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Transcript of 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
Slide 2Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 3Copyright © 2007 Lippincott Williams & Wilkins.
Figure 34-1Right and left cardiac pumps
Heart Failure
Slide 4Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 5Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 6Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 7Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 8Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 9Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 10Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 11Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 12Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 13Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 14Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 15Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 16Copyright © 2007 Lippincott Williams & Wilkins.
Heart Failure
Medical ManagementIntra-aortic balloon pump (cont’d)
FunctionsTemporary Secondary Mechanical Circulatory pump
ProcedureLeft femoral artery, counterpulsation
Figure 34-4Intra-aortic balloon
pump
Slide 17Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 18Copyright © 2007 Lippincott Williams & Wilkins.
Heart Failure
Figure 34-5
LVAD pump
Figure 34-6Cardiomyoplasty
Slide 19Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 20Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 21Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 22Copyright © 2007 Lippincott Williams & Wilkins.
Nursing Process: The Client With Congestive Heart Failure
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
Slide 23Copyright © 2007 Lippincott Williams & Wilkins.
Nursing Process: The Client With Congestive Heart Failure
Diagnosis, Planning, and InterventionsNurse
Monitors for evidence of hypokalemia
Slide 24Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 25Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 26Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 27Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 28Copyright © 2007 Lippincott Williams & Wilkins.
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
Slide 29Copyright © 2007 Lippincott Williams & Wilkins.
General Considerations
Gerontologic Older clients
Dyspnea on exertionChange in mental statusVascular changesDrug historyAge-related changesRisk for toxicityLimited finances
Slide 30Copyright © 2007 Lippincott Williams & Wilkins.
End of Presentation