Interventions for Clients Interventions for Clients with Cardiac Problemswith Cardiac Problems

Heart FailureHeart Failure Also called pump failure, general term for the Also called pump failure, general term for the

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

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

Compensatory Compensatory MechanismsMechanisms

Increased heart rateIncreased heart rate

Improved stroke volumeImproved stroke volume

Arterial vasoconstrictionArterial vasoconstriction

Sodium and water Sodium and water retentionretention

Myocardial hypertrophyMyocardial hypertrophy

Etiology Etiology

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

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

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

Assessments Assessments

Laboratory assessmentLaboratory assessment Radiographic assessmentRadiographic assessment Electrocardiography – may demonstrate ventricular Electrocardiography – may demonstrate ventricular

hypertrophy, dysrhythmias, and any degree of myocardial hypertrophy, dysrhythmias, and any degree of myocardial ischemia, injury, or infarctionischemia, injury, or infarction

Echocardiography - is useful in diagnosing cardiac valvular Echocardiography - is useful in diagnosing cardiac valvular changes, pericardial effusion, chamber enlargement, and changes, pericardial effusion, chamber enlargement, and ventricular hypertrophyventricular hypertrophy

Pulmonary artery catheters Pulmonary artery catheters

Impaired Gas ExchangeImpaired Gas Exchange

Interventions include:Interventions include:– Ventilation assistance (promotion of the Ventilation assistance (promotion of the

optimal spontaneous breathing pattern optimal spontaneous breathing pattern that maximizes oxygen and carbon that maximizes oxygen and carbon dioxide exchange in the lungs)dioxide exchange in the lungs)

– Hemodynamic regulation (optimization Hemodynamic regulation (optimization of heart rate, preload, afterload, and of heart rate, preload, afterload, and contractility)contractility)

– Energy management, diet therapy, drug Energy management, diet therapy, drug therapytherapy

Decreased Cardiac Decreased Cardiac OutputOutput

Interventions include:Interventions include:– Optimization of cardiac output: stroke volume Optimization of cardiac output: stroke volume

(determined by preload, afterload, and (determined by preload, afterload, and contractility) and heart ratecontractility) and heart rate

– Drug therapy including:Drug therapy including: Angiotensin-converting enzyme inhibitors (Angiotensin-converting enzyme inhibitors (

afterload)afterload) Diuretics (Diuretics ( preload) preload) Human B-type natriuretic peptides (Human B-type natriuretic peptides ( afterload) afterload) Nitrates Nitrates InotropicsInotropics Beta-adrenergic blockers (Beta-adrenergic blockers ( preload) preload)

Hemodynamic Hemodynamic RegulationRegulation

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

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

Interventions That Interventions That Reduce PreloadReduce Preload

Diet therapyDiet therapy– Fluid, sodium restrictionsFluid, sodium restrictions

Drug therapy Drug therapy – DiureticsDiuretics– Venous vasodilatorsVenous vasodilators

Drugs That Enhance Drugs That Enhance ContractilityContractility

DigitalisDigitalis– Digitalis toxicity includes anorexia, Digitalis toxicity includes anorexia,

fatigue, changes in mental status.fatigue, changes in mental status.– Monitor heart rate and electrolytes.Monitor heart rate and electrolytes.

Other inotropic drugs including Other inotropic drugs including dobutamine, milrinone, and dobutamine, milrinone, and levosimendanlevosimendan

Beta-adrenergic blockers Beta-adrenergic blockers

Other Nonsurgical Other Nonsurgical Options Options

Continuous positive airway Continuous positive airway pressure pressure

Cardiac resynchronization Cardiac resynchronization therapytherapy

Investigative gene therapyInvestigative gene therapy

Surgical ManagementSurgical Management

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

Activity IntoleranceActivity Intolerance

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

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

Potential for Pulmonary Potential for Pulmonary EdemaEdema

Interventions include:Interventions include:– Assess for early signs, such as Assess for early signs, such as

crackles in the lung bases, dyspnea crackles in the lung bases, dyspnea at rest, disorientation, and at rest, disorientation, and confusion.confusion.

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

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

output.output.

Valvular Heart Disease Valvular Heart Disease Mitral stenosisMitral stenosis Mitral regurgitation (insufficiency)Mitral regurgitation (insufficiency) Mitral valve prolapse Mitral valve prolapse Aortic stenosisAortic stenosis Aortic regurgitation (insufficiency)Aortic regurgitation (insufficiency)

Common Nursing Common Nursing DiagnosesDiagnoses

Decreased Cardiac Output related Decreased Cardiac Output related to altered stroke volumeto altered stroke volume

Impaired Gas Exchange related to Impaired Gas Exchange related to ventilation perfusion imbalanceventilation perfusion imbalance

Activity Intolerance related to Activity Intolerance related to inability of the heart to meet inability of the heart to meet metabolic demands during activitymetabolic demands during activity

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

Nonsurgical Nonsurgical Management Management

Drug therapy, including Drug therapy, including diuretics, beta blockers, digoxin, diuretics, beta blockers, digoxin, oxygen, and sometimes nitrates oxygen, and sometimes nitrates

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

cardioversioncardioversion AnticoagulantAnticoagulant Rest with limited activityRest with limited activity

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

Infective EndocarditisInfective Endocarditis

Microbial infection involving the Microbial infection involving the endocardiumendocardium

Occurs primarily with IV drug Occurs primarily with IV drug abuse, valvular replacements, abuse, valvular replacements, systemic infections, or structural systemic infections, or structural cardiac defectscardiac defects

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

ManifestationsManifestations

Splinter hemorrhage lesions in endocarditis

Janeway's lesions on the sole of the foot

Interventions Interventions

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

failurefailure AnticoagulantsAnticoagulants Surgical management Surgical management

Pericarditis Pericarditis Inflammation or alteration of the pericardium, the Inflammation or alteration of the pericardium, the

membranous sac that encloses the heartmembranous sac that encloses the heart Dressler’s syndromeDressler’s syndrome Postpericardiotomy syndromePostpericardiotomy syndrome Chronic constrictive pericarditisChronic constrictive pericarditis

Assessment Assessment

Substernal precordial pain Substernal precordial pain radiating to left side of the neck, radiating to left side of the neck, shoulder, or backshoulder, or back

Grating, oppressive pain, Grating, oppressive pain, aggravated by breathing, aggravated by breathing, coughing, swallowingcoughing, swallowing

Pain worsened by the supine Pain worsened by the supine position; relieved when the client position; relieved when the client sits up and leans forwardsits up and leans forward

Pericardial friction rubPericardial friction rub

InterventionsInterventions Hospitalization for diagnostic evaluation, observation Hospitalization for diagnostic evaluation, observation

for complications, and symptom relieffor complications, and symptom relief Nonsteroidal anti-inflammatory drugsNonsteroidal anti-inflammatory drugs Corticosteroid therapyCorticosteroid therapy Comfortable position, usually sittingComfortable position, usually sitting Pericardial drainagePericardial drainage Chronic pericarditis: radiation or chemotherapyChronic pericarditis: radiation or chemotherapy Uremic pericarditis: dialysisUremic pericarditis: dialysis PericardiectomyPericardiectomy

Rheumatic Carditis Rheumatic Carditis

Sensitivity response that develops Sensitivity response that develops following an upper respiratory following an upper respiratory tract infection with group A beta-tract infection with group A beta-hemolytic streptococcihemolytic streptococci

Inflammation in all layers of the Inflammation in all layers of the heartheart

Impaired contractile function of Impaired contractile function of the myocardium, thickening of the the myocardium, thickening of the pericardium, and valvular damagepericardium, and valvular damage

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

Cardiomyopathy Cardiomyopathy

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

Dilated cardiomyopathy Dilated cardiomyopathy Hypertrophic cardiomyopathyHypertrophic cardiomyopathy Restrictive cardiomyopathyRestrictive cardiomyopathy

Interventions Interventions

Nonsurgical managementNonsurgical management Surgical managementSurgical management

– CardiomyoplastyCardiomyoplasty– Heart transplantationHeart transplantation