapy
• Dietary restrictions
– Sodium restriction
– Fluid restriction
• Cardiac
resynchronization –
biventricular pacing
(Medtronic InSyn)
• Mechanical assist
devices
• Transplantation
Pharmacologic Management of
Heart Failure
• ACE inhibitors
– Vasodilate
– Promote diuresis
– Drugs – Vasotec, Captopril, Zestril,
• Angiotensin II Receptor Blockers (ARBs)
– Prescribed when patient intolerant of ACE-I
– Drugs – Diovan, Aticand
• Beta1 Blockers
– Decrease cytotoxic effects of constant
stimulation of SNS
– Decrease workload by decreasing heart rate
– Drugs - Coreg, Lopressor, Atenolol
• Vasodilators
– Cause venous dilation
– Cause arterial dilation
– Drugs – Nitrates ie. Isordil (isosorbide) and
other meds ie. Apresoline (hydralazine); BiDil
( isosorbide & hydralazine combination)
• Diuretics
– Control Na and H2O retention
– Three types
• Potassium sparing –Aldactone
(spironalactone), Inspra (eplerenone)
• Loop diuretics – Lasix (furosemide)
• Thiazide diuretics – Zaroxolyn (metolazone),
HCTZ (hydrochlorazide)
– Monitor for hypotension, lyte imbalances
and dehydration, worsening renal failure
• Cardiac glycosides
– Increase force of myocardial contraction
and slow conduction through AV node
– Drugs – Lanoxin (digoxin), Primacor,
Inocor
– Precautions with Lanoxin administration
• Decreased renal function slows elimination
• Will need to decrease dose with certain meds
ie. amiodarone, erythromycin, quinidine
• Usual dose – 0.125 mg to 0.5 mg (PO,IV,IM)
• Lanoxin toxicity – Therapeutic level 0.5-2.0
ng/mL
– Symptoms – anorexia, N/V, fatigue, H/A,
yellow or green halos, new dysrhythmias
– Reversal – hold dose or administer Digibind
(digoxin immune FAB)
• Nursing considerations for Lanoxin
administration
– Assess heart rate for 1 min
– Give after breakfast
– Monitor for hypokalemia
• Calcium channel blockers
– Contraindicated with severe systolic
dysfunction
– Drugs – Norvasc, Cardizem, Procardia
• Natrecor (nesiritide)
– Indicated for the IV treatment of clients with
acutely decompensated congestive heart
failure with dyspnea at rest
– Manufactured from E-coli
– Effects - dilates veins and arteries,
suppresses Aldosterone
– Administration - IV bolus, then drip for 48
hrs
– Contraindications - systolic pressure
<90mm Hg, binds with Heparin
– Side effects - hypotension, VT, HA, nausea
– Incompatible with Heparin in same line
Medical Management Of
Pulmonary Edema
• Sit patient in high Fowlers with legs and
feet dependent
• Oxygen
• Morphine
• Diuretics
• Other meds as with heart failure
Nursing Diagnoses For The
Client With Heart Failure
Nursing Interventions For The
Client With Heart Failure
• Monitor and manage potential
complications
– Assess cardiovascular status frequently
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Vital signs
Heart sounds
Degree of JVD & HJR
All peripheral pulses
– Assess respiratory status frequently
• Lung sounds
• Assess degree of dyspnea
• Assess O2 sats
– Assess renal status
• I&O
• BUN & Cr
• Assess for nocturia
• Assess GI system
– HJR
– Ascites
– Appetite and constipation
• Monitor fluid status closely
– Daily weights
– I&O
– Peripheral and sacral edema
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Reduce fatigue
Promote activity tolerance
Control anxiety
Referrals
Teach client and family
Client and Family Teaching
Related to Heart Failure
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Weigh daily
2-3 gm Na diet
Fluid restrictions
Meds and side effects
• Signs and symptoms to report to physician
– Weight gain
– Loss of appetite
– Syncopy or palpitations
– Worsening SOB
– Persistent cough
Expected Outcomes
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Maintains or improves cardiac function
Maintains or increases activity tolerance
Adheres to self-care program
Absence of complications
Cardiomyopathy
• Disease of the myocardium which affects
its function
• Three major types of cardiomyopathy
– Dilated - DCM
– Hypertropic - HCM
– Restrictive
Dilated Cardiomyopathy
• Contractility
decreases and
ventricles dilate.
Affects systolic
function.
• Etiology – viral
myocarditis, toxins,
alcohol, pregnancy,
ischemia
• Clinical manifestations same as with LVF
• Dx tests – ECHO, endomyocardial biopsy,
ECG, chest x-ray, blood chemistries
• Tx – same as with LVF; tx dysrhythmias;
heart transplant
Hypertropic Cardiomyopathy
• Myocardium
increases in size and
mass
• Reduces inner cavity
of ventricles and
ventricles take longer
to relax and fill.
Affects diastolic
function
• Etiology – genetic,
HTN, and
hypoparathyroidism
• Appears most often in young adults
• Clinical manifestations – sudden cardiac
death; dyspnea, palpitations, dizziness
• Dx tests – radionuclide scans, ECHO,
chest x-ray, ECG
• Tx – Beta blockers and Ca channel
blockers. Avoid meds that decrease
preload or increase contractility
(Lanoxin). Tx dysrhythmias - may insert
ICD
Restrictive Cardiomyopathy
• Ventricle walls are
rigid and do not
stretch normally
during filling. Cardiac
output decreases.
Affects diastolic
function.
• Etiology Amylodiosis,
Sarcoidosis
• Clinical manifestations – fatigue, activity
intolerance, dyspnea and other symptoms
of LVF
• Dx tests – same as other
cardiomyopathies
• Tx – similar to hypertropic
cardiomyopathy; tx dysrhythmias. Also tx
underlying cause
Rheumatic Endocarditis
• Results directly from group A betahemolytic strep
• Can be prevented if strep infection treated
early
• Myocardium, valves and pericardium are
affected
– Contractility is decreased
– Valve leaflets develop vegetative bodies
• Clinical manifestations
– Signs of rheumatic fever (fever, chills, sore throat)
– Heart murmur, heart failure
• Dx tests – Positive throat culture; ECHO;
increased strep antibody titer
• Tx
– Prevention is best treatment
– Bed rest and treat heart failure if present
– Penicillin or mycin drugs (Cleocin, EES) if
Penicillin allergy
Infective Endocarditis
• Infection of the
endocardium and
valves
• Etiology – staph,
strep, fungi
• Increased risk in
patients with valve
disorders and IV drug
abusers
• Clinical
manifestations –
malaise, intermittent
fever and chills,
night sweats, Roth
spots, splinter
hemorrhages in
nails, Janeway
lesions, Osler’s
nodes, murmur, HF,
stroke, pulmonary
embolus
• Dx – blood cultures, CBC,
transesophageal ECHO (TEE)
• Prevent in patients with valve disorders
with prophylactic antibiotics before and
after invasive procedures
• Tx - parenteral antibiotics for 6 wks
(penicillin, vancomycin, gentamycin,
ciprofloxacin)
Myocarditis
• Inflammation of myocardium results in
degeneration and dilation
• Thrombi form on endocardial lining (mural
thrombi)
• Etiology – viruses, parasites, bacteria,
toxins, radiation
• Clinical manifestations – asymptomatic or
fever, fatigue, tachycardia, palpitations,
dyspnea, symptoms of HF
• Dx – endomyocardial biopsy, ECHO, chest
x-ray, ECG, elevated cardiac enzymes
• Tx
– Tx underlying cause
– Bed rest
– Tx heart failure
– Anti-inflammatory or immunosuppressive
medications
Pericarditis
• Inflammation of the pericardial sac
• Fibrinous adhesions or exudate can form
in pericardial sac
• Etiology – viruses, bacteria, fungi,
myocardial injury, collagen diseases, drug
reaction, radiation, neoplasms
• Clinical manifestations – chest pain,
pericardial friction rub, fever, chills,
dyspnea
• Dx – ECG changes, elevated ESR and
possibly WBC, enzymes negative,ECHO
• Tx
– Tx cause
– NSAIDS, analgesics, steroids
Valvular Disorders
• Stenosis – valve does not open completely
• Regurgitation – valve does not close
properly
Mitral Valve Prolapse (MVP)
• Portion of a leaflet balloons backward
during systole
• Valve may not remain closed and
regurgitation can occur
• Clinical manifestations – fatigue, dyspnea,
chest pain, anxiety, dizziness, syncope,
palpitations (atrial or ventricular
dysrhythmias)
• Dx – ECHO with Doppler flow studies
• Tx
– Beta blockers
– Eliminate caffeine, alcohol, and smoking
– Antibiotics prophylactically before and after
invasive procedures
Mitral Regurgitation or Mitral
Insufficiency
• Leaflets do not close properly and blood
flows backward
• Pressure increases in left atrium and
blood backs up into lungs
• Etiology - MI, heart enlargement,
rheumatic endocarditis
• Clinical manifestations – asymptomatic
or symptoms of LVF, palpitations (atrial
fib or PVCs), systolic murmur
• Dx – ECHO with
Doppler flow , TEE,
cardiac cath
• Tx – tx LVF, mitral
valve replacement
(MVR) or
valvuloplasty
• Prophylactic
antibiotics for
invasive
procedures
Mitral Stenosis
• Leaflets are thickened and contracted
• Flow of blood from left atrium into left
ventricle is obstructed
• Left atrium dilates and hypertropies
• Blood backs up into lungs and eventually
the right side of heart
• Clinical manifestations – Diastolic murmur,
fatigue, dyspnea, hemoptyosis, cough,
crackles, atrial fib
• Dx – ECHO, cardiac cath
• Tx – tx LVF, valvuloplasty or MVR,
anticoagulation if atrial fib
Aortic Stenosis
• Narrowing of aortic valve orifice or
calcification of leaflets
• LV hypertrophies, dilates, and contractility
eventually decreases
• Blood backs up into lungs and right heart
• Clinical manifestations – angina, dizziness
or syncope, dysrhythmias, DOE, systolic
murmur, and possibly a thrill
• Dx – ECHO, TEE, cardiac cath
• Tx – Bed rest, aortic valve replacement
(AVR), valvuloplasty, prophylactic
antibiotics for invasive procedures
Aortic Regurgitation or Aortic
Insufficiency
• Backflow of blood into LV from aorta
during diastole
• LV hypertropies and dilates
• Competent mitral valve keeps blood from
backing up into LA and lungs for a long
time
• Clinical manifestations – sensations of forceful
heart beat especially in the head or neck, head
bobbing, marked visible carotid pulsations,
water-hammer pulse, widened pulse pressure,
diastolic murmur, fatigue, DOE, signs of heart
failure
• Dx – ECHO, TEE, cardiac cath
• Tx – AVR or valvuloplasty, prophylactic
antibiotics
Valvuloplasty
• Commisurotomy –
procedure to
separate fused
leaflets
• Annuloplasty – repair of the valve annulus
• Chordoplasty – repair of chordae tendineae
Valve Replacement
• Open heart procedure and requires heart
lung bypass
• Two types of valve prostheses
– Mechanical valves
• Ball-and-cage or disc design
• More durable
• Valves are susceptible to thromboemboli
– Tissue grafts
• Xenograft – porcine or bovine
• Homograft (allograft) - from cadavar
• Autograft (autologous) – use patient’s pulmonic
valve
Complications Related To Valve
Replacement
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Hemorrhage
Thromboembolism
Infection
Dysrhythmias
Hemolysis of RBCs
Heart failure
Educational Needs of Client
With Valve Replacement
• Wound care, diet, meds, activity
restrictions
• Long term anticoagulant therapy if
mechanical valve used
• Prophylactic antibiotic therapy if
mechanical valve used