Care of Adult With Altered Cardiac Function

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Care of Adult With Altered Cardiac Function

• Presented by Jayson T. Valerio RN. MSN
• Esmeralda Garza RN, MSN

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The Heart
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Concepts of Optimal Cardiac Function
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Assessment of the Cardiovascular System (CVS)

• Subjective
• Demographic data
• Personal and Family History
• Diet history
• Socioeconomic status
• Modifiable risk factors
• Current health problems
• Objective
• General Appearance
• Integumentary System
• Blood Pressure
• Venous Arterial Pulsations
• Precordium

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How to assess jugular vein pressure?
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External Jugular Vein Distention
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Question

• The nurse is performing a cardiac assessment,
  identify where the nurse places the stethoscope
  to best auscultate the point of maximal impulse..

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Diagnostic Assessment

• Nurses responsibilities
• -identification of allergies and client safety
• -explanation of procedure including purpose
• -consent obtained, if needed.
• -administration of pre-procedure medication
• -administer comfort measures.
• -explain results after physician has discussed
  with client.
• -positioning of patient-keeping NPO
• -ensure test is scheduled

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Diagnostic Tests

• Blood Coagulation Tests
• - Prothrombin and international normalized ratio
  (PT and INR)
• - Partial Thromboplastin Time (PTT)
• Arterial Blood Gases
• Serum electrolytes
• Complete Blood Count

• Laboratory Tests
• Serum markers of myocardial damage
• Creatinine kinase
• Troponin
• Lactate dehydrogenase
• Serum lipids
• Homocysteine
• C-reactive protein
• BNP

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Critical Thinking Challenge

• A middle aged man with multiple cv risk factors
  comes to the ER with c/o dull aching feeling in
  his shoulder and arm. His admission lab results
  include creatinine kinase 190 units/l troponin
  greater than 2.0ng/ml,, and c reactive protein of
  1.0mg/dl.
• 1. What additional assessment should you perform
  for this client?
• 2. What is the significance of each of this test
  results.

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Diagnostic Tests

• Radiographic Exams
• Chest X-ray
• Cardiac Fluoroscopy
• Angiography
• Cardiac Catheterization

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Critical thinking challenge

• A nurse is taking a health history for a client
  about to have a cardiac catheterization. Which of
  the following findings must the physician know
  about immediately?
• A. smoking 1 pack of cigarettes per day
• B. digoxin .25mg held today
• C. client ate a liquid breakfast
• D. presence of seafood allergy

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Critical thinking challenge

• Immediately following a femoral artery approach
  for cardiac catheterization, it would be most
  important to include which of these measures in
  the clients care?
• A. Auscultating lungs and cardiac sounds
• B. Observing insertion site for infection
• C. Elevating the head of bed to 60-90 degrees.
• D. Maintaing strict bedrest for 4-6 hour and
  palpating distal pulses.

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Other Diagnostic Tests
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Other Diagnostic Tests

• Electrophysiologic Studies
• Exercise Electrocardiography (Stress test)
• Echocardiography

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Coronary Artery Disease

• Coronary arteries become narrow or even blocked
  secondary to plaque deposits.
• These are the arteries that deliver oxygen
  enriched blood to the heart muscle (myocardium)
• If there is a complete block (occlusion) then a
  heart attack (myocardial infarction) occurs.

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How prevalent is Coronary Artery Disease?

• Most common form of Heart Disease
• Number 1 cause of death in both men and women in
  the United States
• CAD caused more than 1 out of every five deaths
  in the US in 2001
• About every 26 seconds an American suffers a
  coronary event and every minute there is a death

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Prevalence .continuation

• About 340,000 deaths occur within the ER or
  before the person reaches the hospital.
• 64 of females and 50 of males who died
  suddenlyhad NO previous symptoms of disease.
• 38 of females and 25 of males will die within
  one year after an initial recognized MI.

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Hospital Readmissions and Costs

• The estimated cost in 2004 of CVD is 368.4
  billion dollars.
• In 1999 an avg. of 7,883 per discharge was paid
  out by Medicare alone ( about 26 billion)
• When the client is readmitted it is expensive,
  very stressful, and significantly diminishes
  their quality of life

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• In order to reduce readmission rates, a
  comprehensive d/c plan must be implemented and
  must include patient teaching.
• They may have had their treatment, but there is
  still a risk of CAD progression
• Lifestyle changes are needed to protect the
  patient and avoid unnecessary readmissions

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The Nurse as Key Educator

• Research has shown repeatedly that education
  contributes to prevention, early detection, and
  eventual recovery
• Patient teaching cornerstone of standards of care
• NLN officially established teaching as an
  independent function for each nurse
• Education regarding lifestyle changes are
  associated with decreased mortality and
  retardation of atherosclerosis

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Pathophysiology

• Fatty streaks-earliest lesion lipid filled smooth
  muscle cells. Yellow tinge appears.
• Raised fibrous plaque resulting from smooth
  muscle cell proliferation
• Complicated lesion-is most dangerous plaque
  consists of core of lipid materials (mainly
  cholesterol) with an area of dead tissue.
  Partially or totally occlude an artery.
• Plaque may rupture Collateral circulation
  develops.

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Risk Factors

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Benefits of Smoke Cessation

• 20 minutes- after quitting the BP and pulse
  decrease and body temp of feet and hands
  increase.
• At 6 hours- the Carbon Monoxide and Oxygen levels
  return to normal.
• At 24 hours- the chances of heart attack
  decreases.
• Within 3 months- circulation improves, walking is
  easier and lung function improves.
• At 1 year- the ex-smokers risk of CHD is
  decreased to ½ that of a smoker.
• By 15 years- the risk of CAD is then similar to
  that of a person who has never smoked.

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Clinical Manifestations

• Symptoms typically associated with CAD include
  chest pain (angina) and shortness of breath,
  especially after stress or exercise. Women with
  CAD may experience breast pain or a feeling of
  indigestion in the upper abdomen.

• However, about 25 to 30 percent of patients have
  no symptoms, despite the presence of CAD. They
  may have silent ischemia, or be unaware of
  potentially dangerous abnormal heart rhythms
  (arrhythmias). The absence of chest pain or other
  common symptoms can also set the stage for a
  heart attack that occurs without warning.

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• Stable Angina
• Exercise induced.
• Take med and wait 30min to 1 hr before engaging
  in activity.

• Unstable Angina
• Unpredictable, can occur at rest
• ASA, anticoagulants, nitrates and beta blockers
  first line of treatment.
• If spasm is cause, calcium channel blockers are
  ordered.

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Therapeutic Management
Angioplasty
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Therapeutic Management
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• Antiplatelet aggregation
• -ASA, Persantine(dipyridamole)
• Nitrates(vasodilate) first line therapy
• -nitroglycerin
• Beta-Adrenergic blocking agents
• -lopressor, inderal (Generics ending in olol)
• Calcium Channel blocking agents
• -nifedipine, Cardizem, verapamil

• ASA-inhibits platelet aggregation
• Nitrates-decrease SVR,venous pooling and decrease
  venous return to the heart and dilate coronary
  arteries.
• Beta adrenergic blockers-decrease myocardial
  contractility,HR, SVR and BP which decrease
  myocardial O2 demand.
• Calcium channel blockers
• 1. Systemic vasodilation-decrease SVR
• 2. Decrease myocardial contractility
• 3. Coronary vasodilation.

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Interactions

• A 50 year old diabetic client is hospitalized
  with a diagnosis of CAD. In monitoring the blood
  sugar the nurse attains a reading of 30mg per
  100cc, yet the client is asymptomatic. Which of
  the following drugs used to treat the clients
  CAD would affect the blood glucose level results?
• 1. digoxin
• 2. nadolol
• 3. furosemide
• 4. isosobide

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Nursing Management

• Nursing Dxes
• Pain
• Anxiety
• Decreased CO
• Activity intolerance

• Acute Intervention (ER Setting)
• - Assess pain, ECG, Cardiac enzymes
• T
• M
• O
• N
• A

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Heart Failure

• Heart failure (sometimes known as congestive
  heart failure CHF) is a serious condition in
  which the heart is not pumping well enough. In
  late stages, the heart is unable to meet the
  bodys demand for oxygen. Heart failure is so
  named because the heart is failing to pump
  efficiently, which often results in congestion in
  the lungs. As a result, the heart tries to work
  harder, which only makes the problem worse.

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Case Study

• Bea Singer age 67 awakens with a start from a
  sound sleep gasping. She sits up, trying to catch
  her breath, and shakes her husband, Fix my
  pillows.. Just as he has every night he fetches
  three pillows and arranges them behind her back
  to prop her up. This time it does not help.

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Epidemiology.. as of February 2004

• According to current statistics from the American
  Heart Association, there are about five million
  heart failure patients in the United States, and
  550,000 new cases of heart failure diagnosed in
  the United States every year. This includes 10
  out every 1,000 people over the age of 65. Of
  newly diagnosed patients under the age of 65, 80
  percent of the men and 70 percent of the women
  will die within 8 years. In people diagnosed with
  heart failure, sudden cardiac death occurs at six
  to nine times the rate of the general
  population.

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Risk Factors

• Conditions that could lead to heart failure
  include the following
• Coronary artery disease
• High blood pressure (hypertension)
• Heart attack
• Diabetes mellitus
• Cardiomyopathy
• Heart valve disease (e.g., valvular stenosis or
  valvular regurgitation)
• Infection in the heart valves (valvular
  endocarditis) or of the heart muscle
  (myocarditis)
• Congenital heart disease (cardiac conditions
  present since birth)
• Severe lung disease (e.g., pulmonary
  hypertension) or obstructive sleep apnea
• Pericardial disease (pericarditis)

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Types of Heart Failure

• Left-sided heart failure occurs when the left
  ventricle cannot adequately pump oxygen-rich
  blood from the heart to the rest of the body. The
  main symptoms for this condition include
  shortness of breath, fatigue and coughing,
  especially at night or while lying down. There
  may also be lung congestion (with both blood and
  fluid).

• Right-sided heart failure (cor pulmonale) takes
  place when the right ventricle is not pumping
  adequately, which tends to cause fluid build-up
  in the veins and swelling (edema) in the legs and
  ankles. Right-sided heart failure usually occurs
  as a direct result of left-sided heart failure.
  It can also be caused by severe lung disease
  (e.g., chronic obstructive pulmonary disease,
  pulmonary hypertension) in which the right side
  of the heart cannot generate enough force to pump
  blood through a diseased pair of lungs.

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Clinical Manifestations

• Left sided failure-excessive preload lungs
• Cheyne-stokes respirations, increases HR, poor
  oxygen exchange
• Pulmonary edema, S3 S4
• Dyspnea,dry hacking cough, nocturia
• Low PAO2 , increased PCO2
• Orthopnea, Paroxysmal nocturnal dyspnea
• Crackles , wheezing, frothy pink-tinged sputum
• Elevated B/P
• Fatigue

• Right-sided failure-excessive preload on right
  side of heart
• RV heaves
• Murmurs
• Peripheral edema
• Weight gain
• Edema dependent body parts
• Ascites
• Anasarca
• JVD
• Liver engorgement
• Right pleural effusion
• Fatigue, nausea, anorexia, bloating

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Left-sided Heart Failure

• Systolic ventricular dysfunction- occurs when the
  heart muscle is too weak to contract fully. A
  reduced volume leaves the ventricle.
• Diastolic dysfunction- occurs when the left
  ventricle has increased diastolic stiffness and
  cant adequately fill at normal diastolic
  pressures.

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Diagnostic Testing

• Transthoracic Echocardiogram
• Doppler flow studies
• 12-lead EKG
• MRI
• CXR

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Therapeutic Management

• ACUTE WITH PULMONARY EDEMA
• High Fowlers position
• O2 with mask or nasal cannula
• Morphine IV
• Diuretics IV(Lasix, Bumex)
• Nitroglycerin,nitroprusside
• Dopamine, dobutrex
• V/S q1 hr
• Daily weights
• Endotracheal intubation/mechanical ventilation

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Therapeutic Management Chronic CHF

• O2 2-6l/min
• Rest
• Digitalis preparations
• Diuretics
• Vasodilators-Ace inhibitors, Nitrates,nesiritide(n
  atrecor)
• Inotropic drugs- dopamine, dobutrex, inocor
• Daily weights
• Sodium restricted diets
• Intraaortic balloon pump
• Ventricular assist device
• Cardiac transplant

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Nursing Management

• Impaired gas exchange r/t inadequate cardiac pump
  function
• Decreased cardiac output r/t a reduction in
  stroke volume
• Activity tolerance r/t an imbalance between
  oxygen demand and supply

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Nursing Interventions

• Health maintenance Promotion
• -prevention of heart failure
• -teaching about importance of medications
• -early detection of s/s of failure
• -importance of diet and exercise

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Hypertension

• High blood pressure (hypertension), is a
  condition commonly associated with narrowing of
  the arteries.

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Epidemiology

• In 1999 to 2000, an estimated 28.7 population or
  more than 58 million Americans had hypertension.
  This represents an increase of 3.7 since 1988 to
  1991.
• In 2000, HTN was listed as a primary or
  contibuting cause of death in about 251,000
  Americans.

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Types of Hypertension

• Primary Hypertension (Essential)- etiology is
  unknown ,accounts for 95 of all cases
• Contributing factors
• - increased SNS activity
• - overproduction of sodium retaining
  hormones
• - obesity
• - diabetes mellitus
• - excessive alcohol intake

• Secondary Hypertension
• causes- renal disease, adrenal tumors, Cushings
  syndrome, Coarctation or narrowing of the aorta,
  head injury, neurologic disorders such as brain
  tumors,medications such as sympathetic stimulants
  and pregnancy induced hypertension.

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Blood Pressure Classification
Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation and Treatment
of High Blood Pressure
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Risk Factors

• Age-65 and older
• Sex- men young adulthood and middle age
• Race - African Americans
• Obesity
• Cigarette Smoking
• Excess Sodium Intake
• Elevated Serum Lipids
• Sedentary Lifestyle
• Diabetes Mellitus
• Socioeconomic Status
• Stress

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Blood Pressure
Blood Volume
Peripheral Resistance Diameter of Arterioles
Cardiac Output

• Fluid loss
• Dehydration
• Fluid Retention
• Aldosterone
• ADH

• Sympathetic nervous
• system activity
• Renin/Angiotensin II
• Increase Blood Viscosity

• Stroke Volume
• Preload
• Contractility
• Afterload
• Heart Rate
• SNS
• Epinephrine

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? BP
Compensatory action by CVS
Compensatory action by kidneys
Vasodilation ? Stroke Volume ? Heart Rate ?
Urine Output
? Cardiac output ? Blood Volume
Blood pressure returns to normal
Blood Pressure Homeostasis
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Gerontology Considerations

• Loss of tissue elasticity
• Increased collagen content and stiffness of
  myocardium
• Increased peripheral vascular resistance
• Decreased renal function
• Decreased renin response to sodium and water
  depletion

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Clinical Manifestations

• Silent Killer asymptomatic
• Secondary symptoms-fatigue, reduced activity
  tolerance, dizziness, palpitations, angina, and
  dyspnea.
• Nosebleeds,Headache and dizziness in
  hypertension and general population.

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Nursing Management

• Nursing Diagnosis
• Risk for ineffective therapeutic management r/t
  non compliance with treatment
• Deficient knowledge r/t information
  misinterpretation

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Untreated Hypertension
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Therapeutic Management

• The ultimate goal of antihypertensive therapy is
  to reduce cardiovascular and renal morbidity and
  mortality.
• Lifestyle modifications
• Weight reduction

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Lifestyle modifications ..continuation

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Therapeutic Management

• B. Drug Therapy
• Facts.
• Based on clinical outcomes data, the JNC 7
  recommends thiazide diuretics as initial therapy
  in most patients with HTN, either alone or
  combined with an ACEI, ARB, BB, CCB
• Most people with HTN will require two or more
  drugs to meet BP goals with adequate doses of one
  drug, a second agent from another class should be
  added.
• When BP is gt 20 mmHg above the SBP goal or 10
  mmHg above the DBP, consideration should be given
  to initiating therapy with 2 drugs , one of which
  usually should be thiazide-type diuretic.

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Drug Therapy

• Commonly prescribed drugs
• A. Diuretics
• B. ACEIs
• C. ARBs
• D. BBs
• E. CCBs

• Alternative Agents
• Spironolactone (Aldactone)
• Eplerenone (Inspra) new agent
• Doxazosin (Cardura)
• Clonidine (Catapres)
• Hydralazine (Apresoline)

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Special Populations

• In older people, drug therapy is started at lower
  doses and titrated slowly to avoid orthostatic
  hypotension.
• In African Americans, BP response during
  monotherapy is usually better with diuretics or
  CCBs than with ACEIs, ARBs, or beta-blockers.
• In pregnancy, methyldopa (Aldomet) is the drug of
  choice.
• ACEIs and ARBs are contraindicated in pregnancy.

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Critical thinking

• The nurse is caring for a cardiac patient who is
  taking Digoxin, Lasix, Colace and Isordil. Which
  of the following side effects can be caused by a
  potential drug interaction?
• A. Hypokalemia
• B. Constipation
• C. Headache
• D. Hypotension

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Critical Thought

• When administering any drug that effects cardiac
  rhythm, which is the most important for the nurse
  to assess?
• A. EKG
• B. Pulse rate
• C. Respiratory rate
• D. Blood Pressure.

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Critical Thought

• When evaluating effectiveness of digoxin, which
  blood test results indicates a positive outcome?
• A. Potassium 3 mEq/L.
• B. Calcium 8.8mEq/l.
• C. Digoxin 0.5-2.0mg/ml
• D. Digoxin 2.5-3.0mg/ml.

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Critical thought

• A client with diagnosis of MI is receiving
  nitroglycerine. The client c/o headache. What
  would be the most appropriate statement by the
  nurse?
• A. I will increase the medication
• B. Headache is a common side effect. Take a
  tylenol
• C. Your headache is probably due to stress.
• D. I will call your health care provider to
  change your medication.

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Critical Challenge

• Which lifestyle changes decrease risk status
  after an MI? Which habits increase risk?

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Critical Challenge

• Compare and contrast the risk factors of CV
  disease for a 36 year old and a 72 year old man.

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Critical challenge

• The EKG and blood work for a client with chest
  pain were inconclusive but the physician is
  concerned about his symptoms. Discuss why there
  is reason for concern.

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Too pooped to pump

• Normal ejection fraction is
• A. 40-55
• B. 60-80
• C. 85-95

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Too pooped to pump

• Which of the following are considered the
  cardinal signs of heart failure?
• A. shortness of breath, hypotension and edema
• B. anxiety chest pain and diaphoresis
• C. dyspnea, fatigue and fluid retention

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Too pooped to pump

• Raising the heart rate causes the cardiac output
  to
• A. also increase
• B. decrease
• C. stay the same

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Too pooped to pump

• Which of the following is the most commonly used
  and most useful diagnostic test for heart
  failure?
• A. 12 lead ekg
• B. cardiac cath
• C. transthoracic echocardiogram

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Too pooped to pump

• Which of the following drugs is usually the
  initial treatment of heart failure?
• A. digoxin
• B. lasix
• C. lopressor

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Too pooped to pump

• Obtaining a baseline weight for a patient with
  heart failure is most important for
• A. assess intake and output
• B. indicating when the patient needs to have
  afterload increased
• C. evaluating the effectiveness of therapies.

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Too pooped to pump

• Administration of nesiritide results in
• A. fluid retention
• B. an increase in preload
• C. a decrease in preload.

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Too pooped to pump

• Advise your patient to notify her primary care
  provider or cardiologist if
• A. awakens at night to urinate
• B. loses 5 pounds in a week
• C. gains 2 pounds over night.