Interventions Interventions for Clients with for Clients with

Cardiac Cardiac ProblemsProblems

Heart FailureHeart Failure• Also called pump failure, general Also called pump failure, general

term for the inadequacy of the heart term for the inadequacy of the heart to pump blood throughout the body; to pump blood throughout the body; causes insufficient perfusion of body causes insufficient perfusion of body tissue with vital nutrients and oxygentissue with vital nutrients and oxygen

• Left-sided heart failureLeft-sided heart failure• Right-sided heart failureRight-sided heart failure• High-output failureHigh-output failure

Compensatory Compensatory MechanismsMechanisms• Sympathetic nervous system Sympathetic nervous system

stimulationstimulation• Renin-angiotensin system Renin-angiotensin system

activationactivation• Other neurohumoral responsesOther neurohumoral responses• Myocardial hypertrophyMyocardial hypertrophy

Etiology Etiology

•Heart failure is caused by systemic Heart failure is caused by systemic hypertension in 75% of cases.hypertension in 75% of cases.

•About one third of clients About one third of clients experiencing myocardial infarction experiencing myocardial infarction also develop heart failure.also develop heart failure.

•Structural heart changes, such as Structural heart changes, such as valvular dysfunction, cause pressure valvular dysfunction, cause pressure or volume overload on the heart.or volume overload on the heart.

Left-Sided Heart FailureLeft-Sided Heart Failure

• Manifestations include:Manifestations include:– WeaknessWeakness– FatigueFatigue– DizzinessDizziness– ConfusionConfusion– Pulmonary congestionPulmonary congestion– Shortness of breathShortness of breath

(Continued)(Continued)

Left-Sided Heart Failure Left-Sided Heart Failure (Continued)(Continued)

– OliguriaOliguria– Organ failure, especially renal Organ failure, especially renal

failurefailure– Death Death

• Assess blood pressure, mental Assess blood pressure, mental status, breath soundsstatus, breath sounds

Right-Sided Heart Right-Sided Heart FailureFailure• Manifestations include:Manifestations include:

– Distended neck veins, increased Distended neck veins, increased abdominal girthabdominal girth

– Hepatomegaly (liver engorgement)Hepatomegaly (liver engorgement)– Hepatojugular refluxHepatojugular reflux– AscitesAscites– Dependent edemaDependent edema– Weight: the most reliable indicator Weight: the most reliable indicator

of fluid gain or lossof fluid gain or loss

Assessments Assessments

• Laboratory assessmentLaboratory assessment• Radiographic assessmentRadiographic assessment• ElectrocardiographyElectrocardiography• EchocardiographyEchocardiography• Pulmonary artery cathetersPulmonary artery catheters

Impaired Gas ExchangeImpaired Gas Exchange

• Interventions include:Interventions include:– Ventilation assistanceVentilation assistance– Hemodynamic regulationHemodynamic regulation– Energy management, diet therapy, Energy management, diet therapy,

drug therapydrug therapy

Decreased Cardiac Decreased Cardiac OutputOutput• Interventions include:Interventions include:

– Optimization of cardiac output: Optimization of cardiac output: stroke volume (determined by stroke volume (determined by preload, afterload, and preload, afterload, and contractility) and heart ratecontractility) and heart rate

(Continued)(Continued)

Decreased Cardiac Decreased Cardiac OutputOutput (Continued)(Continued)

– Drug therapy including:Drug therapy including:•Angiotensin-converting enzymeAngiotensin-converting enzyme•ACE inhibitorsACE inhibitors•DiureticsDiuretics•Human B-type natriuretic peptidesHuman B-type natriuretic peptides•NitratesNitrates•InotropicsInotropics•Beta-adrenergic blockersBeta-adrenergic blockers

Hemodynamic Hemodynamic RegulationRegulation• Interventions include:Interventions include:

– Reduce afterload.Reduce afterload.– Reduce preload.Reduce preload.– Improve cardiac muscle contractility.Improve cardiac muscle contractility.– Administer drugs as prescribed.Administer drugs as prescribed.– Monitor for therapeutic and adverse Monitor for therapeutic and adverse

effects.effects.– Teach client and family drug therapy.Teach client and family drug therapy.

Drugs That Reduce Drugs That Reduce AfterloadAfterload• Angiotensin-converting enzyme Angiotensin-converting enzyme

(ACE) inhibitors(ACE) inhibitors• Human B-type natriuretic Human B-type natriuretic

peptidespeptides

Interventions That Interventions That Reduce PreloadReduce Preload• Diet therapyDiet therapy• Drug therapy Drug therapy

– DiureticsDiuretics– Venous vasodilatorsVenous vasodilators

Drugs That Enhance Drugs That Enhance ContractilityContractility• DigitalisDigitalis

– Digitalis toxicity includes anorexia, Digitalis toxicity includes anorexia, fatigue, changes in mental status.fatigue, changes in mental status.

– Monitor heart rate and electrolytes.Monitor heart rate and electrolytes.• Other inotropic drugs including Other inotropic drugs including

dobutamine, milrinone, and dobutamine, milrinone, and levosimendanlevosimendan

• Beta-adrenergic blockers Beta-adrenergic blockers

Other Nonsurgical Other Nonsurgical Options Options • Continuous positive airway Continuous positive airway

pressure pressure • Cardiac resynchronization Cardiac resynchronization

therapytherapy• Investigative gene therapyInvestigative gene therapy

Surgical ManagementSurgical Management

• Newer surgical therapies include Newer surgical therapies include the following:the following:– Partial left ventriculectomyPartial left ventriculectomy– Endoventricular circular patchEndoventricular circular patch– Acorn cardiac support deviceAcorn cardiac support device– Myosplint Myosplint

Activity IntoleranceActivity Intolerance

• Interventions include:Interventions include:– Ventilation assistanceVentilation assistance– Hemodynamic regulationHemodynamic regulation– Energy managementEnergy management– Interdisciplinary interventions, Interdisciplinary interventions,

which regulate energy to prevent which regulate energy to prevent fatigue and optimize functionfatigue and optimize function

Potential for Pulmonary Potential for Pulmonary EdemaEdema• Interventions include:Interventions include:

– Assess for early signs, such as crackles Assess for early signs, such as crackles in the lung bases, dyspnea at rest, in the lung bases, dyspnea at rest, disorientation, and confusion.disorientation, and confusion.

– Rapid-acting diuretics are prescribed, Rapid-acting diuretics are prescribed, such as Lasix or Bumex.such as Lasix or Bumex.

– Oxygen is always used.Oxygen is always used.– Strictly monitor fluid intake and Strictly monitor fluid intake and

output.output.

Valvular Heart Disease Valvular Heart Disease

• Mitral stenosisMitral stenosis• Mitral regurgitation Mitral regurgitation

(insufficiency)(insufficiency)• Mitral valve prolapse Mitral valve prolapse • Aortic stenosisAortic stenosis• Aortic regurgitation Aortic regurgitation

(insufficiency)(insufficiency)

Assessment Assessment • Client may become suddenly ill or Client may become suddenly ill or

slowly develop symptoms over many slowly develop symptoms over many years.years.

• Question client about attacks of Question client about attacks of rheumatic fever, infective rheumatic fever, infective endocarditis, and possibility of IV endocarditis, and possibility of IV drug abuse.drug abuse.

• Obtain chest x-ray, echocardiogram, Obtain chest x-ray, echocardiogram, and exercise tolerance test.and exercise tolerance test.

Common Nursing Common Nursing DiagnosesDiagnoses• Decreased Cardiac Output related to Decreased Cardiac Output related to

altered stroke volumealtered stroke volume• Impaired Gas Exchange related to Impaired Gas Exchange related to

ventilation perfusion imbalanceventilation perfusion imbalance• Activity Intolerance related to inability Activity Intolerance related to inability

of the heart to meet metabolic of the heart to meet metabolic demands during activitydemands during activity

• Acute Pain related to physiologic injury Acute Pain related to physiologic injury agent (hypoxia)agent (hypoxia)

Nonsurgical Nonsurgical Management Management • Drug therapy, including diuretics, Drug therapy, including diuretics,

beta blockers, digoxin, oxygen, and beta blockers, digoxin, oxygen, and sometimes nitrates sometimes nitrates

• Prophylactic antibiotic Prophylactic antibiotic • Management of atrial fibrillation, Management of atrial fibrillation,

cardioversioncardioversion• AnticoagulantAnticoagulant• Rest with limited activityRest with limited activity

Surgical ManagementSurgical Management

• Reparative proceduresReparative procedures• Balloon valvuloplastyBalloon valvuloplasty• Direct, or open, commissurotomyDirect, or open, commissurotomy• Mitral valve annuloplastyMitral valve annuloplasty• Replacement procedures Replacement procedures

Infective EndocarditisInfective Endocarditis• Microbial infection involving the Microbial infection involving the

endocardiumendocardium• Occurs primarily with IV drug abuse, Occurs primarily with IV drug abuse,

valvular replacements, systemic valvular replacements, systemic infections, or structural cardiac infections, or structural cardiac defectsdefects

• Possible ports of entry: mouth, skin Possible ports of entry: mouth, skin rash, lesion, abscess, infections, rash, lesion, abscess, infections, surgery, or invasive procedures surgery, or invasive procedures including IV line placementincluding IV line placement

Manifestations Manifestations

• MurmurMurmur• Heart failureHeart failure• Arterial embolizationArterial embolization• Splenic infarctionSplenic infarction• Neurologic changesNeurologic changes• Petechiae (pinpoint red spots)Petechiae (pinpoint red spots)• Splinter hemorrhages Splinter hemorrhages

Interventions Interventions

• AntimicrobialsAntimicrobials• Rest, balanced with activityRest, balanced with activity• Supportive therapy for heart Supportive therapy for heart

failurefailure• AnticoagulantsAnticoagulants• Surgical management Surgical management

Pericarditis Pericarditis

• Inflammation or alteration of the Inflammation or alteration of the pericardium, the membranous pericardium, the membranous sac that encloses the heartsac that encloses the heart

• Dressler’s syndromeDressler’s syndrome• Postpericardiotomy syndromePostpericardiotomy syndrome• Chronic constrictive pericarditisChronic constrictive pericarditis

Assessment Assessment • Substernal precordial pain radiating to Substernal precordial pain radiating to

left side of the neck, shoulder, or backleft side of the neck, shoulder, or back• Grating, oppressive pain, aggravated Grating, oppressive pain, aggravated

by breathing, coughing, swallowingby breathing, coughing, swallowing• Pain worsened by the supine position; Pain worsened by the supine position;

relieved when the client sits up and relieved when the client sits up and leans forwardleans forward

• Pericardial friction rubPericardial friction rub

InterventionsInterventions • Hospitalization for diagnostic Hospitalization for diagnostic

evaluation, observation for evaluation, observation for complications, and symptom reliefcomplications, and symptom relief

• Nonsteroidal anti-inflammatory Nonsteroidal anti-inflammatory drugsdrugs

• Corticosteroid therapyCorticosteroid therapy• Comfortable position, usually sittingComfortable position, usually sitting• Pericardial drainagePericardial drainage

(Continued)(Continued)

InterventionsInterventions (Continued)(Continued)

• Chronic pericarditis: radiation or Chronic pericarditis: radiation or chemotherapychemotherapy

• Uremic pericarditis: dialysisUremic pericarditis: dialysis• PericardiectomyPericardiectomy

Emergency Care of Emergency Care of Cardiac TamponadeCardiac Tamponade• Cardiac tamponade—an extreme Cardiac tamponade—an extreme

emergencyemergency• Increased fluid volumeIncreased fluid volume• Hemodynamic monitoringHemodynamic monitoring• PericardiocentesisPericardiocentesis• Pericardial windowPericardial window• Pericardiectomy Pericardiectomy

Rheumatic Carditis Rheumatic Carditis • Sensitivity response that develops Sensitivity response that develops

following an upper respiratory tract following an upper respiratory tract infection with group A beta-hemolytic infection with group A beta-hemolytic streptococcistreptococci

• Inflammation in all layers of the heartInflammation in all layers of the heart• Impaired contractile function of the Impaired contractile function of the

myocardium, thickening of the myocardium, thickening of the pericardium, and valvular damagepericardium, and valvular damage

Clinical ManifestationsClinical Manifestations• TachycardiaTachycardia• CardiomegalyCardiomegaly• New or changed murmurNew or changed murmur• Pericardial friction rubPericardial friction rub• Precordial painPrecordial pain• Changes in electrocardiogramChanges in electrocardiogram• Indications of heart failureIndications of heart failure• Existing streptococcal infection Existing streptococcal infection

Cardiomyopathy Cardiomyopathy

• Subacute or chronic disease of Subacute or chronic disease of cardiac musclecardiac muscle

• Dilated cardiomyopathy Dilated cardiomyopathy • Hypertrophic cardiomyopathyHypertrophic cardiomyopathy• Restrictive cardiomyopathyRestrictive cardiomyopathy

Interventions Interventions

• Nonsurgical managementNonsurgical management• Surgical managementSurgical management

– CardiomyoplastyCardiomyoplasty– Heart transplantationHeart transplantation