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What is heart failure?
- it is a condition of impaired cardiac pumping and filling as a result of other diseases like:
Risk factors for heart failure
- Cigarette Smoking
- High Serum Cholesterol
What is systolic heart failure?
Caused by (4)?
an inability of the heart to pump blood cuz ventricles don't contract effectively
sign-decreased ejection fraction
- impaired contractile function
- increased afterload (HTN)
- mechanical abnormalities/valve dysfunction
What is diastolic heart failure?
impaired ability of the ventricles to fill during diastole that results in decreased stroke volume.
signs-pulmonary congestion and HTN, ventricular hypertrophy
If a persons in diastolic heart failure what is up with the hearts systolic function and ejection fraction?
Both are normal
Clinical manifestations of chronic heart failure
- ventricular hypertrophy
- skin changes
- behavioral changes
- angina/chest pain
- gain weight
How does the skin change with CHF?
- turns dusky and cool
- lower extremities are shiny and swollen with absent hair growth
- brown spots on the lower legs
What are the behavioral changes seen with CHF
- decreased attention span and memory
Why are their weight changes with CHF?
- fluid retention...ascites, hepatomegaly and renal failure
- *Person loses fat cuz ascites and hepatomegaly cause anorexia and nausea
- **Accurate weight loss unknown unless edema has subsided (dry weight)
Complications of heart failure
- pleural effusion
- Left Ventricular Thrombus
- Renal Failure
Two kind of dysrhythmias with CHF....and their treatments
A-fib-numerous atria sites firing spontaneously and uncontrollably. Stasis blood of the atria can cause thrombosis and emboli
Treat with anticoagulants to prevent stroke
Poor Left Ventricle function patients have an EF of <35% and are at risk for a fatal dysrhythmia so on antidysrhythmics
When do you see hepatomegaly with heart failure?
when it is right ventricle failure...causing the liver lobules to become engorged impairing liver function
How does renal failure occur with CHF?
decreased CO of CHF can decrease perfusion to the kidneys causing renal insufficiency and renal failure
Chronic Heart Failure Goals
- treat underlying cause and contributing factors
- maximize CO
- alleviate symptoms
- improve ventricular function
- improve quality of life
- preserve target organ function
How much sodium should a person have with CHF?
DONT EAT CANNED OR FROZEN FOODS
When does a person have fluid restrictions with CHF?
when they are in severe HF and have renal insufficiency
Weights to report with CHF
- a gain of 3 lbs over 2 days
- 3-5 lbs gain in 1 week
Why is left sided heart failure the most common?
causes it causes blood to back up in to the left atrium and in to the pulmonary veins causing pulmonary congestion and edema
What does right sided heart failure cause?
- it causes a backward flow of blood to the right atrium and venous circulation causing...
- peripheral edema
- vascular congestion of GI tract
- jugular vein distention
What is the primary cause of right sided heart failure?
Left ventricule failure
What is peripheral artery disease?
What is it's main cause?
- a progressive narrowing of the arteries of the:
When do you typically see PAD?
unless you are Hispanic or African American or have DM
What's collateral circulation
when one vessel gets small from PAD, another one gets big to compensate
Clinical Manifestations of Peripheral Artery Disease
- Intermittent Claudication
What is intermittent claudication?
ischemic muscle ache or pain caused by exercise
What is parasthesia?
nerve tissue ischemia causing numbness/tingling
Changes you will see with PAD...but it all depends on the degree of impaired blood flow to the extremities
- Diminished or absent pedal/femoral/pop pulses
- Pallor or blanching of foot
- Redness of foot
- Continuous pain where there is insuff blood flow
- Rest Pain
- Leg Pain
Describe Rest Pain from PAD
it occurs at night cuz the person is laying down and there is a decreased CO, so the person will stand up to stop the pain
How does a person with PAD combat leg pain?
dangles it over the side of the bed at night to use gravity to maximize arterial blood flow
How does a Doppler ultrasound diagnose PAD
assesses blood flow and outlines the vascular system
If you are doing a Segmental Blood Pressure to dx PAD what is a positive result?
segmental pressure >30mmHg
What is a normal reading when using the Ankle Brachial Index to dx PAD?
What does an angiography do for dx of PAD?
it identifies the location and extent of the disease process and provides information on inflow and outflow of vessel for surgery.
If a person has PAD what are the modifiable risk factors you can eliminate?
- STOP SMOKING!
- decrease hyperlipidemia
- control DM
What meds do you give a person with PAD?
Antiplatelets like aspirin or Plavix
What are the 3 meds to treat Intermittent Claudication?
- Ginkgo Biloba
2 things important for interventions for a person with PAD
- a formal exercise program 30min/day
- decrease your weight by lowering calories, cholesterol, saturated fat and sodium
People with DM and PAD have this same issue that is very important to manage....
Leg/Foot care with Critical Limb Eschemia
- don't injure yourself
- do skin checks daily
- keep skin dry and in tact
- wear good shoes
Interventional Radiology procedures for a person with PAD
- Percutaneous Transluminal Balloon Angiplasty
What's artherectomy for PAD and its risk?
removal of plaque in the artery
What's cryoplasty for PAD?
combo of balloon angioplasty and cold therapy
Surgical Therapies for PAD
- Peripheral Arterial Bypass Graft
- Femoral Popliteal Bypass Graft
- Patch Graft Angioplasty
- Amputation-LAST RESORT
What's Endarterectomy for PAD?
opening the artery and removing the obstructing plaque at the carotid artery
What is a Patch Graft Angioplasty for PAD?
- opening the artery
- removing the plaque
- sewing a patch to the opening to widen the lumen
Name 3 Peripheral Arterial Diseases that are NOT from Atherosclerosis
- Acute Arterial Ischemic Disorder
- Buerger's Disease
- Raynaud's Phenomenon
What is Acute Arterial Ischemic Disorder (AAID)
an emergent blood clot of the larger arteries
What is Buerger's Disease?
an inflammatory disorder of the medium arteries, veins and nerves of the upper and lower extremities
Who typically gets Buerger's disease?
young men with a long history of tobacco use
What is Raymond's Phenomenon?
a vasospastic disorder of small cutaneous arteries....usually seen in the fingers and toes.
Usually seen in women
Clinical Manifestions of AAID
- 6 P's
limb takes on the temperature of it's external environment
Clinical Manifestations of Bruegers Disease
- *Intermittent Claudication of feet
- Ulcerations as disease progresses
Clinical Manifestations of Raynaud's Phenomenon
- Vasospasm induced color changes in the fingers, toes, ears and nose
- (white-pallor, blue-cyanotic, red-perfusion restored)
- throbbing, aching, tingling and swelling
What triggers Raynaud's Phenomenon?
- exposure to cold
- emotional upsets
- tobacco use
Interventions for AAID
- anticoagulant therapy
without immediate intervention, ischemia can lead to tissue necrosis and gangrene in a few hours
Interventions for Buerger's Disease
COMPLETE CESSATION OF TOBACCO....no nicotine replacement products
**amputation is likely if they continue to smoke**
Interventions for Raynaud's Phenomenon
- Patient teaching-wear loose/warm clothes and avoid temp. extremes
- Don't smoke or drink caffeine
Drug therapy for Raynaud's
Calcium Channel Blockers to relax smooth muscles of the arterioles
How do you get Superficial Thrombophlebitis and DVT's?
- Virchow's Triad
- venous stasis
- damage of the endothelium
- blood hypercoagulability
Patho of Superficial Thrombophlebitis and DVT
RBC's, WBC's, platelets and fibrin adhere to form a thrombus that eventually occludes the lumen of the vein.
IF it doesn't get detached it under goes lysis
What will cause a thrombus to detach from a vein wall and cause an embolism?
Turbulent Blood flow
Clinical Manifestations of Superficial Thrombophlebitis
- Palpable, firm, subcutaneous cordlike vein
- surrounding area is tender to touch, reddened and warm
- Mild Leukocytosis
- Low grade temp
Clinical Manifestations of DVT
- Unilateral leg edema
- extremity pain
- warm, red skin
- Temp >100.4
- Tenderness in palpation
- Positive Homan's sign
Diagnostic studies for Superficial Thrombophlebitis
Most often caused by....
Based on physical exam
caused by cannulation of a vein or IV therapy with HYPERTONIC solutions (anything with Dextrose)
Diagnostic Studies for DVT
- Platelet count
- INR APTT
- Venous Doppler Study
- Duplex Scan
- Lung Scan
- Pulmonary angiogram
- Spiral CT
Nursing interventions for Superficial Thrombophlebitis
Remove IV if caused it and elevate that extremity and put moist warm heat on site
Oral NSAIDS for inflammation for 2 weeks
Apply elastic compression stockings to lower extremities once acute thrombophlebitis is resolved and walk
Nursing Interventions for DVT
- Watch for s/s of PE
- Bed rest
- Elevate extremity with Warm compress
- TEDS for 3-6 months
How do you prevent a DVT
- early ambulation
- Dorsiflexion if on bed rest
What's the drug therapy for DVT?
Anticoagulants-Heparin and Warfarin
What is your surgical intervention for a DVT?
IVC Filter to prevent a PE
Risk factors for any form of a Vein Thrombosis
- hip surgery
- heart failure
- oral contraceptives
Clinical Manifestations for any vein thrombosis
- Calf/groin pain or tenderness with edema
- Hardness at painful site
- changes in circumfrance of that area
- Chest pain
What does Unfractionated Heparin do for vein thrombi?
given in an IV to prevent formation of other clots and prevent enlargement of the existing clot
What labs do you look at prior to giving Unfractionated Heparin?
What is the antidote for Unfractionated Heparin?
Ensure Protamine Sulfate
What is the Low Molecular Weight Heparin called and how do you give it?
Lovenox and SubQ
How does Warfarin work?
What labs do you look at?
What's the antidote?
- inhibits synthesis of vitamin K dependent clotting factors
- PT and INR
- Vitamin K
Patient teaching for Warfarin
- don't eat foods rich in vitamin K
How does Thrombolytic Therapy work?
dissolves clots that have already developed. MUST BE STARTED WITHIN 5 days of DEVELOPMENT OF CLOT.
- TPA (Tissue Plasminogen Activator)
Complication of Vein Thrombi
clot becomes mobile and causes a PE
Risk factors for PE
- Pelvic or lower extremity surgery within past 3 months
- Hx of DVT
- Obesity in women
- Cigarette smoker
Classic Triad of symptoms for a PE
- Chest Pain
DX studies for PE
- Spiral CT
- V/Q Scanner
What's a spiral CT do for a PE?
takes a 3D view of lungs in all areas....rotates
What does a D-Dimer test do for PE
measures the amount of fibrin fragments during fibrinolysis
Prevention for PE
- Same as DVT.....
- Early ambulation
- Prophylactic Anticoagulant meds
dilated, tortuous subcutaneous veins (saphenous) that become large and bulging.
Also have then is esophagus and anorectal area
How do you get varicose veins?
As veins enlarge their valves get stretched and become incompetent allowing venous blood flow to be reversed......increased venous pressure makes these veins become dilated and torturous
Risk factors for Varicose veins
- chronic cough
- family history
- oral contraceptives/hormone replacement
Who gets varicose veins?
- over 30
- occupations that stand alot
Trendelenberg test for varicose veins
- pt. lays supine with legs elevated
- when pt. sits up the veins will fill from PROXIMAL end if variscosities are present
Nursing management for varicose veins
- PREVENTION by avoid standing or sitting for long periods of time
- Maintain ideal body weight
- Participate in daily walking program
How do you get Venous Leg Ulcers?
from chronic venous insufficiency....and can lead to amputation or death
Patho of venous leg ulcers
incompetent valves of deep veins cause an increase in hydrostatic pressure in the veins and serous fluid and RBC's leak from the capillaries and venules in to the tissues resulting in edema.
What causes a brownish skin color on lower extremities with venous leg ulcers?
breakdown of RBC's over time
Clinical manifestations of Venous Leg Ulcers
- Lower extremity is leathery with a brown appearance
- Chronic Edema
- Eczema or stasis dermatitis
- Neuropathy....so may not cause much discomfort!
Nursing Management for Venous Leg Ulcers
- COMPRESSION is KEY!!!
- Moist environment dressings are recommended
- Assess nutritional status (protein, calories, Vit. A, C and Zinc)
- Maintain normal glucose levels if diabetic
- Debridement with moist saline dressings
What kind of dressing do you put on a patient with venous leg ulcer?
Occlusive hydrocolloid dressing and leave it on for 3-5 days
If you are doing a chemical debridement for a venous leg ulcer what do you use?
a topical enzymatic agent
What helps wounds heal?
- High Protein diet
- Vitamin A and C
2 off label uses for Calcium Channel Blockers
- Angina/Prinzmetal Angina
Patient teaching for Calcium Channel Blockers
- Avoid Grapefruit juice
- Caution with Heart Failure patients
Patient teaching with Beta Blockers
- Hold if HR is lower than 50bpm
- don't stop taking abruptly
Patient teaching with ACE Inhibitors
- Aspirin and NSAID reduce drug effectiveness
- DONT use with Potassium sparing Diuretic-
Patient teaching for Statins
watch out for hepatoxicity...monitor LFT's
With Zetia you need to watch for this in your patient....
- Hepatitis-so watch LFT
- CK-watch for muscle aches and pains
Patient teaching for Niacin
- Take with food
- take aspiring 30 min before each dose to prevent facial flushing
- Monitor LFT, Kidney fxn and Blood Glucose
With Digoxin, positive inotrope, monitor....(2)
- Serum levels of drug 3.5-5.0
- watch for hypokalemia so eat more potassium
Patient teaching for Heparin, Lovenox and Warfarin
- watch for bleeding disorders
- monitor VS
- monitor labs-platelets, aPTT