The Client with Alterations in
Cardiac Output
Lecture
9/26/05
Sherry Burrell, RN, MSN
Rutgers University
Nursing III
Assessment Parameters
• Cardiac Output
• Measures the effectiveness of the heart’s
pumping abilities.
• CO is defined as the amount of blood that leaves
the heart in one minute.
CO = Stroke Volume (SV) X Heart Rate (HR)
• Normal CO: Approximately 4-8 liters/minute
• Cardiac Index: CO per square meter of BSA
• CO ÷ body surface area = CI
C0= SV x HR
• Stroke Volume (SV)
• The amount of blood that leaves the heart with
each beat or ventricular contraction.
• Not all blood ejected
• Normal Adult 70 ml / beat
• Ejection Fraction (EF)
• The percentage of end-diastole blood actually
ejected with each beat or ventricular contraction.
• Normal adult 55-70% (healthy heart)
Stroke Volume
• Three factors regulate stroke volume:
• Preload
• The degree of stretch of the ventricle at the end
of diastole.
• Contractility
• Force of ventricular contraction (systole);
inotropy.
• Afterload
• The amount of resistance the ventricular wall
must overcome to eject blood during systole.
Stroke Volume Cont.,
• Preload
• The degree of ventricular stretch at end-diastole
• The Frank-Starling Law of the Heart
•  Preload =  Contractility (to a point)
• Factors Affecting Preload
•
•
•
•
Circulating volume
Body positioning
Atrial systole or “kick”
Medications
• Diuretics (i.e. Lasix)
• ACE Inhibitors (i.e. Vasotec)
• I.V. Fluids
Starling Curve
Stroke Volume Cont.,
• Contractility
• Positive inotropic agents
•  Force of contraction
• Negative inotropic agents
•  Force of contraction
• Factors that affect contractility
• Autonomic nervous system (ANS)
• Medications:
• Digoxin (Lanoxin)
• Beta-adrenergic blockers (i.e. metoprolol )
• Calcium channel blockers (i.e. verapamil )
Stroke Volume Cont.,
• Afterload
• Resistance to ventricular ejection during systole
• Factors that affect afterload
• Outflow impedance
• Left side
• High systemic blood pressures (SVR)
• Aortic valve stenosis
• Right side
• High pulmonary blood pressures (PVR)
• Pulmonary valve stenosis
• Diameter of arterial vessels
• Blood characteristics
• Medications:
• ACE (angiotension converting enzyme) inhibitors
CO = SV x HR
• Heart Rate: beats per minute (bpm)
•  HR =  CO (to a point)
• HR >160 bpm =  CO
• Leads to inadequate diastolic filling time = time for
coronary artery filling and an increase workload of
the heart.
• Factors that affect heart rate
• ANS
• Medications
• Atropine sulfate
• Digoxin (Lanoxin)
• Beta-adrenergic blockers / calcium channel blockers
Assessment Considerations
• General Cardiac Symptoms
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Fatigue
Chest pain or discomfort
Palpitations
Shortness of breath
Edema
Weight gain
Dizziness
Syncope, loss of consciousness
Assessment: Special Populations
• Gerontologic Considerations
• Heart function is adequate at rest; limited ability to
respond to stress and takes longer to return to baseline.
• Decrease sensation of chest pain; tend to be under
quantified or even absent.
• Gender Considerations
• Women:
• Smaller hearts and coronary arteries
• Tend to present with “atypical symptom” of CAD
• Other Considerations
• Diabetes mellitus and cardiovascular disease
• Increased threat; decreased symptoms !!
Laboratory Analysis
• Serum Enzymes
• Blood Chemistry
• Lipid Studies
• Electrolytes
• Renal Function Studies
• Coagulation Studies
• Hematologic Studies
Serum Enzymes: Cardiac
• Creatine Phosphokinase (Total CK / CPK)
• Non-Specific: enzyme elevated with damage to
heart or skeletal muscles and brain tissue.
• Elevates in 4 to 8 hours
• Peaks in 15 to 24 hours
• Returns to normal in 3 to 4 days
• Creatine Phosphokinase Isoenzyme (CPK-MB)
• Specific: isoenzyme of CPK; elevated with cardiac
muscle damage.
• Elevates in 4 to 8 hours
• Peaks in 15 to 24 hours
• Returns to normal in 3 to 4 days
Cardiac Enzymes
• Myoglobin
• Non-specific: a heme protein found in muscle tissue;
elevated with damage to skeletal or cardiac muscle.
• Elevates in 2 to 3 hours
• Peaks 6-9 hours
• Returns to normal 12 hours
• Lactic Acid Dehydrogenase (LDH)
• Non-specific: enzyme elevated with damage to many
body tissues. (i.e. heart, liver, skeletal muscle, brain and
RBC’s); Not frequently used today.
• Elevates in 1 to 3 days
• Peaks in 2 to 5 days
• Returns to normal 10 to 14 days
Cardiac Enzymes Cont.,
• Troponin I / T
• Specific: a contractile protein released with
cardiac muscle damage; not normally present in
serum.
• Elevates in 4 to 6 hours
• Peaks in 10 to 24 hours
• Returns to normal in 10 to 15 days
• Sensitivity superior to CK-MB within the first 6
hours of event.
• Has replaced LDH for client’s who delay seeking
treatment.
Other Serum Enzymes
• C-Reactive Protein
• Protein marker of acute inflammatory reactions
• Increased serum levels associated with increased risk of acute
cardiovascular events.
• Homocysteine
• Amino acid; presence in serum suggests increased
risk of cardio-vascular events.
• Natriuretic Peptides
• Hormone-like substances released into bloodstream
with cardiac chamber distention.
• Atrial Natriuretic Peptide (ANP)
• Brain or B-type Natriuretic Peptide (BNP)
Blood Chemistry Analysis
• Lipoprotein (Lipid) Profile
• Total Cholesterol
• Normal < 200mg/dl
• Triglyceride
• Normal < 150 mg/dl
• Low Density Lipoproteins (LDL)
• Normal <130 mg/dl / “Optimal” <100mg/dl
• High Density Lipoproteins (HDL)
• Normal: > 40 mg/dl
> 60 mg/dl cardio-protective
Blood Chemistry Analysis Cont.,
• Serum Electrolytes
• i.e. Na, K, Ca and Mg
• Glucose / Hemoglobin A1C
• Coagulation Studies
• PTT / aPTT
• PT / INR
• Hematologic Studies
• CBC
• Renal Function Studies
• BUN
• Creatinine
Diagnostic Testing
• Electrocardiography *
• 12-Lead EKG
• Continuous bedside monitoring
• Ambulatory monitoring
• Stress Tests
• Thallium Scans
• Echocardiograms
• Cardiac Catheterizations
* Previously Discussed
Cardiac Stress Tests
• Stressing the heart to monitor performance
• Assists in Determining
• Coronary artery disease
• Cause of chest pain
• Functional capacity of heart
• Identify dysrhythmias
• Effectiveness of medications
• Establish goals for a physical fitness routine
Cardiac Stress Tests Cont.,
• Types of Stress Tests
• Exercise
• Treadmill (most common)
• Bike
• Arm crank
• Pharmacological
• Vasodilating agents to mimic the effects of exercise
• Persantin
• Adenosine
• Mental / Emotional (new; under investigation)
• Simulated public speaking
• Mental arithmetic test
Cardiac Stress Tests Cont.,
• Thallium Scan
• Often combined with stress tests
• Radiological exam to assess how well the
coronary arteries perfuse the myocardium.
• Images are taken 1 to 2 minutes prior to end
of stress test and again 3 hours later.
• Nursing Considerations
• NPO
• IV Access
Cardiac Stress Tests Cont.,
• Nursing Considerations
• Explain procedure to client
• Maintain NPO status 4 hour before test
• Instruct client to avoid stimulants (i.e.
chocolate, caffeine and cigarettes)
• Hold certain medications before testing
• Exercise: i.e. beta-adrenergic blockers
• Pharmacologic: i.e. Theophylline (24-48 hours prior)
• I.V. access must be obtained
Echocardiogram
• Ultrasound procedure of the heart combined
with an electrocardiogram (EKG).
• Assesses
• Cardiac geometry (size & shape)
• Motion of structures (chamber walls / valves)
• Simultaneous EKG assists in interpretation
• Can be done in conjunction with stress testing
• Referred to as a stress echocardiography or
exercise echocardiography
Echocardiogram Cont.,
• Types of Echocardiograms
• Transcutanoeous
• Non-invasive / painless
• Transesphogeal (TEE)
• Invasive / Clearer images
• Nursing Considerations:
• Explain procedure
• NPO 6 hours prior procedure
• I.V. access
• NPO 4 hours post-procedure
• Monitor for complications
Cardiac Catheterization
• “Gold Standard” of cardiac diagnostics
• Invasive procedure to assess
• Cardiac chamber pressures & oxygen saturations
• Detect congenital or acquired structural defects
• Ejection fraction
• Often Includes:
• Coronary arteriography: to assess coronary artery
patency
• Using X-ray technique called fluoroscopy
• Requiring the use of I.V. contrast / dye
Cardiac Catheterization Cont.,
• Nursing Care
• Prior to procedure
• Explain procedure
• NPO prior to procedure (8 to 12 hours)
• Check allergies (I.V. dye / shellfish / iodine)
• Laboratory tests
• During procedure
• I.V. access
• Hemodynamic monitoring
• Arterial and venous access via catheters (sheaths)
• Femoral (most common) or brachial
Cardiac Catheterization Cont.,
• Post-Procedure Nursing Care
• Maintain Client Bedrest for 6 to 8 hours
• Extremity straight & HOB up < 30 degrees
• Maintain Adequate Hydration
• IV Fluids (if ordered)
• Encourage Fluids
• Frequent Monitoring For Complications
• Vital signs
• Puncture site
• Distal pulses
• Laboratory results
The Client with Alterations in
Cardiac Output
Lecture II
9/30/05
Sherry Burrell, RN, MSN
Rutgers University
Nursing III
Coronary Artery Disease (CAD)
• An insidious, progressive disease resulting
in coronary artery narrowing or total
occlusion.
• Atherosclerosis
• Most common cause of CAD
• The abnormal accumulation of plaques on the
vessel wall; involves inflammatory process.
• Causes narrowing then eventually blockages in
the coronary arteries that reduces myocardial
blood flow = CAD
• Asymptomatic until 75% occlusion of
coronary artery lumen.
Coronary Artery Disease Cont.,
• Basis of CAD Management
• Framingham Study (1948- cont. today)
• Identified specific risk factors and life-style
habits that increase one’s risk for developing
atherosclerotic heart disease.
CAD: Risk Factors
• Modifiable
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Cigarette smoking
Hypertension (HTN)
Hyperlipidema
Physical inactivity
Diabetes Mellitus
Obesity
Stress / Anxiety
Diet
• Non-Modifiable
• Increasing Age
• Males >45 years old
• Females >55 years old
• Gender
• Affects both men and
women; #1 killer is U.S.
• Genetics
• Strong genetic component
• Ethnicity
• Non-whites increased
incidences versus whites
CAD: Interventions
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•
•
•
•
Smoking Cessation
• HTN Management
• BP Screenings
Diet
• Medications:
Exercise
• i.e. antihypertensives &
Weight Management
diuretics.
Cholesterol Management • Diabetes Management
• Lipid Profile
• Normal: every five years
• Medications:
• i.e Zocor, Crestor & Niaspan
• Blood glucose testing
• Medications:
• i.e. oral hypoglycemics &
insulin
Angina Pectoris
• As CAD progresses the atherosclerotic plagues
become significant, reducing blood flow to
portions of the myocardium = Ischemia.
• Myocardial ischemia clinically manifests most
often as angina or chest pain.
• Angina pectoris is defined as myocardial
ischemia without cellular death.
• Imbalance between myocardial oxygen supply
and demand
Myocardial Oxygen
Supply and Demand Balance
Demand
Supply
O2
Preload
Contractility
O2
Afterload
Heart
Rate
Arterial
Oxygen
Content
Coronary
Artery
Blood flow
Precipitating Factors: Angina
• Any situation where oxygen demands
are increased:
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Physical exertion
Tachycardia
Dysrhythmias
Cold weather
Eating a heavy meal
Stress or emotional states
Angina Pectoris
• Signs and Symptoms
• Chest Discomfort or Pain
• Can occur anywhere in chest; most commonly behind
sternum; poor localization
• Pain may radiate to the back, arms (left most common),
shoulder, neck or jaw.
• Described as pressure, tightness or burning sensation
• Often precipitated by physical exertion or stress
• Maybe associated with a few of the following
symptoms:
• SOB, weakness, anxiety, diaphoresis, N/V, dizziness or
numbness in upper extremities
Types of Angina
• Stable Angina
• Predictable, consistent pain with physical exertion
& relieved with rest; “my usual chest pain”
• Rest & NTG; can be managed medically for years
• Unstable Angina
• Last longer than stable angina, new onset or
increased frequency / intensity of symptoms;
pain at rest
• Preinfarction or Crescendo Angina
• Lasting longer than 15 minutes /unrelieved by NTG x3 is
a medical emergency!
• Call 911 / hospitalization for management
Types of Angina Cont.,
• Variant / Prinzmetal Angina
• Pain at rest; maybe cyclic, + ST segment elevation
(reversible); usual cause is coronary artery
vasospasm with or without atherosclerotic plaques
• Nitrates & calcium channel blockers
• Silent Angina
• No signs or symptoms; + ST segment elevation
• Nitrates, beta blockers, calcium channel blockers &
lifestyle changes
Management: Unstable Angina
• Goals of Medical Management
• Increase O2 supply & decrease O2 demand to the
myocardium.
• Prevent MI and death
• To actively intervene !!
• 12-Lead Electrocardiogram (EKG)
• Significant CP without EKG changes; + changes treated
as an MI.
• Laboratory Tests
• Electrolytes
• Cardiac Enzyme Panel
• Rule-out MI: every 8 hours x 3 / 6 hours x4
Management: Unstable Angina
• Relief of Chest Pain: “MONA”
• Morphine (drug of choice)
• Oxygen
• Nitroglycerine
• Increase Coronary Artery Blood Flow
• Antiplatelet medications
• ASA
• Glycoprotein (GP) IIb/IIIa Inhibitors
• Heparin
• Percutaneous Coronary Intervention (PCI)
Management of Unstable Angina
O2
Contractility
HR
Beta
Blockers
Ca Channel
Blockers
 Afterload
ACE I
 Preload
NTG
ACE I
Morphine
O2
 Blood Flow
Open Occluded
Arteries
NTG
Ca Channel Blockers
ASA
Anticoagulants
Morphine
PCI
Nursing Interventions: Unstable Angina
• Early Identification of Chest Pain
• Assessment of Chest Pain
• Chest Pain: Intensity- Scales (0-10) &
Characteristics- “OLD CART”
• Mentation, overall tissue perfusion
• Vital signs, heart rhythm, pulse oximetery
• Diagnostics: 12- lead EKG and Laboratory tests
• Management of Chest Pain =“MONA”
Nursing Interventions: Unstable Angina
• Calm Environment
• Anxiety and fear of impending doom (death)
• Activity Restrictions
• Avoid the valsalva maneuver
• Patient Education
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Risk factors for CAD
Signs and symptoms of angina
Medications
When to call the doctor
Stress management techniques
See pp.403 box 16-8 Thalen
Acute Coronary Syndromes (ACS)
• Umbrella term to describe a wide range of clinical
presentations of CAD from unstable angina to
acute myocardial infarction (MI).
• Continuum, Not separate disorders!
Unstable
Angina
Acute
Myocardial
Infarction
Myocardial Infarction (MI)
• An MI is defined as irreversible necrosis (death) of
myocardial tissue, resulting from an abrupt
decrease or total lack of coronary blood supply.
• An abrupt and severe disruption of O2 supply and
demand to the myocardium.
• Causes:
• Coronary artery thrombosis (most common)
• Coronary artery vasospasm
• Cocaine
• Trauma
• Severe and abrupt hypotension
Myocardial Infarction (MI) Cont.,
• Signs and Symptoms:
• Chest Pain
• Severe and unrelenting substernal chest pain; often
radiating to the back, left arm or jaw.
• Lasting for 30 minutes or more
• Only relieved by opioids
• Occurs without a know precipitating event; usually
occurring in the morning
• Associated Symptoms
• SOB, weakness, anxiety, diaphoresis, N/V, dizziness or
numbness in upper extremities.
Myocardial Infarction Cont.,
• Pathophysiology
• Irreversible cell death within 20-40 minutes of
cessation of blood flow.
• Wavefront of cellular death proceeds from
endocardium to epicardium.
• EKG changes associated with an MI:
• Ischemia: T wave inversion
• Injury: ST segment elevation
• Infarction: Pathological Q waves
Types of Myocardial Infarctions
• Classified according to muscle layer affected:
• Q wave MI
• Transmural: full thickness muscle wall necrosis
• Often associated with a more prolonged MI
• Non-Q wave MI
• Partial-thickness muscle wall necrosis
• Often associated with smaller, less complete
occlusions.
• i.e. Subendocardial- necrosis of the inner 1/3 to 1/2
of the muscle wall.
Types of Myocardial Infarctions
• According to anatomical location
• Left Ventricle
• Anterior Wall
• Left Anterior Descending (LAD)
• Associated with left ventricular failure, pulmonary
edema & cardiogenic shock
• Inferior Wall
• Right Coronary Artery (RCA)
• Associated with dysrhythmias & conduction disturbances
• Posterior Wall
• RCA or Circumflex Artery
• Right Ventricle
• Portion of the RCA; Rare
Complications: Post-Acute MI
• Dysrhythmias (Most Common)
• Sinus Bradycardia
• Occurs in about 40% of clients after an acute MI
• Sinus Tachycardia
• Must be corrected !!
• Atrial
• PAC’s or Atrial fibrillation common
• Ventricular
• PVC’s and ventricular tachycardia (VT)
• AV Heart Blocks
• Most common with inferior wall MI
Complications: Post-Acute MI
• Ventricular Aneurysm
• Non-contractile, thin ventricular wall =  SV
• Leads to acute heart failure, emboli and VT
• Ventricular Septal Defect
• Rupture of septum; shunting of blood
• S/Sx: Severe CP, syncope, BP & holosystolic murmur
• Medical emergency; high mortality; surgery to correct
• Pericarditis
• An inflammation of the pericardial sac
• S/Sx: Pain, friction rub (left sternal border)
• Treatment: NSAIDS and ASA
CAD / Angina / MI: Nursing Diagnoses
• Acute pain related to an imbalance between
myocardial oxygen supply and demand.
• Anxiety related to fear of unknown or death.
• Ineffectual coping related to effects of acute illness
and major lifestyle changes.
• Activity intolerance related to fatigue (secondary to an
imbalance between oxygen supply and demand).
• Knowledge deficit related to CAD /angina / MI and its
treatments.
CAD / Angina / MI: Nursing Diagnoses
• Powerlessness related to the lack of control over
current situation or disease progression.
• Ineffective (cardiopulmonary) tissue perfusion
related to impaired arterial blood flow.
• Decreased cardiac output related to altered…
•
•
•
•
Preload
Afterload
Contractility
Heart rate / rhythm
Acute MI: Management
• Goals of Medical Management
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•
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Chest pain control
To preserve the myocardium
Prevention or management of complications
Pharmacological / intervention-based therapies
• EKG
• Positive changes and/or severe CP despite medical
therapies
• Laboratory Tests
• Electrolytes
• Cardiac Enzyme Panel
• Rule-in MI and then to monitor response to treatments
Thrombolytic Therapy
• Preserves the ischemic myocardium; limits the
size of infarction by restoring blood flow quickly;
can be done in emergency room.
• Thrombolytic Agents
• Work by causing lysis of clots; “clot busters”
• i.e. Alteplase (t-PA) or Reteplase (r-PA)
• Eligibility Criteria
• CP >30 minutes
• < 12 hours from onset (many institutions < 6 hours)
• Positive EKG changes
• CP unrelieved with medical therapies (i.e. NTG)
Thrombolytic Therapy Cont.,
• Exclusion Criteria
• History of CVA or any bleeding disorder
• Active internal bleeding or recent surgery
• Complications
• Bleeding and reperfusion dysrhythmias
• Nursing Role
• I.V. Access
• Baseline labs
• Monitoring
• Subsequent labs, vital signs & for complications
• Bleeding Precautions
Percutaneous Coronary Intervention
• Umbrella term for all various of interventional
cardiac catheterization procedures.
• Indications
• Angina refractory to medical therapies
• Proximal coronary artery stenosis; single or double
vessels disease
• Procedure & Nursing Care
• Much the same as cardiac catheterizations
• Except: venous & arterial catheters; larger lumen with
interventional catheterizations (i.e. stents)
Percutaneous Coronary Intervention
• Procedural Variations
• Angioplasty
• Percutaneous Transluminal Coronary Angioplasty (PTCA)
• Balloon tipped-catheter; expanded to dilate vessel
• Laser- UV pulse laser to “vaporize” lesion
• Atherectomy
• Removal of plaque from vessel
• Coronary Artery Stenting
• Tiny metal mesh tubes
• Drug-eluting Stents: Coated with Rapamune
• Brachytherapy
• For in-stent re-stenosis; gamma radiation therapy
PCI Cont.,
• Nursing Care
• Prior to procedure
• Explain procedure
• NPO prior to procedure ( 8 to 12 hours)
• Check allergies (I.V. dye / shellfish / iodine)
• Laboratory tests
• During procedure
• I.V. access
• Hemodynamic monitoring
• Arterial and venous access via catheters (sheaths)
• Femoral (most common) or brachial
PCI Cont.,
• Post-Procedure Nursing Care
• Maintain Client Bedrest for 6 to 8 hours
• Extremity straight & HOB up < 30 degrees
• Maintain Adequate Hydration
• IV Fluids (if ordered)
• Encourage Fluids
• Frequent Monitoring For Complications
• Vital signs
• Puncture site
• Distal pulses
• Laboratory results
PCI: Complications
• Acute Coronary Artery Occlusion
• Thrombosis /emboli or persistent vasospasm
• Impaired circulation to distal extremity
• Distal arterial emboli
• “Blue toe syndrome”
• Disrupted plaques occludes small vessels; pulses and
circulation checks are good but, severe pain.
• Hemorrhagic Event
• i.e. Arterial tear: retroperitoneal bleeding
• Puncture Site Complications
• i.e. Bleeding or hematoma formation
• Reperfusion Dysrhythmias
See pp. 735 table 28-7; Smeltzer & Bare
Cardiac Surgery
• Coronary Artery Bypass Graft (CABG)
• A surgical revascularization procedure; blockages
are bypassed using internal mammary artery or
great saphenous vein.
• Indications
• Angina unrelieved by medical therapies
• Left main disease
• Triple vessel disease
• Single or double vessel disease not amendable to
PCI or failed PCI
Cardiac Surgery: CABG
• Different Surgical Approaches
• On-Pump (Traditional CABG)
• Cardiopulmonary bypass machine (extracorporeal
circulation); heart stopped during procedure
• Off-Pump
• “Beating heart” procedure; uses “octopus device” to
stabilize the myocardium during procedure
• Minimally Invasive Direct CABG (MIDCABG)
• Single vessel disease not amendable by PCI procedures
• Small thoracotomy incision; off-pump approach
Cardiac Surgery: CABG
• Complications
•
•
•
•
•
•
Stroke (2% post-bypass reperfusion)
Hypertension
Hypotension
Bleeding
Dysrhythmias
Cardiac Tamponade
CABG: Post-Operative Nursing Care
• Maintain airway patency
• Continuous bedside monitoring
• Mediastinal chest tube management
• Monitor drainage & avoid kinks in tubing
• Assess pain levels frequently and provide relief
• Provide relief from anxiety and fear
• Assess the surgical incisions for s/sx of infection
• Assess the extremity from which vessel harvested
• Look for signs impaired circulation & edema
• Monitor for complications
Management of an Acute MI
O2
Contractility
HR
Beta
Blockers
Ca Channel
Blockers
 Afterload
ACE I
 Preload
NTG
ACE I
Morphine
O2
 Blood Flow
NTG
Ca Channel Blockers
ASA
Anticoagulants
Morphine
Open Occluded
Arteries
PCI
Thrombolytics
CABG
Cardiac Rehabilitation
• Education and support for client and family
• Initiated once client is free of symptoms
• Focuses:
• Education
• Psychological Support
• Physical Conditioning
• Goals:
• Maximize QOL
• Limit progression of CAD
• Prevent further cardiac events
Cardiac Rehabilitation
• Phases of Cardiac Rehabilitation
• Phase I: Inpatient (post-event)
• Education on medications, rest-activity balance, followup appointments & when to call doctor or “911”.
• Low-level physical conditioning i.e. self-care &
mobilization.
• Phase II: Outpatient Supervised
• Physical conditioning & education on risk factor
modification
• Phase III: Outpatient Self-Directed
• Maintain cardiovascular stability & long-term physical
conditioning
The Client with Alterations in
Cardiac Output
Lecture III
10/10/05
Sherry Burrell, RN, MSN
Rutgers University
Nursing III
Hemodynamics
• Describe the intravascular pressures and the flow
occurring when the myocardium contracts and
blood is pumped via the vascular system throughout the body.
• Basic Principles
• Blood flow throughout the cardiovascular system
from area of higher pressures to areas of lower
pressures.
• Pressures created by cardiac cycle: systole & diastole
• Pressures: Cardiac chambers and vessels
Hemodynamic Monitoring
• Two Major Categories
• Non-Invasive
• i.e. Taking a blood pressure or a pulse
• Invasive
• Intra-arterial blood pressure monitoring (A-lines)
• Central venous pressures (CVP) catheters
• Pulmonary artery (PA) catheters (Swan-Ganz)
Invasive Hemodynamic Monitoring
• Three Components:
• Transducer: Converts fluid waves into electrical signals
• Amplifier: Increases the size of the electrical signal
• Monitor / Recorder: Displays the signal and saves data
• Specialized Equipment:
• Catheter access to client
• Semi-rigid (high pressure) tubing
• Three-way stop cock
• Intraflow or In-line flow device
• Inflatable pressurized sleeve / bag
• I.V. Solution: 0.9 % NSS with heparin added
Invasive Hemodynamic
Monitoring Cont.,
• Calibration of Equipment
• Leveling:
• Transducer at the
level of right atrium
• Zeroing:
• Atmospheric pressure
 Let’s see how it’s done…
http://www.eonreality.com/demos/e-learning/ccn/unit3_4demo/e2_electdemo.html
Intra-arterial BP Monitoring
• Indicated for direct, continuous blood
pressure monitoring in the critically ill client.
• Measures systolic, diastolic & mean arterial
pressures (MAP)
• Allows for serial samplings of ABG’s
• Considered “low-risk”
• More accurate than cuff pressures in low CO
and shock (not affected by vasoconstriction)
• NEVER USED TO GIVE MEDICATIONS !!
Intra-arterial BP Monitoring Cont.,
• Insertion Sites:
• Radial (most common)
• Brachial
• Femoral
• Insertion Techniques:
• Percutaneous
• Cut-down (if necessary)
• Insertion Assessment:
• Distal Blood Flow
• Doppler Ultrasound
• Allen’s Test
Intra-arterial BP Monitoring Cont.,
• Nursing Considerations
• Monitor for complications
• Compromised blood flow to distal extremity
• i.e. thrombosis or arterial spasm
• Insertion Site
• i.e. Infection, bleeding, hematoma or skin breakdown
• Maintenance of System
• Sterile dressing changes
• Tubing, caps and flush bag changes
Central Venous Pressure (CVP) Catheters
• Measures the pressures in the right atrium.
• Used to assess right ventricular function and
venous blood return to heart.
• CVP / Right Atrial Pressures: Reflection of
right ventricular filling pressures (preload).
• Normal Limit: 2- 6 mm Hg
• Increased CVP = Fluid Overload
• Decreased CVP = Hypovolemia
CVP Catheters Cont.,
• Insertion Sites
• Internal Jugular
• Subclavian Vein
Tip advanced to the
Superior Vena Cava
• Prior to Use:
• Chest X-Ray
• Confirm placement
• Rule-out pneumo- or hemo- thorax
CVP Catheters Cont.,
• Complications
•
•
•
•
Dislodgement
Infection
Air Embolism
Cardiac dysrhythmias
• Nursing Care
• Sterile dressing changes
• Tubing, caps and fluid bag changes
• Flushing of lumens; never tie off !!
Pulmonary Artery (PA) Catheters
• Used to assess left ventricular function.
• “Multi-Tasking” Catheters
• Right Atrial Pressures (same as CVP)
• Pulmonary Artery:
• Pulmonary artery systolic pressures (PAS)
• Pulmonary artery diastole pressures (PAD)
• Pulmonary artery mean pressure (MAP)
• Left Atrial Pressures:
• Pulmonary artery occluded pressures (PAOP)
• Normal limit = 5-13 mmHg
• Reflection of left ventricular filling pressures (preload)
PA Catheters Cont.,
• “Multi-Tasking” Catheters Cont.,
• Intermittent Cardiac Output
• Specialized PA Catheters
• Additional Features
• Continuous I.V. infusions
• Continuous CO monitoring
• Continuous venous mixed oxygen saturation monitoring
• Represents venous blood saturations from many body tissues
• Monitors balance between O2 supply and demand
• Temporary transvenous pacing wires
PA Catheters Cont.,
• Insertion Sites:
• Internal Jugular
• Subclavian Vein
Threaded into the right
atrium, to right ventricle
finally resting in the
pulmonary artery.
• Prior To Use:
• Chest x-ray
• Ensure proper placement
• R/O pneumo- or hemo- thorax
PA Catheters Cont.,
• Complications
•
•
•
•
•
•
Dislodgement
Infection
Air embolism
Cardiac Dysrhythmias
Thromboembolism
Pulmonary Artery rupture
• Nursing Care
• Sterile dressing changes
• Tubing, caps and fluid bag changes
• Flushing of lumens; Never tie off !!
Heart Failure
• The inability of the heart to pump adequate
amounts of blood to meet body’s needs for
oxygen & nutrients.
• Common causes:
• CAD
• HTN
• Cardiac Infections
• Cardiomyopathy
• Valvular Disorders
• Myocardial Infarction
• Dysrhythmias
Classification of Heart Failure
• Onset:
• Acute heart failure
• Chronic heart failure
• Affected portion of the cardiac cycle:
• Diastolic heart failure
• Systolic heart failure
• Affected side of the heart:
• Left heart failure
• Right heart failure
• Stages of heart failure severity:
• New York Heart Association
• American Heart Association/American College of Cardiology
Acute or Chronic Heart Failure
• Describes the speed of onset of heart failure
• Acute Heart Failure
• Sudden onset
• No compensatory mechanisms
• May experience acute pulmonary
edema,CO or cardiogenic shock
• Chronic Heart Failure
• Gradual (insidious) Onset
• Presence of compensatory mechanisms
• Structural heart chamber changes (dilation or hypertrophy)
• Fluid overload & sodium and water retention
• Ongoing process; may deteriorate into acute HF
• i.e. Onset of dysrhythmias or cessation of medications
Heat Failure: Compensatory Mechanisms
• Sympathetic Nervous System:
• Decreased tissue perfusion results in activation of the
sympathetic nervous system, resulting in:
• ↑ Heart rate
• ↑ Contractility
• Vasoconstriction of arteries, arterioles & veins (↑afterload
& ↑preload)
• RAAS: Renin-Angiotension-Aldosterone System
• Decreased renal perfusion stimulates the increased
release of renin→ angiotensin II production, resulting in:
• Vasoconstriction (↑ afterload)
• Release of aldosterone: Na+ & water retention (↑preload)
Heat Failure: Compensatory Mechanisms
• Ventricular Remodeling:
• Final compensatory mechanism
• The ventricles change in size & shape in order to
overcome the ↑ resistance (afterload) of heart failure.
• Hypertrophy
• The ventricles thicken and become stiff resulting in
impairing filling during diastole.
• Dilation
• The heart muscle becomes over-stretched resulting in a
decreased force of contraction during systole.
• Overtime these mechanisms may actually
worsen heart failure !!
Myocardial Disease / Injury
Impaired Ventricular Performance
Cardiac
Workload
Ventricular
Remolding
Dilation &
Hypertrophy
Cardiac
Output
Vicious Cycle
of
Heart Failure
↑ SNS
↑ HR
↑ Contractility
Vasoconstriction
↑ RAAS
Vasoconstriction
Na/H2O
Retention
Systolic or Diastolic Heart Failure
• Described HF based on cardiac cycle
• Diastolic Heart Failure
• Disorder of ventricular filling
• Structural changes: usually ventricular hypertrophy
• Normal Ejection Fraction
• Systolic Heart Failure (more common)
• Disorder of ventricular contraction
• Structural changes: usually ventricular dilation
•  Ejection Fraction (< 40%)
• Combined diastolic & systolic impairments are
common.
Systolic & Diastolic Heart Failure:
Remodeling
(Jessup & Brozena, 2003)
Left & Right Sided Heart Failure
• Describes Heart failure based on the side of
the heart that is affected.
• Left-Sided Failure
• Left ventricular failure
• Pulmonary congestion
• Sign/Symptoms: i.e. fatigue, SOB, dyspnea, PND,
orthopena, crackles, dry cough, & tachycardia
• Right-Sided Failure
• Right ventricular failure
• Systemic congestion
• Signs/Symptoms: i.e. weakness, peripheral edema,
weight gain, JVD, hepatomegaly, anorexia & N/V.
NYHA: Functional Classification of HF
I
II
III
IV
No symptoms and no limitation in ordinary
physical activity.
Mild symptoms and slight limitation
during ordinary activity. Comfortable at rest.
Marked limitation in activity due to
symptoms, even during less-than-ordinary
activity. Comfortable only at rest.
Severe limitations. Experiences symptoms
even while at rest.
AHA/ACC: Classification System of HF
(Jessup & Brozena, 2003)
Heart Failure: Nursing Diagnoses
• Impaired gas exchange related to ventilation perfusion
imbalance.
• Decreased cardiac output related to altered…
•
•
•
•
Preload
Contractility
Afterload
Heart rate /rhythm
• Activity intolerance related to fatigue (secondary to by
an imbalance between oxygen supply and demand).
• Ineffective (cardiopulmonary) tissue perfusion related
to impaired arterial blood flow.
Heart Failure: Nursing Diagnoses
• Excess fluid volume related to excess fluid or sodium
intake and retention of fluid secondary to heart failure
and its treatments.
• Anxiety related to breathlessness and / or restlessness
secondary to inadequate oxygenation.
• Powerlessness related to inability to perform usual role
responsibilities.
• Knowledge deficit related to heart failure and its
treatments.
Nursing Management: Heat Failure
• Nursing Considerations
• Respiratory
• Supplemental oxygen
• Good lung assessment
• Monitoring
• Hemodynamic Monitoring
• Daily Weights
• I & O’s
• Laboratory Results
• i.e. electrolytes, BNP & digoxin levels
• Maintain
• Small frequent meals; low in salt
• Skin integrity
Nursing Management: Heat Failure
• Nursing considerations Cont.,
• Promote rest and avoid fatigue
• Assess for peripheral edema
• Client Education
• Medications
• Lifestyle changes
• i.e. low-sodium diet & activity-rest balance
• Daily weights
• S/Sx of worsening heart failure to report
• Importance of follow-up care
Heart Failure Management
• Goals of management
• Relief of health failure symptoms
• Enhance cardiac performance
• Pharmacologic Management
• Reduce Cardiac Workload
• Diuretics: Preload; watch for hypokalemia
• Nitrates:  Preload
• ACE I / ARB’s: Preload & Afterload
• Beta blockers / ACE I: Enhance reverse remolding
• Increase Positive Inotropic Effects
• i.e. Digoxin (Lanoxin)
Heart Failure Management
• Mechanical Assist Devices
• Intra Aortic Balloon Pump (IABP)
• Most widely used temporary assist
device
• Augments diastolic coronary artery
blood flow, enhances renal perfusion
& reduces afterload
• Used to reduce cardiac workload
when medical therapies are refractory
• i.e. Acute MI, after cardiac surgery
or heart Failure
Heart Failure Management
• Ventricular Assist Devices
• Provide flow assistance to the failing ventricle
• Three types available
• Left ventricular assist devices (LVAD); Most Common
• Bilateral ventricular assist devices (BiVAD)
• Right ventricular assist devices (RVAD)
• Categories of use
• Support to pending recovery
• Bridge to transplantation
• Destination therapy
Heart Failure Management
• Surgical Interventions
• Correct Underlying Problem
• Revascularization; CABG
• Valvular repair or replacement
• Artificial, human or animal valves
• Cardiac support devices
• ACORN CorCap
• Heart transplantation
• UNOS Stats (2003 U.S.)
• 3,519 wait listed
• 2,055 transplanted
Not enough to go around !!
Complications of Heart Failure
• Electrolyte Imbalances
• i.e. Hypokalemia
• Medication Toxicity
• i.e. Digoxin
•
•
•
•
Dysrhythmias
Cardiac Tamponade
Cardiogenic Shock
Pulmonary Edema
Pediatric Considerations
• Most causes of heart failure are congenital
heart defects.
• Three categories of signs & symptoms
• Impaired Myocardial Function
• Tachycardia, gallop rhythm (S3 & S4) & diaphoresis
• Pulmonary Congestion
• Tachypnea*, dyspnea, costal retractions &
developmental delays
• Systemic Congestion
• Hepatomegaly*, JVD, weight gain & peripheral edema
* See Box 34-1, pp. 1478 Wong