heart failure课件

HeartFailure 2 27 2020 1 Mrs MahdiaSamahaKony CardiacHemodynamics Cardiacoutput CO theamountofbloodpumpedin1minute COisdeterminedbymeasuringtheheartrate HR andmultiplyingitbythestrokevolume SV CO HR SVStrokevolume istheamountofbloodpumpedoutoftheventriclewitheachcontraction beat 2 27 2020 2 Mrs MahdiaSamahaKony Heartrate OneofthefactorscontrollingHRistheautonomicnervoussystem WhenSVfalls thenervoussystemisstimulatedtoincreaseHRandtherebymaintainadequateCO 2 27 2020 3 Mrs MahdiaSamahaKony Strokevolume SV Dependson Preload istheamountofmyocardialstretchjustbeforesystolecausedbythepressurecreatedbythevolumeofbloodwithintheventricle Toolittleortoomuchmusclefiberstretchdecreasesthevolumeofbloodejected 2 27 2020 4 Mrs MahdiaSamahaKony Factorthatdeterminespreload Venousreturn thevolumeofbloodthatenterstheventricleduringdiastole Ventricularcompliance whichistheelasticityoramountof give whenbloodenterstheventricle 2 27 2020 5 Mrs MahdiaSamahaKony Causesofdecreasedelasticity compliance Thickensofthecardiacmuscle asinhypertrophiccardiomyopathy Increasedfibrotictissuewithintheventricle asinMI Anoncompliantventriclehasahigherintraventricularpressurethanacompliantone Thehigherpressureincreasestheworkloadoftheheartandcanleadtoheartfailure HF 2 27 2020 6 Mrs MahdiaSamahaKony Afterload Referstotheamountofresistancetotheejectionofbloodfromtheventricle Themajorfactorsthatdetermineafterloadare thediameteranddistensibilityofthegreatvessels aortaandpulmonaryartery theopeningandcompetenceofthesemilunarvalves pulmonicandaorticvalves Themoreopenthevalves thelowertheresistance Ifthepatienthassignificantvasoconstriction hypertension oranarrowedopeningfromastenoticvalve resistance afterload increases Whenafterloadincreases theworkloadoftheheartmustincreasetoovercometheresistanceandejectblood 2 27 2020 7 Mrs MahdiaSamahaKony Contractility Theforceofcontraction isrelatedtothenumberandstatusofmyocardialcells Factorsthatincreasecontractility Catecholamines releasedbysympatheticstimulationsuchasexerciseadministrationofpositiveinotropicmedicationsFactorsthatdecreasecontractility MIcausesnecrosisofsomemyocardialcells shiftingtheworkloadtotheremainingcells SignificantlossofmyocardialcellscandecreasecontractilityandcauseHF 2 27 2020 8 Mrs MahdiaSamahaKony Definition Congestiveheartfailure CHF istheinabilityofthehearttopumpsufficientbloodtomeettheneedsofthetissuesforoxygenandnutrients HFindicatesmyocardialheartdiseaseinwhichthereisaproblemwithcontractionoftheheart systolicdysfunction orfillingoftheheart diastolicdysfunction andwhichmayormaynotcausepulmonaryorsystemiccongestion 2 27 2020 9 Mrs MahdiaSamahaKony CHRONICHEARTFAILURE ItisincreasedwithageMedicalmanagementisbasedonthetype severity andcauseofHF Types DiastolicheartfailureSystolicheartfailure 2 27 2020 10 Mrs MahdiaSamahaKony Ejectionfraction EF isperformedtoassistindeterminingthetypeofHF TheEFisnormalindiastolicHFTheEFislessthan40 insystolicHF TheseverityofHFisfrequentlyclassifiedaccordingtothepatient ssymptoms 2 27 2020 11 Mrs MahdiaSamahaKony Pathophysiology SystolicHFdecreasestheamountofbloodejectedfromtheventricle whichstimulatesthesympatheticnervoussystemtoreleaseepinephrineandnorepinephrine Thepurposeofthisinitialresponseistosupportthefailingmyocardium butthecontinuedresponsecauseslossofbeta1 adrenergicreceptorsitesandfurtherdamagetotheheartmusclecells 2 27 2020 12 Mrs MahdiaSamahaKony Thesympatheticstimulationandthedecreaseinrenalperfusionbythefailingheartcausethereleaseofreninbythekidney ReninpromotestheformationofangiotensinI Angiotensin convertingenzyme ACE convertsangiotensinItoangiotensinII avasoconstrictorthatalsocausesthereleaseofaldosterone Aldosteronepromotessodiumandfluidretentionandstimulatesthethirstcenter Aldosteronecausesadditionaleffectstothemyocardium 2 27 2020 13 Mrs MahdiaSamahaKony Angiotensin aldosterone andotherneurohormonesleadtoanincreaseinpreloadandafterload whichincreasesstressontheventricularwall causinganincreaseintheworkloadoftheheart Astheheart sworkloadincreases contractilityofthemyofibrilsdecreases 2 27 2020 14 Mrs MahdiaSamahaKony Decreasedcontractilityresultsinanincreaseinend diastolicbloodvolumeintheventricle stretchingthemyofibersandincreasingthesizeoftheventricle ventriculardilation Theincreasedsizeoftheventriclefurtherincreasesthestressontheventricularwall addingtotheworkloadoftheheart Onewaytheheartcompensatesfortheincreasedworkloadistoincreasethethicknessoftheheartmuscle ventricularhypertrophy 2 27 2020 15 Mrs MahdiaSamahaKony DiastolicHF Developsbecauseofcontinuedincreasedworkloadontheheart whichrespondsbyincreasingthenumberandsizeofmyocardialcells Theseresponsescauseresistancetoventricularfilling whichincreasesventricularfillingpressuresdespiteanormalorreducedbloodvolume LessbloodintheventriclescausesdecreasedCO ThelowCOandhighventricularfillingpressurescausethesameneurohormonalresponsesasdescribedforsystolicHF 2 27 2020 16 Mrs MahdiaSamahaKony Etiology coronaryarterydiseaseCardiomyopathyHypertensionvalvulardisorders AtherosclerosisofthecoronaryarteriesistheprimarycauseofHF MyocardialinfarctionSystemicorpulmonaryhypertensionincreasesafterload resistancetoejection ValvularheartdiseaseSeveralsystemicconditions increasedmetabolicrate eg fever thyrotoxicosis ironoverload hypoxia andanemia serumhematocritlessthan25 2 27 2020 17 Mrs MahdiaSamahaKony ClinicalManifestationsofLSHF Pulmonarycongestionoccurswhentheleftventriclecannotpumpthebloodoutoftheventricletothebody asmanifestedby DyspneaCoughPulmonarycracklesLowlevelofoxygensaturation Anextraheartsound S3 maybedetectedonauscultation 2 27 2020 18 Mrs MahdiaSamahaKony ClinicalManifestationsofLSHF Dyspnea orshortnessofbreath dyspneaonexertion DOE dyspneaalsocanoccuratrest Orthopnea difficultyinbreathingwhenlyingflat Paroxysmalnocturnaldyspnea PND suddenattacksoforthopneaatnightDryhackingcoughthatmaybemislabeledasasthmaor COPD 2 27 2020 19 Mrs MahdiaSamahaKony ClinicalManifestationsofLSHF Bloodflowtothekidneysdecreases causingdecreasedperfusionandreducedurineoutput oliguria Renalperfusionpressurefalls whichresultsinthereleaseofreninfromthekidney However whenthepatientissleeping thecardiacworkloadisdecreased improvingrenalperfusion whichthenleadstofrequenturinationatnight nocturia 2 27 2020 20 Mrs MahdiaSamahaKony ClinicalManifestationsofLSHF Decreasedgastrointestinalperfusioncausesaltereddigestion Decreasedbrainperfusioncausesdizziness lightheadedness confusion restlessness andanxietyStimulationofthesympatheticsystemalsocausestheperipheralbloodvesselstoconstrict sotheskinappearspaleorashenandfeelscoolandclammy 2 27 2020 21 Mrs MahdiaSamahaKony ThepulsesbecomeweakandthreadyFatigueInsomnia 2 27 2020 22 Mrs MahdiaSamahaKony RIGHT SIDEDHEARTFAILURE Congestionofthevisceraandtheperipheraltissuespredominates Theincreaseinvenouspressureleadstojugularveindistention JVD Edemaofthelowerextremities dependentedema Hepatomegaly enlargementoftheliver Ascites accumulationoffluidintheperitonealcavity WeaknessAnorexiaandnauseaWeightgainduetoretentionoffluid 2 27 2020 23 Mrs MahdiaSamahaKony AssessmentandDiagnosticFindings Echocardiogram isusuallyperformedtoassistintheidentificationoftheunderlyingcause anddeterminethepatient sejectionfractionCardiaccatheterizationprocedure Achestx rayElectrocardiogramLaboratorystudiesincludeserumelectrolytes bloodureanitrogen BUN creatinine B typenatriureticpeptide BNP thyroid stimulatinghormone TSH acompletebloodcellcount CBC routineurinalysis 2 27 2020 24 Mrs MahdiaSamahaKony MedicalManagement objectives Eliminateorreduceanyetiologiccontributoryfactors especiallythosethatmaybereversible suchasatrialfibrillationorexcessivealcoholingestion Reducetheworkloadontheheartbyreducingafterloadandpreload 2 27 2020 25 Mrs MahdiaSamahaKony MedicalManagement MonitoringdailyweightsandothersignsoffluidretentionEncouragingregularexerciseAvoidanceofexcessivefluidintakealcohol andsmoking Oxygentherapyisbasedonthedegreeofpulmonarycongestionandresultinghypoxia Hospitalizationandendotrachealintubation 2 27 2020 26 Mrs MahdiaSamahaKony PHARMACOLOGICTHERAPY Angiotensin ConvertingEnzymeInhibitors captopril Capoten AngiotensinIIReceptorBlockers ARBs HydralazineandIsosorbideDinitrate Acombinationofhydralazine Apresoline andisosorbidedinitrateBeta Blockers Diuretics Digitalis ThemostcommonlyprescribedformofdigitalisforpatientswithHFisdigoxin Lanoxin CalciumChannelBlockers adalat 2 27 2020 27 Mrs MahdiaSamahaKony NUTRITIONALTHERAPY Alow sodium 2to3g day dietandavoidanceofexcessiveamountsoffluidareusuallyrecommended 2 27 2020 28 Mrs MahdiaSamahaKony NursingManagement Keepinganintakeandoutputrecordtoidentifyanegativebalance moreoutputthaninput Weighingthepatientdailyatthesametimeandonthesamescale usuallyinthemorningafterurination monitoringfora2 to3 lbgaininadayor5 lbgaininweek Auscultatinglungsoundsatleastdailytodetectanincreaseordecreaseinpulmonarycrackles 2 27 2020 29 Mrs MahdiaSamahaKony NursingManagement DeterminingthedegreeofJVD Identifyingandevaluatingtheseverityofdependentedema Monitoringpulserateandbloodpressure aswellasmonitoringforposturalhypotensionandmakingsurethatthepatientdoesnotbecomehypotensivefromdehydration Examiningskinturgorandmucousmembranesforsignsofdehydration Assessingsymptomsoffluidoverload eg orthopnea paroxysmalnocturnaldyspnea anddyspneaonexertion andevaluatingchanges 2 27 2020 30 Mrs MahdiaSamahaKony MONITORINGANDMANAGINGPOTENTIALCOMPLICATIONS Profuseandrepeateddiuresiscanleadtohypokalemia HypokalemiaposesnewproblemsforthepatientwithHFbecauseitmarkedlyweakenscardiaccontractions Inpatientsreceivingdigoxin hypokalemiacanleadtodigitalistoxicity Digitalistoxicityandhypokalemiaincreasetheriskofdysrhythmias Lowlevelsofpotassiummayalsoindicatealowlevelofmagnesium whichcanaddtotheriskfordysrhythmias Hyperkalemiamayalsooccur especiallywiththeuseofACE IsorARBsandspironolactone 2 27 2020 31 Mrs MahdiaSamahaKony MONITORINGANDMANAGINGPOTENTIALCOMPLICATIONS Prolongeddiuretictherapymayalsoproduce hyponatremiahyperuricemia excessiveuricacidintheblood volumedepletionfromexcessiveurinationhyperglycemia 2 27 2020 32 Mrs MahdiaSamahaKony ACUTEHEARTFAILURE PULMONARYEDEMA 2 27 2020 33 Mrs MahdiaSamahaKony Definition Pulmonaryedemaistheabnormalaccumulationoffluidinthelungs Thefluidmayaccumulateintheinterstitialspacesorinthealveoli 2 27 2020 34 Mrs MahdiaSamahaKony Pathophysiology Myocardialscarringcanlimittheventriculardistensibilityandincreasetheworkload Withincreasedresistancetoleftventricularfilling thebloodbacksupintothepulmonarycirculation Pulmonaryedemacanbecausedbynoncardiacdisorders suchas renalfailureliverfailureoncologicconditionsTheleftventriclecannothandletheresultinghypervolemia preventingbloodfromeasilyflowingfromtheleftatriumintotheleftventricle Thiscausesthepressuretoincreaseintheleftatrium Theincreaseinatrialpressuremayresultinanincreaseinpulmonaryvenouspressure whichproducesanincreaseinhydrostaticpressurethatforcesfluidoutofthepulmonarycapillariesintotheinterstitialspacesandalveoli 2 27 2020 35 Mrs MahdiaSamahaKony ClinicalManifestations Restlessnessandanxious asuddenonsetofbreathlessnessandasenseofsuffocationcoldandmoisthands cyanoticnailbedstheskinturnsashen gray WeakandrapidpulseDistendedneckveins Coughofmucoidsputum confused thenstuporous Rapid noisy andmoistbreathingsound Decreasedoxygenlevels saturation 2 27 2020 36 Mrs MahdiaSamahaKony AssessmentandDiagnosticFindings Evaluatetheclinicalmanifestations achestx rayisobtainedtoconfirmthatthepulmonaryveinsareengorged Physicalexamination 2 27 2020 37 Mrs MahdiaSamahaKony Prevention Recognizeitinitsearlystagesby AuscultatesthelungfieldsandheartsoundsmeasuresJVDassessesthedegreeofperipheraledemaandtheseverityofbreathlessness Adry hackingcough fatigue weightgain developmentorworseningofedema anddecreasedactivitytolerancemaybeearlyindicatorsofdevelopingpulmonaryedema Inanearlystage theconditionmaybecorrectedbyplacingthepatientinanuprightpositionwiththefeetandlegsdependentEliminatingoverexertion andminimizingemotionalstressAre examinationofthepatient streatmentregimenIdentifyingtheprecipitatingfactors 2 27 2020 38 Mrs MahdiaSamahaKony MedicalManagement OxygenTherapy Oxygenisadministeredinconcentrationsadequatetorelievehypoxemiaanddyspnea Morphine Morphineisadministeredintravenouslyinsmalldoses 2to5mg toreduceperipheralresistanceandvenousreturnsothatbloodcanberedistributedfromthepulmonarycirculationtootherpartsofthebody Diuretics Diureticspromotetheexcretionofsodiumandwaterbythekidneys Dobutamine Itsmajoractionistoincreasecardiaccontractility 2 27 2020 39 Mrs MahdiaSamahaKony MedicalManagement Milrinone Milrinone Primacor isaphosphodiesteraseinhibitorthatdelaysthereleaseofcalciumfromintracellularreservoirsandpreventstheuptakeofextracellularcalciumbythecells Thispromotesvasodilation decreasingpreloadandafterload reducingtheworkloadoftheheart 2 27 2020 40 Mrs MahdiaSamahaKony NursingManagement POSITIONINGTHEPATIENTTOPROMOTECIRCULATION Thepatientispositionedupright preferablywiththelegsdanglingoverthesideofthebed PROVIDINGPSYCHOLOGICALSUPPORTMONITORINGMEDICATIONS 2 27 2020 41 Mrs MahdiaSamahaKony CARDIOGENICSHOCK 2 27 2020 42 Mrs MahdiaSamahaKony Cardiogenicshockoccurswhentheheartcannotpumpenoughbloodtosupplytheamountofoxygenneededbythetissues 2 27 2020 43 Mrs MahdiaSamahaKony Pathophysiology 2 27 2020 44 Mrs MahdiaSamahaKony ClinicalManifestations Theclassicsignsofcardiogenicshockaretissuehypoperfusionmanifestedascerebralhypoxia restlessness confusion agitation lowbloodpressure rapidandweakpulse coldandclammyskinincreasedrespiratorycrackleshypoactivebowelsoundsDecreasedurinaryoutput arterialbloodgasanalysismayshowrespiratoryalkalosis Dysrhythmiasarecommonandresultfromadecreaseinoxygentothemyocardium 2 27 2020 45 Mrs MahdiaSamahaKony AssessmentandDiagnosticFindings PAcathetertomeasureleftventricularpressuresandCOContinuouscentralvenousoximetrymeasurementofbloodlacticacidlevelsmayassistinassessingtheseverityoftheshockaswellastheeffectivenessoftreatment Continuedcellularhypoperfusioneventuallyresultsinorganfailure 2 27 2020 46 Mrs MahdiaSamahaKony MedicalManagement CorrecttheunderlyingproblemsReduceanyfurtherdemandontheheartImproveoxygenationRestoretissueperfusion Inacutemyocardialinfarction emergencypercutaneouscoronaryinterventionDysrhythmiastobecorrectedDiuretics vasodilators andmechanicaldevices suchasfiltration continuousrenalreplacementtherapy CRRT anddialysis havebeenusedtoreducethecirculatingbloodvolume 2 27 2020 47 Mrs MahdiaSamahaKony MedicalManagement Ifhypovolemiaissuspectedthepatientisgivenintravenousvolumeexpanders eg normalsalinesolution lactatedRinger ssolution albumin ThepatientisplacedonstrictbedresttoconserveenergyIntubationandsedationmaybenecessarytomaintainoxygenation 2 27 2020 48 Mrs MahdiaSamahaKony PHARMACOLOGICTHERAPY Vasopressors orpressoragents aremedicationsusedtoraisebloodpressureandincreaseCODiureticsandvasodilatorsmaybeadministeredcarefullytoreducetheworkloadoftheheartaslongastheydonotcauseworseningofthetissuehypoperfusion Positiveinotropicmedicationsaregiventoincreasemyocardialcontractility 2 27 2020 49 Mrs MahdiaSamahaKony NursingManagement constantmonitoringandintensivecare carefullyassessthepatient observethecardiacrhythm monitorhemodynamicparametersrecordfluidintakeandurinaryoutput closelyassessthepatientforresponsestothemedicalinterventionsandforthedevelopmentofcomplications 2 27 2020 50 Mrs MahdiaSamahaKony PERICARDIALEFFUSIONANDCARDIACTAMPONADE 2 27 2020 51 Mrs MahdiaSamahaKony Pathophysiology Pericardialeffusionreferstotheaccumulationoffluidinthepericardialsac Normally thepericardialsaccontainslessthan50mLoffluid whichisneededtodecreasefrictionforthebeatingheart 2 27 2020 52 Mrs MahdiaSamahaKony Effectsofpericardialeffusion Increasedrightandleft