31 Nursing Care of Patients with Cardiac Disorders LEARNING OUTCOMES 1. Compare and contrast the etiology, pathophysiology, and 3. Discuss indications for and management of patients with manifestations of common cardiac disorders, including heart hemodynamic monitoring. failure, structural disorders, and inflammatory disorders. 4. Discuss the effects and nursing implications for medications 2. Explain risk factors and preventive measures for cardiac commonly prescribed for patients with cardiac disorders. disorders such as heart failure, inflammatory disorders, and 5. Describe nursing care for the patient undergoing cardiac valve disorders. surgery or cardiac transplant. CLINICAL COMPETENCIES 1. Apply knowledge of normal cardiac anatomy and physiology 5. Safely and knowledgeably administer prescribed medica- and assessment techniques in caring for patients with car- tions and treatments to patients with cardiac disorders. diac disorders. 6. Actively participate in planning and coordinating interprofes- 2. Assess the functional health status of patients with cardiac sional care for patients with cardiac disorders. disorders, documenting and reporting deviations for ex- 7. Provide appropriate teaching and community-based care for pected findings. patients with cardiac disorders and their families. 3. Based on patient assessment and knowledge of the disorder, 8. Evaluate the effectiveness of nursing care, revising the plan determine priority nursing diagnoses. of care as needed to promote, maintain, or restore the func- 4. Plan, prioritize, and provide evidence-based, individualized tional health status of patients with cardiac disorders. care for patients with cardiac disorders. MAJOR CHAPTER CONCEPTS • Heart failure, the most common cardiac disorder, is a condi- medication use including ACE inhibitors, beta-blockers, di- tion in which the heart is unable to pump effectively to meet uretics, and vasodilators to reduce the cardiac workload. the body’s needs for blood and oxygen to the tissues. • Nursing care of the patient with heart failure is primarily sup- • Heart failure is due to impaired myocardial contraction or portive and educative, providing the patient and family with excessive workload. the necessary knowledge and resources to manage this • Goals of heart failure management are to reduce the work- chronic condition. load and improve its function. Medical management includes KEY TERMS aortic valve, 950 mean arterial pressure paroxysmal nocturnal dyspnea rheumatic fever, 939 cardiac tamponade, 947 (MAP), 927 (PND), 924 rheumatic heart disease cardiomyopathy, 959 mitral valve, 950 pericarditis, 946 (RHD), 939 endocarditis, 941 murmur, 951 pulmonary edema, 935 stenosis, 939 heart failure, 920 myocarditis, 945 pulmonic valve, 950 tricuspid valve, 950 hemodynamics, 926 orthopnea, 924 regurgitation, 939 valvular heart disease, 950 Cardiac disorders affect the structure and/or function of the heart. failure and death. Emergence of symptoms (fatigue, dyspnea, chest These disorders interfere with the heart’s primary purpose: to pain) is common with the progression of cardiac disorders. The pump enough blood to meet the body’s demand for oxygen and New York Heart Association (NYHA) classification is commonly nutrients. Disruptions in cardiac function affect the functioning used to describe the severity of exertional symptoms observed of other organs and tissues, potentially leading to organ system (see Table 31–1). 919 DESIGN SERVICES OF # 151615 Cust: Pearson Au: LeMone Pg. No. 919 C/M/Y/K S4CARLISLE Title: Medical-Surgical Nursing: Critical Thinking in Patient Care 6e Short / Normal Publishing Services 920 Unit 8 • Responses to Altered Cardiovascular Function New York Heart Association Heart failure is the most common cardiac disorder. Other TABLE 31–1 Classification cardiac disorders discussed in this chapter include structural car- diac disorders, such as valve disorders and cardiomyopathy, and Class Severity of Symptoms inflammatory cardiac disorders, such as endocarditis and pericar- I No limitation in physical activity/asymptomatic ditis. Before continuing with this chapter, please review the heart’s II Symptoms with strenuous activity anatomy and physiology, nursing assessment, and diagnostic tests III Symptoms with mild activity in Chapter 29. IV Symptoms at rest Heart Failure Heart failure is a complex syndrome resulting from cardiac disor- prevalence of hypertension in African Americans contributes signifi- ders that impair the ventricles’ ability to fill with and effectively pump cantly to their risk for and incidence of heart failure. blood. In heart failure, the heart is unable to pump enough blood to meet the metabolic demands of the body. It is the end result of many Incidence, Prevalence, and Risk Factors conditions. Frequently, it is a long-term effect of coronary heart dis- More than 6.6 million people in the United States are currently living ease and myocardial infarction (MI) when left ventricular damage with heart failure; approximately 550,000 new cases of heart failure is extensive enough to impair cardiac output (refer to Chapter 29). are diagnosed annually (American Heart Association [AHA], 2013). Other diseases of the heart also may cause heart failure, including Estimates predict an additional 3 million people will have heart fail- structural and inflammatory disorders. In normal hearts, failure can ure by 2030. Its incidence and prevalence increase with age: Fewer result from excessive demands placed on the heart. Heart failure may than 5% of people between ages 55 and 64 have heart failure, whereas be acute or chronic. 6% to 10% of people ages 65 to 74 are affected. There is a rapid rise in heart failure prevalence after age 65. Those ages 75 to 84 have a 14.8 THE Patient WITH Heart FAILURE to 22.3/1000 person (per) years incidence, while those older than As mentioned, heart failure develops when the heart cannot effec- 85 years have a 32.7 to 41.9/1000 person-years incidence (see Nurs- tively fill or contract with adequate strength to function as a pump to ing Care of the Older Adult box). At age 40, the lifetime risk of devel- meet the needs of the body. As a result, cardiac output falls, leading oping heart failure is one in five (AHA, 2013). The estimated direct to decreased tissue perfusion. The body initially adjusts to reduced and indirect cost of heart failure in the United States in 2011 was cardiac output by activating inherent compensatory mechanisms $34.4 billion. The prevalence and mortality rate for heart failure is to restore tissue perfusion. These normal mechanisms may result higher in African Americans than in Whites. See the accompanying in vascular congestion—hence, the commonly used term congestive Focus on Cultural Diversity box. heart failure (CHF). As these mechanisms are exhausted, heart failure Ischemic heart disease (coronary heart disease) is the leading ensues, with increased morbidity and mortality. risk factor for heart failure. Up to 75% of individuals with heart failure Heart failure is a disorder of cardiac function. It frequently is due have a history of hypertension. to impaired myocardial contraction, which may result from coronary The prognosis for a patient with heart failure depends on its un- heart disease and myocardial ischemia or infarct or from a primary derlying cause and how effectively precipitating factors can be treated. cardiac muscle disorder such as cardiomyopathy or myocarditis. Most patients with heart failure die within 8 years of the diagnosis. The Structural cardiac disorders, such as valve disorders or congenital risk for sudden cardiac death is dramatically increased, occurring at a heart defects, and hypertension also can lead to heart failure when the rate six to nine times that of the general population. In 2009, one in heart muscle is damaged by the long-standing excessive workload as- nine death certificates in the United States mentioned heart failure as sociated with these conditions. Other patients without a primary ab- the primary or a contributing cause of death (AHA, 2013). normality of myocardial function may present with manifestations of heart failure due to acute excess demands placed on the myocardium, Physiology Review such as volume overload, hyperthyroidism, and massive pulmonary The mechanical pumping action of cardiac muscle propels the blood embolus (see Table 31–2). Hypertension and coronary heart disease it receives to the pulmonary and systemic vascular systems for reoxy- are the leading causes of heart failure in the United States. The high genation and delivery to the tissues. Cardiac output (CO) is the amount TABLE 31–2 Selected Causes of Heart Failure Impaired Myocardial Function Increased Cardiac Workload Acute Noncardiac Conditions • Coronary heart disease • Hypertension • Volume overload • Cardiomyopathies • Valve disorders • Hyperthyroidism • Rheumatic fever • Anemias • Fever, infection • Infective endocarditis • Congenital heart defects • Massive pulmonary embolus DESIGN SERVICES OF # 151615 Cust: Pearson Au: LeMone Pg. No. 920 C/M/Y/K S4CARLISLE Title: Medical-Surgical Nursing: Critical Thinking in Patient Care 6e Short / Normal Publishing Services Chapter 31 • Nursing Care of Patients with Cardiac Disorders 921 Explaining Physiologic Terms FOCUS ON CULTURAL DIVERSITY BOX 31–1 Using Practical Examples Heart Disease The concepts of preload, the Frank-Starling mechanism, compli- • Up to 6.6 million Americans have heart failure. Of these, about ance, and afterload can be difficult to understand and