CARING FOR CLIENTS WITH HEART FAILURE

MEDICAL SURGICAL

CARING FOR CLIENTS WITH HEART FAILURE

HEART FAILURE

The heart is a double pump. The right side pumps
deoxygenated blood to the lungs to be oxygenated. The left side pumps that
oxygenated blood into the systemic circulation . If either one of the sides
doesn’t work properly it will effect systemic circulation.

Heart failure is the inability of the heart to
pump a sufficient amount of blood to meet the body’s metabolic needs.

Congestive heart failure (CHF) is the
accumulation of blood and fluid within organs & tissues due to impaired
circulation

HEART FAILURE

Ejection fraction is an estimation of the heart’s efficiency as
a pump. It is a measurement of the % of blood that the left ventricle ejects
when it contracts

Normal is 55% or greater

CLASSIFICATION OF HEART FAILURE – table 34-1

ACUTE - a sudden change in the heart’s ability
to contract that can lead to life threatening symptoms and pulmonary edema

CHRONIC – occurs when some other chronic
condition gradually comprises the heart’s ability to pump effectively

Left and Right Sided Heart Failure

LEFT SIDED HEART FAILURE – when the left
ventricle does not eject blood into the aorta normally

RIGHT SIDED HEART FAILURE – when the right
ventricle fails to eject it’s total filling volume into the pulmonary
artery, causing congestion in the venous vascular system. Most common
cause of right sided heart failure is left sided heart failure

Pathophysiology & Etiology

Inability of the heart muscle to contract forcefully because of
direct damage to the heart wall:

Acute MI

When the pumping chambers enlarge & weaken & are unable to
eject all the blood received

Cardiomyopathy

HTN

Diagnostic Findings

Left sided failure

cxr shows cardiac enlargement

echocardiogram shows enlarged left ventricle,
decreased ejection fraction

MUGA scan measures the ejection fraction more
accurately

Right sided failure: all show enlarged right
ventricle

cxr

echocardiogram

ECG

LEFT SIDED FAILURE

Decreased cardiac output

Blood backs up into the left atrium, & finally the pulmonary
vasculature causing impaired gas exchange

Causes: HTN, tachydysrhythmias, valvular disease,
cardiomyopathy & renal failure

RIGHT-SIDED FAILURE

Blood backs up into the right atrium, superior & inferior vena
cava, & then the venous vasculature

Causes: Most common cause is left-sided heart failure,
MI, respiratory diseases

cor pulmonale – when the heart is affected by lung disease such
as COPD, asthma & can lead to

pulmonary HTN – vasoconstriction in the arterial pulmonary
circulation

Compensatory Mechanisms

These mechanism usually make matters worse by increasing the
amount of blood the heart must pump & the resistance it must overcome from
arterial constriction

Assessment Findings:

Left-sided Failure

Hypoxemia which leads to:

exertional dyspnea

orthopnea

paroxysmal nocturnal dyspnea

hemoptysis

Assessment Findings:

Right-sided Failure

gradual wt gain from fluid retention

dependent pitting edema

ascites

hepatomegaly

jugular vein distention

enlarged right ventricle on chest xray

Medical Management

Focuses on reducing the workload of the heart and improving
cardiac output

Fluid restriction

Low Na+ diet

Drugs-see table 34-1

Digitalization – initially using large doses of digoxin
to build up therapeutic drug levels

diuretics

vasodilators

B-type Natriuretic Peptide - BNP

A cardioprotective neurohormone that functions to decrease BP
by increasing excretion of Na+ & H2O, promoting arterial dilation, &
counteracting renin, angiotension, & aldosterone

BNP is measured via a blood test to estimate how far advanced
the CHF is

See box 34-2

Medical Management

Cardiac Resynchronization Therapy (CRT) – used to restore
synchronization to the right & left ventricles via a pacemaker thereby
improving force of contraction & cardiac ejection fraction

Intra-aortic balloon pump (IABP) – fig 34-4 – a temporary
secondary circulatory pump

Surgical Management

Ventricular Assist Device (LVAD) – fig 34-5 – an auxiliary pump
that supplements the heart’s ability to eject blood. Used for those awaiting
heart transplants

Cardiomyoplasty – a surgical procedure in which the client’s
own chest muscle is grafted to the aorta & wrapped around the heart
augmenting the ineffective heart muscle contraction fig 34-6

Artificial Heart – used for adults < 55 who are waiting heart
transplant – usually temporary – fig 34-9

　

NURSING MANAGEMENT

Medication administration and teaching

Hx of symptoms

Baseline physical assessment

Daily wts

Accurate I & O

Watch electrolytes & other labs

Measure abdominal girth

See client & family teaching for Heart Failure
34-1

Nursing process – the client with CHF

PULMONARY EDEMA

Fluid accumulation in the lungs that interferes with gas
exchange

An acute emergency

S/S – sudden dyspnea, wheezing, orthopnea, restlessness, cough
often with pink, frothy sputum, cyanosis, tachycardia & severe apprehension,
moist, gurgly respirations

MEDICAL MANAGEMENT

DRUGS

Inatropic agents used to improve myocardial
contractility: dopamine, dobutamine, Inocor, or digitalis

To reduce venous return: diuretics & promote
vasodilation: nitrates, ACE inhibitors, calcium channel blockers

IV morphine to reduce anxiety

OXYGENATION usually by mask or if respiratory
failure occurs may be intubated & put on mechanical ventilator

Nursing Management

IV access

Medication administration

Pulse oximetry

V/S with cardiac monitoring

Foley catheter insertion for accurate monitoring of I&O

　

GENERAL NUTRITIONAL CONSIDERATIONS

Clients with severe heart failure may require Na+ restriction
to as little as 500-1000mg/day

Clients with mild heart failure may tolerate 3000mg Na+/day

Encourage weight loss in obese clients

Provide 5-6 small meals a day to reduce dyspnea & nausea
related to enlarged abdominal organs

GENERAL PHARMALOGICAL CONSIDERATIONS

Mild heart failure usually responds to thiazide diuretics such
as HCTZ or Hygroton

Severe heart failure usually requires loop diuretics such as
Lasix

For those who don’t respond to diuretics & digitalis ACE
inhibitors are used

GENERAL GERONTOLOGIC CONSIDERATIONS

Dyspnea on exertion is the earliest s/s of heart failure in the
elderly + change in mental status such as confusion

Older adults who take digitalis are at an increased risk for
toxicity due to reduced kidney function & decreased drug excretion

CARING FOR CLIENTS WITH CARDIAC DYSRHYTHMIAS

MEDICAL SURGICAL NURSING

CARING FOR CLIENTS WITH
CARDIAC DYSRHYTHMIAS

NORMAL

CARDIAC RHYTHM – the pattern or pace of the heartbeat, regular
or irregular

USUAL RHYTHM/NORMAL called normal sinus rhythm – box 32-1, fig
32-1, fig 32-2 (A)

DYSRHYTHMIA – or arrhythmia is a conduction disorder that
causes a rate that is either too fast, too slow and is either regular or
irregular

Most common cause is CAD

ARRHYTHMIAS THAT ORIGINATE IN THE SA NODE

SINUS BRADYCARDIA – fig 32-2, B; regular, less
than 60; found in clients with heart disorders, ICP, hypothyroidism,
digitalis toxicity. Can also be found in healthy athletes & laborers- may be
treated with drugs, Atropine.

SINUS TACHYCARDIA – fig 32-2, C; regular,
100-150. Found in healthy hearts with strenous exercise, anxiety, fear,
pain, fever, hyperthyroidism, hemorrhage, shock or hypoxemia – no treatment
necessary

Supraventricular Tachycardia-SVT – rate more
than 150 Dangerous because it decreases the cardiac output. Can cause heart
failure, hypotension, syncope & reduced renal output. Drugs used to slow the
rate, digitalis, adrenergic blockers, & calcium channel blockers

ATRIAL FLUTTER – originates outside the SA node
– atrial rate is 200-400. Slower ventricular rate/response Characteristic
sawtooth pattern fig 32-4

ATRIAL FIBRILLATION

fig 32-5 – no identifiable P wave seen

Several areas in the right atrium initiate impulses;
disorganized, rapid atrial activity. Irregular ventricular rate, may cause
decreased cardiac output. Treated with digitalis, Corvert, Tambocor or
Rythmol or elective cardioversion

ARRHYTHMIAS ORIGINATING IN THE AV NODE

HEART BLOCK

disorders in the conduction pathway that
interferes with the conduction of impulses from the SA node to the AV node
to the ventricles.

First degree – impulse delayed, PR interval
prolonged

Second degree – impulse delayed

Third degree or
complete – fig 32-6
requires a pacemaker due to rate of 30-40 only. Cannot sustain life at a
rate that low

ARRHYTHMIAS ORIGINATING IN THE VENTRICLES

PREMATURE VENTRICULAR
CONTRACTIONS (PVC) occurs before the SA node initiates an impulse. No P
wave, wide and bizzare QRS Usually harmless, can be dangerous if are
precursors of lethal arrhythmias. Treatment for lethal PVCs is an IV bolus
of Lidocaine followed by a continuous infusion

Fig 32-7, fig 32-8

VENTRICULAR TACHYCARDIA

(VTACH) – impulse originates in the ventricle, very fast
150-250. Cardiac output decreased. May stop on it’s own or may go into
ventricular fibrillation

VENTRICULAR FIBRILLATION

The rhythm of the dying heart

usually preceded by PVCs and/or VTACH

fig 32-9

Assessment findings

No cardiac output. The ventricles are just quivering. Requires
immediate CPR with defibrillation

S/S – weakness, fatigue, anginal pain, fainting,
palpitations, fluttering feeling in the chest, hypotension. Skin pale, cool,
or diaphoretic or clammy if having pain

Assess the cardiac monitor & the pt, vs,
administer meds as ordered. May need to assist with cardioversion,
defibrillation or pacemaker insertion.

Medical & Surgical Management

Drug therapy table 32-1

Elective Electrical Cardioversion - table 32-1

Nonemergency procedure used to stop rapid, non-life threatening
atrial dysrhythmias

Defibrillation – table 32-1

Emergency procedure performed during resusitation

Automated Implanted Cardiac Defibrillator
(AICD)

An internal electrical device used for selected clients with
recurrent life-threatening tachydysthythmias

Consists of a generator with a battery & one lead placed in the
right ventricle

It senses the dysrhythm & delivers an electrical shock to
restore the heart to a life-sustaining cardiac rhythm

Clients must avoid devices with a magnetic field

PACEMAKERS

Used to treat slow abnormal heart rhythms; may
be temporary or permanent

demand or synchronous mode

fixed-rate or asynchronous mode

transcutaneous, usually temporary

transvenous, usually temporary

implanted, permanent

Radiofrequency Catheter Ablation- a heated
catheter tip is introduced transvenously into the heart & destroys the
tissue causing the dysrhythmia

Nursing Care – nursing process,

Client with a Dysrhythmia

Elective Electrical Cardioversion

Keep NPO

Consent form signed

Make sure an IV is established; give meds as
ordered to include sedatives

Make sure all equipment is in room

v/s after procedure

Defibrillation

Ensure that all equipment is in room

Perform CPR until ready to defibrillate

Pacemakers

Place on monitor & assess for the "spike" of the
pacer

Client & family teaching 32-1

General Nutritional Considerations

Clients with history of ETOH abuse are more at
risk for dangerous during withdrawal

General Pharmacologic Considerations

Administration of lidocaine can have serious adverse effects
including convulsions & cardiac arrest. Use very cautiously

Drug toxicity can occur even with normal doses of digitalis &
cardiac glycosides. Signs of toxicity are anorexia, n/v, visual disturbances
such as halos around dark objects, objects appearing green or yellow.
Withhold the drug & notify MD if heart rate is < 60beats/min

General Gerontologic Considerations

Older adults have an increased risk for dysrhythmias due to
cardiac degenerative changes

Sinus bradycardia and heart block are common dysrhythmias in
older adults

Adult health: CARING FOR CLIENTS WITH VALVULAR DISORDERS OF THE HEART

MED SURG

CARING FOR CLIENTS WITH VALVULAR DISORDERS
OF THE HEART

AORTIC VALVE

LOCATED BETWEEN THE LEFT VENTRICLE AND THE AORTA.

THE HEART PUMPS OXYGENATED BLOOD THROUGH IT TO THE AORTA & THEN
THE REST OF THE BODY.

AORTIC STENOSIS

Narrowing of the opening in the aortic valve when the cusps
become stiff & rigid leading to pooling of blood in the left ventricle &
decreased cardiac output; fig 30-3

S/S – asymptomatic for years then dizziness, fainting & anginal
pain, dyspnea

Treatment – meds to support heart, digitalis, antiarrhythmics,
diuretics, antibiotics, NTG, restricted Na+ diet

May have balloon valvuloplasty to stretch the opening, usually
reoccurs within 6-12 months

May need aortic valve replacement eventually

Nursing management- monitor s/s, vs, bedrest, focus assesments
of the pulse rate & rhythm

See nursing care plan 30-1

AORTIC INSUFFICIENCY or
REGURGITATION

Incomplete closing of the aortic valve causing
backflow or reguritation of blood into the left ventricle

Caused by rheumatic fever, endocarditis,
syphilis or age related

Asymptomatic unless the ventricle cannot
maintain adequate circulation then may have palpitations, dyspnea and cxp,
widened pulse pressure

Treatment – drug therapy, replacement of valve if becomes
symptomatic

Nursing – prepare for procedures, adm meds, focused assessments

See drug therapy table 30-1

MITRAL VALVE

LOCATED BETWEEN THE LEFT ATRIUM AND LEFT VENTRICLE

SHOULD OPEN WIDELY TO ALLOW OXYGENATED BLOOD TO ENTER THE LEFT
VENTRICLE & THEN CLOSE TIGHTLY TO KEEP BLOOD FROM REENTERING THE LEFT ATRIUM

MITRAL STENOSIS

Narrowing of the mitral valve, see fig 30-5

Secondary to rheumatic fever, lf atrium cannot
empty completely it becomes enlarged, leads to pulmonary HTN

May take 20-40 yrs to develop after infection

S/S – fatigue & dyspnea with slight exertion,
then at later stages dyspnea at night, productive cough with pink, frothy
sputum

Treatment – antx, asa, oral anticoagulants,
surgery if candidate

Percutaneous balloon valvuloplasty, fig 30-6

Nsy care: assessments, teaching re: drug therapy
& diagnostic procedures

MITRAL REGURGITATION OR
INSUFFICIENCY

Mitral valve does not close completely, also causes enlargement
of the left atrium.

Associated with rheumatic fever & mitral valve prolapse

S/S same as stenosis

Treatment – meds, digitalis & anticoagulants, antx,
vasodilators

Surgery to repair the valve called annuloplasty

Nursing care – vs, focused cardiac assessment, daily wts

MITRAL VALVE PROLAPSE

The valve cusps enlarge, become floppy & bulge
backward into the left atrium, fig 30-8

Most common valvular disorder

Associated with inherited connective tissue
disorders, CAD; more common in women

Mitral valve prolapse syndrome- symptoms mimic a
severe anxiety attack

S/S – atypical chest pain, fatigue, anxiety or
panic attacks, sob, difficulty concentrating, impending doom feelings

Treatment – periodic antx therapy, drugs for
tachyarrhythmias, antianxiety meds, ASA, if symptoms severe may need valve
replacement

Nursing care – relief of cxp , avoid caffeine,
ETOH & med teaching

General Nutritional
Considerations

For those on low Na+ diets encourage them to substitute
homemade foods for mixes or prepared items which contain major amounts of
Na+

Foods that liquefy at room temperature (ice cream, sherbet,
etc) count as liquids for those on fluid restrictions

General Pharmacologic Considerations

Closely monitor those receiving oral anticoagulants for
episodes of bleeding

Therapeutic PT levels are 1.5 to 2.5 times the control value.
INR range is 2.0 to 3.0. Those with mechanical valves should have INR of 2.5
to 3.5

Before administering beta-blockers take the apical pulse. If <
60 hold med & notify MD

General Gerontologic Considerations

Older adults may require lower doses of cardiac glycosides than
younger adults

Monitor the HR & BP of older adults on beta blockers; the
adverse effects of bradycardia & hypotension can cause confusion & falls

Syncope & falls due to decreased cardiac output occur more
often in older adults

Adult health INFECTIOUS INFLAMMATORY DISORDERS OF THE HEART BLOOD VESSELS

MED/SURG Adult health CARING
FOR CLIENTS WITH INFECTIOUS & INFLAMMATORY DISORDERS OF THE HEART & BLOOD
VESSELS

RHEUMATIC FEVER & RHEUMATIC CARDITIS

Rheumatic Fever - Systemic inflammatory disease
due to group A strep infection of the throat

Rheumatic Carditis- inflammatory cardiac
manifestations; acute or later stages: affects heart valves, esp mitral
valve, endocardium, myocardium & pericardium – fig 29-1

S/S: most common in children 2-3 wks after a
strep infection; carditis, inflammation in the layers of the heart,
polyarthritis, rash, SQ nodules, chorea which is involuntary grimacing;
adults have more vague symptoms

RHEUMATIC FEVER & RHEUMATIC CARDITIS

Treatment – IV antx, PCN drug of choice, bedrest, aspirin,
steroids

Nursing care – administer meds, focused cardiac assessments;
education re: need for prophalactic antx before invasive procedures

INFECTIVE ENDOCARDITIS

Inflammation of the inner layer of the heart tissue

Caused by a bacteria or fungi, box 29-2

Persons with hx of rheumatic fever are most at risk

Nursing care: client teaching, med adm, lifelong susceptibility

MYOCARDITIS

Inflammation of the middle (muscle) layer of the
heart

Caused by viral, bacterial, fungal or parasitic
infection. Mostly viral cause in the US.

S/S: General chest discomfort, relieved by
sitting up, low-grade temp, tachycardia, arrhythmias

CARDIOMYOPATHY

Chronic condition

Structural changes in heart muscle

Table 29-1 – types

Med/surgical mgmt: drug therapy; pacemakers; surgical
intervention

PERICARDITIS

Inflammation of the pericardium – the saclike structure that
surrounds the heart

Can be primary or secondary due to endocarditis, myocarditis,
chest trauma, MI or cardiac surgery

Can have effusion or accumulation of fluid within the 2 layers
of tissue, fig 29-5

PERICARDITIS

If effusion occurs can lead to cardiac tamponade – acute
compression of the heart leading to impaired filling, fig 29-6

Pulsus paradoxus, nsy guidelines 29-1

S/S – fever, malaise, dyspnea, precordial pain, which is pain
in the anterior chest over the heart, this pain may mimic an MI

Treatment – r/o MI, rest, analgesics, antipyretics, NSAIDS,
steroids

THROMBOPHLEBITIS

See nursing process

Inflammation of a vein with clot formation; most common in the
veins deep in the lower extremities, DVT

Caused by venous stasis, altered blood coagulation, trauma to
the vein

THROMBOPHLEBITIS

Dx – clinical findings, venous doppler, venography

Treatment – bedrest, anticoagulants, warm, wet packs, if large
vein affected may have thrombectomy

Nursing care – prevention, exercises for at risk pts

See nursing process

THROMBOANGIITIS OBLITERANS (Buerger’s dz)

Intermittent spasms of arteries associated with formation of
inflammatory lesions which cause restricted blood flow to the extremities,
usually the legs; cause unknown

More common in young men, aggravated by smoking

S/S – intermittent claudication (cramps in the legs after
exercise), one or both feet cold with burning, numbness, tingling of the
feet, ulcers may development

THROMBOANGIITIS OBLITERANS (Buerger’s dz)

Treatment – restrict tobacco use, Buerger Allen exercises, nsy
guidelines 29-2

Sympathectomy, interrruption of the sympathetic nerve pathway
to relieve vasoconstriction may be performed

Nursing

teaching; tobacco restriction; exercises

pain control

GENERAL NUTRITIONAL CONSIDERATIONS

Anorexia & wt loss are common side effects of infections;
increase calories & protein prn. Encourage small, frequent feedings

Encourage weight loss in clients with thrombophlebitis

General Pharmacological Considerations

Most clients with PVD have pain, which may be
treated with non-narcotic analgesics.

Trental may be used to improve intermittent
claudication

Coumadin may be prescribed for those with venous
thrombosis. Monitoring of PT is very important.

Vitamin K is given as an antidote for Coumadin
OD.

Heparin may be given for clients with
thrombophlebitis

Clients receiving anticoagulant therapy must be
closely monitored for signs of bleeding tendency

General Gerontologic Considerations

Discourage older adults from using electric heating devices due
to their decreased temperature perception

Many older have peripheral vascular insufficiency manifested by
weak or absent pedal pulses; cold, clammy feet; thickened toenails, shiny
skin on the lower extremeties

MEDICAL SURGICAL NURSING :INTRO TO THE CARDIOVASCULAR SYSTEM

MEDICAL SURGICAL NURSING

INTRO TO THE CARDIOVASCULAR SYSTEM

A & P OF THE HEART

QUALITIES UNIQUE TO CARDIAC TISSUE:

Automaticity – initiates own electrical stimulus

Excitability – responds to electrical stimulation

Conductivity – transmits electrical stimulus cell to cell

Contractility- stretches as a single unit & recoil

Rhythmicity – repeats the cycle regularly

HEART CHAMBERS & LAYERS – fig 28-1

Atria – upper chambers

Ventricles – lower chambers

Septum – wall between rt & lt sides

Base-upper portion

Apex-tip, lower portion

VALVES, ARTERIES & VEINS

VALVES – ensure that blood goes one way: forward

2 A-V valves separate atria & ventricles

2 semilunar valves between ventricles & pulmonary artery &
aorta

CIRCULATION - fig 28-3

Inferior/superior venae cava bring deoxygenated venous blood
from the body into the rt atrium

Blood pumped into the rt ventricle through the av / tricuspid
valve

BLOOD SUPPLY TO THE HEART

Blood goes from the rt ventricle through the pulmonic valve
into the pulmonary artery to the lungs to be oxygenated

Oxygenated blood is supplied to the heart muscle by left &
right coronary arteries

Heart muscle is lst to receive oxygenated blood –fig 28-4B

Left coronary arteries supply the blood to the left side which
is responsible for the pumping action of the heart

Right coronary arteries supply the blood to the right side
which is the conduction system

CARDIAC CYCLE

Contraction of the heart chambers – systole

Relaxation of the heart chambers– diastole

Atria contract at the same time

Ventricles contract at the same time

Lub dub sound – contraction of the atria & then the ventricles

Starling’s law-the greater the stretch of the myocardium the
stronger is the ventricular contraction- like the rubber band being
stretched.

CONDUCTION – fig 28-6

Electrical activity starts at the SA node- pacemaker of the
heart

AV node

Bundle of His

Bundle branches

Purkinje fibers

Polarization- cardiac cells in resting state

Depolarization – during spread of the electrical impulse

Refractory period – time when cells are resistant to electrical
stimulation

CONDUCTION

Depolarization & repolarization produce electrical changes in
the heart muscle

These changes can be detected by electrodes placed on the chest
wall & recorded by the electrocardiograph (EKG) machine

See fig 28-7

Regulation of Heart Rate

Autonomic nervous system

sympathetic – speeds up system

parasympathetic – slows down system

Baroreceptors

pressure sensitive

located in walls of atria & major blood vessels

Cardiac Output

Amount of blood pumped out of the left ventricle each minute

Normal in healthy adult: 4 – 8 L/min – varies with body size &
the body’s changing needs

Stroke volume – amount of blood pumped with each heart
contraction

Cardiac Output = heart rate x stroke volume

HISTORY

Present symptoms

Past medical hx of cardiac problems

Prescription & nonprescription drugs

Drug & food allergies – in case of allergy to seafood may also
be allergic to radiopaque dye used in diagnostic tests

If client in acute distress may have to get information from
family member

PHYSICAL EXAMINATION

General Appearance: nonverbal behavior &body position

Pain may be a sign of ischemia

V/S:

temperature – sign of inflammatory response

pulse - rate, rhythm & quality

respirations – rate, quality

BP – orthostatic, baseline, both arms & compare – nursing
guidelines 28-1

PHYSICAL EXAMINATION

Cardiac Rhythm – continuous cardiac monitoring, telemetry

Normal heart sounds-lub-dub

Abnormal heart sounds – extra sounds, friction rubs

Peripheral pulses – present or absent, equal on both sides,
quality

Skin – color, temperature, dry or clammy

PHYSICAL EXAMINATION

Peripheral edema – pitting or non – pitting, 1+ to 4+

Weight – recorded daily at the same time in same clothes on
same scale

Jugular Vein Distention– see fig 28-10

DIAGNOSTIC TESTING

Blood chemistry – FBS, electrolytes, cholesterol &
triglycerides

Serum enzymes & isoenzymes – specific to damage of heart
muscle:

troponin

creatine kinase (CK)

LDH

AST

DIAGNOSTIC TESTING

Electron Beam CT – xrays of the coronary
arteries

Radiography – xrays of the heart determine size & position of
the heart & condition of the lungs

MRI – used as a noninvasive method to identify structural
abnormalities; those with metallic implants, implanted pacemaker &/or
defibrillators are excluded

Echocardiography – sonogram of the heart to determine left
ventricular function, congenital defects & changes in the tissue layers of
the heart

DIAGNOSTIC TESTING

Electrocardiography or EKG/ECG – graphic recording of the
electrical activity of the heart. Should have a P wave, QRS complex

12 lead EKG done to diagnose cardiac problems, read by computer
& later by MD

CARDIAC CATHETERIZATION

Used to measure fluid pressures in the heart chambers & obtain
blood samples for analyzing O2 & CO2 levels

May be done to check left side of heart via artery or right
side of the heart via vein

Flexible catheter inserted into peripheral blood vessel in the
groin, arm or neck & threaded up into the heart

Dye instilled; client may feel warm sensation

Afterwards site covered with a pressure dressing

See box 28-2 for discharge teaching

　

ARTERIOGRAPHY

Coronary – most commonly used along with left sided cardiac
cath to determine degree of blockage in coronary arteries; dye instilled
into the artery

Angiocardiography – radiopaque dye injected into a vein.
Usually used to diagnose congenital abnormalities of the heart & great
vessels

Peripheral arteriography – used to diagnose occlusive disease
in the smaller arteries

Hemodynamic Monitoring

Used to assess the volume & pressure of blood in the heart &
vascular system

Methods

direct BP-cath placed in peripheral artery

central venous pressure (CVP)-rt atrial pressure – cath
inserted into large vein – fig 28-15

GENERAL NUTRITIONAL CONSIDERATIONS

Food & fluids are withheld before invasive
diagnostic procedures & are not resumed until the client is stable & free of
n/v

GENERAL PHARMACOLOGIC CONSIDERATIONS

All medications to include herbal or OTC can affect pulse rate
& BP. Be sure that all of them are listed in the pt’s history

Instruct a pt who is going to have a contrast medium injected
during a cardiac cath or arteriogram that they may feel an intense flushed
feeling & the urge to void when it is injected. The feelings should pass
within 30-60 secs

GENERAL GERONTOLOGIC CONSIDERATIONS

The aging heart is less able to meet the demands placed on it
during times of stress & requires more time to return to baseline levels

Older adults with renal impairment or chronic dehydration is at
increased risk of complications during & after any procedures requiring use
of contrast dye because it is nephrotoxic

Older adults are at increased risk for cardiac dysrhythmias due
to deteriorating heart structures

CARING FOR CLIENTS WITH DISORDERS OF
CORONARY & PERIPHERAL BLOOD VESSELS

STATISTICS

Cardiovascular disease is the leading cause of death in the US

Occlusive disorders of the coronary arteries and resulting
complications are largely responsible

The most common causes of occlusive vascular diseases are
atherosclerosis, arteriosclerosis, clot formation and vascular spasm

ARTERIOSCLEROSIS & ATHEROSCLEROSIS

Arteriosclerosis – during the natural aging process loss of
elasticity or hardening of the arteries

Atherosclerosis – the lumen of the artery fills with fatty
deposits or plaque – fig 31-1

Hyperlipidemia triggers atherosclerotic changes:

Factors contributing to hyperlipidemia:

gender

heredity

diet

diseases such as metabolic syndrome

inactivity

ATHEROSCLEROSIS

Current research now shows that development of atherosclerosis
may be linked to prior infection with Chlamydia pneumoniae a
respiratory infection

A relationship between body fat & production of inflammatory &
thrombotic or clot forming proteins

Presence of multiple risk factors contribute to development of
arteriovascular disease

CORONARY ARTERY DISEASE (CAD)

Arteriosclerotic & atherosclerotic changes in the coronary
arteries that supply the heart

Causes: multiple factors Box 31-1

S/S –depend on severity; range from mild fatigue to severe
chest pain or angina see table 31-1

DX: Lipid panels, exercise stress testing, EKG changes

CORONARY ARTERY DISEASE (CAD)

Treatment-lifestyle changes, meds: NTG, beta blockers, calcium
channel blockers, ace inhibitors, antilipimic agents

Noninvasive: Enhanced External Counterpulsation or EECP; fig
31-5

Invasive: PTCA, stents, CABG, TMR

Nursing: client education, med administration & assessments

Percutaneous Transluminal Coronary
Angioplasty (PTCA)

Also known as balloon angioplasty

Fig 31-6

Complications may include arterial rupture, MI & abrupt
reclosure

See discharge instructions

Coronary Stent

During PTCA a small metal coil with meshlike openings is placed
in the coronary artery

See fig 31-7

The stent stays in place. Restenosis usually does occur

New stents coated with an antiinflammatory/antibiotic substance
are available

Atherectomy

Removal of the fatty plaque from the artery wall

Done by:

inserting a cardiac catheter with a cutting tool at the tip,
see fig 31-8

performing laser angioplasty

Coronary Artery Bypass Graft CABG

Used to revascularize the myocardium

A 10 – 12 inch midsternal incision is made

Heart is stopped during the procedure & blood routed through a
heart-lung machine

Use either a healthy leg vein or chest artery to reroute the
oxygenated blood to an area below the obstruction in the diseased coronary
artery

Recovery time is several weeks, but results last longer than
the PCTA or stents

Transmyocardial Revascularization

TMR

A laser procedure used for those who do not respond to meds &
are not candidates for CABG

Performed through an incision in the chest wall. A laser is
aimed at the beating heart & it creates channels in the heart tissues which
seep blood. The heart muscle absorbs the oxygenated blood from them instead
of the coronary arteries

Myocardial Infarction (MI)

Infarct – an area of tissue that dies from inadequate
oxygenation

This occurs in the heart when there is a prolonged total
occlusion of coronary arterial blood flow

The location of the infarct depends on the area where the blood
supply to the myocardium is interrupted by the respective occluded coronary
artery - fig 31-9

Transmural or Qwave MI – extends through the full thickness of
the myocardium

NON Q wave MI – or subendocardial infarction only goes thru
partial thickness of the wall of the myocardium

Myocardial Infarction (MI)

Cause – most common is coronary thrombosis

Complications

dysrhythmias

cardiogenic shock

ventricular rupture

ventricular aneurysm

arterial embolism

venous thrombosis

pulmonary embolism

pericarditis

mitral insufficiency

MYOCARDIAL INFARCTION

S/S – vary but typically include sudden, severe cxp, may
radiate to jaw, left arm, shoulder, teeth, or throat. Rest or use of NTG
does not help

If dx within 6 hours of onset of symptoms may give thrombolytic
drugs to stop the process

Dx – series of serum enzymes that are elevated – table 31-3,
EKG changes usually within 2-12 hrs

Myocardial Infarction

Treatment –

thrombolytics or clot busters used unless contraindicated

symptomatic treatment

Drug Table 31-1

Nursing Care Plan 31-1

OCCLUSIVE DISORDERS OR PVD

Raynaud’s Disease

periodic constriction of the arteries that supply the
extremities

Cause unknown

Brief spasm of arteries in fingers, toes, nose, ears or chin
causing ischemia, pain & paresthesia, coldness.

Place affected area in warm water, avoid smoking, use of
peripheral vasodilators

Thrombosis-a clot in a blood vessel

Phlebothrombosis-a clot in a vein without inflammation

Embolism-moving, mass/clot , solid or gas within the
bloodstream

Usually found in lower extremities due to venous stasis caused
by inactivity, immobility or trauma to the vein

OCCLUSIVE DISORDERS

S/S:

Arterial clot – white, cold, & extremely painful

Venous clot - phlebothrombosis – may be asymptomatic

DVT- mild fever, pain, swelling & tenderness to affected
extremity; + Homan’s sign

DX: arteriography or venography with contrast dye

Treatment:

Arterial clot - IV heparin, narcotics for pain, thrombolitic
agents, surgery

Venous thrombosis: bed rest, elevate extremity, local heat,
analgesics, IV heparin, oral anticoagulants

Nursing care: monitor heparin therapy & labs, s/s of bleeding,
have antidote available:

for heparin – protamine sulfate

for oral anticoagulants – vit K

DISORDERS OF BLOOD VESSEL WALLS

VARICOSE VEINS

Valves become incompetent

saphenous veins in the legs are usually affected

Familial tendency, prolonged standing, obesity, pregnancy

S/S – tiredness, heaviness in legs esp after excessive
standing, dark discolored veins

Treatment: exercise, wt loss, TED hose, avoid prolonged sitting
or standing

Surgical: vein ligation or stripping, see fig 31-14

Nursing: assessment, teaching regarding risk factors

ANEURYSMS

A stretching or bulging of an arterial wall

Most common site is the aorta

Causes: arteriosclerosis, HTN, trauma or congenital weakness
that affects elasticity of arterial wall

S/S: usually asymptomatic; may be diagnosed during xrays;
during physical or when the client has a massive hemorrhage

Treatment: control HTN; surgical intervention

Nursing: control HTN, avoid straining, monitor v/s, uop,
prepare for surgery

General Nutritional Considerations

High levels of LDL increases the risk of CAD

Persons 2 years of age & older are urged to follow the Step-One
diet to reduce their risk of heart disease

Omega-3 fatty acids, abundant in fish oils, lowers serum
triglyceride levels & platelet aggregation

ETOH intake should remain moderate in order to increase HDL
cholesterol & not have the adverse side effects of excessive intake: for men
-1- 2 drinks per day & for women < 1 drink per day

General Pharmacologic Considerations

MDs may prescribe aspirin, 325mg or 81mg per day for clients
with CAD to prevent MI

All NTG preparations are stored in their original container &
not mixed with other medications. Make sure the cap is tightly closed after
each use

NTG can cause a throbbing headache, flushing & nausea; these
effects can usually be relieved by decreasing the dose

Antidote for overdosage of thrombolytic therapy is Amicar

General Gerontologic Considerations

General physiological changes in the older adult predispose
them to vascular occlusive disorders

CAD is the most common cause of death in older adults

Older adults are more sensitive to the hypotensive effects of
nitrates

Things to note

Somethings that came up on a test..

1. When you give the FIRST DOSE of captopril (ACE inhibitor) have your client lie down for about 3 hours because they will be hypotensive after.
2. Make sure you check your clients apical pulse before you give captopril because it can cause you client to be hypotensive, you need to make sure they are not bradychardic before you give the med to them. If they are bradychardic then hold the med according to hospital policy i think.
3. Pentam can make your client hypoglycemic
4. To test for cryptoccocal infection in HIV ask the client to put his chin to his chest if infected he/she will find it difficult because it causes a stiff neck
5. Before you do anything to a client with eye complaints assess for visual acuity
6. Assess for orthostatic hypotension after you give lisinopril
7. First priority in sickle cell crisis patient is pain second is risk of injury due to decreased oxygenation
8. No Benadryl with alchohol.
9. If you get a question that says whats the first thing the nurse should do always go for the answer with assess especially if theres only one asnwer with assess.
10. Hope this helps.

Care of the Patient With HIV Adult healthh 1

Care of the Patient With HIV Adult healthh 1 Lecture notes




Care of the Patient With HIV
Adult Health I

Human Immunodeficiency Virus Infection
 HIV varied course to AIDS
 AIDS is the End Stage of this chronic, progressive immune function disorder

Pathophysiology
 Retrovirus
 HIV is an RNA virus that replicates backwards
 Replicate within a living cell
HIV infects cells with CD4+T cells
 Lymphocytes, monocytes
 Normal CD4 +T cells = 800-1200cells/ul
 Live for 100 days, with HIV die after only 2
 Virus destroys 1 billion cells a day
 HIV cells destroys the bodies abilities to replace cells
 Decrease in immune capacity and
 Develop opportunistic infections

Transmission
 Fragile virus
 Specific conditions allow transmission
 Sexual intercourse with infected partner
 Blood and blood products
 Pregnancy during delivery
 Breast feeding
 It is not spread casually


Primary Infection: Acute HIV Infection
 The development of HIV antibodies or seroconversion:
 Symptoms 1-3 weeks after infection
 HIV level is ↑and CD4+T cell decrease but returns to normal
 Lasts 1-2 weeks
 Symptoms include:
 Flu like symptoms, ,Fever, enlarged lymph nodes, pharyngitis, headache, malaise, nausea and rash
 Symptoms can be misinterpreted

HIV Asymptomatic: CDC Category A
 Often asymptomatic
 Can develop symptoms: fatigue, headache, low grade fever, night sweats and lymphadenopathy
 Symptoms are vague and non specific
 People unaware of infection
 Continue high-risk behavior
 A1: CD4 ≥ 500/µL
 A2: CD4 = 200-499/µL
 A3: CD4 <>HIV Symptomatic: CDC Category B
 Development of 1 or more opportunistic infections
 B1: CD4 ≥ 500/µL
 B2: CD4 = 200-499/µL
 B3: CD4 <>AIDS: CDC Category C
 Development of opportunistic infections, cancers, wasting syndrome, HIV encephalopathy, etc
 Classified as having AIDS
 C1: CD4 ≥ 500/µL
 C2: CD4 = 200-499/µL
 C3: CD4 <>Diagnostic and Laboratory Studies
 Based on detection of HIV specific antibodies EIA – detects serum antibodies
 Western Blot - immunfluorescence assay
 ELISA enzyme-linked immunosorbent assay (detect antibodies that bind to HIV antigens)
 Viral Load
 Quantifies HIV viral load
 Lower level associated with longer survival time and longer delay in onset to AIDS
 Other pertinent lab data:
 WBC – neutropenia, thrombocytopenia
 Anemia – disease or drug related
 Abnormal LFT – disease or drug related

Aims of Collaborative Care
 Monitoring of disease progression
 Baseline assessment
 Patient education
 Psycho-social aspects
 Prevent opportunistic infections
 Monitoring antiretroviral treatment
 Management of signs and symptoms
 Prevent complications of treatment


Drug Therapy and Interventions
Three classifications of drug therapy
1. Inhibit the activity of reverse transcriptase
Zidovudine ( AZT, Retrovir)
Lamivudine (3TC, Epiver)
Stavudine (D4T, Zerit)
Combivir (lamivudine, zidovudine combination)


Drug Therapy and Interventions
2. Protease inhibitors
Indinavir (Crixivan)
Nelfinavir (Viracept)
Ritonivir ( Norvir)
3. Fusion inhibitors
Enfuvirtide (Fuzeon)


Use of Antiviral Drugs
 Multiple medications
 Rigid dosing schedule
 Multiple side effects:
 Nausea, vomiting, diarrhea
 Rash
 Liver function changes
 Peripheral neuropathy
 Taste changes

Preventive Prophylactic Interventions
 Hepatitis B vaccine
 Influenza Vaccine
 Pneumonia
 INH
 Zovirax
 PPD

Nursing Diagnosis
 Pain, neuropathy, arthralgia
 Anxiety
 Altered thought process r/t hypoxemia
 Altered nutrition less than body requirements
 Risk for activity intolerance
 Diarrhea
 Impaired gas exchange

Nursing Interventions
 Reduce Fear
 Prevent Infection
 Improve Nutritional status
 Relieve oral Discomfort
 Minimize effects of diarrhea
 Managing altered thought process
 Reducing a fever
 Improve breathing pattern
 Improve management of therapeutic regimen

Patient Teaching
 Perinatal Risks
 Occupational exposure Risks
 Reduce Risk-reducing behaviors
 Safe sex
 Drug paraphernalia
 Patient Teaching
 Side effects of drugs
 Alternate methods of pain relief
 Energy conservation
 Infection control measures
 Information about support groups and community resources


Transmission to Health Care Workers
 Use standard precautions with ALL patients
 Use needle safe devices
 If exposed, immediately wash area
 Report exposure
 Depending on level of exposure, may need Post exposure prophylaxis (PEP)
 Give ASAP, but more than 72h post-exposure
 Give for 4 weeks
 http://www.cdc.gov/MMWR/preview/mmwrhtml/rr5409a1.htm