EXAM #3- Modules 7,8,9,10,11 ALL ANSWERS 100% CORRECT FALL-2021/2022 EDIION AID GRADE A+

Heart Failure- Left and Right Pathophysiology ○ Congestive heart failure (CHF) occurs when the heart muscle is overworked or has congenital defects and is unable to fill or pump effectively to meet the body's demand → This leads to inadequate cardiac output, myocardial hypertrophy, and pulmonary and systemic edema. ○ Right-sided heart failure causes systemic edema in the lower extremities, and left-sided heart failure causes pulmonary edema. Edema is the result of blood stasis due to the heart’s reduced ability to pump effectively. ○ CHF most often begins with left-sided and if left untreated it progresses to right-sided. ○ Major types of heart failure: ■ Left sided → Lungs (Fluid build-up in the lungs - pulmonary edema) ● Systolic HF: (Squeezing) inability for ventricle to contract & pump blood adequately ○ Decreased ejection fraction ■ The amount of blood that is ejected from the heart during systole when the blood is pushed into the body system ■ Normal EF: 55 - 70% ● Diastolic HF: (Relaxing) unable to fill with enough blood to adequate cardiac output ■ Right sided → Rest of the body (peripheral edema & increase volume and pressure in venous system) ● Right ventricle unable to completely empty ● Caused by: ○ Left ventricular failure (most common) ○ Right ventricular MI ○ Pulmonary hypertension ○ COPD ○ ARDS ■ High-output failure → cardiac output stays normal or above normal (not as common) ● Normally functioning heart can't keep up with the unusually high demand for blood ● Caused by body’s increased metabolic/hyperkinetic needs: ○ Septicemia ○ High fever ○ Anemia ■ Hyperthyroidism Risk Factors ○ Hypertension → L ○ Coronary artery disease → L ○ Aging (stiffness & thickening of muscle - hypertrophy) → L ○ Substance abuse (alcohol & illicit/prescribed drugs) ○ Valvular disease ○ Congenital defects ○ Dysrhythmias ○ Diabetes mellitus ○ Smoking & tobacco use ○ Family history ○ Obesity ○ Sleep apnea & dyspnea ○ Infection/inflammation of the heart ○ Severe lung disease ○ Hyperkinetic conditions (ex: Hyperthyroidism) Assessment/Manifestations○ Left-sided: ■ Fluid backs up into lungs, low cardiac output ● Body is starved for oxygen, and nutrients, decreased perfusion ■ SOB ■ Crackles (&/or wheezes) in the lungs (pulmonary edema) *** main assessment finding ■ Cough with frothy pink-tinged sputum ■ Dyspnea at night (orthopnea) nocturnal dyspnea ■ Tachycardia ■ Unusual fatigue/weakness → tripod position ■ Weight gain ■ Paroxysmal Nocturnal Dyspnea - difficulty breathing at night & laying down ■ Oliguria ■ Disorientation or acute confusion/dizziness (esp older adults) ■ Looking at EKG → premature ventricular contractions (PVCs) or other dysrhythmias ■ Anxiety and restlessness because uncomfortable and oxygen status compromised ○ Right-sided: ■ Fluid backs up into systemic circulation ● Congestion in liver, GI tract, and arms/legs ■ Systemic edema: lower pitting extremities ● Sacral (dependent) & abdominal distention ■ Ascites (fluid build up in the abdomen) ■ Weight gain ■ Cor pulmonale - puts fluid on the systemic vessels ? ■ Enlarged liver & spleen ■ Nausea ■ Anorexia - nutritional deficit ■ Diuresis at rest ■ Increased thirst ■ Nocturnal diuresis - peeing at night excessive ■ Jugular vein distention ■ Increased venous pressure ○ Indications of worsening CHF ■ Rapid weight gain (3 lbs per week) or (1-2 lb overnight) ■ Decrease in exercise tolerance ■ Cold symptoms lasting longer than 3-5 days ■ Excessive awakening at night to urinate ■ New onset of dyspnea/angina at rest ■ Increased edema in feet, ankles (Ex: +1 moves up to +3) Diagnostic Tests/Labs ○ Echocardiogram is the gold standard for diagnosis. Shows structure and function of the heart and ejection fraction (EF). ■ EF < 50% indicative of CHF ○ Stress test shows how much the heart can tolerate when stressed ○ ABG values show hypoxemia ○ Chest x-ray shows cardiomegaly ○ Labs ■ BNP shows severity of heart failure - hormone found in left ventricle ■ CBC ■ BUN/Creatinine ■ UA shows proteinuria, high specific gravity, and microalbuminuria (early warning sign) ■ CRP - inflammatory marker ○ Invasive hemodynamic monitoring ○ EKG does not show any information for CHFTreatment options ○ Meds ■ Drugs used to reduce afterload (meds that control BP) ● ACE inhibitors ● ARBs ● ARNI ● Human BNP ■ Drugs used to reduce preload ● Diuretics (reduce preload) ● Vasodilators (reduce preload) ● Nutrition therapy (fluid & Na restriction) ■ Drugs that enhance contractility ● Inotropic drugs → Digoxin ● Beta blockers ● Aldosterone antagonists ● HCN Channel blockers ● Digitalis ■ Preventing & Managing Pulmonary Edema ● Oxygen therapy (high fowler’s position) ● Nitrates → Nitroglycerin ● Rapid-acting diuretics ● Morphine → given to reduce anxiety, slow respirations, and reduce pain. (reduces pre- and afterload) ■ Aspirin ○ Interventions ■ Fluid and sodium restriction (reduce preload) ○ Procedures■ Cardiac resynchronization therapy → Little electrical shocks to get heart beating the correct way ■ Heart transplant ■ Ventricular assistive devices Complications ○ If left untreated- MI and death ○ Of surgery/treatment- Organ transplant rejection, infection of incisions, bleeding Nursing Care and Consideration – Patient education ○ Daily weight - most reliable indicator of fluid retention or loss ■ Educate patient to call provider if gain 3 lb in a week, or 1-2 lbs overnight ○ Strict I/O monitoring ○ Anxiety post MI → Give morphine to reduce anxiety ○ Energy management - periods of rest ○ Encourage activity ○ Assess for early signs of pulm edema (crackles in bases of lungs) ■ High fowler’s, oxygen, IV diuretics and morphine ○ Patient education: Heart Failure Self-Management Health Teaching (MAWDS) ■ Medications: ● Take medications as prescribed and do not run out ● Know the purpose & side effects of each drug ● Avoid NSAIDs to prevent sodium & fluid retention ■ Activity: ● Stay as active as possible but don’t overdo it ● Know your limits ● Be able to carry on a conversion while exercising ■ Weight: ● Weigh each day at the same time on the same scale to monitor fluid retention ■ Diet: ● Limit daily sodium intake to 2-3 grams as prescribed ● Limit daily fluid intake to 2 liters ■ Symptoms: ● Note any new or worsening symptoms & notify provider immediately Valve diseases Pathophysiology ○ Structural or functional abnormalities of the mitral or aortic valves. ■ Mitral valve controls blood flow from the left atrium to the left ventricle ■ Aortic valve controls blood flow from the left ventricle to the aorta ○ Mitral stenosis (narrowing of mitral valve) → thickening, calcification → doesn’t open all the way → blood backs up into left atrium → atrial tissue dilates and blood backs up into lungs ○ Mitral regurgitation (insufficiency) → thickening, calcification → doesn’t close all the way → blood leaks back into left atrium → atrial tissue dilates and blood backs up into lungs ○ Mitral valve prolapse → enlargement of mitral valve leaflets → prolapse into left atrium → Benign unless left untreated. Common cause of mitral regurgitation. ■ MVP can cause Mitral regurgitation (hand-in-hand) ○ Aortic stenosis (narrowing of aortic valve/stiffness) → obstructs left ventricular outflow → backflow of blood into left ventricle → increased pressure leads to ventricular hypertrophy → Reduces CO and systemic perfusion → HF if left untreated ■ Most common valve dysfunction in the U.S. ■ “Wear and tear” dysfunction ○ Aortic regurgitation (insufficiency) → aortic leaflets do not close all the way → backflow into left ventricle → left ventricular hypertrophy Risk Factors ○ Mitral stenosis ■ Congenital abnormalities ■ Rheumatic fever ○ Mitral regurgitation ■ Congenital abnormalities ■ Rheumatic fever ■ Infective endocarditis (endocarditis w/IV drug users) ■ Papillary muscle dysfunction○ Mitral valve prolapse ■ Congenital abnormalities ■ Marfan syndrome ■ Genetics ○ Aortic stenosis ■ Congenital abnormalities - bicuspid or unicuspid aortic valve (most common cause) ■ Rheumatic fever ■ Atherosclerosis ○ Aortic regurgitation ■ Congenital abnormalities ■ HTN ■ Marfan syndrome Assessment/Manifestations Mitral stenosis ● Typically asymptomatic ● Rumbling diastolic apical murmur ● Neck vein distention Mitral regurgitation ● Typically asymptomatic until end of life ● High pitched systolic murmur at the apex (base of the heart), may radiate to left axilla ● Severe → S3 heart sound ● Neck vein distention Mitral valve prolapse ● Mid systolic click, and late systolic murmur at apex Aortic stenosis ● Systolic crescendo decrescendo murmur (gets really loud and then really soft) Aortic regurgitation ● Palpate a bounding arterial pulse ● High-pitched blowing decrescendo diastolic murmur Diagnostic Tests/Labs ○ Echocardiogram ○ Transesophageal echocardiography (TEE) ○ Transthoracic echocardiography (TTE) ○ Exercise tolerance testing ○ Stress echocardiography ○ Cardiac catheterization (for aortic or mitral stenosis) ○ Chest x-ray shows enlargement, dilation, and congestion Treatment options ○ Meds*** ■ Diltiazem if A Fib develops ■ Meds to improve symptoms of HF: ACE inhibitors, diuretics, beta blockers (strengthen the heart as a pump), digoxin, Ca+ channel blockers ■ Oxygen ■ Vasodilators (i.e. Ca channel blockers) used to reduce regurgitant flow in aortic and mitral stenosis ■ Anticoagulants (warfarin) because clots can develop with A Fib or on defective segments of valves ○ Interventions ■ Balance of rest and activity ○ Procedures ■ Reparative procedures ■ Balloon valvuloplasty → balloon inflates and enlarges openings for stenotic valves ■ Trancathter aortic valve replacement (TAVR) → prosthetic valve inserted using balloon ■ Surgical management → Open heart surgery ● Direct commissurotomy ● Mitral valve annuloplasty (reconstruction