Adult Health Nursing II
Block 7.0
Topic:
Cardiovascular Nursing
& EKG Monitoring, part 1
Module: 2.2
It’s All About
Cardiac Output
Cardiovascular Nursing
Selected Topics PT 1
Block 7.0
Module 2.2
Learning Outcomes
a.k.a. “What’s On the Test?”
• See the Study Guides!
• Setting the Stage / Context for Cardiac
Monitoring & EKGs
• AAA
• “It’s All About Cardiac Output”—EKGs
• Cardiac Monitoring: Selected
Dysrhythmias, Recognition, Assessment,
Nursing Interventions,
Block 7.0
Module 2.2
Selected Topics in Cardiovascular Nursing_____
ASSESSMENT
Physical Assessment
Inspection
Palpation
Percussion
Auscultation
Cardiac Monitoring
Lab Monitoring
PATHOPHYSIOLOGY
Myocardial Infarction
Acute Coronary Syndrome
Valvular Heart Disease
Pacemakers
CABG
Abdominal Aortic Aneurysm
Pericarditis
Peripheral Vasc Disease (PVD)
Fem-Pop Bypass Graft
Shock / Fluid Deficit
Raynaud’s Phenomenon
Arrhythmias / Dysrhythmias
Care Planning
PHARMACOLOGY
Cardiac Glycosides
ACE Inhibitors
Beta Blockers
Antiarrhythmics
Catecholamines
Anticoagulants
Nursing Interventions & Evaluation
Execute the care plan, evaluate for
Efficacy, revise as necessary
Plan for client adl’s,
Monitoring, med admin.,
Patient education, more…
Block 7.0
Module 2.2
Remember: It’s All About
C.O.
= Heart
Rate
x= Stroke
Cardiac
Output
HR XVolume
SV
Block 7.0
Module 2.2
*More about this in Adult Health II
What Factors
Affect
Cardiac Output ?
It’s All About…
C.O.
= Heart
Rate
x= Stroke
Cardiac
Output
HR XVolume
SV
Block 7.0
Module 2.2
*More about this in Adult Health II
What Factors
Affect
Cardiac Output ?
It’s All About…
Sympathetic
Nervous
System (+)
C.O.
= Heart
Rate
x= Stroke
Cardiac
Output
HR XVolume
SV
Parasympathetic
Nervous
System (-)
Block 7.0
Module 2.2
*More about this in Adult Health II
What Factors
Affect
Cardiac Output ?
Baroreceptors
It’s All About…
Sympathetic
Nervous
System
Chemoreceptors
C.O.
= Heart
Rate
x= Stroke
Cardiac
Output
HR XVolume
SV
Parasympathetic
Nervous
System
Block 7.0
Module 2.2
*More about this in Adult Health II
What Factors
Affect
Cardiac Output ?
Baroreceptors
It’s All About…
Sympathetic
Nervous
System
Blood
Volume
Chemoreceptors
C.O.
= Heart
Rate
x= Stroke
Cardiac
Output
HR XVolume
SV
Blood
Volume
Viscosity
Of
Blood
Parasympathetic
Nervous
System
Block 7.0
Module 2.2
*More about this in Adult Health II
What Factors
Affect
Cardiac Output ?
It’s All About…
Medications
Baroreceptors
Sympathetic
Nervous
System
Medications
Blood
Volume
Chemoreceptors
C.O.
= Heart
Rate
x= Stroke
Cardiac
Output
HR XVolume
SV
Blood
Volume
Condition of
Heart
Valves
Parasympathetic
Nervous
System
Block 7.0
Module 2.2
*More about this in Adult Health II
Viscosity
Of
Blood
What Factors
Affect
Cardiac Output ?
It’s All About…
Medications
Baroreceptors
Sympathetic
Nervous
System
Medications
Blood
Volume
Chemoreceptors
Preload,
Afterload
C.O. =
Blood
Volume
Heart Rate
x
Stroke Volume
Parasympathetic
Nervous
System
Condition of
Cardiac
Conduction
System*
Block 7.0
Module 2.2
*More about this in Adult Health II
Condition
Of
Myocardium
Condition of
Heart
Valves
Viscosity
Of
Blood
What Factors
Affect
Cardiac Output ?
It’s All About…
Medications
Baroreceptors
Sympathetic
Nervous
System
Medications
Blood
Volume
Chemoreceptors
Preload,
Afterload
C.O. =
Heart Rate
x
Stroke Volume
And,
Many more
factors !
Blood
Volume
Parasympathetic
Nervous
System
Condition of
Cardiac
Conduction
System*
Block 7.0
Condition
Of
Myocardium
Condition of
It’sHeart
All
About
Valves
Cardiac Output !
Module 2.2
*More about this in Adult Health II
Viscosity
Of
Blood
Atrial Fibrillation
Complicated
Patient
Cardiovascular Nursing
Selected Topics PT 1
Block 7.0
Module 2.2
Page R. 78 y.o.
Sick Sinus Syndrome
S/P Pacemaker Insertion
Renee C. 29 y.o.
Pericarditis
Admission Pending
Pre-Op CABG
CARDIAC MONITORING
James H. 68 y.o.
R/O MI ,
Atrial Fibrillation
Haynes H. 55 y.o.
PVD
S/P Femoral-Popliteal Bypass
Kam H. 48 y.o.
AAA
Block 7.0
Module 2.2
V.S. &
Graphics
Treatments
I&O
Dr’s
Labs & Dx
Orders
Name: James H.
Patient
Record
Age: 68 y.o Male
Occupation: Architect
Adm: Date
DX: R/O MI, R/O CVA,
S/P CABG X 4 date
Name:
OTHER DX: DM, AAA,
PVD, Atrial Fibrillation
Consults
Assessments
History &
Physical
Block 7.0
James H.
Module 2.2
Reports
MISC
Nurse’s
Notes
M.A.R.
Dr’s Orders
1.
2.
3.
4.
5.
6.
Admit to Telemetry Unit; continuous cardiac monitoring
DX: R/O MI, R/O Embolic CVA
Activity: BR, BSC
Diet: Clear Liquids, adv as tol to 1500 calorie ADA Diet
FSBG q ac & hs with Moderate SSRI Coverage
Meds:
Humulin 70/30 35 units sq q am / 20 units sq q pm
Digoxin 0.250 mg po daily
Amiodarone 400 mg po bid
Colace 200 mg po daily
Heparin IV per weight-based protocol
NTG 0.4 mg sl q5 min x 3, PRN CP
Morphine SO4 2 mg IVP PRN CP
Lidocaine 2 mg / minute IV / continuous
7.
8.
What are your concerns about the
patient?
What is the cause of the concern?
What are you going to do about it?
What is the patient experiencing?
IV: Saline Lock
Labs / Diagnostics: Continue Serial Cardiac Enzymes; BMP q day; CBC; Coag
studies per heparin weight-based protocol; schedule for CT of brain
9. Telemetry Protocols; ACLS Protocols
10. Daily EKG; EKG with any chest pain
Block 7.0
Module 2.2
History & Physical
Admitted 2/10/2009 after c/o crushing, substernal chest pain rated as 9 on a scale of 1-10.
(Presented with Cardiac Rhythm as noted on ( ER rhythm strip #1 and ER rhythm strip #2 );
( later, developed (Rhythm strip #3) while being transported from the Emergency Department to
the telemetry unit.) Also was noted to have rhythm noted on Rhythm strip #4. Rhythm strip #5 is
attached for your enlightenment.
Client was successfully resuscitated, including use of ACLS protocols and
Defibrillation with 360 joules x 2. Converted to atrial fibrillation w/controlled ventricular response. After defibrillation and transfer to the nursing unit, pt exhibited s/s
disorientation-see Rhythm Strip #6.
Five hours after admission to the telemetry floor, became agitated and c/o (R)-side chest pain:
See Nurse’s Notes.
Surgical history includes 4 vessel CABG in 1/2008; PTCA with 3 stents in
2002; Laparascopic Cholecystectomy in 1999.
Other pertinent Medical History includes diagnosis of DM in 1990; blood sugars controlled
moderately well with Humulin 70/30 35 units q am / 20 units q pm. Long history of atrial fibrillation
with concomitant control via digoxin 0.25 mg daily.
Block 7.0
Module 2.2
RHYTHM STRIP #1  The Patient
airway, breathing, LOC
Block 7.0
Module 2.2
Awake and alert;
BP= 112/72
RHYTHM STRIP #2
Awake & Alert
C/O Chest Pressure
and Feeling Nervous
BP = 106/68
 Check The Patient
airway, breathing, LOC
Block 7.0
Module 2.2
RHYTHM STRIP #3
 The Patient
Awake and alert; BP= 88/40
C/O “Feeling Funny”
airway, breathing, LOC
Block 7.0
Module 2.2
RHYTHM STRIP #4
NON-RESPONSIVE
BP=
 The Patient (!)
airway, breathing, LOC
CO = HR&R x SV
Block 7.0
BP = CO x SVR
Module 2.2
RHYTHM STRIP #5
 The Patient (!)
Airway, breathing, LOC
AWAKE & ALERT
BP = 112/78
CHEST LEAD RECONNECTED
(It fell off…)
(Oops, MY BAD!)
TREAT THE PATIENT, NOT
THEModule
MONITOR
!
Block 7.0
2.2
RHYTHM STRIP # 6
BP = 112/72
Speech slurred
(Check cranial nerves)
 The Patient
airway, breathing, LOC
II
III
IV
V
VI
VII
IX, X
Optic
Oculomotor
Trochlear
Trigeminal
Abducens
Facial
Glossopharyngeal
Vagus
Block 7.0
Module 2.2
Nurse’s Notes
What are your concerns about the patient?
What is the cause of the concern?
What are you going to do about it?
What is the patient experiencing?
SEE CONCEPT MAP
0700: Unable to initiate additional peripheral IV line, attempts x 3. VS: P=90,
irregular; R=22, unlabored; BP= 118/78; SaO2=95%. Monitor displaying
atrial fibrillation with occasional PVC. Physician notified re: IV; will continue
Lidocaine gtt @ 2 mg/min per available site on (L) forearm; Heparin infusion per
WBP on hold until additional IV site accessed. Consult for central line placement
pending.------------------------------------------------------------------------------J. Nurse, RN
0900: C/O sharp pain, pointing to area (R) thorax; became agitated and disoriented . VS: BP = 90/50; P = 110, irregular; R = 32, labored; T =98*;
SaO2 = 86 %. ABG’s obtained, results pending. O2 increased to 4L/NC.
Note absent breath sounds, RLL;Cardiac monitor: Atrial fibrillation w/ rapid
ventricular response. Physician notified and enroute to hospital. Will continue
to Monitor.---------------------------------------------------------------------------J. Nurse, RN
0920: Non-responsive; VS: BP = 80/40, P = 156, irreg, R = 10,
SaO2 = 80%; central cyanosis noted. Intubated and ventilated with 100% 02.
Absent lung sounds RLL & RML. Cardiac monitor shows atrial fibrillation w/
uncontrolled ventricular response. Report provided to ICU nurse,
7.0 Module 2.2
Transported via gurney to ICUBlock
for ventilator
support.-----------------------J. Nurse, RN
NSG DX #1:
PAIN, ACUTE
NSG DX #3:
Ineffective Tissue
Perfusion, Cerebral
NSG DX #2:
Ineffective Tissue
Perfusion, Cardiopulmonary
KEY ASSESSMENTS
PAIN
VS
O2 Sats
ABG’s
LOC
Cranial Nerve Assmt
Capillary Refill
Breath Sounds
Swallowing / Gag Reflex
MED DX:
MI
Atrial Fib
CVA
PE
CONCEPT MAP
James H.
Block 7.0
Module 2.2
NSG DX #4:
Impaired Gas
Exchange
Other Nursing DX:
4. Decreased Cardiac Output
5. IMPAIRED SWALLOWING
6. RISK for INJURY
7. Self-Care Deficit
8. Impaired Communication
Abdominal
Aortic
Aneurysm
Block 7.0
Module 2.2
Cardiovascular
Nursing Selected
Topics PT 2
AAA
Patient
Record
NAME: Kam H.
AGE: 48 y.o.
OCCUPATION: Attorney
ADM:
DX: AAA
Pre-Op: AAA Repair
NAME: Kam H.
Block 7.0
Module 2.2
AAA
Abdominal Aortic Aneurysm
S/S
FREQUENTLY: ASYMPTOMATIC
Gnawing, constant, abdominal, flank, and
groin pain
Pulsating abdominal mass
Bruit
RUPTURE
Sudden onset “tearing,” “ripping,” or
“stabbing” abdominal or back pain
Shock (Hypovolemic)
GRAFT OCCLUSION
Changes in Pulses
Coolness & cyanosis of extremities below
graft
Severe Pain
Decreased Urine Output
Block 7.0
Module 2.2
AAA Procedure
Block 7.0
Module 2.2
AAA
Block 7.0
Module 2.2
Nursing Care:
AAA Repair
NSG DX
#1:
Fear /
Anxiety
KEY
ASSESSMENTS?
?
?
?
Abdominal Aortic
Aneurysm
(Pathophysiology)
Block 7.0
Module 2.2
Other Nursing
Diagnoses That May
Apply:
?
AAA: Pathophysiology
•
An abdominal aortic aneurysm is an
abnormal dilation of the wall of the
abdominal aorta. The aneurysm usually
develops in the segment of the vessel that is
between the renal arteries and the iliac
branches of the aorta. The most common
cause of an abdominal aortic aneurysm is
atherosclerosis. The plaque that forms on
the wall of the artery causes degenerative
changes in the medial layer of the vessel.
These changes lead to loss of elasticity,
weakening, and eventual dilation of the
affected segment. Some other causes of
abdominal aortic aneurysm include
inflammation (arteritis), trauma, infection,
congenital abnormalities of the vessel, and
connective tissue disorders that cause
vessel wall weakness.
Ulrich & Canale: (2006)
Nursing Care Planning Guides:
For Adults in Acute, Extended, and Home Care Settings, 6th
Edition7.0
Block
•
•
Most abdominal aortic aneurysms are
asymptomatic and are discovered during a
routine physical examination (signs include
palpation of a pulsatile mass in the abdomen
and/or auscultation of a bruit over the
abdominal aorta) or during a review of x-ray
results of the abdomen or lower spine. The
presence of symptoms such as mild to
severe abdominal, lumbar, or flank pain
and/or lower extremity arterial insufficiency
is usually indicative of a large aneurysm that
is exerting pressure on surrounding tissues
or an aneurysm that is leaking.
Surgical repair of an aneurysm is usually
performed if the aneurysm is growing rapidly
and/or reaches a size of 5-6 cm or larger or
if the client experiences symptoms. The
procedure often involves the use of a
synthetic graft, which is inserted to replace
or support the weakened vessel.
Module 2.2
NURSING DIAGNOSIS: Fear/Anxiety
related to:
•
•
•
•
•
•
1. unfamiliar environment and
separation from significant
others;
2. lack of understanding of
diagnostic tests, surgical
procedure, and postoperative
care;
3. anticipated loss of control
associated with effects of
anesthesia;
4. risk of disease if blood
transfusions are necessary;
5. anticipated postoperative
discomfort and potential
change in sexual functioning;
6. possibility of death.
Block 7.0
•
Desired Outcome
The client will experience a reduction
in fear and anxiety
Nursing Actions and Selected
Purposes/Rationales
1. Preoperative Care Plan, for measures related to
the assessment and reduction of fear and anxiety.
2. Implement additional measures to reduce fear
and anxiety:
a. orient client to critical care unit if appropriate
b. describe and explain the rationale for
equipment and tubes that may be present
postoperatively (e.g., cardiac monitor, ventilator,
intravenous and intra-arterial lines, nasogastric
tube, urinary catheter)
c. explain that B/P may be taken in both arms
and thighs in order to better evaluate circulatory
status
d. reinforce physician's explanations and clarify
misconceptions client has about effects of the
surgery on sexual functioning (impotence can result
from diminished blood flow in the mesenteric or
internal iliac arteries during or after surgery and/or
from nerve damage during surgery).
Module 2.2
COLLABORATIVE DIAGNOSIS:
Potential complication: hypovolemic shock
R/T related to excessive blood loss if the
aneurysm ruptures.
• Desired Outcome:
The client will not
develop hypovolemic
shock as evidenced
by:
1. usual mental status
2. stable vital signs
3. skin warm and usual color
4. palpable peripheral pulses
5. urine output at least 30
ml/hour.
Block 7.0
• NURSING ACTIONS:
• (next page)
Module 2.2
Nursing Actions and Selected Purposes/Rationales
•
1. Assess for and immediately report
signs and symptoms of conditions that
indicate impending aneurysm rupture:
•
A. Leaking aneurysm:
a. increasing abdominal girth
b. ecchymosis of flank area or perineum
c. frank or occult gastrointestinal bleeding
(occurs if the aneurysm ruptures into the
duodenum)
d. decreasing RBC, Hct, and Hgb levels
e. new or increased reports of lumbar, flank,
abdominal, pelvic, or groin pain (accumulation of
blood in the peritoneum and/or retroperitoneal
spaces causes irritation of and pressure on the
tissues and nerves)
f. diminishing or absent peripheral pulses
g. further decline in thigh B/P as compared with
B/P in arm (thigh B/P is usually slightly lower than
B/P in arm of a client with an abdominal aortic
aneurysm)
Block 7.0
•
B..Expanding aneurysm:
a. new or increased reports of lumbar, flank, or
groin pain (results from pressure on lumbar nerves)
b. increased size of pulsating mass in abdomen
c. increasing sense of abdominal and/or gastric
fullness (results from pressure on duodenum)
d. decreasing motor or sensory function of lower
extremities (results from pressure on lumbar and/or
sacral nerves).
•
C. Assess for and report signs and symptoms
of hypovolemic shock:
a. restlessness, agitation, confusion, or other
change in mental status
b. significant decrease in B/P
c. postural hypotension
d. rapid, weak pulse
e. rapid respirations
f. cool skin
g. pallor, cyanosis
h. diminished or absent peripheral pulses
i. urine output less than 30 ml/hour.
Module 2.2
•
D. Implement measures to decrease risk of
aneurysm rupture:
a. instruct client to avoid elevating legs when in
bed, using knee gatch, and crossing legs in order to
prevent restriction of blood flow to the lower
extremities and subsequent increase in vascular
pressure at the aneurysm site
b. perform actions to prevent an increase in
blood pressure:
c. limit client's activity as ordered
d. nstruct client to avoid activities that create a
Valsalva response (e.g., straining to have a bowel
movement, holding breath while moving up in bed,
lifting heavy objects)
Block 7.0
•
E. implement measures to reduce fear and
anxiety (see Preoperative Diagnosis 1)
•
F. administer antihypertensives if ordered to
reduce pressure in the dilated vessel.
•
G. If signs and symptoms of hypovolemic
shock occur:
•
a. place client flat in bed unless contraindicated
b. monitor vital signs frequently
c. administer oxygen as ordered
d. administer blood and/or volume expanders as
ordered (these need to be used with caution since
increased vascular pressure can extend a tear at
site of rupture)
e. prepare client for insertion of hemodynamic
monitoring devices (e.g., central venous catheter,
intra-arterial catheter) if indicated
f. prepare client for emergency surgical repair of
aneurysm if indicated.
Module 2.2
NURSING DIAGNOSIS:
Risk for imbalanced fluid and electrolytes
•
Third-spacing of fluid related to:
•
1. increased capillary permeability in
surgical area associated with the
inflammation that occurs following extensive
dissection of tissue during major abdominal
surgery
•
•
2. increased vascular hydrostatic pressure
associated with excess fluid volume if
present
3. hypoalbuminemia associated with the
escape of proteins from the vascular space
into the peritoneum (a result of increased
capillary permeability in the surgical area);
Block 7.0
•
Excess fluid volume related to:
•
1. vigorous fluid replacement
•
Fluid retention associated with:
•
1. increased secretion of antidiuretic hormone
(output of ADH is stimulated by trauma, pain, and
anesthetic agents)
2. renal insufficiency (can occur if there is
inadequate blood flow to the kidneys during or after
surgery)
3. reabsorption of third-space fluid (occurs about
the 3rd postoperative day);
•
•
•
Deficient fluid volume related to restricted oral
fluid intake before, during, and after surgery;
blood loss; and loss of fluid associated with
nasogastric tube drainage;
•
Electrolyte Imbalance: hypokalemia,
hypochloremia, and metabolic alkalosis related
to loss of electrolytes and hydrochloric acid
associated with nasogastric tube drainage.
Module 2.2
• Desired Outcome
The client will
experience resolution
of third-spacing as
evidenced by:
1. absence of ascites
2. B/P and pulse
within normal range
for client and stable
with position change.
Block 7.0
Module 2.2
Peripheral
Vascular
Disease
Block 7.0
Module 2.2
Cardiovascular
Nursing Selected
Topics PT 3
PVD
Patient
Record
NAME: Haynes H.
AGE: 55 y.o.
OCCUPATION: Registered Nurse
ADM: DX: Peripheral Vascular Dise
Procedure: Femoral-Popliteal
Bypass
NAME: Haynes H.
Block 7.0
Module 2.2
Peripheral Arterial Disease
• Pathophysiology
•
PAD results from atheroclerosis in the arteries of the lower
extremities, characterized by inadequate blood flow (ischemia).
• Intermittent Claudication:
pain caused by insufficient arterial blood supply
Block 7.0
Module 2.2
Block 7.0
Module 2.2
PTA :
Percutaneous
Transluminal
Angioplasty
An intraoperative photograph of a right femoral
to posterior tibial artery bypass using the greater
saphenous vein to correct peripheral arterial disease.
Block 7.0
Module 2.2
Nursing Considerations
Post Femoral-Popliteal Bypass
MEDS
• Hemorheologic Drugs: pentoxifyline (Trental) increases RBC
flexibility, decreases viscosity
• Antiplatelet Agents: ASA, clopidogrel (Plavix)
ASSESSMENT
• Pedal Pulses (palpated or Doppler)
• Color, temp., capillary refill, pain (warmth, redness, & edema
are EXPECTED OUTCOMES of the revascularlization).
COMPLICATIONS
• Graft Occlusion
• Compartment Syndrome
• Acute Arterial Occlusion
NOTIFY PHYSICIAN
NOTIFY PHYSICIAN
NOTIFY PHYSICIAN
THE 6 P’s of Ischemia:
PAIN, PALLOR, PULSELESSNESS, PARESTHESIA, PARALYSIS, POIKILOTHERMIA
Block 7.0
Module 2.2
PAD
• Buerger’s Disease
•
thromboangiitis obliterans
• Raynaud’s Disease
• Raynaud’s phenomenon
Block 7.0
Module 2.2
Pacemaker
Patient
Record
NAME: Page R.
AGE: 78 y.o.
OCCUPATION: Retired Teacher
ADM: DX: Sick Sinus Syndrome
Procedure: Pacemaker Insertion
today
Block 7.0
NAME: Page R.
Module 2.2
Cardiac Pacemakers
• Pathophysiology
• Nursing
Considerations
Block 7.0
Module 2.2
Block 7.0
Module 2.2
Cardiac Pacemakers
• IMMEDIATELY POST-OP:
• Monitor heart rate & rhythm
• Minimize shoulder movement
w/ sling for 24 hrs; Gentle
passive ROM after 24 hrs
Block 7.0
•
•
•
•
•
•
•
•
Indications:
Symptomatic bradycardia
Complete Heart Block
Sick Sinus Syndrome
Sinus arrest
Asystole
Atrial tachydysrhythmias
Ventricular
tachydysrhythmias
Module 2.2
Block 7.0
Module 2.2
Pacemaker Complications
• Failure to Capture—
Pacemaker initiates a stimulus, but depolarization of the
myocardium does not occur
Stimulation of Chest Wall or Diaphragm
Hiccoughs
Cardiac Tamponade
Block 7.0
Module 2.2
Pending Admission
PTCA
CABG
Patient
Record
NAME:
DX: CAD, 4-Vessel
Pre-Op: Coronary Artery
Bypass Graft (CABG)
Block 7.0
Module 2.2
PTCA &
CABG
Block 7.0
Module 2.2
Cardiovascular
Nursing Selected
Topics PT 5
Page R. 78 y.o.
Sick Sinus Syndrome
S/P Pacemaker Insertion
Renee C. 29 y.o.
Pericarditis
Admission Pending
Pre-Op CABG
CARDIAC MONITORING
James H. 68 y.o.
R/O MI ,
Atrial Fibrillation
Haynes H. 55 y.o.
PVD
S/P Femoral-Popliteal Bypass
Kam H. 48 y.o.
AAA
Block 7.0
Module 2.2
Pending Admission
PTCA
CABG
LVAD
Patient
Record
NAME:
DX: CAD, 4-Vessel
Pre-Op: Coronary Artery
Bypass Graft (CABG)
Block 7.0
Module 2.2
Left Ventricular Assist Device
(LVAD)
A left ventricular assist device (LVAD) is implanted under the skin via “open heart”
surgery. It helps pump blood from the left ventricle of the heart and on to the rest of the
body. A control unit and battery pack are worn outside the body and are connected to the
LVAD through a port in the skin.
This is a typically a temporary measure while the patient is awaiting a heart transplant,
though in some cases it may be used
for7.0
the long
term
Block
Module
2.2when the patient is not a good
heart transplant candidate.
Intra-Aortic Balloon Pump
IABP
•
The IABP can be used along with
interventional cardiology
procedures and medical therapy
(medications).
•
Indications for IABP use include:
•
Failure to wean from
cardiopulmonary bypass.
•
Cardiogenic shock.
•
Heart failure.
•
Acute heart attack.
•
Block 7.0
Support during high-risk
percutaneous transluminal
coronary
(balloon) angioplasty, and
Module
2.2
coronary stent placement.
IABP
•
•
•
•
The IABP is a polyethylene balloon
mounted on a catheter, which is
generally inserted into the aorta
through the femoral artery in the
leg.
The balloon is guided into the
descending aorta, approximately
2 cm from the left subclavian
artery.
At the start of diastole, the balloon
inflates, augmenting coronary
perfusion.
At the beginning of systole, the
balloon deflates; blood is ejected
from the left ventricle, increasing
the cardiac output by as much as
40 percent and decreasing the left
ventricular stroke work and
myocardial oxygen requirements.
Block 7.0
Module 2.2
PTCA
percutaneous transluminal coronary angioplasty
• Patient has had a
history of CAD for
several years.
• Underwent PTCA with
stent placement x 1
year ago
• Increasing angina
• PTCA last week
shows near occlusion
of four coronary
Block 7.0
arteries
Module 2.2
Block 7.0
Module 2.2
Nursing Care After PTCA
• Frequent assessment
• Monitor Cardiac
of affected leg for
Rhythm
tissue perfusion distal
• Maintain Bedrest for
to cath insertion site
Specified time
• Frequent assessment
of affected leg / groin
site for bleeding
Block 7.0
Module 2.2
•
The goal of treatment for heart
disease is to maximize cardiac
output.
•
Surgically this may be done by
improving myocardial muscle function
and blood flow through procedures
such as the traditional CABG (or via
less invasive procedures such as
MIDCAB, percutaneous
transmyocardial revascularization
[PTMR], and/or port access requiring
four small incisions under the left
breast), wrapping the latissimus dorsi
muscle around the heart, and/or repair
or replacement of defective valves.
Block 7.0
•
Of the three types of cardiac surgery—
(1) reparative (e.g., closure of atrial or
ventricular septal defect, repair of
mitral stenosis), (2) reconstructive
(e.g., CABG, reconstruction of an
incompetent valve), and (3)
substitutional (e.g., valve replacement,
cardiac transplant)—reparative
surgeries are more likely to produce
cure or prolonged improvement.
Module 2.2
Block 7.0
Module 2.2
•
•
An open heart bypass surgery is
performed under general
anesthesia, which requires that
the patient be on a ventilator
during surgery.
Surgery begins with harvesting the
blood vessels that will become the
grafts. The saphenous vein in the
leg is commonly used because it
is long enough to create multiple
grafts. If the saphenous vein
cannot be used, vessels from the
arm can be used instead. The left
internal mammary artery is used
for a single graft and is taken once
the chest is opened for surgery.
Block 7.0
•
Once the saphenous vein has
been recovered, the chest is
opened by making an incision
along the sternum, or breastbone.
The surgeon then cuts the
sternum, allowing the chest cavity
to be opened, giving the surgeon
access to the heart.
• In the traditional CABG procedure,
the heart is stopped with a
potassium solution so the surgeon
is not attempting to work on a
moving vessel, and the blood is
circulated by a heart-lung
machine. At this time the heartlung machine does the work of the
heart and the lungs, and the
Module 2.2
ventilator is not used.
•
•
The surgeon places the grafts,
either rerouting blood around the
blockage, or removing and
replacing the blocked vessel. The
amount of time on the heart-lung
bypass machine is determined by
the speed at which the surgeon is
able to work, primarily, how many
grafts are needed.
Once the grafts are complete, the
heart is started and provides blood
and oxygen to the body. The
sternum is returned to its original
position and closed using surgical
wire, to provide strength the bone
needs to heal, and the incision is
closed.
Block 7.0
Module 2.2
Coronary Artery Bypass Graft
CABG
Block 7.0
Module 2.2
Sternal Wires
Block 7.0
Module 2.2
Block 7.0
Module 2.2
Care Planning
• DISCHARGE GOALS
• NURSING
PRIORITIES
1. Activity tolerance adequate
to meet self-care needs.
2. Pain alleviated/managed.
1. Support hemodynamic
stability/ventilatory function.
2. Promote relief of
pain/discomfort.
3. Complications
prevented/minimized.
4. Incisions healing.
3. Promote healing.
4. Provide information about
postoperative expectations
and treatment regimen.
Block 7.0
5. Postdischarge medications,
exercise, diet, therapy
understood.
6. Plan in place to meet needs
Module 2.2
after discharge.
Pericarditis
Block 7.0
Module 2.2
Cardiovascular
Nursing Selected
Topics PT 6
Page R. 78 y.o.
Sick Sinus Syndrome
S/P Pacemaker Insertion
Renee C. 29 y.o.
Pericarditis
Admission Pending
Pre-Op CABG
CARDIAC MONITORING
James H. 68 y.o.
R/O MI ,
Atrial Fibrillation
Haynes H. 55 y.o.
PVD
S/P Femoral-Popliteal Bypass
Kam H. 48 y.o.
AAA
Block 7.0
Module 2.2
Pericarditis
Patient
Record
NAME: Renee C.
AGE: 29 y.o.
Occupation: Graduate Student
DX: Pericarditis,
Mitral Valve Prolapse
NAME: Renee C.
Block 7.0
Module 2.2
Overview: Pericarditis
• Pericarditis - inflammation of the lining surrounding the heart (the
pericardial sac).
• Pericardial effusion - a collection of fluid in the pericardial sac. This
fluid may be produced by inflammation.
• The etiology of pericarditis in most patients is unknown, although
many diseases can cause pericarditis.
• The diagnosis of pericarditis is made by history and physical
examination including presence of a pericardial friction rub. It may
confirmed by EKG and echocardiogram.
• Pericarditis is treated with anti-inflammatory medications and by
treating any underlying disease.
• Pericardial tamponade occurs when enough fluid accumulates in the
sac to compromise the heart's ability to adequately pump blood.
• Tamponade is treated by pericardiocentesis, removing the fluid with
a needle.
Block 7.0 Module 2.2
Etiology
• Idiopathic
• The cause of the illness is not
identified (although often it's
the result of a minor viral
illness or "cold")
• Mechanical injury to the
heart
• Heart attack (myocardial
infarction) and Dressler's
syndrome
• Heart surgery and post
pericardiotomy syndrome
• Trauma
• Infection
•
Bacterial
•
Viral
•
Fungal
Block 7.0
• Tumors or cancer
•
Primary (rare)
•
Metastatic
• Connective Tissue Disease
•
Rheumatoid arthritis
•
Systemic Lupus
Erythematosus (SLE)
•
Sarcoidosis
•
Scleroderma
• Metabolic diseases
• Uremia (kidney failure)
• Hypothyroidism
• Medication Reactions (next
page)
Module
2.2
Etiology
• Side effects of certain
medications can cause an
immune response causing an
inflammation of the pericardial
sac and pericarditis.
• Medicines that have been
implicated include phenytoin
(Dilantin), hydralazine
(Apresoline) and procainamide
(Pronestyl, Procan-SR,
Procanbid).
Block 7.0
Module 2.2
Symptoms
• Chest pain is the most
common symptom of
pericarditis.
• The pain is usually sharp and
stabbing.
• It can arise slowly or suddenly
and can radiate directly to the
back, to the neck or to the arm.
• The pain can be made worse
with deep breaths (pleuritic).
• The pain is frequently
positional and made worse
when lying flat and better when
leaning forward.
Block 7.0
• The most common physical
finding that almost always
confirms the diagnosis is a
pericardial friction rub.
Module 2.2
• Medicines that reduce
inflammation are the primary
treatment for pericarditis.
Nonsteroidal anti-inflammatory
drugs, such as ibuprofen, are
used to decrease the
inflammation and fluid
accumulation in the pericardial
sac. process.
Block 7.0
• Occasionally, a short course of
narcotic pain medication
[codeine, hydrocodone
(Vicodin) or oxycodone
(OxyContin, Roxicodone)] will
be needed.
• In recurrent cases, especially
in immunologically-mediated
causes, corticosteroids are
often very effective.
• Treatment of the underlying
cause of pericarditis is
essential and will be based on
the disease
Module 2.2
• Cardiac tamponade
• If there is enough fluid in the
pericardia sac, there may be
enough pressure on the
outside of the heart to prevent
it from beating adequately to
push blood to the body and
lungs.
• The pressure within the sac
itself needs to be higher than
the pressure within the heart
chambers, but symptoms
gradually progress as the heart
function is compromised.
Block 7.0
• Treated by pericardiocentesis,
a procedure where a long needle
is inserted through the chest wall
into the pericardial sac and fluid
is removed.
• This relieves the pressure within
the sac and temporarily resolves
the acute emergency. A plastic
tube or catheter may be left in
the chest until the underlying
illness that cause the tamponade
is addressed and further
accumulation of fluid in the
pericardium is prevented.
Module 2.2
Pericarditis
Cardiac Tamponade: Most serious complication of pericarditis
Pulsus Paradoxus
Pulsus Paradoxus (PP) is an exaggeration of
the normal variation in the pulse during the
inspiratory phase of respiration, in which the pulse
becomes weaker as one inhales and stronger as
one exhales.
It is a sign that is indicative of several
conditions including cardiac tamponade, pericarditis,
chronic sleep apnea, croup, and obstructive lung
disease
asthma,
Block 7.0 (e.g.
Module
2.2 COPD).
Block 7.0
Module 2.2