Chapter 26.

Management of Patients With Complications From Heart Disease

Heart Failure #1

• Definition and Overview

  • Heart failure (HF) is a clinical syndrome resulting from structural or functional cardiac disorders.

  • The heart is unable to pump enough blood to meet the body's metabolic demands.

• Types of Heart Failure

  • Systolic dysfunction: Impaired contraction of the heart.

    • Decreased blood ejected from the left ventricle

    • Baroreceptors since decreased blood flow, stimulating the SNS

      • Diastolic dysfunction: Impaired filling of the heart.

Clinical Manifestations of Heart Failure #1

• Cardinal Manifestations of HF:

  • Dyspnea: Difficulty in breathing, particularly during exertion or at rest.

  • Fatigue: Reduced exercise tolerance due to inadequate cardiac output.

  • Fluid retention: Congestion leading to pulmonary and dependent edema.

• Left-Sided Heart Failure:

  • Symptoms include pulmonary congestion due to inability to pump blood efficiently into systemic circulation:

  • Dyspnea

  • Cough

  • Pulmonary crackles

  • Low oxygen saturation levels

  • Orthopnea: Discomfort while lying flat.

  • Paroxysmal nocturnal dyspnea: Sudden shortness of breath at night.

• Right-Sided Heart Failure:

  • Symptoms include peripheral congestion due to inability to pump blood to the lungs:

  • Jugular venous distention

  • Dependent edema

  • Hepatomegaly: Enlargement of the liver.

  • Ascites: Fluid accumulation in the abdominal cavity.

  • Weight gain due to fluid retention.

Assessment and Diagnostic Findings #1

• Diagnostic Testing:

  • Echocardiogram: Evaluates ejection fraction (EF) and detects structural abnormalities.

  • Chest X-ray: Checks for heart size alterations and pulmonary congestion.

  • 12-lead ECG: Assess electrical activity and arrhythmias.

  • Laboratory Studies: Examines serum electrolytes, BUN, creatinine, liver function tests, thyroid-stimulating hormone, complete blood count (CBC), BNP, urinalysis.

Medical Management of Heart Failure

• Guideline Directed Medical Therapy (GDMT):

  • Evidence-based protocols tailored by stage and type of heart failure (clinic-s).

• Management Goals:

  • Improvement of cardiac function through optimal pharmacological management.

  • Reduction of symptoms and enhancement of functional status.

  • Stabilization of patient condition and decreased hospitalization risk.

  • Delaying heart failure progression and extending life expectancy.

  • Promotion of a lifestyle conducive to cardiac health.

• Treatment Options:

  • Incorporates oral and IV medications, lifestyle modifications, supplemental oxygen, surgical interventions, cardiac devices, and transplantations.

Pharmacologic Therapy for Heart Failure #1

• Sodium–Glucose Cotransporter 2 (SGLT2) Inhibitors:

  • Reduce preload and afterload, improving myocardial metabolism.

  • Examples: Dapagliflozin (Farxiga), Empagliflozin.

• Diuretics:

  • Aid in removing excess extracellular fluid and alleviating heart failure symptoms.

  • Types:

  • MRAs (Mineralocorticoid Receptor Antagonists): E.g., Spironolactone.

  • Loop Diuretics: E.g., Furosemide.

  • Thiazide Diuretics: E.g., Metolazone.

• Renin–Angiotensin System Blockers:

  • Various types include ARNIs (e.g., Sacubitril–Valsartan), ACE inhibitors (e.g., Lisinopril), ARBs (e.g., Valsartan).

• Beta-Blockers:

  • Target sympathetic nervous system effects, enhancing functional status and reducing mortality.

  • Examples: Carvedilol, Metoprolol.

Pharmacologic Therapy for Heart Failure #2

• Select Medications Used to Treat Heart Failure:

  • SGLT2 Inhibitors:

  • Therapeutic effects include decreasing preload and afterload while improving myocardial metabolism.

  • Key nursing considerations: Monitor for kidney dysfunction and blood pressure changes; may cause urinary and genital infections.

  • Diuretics:

  • Types include loop diuretics (e.g., Furosemide), and should monitor for signs and symptoms of heart failure.

  • Key nursing considerations: Watch for increases in serum K+, decreases in serum Na+, and renal function indicators.

  • Renin-Angiotensin System Blockers:

  • Therapeutic effects include reducing blood pressure and fluid volume overload.

  • Key nursing observations: Monitor for hypotension, hyperkalemia, and signs of HF.

  • Beta-Adrenergic Blocking Agents:

  • Promote blood vessel dilation and improve exercise capacity.

  • Nursing considerations include observing heart rate, blood pressure, dizziness, and fatigue.

Nursing Assessment for Heart Failure

• Focus of Nursing Assessment: Evaluating therapy effectiveness and patient's capacity for self-care management.

• Health History:

  • Inquire about signs and symptoms of HF, including dyspnea, fatigue, edema, and sleep disturbances.

  • Assess patient's understanding of HF and self-care strategies.

• Physical Examination:

  • Assess patient for restlessness, anxiety levels, and consciousness.

  • Auscultate lung sounds, evaluate blood pressure, and assess heart sounds.

  • Observe for jugular venous distention (JVD), skin color, edema, and abdominal tenderness.

  • Monitor urinary output and maintain daily weight records.

• Potential Complications:

  • Cardiogenic shock, pulmonary edema, arrhythmias, thrombosis, pericardial effusion.

Question #1

• Which of the following statements best describes heart failure (HF)?

  • A. HF is a condition where the heart pumps blood efficiently to meet the body's demands.

  • B. HF is a clinical syndrome resulting from structural or functional cardiac disorders.

  • C. HF is a temporary condition that does not require long-term management.

  • D. HF is primarily caused by infections in the heart.

  • E. HF only affects individuals younger than 65 years.

Nursing Interventions for Heart Failure

• Promoting Activity Tolerance:

  • Encourage daily physical activity, avoid prolonged inactivity, and alternate activity/rest periods.

  • Monitor patient's response to various activities.

• Managing Fluid Volume:

  • Keep track of fluid intake, daily weights, and adherence to low-sodium diets.

  • Positioning patients to ease breathing and mitigate venous return.

• Controlling Anxiety:

  • Provide support and comfort, enhance psychological well-being, and educate families on anxiety-reduction techniques.

• Minimizing Powerlessness:

  • Foster patient involvement in decision-making concerning treatment.

  • Screen for signs of depression and provide appropriate support.

• Assisting Patients and Families:

  • Develop an education and discharge plan to support adherence to dietary and pharmacological treatments.

Monitoring and Managing Potential Complications

• Pulmonary Edema:

  • Detect early signs and implement actions to reduce preload.

  • Management should include oxygen support, IV medications, and ongoing nursing assessment.

• Transitioning Care:

  • Ensure effective transfer to community settings, educate patients and families on health management.

• End-of-Life Considerations:

  • Discuss preferences, establish advance directives and evaluate options for palliative/hospice care when necessary.