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Cardiac output
- volume of blood ejected from ventricular per min
- end diastole- ventricle has @ 120ml blood
- 2/3 of that (preload) ejected with each beat "stroke volume"
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Cardiac output- calculations
- CO=SV x HR
- Normal EF- 60-65
- EF <40 (systolic worry)
- diastole ef- not filling enough
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Cardiac output influenced by
- preload- volume of blood at the end of diastole
- afterload- resistance to LV ejection
- contractility- force of contraction
- - +/- inotrope
- medication
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Heart Failure
- acute or chronic
- > 5 million people
- changes in preload, afterload, CO, inotrophy, SV
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Heart failure- 3 categories of cause
- 1. conditions that effect preload and afterload
- 2. abnormal contractility
- 3. precipitating/exacerbating conditions
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Patho for HF
- failing heart has little cardiac reserve
- heart dilates +/- hypertrophies to compensate
- - ventricular dilation- fibers lengthen, inc O@ requirements
- - ventricular hypertrophy- fibers widen, lacks sufficient blood supply
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Patho for HF
- Increased SNS stimulation
- - least effective compensation
- - increased afterload and workload, dec renal flow
- RAAS stimulation- due to renal hypoperfusion
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Patho 3
- systolic failure- most commons
- - LV can't get enough force to eject blood
- - low EF
- - MI, angina, increa afterload, valvular disease
- Diastolic HF-
- - ventricules do not fill up
- - normal EF
- - systemic and pulmonary venous engorgement
- - LV hypertrophy
- reminder- you can have L and R sided heart failure
- HTN- L HF
- COPD- R HF- cant get blood into lungs and pt has to work harder
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LVF v RVF
- LVF- Lungs
- - dyspnea, PND
- - cough
- - crackles
- - nocturia
- - orthopnea
- - +/- S3, S4
- - fatigue
- RVF- rest of the body
- - peripheral edema
- - N/V
- - anoerexia
- - cardiac cachexia?
- - JVD
- - fear
- - anxiety
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extra heart sounds
- S3- dec ventricle compliance
- - CHF
- - may be normal in those < 30
- S4- resistance to atrial systole and active filling
- - hypertrophy
- - listen to different heart sounds
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acute pulmonary edema
- emergent, life-threatening
- restless, anxiety, severe dyspnea, pallor, tachycardia, ***pink frothy sputum, crackles, wheezing, diaphoresis, cyanosis, nasal flaring, accessory muscle use, hypoxemia
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acute pulmonary edema- interventions
- watch for early signs
- positioning
- O2
- diuretics
- morphine
- IV vasodilators
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HF- diagnostic test
- CXR
- BNP- release when ventricle strenches
- SaO2
- BUN, crt
- ABG
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HF diag more
- echo- noninvasive US, evaluate, structural and functional changes of heart, wall motion, valve performance, EF
- TEE (transesophogeal Echo)- higher quality picture
- - **NPO 8-10 hrs before, sedation as PRN
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hemodynamic studies-for info
- usually in critical care areas
- earliest changes- usually before s/s
- info @ blood volume, fluid balance, efficiency of heart
- PA line- inserted by MD * sterile local
- - connect to a transducer for graphic and # display
- - complications- pneumothorax, air embolus, dysrthythmias, sepsis
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hemodynamic studies- for info 2
- intraarterial monitoring
- "A-line"
- catheter placed directly in artery radial
- continous BP, blood sampling
- complication- hemorrhage, hematoma, infection
- nursing- check connections, CSM, DSD
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Medical management
- improve ventricular performance, decrease myocardial workload
- positioning- high fowlers or chair
- O2- may require intubation
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medical managament- meds
- Ace I- suppress RAAS***
- Arb- losartan
- B-blocker
- diurectics- thiazide, loop, K+ sparing, osmotic
- Ca channel blocker
- digoxin
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med management- more meds
- nesiritide- exogenous BNP- brain naurepeptide- release when ventricular strecth bc too much blood- goes to kidney- to get rid of blood
- - BNP inc in pt with HF
- Dopamine, dobutamine -/+ inotropes
- - IV, vesicants
- - helps with strengthening the heart
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Medical management- diet etc
- diet- NA restrictions
- - adequate K+
- - fluid restriction if advance
- decr stress
- rest- level correlates with stage of disease- NY heart Assoc- Class I- IV
- helpt with energy conservation
- passive ROM, anticoag- advance
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nursing management- dec CO
- VS q1hr
- Lung and heart sounds q 2-4hr
- strict I&O q1h
- assess mental status q1h
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nursing managment- fluid volume excess
- fowler position
- mouthcare q4h
- daily weight
- monitor edema
- low Na diet
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nursing management- nx dx
- impaired gas exch
- alt tissue perfusion
- - check pulses q4h, ROM, monitor for DVT, smoking cessation
- risk for activity intolerance
- - rest periods
- risk impaired skin integrity
- - edema- shiny skin
- risk dig toxicity
- anxiety- calm, emotional support
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Nursing responsibilities HF
- what is pt EF?
- if < 40 your pt requires an Ace or Arb
- if not on Ace or Arb have MD document why
- the rrason for not getting an Ace is not always a valid reason not getting ARB. if pt is getting neither has the reason been documented for both
- has pt smoked cigarettes anytime in the past 12 months, if so your pt needs smoking cessation. a brief note stating "I advised the pt to quit smoking" will work
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Nursing responsibilities- 2
- if pt is going home she/he needs complete d/c instructions addressing six areas: activity, diet, f/u, weight management, worsening symptoms, and a complete med list. you must look at d/c med worksheet done by the physician, the d/c summary (if available) and the pages 1 referral to make sure all meds are listed on the copy given to the pt
- d/c instructions are an all or nothing measure. if you do not address one area, the entire measure fails.
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Surgical management
- cardiac transplant- hard to get donor
- implantable LVAD, RVAD, biVAD (ventricular assist device)
- - machine is pump- takes over job of heart
- - 5-10% EF barely move- SOB
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