CARE OF PATIENTS WITH
DECREASED CARDIAC
OUTPUT
CHAPTERS 13, 14
Cindy Young, MSN, RN
• General classifications of medications
VASOACTIVE MEDICATIONS
Vasopressors - drugs that induce
vasoconstriction thereby elevating the
mean arterial pressure (MAP)
Inotrope – drugs that increase the
contracting force
Chronotrope – drugs that increase
the heart rate
Dromotrope - drugs that affect the electrical
conduction speed
CARDIOVASCULAR MEDICATIONS
Commonly utilized vasoactive medications to alter
cardiac output. Many vasopressors also have
ionotropic and chronotropic affects
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Nitroprusside
Milrinone
Nitroglycerine
Dobutamine
Dopamine
Norepinephrine
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Epinephrine
Phenylephrine
Vasopressin
Lisinopril
Metoprolol
Furosemide
REVIEW OF BLOOD PRESSURE
• 2 types of measurable blood pressure
• Arterial pressure (AP) – function of peripheral
resistance and CO
• Venous pressure – low pressure system
influenced by 4 factors
• Systemic filling pressure – force available to
return blood
• Venous muscle pump – adequacy
• Venous Peripheral Resistance – lumen size
• Right Atrial Perssure – near zero at rest,
slight negative during systole
REGULATION OF ARTERIAL BP
• 3 major regulatory systems
• Renin-Angiotensin-Aldosterone System (RAAS)
• Vasoconstriction
• Water retention
• Kidneys
• RAAS
• Water Retention based on GFR
• Autonomic Nervous System (ANS)
• Sympathetic Nervous System
• Increases CO by vasoconstriction, increasing HR,
increasing contractility
• Parasympathetic Nervous System
• Decreases CO by decreasing HR, decreasing
contractility, vasodilation
ASSESSMENT OF
CARDIAC FUNCTION
• Patient History
• Physical Assessment
• Diagnostic Laboratory Tests
• Specific Components of Cardiac Output
ASSESSMENT OF
CARDIAC FUNCTION
• Patient History
• Present Illness
• Events leading up to admission
• Possible etiologies
• Medical History
• Demographic data, family history, dietary
information, functional status, prior medical history
• Cardiac risk factors: smoking, exercise stress,
obesity
• PQRST
ASSESSMENT OF
CARDIAC FUNCTION
• Physical Assessment
• Inspection
• Peripheral Assessment
• Urine Output
• Edema
• Jugular Vein Distention
• Palpation
• Auscultation
• S3 – ventricular gallop - heard early in
diastole
• S4 – atrial gallop – heard during atrial
contractions – late diastole
• Pulmonary edema - wet-sounding
crackles and frothy pink sputum
ASSESSMENT OF
CARDIAC FUNCTION
• Diagnostic Laboratory Tests
• Cardiac Markers
• Creatine Kinase-Myocardial Band (CK-MB) :
cardiac-specific myocardial isoenzyme – releases
4-12 hours after onset of myocardial necrosis
• Troponin: protein that appears as early as 1-3 hours
after symptom
• Other Lab Tests
• C-reactive Protein (CRP) : peptide released in
response to systemic inflammation, infection, and
tissue damage
• B-type Natriuretic Peptide (BNP) : neurohormone
release in response to increased preload
• Lipid profile : high level of lipids associated with
high risk of coronary heart disease
ASSESSMENT OF
CARDIAC FUNCTION
• Specific Components of Cardiac Output
• Assess Heart Rate
• Check for apical-radial pulse deficit
• 60 second counting interval
• Assess Preload
• Right Ventricular Preload: systemic venous system
• Left Ventricular Preload: pulomonary venous
system
• Assess Contractility
• Palpation of radial pulse
• S2 split
• Pulse Pressure – 30-40 mm Hg
• Assess Afterload
• Increased afterload – cool, clammy extremities
• Decreased afterload – warm flushed extremities
NONINVASIVE
DIAGNOSTIC PROCEDURES
• Exercise Electrocardiogram
• Stress test
• Evaluates heart muscle and blood supply
• Treadmill or administration of dobutamine
• Echocardiogram
• Diagnose cardiomyopathies, valvular function, cardiac
tumors, left ventricular function
• Ejection Fraction
http://rwjms1.umdnj.edu/shindler/vsd.html
INVASIVE
DIAGNOSTIC PROCEDURES
• Transesophageal Echocardiogram (TEE)
• Cardiac Catheterization
• Electrophysiology (EPS)
INVASIVE
DIAGNOSTIC PROCEDURES
• Transesophageal Echocardiogram (TEE)
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Conscious sedation
Informed Consent
Suction equipment
Constant cardiac and respiratory
monitoring during procedure
INVASIVE
DIAGNOSTIC PROCEDURES
• Cardiac Catheterization
• Determine presence and extent of coronary artery
disease
• Pre procedure – check for allergies to iodine or
seafood, get informed consent
• Procedure – most common route – femoral artery,
monitor access site and distal pulses
• Post procedure – monitor for complications of:
peripheral artery thrombosis or embolism,
stroke, dye allergy, acute myocardial infarction,
peritoneal bleeding
INVASIVE
DIAGNOSTIC PROCEDURES
• Electrophysiology Study (EPS)
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Evaluates cardiac conduction system
Classify cardiac arrhythmias
Informed consent
Moderate sedation
Electrical stimuli to heart – constant monitoring
VALVULAR
HEART DISEASE
• Valve Stenosis – resistance of blood flow
• Valve Regurgitation – back flow of blood
• Valve Prolapse – valve cusps or balloons
VALVULAR
HEART DISEASE
• Assessment and Diagnosis
• Auscultation of heart
• Severe valvular dysfunction patient may develop:
syncope, decreased CO, decreased BP, heart failure,
pulmonary edema
• S & S: dyspnea, tachypnea, crackles, tachycardia,
chest pain
VALVULAR
HEART DISEASE
• Collaborative Management
• Medications: beta blockers, calcium channel blockers,
digoxin, diuretics
• Cardioversion
• Afterload reduction: ace inhibitors, long-acting
nifedipine
• Valvuloplasty
• Valve replacement
• Biologic
• Mechanical
• Anticoagulation therapy
HEART FAILURE
• Assessment
• Dyspnea, orthopnea, paroxysmal nocturnal dyspnea
• JVD, peripheral edema,S3
• Diagnosis
• Echocardiogram – EF
• Electrocardiogram
• BNP
• Collaborative Management
• Control Risk Factors
• Management of Hypertension, Diabetes, Hyperlipidemia
• Prevention of Atherosclerosis, Coronary Atery Disease
• Pharmacologic Therapy
• ACE inhibitor, ARBs, beta blocker, diuretics, inotropic
agents
CARDIOGENIC SHOCK
Acute heart failure patients with pump failure may experience
cardiogenic shock
Patient may exhibit: mean arterial pressure (MAP) < 65, weak and
thready pulse
Interventions: continuous monitoring, mechanical
ventilation,vasopressors, positive inotropes, diuretics
HYPERTENSIVE CRISIS
HYPERTENSIVE CRISIS
HTN Urgency
Give Oral anti-HTN meds to decrease BP gradually over 12-24
hours to a lower BP Target
This will decrease chance of ischemia from a rapid BP change
Manage any other symptoms
Alleviate Pain, Anxiety
Monitor for escalation of BP and movement into HTN
Emergency
If OK, can go home with good medical follow-up
HTN Emergency - MEDICAL EMERGENCY
Admit To ICUà needs rapid reduction of BP to reduce target
organ damage (heart, brain, kidneys)
Begin Anti-HTN Therapy: Bring BP down by 10% 1st hr; In 2-3 hr
down by another 15%
Adrenergic Inhibitors- Esmolol, Labetalol, Metoprolol
Vasodilators- Nitroprusside (Nipride), Nitroglycerine,
Nicardipine
Diuretics- Furosemide (Lasix)
Treat End Organ damage Problems
AORTIC ANEURYSM
One end organ that hypertension has a
profound affect on is the vascular wall.
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A silent disease
Abnormal localized dilation of artery
Results from a weakened arterial wall
Often only becomes symptomatic
when aneurysm ruptures or dissects
AORTIC ANEURYSM
Results from a weakened arterial
wall
Risk Factors: (many similar to
Atherosclerosis)
hypertension
smoking (a particular concern)
age
male gender
hyperlipidemia
history of peripheral arterial disease
Other:
Genetic predisposition (Marfan’s
Syndrome {connective tissue);
Polycystic Kidney disease)
Infection (called Mycotic aneurysm)
Trauma, Injury
AORTIC ANEURYSM
• Once discovered, aneurysms are monitored closely
through regular diagnostic imaging to track changes in
diameter
• The goal is to keep the aneurysm small in size
• PREVENT RUPTURE
• Primarily accomplished by aggressive blood pressure
control
AORTIC ANEURYSM
http://www.activebeat.com/wp-content/uploads/2013/06/Abdominal-Aortic-Aneurysms1.jpg
AORTIC ANEURYSM
• There are two major repair interventions:
• Open surgical repair
• Endovascular aneurysm repair (EVAR)
• Nursing care:
• Blood pressure monitoring in both arms
• Peripheral pulses checked, each side compared
• Recognize S & S of rupture and dissection
• Rupture: rapid onset sever pain in chest, flank,
back, or abdomen
• Abdominal aortic aneurysm (AAA) – triad
of classic signs in rapid sequence:
syncope, abdominal pain, hypotention
• Surgical Emergency and time is critical
• Fluid resuscitation and blood replacement
AORTIC DISSECTION
Potentially catastrophic event :
Arterial blood enters aorta’s
tunica mediaà separation of
tunica media (middle layer)
from tunica intima (inner layer)
More common than aortic rupture;
usually develops in the thoracic
aorta
Extremely high early mortality rate
http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_aortic_aneurysm.htm
AORTIC DISSECTION
Most common presenting
symptom=
Acute onset severe pain
that does not change in
severity
Additional pain descriptors:
ripping,
stabbing,
tearing,
burning
Location may migrate along the
extension path
Small percentage of cases,
no pain is present
http://www.urmc.rochester.edu/Encyclopedia/GetImage.aspx?ImageID=126150
AORTIC DISSECTION
• Treatment of aortic dissection requires
rapid stabilization of the patient
• Goals of therapy include:
• rapid control of blood pressure
• PREVENT RUPTURE
• fluid management
• anticoagulation
• decreasing shear stress on the aorta
• pain control