Chapter 32: Cardiac problems

infective endocarditis care coordination and transition management

-may need IV antibiotics at home -encourage proper oral hygiene

Aortic Stenosis

-most common valve dysfunction in the US -disease of "wear and tear" -right sided heart failure can occur late in the disease -when surface area of the valve is 1cm or less, surgery is indicated urgently

aortic regurgitation interventions

-nonsurgical management -surgical management

Class IV NYHA

-patients with cardiac disease resulting in inability to carry out any physical activity without discomfort -symptoms of cardiac insufficiency or of the anginal syndrome may be present, even at rest -if any physical activity is undertaken, discomfort is increased

Class III NYHA

-patients with cardiac disease resulting in marked limitation of physical activity -comfortable at rest -less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain

Class II NYHA

-patients with cardiac disease resulting in slight limitation of physical activity -comfortable at rest -ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain

B-type natriuretic peptide (compensatory mechanism that improves output)

-produced and released by the ventricles as they stretch in response to fluid overload from HF

pericarditis interventions

-relieve pain (NSAIDs, corticosteroid therapy, colchicine twice a day orally for 3 months can prevent pericarditis recurrence. -treat cause of pericarditis (bacterial, malignant disease radiation or chemotherapy, uremic pericarditis is treated by hemodialysis, surgical excision of the pericardium)

infective endocarditis surgical interventions

-removing the infected valve (either biologic or prosthetic) -repairing or removing congenital shunts -repairing injured valves and chordae tendinaea -draining abscesses in the heart

aortic regurgitation (insufficiency)

-results from nonrheumatic conditions -may be asymptomatic for years because of the compensatory mechanisms of the left ventricle -symptoms include exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, palpitations (severe disease) -nurse will note a bounding arterial pulse. pulse pressure is usually widened, with an elevated systolic pressure and diminished diastolic pressure. High pitched, blowing, decrescendo diastolic murmur

Mitral Stenosis

-rheumatic fever is the most common cause -pulmonary congestion and right sided heart failure occur first -later, preload decreases and cardiac output falls -people with mild mitral stenosis may be asymptomatic -symptoms may include dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, palpitations, dry cough

heart failure lab assessment

-serum electrolytes -hemoglobin and hematocrit -BNP -urinalysis-> can reveal proteinuria and high specific gravity. Microalbuminuria is an early indicator of decreased compliance of the heart and occurs before the BNP rises "early warning detector" -ABGs-> often reveal hypoxemia because oxygen does not diffuse easily through fluid filled alveoli; respiratory alkalosis may occur because of hyperventilation; respiratory acidosis may occur because of CO2 retention; metabolic acidosis may indicate an accumulation of lactic acid

cardiomyopathy

-subacute or chronic disease of cardia muscle *types: -dilated cardiomyopathy -hypertrophic cardiomyopathy -restrictive cardiomyopathy -arrhythmogenic right ventricular cardiomyopathy (dysplasia)

aortic regurgitation assessment

-sudden illness or slowly developing symptoms over many years -ask about attacks of rheumatic fever, infective endocarditis, IV drug use -echocardiography, CXR, ECG

high output heart failure

*can occur when cardiac output remains normal or above normal, unlike left and right sided heart failure, which are typically low-output states -caused by increased metabolic needs or hyperkinetic conditions such as septicemia, high fever, anemia, and hyperthyroidism -uncommon

diastolic heart failure (HFpEF)

*heart failure with preserved left ventricular function -occurs when the left ventricle cannot relax adequately during diastole -inadequate relaxation or "stiffening" prevents the ventricle from filling with sufficient blood to ensure an adequate cardiac output -EF is more than 40%, the ventricle becomes less compliant over time because more pressure is needed to move the same amount of volume compared with a healthy heart

systolic heart failure (HFrEF)

*heart failure with reduced ejection fraction -when the heart cannot contract forcefully enough during systole to eject adequate amounts of blood into circulation -preload increased with decreased contractility -afterload increases as a result of increased peripheral resistance -the ejection fraction drops from a normal 50-70% to below 40% with ventricular dilation -tissue perfusion diminishes and blood accumulates in the pulmonary vessels -often called forward failure because cardiac output is decreased and fluid backs up into the pulmonary system

right sided heart failure

*may be caused by ventricular failure, right ventricular MI, or pulmonary hypertension -right ventricle cannot empty completely -increased volume and pressure develop in the venous system, and peripheral edema results

Class I NYHA

- patients with cardiac disease but without resulting limitations of physical activity -ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain

heart failure incidence and prevalence

-6.5 million people in the U.S. -Most common reason for hospital admission for people > 65 years old -More common in African American individuals under 50 years old than in Euro-Americans

heart failure imaging assessment

-CXR->cardiomegaly -Echocardiography-> the best tool in diagnosing heart failure (cardiac valvular changes, pericardial effusion, chamber enlargement, and ventricular hypertrophy can be diagnosed with this), can also be used to test EF -Radionucleotide studies (thallium imaging or technetium pyrophosphate scanning) can indicate the presence and cause of HF -thyroxine (T4) and TSH levels should be assessed in patients older than 65 years, have A-fib, or have evidence of thyroid disease-> HF may be caused or aggravated by hypothyroidism or hyperthyroidism

right-sided heart failure S/S

-JVD -increased abdominal girth -dependent edema -hepatomegaly -hepatojugular reflux-> can cause nausea and anorexia -ascites -weight most reliable indicator of fluid gain/loss

pericarditis assessment

-include substernal precordial pain that radiates to the left side of the neck, the shoulder, or the back. The pain is classically grating and oppressive and is aggravated by breathing (mainly on inspiration), coughing, and swallowing. The pain is worse when the patient is in the supine position and may be relieved by sitting up and leaning forward. -A pericardial friction rub may be heard with the diaphragm of the stethoscope positioned at the left lower sternal border. This scratchy, high-pitched sound is produced when the inflamed, roughened pericardial layers create friction as their surfaces rub together. -Patients with acute pericarditis may have an elevated white blood cell count and usually have a fever. Therefore blood culture and sensitivity may be analyzed in the laboratory. The ECG usually shows ST elevation in all leads, which returns to baseline with treatment. Atrial fibrillation is also common. Echocardiograms may be used to determine a pericardial effusion.

mitral regurgitation (insufficiency)

-caused by mitral valve prolapse, rheumatic heart disease, ineffective endocarditis, MI, connective tissue diseases, dilated cardiomyopathy -progresses slowly, patient may be symptom free for decades -symptoms include fatigue, chronic weakness, anxiety, atrial fibrillation, respiration changes

heart failure analysis

-decreased gas exchange due to ventilation/perfusion imbalance -potential for decreased perfusion due to inadequate cardiac output -potential for pulmonary edema due to left sided HF

infective endocarditis assessment

-development of heart failure -evidence of systemic embolization -petechiae -splinter hemorrhages -Osler nodes (on palms of hands and soles of feet) -Janeway lesions (flat, reddened maculae on hands and feet) -Roth spots (hemorrhagic lesions that appear as round or oval spots on the retina) -positive blood cultures

infective endocarditis nonsurgical interventions

-drug therapy -antimicrobials are the main treatment (ideal antibiotics are the penicillins and cephalosporins) -IV therapy -anticoagulants do not prevent embolization from vegatations -adequate rest

left-sided heart failure S/S

-dyspnea (exertional dyspnea, paroxysmal nocturnal dyspnea- feeling of breathlessness 2-5 hrs after falling asleep), orthopnea -fatigue, activity intolerance -weakness -arm/leg heaviness -chest pain or palpitations, skipped beats, fast rate -nocturnal cough, PINK TINGED SPUTUM LIFE THREATENING PULMONARY EDEMA

myocardial hypertrophy (compensatory mechanism that improves output)

-enlargement of the myocardium -the walls of the heart thicken to provide more muscle mass which results in more forceful contractions, further increasing cardiac output -cardiac muscle may hypertrophy more rapidly than collateral circulation can provide adequate blood supply to the muscle -often a hypertrophied heart is slightly oxygen deprived

heart failure evaluation

-have adequate pulmonary tissue perfusion -have increased cardiac pump effectiveness -be free of pulmonary edema

sympathetic nervous system stimulation (compensatory mechanism that improve output)

-increase in PVR from vasoconstriction and increases in HR. -Increased oxygen demand from increased HR

heart failure planning and implementation

-increasing gas exchange-> ventilation assistance as needed -increasing perfusion-> drugs to improve stroke volume include those that reduce afterload, reduce preload, and improve cardiac muscle contractility, sodium restriction, fluid restriction, salt substitutes -preventing or managing pulmonary edema

rheumatic carditis assessment

-tachycardia -cardiomegaly • Development of a new murmur or a change in an existing murmur • Pericardial friction rub • Precordial pain • Electrocardiogram (ECG) changes (prolonged P-R interval) • Indications of HF • Evidence of an existing streptococcal infection -Primary prevention is extremely important. Teach all patients to remind their primary health care providers to provide appropriate antibiotic therapy if they develop the indications of streptococcal pharyngitis: • Moderate-to-high fever • Abrupt onset of a sore throat • Reddened throat with exudate-pus • Enlarged and tender lymph nodes

mitral valve prolapse (MVP)

-valvular leaflets enlarge and prolapse into the left atrium during systole -etiology varies, has a family tendency -most people are asymptomatic -some may report chest pain, palpitations, exercise intolerance -may have midsystolic click and late systolic murmur at apex

The nurse is caring a college athlete who collapsed during soccer practice. The client has been diagnosed with hypertrophic cardiomyopathy and states, "This can't be. I am in great shape. I eat right and exercise." Which nursing response is appropriate?

A. "How does this make you feel?" B. "This can be caused by taking performance-enhancing drugs." C. "It could be worse if you weren't in good shape." D. "This may be caused by a genetic trait." D. -The appropriate nursing response is that this may be caused by a genetic trait. Hypertrophic cardiomyopathy is often transmitted as a single gene autosomal dominant trait. Exploring the client's feelings is important, but does not address the client's question. Hypertrophic cardiomyopathy is not caused by performance-enhancing drugs. Reminding the client that he or she is in good shape is not at all therapeutic and does not address the client's question.

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which client statement indicates understanding of the teaching?

A. "I should expect occasional chest pain." B. "I will try walking for 1 hour each day." C. "I will report to the provider weight loss of 2 to 3 lb (0.9 to 1.4 kg) in a day." D. "I will call the provider if I have a cough lasting 3 or more days." D. The client understands the discharge teaching about when to seek medical attention when the client says: "I will call the provider if I have a cough lasting 3 or more days." Cough, a symptom of heart failure, is indicative of intra-alveolar edema; it is important to notify the provider if this occurs. The client would call the provider for weight gain of 3 lb (1.4 kg) in a week or 1-2 lb (0.45 to 0.9 kg) overnight. The client would begin by walking 200 to 400 feet (61 to 123 m) per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure. The provider must be notified if this occurs.

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which client statement indicates the need for further teaching?

A. "I won't put the salt shaker on the table anymore." B. "I need to avoid eating hamburgers." C. "I need to avoid lunchmeats but may cook my own turkey." D. "I must cut out bacon and canned foods." B. Further teaching about restricting sodium in the diet for a client with heart failure is needed when the client says, "I need to avoid eating hamburgers." Cutting out beef or hamburgers made at home is not necessary, but fast-food hamburgers are to be avoided owing to higher sodium content. Bacon, canned foods, lunchmeats, and processed foods are high in sodium, which promotes fluid retention, and must be avoided. The client correctly understands that adding salt to food must be avoided.

After receiving change-of-shift report about these four clients, which client would the nurse assess first?

A. A 79 year old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min. B. A 55 year old admitted with pulmonary edema who received furosemide and whose current O2 saturation is 94%. C. A 46 year old with aortic stenosis who takes digoxin and has new-onset frequent premature ventricular contractions. D. A 68 year old with pericarditis who is reporting sharp chest pain with inspiration. C. -The nurse would first assess the 46 year old with aortic stenosis on digoxin and now has new-onset frequent PVCs. The PVCs may be indicative of digoxin toxicity. Further assessment for clinical signs and symptoms of digoxin toxicity must be done and the primary health care provider notified about the dysrhythmia. The 55 year old is stable and can be assessed after the client with aortic stenosis. The 68 year old may be assessed after the client with aortic stenosis. This type of pain is expected in pericarditis. Tachycardia is expected in the 79 year old because rejection will cause signs of decreased cardiac output, including tachycardia. This client may be seen after the client with aortic stenosis.

The nurse caring for a client with heart failure who is taking digoxin. What assessment data requires that nurse notify the health care provider? (Select all that apply.)

A. Anorexia B. Blurred vision C. Fatigue D. Heart rate 110/beats/min E. Serum digoxin level of 1.5 ng/mL (1.92 nmol/L) A, B, C- The signs and symptoms of digoxin toxicity that the nurse notifies the provider include: blurred vision, fatigue, and anorexia. Changes in mental status, especially in older adults, may also occur. Sinus bradycardia and not tachycardia is a sign of digoxin toxicity. A serum digoxin level between 0.8 and 2.0 (1.02 and 2.56 nmol/L) is considered normal and is not a symptom.

The home health nurse visits a client with heart failure who has gained 5 lb (2.3 kg) in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first?

A. Auscultate the client's posterior breath sounds. B. Notify the health care provider about the client's weight gain. C. Remind the client about dietary sodium restrictions. D. Assess the client for peripheral edema. A. Auscultate the client's posterior breath sounds. The action the home care nurse takes first is to auscultate the heart failure client's posterior breath sounds. Because the client is at risk for pulmonary edema and hypoxemia, the breath sounds must be assessed.Assessment of edema may be delayed until after breath sounds are assessed. After a full assessment, the nurse must notify the health care provider. After physiologic stability is attained, then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.

The nurse is caring for a client with heart failure in a cardiac clinic. What assessment data indicates that the client has demonstrated a positive outcome related to the addition of metoprolol to the medication regimen?

A. Client states, "I can sleep on one pillow." B. Current ejection fraction is 25%. C. Client reports feeling like her heart beats very fast at times. D. Records indicate five episodes of pulmonary edema last year. A. A client with heart failure has had a positive outcome to metoprolol when she states that she is able to sleep on one pillow. Improvement in activity tolerance, less orthopnea, and improved symptoms represents a positive response to beta blockers such as metoprolol. An ejection fraction of 25% is well below the normal of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest. This is not a positive outcome.

Which client is best to assign to an LPN/LVN working on the telemetry unit?

A. Client with pericarditis who has a paradoxical pulse and distended jugular veins. B. Client with heart failure who is receiving dobutamine. C. Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea. D. Client with rheumatic fever who has a new systolic murmur. C. The best client to assign to the LPN/LVN working on the telemetry unit is the client with dilated cardiomyopathy who uses oxygen for exertional dyspnea. This client is the most stable. Administration of oxygen to a stable client is within the scope of LPN/LVN practice. The client with heart failure is receiving an intravenous inotropic agent, which requires monitoring by the RN. The client with pericarditis is displaying signs of cardiac tamponade and requires immediate lifesaving intervention. The client with a new-onset murmur requires assessment and notification of the primary health care provider, which is within the scope of practice of the RN.

The nurse is caring for a client with heart failure. What assessment data will the nurse anticipate? (Select all that apply.)

A. Fatigue B. Sleeping on back without a pillow C. Chest discomfort or pain D. Tachycardia E. Expectorating thick, yellow sputum A, C, D- When caring for a client with heart failure, the nurse needs to assess for chest discomfort or pain, tachycardia, and fatigue. Decreased tissue perfusion with heart failure may cause chest pain or angina. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Fatigue is a symptom of poor tissue perfusion in clients with heart failure. Presence of a cough or dyspnea results as pulmonary venous congestion ensues. Clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. Thick, yellow sputum is indicative of infection. Position for sleeping isn't a symptom. Clients usually find it difficult to lie flat because of dyspnea symptoms.

The nurse is preparing to administer digoxin as prescribed to a client with heart failure and notes: Temperature: 99.8° F (37.7° C), Pulse: 48 beats/min and irregular, Respirations: 20 breaths/min, Potassium level: 3.2 mEq/L (3.2 mmol/L). What action will the nurse take?

A. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. B. Hold the digoxin, and obtain a prescription for a potassium supplement. C. Give the digoxin; document assessment findings in the medical record. D. Give the digoxin; reassess the heart rate in 30 minutes B. -The nurse needs to hold the digoxin and gets a prescription for a potassium supplement. Digoxin causes bradycardia and hypokalemia potentiates digoxin toxicity. Furosemide decreases circulating blood volume and depletes potassium. There is no indication suggesting that the client has fluid volume excess at this time.

The nurse is caring for a client with heart failure in the coronary care unit. The client is exhibiting signs of air hunger and anxiety. Which nursing intervention will the nurse perform first for this client?

A. Monitor and document heart rate, rhythm, and pulses. B. Encourage alternate rest and activity periods. C. Position the client to alleviate dyspnea. D. Determine the client's physical limitations. C. -The nurse's first action is to position the client to alleviate dyspnea. This action will help ease air hunger and anxiety. Administering oxygen therapy is also an important priority action. Determining the client's physical limitations is not a priority in this situation. Encouraging alternate rest and activity periods is not the immediate priority. Monitoring of heart rate, rhythm, and pulses is important, but is not the priority.

Which nursing action may be delegated to assistive personnel (AP) working on the medical unit?

A. Obtain daily weights for several clients with class IV heart failure. B. Check for peripheral edema in a client with endocarditis. C. Monitor the pain level for a client with acute pericarditis. D. Determine the usual alcohol intake for a client with cardiomyopathy A. -The nursing action that can be delegated to a UAP on the medical unit is to obtain daily weights for several clients with class IV heart failure. Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN. The role of the professional nurse is to perform assessments. Determining alcohol intake, monitoring pain level, and assessing for peripheral edema would not be delegated.

The nurse is assessing a client with right-sided heart failure. What assessment findings will the nurse anticipate? (Select all that apply.)

A. Oliguria B. Ascites C. Pulmonary congestion D. Peripheral edema E. Shortness of breath F. Third heart sound B,D -Right-sided heart failure is associated with increased systemic venous pressure and congestion; producing signs such as peripheral edema, ascites, liver enlargement, and neck vein distension. Left-sided heart failure is associated with pulmonary congestion and can produce shortness of breath, weakness, fatigue, oliguria, and a third heart sound (S3 gallop).

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea?

A. Place the client in high-Fowler position with the legs down. B. Reassure the client that distress can be relieved with proper intervention. C. Ask a family member to remain with the client. D. Monitor pulse oximetry and cardiac rate and rhythm. A. -The best intervention to help the client with acute pulmonary edema to reduce anxiety and dyspnea is to place the client in high-Fowler position with the legs down. High-Fowler position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion. Monitoring of vital signs will detect abnormalities, but will not prevent them. Reassuring the client and a family member's presence may help alleviate anxiety, but dyspnea and anxiety resulting from hypoxemia secondary to intra-alveolar edema must be relieved.

A client with heart failure is prescribed furosemide. Which assessment data concerns the nurse with this new prescription?

A. Serum sodium level of 135 mEq/L (135 mmol/L) B. Serum magnesium level of 1.9 mEq/L (0.95 mmol/L) C. Serum creatinine of 1.0 mg/dL (88.4 mcmol/L) D. Serum potassium level of 2.8 mEq/L (2.8 mmol/L) D. -The nurse is concerned with the serum potassium level of 2.8 mEq/L (2.8 mmol/L) in a heart failure client taking furosemide. Furosemide is a loop diuretic and clients taking this drug must be monitored for potassium deficiency from diuretic therapy.A serum sodium level of 135 mEq/L (135 mmol/L) is a normal value. Heart failure may cause renal insufficiency, but a serum creatinine of 1.0 mg/dL (88.4 mcmol/L) represents a normal value. A diuretic may deplete magnesium, but a serum magnesium level of 1.9 mEq/L (0.95 mmol/L) represents a normal value.

A client begins therapy with lisinopril. What does the nurse consider at the start of therapy with this medication?

A. The client's ability to understand medication teaching B. The potential for bradycardia C. Liver function tests D. The risk for hypotension D. At the start of therapy with lisinopril, the nurse needs to consider the risk for hypotension. Angiotensin-converting enzyme (ACE) inhibitors like lisinopril are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years. Although desirable, ability to understand teaching is not essential. ACE inhibitors are vasodilators and do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which nursing assessment data, obtained the day after admission, is the best indicator that the treatment has been effective?

A. The client's weight decreases by 2.5 kg. B. The client has diuresis of 400 mL in 24 hours. C. The client's blood pressure is 122/84 mm Hg. D. The client has an apical pulse of 82 beats/min. A. -The best indicator that treatment is effective on a client with heart failure and problems of hypervolemia is the client's weight decreased by 5.5 lb (2.5 kg) in 1 day. The best indicator of fluid volume gain or loss is daily weight. Because each kilogram represents approximately 1 L, this client has lost approximately 2500 mL of fluid. Diuresis of 400 mL in 24 hours represents oliguria. Although a blood pressure of 122/84 mm Hg is a normal finding alone, it is not significant for relief of hypervolemia. Although an apical pulse of 82 beats/min is a normal finding alone, it is not significant to determine whether hypervolemia is relieved.

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy?

A. The nurse monitors the client's pulse and blood pressure frequently. B. The client ambulates around the nursing unit with a walker. C. The nurse obtains a bedside commode before administering furosemide. D. The nurse returns the client to bed when the client becomes tachycardia. C. The nursing intervention that can help the client admitted today with heart failure is to have a bedside commode available to the client before administering furosemide. Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand. Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand. The nurse must prevent this situation.

The nurse is assessing a client with a cardiac infection. Which nursing assessment data causes the nurse to suspect infective endocarditis instead of pericarditis or rheumatic carditis?

A. Thickening of the endocardium B. Pain aggravated by breathing, coughing, and swallowing C. Splinter hemorrhages D. Friction rub auscultated at the left lower sternal border C. Splinter hemorrhages are indicative of infective endocarditis. Petechiae (pinpoint red spots) occur in many clients with endocarditis. Splinter hemorrhages appear as black longitudinal lines or small red streaks along the distal third of the nail bed. Friction rub in the left lower sternal border and pain aggravated by breathing, coughing, and swallowing are signs and symptoms indicative of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis.

The nurse expects which outcome in a client who is taking a beta blocker for mild heart failure?

A. increased orthopnea B. improved urinary output C. improved activity intolerance D. increased myocardial contractility C. ±Beta-blocker therapy for mild and moderate heart failure can lead to improvement in symptoms, including improved activity tolerance and less orthopnea.

rheumatic carditis

Inflammatory lesions in the heart due to a sensitivity response that develops after an upper respiratory tract infection with group A beta-hemolytic streptococci, which occurs in about 40% of patients with rheumatic fever. Inflammation results in impaired contractile function of the myocardium, thickening of the pericardium, and valvular damage. -primary prevention is extremely important -penicillin or erythromycin

Diuretics

Loop diuretics act on the ascending limb of the loop of Henle to inhibit sodium and chloride reabsorption, leading to increased urinary excretion of sodium and water. -examples are furosemide, bumetanide, and torsemide. -Instruct patients to decrease their dietary intake of sodium, weigh themselves daily, and take the diuretic early in the day to prevent nocturia. Hypokalemia is a side effect of loop diuretics, so monitor patients' serum potassium levels.

cardiomyopathy interventions (surgical)

Myectomy and Ablation The type of surgery performed depends on the type of cardiomyopathy. The most commonly used surgical treatment for obstructive HCM involves excising a portion of the hypertrophied ventricular septum to create a wider outflow tract (ventricular septal myectomy). This procedure results in long-term improvement in activity tolerance for most patients. Percutaneous alcohol septal ablation is another option for patients with HCM. Absolute alcohol is injected into a target septal branch of the left anterior descending coronary artery to produce a small septal infarction. Over time this will result in remodeling of the area, reducing the obstruction

ARBs

Similar to ACE inhibitors, ARBs block the action of angiotensin II. However, they work at a different level of interaction with angiotensin II, reducing the risk of hyperkalemia or cough that's seen with ACE inhibitors. ARBs block angiotensin II receptors in the blood vessels and the adrenal glands. In the blood vessels, ARBs cause venous and arterial dilation to re-duce both preload and afterload. -examples are valsartan and losartan *often for those who cant tolerate ACEs

PAP

positive airway pressure

PAWP

pulmonary artery wedge pressure is a measurement of pulmonary capillary pressure

cardiomyopathy interventions (nonsurgical)

The care of patients with dilated or restrictive cardiomyopathy is initially the same as that for HF. Drug therapy includes the use of diuretics, vasodilating agents, and cardiac glycosides to increase CO. Because patients are at risk for sudden death, teach them to report any palpitations, dizziness, or fainting, which might indicate a dysrhythmia. Antidysrhythmic drugs or implantable cardiac defibrillators may be used to control life-threatening dysrhythmias. To block inappropriate sympathetic stimulation and tachycardia, beta blockers (e.g., metoprolol) are used. If cardiomyopathy has developed in response to a toxin (such as alcohol), further exposure to that toxin must be avoided

Valvular Heart Disease (VHD)

When valve function has deteriorated to where heart cannot maintain adequate blood flow *patho overview: mitral valve prolapse, aortic stenosis, aortic regurgitation

which assessment finding does the nurse anticipate in a client with right sided heart failure?

a. pulmonary congestion b. SOB c. neck vein distention d. enlarged abdominal girth e. a third heart sound C, D Right ventricular failure is associated with increased systemic venous pressures and congestions, which creates neck vein distension and enlarged abdominal girth. The other options are associated with left-sided heart failure

A client with chronic heart failure has been prescribed ivabradine. Which assessment data requires the nurse to contact the health care provider before administering this medication?

a. hypotension b. EF of 29% c. Resting heart rate of 80 bpm d. patient is currently on a beta blocker A Ivabradine is used for HF clients who have an ejection fraction (EF) <32% who are in sinus rhythm with a resting heart rate ≥70 beats/min. This medication is used for clients who are either on the maximally tolerated dose of beta blocker therapy or have a contraindication to beta blocker therapy. Ivabradine is contraindicated with hypotension, sick sinus syndrome, 3rd degree heart block, pacemaker dependence, severe hepatic impairment, and use of cytochrome P4503A4 inhibitors

ACE inhibitors

cause vasodilation in both the venous and arterial systems, so they decrease both preload and afterload, increasing blood flow to vital organ systems and improving ejection fraction. -also block the enzyme needed to convert angiotensin I to angiotensin II. Angiotensin II is a strong vasoconstrictor that raises blood pressure, releases aldosterone, and leads to sodium and water retention. ACE inhibitors prevent this cascade of effects. -examples are captropril, enalapril, and lisinopril *dry cough is hallmark *renal protectants decreasing kidney damage *preferred over ARBs because they decrease morbidity and mortality

heart failure etiology

caused by: -systemic hypertension in most cases -MI sometimes -structural heart changes (pulmonic or aortic stenosis) -right sided HF in absence or left-sided HF often the result of pulmonary problems

Aldactone antagonists (potassium sparing diuretics)

decrease all-cause mortality, sudden cardiac death, and heart failure symptoms when added to the treatment regimen of patients with heart failure and HFrEF. -spironlactone and eplerenone -Advise patients taking an aldactone antagonist to avoid salt substitutes, nonsteroidal anti-inflammatory drugs, and foods in potassium

Beta Blockers

decrease sympathetic nervous system stimulation, lowering heart rate and blood pressure and improving left ventricular function, hemodynamics, and exercise tolerance. They have moderate afterload reduction effects and slightly reduce preload -examples are bisoprolol, carvedilol, sustained-release metoprolol. -Because of decreased heart rate and blood pressure associated with beta blockers, they shouldn't be ad-ministered at the same time as ACE inhibitors.

heart failure assessment

history -heart conditions -activity intolerance -breathing, sleeping, urinary patterns

heart failure care coordination and transition management

home care management, self management education, health care resources

aortic regurgitation care coordination and transition management

home care management, self-management education, health care resources

heart failure patho

inability of the heart to work effectively as a pump -results from a number of acute and chronic cardiovascular problems *left sided and right sided

pericarditis

inflammation or alteration of the pericardium -associated with infective organisms (bacteria, viruses, fungi) (usually respiratory) -post MI syndrome -Dresslers syndrome- blood cultures would be normal -post pericardiotomy syndrome -acute exacerbations of systemic connective tissue disease

infective endocarditis

microbial infection of the endocardium -often occur in those who use IV drugs

Renin-angiotensin system activation (compensatory mechanism that improves output)

vasoconstriction worsens, pre-load and afterload increases

cardiomyopathy assessment

±Findings are dependent upon structural and functional abnormalities

rheumatic carditis interventions

±Penicillin is the antibiotic of choice for treatment. Erythromycin is the alternative for penicillin-sensitive patients. ±Teach the patient to continue the antibiotic administration for the full 10 days to prevent reinfection. Suggest ways to manage fever, such as maintaining hydration and taking antipyretics. Encourage the patient to get adequate rest. Explain to the patient and family that a recurrence of rheumatic carditis is most likely the result of reinfection by Streptococcus. Antibiotic prophylaxis is necessary for the rest of the patient's life to prevent infective endocarditis