med surg ch 34, CD-ROM pp

Slide 1Copyright © 2007 Lippincott Williams & Wilkins.

Timby/Smith: Introductory Medical-Surgical Nursing, 9/e

Chapter 34: Caring for Clients With Heart Failure


IntroductionInability of the heart to pump sufficient blood; ejection fractionDecreased amount of ejected blood Echocardiogram: Measurement of ejection fractionCongestive heart failure

Accumulation of blood and fluid in organs Tissues from impaired circulation

Heart Failure


Figure 34-1Right and left cardiac pumps

Heart Failure


Heart Failure

TypesClassification factors: Develops—acute or chronic; location—right- or left-sided failureAcute and chronic heart failure

Acute: Change in heart contraction; pulmonary edema Chronic: Prolonged impaired contractility; four stages

Left-sided and right-sided heart failureFactors: Location of pumping dysfunctionLeft-sided heart failure: Conditions that impair ejection of blood into the aorta


Heart Failure

TypesLeft-sided and right-sided heart failure (cont’d)

Right-sided heart failure: Failure to eject total diastolic filling volume into the pulmonary arteryLeft-sided failure is a major cause

Pathophysiology and EtiologyTwo mechanisms

1. Inability of the heart muscle to contract

Myocardial infarction (MI) leads to acute heart failure


Heart Failure

Pathophysiology and Etiology (Cont’d)2. Cardiomyopathy and hypertensionLeft-sided heart failure

Causes: Failure of contraction; congested blood; impaired gas exchange; accumulation of CO2 in the blood; factors contributing to chronic heart failureConditions reducing cardiac output

Increased afterload Reduction of ventricular ejection volume and loss of elasticity


Heart Failure

Pathophysiology and Etiology (Cont’d)Right-sided heart failure

CausesFailure of forceful contraction to expel blood into the pulmonary arteryCongested blood; myocardial infarction; cor pulmonaleChronic respiratory disorders

Pulmonary arterial vasoconstrictionPulmonary hypertension


Heart Failure

Pathophysiology and Etiology (Cont’d)Compensatory mechanisms

Increase stroke volume and maintain blood pressureTemporarily improve the client’s cardiac output; fails when contractility is further compromisedHypotensive: Cardiac output falls; release of catecholamines; increase myocardial oxygenEpinephrine: Supplies blood to vital organs of brain and heart; decreased blood supply to the kidneys


Heart Failure

Pathophysiology and Etiology (Cont’d)Compensatory mechanisms

Initiation of renin-angiotensin-aldosterone mechanismSecretion of B-type natriuretic peptide: Cardioprotective and functionsFailure of compensatory mechanisms to restore homeostasisDecrease cardiac outputVentricle of the heart experiences dysfunction


Heart Failure

Assessment Findings: Signs and Symptoms

Severity of symptoms: Body’s ability to adjust to the decreased cardiac outputLeft-sided heart failure

Hypoxemia; fatigueExertional dyspnea; orthopnea Rapid or irregular pulse, paroxysmal

nocturnal dyspnea, cough, restlessnessHemoptysis; elevated BPRespiratory findings—crackles Diminished urine output; left-sided heart failure with pulmonary edema


Heart Failure

Assessment Findings: Signs and Symptoms

Right-sided heart failure

Weight gain from fluid retention; pitting edema—feet and ankles; ascitesHepatomegaly Jugular veins Enlarged abdominal organsAccumulation of blood in abdominal organs

Figure 34-3Pitting edema


Heart Failure

Assessment Findings: Diagnostic FindingsLeft-sided heart failure

Chest radiography; echocardiogramMultigated acquisition scan (MUGA)

Decrease in the ejection fractionGamma camera: Radioactive; contraindicated—diuretics; medicated to relieve cough; allergic reactionsArterial blood gas analysis; serum sodium levelsBlood urea nitrogen Hemodynamic monitoringPulmonary artery catheter; BNP levels


Heart Failure

Diagnostic FindingsRight-sided heart failure

Chest radiograph, ECG, and echocardiograph Lung scan; pulmonary arteriography Impaired liver: Elevated liver enzymesVentricular enlargement

Cor pulmonale; liver enzymes


Heart Failure

Medical Management Drug therapy

Digoxin: Slow and strengthen the heartDigitalization; apical heart rate Digitalis drugs: Drugs are withheld Diuretic therapy: Decreases exertion Digitalis toxicity; vasodilators reduce afterload; angiogenesisDrug therapy for clients with

History of heart failure—ACE inhibitors


Heart Failure

Medical Management Cardiac resynchronization therapy (CRT)

Synchronizes contractions of the right and left ventriclesUsed for heart failure caused by dilated cardiomyopathyBiventricular pacemaker; dual ventricular lead stimulation

Intra-aortic balloon pump (IAPD)Used in cardiogenic shock and left ventricular heart failure


Heart Failure

Medical ManagementIntra-aortic balloon pump (cont’d)

FunctionsTemporary Secondary Mechanical Circulatory pump

ProcedureLeft femoral artery, counterpulsation

Figure 34-4Intra-aortic balloon

pump


Heart Failure

Surgical ManagementSurgery; insertion of a VAD Cardiomyoplasty; artificial heartVentricular assist device (VAD)

Type of clients; LVAD Types of VADs Function: Auxiliary heart pump

CardiomyoplastyChest muscle grafted to aorta Electrical stimulatorVentricular containment procedure


Heart Failure

Figure 34-5

LVAD pump

Figure 34-6Cardiomyoplasty


Heart Failure

Surgical ManagementPartial ventriculectomy and ventricular restoration

Poor resultsSurgical ventricular restoration (SVR)

Decreases size of heart Coronary artery bypass

Artificial heart Age group; long-term use Complications; AbioCor


Heart Failure

Nursing ManagementControl heart failure: Medications, lifestyle changes, and diet restrictionsNursing interventions

Monitor therapeutic and adverse effects; signs of excess fluid volume and evidence of electrolyte imbalance Promote heart’s ability to eject blood

Promote oxygenation; client and family education


Nursing Process: The Client With Congestive Heart Failure

AssessmentClient history, symptoms, and medications; physical assessmentObserve dyspnea, vital signs, weight, and distended neck veins; auscultate apical heart rate Signs of peripheral edema, lethargy, or confusionMonitor lab results; report abnormalitiesAbdominal girth; respiratory difficultiesNocturnal dyspnea; pulse oximetry



Diagnosis, Planning, and InterventionsDecreased cardiac outputExcess fluid volumeRisk for impaired gas exchangeActivity intolerance Expected outcome

Client willHave increased cardiac output Have reduced fluid volumeMaintain adequate gas exchangeTolerate activity associated with daily living



Diagnosis, Planning, and InterventionsNurse

Monitors for evidence of hypokalemia


Pulmonary Edema

IntroductionFluid accumulation in the lungs Interferes with gas exchange in alveoliNoncardiogenic pulmonary edema—ARDSCauses: Pulmonary embolism, infection, and blast injury

Pathophysiology and EtiologyCardiogenic pulmonary edema

Left ventricle becomes incapable of maintaining sufficient output of bloodRetrograde fluid accumulation; effects of hyperventilation; respiratory acidosis; metabolic acidosis


Pulmonary Edema

Assessment Findings: Signs and SymptomsSudden dyspnea, wheezing, orthopnea, restlessness, and cough—pink frothy sputum Cyanosis; tachycardia; severe apprehensionRespiratory sound; pulmonary artery catheter; hypotensive and loss of peripheral pulses; radiographs; ABGs

Medical ManagementRelieve lung congestion: Can be fatalInotropic medications; supplemental oxygen Mechanical ventilation; surgical procedure


Pulmonary Edema

Medical Management Drug therapy

Inotropic agents, diuretics, morphine, ACE inhibitors, and calcium channel blockersIV administration: Force of ventricular contraction; reduction of myocardial oxygen consumptionPromote vasodilation; lessen anxiety

Oxygenation Facilitate gas exchange; methods of administration; respiratory failure—intubation, CPAP, and PEEP


Pulmonary Edema

Medical Management Invasive measures

Insertion of an IABP, biventricular pacemaker, or LVADCardiomyoplasty: Artificial heart and heart transplantation

Nursing ManagementCritically ill clients: Pulmonary artery catheter insertion; urinary catheter Monitoring equipment: Mechanical ventilation


General Considerations

NutritionalEdema; dietary changes—sodium restriction; weight lossDyspnea and nausea; small meals

PharmacologicMild heart failure: Thiazide diuretics Severe heart failure: Loop diuretic; clients not responding to digitalis and diuretics Digitalis preparations; eat foods high in potassiumDrug therapy for acute pulmonary edema Common drugs


General Considerations

Gerontologic Older clients

Dyspnea on exertionChange in mental statusVascular changesDrug historyAge-related changesRisk for toxicityLimited finances


End of Presentation

med surg ch 34, CD-ROM pp

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