cardiovascular disorders understanding medical surgical nursing 4 th ed., ch 21, 23, 24,...

Cardiovascular DisordersUnderstanding Medical Surgical Nursing 4th ed., Ch 21, 23, 24, (p.459-483), 26 Pharmacology Clear & Simple, Ch 16.

Objectives1. Describe diagnostic test for the cardiovascular system.2. Compare nonmodifiable risk factors in coronary artery disease (CAD) with factors that are modifiable in lifestyle & heath management.3. Compare etiology/pathophysiology, S&S, medical management, & nursing interventions for clients with cardiovascular disorders.4. Specify teaching for clients with cardiovascular disorders.

Normal Aging Patterns•Δ’s in cardiac musculature lead to reduced efficiency & strength, resulting in ↓’ed cardiac output.•Older Adult Considerations•Age 65 years

•Older Adult Considerations•Heart Failure•Edema •Medications•Teaching

Aging & the Cardiovascular System

•Atherosclerosis•Arteriosclerosis•BP ↑’s•Vein Valves More Incompetent•Heart Muscle Less Efficient•Dysrhythmias Common

Cardiovascular Disease •Number 1 Killer •Healthy Lifestyle

• Smoking Cessation• Dietary Fat Reduction• 2 Servings of Fish Weekly• Exercise

Cardiovascular Disease (cont’d)•Go Red for Women

•American Heart Association’s Nationwide Movement to Celebrate the Power Women Have to Band Together to Wipe Out Heart Disease

•Color Red & Red Dress Linked with This Ability

Cardiovascular Assessment•Health History

•Symptoms – WHAT’S UP?•Allergies•Past Medical Hx•Medications•Family Hx•Health Promotion Methods

•Diagnostic Studies

Cardiovascular Assessment cont’d

• Physical Assessment• VS’s (T, P, R, BP, & Pain)

• Inspection• Oxygenation, Skin Color• Extremities: Hair, Skin, Nails, Edema, Color • JVD• Capillary Refill• Clubbing

Physical Assessment (cont’d)•Palpation

•Point of Maximum Impulse•Extremity Temperature •Edema•Homans’ Sign*

Auscultation•Heart Sounds

Joint Commission National Client Safety Goal• Improve Accuracy of Client Identification• Use at Least 2 Client Identifiers (Neither Client's Location) Whenever Collecting Laboratory Samples or Administering Medications or Blood Products

• Use 2 Identifiers to Label Sample Collection Containers in Presence of Client

Joint Commission National Client Safety Goal (cont’d)

• Immediately Prior to Any Invasive Procedure, Conduct Final Verification Process to Confirm Correct Client, Procedure, Site, & Availability of Appropriate Documents

• Improve Effectiveness of Communication Among Caregivers • For Orders/Telephonic Reporting of Critical Test Results, Verify Complete Order/Test Result by Reading Back Complete Order/ Test Result to Person Giving it

Blood Studies• Blood Lipids

• Triglycerides, Cholesterol, Phospholipids

• hs-CRP • Homocysteine • Cardiac Biomarkers

• Creatine Kinase, Troponin, Myoglobin

Blood Studies• B-type natriuretic peptide (BNP)

• Protein secreted from ventricles in response to overload, such as in heart failure

• BNP levels below 100 pg/mL indicate no HF. • BNP levels of 100-300 pg/mL suggest HF

present. • BNP levels above 300 pg/mL indicate mild HF• BNP levels above 600 pg/mL indicate

moderate HF. • BNP levels above 900 pg/mL indicate severe

HF.

• Blood cultures• Complete blood count (CBC)

–Erythrocyte sedimentation rate (ESR)• Coagulation studies• Electrolytes

–Magnesium, K+, Calcium, Phosphorus, Glucose

• Arterial blood gases

Blood Studies

Diagnostic Studies

•Chest X-Ray•CT Scan •Magnetic Resonance Imaging•Cardiac Calcium Scan

Diagnostic Studies

•Plethysmography•Diagnoses Deep Vein Thrombosis/Pulmonary Emboli/Peripheral Vascular Disease

•Pressure Measurement•BP Readings Along Extremity

Diagnostic Studies (cont’d)• Arterial Stiffness Index

http://www.healthfair.com/schedule-a-screening/arterial-stiffness-index/

• Atherosclerosis/Cardiovascular Disease • Tilt Table Test http://www.youtube.com/watch?v=5H5FZTAic7c

• Lying to Standing BP & HR • Doppler Ultrasound

• Impaired Blood Flow Reduces Sound Waves

Diagnostic StudiesElectrocardiogram (ECG or EKG)

• Shows Cardiac Electrical Activity• 12-lead ECG = 12 Different Views• Waveforms Change Appearance in

Different Leads• Continuous Monitoring Often in Lead II

–Waveforms Upright in Lead II

Interpretation of Cardiac Rhythms

• Six-step Process1. Regularity of Rhythm2. Heart Rate3. P Wave4. P–R Interval5. QRS Complex6. QT IntervalNormal Cardiac Waves Are Equal

Distances Apart

• Holter Monitor• Cardiac Monitors: Continuous

assessment of cardiac electrical activity.

• Telemetry: ambulatory pts.

Diagnostic Studies

Exercise StressTest• Cardiac Stress Test

• Cardiac Response to Exercise & ↑’ed Oxygen Needs

• Peripheral Vascular Stress Test• Vascular Response to Walking

• U/S • Records Motion

• Heart Structures• Valves• Heart Size, Shape,

Position Transesophageal

Echocardiogram• Probe in Esophagus • Clearer Picture • NPO Until Gag Reflex Returns

Echocardiographyhttp://www.youtube.com/watch?v=482CdbvapBU

Radioisotope Imaging• Radioisotopes IV, Gamma Camera Scan

• Detects Cardiac Ischemia/ Damage/ Perfusion•Thallium Imaging•Technetium Pyrophosphate Scan•Technetium 99m Sestamibi•MUGA Scan •Positron Emission Tomography (PET) scan

Diagnostic Studies• Fluoroscopy: action-picture

radiograph, observation of movement.

• Angiogram: use of fluoroscopy to view cardiovascular system. radiographs w/radiopaque dye artery.

• Aortogram: x-ray w/dye aorta

Digital subtraction angiography: visualizes heart’s chambers, valves, great vessels & coronary arteries.

1.Pressures w/in heart2. bld.-volm. Relationship to cardiac competence3.Valvular defects, arterial occlusion, congenital

anomalies• Consent needed• Assess allergy to contrast medium, iodine, &

seafood http://www.youtube.com/watch?v=O9-gNv_-k48

Cardiac Catherization (Angiography)

Cardiac Catherization (Angiography)

Post procedure:–Monitor Pedal pulses–Enc. Fluids after procedure–Avoid movement of leg keep extended

–Maintain pressure over the femoral access site

–Check drsing & access site for bleeding

–HOB no more than 30°

Percutaneous Transluminal Coronary Angioplasty (PTCA)

http://www.youtube.com/watch?v=j9498DF8TU4

Catheter containing a balloon used to dilate occluded arteries•Preprocedure, maintain NPO status after midnight•Postprocedure, assess distal pulses in both extremities; maintain bedrest with limb straight for 6 to 8 hrs; assess for bleeding, changes in VSs

Laser angioplastyPreprocedure & postprocedure care similar to

PTCA

Dysrhythmias

Rhythm Disturbances Impulse Formation DisturbedDisturbance in Conduction

Normal Sinus Rhythm RulesOriginates from SA node with atrial & ventricular rates of 60 to 100 beats/min• Rhythm: Regular • Heart Rate: 60 to 100 bpm• P Wave: Rounded, Before each

QRS • PR Interval: 0.12 to 0.20 Seconds• QRS Interval: < 0.10 Seconds

Sinus bradycardia• Atrial & ventricular rates less than 60

beats/min• Attempt to determine cause; if medication is

suspected cause, hold, notify health care provider

• Administer atropine sulfate as prescribedSinus tachycardiaAtrial & ventricular rates greater than 100 beats/minIdentify, remove cause of tachycardia

Dysrhythmias

DysrhythmiasPremature Atrial ContractionsAtrial Flutter Atrial fibrillation•No definitive P wave can be observed•Administer oxygen & anticoagulants, prepare for cardioversion as prescribed•atrial rate 350 – 600 bpm, ventricular rate 100 –180

Premature ventricular contractionNotify health care provider if PVCs, c/o CP,

runs of ventricular tachycardia occur

Ventricular tachycardia: rate 140 - 240•Repetitive firing of irritable ventricular ectopic focus at rate of 140 to 250 beats/min

•Client may be stable or unstable•Administer lidocaine (Xylocaine) as prescribed

Ventricular fibrillationChaotic rapid rhythm; ventricles quiverDefibrillate immediately as prescribed; initiate cardiopulmonary resuscitation (CPR)

Defibrillation: Asynchronized countershock; terminates pulseless VT or VF. Delivers a direct electric shock to the myocardium to restore NSR

Automatic External Defibrillator http://www.youtube.com/watch?v=ZOBEidFXezA

Implantable Cardioverter fibrillatorInstruct client on:• basic functions of ICD, complications to report immediately•how to take pulse •to avoid strenuous activity or contact sports •to report any signs of infection or feelings of faintness or N/V

Asystole • Rhythm: None• Heart Rate: None• P Waves: None• P–R Interval: None• QRS Interval: None

•Cardioversion (synchronized shock) delivery of a synchronized electrical shock to the myocardium to restore normal sinus rhythm.monitor • Skin burns• Respiratory problems• Changes in ST segment• Rhythm disturbances• BP

Increase the force of myocardial contraction & slow the HR

Side effects, toxic effectsGI disturbances (anorexia, N/V, diarrhea)Visual disturbancesBradycardia

InterventionsMonitor for toxicity; digoxin level above 2 ng/mLMonitor K+ level for hypokalemiaMonitor AP; if less than 60/min, hold medication, notify health care provider

Cardiac Glycosides

Classification: CardioglycosideAgent: Digoxin (Lanoxin)Action: ↑ cardiac force & efficiency, slows HR, ↑ cardiac output, ↓ cardiac workload.Nursing Interventions: monitor AP to ensure rate ≥ 60 (call MD if held). Monitor for digitalis toxicity (N/V, HA, anorexia, dysrhythmias, bradycardia, tachycardia, fatigue, visual disturbance: blurred vision, double vision & yellow-green vision, seeing halos around objects & seeing flickering lights). confusion, seizures, diarrhea

• Monitor for hypokalemia, hypomagnesemia & hypercalcemia may predispose pt to Digoxin toxicity.

• Therapeutic level: 0.5 - 2 mg/dL• Advise pts to consume foods high in potassium &

magnesium & foods low in calcium.• Monitor potassium levels.• High Potassium Foods:• bananas, potatoes, beets, parsnips, turnips, broccoli,

melons, peaches, cantaloupes, kiwi, prunes, dried apricots, dates, figs, oranges, tomatoes & squash

Digoxin Nursing Interventions cont’d

Beta-adrenergic BlockersBeta Blockers (“lols”)

– ↓ the workload of the heart & ↓ myocardial oxygen demands• ↓ HR & BP• May mask symptoms of hypoglycemia in DM client

– Side effects• Bradycardia• Hypotension• Bronchospasm

– Interventions• Monitor apical pulse rate & BP• Monitor for respiratory distress • Instruct the DM client to monitor for signs of

hypoglycemia

Classification: B-adrenergic blockersAgent: Propanolol (Inderal)

Metoprolol (Lopressor)Action: ↓ myocaridal O2 demand, ↓ work load of heart, & HRNursing Interventions: Monitor HR & BP, bradycardia, hypotension, new dysrhythmias, dizziness, HA, nausea, diarrhea, sleep disturbances. Use caution w/clients w/bronchospastic disease.

Beta-Adrenergic Blocker

carvedilol (Coreg)

Mechanism of action - blocks beta1, beta2, & alpha1 receptors, which ↓’s HR& BP, ↓’s afterload, & reduces the workload on the heart

Ace Inhibitors “prils”Angiotensin-converting enzyme

Prevent peripheral vasoconstrictionUsed to treat HTN & HF

Side effectsPersistent dry coughHypotensionTachycardiaHyperkalemiaHypoglycemia in diabetic client

InterventionsAvoid use with K+ supplements & potassium-sparing diureticsMonitor VSs & for signs of hyperkalemiaInstruct DM client about the risk for hypoglycemiaInstruct client to report persistent dry cough

ACE Inhibitor lisinopril (Prinivil)

Mechanism of action - blocks ACE enzyme, which ↓’s BP, ↑’s cardiac output, ↓’s preload & reduces peripheral edema; ↑’ed excretion of Na⁺ & water leads to ↓’ed blood volume

primary use - HF & HTNImportant adverse effects - ↑ K⁺ levels, cough, taste disturbances, hypotension

– ↓ the workload of the heart & ↓ myocardial oxygen demands• Promote vasodilation of coronary & peripheral vessels

• Used to treat angina, dysrhythmias, & HTN

• Used with caution in HF, bradycardia, or atrioventricular block

–Side effects• Bradycardia• Hypotension• Reflex tachycardia

Calcium channel blockershttp://www.youtube.com/watch?v=dE-4D1dwMZQ

– Interventions• Monitor apical HR & BP• Monitor for signs of HF• Instruct the client to report dizziness or

faintingM “Meals”U “under” 100 for systolic BP holdC “calcium” blockerH “HTN” treatment

Common Calcium Channel Blockers•amiodipine (Norvasc) •nifedipine (Procardia) •verapamil (Isoptin, Verelan)•diltriazem (Cardizem)

Calcium channel blockers cont’d

Classification: Calcium channel blockersAgent: Verpamil (Calan, Isoptin)

Diltiazem HCL (Cardizem)Action: produces relaxation of coronary vascular smooth muscle, dilates coronary arteries.Nursing Interventions: Use caution in clients w/CHF; Monitor AP & BP, watch for fatigue, HA, Dizziness, peripheral edema, nausea, tachycardia

Suppress dysrhythmias by inhibiting abnormal pathways of electrical conduction through the heart

Classifications Class I: sodium channel blockersClass II: β-blockersClass III: potassium channel blockersClass IV: calcium channel blockers

Interventions for antidysrhythmicsMonitor HR, respiratory rate, & BPProvide continuous cardiac monitoring Administer IV antidysrhythmics Monitor for signs of fluid retentionMonitor for effective response

Antidysrhythmic Medications

• Amiodarone (Cordarone, Pacerone)• Flecainide (Tambocor)• Lidocaine (Xylocaine)• Procainamide (Procan, Procanbid)• Propranolol (Inderal)• Quinidine (many trade names)Interventions• Monitor for Worsening arrhythmias• Allergic reaction• Chest pain, dizziness, syncope, SOB,

cough• Edema of the feet or legs• Blurred vision

Common Cardiac Dysrhythmias Medications

Prevent extension & formation of clots by inhibiting factors in clotting cascade & decreasing blood coagulability–Side effects

• Bleeding–Heparin sodium

• Normal activated partial thromboplastin time (aPTT) 20 to 30 seconds

• Antidote is protamine sulfate–Enoxaparin (Lovenox)–Warfarin sodium (Coumadin)

Anticoagulants

Normal lab values •Bleeding time: 1 – 9 minutes•PTT: 20 – 26 seconds•PT: 9.05 – 11.8 seconds•INR: 2 -3 (standard warfarin therapy)

Classification: AnticoagulantAction: Used in tx of A-Fib w/embolization to prevent complication of stroke.Nursing Interventions: Assess for signs of bleeding & hemorrhage: monitor prothormbin time (PT) freq during therapy; review foods high in vitamin K. Clients should have consistently limited intake of these foods d/t foods causing levels to fluctuate.

Warfarin (Coumadin)

Warfarin (Coumadin)Teach Pt.• Wear a Medic-Alert identification

when on anticoagulation therapy. • A steady (rather than fluctuating)

amt of green leafy vegetables should be eaten so that INR values do not fluctuate d/t the vitamin K found in these foods.

• Monthly blood tests are done. • Avoid a straight razor to avoid cuts

& bleeding.

GENERIC NAME: enoxaparin BRAND NAME: Lovenox MECHANISM: Enoxaparin is a low molecular weight heparin (LMWH) that is used to prevent blood clots. It is produced by chemically breaking heparin into smaller-sized molecules. Unlike heparin, the effect of enoxaparin does not need to be monitored with blood tests. Enoxaparin is used to treat or prevent blood clots & their complications (DVT or PE).SIDE EFFECTS: The most common is bleeding.Clients should avoid: anti-platelet medications (ASA, clopidogrel, warfarin, or nonsteroidal anti-inflammatory drugs (NSAIDs) ibuprofen or naproxen.Antidote: protamine sulfate

Antiplatelet Agents

Inhibit aggregation of platelets & prolong bleeding timeSide effects

BleedingInterventions

Monitor for bleedingImplement bleeding precautions

Classification: non-narcotic analgesic, anti-inflammatoryAction: Used in tx of MI, A-Fib w/embolization to prevent complication of stroke.Nursing Interventions: Assess for signs of GI bleeding & hemorrhage: monitor for GI distress. For S&S of MI give 325 mg PO.

acetylsalicylate (ASA)

Cardiac Pacemakershttp://www.youtube.com/watch?v=Y5rvTeAYuIY

• External & Temporary• Internal & Permanent • Override Dysrhythmias • Generate an Impulse • Can Be Placed in Atria, Ventricle, or

Both

Dual-chamber Pacemaker

Nursing Care for Pacemakers• Monitor ECG• Rest Several Hours• Monitor AP,

Symptoms• Incision Care• How to Take Radial

Pulse

• Symptoms to Report• Pacemaker ID Card• Things to Avoid • Trigger Metal

Detectors• Grounded Appliances

Safe• Periodic Pacemaker

Checks

Cardiac ArrestSudden cessation of cardiac output & circulatory process.S&S: abrupt loss of consciousness, gasping respirations followed by apnea, absence of pulse, absence of BP, pupil dilation, pallor & cyanosis.

Coronary Atherosclerotic Heart Disease

Coronary artery disease (CAD): Narrowing or obstruction of one or more coronary arteries as result of atherosclerosisAtherosclerosis: common arterial disorder characterized by yellowish plaques of cholesterol, lipid & cellular debris in inner layers of walls of lg. & medium-size arteries, primary cause of atherosclerotic heart disease (ASHD).

ArteriosclerosisArtery/arteriole walls • Thicken• Harden • Loose elasticityAtherosclerosis• Type of Arteriosclerosis • Plaque Formation in Arterial Wall• Childhood Onset

Total Cholesterol: •Desirable less than 200 mg/dL •Borderline 200 – 239 mg/dL •High 240 mg/dL or greaterHDL Cholesterol (high-density lipoproteins) •Desirable 60 mg/dL or greater LDL Cholesterol (low-density lipoproteins)

•Desirable less than 130 mg/dL (+risk factors•Triglycerides: less than 150 mg/dL

Antilipemic MedicationsHMG-CoA reductase enzyme inhibitors “statins”• Reduce cholesterol, triglyceride, or low-density lipoprotein levels

• Bile sequestrants• Side effects

• Constipation• Interventions

• Increase fluid intake & fiber in diet• 3-Hydroxy-3-methyl-glutaryl–coenzyme A (HMG-CoA) reductase inhibitors

• Side effects• GI disturbances, visual disturbances, elevated serum liver enzyme levels

Antilipemic Medications cont’d

• Nursing interventions• Monitor serum cholesterol & triglyceride levels

• Instruct client about foods low in fat & cholesterol

• Instruct client to follow an exercise program

• Instruct client to report visual problems or GI disturbances

Medications for HyperlipidemiasClassification: AntihyperlipidemicsAgent: atorvastatin (Lipitor), simvastatin (Zocor), lovastatin (Mevacor)Action: Inhibits HMG-CoA reductase, the enzyme that catalyzes the early step in cholesterol syntheisis.Nursing Interventions: Assess baseline labs, cholesterol & triglyceride, & liver function. Adm. in pm. Instruct pt. to follow prescribed diet & periodic lab tests are needed.

ASHD/CAD • Non-modifiable Risk Factors

• Age • Gender• Ethnicity• Genetic Predisposition for Hyperlipidemia

ASHD/CAD (cont’d)• Modifiable Risk Factors

• DM • HTN•  Smoking•  Obesity•  Sedentary Lifestyle•  ↑’ed Serum Homocysteine

• ↑ C-reactive protein (CRP)

ASHD/CAD (cont’d)• Modifiable Risk Factors (cont’d)

• ↑’ed Serum Iron Levels• Infection• Depression • Hyperlipidemia http://www.youtube.com/watch?v=N2diPZOtty0

• Elevated Apolipoprotein B • Excessive Alcohol Intake

ASHD/CAD (cont’d)• Diagnostic Tests for Increased CVD

• Cholesterol• Elevated Increases Risk

• Low-density Lipoproteins (LDL) • Increased risk

• High-density Lipoproteins (HDL) • Protective

ASHD/CAD (cont’d)• Diagnostic Tests (cont’d)

• Lp(a) Cholesterol • Elevated Increases Risk

• Apolipoprotein B > Apolipoprotein A• Increased Risk

• Triglycerides • Increased Risk

ASHD/CAD (cont’d)• Diagnostic Tests (cont’d)

• C-reactive Protein• Inflammation in Coronary Artery• Shows Increased Risk

• Elevated Leukocyte Count in Women

• Increased Risk

Atherosclerosis/CADContributes to Complications:

• Angina, MI, HTN, TIA, Stroke• Sudden Death

Prevention•Modify Risk Factors

•Low-cholesterol Diet•Lipid-lowering Agents

• Low Dose ASA

ASHD/CAD (cont’d)Nursing Interventions

• Reduce activity, Exercise • Assess VSs, Monitor ECG• Support & reassure client • Administer oxygen, nitrates, Lipid-lowering Agents,

• Prepare for possible tx’s

Instruct on Medications• Nitrates: dilate coronary arteries;

decrease preload & afterload: (nitroglycerin)

• Calcium channel blockers: dilate coronary arteries & reduce vasospasm: nifedipine (Procardia)

• Cholesterol-lowering medications: reduce development of atherosclerotic plaques: lovastatin (Mevacor)

• β-blockers: reduce BP in individuals with HTN: sotalol (Betapace)

Nursing Interventions

ASHD/CAD (cont’d)Nursing Interventions

• Educate client about:• diagnostic tests • modifiable risk factors

• Instruct client to:• eat low-calorie, low-sodium, low-cholesterol, low-fat diet, with increase in dietary fiber

• importance of regular exercise

ASHD/CADSurgical procedures

• Percutaneous Transluminal Coronary Angioplasty (PTCA)

• Laser angioplasty • Atherectomy • Vascular stent • Transmyocardial Laser Revascularization

– http://www.youtube.com/watch?v=Fq4m0ajqcd0– http://www.youtube.com/watch?v=5rQjJ5hsgKw

• Coronary artery bypass graft (CABG)–Dx after cardiac catheterization

Angina Pectoris• Angina chest pain or discomfort that occurs if an area of heart muscle doesn't get enough oxygen-rich blood.

• may feel like indigestion.• symptom of underlying heart problem, (CAD)

• Chest pain resulting from myocardial ischemia

Types of AnginaStable Angina• Most common• exertional; occurs with activities that involve exertion, exercise, emotional stress• Arteries Cannot ↑ Blood to Heart During ↑’ed Activity

• Usually Stops with Rest/Vasodilator

Unstable Angina• occurs with unpredictable degree of exertion or emotion; increases in occurrence, duration, severity over time

• No pattern. May occur more often & be more severe than stable angina. Can occur with or without physical exertion, & rest or medicine may not relieve the pain.

• Requires emergency treatment, is a sign that an MI may happen soon.

Types of Angina (cont’d)Variant Angina (Prinzmetal’s Angina)• Rare. A spasm in a coronary artery causes this type of angina. Medicine can relieve this type of angina• Longer Duration• Usually Occur at Rest • Often Same Time Each Day (btw midnight & early morning

• Coronary Artery Spasm pain can be severe

• Serious

Angina S&S• Mild or moderate pain; may radiate to shoulders, arms, jaw, neck, back; usually lasts less than 5 minutes; relieved by rest &/or NTG; dyspnea; pallor; diaphoresis

Female Angina S&S• Chest Pain, Jaw Pain, Heartburn• Atypical Symptoms

• Describe Less Severe Pain • Fatigue • Nausea• Breathlessness

Diagnostic Tests• ECG• Stress Test• Echocardiography• Chemical Stress Testing• Radioisotope Imaging• Coronary Angiography/catherization

• Blood Test (cardiac enzymes normal)

Angina Interventions• Surgical procedures

• Same as for CAD• Medications

• Same as for CAD• Antiplatelet medications inhibit platelet aggregation, reduce risk of developing acute MI

Angina Interventions• Nursing Interventions

• Assess pain • Bedrest • Administer oxygen, nitroglycerin as prescribed

• Assess ECG strip • Instruct client about diet, wt management, exercise, lifestyle changes following acute episode

2 Types of Organic NitrateShort-acting is taken sublingually – nitroglycerinDrug Profile - Organic Nitrate, Vasodilator

Nitroglycerin (Nitrostat, Nitrobid, Nitro-Dur), short-acting nitrateLong-acting is taken orally or transdermally - isosorbide dinitrate

Tolerance often developsReduce symptoms of HF

Medications for AnginaClassification: AntianginalsAgent: Nitroglycerin

Action: to dilate coronary arteries & increase blood flow to damaged areas. Rapid onset of action within 2 – 5 mins.

Nursing Interventions: Nitroglycerin SL (doesn’t relieve MI) Nitroglycerin SL, may repeat dose in 5min. intervals if pain doesn’t subside, up to 3x. Oxygen & ASA unless contraindicated.

Myocardial Infarction (MI)• Pathophysiology

• Occurs when myocardial tissue is abruptly, severely deprived of oxygen, leading to necrosis and infarction; develops over several hours

• Location of MI• Left anterior descending artery: anterior or septal MI

• Circumflex artery: posterior or lateral wall MI

• Right coronary artery: inferior wall MI

Silent IschemiaMyocardial Ischemia Without CP

Sudden Cardiac DeathCardiac Arrest Triggered by Lethal Ventricular Dysrhythmias or Asystole from an Abrupt Occlusion of a Coronary Artery

MI S&S• Crushing, Viselike Pain

• Radiates to Arm/Shoulder/Neck/Jaw

• SOB• Restlessness • Dizziness, Fainting• Nausea • Sweating

Women & MI

• Leading Cause of Death • African American Women at Higher Risk• Higher Mortality Rate, More Complications

than Men• Prodromal Symptoms the Month Before MI

–Unusual Fatigue, Sleep Disturbances, Dyspnea

•Delay Treatment •Less Aggressive Treatment Given

S&S• Atypical—Women/Older Adult

–Absence of Classic Pain –Epigastric or Abdominal Pain–Chest Cramping –Fatigue–Anxiety–Dyspnea–Restlessness–Falling

Older Adults & MI

• Report Shortness of Breath, Fatigue,Fast/Slow Heartbeats, Chest Discomfort

• Silent MI • Collateral Circulation

Timely Medical Care• “Act in Time to Heart Attack Signs”

• Call 9-1-1 (or Local Emergency #)

• www.nhlbi.nih.gov/actintime/ • National Heart Attack Alert Program

• “60 Minutes to Treatment”• www.nhlbi.nih.gov/about/nhaap

Diagnostic Tests• Consider Patient History• Serial ECG• Cardiac Troponin I or T • Myoglobin• CK-MB • C-reactive Protein • Magnesium

ECG Changes With MI

Pre-Hospital Care • “Time is Muscle” • Chew One Uncoated Adult ASA• Call 911 in 5 Minutes for Unrelieved Chest Pain

• Do Not Drive SelfEmergency Percutaneous Coronary Intervention • Mission: Lifeline www.americanheart.org/• Door-to-Balloon Time: 90 Minutes

• www.d2balliance.org/

Nursing InterventionsAcute Stage• Monitor• Oxygen• ASA• Morphine Sulfate

• Thrombolytics• Remain w/pt• “MOAN”

• Vasodilators• Nitrates• Beta Blockers• Antidysrhythmias• Place in semi-Fowler’s position

Nursing Interventions following acute episode• Bedrest

• Bedside Commode • ROM exercises as prescribed; activity progression as tolerated & as prescribed; monitor for complications

• Emotional Supportfor Complications of MI

Dysrhythmias, HF, pulmonary edema, cardiogenic shock, thrombophlebitis, pericarditis

Nursing Interventions (cont’d)• Intra-aortic Balloon Pump• Glucose Control • Daily Wt. • No Caffeine, Clear Liquids• Fluid Restriction• Low-fat, Low-cholesterol, Low-Na⁺ Diet

Cardiac Rehabilitation

• Arrange for client to begin before the time of discharge

• Optimizes Functioning• Protocols Specify Activities

•Wt. Loss•Smoking Cessation

• Outpatient Program After Discharge

Medication Interventions

• Vasodilators• Nitroglycerin (NTG)

• Calcium Channel Blockers• Diltiazem, Amlodipine, Nifedipine, Verapamil

• Beta blockers• Propranolol, Metoprolol, Atenolol

Medication Interventions (cont’d)• ACEI

• Captopril, Lisinopril, Ramipril, Enalapril

• Statins• Atorvastatin, Fluvastatin, Lovastatin, Pravastatin, Simvastatin, Rosuvastin

• Antiplatelets• Aspirin, Clopridogrel (Plavix)

ThrombolyticsDissolve clotsContraindications

Active bleeding, stroke or other intracranial problems, surgical client, hepatic or renal disease, uncontrolled HTN, recent cardiopulmonary resuscitation, or hypersensitivity

Side effectsBleeding

InterventionsMonitor for bleedingImplement bleeding precautions

AntidoteAminocaproic acid (Amicar) is antidote for streptokinase

alteplase (Activase)

Mechanism of action - convert plasminogen to plasmin which causes fibrin to degrade, then preexisting clot dissolves

Primary uses - acute MI, pulmonary embolism, acute ischemic CVA, DVT, arterial thrombosis, coronary thrombosis, clear thrombi in arteriovenous cannulas and blocked IV cathetersAdverse effects - abnormal bleeding; contraindicated in clients w/active bleeding or recent trauma

Medication Interventions (cont’d)

•Fab Four Cardiac Drugs•Antiplatelets•Statins•ACEIs•Beta Blockers

Invasive Procedures• PCI

• Balloon Angioplasty• Coronary Artery Stents

• Myocardial Revascularization• Coronary Artery Bypass Graft

• Coronary Artery Occlusions Bypassed with Vein/Artery Grafts

• ↑’s Blood Flow/Oxygen to Myocardium

Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) Thoracoscope • No Cardiopulmonary Bypass • Small Incisions• Two Coronary Arteries Maximum

Port-Access Coronary Artery Bypass• Combines Peripheral Cardiopulmonary Bypass (CPB) with Minimally Invasive Heart Access

Nursing Interventions • Monitor VSs• Report Symptoms• Incisional CarePatient Education • Disease Information• Medications• Diet• Activity• Rehabilitation

Valvular Heart Disease • Stenosis

Narrowed, Valve Does Not Open CompletelyForward Blood Flow HinderedDecreases Cardiac Output

• Regurgitation (Insufficiency) Valve Does Not Close Completely Blood Flow Backs Up

Mitral Valve Prolapse (MVP)Etiology

• Unknown• Hereditary • Women 20 - 55 Years of Age

S&S• Often None• Anxiety, Fatigue• CP, Palpitations • Dysrhythmias• Dyspnea

Mitral Valve Prolapse (MVP)Therapeutic Interventions

• None, Unless Symptoms• Healthy Lifestyle• Avoid Stimulants/Caffeine• Stress Management • Beta Blockers for Tachycardia• Valve Surgery for Severe MVP• monitor for fatigue, atypical chest

pain, palpitations, syncope, systolic click

Mitral StenosisEtiology• Common – Prior Rheumatic Fever• Congenital Defects, Tumors• Rheumatoid Arthritis• Systemic Lupus Erythematosus• Calcium Deposits Signs & Symptoms

• None Early• Murmur, A Fib, CP, Palpitations • Exertional Dyspnea, Cough, Hemoptysis • Fatigue

Mitral Stenosis (cont’d)• Diagnostic Tests

• ECG: P-wave Δ’s• CXR: Enlarged Chambers• 2-D & Doppler Echocardiography• Coronary Angiogram

Therapeutic Interventionsmonitor for dyspnea, orthopnea, rumbling apical diastolic murmur, pitting peripheral edema• Prophylactic Antibiotics per Criteria• Anticoagulants: Atrial Fibrillation• Percutaneous Balloon Valvuloplasty

Mitral Regurgitation (insufficiency)• Etiology

• Rheumatic Heart Disease (Most)• Endocarditis • Congenital Defects• Chordae Tendineae Dysfunction• Mitral Valve Prolapse

• S&S• None Early• Murmur, Palpitations, Fatigue, A-Fib, CP

• Dyspnea, Cough, Hemoptysis

Mitral Regurgitation (cont’d) • Diagnostic Tests

• ECG: P-Wave Δ’s• CXR: Enlarged Chambers• 2-D & Doppler Echocardiography

• Coronary Angiogram

Mitral insufficiency (Regurgitation)cont’d Therapeutic Interventions• monitor for dyspnea, orthopnea,

dizziness, signs of right ventricular failure, pitting peripheral edema, high-pitched systolic murmur• None, Unless Symptoms• Prophylactic Antibiotics per Criteria• ACE Inhibitors • Anticoagulants: A-Fib• Mitral Valve Repair/Replacement

http://www.youtube.com/watch?v=QVk7zmJbX1s

Valvular Heart Disease(cont’d)• Tricuspid stenosis: monitor for effort intolerance, fluttering sensations in neck, cyanosis, ↓ cardiac output, peripheral edema, rumbling diastolic murmur

• Tricuspid insufficiency: monitor for signs of right ventricular failure, ascites, pleural effusion, peripheral edema, systolic murmur

• Pulmonary stenosis: monitor for dyspnea, syncope, signs of right ventricular failure, ascites, systolic thrill

• Pulmonary insufficiency: monitor for signs of right ventricular failure, ascites, systolic thrill

Aortic Stenosis

• Pathophysiology• Aortic Valve Narrowed• Left Ventricle Contracts More Forcefully

• Left Ventricle Hypertrophies• Decreased Cardiac Output• Eventual Heart Failure

Aortic Stenosis (cont’d)Signs & Symptoms

• None Early• Angina• Murmur• Syncope

• Orthopnea• Dyspnea on Exertion

• Fatigue • Pulmonary Edema

Diagnostic TestsECG Chest X-Ray: Enlarged Left Ventricle2-D & Doppler EchocardiographySerial Echocardiography Cardiac Catheterization

Aortic Stenosis (cont’d)• Therapeutic Interventions• monitor for dyspnea on exertion,

angina, syncope, orthopnea, harsh systolic murmur• Surgery

• Aortic Valve Replacement• Valvotomy

• Treat HF Symptoms• Prophylactic Antibiotics per Criteria

Aortic insufficiency (Regurgitation) Pathophysiology

• Aortic Valve Does Not Close• Left Ventricle’s Volume Increases• Left Ventricle Dilates• Left Ventricle Fails

• Decreased Cardiac Output• Pulmonary Edema

Aortic insufficiency (Regurgitation) • Etiology

• Rheumatic Heart Disease (Most)• Congenital Defects • Syphilis• Endocarditis• Severe HTN• Rheumatoid Arthritis • Aortic Dissection

Aortic insufficiency (Regurgitation) cont’d

• Signs & Symptoms• None Early• Exertional Dyspnea, Fatigue • Corrigan’s Pulse: Palpated Pulse Forceful, Quickly Collapses

• Widened Pulse Pressure• Angina at Night

Aortic insufficiency cont’d• Diagnostic Tests

• ECG, Chest X-Ray • 2-D & Doppler Echocardiography• Coronary AngiogramTherapeutic Interventions• Monitor for dyspnea, orthopnea, angina, tachycardia, diastolic murmur

• Vasodilator • Surgical Valve Replacement• Prophylactic Antibiotic Therapy per Criteria

Valvular Heart Disease (cont’d)• General Nursing interventions

• Administer prescribed treatment for heart failure as prescribed

• Administer oxygen as prescribed• Administer IV fluids as prescribed• Administer diuretics, digoxin (Lanoxin) as prescribed

• Provide low-sodium diet as prescribed

• Administer antibiotics as prescribed

Nursing Interventions (cont’d)• Maintain Fluid Volume

• Daily Wt.s, Assess for Edema, I&O • Diuretics as Ordered; Monitor K⁺ Levels

• Education• Medications • Anticoagulants

• Monthly INR/PT Tests• Medic Alert Identification

• Include Caregivers for Elderly• Revised Endocarditis Prevention – Prophylactic Antibiotics

Evaluation• Reports Satisfactory Pain Relief• VS’s Normal/No HF Signs• Reports Reduced Fatigue, Task Completion

• Remains Free of Edema, Maintains Wt, Clear Lung Sounds

• Verbalizes Understanding of Teaching/with No Symptom Recurrence

Cardiac Valvular Surgery• Minimally Invasive Surgery

• Endoscopy• Robotic

• Traditional • Open Cardiac Surgery with Cardiopulmonary Bypass

• Stenosed Valve Repair• Balloon Valvotomy• Commissurotomy • http://www.youtube.com/watch?v=VrIxRfWDOm8

• Insufficient Valve Repair• Annuloplasty • http://www.youtube.com/watch?v=m0qotSyH5CE http://www.youtube.com/watch?v=7LfWleowgUk

Heart Valve Replacement• Mechanical

• Durable• Creates Turbulent Blood Flow

• Lifelong Anticoagulation• Used for Younger Adults

Heart Valve Replacement (cont’d)• Biological

• Types• Porcine (Pig) • Bovine (Cow) • Allografts (Human)• Autograft • Cultural Considerations

• Not as Durable as Mechanical Valves

• No Lifelong Anticoagulation• Used for Older Adults

Valve Replacement Complications• Biological Valves

• Degenerative Changes• Calcification

• Mechanical Valves • INR/PT Monitoring for Bleeding Risk

• Thrombus/Embolism Formation• Anemia• Endocarditis

Nursing Process:Cardiac Surgery Preparation Assessment

• Circulatory Status • Pain Control Needs• Diagnostic Tests• Typing & Cross-matching of Blood Needed

Preoperative Vascular Nursing Diagnoses• Acute or Chronic Pain • Anxiety • Deficient Knowledge

Cardiac Surgery Preparation • Teaching

• Pain Management • Endotracheal Tube/Ventilator• Communicating • Chest Tubes • Coughing/Deep Breathing• IV Lines• Urinary Catheter

• Preoperative Medications• prophylactic antibiotics

• Antiseptic Scrub Showers• NPO

Postoperative Cardiac Surgery Nursing Care • Pain/Provide Relief• VSs, ECG, ABGs, I&O• Lung Sounds• Incision• Promote Lung Expansion

• Cough & Deep Breathe• Turn • Ambulate

Postoperative Cardiac Surgery Nursing Care (cont’d)• Prevent Infection

•Hand Hygiene, Sterile Technique•Cleanse Stethoscope

• Each Client, Each Handwashing•Monitor Temperature

• Teaching•Pain Management, Medications•Activity •Follow-up Monitoring/Care

Layers of the Heart

Infective Endocarditis• Entry of Organism into Bloodstream • Risk Factors

• Immunocompromised • Artificial Heart Valve• Congenital/Valvular Heart Disease• IV Drug Use• Gingival Disease

• Prevention• Oral/Dental care• Prophylactic Antibiotics per Criteria

Infective Endocarditis (cont’d)• S&S

• Fever • Murmur • Splinter Hemorrhages • Petechiae• Janeway Lesions • Osler’s Nodes

PetechiaeJaneway Lesions

Osler’s Nodes

Infective Endocarditis (cont’d)• Diagnostic Tests

• Blood Cultures • Echocardiography

• Therapeutic Interventions• IV Antimicrobial Drug• Rest/Supportive Care• Home IV Antimicrobial Therapy

• Surgical Valve Replacement/Repair

Infective EndocarditisTherapeutic Nursing Interventions cont’d

• Monitor VSs & Cardiac status• Report HF/Emboli Signs• Maintain antiembolic stockings as prescribed

• Teach• Good Hygiene, Oral/Dental Care• Report Symptoms: Fever, Chills, Sweats

Pericarditis• Inflammation of Pericardium

• Acute• ChronicEtiology

• Infections, Lyme Disease• Drug Reactions, Trauma• Connective Tissue Disorders• Neoplastic Disease• Postmyocardial Infarction• Dressler’s Syndrome• Renal Disease or Uremia

Pericarditis (cont’d)• S&S

• CP; Substernal, Radiates, Grating• Increases with Deep Inspiration

• Pericardial Friction Rub• Dyspnea• Low-grade Fever• Cough

• Diagnostic Tests• ECG, Echocardiogram, CT Scan, MRI

• WBC• Pericardial Fluid

Pericarditis Nursing Interventions

•Position in high Fowler’s position, upright, leaning forward•Bedrest•Pericardiocentsis •Monitor for signs of cardiac tamponade & Cardiac Function• Monitor VSs• Provide Pain Relief

• NSAIDs, Corticosteroids

Pericarditis Nursing Management

•Treat Cause•Antibiotics •Hemodialysis•Pericardial Window •Pericardiectomy

• Education

Pericardiocentsis http://www.youtube.com/watch?v=nRFa6OdX9xU

Cardiac TamponadePericardial effusion; occurs when space between parietal & visceral layers of pericardium fill with fluid

Data collection•Pulsus paradoxus; ↑ central venous pressure; jugular vein distention with clear lungs; distant, muffled heart sounds; ↓ cardiac output•Interventions•critical care unit as prescribed•Administer IV fluids as prescribed•Prepare client for pericardiocentesis as prescribed•Monitor for recurrence of tamponade following pericardiocentesis

Myocarditis• Pathophysiology & Etiology

• Acute or chronic inflammatory disorder of myocardium as result of pericarditis

• Rare • Often Follows VirusS&S• None • fever; pericardial friction rub; murmur• Possible Viral Infection Signs• Chest Pain, Tachycardia

Myocarditis (cont’d)Therapeutic Nursing Interventions• Reduce Heart’s Workload• Oxygen• Treat Cause

• Antimicrobial• Treat Heart Failure

• administer analgesics, salicylates, NSAIDs drugs, antibiotics, digoxin (Lanoxin) as prescribed

• VSs/Cardiac Status• Diversional Activities • Energy Conservation• Education

Rheumatic Heart Disease A result of rheumatic fever, an inflammatory disease that predominantly results from delayed childhood reaction to inadequately treated childhood pharyngeal or URT infection (group A-B-hemolytic streptococci).

Cardiomyopathy• Enlargement of Heart Muscle

• Subacute or chronic disorder of heart muscle

• Dilated cardiomyopathy: heart ejects less than 40% of blood in left ventricle (normal is 70%); reduced cardiac output leads to HF

• Hypertrophic cardiomyopathy: characterized by massive ventricular hypertrophy; may cause obstruction of left ventricular outflow

• Restrictive cardiomyopathy• Characterized by restricted filling of ventricles

• http://www.youtube.com/watch?v=rXyVzOmyWfo

Cardiomyopathy Secondary type•Infective: viral, bacterial, fungal, protozoal (myocarditis)•Metabolic, Nutritional•Alcohol•Drugs (prescribed & Cocaine “crack”)•Radiation therapy•Systemic lupus erythematosus, Rheumatoid arthritis

Cardiomyopathy (cont’d)• S&S

• Symptoms of left ventricular heart failure

• Diagnostic Tests• Chest X-Ray (Cardiomegaly) • Echocardiography• ECG• Cardiac Catheterization

Cardiomyopathy (cont’d)• Therapeutic Interventions

• Treatment symptomatic, similar to care of heart failure (dilated & restrictive cardiomyopathy), similar to care of MI (hypertrophic cardiomyopathy)

• No Cure• Palliative Care• Anticoagulants • Dilated

• ACE Inhibitors, Beta Blockers, Diuretics, Digoxin

• Biventricular Pacing • Implantable Defibrillators• Heart Transplant

• Inability of heart to maintain adequate circulation to meet metabolic needs of body

Older Term: Congestive Heart Failure(cardiac insufficiency)http://www.youtube.com/watch?v=RHJBVTdBJvI

–Classification•Acute, chronic

Heart Failure (HF)

Causes: MI, chronic HTNS&S•Dyspnea, Orthopnea, Cough•Paroxysmal nocturnal dyspnea (PND)•Pulmonary crackles •Evidence of pulm vascular congestion w/pleural effusion (CXY)

Left Ventricular Failure (HF)

• Acute HF, Life-threatening • pallor• dyspnea, orthopnea, Severe Fluid

Congestion in Alveoli, ↑Resp with Accessory Muscles

• large amts of blood-tinged mucus• diaphoresis• Crackles, Wheezes • Anxiety, Restlessness• a medical emergency

Pulmonary Edema

• X-Ray, CT, MRI • ABGs• Pulmonary Pressures• BNP – B type Natriuretic Peptide• NT – proBNP – N-terminal pro BNP

Pulmonary Edema Diagnosis

PE Therapeutic Interventions• Immediate Treatment• Reduce Workload of Left Ventricle• Treat Underlying Cause• Fowler’s Position • Oxygen/Mechanical Ventilation• Morphine IV• Diuretics IV• Inotropic Agents IV

• Vasodilators IV

Right Ventricular Failure (HF)Causes: Lt. HF, Chronic lung diseaseS&S•Distention jugular veins (severe)•Anorexia, nausea, & abd distention •Liver enlargement w/RUQ pain•Edema (pitting) feet, ankles, sacrum

Pitting Edema

Pitting Edema ScaleSCALE DEGREE RESPONSE

1 + Trace Slight Rapid

2 + Mild 4 mm(0 - 1/4 in)

10 – 15 seconds

3 + Moderate

6 mm (¼ - ½ in)

1 – 2 minutes

4 + Severe 8 mm (1/2 - 1 in)

2 – 5 minutes

Immediate Nursing management• Place in high Fowler’s position • Administer oxygen as

prescribed • Suction PRN as prescribed • Monitor VS frequently • Maintain strict I&O

• Administer diuretics, morphine sulfate & digitalis as prescribed

• Assess lung sounds• Monitor Labs – K+• Monitor Wt.

Heart Failure (cont’d)

Following acute episode• Instruct client about: • modifiable risk factors • proper administration of

medication regimen • to avoid over-the-counter

medications • to eat a low-sodium, low-fat,

low-cholesterol diet • to balance activity levels

Heart Failure (cont’d)

Heart Failure (HF)TX: Medications to ↑ cardiac efficiency•Angiotensin-converting enzyme inhibitors (ACE inhibitors - ACEIs)•Angiotensin-receptor blockers (ARBs)•Beta-adrenergic blockers•Digitalis •Vasodilators•Diuretics, Potassium Supplements

First-Choice Drugs • ACE Inhibitors & Diuretics

• Given first• Reduce most symptoms of

mild to moderate HF• Fewer side effects

Diuretic furosemide (Lasix)Mechanism of action - prevents reabsorption of Na⁺ by the nephron of the kidney, which ↑’s excretion of Na⁺ & water; ↓’s blood volume, edema, & congestion; ↓’s BP, & ↓’s workload on heart. Cardiac output then ↑’s

Primary use - acute HFImportant adverse effects - electrolyte imbalances

Second-Choice Drugs• Phosphodiesterase inhibitors,

vasodilators, & beta-adrenergic blockers

• Used in severe HF• First-choice drugs not

effective

Phosphodiesterase Inhibitors milrinone (Primacor)Mechanism of action - blocks phosphodiesterase enzyme, which ↑’s the amt. of calcium available for myocardial contraction, which then ↑’s force of contraction & vasodilation

Primary use - short-term support of advanced HFImportant adverse effects - ventricular dysrhythmia

Vasodilators

Isosorbide (Isordil)Mechanism of action - relaxes vascular smooth muscle, which leads to vasodilation, which ↓’s cardiac workload & ↑’s cardiac output

Primary use - cannot tolerate ACE inhibitors, angina pectoris, HTNImportant adverse effects - HA, hypotension, reflex tachycardia

Natriuretic Peptide

nesiritide (Natrecor)Mechanism of action - acts on kidney, which increases excretion of Na⁺ & water, thereby ↓ BP; also causes vasodilation, which ↓’s preload

Primary use - severe HFImportant adverse effects - severe hypotension

Nonpharmacological Methods for HF•Stop using tobacco•Limit salt (Na⁺) intake & eat foods rich in K⁺ & magnesium•Limit alcohol consumption•Implement a medically supervised exercise plan•Learn & use effective ways to deal w/stress•Reduce wt. to an optimum level•Limit caffeine consumption

Chronic Heart Failure•Progressive •Signs & Symptoms May Worsen Over Time

Signs & Symptoms• Fatigue & Weakness, Cyanosis• Exertional Dyspnea

• Orthopnea, Paroxysmal Nocturnal Dyspnea

• Cough, Crackle & Wheezes• Tachycardia, CP• Cheyne-Stokes Respiration• Edema, Anemia, Malnutrition• Nocturia• Altered Mental Status

Complications of Heart Failure•Liver & Spleen Enlargement•Pleural Effusion •Thrombosis & Emboli •Cardiogenic Shock

Diagnostic Tests • Screening Tests

• BNP• Serum BUN, Creatinine • Liver Function Tests• Thyroid Function Test• Ferritin

• Chest X-Ray, Echocardiography, ECG• Exercise Stress Testing• Cardiac Magnetic Imaging• Cardiac Catheterization/Angiography • Sleep Studies

Therapeutic Intervention Goals• Improve Heart’s Pumping Ability &

↓ Heart’s Oxygen Demands• Identify & Correct Underlying Cause

• ↑ Strength of Heart’s Contraction• Maintain Optimum Water & Na⁺ Balance

• ↓ Heart’s Workload

Drug Therapy • Oxygen Therapy• ACE Inhibitors or ARBs • Beta Blockers• Diuretics• Inotropic Agents• Vasodilators

Therapeutic Interventions

• Activity • Na⁺ & Wt. Control• Pacemakers, ICD• Cardiac Resynchronization Therapy

• Mechanical Assistive Devices• Intra-aortic Balloon Pump• Ventricular Assist Device• Total Artificial Heart• Implantable Replacement Heart

Ventricular Assist Devices & Artifical Heart•Support Failing Heart•Bridge to Transplantation •Destination Therapy•Heart Replacement

Surgical Interventions •CABG•Valve Replacement•Ventricular Reconstruction

Nursing Interventions• Oxygen• Rest & Activity• Positioning• Fluid Management• Reduce Oxygen Consumption• Medications/Teaching • Low-Na⁺ Diet• Wt. Control• Education• Coping

Cardiac Transplantation • End Stage Heart Failure• Strict Selection Criteria

•Suitable physiologic/chronologic age•End-stage heart disease refractory to medical therapy•Dilated cardiomyopathy•Inoperable CAD Compliance with medical regimens•Demonstrated emotional stability & social support system•Financial resources available

Indications

•Systemic disease w/poor prognosis•Active infection, Active or recent malignancy•DM, type 1, w/end-organ damage•Recent or unresolved pulmonary infarction•Severe pulmonary HTN unrelieved w/meds•Irreversible renal or hepatic dysfunction•Active peptic ulcer disease•Severe osteoporosis•Severe obesity•Hx of drug or alcohol abuse or mental illness

Contraindications

Criteria for a Potential Heart Donor

• Younger than 40 years • Weigh within 20 lbs of

prospective recipient.• Presence of no active infections• Presence of no significant

cardiac or malignant disease• No HTN or DM

Cardiac Transplantation (cont’d)• Immunosuppressive Therapy Preoperatively• Lifelong Antirejection Therapy• Complications

• Rejection • Infection• Malignancies • Anti-rejection Medicine Side Effects

• Grapefruit juice may ↓ potency of meds as it ↑’s body metabolism.

Nursing Interventions• Pre & Postop surgical care• Monitor temporary pacemaker, labs• Monitor NGT & CT• Monitor O2, I/O’s, IVs, urine cath• Assess Pain• Assess Pt. emotional state• Assess for complications of rejections

Cardiac Transplantation (cont’d)