Interventions for Clients with Cardiac Problems

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• Interventions for Clients with Cardiac Problems

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Heart Failure

• Also called pump failure, general term for the
  inadequacy of the heart to pump blood throughout
  the body causes insufficient perfusion of body
  tissue with vital nutrients and oxygen
• Left-sided heart failure
• Right-sided heart failure
• High-output failure

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Compensatory Mechanisms

• Sympathetic nervous system stimulation
• Renin-angiotensin system activation
• Other neurohumoral responses
• Myocardial hypertrophy

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Etiology

• Heart failure is caused by systemic hypertension
  in 75 of cases.
• About one third of clients experiencing
  myocardial infarction also develop heart failure.
• Structural heart changes, such as valvular
  dysfunction, cause pressure or volume overload on
  the heart.

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Left-Sided Heart Failure

• Manifestations include
• Weakness
• Fatigue
• Dizziness
• Confusion
• Pulmonary congestion
• Shortness of breath
• (Continued)

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Left-Sided Heart Failure (Continued)

• Oliguria
• Organ failure, especially renal failure
• Death
• Assess blood pressure, mental status, breath
  sounds

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Right-Sided Heart Failure

• Manifestations include
• Distended neck veins, increased abdominal girth
• Hepatomegaly (liver engorgement)
• Hepatojugular reflux
• Ascites
• Dependent edema
• Weight the most reliable indicator of fluid gain
  or loss

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Assessments

• Laboratory assessment
• Radiographic assessment
• Electrocardiography
• Echocardiography
• Pulmonary artery catheters

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Impaired Gas Exchange

• Interventions include
• Ventilation assistance
• Hemodynamic regulation
• Energy management, diet therapy, drug therapy

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Decreased Cardiac Output

• Interventions include
• Optimization of cardiac output stroke volume
  (determined by preload, afterload, and
  contractility) and heart rate
• (Continued)

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Decreased Cardiac Output (Continued)

• Drug therapy including
• Angiotensin-converting enzyme
• ACE inhibitors
• Diuretics
• Human B-type natriuretic peptides
• Nitrates
• Inotropics
• Beta-adrenergic blockers

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Hemodynamic Regulation

• Interventions include
• Reduce afterload.
• Reduce preload.
• Improve cardiac muscle contractility.
• Administer drugs as prescribed.
• Monitor for therapeutic and adverse effects.
• Teach client and family drug therapy.

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Drugs That Reduce Afterload

• Angiotensin-converting enzyme (ACE) inhibitors
• Human B-type natriuretic peptides

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Interventions That Reduce Preload

• Diet therapy
• Drug therapy
• Diuretics
• Venous vasodilators

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Drugs That Enhance Contractility

• Digitalis
• Digitalis toxicity includes anorexia, fatigue,
  changes in mental status.
• Monitor heart rate and electrolytes.
• Other inotropic drugs including dobutamine,
  milrinone, and levosimendan
• Beta-adrenergic blockers

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Other Nonsurgical Options

• Continuous positive airway pressure
• Cardiac resynchronization therapy
• Investigative gene therapy

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Surgical Management

• Newer surgical therapies include the following
• Partial left ventriculectomy
• Endoventricular circular patch
• Acorn cardiac support device
• Myosplint

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Activity Intolerance

• Interventions include
• Ventilation assistance
• Hemodynamic regulation
• Energy management
• Interdisciplinary interventions, which regulate
  energy to prevent fatigue and optimize function

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Potential for Pulmonary Edema

• Interventions include
• Assess for early signs, such as crackles in the
  lung bases, dyspnea at rest, disorientation, and
  confusion.
• Rapid-acting diuretics are prescribed, such as
  Lasix or Bumex.
• Oxygen is always used.
• Strictly monitor fluid intake and output.

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Valvular Heart Disease

• Mitral stenosis
• Mitral regurgitation (insufficiency)
• Mitral valve prolapse
• Aortic stenosis
• Aortic regurgitation (insufficiency)

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Assessment

• Client may become suddenly ill or slowly develop
  symptoms over many years.
• Question client about attacks of rheumatic fever,
  infective endocarditis, and possibility of IV
  drug abuse.
• Obtain chest x-ray, echocardiogram, and exercise
  tolerance test.

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Common Nursing Diagnoses

• Decreased Cardiac Output related to altered
  stroke volume
• Impaired Gas Exchange related to ventilation
  perfusion imbalance
• Activity Intolerance related to inability of the
  heart to meet metabolic demands during activity
• Acute Pain related to physiologic injury agent
  (hypoxia)

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Nonsurgical Management

• Drug therapy, including diuretics, beta blockers,
  digoxin, oxygen, and sometimes nitrates
• Prophylactic antibiotic
• Management of atrial fibrillation, cardioversion
• Anticoagulant
• Rest with limited activity

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Surgical Management

• Reparative procedures
• Balloon valvuloplasty
• Direct, or open, commissurotomy
• Mitral valve annuloplasty
• Replacement procedures

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Infective Endocarditis

• Microbial infection involving the endocardium
• Occurs primarily with IV drug abuse, valvular
  replacements, systemic infections, or structural
  cardiac defects
• Possible ports of entry mouth, skin rash,
  lesion, abscess, infections, surgery, or invasive
  procedures including IV line placement

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Manifestations

• Murmur
• Heart failure
• Arterial embolization
• Splenic infarction
• Neurologic changes
• Petechiae (pinpoint red spots)
• Splinter hemorrhages

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Interventions

• Antimicrobials
• Rest, balanced with activity
• Supportive therapy for heart failure
• Anticoagulants
• Surgical management

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Pericarditis

• Inflammation or alteration of the pericardium,
  the membranous sac that encloses the heart
• Dresslers syndrome
• Postpericardiotomy syndrome
• Chronic constrictive pericarditis

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Assessment

• Substernal precordial pain radiating to left side
  of the neck, shoulder, or back
• Grating, oppressive pain, aggravated by
  breathing, coughing, swallowing
• Pain worsened by the supine position relieved
  when the client sits up and leans forward
• Pericardial friction rub

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Interventions

• Hospitalization for diagnostic evaluation,
  observation for complications, and symptom relief
• Nonsteroidal anti-inflammatory drugs
• Corticosteroid therapy
• Comfortable position, usually sitting
• Pericardial drainage
• (Continued)

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Interventions (Continued)

• Chronic pericarditis radiation or chemotherapy
• Uremic pericarditis dialysis
• Pericardiectomy

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Emergency Care of Cardiac Tamponade

• Cardiac tamponadean extreme emergency
• Increased fluid volume
• Hemodynamic monitoring
• Pericardiocentesis
• Pericardial window
• Pericardiectomy

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Rheumatic Carditis

• Sensitivity response that develops following an
  upper respiratory tract infection with group A
  beta-hemolytic streptococci
• Inflammation in all layers of the heart
• Impaired contractile function of the myocardium,
  thickening of the pericardium, and valvular damage

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Clinical Manifestations

• Tachycardia
• Cardiomegaly
• New or changed murmur
• Pericardial friction rub
• Precordial pain
• Changes in electrocardiogram
• Indications of heart failure
• Existing streptococcal infection

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Cardiomyopathy

• Subacute or chronic disease of cardiac muscle
• Dilated cardiomyopathy
• Hypertrophic cardiomyopathy
• Restrictive cardiomyopathy

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Interventions

• Nonsurgical management
• Surgical management
• Cardiomyoplasty
• Heart transplantation