The Client with Alterations in Cardiac Output

1
The Client with Alterations in Cardiac Output

• Lecture
• 9/26/05
• Sherry Burrell, RN, MSN
• Rutgers University
• Nursing III

2
Assessment Parameters

• Cardiac Output
• Measures the effectiveness of the hearts 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

3
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)

4
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.

5
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
• Circulating volume
• Body positioning
• Atrial systole or kick
• Medications
• Diuretics (i.e. Lasix)
• ACE Inhibitors (i.e. Vasotec)
• I.V. Fluids

Starling Curve
6
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 )

7
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

8
CO SV x HR

• Heart Rate beats per minute (bpm)
• ? HR ? CO (to a point)
• HR gt160 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

9
Assessment Considerations

• General Cardiac Symptoms
• Fatigue
• Chest pain or discomfort
• Palpitations
• Shortness of breath
• Edema
• Weight gain
• Dizziness
• Syncope, loss of consciousness

10
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 !!

11
Laboratory Analysis

• Serum Enzymes
• Blood Chemistry
• Lipid Studies
• Electrolytes
• Renal Function Studies
• Coagulation Studies
• Hematologic Studies

12
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

13
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 RBCs) Not frequently used
  today.
• Elevates in 1 to 3 days
• Peaks in 2 to 5 days
• Returns to normal 10 to 14 days

14
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 clients who delay seeking
  treatment.

15
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)

16
Blood Chemistry Analysis

• Lipoprotein (Lipid) Profile
• Total Cholesterol
• Normal lt 200mg/dl
• Triglyceride
• Normal lt 150 mg/dl
• Low Density Lipoproteins (LDL)
• Normal lt130 mg/dl / Optimal lt100mg/dl
• High Density Lipoproteins (HDL)
• Normal gt 40 mg/dl
• gt 60 mg/dl cardio-protective

17
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

18
Diagnostic Testing

• Electrocardiography
• 12-Lead EKG
• Continuous bedside monitoring
• Ambulatory monitoring
• Stress Tests
• Thallium Scans
• Echocardiograms
• Cardiac Catheterizations

Previously Discussed
19
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

20
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

21
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

22
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

23
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

24
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

25
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

26
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

27
Cardiac Catheterization Cont.,

• Post-Procedure Nursing Care
• Maintain Client Bedrest for 6 to 8 hours
• Extremity straight HOB up lt 30 degrees
• Maintain Adequate Hydration
• IV Fluids (if ordered)
• Encourage Fluids
• Frequent Monitoring For Complications
• Vital signs
• Puncture site
• Distal pulses
• Laboratory results

28
The Client with Alterations in Cardiac Output

• Lecture II
• 9/30/05
• Sherry Burrell, RN, MSN
• Rutgers University
• Nursing III

29
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.

30
Coronary Artery Disease Cont.,

• Basis of CAD Management
• Framingham Study (1948- cont. today)
• Identified specific risk factors and life-style
  habits that increase ones risk for developing
  atherosclerotic heart disease.

31
CAD Risk Factors

• Modifiable
• Cigarette smoking
• Hypertension (HTN)
• Hyperlipidema
• Physical inactivity
• Diabetes Mellitus
• Obesity
• Stress / Anxiety
• Diet

• Non-Modifiable
• Increasing Age
• Males gt45 years old
• Females gt55 years old
• Gender
• Affects both men and women 1 killer is U.S.
• Genetics
• Strong genetic component
• Ethnicity
• Non-whites increased incidences versus whites

32
CAD Interventions

• Smoking Cessation
• Diet
• Exercise
• Weight Management
• Cholesterol Management
• Lipid Profile
• Normal every five years
• Medications
• i.e Zocor, Crestor Niaspan

• HTN Management
• BP Screenings
• Medications
• i.e. antihypertensives diuretics.
• Diabetes Management
• Blood glucose testing
• Medications
• i.e. oral hypoglycemics insulin

33
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

34
Myocardial Oxygen Supply and Demand Balance
Demand
Supply
O2
O2


Preload
Afterload
Arterial Oxygen Content
Coronary Artery Blood flow
Heart Rate
Contractility
35
Precipitating Factors Angina

• Any situation where oxygen demands are increased
• Physical exertion
• Tachycardia
• Dysrhythmias
• Cold weather
• Eating a heavy meal
• Stress or emotional states

36
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

37
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

38
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

39
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

40
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)

41
Management of Unstable Angina
?Demand
?Supply
O2

• ?Contractility
• HR
• ? Afterload

O2
? Preload
NTG ACE I Morphine
Beta Blockers Ca Channel Blockers ACE I
? Blood Flow
Open Occluded Arteries
NTG Ca Channel Blockers ASA Anticoagulants Morphin
e
PCI
42
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

43
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
44
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 Myocardial Infarction
Unstable Angina
45
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

46
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.

47
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

48
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.

49
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

50
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
• PACs or Atrial fibrillation common
• Ventricular
• PVCs and ventricular tachycardia (VT)
• AV Heart Blocks
• Most common with inferior wall MI

51
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

52
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.

53
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

54
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

55
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 gt30 minutes
• lt 12 hours from onset (many institutions lt 6
  hours)
• Positive EKG changes
• CP unrelieved with medical therapies (i.e. NTG)

56
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

57
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)

58
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

59
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

60
PCI Cont.,

• Post-Procedure Nursing Care
• Maintain Client Bedrest for 6 to 8 hours
• Extremity straight HOB up lt 30 degrees
• Maintain Adequate Hydration
• IV Fluids (if ordered)
• Encourage Fluids
• Frequent Monitoring For Complications
• Vital signs
• Puncture site
• Distal pulses
• Laboratory results

61
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
62
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

63
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

64
Cardiac Surgery CABG

• Complications
• Stroke (2 post-bypass reperfusion)
• Hypertension
• Hypotension
• Bleeding
• Dysrhythmias
• Cardiac Tamponade

65
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

66
Management of an Acute MI
?Demand
?Supply
O2

• ?Contractility
• HR
• ? Afterload

O2
? Preload
NTG ACE I Morphine
Beta Blockers Ca Channel Blockers ACE I
Open Occluded Arteries
? Blood Flow
NTG Ca Channel Blockers ASA Anticoagulants Morphin
e
PCI Thrombolytics CABG
67
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

68
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

69
The Client with Alterations in Cardiac Output

• Lecture III
• 10/10/05
• Sherry Burrell, RN, MSN
• Rutgers University
• Nursing III

70
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

71
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)

72
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

73
Invasive Hemodynamic Monitoring Cont.,

• Calibration of Equipment
• Leveling
• Transducer at the
  level of right atrium
• Zeroing
• Atmospheric pressure

• Lets see how its done

http//www.eonreality.com/demos/e-learning/ccn/uni
t3_4demo/e2_electdemo.html
74
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 ABGs
• Considered low-risk
• More accurate than cuff pressures in low CO and
  shock (not affected by vasoconstriction)
• NEVER USED TO GIVE MEDICATIONS !!

75
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
• Allens Test

76
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

77
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

78
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

79
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 !!

80
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)

81
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

82
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

83
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 !!

84
Heart Failure

• The inability of the heart to pump adequate
  amounts of blood to meet bodys needs for oxygen
  nutrients.
• Common causes
• CAD
• HTN
• Cardiac Infections
• Cardiomyopathy
• Valvular Disorders
• Myocardial Infarction
• Dysrhythmias

85
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

86
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

87
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)

88
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 !!

89
Myocardial Disease / Injury Impaired Ventricular
Performance

• Cardiac
• Output

• Cardiac
• Workload

Vicious Cycle of Heart Failure

• ? SNS
• ? HR
• ? Contractility
• Vasoconstriction

Ventricular Remolding Dilation Hypertrophy
? RAAS Vasoconstriction Na/H2O Retention
90
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 (lt 40)
• Combined diastolic systolic impairments are
  common.

91
Systolic Diastolic Heart Failure Remodeling
(Jessup Brozena, 2003)
92
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.

93
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.

94
AHA/ACC Classification System of HF
(Jessup Brozena, 2003)
95
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.

96
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.

97
Nursing Management Heat Failure

• Nursing Considerations
• Respiratory
• Supplemental oxygen
• Good lung assessment
• Monitoring
• Hemodynamic Monitoring
• Daily Weights
• I Os
• Laboratory Results
• i.e. electrolytes, BNP digoxin levels
• Maintain
• Small frequent meals low in salt
• Skin integrity

98
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

99
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 / ARBs ?Preload ?Afterload
• Beta blockers / ACE I Enhance reverse remolding
• Increase Positive Inotropic Effects
• i.e. Digoxin (Lanoxin)

100
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

101
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

102
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 !!

103
Complications of Heart Failure

• Electrolyte Imbalances
• i.e. Hypokalemia
• Medication Toxicity
• i.e. Digoxin
• Dysrhythmias
• Cardiac Tamponade
• Cardiogenic Shock
• Pulmonary Edema

104
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