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Congestive Heart Failure & Valvular Disease

Understand CHF pathophysiology, valvular disorders, pharmacological management, nursing care priorities, diagnostic assessments, and collaborative management strategies. Learn to prevent complications and address special considerations in older adults with heart failure.

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Congestive Heart Failure & Valvular Disease

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  1. Congestive Heart Failure &Valvular Disease Keith Rischer RN, MA, CEN

  2. Todays Objectives… • Review essential cardiac patho concepts • Compare and contrast left-sided heart failure to right • Describe special considerations for older adults with heart failure • Discuss the prevention of complications for patients with heart failure • Prioritize nursing care for clients with heart failure • Identify common nursing diagnoses and collaborative problems for patients with heart failure • Evaluate the effects of interventions for reducing preload and afterload through pharmacological management • Compare and contrast common valvular disorders

  3. Definition of CHF Etiology HTN MI Left sided vs. Right sided Rt sided COPD Systolic vs. Diastolic Ejection Fraction 50-70% normal Introduction

  4. Cardiac Output • CO = Stroke volume x heart rate • SV (80cc) x HR (80)= 6400cc (6.4 lpm) • Daily pumps 1800 gallons • 657,000 gallons every year • Over 80 year lifetime: • 52,560,000 gallons

  5. Definitions • Pre-load • primarily venous blood return to RA • Right and left side of heart filling pressure (atria>ventricles) • Pressure/Stretch in ventricles end diastole • Stroke volume • Amount of blood ejected from the ventricle with each contraction • Systole • Contraction; myocardium are tightening and shortening

  6. Definitions • Inotropic state/contractility • Afterload: • Force of resistance that the LV must generate to open aortic valve • Correlates w/SBP • Diastole • Muscle fibers lengthen, the heart dilates, and cavities fill with blood

  7. Maximum efficency of CO achieved when myocardium stretched appx 2 ½ times length Think rubber band CO decreased with lower preload/filling pressures or too high Patho: Starling’s Law of the Heart

  8. Compensatory Mechanisms in CHF • Increased Sympathetic Nervous System Stimulation • Renin-angiotensin system activation • Natriuretic peptides • BNP • Ventricular hypertrophy

  9. Elevated capillary pressure within the lungs  fluid pushed from circulating blood to interstitial tissues  then to the alveoli, bronchioles, and bronchi Acute Pulmonary Edema:

  10. Nursing Assessment:Left Failure • Dyspnea • Cough • Bilateral crackles • Orthopnea • PND • Pulmonary Edema • S3 (ken-tuck-ee) • confusion • fatigue and muscular weakness • nocturia • increase retention of sodium and water due to lowered glomerular filtration  edema

  11. Nursing Assessment: Right Failure • Dependent edema – • early sign • symmetric pitting edema • Bedrest-sacral edema • anasarca- late sign of CHF • Ascites • Anorexia, nausea and bloating • Cyanosis of nail beds • Anxious, frightened, depressed • Weight gain >2# daily

  12. Diagnostic Assessment • Chest x-ray • Cardiac Enlargement • 12 lead EKG • Echocardiogram • assess ejection fraction • Labs • BNP • Liver enzymes…AST, ALT • Creatinine/GFR

  13. Acute Left Failure/Pulmonary Edema: Collaborative Management: • O2 treatment • Drug Treatment • Diuretics • Vasodilators-NTG • MS • Digitalis • Semi- Fowler’s position • Frequent Heart and Lung Assessment • Dietary Restrictions • Planned rest periods • Weigh daily • Report to MD immediately: • persisting productive cough; dyspnea; pedal edema; restlessness

  14. Drug therapy: • Diuretics • ACE Inhibitors • Beta Blockers • Calcium Channel Blockers • Nitroglycerine • Positive Inotropic agents • Digitalis • Beta Adrenergic Stimulator • Dopamine,Dobutamine • .

  15. Pharmacologic: Diuretics • Mechanism of Action: • Thiazides, Loop, Potassium Sparing • S/E: • fluid and electrolyte imbalances • CNS effects • GI effects • Nursing Considerations: • Monitor for orthostatic hypotension • Hypokalemia

  16. Angiotensin Converting Enzyme (ACE) Inhibitors Mechanism of Action • S/E: • Hypotension • cough • Hyperkalemia…esp w/CHF, CKD, DM • Angioedema • Facial/laryngeal swelling • Nursing considerations: • Do not use with potassium sparing diuretic • Metabolized by liver-excreted by kidneys

  17. Adrenergic Inhibitors:Beta Blockers Mechanism of Action • Recommended for initial drug therapy of uncomplicated HTN (along with diuretic) • S/E: • Orthostatic hypotension • bradycardia • bronchospasm • Nursing considerations: • monitor pulse regularly

  18. Calcium Channel Blockers Amlodipine, Diltiazem, Nifedipine Mechanism of Action: S/E: • Nausea • H/A • Peripheral edema Nursing considerations: • use with caution in patients with heart failure • Orthostatic changes • contraindicated in patients with 2nd or 3rd degree heart block • Concurrent use w/b-blockers incr risk of CHF

  19. Vasodilators Mechanism of Action-NTG • Vasodilater-predominant on venous system by relaxing smooth muscles of vessels • Dilates coronary arteries/improves collateral flow • Up to 20% normal coronaries…30-40% pre/post stenosis • Decreases LVEDP…why? • Decreases O2 needs myocardium Side effects • HA, hypotension, tachycardia Hydralazine • arterial vasodilator

  20. Priority Nursing Diagnosis • Impaired Gas exchange r/t ventilation perfusion imbalance • Decreased Cardiac Output r/t altered contractility, preload and afterload • Activity Intolerance r/t imbalance between O2 supply and demand • Knowledge Deficit • Activity schedule • Recognizing worsening heart failure • Medications • Diet therapy

  21. Mitral Stenosis Patho Mitral Regurgitation Patho Mitral Valve Prolapse Patho Valvular Heart Disease:Mitral Valve

  22. Valvular Heart Disease:Aortic Valve • Aortic Stenosis • Patho • Causes • Congenital • Atheroclerosis • Calcification • Aortic Regurgitation (Insufficiency) • Patho

  23. Treatment Valvular Disease • Non-surgical Management • Diuretics • Beta blockers • Digoxin • Antibiotics • Before any invasives • Coumadin-if artificial valve • Surgical Management • Balloon Valvuloplasty • Open heart

  24. Pericarditis • Patho • Open heart • AMI • Assessment findings • Friction rub • CP w/insp • CP relieves sitting up • Global ST elevation • Complications • Pericardial effusion • Cardiac tamponade • pericardiocentesis

  25. Endocarditis • Patho • Etiology • Valve replacement • Structural cardiac defects • Invasive procedures • Clinical Manifestations • New murmur • Heart failure • Embolic • Diagnosis • Transesophageal Echo • + blood cultures • Interventions • IV abx • Surgical

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