Unit 1
Critical Care Nursing
Critical Care Units
- Designed to meet the special needs of acutely and critically ill patients
o ICU
o CCU/CVICU
o Special populations – NICU, PICU, neuro, ICU, burn ICU, trauma ICU, etc.
o Progressive and intermediate care units “step downs”
 These are patient’s who are hemodynamically stable without liability in vital signs (no
arrhythmias), but for some reason they are not ready to be extubated (need more time to
be weaned from the vent) – ex. LTAC.
 Titrating cardiac drugs, etc. will require a specialty floor
 Step down – don’t need the excessive monitoring in ICU, but aren’t stable enough to be
on a regular floor
 Use of PCU floors provides critical care nursing for an at-risk patient population in a
more cost-effective environment
 What are some monitoring capabilities of PCUs?
 Continuous EKG, arterial BP
 O2 saturation, end-tidal CO2
 What are some examples of a patient that can be found in the PCU?
 Scheduled for interventional cardiac procedures (stent placement)
 Awaiting heart transplant
 Receiving stable doses of vasoactive IV drugs (Cardizem)
 Being weaned from prolonged mechanical ventilation
 ---Pt. will move from specialty ICU when still critical but IS hemodynamically
stable; however, pt. still can’t be extubated so may move to an intubation unit
 ---Some pt. may move from ICU to LTAC – transition of where pt. go once out of
critical condition (based on condition, diagnosis, acuity level, and also insurance)
- Frequent assessments
o Minimum of every 2 hours (esp. focused assessment)
- Frequent vital signs
o Minimum of every 2 hours
- Advanced monitoring (usually an indication to be in the ICU) – examining the CV system
o Hemodynamic
o Intracranial pressure
o Brain tissue oxygen saturation
- Advanced life support systems and interventions – impella, intra-aortic balloon pump, mechanical
ventilator, therapeutic hypothermia, pentobarbital coma (inducing a coma)
Critical Care Nursing
- Nursing specialty since the 1960’s
- Specialty dealing with human responses to life-threatening problems [actual or potential]
o Acute and unstable physiologic problems
 Assessing life-threatening conditions
 Initiating appropriate interventions
 Evaluating outcomes
 Providing teaching and emotional support to patients and their caregivers
 Works collaboratively with the inter-professional team
o Actual: heart attack, stabbing, MVA, gunshot wound, overdose
o Potential: attempted suicide, DVT embolizing to lungs, hypoglycemia, colorectal resection
Critical Care Nurse
- In-depth knowledge of:
o Anatomy and physiology
o Pathophysiology
o Pharmacology
o Advanced assessment
o Advanced healthcare technology
- An astute nurse can prevent many complications and [significantly] contribute to good patient outcomes
(will recognize a subtle change in hemodynamic monitoring, will notice subtle changes and do
appropriate interventions to prevent complications)
o Ex: Rhonchi can always be cleared with coughing; crackles is from fluid; can’t clear crackles and
rales with coughing so will give a type of diuretic to clear them or improve their cardiac output
with positive inotropes (digoxin, dobutamine, primacore)
Critical Care Certifications
- CCRN: adult, pediatric or neonatal
o Must work in a specialty area for a set number of years, take the exam and maintain the number
of hours needed for the certification each year
- CCRN – K: for adult, pediatric and neonatal critical care nurses who do not provide direct care but
affect acute and critically ill patient’s and families in their role
o This is for the people who do not meet the number of hours worked that is needed for the CCRN
- PCCN – progressive care certification
- CCRN – E: telemetry ICU
- Additional sub-certifications (must first have the CCRN or PCCN)
o CMC – cardiac medicine
o CSC – cardiac surgery
Advanced Practice – APRN
- Master’s or Doctoral Degree
o Clinical Nurse Specialist
 Provides advanced nursing care to meet the needs of adult-gerontology, pediatric, or
neonatal patient populations
 AACNS – certification in acute and critical care
 May/may not have prescriptive authority
o Acute Care Nurse Practitioner
 Comprehensive assessments, orders and interprets diagnostic test, manages health
problems and disease-related symptoms, prescribes treatments, and coordinates care
during transitions in settings
 Independently function from the doctor; prescriptive authority
 Based on more medical models
Critical Care Patients
- High-risk for actual or potential life-threatening health problems
o Physiologically unstable (B/P, cardiac, respiratory, neurological, or GI)
 Cardiac drug titration, bradycardia, ventricular tachycardia, rigid/distended abdomen,
paralytic ileus, septic, hemodynamic instability, overdose, altered LOC, decreased pulse
ox, tachypnea, etc.
o At risk for serious complications and need frequent assessment and/or invasive interventions
 These patient’s may not be unstable, but their chances for complications are greater
 Ex. Patient went in for surgery and has more co-morbidities that puts them at an
increased risk for complications
 Pressures, vent, craniotomies
o Require intensive and complicated nursing support related to the use of:
 PA Catheter, LVAD (left ventricular assistant device), CRRT (continuous renal
replacement therapy)
 IV polypharmacy (e.g., sedation, thrombolytics, drugs requiring titration [vasopressors],
and advanced technology [mechanical ventilation, intracranial pressure monitoring,
continuous renal replacement therapy, hemodynamic monitoring])
- Despite the emphasis placed on caring for individuals expected to survive, the incidence of death is
higher in ICU pt. than non-ICU patients. In general, non-survivors are typically:
o Older, have co-morbidities & experience longer ICU stays
Common Problems of Critical Care Patients
- Anxiety
o If patient is on a vent – propofol is given
o Treat pain before anxiety
- Pain
o Visceral or somatic?
o Can lead to anxiety and delirium
- Impaired communication
o Have to establish some non-verbal way to communicate
o If patient has impaired barriers before they came in, it will be worse in the ICU
- Sleep disturbances
o Nurse should cluster the care of the patient
 A patient with increased intracranial pressure is excluded from this
o Decreased sleep duration and sleep loss influence pain perception
o Environmental factors: lights, alarms, ventilator sounds, pain dyspnea, nausea, fear, etc.
- Sensory-perceptual problems (delirium)
-
o Coincides with the lack of sleep in the hospital
o Older adults are more at risk for sensory overload
Nutrition
o Enteral feeding – includes NG tubes, OG tubes, Dobhoff tubes
 Keeps the gut functioning if already working; enteral is best
o Parenteral feeding – includes PPN (peripheral line w/ mostly proteins) and TPN (central line
with lipids, vitamins, insulin, etc.)
 TPN – high risk for infection; must be given through a central line or PICC line because
of the viscosity
o If the intestines is not fed appropriately, it will slow down and ileus can occur – “if you don’t use
it, lose it”
Anxiety
- Characterized by apprehension and autonomic arousal, an internal feeling (hyper-aroused state of the
CNS) which is accompanied with tachycardia, increased B/P and tachypnea.
- Causes:
o Perceived or anticipated threat to life
o Intense pace of activity
or health
o Pain, impaired communication
o Loss of control of body functions
o Sleeplessness
o Foreign environment
o Immobilization
o Discomfort
o Loss of control
o High noise and light levels
- Nurses can help reduce anxiety
o Good communication
o Reduce environmental stimuli
o Encourage patient and family to express concerns, ask questions, state their needs
o Relaxation techniques – music therapy, guided imagery, breathing exercises
o Involve caregivers
o Pain management
o Anti-anxiety medications – propofol, lorazepam
Pain
-
-
70% of ICU patients report moderate to severe pain
Inadequate pain control linked to agitation and anxiety
Anxiety triggers the stress response
Patients at high risk for pain include:
o Ischemic, infectious, or inflammatory processes
o Immobilization
o Invasive monitoring devices
o Endotracheal tubes
Treat pain first, then anxiety
Impaired Communication
- Intubation and mechanical ventilation
- Sedatives or paralyzing drugs
- Language barriers
- Interventions:
o Explore other methods of communication
 Picture boards
 Notepads
 Magic slates
 Computer keyboard
o Look directly at the patient (read lips) and use hand gestures when appropriate
o Interpreters with language barriers
Sleep Disturbances
- Because of:
o Noise
o Anxiety and pain
o Frequent monitoring
o Treatments and procedures
o Altered circadian rhythm and melatonin levels
o Decreased total sleep time, SWS (short wave or deep sleep) and REM (rapid eye movement)
sleep
- Associated with delirium and delayed recovery
- Interventions:
o Modify environment
 Turn off alarms in room
 Close doors
 Curtains – open during day, close at night
 Dim lights
o Cluster care (unless IICP)
 Any time you do interventions with ICP patient, it increases the pressure and we do not
want their pressure to stay high for long periods of time
o Eye masks/ear plugs
o Medication sleep aids (benzodiazepines)
 Last line of defense – increases delirium
Dementia
- Clinical manifestations of dementia
o Slow, progressive, irreversible loss of intellectual or cognitive abilities like abstract thinking,
reasoning
 Ex. Can’t remember how to drive, but can remember how to dress themselves, etc.
o Delirium and dementia can co-exist
 A patient with dementia can still have delirium as well
o Patients with dementia are high-risk for developing delirium
Sensory-Perceptual Problems (Delirium)
- Acute, quick, reversible impairment of cognitive processes
- Alterations in:
o Mentation (delusions, short attention span, loss of recent memory)
o Psychomotor behavior (restlessness, lethargy)
o Sleep-wake cycle (e.g., daytime sleepiness, night time agitation)
- Risk factors:
o Pre-existing dementia
o Hemodynamic instability
o History of baseline hypertension or
o Hypoxemia
alcohol abuse
o Hypercarbia
o Severe illness on admission
o Electrolyte disturbances
o Sleep deprivation
o Drugs – sedatives, analgesics,
o Anxiety
antimicrobials
- Assessment
o Confusion assessment method (CAM)
o Confusion assessment method ICU (CAM-ICU)
o Intensive care delirium screening checklist (ICDSC)
- Diagnosis
o History and physical
o Medication review (anything that we can stop giving?)
- Mnemonic for causes of delirium:
o D – dementia, dehydration
o E – electrolyte imbalances, emotional stress
o L – lung, liver, heart, kidney, brain
o I – infection, ICU
o R – Rx drugs
o I – injury
o U – untreated pain unfamiliar environment, UTI
o M – metabolic disorders
- Management
o Goal is early recognition and treatment
o Try to ID and eliminate possible causes
o Protect from harm
o Reduce environmental stimuli
o Familiar objects and family
o Frequent reorientation
- Drug therapy (last resort – can worsen delirium)
o Dexmedetomidine – ICU setting only
 IV drug that blocks alpha 2
o Low-dose antipsychotics
 Haloperidol, risperidone, olanzapine, quetiapine
o Short acting benzodiazepines when associated with sedate and alcohol withdrawal or in
conjunction with antipsychotics to reduce extrapyramidal side effects
Nutrition
- Conditions seen with ICU patients:
o Hypermetabolic states (esp. burns, sepsis, fever)
o Catabolic states (acute kidney injury)
o Malnourished (chronic heart, lung, or liver disease)
o Poor nutrition increases mortality and morbidity
- Nursing management:
o Administer prescribed treatment
o Monitor intake and output
o Monitor weights
o Monitor labs
 Serum protein total albumin, pre-albumin
 BUN
 Glucose
 Electrolytes
- Collaborative management (hcp, dietician, nurse):
o Goal – support or correct nutritional deficiencies
o Early enteral/parental nutrition (PN) when oral is inadequate or not an option
 Enteral nutrition preferred
 Preserves the structure and function of gut mucosa
 Stops movement of gut bacteria across the intestinal wall and into blood stream
 Associated with fewer complications and shorter hospital stays
 Parental nutrition - paralytic ileus, GI ischemia, diffuse peritonitis, intestinal obstruction,
pancreatitis, abdominal trauma or surgery, severe diarrhea
Caregivers
- Link the patient to the outside world
- Facilitate decision making and
advising the patient
- Help with activities of daily living
- Act as liaison to advise the health care
team of the patient’s wishes
- Provide safe, caring, familiar relationships
for the patient
- Can be emotionally and physical exhausted
- Anxiety about patient’s condition,
prognosis and pain
- Financial concerns
- Disrupted daily routine
- May be far from home
- ICU visiting hours
-
Nursing management:
o Good communication
o Active listening
o Case management
o Consult chaplains, psychologist
patient representatives
o Involve family in care planning
and inter-professional conferences
-
Presence during CPR and invasive
bedside procedures helps caregivers to:
o Overcome doubts about the
patient’s condition
o Reduce their anxiety and fear
o Meet their need to be together
with and to support their loved
one
o Begin the grief process if death
occurs
Culturally Competent Care
- Meeting physiological needs of the patient often overshadow the patient’s culture on the illness
experience
- Important to consider cultural aspects
o Advance directives:
 Some view advanced directives as a way to prepare
 Some are suspicious advance directives are a way to legally deny care
o Customs surround dying and death vary
Critically Ill Elderly
- Symptoms may be atypical
- Confusion may be a sign of infection
- Depression is often misdiagnosed as dementia
- Most common atypical illness presentations are “delirium” or “acute change in mental status,” caregiver
may say the patient is “acting differently” or no longer participating in self-care activities
- May have multiple co-morbidities, diagnosed and undiagnosed
- Care can be complex and challenging requiring skills assessment and creative nursing interventions
Rapid Response Teams (RRT)
- Anybody can activate this due to respiratory changes, heart rate changes, B/P changes, anytime you feel
that the patient is unstable “anything that is urgent”
- Inter-professional team (facility determines RRT team members) that bring critical care expertise to the
bedside – must be able to respond immediately and have critical care skills
o Critical care RN
o Critical care physician
o Advanced practice RN (APRN)
o Respiratory therapist
- Bring rapid and immediate care to an unstable patient in non-critical settings
- 3 problems that can lead to failure to rescue:
o Failures in planning (assessment, treatments)
o Failure to communicate
o Failure to recognize deteriorating patient condition
- Goal is to prevent from having to call a code
RRT Triggers
- Respiratory
o RR < 8 or > 28
o O2 SAT < 90%
o Threatened airway
- Cardiovascular
o Acute change in systolic BP to < 90
o Acute sustained increase in diastolic BP > 110
o Acute change in heart rate to < 50 or > 120
o Onset of chest pain
o Acutely cold, pulseless, or cyanotic extremity
-
-
Neurological
o Confusion, agitation, delirium
o Unexplained difficulty to arouse
o Difficulty speaking or swallowing
o Changes in pupillary responses
o Seizure
Other
o Confusion, agitation, delirium
o Unexplained difficulty to arouse
o Difficulty speaking or swallowing
o Changes in pupillary responses
ICU Bundles
- Ventilator bundle (VAP)
- Central line (CLABSI)
- Urinary catheter (CAUTI)
- ABCDE bundle
o Awaken
 Awakening trials for ventilated patients
o Breathe
 Spontaneous deep breathing trials
o Choose medication/coordinate care
 Coordinate effort between the registered nurse and respiratory therapist to perform the
spontaneous breathing trial when the patient is awakened by reducing or stopping the
patient's sedation. The combination of sedation and analgesics being used are reviewed,
and changes or reductions in the doses are considered.
o Delirium
 A standardized delirium assessment program, including treatment and prevention options
o Early ambulation
 Early mobilization and ambulation of critical care patients
Other Codes for Acute Issues
- Code STEMI – ST elevation (myocardial infarction)
o Alerts the supervisor to call the cath lab crew, EKG
o Expedite the time so that the patient’s outcome is improved
- Code TRAUMA
- Code FAST – stroke alert
o Facial drooping, arm weakness, speech difficulties, time
Critical Care Organizations
- American Association of Critical Care Nurses (AACN)
o Professional nursing organization
o Offers certifications – CCRN, PCCN, CMC, CSC
- Society of Critical Care Medicine (SCCM)
o Surviving sepsis campaign
Unit 2
Advanced Assessment Tools for Acute and Critical Care
HEMODYNAMIC MONITORING
Hemodynamic Monitoring
- The measurement of pressure, flow, and oxygenation within the cardiovascular system (everything that
controls homeostasis)
- Purposes:
o Assess heart function
o Fluid balance
o Effects of fluids and drugs on cardiac output
- Uses non-invasive tools, invasive catheters and highly technical monitoring systems that the nurse can
evaluate a patient’s cardiac function, circulating blood volume and physiologic response to treatment.
Hemodynamic Pressures
- Systemic pressure (arterial pressures) – arterial line is in place
- Pulmonary artery pressure (PA) – pulmonary artery catheter is in place
- Pulmonary artery wedge pressure (PAWP, PCWP, PAOP) – indicative of what is happening on the left
side of the heart
- Other data
o Cardiac output/cardiac index
o Stroke volume/stroke volume index
o Stroke volume variation
o Oxygen saturation
o Mixed venous oxygen saturation
Calculated Values
- Systemic vascular resistance (SVR)
- Pulmonary vascular resistance (PVR)
- Oxygen content, delivery, and consumption
Indications for Hemodynamic Monitoring
- Post-op CABG
- Multiple traumas
- MI
- Extensive surgery
- Multiple organ dysfunction syndrome (MODS)
Cardiac Cycle
- Diastole – period of relaxation during which the ventricle is filling
- Systole – period during which the chamber is contracting, and blood is being ejected from the ventricle
Heart: Two-Sided Pump
- Right side: low-pressure pump
o Right ventricle pumps against pressure in the pulmonary system
- Left side: high-pressure pump
o Left ventricle pumps against the systemic vascular pressure
Cardiac Output
- The volume of blood pumped by the heart from the (left) ventricles in liters per minutes (L/min)
- Reasons for decreased CO: volume loss, leaking protein
- Normal range – 4 to 8 L/min
- CO = SV x HR
o Example: SV (70) x HR (80) = 5,600 mL = 5.6 L/min
Stroke Volume
- The amount of blood ejected from the heart per beat
- Normal range – 60 to 150 mL
- Affected by fluid status
o Decrease with dehydration
o Increase with fluid volume overload
- If SV decreases, the HR will compensate by increasing, so initially the CO remains the same
- If HR increases, SV will stay the same but eventually will decrease because there is not enough time for
the ventricles to fill
Factors Influencing Stroke Volume
- Preload – the amount of blood in the ventricle at the end of diastole (venous return)
o Right: central venous pressure (CVP)
o Left: pulmonary artery wedge pressure
- Afterload – forces opposing ventricular ejection: the pressure the ventricle must generate to empty its
contents (vascular resistance)
o Right: pulmonary pressure
o Left: systemic pressure
- Contractility – force of contraction
Cardiac Output/Cardiac Index
- Cardiac output
o SV x HR = CO
o Measured in L/min
o Normal range 4 – 8 L/min
o SV (70 mL) x HR (80) = 5,600 mL = 5.6 L/min
- Cardiac index
o Cardiac output adjusted for body size
 i.e. height and weight
o More precise measurement of the efficiency of the pumping action of the heart
o Lower the body surface area (BSA), higher the cardiac index
o Normal range 2.2 – 4.0 L/min/m2 (usually about ½ of the cardiac output)
o CI = CO / body surface area (BSA)
Factors Affecting Heart Rate
- Autonomic nervous system
o Sympathetic: fight or flight – increases HR
o Parasympathetic: rest and digest – decreases HR, bradycardia at night with fluctuations in sleep
patterns
- Medications
o Anti-arrhythmic drugs, thyroid drugs, stimulants
- Conduction defects
o Abnormal rhythms that can result in an increased/decreased HR include:
 PSVT, SVT, runs of V-tach, AV blocks, V-fib, A-fib
Systemic Pressures
- Mean arterial pressure (MAP) – tissue perfusion pressure
o Systolic BP + 2 (diastolic BP) / 3
- Normal range: 70 – 105 mmHg
Hemodynamic Monitoring
- Special monitoring tubing
o Non-distensible tubing is used – regular tubing would lose some of that pressure and readings
would be innacurate
o Transducer – has a wire that plugs to the monitor – takes this information form the sensor and
brings it to the monitor
o Delivers ~ 3 cc/hr to keep the line open
- Pressure bag (300 mm hg)
o Line has to stay open (especially for an arterial line) so we have to put continue pressure on the
line for this to happen
- Normal saline for priming – no heparin
Phlebostatic Axis
- Transducer must be level with the atria for accurate measurements
- Anatomical landmark is the phlebostatic axis
o 4th intercostal space mid-chest
- Where transducer opens to atmospheric air – stopcock must be aligned to the axis
o Transducer too high – false low
o Transducer too low – false high
Zero
-
Confirms pressure within the system is zero
Open the stopcock at the transducer to atmospheric air
Press the “zero” button on the monitor screen
Observe the wave flatten and reading of zero
Every four hours and anytime a reading is questioned
Dynamic Response Test
- Flattened or dampened waveform may mean:
o Tiny air bubbles in tubing
o Kinked catheter tubing
o Clot occluding the catheter
o Poor catheter position
o Vasospasm
o Inadequate pressure in pressure bag
o Out of fluid in pressure bag
Pressure Line Maintenance
- To maintain line patency and limit thrombus formation
o Flush system every 1 to 4 hours to determine
that:
 Keep pressure bag inflated to 300 mg hg
 Ensure flush bag contains fluid
 Ensure system is delivering a continuous slow (1 to 3 ml/hr) flush
- Relevel with position changes
- Zero q 4 hours and anytime a reading is questioned
Assessment
- Assess neurovascular status distal to insertion site hourly (arterial line)
o Compromised arterial flow
 Cool and pale limb
 Prolonged capillary refill > 3 seconds
 Symptoms of neurovascular impairment
 Paresthesia, pain, paralysis
 Report to HCP immediately
o Monitor for bleeding
Nursing Considerations
- Position patient supine, flat or < 45 degrees
- Read measurements from pulmonary artery (PA) catheter at end expiration
o Arterial catheter does not matter as much for this
- Transducer too high = false low
- Transducer too low = false high
- Trend data and correlate with clinical picture
Complications
- Infection
- Impaired circulation
- Hemorrhage
- Thrombus formation
- Neurovascular impairment
ARTERIAL LINE
Arterial Line
- Placement of a catheter into the radial, brachial or femoral artery
o Put in by nurse anesthetist, radiologist, physician, etc.
- Continuous arterial blood pressure monitoring
- To obtain arterial blood gas and serum lab samples
Indications for Arterial Line
- Hypertension/hypotension
- Shock
- Coronary interventional procedures
- Head injury
- Multiple trauma
- Vasoactive drugs
- Frequent lab/ABG draws
Procedure
- Inserted by an anesthesiologist, nurse anesthetist, respiratory therapist, physician, nurse practitioner
- JELCO or special arterial catheter
- Allen’s test before insertion to assess arterial flow of ulnar artery
o Allen’s test is putting pressure on the ulnar until the hand is blanched. They will let the ulnar go
and then see if the hand pinks up again
- Once catheter is inserted, connect to monitoring tubing and cardiac monitor
- Zero system
- Level with phlebostatic axis
Arterial Waveform
- Components of good wave form – rapid upstroke
- Clear dicrotic notch (closure of the aortic valve)
- Clear end diastole point
PULMONARY ARTERY CATHETER
Pulmonary Artery Catheter
- Invasive multi-lumen catheter
- Brand name = Shaw-ganz
- Distal tip sits in pulmonary artery (sensor is here)
- Inserted by anesthesiologist, intensivist, physician’s assistant
- Can be inserted at bedside
PA Catheter
- Measures pressures within the right heart
o Central venous pressure (CVP) or right atrial pressures (RAP)
o Pulmonary artery pressures (PAP aka PA)
- Indirectly measures left heart pressures
o Pulmonary artery wedge pressure (PAWP)
- Can also be used to:
o Measure cardiac output
o Obtain mixed venous samples
o Monitor mixed venous oxygen saturation (SVO2) with some catheters
o Infuse fluids and medications
o Calculate:
 Systemic vascular resistance (SVR)
 Pulmonary vascular resistance (PVR)
 Stroke volume (SV)
Nurses’ Role
- Prepare patient
- Explain procedure
- Gather equipment
- Maintain patency
- Level and zero
- Obtain and evaluate reading
- Monitor site and equipment
“Floating the Catheter”
- Catheter is inserted in internal jugular or subclavian vein via the introducer catheter
- Balloon is inflated
- The balloon floats into the right atrium
- Crosses the tricuspid valve and into the right
ventricle
- Balloon then floats up into the pulmonary artery
- Then gets stuck in a capillary “capillary wedge”
o We don’t want it to stay in this position –
we just get the reading and deflate the
balloon. When this happens, it should tuck
back and stay in the pulmonary artery
continuously. Intermittently (push air) we
will go and get a wedge pressure by ourselves.
Proximal Port
- Sits in right atrium
o Measures CVP/RAP
o Administer injectate to measure CO
o Injection port for fluids and medications
o Draw blood
- CVP/RAP Pressures
o Mean reading
o Normal 2 – 8 mmHg
o Right heart preload
o Indication of volume status
o “Filling pressures”
CVP Values
- High pressures
o Volume overload
o Right ventricular failure
o Tricuspid regurgitation
- Low pressures
o Dehydration
Distal Port
- Terminates in the pulmonary artery
- Allows to obtain mixed venous/arterial blood samples – not usually done from the distal
- Continuously monitors pulmonary artery and pulmonary artery wedge pressures
o Pulmonary artery pressures (PAP)
 Systolic and diastolic measurement
 Measure at end expiration
 Systolic – 15 to 30 mmHg
 Diastolic – 4 to 12 mmHg
 Reflects both right and left heart pressures
o Pulmonary artery wedge pressures (PAWP)
 Mean reading
 Measure at end expiration
 Important when the patient is having trouble breathing, intrathoracic pressure is
high or the patient is taking large breaths
 Normal range of 6 to 12 mmHg
 Deflate balloon after reading
 Inflate at least 15 seconds, no more than 30 seconds
 Preload of left side of heart
Distal Port Values
- Pulmonary artery pressures (PAP)
o Reflects both right and left heart pressures
o High pressures
 Pulmonary hypertension/edema
 Left sided heart failure
 Volume overload
o Low pressures
 Dehydration
 Pulmonary vasodilation
- Pulmonary artery wedge pressures (PAWP) – when the balloon is inflated
o Indicative of pressure on left side of heart at end diastole
o High pressures
 Left-sided heart failure
 Volume overload
 Mitral regurgitation
o Low pressures
 Dehydration
 Arterial vasodilation
Balloon Inflated
Overinflated
- Too much air is in the balloon – just let air out and will go back to waveform
Cardiac Output/Cardiac Index
- Computer calculated by measuring temperature changes
- Temperature sensor on catheter
o Manual readings
o Continuous cardiac output monitoring
- Normal values
o CO: 4 to 8 L/min
o CI: 2.2 to 4 L/min
- Low values
o Left sided heart failure
o Dehydration
- High values
o Hyper-dynamic state/fever
o Early sepsis (stress response)
o Vasodilation
Systemic Vascular Resistance (SVR)
- Calculated value
o Afterload of left side of heart
o Normal range = 800 – 1200 dynes/sec/CM-5
- Too high > 1200 (makes the left ventricle work harder to overcome the resistance)
o Vasoconstriction
o Hypertension
- Too low < 800 (makes it easy for heart to overcome resistance)
o Vasodilation
o Sepsis
Pulmonary Vascular Resistance (PVR)
- Calculated value
o Afterload of right side of heart
o Normal range = < 250 dynes/sec/CM-5
- High values
o Pulmonary hypertension
o Volume overload
- Low values
o Dehydration
o Pulmonary vasodilation
Mixed Venous Oxygen Saturation (SVO2)
- Fiberoptic sensor on distal tip of PA catheter
- Oxygen saturation of blood in pulmonary artery (deoxygenated blood)
o We normally use about 25% of our oxygen
- Blood from all parts of the body returning to the right side of heart
- Normal values 60-80% at rest
- Balance of O2 delivery and O2 consumption
-
-
Low value <60
o Heart failure
o Anemia
o Hypoxia (low sao2)
o Hyper-dynamic state/fever
o Increased oxygen demand
High value >80
o Catheter fault (needs calibration)
o Sepsis
 Unable to extract oxygen at tissue level
Complications of PA Pressure Monitoring
- Infection
- Air emboli
- Thromboembolism
- Fluid overload
- Hemorrhage
- Pulmonary infarct
Arterial Pressure – Based CO
- Minimally invasive technique to measure CO/CI
- Special sensor attached to a standard arterial pressure line and monitor
- Assesses fluid responsiveness by measuring the increase in SV after fluid bolus
o Stroke volume variation (SVV) – normal value <13%
o High values = fluid responsive/hypovolemic
- Limitations
o Adult patients on controlled mechanical ventilation
o Cannot be used with intra-aortic balloon pump
o May give erroneous values with certain dysrhythmias (specifically atrial fibrillation)
Non-Invasive Cardiac Output
- Bioimpedance Technology
o BIO Z®
o Not accurate in patients with fluid overload
- Bioreactance Technology
o CHEETAH®
o More accurate than BIO Z®
ALARMS
- Tailor alarms to patient status
o Can be a life saver when used appropriately
o Can be nuisance if not used appropriately
- Alarm fatigue is a real thing
OXYGENATION AND MECHANICAL VENTILATION
Mechanical Ventilation
- The process by which oxygen is moved into and out of the lungs by a mechanical ventilator
o “Blowing air into the patient and they exhale passively”
Key Terms
- Tidal volume (Vt): volume of air exchanged during a normal breath
o With the vent, we set this number. For example, we want this patient to inhale 500 cc’s with each
breath they take
- Vital Capacity (VC): volume of air exhaled with maximal effort after maximal inspiration
o Ex. Patient takes a big, deep breath in and exhales while pushing all of the air out
o This also indicates the most that your lung volume can hold at one time (includes both vital and
residual capacity)
- Fraction of inspired oxygen (FIO2): the concentration of oxygen delivered to patient (room air is 21%)
o Nasal cannula
o Venti mask
o Partial NRB
o 100% NRB
o BiPAP, CPAP
o Invasive ventilation (ET tube)
- Functional residual capacity: that volume of air remaining in the lungs after maximal exhalation (we do
not exhale all of the air in our lungs because then they would collapse)
o This numerical value is what is used to direct treatment with PIP and CPAP – treatment increases
the amount of residual air allowing for a longer time for air exchange
Indications for Mechanical Ventilation
- Apnea or impending inability to breathe
o Ex. Stroke, cardiac arrest, high cervical spine injury, paralytics, overdose, ARDS
- Ventilatory failure
o Hypoventilation
o pH < 7.35 and PaCO2 > 50 mmHg (respiratory acidosis)
 Patient must have both of these values to be considered ventilatory failure
o PaO2 = PaCO2
- Severe hypoxia (respiratory failure)
o Requires FiO2 of > 50% to maintain adequate oxygenation
o PaO2 < 60 mmHg on oxygen
- Respiratory muscle fatigue
o Neuromuscular problems such as ALS, Guillan Barre syndrome, COPD
o Stridor, tripod positioning
- Respiratory rate more than 35 or less than 8 – 10
Artificial Airways
- Endotracheal tube (1st airway usually used)
o Tube is placed into the trachea via the mouth or nose past the larynx
 Can occur quickly and safely at the bedside
 Should only be indicated for patients who are expected to require < 2 weeks on the
ventilator
 Do not place the tube through the nose if head/neck injury or any real/suspected facial
injuries or surgery
o A cuffed tube is most likely being used – prevents air from coming out and partially helps to
protect the airway from fluids, etc.
 The patient should not be able to make vocal sounds with the cuff inflated
 Makes it hard for the patient to swallow due to pressure on the esophagus
o Indications
 Upper airway obstruction
 Apnea
 High risk of aspiration
 Ineffective clearance of secretions
 Respiratory distress
o Assisting with intubation
 Prepare for a rapid sequence intubation (RSI)
 Administration of both a sedative and paralytic agent during emergency airway
management (Versed, Fentanyl, Succinylcholine)
o MAKE SURE TO GIVE THE SEDATIVE FIRST!
 Position patient to allow visualization of the vocal cords
 Pre-oxygenate the patient using the ambu-bag and 100% O2 for 3 – 5 minutes (hyperoxygenate)
 Confirm placement of the tube using an end-tidal CO2 detector
 Auscultate lungs for bilateral breath sounds and the epigastrium for the absence of air
sounds
 Observe chest for symmetric chest wall movement
 Obtain ABG lab values within 25 minutes after intubation is confirmed to determine the
patient’s baseline oxygenation and ventilation status
o Complications
 Pain/discomfort
 Obstructed tube
 Anxiety
 TE fistula
 Infection
 Self-extubation
 Aspiration
 Pressure sore
 Displaced tube
o **If the patient has an endotracheal tube and his condition changes (tachycardia, tachypnea,
decreased LOC), CHECK THE TUBE!
 If vent is malfunctioning, use the ambu-bag and bag them at FiO2 100%
- Tracheostomy tube
o Surgical procedure that is performed if the patient needs ventilation for < 2 weeks
o Tube is placed through a stoma that is surgically created in the neck
Nursing Management: Artificial Airway
- Maintaining correct tube placement
o Place a mark, tape on the tube where the tube is placed or pass off in report the number of where
it hits either the lips or teeth
o Continuously monitor for symmetrical chest movement and bilateral breath sounds
o Improper position of the ET tube is considered a MEDICAL EMERGENCY! Bag patient
immediately with FiO2 100% and call for help.
- Maintaining proper cuff inflation
o ET tube cuff pressure: 20 – 25 mmHg (asses q8h)
o Over inflation can result in tissue erosion or a TE fistula
- Monitoring oxygenation and ventilation – ABG’s give you both
o Assess clinical findings related to oxygenation: ABGs, SpO2, SvO2
 Signs of hypoxemia – LOC change, anxiety, dusky skin and dysrhythmias
o Assess respiratory and ABG’s
 PaCO2 is the best indicator of alveolar hyperventilation/hypoventilation
 Decreased PaCO2, increased pH = respiratory alkalosis
 Increased PaCO2, decreased pH = respiratory acidosis
- Maintaining tube patency
o Asses the need for suctioning by checking patency – indicators of suctioning include:
 Visible secretions, sudden respiratory distress, suspected aspiration, abnormal breath
sounds (rhonchi, snores), increased RR or sustained coughing, any changes in PaO2 or
SpO2, high pressures from the ventilator monitor
o Closed suctioning – oxygenation and ventilation are maintained – minimal exposure to secretions
 Perform this with high PEEP, bloody/infectious secretions, frequent suctioning
 Complications: hypoxemia, bronchospasm, increased ICP, HTN, hypotension,
dysrhythmias
o Tracheal mucosal damage is likely with pressures > 120 mmHg or with overly vigorous catheter
insertion
o Thick secretions can be limited by ensuring hydration and humidification
 Do not instill NS into the ET tube itself because it can decrease SvO2 – only if needed
- Providing oral care and maintaining skin integrity
o Lips, tongue, and mouth should be moistened with saline/water swabs to prevent drying
o Oral care is brushing teeth twice a day, suctioning and swabbing q 2 hours, reposition and re-tape
ET tube q24h
- Fostering comfort and communication
o Use writing or blinking as a way to communicate
o Physical discomfort often requires sedation (Propofol, Morphine, Fentanyl)
o May need to use the bathroom
o Turning, pillows for comfort, music, etc.
Types of Mechanical Ventilation
- Non-invasive ventilation
o Negative pressure ventilation (iron lung)
 Used for patients with chronic respiratory failure who require assistance ventilation for
short periods of time; does not require an artificial airway
 Spinal cord injuries
 Guillain-Barre’
 ALS
 Increases and decreases pressure around chest – causes changes in intrathoracic pressure
 Negative pressure pulls the chest outward, forcing air to flow inward until the
machine cycles off and passive expiration takes place
 Ex. Iron lung, chest vest, body wrap, and body suits
o Non-invasive positive pressure ventilation (NIPPV)
 During inspiration, the ventilator pushes air into the lungs under positive pressure
(intrathoracic pressure is raised during lung inflation rather than lowered – expiration still
occurs passively)
 Used short term in weaning, after extubation, or in acute respiratory insufficiency that is
expected to resolve quickly; can also be used to try to prevent intubation
 Used long term in management of sleep apnea
 Requires face mask, nasal pillows (prongs), or can be applied via ventilator and artificial
airway
 Types:
 CPAP
o Continuous positive pressure to maintain continuous level of positive
pressure (the same one pressure)
 Usually for obstructive sleep apnea – splints the airway open
o Similar to PEEP, but applied continuous – PEEP is just on exhalation
o Caution in patient with myocardial compromise because this increases the
workload of breathing and the patient has to breathe against the
continuous pressure
 BiPAP
o Delivers 2 levels of positive airway pressure:
 Inspiratory positive airway pressure (IPAP) – higher
 Expiratory positive airway pressure (EPAP) – lower
o Similar to pressure support ventilation because the patient must be able to
spontaneously breath and cooperate with treatment
o Indicated for acute respiratory failure, COPD, HF, sleep apnea
-
Invasive Positive Pressure Ventilation
o Primarily used in acute care settings
o Requires artificial airway such as ET tube or tracheostomy
o Breaths are delivered either until pre-set volume or pressure is reached; exhalation is passive
o Types (how air is delivered):
 Volume ventilation
 Ventilator controlled by pre-set volume

o If we set the volume to be 500 cc, with each breath 500 cc will be given
and the patient exhales passively. It does not matter the pressure for this.
 Will deliver set volume regardless of changes in lung compliance or resistance
 Exhalation occurs when inflow stops
 Volume is consistent with each breath, but airway pressures will vary
Pressure ventilation
 Ventilator delivers air until preset inspiratory airway pressure is present
o Inverse I:E ratio (normal is 1:2)
 Patients who have trouble oxygenating, the pulmonologist may
want the ratio to be 1:1 or 2:1 so that they patient has more time
for the gases to come in and exchange
o Disadvantage: tidal volume varies according to patient’s pulmonary
system
 Hypoventilation and respiratory acidosis may occur in patients
with increased resistance to flow or decreased compliance
o With this, nurses MUST watch closely to ensure adequate tidal volume
 Usually used for stuff lungs or ARDS
Settings for Vents
- Settings
o Rate – how many times we want the ventilator to give the patient a breath
 Normal rate is
o Tidal volume (volume ventilation) – how much air/gas we want for them to get with each breath
o Pressure (pressure ventilation) – how much pressure to use to give the patient the breath
o Inspiratory time – how much time we want to deliver the breath over
o Alarms – tailor the alarms to that specific patient
o FIO2 – percentage of oxygen that the patient will receive
 The green and yellow meters on the wall are both plugged into the ventilator and are
combined to get the percentage needed
Modes of Ventilation
- Modes of Ventilation [Most control to least control]
o Controlled Mandatory Ventilation (CMV)
 Delivers preset volume at regular interval regardless of patient inspiratory effort (set rate
& tidal volume)
 Used in patients with no respiratory effort or unable to breathe spontaneously
 High c-spine injuries
 End-stage degenerative neuro disease
 Chemical paralysis with surgery (anesthesia)
 Used less often than assist-control (AC)
 Causes patient to panic and fight if they have spontaneous respiratory effort because they
are trying to breathe with the ventilator
 We have total control over the patient’s breathing so this is why we only use it for
the patient’s that are not able to breathe at all
o Assist-Control Mechanical Ventilation (AC)
 Breath can be triggered by the patient or can be time triggered – tidal volume will be the
same either way
 Delivers a preset volume or pressure when initiated by patient – share the work of
breathing
 Preset rate ensures adequate ventilation
 Patient can breathe faster than the preset rate, but cannot breathe slower then rate
 May cause respiratory alkalosis in patients with high RR or respiratory acidosis in
patients with low RR
 Indications: neuromuscular weakness, pulmonary edema, acute respiratory failure
 Disadvantage: if it is too difficult for the patient to breathe, the work of breathing is
increased and the patient may become tired and develop ventilatory asynchrony –
fighting the vent
o *Synchronized Intermittent Mandatory Ventilation (SIMV)
 Preset rate during which a preset volume or pressure is delivered (mandatory ventilations)
 Allows patient to breathe at their own respiratory rate and volume between respirations
 If the patient is not initiating enough spontaneous breaths and the ventilator is set
too low, the patient O2 status may decline resulting in inadequate support and
oxygenation
 This machine will wait for the patient to take their breath and then deliver the
tidal volume. For example, if we set the tidal volume to be a certain number at 10
times a minute and the patient breathes more than this, the tidal volume for those
extra breaths will be at whatever volume the patient generates.
 Prevents respiratory muscle weakness
 Most used in ICU – typically for weaning
o Airway Pressure Release Ventilation (APRV)
 Inverse ratio
 Pressure controlled intermittent mandatory ventilation (IMV)
 Unrestricted spontaneous breathing
 Rescue therapy for ARDS
 Alveolar recruitment
 Lung protective strategies
 Description
 Two levels of pressure: high (P-high) and low (P-low)
 Patient breaths spontaneously during P-high and P-low
 Time in P-high (T-high) is longer than P-low (T-low) to maintain recruitment (8595%)
o We are trying to keep the alveoli open, but caution for autoPEEP
 Results in a degree of autoPEEP due to the short release time (T-low)
o If the patient is not exhaling well and we keep stacking new breaths on
top, the lungs can over-inflate. We must watch out for this with the low
expiratory pressure.
“ADD-ONS” to Modes of Ventilation
-
Pressure Support Ventilation (PS)
o Preset amount of pressure is delivered during inspiration – slightly higher pressure during
inspiration (duration of a spontaneous breath) – basically a little extra help for inspiration
 Patient must be able to initiate breaths – determines inspiratory length, tidal volume and
respiratory rate
o Augments patient’s spontaneous respiration and decreases work of breathing
o Volume and pressure levels are affected by patient lung compliance
o Can be used with other SIMV or as a stand-alone in weaning
o Advantages: increased patient comfort, decreased work of breathing, decreased O2 consumption,
increased endurance conditioning
o NOT used as the sole ventilator support during acute respiratory failure because of risk for
hypoventilation
-
Positive End Expiratory Pressure (PEEP)
o Positive pressure is supplied during exhalation – patient exhale remains passive, but the pressure
falls to a level greater than 0
 Lung volume during expiration and between breaths is greater than normal
 Major purpose – maintain or improve oxygenation while limiting the risk of O2 toxicity
o Facilitates oxygenation by increasing surface area for gas exchange and preventing airway
collapse
 Maximizes number of alveoli available for oxygen exchange
 Allows oxygenation with less FiO2
o Physiological PEEP is 5 sonometers of H20 (pressure left in lungs)
 PEEP higher than 5 cm result in decreased cardiac output
 Higher levels of PEEP can result in pneumothorax
 Do not increase PEEP in patient with COPD/atelectasis
o Indications
 Class indication – ARDS
 Lungs with diffuse disease
 Severe hypoxemia – unresponsive to FiO2 > 50%
 Loss of compliance or stiffness
 Pulmonary edema
o Contraindications
 Highly compliant lungs (COPD)
 Unilateral or non-uniform disease (atelectasis)
 Hypovolemia
 Low cardiac output
o Complications
 Decreased cardiac output due to decreased venous return
 IICP related to decreased venous return – usually no PEEP or less than 5 sm PEEP
 Alveolar barotrauma and pneumothorax
 May stimulate renin-angiotensin release and later decrease renal function due to
decreased renal flow
-
Continuous Positive Airway Pressure (CPAP)
o Continuous positive pressure to maintain continuous level of positive pressure-constant flow
 Usually for obstructive sleep apnea
o Similar to PEEP, but applied continuous – PEEP is just on exhalation
o Caution in patient with myocardial compromise because this increases the workload of breathing
and the patient has to breathe against the continuous pressure
Newer Modes of Ventilation
- Volume assured ventilation
- Adaptive support ventilation
Complications of Positive Pressure Ventilation
- Pulmonary system
o Barotrauma (pressure ventilation)
o Volutrauma (volume ventilation)
o Alveolar hypoventilation/hyperventilation
o Ventilator – associated pneumonia (VAP)
- Sodium and water imbalance r/t renin system
o Progressive fluid retention 48 – 72 hours after positive pressure ventilation, especially PEEP
- Neurologic system
o PEEP can impair cerebral blood flow; may also have increased ICP with JVD
- Gastrointestinal system
o Use of a peptic-ulcer prophylaxis is recommended (Zantac, enteral nutrition)
- Musculoskeletal system
o Early progressive ambulation – helps prevent immobility associated problems
- Psychosocial needs
o Patients want to feel safe – help them gain control and give them hope
- Machine disconnection or malfunction
o ALWAYS LEAVE THE ALARM ON!
Special Considerations for Nursing Care
- Sedation
- Neuromuscular blocking agents
o Used to provide more effective synchrony with the ventilator thereby increasing oxygenation
o Note: this does not provide sedation or analgesia
o Prone positioning
Vent Settings
- TV: usually 6-10 cc/kg
- RR
- FiO2: lowest % to achieve PaO2 at least 60%
- PEEP: usually 5-10 (avoid ­ r/t barotrauma and ↓ CO)
- PS: usually 5-10 (support needed to get through the tubing)
Nursing Report Example
- On vent per OETT taped 22 cm at the lip. TV 700, SIMV 10, PS 10, P 5, 50% FIO2.
Weaning
Weaning
- The process of reducing ventilator support and resuming spontaneous ventilation
- Collaborative process between provider (physician/NP), respiratory therapy and nursing
Weaning Indicators
- Reversal of underlying cause of respiratory failure
- Adequate oxygenation
o PaO2/FIO2 >150 – 400
o SpO2 ≥ 90%
o PEEP ≤ 5 – 8 cm H2O
o FIO2 ≤ 40-50%
o pH ≥7.25
- Hemodynamic stability
o Absence of myocardial ischemia
o Absence of clinically significant hypotension (no vasopressor therapy or low dose)
- Patient ability to initiate an inspiratory effort
- Other considerations
o Hemoglobin ≥ 7-10 mg/dL
o Core temperature ≤ 100.4
o Mental status awake and alert or easily arousable
Readiness for Weaning
- RR (> 8 and < 35) and TV  10 LmL/kg
- Rapid shallow breathing index (RSBI) < 105
- Negative inspiratory force (NIF) > - 20
- Compliance, respiratory rate, oxygenation, maximal inspiratory pressure index (CROP) > 13
Process of Weaning
- Use of pressure support or CPAP is common
- T-piece with O2 for one hour
o Take patient off the vent for 1 – 2 hours and watch oxygenation status
o Do ABGs at the end of the hours and assess their status
- Once-daily trial of spontaneous breathing; take off during day and put back on at night
- Monitor SP02, HR, RR, BP
- Return patient to the ventilator if the patient is in acute distress
Ventilator Bundle and VAP Prevention
- Head of bed (HOB) elevation ≥ 30 degrees reduces the frequency and risk for nosocomial pneumonia
compared to supine position
- The use of thrombo-prophylaxis is effective for preventing deep venous thrombosis (DVT)
- The use of peptic ulcer disease (PUD) prophylaxis reduces the risk of upper gastrointestinal bleeding
- Daily interruption of sedative drug infusions decreases the duration of mechanical ventilation and length
of stay (LOS) in the ICU – “sedation vacation’s”
-
NG tube placement to prevent aspiration of gastric content with vomiting and keeps gut functioning
Intensive insulin therapy to maintain blood glucose ≤ 110 mg/dL reduces morbidity and mortality
among critically ill patients
Daily screening of the respiratory function followed by trials of spontaneous breathing can reduce the
duration of mechanical ventilation, decrease complications and costs of ICU care
Mouth care every 2-4 hours with chlorohexadine solution
Review
-
-
Causes for a high-pressure alarm to go off:
o Biting the tube
o Kinked tubing
o Secretions (mucous plugs)
o Bronchospasm/pneumothorax
Causes for a low-pressure alarm to go off:
o Vent becomes detached
o Patient self-extubates
CASE SCENARIOS
1. The high-pressure alarm on the ventilator sounds.
a. What are some potential causes of a high-pressure alarm on a ventilated patient?
b. How would you troubleshoot the alarm?
2. You hear vocal sounds coming from a ventilated patient’s mouth.
a. Should you be able to hear vocal sounds from a ventilated patient?
b. What are some of the potential causes of vocal sounds in a ventilated patient?
c. How would you intervene for each of the identified problems?
3. The low minute ventilation alarm sounds on the vent. The patient’s settings are SIMV with a TV (tidal
volume) of 650, rate of 4, PS (pressure support) 10, P (peep) 5.
a. What could be the potential problem and how would you intervene?
4. The low-pressure alarm sounds on the vent.
a. What are the potential causes of a low-pressure alarm and how would you intervene for each of
the identified causes?
5. Your patient is on CPAP and the apnea alarm keeps going off.
a. What is the problem?
6. Your patient is sedated and on full ventilator support. The power to the building goes out due to an
electrical storm.
a. What do you need to do?
7. You walk into your patient’s room and find him self-extubated with endotracheal tube in his hand. At
the time this happened, he had been on FIO2 of 0.4 and a PEEP of 5 cm H20. His PAO2 earlier in the
day was 100 mm Hg. The team had been planning to do a spontaneous breathing trial in the morning.
a. What should you do?
ACUTE/PAIN SEDATION
Pain Management and Sedation
- Humane/compassionate care
- Pain and discomfort elicit physiologic responses that are maladaptive
o Increased HR, BP, RR, cortisol release; anxiety
- Pain, agitation, and delirium are associated with poor outcomes
o Discharge criteria: have to be eating and back at baseline in terms of functioning
- Caveat: can limit patients' ability to cooperate with pulmonary hygiene, weaning, mobilization and other
aspects of care
Physiological Responses to Pain and Anxiety
- Tachycardia
- Tachypnea
- Hypertension
- Increased cardiac output (only initially)
- Pallor and/or flushing
- Cool extremities
- Mydriasis (pupillary dilation)
- Diaphoresis
-
Increased glucose production
(gluconeogenesis)
Nausea
Urinary retention
Constipation
Sleep disturbances
Atelectasis in bases of lungs (from breathing
shallow breaths)
A Difficult Dilemma: Pain and Anxiety are Inter-related
- One exacerbates the other; physiological responses are similar
- Anxiety contributes to pain by activating pain pathways
o Alters perception of pain (usually increased)
o Increases aversion and decreases tolerance of pain
o May increase the reporting of pain
o Always treat the PAIN 1st and hopefully anxiety with subside
- Nurses must accurately assess the problem
- Treating anxiety when pain is the problem (and vice versa) leads to the escalation of both
- IMPORTANT: assess pain and anxiety continuously and independently
Society of Critical Care Medicine Multidisciplinary Document on Pain and Sedation
- Use of standardized scales necessary
- Treat pain FIRST, then anxiety AFTER
- Morphine is usually the gold standard (other drugs may be more appropriate)
o Causes vasodilation – may also cause sedation, hypotension, etc. so if a patient has low cardiac
output or blood pressure, this may not be the best option.
- Drugs are not always the answer
o Pre-operative teaching will help
 Ex. Pain related to chest tubes will be relieved with ambulation and removal
Pain
-
-
The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and
emotional experience associated with actual or potential tissue damage”
o Tissue damage may result from more than things such as trauma or wounds, can occur from IV
sticks, invasive lines, etc.
Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it
does (do not impose our beliefs when making assessments, etc.)
Acute Pain
- Onset is sudden and duration is short term (< 3 months)
- May be brief, acute pain or acute persistent pain
- Accompanied by a high level of autonomic arousal (increased HR, RR, BP, anxiety, confusion)
- Associated with tissue pathology, injury, or surgery
Sources of Pain and Discomfort
- Physical illness, trauma, surgery
- Monitoring devices
- ET tubes, tracheostomy tubes, mechanical ventilation
- Routine nursing care (suctioning, dressing changes, position changes, ambulation)
- Prolonged immobility
Procedures Rated as Moderately or Severely Painful in ICU Patients
- ABG/arterial line insertion
- Mechanical ventilation
- Central line insertion
- Moving from bed to chair
- ET suctioning
- NG tube insertion
- ET tube in place
- IV insertion
- Indwelling urinary catheter
- Turning in bed
Pain Assessment
- The patient’s self-report is the most reliable indicator of the existence and intensity of adult pain
- Nurses often assume that the patient who is extremely ill, weak or confused cannot self-report pain
- Assessment:
o Precipitating factors
o Quality (stabbing, dull, sharp)
o Radiation
o Severity
o Timing
Pain Scales
- Numeric Pain Rating Scale
-
Visual Analog Scale
-
Verbal Intensity Pain Scale
-
Faces Pain Scale
-
Critical Care Pain Observation Tool (more for critical care patients who are sedated or unable to explain
their pain)
Descriptive scale (i.e., elephant on my chest, stubbing a toe, burning hand on stove, etc.)
Behavioral observation scale (i.e., HR>140, grimacing, rapid respirations, rocking, crying)
-
Critical Care Pain Observation Tool
Pain History
- Prior acute pain experiences
o Ever had this pain before? What treated it?
o Older adults usually do well with just Tylenol for pain relief due to higher pain threshold because
opioids typically alter LOC
- Chronic pain – usually a higher tolerance of pain meds and may take a lot more to get under control
- Usual relief measures
Nursing Management: Acute Pain
- Selecting the appropriate analgesic
- Evaluating when to administer the analgesic
o Address pain early on – if someone’s pain gets really severe, it is hard to later control the pain
- Evaluating how much to administer
o Pain history, hemodynamic status, patient size, opioid-naïve, etc.
- Obtaining a change in prescription when needed
- Routes of administration from fastest onset to slowest: IV, IM, PO, transdermal
SCCM Recommendations
- Scheduled analgesia recommended as opposed to titration
- Infusion when control is difficult with scheduled doses
o Ex. Continuous infusion or PCA
- Use of slow release medications recommended for de-intensifying therapy and providing baseline
analgesia for breakthrough pain
- Use multiple approaches other than medications
2 Approaches to Pain Management
- Preventive
o Analgesics are given BEFORE the patient
complains of pain – give around the clock
(ATC) instead of PRN
 Teach the patient not to wait until
pain becomes a 10 before asking for
medication
- Titration
o Using the PRN dose while adjusting and
individualizing therapy based on the effect
the drug is having on the patient
o Use your judgment and refrain from administering entirety of the ordered dose if it seems like it
is too high of a dose (can always give less, but not more)
o Titration depends on the level of pain (mild, moderate, severe)
PCA Pumps
- PCA pumps have a time interval between each possible dose: max of ___ ml/hr
o If the patient pushes the pump before the next time interval, it will not administer a dose
- Educate the patient about how the pump works
- Can have a PCA pump with just a basal rate, just a bolus dose or both
o Basal rate is set so the patient will get a pre-determined dose every hour like 1 mg/hr
o Bolus dose is set up so if the pain control is not good enough, the patient can get extra
medication by pressing the button and the bolus will have a maximum
- Another type is the epidural PCA – these do NOT provide bolus doses, typically just a basal rate
Benefits and Risks of Analgesics
- Benefits
o Reduce stress response, improves patient comfort
o Increased participation in care – to a point (ambulation, toileting, etc.)
- Risks
o Respiratory depression (narcotics, increased risk for aspiration, respiratory acidosis)
o GI motility reduction (constipation, impaction, ileus)
 Often times the patient is simultaneously on a stool softener to prevent this
o Additive sedation
o N&V (Zophran)
o Pruritus (Nubain usually treats – used for pain but also relieves itching)
Analgesics for Acutely Ill Patients
- Opioids
o Morphine (IV, Duramorph, MS Contin, Roxanol)
 Gold standard for analgesia
 Longer interval of action than Fentanyl (short acting)
 Give this when a longer duration of action is needed
 Easy to titrate – give 1 to 2 mg at a time and then re-assess
 Available in various routes
 *Roxanol (liquid morphine) is HIGHLY concentrated and should be given in very
minute amounts – very careful with dosage calculations – usually used with
cancer patients or hospice patients
 Has active metabolite that can accumulate with renal insufficiency (high creatinine and/or
dialysis patient) and leads to prolonged sedation – careful with patients with renal
problems
 Decrease the dose or decrease frequency of administration
 Causes direct vasodilation (pro and con)
 HTN or pulmonary edema – good
 MAP of 65 – bad
o Fentanyl (sublimaze IV or Duragesic patch)
 Rapid onset of action – like a patient in acute distress
 Hemodynamic stability (no direct vasodilation)
 Ex. A highly-anxious patient with HTN can receive this medication and although
it does not directly cause vasodilation, when the patient’s anxiety is reduced, they
can settle down and indirectly lower their BP.
 Better option for when the patient has low blood pressure
 Short duration with intermittent dose
 Good to use for weaning a patient
 Chronic pain
 Typically given during recovery or short procedures
 100-fold analgesic potency of morphine (1/100 dose of Morphine)
 No renal dosing – does not have any active metabolites
 Patches (Duragesic)
 Provides low constant dose – change the patch q72h and rotate sites)
 Questionable absorption with edema or diaphoresis
 Used in weaning patient off of pain medications
 Often used with cancer patients along with MS Contin
o Hydromorphone (Dilaudid)
 Used for patients who are hemodynamically unstable
 Given if the patient is allergic to Morphine
 Smaller dosing compared to Morphine
 No direct vasodilation
 Longer duration of analgesia than Fentanyl
 Lack of active metabolite – good for renal insufficiency
 Stronger than morphine
-
o Meperidine (Demerol)
 Avoid repeated dosing
 Active metabolite (normeperidine) – accumulates in renal insufficiency
 CNS stimulant; lowers the seizure threshold
 Tremors
 Agitation
 Psychosis
 Seizures (ALWAYS ASK PATIENT ABOUT SEIZURES)
 Contraindicated: patient with acute pain lasting more than 2 days or requiring large doses
Non-narcotic analgesic
o NSAIDS
 Ketorolac (Toradol)
 Non-sedative/respiratory effect
 350x stronger ASA
 PO, IV, IM
 30 mg = 10 – 12 mg Morphine
 Opioid sparing – allows you to give 25 – 50 % less of Morphine
 Change dose related to renal function (decreases renal blood flow), age over 70
 No longer 5 days due to increased bleeding and renal indices
o Acetaminophen
 Ofirmev (acetaminophen) injection 1000mg/100ml – IV piggyback
 Indications – management of:
o Mild to moderate pain adult and pediatrics > age 2
o Moderate to severe pain with opioid in adult and pediatrics > age 2
o Reduction of fever in adult and pediatric patients
 Dosage
o Adult: 1000 mg IVPB over 15 minutes q 6 hours x 24 hours
o Adult and adolescents < 50 kg and pediatrics: 15 mg/kg q 6 hours
Agonist-Antagonist Agents
- Nubain, Buprenex, Stadol
o Work on a different pain receptor than the opioids
o Tend to not cause as much sedation or respiratory depression
- BE CAREFUL – may precipitate withdrawal in chronic opioid users
Adjuvant Therapy
- Drug that has a primary indication other than pain (i.e., anticonvulsant, antidepressant, muscle relaxant)
but an analgesic for some conditions
o Ex. Neurontin – is an anticonvulsant drug, but used a lot for neuropathic pain
Alternate Pain Control
- PCA – IV/epidural
o Also PCA morphine/hydromorphine
- Epidural- thoracic/abdominal surgery (goal is to increase pain management without increasing
respiratory depression)
o Fentanyl/ bupivacaine
 Increase respiratory sedation
 CMS – circulation, movement, sensation below the level of insertion
 Risk of epidural hematoma
o Absolutely not anti-coagulants (Lovenox, etc.)
- On Q ball
On-Q
- Better pain relief and less need for narcotics
o Delivers an anesthetic (ex. lidocaine)
- Feel better faster
- Quicker return to normal body function
- Less chance of grogginess (do not use as much opioids with this)
- Greater mobility
- Potential for earlier hospital release
o Usually used in patients with thoracic surgeries and orthopedic procedures
SCCM Clinical Practice Guidelines
- If IV analgesia is required, Fentanyl, hydromorphone (Dilaudid), and MS are recommended agents
- Fentanyl is preferred for rapid onset of analgesia in acutely distressed patients
- Fentanyl or hydromorphone best for hemodynamic unstability or renal insufficiency
- MS and hydromorphone are preferred for intermittent therapy because of longer duration of action
Equianalgesia
- To provide equal analgesic effect with new agents
o If we are trying to switch someone over from IV to PO or opposite
- Conversion Equivalence conversion
o How do you change from PO to IV and get the same pain relief
- Several Apps: Opioids Conversion
What to use other than drugs?
- Family
- Music
- Massage, lighting
- Positioning
-
Temperature
Sleep
Spirituality
Pet therapy
Under-treatment of Pain
- Oligoanalgesia: the practice of treating pain with minimal drug use – the MD does not think that the
patient is really in pain
Inadequate Treatment of Pain
- 4 common misconceptions regarding opiate use that contribute to inadequate treatment of pain:
o Fear of addiction (opiophobia)
o Fear of physical dependence
o Fear of tolerance
o Fear of respiratory depression
Sedation
- The process of allaying nervous excitement
- The goal is to have a calm patient that can easily be aroused with maintenance of a normal sleep
schedule
- Levels
o Light sedation (minimal sedation,
anxiolysis)
 Patient follows commands
 Cognitive functions and
motor coordination may be
impaired
 Ventilation and
cardiovascular function are
unaffected
o Moderate sedation (AKA:
conscious sedation or procedural
sedation)
 Depression of consciousness during which patients respond purposefully to verbal
commands or shaken
 Minimize anxiety and discomfort while reducing undesirable autonomic responses to
painful stimuli or to help a patient through a procedure that requires that they remain still
for an extended period of time
 Conscious sedation requires nurse to be certified
 Patient maintains his own airway
 Cardiovascular function usually unaffected, but respiratory IS affected
 Typically used for someone having wisdom teeth pulled, cardioversion, colonoscopy
o Deep sedation and analgesia
 Depression of consciousness during which patient cannot be easily aroused but may
respond purposefully after repeated or painful stimulation
 Require assistance in maintaining a patent airway (bagging, ET tube LMA); spontaneous
ventilations may be inadequate
 Cardiovascular function is usually maintained
o General anesthesia
 A drug-induced loss of consciousness during which patients are not arousable, even by
painful stimulation
 The ability to independently maintain ventilatory function is often impaired
 Patients often require assistance in maintaining a patent airway




Positive pressure ventilation may be required because of depressed spontaneous
ventilation or drug-induced depression of neuromuscular function
Cardiovascular function may be impaired
Highest level of sedation; total loss of consciousness
A sedative is usually given before they put someone under general anesthesia
Anxiety Management (SCCM)
- Rule out other causes for the behaviors
o Hypoxia, hypoglycemia, sensory overload, drug interaction, sleep deprivation, pain, fear
- Once other causes are ruled out, move to medications with a plan
- Most desirable to have PRN orders
Sedation Measurement
- Sedation-Agitation Scale (SAS)
-
Motor Activity Assessment Scale
Sedatives used in Critically Ill Patients
- Benzodiazepines [antidote  Flumozenil]
o Midazolam (Versed)
 Used for conscious/procedural sedation – short acting
 Ex. Pre-op, cath lab
 Causes amnesia
o Diazepam (Valium)
 Typically used for seizure patient and status epilepticus
o Lorazepam (Ativan) **
 Used for long-term (24, 48 hours or days) sedation
 Ex. Seizures, agitation, etc.
- Non-benzodiazepine sedative
o Propofol (Diprivan)
 In low doses, induces a state of deep sedation
 Short half-life, patient can be fully conscious within 30 minutes after stopping infusion
 Slows cerebral metabolism and decreases IICP
 Sedative of choice for closed-head injury or bleed
 Not a reliable amnesic – they may still be able to hear you
 High lipid content-delivers 1.1 kcal/mL as fat – all tubing and solution must be changed q
12 h (usually tubing will be harder and have a yellowish color than normal tubing)
 *Patient must be on the vent and intubated – they need airway support
 Contraindication: allergy to eggs, egg products and soy
 “PRIS” – Propofol Related Infusion Syndrome
 Rare; generally associated with high doses and prolonged use
 Characteristics include:
o Acute refractory bradycardia
o Severe metabolic acidosis
o Cardiovascular collapse
o Rhabdomyolysis
o Hyperlipidemia
o Renal failure
o Hepatomegaly
- Selective alpha 2 receptor agonist
o Dexamedetomidine (Precedex)
 Centrally acting alpha-2 agonist
 Short-term sedative for mechanically ventilated patient (24 hours)
 Decreases norepinephrine levels
 Reduces brain noradrenergic activity (blocks stress response)
 Decreases blood pressure and heart rate
 Reduces need for add-on morphine
 Little amnesic effect
 Still address them as a patient who is awake/alert because they will remember
what they hear
 Caution in diabetes – related to more pronounced hypotension and decreased sympathetic
response (bradycardia)
Over Sedation
- A state of unintended patient unresponsiveness in which the patient resides in a state of suspended
animation that resembles general anesthesia
- Narcan is used as the antidote for narcotics, Romazicon is given for benzodiazepines
o Caution should be used with patients who have renal impairments, COPD with CO2 at home,
etc.
Too Little Sedation
- Unplanned extubation in restless, anxious, agitated patients occurs in 8-10% of intubated patients after
an average of 3.5 days in the CCU
o Of these self-extubations, 6% cause significant complications (aspiration, dysrhythmias,
bronchospasm, bradycardia)
Who Can Administer Procedural Sedation?
- Adult patients classified as Status I, II or III and pediatric patients classified as Status I or II are
appropriate for administration of mild to moderate sedation by a qualified Registered Nurse.
- Adult patients classified as ASA status IV or V and Pediatric Patients classified as status II, IV, or V are
not appropriate for administration of mild to moderate sedation agents by an RN and should have
anesthesia provider responsible for care.
ASA Classification
The purpose of the grading system is simply to assess the degree of a patient’s "sickness" or "physical state"
prior to selecting the anesthetic or prior to performing surgery
-
ASA Physical Status 1 - A normal healthy patient
ASA Physical Status 2 - A patient with mild systemic disease
ASA Physical Status 3 - A patient with severe systemic disease
ASA Physical Status 4 - A patient with severe systemic disease that is a constant threat to life
ASA Physical Status 5 - A moribund patient who is not expected to survive without the operation
ASA Physical Status 6 - A declared brain-dead patient whose organs are being removed for donor
purposes
Narcan
- Reverses opioid agonists
- Dose:
o Adult
 Post-anesthetic or opioid dependent: 0.1-0.2 mg/kg IV; may repeat q2-3min PRN
 Opioid overdose: 0.4-2 mg IV; may repeat q2-3min PRN
o Pediatric
 Post-anesthetic reversal: 0.005-0.01 mg/kg IV/IM; may repeat q2-3min PRN
 Opiate intoxication: 0.01-0.1 mg/kg dose IV/IM; may repeat every min; not to exceed 2
mg/dose
- Onset of action for IV is 1-3 minutes vs 10 -15 minutes for IM; rebound sedation may occur; if used in
patient with chronic opioid use, will precipitate acute withdrawal and abrupt sympathetic discharge
possible leading to acute pulmonary edema
Flumazenil (Romazicon)
- Reverses benzodiazepines
- Adult dose:
o Partial antagonism (for sedation reversal): 0.1-0.2 mg IV infused over 15 sec; may repeat after
45 sec and then every min; not to exceed total cumulative dose of 1 mg
o Complete antagonism (for overdose): 0.2 mg IV infused over 30 sec; may repeat with additional
doses of 0.5 mg over 30 sec at 1-min intervals; not to exceed a total cumulative dose of 3 mg
- Pediatric Dose:
o 0.01 mg/kg/dose IV infused over 15 sec; not to exceed 0.2 mg/dose; may repeat every min; not
to exceed total cumulative dose of 0.05 mg/kg or 1 mg (whichever is lower)
- Rebound sedation may occur; if used in patient with chronic BZP use, will precipitate acute withdrawal;
may precipitate seizures unresponsive to BZPs
Post Procedure Monitoring
Delirium
- Occurs in up to 87% of mechanically ventilated patients in the ICU
- Associated with increased mortality, ICU stay, and health care costs
- 98% of nurses routinely assess sedation level whereas only 47% assess for the presence of delirium
Assessing for Delirium (S/S)
- Reduced awareness of the environment
o This may result in:
 An inability to stay focused on a topic or to change topics
 Don’t ask a specific date, rather try to ask the day of the week, month, year
 Wandering attention
 Getting stuck on an idea rather than responding to questions or conversation
 Being easily distracted by unimportant things
 Being withdrawn, with little or no activity or little response to the environment
- Poor thinking skills (cognitive impairment)
o This may appear as:
 Poor memory, particularly of recent events
-
 Disorientation, or not knowing where one is, who one is or what time of day it is
 Difficulty speaking or recalling words
 Rambling or nonsense speech
 Difficulty understanding speech
 Difficulty reading or writing
Behavior changes
o Seeing things that don't exist (hallucinations)
 Often times they see family members that are not living
o Restlessness, agitation, irritability or combative behavior
o Disturbed sleep habits
o Extreme emotions such as fear, anxiety, anger or depression
Causes of Delirium
- Neuro: TIA, meningitis, encephalitis, brain abscess
- MI
- Infection
- Respiratory hypoxia, PE
- Alcohol withdrawal
- Glucose
- Metabolic: sodium
Treatment of Delirium
- Correct cause if identified
- Neuroleptic
o Haloperidol (Haldol) is usually the drug of choice
 IM, IV
 10 – 20 minute onset, lasts for hours
 SE: EPS (increases with Benzo use)
 Neuroleptic malignant syndrome / Torsades de pointes
 Avoid with Parkinson’s patient
- Antipsychotic
o Olanzapine (Zyprexa)
Unit 3
Management of Patients with Cardiac Disorders
ARTERIOSCLEROTIC CARDIOVASCULAR DISEASE
Arteriosclerotic Cardiovascular Disease (ASCVD)
- Type of blood vessel disorder that is included in general category of atherosclerosis
o Atherosclerosis major cause of CAD
- Focal deposit of cholesterol and lipids in the intimal wall of the artery
- Other causes of injury to intimal lumen of artery:
o Tobacco use, hypertension, diabetes, some infectious processes
Development of Plaque
- Occurs over many years – progressive disease
o Fatty streak: lipid filled smooth muscle cells
 Usually develops a yellow tinged appearance in the vessel
 Can occur as early as age 20
o Fibrous plaque: beginning of progressive changes in the endothelium of vessel
 LDL and growth factors from platelets stimulate smooth muscle proliferation and
thickening of the arterial wall
 Lipoproteins transport cholesterol and other lipids into the arterial intima
 Can occur as early as age 30
o Complicated lesion: final stage, most dangerous, continued inflammation
 Plaque grows, instability, ulceration, and rupture
 CRP is a non-specific inflammation marker that is increased in patients with
CAD, which can trigger rupture of plaque in the arteries – heart attack
 Activation of platelet, exposed platelets cause expression of glycoprotein llb, lla receptors
that bind fibrin
 Causes further platelet aggregation and adhesions
Risks
- Non-modifiable
o Age
o Gender
o Ethnicity
o Genetic inheritance/family history
- Modifiable
o Lipids
 Total cholesterol
 < 200 desirable
 200 – 239 borderline high
 > 240 high
 LDL cholesterol
 If ASCVD, < 70
 < 100 optimal
o
o
o
o
o
o
o
o
o
 100 – 129 near/above optimal
 150 – 199 borderline high
 200 – 499 high
 > 500 very high
 VLDL
 Desirable < 30
 HDL cholesterol – GOOD CHOLESTEROL!
 < 40 low for men
 < 50 low for women
 > 60 high (this is what we want)
o #1 way for patients to increase HDL is exercise
o If HDL is really high, the total cholesterol total will be high too, which is
not a bad thing
 Triglycerides
 < 150 normal
Blood pressure
 HTN high risk patients (>10% risk [CAD, DM, CKD]) target BP of 130/80
 HTN low risk patients (<10% risk) target BP of 140/90
Tobacco use
Activity
 30 minutes five or more times/week
 Physical inactivity is a major contribute to CAD
Psychological states
 Depression, chronic stress, Type A personality
Obesity
 Abdominal obesity: men (> 102 cm or > 40 in), women (>88 cm or > 35 in)
Diabetes
 Hb A1C level < 7%
Elevated homocysteine
Substance abuse
 Cocaine and methamphetamines use
Metabolic syndrome (3 or more of the following)
Recommendations for Statins
- People without cardiovascular disease who are 40 to 75 years old with 1 or more CVD risk factors and a
CVD event risk of 10% or greater
- People with a history of heart attack, stroke, stable or unstable angina, peripheral artery disease,
transient ischemic attack, or coronary or other arterial revascularization
- People 21 and older who have a very high level of LDL cholesterol (190 mg/dL or higher)
- People with Type 1 or Type 2 diabetes who are 40 to 75 years old
ACUTE CORONARY ARTERY SYNDROME (ACS)
Acute Coronary Syndrome
- A term used to describe a spectrum of clinical syndromes (in patients with coronary atherosclerosis)
representing varying degrees of coronary artery occlusion
o Syndromes:
 ST elevation MI (STEMI)
 Non-ST elevation MI (NSTEMI)
 Look at cardiac enzymes
 Unstable angina (UA)
- Deterioration of a once stable plaque – rupture – platelet aggregation – thrombus formation
- Results in:
o Partial occlusion of coronary artery – UA or NSTEMI
o Total occlusion of coronary artery – STEMI
- S/S
o Angina pectoris (chest pain)
 Severe, immobilizing chest pain usually described as crushing, unrelieved by rest,
nitroglycerin, or position changes
 Can be described as an uncomfortable pressure, fullness, squeezing
 Women and DM do not present with the classical presentation – may complain of scapula
pain
 Chest pain will not be able to be reproducible by palpitation (“If I touch does it hurt?”)
o SOB – DOE
o Palpitations
o Severe weakness
o Moderate to severe anxiety
o Lightheadedness
o Fatigue
o Diaphoresis
o Diabetics and women often have
o N&V
atypical symptoms
 Usually with RCA/inferior
ANGINA
Precipitating Factors
- Physical exertion
- Temperature extremes – usually extremely cold
- Strong emotions – anxiety, fear
- Consumption of heavy meals – blood diverts to the GI tract
- Tobacco use
- Sexual activity
- Stimulants – drugs
o Increase HR and myocardial oxygen demand
- Circadian rhythm pattern
o Based on cortisol – increased in the morning
o Cortisol levels increase in the morning to wake us up, thus increasing O2 demand of the heart
(i.e., increase incidence of strokes and heart attack in the morning)
Unstable Angina – unpredictable
- Chest pain that is not predictable, often occurring at rest and increasing in frequency and severity
- Rarely sharp or stabbing, no change with position or breathing – not reproducible
- Most common pathophysiology is thrombus resulting from disruption of atherosclerotic plaque
o Adherence of platelets and fatty acids
- Some blood continues to flow through affected artery; however, blood flow is severely diminished
- Patient generally seeks medical attention, frequently fearful of MI
- Women and diabetics present differently than men
- Pain is more severe than stable angina
- Pain may occur at rest
- Requires more frequent NTG therapy
o Vasodilator that is used for immediate vasodilation of the coronary arteries
- ECG may show ST segment depression during acute attack (ischemia)
o ST segment may return to normal or may progress to AMI (elevation)
Management of UA
- Serial ECGs
- Serial enzymes
- Cardiac catheterization – not as urgent as STEMI and NSTEMI
- PCI if indicated
ACUTE MYOCARDIAL INFARCTION (AMI)
Acute Myocardial Infarction
- Ischemia (prolonged – evolves over time) resulting in the death of myocardial tissue in coronary artery
o Myocardial tissue can be salvaged for up to 12 hours from onset of symptoms – this tissue does
not regenerate
 First question to ask patient – “when did symptoms start?”
o Infarcted area cannot conduct electrical impulses and cannot contract – leads to dysrhythmias
- Caused by occlusion of coronary artery or its branches
o Tissue death leads to malfunctioning portion of the heart which is the ultimate cause of abnormal
heart rhythms
- Irreversible myocardial necrosis
- Mostly secondary to atherosclerosis (95%)
- Other causes: coronary spasm (Prinzmetal), coronary embolism, blunt trauma, and cocaine use
Diagnosis [symptoms, 12 lead EKG, enzymes]
- ECG changes
o ST elevation (> 1 mm in limb or 2 mm in chest leads) in 2 or more contiguous leads – STEMI
o ST depression (> 0.5 – 1 mm) – unstable angina, NSTEMI
- Serial cardiac enzyme values – elevated enzymes are not necessary for a decision to administer
fibrinolytics or perform PCI – can take a while for these to rise
o Myoglobin – in all muscles – levels rise with any type of muscle damage
 Levels rise very quickly and is the first one to see rise. It may be very significant if
someone comes in complaining of chest pain and there are other symptoms that are a
characteristic of an MI
o CK MB – more indicative of myocardial tissues
o Troponin levels – MOST INDICATIVE MARKER – only marker specific to heart muscle
- High level of suspicion for anyone over 35 who presents with chest pain longer than 20 minutes and
have a history/presence of multiple risk factors
Clinical Manifestations
- Pain – severe, immobilizing, not relieved by position changes, rest or NG therapy (hallmark)
o Usually occurs in the early morning hours lasting  20 minutes and is more severe than angina
o OA may experience a change in mental status (confusion), SOB, dizziness, etc.
- SNS stimulation – catecholamine release results in the release of glycogen, diaphoresis and
vasoconstriction (skin may be cool, clammy, ashen)
- CV changes
o Initial elevation of BP and HR, followed by a drop in BP
o May hear crackles and see JVD, heart sounds S3 and S4
- N/V
- SOB
- Diaphoresis
- Fever
- *Does it evolve with position changes?
12 Lead ECG
- #1 priority with patient presenting with chest pain
- Central to initial risk and treatment stratification – must conduct within 10
minutes of presenting to emergency department and read by a doctor
o Principle: ischemic/necrotic tissue does not conduct electrical
impulses normally – reperfusion dysrhythmias
- Elevated enzymes are NOT necessary for a decision to administer
fibrinolytics or perform PCI if the patient present with ST elevation in 2+
contiguous leads and multiple symptoms – send straight to the cath lab
o It can sometimes take 1 – 2 hours for enzyme levels to rise
- If the patient has ST depression, this is not as declarative – may need to
wait for enzymes
Cardiac Markers
- Time Review
o Myoglobin
 1st to rise
 Rise 2 hours, peak 3 – 15 hours, and normal at 24 hours
 Rapidly excreted in the urine, resulting in a rapid return to baseline
 NOT a specific heart enzyme, so can’t be used as a diagnostic alone. Must be present
with other things like ST elevation, several risk factors, etc.
o Troponin
 Myocardial muscle protein
 Slightly more specific than CKMB and will stay elevated longer
 Rise 4 – 6 hours, peak at 10 – 24 hours, and normal between 10 – 14 days
o CKMB
 Last to rise
 Rise at 6 hours, peak at 18 hours and normal between 24 – 36 hours
 CKMD specific marker for myocardial tissue
Localization of Infarction
- Since myocardial infarction is the result of an occluded coronary artery, it is worthwhile to develop a
familiarity with the coronary arteries that supply the heart. Once the infarction has been recognized and
localized, an understanding of coronary artery anatomy makes it possible to predict which coronary
artery is occluded.
Coronary Circulation
- The higher the MI, the more muscle that is involved.
- Right Coronary Artery – posterior
o Better to have this than L MI)
o Right atrium, right ventricle, SA node, AV bundle,
posterior LV
o Ischemia of SA node and AV bundle – arrhythmias, heart
blocks, bradycardia
 If patient has occlusion of the right coronary
artery – we would see a loss of P wave and
bradycardia due to the disruption of main SA node
conduction
- Left Coronary Artery – anterior and septum
o Left anterior descending – anterior wall is part of the L ventricle
 Anterior 2/3 of intraventricular septum
 Infarct/ischemia of inter-ventricular septum = high risk for bundle branch block –
responsible for sending impulses to right and left ventricles
 Anterior LV
 Lateral LV
 Anterior and lateral ventricle infarct/ischemia of this will cause cardiogenic
shock, or at the very least, HF
o Circumflex – lateral wall
 LA
 Posterior LV
 Lateral LV
- *If the occlusion is in the L main, before it branches off, it will cause ischemia in both left coronary
artery and circumflex. Blockage in the left main artery is commonly called the “widow maker”
Collaborative Management/Goals
- Reduce the amount of myocardial necrosis that occurs in patients with MI
- Prevent Major Adverse Cardiac Events (MACE)
o Lethal dysrhythmias, heart failure, cardiogenic shock, papillary muscle rupture, left ventricular
aneurysm, ventricular septal wall rupture
o Highest risk of 1 hour onset of chest pain – encourage patient to call 911 and NOT drive
themselves or have others
- Treat acute, life-threatening complications
- Prevention – aimed at modifiable risk factors
o Lifestyle changes – exercise, heart healthy diet,
weight loss
o Lipid lowering medications
o Aspirin
o Smoking cessation
o Hypertension and diabetes management
- Assessment of chest pain – LOCATE
Management of MI
- The mainstay of treatment for STEMI and NSTEMI with positive cardiac markers is early reperfusion
(within 12 hours of symptoms)
o PCI – placement of balloon/stent to widen narrowed artery – first line of treatment
 Preferred if onset of symptoms  3 hours (still can do outside this window)
 Skilled PCI facility with surgical back-up
 “Door to balloon” is < 90 minutes
 Diagnosis if STEMI is in doubt or confirmed STEMI has occurred
 Cardiac catheterization is first done to assess the location of blockage, severity, collateral
circulation and left ventricular dysfunction
o Thrombolytics/fibrinolytics – STEMI only!!!!
 Used on in ST elevation MI, only if PCI is not available
 Patient will still need to follow-up for a PCI or a bypass because it only de-solves
the clot. Plaque will still need to be removed.
 “Door to needle” is < 30 minutes
 Preferable to administer within 3 hours of symptoms, but can be administered up to 12h
 Streptokinase
 Anistreplase – eminase
 Alteplase – activase
 Reteplase – retavase
 Tenecteplase – TNK
 Complications
 Reperfusion arrhythmias (v-tach and v-fib)
o Ischemic myocardium finally gets blood supply and causes muscle to “get
excited” – starts having arrhythmias and need to be monitored closely
 Bleeding
o STOP INFUSION IMMEDIATELY!
o Obtain V/S and assessment
 Decreased BP, increased HR, LOC, or urine changes
o Notify MD
 Contraindications
 Absolute – intracranial hemorrhage, intracranial neoplasm, closed head injury
w/in 3 months, active internal bleed, suspected aortic dissection
 Relative (HCP and family weight benefit vs risk) – hypertension SBP > 180 /
DBP > 110, ischemic stroke < 3 months, prolonged CPR > 10 min, rectal bleed,
pregnancy, use of anticoagulants
o CABG
 If severe left ventricular dysfunction is thought, this may also be required
o Medical management
- If UA or STEMI with negative cardiac markers and ongoing angina:
o Combination of aspirin, heparin and a glycoprotein llb/lla
o PCI considered once angina is controlled or angina returns and increases in severity
- Time is muscle – the shorter the time to reperfusion, the greater the benefit. A 47% reduction in
mortality was noted when fibrinolytic therapy was provided in the first hour.
Complications
- Dysrhythmias – 80% of MI patients
o V. fib is a common cause of cardiac death – a lethal dysrhythmia that occurs most often in the
first 4 hours after the onset of pain
o Patients must be monitored on telemetry
- Heart failure
o Especially if in the left ventricular wall – “work horse” – the blood is backing up into lungs
 SOB, pulmonary edema, decreased O2, tachypnea, restlessness, agitation
- Cardiogenic shock
o Occurs when inadequate oxygen and nutrients are supplied to the tissues because of severe left
ventricular dysfunction
o Occurs less often now because of early PCI and fibrinolytic therapy
o Treatment: aggressive control of dysrhythmia, IABP therapy, support of contractility with
vasoactive drugs
o The goal of therapy is to maximize oxygen delivery, reduce oxygen demand and prevent
complications such as acute renal failure
- Papillary muscle dysfunction
o Papillary muscles hold the valves down. If these rupture, the valve becomes incompetent and
causes severe regurgitation = surgical emergency
o S/S: systolic murmur at apex of heart radiating toward axilla
o Occurs if infarcted area includes or is adjacent to the papillary muscle that attaches to the mitral
valve
 Causes mitral regurgitation, which increases blood in left atrium and decreases CO
o Detected by a systolic murmur at the apex of the heart radiating toward the axilla
- Ventricular aneurysm
o Ventricular MI – walls of ventricles stretch out = weakened area
o When infarcted myocardial wall becomes thinned and bulges out during contraction
o Besides ventricular rupture (fatal) ventricular aneurysms harbor thrombi – lead to emboli stroke
- Pericarditis
o Inflammation of the pericardial sac (inflammatory process), resulting in cardiac compression,
decreased ventricular filling and emptying, and HF
o Occurs 2-3 days after an acute MI
o Characterized by chest pain that is aggravated by inspiration, coughing, and upper body
movement
o Pain is relieved by sitting in a forward position
o Auscultation reveals pericardial friction rub and fever may also be present
o Diagnosis is with ECG and treatment includes Aspirin, corticosteroids, and NSAIDS
- Dressler syndrome – common post MI
o Caused by antigen-antibody reaction to the necrotic myocardial tissue
o S/S: Fever, pleural effusion, joint pain – usually self-limiting
o Symptoms include pericardial pain, fever, friction rub, pleural effusion, and arthralgia
o Specifically characterized by pericarditis with effusion (escaped fluid into cavity) and fever that
develops 4-6 weeks after MI or open-heart surgery
o Treatment: short term corticosteroids – usually treated with NSAIDs like Naproxen
o Lab findings: elevated WBC and elevated sedimentation rate
OTHER
Differential Diagnoses – Can cause non-cardiac chest pain
- Pulmonary
o Pneumonia
o Pleuritis
o Pneumothorax
o Pulmonary embolus
 If patient has chest pain that is not relieved with nitroglycerin, cardiac enzymes are not
elevated then the HCP will rule out PE
o Pulmonary HTN
- GI Causes
o Reflux
o Esophageal spasm
o PUD
o Pancreatitis
- MS and Misc
o Chostochondritis
 An inflammation of the junctions where the upper ribs join with the cartilage that holds
them to the breastbone, or sternum.
o Herpes zoster
o Anxiety
MEDICATIONS
Pharmacology Treatment
- Beta Blocker (typically always given)
o Decreases the myocardial oxygen demand by slowing the workload of the heart –  HR/BP
o All patient’s that come in with unstable angina or ACS get this
 Used in the first 24 hours of an MI to reduce the size of the infarction
o Metoprolol IV push q 5 minutes x 3 doses
o Contraindicated if the HR < 50 / SBP < 90
- Morphine Sulfate
o Pulmonary artery vasodilator – decreases workload of heart; treats the patient’s pain & decreases
anxiety
 Monitor for bradypnea or hypoxia
o Good for persistent symptoms and pulmonary edema
- Ca Channel Blocker (CCB)
o Given if patient cannot tolerate a beta blocker
- Nitroglycerin
o Coronary artery vasodilator
o Decreases angina
o Give this first if chest pain is unrelieved by other measures THEN give morphine
-
-
-
ACEI/ARB
o Consider for patients with HF or EF < 40%
o Reduces HF – used for EF < 40% , SBP > 100 (**within ~ 24 hr)
o Decreases afterload
o Usually not started in the ED, may be started 24 hours after
Aspirin (ASA)
o 162 – 325 mg crush/chew
o In acute phase, most cardiologists will start with large doses (325 mg) – CHEW
o Maintenance – when patient is stable enough to go home, they will have lower dose (162 mg)
and they don’t have to chew
Oxygen
o PRN for O2 sats < 90%
o Used to keep O2 sat > 90%
Nitroglycerin
- Coronary vasodilator – decreases angina (given BEFORE resorting to morphine)
o Vasodilates coronary and peripheral arteria – watch for hypotension
- Used to increase the preload and afterload of the heart while increasing the myocardial oxygen supply
- NO maximum dose that can be given
- Titrate to effect (chest pain)
o Keep SBP > 90; limit drop BP to 30 mmHg below the baseline in HTN patients
- Types
o Short acting (sublingual): spray, tablets
 Keep out of light
 Typically used in acute care settings – usually lasting about 6 hours
o IV – Tridil *usually what happens in the ER
o Long acting (extended release): Imdur (isosorbide monotitrate), Isordil (isosorbide dinitrate)
 May last up to 24 hours
o Ointment – paste
 Changed q6h
 ONLY used in hospitals
o Transdermal patches – 12 hours on / 12 hours off – prevents NTG induced vasodilation tolerance
- Nursing considerations
o IV nitroglycerin – titrate to effect: keep SBP > 90 and limit the drop in BP to 30 mmHg below
baseline in HTN patient
 Titrate up if patient continues to have chest pain
 Must watch BP when doing this – monitor frequently
 If patient complains of a headache, titrate down and give acetaminophen (Tylenol)
- Teaching
o Headaches are common with nitroglycerin use, not a side effect – give patient acetaminophen
o When patient goes home with nitroglycerin, can take up to 3 doses if initial doses do not help,
but must call 911 after taking the third dose
o Sit down for 5 minutes when taking this medication because it can cause faintness since it is
decreasing the blood pressure
o Replace every 6 months because they will start to lose potency
Fibrinolytics
- Decreases risk of thrombus formation
- “Dissolves clots” – not specific to coronary clots (dissolves clots anywhere) – this is why patients with
injuries or bleeds may not be safe/good candidates – increases bleeding risk
- *Used only in ST elevation MI
- “Door to needle” < 30 minutes
o Time is muscle” – aka very time sensitive; Integrilin
- Preferable to administer within 3 hours of symptoms but can be administered up to 12 hours – that’s
why always ask when did your chest pain start
- Most reliable sign that reperfusion has taken place: ST segment returning to baseline
- Treatment with fibrinolytics is aimed at stopping the infarction process by dissolving the thrombus in
the coronary artery and reperfusion of the myocardium
Other medications – used more from STEMI than NSTEMI + UA
- Heparin (continuous drip)
o Used as adjunctive therapy with fibrinolytics – therapeutic dose
o Used with Aspirin and other platelet inhibitors in UA and NSTEMI
o Therapeutic dose rather than prophylactic dose – 1 mg/kg BID
- Glycoprotein 2-b/3-a Inhibitors (ReoPro, Integrillin, Aggrastat)
o IV platelet inhibitors
o Used with Aspirin, Heparin, and clopidogrel (Plavix) and early PCI for UA/NSTEMI
- Oral anti-platelets after PCI
o Plavix (clopidogrel), Effient (prasugrel), Brilinta (ticagrelor)
o Post-stent placement especially – decrease platelet aggregation until endothelial grows over stent
o Important to educate about not missing doses – will go home on this
- Anti-dysrhythmic drugs – if indicated
o Ex. Amiodarone, Lidocaine
- Lipid lowering medications – within 24 hours
- Stool softeners
o Prevent straining – do not want a vagal response and cause other problems
EXAMPLE
Acute Coronary Syndrome
- A 62-year-old man present to the ED with c/o pain in his chest and jaw. The pain originally occurring
only with exertion and resolving with rest became increasingly persistent over the past 2 to 3 days.
Today, the patient experienced a 25-minute episode of severe pain while watching television. He
describes his pain as a “tight, burning feeling in my chest and an aching in my jaw.” It does not vary
with respiratory effort, it is accompanied by diaphoresis, nausea, SOB.
o What assessments do you wish to make?
 Labs – to view cardiac enzyme levels
o What interventions would you think would be done?
 Must be placed on 12 lead EKG immediately
 Start IV
o Treatment /Interventions
 STEMI (ST-Elevation MI) – PCI
 STEMI but not at facility where PCI is available – thrombolytics – UNLESS can be
transferred within reasonable time (< 120 minutes); but if > 120 minutes, evaluate patient
for thrombolytic therapy
 NONSTEMI/NSTEMI with elevated cardiac enzymes – PCI
CARDIAC REPERFUSION: PCI AND CABG
Cardiac Reperfusion
- Reperfusion = goal when someone has MI or ischemia
- Management of ACS
o PCI – short recovery time, back to daily living quickly
o Thrombolytic therapy
 Rescue treatment – not definitive treatment
 Temporary aid in acute MI
 Re-establishes blood flow and dissolves clot – does not affect fat build up over vessel
 Will need PCI after this to resolve plaque build up
o CABG – surgery – longer recovery time than PCI
 Reroutes blockage in vessels
o Medical management
 Nitroglycerin
 Ca+ channel blockers
 Beta blockers
Medical Management of CAD
- Patients who are not candidates for PCI or CABG will be managed with medications
o Aspirin
 All should be on Aspirin
 Acute treatment: 325 mg
 Long term treatment: 81 mg / 162 mg
o Anti-platelets
 Prevent clotting and platelets sticking together
o Beta blockers
 Slow HR, BP and decreases myocardial O2 demand
o Short and long acting nitrates
 Short acting: sublingual, pills, spray, IV
 Long acting: patch, oral
o Lipid lowering agents
 If LDL is elevated … optimal is < 100
o ACE or ARB
 Especially if EF < 40%
o Ranolazine
 Patients with angina and current medications are not working
Angiogram vs PCI
- Similar – both a percutaneous approach
o Angiogram is diagnostic diagnostic procedure
 Injects dye and use x-ray technology to visualize where the clot is narrowing in the
coronary arteries
o PCI is therapeutic
-
Angiogram – “heart catheterization”
o Left “heart cath” – arterial approach
 To visualize blockages and/or do a left ventriculogram
 Through femoral or radial (most common) and into the aorta
 When reach aortic valve, inject dye and it flows through coronary arteries
 Can do a ventriculogram – gives ejection fraction (EF)
o Right “heart cath” – venous approach
 Insert pulmonary artery catheter to measure pressures
 Through IVC and into the RA to insert the PA catheter to obtain pressures
*EXTRA
- If a patient is renal insufficient, but not on dialysis, we have to make sure that the patient is well
hydrated prior to an angiogram because the dye is nephrotoxic. If the renal indices are bad enough, the
study may not take place.
- If the patient is on dialysis, the diagnostic evaluation will take place and the patient will go to dialysis to
“wash out” the dye.
- Dye allergy – pre-medicate with steroids
o Patient will feel a warm sensation
o Patient allergic to shellfish requires a MD notification
o Dye acts as a diuretic – give 1 to 2 L of NS after procedure
 It is nephrotoxic as well
Atherectomy
- Removal of plaque by excision
- Uses a rotational blade to shave plaque off and then sucks out
- Less incidence of abrupt closure when compared to PCI
- Limited to select location(s) of lesion in the artery due to size of catheter
o Performed on distal vessels
o Not done on the LAD because the patient would be placed at a higher risk for an emboli
PERCUTANEOUS CORONARY INTERVENTION (PCI)
Percutaneous Coronary Intervention (PCI)
- Performed in catheterization lab using conscious sedation
- Less invasive and less recovery time than surgery
- Balloon angioplasty/stent placement/atherectomy (right femoral approach most common)
o Balloon angioplasty – uses high pressure balloon to open up coronary artery
o Stent placement – not done unless blockage is 60 – 70% or greater
o Atherectomy – sucks plaque out of the vessels – acts like a drill
- Femoral approach – patient lays on back for 4 to 6 hours
o Most common approach
- Radial approach – catheter will not be as large; may irritate radial nerve; don’t have to lay straight
PCI for Left Main Disease “Widow Maker”
- Non-complex lesion near the ostium or on shaft of LM artery
- Syntax score – an angiographic grading tool to determine the complexity of coronary artery disease
- Both US and European guidelines emphasize the need for a Heart Team approach for deciding
revascularization strategies for LMCA disease
Coronary Stents
- Placement during PCI
o There are self-expanding stents and stents that are balloon-expandable
 Always have a balloon angioplasty with stent placement because the balloon is used to
ploy the stent
o Inserted to treat abrupt or possible abrupt closure
- Reduces restenosis rate of PCI
- Two types of stents (thrombogenic) – prevent new tissue from forming and reclog artery
o Bare Metal
 Just the stent inserted – but hyperplasia problem can occur with this
 With the use of oral anti-platelet agents for about 6 months – usually Plavix
o Drug-eluding
 Elude a drug to block cell proliferation (hyperplasia)
 Patient is usually on oral anti-platelet agents (Plavix) for an entire year after
Successful PCI
- Goal: to restore circulation – stretches vessel wall, fractures plaque, and enlarges the vessel lumen
- Reduces stenosis to less than 50% of the vessel lumen diameter 90% of the time
- In-stent restenosis can occur within a few months to a year
o Angioplasty with no stent placed
o Due to platelet-mediated intimal hyperplasia (lumen narrows again)
 Tissue hyperplasia from stretching that occurred
- Patients should NOT have chest pain after the procedure
o It is not uncommon for the patient to have pain during the procedure
Complications
- Dissection of dilated artery
o Can happen when putting in or taking out the catheter
o Can lead to cardiac tamponade, ischemia, and infarct
- Plaque embolus
o Dislodged piece of plaque during procedure – can lead to MI
- Coronary spasm
o Vessels vasoconstrict and can “spasm down” causing chest pain; if lasts long enough can lead to
an MI
o Calcium channel blockers can be injected right into the artery
- *Spontaneous restenosis
o Reason that patient’s stay overnight – we must monitor for this
o Acute – happens between 12 to 24 hours after procedure
 It can also happen within weeks or months after
- Emergent CABG required for 3-4% of PCI patients
Nursing Management Post PCI
- Monitor for chest pain and ST changes
o Possible signs of acute/abrupt closure of the artery
o Chest pains can also be an indication of vasospasm
o STAT 12 lead for complaints of chest pain
 Ex. If RCA stent was put, we should monitor leads II, III, aVF
- Monitor vital signs
o A sudden drop in B/P can mean that the patient is ‘vagaling’ or that the patient is bleeding from
the femoral artery (or the artery where procedure was done)
- Monitor anticoagulant or antiplatelet drips – bleeding/hematoma risk
o Prevent platelets from aggregating on the new stent
o Patient may come back from the procedure with 1 or more drips hanging – these medications
need to be monitored; the physician will order the time to hang these drips
 llb – lla inhibitors – IV antiplatelets
 Eptifibatide (Integrillin)
 Tirofiban (Aggrastat)
 IV anticoagulants
 Bivalirudin (Angiomax)
o Wait 2 hours before pulling the sheath if this medication is used
o Also, we MUST keep the HOB flat if this is given to patient
- Diabetics – HOLD METFORMIN
o There is an interaction with Metformin and contrast dye that is used
o Hold for 48 hours (2 days) after patient has received the dye
 May have to even hold for 24 hours before the procedure
- Monitor vasodilator drips
o Nitroglycerine (Tridil)
- Administer oral antiplatelet medication – Dual Anti-Platelet Therapy (DAPT)
o Clopidogrel (Plavix)
 Usually given as a bolus/loading dose in catheterization lab – ALWAYS done

-
Loading dose is administered and the amount is based on whether a patient was already
on Plavix when admitted
 Given for CVA, stent or circulatory issues
o Prasugrel (Effient)
 Only used for stents
o Ticagrelor (Brilinta)
o Aspirin
 Started within 24 hours
Managing the vascular access site
o Monitor site for bleeding
 Any pain? Any back pain… possible bleeding
 Palpate site for hematoma … hard knot
 Check the site when patient returns
 Check opposite leg for comparison
 Mark any drainage for comparison over the hours
o Assess for hematoma
 Painful “egg” underneath skin – very painful and throbbing
 First we would want to stop the bleeding – hold pressure
o Check distal pulses
 Circulation, movement, sensation, pulse
 Femoral approach
 Check feet – pedal pulses
 Radial approach
 Check hands – radial pulses
o Instruct patient to keep leg straight and head down
 Usually keep patient flat for 4 – 6 hours, but some allow a 30 degree angle
 If patient wants to eat – reverse trendelenberg is helpful
o HOB flat when sheath in place
o When sheath is pulled, apply direct pressure for 10-15 minutes 1 cm above site
 If you can feel the pulse, hold pressure right on top of site
 If the B/P is high before, get MD orders for medication to lower
o Closure devices – have properties that help coagulation of the site and early ambulation
 Angio-seal – plug of collagen that occludes the artery
 Perclose – artery is sutured
 Starclose – 2 hour bed rest instead of 4 to 6
Discharge Instructions
- Keep incision site clean and dry
o Will usually say to put nothing on it and be open to air – unless femoral
o No ointments, powders or peroxide
- Activity
o No lifting over 5 lbs.
o Activity is limited for a week
 i.e., no cutting the grass
-
-
Medications
o Dual anti-platelet therapy (DAPT)
 Aspirin plus a P2Y12 receptor inhibitor (clopidogrel, prasugrel, or ticagrelor) daily
Beta Blockers if myocardial infarction to slow HR
Ca+ Channel blockers to reduce workload of the heart and vasospasms
Nitrates to reduce incidence of angina attacks and re-occlusion
What to Watch For!
- Chest pain or shortness of breath
o Can indicate possible re-occlusion of the artery
o Come back to hospital!!!!
o STAT 12 lead EKG
- Bleeding or swelling at insertion site
o Arteries bleed extremely fast
o Lay flat, hold pressure, call 911
- Pain at insertion site
o Possible hematoma (dropping B/P or severe back pain are signs of retroperitoneal bleeding –
diagnosed with CT scan)
o Area should be soft with no high levels of pain
- Feeling faint or weak – possible internal bleeding
- Signs of infection
o Redness, drainage, fever
o Notify doctor for signs of infection
CASE SCENARIOS
1. You are caring for a 64-year-old female who has returned from PCI (angioplasty + stent) 10 minutes
ago. The monitor alarm sounds and her HR is 45. You go into the room to assess her and she is
complaining of severe substernal chest pain and her BP is 74/40. What do you do?
STAT EKG, call provider
2. You receive a patient from catheterization lab s/p PCI (angioplasty + stent) who returned with a sheath
in place. You remove the sheath and while you are holding pressure the monitor alarm sounds, HR is 20
and patient is now unresponsive. What is likely happening? What do should you do?
If we hold the nerve instead of the artery in the femoral artery, the patient will have a vagal response
Always take atropine with you to pull the sheath and the patient begins to vagal, lay the patient flat and
move your hand placement
3. You are caring for a patient who is 45 min. post angiogram. He called you complaining of severe right
groin pain. When you assess the right groin puncture site you find it to be very swollen and tender. What
is likely happening? What should you do?
Hold pressure until we can get in under control. If your hands hurt, call for help to replace you.
4. You are caring for a 52-year old male who is 2 hours post PCI (angioplasty & stent) who starts
complaining of back pain and N&V. VS are HR 118, BP 91/52. Right groin site is without bleeding or
hematoma. What is likely going on with this patient? What should you do?
Retro-peritoneal bleeding (back pain) – bleeding that leaks into the peritoneal space and then they
become hypotensive, HR becomes elevated
CT scan for diagnosing, surgeon to come repair the vessel
CORONARY ARTERY BYPASS GRAFT (CABG)
CABG
- Open heart surgery in which a prosthesis or a section of a blood vessel is grafted onto one of the
coronary arteries bypassing a narrowing or blockage in a coronary artery
- Has been performed since 1960s
- Overall mortality is 1-3%
- Can be done on-pump or off
o “Cardiopulmonary bypass pump”
o Arrest the heart and take blood out and put it through an oxygenation machine while the
surgeons work on the heart
- Advantage over PCI
o Can provide more complete revascularization and show better long-term relief of symptoms
o Less than 10% of patients need subsequent revascularization within 5-7 years
- Disadvantage
o More procedural related pain
o Longer hospital stay
o More procedural infarctions
Indications (NO TEST QUESTIONS)
- Over 50% left main coronary artery stenosis
- Over 70% stenosis of the proximal left anterior descending (LAD) and proximal circumflex arteries
- 3 vessel disease in asymptomatic patients or those with mild or stable angina
- 3 vessel disease with proximal LAD stenosis in patients with poor left ventricular (LV) function
- 1 or 2 vessel disease and a large area of viable myocardium in high-risk area in patients with stable
angina
- Over 70% proximal LAD stenosis with either an ejection fraction (EF) below 50% or demonstrable
ischemia on noninvasive testing
- Other
o Disabling angina
o Ongoing ischemia in the setting of a non-ST segment elevation myocardial infarction (MI) that is
unresponsive to medical therapy
o Poor LV function but with viable, nonfunctioning myocardium above the anatomic defect that
can be re-vascularized
- STEMI (urgent)
o Failed angioplasty with persistent pain
o Persistent or recurrent ischemia refractory to medical therapy
o Life threatening ventricular arrhythmia in the presence of > 50% of left main stenosis and/or
triple vessel disease
 Ventricular tachycardia – check pulse first
 Ventricular fibrillation – defibrillate first
Types of Bypass Surgery
- Traditional sternotomy approach with cardiopulmonary bypass
o Skilled physician who does quality work, but in a quick time
- MIDCAB – Minimally invasive direct coronary artery bypass
o LAD or RCA
o No sternotomy
 But, they do a mini-thoracotomy (pull the ribs open)
o No CBP
o Beating heart
o Beta or calcium channel blockers to slow HR
o IMA – LAD or RCA (Internal mammary connected to a coronary)
- OPCAB - Off pump CAB – full or partial sternotomy on a beating heart
o Sternotomy approach
o Performed on a beating heart
o Beta or calcium channel blockers to slow HR
o Less blood loss, less renal dysfunction, less postoperative atrial fibrillation, and fewer
neurological complications
o Primarily used for patients with multiple co-morbidities who should avoid CPB
- TECAB – totally endoscopic coronary artery bypass
o Robotic
o No CPB or with femoral cannulation
o Limited
o Increased precision, smaller incisions, decreased blood loss, less pain, and shorter recovery time
- Transmyocardial Laser Revascularization
o For patients with advanced CAD who are not candidates for traditional CABG or who have
persistent angina despite maximum medical therapy
o High energy laser creates channels in the heart muscle to also blood flow to ischemic areas
o Left thoracotomy or in combinational with traditional CABG as adjunct when bypass grafts
cannot be placed
Internal mammary artery
- Sew onto the aorta and then distal to where the blockage is
o Can use each the L and R side once
- Less likely to get re-occluded than a vein
- Must clip off the extra endings from the artery and clip the ends
o Post-op, these clips can come unattached and the bleeding will be profuse. In the mediastinal
drain, the drains will be flowing with blood. Immediate surgery needed.
Complications
- Postperfusion syndrome (“pump head”)
- Hemolysis
- Capillary leak syndrome
- Clotting of blood in the circuit
- Air embolism
- ARDS (1.5% of patients)
Post-Operative Care
- Usually taken directly to ICU and stays for 24 – 36 hours
- Nurse should receive report to include:
o Summary of surgery performed (examples)
 LIMA  LAD
 SVG  RCA
 RIMA  PDA
o “Pump time”
 If long, we should be watching for neurological problems
o IVs running
o Recent lab values including ABGs
o Tubes and drains – possible to have 3
 Mediastinal tube (if bleeding does occur to prevent tamponade)
 Pleural tubes (if mammary artery – they had to deflate the lungs)
 Because it is possible to have one on each side – up to 2
o Blood products
o Baseline hemodynamics
o EVH – endovascular vein harvest
- Patient is initially intubated
o Goal is to extubate as early as possible, 4-6 hours
- PA line/arterial based cardiac output
- Arterial line – almost every time will have this
- Pacer wires
- Multiple IVs
- Nasogastric Tube
o Put on suction
o Once extubated, can take this out
- Chest drainage
o Mediastinal
o Pleural
Nursing Assessment
- Vital Signs
- Hemodynamic Status
o Ex.  PAP & PAWP – positive inotropes;  CVP & urinary output – crystalloids/colloids/PRBC
- 02 sat, ABGs, Ventilator settings
- Electrolytes, CBC, coagulants
- Chest tube drainage
o Drainage should slow down within a few hours
- Urine output
o Can have acute kidney injury from the hemodynamic instability during procedure and pump
o BUN and creatinine (done the next morning)
- Neurologic complications
o Post-cardiotomy delirium
o Intraoperative CVA, MI
Nursing Management
- Normalize cardiac output
o Optimize heart rate
 Temporary pacing
 Drug therapy
- Monitor for dysrhythmias (esp. ventricular)
o Watch for atrial fibrillation (occurs in 20-40% of patients) – frequent PAC is typically indicative
of a patient that is about to go into atrial fibrillation
 Monitor the patient’s rate more than the rhythm with atrial fibrillation – occurs more
often 2 – 3 days post-op when they start ambulating
 Treat with Amiodarone and Ca channel blocker (go home on these for 3 months)
o Bradycardia – pacemaker or atropine
- Manage preload
o Administer volume as needed for low PAWP/CVP
 Crystalloids, colloids [albumin], PRBCs
o Albumin is another option for increasing preload
o Diuretics as needed if overloaded
 Not usually given until the next day, but almost all of them will gain 10 pounds
- Manage afterload
o Increased SVR & HTN common after surgery (due to vasoconstrictive effect of hypothermia)
 Can exacerbate bleeding and increase LV workload
 Stress on graft suture lines
o Control hypertension (Nipride, NTG, IV anti-hypertensive)
 Decreased SVR through vasodilation
 If BP is high, we worry about the suture being ripped open
- Manage contractility
o Positive inotropes (dopamine, dobutamine, primacor)
o IABP (mechanical device)– only used to give the heart time to rest if the patient does not
respond to inotropes
o Impella – mechanical device
- Controlling bleeding complications
o More than 150 mL/hour requires intervention
 Clotting factors (FFP, platelets)
 Protamine sulfate
 Blood replacement based on loss and hct
o Assess for cardiac tamponade – too much blood in thoracic cavity – EMERGENCY
 Beck’s triad: low BP, JVD, muffled heart tones
 Sudden cessation of chest tube drainage, PEA
 Requires emergency sternotomy – relieves pressure and BP begins to increase
- Prevent infection
o Operative wound infection
o Infective endocarditis
o Pneumonia (early ambulation)
o UTI – due to foley catheters
o Maintaining a normal glucose level is important
-
-
-
Preserve renal function
o Hemolysis caused by pump may damage renal tubules, ARF caused by decreased renal perfusion
o Vigilant monitoring of urine output – report if less than 30 cc/hour
o Vigilant monitoring of electrolytes, BUN, creatinine
 BUN – more affected by dehydration (will be elevated)
 Creatinine – more of a specific indicator of renal function
o Maintain adequate hydration and preload – administer diuretics as needed
o Monitor daily weights
Manage hypokalemia
o Causes of low potassium: loss of reabsorption due to administration of Lasix
o Concentration of IV K solution should not exceed 20 mEq/100 mL when administered on a
regular nursing floor or 40 mEq/100 mL in the ICU/telemetry units
o Maximum administration
 Rate should be < 20 mEq/hr
 Daily dose may not exceed 200 mEq/day
Manage hyperkalemia
o Stabilize myocardial cell membrane
o Shift K into cells
o Promote K excretion
 Furosemide, kayexalate, dialysis
Outcomes
- Extubation ASAP
- PA catheter is usually removed on post-op day 1
- Out of bed and to a chair on post-op day 1
- Out of ICU on post-op day 1 – 2
- Home in 4 – 5 days if uncomplicated (average 5 – 7 days)
Post-Op (After Extubated)
- Chair for meals
- Arm limitations
o Do not allow them to push up with their arms
o Teach them to use their thighs for help
o Get at least 2 – 3 people to help get the patient up
- Ambulate 3-4 times a day
- Incentive spirometry q 1 hour while awake
- Nutrition
o Cardiac diet does not have to be followed until going home
- Wean oxygen PRN (once extubated)
- Shower after chest tubes are out
Discharge
- Medications
o Aspirin
o Beta blockers
o ACE inhibitors
o Statins
o Pain medication
- Expectations
o 6 to 8-week recovery
- Wound care
o After day one, open to air and clean with soap and water
- No driving in case of wreck
o Should really be in back seat to protect the sternum
- Activity
o Walk about 4 times a day and gradually increase activity level
- TED hose
o Due to the SVG, some have problems with edema
- Follow-up appointments
o Surgeon, cardiologist
- Cardiac rehab
- Patient teaching
o Limit use of arms in addition to gradually increasing activity level
o Wear TED hoses, continue incentive spirometer, elevate legs for edema, shower not bath tub
Research
- Stem cell injection after AMI to stimulate new growth of myocardial cells.
- Gene therapy for chronic CAD to stimulate angiogensis
CASE STUDIES
1. You are caring for a patient who is two days post CABG. The telemetry tech calls you and tells you your
patient is now in atrial fibrillation (he was previously in sinus rhythm) with a rate of 135. What should
you do first? What if he was in atrial fibrillation with a HR of 105?
a. First, the patient should be assessed. If hemodynamically unstable, activate the RRT. He should
be stable with a HR of 105. Call and notify the physician.
2. You are caring for a patient who is day 3 post CABG. The physician's assistant made rounds at 6AM
and removed his left pleural chest tube. When you assess him at 8:00 AM you note subcutaneous
emphysema on his left upper chest and neck. What is likely happening? What should you do?
a. Call the physician because the chest tube was probably removed too early. He will need to order
a chest x-ray and possible replace the chest tube.
3. You have a 66-year-old female 4 days post CABG who is eating poorly, complains of fatigue and
refuses to walk. She wants to stay in bed all day and sleep. What are some assessments that should be
completed on this patient? Can you think of some strategies/interventions for this patient?
a. Assessments that need to be completed on this patient are H&H and depression. As a nurse, I
could offer her a variety of foods by not necessarily being strict with a heart healthy diet in the
immediate post-op period.
4. You are caring for a 42-year-old male patient who is day one post CABG. He continues to complain of
pain despite a dose of hydromorphine 2mg PO 2.5 hours ago and 10mg IM dose of morphine 1 hour
ago. He doesn’t want to do his IS or get OOB to the chair because he says it “hurts too much.” Can you
think of some strategies for managing this patient's pain?
a. NSAID (Toradol) if the creatinine level if normal. Acetaminophen IV is another option.