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Septal Defects Chapter 29 (Brunner) Chapter 41 (Pillitteri: 1206-14) Septal Defects Congenital Heart Disorders Management of Pts with Complications from Heart Disease Chapter 30 (Brunner) HF, Pulmonary Edema, Cardiogenic Shock, Pulmonary Emboli, Pericardial Effusion, Cardiac Tamponade, & Sudden Cardiac Death/Cardiac Arrest

Outline
1. d Pulmonary Blood Flow (Acyontic Defect) 1. Septal Defects 1. Ventricular Septal Defect (VSD) 2. Atrial Septal Defect (ASD) 2. Atrioventricular Canal Defect 3. Patent Ductus Arterious 2. d pulmonary blood flow (cyanotic defect) 1. Tetralogy of Fallot 3. Obstruction of Blood Flow 1. Aortic Stenosis 2. Pulmonary Stenosis 3. Coartation of Aorta 4. Cyanotic Defects (Mixed blood flow) 1. Transposition of Great Vessels 2. Tetralogy of Fallot (also falls under category of d pulmonary blood flow)

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Question
Meena was born with a ventricular septal defect. A chief concern that parents of children with heart disease often report is:
a) b) c) d) infant is gaining weight rapidly. the baby always seems hungry. she seems to have trouble sucking. their babys face appears pale.

d Pulmonary Blood Flow Acyontic Defects

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Septal Defects Chapter 29 (Brunner) Chapter 41 (Pillitteri)

Atrial or ventricular septum has abnormal opening b/t right & left side of heart Most septal defects are Congenital Repaired during infancy or childhood Adults may develop septal defects as a result of MI or trauma Symptoms May not experience symptoms Or may gradually develop symptoms Or may rapidly develop heart failure Types d pulmonary blood flow Obstruction of blood flow Mixed blood flow d pulmonary blood flow

Septal Defects Brunner Chapter 29

Atrial septal defect (ASD) Right atrial pressures become > than left atrial pressures Blood begins to flow from right atrium into left atriuma rightto-left shunt Symptoms gradually develop d exercise tolerance DOE Palpitations Syncope Symptoms of right ventricular or CHF May cause cyanosis May cause CVA Ventricular septal defect (VSD) Extra blood volume causes right ventricle to dilate Also causes pulmonary vascular congestion & HTN Symptoms gradually develop SOB Syncope Chest pain Symptoms of left ventricular failure

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Septal Defects Brunner Chapter 29

Septal DefectTreatment Vasodilators left-to-right shunting s resistance to ventricular ejection Septal Defect Repair Percutaneous septal defect repair Many septal defects can be repaired percutaneously in cardiac cath lab Post-op care Same care as post-procedure cardiac cath or PTCA Pt remains in the hospital for 24 to 48 hours Surgical septal defect repair Post-op care Same as other cardiac surgeries

d Pulmonary Blood Flow Acyontic Defects

Ventricular Septal Defect (acyanotic) Opening is present in septum b/t two ventricles Blood gets shunted from left ventricle, across septum, to right ventricle 2 pressure > left ventricle than right ventricle Refer to next slide Assessment May not evident at birth Usually evident at about 4 to 8 wks Baby becomes easily fatigued when shunting begins Has abnormal murmur as opposed to functional innocent murmur Abnormal murmur associated with VSD Loud, harsh systolic murmur Heard along left sternal border (at 3rd or 4th intercostal space) Murmur may be palpable (has thrill vibration) Functional innocent heart murmurs Normal heart sounds heard in children Made as blood flows through the heart

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d Pulmonary Blood Flow Acyontic Defects

Ventricular Septal Defect (cont) Ineffective tissue perfusion r/t inefficiency of heart as a pump Treatment Must be closed (2 can cause HF) Can cause right ventricular hypertrophy & d pulmonary artery pressure 2 blood is getting shunted back into pulmonary circulation instead of going out of aorta & to body 85% of VSDs are so small they close spontaneously Moderate sized VSD are closed by cardiac catheterization Large sized VSD are closed by open-heart surgery Requires general anesthesia & cardiopulmonary bypass Ventricular septal defect is occluded by using a Silastic or Dacron patch As time passes, babys septal tissue will grow across synthetic patch Prophylactic antibiotics for 6 months to prevent bacterial endocarditis May participate in normal activities after surgery as long as without complications

Acyanotic defects d pulmonary blood flow

Atrial Septal Defect (ASD) Abnormal opening b/t two atria Blood ends up shifting from left (oxygenated) atrium to right (deoxygenated) atrium 2 stronger contraction of left side of heart Adverse Side Effects d volume in right side of heart Inventricular hypertrophy d pulmonary artery blood ow (like VSD)

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d pulmonary blood flow Atrial Septal Defect (ASD)

Atrial Septal Defect (ASD) cont Assessment Harsh systolic murmur over 2nd or 3rd intercostal space (around pulmonic area) 2 can hear extra blood being shunted across pulmonic valve This causes pulmonic valve to close later than aortic valve [AKA a split S2] Fixed splinting of 2nd heart sound is indicative of ASD Treatment Elective surgery Needs to be done b/t 1 3 y/o 2 must be closed b/c baby is at risk for infectious endocarditis & HF Women are at risk for emboli during pregnancy Closed by: (1) Cardiac catheterization or (2) Open-heart surgery (Silastic or Dacron patch to occlude space)

d Pulmonary Blood Flow Acyontic Defects

1. 2. 3. 4. Ventricular Septal Defect (VSD) Atrial Septal Defect (ASD) Atrioventricular Canal Defect Patent Ductus Arterious
Example Atrioventricular canal defect

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d pulmonary Blood Flow Acyontic Defects

Atrioventricular Canal Defect AKA endocardial cushion defect Incomplete fusion of endocardial cushion This is where septum of heart joins junction of atria & ventricles AEB low ASD & high VSD; & distorted mitral & tricuspid valves Blood flow is left-to-right, but may flow b/t all 4 heart chambers Approximately 50% of children with trisomy 21 (Down syndrome) who have heart disease have this type of congenital cardiac defect

d pulmonary Blood Flow Acyontic Defects

Atrioventricular Canal Defect cont Assessment ECG often shows 1st -degree heart block 2 impulse is halted before AV node Symptoms Same as ASD: (1) right ventricular hypertrophy (2) d pulmonary blood flow (3) xed S2 splitting Treatment: Surgery is always necessary 2 defects are too large to close spontaneously Requires septal repair & possibly valve repair Hence, may need prophylactic anticoagulation & antibiotics

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d pulmonary Blood Flow Acyontic Defects

Ductus arterious An accessory fetal structure that connects pulmonary artery to aorta Allows babys lungs to be bypassed Begins to close at birth with 1st breath Completely closes b/t 7-14 days old Prostaglandins when baby begins to breath on own 2 oxygen levels make ductus arteriosus close d incidence in babies born at higher altitudes Patent Ductus Arteriosus Ductus arteriosus fails to close 2 babys prostaglandin levels fail to

d pulmonary Blood Flow Acyontic Defects

Patent Ductus Arteriousus cont Pathophyiology Blood gets shunted from aorta (oxygenated blood) to pulmonary artery (deoxygenated blood) 2 to d pressure in aorta From pulmonary artery Blood then goes to lungs, to pulmonary vein, & then back to left atrium, to left ventricle, & back to aorta Hence, blood never makes it out to body It just continues to get shunted through pulmonary artery, & the cycle continues

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d pulmonary Blood Flow Acyontic Defects

Patent Ductus Arteriousus cont Adverse Effects d pressure in pulmonary circulation r/t extra shunted blood Results in right ventricle hypertrophy Assessment (1) Widened pulse pressure (2) Continuous (systolic & diastolic) machinery murmur Heard at upper left sternal border Or under left clavicle in older children Treatment Prostaglandin Inhibitors IV indomethacin or ibuprofen Ibuprofen is becoming drug of choice 2 has fewer SEs

Question
Which happening makes an infant high risk for patent ductus arteriosus?
a) b) c) d) Infant had difficulty beginning respirations. Infants mother had an epidural block for labor. Infants father worked at a sedentary desk job. Infants mother had an infection during pregnancy.

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Obstruction of Blood Flow Defects

1. 2. 3. 4. Aortic Stenosis Pulmonary Stenosis Coartation of Aorta Cyanotic Defects (Mixed blood flow) 1. Transposition of Great Vessels 2. Tetralogy of Fallot 1. Also falls under category of d pulmonary blood flow

Obstruction of Blood Flow

Coarctation of the Aorta Narrowing of aortas lumen 2 constricting band Blood has difficulty passing through narrowed aorta lumen Results in BP changes d BP proximal (close) to coarctation AEB d BP in heart & upper portions of childs body & d BP distal to coarctation Assessment d upper-body BP causes HA & vertigo But, baby cant tell you Hence, S&S: irritability, epistaxis, & possible CVA (for dangerously d BP) BP in arms At least 20 mm Hg > legs (reversal of normal pattern) For slight coarctation Absent palpable femoral pulses may be the only symptom Hence, newborn femoral pulses are always assessed

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Obstruction of Blood Flow

Coarctation of the Aorta Treatment Digoxin & diuretics 2 CHF from HTN Angiography (a balloon catheter) Surgery Narrowed portion of aorta is removed & new ends of aorta are anastomosed Usually occurs before 2 y/o But, ideal situation would be to operate on adult height 2 prevents strain on incision line as they grow Girls need to have surgery before childbearing age 2 extra blood volume during pregnancy can cause HF If surgery is successful, child can expect to live a normal life

Questions
1. If an infant were born with coarctation of the aorta, this produces few symptoms at first. An important finding to assess to best suggest this exists is
a) b) c) d) excessive sleeping and crying. presence of a cardiac murmur. elevated body temperature. lack of both femoral pulses.

2. Which of the following is a symptom of coarctation of aorta that a school nurse might notice when the child reaches school age?
a) b) c) d) Pain in the legs on physical exercise An especially short attention span Eating little lunch from lack of appetite Abdominal bloating and chronic pain

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Obstruction of Blood Flow To be covered in Brunner Chapter 29

Cyanotic Defects Mixed blood flow

1. Transposition of Great Vessels 2. Tetralogy of Fallot

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Cyanotic Defect Mixed blood flow

Transposition of Great Vessels Severe defect that is incompatible with life Baby is usually cyanotic at birth Aorta arises from right ventricle instead of left Pulmonary artery arises from left ventricle instead of right Blood flow Comes into heart from vena cava to right atrium To right ventricle Then to aorta (instead of pulmonary artery) Hence, blood goes out to body completely deoxygenated There is an existence of a second closed circulatory system Sp, blood enters heart from pulmonary veins to left atrium To left ventricle, to pulmonary artery, to lungs to be oxygenated & returns to left atrium So, b/c of this closed circulatory system, none of this oxygenated blood ever makes it out to body

Cyanotic Defect Mixed blood flow

Transposition of the Great Vessels Treatment Need to get blood to lungs Prostaglandins 2 to keep ductus arteriosus patent Creation of artifical atrial septal defect 2 allows deoxygenated blood to get to lungs for oxygenation In most cases, baby has an atrial & ventriclular septal defect, as well as the transposed vessels Hence, some of deoxygenated blood is getting oxygenated Surgical correction of transposed great vessels Surgery is done to separate the great vessels Performed when baby is about 1 to 3 months of age

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Question
Suppose an infant had been born with transposition of the great vessels so the baby was prescribed ibuprofen. The purpose of this medication is to
a) b) c) d) increase blood pressure to reverse blood flow. increase the strength of atrial contractions. decrease and strengthen the heart rate. keep the ductus arteriosus from closing.

d pulmonary Blood Flow

Tetralogy of Fallot

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d pulmonary blood flow Tetralogy of Fallot

Tetralogy of Fallot Consists of 4 anomalies 1. Pulmonary stenosis Causes d pressure in right side of heart Causes blood to be shunted from right side of heart to left ventricle (via VSD) Systolic murmur (heard at left 2nd, 3rd, or 4th intercostal space) & then out through overriding aorta 2. Hypertrophy of right ventricle Caused by d force to push blood through stenosed pulmonary artery 3. VSD (usually large) Systolic murmur (heard at left 2nd, 3rd, or 4th intercostal space) 4. Dextroposition (overriding) of aorta Many children with Tetralogy of Fallot have deletion abnormality of chromosome 22

Tetralogy of Fallot
Assessment Squatting in knee-chest position 2 overstressed heart is relieved Squatting Traps blood in lower extremities Helps trapped blood supply oxygen to major body organs Cyanosis Polycythemia May not be evident immediately after birth Systolic murmur But, as become more active, skin has bluish tint Clubbing Child develops severe dyspnea, growth restriction, & clubbing of the fingers Syncope (fainting) & hypercyanotic episodes AKA tet spells 2 d blood flow & oxygen to brain (risk for cognitive defects) Polycythemia (d RBCs) 2 helps supply body with extra oxygen This is dangerous 2 causes thickening of blood (d viscosity) Risk for clot; thrombophlebitis, embolism, & CVA Systolic murmur Heard at left 2nd, 3rd, or 4th intercostal space

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Tetralogy of Fallot
Blalock-Taussig Procedure Temporary surgery 2 Tetralogy of Fallot is not fully corrected until child is 1-2 y/o Need to correct, or will cause severe dyspnea, growth restriction, & clubbing of the ngers Prior to surgery hypercyanotic episodes Give O2 for hypoxic episode Place in kneechest position To trap blood into LEs Keeps heart from being overwhelmed Morphine sulfate To symptoms

Tetralogy of Fallot
Blalock-Taussig Procedure A shunt is created b/t aorta & pulmonary artery (it creates a ductus arteriosus) Allows blood to leave aorta & enter pulmonary artery to oxygenate lungs Blood then returns to left side of heart, to aorta, & out to body Uses subclavian artery Hence, at post-op, baby will have no palpable pulse in right arm Need to avoid all BPs & venipunctures to affected arm Brock Procedure Corrects pulmonary stensosis, VSD, & overiding aorta Performed when child is old enough to have full surgery to correct pulmonary stensosis, VSD, & overriding aorta

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Question
1. Tetralogy of Fallot is the most frequently occurring type of cyanotic heart disease. What are the four anomalies associated with this defect are: a) atrial septal defect, pulmonary stenosis, left ventricular hypertrophy, and overriding aorta. b) ventricular septal defect, aortic stenosis, mitral stenosis, and right-sided aorta. c) mitral stenosis, right ventricular hypertrophy, pulmonary stenosis, and atrial septal defect. d) ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and overriding aorta. 2. Suppose an infant with Tetralogy of Fallot turns cyanotic and short of breath. Your best action would be to: a) put her head between her legs. b) place her in a knee-chest position. c) tell her to breathe into a paper bag. d) sit her upright to lower blood pressure.

Questions
1. What is a common laboratory finding with children with cyanotic heart disease?
a) b) c) d) Decreased platelet count Elevated sedimentation rate Elevated total red cell count Elevate white blood count

2. The best place to assess if cyanosis is present in children is in the

a) b) c) d) conjunctiva of the lower eyelid. fingertips or toes for color. circumoral area by the mouth. tongue or buccal membrane.

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Questions
1. A baby had a cardiac catheterization to diagnose congenital heart disease. Following cardiac catheterization, which of the following is the most important measure?
a) b) c) d) Assessing the pressure dressing is intact Assuring the baby the procedure is now over Letting the baby adjust to room light gradually Letting the baby kick and exercise her legs

2. Which nursing diagnosis would best apply to an infant with Tetralogy of Fallot?
a) b) c) d) Impaired gas exchange related to a left to right septal shunt Impaired skin integrity related to consistent cyanosis Ineffective airway clearance related to a constricted aorta Altered tissue perfusion related to pulmonary artery stenosis

Questions
1. An infant is prescribed digoxin. The action of digoxin is to
a) b) c) d) increase the heart rate and dilate blood vessels. slow heart rate and strengthen heart contractions. decrease the amount of blood filling the ventricles. stimulate angiotension to increase blood pressure.

2. What is the usually designated level of pulse rate considered safe for administration of digoxin for a 6-month-old infant?
a) b) c) d) 40 beats per minute 60 beats per minute 100 beats per minute 150 beats per minute

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Chapter 30 Managing Pts with Complications from Heart Disease

HF, Pulmonary Edema, Cardiogenic Shock, Pulmonary Emboli, Pericardial Effusion, Cardiac Tamponade, & Sudden Cardiac Death/Cardiac Arrest

Heart Failure
Inability of heart to pump sufficient blood to meet needs of tissues for oxygen & nutrients Incidence of HF s with age Most common in pts > 75 y/o Most HF is a progressive, lifelong disorder managed with lifestyle changes & meds Recognized as a Syndrome AEB Fluid overload or inadequate tissue perfusion 2 heart cant generate sufficient CO to meet bodys demands Ejection fraction (EF) Assists in determining HF type WNL EF is 55% to 65% of ventricular volume 2 ventricle does not completely empty b/t contractions

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Heart Failure
2 major types of HF Systolic heart failure More common type Characterized by altered ventricular contraction Low EF is a hallmark of systolic HF
EF is < 55% to 65% of ventricular volume

Diastolic heart failure Less common type Characterized by stiff & noncompliant heart muscle Makes it difficult for ventricle to fill EF is normal

Heart Failure
Primary Cause Atherosclerosis of coronary arteries in CO activates multiple neurohormonal mechanisms Results in S&S of HF Compensatory mechanisms of HF AKA vicious cycle of HF

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Heart Failure Symptoms

Left-sided HF Pulmonary congestion Occurs when left ventricle cant effectively pump blood out of ventricle into aorta & to systemic circulation d pulmonary venous blood volume & pressure This forces fluid from pulmonary capillaries into pulmonary tissues & alveoli Results in pulmonary edema AEB Dyspnea Cough May have frothy pink tinged sputum pink 2severe pulmonary edema Pulmonary crackles Low O2 sat Heart Sounds May have S3 heart sound ventricular gallop, 2 large volume of fluid entering ventricle at beginning of diastole

Heart Failure
Right-sided HF As right ventricle fails, it will cause congestion in peripheral tissues & viscera 2 right side of heart Cant eject blood Cant accommodate blood that normally returns from venous circulation d venous pressure leads to JVD & d capillary hydrostatic pressure throughout venous system Systemic S&S Lower extremity edema (dependent edema) Usually affects feet &ankles Worsens when stands or sits for long period Hepatomegaly (enlarged liver) Ascites (fluid in peritoneal cavity) Anorexia & nausea, & weakness Weight gain 2 retention of fluid

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Questions

Heart Failure
Overall goals Relieve symptoms Improve functional status & quality of life Extend survival Treatment options
Vary according to severity of condition
Meds Major lifestyle changes Supplemental oxygen Implantation of assistive devices Cardiac transplantation

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Questions
1. Medications routinely prescribed for systolic HF a. ACE inhibitors (eg, lisinopril [Prinivil, Zestril]) b. Beta-blockers c. Diuretics d. Digitalis

2. Which of the following is a primary cause of chronic heart failure? a. Atherosclerosis b. Valvular dysfunction c. Hypertension d. Cardiomyopathy Suppose an infant develops congestive heart failure. An important nursing intervention would be to a) restrict milk or dairy-product intake. b) Maintain a semi-Fowlers position. c) plan ways to reduce potassium intake. d) Keep lower extremities elevated.

Heart Failure
Systolic HF Meds ACE Inhibitors Prescribed for mild failure AEB Fatigue or DOE But, without signs of fluid overload & pulmonary congestion Start at low dose for 2 weeks Then until optimal dose is achieved & is hemodynamically stable Angiotensin II receptor blockers An alternative to ACE inhibiters 2 some pts cant tolerate ACE inhibitors AEB develops cough, d creatinine level, or hyperkalemia Or combo of hydralazine (antihypertensive) & isosorbide dinitrate (vasodilator) Drug tx specifically indicated for African Americans with HF

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Systolic HF Meds
Beta-blockers (carvedilol (Coreg) & metoprolol (Lopressor, Toprol) adverse effects from constant SNS stimulation B/c of SEs, when pt is stable & euvolemic (WNL volume), pt is started low dose Dose is titrated slowly (every 2 weeks) Educate after each titration: Risk for potential worsening of symptoms & improvement may take several week 2 beta-blockers can cause bronchiole constriction Ex. beta-1selective betablocker blocks beta-adrenergic receptor sites in heart

Systolic HF Meds
Beta-blockers (cont)
Asthma Well-controlled, mild to moderate asthma
Recommend metropolol
But, still need to monitor closely for d asthma symptoms 2 cardioselective beta-blockers retain some beta-2 effects

Severe or uncontrolled asthma

All types of beta-blocker are contraindicated

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Systolic HF Meds

Systolic HF Meds

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Systolic HF Medications
IV Systolic HF Meds Nesiritide (Natrecor) A BNP to tx acute decompensated HF BNP is naturally produced by myocardium as compensatory mechanism in response to HF, such as: d ventricular end-diastolic pressure & d release of neurohormones (eg, norepinephrine, renin, aldosterone) Causes arterial & venous dilation Suppresses neurohormones responsible for fluid retention Promotes diuresis Results in d preload & afterload & d SV Most common side effect Dose-related hypotension

Systolic HF Medications
IV Systolic HF Meds (cont) Milrinone (Pimacor) Delays release of calcium from cell Prevents uptake of extracellular calcium Promotes vasodilation Resulting in d preload & afterload & d cardiac workload. Administered if has not responded to other therapies Major side effect is hypotension Dobutamine (Dobutrex) Given for significant left ventricular dysfunction & hypoperfusion Stimulates the beta-1adrenergic receptors to cardiac contractility

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Question
Tell whether the following statement is true or false. Digoxin immune FAB (Digibind) may be given to treat severe digoxin toxicity.

Questions

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Questions

Heart Failure
Nutritional Therapy Low-sodium (2 to 3 g/day) diet
Dietary restriction of sodium
s fluid retention & symptoms of peripheral and pulmonary congestion

Purpose of sodium restriction

amount of circulating blood volume s myocardial work

Need to avoid drinking excessive amounts of fluid

Pt compliance is important
2 dietary indiscretions may result in severe exacerbations of HF requiring hospitalization

Oxygen therapy
May become necessary as HF progresses

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Heart Failure
Other Interventions PCI or CABG: for underlying CAD Implantable cardioverter defibrillator (ICD) For pts with severe left ventricular dysfunction & possibility of life-threatening dysrhythmias HF places pt at high risk for dysrhythmias 2 sudden cardiac death is common cause of death for pts advanced HF Cardiac resynchronization therapy (CRT) For pts with conduction defect Example: left bundle branch block is frequently seen in HF Results in dyssynchronous conduction & contraction of both ventricles, which can further EF CRT uses of biventricular pacemaker Txs conduction defects Improves CO s mitral regurgitation Slows ventricular remodeling process

Heart Failure
Other Interventions (cont) Ultrafiltration To tx severe fluid overload Removes fluid via small bedside machine Implanted ventricular assist device A mechanical circulatory assistance device Serves as bridge therapy to a cardiac transplant Cardiac transplantation May be only option for long-term survival.

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Care of the Patient with HF

Assessment Mental status Assess for confusion 2 EF s O2 to brain Lung sounds Assess for crackles & wheezes Heart sounds Assess for S3 S3 means heart is failing & d blood is filling ventricle with each beat Fluid status/signs of fluid overload JVD: estimates central venous pressure Abnormal: > 3 cm above the sternal angle Hepatojugular reux of Liver Apply pressure to right upper abdominal quadrant for 30 to 60 seconds If neck vein distends > 1 cm, then positive for d venous pressure

Care of Patient with HF

Assessment (cont) Dependent edema d SV can cause perfusion to periphery AEB Cool, pale, cyanotic skin Edema to sacrum, back, & hands, & fingers Daily weight Weigh at same time of day, with same type of clothing, & on same scale Notify the MD if gained 2- to 3-lb in a day Or 5-lb in a week (may need diuretics adjusted) I&O Assess if ingested more fluid than excreted (positive fluid balance) Compare positive fluid balance to any gain in weight Monitor for oliguria d urine output, < 500 mL/24 h Monitor for anuria Urine output < 50 mL/24 h Monitor responses to meds

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Questions

Questions

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Care of Patient with HF

Nursing Diagnoses
Activity intolerance & fatigue r/t d CO Excess fluid volume r/t HF syndrome Anxiety r/t breathlessness from inadequate oxygenation Powerlessness r/t chronic illness & hospitalizations Ineffective therapeutic regimen management r/t lack of knowledge

Heart Failure
Major Teaching Goals
Promote activity and fatigue Relieving fluid overload symptoms anxiety ability to manage anxiety Verbalizes ability to make decisions & influence outcomes Verbalizes understanding about self-care program

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Activity Intolerance
Bed rest for acute exacerbations Encourage regular physical activity (AEB 30 minutes daily) Exercise training Pacing of activities Wait 2 hours after eating before doing physical activity Avoid activities in extremely hot, cold, or humid weather. Modify activities to conserve energy. Positioning HOB (semi-Fowlers) to facilitate breathing & rest, and support of arms

Caring for HF
Fluid Volume Excess Assess for symptoms of fluid overload Daily weight I&O Diuretic therapy Fluid intake Fluid restriction Maintenance of sodium restriction (refer to Chart 30-4) Lifestyle changes & meds to education to: (1) number of recurrences of acute HF (2) life expectancy (3) unnecessary hospitalizations

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Patient Teaching for HF

Self-Care Program Meds Timing of med administration Oral diuretics should be taken early in morning 2 diuresis wont interfere with nighttime rest Diet Low-sodium diet & fluid restriction Low sodium foods Example: Potatoes & chicken High sodium foods Example: Ham, sardines, & bouillon Monitor for signs of excess fluid: Example daily weight Exercise & activity program Stress management Prevention of infection Know how & when to contact health care provider Include family in teaching

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Pulmonary Edema
Abnormal accumulation of fluid in interstitial spaces of lungs that diffuses into alveoli Resistance to left ventricular filling Causes blood to back up into pulmonary circulation Can result in flash pulmonary edema Etiology MI Exacerbation of chronic HF Renal failure S&S LOC Hypoxemia Restlessness Anxiety Dyspnea Cool & clammy skin Cyanosis Weak & rapid pulse Cough sputum production (may be mucoid, frothy & bloodtinged) Lung congestion Moist, noisy respirations

Pulmonary Edema Pathophysiology

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Management of Pulmonary Edema

Prevention Early recognition Monitor lung sounds Signs of d activity tolerance Signs of d fluid retention Place pt upright & dangle legs Oxygen exertion & stress As ability to breathe s, pts fear & anxiety s Makes condition more severe. Hence, pt is unstable, nurse must remain with pt Medications Morphine Assess for resp depression, hypotension,vomiting Keep morphine antagonist (naloxone hydrochloride (Narcan) available Give if exhibits serious respiratory depression Diuretic (furosemide) If on continuous IV of vasoactive meds Needs to be on ECG monitoring & frequent VS (BP, pulse, resp)

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Pulmonary Edema Case Study (cont)

Pulmonary Edema Case Study (cont)

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Potential Complications of HF
Cardiogenic shock Dysrhythmias Thromboembolism Pericardial effusion Cardiac tamponade

Complications of HF
Cardiogenic Shock Life-threatening condition with a high mortality rate CO leads to inadequate tissue perfusion & initiation of shock syndrome. High risk pts S/p MI End-stage HF Cardiac tamponade Pulmonary embolism Cardiomyopathy Dysrhythmias. S&S: symptoms of HF, shock state, & hypoxia Pt is managed in ICU to assess: Cardiac rhythm Hemodynamic parameters Fluid status Action of meds

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Complications of HF
Cardiogenic Shock Management
Correct underlying problem Meds
Diuretics Positive inotropic agents Vasopressors
Cardiogenic Shock

Circulatory assist devices

Intra-aortic balloon pump (IABP)

Complications of HF
Cardiogenic Shock Mechanical Circulatory Assistive Devices Intra-Aortic Balloon Pump Uses internal counterpulsation through inflation & deflation of balloon Augments pumping action of heart Balloon inates during diastole s perfusion of coronary & peripheral arteries Balloon deates just before systole s afterload resistance to ejection left ventricular workload inflates

deflates

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Complications of HF
Thromboembolism Intracardiac thrombi Especially common in pts with A-fib Pulmonary embolism Most common complication of HF Hence, HF places pt at d risk for pulmonary embolism 2 d mobility & d circulation 2 blood clots may form in deep veins of legs & embolize to pulmonary vasculature Results in life-threatening embolic event Pulmonary emboli may be single or multiple

Questions

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Complications of HF
Pericardial Effusion
Accumulation of fluid in pericardial sac May accompany advanced HF Normally, pericardial sac contains 20 mL of fluid 2 s friction as heart beats d fluid in pericardial sac causes: pressure inside pericardial sac & compresses heart Slow in pericardial fluid Results in no noticeable symptoms. Rapid in pericardial fluid Results in stretching pericardium to maximum size Results in CO Results in cardiac tamponade (compression of heart) S&S of Pericardial Effusion Feeling of pressure in chest Engorged neck veins SOB Labile or low BP Pulsus paradoxus Systolic BP is markedly lower during inhalation AEB > 10 mm Hg in systolic BP during inhalation & exhalation Refer to next slide

Pulsus Paradoxus
Normal conditions of rest Inspiration will cause a of arterial systolic pressure of < 10 mm Hg occurs Inspiration will cause a fall in venous pressure Paradoxical pulse Pulsus paradoxus differs from a normal pulse in two respects 1) inspiration will cause a in arterial pressure is > 10 mm Hg 2) inspiraion will cause venous pressure to remain steady or increases. The exaggerated waxing & waning in pulse volume can usually be palpated & demonstrated with a sphygmomanometer or arterial catheter.

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Complications of HF
Cardiac Tamponade Restricts heart function Results in: d venous return CO S&S of cardiac tamponade 2 pericardial effusion CO causes pt to feel anxiety, faintness, & SOB Cough 2 swelling of pericardial sac causes pressure on trachea Distended neck veins 2 venous pressure Paradoxical pulse Cardinal signs Indicative sign of: cardiac tamponade, ing systolic BP pericarditis chronic sleep apnea, COPD, Narrowing pulse asthma pressure ing venous pressure AEB > 10 mm Hg in systolic BP during Distant heart sounds inhalation & exhalation Muffled or distant heart sounds

Cardiac Arrest
Heart ceases to produce effective pulse & circulate blood Causes Dysrhythmia (e.g. V-Fib) Profound bradycardia Asystole (absense of a cardiac rhythm) Respiratory arrest Pulseless electrical activity (PEA) Electrical activity is present But, has no effective cardiac contraction or circulating volume Causes Hypovolemia (eg, from excessive bleeding) Hypoxia, Hypothermia Hyperkalemia Massive pulmonary embolism MI Med overdose (eg, beta-blockers, calcium channel blockers).

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Cardiac Arrest
Assessment
Pt will immediately lose consciousness, pulse, & BP Pupils will begin dilating within 45 seconds. Seizures may or may not occur Risk of irreversible brain damage & death
s with every minute from time that circulation ceases

Need to take immediate measures to restore circulation

Cardiac Arrest Interventions

Provide CPR 2 s blood flow to vital organs until effective circulation can be reestablished Start CPR after recognition of unresponsiveness, lack of pulse & respiration First Assess LOC (which is first step in basic life support) Shake pts shoulders & shout, "Are you OK?" Second Open airway & check for respirations If breathing is absent, give two mouth-tomouth breaths Then check circulation by palpating carotid artery Once LOC is restored Priority for adults Activate code team or EMS 911 home 77 SVC Exceptions Near drowning Drug or med overdose Respiratory arrest These need 2 minutes of CPR performed before activating EMS

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Sudden Cardiac Death/Cardiac Arrest

The ABCDs of Basic CPR A- airway Maintain an open airway B- breathing Provide artificial ventilation by rescue breathing C- circulation Promote artificial circulation by external cardiac compression if has no pulse Give meds (example: epinephrine for asystole) D- defibrillation for VT and VF; with standard defibrillator Perform CPR initially only if defibrillator is not immediately available. Survival rate s for every minute defibrillation is delayed Pts who have not been defibrillated within 10 minutes, have little chance of survival.

Question
1. All of the following are clinical manifestations of right-sided heart failure except:
a. b. c. d. Hepatomegaly Jugular vein distention Ascites Orthopnea

2. Tell whether the following statement is true or false.

The most reliable sign of cardiac arrest is absence of breath sounds.

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Questions

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