Cardiac valve disorders

7/29/2019 Cardiac valve disorders

1/46

12/17/20

Septal Defects

Chapter 29 (Brunner)

Chapter 41 (Pillitteri: 1206-14)

Septal Defects

Congenital Heart Disorders

Management of Pts with Complications from Heart Disease


HF, Pulmonary Edema, Cardiogenic Shock, Pulmonary Emboli,

Pericardial Effusion, Cardiac Tamponade, & Sudden CardiacDeath/Cardiac Arrest

Outline1. d Pulmonary Blood Flow (Acyontic Defect)

1. Septal Defects

1. Ventricular Septal Defect (VSD)

2. Atrial Septal Defect (ASD)

2. Atrioventricular Canal Defect

3. Patent Ductus Arterious

2. d pulmonary blood flow (cyanotic defect)

1. Tetralogy of Fallot

3. Obstruction of Blood Flow

1. Aortic Stenosis

2. Pulmonary Stenosis

3. Coartation of Aorta

4. Cyanotic Defects (Mixed blood flow)

1. Transposition of Great Vessels

2. Tetralogy of Fallot (also falls under

category of d pulmonary blood flow)


2/46

12/17/20

Question

Meena was born with a ventricular septal

defect. A chief concern that parents of

children with heart disease often report is:

a) infant is gaining weight rapidly.

b) the baby always seems hungry.

c) she seems to have trouble sucking.

d) their babys face appears pale.

d Pulmonary Blood FlowAcyontic Defects


3/46

12/17/20

Septal Defects


Chapter 41 (Pillitteri)

Atrial or ventricular septum has abnormal opening b/t right & left side of heart

Most septal defects are

Congenital

Repaired during infancy or childhood

Adults may develop septal defects as a result of MI or trauma

Symptoms

May not experience symptoms

Or may gradually develop symptoms

Or may rapidly develop heart failure

Types

d pulmonary blood flow

Obstruction of blood flow

Mixed blood flow


Septal DefectsBrunner Chapter 29

Atrial septal defect (ASD)

Right atrial pressures become >than left atrial pressures

Blood begins to flow from rightatrium into left atriuma right-to-left shunt

Symptoms gradually develop

d exercise tolerance

DOE Palpitations

Syncope

Symptoms of rightventricular or CHF

May cause cyanosis

May cause CVA

Ventricular septal defect (VSD)

Extra blood volume causes rightventricle to dilate

Also causes pulmonary vascularcongestion & HTN

Symptoms gradually develop

SOB

Syncope

Chest pain

Symptoms of left ventricularfailure


4/46

12/17/20

Septal Defects

Brunner Chapter 29 Septal DefectTreatment

Vasodilators

left-to-right shunting

s resistance to ventricular ejection

Septal Defect Repair

Percutaneous septal defect repair

Many septal defects can be repaired percutaneously in cardiac cath lab

Post-op care

Same care as post-procedure cardiac cath or PTCA

Pt remains in the hospital for 24 to 48 hours

Surgical septal defect repair

Post-op care

Same as other cardiac surgeries

d Pulmonary Blood FlowAcyontic Defects

Ventricular Septal Defect (acyanotic)

Opening is present in septum b/t two ventricles

Blood gets shunted from left ventricle, across septum,to right ventricle

2 pressure > left ventricle than right ventricle

Refer to next slide

Assessment

May not evident at birth

Usually evident at about 4 to 8 wks Baby becomes easily fatigued when shunting begins

Has abnormal murmur as opposed to functional innocent murmur

Abnormal murmur associated with VSD

Loud, harsh systolic murmur

Heard along left sternal border (at 3rd or 4th intercostal space)

Murmur may be palpable (has thrill vibration)

Functional innocent heart murmurs

Normal heart sounds heard in children

Made as blood flows through the heart


5/46

12/17/20

d Pulmonary Blood Flow

Acyontic Defects

Ventricular Septal Defect (cont)

Ineffective tissue perfusion r/t inefficiency of heart as a pump

Treatment

Must be closed (2 can cause HF)

Can cause right ventricular hypertrophy & d pulmonary artery pressure

2 blood is getting shunted back into pulmonary circulation instead ofgoing out of aorta & to body

85% of VSDs are so small they close spontaneously

Moderate sized VSD are closed by cardiac catheterization

Large sized VSD are closed by open-heart surgery

Requires general anesthesia & cardiopulmonary bypass

Ventricular septal defect is occluded by using a Silastic or Dacron patch As time passes, babys septal tissue will grow across synthetic patch

Prophylactic antibiotics for 6 months to prevent bacterial endocarditis

May participate in normal activities after surgery as long as withoutcomplications

Acyanotic defectsd pulmonary blood flow

Atrial Septal Defect (ASD)

Abnormal opening b/t two atria

Blood ends up shifting from left (oxygenated)

atrium to right (deoxygenated) atrium

2 stronger contraction of left side of heart

Adverse Side Effects

d volume in right side of heart

Inventricular hypertrophy

d pulmonary artery blood flow (like VSD)


6/46

12/17/20


Atrial Septal Defect (ASD) Atrial Septal Defect (ASD) cont

Assessment

Harsh systolic murmur over 2nd or 3rd intercostal space (around pulmonic area)

2 can hear extra blood being shunted across pulmonic valve

This causes pulmonic valve to close later than aortic valve [AKA a split S2]

Fixed splinting of 2nd heart sound is indicative of ASD

Treatment

Elective surgery

Needs to be done b/t 1 3 y/o

2 must be closed b/c baby isat risk for infectious endocarditis & HF

Women are at risk for emboli during pregnancy Closed by:

(1) Cardiac catheterization

or (2) Open-heart surgery(Silastic or Dacron patch to occlude space)

d Pulmonary Blood Flow

Acyontic Defects

1. Ventricular Septal Defect (VSD)

2. Atrial Septal Defect (ASD)

3. Atrioventricular Canal Defect

4. Patent Ductus Arterious

Atrioventricular canal defect

Example


7/46

12/17/20

d pulmonary Blood Flow

Acyontic Defects

Atrioventricular Canal Defect

AKA endocardial cushion defect

Incomplete fusion of endocardialcushion

This is where septum of heartjoins junction of atria & ventricles

AEB low ASD & high VSD; &distorted mitral & tricuspid valves

Blood flow is left-to-right, but mayflow b/t all 4 heart chambers

Approximately 50% of children withtrisomy 21 (Down syndrome) whohave heart disease have this type ofcongenital cardiac defect

d pulmonary Blood FlowAcyontic Defects

Atrioventricular Canal Defect cont

Assessment

ECG often shows 1st -degree heart block

2 impulse is halted before AV node

Symptoms

Same as ASD:

(1) right ventricular hypertrophy

(2) d pulmonary blood flow

(3) fixed S2 splitting

Treatment:

Surgery is always necessary

2 defects are too large to close spontaneously

Requires septal repair & possibly valve repair

Hence, may need prophylactic anticoagulation & antibiotics


8/46

12/17/20


Acyontic Defects

Ductus arterious

An accessory fetal structure that connects pulmonary artery to aorta

Allows babys lungs to be bypassed

Begins to close at birth with 1st breath

Completely closes b/t 7-14 days old

Prostaglandins

when baby begins to breath on own

2 oxygen levels make ductus arteriosus close

d incidence in babies born at higher altitudes

Patent Ductus Arteriosus

Ductus arteriosus fails to close 2 babys prostaglandin levels fail to

d pulmonary Blood FlowAcyontic Defects

Patent Ductus Arteriousus cont

Pathophyiology

Blood gets shunted from aorta(oxygenated blood) topulmonary artery (deoxygenatedblood)

2 to d pressure in aorta

From pulmonary artery

Blood then goes to lungs, topulmonary vein, & thenback to left atrium, to leftventricle, & back to aorta

Hence, blood never makesit out to body

It just continues to getshunted throughpulmonary artery, & thecycle continues


9/46

12/17/20


Acyontic Defects Patent Ductus Arteriousus cont

Adverse Effects

d pressure in pulmonary circulation r/textra shunted blood

Results in right ventricle hypertrophy

Assessment

(1) Widened pulse pressure

(2) Continuous (systolic & diastolic)machinery murmur

Heard at upper left sternal border

Or under left clavicle in older children

Treatment

Prostaglandin Inhibitors

IV indomethacin or ibuprofen

Ibuprofen is becoming drug of choice2 has fewer SEs

Question

Which happening makes an infant high risk for

patent ductus arteriosus?

a) Infant had difficulty beginning respirations.

b) Infants mother had an epidural block for labor.

c) Infants father worked at a sedentary desk job.d) Infants mother had an infection during

pregnancy.


10/46

12/17/20

Obstruction of Blood Flow Defects

1. Aortic Stenosis

2. Pulmonary Stenosis

3. Coartation of Aorta

4. Cyanotic Defects (Mixed blood flow)

1. Transposition of Great Vessels

2. Tetralogy of Fallot

1. Also falls under category of


Obstruction of Blood Flow Coarctation of the Aorta

Narrowing of aortas lumen

2 constricting band

Blood has difficulty passing through

narrowed aorta lumen

Results in BP changes

d BP proximal (close) to coarctation

AEB d BP in heart & upper portions of childs body

& d BP distal to coarctation

Assessment d upper-body BP causes HA & vertigo

But, baby cant tell you

Hence, S&S: irritability, epistaxis, & possible CVA (for dangerouslyd BP)

BP in arms

At least 20 mm Hg > legs (reversal of normal pattern)

For slight coarctation

Absent palpable femoral pulses may be the only symptom

Hence, newborn femoral pulses are always assessed


11/46

12/17/20

Obstruction of Blood Flow

Coarctation of the Aorta

Treatment

Digoxin & diuretics

2 CHF from HTN

Angiography (a balloon catheter)

Surgery

Narrowed portion of aorta is removed & new ends of aorta areanastomosed

Usually occurs before 2 y/o

But, ideal situation would be to operate on adult height

2 prevents strain on incision line as they grow

Girls need to have surgery before childbearing age 2 extra blood volume during pregnancy can cause HF

If surgery is successful, child can expect to live a normal life

Questions

1. If an infant were born with coarctation of the aorta, thisproduces few symptoms at first. An important finding to assess tobest suggest this exists isa) excessive sleeping and crying.

b) presence of a cardiac murmur.

c) elevated body temperature.

d) lack of both femoral pulses.

2. Which of the following is a symptom of coarctation of aorta thata school nurse might notice when the child reaches school age?a) Pain in the legs on physical exercise

b) An especially short attention span

c) Eating little lunch from lack of appetite

d) Abdominal bloating and chronic pain


12/46

12/17/20

Obstruction of Blood Flow

To be covered in Brunner Chapter 29

Cyanotic Defects

Mixed blood flow

1. Transposition ofGreat Vessels

2. Tetralogy ofFallot


13/46

12/17/20

Cyanotic Defect

Mixed blood flow

Transposition of Great Vessels Severe defect that is incompatible with life

Baby is usually cyanotic at birth

Aorta arises from right ventricle instead of left

Pulmonary artery arises from left ventricle instead of

right

Blood flow

Comes into heart from vena cava to right atrium

To right ventricle

Then to aorta (instead of pulmonary artery)

Hence, blood goes out to body completely deoxygenated

There is an existence of a second closed circulatory system

Sp, blood enters heart from pulmonary veins to left atrium

To left ventricle, to pulmonary artery, to lungs to be oxygenated & returns to

left atrium

So, b/c of this closed circulatory system, none of this oxygenated blood ever

makes it out to body

Cyanotic DefectMixed blood flow

Transposition of the Great Vessels

Treatment

Need to get blood to lungs Prostaglandins

2 to keep ductus arteriosus patent Creation of artifical atrial septal defect

2 allows deoxygenated blood to getto lungs for oxygenation

In most cases, baby has an atrial& ventriclular septal defect, aswell as the transposed vessels

Hence, some of deoxygenatedblood is getting oxygenated

Surgical correction of transposed greatvessels

Surgery is done to separate the greatvessels

Performed when baby is about 1 to 3months of age


14/46

12/17/20

Question

Suppose an infant had been born with

transposition of the great vessels so the baby

was prescribed ibuprofen. The purpose of this

medication is to

a) increase blood pressure to reverse blood flow.

b) increase the strength of atrial contractions.

c) decrease and strengthen the heart rate.

d) keep the ductus arteriosus from closing.


Tetralogy of Fallot


15/46

12/17/20


Tetralogy of Fallot

Tetralogy of Fallot

Consists of 4 anomalies

1. Pulmonary stenosis

Causes d pressure in right side of heart

Causes blood to be shunted from right side of heart to left ventricle (via

VSD)

Systolic murmur (heard at left 2nd, 3rd, or 4th intercostal space)

& then out through overriding aorta

2. Hypertrophy of right ventricle

Caused by d force to push blood through stenosed pulmonary artery3. VSD (usually large)

Systolic murmur (heard at left 2nd, 3rd, or 4th intercostal space)

4. Dextroposition (overriding) of aorta

Many children with Tetralogy of Fallot have deletion abnormality of chromosome 22

Tetralogy of FallotAssessment

Squatting in knee-chest position

2 overstressed heart is relieved

Squatting

Traps blood in lower extremities

Helps trapped blood supply oxygen to major body organs

Cyanosis

May not be evident immediately after birth

But, as become more active, skin has bluish tint

Clubbing

Child develops severe dyspnea, growth restriction, & clubbing of the fingers Syncope (fainting) & hypercyanotic episodes

AKA tet spells

2 d blood flow & oxygen to brain (risk for cognitive defects)

Polycythemia (d RBCs)

2 helps supply body with extra oxygen

This is dangerous 2 causes thickening of blood (d viscosity)

Risk for clot; thrombophlebitis, embolism, & CVA

Systolic murmur

Heard at left 2nd, 3rd, or 4th intercostal space

Polycythemia

Systolic

murmur


16/46

12/17/20

Tetralogy of Fallot

Blalock-Taussig Procedure

Temporary surgery

2 Tetralogy of Fallot is not fully

corrected until child is 1-2 y/o

Need to correct, or will cause severe

dyspnea, growth restriction, &

clubbing of the fingers

Prior to surgery

hypercyanotic episodes

Give O2 for hypoxic episode

Place in kneechest position

To trap blood into LEs

Keeps heart from being

overwhelmed

Morphine sulfate

To symptoms

Tetralogy of Fallot

Blalock-Taussig Procedure

A shunt is created b/t aorta & pulmonary artery (it creates

a ductus arteriosus)

Allows blood to leave aorta & enter pulmonary artery to

oxygenate lungs

Blood then returns to left side of heart, to aorta, & out

to body

Uses subclavian artery Hence, at post-op, baby will have no palpable pulse in

right arm

Need to avoid all BPs & venipunctures to affected arm

Brock Procedure

Corrects pulmonary stensosis, VSD, & overiding aorta

Performed when child is old enough to have full surgery to

correct pulmonary stensosis, VSD, & overriding aorta


17/46

12/17/20

Question

1. Tetralogy of Fallot is the most frequently occurring type of cyanotic heart

disease. What are the four anomalies associated with this defect are:

a) atrial septal defect, pulmonary stenosis, left ventricular hypertrophy, and

overriding aorta.

b) ventricular septal defect, aortic stenosis, mitral stenosis, and right-sided

aorta.

c) mitral stenosis, right ventricular hypertrophy, pulmonary stenosis, and atrial

septal defect.

d) ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy,

and overriding aorta.

2. Suppose an infant with Tetralogy of Fallot turns cyanotic and short of breath.

Your best action would be to:

a) put her head between her legs.

b) place her in a knee-chest position.

c) tell her to breathe into a paper bag.

d) sit her upright to lower blood pressure.

Questions

1. What is a common laboratory finding with children withcyanotic heart disease?a) Decreased platelet count

b) Elevated sedimentation rate

c) Elevated total red cell count

d) Elevate white blood count

2. The best place to assess if cyanosis is present in childrenis in thea) conjunctiva of the lower eyelid.

b) fingertips or toes for color.

c) circumoral area by the mouth.

d) tongue or buccal membrane.


18/46

12/17/20

Questions

1. A baby had a cardiac catheterization to diagnose congenitalheart disease. Following cardiac catheterization, which of thefollowing is the most important measure?a) Assessing the pressure dressing is intact

b) Assuring the baby the procedure is now over

c) Letting the baby adjust to room light gradually

d) Letting the baby kick and exercise her legs

2. Which nursing diagnosis would best apply to an infant withTetralogy of Fallot?a) Impaired gas exchange related to a left to right septal shunt

b) Impaired skin integrity related to consistent cyanosisc) Ineffective airway clearance related to a constricted aorta

d) Altered tissue perfusion related to pulmonary artery stenosis

Questions

1. An infant is prescribed digoxin. The action of digoxin is toa) increase the heart rate and dilate blood vessels.

b) slow heart rate and strengthen heart contractions.

c) decrease the amount of blood filling the ventricles.

d) stimulate angiotension to increase blood pressure.

2. What is the usually designated level of pulse rate considered safe

for administration of digoxin for a 6-month-old infant?a) 40 beats per minuteb) 60 beats per minute

c) 100 beats per minute

d) 150 beats per minute


19/46

12/17/20

Chapter 30

Managing Pts with

Complications from

Heart Disease

HF, Pulmonary Edema,

Cardiogenic Shock, PulmonaryEmboli, Pericardial Effusion,

Cardiac Tamponade, & Sudden

Cardiac Death/Cardiac Arrest

Heart Failure

Inability of heart to pump sufficient blood to meet needs of tissues for oxygen &

nutrients

Incidence of HF s with age

Most common in pts > 75 y/o

Most HF is a progressive, lifelong disorder managed with lifestyle changes &

meds

Recognized as a Syndrome AEB

Fluid overload

or inadequate tissue perfusion

2 heart cant generate sufficient CO to meet bodys demands

Ejection fraction (EF)

Assists in determining HF type

WNL EF is 55% to 65% of ventricular volume

2 ventricle does not completely empty b/t contractions


20/46

12/17/20

Heart Failure

2 major types of HF

Systolic heart failure

More common type

Characterized by altered ventricular contraction

Low EF is a hallmark of systolic HF

EF is < 55% to 65% of ventricular volume

Diastolic heart failure

Less common type

Characterized by stiff & noncompliant heart muscle

Makes it difficult for ventricle to fill

EF is normal

Heart Failure

Primary Cause

Atherosclerosis of coronary

arteries

in CO activates multiple

neurohormonal mechanisms

Results in S&S of HF

Compensatory mechanisms of HF

AKA vicious cycle of HF


21/46

12/17/20

Heart Failure Symptoms Left-sided HF

Pulmonary congestion Occurs when left ventricle cant effectively pump blood out of ventricle

into aorta & to systemic circulation

d pulmonary venous blood volume & pressure

This forces fluid from pulmonary capillaries into

pulmonary tissues & alveoli

Results in pulmonary edema AEB

Dyspnea

Cough

May have frothy pink tinged

sputum pink 2severe pulmonary edema

Pulmonary crackles Low O2 sat

Heart Sounds

May have S3 heart sound ventricular gallop,

2 large volume of fluid entering ventricle at beginning of diastole

Heart FailureRight-sided HF As right ventricle fails, it will cause congestion in peripheral

tissues & viscera

2 right side of heart

Cant eject blood

Cant accommodate blood that normally returns

from venous circulation

d venous pressure leads to

JVD

& d capillary hydrostatic pressure

throughout venous system

Systemic S&S

Lower extremity edema (dependent edema)

Usually affects feet &ankles

Worsens when stands or sits for long period

Hepatomegaly (enlarged liver)

Ascites (fluid in peritoneal cavity)

Anorexia & nausea, & weakness

Weight gain 2 retention of fluid


22/46

12/17/20

Questions

Heart Failure

Overall goals

Relieve symptoms

Improve functional status & quality of life

Extend survival

Treatment options Vary according to severity of condition

Meds

Major lifestyle changes

Supplemental oxygen

Implantation of assistive devices

Cardiac transplantation


23/46

12/17/20


24/46

12/17/20

Questions1. Medications routinely prescribed for systolic HF

a. ACE inhibitors (eg, lisinopril [Prinivil, Zestril])

b. Beta-blockersc. Diuretics

d. Digitalis

2. Which of the following is a primary cause of chronic heart failure?

a. Atherosclerosis

b. Valvular dysfunction

c. Hypertension

d. Cardiomyopathy

Suppose an infant develops congestive heart failure. An important nursing

intervention would be to

a) restrict milk or dairy-product intake.

b) Maintain a semi-Fowlers position.

c) plan ways to reduce potassium intake.

d) Keep lower extremities elevated.

Heart Failure Systolic HF Meds

ACE Inhibitors

Prescribed for mild failure AEB

Fatigue or DOE

But, without signs of fluid overload &

pulmonary congestion

Start at low dose for 2 weeks

Then until optimal dose is achieved & is

hemodynamically stable

Angiotensin II receptor blockers

An alternative to ACE inhibiters

2 some pts cant tolerate ACE inhibitors

AEB develops cough, d creatinine level,

or hyperkalemia

Or combo of hydralazine (antihypertensive) &

isosorbide dinitrate (vasodilator)

Drug tx specifically indicated for African

Americans with HF


25/46

12/17/20

Systolic HF Meds

Beta-blockers

(carvedilol (Coreg)

& metoprolol (Lopressor, Toprol)

adverse effects from constant SNS stimulation

B/c of SEs, when pt is stable & euvolemic (WNL volume),

pt is started low dose

Dose is titrated slowly (every 2 weeks)

Educate after each titration:

Risk for potential worsening of symptoms

& improvement may take several week

2 beta-blockers can cause bronchioleconstriction

Ex. beta-1selective betablocker blocks

beta-adrenergic receptor sites in heart

Systolic HF Meds

Beta-blockers (cont)

Asthma

Well-controlled, mild to moderate asthma

Recommend metropolol

But, still need to monitor closely for d asthma symptoms

2 cardioselective beta-blockers retain some beta-2 effects

Severe or uncontrolled asthma

All types of beta-blocker are contraindicated


26/46

12/17/20

Systolic HF Meds

Systolic HF Meds


27/46

12/17/20

Systolic HF Medications

IV Systolic HF Meds

Nesiritide (Natrecor)

A BNP to tx acute decompensated HF

BNP is naturally produced by myocardium as compensatory mechanism

in response to HF, such as:

d ventricular end-diastolic pressure

& d release ofneurohormones (eg, norepinephrine, renin,

aldosterone)

Causes arterial & venous dilation

Suppresses neurohormones responsible for fluid retention

Promotes diuresis

Results in d preload & afterload

& d SV

Most common side effect

Dose-related hypotension

Systolic HF Medications

IV Systolic HF Meds (cont)

Milrinone (Pimacor)

Delays release of calcium from cell

Prevents uptake of extracellular calcium

Promotes vasodilation

Resulting in d preload & afterload

& d cardiac workload.

Administered if has not responded to other therapies

Major side effect is hypotension

Dobutamine (Dobutrex)

Given for significant left ventricular dysfunction & hypoperfusion

Stimulates the beta-1adrenergic receptors to cardiac contractility


28/46

12/17/20

Question

Tell whether the following statement is true or

false.

Digoxin immune FAB (Digibind) may be given to

treat severe digoxin toxicity.

Questions


29/46

12/17/20

Questions

Heart Failure

Nutritional Therapy

Low-sodium (2 to 3 g/day) diet

Dietary restriction of sodium

s fluid retention & symptoms of peripheral and pulmonary congestion

Purpose of sodium restriction

amount of circulating blood volume

smyocardial work Need to avoid drinking excessive amounts of fluid

Pt compliance is important

2 dietary indiscretions may result in severe exacerbations of HF

requiring hospitalization

Oxygen therapy

May become necessary as HF progresses


30/46

12/17/20

3

Heart FailureOther Interventions

PCI or CABG: for underlying CAD

Implantable cardioverter defibrillator (ICD)

For pts with severe left ventricular dysfunction & possibility of life-threatening

dysrhythmias

HF places pt at high risk for dysrhythmias

2 sudden cardiac death is common cause of death for pts advanced HF

Cardiac resynchronization therapy (CRT)

For pts with conduction defect

Example: left bundle branch block is frequently seen in HF

Results in dyssynchronous conduction & contraction of both

ventricles, which can further EF

CRT uses of biventricular pacemaker

Txs conduction defects

Improves CO

s mitral regurgitation

Slows ventricular remodeling process

Heart Failure

Other Interventions (cont)

Ultrafiltration

To tx severe fluid overload

Removes fluid via small bedside machine

Implanted ventricular assist device

A mechanical circulatory assistance device

Serves as bridge therapy to a cardiac transplant Cardiac transplantation

May be only option for long-term survival.


31/46

12/17/20

3

Care of the Patient with HF

Assessment Mental status

Assess for confusion

2 EF s O2 to brain

Lung sounds

Assess for crackles & wheezes

Heart sounds

Assess for S3 S3 means heart is failing & d blood is filling ventricle with each beat

Fluid status/signs of fluid overload

JVD: estimates central venous pressure

Abnormal: > 3 cm above the sternal angle

Hepatojugular reflux of Liver Apply pressure to right upper abdominal quadrant for 30 to 60 seconds

If neck vein distends > 1 cm, then positive for d venous pressure

Care of Patient with HFAssessment (cont)

Dependent edema

d SV can cause perfusion to periphery AEB

Cool, pale, cyanotic skin

Edema to sacrum, back, & hands, & fingers

Daily weight

Weigh at same time of day, with same type of clothing, & on same scale

Notify the MD if gained 2- to 3-lb in a day

Or 5-lb in a week (may need diuretics adjusted) I&O

Assess if ingested more fluid than excreted (positive fluid balance)

Compare positive fluid balance to any gain in weight

Monitor for oliguria

d urine output, < 500 mL/24 h

Monitor for anuria

Urine output < 50 mL/24 h

Monitor responses to meds


32/46

12/17/20

3

Questions

Questions


33/46

12/17/20

3

Care of Patient with HF

Nursing Diagnoses

Activity intolerance & fatigue r/t d CO

Excess fluid volume r/t HF syndrome

Anxiety r/t breathlessness from inadequate oxygenation

Powerlessness r/t chronic illness & hospitalizations

Ineffective therapeutic regimen management r/t lack of

knowledge

Heart Failure

Major Teaching Goals

Promote activity and fatigue

Relieving fluid overload symptoms

anxiety

ability to manage anxiety Verbalizes ability to make decisions & influence

outcomes

Verbalizes understanding about self-care program


34/46

12/17/20

3

Activity Intolerance

Bed rest for acute exacerbations

Encourage regular physical activity (AEB 30 minutes daily)

Exercise training

Pacing of activities

Wait 2 hours after eating before doing physical activity

Avoid activities in extremely hot, cold, or humid weather.

Modify activities to conserve energy.

Positioning

HOB (semi-Fowlers) to facilitate breathing & rest, andsupport of arms

Caring for HF

Fluid Volume Excess

Assess for symptoms of fluid overload

Daily weight

I&O

Diuretic therapy

Fluid intake

Fluid restriction

Maintenance of sodium restriction (refer to Chart 30-4)

Lifestyle changes & meds to education to:

(1) number of recurrences of acute HF

(2) life expectancy

(3) unnecessary hospitalizations


35/46

12/17/20

3

Patient Teaching for HFSelf-Care Program

Meds

Timing of med administration Oral diuretics should be taken early in morning

2 diuresis wont interfere with nighttime rest

Diet

Low-sodium diet & fluid restriction

Low sodium foods

Example: Potatoes & chicken

High sodium foods

Example: Ham, sardines, & bouillon

Monitor for signs of excess fluid:

Example daily weight

Exercise & activity program

Stress management

Prevention of infection

Know how & when to contact health care provider

Include family in teaching


36/46

12/17/20

3

Pulmonary Edema

Abnormal accumulation of fluid in

interstitial spaces of lungs that

diffuses into alveoli

Resistance to left ventricular

filling

Causes blood to back up into

pulmonary circulation

Can result in flash

pulmonary edema

Etiology

MI

Exacerbation of chronic HF

Renal failure

S&S

LOC

Hypoxemia

Restlessness

Anxiety

Dyspnea

Cool & clammy skin

Cyanosis

Weak & rapid pulse

Cough

sputum production (maybe mucoid, frothy & blood-

tinged)

Lung congestion

Moist, noisy respirations

Pulmonary EdemaPathophysiology


37/46

12/17/20

3

Management of Pulmonary Edema Prevention

Early recognition

Monitor lung sounds

Signs of d activity tolerance

Signs of d fluid retention

Place pt upright & dangle legs

Oxygen

exertion & stress

As ability to breathe s, pts fear

& anxiety s

Makes condition more severe.

Hence, pt is unstable, nurse must

remain with pt

Medications

Morphine

Assess for resp depression,

hypotension,vomiting

Keep morphine antagonist

(naloxone hydrochloride

(Narcan) available

Give if exhibits serious

respiratory depression

Diuretic (furosemide)

If on continuous IV of vasoactive

meds

Needs to be on ECG

monitoring & frequent VS

(BP, pulse, resp)


38/46

12/17/20

3

Pulmonary Edema

Case Study (cont)

Pulmonary EdemaCase Study (cont)


39/46

12/17/20

3

Potential Complications of HF

Cardiogenic shock

Dysrhythmias

Thromboembolism

Pericardial effusion

Cardiac tamponade

Complications of HFCardiogenic Shock

Life-threatening condition with a high mortality rate

CO leads to inadequate tissue perfusion & initiation of shock syndrome.

High risk pts

S/p MI

End-stage HF

Cardiac tamponade

Pulmonary embolism

Cardiomyopathy

Dysrhythmias.

S&S: symptoms of HF, shock state, & hypoxia

Pt is managed in ICU to assess:

Cardiac rhythm

Hemodynamic parameters

Fluid status

Action of meds


40/46

12/17/20

4

Complications of HF

Cardiogenic Shock

Management

Correct underlying problem

Meds

Diuretics

Positive inotropic agents

Vasopressors

Circulatory assist devices

Intra-aortic balloon pump

(IABP)

Cardiogenic Shock

Complications of HF

Cardiogenic Shock

Mechanical Circulatory Assistive Devices

Intra-Aortic Balloon Pump

Uses internal counterpulsation

through inflation & deflation of

balloon

Augments pumping action of heart

Balloon inflates during diastole

s perfusion of coronary &

peripheral arteries

Balloon deflates just before systole

s afterload

resistance to ejection

left ventricular workload

inflates

deflates


41/46

12/17/20

4

Complications of HF

Thromboembolism

Intracardiac thrombi

Especially common in pts with A-fib

Pulmonary embolism

Most common complication of HF

Hence, HF places pt at d risk for

pulmonary embolism

2 d mobility & d

circulation

2 blood clots may form in

deep veins of legs & embolize

to pulmonary vasculature

Results in life-threatening

embolic eventPulmonary emboli may be single or multiple

Questions


42/46

12/17/20

4

Complications of HF

Pericardial Effusion Accumulation of fluid in pericardial sac May accompany advanced HF

Normally, pericardial sac contains20 mL of fluid

2 s friction as heart beats

d fluid in pericardial sac causes:

pressure inside pericardialsac

& compresses heart

Slow in pericardial fluid

Results in no noticeablesymptoms.

Rapid in pericardial fluid

Results in stretchingpericardium to maximum size

Results in CO

Results in cardiactamponade (compressionof heart)

S&S of Pericardial Effusion

Feeling of pressure in chest Engorged neck veins

SOB

Labile or low BP

Pulsus paradoxus

Systolic BP is markedly lower

during inhalation

AEB > 10 mm Hg in

systolic BP during

inhalation & exhalation

Refer to next slide

Pulsus Paradoxus Normal conditions of rest

Inspiration will cause a of arterial systolic pressure of < 10 mm Hg occurs

Inspiration will cause a fall in venous pressure

Paradoxical pulse

Pulsus paradoxus differs from a normal pulse in two respects

1) inspiration will cause a in arterial pressure is > 10 mm Hg

2) inspiraion will cause venous pressure to remain steady or increases.

The exaggerated waxing & waning in pulse volume can usually be

palpated & demonstrated with a sphygmomanometer or arterial catheter.


43/46

12/17/20

4

Complications of HFCardiac Tamponade

Restricts heart function

Results in:

d venous return

CO

S&S of cardiac tamponade 2 pericardial effusion

CO causes pt to feel anxiety, faintness, & SOB

Cough

2 swelling of pericardial sac causes pressureon trachea

Distended neck veins

2 venous pressure

Paradoxical pulse

Indicative sign of: cardiac tamponade,

pericarditis chronic sleep apnea, COPD,asthma

AEB > 10 mm Hg in systolic BP during

inhalation & exhalation

Muffled or distant heart sounds

Cardinal signsing systolic BP

Narrowing pulsepressureing venous pressureDistant heart sounds

Cardiac Arrest Heart ceases to produce effective pulse & circulate blood

Causes

Dysrhythmia (e.g. V-Fib)

Profound bradycardia

Asystole (absense of a cardiac rhythm)

Respiratory arrest

Pulseless electrical activity (PEA)

Electrical activity is present

But, has no effective cardiac contraction or circulating volume

Causes

Hypovolemia (eg, from excessive bleeding)

Hypoxia,

Hypothermia

Hyperkalemia

Massive pulmonary embolism

MI

Med overdose (eg, beta-blockers, calcium channel blockers).


44/46

12/17/20

4

Cardiac Arrest

Assessment

Pt will immediately lose consciousness, pulse, & BP

Pupils will begin dilating within 45 seconds.

Seizures may or may not occur

Risk of irreversible brain damage & death

s with every minute from time that circulation ceases

Need to take immediate measures to restore circulation

Cardiac ArrestInterventions

Provide CPR

2 s blood flow to vital organs until effective

circulation can be reestablished

Start CPR after recognition of unresponsiveness,

lack of pulse & respiration

First

Assess LOC (which is first step in basic life

support) Shake pts shoulders & shout, "Are you OK?"

Second

Open airway & check for respirations

If breathing is absent, give two mouth-to-

mouth breaths

Then check circulation by palpating carotid

artery

Once LOC is restored

Priority for adults

Activate code teamor EMS

911 home

77 SVC

Exceptions

Near drowning

Drug or medoverdose

Respiratory arrest

These need 2minutes of CPRperformed beforeactivating EMS


45/46

12/17/20

4

Sudden Cardiac Death/Cardiac Arrest

The ABCDs of Basic CPR A- airway

Maintain an open airway

B- breathing

Provide artificial ventilation by rescue breathing

C- circulation

Promote artificial circulation by external cardiac compression if has no

pulse

Give meds (example: epinephrine for asystole)

D- defibrillation for VT and VF; with standard defibrillator

Perform CPR initially only if defibrillator is not immediately available.

Survival rate s for every minute defibrillation is delayed

Pts who have not been defibrillated within 10 minutes, have little chance

of survival.

Question

1. All of the following are clinical manifestations ofright-sided heart failure except:a. Hepatomegaly

b. Jugular vein distention

c. Ascites

d. Orthopnea

2. Tell whether the following statement is true orfalse.The most reliable sign of cardiac arrest is absence of

breath sounds.


46/46

12/17/20

Questions

Cardiac valve disorders

Documents

Transcript of Cardiac valve disorders