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The Client with Altered Cardiac Output

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					The Client with Alterations in
       Cardiac Output
           Lecture
            9/26/05
     Sherry Burrell, RN, MSN
       Rutgers University
           Nursing III
      Assessment Parameters
• Cardiac Output
  • Measures the effectiveness of the heart’s
    pumping abilities.
  • CO is defined as the amount of blood that leaves
    the heart in one minute.
    CO = Stroke Volume (SV) X Heart Rate (HR)
  • Normal CO: Approximately 4-8 liters/minute
  • Cardiac Index: CO per square meter of BSA
    • CO ÷ body surface area = CI
               C0= SV x HR
• Stroke Volume (SV)
  • The amount of blood that leaves the heart with
    each beat or ventricular contraction.
     • Not all blood ejected
     • Normal Adult 70 ml / beat
• Ejection Fraction (EF)
     • The percentage of end-diastole blood actually
       ejected with each beat or ventricular contraction.
     • Normal adult 55-70% (healthy heart)
              Stroke Volume
• Three factors regulate stroke volume:
  • Preload
     • The degree of stretch of the ventricle at the end
       of diastole.
  • Contractility
     • Force of ventricular contraction (systole);
       inotropy.
  • Afterload
     • The amount of resistance the ventricular wall
       must overcome to eject blood during systole.
         Stroke Volume Cont.,
• Preload
  • The degree of ventricular stretch at end-diastole
  • The Frank-Starling Law of the Heart
    •  Preload =  Contractility (to a point)
  • Factors Affecting Preload
                                            Starling Curve
    •   Circulating volume
    •   Body positioning
    •   Atrial systole or “kick”
    •   Medications
         • Diuretics (i.e. Lasix)
         • ACE Inhibitors (i.e. Vasotec)
         • I.V. Fluids
       Stroke Volume Cont.,
• Contractility
  • Positive inotropic agents
     •  Force of contraction
  • Negative inotropic agents
     •  Force of contraction
  • Factors that affect contractility
     • Autonomic nervous system (ANS)
     • Medications:
        • Digoxin (Lanoxin)
        • Beta-adrenergic blockers (i.e. metoprolol )
        • Calcium channel blockers (i.e. verapamil )
         Stroke Volume Cont.,
• Afterload
  • Resistance to ventricular ejection during systole
  • Factors that affect afterload
    • Outflow impedance
       • Left side
           • High systemic blood pressures (SVR)
           • Aortic valve stenosis
       • Right side
           • High pulmonary blood pressures (PVR)
           • Pulmonary valve stenosis
    • Diameter of arterial vessels
    • Blood characteristics
    • Medications:
       • ACE (angiotension converting enzyme) inhibitors
              CO = SV x HR
• Heart Rate: beats per minute (bpm)
  •  HR =  CO (to a point)
  • HR >160 bpm =  CO
     • Leads to inadequate diastolic filling time = time for
       coronary artery filling and an increase workload of
       the heart.
  • Factors that affect heart rate
     • ANS
     • Medications
        • Atropine sulfate
        • Digoxin (Lanoxin)
        • Beta-adrenergic blockers / calcium channel blockers
  Assessment Considerations
• General Cardiac Symptoms
  •   Fatigue
  •   Chest pain or discomfort
  •   Palpitations
  •   Shortness of breath
  •   Edema
  •   Weight gain
  •   Dizziness
  •   Syncope, loss of consciousness
   Assessment: Special Populations
• Gerontologic Considerations
  • Heart function is adequate at rest; limited ability to
    respond to stress and takes longer to return to baseline.
  • Decrease sensation of chest pain; tend to be under
    quantified or even absent.
• Gender Considerations
  • Women:
     • Smaller hearts and coronary arteries
     • Tend to present with “atypical symptom” of CAD
• Other Considerations
  • Diabetes mellitus and cardiovascular disease
     • Increased threat; decreased symptoms !!
       Laboratory Analysis
• Serum Enzymes
• Blood Chemistry
  • Lipid Studies
  • Electrolytes
  • Renal Function Studies
• Coagulation Studies
• Hematologic Studies
       Serum Enzymes: Cardiac
• Creatine Phosphokinase (Total CK / CPK)
  • Non-Specific: enzyme elevated with damage to
    heart or skeletal muscles and brain tissue.
        • Elevates in 4 to 8 hours
        • Peaks in 15 to 24 hours
        • Returns to normal in 3 to 4 days
• Creatine Phosphokinase Isoenzyme (CPK-MB)
  • Specific: isoenzyme of CPK; elevated with cardiac
    muscle damage.
        • Elevates in 4 to 8 hours
        • Peaks in 15 to 24 hours
        • Returns to normal in 3 to 4 days
                Cardiac Enzymes
• Myoglobin
  • Non-specific: a heme protein found in muscle tissue;
    elevated with damage to skeletal or cardiac muscle.
        • Elevates in 2 to 3 hours
        • Peaks 6-9 hours
        • Returns to normal 12 hours
• Lactic Acid Dehydrogenase (LDH)
  • Non-specific: enzyme elevated with damage to many
    body tissues. (i.e. heart, liver, skeletal muscle, brain and
    RBC’s); Not frequently used today.
        • Elevates in 1 to 3 days
        • Peaks in 2 to 5 days
        • Returns to normal 10 to 14 days
       Cardiac Enzymes Cont.,
• Troponin I / T
  • Specific: a contractile protein released with
    cardiac muscle damage; not normally present in
    serum.
       • Elevates in 4 to 6 hours
       • Peaks in 10 to 24 hours
       • Returns to normal in 10 to 15 days
  • Sensitivity superior to CK-MB within the first 6
    hours of event.
  • Has replaced LDH for client’s who delay seeking
    treatment.
         Other Serum Enzymes
• C-Reactive Protein
  • Protein marker of acute inflammatory reactions
     • Increased serum levels associated with increased risk of acute
       cardiovascular events.
• Homocysteine
  • Amino acid; presence in serum suggests increased
    risk of cardio-vascular events.
• Natriuretic Peptides
  • Hormone-like substances released into bloodstream
    with cardiac chamber distention.
        • Atrial Natriuretic Peptide (ANP)
        • Brain or B-type Natriuretic Peptide (BNP)
    Blood Chemistry Analysis
• Lipoprotein (Lipid) Profile
  • Total Cholesterol
    • Normal < 200mg/dl
  • Triglyceride
    • Normal < 150 mg/dl
  • Low Density Lipoproteins (LDL)
    • Normal <130 mg/dl / “Optimal” <100mg/dl
  • High Density Lipoproteins (HDL)
    • Normal: > 40 mg/dl
              > 60 mg/dl cardio-protective
Blood Chemistry Analysis Cont.,
• Serum Electrolytes
  • i.e. Na, K, Ca and Mg
  • Glucose / Hemoglobin A1C
• Coagulation Studies
  • PTT / aPTT
  • PT / INR
• Hematologic Studies
  • CBC
• Renal Function Studies
  • BUN
  • Creatinine
        Diagnostic Testing
• Electrocardiography *
  • 12-Lead EKG
  • Continuous bedside monitoring
  • Ambulatory monitoring
• Stress Tests
  • Thallium Scans
• Echocardiograms
• Cardiac Catheterizations
                               * Previously Discussed
          Cardiac Stress Tests
• Stressing the heart to monitor performance
• Assists in Determining
  • Coronary artery disease
  • Cause of chest pain
  • Functional capacity of heart
  • Identify dysrhythmias
  • Effectiveness of medications
  • Establish goals for a physical fitness routine
    Cardiac Stress Tests Cont.,
• Types of Stress Tests
  • Exercise
     • Treadmill (most common)
     • Bike
     • Arm crank
  • Pharmacological
     • Vasodilating agents to mimic the effects of exercise
        • Persantin
        • Adenosine
  • Mental / Emotional (new; under investigation)
     • Simulated public speaking
     • Mental arithmetic test
   Cardiac Stress Tests Cont.,
• Thallium Scan
  • Often combined with stress tests
    • Radiological exam to assess how well the
      coronary arteries perfuse the myocardium.
    • Images are taken 1 to 2 minutes prior to end
      of stress test and again 3 hours later.
    • Nursing Considerations
       • NPO
       • IV Access
   Cardiac Stress Tests Cont.,
• Nursing Considerations
  • Explain procedure to client
  • Maintain NPO status 4 hour before test
  • Instruct client to avoid stimulants (i.e.
    chocolate, caffeine and cigarettes)
  • Hold certain medications before testing
     • Exercise: i.e. beta-adrenergic blockers
     • Pharmacologic: i.e. Theophylline (24-48 hours prior)
  • I.V. access must be obtained
            Echocardiogram
• Ultrasound procedure of the heart combined
  with an electrocardiogram (EKG).
  • Assesses
    • Cardiac geometry (size & shape)
    • Motion of structures (chamber walls / valves)
  • Simultaneous EKG assists in interpretation
  • Can be done in conjunction with stress testing
    • Referred to as a stress echocardiography or
      exercise echocardiography
       Echocardiogram Cont.,
• Types of Echocardiograms
  • Transcutanoeous
    • Non-invasive / painless
  • Transesphogeal (TEE)
    • Invasive / Clearer images
    • Nursing Considerations:
       • Explain procedure
       • NPO 6 hours prior procedure
       • I.V. access
       • NPO 4 hours post-procedure
       • Monitor for complications
       Cardiac Catheterization
• “Gold Standard” of cardiac diagnostics
• Invasive procedure to assess
  • Cardiac chamber pressures & oxygen saturations
  • Detect congenital or acquired structural defects
  • Ejection fraction
• Often Includes:
  • Coronary arteriography: to assess coronary artery
    patency
• Using X-ray technique called fluoroscopy
  • Requiring the use of I.V. contrast / dye
   Cardiac Catheterization Cont.,
• Nursing Care
  • Prior to procedure
    • Explain procedure
    • NPO prior to procedure (8 to 12 hours)
    • Check allergies (I.V. dye / shellfish / iodine)
    • Laboratory tests
  • During procedure
    • I.V. access
    • Hemodynamic monitoring
    • Arterial and venous access via catheters (sheaths)
       • Femoral (most common) or brachial
  Cardiac Catheterization Cont.,
• Post-Procedure Nursing Care
  • Maintain Client Bedrest for 6 to 8 hours
    • Extremity straight & HOB up < 30 degrees
  • Maintain Adequate Hydration
    • IV Fluids (if ordered)
    • Encourage Fluids
  • Frequent Monitoring For Complications
    • Vital signs
    • Puncture site
    • Distal pulses
    • Laboratory results
The Client with Alterations in
       Cardiac Output
          Lecture II
             9/30/05
      Sherry Burrell, RN, MSN
        Rutgers University
            Nursing III
    Coronary Artery Disease (CAD)
• An insidious, progressive disease resulting
  in coronary artery narrowing or total
  occlusion.
  • Atherosclerosis
     • Most common cause of CAD
     • The abnormal accumulation of plaques on the
       vessel wall; involves inflammatory process.
       • Causes narrowing then eventually blockages in
         the coronary arteries that reduces myocardial
         blood flow = CAD
           • Asymptomatic until 75% occlusion of
             coronary artery lumen.
 Coronary Artery Disease Cont.,
• Basis of CAD Management
  • Framingham Study (1948- cont. today)
    • Identified specific risk factors and life-style
      habits that increase one’s risk for developing
      atherosclerotic heart disease.
             CAD: Risk Factors
• Modifiable                • Non-Modifiable
  •   Cigarette smoking       • Increasing Age
                                 • Males >45 years old
  •   Hypertension (HTN)         • Females >55 years old
  •   Hyperlipidema           • Gender
  •   Physical inactivity        • Affects both men and
                                   women; #1 killer is U.S.
  •   Diabetes Mellitus       • Genetics
  •   Obesity                    • Strong genetic component

  •   Stress / Anxiety        • Ethnicity
                                 • Non-whites increased
  •   Diet                         incidences versus whites
               CAD: Interventions
•   Smoking Cessation      • HTN Management
•   Diet                     • BP Screenings
•   Exercise                 • Medications:
                                • i.e. antihypertensives &
•   Weight Management             diuretics.
•   Cholesterol Management • Diabetes Management
    • Lipid Profile                     • Blood glucose testing
       • Normal: every five years       • Medications:
    • Medications:                         • i.e. oral hypoglycemics &
       • i.e Zocor, Crestor & Niaspan        insulin
             Angina Pectoris
• As CAD progresses the atherosclerotic plagues
  become significant, reducing blood flow to
  portions of the myocardium = Ischemia.
  • Myocardial ischemia clinically manifests most
    often as angina or chest pain.
  • Angina pectoris is defined as myocardial
    ischemia without cellular death.
     • Imbalance between myocardial oxygen supply
       and demand
          Myocardial Oxygen
       Supply and Demand Balance

                 Demand      Supply




           O2                           O2

 Preload         Afterload   Arterial         Coronary
                             Oxygen            Artery
                Heart
Contractility                Content         Blood flow
                Rate
 Precipitating Factors: Angina
• Any situation where oxygen demands
  are increased:
  •   Physical exertion
  •   Tachycardia
  •   Dysrhythmias
  •   Cold weather
  •   Eating a heavy meal
  •   Stress or emotional states
               Angina Pectoris
• Signs and Symptoms
  • Chest Discomfort or Pain
    • Can occur anywhere in chest; most commonly behind
      sternum; poor localization
       • Pain may radiate to the back, arms (left most common),
         shoulder, neck or jaw.
       • Described as pressure, tightness or burning sensation
    • Often precipitated by physical exertion or stress
    • Maybe associated with a few of the following
      symptoms:
       • SOB, weakness, anxiety, diaphoresis, N/V, dizziness or
         numbness in upper extremities
             Types of Angina
• Stable Angina
  • Predictable, consistent pain with physical exertion
    & relieved with rest; “my usual chest pain”
    • Rest & NTG; can be managed medically for years
• Unstable Angina
  • Last longer than stable angina, new onset or
    increased frequency / intensity of symptoms;
    pain at rest
    • Preinfarction or Crescendo Angina
       • Lasting longer than 15 minutes /unrelieved by NTG x3 is
         a medical emergency!
           • Call 911 / hospitalization for management
        Types of Angina Cont.,
• Variant / Prinzmetal Angina
  • Pain at rest; maybe cyclic, + ST segment elevation
    (reversible); usual cause is coronary artery
    vasospasm with or without atherosclerotic plaques
     • Nitrates & calcium channel blockers

• Silent Angina
  • No signs or symptoms; + ST segment elevation
     • Nitrates, beta blockers, calcium channel blockers &
       lifestyle changes
 Management: Unstable Angina
• Goals of Medical Management
  • Increase O2 supply & decrease O2 demand to the
    myocardium.
  • Prevent MI and death
  • To actively intervene !!
• 12-Lead Electrocardiogram (EKG)
  • Significant CP without EKG changes; + changes treated
    as an MI.
• Laboratory Tests
  • Electrolytes
  • Cardiac Enzyme Panel
     • Rule-out MI: every 8 hours x 3 / 6 hours x4
Management: Unstable Angina
• Relief of Chest Pain: “MONA”
    • Morphine (drug of choice)
    • Oxygen
    • Nitroglycerine
• Increase Coronary Artery Blood Flow
  • Antiplatelet medications
     • ASA
     • Glycoprotein (GP) IIb/IIIa Inhibitors
     • Heparin
  • Percutaneous Coronary Intervention (PCI)
      Management of Unstable Angina


               O2


Contractility
                     Preload                O2
    HR
                      NTG
     Beta
                     ACE I
   Blockers                      Blood Flow      Open Occluded
                    Morphine
  Ca Channel                           NTG           Arteries
   Blockers                     Ca Channel Blockers
  Afterload                           ASA             PCI
                                  Anticoagulants
                                     Morphine
     ACE I
Nursing Interventions: Unstable Angina
 • Early Identification of Chest Pain
 • Assessment of Chest Pain
   • Chest Pain: Intensity- Scales (0-10) &
                   Characteristics- “OLD CART”
   • Mentation, overall tissue perfusion
   • Vital signs, heart rhythm, pulse oximetery
   • Diagnostics: 12- lead EKG and Laboratory tests
 • Management of Chest Pain =“MONA”
Nursing Interventions: Unstable Angina
 • Calm Environment
   • Anxiety and fear of impending doom (death)
 • Activity Restrictions
   • Avoid the valsalva maneuver
 • Patient Education
   •   Risk factors for CAD
   •   Signs and symptoms of angina
   •   Medications
   •   When to call the doctor
   •   Stress management techniques
                                      See pp.403 box 16-8 Thalen
   Acute Coronary Syndromes (ACS)
• Umbrella term to describe a wide range of clinical
  presentations of CAD from unstable angina to
  acute myocardial infarction (MI).
   • Continuum, Not separate disorders!

                              Acute
          Unstable
                            Myocardial
           Angina
                            Infarction
     Myocardial Infarction (MI)
• An MI is defined as irreversible necrosis (death) of
  myocardial tissue, resulting from an abrupt
  decrease or total lack of coronary blood supply.
  • An abrupt and severe disruption of O2 supply and
    demand to the myocardium.
  • Causes:
     • Coronary artery thrombosis (most common)
     • Coronary artery vasospasm
     • Cocaine
     • Trauma
     • Severe and abrupt hypotension
Myocardial Infarction (MI) Cont.,
• Signs and Symptoms:
  • Chest Pain
    • Severe and unrelenting substernal chest pain; often
      radiating to the back, left arm or jaw.
    • Lasting for 30 minutes or more
    • Only relieved by opioids
    • Occurs without a know precipitating event; usually
      occurring in the morning
  • Associated Symptoms
    • SOB, weakness, anxiety, diaphoresis, N/V, dizziness or
      numbness in upper extremities.
    Myocardial Infarction Cont.,
• Pathophysiology
  • Irreversible cell death within 20-40 minutes of
    cessation of blood flow.
  • Wavefront of cellular death proceeds from
    endocardium to epicardium.
  • EKG changes associated with an MI:
    • Ischemia: T wave inversion
    • Injury: ST segment elevation
    • Infarction: Pathological Q waves
   Types of Myocardial Infarctions
• Classified according to muscle layer affected:
  • Q wave MI
     • Transmural: full thickness muscle wall necrosis
     • Often associated with a more prolonged MI
  • Non-Q wave MI
     • Partial-thickness muscle wall necrosis
     • Often associated with smaller, less complete
       occlusions.
        • i.e. Subendocardial- necrosis of the inner 1/3 to 1/2
          of the muscle wall.
   Types of Myocardial Infarctions
• According to anatomical location
  • Left Ventricle
     • Anterior Wall
        • Left Anterior Descending (LAD)
        • Associated with left ventricular failure, pulmonary
          edema & cardiogenic shock
     • Inferior Wall
        • Right Coronary Artery (RCA)
        • Associated with dysrhythmias & conduction disturbances
     • Posterior Wall
        • RCA or Circumflex Artery
  • Right Ventricle
     • Portion of the RCA; Rare
      Complications: Post-Acute MI
• Dysrhythmias (Most Common)
  • Sinus Bradycardia
     • Occurs in about 40% of clients after an acute MI
  • Sinus Tachycardia
     • Must be corrected !!
  • Atrial
     • PAC’s or Atrial fibrillation common
  • Ventricular
     • PVC’s and ventricular tachycardia (VT)
  • AV Heart Blocks
     • Most common with inferior wall MI
    Complications: Post-Acute MI
• Ventricular Aneurysm
  • Non-contractile, thin ventricular wall =  SV
     • Leads to acute heart failure, emboli and VT
• Ventricular Septal Defect
  • Rupture of septum; shunting of blood
     • S/Sx: Severe CP, syncope, BP & holosystolic murmur
     • Medical emergency; high mortality; surgery to correct
• Pericarditis
  • An inflammation of the pericardial sac
     • S/Sx: Pain, friction rub (left sternal border)
     • Treatment: NSAIDS and ASA
CAD / Angina / MI: Nursing Diagnoses
• Acute pain related to an imbalance between
  myocardial oxygen supply and demand.
• Anxiety related to fear of unknown or death.
• Ineffectual coping related to effects of acute illness
  and major lifestyle changes.
• Activity intolerance related to fatigue (secondary to
  an imbalance between oxygen supply and demand).
• Knowledge deficit related to CAD /angina / MI and its
  treatments.
CAD / Angina / MI: Nursing Diagnoses
• Powerlessness related to the lack of control over
  current situation or disease progression.
• Ineffective (cardiopulmonary) tissue perfusion
  related to impaired arterial blood flow.

• Decreased cardiac output related to altered…
  •   Preload
  •   Afterload
  •   Contractility
  •   Heart rate / rhythm
          Acute MI: Management
• Goals of Medical Management
  •   Chest pain control
  •   To preserve the myocardium
  •   Prevention or management of complications
  •   Pharmacological / intervention-based therapies
• EKG
  • Positive changes and/or severe CP despite medical
    therapies
• Laboratory Tests
  • Electrolytes
  • Cardiac Enzyme Panel
      • Rule-in MI and then to monitor response to treatments
           Thrombolytic Therapy
• Preserves the ischemic myocardium; limits the
  size of infarction by restoring blood flow quickly;
  can be done in emergency room.
  • Thrombolytic Agents
     • Work by causing lysis of clots; “clot busters”
        • i.e. Alteplase (t-PA) or Reteplase (r-PA)
  • Eligibility Criteria
     • CP >30 minutes
     • < 12 hours from onset (many institutions < 6 hours)
     • Positive EKG changes
     • CP unrelieved with medical therapies (i.e. NTG)
   Thrombolytic Therapy Cont.,
• Exclusion Criteria
   • History of CVA or any bleeding disorder
   • Active internal bleeding or recent surgery
• Complications
   • Bleeding and reperfusion dysrhythmias
• Nursing Role
   • I.V. Access
   • Baseline labs
   • Monitoring
      • Subsequent labs, vital signs & for complications
   • Bleeding Precautions
 Percutaneous Coronary Intervention
• Umbrella term for all various of interventional
  cardiac catheterization procedures.
  • Indications
     • Angina refractory to medical therapies
     • Proximal coronary artery stenosis; single or double
       vessels disease
  • Procedure & Nursing Care
     • Much the same as cardiac catheterizations
     • Except: venous & arterial catheters; larger lumen with
       interventional catheterizations (i.e. stents)
  Percutaneous Coronary Intervention
• Procedural Variations
  • Angioplasty
     • Percutaneous Transluminal Coronary Angioplasty (PTCA)
     • Balloon tipped-catheter; expanded to dilate vessel
     • Laser- UV pulse laser to “vaporize” lesion
  • Atherectomy
     • Removal of plaque from vessel
  • Coronary Artery Stenting
     • Tiny metal mesh tubes
        • Drug-eluting Stents: Coated with Rapamune
     • Brachytherapy
        • For in-stent re-stenosis; gamma radiation therapy
                    PCI Cont.,
• Nursing Care
  • Prior to procedure
    • Explain procedure
    • NPO prior to procedure ( 8 to 12 hours)
    • Check allergies (I.V. dye / shellfish / iodine)
    • Laboratory tests
  • During procedure
    • I.V. access
    • Hemodynamic monitoring
    • Arterial and venous access via catheters (sheaths)
       • Femoral (most common) or brachial
                   PCI Cont.,
• Post-Procedure Nursing Care
  • Maintain Client Bedrest for 6 to 8 hours
    • Extremity straight & HOB up < 30 degrees
  • Maintain Adequate Hydration
    • IV Fluids (if ordered)
    • Encourage Fluids
  • Frequent Monitoring For Complications
    • Vital signs
    • Puncture site
    • Distal pulses
    • Laboratory results
              PCI: Complications
• Acute Coronary Artery Occlusion
   • Thrombosis /emboli or persistent vasospasm
• Impaired circulation to distal extremity
   • Distal arterial emboli
   • “Blue toe syndrome”
      • Disrupted plaques occludes small vessels; pulses and
        circulation checks are good but, severe pain.
• Hemorrhagic Event
   • i.e. Arterial tear: retroperitoneal bleeding
• Puncture Site Complications
   • i.e. Bleeding or hematoma formation
• Reperfusion Dysrhythmias
                                   See pp. 735 table 28-7; Smeltzer & Bare
             Cardiac Surgery
• Coronary Artery Bypass Graft (CABG)
  • A surgical revascularization procedure; blockages
    are bypassed using internal mammary artery or
    great saphenous vein.
  • Indications
    • Angina unrelieved by medical therapies
    • Left main disease
    • Triple vessel disease
    • Single or double vessel disease not amendable to
      PCI or failed PCI
       Cardiac Surgery: CABG
• Different Surgical Approaches
  • On-Pump (Traditional CABG)
    • Cardiopulmonary bypass machine (extracorporeal
      circulation); heart stopped during procedure
  • Off-Pump
    • “Beating heart” procedure; uses “octopus device” to
      stabilize the myocardium during procedure
  • Minimally Invasive Direct CABG (MIDCABG)
    • Single vessel disease not amendable by PCI procedures
    • Small thoracotomy incision; off-pump approach
        Cardiac Surgery: CABG
• Complications
  •   Stroke (2% post-bypass reperfusion)
  •   Hypertension
  •   Hypotension
  •   Bleeding
  •   Dysrhythmias
  •   Cardiac Tamponade
CABG: Post-Operative Nursing Care
• Maintain airway patency
• Continuous bedside monitoring
• Mediastinal chest tube management
  • Monitor drainage & avoid kinks in tubing
• Assess pain levels frequently and provide relief
  • Provide relief from anxiety and fear
• Assess the surgical incisions for s/sx of infection
• Assess the extremity from which vessel harvested
  • Look for signs impaired circulation & edema
• Monitor for complications
             Management of an Acute MI


               O2


Contractility
                     Preload                O2
    HR
                      NTG
     Beta
                     ACE I
   Blockers
                    Morphine       Blood Flow        Open Occluded
  Ca Channel
   Blockers                            NTG               Arteries
  Afterload                    Ca Channel Blockers         PCI
                                       ASA             Thrombolytics
                                  Anticoagulants           CABG
     ACE I                           Morphine
        Cardiac Rehabilitation
• Education and support for client and family
  • Initiated once client is free of symptoms
  • Focuses:
     • Education
     • Psychological Support
     • Physical Conditioning
  • Goals:
     • Maximize QOL
     • Limit progression of CAD
     • Prevent further cardiac events
          Cardiac Rehabilitation
• Phases of Cardiac Rehabilitation
  • Phase I: Inpatient (post-event)
     • Education on medications, rest-activity balance, follow-
       up appointments & when to call doctor or “911”.
     • Low-level physical conditioning i.e. self-care &
       mobilization.
  • Phase II: Outpatient Supervised
     • Physical conditioning & education on risk factor
       modification
  • Phase III: Outpatient Self-Directed
     • Maintain cardiovascular stability & long-term physical
       conditioning
The Client with Alterations in
       Cardiac Output
        Lecture III
           10/10/05
     Sherry Burrell, RN, MSN
       Rutgers University
           Nursing III
                Hemodynamics
• Describe the intravascular pressures and the flow
  occurring when the myocardium contracts and
  blood is pumped via the vascular system through-
  out the body.
• Basic Principles
   • Blood flow throughout the cardiovascular system
     from area of higher pressures to areas of lower
     pressures.
      • Pressures created by cardiac cycle: systole & diastole
      • Pressures: Cardiac chambers and vessels
      Hemodynamic Monitoring
• Two Major Categories
  • Non-Invasive
    • i.e. Taking a blood pressure or a pulse
  • Invasive
    • Intra-arterial blood pressure monitoring (A-lines)
    • Central venous pressures (CVP) catheters
    • Pulmonary artery (PA) catheters (Swan-Ganz)
Invasive Hemodynamic Monitoring
• Three Components:
  • Transducer: Converts fluid waves into electrical signals
  • Amplifier: Increases the size of the electrical signal
  • Monitor / Recorder: Displays the signal and saves data
• Specialized Equipment:
  • Catheter access to client
  • Semi-rigid (high pressure) tubing
     • Three-way stop cock
     • Intraflow or In-line flow device
  • Inflatable pressurized sleeve / bag
     • I.V. Solution: 0.9 % NSS with heparin added
            Invasive Hemodynamic
               Monitoring Cont.,
• Calibration of Equipment
   • Leveling:
       • Transducer at the
         level of right atrium
   • Zeroing:
       • Atmospheric pressure
                  Let’s see how it’s done…




http://www.eonreality.com/demos/e-learning/ccn/unit3_4demo/e2_electdemo.html
    Intra-arterial BP Monitoring
• Indicated for direct, continuous blood
  pressure monitoring in the critically ill client.
  • Measures systolic, diastolic & mean arterial
    pressures (MAP)
  • Allows for serial samplings of ABG’s
  • Considered “low-risk”
  • More accurate than cuff pressures in low CO
    and shock (not affected by vasoconstriction)
  • NEVER USED TO GIVE MEDICATIONS !!
Intra-arterial BP Monitoring Cont.,
• Insertion Sites:
   • Radial (most common)
   • Brachial
   • Femoral
• Insertion Techniques:
   • Percutaneous
   • Cut-down (if necessary)
• Insertion Assessment:
   • Distal Blood Flow
      • Doppler Ultrasound
      • Allen’s Test
 Intra-arterial BP Monitoring Cont.,
• Nursing Considerations
  • Monitor for complications
    • Compromised blood flow to distal extremity
       • i.e. thrombosis or arterial spasm
    • Insertion Site
       • i.e. Infection, bleeding, hematoma or skin breakdown
  • Maintenance of System
    • Sterile dressing changes
    • Tubing, caps and flush bag changes
Central Venous Pressure (CVP) Catheters
 • Measures the pressures in the right atrium.
   • Used to assess right ventricular function and
     venous blood return to heart.
   • CVP / Right Atrial Pressures: Reflection of
     right ventricular filling pressures (preload).
   • Normal Limit: 2- 6 mm Hg
      • Increased CVP = Fluid Overload
      • Decreased CVP = Hypovolemia
        CVP Catheters Cont.,
• Insertion Sites
  • Internal Jugular
  • Subclavian Vein
     Tip advanced to the
      Superior Vena Cava
• Prior to Use:
  • Chest X-Ray
     • Confirm placement
     • Rule-out pneumo- or hemo- thorax
         CVP Catheters Cont.,
• Complications
  •   Dislodgement
  •   Infection
  •   Air Embolism
  •   Cardiac dysrhythmias
• Nursing Care
  • Sterile dressing changes
  • Tubing, caps and fluid bag changes
  • Flushing of lumens; never tie off !!
    Pulmonary Artery (PA) Catheters
• Used to assess left ventricular function.
  • “Multi-Tasking” Catheters
     • Right Atrial Pressures (same as CVP)
     • Pulmonary Artery:
        • Pulmonary artery systolic pressures (PAS)
        • Pulmonary artery diastole pressures (PAD)
        • Pulmonary artery mean pressure (MAP)
     • Left Atrial Pressures:
        • Pulmonary artery occluded pressures (PAOP)
        • Normal limit = 5-13 mmHg
        • Reflection of left ventricular filling pressures (preload)
             PA Catheters Cont.,
• “Multi-Tasking” Catheters Cont.,
  • Intermittent Cardiac Output
• Specialized PA Catheters
  • Additional Features
     • Continuous I.V. infusions
     • Continuous CO monitoring
     • Continuous venous mixed oxygen saturation monitoring
        • Represents venous blood saturations from many body tissues
        • Monitors balance between O2 supply and demand
     • Temporary transvenous pacing wires
          PA Catheters Cont.,
• Insertion Sites:
  • Internal Jugular
  • Subclavian Vein
     Threaded into the right
      atrium, to right ventricle
      finally resting in the
      pulmonary artery.
• Prior To Use:
  • Chest x-ray
     • Ensure proper placement
     • R/O pneumo- or hemo- thorax
          PA Catheters Cont.,
• Complications
  •   Dislodgement
  •   Infection
  •   Air embolism
  •   Cardiac Dysrhythmias
  •   Thromboembolism
  •   Pulmonary Artery rupture
• Nursing Care
  • Sterile dressing changes
  • Tubing, caps and fluid bag changes
  • Flushing of lumens; Never tie off !!
                 Heart Failure
• The inability of the heart to pump adequate
  amounts of blood to meet body’s needs for
  oxygen & nutrients.
  • Common causes:
     • CAD
     • HTN
     • Cardiac Infections
     • Cardiomyopathy
     • Valvular Disorders
     • Myocardial Infarction
     • Dysrhythmias
    Classification of Heart Failure
• Onset:
   • Acute heart failure
   • Chronic heart failure
• Affected portion of the cardiac cycle:
   • Diastolic heart failure
   • Systolic heart failure
• Affected side of the heart:
   • Left heart failure
   • Right heart failure
• Stages of heart failure severity:
   • New York Heart Association
   • American Heart Association/American College of Cardiology
  Acute or Chronic Heart Failure
• Describes the speed of onset of heart failure
  • Acute Heart Failure
     • Sudden onset
     • No compensatory mechanisms
     • May experience acute pulmonary
       edema,CO or cardiogenic shock
  • Chronic Heart Failure
     • Gradual (insidious) Onset
     • Presence of compensatory mechanisms
        • Structural heart chamber changes (dilation or hypertrophy)
        • Fluid overload & sodium and water retention
     • Ongoing process; may deteriorate into acute HF
        • i.e. Onset of dysrhythmias or cessation of medications
Heat Failure: Compensatory Mechanisms
• Sympathetic Nervous System:
  • Decreased tissue perfusion results in activation of the
    sympathetic nervous system, resulting in:
     • ↑ Heart rate
     • ↑ Contractility
     • Vasoconstriction of arteries, arterioles & veins (↑afterload
       & ↑preload)
• RAAS: Renin-Angiotension-Aldosterone System
  • Decreased renal perfusion stimulates the increased
    release of renin→ angiotensin II production, resulting in:
     • Vasoconstriction (↑ afterload)
     • Release of aldosterone: Na+ & water retention (↑preload)
Heat Failure: Compensatory Mechanisms
 • Ventricular Remodeling:
   • Final compensatory mechanism
   • The ventricles change in size & shape in order to
     overcome the ↑ resistance (afterload) of heart failure.
      • Hypertrophy
         • The ventricles thicken and become stiff resulting in
           impairing filling during diastole.
      • Dilation
         • The heart muscle becomes over-stretched resulting in a
           decreased force of contraction during systole.
   • Overtime these mechanisms may actually
     worsen heart failure !!
             Myocardial Disease / Injury
           Impaired Ventricular Performance

Cardiac                                      Cardiac
                                               Output
Workload
                   Vicious Cycle
                        of
                   Heart Failure
Ventricular                                    ↑ SNS
                                               ↑ HR
Remolding                                  ↑ Contractility
  Dilation &                              Vasoconstriction
 Hypertrophy
                      ↑ RAAS
                    Vasoconstriction
                        Na/H2O
                       Retention
Systolic or Diastolic Heart Failure
 • Described HF based on cardiac cycle
   • Diastolic Heart Failure
      • Disorder of ventricular filling
      • Structural changes: usually ventricular hypertrophy
      • Normal Ejection Fraction
   • Systolic Heart Failure (more common)
      • Disorder of ventricular contraction
      • Structural changes: usually ventricular dilation
      •  Ejection Fraction (< 40%)
   • Combined diastolic & systolic impairments are
     common.
     Systolic & Diastolic Heart Failure:
                Remodeling




(Jessup & Brozena, 2003)
    Left & Right Sided Heart Failure
• Describes Heart failure based on the side of
  the heart that is affected.
  • Left-Sided Failure
     • Left ventricular failure
     • Pulmonary congestion
        • Sign/Symptoms: i.e. fatigue, SOB, dyspnea, PND,
          orthopena, crackles, dry cough, & tachycardia
  • Right-Sided Failure
     • Right ventricular failure
     • Systemic congestion
         • Signs/Symptoms: i.e. weakness, peripheral edema,
           weight gain, JVD, hepatomegaly, anorexia & N/V.
NYHA: Functional Classification of HF
 I     No symptoms and no limitation in ordinary
       physical activity.
 II    Mild symptoms and slight limitation
       during ordinary activity. Comfortable at rest.
 III   Marked limitation in activity due to
       symptoms, even during less-than-ordinary
       activity. Comfortable only at rest.
 IV    Severe limitations. Experiences symptoms
       even while at rest.
AHA/ACC: Classification System of HF




                        (Jessup & Brozena, 2003)
  Heart Failure: Nursing Diagnoses
• Impaired gas exchange related to ventilation perfusion
  imbalance.
• Decreased cardiac output related to altered…
   •   Preload
   •   Contractility
   •   Afterload
   •   Heart rate /rhythm
• Activity intolerance related to fatigue (secondary to by
  an imbalance between oxygen supply and demand).
• Ineffective (cardiopulmonary) tissue perfusion related
  to impaired arterial blood flow.
   Heart Failure: Nursing Diagnoses
• Excess fluid volume related to excess fluid or sodium
  intake and retention of fluid secondary to heart failure
  and its treatments.
• Anxiety related to breathlessness and / or restlessness
  secondary to inadequate oxygenation.

• Powerlessness related to inability to perform usual role
  responsibilities.
• Knowledge deficit related to heart failure and its
  treatments.
Nursing Management: Heat Failure
 • Nursing Considerations
   • Respiratory
     • Supplemental oxygen
     • Good lung assessment
   • Monitoring
     • Hemodynamic Monitoring
     • Daily Weights
     • I & O’s
     • Laboratory Results
        • i.e. electrolytes, BNP & digoxin levels
   • Maintain
     • Small frequent meals; low in salt
     • Skin integrity
Nursing Management: Heat Failure
• Nursing considerations Cont.,
  • Promote rest and avoid fatigue
  • Assess for peripheral edema
• Client Education
  • Medications
  • Lifestyle changes
     • i.e. low-sodium diet & activity-rest balance
  • Daily weights
  • S/Sx of worsening heart failure to report
  • Importance of follow-up care
     Heart Failure Management
• Goals of management
   • Relief of health failure symptoms
   • Enhance cardiac performance
• Pharmacologic Management
  • Reduce Cardiac Workload
     • Diuretics: Preload; watch for hypokalemia
     • Nitrates:  Preload
     • ACE I / ARB’s: Preload & Afterload
     • Beta blockers / ACE I: Enhance reverse remolding
  • Increase Positive Inotropic Effects
     • i.e. Digoxin (Lanoxin)
     Heart Failure Management
• Mechanical Assist Devices
  • Intra Aortic Balloon Pump (IABP)
    • Most widely used temporary assist
      device
    • Augments diastolic coronary artery
      blood flow, enhances renal perfusion
      & reduces afterload
    • Used to reduce cardiac workload
      when medical therapies are refractory
        • i.e. Acute MI, after cardiac surgery
          or heart Failure
     Heart Failure Management
• Ventricular Assist Devices
  • Provide flow assistance to the failing ventricle
  • Three types available
     • Left ventricular assist devices (LVAD); Most Common
     • Bilateral ventricular assist devices (BiVAD)
     • Right ventricular assist devices (RVAD)
  • Categories of use
     • Support to pending recovery
     • Bridge to transplantation
     • Destination therapy
     Heart Failure Management
• Surgical Interventions
  • Correct Underlying Problem
     • Revascularization; CABG
     • Valvular repair or replacement
        • Artificial, human or animal valves
     • Cardiac support devices
        • ACORN CorCap
     • Heart transplantation
        • UNOS Stats (2003 U.S.)
           • 3,519 wait listed
           • 2,055 transplanted
           Not enough to go around !!
Complications of Heart Failure
• Electrolyte Imbalances
    • i.e. Hypokalemia
• Medication Toxicity
    • i.e. Digoxin
•   Dysrhythmias
•   Cardiac Tamponade
•   Cardiogenic Shock
•   Pulmonary Edema
      Pediatric Considerations
• Most causes of heart failure are congenital
  heart defects.
• Three categories of signs & symptoms
  • Impaired Myocardial Function
     • Tachycardia, gallop rhythm (S3 & S4) & diaphoresis
  • Pulmonary Congestion
     • Tachypnea*, dyspnea, costal retractions &
       developmental delays
  • Systemic Congestion
     • Hepatomegaly*, JVD, weight gain & peripheral edema

                                   * See Box 34-1, pp. 1478 Wong

				
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