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Cardiovascular Nursing Part II

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Title: Cardiovascular Nursing Part II


1
Cardiovascular NursingPart II

2
FYI - Hospital Language
  • Code Teams
  • Rapid Response Teams
  • Came out of Research studies (EBP)
  • SBAR
  • Centers of Excellence examples (EBP)
  • Primary Stroke Centers
  • Heart Centers
  • Magnet Hospitals
  • Core Measures
  • AMI, CHF, Stroke
  • National Patient Safety Goals
  • Lets discuss these
  • What do these terms mean??

3
V-O-M-I-T
  • V Vital Signs
  • O Oxygen
  • M Monitor
  • I IV Access
  • T Treatment

4
Cardiovascular Conditions and Disease Processes
5
CV Disease Risk Factors
  • Smoking
  • Metabolic Syndrome
  • Sedentary lifestyle, obesity
  • Diabetes
  • HTN
  • Hyperlipidemia
  • Diet, drugs
  • Anger, stress, depression
  • Genetics
  • Gender depending on age
  • Age

6
Coronary Artery Disease
  • Inflammatory disorder
  • Atherosclerosis main cause R/T
  • Endothelial injury from Inflammatory response-
    (strongest theory)
  • Low density lipoproteins (LDL) and growth factor
    from platelet aggregation prevent repair of
    endothelium

7
Big 4 Modifiable Risk Factors
  • Elevated serum lipids (?LDL, ? HDL)
  • Hypertension
  • Cigarette smoking ( other)
  • Physical Inactivity
  • Diabetes - partially modifiable

8
CAD mortality drops to non-smoker level in 12
months!
9
Benefits of physical exercise
  • ? HDL Levels
  • ? fibrinolytic activity
  • ? oxygen perfusion to muscles
  • Goal 30 minutes 5X/Week
  • Need to sweat
  • ?HR 30-50 beats/minute
  • Encourages development of collateral circulation

10
Cardiology and Gender
Page 747 785
11
Un-Modifiable Risk Factors
  • Diabetes (partially un-modifiable!)
  • Age
  • Gender
  • Family hx
  • Heredity- Familial hypercholesterolemia

12
Lipid Control
  • Lipid panel every 5 years
  • Treat serum cholesterol gt 200 mg/dl
  • LDL gt160
  • Treatment consist of
  • Dietary modifications exercise
  • Resins (Questran),
  • Fibrins( Tricor, Lopid),
  • Statins (Zocor, Lipitor, Crestor, pravachol),
  • ( Zetia) Lipid Lowering agent as well

13
Hypertension
  • gt 140 SBP and/or gt 90 DBP over extended period of
    time
  • Stress from continual elevated B/P-?rate of
    atherosclerotic development
  • Atherosclerosis causes narrowed arteries,
    requiring more force to pump blood ?B/P
  • Cardiac implications CAD, LVH, Heart Failure,
    Atrial hypertrophy, PVD

14
Patient Teaching Focus on
  • Monitor control blood glucose levels
  • B/P control
  • Reduction of cholesterol Triglycerides
  • Eliminate all tobacco products
  • Physical exercise
  • Manage stressful situations
  • Maintain appropriate body weight

  • Table 34-3

15
Clinical Manifestations of
CAD/ACS
  • Myocardial Infarction
  • Angina Pectoris
  • Stable/Unstable Angina
  • Silent Ischemia
  • Prinzmetals Angina
  • Nocturnal Angina

VS
16
Angina
  • Supply vs. Demand
  • Ischemia is limited and does not cause permanent
    damage
  • ECG may or may not show changes
  • CPK--MB will be negative
  • Rest and Nitroglycerin should alleviate
  • Pain is usually less than 5 minutes

17
Stable vs. Unstable Angina
  • Stable widespread, irregular disease in the
    coronary arteries
  • Fixed Obstruction
  • Usually occurs with activity
  • Sufficient blood gets through when the heart
    slows down and rests
  • Intermittent and sometimes predictable
  • May have ST segment depression
  • Unstable caused by sudden interruption of blood
    flow
  • Occurs at rest, asleep, or activity

18
Characteristics of Angina
  • Vague pressure, ache, heaviness or tightness.
  • Does not change with breathing or position
  • May be anxious, a sense that someth9ing is wrong,
    sweating, nauseous, SOB or fatigued.
  • Usually relieved with NTG.
  • ST Segment Depression

P, Q, R, S, T
19
Collateral Circulation
20
Treatment
  • Goal ? O2 consumption
  • Control the HR ?
  • Initial Therapeutic intervention Includes
  • Apply oxygen at 2 liters N/C
  • ? Coronary Blood Flow
  • Nitrates Nitro SL, Nitro paste, Nitro Spray
  • Controls pain, anxiety
  • Additional Treatment includes
  • Anti-platelet therapy ASA for stable Angina
  • Plavix for Unstable Angina
  • Can reduce progression to an MI
  • Beta blockers, - preferred drug for chronic
    stable angina
  • ACE Inhibitors - B/P control and ?Ventricular
    Remodeling
  • PCI
  • PTCA/stent
  • CABG

21
Nitroglycerin SL (Nitrostat)
  • Keep in brown bottle (sensitive to light)
  • Keep away from heat
  • Including body heat ( keep out of pants pocket)
  • Destroys the medication
  • Good for 6 months
  • Instruct patient
  • Should have tingling sensation
  • May have Headache can take tylenol
  • May feel increase in HR
  • Should take effect within 3 minutes and last up
    to 30 minutes
  • Caution to rise slowly causes Orthostatic
    Hypotension
  • Place one under tongue allow to dissolve
  • if no relief within 3-5 minutes call 911
  • May also be used prophalactally prior to sexual
    activity

22
Myocardial Infarction
23
Myocardial Infarction
  • Myocardial tissue is abruptly and severely
    deprived of oxygen
  • Ischemia develops when blood flow is reduced by gt
    80--90
  • Ischemia is not reversed
  • Tissue necrosis occurs
  • Described by the area of the heart affected
  • Anterior
  • Inferior
  • Lateral
  • Posterior
  • Anterolateral
  • Anteroseptal
  • Subendocardial MI

24
Clinical manifestations
  • Pain/Pressure, not relieved by rest or nitro SL
  • Nausea, vomiting
  • Diaphoresis
  • Vasoconstriction of peripheral nerves, BP/HR
    changes
  • Fever due to necrosis of tissue
  • Can start within 24 hours and last 7 days
  • ST elevation of gt 1mm in two or more leads
  • Elevated cardiac markers ( CKMB, Troponin, BNP,
    Myoglobin )

25
Premature Ventricular Contraction
26
Ventricular Tachycardia
27
Multi focal PVCs
28
(No Transcript)
29
Initial Treatment for AMI
  • Goal Reduce the size of the infarct
  • Remember VOMIT
  • Monitor for arrhythmias--number one complication
    of MI
  • Oxygen, Aspirin, Nitroglycerin, Morphine, Beta
    blockers,
  • MONA plus Beta Blocker (ACLS)
  • Lab tests Enzymes - CPK, Triponins
  • EKG--12 lead/15 lead
  • Reperfusion
  • Fibrinolytic Therapy if no access to cath lab
  • Cardiac Cath w/ PTCA/Stent - 90 minutes
  • NEW EBP Hypothermia as endorsed by the AHA
    (ANA, 2007)

30
Treatment (contd)
  • Bed rest up to 48 hours depends on severity (
    usually allow BSC)
  • Up to chair within 12-24 hours depends on
    severity
  • Supervised OOB and ambulation activity
  • Hospital stay (uncomplicated) 3-5 days
  • Discharge teaching activity based on how pt.
    feels, S/S of angina MI, medication therapy,
    sexual activity (7-10 days 2 flights of
    stairs), return to work depends on occupation,
    quit smoking
  • Cardiac Rehab (AMI) Mended Hearts (CABG)
  • Takes 6 weeks for heart to heal (scar tissue
    replaces necrosis)
    Table 34-21

31
Patient Tracking Scenario
  • Emergency Department RN
  • Assigned 3 patient rooms and one empty room
  • One hour into your shift you receive a patient
    from the waiting room who is complaining of chest
    pain.
  • Lets discuss how you will respond when the
    patient lays down on your stretcher.
  • This discussion will include your
    responsibilities as a critical thinking RN and
    the reasons behind your actions!

32
Complications of MI
  • Arrhythmias
  • Congestive Heart Failure
  • Cardiogenic Shock
  • Papillary Muscle dysfunction
  • Ventricular aneurysm
  • Pericarditis
  • Dressler Syndrome
  • Pulmonary Embolism

33
Myocardial Injury/Infarction
  • ST abnormalities signify acute process
  • ST segment returns to baseline over time
  • Q wave associated with ST elevation indicates
    acute or recent injury
  • Non-q wave or ST depression may indicate
    sub-endocardial injury

34
Myocardial Necrosis
  • 1mm wide or 1/3 amplitude of QRS complex
  • Q waves may be permanent check other criteria to
    determine if infarction is old or acute

35
Anterior Infarction -picture
36
Inferior Infarction - picture
37
Lateral Wall Infarction - picture
38
Nursing Considerations
39
Acute Coronary Syndrome (ACS)
  • Umbrella term that encompasses
  • Unstable angina
  • Myocardial Infarction which may or may not have
    elevated ST segment (NSTEMI vs. STEMI)
  • Goes from a stable to unstable atherosclerotic
    plaque rupture

40
Care Plan Practice
  • Generate 3 Nursing diagnosis and at least 3
    interventions for each diagnosis.
  • Be Specific with your goals and interventions
  • Do this for the patient with
  • Angina
  • MI/ACS

41
AMI Core Measures
  • Reperfusion Therapy (PTCA/Stent, Fibrinolytics)
  • ASA within 24 hours of arrival to hospital
  • ASA at discharge
  • Beta-Blockers at discharge unless contraindicated
  • ACE Inhibitor at discharge for LVF or EF lt 40
    unless contraindicated
  • Lipid Control Statin
  • Smoking cessation education

42
Heart Failure

43
(No Transcript)
44
Heart Failure
  • Inability of the heart to pump sufficient blood
    to meet the demands of the body
  • Systolic or Diastolic failure or mixed
  • Can occur rapidly or over time without notice
  • Can be divided into left or right ventricular
    failure
  • Most common cause is CAD and Myocardial
    Infarction

45
Heart Failure Society
www.hfsa.org
46
Grading Heart Failure
  • NYHA
  • Class I No limitation
  • Class II slight limitation
  • Class III Marked limitation
  • Class IV Inability to carry on any physical
    activity without discomfort
  • AHA
  • Stage A
  • Stage B
  • Stage C
  • Stage D

47
Left Ventricular Failure(most common)
  • Signs and Symptoms
  • Tachycardia (early sign)
  • Exertional and nocturnal dyspnea
  • Orthopnea
  • Dry Cough
  • Nocturia
  • Crackles in the lungs? Pulmonary Edema
  • S3 and S4 heart sounds
  • ? HR (early sign)
  • PMI displaced
  • Fatigue
  • Mental Confusion
    Table 35-3

48
Right Ventricular Failure
  • Tachycardia (early sign)
  • By itself usually from pulmonary disease
  • Most often occur 2nd-ary to Left Heart Failure
  • Ascites, GI Disorders (nausea), abd. pain
  • Liver and Spleen engorgement
  • JVD
  • Dependent bilateral edema
  • Weight Gain
  • Murmurs
  • Anxiety
  • Anorexia
  • Nocturia
  • Fatigue

49
Jugular Vein Distention (JVD)
50
Diagnostics of Acute Heart Failure
  • CXR
  • EKG
  • MUGA Scan
  • ECHO
  • Pressure monitoring catheters
  • PA Catheter Swan-Ganz
  • Arterial line SBP, DBP, MAP

51
MUGA SCAN
52
MUGA SCAN Images
53
Goals Treatment of HF
  • ? Gas exchange/oxygenation
  • ? Cardiac Function
  • ? Preload
  • ? Afterload
  • ? Anxiety

54
Treatment of Heart Failure
  • Preload Low Sodium Diet (Refer to Table 35-11
    13)
  • 500 - 2500 mg/day
  • Preload Daily Weights
  • gt 3 lbs. within 2 days should be reported to
    MD/ARNP
  • Preload Fluid Restrictions typically reserved
    for Class III IV patients
  • Strict I O records
  • Assess for depression
  • Assess for family or social support
  • Cardiac Rehab for some
  • Stop Smoking
  • Medication diet adherence teaching
  • ?Gas Exchange Oxygen

55
CHF Treatment (contd.)
  • CF ACE inhibitors ? CO
  • Preload Diuretics , NTG, Vasodilators
  • Potassium-sparing Diuretics and ACE Inhibitors
    both spare potassium. Pts. Taking both types of
    meds are at risk for Hyperkalemia
  • Afterload Vasodilators, ACE Inhibitors
  • CF Cardiac Glycosides--Digoxin
  • Inotropics/Adrenergics--Dopamine,
    Dobutamine
  • Beta Blockers (Coreg is best) and ARB
  • Afterload, Preload, anxiety Morphine
  • Preload Position patient to ? Venous return
  • Horizontal in bed or dangling at bedside
  • Gas Rest-activity
  • Circulatory assist devices VAD
  • Cardiac Transplantation

56
CHF Core Measures
  • Documentation of Heart Failure education by
    nursing or case management
  • ACE Inhibitor for patients with LVF or EF lt 40
    unless contraindicated
  • Prior to discharge - LV Assessment by Nuclear
    Medicine, Echo or Cardiac Cath unless a valid
    documented reason why the assessment was not
    obtained.
  • Smoking cessation education

  • Table 35-8

57
Heart Failure Complications
  • Pleural Effusion
  • Arrhythmias
  • Thrombus
  • Pulmonary Edema
  • Hepatomegaly
  • Renal Failure

58
Pleural Effusion
59
CXR Pleural Effusion
60
Arrhythmias - Atrial Fibrillation
61
Arrhythmias - Atrial Flutter
62
Pulmonary Edema
  • Results from Left Heart Failure
  • Signs and Symptoms
  • Severe dyspnea
  • Pink, blood tinged, frothy sputum
  • Crackles, wheezes, rhonchi
  • Anxiety
  • Pale/clammy/cold skin
  • Tachypnea gt 30
  • Increased Heart rate

63
CXR picture
64
Picture- fluid shift
65
Treatment of Pulmonary Edema
  • Oxygen
  • Morphine in small doses
  • Diuretics with Potassium supplementation
  • Nitrates
  • High Fowlers position
  • C-PaP
  • Possible endotracheal intubation
  • with ventilator assistance

66
Nursing Care Plan Considerations
  • Gas Exchange
  • Fluid Balance
  • Anxiety
  • Activity
  • Knowledge Deficit

67
Discharge Teaching Focus re CHF
  • Understand the cause
  • Progressive disease
  • Patient controls symptom management
  • Daily weights, Medications, Exercise, ? Na diet
  • Stop smoking
  • Conserve Energy
  • Support Systems important to combat depression
  • Goal ? To manage the disease process outside of
    the hospital

68
Cardiomyopathy
69
Types
  • Primary
  • Secondary
  • Dilated
  • Hypertrophic
  • Restrictive

70
  • Widened QRS seen with ventricular hypertrophy

71
Cardiac Transplantation
  • Treatment of choice for end-stage heart disease
  • gt50 of patients have cardiomyopathy
  • 40 In-operable CAD
  • Extensive evaluation process to determine
    acceptability
  • Long Wait time
  • An artificial heart now exists to decrease wait
    time for transplantation

72
Inflammatory Heart Diseases
  • Infective Endocarditis
  • Myocarditis
  • Rheumatic Fever
  • Rheumatic Heart Disease
  • Pericarditis

73
Infective Endocarditis
  • Infection of the endocardium of the heart
  • Etiology
  • Aging process
  • IV drug cocaine abusers
  • Clients who have had valve replacements
  • Recent dental or surgical procedures
  • Signs and Symptoms
  • Flu like Symptoms
  • 80 develop either aortic or mitral valve murmurs
  • Diagnostics
  • Blood Cultures
  • Cultures should be done prior to antibiotic
    administration
  • New or changed murmur
  • Treatment Prophlatic antibiotics prior to dental
    or surgical procedures

74
Myocarditis
  • Inflammation of the myocardium
  • Due to infection, radiation, meds
  • Most common viruses (flu)
  • Associated with acute Pericarditis
  • SS are benign to severe heart involvement, even
    sudden death
  • Cardiac involvement can be seen 7-10 days after
    viral infection

75
Myocarditis (contd)
  • SS Pleuritic Chest pain, friction rub, S3,
    crackles,
  • JVD
  • Diagnosis ECG Lab findings are vague
  • Biopsy most diagnostic
  • Goal Manage the symptoms of poor cardiac
    function
  • Tx Oxygen, Rest, restricted activity, Digoxin
  • Nursing Mgt monitor tx for CHF

76
Rheumatic Fever
  • Inflammation that can affect up to all three
    layers of the heart
  • May or may not cause permanent structural damage
    to the heart
  • Occurs 2-3 weeks after Strept infection
  • Other contributing Factors
  • Lower socioeconomic groups (overcrowding)
  • Familial tendencies
  • Altered Immune response

77
Diagnosing Rheumatic Fever
  • No single test
  • Throat cultures are usually negative by the time
    the individual seeks medical care
  • CRP and ESR are indicating systemic
    inflammation
  • ? WBC, Fever
  • Echo valve insufficiency and pericardial fluid
  • CXR enlarged heart if CHF is present
  • Tx Antibiotics, NSAIDS, cortcosteroids

78
Rheumatic Heart Disease
  • Chronic Condition
  • Results from scarring and deformity of the heart
    valves
  • Term used to signify when damage has occurred to
    the heart from Rheumatic Fever

79
Pericarditis
  • An inflammation or alteration of the pericardium
  • Signs and Symptoms
  • Pain usually sharp stabbing, but can be dull
    ache is minority of cases
  • Pain that radiates to shoulder or back
  • Pain aggravated by breathing
  • Pain aggravated by lying down
  • Slow shallow breaths
  • Pericardial friction rub on auscultation
  • ST segment elevation in all 12 Leads

80
Treatment of Pericarditis
  • Identify and treat the underlying problem
  • NSAIDS
  • ASA
  • Rest
  • Overbed table for leaning forward
  • Corticosteroids
  • Antibiotics if bacterial
  • Pericardiocentesis if there is an ? in fluid
    between the layers of the pericardial sac
  • Watch for arrhythmias, pneumothorax

81
Complications
  • Pericardial Effusion
  • Distant heart sounds
  • Cough, dyspnea, tachypnea
  • Cardiac Tamponade
  • Agitation, confusion, restlessness
  • Tachycardia, tachypnea
  • Distended neck veins

82
Pericardial Effusion
  • When the pericardium becomes inflamed, sometimes
    the fluid between the two layers will increase
    causing a Pericardial Effusion
  • MayoClinic (2005)

83
Cardiac Tamponade
84
Clinical Signs of Tamponade
Becks Triad Tachycardia Hypotension (although
could be normal) Narrowed Pulse Pressure
85
Treatment of Pericardial Effusion or Cardiac
Tamponade
  • Pericardiocentesis

86
Valvular Heart Disease
87
Understanding Terms
  • Stenosis Constriction or narrowing of orifice
  • Regurgitation Retrograde of the flow of blood
    from one chamber back into another
  • Prolapse valve leaflets billow back or buckle
    back into the atrium

88
Mitral Stenosis
  • Mitral valve becomes narrow and constricted
  • Causes ? L. Atrial pressure and volume
  • Most are due to Rheumatic Heart disease
  • Symptoms murmur at 5th ICS
  • Extended dyspnea and fatigue

89
Mitral Valve Prolapse
  • Valve billows back into L. Atrium
  • Cause is unknown
  • Heard as a murmur
  • Can be familial due to connective tissue disorder
  • Most people asymptomatic, benign
  • Most common valve disorder
  • May lead to Mitral Valve Regurgitation
  • Diagnosed by ECHO

90
Mitral Regurgitation
  • Retrograde blood flow from L. Ventricle to L.
    Atrium
  • Etiology R/T MI, Rheumatic heart disease, MVP
  • Symptoms R/T acute or chronic murmur
  • Heard best at 5th ICS
  • May feel a thrill
  • More common in women than men

91
Valvular Regurg - picture
92
Aortic Stenosis
  • Blood flow restricted from L. Ventricle to Aorta
  • Results in LVH, ?myocardial oxygen consumption
  • Causes congenital, Rheumatic Fever,
    atherosclerosis
  • Symptoms - ? S1 or S2 sound
  • Murmur
  • S4

93
Aortic Regurgitation
  • Retrograde blood flow from the Ascending Aorta
    into L. Ventricle
  • Results in L. Ventricle dilation LVH, leading
    to ?contractility of the heart
  • murmur
  • Soft S1, S3 or S4
  • Causes Congenital, Rheumatic Heart Disease
  • May have Orthopnea, Exertional dyspnea,
    paroxysmal nocturnal dyspnea

94
Tricuspid Valve Disease
  • Stenosis Regurgitation
  • Tricuspid Stenosis is uncommon
  • R. Atrium enlargement ?systemic venous pressure
  • Tricuspid Regurgitation
  • Volume overload in R. Atrium and Ventricle occurs
  • Causes R. Ventricular dysfunction, or pulmonary
    HTN

95
Diagnosing Valve Disease
  • History and Physical Exam
  • Echocardiography
  • Cardiac Catheterization
  • ECG

96
Collaborative Care for Valvular Disease
  • Ask about history of Rheumatic Heart Disease
  • Use of antibiotic prophylaxis
  • Digitalis
  • Diuretics
  • Anticoagulation (ASA, Coumadin)
  • Surgical repair or replacement

97
Nursing Management/Goals
  • Maintaining normal cardiac function
  • Monitoring Cardiac output, fluid volume excess
  • Improving activity tolerance
  • Educating patients on the disease process and
    preventative measures

98
Mitral Valve repair
99
Valve Replacement
  • Mechanical/Biologic
  • Antibiotics
  • Lifelong anticoagulation therapy
  • mechanical
  • Good oral hygiene
  • Prevent infections

100
Cardiovascular Interventions
101
Synchronized Cardioversion
102
Procedure Requirements
  • Consent
  • Conscious sedation , Propofol/Diprivan
  • 50 -100 joules initially
  • Usually performed in procedure room/cath lab
  • Can be performed in ER/ICU/Step-down unit/PCU

103
Defibrillation
  • Treatment for Pulseless Ventricular Tachycardia
    Ventricular Fibrillation
  • Defibrillator 2 Types
  • Monophasic delivers energy in one direction
  • 360 joules
  • Biphasic delivers energy in two directions
  • 150 or 200 joules

104
Percutaneous Transluminal Coronary Angioplasty
(PTCA)/Stent
  • Previously discussed under diagnostic cardiac
    cath
  • An invasive but technically nonsurgical technique
  • Used to reduce frequency and severity of chest
    discomfort for clients with angina
  • Also used with client with an evolving acute MI
    to reperfuse myocardium

105
PTCA(cont)
  • Catheter is introduced through a guide wire
  • Balloon is inflated to compress plaque
  • Success rate can be as high as 90 upon initial
    reopening

106
Balloon Angioplasty - picture
107
Blockages - picture
108
Stents
109
(No Transcript)
110
Coronary Artery Bypass Graft Surgery (CABG)
  • Most common type of Cardiac Surgery
  • Occluded coronary arteries are bypassed with
    clients own blood vessels or synthetic grafts
  • Saphenous Vein66 patency rate _at_ 10 yrs
  • Internal Mammary Artery
  • Patency rate-90 _at_ 10 yrs

111
CABG (cont)
  • Pre-Op care
  • May be elective or emergency
  • Pre-Op teaching
  • Check administration of cardiac meds,
    anticoagulants
  • NPO after midnight
  • Explain Post-Op procedure
  • Teach Sternal Precautions

112
Cardiac Bypass- picture
Harvested vessels are connected to the blocked
arteries. Several medical centers are now
offering minimally invasive coronary artery
surgery. Less invasive technique for 1 or 2
clogged arteries.
113
Cardiac bypass - picture
114
CABG (cont)
  • Post-Op ICU for at least 24 hours
  • Monitor for arrhythmias
  • Monitor Vital Signs and Electrolytes
  • Emotional status
  • Discharge Planning and teaching

115
Intra-Aortic Balloon Pump
  • Purpose Provides temporary circulatory
    assistance to a compromised heart
  • Indications
  • Cardiac Bypass surgery
  • Acute Myocardial infarction with complications
  • Awaiting cardiac transplantation
  • Effects
  • Increased coronary perfusion
  • Improved oxygen delivery
  • Decreases anginal pain
  • Decreases Afterload
  • Decreases Preload
  • Increases Stroke Volume
  • Facilitates left ventricular emptying

116
Intra-Aortic Balloon Pump Procedure
  • Catheter is inserted into femoral artery
  • Advanced into descending Aorta
  • Balloon inflates during Diastole
  • Balloon deflates during Systole

117
Intraaoritc pump
118
Ventricular Assist Devices(VAD)
  • Purpose Provides longer term support for a
    decompensated heart
  • Assist or replace the action of the ventricle
  • May be implanted or external
  • Indications
  • Ventricular failure associated with an MI
  • Waiting for a donor or artificial heart

119
Pacemakers
  • Triggers electrical activity.
  • Used in place of SA node
  • Permanent or Temporary
  • Single and Dual Chamber Permanent Pacemakers
  • Atrial or Ventricular single chamber
  • Atrial and Ventricular dual chambers (AV)
  • CRT pacing technique that paces both ventricles
  • Malfunctions can occur
  • -R/T sensing or capture

120
Pacemaker Malfunction
121
Pacemaker Malfunction
122
Indications for Permanent pacing
  • Symptomatic Brady arrhythmias
  • Sick Sinus Syndrome
  • Third Degree Heart Block
  • Tachy arrhythmias
  • Chronic A-Fib with a slow Ventricular rate
  • See Table 35-10

123
Care and Considerations
  • Keep incision w/ staples dry
  • No pushing, pulling, lifting or raising arm for 2
    weeks
  • Encourage use of sling
  • Watch for s/s of infection
  • Keep wallet card
  • Avoid large electrical generators,
  • and large magnets like MRI
  • Teach pulse taking daily with log daily till MD
    visit

124
Pacemaker Insertion
125
Types of Pacemakers
126
External Pacemaker
  • Indications
  • Used for Temporary pacing
  • Pt waiting for permanent pacemaker surgery
  • Post CABG surgery using Epicardial pacing wires
  • Post MI
  • See Table 35-11

127
Internal Automated Defibrillators
128
AICD
129
AICDs
  • Treats life threatening arrhythmias
  • Detects abnormally fast rhythm and deliver small
    electrical charge to convert the heart into a
    normal rhythm.
  • Leads placed via sub-clavian catheter into
    endocarium

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Patient Teaching
  • Lie down when it fires
  • If pt. loses consciousness, call 911
  • Airport security should be alerted
  • Do not allow for wanding to go over the site

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Artificial Airways
  • Oral or nasal ET (endotracheal tube) intubation
  • Indications
  • Airway obstruction
  • Respiratory distress
  • Ineffective clearance of secretions
  • High risk for aspiration
  • Insertions
  • Physician (ED or Pulmonologist)
  • Credentialed Respiratory Therapist

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ET Tubes
  • Oral
  • Nasal

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Goal of Mechanical Ventilation
  • ? Work of breathing
  • Assure patient comfort
  • Patient breathing works with ventilator not
    against
  • Maintain adequate oxygenation
  • Protect the airway

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Nursing Responsibilitiesfor Mechanical
Ventilation
  • Maintain correct tube placement
  • Checked every 2-4 hours
  • Ascultates for bilateral breath sounds
  • Maintain proper cuff inflation
  • Maintains at 20-25mm Hg
  • Monitor oxygenation and ventilation
  • Assess clinical data for ABGs, SpO2
  • Assess for S/S of hypoxemia
  • Confusion, anxiety, arrhythmias and dusky skin
    color)
  • Assess for complications
  • Maintain tube patency
  • Open or Closed suctioning
  • Provide oral care
  • Maintain skin integrity
  • Watch for skin breakdown on the face and lips
  • Provide skin care daily and re-tape and secure ET
    tube

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The Ventilated Patient
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Ventilators
  • Not a cure but a means to support patient
    breathing
  • Negative pressure
  • Positive Pressure most common for acutely ill
    patients
  • Several manufacturers
  • Several types/modes
  • Controlled
  • Assist-controlled
  • Intermittent
  • Positive End-Expiratory (PEEP)
  • CPAP
  • High frequency/flow
  • Process for weaning and extubation

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Considerations for Mechanical Ventilation
  • Consider the implications for short term-versus
    long-term need
  • What is the long term goal for the patient/family
  • Is the patient needing ventilation for acute
    reasons or for a chronic illness/disease
  • Patients and families should discuss the
    implications for removal of ventilation support

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Remote Intensive Care Units
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Resources
  • www.theheart.org
  • www.societyofcriticalcaremedicine.org
  • www.guoideline.gov
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