401-LEC-MIDTERMS-.pdf

TRANSES Subject Code: NRG 401 Mode of Class: LEC Semester: 1st Term: Midterms LESSON OUTLINE f. Diagnostic Procedures i. Nursing Managemen...

TRANSES Subject Code: NRG 401 Mode of Class: LEC Semester: 1st Term: Midterms LESSON OUTLINE f. Diagnostic Procedures i. Nursing Management i. Stress Testing i. Providing 1. Review of Cardiovascular ii. Blood tests Oxygenation System iii. Pulmonary function ii. Decreasing Anxiety a. Anatomy of the Heart testing iii. Facilitating Fluid i. 3 layers of the heart iv. Cardiac CT scans Balance ii. Heart Chambers v. Myocardial biopsy iv. Promoting Nutrition iii. Heart Valves vi. Chest x-rays j. Nursing Diagnosis for Left iv. Coronary Arteries vii. Coronary Sided Heart Failure v. Myocardium angiography k. Nursing Diagnosis for Right b. Function of the Heart viii. Cardiac Sided Heart Failure i. Cardiac catheterization Electrophysiology ix. Echocardiogram ii. Cardiac Action x. Electrocardiogram 3. Congestive Heart Failure Potential (EKG) a. Congestive Heart Failure: c. Cardiac Hemodynamics xi. Electrophysiology Definition i. Cardiac Cycle xii. Radionuclide imaging b. Factors Affecting Cardiac ii. Cardiac Output xiii. Treadmill exercise Output 1. Effect of test i. Heart Rate Heart Rate g. Medical Management ii. Preload on Cardiac i. Non-pharmacologic iii. Afterload Output therapies iv. Contractility 2. Effect of ii. Pharmacologic c. Pathophysiology Stroke therapies d. Risk Factors Volume on h. Surgical Management e. Etiology Cardiac i. Cardiac f. Types of Congestive Heart Output Resynchronization Failure d. Gerontologic Considerations Therapy (CRT) i. Left-sided Failure ii. Pacemakers ii. Right-sided Failure 2. Heart Failure iii. Implantable g. Acute Congestive Heart a. Heart Failure Cardioverter-defibrill Failure b. Types of Heart Failure/ ators (ICDS) h. Chronic Congestive Heart Cardiovascular Disease iv. Coronary Artery Failure i. Left Sided Heart Bypass Grafting i. Classification & Stages Failure (CABG) j. Diagnostic Studies ii. Right Sided Heart v. Percutaneous k. Nursing and Collaborative Failure Coronary Management iii. Diastolic Heart Intervention l. Other Interventions: Heart Failure vi. Transcatheter Aortic Failure iv. Systolic Heart Failure Valve Replacement c. Causes (TAVR) d. Risk Factors vii. Mechanical Valve e. Clinical Manifestations Replacement dfd  Go Back to Lesson Outline 4. Hemodynamic Monitoring a. Hemodynamic Monitoring i. Central Venous 6. Coronary Artery Disease Pressure Monitoring a. Coronary Artery Disease ii. Guidelines i. Angina (Three Major iii. Complications Forms) b. Intra-Arterial BP Monitoring 1. Stable i. Allen test 2. Unstable ii. Nursing 3. Variant Interventions b. Pathophysiology c. Pulmonary Artery Pressure c. Diagnosis Monitoring d. Diagnostic i. Nursing e. Signs and Symptoms Interventions f. Nursing Diagnosis d. Left Atrial Pressure g. Nursing Interventions Monitoring h. Pharmacologic Management e. Mixed Venous Oxygen i. Nitroglycerin Saturation ii. Beta-blockers i. Mixed Venous iii. Calcium channel Oxygen Saturation blockers Monitoring iv. Analgesics ii. Causes of High SvO2 i. Surgical Management despite evidence of j. Prevention End-organ 7. Hypertensive Crisis a. Blood Pressure Categories 5. Cardiogenic Shock b. Hypertensive Emergency a. Classifications i. Assessment b. Causes ii. Pharmacology c. Clinical Manifestations iii. Other Medical d. Clinical Findings in Stages of Management Shock c. Hypertensive urgency e. Assessment and Diagnostic i. Assessment Findings ii. Pharmacology f. Medical Management iii. Nursing Management g. Pharmacologic Therapy d. Discharge/Follow-up Plans h. Surgical Management i. Nursing Assessment j. Nursing Diagnosis k. Nursing Care Planning & Goals l. Nursing Interventions dfd  Go Back to Lesson Outline LESSON 1: Heart Chambers Review of Cardiovascular System Anatomy of the Heart A hollow, muscular organ located in the center of the thorax, where it occupies the space between the lungs (mediastinum) and rests on the diaphragm. It weighs approximately 300 g (10.6 oz); the weight and size of the heart are influenced by age, gender, body weight, extent of physical exercise and conditioning, and heart disease. 3 layers of the heart The pumping action of the heart is accomplished by the rhythmic Endocardium - the inner layer, consists of endothelial tissue and relaxation and contraction of the muscular walls. lines the inside of the heart and valves. ○ Atria (2 top chambers) Myocardium - the middle layer, is made up of muscle fibers and is ○ Ventricles (2 bottom chambers) responsible for the pumping action. Epicardium - the exterior layer of the heart. Systole refers to the events of the heart during contraction of the atria and the ventricles. Atrial systole occurs first, just at the end of diastole, followed by ventricular systole. This synchronization allows the ventricles to fill completely prior to ejection of blood from these chambers. Diastole or period of ventricular filling (Relaxation phase: all 4 chambers relax simultaneously) which allows the ventricles to fill in preparation for contraction. dfd  Go Back to Lesson Outline Heart Valves The four valves in the heart permit blood to flow in only one direction. ○ composed of thin leaflets of fibrous tissue, open and close in response to the movement of blood and pressure changes within the chambers. Right side of the heart, made up of the right atrium and right ventricle, distributes venous blood (deoxygenated blood) to the lungs via the pulmonary artery (pulmonary circulation) for oxygenation. Left side of the heart, composed of the left atrium and left ventricle, distributes oxygenated blood to the remainder of the body via the aorta (systemic circulation). ○ receives oxygenated blood from the pulmonary circulation via four pulmonary veins. 2 types of valves: ○ Atrioventricular (AV) AV valves separate the atria from the ventricles. The tricuspid valve (three cusps) separates the right atrium from the right ventricle. The mitral or bicuspid (two cusps) valve lies between the left atrium and the left ventricle ○ Semilunar Semilunar valves (composed of three leaflets, which are shaped like half-moons) Apical Impulse (also called the point of maximal impulse [PMI]) Pulmonic Valve - is a valve between the ○ pulsation created during normal ventricular contraction, right ventricle and the pulmonary artery. called the apical impulse. In the normal heart, the PMI is Aortic Valve - The valve between the left located at the intersection of the midclavicular line of the left ventricle and the aorta. chest wall and the fifth intercostal space (Bickley, 2014). The semilunar valves are forced open during ventricular systole as blood is ejected from the right and left ventricles into the pulmonary artery and aorta, respectively. dfd  Go Back to Lesson Outline Coronary Arteries Myocardium The left and right coronary arteries Middle, muscular layer of the and their branches supply arterial atrial and ventricular walls blood to the heart. Composed of specialized cells Perfused during diastole called myocytes (which form an With a normal heart rate of 60 to 80 interconnected network of bpm, there is ample time during muscle fibers). These fibers diastole for myocardial perfusion. encircle the heart in a However, as heart rate increases, figure-of-eight pattern, forming a diastolic time is shortened, which spiral from the base (top) of the may not allow adequate time for heart to the apex (bottom). myocardial perfusion. As a result, patients are at risk for myocardial ischemia (inadequate oxygen supply) during tachycardia (heart rate greater than 100 bpm), especially patients with CAD. Function of the Heart Cardiac Electrophysiology The cardiac conduction system generates and transmits electrical impulses that stimulate contraction of the myocardium. 3 physiologic characteristics of two types of specialized electrical cells (nodal cells and the Purkinje cells) provide this synchronization: 1. Automaticity: ability to initiate an electrical impulse. 2. Excitability: ability to respond to an electrical Left Artery (3 branches) impulse. Left main coronary artery - from the point of origin to the first major 3. Conductivity: ability to transmit an electrical branch impulse from one cell to another ○ Left anterior descending artery (which courses down the Sinoatrial (SA) node (the primary pacemaker of the heart) anterior wall of the heart) ○ Located at the junction of the superior vena cava and the ○ circumflex artery (which circles around to the lateral left wall right atrium. of the heart) ○ In a normal resting adult heart has an inherent firing rate of The right side of the heart is supplied by the right coronary artery. 60 to 100 impulses per minute. Posterior descending artery (the posterior wall of the heart receives ○ The electrical impulses initiated by the SA node are its blood supply by an additional branch from the right coronary conducted along the myocardial cells of the atria via artery) specialized tracts called internodal pathways. Superficial to the coronary arteries are the coronary veins. dfd  Go Back to Lesson Outline Atrioventricular (AV) node (the secondary pacemaker of the heart) Repolarization - once depolarization is complete, the exchange of ○ Coordinates the incoming electrical impulses from the atria ions reverts to its resting state. and after a slight delay (allowing the atria time to contract Cardiac action potential - the repeated cycle of depolarization and and complete ventricular filling) relays the impulse to the repolarization* ventricles. Cardiac action potential has 5 phases: ○ Initially, the impulse is conducted through a bundle of ○ Phase 0: Cellular depolarization is initiated as positive ions specialized conducting tissue, referred to as the bundle of influx into the cell. His, which then divides into the right bundle branch ○ Phase 1: Early cellular repolarization begins during this (conducting impulses to the right ventricle) and the left phase as potassium exits the intracellular space. bundle branch (conducting impulses to the left ventricle). ○ Phase 2: This phase is called the plateau phase because SA node has the highest inherent rate (60 to 100 impulses per the rate of repolarization slows. Calcium ions enter the minute) intracellular space. AV node has the second highest inherent rate (40 to 60 impulses ○ Phase 3: This phase marks the completion of repolarization per minute) and return of the cell to its resting state. Ventricular pacemaker sites have the lowest inherent rate (30 to 40 ○ Phase 4: This phase is considered the resting phase before impulses per minute) the next depolarization. If the SA node malfunctions, the AV node generally takes over the pacemaker function of the heart at its inherently lower rate. Should both the SA and the AV nodes fail in their pacemaker function, a pacemaker site in the ventricle will fire at its inherent bradycardic rate of 30 to 40 impulses per minute. Cardiac Action Potential The nodal and Purkinje cells (electrical cells) generate and transmit impulses Myocardial cells must completely repolarize before they can across the heart, stimulating the cardiac myocytes (working cells) to contract. depolarize again. During the repolarization process, the cells are in a ○ Ions- Stimulation of the myocytes occurs due to the REFRACTORY PERIOD. exchange of electrically charged particles ○ Two phases of the refractory period: ○ The channels regulate the movement and speed of specific a. Effective (or absolute) refractory period ions: (enter and exit) i. The cell is completely unresponsive to any a. Sodium (primary electrical stimulus. extracellular ion) ii. It is incapable of initiating an early b. Potassium (primary depolarization. intracellular ion) iii. Corresponds with the time in phase 0 to the c. Calcium middle of phase 3 of the action potential. Depolarization - this exchange of ions b. Relative refractory period creates a positively charged intracellular i. corresponds with the short time at the end of space and a negatively charged extracellular phase 3. space that characterizes the period. ii. if an electrical stimulus is stronger than normal, the cell may depolarize prematurely. dfd  Go Back to Lesson Outline Cardiac Output Cardiac Hemodynamics Refers to the total amount of blood ejected by one of the ventricles in An important determinant of blood flow in the cardiovascular system liters per minute. is the principle that fluid flows from a region of higher pressure to one In a resting adult is 4 to 6 L/min but varies greatly depending on the of lower pressure. The pressures responsible for blood flow in the metabolic needs of the body. normal circulation are generated during systole and diastole. Computed by multiplying the stroke volume by the heart rate. Stroke volume is the amount of blood ejected from one of the ventricles per heartbeat. The average resting stroke volume is about 60 to 130 mL (Woods et al., 2009). Cardiac Cycle Refers to the events that occur in the heart from the beginning of Effect of Heart Rate on Cardiac Output one heartbeat to the next. Each cardiac cycle has three major sequential events: diastole, atrial systole, & ventricular systole. Cardiac Output Atrial systole increases the pressure inside the atria, ejecting the ○ Responds to changes in the metabolic demands of the remaining blood into the ventricles. Atrial systole augments tissues associated with stress, physical exercise, and illness. ventricular blood volume by 15% to 25% and is sometimes referred ○ It is enhanced by increases in both stroke volume and heart to as the atrial kick (Woods et al., 2009). rate to compensate for these added demands. At this point, ventricular systole begins in response to propagation of Changes in heart rate are due to inhibition or stimulation of the SA the electrical impulse that began in the SA node some milliseconds node mediated by the parasympathetic and sympathetic earlier, the pressure inside the ventricles rapidly increases, forcing divisions of the autonomic nervous system. the AV valves to close. As a result, blood ceases to flow from the The balance between these two reflex control systems normally atria into the ventricles, and regurgitation (backflow) of blood into the determines the heart rate. Branches of the parasympathetic nervous atria is prevented. system travel to the SA node by the vagus nerve. The rapid increase in pressure inside the right and left ventricles Stimulation of the vagus nerve slows the heart rate. The sympathetic forces the pulmonic and aortic valves to open, and blood is ejected nervous system increases heart rate by innervation of the beta-1 into the pulmonary artery and aorta, respectively. The exit of blood is receptor sites located within the SA node. at first rapid; then, as the pressure in each ventricle and its The heart rate is increased by the sympathetic nervous system corresponding artery equalizes, the flow of blood gradually through an increased level of circulating catecholamines (secreted decreases. by the adrenal gland) and by excess thyroid hormone, which At the end of systole, pressure within the right and left ventricles produces a catecholamine Vlike effect. rapidly decreases. As a result, pulmonary arterial and aortic In addition, the heart rate is affected by the central nervous system pressures decrease, causing closure of the semilunar valves. These and baroreceptor activity. events mark the onset of diastole, and the cardiac cycle is repeated. Baroreceptors Are specialized nerve cells located in the aortic arch and in both right and left internal carotid arteries (at the point of bifurcation from the common carotid arteries) dfd  Go Back to Lesson Outline Sensitive to changes in blood pressure (BP) iii. Increased contractility results in increased stroke ○ Hypertension - these cells increase their rate of discharge, volume. transmitting impulses to the cerebral medulla. iv. Contractility is depressed by hypoxemia, acidosis, ○ This action initiates parasympathetic activity and inhibits and certain medications (e.g., beta-adrenergic sympathetic response, lowering the heart rate and the BP blocking agents such as metoprolol [Lopressor]). ○ Hypotension - Less baroreceptor stimulation during periods v. The percentage of the end-diastolic blood volume of hypotension prompts a decrease in parasympathetic that is ejected with each heartbeat is called the activity and enhances sympathetic responses. ejection fraction (the normal left ventricle is 55% to 65%, Woods et al., 2009); It is used as a measure of myocardial contractility. An ejection fraction of less Effect of Stroke Volume on Cardiac Output than 40% indicates that the patient has decreased Stroke volume is primarily determined by 3 factors: left ventricular function and likely requires treatment a. Preload of HF. i. Refers to the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. Gerontologic Considerations ii. Commonly referred to as left ventricular end-diastolic pressure. Changes in cardiac structure and function occur with age. A loss of iii. Decreased by a reduction in the volume of blood function of the cells throughout the conduction system leads to a returning to the ventricles slower heart rate. iv. By increasing the return of circulating blood volume The size of the heart increases due to hypertrophy (thickening of the to the ventricles, Frank–Starling (or Starling) law of heart walls), which reduces the volume of blood that the chambers the heart - As the volume of blood returning to the can hold. Hypertrophy also changes the structure of the myocardium, heart increases, muscle fiber stretch also increases reducing the strength of contraction. The resulting backflow of blood (increased preload), resulting in stronger contraction creates heart murmurs, a common finding in older adults (Bickley, and a greater stroke volume. 2014; Woods et al., 2009). b. Afterload As a result of these age-related changes, the cardiovascular system i. Resistance to ejection of blood from the ventricle, is takes longer to compensate from increased metabolic demands due the second determinant of stroke volume. to stress, exercise, or illness. ii. The resistance of the systemic BP to left ventricular Structural differences between the hearts of men and women have ejection is called systemic vascular resistance. significant implications. The heart of a woman tends to be smaller iii. The resistance of the pulmonary BP to right than that of a man. The coronary arteries of a woman are also ventricular ejection is called pulmonary vascular narrower in diameter than a man’s arteries. When atherosclerosis resistance. occurs, these differences make procedures such as cardiac c. Contractility catheterization and angioplasty technically more difficult. i. Refers to the force generated by the contracting Women typically develop CAD 10 years later than men, as women myocardium. have the benefit of the female hormone estrogen and its ii. Enhanced by circulating catecholamines, cardioprotective effects. sympathetic neuronal activity, and certain medications (e.g., digoxin [Lanoxin], dopamine, or dobutamine). dfd  Go Back to Lesson Outline LESSON 2: TYPES HEART FAILURE Heart Failure 1. Left Sided Heart Failure HEART FAILURE It is the most common type of heart failure. The left heart ventricle A chronic, progressive condition in which the heart muscle is unable located in the bottom left side of your heart. to pump enough blood to meet the body’s needs for blood and This area pumps oxygen-rich blood to the rest of your body. oxygen. Basically, the heart can’t keep up with its workload. Left-sided heart failure occurs when the left ventricle doesn’t pump efficiently. This prevents your body from getting enough oxygen-rich At first the heart tries to make up for this by: blood. The blood backs up into your lungs instead, which causes Enlarging. The heart stretches to contract more strongly and keep shortness of breath and a buildup of fluid. up with the demand to pump more blood. Over time this causes the heart to become enlarged. There are two types of left-sided heart failure. Drug treatments are different Developing more muscle mass. The increase in muscle mass for the two types. occurs because the contracting cells of the heart get bigger. This lets a. Heart failure with reduced ejection fraction (HFrEF) the heart pump more strongly, at least initially. - also called systolic failure Pumping faster. This helps increase the heart’s output. - The left ventricle loses its ability to contract normally. The heart can't pump with enough force to push enough blood The body also tries to compensate in other ways: into circulation. The blood vessels narrow to keep blood pressure up, trying to make b. Heart failure with preserved ejection fraction (HFpEF) up for the heart’s loss of power. - also called diastolic failure (or diastolic dysfunction) The body diverts blood away from less important tissues and organs - The left ventricle loses its ability to relax normally (because (like the kidneys), the heart and brain. the muscle has become stiff). The heart can't properly fill These temporary measures mask the problem of heart failure, but with blood during the resting period between each beat. they don’t solve it. Heart failure continues and worsens until these compensating processes no longer work. 2. Right Sided Heart Failure Eventually the heart and body just can’t keep up, and the person experiences the fatigue, breathing problems or other symptoms that The right heart ventricle is responsible for pumping blood to your usually prompt a trip to the doctor. Heart failure can involve the lungs to collect oxygen. Right-sided heart failure occurs when the heart’s left side, right side or both sides. However, it usually affects right side of your heart can’t perform its job effectively. It’s usually the left side first. triggered by left-sided heart failure. The accumulation of blood in the lungs caused by left-sided heart failure makes the right ventricle work harder. This can stress the right side of the heart and cause it to fail. Right-sided heart failure can also occur as a result of other conditions, such as lung disease. Right-sided heart failure is marked by swelling of the lower extremities. This swelling is caused by fluid backup in the legs, feet, and abdomen. dfd  Go Back to Lesson Outline 3. Diastolic Heart Failure RISK FACTORS Occurs when the heart muscle becomes stiffer than normal. The stiffness, which is usually due to heart disease, means that your heart doesn’t fill with blood easily. People with diseases that damage the heart are also at an increased This is known as diastolic dysfunction. It leads to a lack of blood flow risk. These diseases include: to the rest of the organs in your body. ○ Hyperthyroidism ○ Hypothyroidism ○ Emphysema 4. Systolic Heart Failure ○ Anemia Occurs when the heart muscle loses its ability to contract. The contractions of the heart are necessary to pump oxygen-rich Certain behaviors can also increase your risk of developing HF, blood out to the body. including: This problem is known as systolic dysfunction, and it usually ○ Smoking develops when your heart is weak and enlarged. ○ Eating foods high in fat or cholesterol Both diastolic and systolic heart failure can occur on the left or right ○ Living a sedentary lifestyle sides of the heart. You may have either condition on both sides of the ○ Being overweight heart. CLINICAL MANIFESTATIONS CAUSES Heart failure (HF) is most often related to another disease or illness. The Left Sided Heart Failure most common cause of HF is coronary artery disease (CAD), a disorder that causes narrowing of the arteries that supply blood and oxygen to the heart. Cough - A dry, hacking cough can be an early sign, which occurs Other conditions that may increase your risk for developing HF include: due to fluid build-up in the lungs. In later stages, the sufferer can 1. Cardiomyopathy, a disorder of the heart muscle that causes the cough up white secretions that sometimes contain blood. heart to become weak Fatigue - This is due to the heart’s inability to pump enough blood to 2. Congenital heart defect other body parts. Arms and legs become weak. During end- stage 3. Heart attack heart failure, patients find it hard to participate in normal activities, 4. Heart valve disease such as walking or getting dressed. People who are at this point tend 5. Certain types of arrhythmias, or irregular heart rhythms to sleep a lot. 6. High blood pressure Chest discomfort - The heart can beat irregularly, causing 7. Emphysema, a disease of the lung discomfort. The discomfort is described as fluttering, pain, or 8. Diabetes pressure. 9. An overactive or underactive thyroid Confusion - The brain receives less oxygenated blood with 10. HIV left-sided heart failure, so confusion or altered thinking can occur. 11. AIDS Memory loss may also be a problem. 12. Severe forms of anemia Paroxysmal nocturnal dyspnea - This means that the persons 13. Certain cancer treatments, such as chemotherapy awakened from sleep with difficulty breathing. 14. Drug or alcohol misuse S heart sound - This is a murmur due to a variation in blood flow. dfd  Go Back to Lesson Outline Cyanosis - A bluish discoloration of the skin called cyanosis can 4. Cardiac CT scans produce digital x-ray images of your heart so that occur as a result of poor circulation from inadequate oxygenation of your doctor can get a clear visual of what’s going on. blood. 5. Myocardial biopsy is a procedure in which your doctor removes a Elevated pulmonary capillary wedge pressure - This means that portion of the heart muscle by inserting a thin tube through an entry the pressure in the small pulmonary arterial branch is higher than it point on your body and attaching it to your heart. should be. 6. Chest x-rays to examine the how the lungs and heart are Decreased urine output - Since other parts of the body aren’t functioning. receiving blood, the body has a tendency to want to hold on to fluid. 7. Coronary angiography involves your doctor injecting a blue dye Weight gain - When the body holds onto more fluid, overall body into your arteries and heart chambers so that your doctor can weight increases. examine the way in which blood flows through your heart and determine whether there are any abnormalities. 8. Cardiac catheterization: A thin flexible tube is threaded through a Right Sided Heart Failure blood vessel and into the heart and accompanied with a contrast Sleep apnea material so that an X-ray video can show heart functioning. Sudden and frequent shortness of breath 9. Echocardiogram: An ultrasound to take moving pictures of heart Anorexia induced by complete lack of appetite chambers and valves. Massive weight gain 10. Electrocardiogram (EKG): A measurement of electrical activity of Chronic fatigue the heart, which can help determine if there is heart enlargement or Constant urge to urinate heart damage. Capture moving images of the heart to showcase the Nausea and lightheadedness blood pressure and whether it’s pumping as it should. Heavy and uncontrollable coughing and breathlessness 11. Electrophysiology: A test that records the heart’s electrical activity Having a hard time focusing on tasks at hand and pathways, which can detect heart rhythm problems. Extreme weakness felt throughout the body 12. Radionuclide imaging: A radioactive isotope is injected into a vein Fainting and a special camera records it traveling through the heart. This Irregular heartbeat helps highlight areas of heart damage. Intense chest pains 13. Treadmill exercise test: A measurement of a person’s capacity to Coughing pinkish-white phlegm exercise and the amount of oxygen the heart provides the muscles while in motion. This can indicate the severity of left-sided heart failure and can help determine left-sided heart failure prognosis. DIAGNOSTIC PROCEDURE/S 1. Stress testing during exercise to determine whether the patient can exercise and raise their heart rate to a normal level for the level of activity they’re doing. MEDICAL MANAGEMENT 2. Blood tests that look for specific substances that are typically found in the bloodstream when a patient is suffering from right-sided heart failure while also checking other major organs for signs of 1. Non-pharmacologic therapies: abnormality. Dietary sodium and fluid restriction 3. Pulmonary function testing measures the quality of your breath Physical activity as appropriate and how well your lungs are working as you breathe in and out of a Attention to weight gain tube that’s connected to a measuring device. dfd  Go Back to Lesson Outline 2. Pharmacologic therapies: 6. Transcatheter Aortic Valve Replacement (TAVR) Diuretics Is another type of minimally invasive aortic valve replacement that Vasodilators, has a nonsurgical approach. It is also sometimes called Inotropic agents transcatheter aortic valve implantation (TAVI). Anticoagulants 7. Mechanical Valve Replacement Beta-blockers A mechanical valve replaces the damaged valve. Digoxin NURSING MANAGEMENT SURGICAL MANAGEMENT 1. Providing Oxygenation 1. Cardiac Resynchronization Therapy (CRT) Administer oxygen therapy per nasal cannula at 2-6 LPM asordered The procedure involves implanting a half-dollar sized pacemaker, Evaluate ABG analysis results usually just below the collarbone. Three wires (leads) connected to Semi-Fowler’s or High-Fowler’s position to promote greater lung the device monitor the heart rate to detect heart rate irregularities expansion and emit tiny pulses of electricity to correct them. In effect, it is Promoting Rest and Activity "resynchronizing" the heart. Bed rest or limited activity may be necessary during the acute phase 2. Pacemakers Provide an overbed table close to the patient to allow resting the It is a small device with two parts — a generator and wires (leads, or head and arms electrodes) — that's placed under the skin in your chest to help Use pillows for added support when in High-Fowler’s position control your heartbeat Administer Diazepam (Valium) 2-10 mg 3-4x a day as ordered to 3. Implantable cardioverter-defibrillators (icds) allay apprehension An ICD is a battery-powered device placed under the skin that keeps Gradual ambulation is encouraged to prevent risk of venous track of your heart rate. Thin wires connect the ICD to your heart. If thrombosis and embolism due to prolonged immobility an abnormal heart rhythm is detected the device will deliver an Activities should progress through dangling, sitting up on a chair and electric shock to restore a normal heartbeat if your heart is beating then walking in increased distances under close supervision chaotically and much too fast. Assess for signs of activity intolerance (dyspnea, fatigue and 4. Coronary artery bypass grafting (CABG) increased pulse rate that does not stabilize readily) Coronary bypass surgery redirects blood around a section of a blocked or partially blocked artery in your heart to improve blood flow 2. Decreasing Anxiety to your heart muscle. The procedure involves taking a healthy blood Allow verbalization of feelings vessel from your leg, arm or chest and connecting it beyond the Identify strengths that can be used for coping blocked arteries in your heart. Learn what can be done to decrease anxiety 5. Percutaneous Coronary Intervention (PCI) Formerly known as angioplasty with stent 3. Facilitating Fluid Balance Is a non- surgical procedure that uses a catheter (a thin flexible tube) Control of sodium intake to place a small structure called a stent to open up blood vessels in Administer diuretics and digitalis as prescribed the heart that have been narrowed by plaque buildup, a condition Monitor I and O, weight and V/S known as atherosclerosis Dry phlebotomy (rotating tourniquets) dfd  Go Back to Lesson Outline Providing Skin Care 3. Ineffective tissue perfusion r/t decrease cardiac output Edematous skin is poorly nourished and susceptible to pressure Interventions: sores ○ Elevate head of bead Change position at frequent intervals ○ Monitor VS, especially BP and PR q 5 mins. until the Assess the sacral area regularly pain subsides Use protective devices to prevent pressure sores ○ Provide oxygen and monitor oxygen saturation via pulse oximeter, as ordered. 4. Promoting Nutrition Provide bland, low-calorie, low-residue with vitamin supplement NURSING DIAGNOSIS FOR RIGHT SIDED HEART FAILURE during acute phase Frequent small feedings minimize exertion and reduce gastrointestinal blood requirements NURSING DIAGNOSIS FOR LEFT SIDED HEART FAILURE 1. Ineffective breathing pattern related to fatigue and decreased lung expansion and pulmonary congestion secondary to CHF Interventions: ○ Monitor VS ○ Observe breathing pattern for SOB ○ Assist patient to use relaxation techniques 2. Activity intolerance r/t imbalance O2 supply and demand 1. Decrease cardiac output r/t altered heart rate and rhythm Interventions: Interventions: ○ Encourage patient to have adequate bed rest and ○ Assess for abnormal heart and lung sound sleep ○ Monitor blood pressure and pulse ○ Assist the client in a side-lying position ○ Assess mental status and LOC ○ Elevate the head of the bed 2. Excess fluid volume r/t decrease cardiac output of sodium and 3. Knowledge deficient r/t lack of understanding/ misconceptions water retention about interrelatedness of cardiac disease Interventions: Interventions: ○ Monitor I&O q 4 hours ○ Promote rest ○ Assess for presence of peripheral edema ○ Promote healthy nutrition ○ Follow low-sodium diet and/or fluid restriction ○ Educate regarding medication dfd  Go Back to Lesson Outline LESSON 3: Preload Congestive Heart Failure The volume of blood/amount of fiber stretch in the ventricles at the end of diastole (i.e., before the next contraction). Preload increases with: Congestive Heart Failure ○ Fluid volume increases ○ Vasoconstriction (“squeezes” blood from the vascular system Impaired cardiac pumping such that heart is unable to pump into the heart) adequate amount of blood to meet metabolic needs. Preload decreases with: Not a disease but a “syndrome” ○ Fluid volume losses Associated with long-standing hypertension and coronary artery ○ Vasodilation (able to “hold” more blood, therefore less disease. returning to heart) Starling’s Law Factors Affecting Cardiac Output ○ Describes the relationship between preload and cardiac output. ○ The greater the heart muscle fibers are stretched (b/c of increases in volume), the greater their subsequent force of contraction– but only up to a point. Beyond that point, fibers get over-stretched and the force of contraction is reduced. Excessive Preload ○ Excessive stretch → reduced contraction → reduced SV/CO Afterload The resistance against which the ventricle must pump. Excessive afterload = difficult to pump blood → reduced CO/SV Afterload increased with: ○ Hypertension Heart Rate ○ Vasoconstriction Afterload decreased with: In general, the higher the heart rate, the lower the cardiac output. ○ Vasodilation ○ E.g. HR x SV = CO 60/min x 80 ml = 4800 ml/min (4.8 L/min) 70/min x 80 ml = 5600 ml/min (5.6 L/min) But only up to a point. With excessively high heart rates, diastolic filling time begins to fall, thus causing stroke volume and CO to fall. Contractility Ability of the heart muscle to contract; relates to the strength of contraction. dfd  Go Back to Lesson Outline Contractility decreased with: Risk Factors ○ Infarcted tissue – no contractile strength ○ Ischemic tissue – reduced contractile strength. Coronary Artery Disease ○ Electrolyte/acid-base imbalance Age ○ Negative inotropes (medications that decrease contractility, Hypertension such as beta blockers). Obesity Contractility increased with: Cigarette Smoking ○ Sympathetic stimulation (effects of epinephrine) Diabetes Mellitus ○ Positive inotropes (medications that increase contractility, High Cholesterol such as digoxin, sympathomimmetics) African Descent Pathophysiology of CHF Etiology Pump fails → decreased stroke volume /CO. May be caused by any interference with normal mechanisms Compensatory mechanisms kick in to increase CO. regulating cardiac output (CO) ○ SNS stimulation → release of epinephrine/norepinephrine Common causes: Increase HR ○ HTN Increase contractility ○ Myocardial infarction Peripheral vasoconstriction (increases afterload) ○ Dysrhythmias ○ Myocardial hypertrophy: walls of heart thicken to provide ○ Valvular disorders more muscle mass → stronger contractions ○ Hormonal response: ↓’d renal perfusion interpreted by juxtaglomerular apparatus as hypovolemia. Thus, kidneys release renin, which stimulates conversion of angiotensin I → angiotensin II, which causes: Types of Congestive Heart Failure Aldosterone release → Na retention and water retention (via ADH secretion) Peripheral vasoconstriction Left-sided Failure Compensatory mechanisms may restore CO to near-normal. Most common form But, if excessive, the compensatory mechanisms can worsen heart Blood backs up through the left atrium into the pulmonary veins failure because: ○ Pulmonary congestion and edema ○ Vasoconstriction: ↑’s the resistance against which heart Eventually leads to biventricular failure has to pump (i.e., ↑’s afterload), and may therefore ↓ CO Most common cause: ○ Na and water retention: ↑’s fluid volume, which ↑’s preload. ○ HTN If too much “stretch” (d/t too much fluid) → ↓ strength of ○ Cardiomyopathy contraction and ↓’s CO ○ Valvular disorders ○ Excessive tachycardia → ↓’d diastolic filling time → ↓’d ○ CAD (myocardial infarction) ventricular filling → ↓’d SV and CO dfd  Go Back to Lesson Outline Weight changes (r/t fluid retention) Right-sided Failure Skin changes Results from diseased right ventricle ○ Dusky appearance Blood backs up into right atrium and venous circulation Causes: ○ LVF Classification ○ Cor pulmonale Based on the person’s tolerance to physical activity ○ RV infarction ○ Class 1: No limitation of physical activity Venous congestion ○ Class 2: Slight limitation ○ Peripheral edema ○ Class 3: Marked limitation ○ Hepatomegaly ○ Class 4: Inability to carry on any physical activity without ○ Splenomegaly discomfort ○ Jugular venous distension Stages Primary cause is left-sided failure Stages Definitions Examples Cor Pulmonale- RV dilation and hypertrophy caused by pulmonary pathology. Stage A At high risk for HF but without structural heart disease or Risk factors for HF like HTN symptoms Stage B Structural heart disease but without signs or symptoms LV dysfunction, LV Acute Congestive Heart Failure hypertrophy Clinical Manifestations: Stage C Structural heart disease with prior or current symptoms Most forms of chronic HF Pulmonary edema (What will you hear?) Stage D Refractory HF requiring specialized interventions Advanced/end stage HF ○ Agitation ○ Pale or cyanotic ○ Cold, clammy skin Diagnostic Studies ○ Severe dyspnea ○ Tachypnea Primary goal is to determine underlying cause ○ Pink, frothy sputum ○ Physical exam ○ Chest x-ray ○ ECG Chronic Congestive Heart Failure ○ Hemodynamic assessment ○ Echocardiogram (Uses ultrasound to visualize myocardial Clinical Manifestations: structures and movement, calculate EF) Fatigue ○ Cardiac catheterization Dyspnea ○ Paroxysmal nocturnal dyspnea (PND) Tachycardia Edema (lung, liver, abdomen, legs) Nocturia Behavioral changes ○ Restlessness, confusion, low attention span Chest pain (d/t ↓ CO and ↑ myocardial work) dfd  Go Back to Lesson Outline Nursing and Collaborative Management Acute Congestive Heart Failure Primary goal is to improve LV function by: ○ Decreasing intravascular volume Improves LV function by reducing venous return Loop diuretic: drug of choice Reduces preload High Fowler’s position ○ Decreasing venous return ○ Decreasing afterload Drug therapy: vasodilation & ACE inhibitors Decreases pulmonary congestion ○ Improving gas exchange and oxygenation Administer oxygen, sometimes intubate and ventilate ○ Improving cardiac function Positive inotropes ○ Reducing anxiety Morphine- cause sedation = relax Chronic Congestive Heart Failure Collaborative Care: ○ Treat underlying cause ○ Maximize CO ○ Alleviate symptoms ○ Oxygen treatment ○ Rest Drug Therapy: ○ ACE inhibitors ○ Diuretics ○ Inotropic drugs (i.e. Digitalis; IV: Dobutamine) ○ Vasodilators ○ β-Adrenergic blockers ○ Hydralazine and Isosorbide Dinitrate (Alternative for ACE inhibitor) dfd  Go Back to Lesson Outline Nutritional Therapy: Cardiac Resynchronization Therapy (CRT) ○ Fluid restrictions not commonly prescribed ○ Sodium restriction 2g sodium diet ○ Daily weights Same time each day Wearing same type of clothing Nursing Diagnoses: ○ Activity intolerance ○ Excess fluid volume ○ Disturbed sleep pattern ○ Impaired gas exchange ○ Anxiety Planning: ○ Overall goals: ↓ Peripheral edema ↓ Shortness of breath ↑ Exercise tolerance Drug compliance No complications Implementation: ○ Acute intervention Establishment of quality of life goals Symptom management Conservation of physical/emotional energy Support systems are essential Other Interventions: Heart Failure Supplemental Oxygen Coronary Artery Revascularization or CABG (Patients with CAD) An implantable cardioverter defibrillator (ICD) is used for heart-failure treatment when the person is considered to be a high risk of dying from an abnormal heart rhythm—called sudden cardiac death. It is a small device that is implanted in the chest and continually monitors the heart's rhythm. dfd  Go Back to Lesson Outline Stopcock LESSON 4: Hemodynamic Monitoring Hemodynamic Monitoring Critically ill patients require continuous assessment of their cardiovascular system to diagnose and manage their complex medical conditions. Hemodynamic Monitoring This type of assessment is achieved by the use of direct pressure monitoring systems, referred to as Hemodynamic Monitoring. A transducer to convert the pressure coming from the artery or heart Patients requiring hemodynamic monitoring are cared for in critical chamber into an electrical signal care units. Some progressive care units also admit stable patients An amplifier or monitor, which increases the size of the electrical with CVP or intra-arterial BP monitoring. signal for display on an oscilloscope To perform hemodynamic monitoring, a CVP, pulmonary artery, or arterial Nurses caring for patients who require hemodynamic monitoring catheter is introduced into the appropriate blood vessel or heart chamber. It receive training prior to using this sophisticated technology. is connected to a pressure monitoring system that has several components, including: A disposable flush system, composed of IV normal saline solution The nurse helps ensure safe and effective care by adhering to the following (which may include heparin), tubing, stopcocks, and a flush device, guidelines: which provides continuous and manual flushing of the system. 1. Ensuring that the system is set up and maintained properly (free of A pressure bag placed around the flush solution that is maintained at air bubbles) 300 mm Hg of pressure. The pressurized flush system delivers 3 to 5 2. Checking that the stopcock of the transducer is positioned at the mL of solution per hour through the catheter to prevent clotting and level of the atrium before the system is used to obtain pressure backflow of blood into the pressure monitoring system. measurements (uses a marker to identify this level on the chest wall, which provides a stable reference point for subsequent pressure Central Venous Pressure Monitoring readings) 3. Establishing the zero reference point in order to ensure that the system is properly functioning at atmospheric pressure (placing the stopcock of the transducer at the phlebostatic axis, opening the transducer to air, and activating the zero function key on the bedside monitor) dfd  Go Back to Lesson Outline Measurements of CVP, BP, and pulmonary artery pressures can be made seconds, the circulation to the hand may be adequate enough to with the head of the bed elevated up to 60°; however, the system must be tolerate placement of a radial artery catheter. repositioned to the phlebostatic axis to ensure an accurate reading (Urden, Stacy, & Lough, 2014). Complications from the use of hemodynamic monitoring systems are uncommon and can include: a. Pneumothorax (The nurse observes for signs of pneumothorax during the insertion of catheters using a central venous approach (CVP and pulmonary artery catheters) a. Infection (The longer any of these catheters are left in place (after 72 to 96 hours), the greater the risk of infection) b. Air embolism (can be introduced into the vascular system if the stopcocks attached to the pressure transducers are mishandled Nursing Interventions during blood drawing, administration of medications, or other procedures that require opening the system to air) Nursing Interventions to Prevent Intravascular Catheter-Related Intra-Arterial BP Monitoring Bloodstream Infections Used to obtain direct and continuous BP measurements in critically ill Topic Intervention patients who have severe hypertension or hypotension. Arterial catheters are also useful when arterial blood gas measurements and Hand hygiene Wash hands with soap and water or use alcohol-based hand rubs before and after blood samples need to be obtained frequently. contact with the catheter for any reason. Radial artery is the usual site selected Dressing Wear clean or sterile gloves when changing the However, placement of a catheter into the radial artery can further dressing impede perfusion to an area that has poor circulation. As a result, the Cleanse the skin during dressing changes with tissue distal to the cannulated artery can become ischemic or a >0.5% chlorhexidine preparation with alcohol. Dress the site with sterile gauze or sterile, necrotic transparent, semipermeable dressing to cover the catheter site. If the patient is diaphoretic or Traditionally, collateral circulation to the involved extremity was assessed by if the site is bleeding or oozing, use a gauze using the Allen test. dressing until it is resolved. To perform the Allen test, the hand is elevated, and the patient is Change gauze dressings every 2 days or asked to make a fist for 30 seconds. The nurse compresses the transparent dressings at least 7 days and radial and ulnar arteries simultaneously, causing the hand to blanch. whenever dressings become damp, loosened, or visibly soiled. After the patient opens the fist, the nurse releases the pressure on Do not use topical antibiotic ointment or creams the ulnar artery. If blood flow is restored (hand turns pink) within 6 on insertion sites. dfd  Go Back to Lesson Outline port that opens into the pulmonary artery. Once connected by its hub to the Catheter site Assess the site regularly – visually when changing the dressing or by palpation through pressure monitoring system, it is used to continuously measure pulmonary an intact dressing. Remove the dressing for a artery pressures. The proximal lumen has a port that opens into the right thorough assessment if the patient has atrium. It is used to administer IV medications and fluids or to monitor right tenderness at the insertion site, fever without atrial pressures (i.e., CVP). Each catheter has a balloon inflation hub and obvious source, or other signs of local or valve. A syringe is connected to the hub, which is used to inflate or deflate bloodstream infection. the balloon with air (1.5-mL capacity). The valve opens and closes the balloon inflation lumen. Pressure Keep all components of the pressure monitoring monitoring system sterile system Replace transducers, tubing, continuous-flush device, and flush solution every at 96-hour intervals. Do not infuse dextrose containing solutions through the monitoring system. Bathing Do not submerge the catheter or catheter site in water. Showering is permitted if the catheter and The pulmonary artery catheter, covered with a sterile sleeve, is related tubing are placed in an impermeable inserted into a large vein, preferably the subclavian, through a cover. sheath. As noted previously, the femoral vein is avoided; insertion Patient Ask patients to report any new discomforts techniques and protocols mirror those used for inserting a CVP education from the catheter site. catheter. The sheath is equipped with a side port for infusing IV fluids and medications. The catheter flush solution is the same as for pulmonary artery The catheter is then passed into the vena cava and right atrium. In catheters. the right atrium, the balloon tip is inflated, and the catheter is carried A transducer is attached, and pressures are measured in millimeters rapidly by the flow of blood through the tricuspid valve into the right of mercury (mm Hg). ventricle, through the pulmonic valve, and into a branch of the The nurse monitors the patient for complications, which include local pulmonary artery. When the catheter reaches the pulmonary artery, obstruction with distal ischemia, external hemorrhage, massive the balloon is deflated and the catheter is secured with sutures ecchymosis, dissection, air embolism, blood loss, pain, arteriospasm, and infection. Pulmonary Artery Pressure Monitoring - used in critical care for assessing left ventricular function, diagnosing the etiology of shock, and evaluating the patient’s response to medical interventions (e.g., fluid administration, vasoactive medications). A variety of catheters are available for cardiac pacing, oximetry, cardiac output measurement, or a combination of functions. The distal lumen has a dfd  Go Back to Lesson Outline Fluoroscopy may be used during insertion to visualize the progression of the Left Atrial Pressure Monitoring catheter through the right heart chambers to the pulmonary artery. During insertion of the pulmonary artery catheter, the bedside monitor is observed Left atrial pressure (LAP) monitoring is performed to obtain for pressure and waveform changes, as well as dysrhythmias, as the hemodynamic insight into left-sided cardiac structures. catheter progresses through the right heart to the pulmonary artery. LAP may provide value when there is concern for LV function (systolic and diastolic), left atrial hypertension, or concern for LV It is important to note that the pulmonary artery wedge pressure is achieved preload (acute right heart failure, pulmonary hypertension). by inflating the balloon tip, which causes it to float more distally into a smaller Access to left atrial pressures can be acquired via the transthoracic portion of the pulmonary artery until it is wedged into position. This is an route or via the transseptal route. occlusive maneuver that impedes blood flow through that segment of the LAP monitoring can impact management in patients when pulmonary artery. Therefore, the wedge pressure is measured immediately apprehension exists in regard to LV function, such as when and the balloon deflated promptly to restore blood flow. separating from CPB, following heart transplantation, and in neonates with arterial switch procedures. Left atrial hypertension is Quality and Safety Nursing Alert a typical concern in patients with diminutive left-sided structures After measuring the pulmonary artery wedge pressure, the nurse ensures following a two-ventricle repair, mitral valve repair, and acutely that the balloon is deflated and that the catheter has returned to its normal following LV assist device placement. position. This important intervention is verified by evaluating the pulmonary Patients at risk for right heart failure or vulnerable to pulmonary artery pressure waveform displayed on the bedside monitor. hypertensive crisis may benefit from LAP monitoring because an acute decrease in LAP can signify loss of LV preload. Given the risk of introducing thromboemboli to the systemic Nursing Interventions circulation, the risk of bleeding, and the potential for catheter retention at the time of removal, caution has been taken in limiting routine placement of these catheters and emphasis directed to early removal. Increased left atrial pressure resulting from reduced left ventricular contractility or compliance, pulmonary venous obstruction, mitral valve disease, pericardial disease, or hypervolemia causes pulmonary edema and affects lung mechanics and gas exchange Direct measurement of left atrial pressure - is indicated when pulmonary artery catheter monitoring is technically difficult or - when the patient's anatomy or clinical condition makes the use of a pulmonary artery catheter impossible Such conditions exist with tricuspid stenosis or atresia, pulmonary stenosis or atresia, severe pulmonary hypertension, and right heart Catheter site care is essentially the same as for a CVP catheter. Similar to failure. Infants with pulmonary hypertension may benefit from CVP measurement, the transducer must be positioned at the phlebostatic simultaneous measurement of pulmonary artery and left atrial axis to ensure accurate readings. Serious complications include pulmonary pressures via transthoracic lines artery rupture, pulmonary thromboembolism, pulmonary infarction, catheter kinking, dysrhythmias, and air embolism. dfd  Go Back to Lesson Outline The mixed venous sample also captures the blood before it is re-oxygenated in the pulmonary capillary Mixed venous oxygen saturation (SvO2) can help to determine whether the cardiac output and oxygen delivery is high enough to meet a patient's needs. Normal Values ○ Normal SvO2 60-80%. ○ Normal ScvO2 (from an internal jugular or subclavian vein) It is important to note that the left atrial catheter must be placed is >70%. surgically and has the serious disadvantage of being a possible site for air entry into the left side of the heart. The consequences of air or clot embolism on the left (systemic) circulation may be profound: ○ with potential neurologic or coronary vascular occlusion possibly devastating consequences ○ bleeding can also occur with removal of the left atrial line Low left atrial pressure, particularly with low right atrial pressure (CVP), is suggestive of volume depletion High left atrial pressure is suggestive of left ventricular dysfunction, volume overload, tamponade, or mitral valve regurgitation Mixed Venous Ox