Perfusion alterations

What is heart failure

inability of the heart to pump enough blood to meet body’s needs

• HF leads to stretched and diated left ventricle and thin muscle wall

  • reduce ability of heart to contract

Aldosterone effect in heart failure

sodium and water retention → increase preload; ventricular remodeling

Trying to compensate for heart failure

Effect in heart failure

• increases blood volume → increases preload → can lead to fluid overload and edema

Preload

the amount of blood returning to the heart (venous return) that stretches the ventricles before contraction

ventricles stretch before contraction

Afterload

the resistance the ventricles must overcome to pump blood out into circulation

• reistance

• increase afterload = increased workload on the heart

Preload saying

preload=volume

V for venous return, volume, ventricular stretch

Afterload saying

afterload= arteries

A for arteries, after, against pressure

Preload in heart failure

increased due to fluid overload

increased due to impaired ventricular function

leads to higher blood volumes in the ventricles

contributes to symptoms like edema

Afterload in heart failure

can be increased by hypertension or vasoconstriction

higher afterload means the heart must work harder to pump blood

can lead to decreased cardiac output

increases strain on the heart and worsens heart failure, making it harder for the heart to meet the body’s demands

Decreased preload vital signs

d/t diuretics, dehydration, blood loss

decreased BP

increased HR

cool, clammy skin

dizziness/syncope

Increased preload vital signs

increased BP initally

increased HR

Increase RR

decreased O2 sat

risk: pulmonary edema

Increased afterload vital signs

increased BP, HR

decreased CO and O2 sat

poor perfusion

• cap refills, cyanosis

SOB, body trying to catch up

decreased afterload

decreased BP

increased HR, and perfusion

warm, flushed skin

Cardiomyopathy

heart muscle is abnormal (thick, stiff, or stretched) which makes it harder for the heart to pump blood effectively

Big weak pump

• inefficentaly pumping blood to rest of body

Dialated cardiomyopath

most common type d/t

• CAD and MI: most direct cause due to ischemic injury of the heart muscle'

  • causes dilation then heart failure

2 types of heart failure

left sided HF
right sided HF

big two diagnostic for HF

BNP

• brain naturaetic peptide

  • released in response to increased stress and injury

Echocardiogram

Heart failure in older adults causes

age-related changes

reduced physiologic reserve

comorbidities

lifestyle

medications: NSAIDS are a NO

• causes fluid and sodium retention

• educate on non- NSAIDS

Left sided HF causes

hypertension

Coronary artery disease CAD

valvular disease

decreased cardiac output → decreased tissue perfusion

• less blood pumping per liter per second

Clinical manifesations of left sided HF

Mostly respiratory

• dyspnea

• cough

• wheezing

• crackles

• pulmonary edema

• rapid weight gain

• orthopnea

Labs for Left sided HF

Primary:

• BNP>100

  • over 100= heart failure

• NT-pro BNP

• Troponin I

• troponin T

• Hs-cTn

Secondary: ruling out any other issues and help formulate a decision

• UA

• LFTS

• CBC

• CMP

• Cr and BUN

Treatment of Left sided HF

daily weight

monitor

meds

oxygen therapies

pt education

Right sided HF causes

chronic left sided heart failure

chronic fluid overload

valvular disease

chronic lung disease

virus

cardiomypoathy

Chronic left heart failure→ increased workload on right ventricle → insufficient pump

Right sided HF Clinical manifestations

peripheral edema

ascites: fluid backup

JVD

hepatomegaly

splenomegaly

anorexia: always feeling full bc of fluid overload

GI distress

rapid weight gain

Right sided HF labs

Primary

• BNP >100

• NT-pro BNP

• Troponin I

• troponin T

• Hs-cTn

Secondary

• Thyroid function test

  • ABGS

Treatment of Right sided HF

monitor

meds

oxygen therapy

pt education

daily weight

Diuretic treatment for HF

diuretics deplete fluid

Decrease issues pt is having from HF

ex: edema, dsypnea

Assess electrolyte levels specifically K+ before giving diuretics→ if low don’t give

common meds:

• loop diuretic: furosemide

• thiazide diuretic: hydrochlorathiazide

• Pottassium sparing diuretic: aldactone

Pt response to diuretics used for HF

decreased dyspnea

decreased edema

improved exercise tolerance

first line medication for volume overload

Beta blocker treatment for HF

decrease workload on heart

decrease HR first then BP

Carvediol

metopropol

Always asses HR and BP

never give when HR is to low

pt response to beta blocker treatment for HF

decreased HR promotes filling during diastole

enhances LV function

reduce further fluid overload

reduced mortailty

ACEi treatment for HF

vasodilator

direct impact on BP

goal: decrease preload and after load

enalapril

captopril

lisinoprili

Pt response to ACEi treatment for HF

decreased

• BP

• fluid retention

• preload and afterload

improved exercise tolerance

ARB’s treatment for HF

help prevent cardiac remodeling

slow process of remodeling the ventricle

losartan

valsartan

pt response;

• decreased

  • after load

  • dyspnea

• preventing cardiac remodeling

Antiplatelets and anticoagulants

if pt has arrythmia they prevent clots

• decrease risk of stroke

Assess: platelet count, I & R, ptt, patient for bleeding gums, bruising

antiplatelets

• prevents platelet aggregation

• ex: aspirin, clopidogrel

anticoagulants

• prevent formation of new blood clots

• ex: unfractionated heparin

bleeding precautions

apply pressure to site of any needle puncture for longer time than normal

avoid IM injections

avoid tissue injury and bruising from trauma or use of constrictive devices

Patient education with heart failure

low NA diet

stay active

stay compliant with medication

Daily weight vs edema

a sudden gain of 2 to 3 lbs in a day or 5 lbs in a week often indicates fluid retenion before edema is noticiable

Infective endocarditis

infection of the endocardial (innermost) layer of the heart including heart valves

subacute form

• gradual onset

• low grade fever

• malaise

• lethargy

Acute form

• rapid onset

• high fever and chills

Causes of infective endocarditis

bacteria

• staph

• strep

• entreococci

virus

fungi

surgical/dental procedures

injections

Risk factors for infective endocarditis

pre-exisiting heart disease

prosthetic valves

central venous access devices and long-term indwelling catheters

IV drug use

Pathway for infective endocarditits

pathogens enter bloodstream

microbes grow and multiple at endocardial abnormality or injury

inflammation and infection cause endothelial damage

vegetations develop

Clinical manifesations of infective endocarditis

anorexia

myalgias

fever and chills

weight loss

back and joint pain

night sweats

heart murmur

Emolization of infective endocarditis

osler nodes:pimple, painful, dark red

janeway lesions: spotted rash, dark purple and red

roth spots

Diagnostic studies for infective endocarditis

blood cultures

CBC w diff

ESR

CRP

Echocardiogram
ECG: monitor arrythmias

Nursing management of infective endocarditis

antibiotic treatments or long term IV antibiotics

valve replacement surgery

prevent complications of long term IV therapy

assess for new or worsening heart murmurs

monitor labs and blood culutes

assess for joint tenderness

monitor for hemodynamic or emobolic compliations

pt education

• uncover cause and how they can change their lifestyle

Pericarditis

inflammation of the membranous sac surrounding the heart (pericardium)

functions of the pericardium

• holds heart in place

• prevents heart from over-expanding if blood volume increases

• protects heart from infection and malignancy

Common causes of pericarditis

bacteria

viral

fungal

strept

staph

invasive cardiac procedure

types of pericarditis

acute

recurrent

chronic

• effusive

• constrictive

Clinical manifestations of pericarditis

hallmark finding : pericardial friction rub

• creeky and loud at end of exhalation

Chest pain

• progressive, severe, sharp

• worse with deep inspiration, cough, lying down adn turning

• improves with forward -leaning or sitting to decrease pressure

• may radiate to neck arms or left shoulder

major complications of pericarditis

cardiac tamponade

pericardial effustion

diagnostic studies

• echocardiogram

Nursing management for pericarditis

provide symptom relief and detect signs and symptoms of pleural effusion and cardiac tamponade

treat underlying cause

first line treatmetn

• asprin

• NSAIDS

• cochicine

  • prevent reoccurance and acute pericarditis

Pericardial effusion

accumulation of fluid around the pericardial sac

increased pericardial fluid raises the pressure within the pericardial sac and compresses the heart

decreases cardiac output

can result in cardiac tamponade

treatment → drain fluid

Cardiac tamponade

compression of the heart

Manifestation

• Becks' triad

  • distant heart sounds

  • distended jugular veins

  • decreased arterial blood pressure

• pulsus paradoxus: systolic BP being lower during inhalation compared to exhalation

Becks triad

Hypotension + JVD + muffled heart sounds

treatmetn: emergency pericardicentesis