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MANILA CENTRAL UNIVERSITY

College of Nursing . MANILA CENTRAL UNIVERSITY. NCM 104: CRITICAL CARE NURSING Nursing Care Management of Clients with CARDIOVASCULAR DISORDERS: Congestive Heart Failure. Carl Matol, RN. Nursing Care Management 104: CRITICAL CARE NURSING.

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MANILA CENTRAL UNIVERSITY

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  1. College of Nursing MANILA CENTRAL UNIVERSITY NCM 104: CRITICAL CARE NURSING Nursing Care Management of Clients with CARDIOVASCULAR DISORDERS: Congestive Heart Failure Carl Matol, RN

  2. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure CONGESTIVE HEART FAILURE RISK FACTORS IMPAIRED CARDIAC FUNCTION EXCESS WORK DEMANDS Cardiomyopathies Systemic Hypertension MYOCARDIAL DISEASES Myocarditis Pulmonary Hypertension INCREASE PRESSURE WORK Coronary Insufficiency Coarctation of Aorta Myocardial Infarction Stenotic Valvular Disease VALVULAR HEART DISEASE Regurgitant Valvular Disease Arteriovenous Shunt INCREASE VOLUME WORK Excessive Administration of IV Fluids Tetralogy of Fallot CONGENITAL HEART DEFECTS Patent Ductus Arteriosus Thyrotoxicosis INCREASE PERFUSION WORK CONSTRICTIVE PERICARDITIS Pericarditis Anemia

  3. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure BASIC CARDIAC PHYSIOLOGICAL MECHANISM: 1. CARDIAC OUTPUT : Dependent on the relationship between heart rate and stroke volume. : SV X HR = CO : Normal: 5,000 ml/min [5 L/min] STROKE VOLUME: Amount of blood ejected by ventricle during systolic contraction. HEART RATE: The number of times the ventricle contracts per minute

  4. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Cardiac Output BASIC CARDIAC PHYSIOLOGICAL MECHANISM:

  5. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Cardiac Output BASIC CARDIAC PHYSIOLOGICAL MECHANISM:

  6. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure BASIC CARDIAC PHYSIOLOGICAL MECHANISM: 2. PRELOAD : The volume of blood in the ventricles at the end of diastole. FRANK-STARLING LAW OF THE HEART: Stretching of muscle fibers during diastole, Increases force of contraction during systole LVEDP: Index of the left ventricular preload. CVP: Index of the right ventricular preload.

  7. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure BASIC CARDIAC PHYSIOLOGICAL MECHANISM: 3. AFTERLOAD : The resistance against which the ventricles must pump. 4. CONTRACTILITY : The force of contraction generated by the myocardium under given loading conditions.

  8. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure Classification of HEART FAILURE 1. HIGH-OUTPUT VERSUS LOW-OUTPUT: HIGH-OUTPUT FAILURE :Uncommon type of Heart failure. :Caused by an excessive need for cardiac output. Causes: a. Severe Anemia c. Arteriovenous shunt b. Thyrotoxicosis d. Paget’s disease LOW-OUTPUT FAILURE :Caused by disorders that impair pumping ability of the heart Causes: a. Ischemic Heart Disease b. Cardiomyopathy

  9. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure Classification of HEART FAILURE 2. SYSTOLIC VERSUS DIASTOLIC PRESSURE: BACKWARD FAILURE :Failure of one of the ventricles to effectively empty the heart during diastole. :Blood backs up in the venous system FORWARD FAILURE :Characterized by impaired forward movement of blood into the arterial system.

  10. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure Classification of HEART FAILURE 2. SYSTOLIC VERSUS DIASTOLIC PRESSURE: SYSTOLIC DYSFUNCTION :Decrease in cardiac contractility and ejection fraction. DIASTOLIC DYSFUNCTION :Characterized by smaller chamber size, ventricular hypertrophy, and poor ventricular compliance.

  11. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure Classification of HEART FAILURE 3. RIGHT-SIDED VERSUS LEFT-SIDED HEART FAILURE:

  12. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure Classification of HEART FAILURE 3. RIGHT-SIDED VERSUS LEFT-SIDED HEART FAILURE: RIGHT-SIDED HEART FAILURE Clinical Findings: SUBJECTIVE: 1. Abdominal pain 2. Fatigue 3. Bloating 4. Nausea OBJECTIVE: 1. Dependent Pitting Edema subsides at night when legs are elevated at night. 2. Ankle Edema (first sign) 3. Ascites 4. Anorexia 5. Respiratory Distress, CVP, and Urine output

  13. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure Classification of HEART FAILURE 3. RIGHT-SIDED VERSUS LEFT-SIDED HEART FAILURE: LEFT-SIDED HEART FAILURE Clinical Findings: SUBJECTIVE: 1. Dyspnea 2. Orthopnea 3. Fatigue and Restlessness 4. Paroxysmal Nocturnal Dyspnea OBJECTIVE: 1. Crackles 2. Peripheral Cyanosis 3. Cheyne-Stoke respiration 4. Frothy-blood-tinged sputum 5. Non-productive cough

  14. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure Classification of HEART FAILURE 3. RIGHT-SIDED VERSUS LEFT-SIDED HEART FAILURE:

  15. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure Complications of HEART FAILURE 1. ACUTE PULMONARY EDEMA Manifestations: 1. Dyspnea 2. Expectoration of frothy, pink-tinged sputum 3. Pallor and Cyanosis 4. Hypotension 5. Obtundation 6. Confusion Nursing Interventions: 1. Position the client in upright. 2. Oxygen Therapy [40%-60% via Face mask] 3. Administer Aminophylline as ordered [Therapeutic level: 20 ug/ml]

  16. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure Complications of HEART FAILURE 2. CARDIOGENIC SHOCK Manifestations: 1. Hypotension 2. Tachycardia 3. Oliguria 4. Impaired mentation 5. Peripheral vascular collapse

  17. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure DIAGNOSIS: Cardiac Failure A. Cardiovascular Findings 1. Cardiomegally 2. Rapid Heart Rate 3. Pulsus Alternans B. Diagnostic Evaluation 1. ECG 2. Echocardiography - Ventricular Hypertrophy - Dilation of Chambers - Abnormal Wall motions 3. Chest X-ray - Cardiomegally, Pleural Effusion - Vascular Congestion 4. ABGStudies: Hypoxemia, Hyperventilation

  18. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure DIAGNOSIS: Cardiac Failure Upon Admission Peribronchial Edema Pulmonary Venous Congestion Interstitial Pulmonary Edema Enlarged HEART [Dilated Left Ventricle] Subpleural Edema 6th Hospitalization Day Pulmonary Congestion subsided Pulmonary Edema cleared HEART much smaller DIAGNOSIS: Acute MI,Left Ventricular Dilation with CHF

  19. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure LABORATORY TESTS: Cardiac Failure A. Blood Chemistry/ Serum Electrolytes 1. Hypokalemia Hyperkalemia 2. Increase BUN, Creatinine and Uric Acid 3. Increase Bilirubin B. Urinalysis 1. Proteinuria 2. Increase Specific Gravity

  20. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure TREATMENT: Cardiac Failure THREE MAJOR APPROACH: 1. Removal of the underlying cause 2. Removal of Precipitating factor. 3. Treatment of the control of cardiac failure

  21. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure PHARMACOLOGICAL THERAPY: Cardiac Faliure 1. DIURETICS MECHANISM OF ACTION: To eliminate excess body of water and decrease ventricular pressure : LOW SODIUM and FLUID RESTRICTIONS compliment this therapy [1.6 to 2.8 g/day] CLASSIFICATION: 1. LOOP DIURETICS – inhibit sodium and chloride reabsorption from the Loop oh Henle and the distal tubule. Example: FUROSEMIDE [Lasix] Rapid-acting diuretics Desired Effect: 5 to 10 minutes

  22. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure PHARMACOLOGICAL THERAPY: Cardiac Faliure Nursing Responsibilities [LOOP DIURETICS]: Monitor signs and symptoms of HYPOKALEMIA: [Hyporeflexia, Drowsiness, Muscle cramps,Paresthesia] May decrease lithium excretion [Lithium Toxicity :2 meq/L ] Administer prescribed potassium supplement. Administer IV doses slowly 1 – 2 minutes to prevent hypotension and tinnitus. When given IM, use Z-track method to minimize irritation. 2. THIAZIDE DIURETICS – increase water excretion by either increasing the GFR or decreasing or inhibiting sodium reabsorption from the tubules. Example: CHLOROTHIAZIDE [Diuril] HYDROCHLOROTHIAZIDE [Hydrodiuril]

  23. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure PHARMACOLOGICAL THERAPY: Cardiac Faiure Nursing Responsibilities [THIAZIDE DIURETICS]: Monitor for Lithium toxicity. [ Fine Tremors, Anorexia, Dehydration (Diarrhea)] Monitor for signs of HYPOKALEMIA. Advise the patient o eat foods high in potassium. Give the diuretic in the morning or early afternoon. 3. POTASSIUM-SPARING DIURETICS – act at the distal tubule to cause excretion of sodium, bicarbonate, and calcium but conserve potassium excretion. Example: SPIRONOLACTONE [Aldactone]

  24. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure PHARMACOLOGICAL THERAPY: Cardiac Faiure Nursing Responsibilities [K-SPARING DIURETICS]: Monitor signs and symptoms of HYPERKALEMIA: [Hyperexcitability, Arrhythmias,Muscle weakness, Flaccid paralysis, Abdominal Distention, Diarrhea] Avoid salt-substitutes and potassium-rich foods, except with physician approval. Monitor Digoxin Toxicity [2 ng/L] MECHANISM OF ACTION: Increase the ability of the heart to pump more effectively by improving the contractile contractile force of the muscles. 2. POSITIVE INOTROPIC AGENT

  25. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure PHARMACOLOGICAL THERAPY: Cardiac Faliure Example: MILRINONE, AMRINONE- Potent Vasodilators DOPAMINE [Inotropin]- improves in renal blood flow. DOBUTAMINE- cardiac contractility & heart rate Nursing Responsibilities [INOTROPIC AGENTS]: Administer the drug through a large vein to prevent extravasation. Correct hypovolemia before infusing Dopamine. MECHANISM OF ACTION: Improves cardiac function as follows: a. Increase the force of myocardial contraction. b. Increase CO by enhancing the force of left ventricular contraction. c. Promotes diuresis by increasing cardiac output. 3. CARDIAC GLYCOSIDE

  26. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure PHARMACOLOGICAL THERAPY: Cardiac Faliure Example: DIGOXIN [Lanoxin] Nursing Responsibilities [CARDIAC GLYCOSIDE]: Assess patient’s apical pulse, serum drug and electrolyte levels, and renal function. Withhold drug: PULSE RATE: Below 60 beats/ minute Monitor signs of DIGITALIS TOXICITY: [ Fatigue, Malaise, Depression, Vomiting, Anorexia, Nausea] Significant Sign: COLORED VISION, XANTOPSIA [Yellowish Spots] Antidote: DIGOXIN IMMUNE FAB [Digibind, DigiFab]

  27. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure PHARMACOLOGICAL THERAPY: Cardiac Faiure MECHANISM OF ACTION: Decreases workload of the heart by dilating peripheral vessels in: a. Relaxing capacitance vessels [veins & venues] b. Relaxing resistance vessels [arterioles] 4.VASODILATOR THERAPY [Peripheral] Examples: NITRATES – dilates systemic veins HYDRALAZINE [Apresoline] – reduces arteriolar tone SODIUM NITROPRUSSIDE [Nipride] – affects arterioles PRAZOCIN [Minipress] – balanced effects on both arterial and venous circulation. MORPHINE SULFATE – decreases venous return

  28. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure PHARMACOLOGICAL THERAPY: Cardiac Faiure MECHANISM OF ACTION: It act by selectively suppressing Renin-Angiotensin 1 enzyme thus causing arterial and venous vessels 5. ACE INHIBITOR Examples: CAPTOPRIL [Capoten] QUINAPRIL [Accupril] ENALAPRIL [Vasotec] MOEXIPRIL [Univasc] Nursing Responsibilities [ACE INHIBITOR]: Administer Captopril on an empty stomach, preferably hour before meals for maximum effectiveness. Advise the patient to avoid sudden position changes to minimize orthostatic hypotension.

  29. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure PHARMACOLOGICAL THERAPY: Cardiac Faiure MECHANISM OF ACTION: It blocks the conversion of Angiotensin I to Angiotensin 2 in inhibiting its adverse effect of vasoconstriction thereby reducing workload of heart and increase cardiac output. 6. ANGIOTENSIN II ANTAGONIST Examples: IRBESARTAN [Approvel] VALSARTAN [Diovan] TELMISARTAN [Pritor] LOSARTAN [Cozaar] 7. BETA ADRENERGIC BLOCKING AGENTS MECHANISM OF ACTION: Decrease myocardial workload and protect against fatal dysrrhythmias by blocking norepinephrine effects of the SNS. Examples: METROPOLOL [Neobloc, Betabloc] CARREDILOL

  30. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure NUTRITIONAL SUPPORT : Cardiac Faiure A. NO ADDED SALT DIET- 4 grams of Na/ day - High Sodium foods are limited. - ½ tsp. table salt is allowed B. MILD-SODIUM RESTRICTIONS - 2 grams of Na/ day - High sodium foods are eliminated. - ¼ tsp. table salt is allowed C. MODERATE-SODIUM RESTRICTIONS - 1 gram of Na/ day - High sodium foods are eliminated. - Table salt is not allowed. - Canned or processed foods containing salt are omitted. SODIUM-RESTRICTED DIETS

  31. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure NUTRITIONAL SUPPORT : Cardiac Faiure D. STRICT SODIUM RESTRICTIONS - 500 mg/ day - High sodium foods are eliminated. - Vegetables high in sodium are omitted [Spinach, carrot, celery] - Meat 6 oz daily. E. SEVERE SODIUM RESTRICTIONS - 250 mg/ day - High sodium foods are eliminated. - Foods in natural sodium are eliminated. SODIUM-RESTRICTED DIETS

  32. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure NURSING MANAGEMENT Nursing Diagnoses: • Fluid Volume Excess related to increase sodium and water retention, decreased organ perfusion, increased ADH production. • Decreased Cardiac Output related to damaged myocardium, decreased contractility, myocardial ischemia, ventricular hypertrophy • Impaired gas exchange related to ventilation/ perfusion imbalance caused from excess fluid in alveoli and reduction of air exchange in lungs. • Risk for Impaired Skin Integrity related to decrease tissue perfusion, edema, altered metabolic rate, decreased peripheral tissue perfusion • Anxiety related to fear of death, threat to body image, threat role functioning

  33. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure KILLIP CLASSIFICATION OF HEART FAILURE K - 1 K - 2 K - 3 K - 4

  34. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure FUNCTIONAL CLASSIFICATION OF PATIENT WITH HEART DISEASE I CLASS II CLASS III CLASS IV CLASS

  35. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM: Congestive Heart Failure THERAPEUTIC CLASSIFICATION OF PATIENT WITH HEART DISEASE CLASS A CLASS B CLASS C CLASS D CLASS E

  36. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM SELF-ASSESSMENT EXERCISE [Congestive Heart Failure]

  37. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM SELF-ASSESSMENT EXERCISE [Congestive Heart Failure] • The nursing assessment of a client diagnosed with congestive heart failure reveals moderate dyspnea, clammy, very pale-skin, and cough producing frothy blood-tinged sputum. Based on these findings, the nurse would suspect the client is experiencing: A. Angina B. Early congestive heart failure C. Pulmonary Edema D. Cardiac Tamponade • The priority nursing intervention for the client experiencing severe pulmonary edema would be: A. Call the physician B. Assess airway, patency, and administer oxygen via face mask. C. Prepare rotating tourniquets in case they are needed to decrease venous return D. Administer an extra dose of digitalis.

  38. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM SELF-ASSESSMENT EXERCISE [Congestive Heart Failure] • Which of the following data would indicate that a client diagnosed with congestive heart failure is being compliant with the various aspects of discharge teachings? A. Demonstrating better nutrition habits by gaining 10 lbs. B. Returning to the hospital as an inpatient less frequently. C. Significantly improving his or her activity level D. Attending all the classes. • While performing discharge teaching for a client with chronic CHF, the nurse should be sure to stress which of the following topics? A. The need for a structured exercise program. B. The use of high sodium and lo potassium foods. C. Signs and symptoms of pulmonary edema D. Possible surgical procedures.

  39. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM SELF-ASSESSMENT EXERCISE [Congestive Heart Failure] • The nursing assessment for a 46-year-old client with CAD reveals noncompliance with the medication regimen and three hospitalizations in the last 6 months for CHF. When planning discharge teaching, the nurse best course of action for this client would be to: A. Reteach the client about the medication schedule, and give pamphlets to read B. Collect more data to help identify reasons for noncompliance. C. Teach the family about the medication schedule and the importance of compliance. D. Arrange for outpatient follow-up to ensure compliance. • The major goal of therapy for client with CHF would be to: A. Increase cardiac output B. Improve respiratory output. C. Decrease peripheral edema D. Enhance comfort

  40. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM SELF-ASSESSMENT EXERCISE [Congestive Heart Failure] • What position should the nurse place the head of the bed to obtain the most accurate reading of jugular vein distention? A. High fowlers B. Raised 10 degrees C. Raised 30 – 45 degrees D. Supine position • Which of the following parameters should be checked before administering Digoxin [Lanoxin]? A. Apical pulse B. Blood pressure C. Radial pulse D. Respiratory rate

  41. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM SELF-ASSESSMENT EXERCISE [Congestive Heart Failure] • Which of the following symptoms is most commonly associated with Left-sided Heart Failure? A. Crackles B. Arrhythmias C. Hepatic engorgement D. Hypotension • Which of the following classes of medication maximizes cardiac performance in clients with heart failure by increasing ventricular contractility: A. Beta-adrenergic blockers B. Calcium-channel blockers C. Diuretics D. Inotropic agents

  42. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM SELF-ASSESSMENT EXERCISE [Congestive Heart Failure] • The nurse is performing her admission assessment on a patient. When grading arterial pulses, a 1+ indicates: A. Above normal perfusion B. Absent perfusion C. Normal perfusion D. Diminished perfusion • The nurse is preparing the client with CHF to go home. The nurse should instruct the client to: A. Monitor urine output daily. B. Maintain bed rest for at least 1 week C. Monitor daily potassium intake D. Weigh daily.

  43. Nursing Care Management 104: CRITICAL CARE NURSING Disorders of the CARDIOVASCULAR SYSTEM SELF-ASSESSMENT EXERCISE [Congestive Heart Failure] • The nurse can best assess the degree of edema in an extremity by: A. Checking for pitting B. Weighing the client C. Measuring the affected area D. Observing intake and output • The client will require careful skin care, primarily because an edematous client is prone to develop: A. Itchy skin B. Decubitus ulcer C. Electrolyte imbalance D. Distention of weakened veins

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