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Chapter 29
Management of Patients With
Complications From Heart Disease Heart Failure (HF)
• A clinical syndrome resulting from structural or functional
cardiac disorders that impair the ability of the ventricles to fill or eject blood • In the past, HF was often referred to as congestive heart failure (CHF), because many patients experience pulmonary or peripheral congestion with edema • HF is recognized as a clinical syndrome characterized by signs and symptoms of fluid overload or inadequate tissue perfusion
• The term heart failure indicates myocardial disease, in
which there is a problem with the contraction of the heart (systolic failure) or filling of the heart (diastolic failure) • Some cases are reversible depending on the cause • Most HF is a chronic, progressive condition managed with lifestyle changes and medications
• Approximately 6 million people in the United States have HF, and 870,000 new cases are diagnosed each year • Most common in people older than 75 years • Most common reason for hospitalization of people older than 65 years and is the second most common reason for visits to a physician's office • Approximately 25% of patients discharged after treatment for HF are readmitted to the hospital within 30 days
vasodilation; diuresis; decreases afterload; monitor for hypotension, hyperkalemia, and altered renal function; cough • Angiotensin II receptor blockers: prescribed as an alternative to ACE inhibitors; work similarly • Hydralazine and isosorbide dinitrate: alternative to ACE inhibitors • Beta-blockers: prescribed in addition to ACE inhibitors; may be several weeks before effects seen; use with caution in patients with asthma
electrolytes • Digitalis: improves contractility, monitor for digitalis toxicity especially if patient is hypokalemic • IV medications: indicated for hospitalized patients admitted for acute decompensated HF – Milrinone: decreases preload and afterload; causes hypotension and increased risk of dysrhythmias – Dobutamine: used for patients with left ventricular dysfunction; increases cardiac contractility and renal perfusion
• May present with atypical signs and symptoms such as
fatigue, weakness, and somnolence • Decreased renal function can make older patients resistant to diuretics and more sensitive to changes in volume • Administration of diuretics to older men requires nursing surveillance for bladder distention caused by urethral obstruction from an enlarged prostate gland
A. ACE inhibitors ACE inhibitors play a pivotal role in the management of HF caused by systolic dysfunction. Beta-blockers have been found to reduce mortality and morbidity in patients with NYHA class II or III HF by reducing the adverse effects from the constant stimulation of the sympathetic nervous system. Diuretics are prescribed to reduce excess extracellular fluid by increasing the rate of urine produced in patients with signs and symptoms of fluid overload. Digitalis increases the force of myocardial contraction and slows conduction through the atrioventricular node
Nursing Process: The Care of the Patient With Heart Failure—Assessment
• Focus – Effectiveness of therapy – Patient’s self-management – S&S if increased HF – Emotional or psychosocial response • Health history • PE – Mental status; lung sounds: crackles and wheezes; heart sounds: S3; fluid status or signs of fluid overload; daily weight and I&O; assess responses to medications
Nursing Process: The Care of the Patient With Heart Failure—Diagnoses
• Activity intolerance related to decreased CO
• Excess fluid volume related to the HF syndrome • Anxiety-related symptoms related to complexity of the therapeutic regimen • Powerlessness related to chronic illness and hospitalizations • Ineffective family therapeutic regimen management
Nursing Process: The Care of the Patient With Heart Failure—Planning
• Goals – Promote activity and reduce fatigue – Relieving fluid overload symptoms – Decrease anxiety or increase the patient’s ability to manage anxiety – Encourage the patient to verbalize his or her ability to make decisions and influence outcomes – Educate the patient and family about management of the therapeutic regimen
• Encourage regular physical activity; 30 to 45 minutes daily • Exercise training • Pacing of activities • Wait 2 hours after eating for physical activity • Avoid activities in extreme hot, cold, or humid weather • Modify activities to conserve energy • Positioning; elevation of the head of bed to facilitate breathing and rest, support of arms
• Medications • Diet: low-sodium diet and fluid restriction • Monitoring for signs of excess fluid, hypotension, and symptoms of disease exacerbation, including daily weight • Exercise and activity program • Stress management • Prevention of infection • Know how and when to contact health care provider • Include family in education
What evaluation most illustrates that the patient with HF has
met outcomes for the nursing diagnosis “Activity intolerance related to decreased CO?” A.Exhibits decreased peripheral edema B.Maintains heart rate, blood pressure, respiratory rate, and pulse oximetry within the targeted range C.Avoids situations that produce stress D.Performs and records daily weights
B. Maintains heart rate, blood pressure, respiratory rate,
and pulse oximetry within the targeted range
Rationale: Patients with HF who exhibit stable VS shows
that they have been able to adjust and plan activities to include rest and allow their bodies to adjust. A decrease in peripheral edema illustrates a reduction of fluid, avoiding situations that produce stress shows a move toward decreasing anxiety, and performing and recording daily weights shows adherence to the therapeutic regimen
• As LV begins to fail, blood backs up into the pulmonary circulation, causing pulmonary interstitial edema • Results in hypoxemia, often severe • Clinical manifestations: restlessness, anxiety, dyspnea, cool and clammy skin, cyanosis, weak and rapid pulse, cough, lung congestion (moist, noisy respirations), increased sputum production (sputum may be frothy and blood tinged), decreased level of consciousness
– Positioned upright with legs dangling • Providing psychological support – Reassure patient and provide anticipatory care • Monitoring medications – I&O
• A life-threatening condition with a high mortality rate
• Decreased CO leads to inadequate tissue perfusion and initiation of shock syndrome • Clinical manifestations: symptoms of HF, shock state, and hypoxia
• Reducing preload and afterload to decrease cardiac workload • Improving oxygenation, and restoring tissue perfusion • Monitor hemodynamic parameters, monitor fluid status, and adjust medications and therapies based on the assessment data
• Decreased mobility and decreased circulation increase
the risk for thromboembolism in patient with cardiac disorders, including those with HF • Pulmonary embolism: blood clot from the legs moves to obstruct the pulmonary vessels • S&S: dyspnea, pleuritic chest pain, tachypnea, cough • Treatment: anticoag therapy – Unfractionated heparin, low--molecular-weight heparin, fondaparinux (Arixtra), or rivaroxaban (Xarelto)
• Pericardial effusion is the accumulation of fluid in the pericardial
sac • Cardiac tamponade is the restriction of heart function because of this fluid, resulting in decreased venous return and decreased CO • Clinical manifestations: ill-defined chest pain or fullness, pulsus paradoxus, engorged neck veins, labile or low BP, shortness of breath • Cardinal signs of cardiac tamponade: falling systolic BP, narrowing pulse pressure, rising venous pressure, distant heart sounds
• Pericardiocentesis – Puncture of the pericardial sac to aspirate pericardial fluid • Pericardiotomy – Under general anesthesia, a portion of the pericardium is excised to permit the exudative pericardial fluid to drain into the lymphatic system
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