heart failure · jlz pcu series cardiac - 2013 32 cardiac glycosides ... –providing patient...

10/6/2016

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HEART FAILURE AND VASCULAR DISORDERS

1 JLZ PCU Series Cardiac - 2015

Objectives

• Understand heart failure and it’s effect on cardiac perfusion

• Understand the difference between systolic and diastolic heart failure

• Understand the nursing care for patients experiencing heart failure

JLZ PCU Series Cardiac - 2015 2

Review of Heart Anatomy


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Heart Failure • Many possible causes

• Chronic and terminal

• Result of bad pump

• Effects all organs by reducing oxygen delivery

Cardiomyopathy

Dilated • Idiopathic

• Inflammatory / infections

• Autoimmune disease

• Toxic (drugs, alcohol)

• Hereditary

• Metabolic

• endocrine

Hypertrophic • Idiopathic

• Systemic hypertension


Constrictive • Idiopathic

• Interstitial disease

• Eosinophilic heart disease

• Radiation

• Drug toxicity


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History of Heart Failure

• Prevalence: 4.9 million

• Incidence: 550,000

• Mortality: 50% within 5 years

• Hospital discharges: 1 million

• Cost: 29 billion (Medicare, 2009)

• 10 out of 1,000 over 65 have heart failure

Source: National Hospital Discharge Survey

http:www.edc.gov/nchs/about/major/hdasd/listpubs.htm.

HF Hospitalization Rates

Current Heart Failure Facts

• Currently, 5.8 million Americans affected; will increase to an estimate 10 million in 2035

• 600,000 new cases annually

• Most common DRG hospital admission

• 1 million admissions directly related; another 2 million with secondary diagnosis of HF

• Costs for 2010 = 39.2 billion, up from 28.8 billion in 2004

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Medicare: The Problem of Heart Failure

• HF patients see an average of 23 different healthcare providers yearly…typical beneficiary 7.9

• HF patients have an average of 61 prescriptions filled yearly … typical beneficiary 29

• HF accounts for 37% of all Medicare spending and for 50% of all hospital in-patient costs

• The cost for HF patients is approximately $24,000 annually … cost for typical Medicare beneficiary $3,000

• 25% HF patients readmitted within 30 days

• 24% diet

• 24% meds

• 19% no follow-up

• 16% inappropriate treatment

• 17% other

Causes of Worsening Heart Failure

Causes of Poor Adherence to Treatment

• Inadequate patient education (diet, meds, lifestyle, s/s, when to call MD)

• Low health literacy • Inability to obtain prescriptions (can’t get to pharmacy,

lack of insurance) • Unable to cook (no support, lives alone, fast foods,

packaged and frozen foods) • Co-morbidities • Lack of follow-up (can’t get to, appointment never

made, insurance doesn’t cover) • Willful non-compliance

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Who is at Risk for Rehospitalization?

• Frequent flyers

• Low health literacy

• Depression

• Substance abuse

• Elderly

• Co-morbidities

• LOS

Systolic Heart Failure

• Systolic is the failure to pump – < 45% EF

– Low stroke volume

– Low cardiac output

• Causes: – Injury (MI, CAD)

– HTN

– Aortic stenosis

– Toxins

Normal vs Systolic Heart Failure

Normal EF> 60% LVEDD 4.4–5.0cm EF < 17% LVEDD >10cm

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Diastolic Heart Failure

• Diastolic indicates failure to relax and fill

– Low fill volume

– Low stroke volume

– High-end diastolic pressure

• Causes

– Cardiomyopathy

– Ischemia

– HTN

Left Sided HF

Left Side Symptoms • Dyspnea

• Orthopnea

• Nocturnal dyspnea

• Pulmonary edema

• Dry throat

• Hypoxia

• Low hemoglobin

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Right Sided HF

Right sided symptoms

• Jugular venous distention

• Dependent edema

• Splenomegaly

• Hepatojugular reflex

• Diminished breath sounds

• Weight gain

• N&V

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Symptom Assessment: Breathing Patterns

• 6 minute walking test

• # of pillows

• Need supplemental oxygen?

• Awaken with SOB?

• Dyspnea

• What are their goals?

Symptom Assessment : Fatigue

• Activity intolerance?

• Activities of daily living?

• Sleeping patterns?

Symptom Assessment: Chest Pain

• How often?

• Where?

• How long?

• Radiating?

• What makes it better or worse?

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Symptom Assessment: Fluid Retention

• Where?

• Time of day?

• What works?

Symptom Assessment: Depression

• Sleep?

• History?

• Support system?

• Coping skills?

Projected Heart Failure Course

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Treatment options

Values

Hopes

Wishes

Personhood

Life story

Goals of Care Medical Options

Patient/Family Clinicians

Medications

Pacemaker/AICD

Pressors/Inatropes

Code Status

VAD, Transplant

Thornberry, Cain, Edmonds 2014

Goals of Care Discussions

Non-pharm, Non-invasive Options

• Diet

• Fluid restrictions

• Skin care

• Reduce sodium

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Medications • Acute, short term treatment

– Inotropes to improve contractility of the ventricle – Balance good (improved CO and SV) and evil (Increase O2

consumption) • Dobutamine, milrinone

• Chronic, long term treatment – Digitalis (Digoxin) – Manipulation of preload – lower volume entering left

atrium • Diuretics, nitroglycerin, fluid/Na restriction

– Manipulation of afterload – resistance of blood, valves and vessels that LV must overcome to eject blood • ACE inhibitors, Ca channel blockers, IABP

– Biventricluar pacing to improve contractility if BBB present


Cardiac Glycosides • Used to increase the efficiency of the

heart and improve the contraction of the heart muscle

• Slows the heart rate by decreasing the

conduction through the SA and AV node (negative inotropic effect) and

• increases the force of contraction of the cardiac muscle (positive inotropic effect)

• Treats CHF or heart failure, A-fib, A

flutter, PAT


Cardiac Glycosides

• Digoxin (Lanoxin) most common drug used- given as a loading dose and followed by maintenance dose – Digoxin toxicity may occur (s/s – nausea, muscle weakness,

dysrhythmias) digoxin level greater than 2 – Digibind may be given if levels are too high – Count apical pulse for full minute before giving. If less than

60-hold dose and notify MD – Monitor K levels – Teach patient to check pulse before giving

• Primacor and Inocor – used if no response to digoxin, diuretics, or vasodilators


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Angiotensin-Converting Enzyme (ACE) Inhibitors

• Positive effect on cardiac function – reduce preload & afterload

– increase cardiac index, ejection fraction and cardiac output

• Mechanism of Action – Suppress formation of angiotensin II (a potent

vasoconstrictor

– Causes vasodilation in the heart on both venous and arterial providing both preload and afterload reduction

– EX: captopril, Vasotec, Monopril, Prinivil, Accupril,

• Monitor BP, UO, BUN/Cr, K+ and Na (excreted through kidneys)


ACE Inhibitors

• Side Effects – First dose Hypotension

– cough

– Dizzyness, headache, fatigue, diarrhea

– Angioedema

– Hyperkalemia

• Contraindications – History of angioedema, low blood pressure, Cr

> 3mg/dL, serum K+ > 5.5 mmol/L, bilateral renal stenosis


Beta-adrenergic Blockers

• Manage angina and reduce cardiac workload, oxygen demand and consumption

• Typically have “olol” on end of word – atenolol, metroprolol, labetolol, propranolol

• Mechanism of Action – Selective agents have preferential affinity to blocking

Beta-1 receptors specifically in the heart – Non-selective agents have affinity to both Beta – 1

and Beta-2 (propanolol) • Blockage of Beta 2 can lead to bronchial constriction • Careful with COPD or asthma


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Beta Adrenergic Blockers • Decrease activity of the sympathetic nervous

system on certain tissue • Decrease the excitability of the heart, decrease

cardiac workload, and O2 consumption, and provide stabilization of dysrhythmias

• Used for hypertension, and certain cardiac arrhythmias

• Nursing Interventions – Vitals – Monitor weight – Teach patient to get up slowly and avoid hot showers – Inderal can cause bronchial constriction


Amiodarone

• Amiodarone is both an antiarrhythmic and a potent vasodilator

• The therapeutic range for amiodarone is generally considered to be roughly 1—2.5 mcg/ml

• PO with or without food

• IV via central line, use low-sorb tubing with inline filter – ACLS dose 300mg IVP


Pill Taking Burden

• Aspirin 81mg EC tablet PO daily

• Bumetanide 4mg PO BID

• Carvedilol 25mg PO BID

• Nitroquick 0.4mg SL q5min PRN, up to 3

per episode

• Valsartan 80mg PO BID

• Hydralazine 50mg 1 tab PO QAM + 2tab

PO QHS

• Spironolactone 50mg PO QAM

• Isosorbide mononitrate 120mg PO QHS

• Metformin 500mg PO BID with food

• Lantus 15units SC QPM

Advair 100-50mcg/dose inhale 1 puff PO

q12h

One UCSD Heart failure patient

• Albuterol 90mcg/act 1–2puffs q4h PRN

• Ferrous sulfate 325mg tablet PO TID

• Klor-Con 20mEq PO BID

• Vicodin 5/500mg tab PO q6h PRN

moderate pain – pt reports taking 1x/wk

• Ibuprofen 800mg PO q6h PRN mild pain –

pt reports taking 1x/mo

• Simvastatin 20mg PO QHS

• Allopurinol 300mg PO daily

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Non-pharm, Invasive Options

• Pacemaker/AICD

• Transplantation

• VADs!

• Paracentesis/thoracentesis-

– Hurts, but can reduce symptoms

Cardiac Resynchronization Device Placement

RA

RV LV

CRTD implant

Primary Endpoint

All-Cause Mortality or

Hospitalization for Major

Cardiovascular Event

P<.001

Secondary Endpoint

All-Cause Mortality

P<.002

39%

20%

55%

30%

0%

10%

20%

30%

40%

50%

60%

CRT Control CRT Control

Cleland JG, et al. N Engl J Med. 2005;352:1539-1549.

CARE-HF: CRT Long-Term Outcomes • Median LV ejection fraction

was 25%

• 409 patients randomized to the CRT device; 95% had a successful implantation

• Primary endpoint of all-cause mortality or hospitalization for a major CV event occurred less frequently in the CRT group than in the medical therapy alone group (HR 0.63, 95% CI 0.51–0.77)

• Major secondary endpoint of all-cause mortality was also lower in the CRT group (HR 0.64, 95% CI 0.48–0.85)

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Heart Transplant

• Remains option of choice for end-stage HF

– Most do not qualify

– Limited organs!

• In 2012, 2,008 were transplanted (more than 5,000 listed)

Ventricular Assist Devices

• Approved in 1994 as bridge to transplant, later for destination

• New generation of continuous flow VAD increased survival (now 20% at 2 years), and QOL

• 4,000 placed since 2006

Nursing Management

• Nursing priorities for patients with heart failure include: – Optimizing cardiopulmonary function. – Promoting comfort and emotional support. – Monitoring effectiveness of pharmacologic

therapy. – Providing adequate nutrition. – Providing patient education.

Slide 45 JLZ PCU Series Cardiac - 2013

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Nursing Interventions for Acute Heart Failure

• Sudden onset! • S/S

– Pulmonary edema, low cardiac output and / or cardiogenic shock – Volume overload, sodium / water retention – May have structural heart chamber changes such as dilation or

hypertrophy

• Goal: Decrease preload, decrease afterload and increase

contractility – Diuretic therapy – Decrease anxiety with analgesics – Provide emotional support and reassurance that treatments are

given – Support cardiac function with inatropes – Hypoxemia with increase FIO2, CPAP or BiPAP for positive

pressure


Test Your Knowledge • Your patient with dilated cardiomyopathy is

admitted with dyspnea, cough palpitations and decreased LOC. – VS on admission

• HR 120 – sinus rhythm

• BP 94/60

• RR 16

– What you anticipate as part of the medication regime • Captopril (ACE inhibitor)

• LVAD

• Loading dose of Digoxin

• Cardiac catheterization


Test Your Knowledge • Your patient with heart failure is on a diuretic and

fluid restriction. Assessment indicates atrial tachycardia, presence of crackles in all lung fields, and S3 at the left apex. Patient is complaining of SOB. – VS 3 hours ago Currently

• BP 130/60 90/40 • HR 72 130 • RR 16 24

• What should the nurse anticipate? – Fluid bolus to enhance preload – Dopamine to support BP – Dobutamine to support CO – Adenosine to reverse tachycardia


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VASCULAR DISORDERS


Objectives

• Understand types of aneurysm

• Understand post-op care for aneurysm repair

• Discuss arterial and venous flow abnormalities

• Discuss care for cardiac surgical patient in the PCU


Types of Aneurysm

• Thoracic Aortic Aneurysm (TAA)

– Potentially life threatening due to rapid progression and shock

– Ascending Aortic is more difficult to correct surgically than descending because of major cardiac structures

• Abdominal Aortic Aneurysm (AAA)

– More common (65%) of all aneurysms

– 5% of individuals over age 60 have an AAA


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52

Diseases of the Arteries and Veins: Aneurysm

JLZ PCU Series Cardiac - 2015

Aneurysm and Dissection

Weakness and bulging of the entire vessel wall (Fusiform)

or

Weakness within the vessel wall ( Sacculated intimal tear or dissection


Aneurysm and Dissection • Saccular Aortic dissection

– Column of blood separates vascular layers

– Creates false lumen which communicates with true lumen through tear in intima • Tears in the intimal layer result in the propagation of

dissection (proximally or distally) secondary to blood entering the intima-media space


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Aneurysm and Dissection • Etiology

– Acquired conditions are mainly chronic hypertension, dyslipidemia, and use of cocaine

–Atherosclerotic changes in the thoracic and abdominal aorta

– Inherited conditions are Marfan syndrome.

– Catheter interventions and aortic surgery (cross-clamp, cannulation site, and graft anastomosis)


Assessment and Diagnosis: Aneurysm

Thoracic Aneurysm • S/S :

– Sudden onset of severe chest pain.

– Shortness of breath, weakness

– Widened mediastimum on CXR

• Diagnosis

– Transesophageal

echocardiography

– Computed tomography (CT)

– Aortic angiogram

Abdominal Aneurysm • S/S:

• Palpable mass identified on physical exam or back pain with tenderness on palpation

– Increased BP and pulse in upper extremities and decrease BP in lower extremities

– Shortness of breath, weakness, or back pain

• Diagnosis – CT and MRI, Abd. Xray – Aortic angiogram


Area of the aorta

with the intimal

tear is usually

resected and

replaced with a

Dacron graft.


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Abdominal Aneurysm Post Op Care

•Post op – Monitor cardiovascular indicators such as CVP, ST seg and

ECG rhythm

•Complications –MI accounts for 50% of post-op mortality

–Bleeding from coagulopathies •Watch for hypovolemia, palpate for strong pulse in femoral artery

–Renal failure especially with preexisting kidney disease •Due to prolonged cross clamping of renal arteries or hypotensive episodes during or after surgery

•Assess renal function, U/O, I&O, lytes, Cr.

–Limb ischemia due to atheroembolism •Can occur in one or both legs

•Assess and document pedal pulses, skin color, movement, temperature and sensation hourly

•Pain in extremity is an indication of acute ischemia


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Abdominal Aneurysm Emergency

• Acute pain is the classic sign of aortic dissection – If you suspect, call Code/RRT for help

• Opiates and sedatives are given for pain management, decrease anxiety, increase comfort – Watch as these medications can mask further

dissection – administer with caution

– Assess neuro status a hourly

– Document pain, pallor, paresthesia, paralysis and movement of limb.

– Control hypertension


Carotid Artery Stenosis

• Bifurcation of the common site for atherosclerotic plaques

• When obstructed, the presenting symptoms are neurologic

– Abrupt blockage for 4-6 minutes will produce permanent brain damage

– Gradual blockage will produce collateral blood supply and may maintain blood flow to the brain



• Modifiable risk factors include – Uncontrolled

hypertension SBP >160

– Afib

– Smoking

– Diabetes with uncontrolled BS

– Hyperlipidemia

– Co-existing CAD

• Diagnosis – Doppler studies to

carotid arteries

– CT scan if stroke is suspected

• Medical Management – Lower atherosclerotic

risk factors

– Antithrombotic therapy (warfarin, aspirin) for Afib


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• Surgical Management

– Carotid endarterectomy when stenosis is >60%

– Stent placement possibly

• Nursing Management

– Assess neurologic status and mental alertness

– Stroke education


Test Your Knowledge

• Which of the following is the MOST indicative of a ruptured abdominal aortic aneurism?

– Back pain

– Bounding peripheral pulses

– Intermittent claudication

– Warm, flush skin


heart failure · jlz pcu series cardiac - 2013 32 cardiac glycosides ... –providing patient...

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