NURS 498 Complex Cardiovascular Disorders PDF

NURS 498 Complex Cardiovascular disorders Pharmacology and Nursing Interventions K. McCartney MN, RN C. Seneviratne PHD, RN C. Fox MN, RN S. De Boer MN, RN Adapted from K. Sealock and T. Ens,  By the end of this 3 hr. lecture, students will: A...

NURS 498 Complex Cardiovascular disorders Pharmacology and Nursing Interventions K. McCartney MN, RN C. Seneviratne PHD, RN C. Fox MN, RN S. De Boer MN, RN Adapted from K. Sealock and T. Ens,  By the end of this 3 hr. lecture, students will: Analyze patient predisposition to developing metabolic syndrome, and creating an appropriate care plan, including preventative strategies. Compare and contrast different methods of pacemaker therapy as indicated for patient therapy. Demonstrate prioritization of nursing Learning interventions for patients post-operatively from open heart surgery. Determine ongoing care planning for patients Objectives with end-stage heart failure. Establish the criteria for patients to receive destination Left Ventricular Assist Device (LVAD) as a treatment for end-stage heart failure. Establish knowledge of long-term collaborative care problems that must be continually assessed for patients who have received a heart transplant. Consider the pharmacokinetics and pharmacodynamics of immunosuppressive therapy post heart transplant. Table of Contents 01 02 03 Check In Cardiomyopathy Pericarditis 04 05 06 Device Therapy Heart failure Cardiac Surgery Interventions  Preload Afterload Contractility Heart Rate Increase Decrease  Cardiac Output Stroke Heart Rate Volume Preload Afterload Contractility Let us meet Pat Metabolic Syndrome There is no specific treatment  Pat’s initial assessment What are your priority BP-150/90 treatments to help Fasting Glucose- 8.0 prevent Pat from Waist- 100cm developing cardiac HDL- 2.0mmol/L disease? Pharmacology and Nursing Interventions Every patient will be different! Lowering LDL Lowering Antihypertensives Antidiabetics Triglycerides This Photo by Unknown Author is licensed under CC BY-SA  Cardiac Diagnostic Tests ECG Lab Work Allow 12 views of 02 Serum B-type 04 the hearts. natriuretic peptide (BNP) Troponin (Trop) More advanced Echocardiogram 01 Visualization of 03 cardiac testing heart structures, Cardiac MRI, Cardiac blood flow, ejection catheterization, fraction Myocardial Perfusion Imaging  Coronary Artery Disease What lab values would you expect to be ordered on Pat to help confirm a diagnosis of coronary artery disease?  Troponin Myocardial muscle protein released into circulation after myocardial injury Troponin I (TnI) and troponin T (TnT) Interventions for Coronary Artery Disease Coronary Artery Bypass surgery  Medical Management for Coronary Artery Disease Goals of medical treatment 1) Prevent further plaque buildup by utilizing Cardiac antiplatelets therapy Output 2) Minimize the workload on the heart by utilizing BB/CBB/ACE/ARB/Nitrates 3) Lower cholesterol by utilizing statins Stroke Heart Rate Volume Preload Afterload Contractility  Nursing interventions for coronary artery disease Pain Management Lifestyle Fluid status Activity modifications Assess cardiac output Diet Coping Education mechanisms Knowledge Medication management  Patient Education You are caring for Pat after she received a stent placement. She is ready to be discharged home. She is asking why she is having to take aspirin and ticagrelor daily. What is your best response? 1) Based on my assessment, you have not made the necessary lifestyle changes, so if you don’t take aspirin and ticagrelor, you will clot off more arteries. 2) Aspirin and Ticagrelor have different mechanisms of action so they are trying to do two different things to help with your recovery post stent placement. 3) As per the cardiac interventionist and your cardiologist, you need to take these medications to decrease your chances of dying. 4) Ticagrelor and aspirin are antiplatelet medications that work to prevent plaque from building up around the stent along with preventing additional plaque build up in other arteries.  Types of Cardiomyopathy Normal Heart Dilated Cardiomyopathy Cardiac Output Stroke Heart Rate Volume Preload Afterload Contractility What are your pharmacology treatments going to be? 01 02 03 Decrease Increase Decrease preload afterload Contractility Diuretics, nitrates ACE, ARB, calcium Digoxin channel blockers  Digoxin: Cardiac Glycoside Mechanism of Action: Adverse Effects: Positive ionotropic medication CV: bradycardia, tachy, hypotension Control ventricular response by CNS: headache, fatigue, confusion, controlling the refractory period—reduces convulsions HR Occular: blurred vision, halo vision Vagal tone: increases diastolic filling GI: anorexia, N & V, diarrhea Indications: HF, Afib and Aflutter Narrow therapeutic window. Normal Contraindications: known drug allergy. 2nd levels 0.5-0.9ng/ml or 3rd O HB, afib, vtach or vfib, heart failure Dig toxicity: ↓ in kidney function (diastolic dysfunction), subaortic Treatment of toxicity: withhold the next stenosis, kidney dysfunction. *May still be dose or digoxin immune Fab prescribed by cardiologist Dosing: usual oral maintenance dose: Interactions: Low K+ or Mag levels may 0.125-0.5mg/day****careful of decimal increase toxicity points**** Amiodarone, quinidine sulfate, and Assessment: Medication typically held if verapamil hydrochloride may increase apical HR for 1 minute < 60 bpm digoxin levels by 50% lab monitoring—when initiating the med and toxicity suspected Goals of Treatment for Hypertrophic Cardiomyopathy Cardiac Output Stroke Heart Rate Volume Preload Afterload Contractility What are your pharmacology treatments going to be? 01 02 03 Decrease Decrease Heart Varied management Contractility Rate for preload and afterload Betablocker Betablocker Calcium Channel Calcium Channel Blocker Blocker Goals of Treatment for Restrictive Cardiomyopathy Cardiac Output Stroke Heart Rate Volume Preload Afterload Contractility What are your pharmacology treatments going to be? 01 02 03 Decrease Increase Decrease preload afterload Contractility Diuretics, nitrates ACE, ARB, calcium channel blockers Beta Blockers, calcium channel blockers, digoxin  Nursing Interventions for **Assess your Cardiomyopathy patient**. Monitoring for decreased cardiac output Activity management Monitoring for pressure injury management Symptom Management Monitor for signs of clotting Monitoring for heart failure Dilated Hypertrophic Restricted Medications- BB/CCB Medication- ACE, **Patient specific* Avoid- nitrates, diuretics, diuretic, BB/CCB ACE inhibitors, digoxin and digoxin Surgical treatment for Pacemaker/ICD enlarged septum to insertion decrease size Resources Helpful videos on cardiomyopathy treatment https://www.youtube.com/watch?v=ithdrJuSj3A Cardiomyopathy Heart and Stroke Foundation of Canada www.heartandstroke.ca/heart/conditions/cardiomyopathy C.Seneviratne, T. Ens, & K. Sealock, 2020 Pericarditis Pericarditis Pinnacle Symptoms Pericardial rub 01 12 lead ECG with ST elevation on all leads 02 This Photo by Unknown Author is licensed under CC BY-NC  Cardiac Tamponade **Assess your patient**. Bedside Echo Muffled Heart Sounds Beck’s Triad Hypotension Elevated JVP (Jugular Vein distention) Pericardiocentesis Uptodate, 2022 Nursing Interventions for Pericarditis Assess your Pain patient management Monitor heart and lung Pharmacological and non- sounds; watch for signs of pharmacological heart failure Lifestyle Psychosocial support Diet, physical activity Support the patient and limitations family Chronic Cardiac dysrhythmias Nursing care and interventions for EP (electrophysiology)  Cardiac Ablation 1) Heart rhythm changes 2) Signs of dizziness, chest discomfort or fainting (Cardiovascular Health and Stroke Strategic Clinical Network, 2019) Catheter Ablation – YouTube- check out this video to see an ablation in action  Cardiac Implantable devices CRT (Cardiac Pacemaker Implantable Cardioverter- Resynchronization Defibrillator therapy) Treatment option for symptomatic Treatment option for patient’s that Treatment option for patients with: rhythms such as have experienced Decreased LV ejection fraction, Bradycardia Cardiac arrest due to a lethal Widened QRS Heart blocks rhythm such as ventricular Left bundle branch block(LBBB), Pauses fibrillation of ventricular and NYHA classification. (Saxon & Tachyarrhythmias tachycardia DeMarco, 2014) Arrhythmias caused by Episodes of lethal rhythm unable to antiarrhythmic drugs be managed with medications Bradyarrhythmias Heart and Stroke, 2022 Some patients requiring ablation therapy may require What type of cardiac implantable device would your patient get based on the following rhythms?  Acute Pacemaker therapy options Transcutaneous pacing Transvenous pacing Epicardial wires placed post open heart surgery This Photo by Unknown Author is licensed under CC BY-NC Permanent Pacemaker Pacemaker Therapy Pediatric considerations: ○ Underlying congenital cardiac defect may precipitate the dysrhythmia. ○ Sometimes, after a structural heart defect is repaired an AV block may occur temporarily. ○ Parents and the child(depending on the age) should be taught how to take a pulse for a full minute. ○ CPR instruction is suggested for parents, as a measure to create psychological well-being. (Perry et al., 2013, p. 1486)  Pacemaker Therapy Nursing Interventions Post operative care Ongoing care 1) Assess pacemaker site for signs of 1) Patient teaching- importance to infection, hematoma formation mention concern about 2) Assess patient’s cardiac output electromagnetic interference so 3) Assess patient’s pulse MRIs, airport screening 4) Review activity restrictions 2) Patient teaching- palpating their 5) Assess for signs of pneumothorax pulse or cardiac tamponade. 3) When to call for help. 4) Carrying documentation or wearing a medical alert bracelet so other are aware they have a pacemaker. Internal Cardioverter-Defibrillator Nursing Interventions 1) Monitor patient’s cardiac output 2) Monitor patient’s electrolytes and fluid status 3) Monitor for signs and symptoms of infection 4) Support and teach patient and family about ICD  ICD Shocks in Emergent situations Telemetry (crash cart available/defib pads on) – Defibrillation pads will not be placed directly on pacemaker Apply magnet over ICD: - Recurrent ICD shocks due to AFib/SVT/VT on telemetry that is hemodynamically tolerated - Patient is getting end of life care - Patient that is being shocked inappropriately Cardiac Resynchronization Therapy (CRT) Purpose A small electronic apparatus is surgically implanted to help both ventricles contract together. This device is made up of three leads which are attached to the heart muscle at one end (one each to the right atrium, right ventricle and left ventricle) and to a pulse generator at the other. What would you do if you were caring for a patient and saw this rhythm?  About 20% of Alberta Heart Failure patients in 2016 were readmitted after initial diagnosis Heart and Stroke, 2016  Chronic Acute CAD Acute MI HTN Dysrhythmia Rheumatic Heart disease Pulmonary Embolism Congenital heart disease Thyrotoxicosis Ventricular septal defect Hypertensive crisis Pulmonary disease Myocarditis Cardiomyopathy Bacterial Endocarditis Anemia Rupture of papillary muscle Bacterial endocarditis C.Seneviratne, T. Ens, & K. Sealock, 2020 Valvular disorders Diabetes  Welcome back, Pat! Pat did not make the necessary lifestyle changes after seeing you She is admitted to your unit with shortness of breath, fatigue and weight gain Over the last two years, she has developed coronary artery disease and had a myocardial event Her admitting diagnosis is heart failure This Photo by Unknown Author is licensed under CC BY-SA-NC Copyright 2017 Canadian Cardiovascular Society  Pat’s test results ECG- Normal sinus rhythm with q waves (identifier that Lab results she has had a previous MI) CBC- normal Echo- Left ventricle is larger Creatine- slight elevated 100 than normal, mild regurgitation Ferritin- normal and ejection fraction of 35% TSH- normal Troponin- slightly elevated 50 Chest X-ray- Larger silhouette BNP-3000- elevated of the heart with mild effusions  B-type Natriuretic Peptide BNP is a protein hormone that shows how well your heart is working NT-proBNP is a protein that’s a part of the BNP hormone Goals of Care Copyright © (2019) Alberta Health Services.  Heart Failure Classification Preserved ejection fraction heart failure called HFpEF Reduced ejection fraction heart failure called HFrEF Copyright 2019 American Heart Association Angiotensin receptor-neprilysin inhibitor (ARNi) Sacubitril/ valsartan Mechanism of Action: vasodilator, antihypertensive Indications: to decrease mortality and hospitalization in NYHA class II- IV with decreased EF Interactions: NSAIDS and selective Cox-2 inhibitors may increase risk renal dysfunction May increase lithium levels Nursing Considerations Adverse Effects: CNS-dizziness Resp-cough Assessment/Intervention: CV-hypotension Hyperkalemia Angioedema Delay for 36 hrs after last dose of ACE BP (orthostatic), pulse. inhibitors for washout period Monitor daily weight. Monitor Fetal Toxicity- do not take well pregnant or renal function, potassium intention of becoming pregnant levels, hemoglobin and HCT Patient Education 1) Importance of monitoring blood pressure 2) Signs of hyperkalemia- monitor foods and medications with potassium 3) Signs of feeling unwell- dizzy, fluid loss from vomiting that could lead to decrease blood pressure This Photo by Unknown Author is licensed under CC BY-SA  SGL2T Inhibitors Dapagliflozin, Empagliflozin and Canagliflozin Class of drug- Antidiabetic medication Mechanism of action- decrease cardiac preload and afterload. **It is still being researched its applicability to cardiac outcomes** Indications- Evidence-based therapies as part of optimal medical regimen for heart failure treatment of HFrEF  Nursing Considerations Adverse Reactions Assessment/Intervention Acute Kidney injury 1) Monitor Cardiac output- vital Bone Fractures signs Hypotension- due to fluid 2) Monitor intake and output depletion 3) Monitor blood glucose Hypoglycemia Hypersensitivity- angioedema, 4) Monitor renal function anaphylaxis and skin rash 5) Monitor for signs of acidosis Ketoacidosis 6) Monitor for signs of urinary tract Lower limb amputation- increase infection with canagliflozin Urinary tract infection  Ivabradine Mechanism of Action: inhibits the cardiac pacemaker If current by acting on the hyperpolarization- active cyclic nucleoside-gated channel blocker. Decreases HR without effecting contractility or ventricular repolarization. Indications: heart failure (decreases mortality and hospitalization) Nursing Considerations Contraindications: acutely decompensated Assessment/Intervention HR, sick sinus syndrome, sinoatrial block 1) Monitor heart rate or 3o heart block, severe hepatic 2) Monitor blood pressure impairment, pacemaker dependent, pregnancy Adverse Effects: phosphenes CV-afib, bradycardia, HB, hypertension, sinus arrest This Photo by Unknown Author is licensed under CC BY-SA Heart Failure Teaching points Daily Fluid weights Restriction Sodium Signs and Restriction Symptoms Medications  Pat’s readmitted to CCU (Coronary care Vital signs unit) HR- 100 bpm, regular BP- 84/43 Her admitting diagnosis is acute heart Spo2- 96% on 8L HFNP failure +/- cardiogenic shock. Resp- 24 bpm Temp- 37.1 She is admitted to the CCU for blood Assessment findings pressure management, heart failure Neuro- Drowsy and Oriented X3, symptom management and Bipap Weak-upper and lower limbs, treatment if required. Cardiac- weak pulses throughout, +2 Concerning lab work pitting edema to bilateral lower limbs, BNP-28,000 cooler to touch, complaining of chest Crea- 160 pain on and off Resp- crackles throughout Medications for Acute Heart Failure Management This Photo by Unknown Author is licensed under CC BY- SA Location Receptor Response Cardiovascular Blood vessels α1 Vasoconstriction β2 Vasodilation Heart muscle β1 Increased contractility SA Node β1 Increased HR AV Node β1 Increased HR Pupillary muscles of iris Mydriasis (dilated pupils) α1 Endocrine Kidney β1 Increased renin secretion Liver β2 Glycogenolysis Gastrointestinal Muscle α1 , β2 Decreased motility (relaxation of GI smooth muscle) Genitourinary Bladder sphincter α1 Constriction Penis α1 Ejaculation Uterus α1 Contraction β2 Relaxation Fig 19.1, p. 327, Sealock and Respiratory Seneviratne, (2021) Bronchial muscles β2 Dilation(relaxation of bronchial smooth muscle)  Dopamine Mechanism of Action: Small doses stimulate dopaminergic receptors, producing renal vasodilation. Larger does (2- 10mcg/kg/min) stimulate dopaminergic and B1 adrenergic receptors—cardiac stimulation and renal dilation Doses larger than 10 mcg/kg/min may cause renal constriction Indications: Low dose- increases renal perfusion Shock unresponsive to fluids—increases BP, CO and urine output Availability: IV route ½ life: 2 min Assessment/ Teaching: Consult physician for vital sign parameters. Monitor BP, HR, pulse pressure, CO, CVP urinary output. Report arrhythmias. Assess peripheral pulses and notify physician if mottling occurs.  Norepinephrine Mechanism of Action: Vasopressor Indications: Produces vasoconstriction and myocardial stimulation; severe hypotension and shock Availability: IV route ½ life: unknown Assessment/ Teaching: Consult physician for vital sign parameters. Monitor arterial pulses, ECG, CO, CVP, urinary output. Report arrhythmias and U/0