Comprehensive Care for Cardiac Patients: Learning Outcomes

1. Caring for Patients With Cardiac Disorders

2. Learning Outcomes • Compare and contrast the causes, pathophysiology, effects, and manifestations of common cardiac disorders. • Safely administer drugs commonly prescribed for patients with heart disease. • Provide individualized and evidence-based nursing care for patients undergoing invasive procedures or surgery of the heart. • Use clinical judgment and the nursing process to conduct focused assessments, contribute to care planning, and provide individualized nursing care for patients with disorders of the heart.

3. Learning Outcomes • Provide and reinforce appropriate teaching for patients with heart disorders and their families, taking patient values, expressed needs, and preferences into consideration. • Use electronic resources for planning and documenting nursing care for patients with heart disorders.

4. Disorders of Cardiac Function

5. Heart Failure • Inability of heart to function as pump • Results from any condition that causes: • Impaired contractions • Increased workload of the heart • Leading causes • Hypertension • CHD with myocardial ischemia and MI

6. Pathophysiology • Cardiac output drops • Compensatory mechanisms activated • Sympathetic nervous system stimulated • Arteries and veins constrict • Venous return increases to the heart • Increase in preload

7. Pathophysiology • Renin–angiotensin–aldosterone system activated • Salt and water retention • Heart chambers dilate • Ventricular hypertrophy • Reduced cardiac reserve • Classified as left-sided or right-sided

8. Pathophysiology • Left-sided heart failure • Manifestations • Pulmonary congestion • Reduced cardiac output • Fatigue, activity intolerance • Dyspnea on exertion (DOE) • Orthopnea • Acute pulmonary edema

9. Pathophysiology • Right-sided heart failure • Manifestations • Fatigue • Activity intolerance • Jugular vein distention (JVD) • Peripheral edema • Anorexia, nausea • Abdominal distention

10. Pathophysiology • Right-sided heart failure • Manifestations • Ascites • Liver/spleen enlarged and tender • Biventricular failure • Paroxysmal nocturnal dyspnea (PND) • Acute and chronic failure • Multisystemic effects

11. Manifestations of Heart Failure

12. Collaborative Care • Diagnostic tests • Cardiac hormones, atrial natriuretic factor, and brain natriuretic peptide • Serum electrolytes • Chest x-ray • Echocardiogram • ECG

13. Collaborative Care • Hemodynamic monitoring • Assess cardiovascular function • Multilumen catheter inserted through central vein in right side of the heart • Pulmonary artery used to measure central venous pressure, pulmonary artery pressures, and cardiac output • Arterial blood pressure measured using a peripheral arterial line

14. The nurse observes tracings of a patient’s hemodynamic pressures. The upper screen in the background shows (from top): heart rate (green); arterial blood pressure (red and yellow); central venous pressure (CVP, light blue); blood oxygen (dark blue); respiration rate (white). (Source: James King-Holmes / Science Source.)

15. Collaborative Care • Medications • ACE inhibitors • ARBs (angiotensin II receptor blockers) • Diuretics • Inotropic medications • Vasodilators

16. Collaborative Care • Medications • Morphine sulfate • Pulmonary edema treatment • Digitalis • Positive inotropic effect on heart • Narrow therapeutic index • Easy digitalis toxicity

17. Collaborative Care • Diet and activity • Low-sodium diet • Bed rest during acute phase • Activity gradually increased • Implanted devices • Implantable cardiac defibrillator (ICD) • Biventricular pacemaker

18. Collaborative Care • Surgery • Heart transplant • Infection and rejection main concerns • Immunosuppressive drugs • Dynamic cardiomyoplasty • Skeletal muscle graft around heart to support myocardium • No real success

19. Nursing Care • Prioritizing nursing care • Oxygen demand • Reduce workload of heart • Health promotion • Measures to prevent CHD • Assessing • Frequent, careful assessment

20. Assessment: Patients with Heart Failure

21. Nursing Care • Identifying potential complications • Acute pulmonary edema • Liver, kidney failure • Mental status changes • Diagnosing, planning, and implementing • Decreased cardiac output • Heart and breath sounds • Mental status

22. Nursing Care • Diagnosing, planning, and implementing • Decreased cardiac output • Urinary output (UOP) • Oxygen • Medications • Rest • Quiet

23. Nursing Care • Diagnosing, planning, and implementing • Excess fluid volume • Panic • I&O • Daily weights • Fowler's position • Diuretics/medications • Fluid restriction

24. Nursing Care • Diagnosing, planning, and implementing • Activity intolerance • VS • Rest periods • Assist with care • Progressive activity plan • Small, frequent meals

25. Nursing Care • Documenting • Note any changes • Note patient's response to treatment • Continuity of care • Chronic, progressive nature • Lifestyle changes • Exercise parameters • Referrals to home health agencies

26. Inflammatory Cardiac Disorders

27. Rheumatic Fever and Rheumatic Heart Disease • Pathophysiology • Streptococcal bacteria • Carditis • Valves swollen and red • Scarring of valves • In RHD, scarring leads to valve stenosis and regurgitation.

28. Rheumatic Fever and Rheumatic Heart Disease • Manifestations • Fever • Migratory joint pain and inflammation • Rash on trunk or extremities • Chest pain/discomfort • Tachycardia • SOB • Heart sound changes • Muscle spasms

29. Rheumatic Fever and Rheumatic Heart Disease • Collaborative care • Laboratory testing • WBC, ESR elevated • C-reactive protein • Rapid antigen test for group A Streptococcus • Antistreptolysin-O titer • Cardiac enzymes • Echocardiogram

30. Rheumatic Fever and Rheumatic Heart Disease • Collaborative care • Treat primary infection, manifestations • Prevent complications and recurrences • Antibiotics • Medications • Antibiotics • Aspirin • Ibuprofen • Steroids

31. Nursing Care • Prioritizing nursing care • Supportive care • Health promotion • Prompt treatment of streptococcal throat infections • Assessing • Recent sore throat or "strep throat" • Chest pain • SOB

32. Nursing Care • Assessing • Fatigue • Weakness • Fever • Joint pain • Rash • Identifying potential complications • Decreasing activity tolerance or change in heart sounds

33. Nursing Care • Diagnosing, planning, and implementing • Acute pain • Report increased chest pain • Administer medications as prescribed • Warm, moist compresses prn

34. Nursing Care • Diagnosing, planning, and implementing • Activity intolerance • Reduce stress on the heart • Diversional activities • Monitor activity intolerance

35. Nursing Care • Evaluating • Degree of pain • VS • Response to activity • Documenting • Any symptoms, changes • Continuity of care • Importance of antibiotics

36. Infective Endocarditis • Inflammation of endocardium • Usually affects patients with underlying heart disease • Acute • Staphylococcus aureus • Subacute • Streptococcus viridans

37. Pathophysiology • Bacteria enter body and settle in mitral valve. • Normal valve closure prevented • Regurgitation of blood • Heart murmurs • Onset can be sudden or gradual.

38. Manifestations and Complications • Elevated temperature • Flu-like • Cough • SOB • Joint pain • Petechiae • Splinter hemorrhages • Heart failure or stroke

39. Collaborative Care • No definitive tests • Prevention • Teach risks of IV drug use • Preventative antibiotics if indicated • Medications • Antibiotics • Surgery • Replace damaged valves

40. Indications for Antibiotic Prophylaxis to Prevent Endocarditis

41. Nursing Care • Prioritizing nursing care • Treat infection process. • Maintain heart function. • Health promotion • Teach prevention. • Advise patients at high risk to avoid body piercing.

42. Nursing Care • Assessing • Risk factors • Recent surgery or dental work • IV drug use • Current S/S • VS • Heart and breath sounds

43. Nursing Care • Diagnosing, planning, and implementing • Hyperthermia • Risk for ineffective tissue perfusion • Review of system • Managing nursing care • Vital signs, I&O, and hygiene

44. Nursing Care • Evaluating • Reduction in symptoms • Documenting • Subjective, objective assessments • Continuity of care • Education and support through course • Importance of reporting unusual manifestations

45. Myocarditis • Inflammatory disorder of heart • Causes include: • Infection • Immunity • Radiation • Poisons • Drugs • Burns

46. Myocarditis • Manifestations • Asymptomatic or fever, fatigue, malaise, dyspnea • Heart failure manifestations • Nursing care • Decrease myocardial work • Explain all procedures, tests to decrease anxiety

47. Pericarditis • Pathophysiology • Damaged pericardial tissue • Fluid and exudates in pericardial space • Manifestations • Chest pain, sharp • Pericardial friction rub • Fever

48. Pericarditis • Complications • Pericardial effusion • Abnormal collection of fluid between pericardial layers • Cardiac tamponade • Fatal if untreated • Paradoxical pulse

49. Pericarditis • Collaborative care • Self-limiting and will resolve • Ecocardiography, CT, MRI • Acetominophen, NSAIDs • Pericardiocentesis • Large (16- to 18-gauge) needle inserted into pericardial sac to remove fluid • May be done as an emergency procedure for cardiac tamponade

50. Nursing Care • Prioritizing nursing care • Acute pain • Pain scale • NSAIDs • Calm/quiet environment • Ineffective breathing pattern • Respiratory rate • Incentive spirometer • Oxygen