College of the Desert Nursing 2

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College of the DesertNursing 2

• Alterations in Cardiovascular Function
• Part I

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Heart Anatomy

• Pericardium Sac that covers the heart
• Myocardium Heart muscle
• Endocardium Sac lining the heart

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Heart Chambers

• Right and left atrium (atria)
• Right and left ventricles

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Heart Valves

• Tricuspid Valve
• Mitral (Bicuspid) Valve
• Pulmonary (Semilunar ) Valve
• Aortic Valve

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Heart Valves

• Tricuspid Valve
• separates right atrium and ventricle
• Mitral (Bicuspid) Valve separates left atrium
  and ventricle

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Location of Mitral Valve
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Heart Valves

• Pulmonary (Semilunar ) Valve
• Right ventricle to Pulmonary Artery
• Aortic Valve Left Ventricle from Aorta

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Anatomy of Heart Valves
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Function of Heart Valves
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Coronary Blood Supply

• Myocardium is given
• blood by coronary
• arteries and veins

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Coronary Arterial System
CORONARY BLOOD SUPPLY
Slide 35.1
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Heart Physiology

• Transports of O2, CO2, hormones, salts,
  antibodies, blood cells
• Assists in heat regulation
• Assists in fluid balance
• Maintains homeostasis of the internal environment

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Autonomic Nervous System Control

• Andrenergic or Sympathetic via epinephrine and
  norepinephrine
• Cholinergic or Parasympathetic via acetylcholine
  and vagal nerve stimulation

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Pulse and Blood Pressure

• Pulse the rhythmic dilation of the arteries as
  the heart contracts
• Pulse Deficit the difference between the apical
  and radial pulses
• Blood Pressure pressure exerted against the
  walls of the arteries by the blood (systolic and
  diastolic)
• Pulse Pressure the difference between the
  systolic and diastolic readings

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Review of Cardiac Circulation

• From Superior and Inferior Vena Cava
• To Right Atrium
• Through Tricuspid Valve
• To Right Ventricle
• Through Pulmonary Valve
• To Pulmonary Artery
• To Lungs

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Review of Cardiac Circulation

• From lungs through
• Pulmonary Vein to
• To Left Atrium
• Through Mitral Valve-?
• To Left Ventricle-?
• Through Aortic Valve
• To Aorta-?
• To systemic circulation

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Systole

• When the ventricles contract
• Begins with S1
• Ends at S 2
• Shorter than diastole

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Diastole

• When the ventricles relax
• Begins with S2
• Ends with S1
• No heart sounds audible

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Cardiac Output

• Cardiac output is
• Blood pumped by ventricles in 1 minute
• Cardiac output stroke volume x heart rate

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Preload
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Preload is about volume

• Preload is the stretch of heart muscle
• at the end of diastole and beginning of systole
• If the volume and pressure are too low, there
  wont be enough blood pumped
• If the volume and pressure are too high, the
  blood will back up

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Preload

• Preload reflects end-diastolic volume,
• which is influenced by
• diastolic pressure and
• the composition of the myocardial wall.

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Frank-Starling Mechanism

• The greater the stretch of
• cardiac muscle fibers,
• the greater the force of contraction

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Afterload
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Afterload is about pressure

• Afterload is
• The ventricular pressure at the end of systole
• The pressure the ventricular muscles need to
  overcome the higher aortic pressure to move blood
  out of the heart

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Afterload is about pressure

• Afterload is determined by
• Ventricular pressure,
• Blood volume in the chamber, and
• Wall thickness

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Cardiovascular Assessment

• Cardiovascular disease is the leading cause of
  death in the United States for persons over 25
  years of age!

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Assess for Pain

• Location
• Duration
• Intensity
• Radiation
• Aggravating Triggers
• Relieving Factors

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Assess Respiratory Status

• Dyspnea Air Hunger
• Exertional with exercise
• Orthopnea reclining position
• Paroxysmal just occurs, especially at night
• Tachypnea rapid respiratory rate
• Cough productive or non-productive

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Also Assess For

• Cyanosis
• Fatigue
• Palpitations
• Syncope
• Hemoptysis
• Edema

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Assessment of Veins and Pulses

• Jugular Vein Distention
• Pedal Pulses
• Femoral Pulses
• Blood Pressure in both arms

• Assess Extremities for
• Cyanosis, Temperature, lesions
• Petechiae small hemorrhages
• Dryness or clamminess
• Clubbing of fingers
• Blanching of nail beds (capillary refill)
• Pulses should be equal bilaterally

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Clubbing of the Fingers
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Auscultation of Heart and Chest

• The apex of the heart is the apical impulse or
  point of maximum impulse (PMI)
• Apex is at approximately the fourth to fifth
  intercostal space just medial to the left
  mid-clavicular

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Auscultation of Heart and Chest
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Heart Sounds

• Contraction (systole) sounds like a lubb from
  the contraction of the ventricles.
• Relaxation (asystole) sounds like a dubb from
  the closure of the valves.

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Heart Sounds

• S1 Closure of the Mitral and tricuspid valves,
  the lubb sound
• S1 occurs at outset of ventricular systole
• S2 Closure of aortic and pulmonary valves, the
  dubb sound
• S2 occurs at outset of ventricular diastole

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Electrocardiogram (EKG or ECG)

• A graphic record of the electrical activity of
  the heart.
• Determines the types and/or extent of heart
  damage or failure
• Diagnoses cardiac irregularities, arrhythmias,
  complications of heart damage, and electrolyte
  imbalances

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Diagnostic Tests Non-Invasive

• The Cardiac Cycle
• P wave atrial contraction
• QRS wave -ventricular contraction
• T wave ventricular diastole

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Other Diagnostic Tests

• Echocardiogram Ultrasound of heart that enables
  visualization of valve function and myocardial
  contractility
• Stress Test Client is closely monitored while
  exercising or given certain medications to stress
  heart

• Fluroscopic Studies reveal heart, lung and
  vessel movements as viewed on a luminescent
  screen in a darkened room or videotaped for later
  study.

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Contractility
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Contractility

• Contractility is
• Ability of myocardium to contract
• Influenced by preload
• The greater the preload,
• the more forceful the contraction of the
  myocardium
• Expressed as ejection fraction

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CARDIAC DISORDERS
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Sinus Tachycardia

• Heart rate 100 180
• May be caused by exercise, anxiety, fear, shock,
  hyperthyroidism, arrhythmias (any deviations from
  the normal heart rhythm)
• Tires cardiac muscle resulting in cardiac failure

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Sinus Bradycardia

• May be normal in well trained athletes and during
  sleep.
• May be secondary to digitalis toxicity, morphine
  overdose, or brain lesions
• May cause fainting
• Treat only when symptomatic with Atropine,
  Isuprel, pacemaker

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Ischemic Heart Disorders

• Angina Pectoris
• Myocardial Infarction
• Congestive Heart Failure

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Coronary Artery Disease

• Decreased blood flow through coronary arteries
  causes inadequate delivery of oxygen to the
  myocardium

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Risk Factors for Coronary Artery Disease (CAD)

• Smoking
• Diet
• Cholesterol
• Physical Activity
• Diabetes
• Blood Pressure
• Obesity

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Activity for the Client with Coronary Artery
Disease

• Begin by walking the same distance at home as in
  the hospital (usually 400 feet) three times each
  day.
• Carry nitroglycerin with you.
• Check your pulse before, during, and after the
  exercise.
• Stop the activity for a pulse increase of more
  than 20 beats per minute, shortness of breath,
  angina, or dizziness.
• Exercise outdoors when the weather is good.
• Gradually increase the walking until the distance
  is 1/4 mile twice daily.
• After an exercise tolerance test and with your
  physicians approval, walk at least three times
  each week.
• Avoid straining.

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Angina Pectoris

• Severe chest pain due to the temporary inability
  of the coronary arteries to meet the metabolic
  needs of the myocardium
• Onset
• Gradual or sudden
• Lasts less that 15 minutes
• Averages about 3 minutes.

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Angina Pectoris

• Pain is precordial, substernal or anterior chest,
  often described as crushing, radiating to back,
  neck, left arm, jaw, finger
• Pain may also manifest only as pain in back, jaw,
  arm, or epigastric
• May be a feeling of crushing or pressure or
  tightness or squeezing
• Immobilizes the person

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Angina Pectoris

• Other Signs and Symptoms dyspnea, nausea,
  desire to void, belching, apprehension
• EKG interpretation Depressed ST segment with
  pain

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Angina Pectoris

• May be precipitated by exercise or stress
• Relieved by rest or nitroglycerin

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Angina PectorisPrecipitating Factors

• The 4 Es
• Exertion
• Effort
• Emotional upset
• Extremes in temperature

• Overeating
• Overweight
• Smoking
• Anemia

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Angina PectorisNursing Management

• Live in moderation physical activity, regular
  mild physical exercise promotes collateral
  circulation
• Avoid stress and emotional upset
• No smoking
• Decrease use of stimulants coffee, tea, cola
• Observe for dyspnea
• Decrease oxygen demand of myocardium
• Reduce caloric intake if overweight

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Angina PectorisMedical Management

• Oxygen

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Angina PectorisMedical Management

• Nitroglycerine short acting nitrate
• Dilates coronary arteries to increase blood flow
  to myocardium
• Usual dose is 0.4 mg or grain 1/150
• Effective sublingual dont swallow.
• Also in spray form
• Side effects headache and hypotension (so
  DIZZINESS!)
• One tablet SL every 5 minutes x 3 times
• If no relief Call Physician
• Not addictive and for anginal pain only

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Angina PectorisMedical Management

• Nitroglycerine
• Must be stored in dry, airtight, dark container
• Replace every 6 months, deteriorates rapidly
• Topical forms for routine use

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Angina PectorisMedical Management

• Aspirin
• Morphine
• Calcium Channel Blockers prevent calcium from
  entering the cell wall and causing contraction
• Beta Blockers reduce heart rate and
  vasoconstriction

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Angiogram
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Coronary Angiogram

• Injection of a radiopaque dye into the arterial
  circulation to see the coronary arteries under
  fluoroscopy
• Determines if coronary arteries are clear, or if
  there are occlusions

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Coronary Angiogram

• NPO
• If anxiety, sedation pre-procedure
• If allergies, antihistamines pre-procedure
• Takes 1 3 hours
• Continuous monitoring of EKG and BP
• Local anesthetic is injected into insertion site
• Long, flexible catheter is inserted into coronary
  arteries via large blood vessel (usually femoral
  artery)
• Strict asepsis

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Possible Angiogram Complications

• Bruising (ecchymosis), hematoma, or hemorrhage at
  insertion site
• Allergic reaction to contrast (dye)
• Thrombosis at the insertion site
• Numbness, tingling, coolness of extremity, loss
  of peripheral pulse (bleeding into site)
• Renal failure (Rare)
• Dislodgement of a plaque resulting in a heart
  attack (MI) (Rare)
• Dissection of a vessel (Rare)

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Angina Pectoris

• Is also called acute angina

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Angina pectoris

• Angina can lead to myocardial infarction if not
  relieved
• Chest pain is of the highest priority!

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Myocardial Infarction(Heart Attack)

• Death of heart tissue (necrosis) the process by
  which the cardiac muscle is destroyed by an
  interruption of, or insufficient blood supply for
  a prolonged period of time resulting in sustained
  oxygen deprivation

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Congestive Heart Failure (CHF)
Im too pooped to pump !
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Congestive Heart Failure (CHF)

• CHF results from
• Decreased cardiac output or
• Overt cardiac failure
• Heart decompensates
• resulting in venous congestion.

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Pathophysiology of Heart Failure
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Risk Factors for CHF

• Previous myocardial infarction (MI)
• Recent open-heart surgery
• Dysrhythmias
• Hypertension (HTN)

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Diagnostics for CHF

• B-type natriuretic peptide (BNP) lab values
• Electrocardiography (ECG or EKG)
• Chest x-ray (CXR)
• Echocardiography (ECHO) with Doppler Heart
  ultrasound
• Thallium scan
• Multiple gated acquisition scan (MUGA)

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Types of Congestive Heart Failure

• Acute or chronic failure
• Backward or forward failure
• High- or low-output failure
• Left ventricular systolic dysfunction or
  diastolic dysfunction
• Right- or left-sided failure

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Acute or Chronic CHF

• Acute heart failure
• Abrupt onset of myocardial injury
• Resulting in sudden decreased cardiac function
  and decreased cardiac output
• Chronic heart failure
• Progressive deterioration
• Related to cardiomyopathy, valve disease, or
  congestive heart disease (CHD)

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Backward Heart Failure

• In Backward failure
• Ventricles fail to eject contents
• Pulmonary edema on left side of heart
• Systemic congestion on right side of heart

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Forward Heart Failure

• In forward failure
• Inadequate cardiac output
• Leads to decreased organ perfusion

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In High-output Heart Failure

• Volume of blood exceeds amount that left
  ventricle can eject
• Heart is unable to meet increased metabolic
  demands
• Despite normal or high cardiac output
• Associated with Mitral valve regurg, aortic
  valve insufficiency, hyperthyroidism, anemia,
  hypervolemia from an extrinsic cause (like,
  excess IV fluids)

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Low-output Heart Failure

• In low-output failure
• When ventricle unable to make enough cardiac
  output to meet metabolic demands
• Impaired peripheral circulation
• Compensatory vasoconstriction
• Associated with MI, cardiomyopathy, impaired
  right ventricle, aortic valve stenosis, pulmonary
  HTN

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Left Ventricular Systolic Dysfunction

• Heart muscle too weak to contract fully
• Reduced volume of blood leaves ventricles during
  systolic ejection
• With normal ejection fraction, 60 to 80
• of the blood in left ventricle is ejected with
  each beat

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Left Ventricular Diastolic Dysfunction

• Left ventricle increased diastolic stiffness
  (reduced compliance) and cant fill adequately at
  normal diastolic pressures
• Caused by cardiac muscle hypertrophy, which can
  lead to this type of diastolic dysfunction

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Congestive Heart FailureLeft Ventricular Failure

• Pathophysiology
• Decreased cardiac output to the systemic
  circulation
• Congestion in the pulmonary circulation is due to
  the inability of the left heart to accommodate
  the blood entering it from the pulmonary
  circulation.

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Congestive Heart FailureLeft Ventricular Failure

• Etiology
• Arterioslerotic heart disease
• Acute MI
• Tachyarrhythmias
• Myocarditis
• Increased circulating volume
• Valvular Heart Disease

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Congestive Heart FailureLeft Ventricular Failure

• Signs and Symptoms
• Anxiety
• Weakness, fatigue
• Dyspnea, orthopnea
• Cough
• Gallop Rhythm
• Palpitations
• Diaphoresis

• Rales
• Rhonchi
• Wheezes
• Frothy, pink sputum
• Cold and clammy

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Key Features of Left-Sided Heart Failure

• Pulmonary Congestion
• Hacking cough, worse at night
• Dyspnea/breathlessness
• Crackles or wheezes in lungs
• Frothy pink-tinged sputum
• Tachypnea

• Decreased Cardiac Output
• Fatigue
• Weakness
• Oliguria during the day
• Angina
• Confusion, restlessness
• Dizziness
• Tachycardia, palpitations
• Pallor
• Weak peripheral pulses
• Cool extremities

Slide 37.2
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Congestive Heart FailureRight Ventricular Failure

• Congestion occurs when blood is not pumped
  adequately from the systemic circulation into the
  pulmonary circulation resulting in systemic
  edema. Dependent edema the lowest part.
  Ankles, calves, sacrum, buttocks

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Congestive Heart FailureRight Ventricular Failure

• Pathophysiology
• Inability to handle systemic venous return
  resulting in systemic venous congestion.

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Congestive Heart FailureRight Ventricular Failure

• Etiology
• 1. Right Ventricular failure
• 2. Pulmonary embolism
• 3. Fluid Overload
• 4. COPD
• 5. Left V failure leading to right V failure

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Congestive Heart FailureRight Ventricular Failure

• Signs and Symptoms
• 1. Peripheral edema in the dependent parts of the
  body (ankles, sacral area of bedridden person)
  need good skin care and positioning and
  prevention of decubiti in the sacral area
• 2. Jugular vein distention
• 3. Ascites - accumulation of fluid in the
  peritoneal cavity
• 4. Weight Gain
• 5. Anorexia and nausea due to the congestion in
  the liver and gut

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Congestive Heart FailureRight Ventricular Failure

• Signs and Symptoms
• 6. Hepatomegaly - liver congestion
• 7. Increased in Central Venous Pressure (CVP)
• 8. Arrhythmias

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Key Features of Right-Sided Heart Failure

• Jugular (neck vein) distention
• Enlarged liver and spleen
• Anorexia and nausea
• Dependent edema (legs and sacrum)
• Distended abdomen
• Swollen hands and fingers
• Nocturia and polyuria
• Weight gain
• Increased blood pressure (from excess volume) or
  decreased blood pressure (from failure)

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Causes of CHF

• Coronary artery disease (CAD)
• Is responsible for 2/3 of all CHF
• Nonischemic cardiomyopathies
• Are responsible for 1/3 of CHF cases
• HTN
• Thyroid dysfunction
• Valve disease
• Cardiotoxic substances

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Causes of CHF

• Nonischemic cardiomyopathies
• Are responsible for 1/3 of CHF cases
• Causes of cardiomyopathies may be from
• HTN
• Thyroid dysfunction
• Valve disease
• Cardiotoxic substances
• May be idiopathic

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Compensatory Mechanisms for CHF

• Sympathetic nervous system
• Renin-angiotensin-aldosterone system
• Anitidiuretic hormone
• Increased stroke volume
• hANP hBNP

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Decompensated Heart Failure

• Loss of balance between mechanisms of heart
  failure and bodys attempts to overcome the
  failure process
• So symptoms of heart failure

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Collaborative Management of CHF

• Echocardiogram with Doppler for diagnosis
• Treat precipitating causes
• Oxygen
• Fluid restriction
• Sodium restriction - NAS diet or 2 gm Na, per
  orders
• Medications
• Surgery PRN

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Nursing Management of CHF

• Rest or activity?
• HOB elevated
• Record I Os
• Daily weights (same time every day)
• Assist with ADLs PRN
• Monitoring
• Education
• Reduce anxiety, fear, grief

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ACE INHIBITORS
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CHF MedicationsTo reduce preload To reduce
afterload

• Diuretics
• ACE Inhibitors
• To reduce preload
• Digoxin (Lanoxin)

• Beta-blockers
• ACE Inhibitors
• Nitrates (low dose)
• Hydralazine
• Nesiritide (Natrecor)
• Eplerenone
• Spironolactone
• (low doses)

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Digoxin

• Digoxin is a
• Positive inotrope (Improves contractility)
• Positive inotrope (Increases force of
  contraction)
• Negative chronotrope (Decreases HR)
• Do not administer if apical pulse
  100 bpm

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Digoxin

• Symptoms of Digitalis Toxicity
• Anorexia
• Abd pain
• N/V
• Blurred, yellow vision
• Bradycardia
• Arrhythmias

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Patient Education for Digoxin Therapy

• Noon is the best time of day to take this
  medication.
• Continue administration of this medication unless
  you are told to stop it by your health care
  provider.
• Do not take digoxin at the same time as antacids
  or cathartics (laxatives).
• Take your pulse rate before taking each dose of
  digoxin. Notify your health care provider of a
  change in pulse rate (100
  beats/minute)or rhythm as well as increasing
  fatigue, muscle weakness, confusion, or loss of
  appetite (signs of digitalis toxicity).

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Patient Education for Digoxin Therapy

• If you forget to take a dose, it may be delayed a
  few hours. However, if you do not remember it
  until the next day, you should take only your
  usual daily dose.
• Report for scheduled laboratory test (such as
  potassium and digoxin levels).
• If potassium supplements are prescribed, continue
  the dose until told to stop by your health care
  provider.

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Focused Assessment for Home Care Clients with
Heart Failure

• Focused assessment for home care clients with
  heart failure
• Assess functional ability
• Assess nutritional status
• Assess home environment
• Assess client's compliance and understanding of
  illness and its treatment
• Assess client and caregiver coping skills

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Inflammatory and Valvular Heart Diseases

• Rheumatic Heart Disease
• Endocarditis
• Pericarditis
• Myocarditis
• Mitral Stenosis
• Aortic Stenosis

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Rheumatic Heart DiseaseEtiology

• a. Reaction to a Group A beta-hemolytic
  streptococcal infections (3 of infected
  persons)
• b. Increased family incidence
• c. Occurs usually in the northern states during
  the winter
• d. Up to 50 have pericarditis, endocarditis, or
  myocarditis
• e. Most common in 5-15 yrs olds

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Rheumatic Heart DiseaseSigns and Symptoms

• a. Systolic murmur
• b. Mitral insufficiency valve is open
• c. Mitral stenosis - narrowing of the valve
• d. Aortic insufficiency - valve is open
• e. Aortic stenosis - narrowing of the valve
• f. Dyspnea, CHF, Atrial fibrillation

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Rheumatic Heart DiseaseMedical and Nursing
Management

• a. Monthly IM injections of penicillin G to
  prevent recurrence for 5 yrs or until 25 yrs
  old
• b. Repair or replacement of Mitral valve in
  adulthood
• c. Rx of congestive heart failure
• d. Digoxin, diuretics, sodium restricted diet,
  02
• e. Prophylactic antibiotics pre/post dental care

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Strep Throat
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Mitral Stenosis

• 1. Dyspnea on exertion
• 2. Heart murmur
• 3. Edema
• 4. Fatigue
• 5. Low systolic S/P
• 6. CHF
• 7. Pulmonary Edema

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Mitral Valve
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Aortic Stenosis

• 1. Syncope
• 2. Angina
• 3. Weak, rapid pulse
• 4. Dyspnea
• 5. CHF
• 6. Edema