heart failure · jlz pcu series cardiac - 2013 32 cardiac glycosides ... –providing patient...
TRANSCRIPT
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HEART FAILURE AND VASCULAR DISORDERS
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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
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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
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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
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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
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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)
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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
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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
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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
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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.
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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
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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
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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
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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
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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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Diseases of the Arteries and Veins: Aneurysm
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Aneurysm and Dissection
Weakness and bulging of the entire vessel wall (Fusiform)
or
Weakness within the vessel wall ( Sacculated intimal tear or dissection
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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)
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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
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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
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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
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Carotid Artery Stenosis
• 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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Carotid Artery Stenosis
• Surgical Management
– Carotid endarterectomy when stenosis is >60%
– Stent placement possibly
• Nursing Management
– Assess neurologic status and mental alertness
– Stroke education
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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
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