COLEGIO de KIDAPAWAN

Quezon Boulevard, Kidapawan City

Paramedical Department
College of Nursing

In Partial Fulfilment of the Requirements

In
NCM 109

Online requirements
Woman with Cardiac Disease

Presented by:
Teves, Kenneth Mark B.

Presented to:
Patrick Poculan, RN

March 23, 2020

 Peripartal cardiomyopathy
o Can originate in pregnancy in women with no previous history of
heart disease
o The cause is unknown, occurs because of stress of the pregnancy
on the circulatory system
o The mortality rate can be as high as 50%
o Occurs most often in Black multiparas in conjunction with
gestational hypertension

A woman develops signs

o Of myocardial failure such as shortness of breath,

o chest pain,
o and nondependent edema. Her heart increases in size
(i.e., cardiomegaly).

Therapy

She must sharply reduce her physical activity Also need a diuretic,
an arrhythmia agent, and digitalis therapy to maintain heart function.

Low–molecular-weight heparin

o Administered to decrease the risk of thromboembolism.

Immunosuppressive therapy

o Another possibility to improve symptoms.

o Cardiomegaly persists past the postpartum period

Suggested a woman not to attempt any further pregnancies,
because the condition tends to recur or worsen in additional
pregnancies.

oral contraceptives are contraindicated because of the danger

of thromboembolism that these can create

Right side hearth failure

DESCRIPTION:

Right-sided heart failure occurs when the right ventricle is

overwhelmed by the amount of blood received by the right atrium from
the vena cava. It can be caused by an unrepaired congenital heart defect
such as pulmonary valve stenosis.

FACTORS.

Congenital Heart Defect.

 Existing at birth CDH result when the heart or blood

vessels near the heart don’t develop normally before
birth.

Eisenmenger Syndrome.

 A right-to-left atrial or ventricular septal defect with an

accompanying pulmonary valve stenosis.
 Refers to any untreated congenital cardiac defect with
intracardiac communication the lead to pulmonary HPN,
Reversal of flow and cyanosis.

ASSESSMENT.

 Decrease CO to the lungs

Cause the blood efficiently or back up into venous
system and limits the cardiac output.
 Congestion of the systemic circulation
 Decrease BP of the Aorta
 Because less blood is able to reach it
 Increase Pressure in SVC
 From back pressure of blood; filling of the right
atrium or movement of the blood into the right
ventricle.
 Jugular distension
The pressure inside the vena cava.
  Portal HTN
 Distend liver and spleen
Blood to back up into the veins, Hepatic veins, these
are the veins that help drain blood from the liver.
 Extreme liver enlargement can cause dyspnea

 Diaphragmatic pain
In a pregnant woman because the enlarged liver, as it
is pressed upward by the enlarged uterus, puts extreme
pressure on the diaphragm.
 Peripheral Edema.
Distention of abdominal and lower extremity vessels
can lead to exudate of fluid from the vessels into the
peritoneal cavity.

MEDICAL AND NURSING MANAGEMENT..

 Oxygenation and Frequent ABG

 To ensure fetal growth
 Hospitalization in the last part of pregnancy
 For at least some days during the last part of
pregnancy
 PAC to monitor pulmonary pressure
 They may need a pulmonary artery catheter inserted
to monitor pulmonary pressure
 Close monitoring during epidural anesthesia
 to minimize the risk of hypotension.

NURSING ASSESSMENT OF A WOMAN WITH CARDIAC DISEASE.

PREPREGNANCY CARDIAC STATUS

Assessment begins with a thorough health history to document:

 Fatigue
 Cough
 Increase respiratory rate
 Tachycardia
 Poor fetal heart tone
 Decrease amniotic fluid from intrautine growth restriction
 Edema from poor venous return

DOCUMENT LEVEL OF EXERCISE PERFORMANCE

What level she can do before growing short of breath and what
physical symptoms she experiences, such as cyanosis of the lips or nail
beds.

ASK IF SHE NORMALLY HAS A COUGH

It’s important that women with cardiac disease always report

coughing during pregnancy because pulmonary edema from heart failure
may first manifest itself as a simple cough.

DOCUMENTING EDEMA

o Because the usual innocent edema of pregnancy must be

distinguished from the beginning of edema from heart failure
(serious).
o The usual edema of pregnancy involves only the feet and
ankles but becomes systemic with heart failure.
o It can begin as early as the first trimester,
o other symptoms such as irregular pulse, rapid or difficult
respirations, and perhaps chest pain on exertion will probably
also be present

BASELINE VS
  record a baseline blood pressure, pulse rate, and respiratory rate
in either a sitting or lying position at the first prenatal visit, always obtain
these in the same position for the most accurate comparison.

NAIL BED FILLING

(should be <5 seconds) and jugular venous distention can also be

helpful throughout pregnancy.

A woman’s heart disease involves right-sided heart failure, assess

liver size at prenatal visits

Keep in mind that liver assessments can become difficult and

probably inaccurate late in pregnancy because the enlarged uterus
presses the liver upward under the ribs and makes it difficult to
palpate.

ECG

 may be done at periodic points in pregnancy

 Assure the woman that an ECG merely measures cardiac electrical
discharge and so cannot harm her fetus in any way
 uses ultrasound and, likewise, will not harm her fetus.

FETAL ASSESSMENT
 If decrease maternal BP, decrease placental perfusion
o fetal health can be compromised. For this reason, the infants
of women with severe heart disease tend to

low birth weights or be small for gestational age

o because of acidosis, which develops due to poor

oxygen/carbon dioxide exchange or not being furnished with
enough nutrients.

result in preterm labor

o which exposes the newborn to the hazards of immaturity as
well as low birth weight.

If the placenta is not filling well, a fetus may not respond

well to labor (evidenced by late deceleration patterns on a
fetal heart monitor)

Cesarean birth may be necessary (an increased risk for both

the mother and fetus).

DURING PREGNANCY
 A. PROMOTE REST

Need two rest periods a day (fully resting, not getting up frequently) and
a full night’s sleep (not tossing and turning) to obtain adequate rest.

Rest should be in

 the left lateral recumbent position to prevent supine

hypotension syndrome and increased heart effort.

Plan activities so they stop exercising before the point when cardiac
output becomes insufficient,

 to meet systemic body demands causing peripheral and

uterine/placental constriction.

Limit their exercise

 discontinue employment early in pregnancy

 washing windows
 turning mattresses
 shoveling snow
B. PROMOTE Healthy NUTRITION

Supervise food intake; needs to gain weight for pregnancy and a healthy
baby.

 because she must gain enough weight to ensure a healthy

pregnancy and a healthy baby
 but she must not gain so much weight that her heart and
circulatory system become overburdened.

VITAMINS
 Prenatal vitamins

 IRON

Help prevent anemia, Anemia is important to prevent because it

places an extra burden on the heart because her circulatory system must
circulate blood more vigorously than usual to distribute oxygen to all
body cells.

 IF ON SODUIM- RESTICTED DIET PREGNANCY.

This may be continued during pregnancy a woman’s sodium intake
is only limited, not severely restricted, during pregnancy

Because it’s important to obtain enough sodium to maintain fluid

volume and balance as well as furnish an adequate supply of blood to the
fetus.

C. EDUCATE REGARDING MEDICATION

PREPREGNANCY DIGOXIN MIGHT BE INCREASED.

 Because of their expanded blood volume during pregnancy.

Woman who was not digoxin dependent before pregnancy may need such
therapy.

 Her cardiac output has to be increased or strengthened

To aid a woman: help her to understand this does not mean her
heart function is weakening, but rather, it is only temporarily being
stressed by the increased circulatory load of pregnancy.

Digoxin

Use during pregnancy as it can be administered to the woman to

slow the fetal heart if fetal tachycardia is present

Antihypertensive and arrhythmia agents:

Adenosine, β- blockers, and calcium channel blockers.

  Reduce hypertension are safe to use during pregnancy and are also
frequently prescribed

Nitroglycerin,

 A compound often prescribed for angina, although not well studied

during pregnancy (a category C drug), is also considered safe

CONTINUE PROPHYLACTIC PENICILLIN

 Because she had rheumatic fever as a child.

 Should continue to take this drug during pregnancy because
penicillin is not known to be a teratogen (a category B drug).

AMPICILLINE, AMOXICILLIN OR CLINDAMYCIN

 To prevent streptococci bacteria from invading the denuded

placental site on the uterus and creating a subacute bacterial
endocarditis.

Help women with heart disease to understand there are valid

exceptions to the rule of “no medicine during pregnancy” so they make
out reminders to adhere to their prescribed regimen.

D. EDUCATE REGARDING AVOIDANCE OF INFECTION

CAUTION WITH HEART DISEASE TO AVOID PEOPLE WITH INFECTION

 Systemic infection almost automatically increases body

temperature.
 To expend more energy and increase her cardiac output as
her metabolism increases.

REPORT URTI AND UTI

  To avoid visiting or being visited by people with infections
and to alert healthcare personnel at the first indication.
 Antibiotic therapy can begin early in the course of the
infection.
 Monthly screening for bacteriuria with a clean-catch urine
test at prenatal visits should help detect UTIs.
E. BE PREPARED FOR EMERGENCY ACTION.
CHECK CPR,
 They may need supplemental oxygen or cardiac
resuscitation.

NURSING INTERVANTIONS

LABOR AND BIRTH

FREQUENTLY ASSESS A WOMAN’S BLOOD PRESSURE, PULSE, AND

RESPIRATIONS AND MONITOR FETAL HEART RATE AND UTERINE
CONTRACTIONS.

 to be certain their circulatory system is not failing

and the placenta is filling adequately

RAPIDLY INCREASING PULSE RATE (.100 beats/min).

 Is an indication a heart is pumping ineffectively

and so has increased its rate in an effort to
compensate.

GOOD TO ADVISE A WOMAN TO ASSUME A SIDE-LYING POSITION

 During labor to reduce the possibility of supine

hypotension syndrome.

 Side-lying position during labor good to advice, to

reduce the possibility of supine hypotension
 syndrome.

A SEMI-FOWLER’S POSITION.

 If a woman has some pulmonary edema, it may be

necessary for her to elevate her head and chest to ease the
work of breathing.
 Place a towel under her right hip to shift the uterus off the
vena cava, the same as would happen with a side-lying
position

DETERMINE IF THE FATIGUE IS DUE TO HEART OR LABOR.

REMEMBER: is a symptom of heart decompensating.

 Evaluate women carefully to determine whether the fatigue a

woman reports is heart or labor related.

OXYGENATION

 Extreme heart disease, oxygen administered during labor

because of the need for extra oxygen due to the exertion of
labor.

HEMODYNAMIC MONITORING.

 Such as by a Swan-Gans catheter to monitor heart function

may be prescribed.
 Many women with heart disease should not push with
contractions pushing requires more effort than they should
expend

EPIDURAL ANESTHESIA
  The anesthetic of choice for women with heart disease
because this decreases the sensation of pushing and can
make both labor and birth less taxing,

POSTPARTUM

The period immediately after birth is a critical time for a woman

Because, with delivery of the placenta, the blood that supplied the
placenta is released into her general circulation, increasing her blood
volume by 20% to 40%.

During pregnancy

The increase in blood volume that occurred did so over a 6-month

period, so her heart had time to gradually adjust to this change

After birth.

The increase in pressure takes place within 5 minutes, so the heart

must make a rapid and major adjustment.

Decrease activity.

To compensate for these circulatory changes, a woman may need a

program of decreased activity

Anticoagulant and digoxin therapy

Until her circulation stabilizes.

Or Blood Thinner.

Ant embolic stockings or intermittent pneumatic compression

(IPC)
 May be prescribed.

 To increase venous return from the legs.

If (-) prophylactic AB, must be started immedietely to prevent

subacute bacterial endocarditis from placental site.

DISCUSS ACROCYNOSIS

A woman with heart disease is often interested in close inspection of her

baby immediately after birth

 To know if her infant has a heart defect or was harmed by

any medication she took during pregnancy.
 Acrocyanosis is normal in new-borns, so she does not
interpret her baby’s peripheral cyanosis as cardiac
inadequacy.

Sign and symptoms.

 Cyanosis in the hands,feets or face.

 Extremities may be cold or clammy some exhibit some
swelling.
 Palms and soles exhibit sweating and moist to profuse,
but peripheral pulse should normal.

Stool softener

 Can be prescribed to prevent straining with bowel movements.

Oxytocin (Pitocin)

 Agents to encourage uterine involution

 Because they tend to increase blood pressure
 Necessitates increased heart action

Encourage BF

o Can be breast feed without difficulty.

o Kegel exercises are acceptable for perineal strengthening
immediately
o But the woman should not begin postpartum exercises to
improve abdominal tone until her primary care provider
approves them
o She can continue getting periods of rest
o Ensure that she schedules a return appointment for a
postpartum check-up for both her gynaecologic health and
her cardiac status.