Week 5: Complications From Heart Disease

Week 5: Complications From Heart Disease

Heart Failure

  • The heart muscle is unable to pump effectively, resulting in inadequate cardiac output, myocardial hypertrophy, and pulmonary/systemic congestion. The heart is unable to maintain adequate circulation to meet tissue needs.

  • HF is the result of an acute or chronic cardiopulmonary problem, such as

    • Systemic hypertension

    • MI

    • Pulmonary hypertension

    • Dysrthmias

    • Valvular heart disease

    • Peridcarditis

    • Cardiomyopathy

Heart Failure Classification

  • New York Heart Association functional classification scale

    • Class I: client has cardiac disease but exhibits manifestations with activity

    • Class II: client has manifestations with ordinary excretion (everyday ADLS)

    • Class III: client displays manifestations with minimal exertion

    • Class IV: client has manifestations at rest

  • American College of Cardiology and American Heart Association staging heart failure

    • A: high risk for developing heart failure

    • B: cardiac structural abnormalities or remodeling, but no manifestations of heart failure

    • C: current or prior manifestations of heart failure

    • D: refractory end-stage heart failure

Heart Failure Key Terms

  • HF: The heart’s inability to effectively fill and/ or pump blood

  • Stroke volume

    • Volume of blood pumped by the heart per contraction

  • Cardiac output

    • Volume of blood pumped by the heart per min

    • CO = SV x HR

  • Preload

    • Amount of blood in the LV before contraction

  • Afterload

    • Stress on the ventricular wall during systole (contraction)

  • Ejection fraction

    • % of blood leaving the heart during each contraction

  • Frank-Straling mechanism

    • Loading the ventricle with blood during diastole, stretching out the cardiac muscle, = increased SV during systole

Heart Failure with Reduced Ejection Fraction (HFrEF)

  • Systolic HF: “pump dysfunction.”

  • Causes

    • Decreased force of contraction (MI)

    • Decreased supply of the heart (CAD)

    • Afterload (HTN)

    • Impaired mechanical function valve disease)

  • Normal preload, decreased force of contraction leading to inadequate emptying of ventricles during systole (contraction), causing decreased EF

Heart Failure with Preserved Ejection Fraction (HFpEF)

  • Diastolic HF: “filling dysfunction.n”

  • Causes

    • Restrictive cardiomyopathy (amyloidosis)

    • Valve disease

    • HTN

  • Ventricles are noncompliant and unable to fill during diastole (rest), leading to increased filling pressure, decreased preload, and normal force of contraction, causing decreased SV and preserved EF.

Heart Failure Risk Factors

  • HTN

  • DM or metabolic syndrome

  • Obesity

  • Smoking

  • CHD

  • Chronic tachyarrhythmias

  • Anemia

  • Increasing age

  • CAD

  • Stroke

  • PVD

  • Valvular heart disease

Heart Failure Complications

  • Cardiogenic shock

  • Biventricular heart failure

  • Arrhythmias

  • Liver damage

  • End organ damage

  • Exacerbation of HF

MNEMONIC: FAILURE

  • Forgot medication

  • Arrhythmia/anemia

  • Ischemia/infarction/infection

  • Lifestyle

  • Upregulation of CO (pregnancy)

  • Renal failure

  • Embolism (pulmonary)

Heart Failure Management

  • Perload agents

    • Loop diuretics

    • Thiazide

    • Potassium-sparing

  • Afterload-reducing agents

    • ACE or ARB

    • CCB

    • Phosphonsiesterase-3 inhibitors

  • Surgery

    • Heart transplant

  • Lifestyle modification

  • Ventricular assist device (VAD)

  • Implanted defibrillator

  • Diventricular pacemaker for resynchronization

Acute Decompensation

Mnemonic: POND

  • Position (upright) +/- positive pressure ventilation

  • Oxygen

  • Nitrates

  • Diuretics

Heart Failure Nursing Management

  • Assess:

    • Observing the effectiveness of therapy

    • Patients' ability to understand and implement self-management strategies

    • s/s of pu,monary and systemic fluid overload

    • I & O

    • Emotional response to the diagnosis of HF

    • Coping skills

  • Health history

    • Fatigue

    • SOB

    • Dyspnea on exertion

    • Cough

    • Sleep distrubancer, PND: number of pillows needed for sleep

    • Edema

    • Abdominal symptoms

    • AMS

    • ADLS

    • Daily weights

    • Activities that cause fatigue

Pulmonary Edema

  • The accumulation of excessive fluid in the alveolar walls and alveolar spaces of the lungs

  • Cardiogenic form of pulmonary edema is caused by disturbances in the Starling forces.

  • The pulmonary capillary pressure increases.d

  • The alveoli are normally kept dry because of the negative pressure in extra-alveolar interstitial spaces, but when there is:

    • Increased pressure/pooling → increased pulmonary venous pressure → increased pulmonary capillary pressure → fluid in interstitial spaces → increased pressure in interstitial spaces → fluid in alveoli (pulmonary edema)

S/S Pulmonary Edema

  • Trouble breathing or SOB

  • Feeling of anxiety related to breathing difficulties

  • Wheezing or noisy breathing

  • Quick, shallow breathing

  • Trouble breathing while lying down

  • Confusion

  • Discomfort related to breathing

  • A feeling of suffocation

  • Coughed-up sputum that appears frothy and pinkish, if blood is present

  • Pale of bluish skin

  • Sweating or feeling clammy

  • Swelling in the feet or ankles

Management of Pulmonary Edema

  • Supplemental oxygen

  • Medications:

    • Diuretics ( to rid the body of excess fluid)

    • Nitroglycerin ( to help lower pressure within the heart)

    • inotropes ( to help the heart pump more efficiently)

    • ACE inhibitors ( to manage blood pressure levels)

  • Morphone can help reduce anxiety and improve breathing

  • Continuous positive airway pressure (CPAP)

  • Ventilators, when other methods are unsuccessful

  • Renal replacement therapy, when pulmonary edema causes kidney failure

Cardiogenic Shock

  • A life-threatening emergency where the heart suddenly cannot pump enough blood to meet the body’s needs, often caused by a MI.

  • Critical hypotension → organ failure

Cardiogenic Shock Pathophysiology

  • Obstruction reduces blood flow into or out of the heart

    • SV decreases

      • CO decreases

  • Organ and tissue hypoperfusion

  • To compensate, the body releases vasoconstrictors

  • When compensatory mechanisms fail

    • Severe tissue hypoxia

    • Multiple organ failure

    • Blood backs up into the pulmonary and systemic circulation

  • Complication

    • Pulmonary edema

    • Peripheral edema

Cardiogenic Shock Causes /Risk Factors

  • Any condition that prevents the heart from pumping sufficient blood:

    • MI

    • Myocardial contusion

    • Myocarditis

    • HF

    • Arrhthmias

    • Valve insufficiency

  • Risk factors

    • Existing heart condition

    • Chronic hypertension

    • Coronary heart disease

    • Diabets

    • Medications

    • Electrolyte imbalances

    • Asian Americans and pacific islanders

Cardiogenic Shock S/S

  • Initial stage

    • Tachycardia

    • Decreased mean arterial pressure (MAP)

    • Blood pressure normal

  • Compensation stage

    • Decreased MAP

    • Skin is cold and clammy

    • Pallor

    • Hypotension

    • Tachycardia

    • Decreased peripheral pulses

    • Oligiura

    • Jugular venous distension

    • Pulmonary edema

    • Peripheral edema

  • Progressive stage

    • Decreased MAP sustained

    • Anxeity

    • Altered LOC

    • Cyanosis

    • Tachypena

    • Low oxygen saturation

    • Hypotension

    • Bradycardia

    • Arrhythmias

  • Refractory stage

    • Decreased MAP sustained

    • Multiple organ dysfunction

    • Sudden loss of consciousness

    • Shallow respirations

    • Unmeasurable oxygen saturation

    • Non-palpable pulses

    • Death

Cardiogenic Shock Management

  • Address the underlying cause

  • Inotropic medications

  • Mechanical support device

  • Goal of care

    • Maintain CO

    • Monitor for complications

    • Monitor for improved hemodynamic stability

  • Assess vital signs, LOC, pulses, heart and lung sounds, and pain

    • Report to HCP immediately

      • Chest pain

      • Hypotension

      • S3 heart sounds

      • Pulsus paradoxus (exaggerated drop in systolic blood pressure during inspiration)

  • Continuous cardiac monitoring

  • Administer IV fluids, review ABG results

    • Notify HCP immediately

      • Tachycardia

      • Tachypnea

      • Confusion

      • Headache

  • Insert an indwelling catheter

  • Measure intake and output

  • Check for decreased cerebral perfusion pressure

  • Notify HCP immediately

    • Minimal urine output

    • Altered LOC

    • Cool or clammy skin decreased peripheral pulses

  • Monitor central venous pressure and MAP

Cardiogenic Shock Patient/ Family Teaching

  • Explain the condition, plan of care, and how to safely self-administer medications.

  • Promote heart health

    • Smoking cessation

    • A healthy diet

  • Provide transitional resources

  • Instruct how to recognize signs of shock

Pericardial Effusion and Cardiac Tamponade

  • Pericardial effusion = fluid accumulation in the pericardial sac

  • Cardiac tamponade = a life-threatening emergency where fluid or blood rapidly accumulates in the pericardial sac, compressing the heart and preventing proper filling

Cardiac Tamponade S/S

  • Beck’s Triad (classic findings)

    • Hypotension

    • Jugular vein distension: a bulging neck vein due to high pressure

    • Muffle Heart Sounds: Heart during auscultation

  • Respiratory and Cardiovascular Distress

    • Dyspnea, tachycardia

    • Chest pain improved by sitting up or leaning forward

    • Chest pain is often sharp, radiating to the neck, shoulders, back, or abdomen

    • Tachycardia

    • Pulsus paradox (decreased systolic BP > 10 mm Hg with inspiration)

Cardiac Tamponade Medical and Nursing Management

  • Puncture of the sac to aspirate pericardial fluid (pericardiocentesis)

  • During procedure

    • Vital signs

    • Hemodynamic pressures

    • Emergency resuscitation equipment should be readily available

    • HOB elevated 45 to 60 degrees

    • Peripheral IV line

  • Complications of pericardioventesis

    • Ventricular or coronary artery puncture

    • Arrhythmias

    • Gastric puncture

    • Myocardial trauma

  • Aftercare

    • Monitor: HR, BP, venous pressure, heart sounds

  • Pericardiotomy can also be done for recurring cardiac tamponade to allow fluid to drain off (pericardial window)

Cardiac Arrest

Normal Cardiac Physiology

  • Myocardial cells

    • Create and transport electrical potential (action potential)

    • Automaticity

    • Excitability

    • Conductivity

    • Contractility

  • Electrical conduction

    • Impulses begin in the SA node

    • Conducts through the atrium (P wave)

    • Through the atrioventricular (AV) node, propagation slows: PR interval

    • Bundle of his

    • Right and left branches

    • Purfinjine fibers

    • Right and left ventricles contract: QRS complex

    • Ventricles depolarize; T wave

    • Late ventricular depolarization: U wave

Cardiac Arrest Risk Factors

  • CAD- a build-up of plaque in your arteries may cause them to narrow, obstructing blood flow to the heart

  • CHD-

  • Structural heart changes

  • Family history

  • Biological female/ children

Cardiac Arrest Causes

  • Primary

    • Problem with the cardiac conduction system

  • Secondary

    • A condition unrelated to the conduction system impairs the heart's ability to fire and conduct impulses

    • 5 HS and 5 TS

Cardiac Arrest Pathophysiology

  • Cessation of electrical activity

  • Ventricles are unable to depolarize and contract

  • Blood isn’t pumped to the body

  • Body tissues deprived of oxygen and nutrients

  • Complications

    • Brain damage

    • Death

Cardiac Arrest S/S and treatment

  • s/s

    • Sudden collapse

    • Loss of consciousness

    • Unresponsive

    • Apnea

    • Pulseless

    • No recordable blood pressure (BP)

  • Treatment

    • CPR

    • Iv epinephrine

    • H’s & T’s management

Cardiac Arrest Care

  • Goal of care

    • Restore perfusing rhythm

  • Call for assistance

  • Begin CPR

  • Admnister 100% oxygen and epinephrine

  • Assess for signs of return of spontaneous circulation (ROSC)

  • Provide post-cardiac arrest care

  • Coordinate transfer to the intensive care unit