Congestive Heart Failure & Valvular Disease

1. Congestive Heart Failure &Valvular Disease Keith Rischer RN, MA, CEN

2. Todays Objectives… • Review essential cardiac patho concepts • Compare and contrast left-sided heart failure to right • Describe special considerations for older adults with heart failure • Discuss the prevention of complications for patients with heart failure • Prioritize nursing care for clients with heart failure • Identify common nursing diagnoses and collaborative problems for patients with heart failure • Evaluate the effects of interventions for reducing preload and afterload through pharmacological management • Compare and contrast common valvular disorders

3. Definition of CHF Etiology HTN MI Left sided vs. Right sided Rt sided COPD Systolic vs. Diastolic Ejection Fraction 50-70% normal Introduction

4. Cardiac Output • CO = Stroke volume x heart rate • SV (80cc) x HR (80)= 6400cc (6.4 lpm) • Daily pumps 1800 gallons • 657,000 gallons every year • Over 80 year lifetime: • 52,560,000 gallons

5. Definitions • Pre-load • primarily venous blood return to RA • Right and left side of heart filling pressure (atria>ventricles) • Pressure/Stretch in ventricles end diastole • Stroke volume • Amount of blood ejected from the ventricle with each contraction • Systole • Contraction; myocardium are tightening and shortening

6. Definitions • Inotropic state/contractility • Afterload: • Force of resistance that the LV must generate to open aortic valve • Correlates w/SBP • Diastole • Muscle fibers lengthen, the heart dilates, and cavities fill with blood

7. Maximum efficency of CO achieved when myocardium stretched appx 2 ½ times length Think rubber band CO decreased with lower preload/filling pressures or too high Patho: Starling’s Law of the Heart

8. Compensatory Mechanisms in CHF • Increased Sympathetic Nervous System Stimulation • Renin-angiotensin system activation • Natriuretic peptides • BNP • Ventricular hypertrophy

9. Elevated capillary pressure within the lungs  fluid pushed from circulating blood to interstitial tissues  then to the alveoli, bronchioles, and bronchi Acute Pulmonary Edema:

10. Nursing Assessment:Left Failure • Dyspnea • Cough • Bilateral crackles • Orthopnea • PND • Pulmonary Edema • S3 (ken-tuck-ee) • confusion • fatigue and muscular weakness • nocturia • increase retention of sodium and water due to lowered glomerular filtration  edema

11. Nursing Assessment: Right Failure • Dependent edema – • early sign • symmetric pitting edema • Bedrest-sacral edema • anasarca- late sign of CHF • Ascites • Anorexia, nausea and bloating • Cyanosis of nail beds • Anxious, frightened, depressed • Weight gain >2# daily

12. Diagnostic Assessment • Chest x-ray • Cardiac Enlargement • 12 lead EKG • Echocardiogram • assess ejection fraction • Labs • BNP • Liver enzymes…AST, ALT • Creatinine/GFR

13. Acute Left Failure/Pulmonary Edema: Collaborative Management: • O2 treatment • Drug Treatment • Diuretics • Vasodilators-NTG • MS • Digitalis • Semi- Fowler’s position • Frequent Heart and Lung Assessment • Dietary Restrictions • Planned rest periods • Weigh daily • Report to MD immediately: • persisting productive cough; dyspnea; pedal edema; restlessness

14. Drug therapy: • Diuretics • ACE Inhibitors • Beta Blockers • Calcium Channel Blockers • Nitroglycerine • Positive Inotropic agents • Digitalis • Beta Adrenergic Stimulator • Dopamine,Dobutamine • .

15. Pharmacologic: Diuretics • Mechanism of Action: • Thiazides, Loop, Potassium Sparing • S/E: • fluid and electrolyte imbalances • CNS effects • GI effects • Nursing Considerations: • Monitor for orthostatic hypotension • Hypokalemia

16. Angiotensin Converting Enzyme (ACE) Inhibitors Mechanism of Action • S/E: • Hypotension • cough • Hyperkalemia…esp w/CHF, CKD, DM • Angioedema • Facial/laryngeal swelling • Nursing considerations: • Do not use with potassium sparing diuretic • Metabolized by liver-excreted by kidneys

17. Adrenergic Inhibitors:Beta Blockers Mechanism of Action • Recommended for initial drug therapy of uncomplicated HTN (along with diuretic) • S/E: • Orthostatic hypotension • bradycardia • bronchospasm • Nursing considerations: • monitor pulse regularly

18. Calcium Channel Blockers Amlodipine, Diltiazem, Nifedipine Mechanism of Action: S/E: • Nausea • H/A • Peripheral edema Nursing considerations: • use with caution in patients with heart failure • Orthostatic changes • contraindicated in patients with 2nd or 3rd degree heart block • Concurrent use w/b-blockers incr risk of CHF

19. Vasodilators Mechanism of Action-NTG • Vasodilater-predominant on venous system by relaxing smooth muscles of vessels • Dilates coronary arteries/improves collateral flow • Up to 20% normal coronaries…30-40% pre/post stenosis • Decreases LVEDP…why? • Decreases O2 needs myocardium Side effects • HA, hypotension, tachycardia Hydralazine • arterial vasodilator

20. Priority Nursing Diagnosis • Impaired Gas exchange r/t ventilation perfusion imbalance • Decreased Cardiac Output r/t altered contractility, preload and afterload • Activity Intolerance r/t imbalance between O2 supply and demand • Knowledge Deficit • Activity schedule • Recognizing worsening heart failure • Medications • Diet therapy

21. Mitral Stenosis Patho Mitral Regurgitation Patho Mitral Valve Prolapse Patho Valvular Heart Disease:Mitral Valve

22. Valvular Heart Disease:Aortic Valve • Aortic Stenosis • Patho • Causes • Congenital • Atheroclerosis • Calcification • Aortic Regurgitation (Insufficiency) • Patho

23. Treatment Valvular Disease • Non-surgical Management • Diuretics • Beta blockers • Digoxin • Antibiotics • Before any invasives • Coumadin-if artificial valve • Surgical Management • Balloon Valvuloplasty • Open heart

24. Pericarditis • Patho • Open heart • AMI • Assessment findings • Friction rub • CP w/insp • CP relieves sitting up • Global ST elevation • Complications • Pericardial effusion • Cardiac tamponade • pericardiocentesis

25. Endocarditis • Patho • Etiology • Valve replacement • Structural cardiac defects • Invasive procedures • Clinical Manifestations • New murmur • Heart failure • Embolic • Diagnosis • Transesophageal Echo • + blood cultures • Interventions • IV abx • Surgical