Transcript Decreased Cardiac Output

Decreased Cardiac Output
Medical Surgical Nursing II
Spring
Charnelle Lee
Decreased Cardiac Output
 In the patient with coronary artery disease this
problem will present in many different ways.
 Your cardiac patient may look fine and sustain great
injury to their myocardium.
 Your cardiac patient may present in shock and sustain
great injury to the myocardium.
 The wonderful thing about CAD it is one of the most
exciting to treat, because in most cases we can
promote positive outcomes.
The Heart
 The Heart is a magnificent pump that perfuses the
tissues of our bodies with five liters of blood per
minute. It survives many insults throughout our life
span and has as its goal the maintenance of tissue
perfusion. Its functioning depends on :
 Synchronous chamber movement
 Electrical conduction
 Muscle strength
Alterations in heart muscle perfusion
 Occur with Coronary Artery disease.
 Decreased perfusion related to plaque buildup
 Decreased perfusion related to completed
obstruction from a clot that forms on the irregular
edges of the plaque buildup begins the cycle of
altered cardiac output. The two processes we need to
discuss and compare are ischemia and infarction.
Alterations in Coronary Perfusion
Ischemia
Infarction
Decrease in blood flow
with decrease in tissue
oxygenation and
nutrition
Cellular death which
results in wall damage,
long term scar tissue
formation
Cells can be saved.
With restoration of
perfusion
Cells in this state are
not usable anymore
Ischemia and Infarction
 Depending on the degree
of occlusion a patient will
experience either
ischemia or infarction.
Many patients experience
degrees of both.
 If a patient has a small
amount of blockage,
there may be no
symptoms or symptoms
that can be attributed to
many other causes
Ischemia and Infarction
 The goal is to prevent
infarction as soon as
possible.
 The patient who receives
treatment before an
acute obstruction with
cardiac interventional
therapies will save the
cardiac muscle from
impairment
 The patient who comes in
as soon as symptoms of
infarction occur with
reperfusion therapies
heart muscle can be
saved with decreased
dysfunctional health
outcomes.
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Stable Angina- fixed lesions of more
than 75% of the CA lumen
 Predictable
 Caused by similar precipitating factors relative to
time, activity
 Patient’s describe it as my usual chest pain
 Pain control achieved by
 Rest
 Sublingual nitroglycerin within five minutes
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Unstable Angina  Change from the usual
angina symptoms
 Medical Emergency
 Signaled by a change in
the level or frequency of
s/s
 Persists for > 5minutes
 One nitroglycerin does
not help the pain
 Action needed – Call 911
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Angina/ MI and the EKG
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 MI
 Injury pattern
 ST elevation in
continguous leads
 ST depression in leads
opposite injury
Angina
Ischemic
No change
T wave inversion
ST depression
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Cardiac Equivalents
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Shortness of breath
Nausea
Sweating
Fatigue
Lightheadedness
Arm Heaviness
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Treatment of the MI versus angina
 Assessment
 EKG within ten minutes of
presentation
 Apply oxygen
 Apply EKG, ABP, Saturation
 IV therapy
 Draw Labs
 Evaluate findings
 Start Treating the pain
Normal EKG
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Cardiac Biomarkers
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CPK-MB
Troponin I
Troponin II
Will be elevated
 Rapid rise and fall in those treated with
PCI/Thrombolytics
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12 Lead EKG – Tool of great importance
 Identifies area of infarction
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Inferior Wall
Anterior Wall
Lateral Wall
Posterior Wall
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Physical Assessment – Rapid focused
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Note cardiac monitor rhythm
Vital signs
Skin color
Rapid check of radial pulses
Mentation
Overall tissue perfusion
Quick auscultation of apical pulse, heart sounds, and
lungs
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Acute Pain – Nursing Focus
 Goal – relief of chest pain as fast as possible
 Assess
 Intensity – scale of 0-10
 Ask about chest discomfort instead of labeling pain
 Characteristics – continuous, intermittent, change with
position, or reproducible with pressure on sternum
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MONA
 Simple pneumonic to remember for treatment of the
cardiac patient
 Morphine
 Oxygen
 Nitro
 Aspirin
 Not necessarily in that order though
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Administer Medications – Assess
patient response
 Oxygen should already be on
 Establish a peripheral line for rapid Fluid Bolus
 Given NTG sl per order assess response
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Pain – is it better or decreased
Take vitals
Note EKG – are the ST changes improved
Hang nitroglycerin drip – titrate to patient chest pain
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Nitroglycerin Drip Correction on this
slide
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Glass Bottle
Pre-mix (100mg in 500 ml)
Administered in mcg/min
Start rate usually about 4.5cc/hour or 15 ug/min
Titrate up by 3 ug/min every 5 minutes
If the drip is increased to 12 cc – how many mcg is the
patient receiving
 Reassess patient after each rate increase
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Controlling Nitro induced side effects
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Hypotension – Take b/p twice over a 3 minute period.
Notify physician
Administer fluid bolus
Reassess patient
Put HOB down lower if tolerated
Headache – tylenol may be needed
Don’t let the headache get bad before you given
analgesic
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Nitro not given if
 Systolic is less than 90 mm/hg
 Viagra has been taken
 Put reason for this here
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Morphine
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Dose range 2 – 4 mg IVP q 5 minutes till pain relieved
Assess vitals and pain level after dose
Anticipate nausea – have emesis basin close by
Ask physician for anti-emetic of choice to have
available
 PHENERGAN/ZOFRAN/BENADYRL IN SOME CASES
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Pain relieved or decreased
 Decreased give another dose of morphine
 Dose may be the lower of the two choices if b/p is
close to 90 systolic
 Decrease Pain – Save cardiac muscle
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Anxiety
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Maintain calm
Display competence
Answer questions simply –
Medicate with ativan prn if ordered
Family presence sometimes helps relieve patient
anxiety
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Educate
 In critical care or ER this intervention is not really
workable
 Patient in acute throes of unstable angina or MI won’t
learn until things have settled down and patient has
been stable for 24 hours or so.
 Most important thing in this time period is short brief
explanation of treatments being performed
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Acute MI no Cardiac Cath Lab AKA as
small Rural hospital treatment option
 Patient comes in with acute chest pain, EKG changes
– Thromblytics are the treatment choice
 What will the EKG Display in this patient who is having
an acute MI? ST elevation or ST depression
 Explain your answer
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The patient is having an MI 
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Team effort
Patient is on oxygen, cardiac monitor, b/p monitor
Nurse starts 3 large bore IV’s If possible
Lab draws are wrapped with pressure dressing
Nurse assesses onset of pain till time patient presents
to the door
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Physician performs a rapid cardiac
assessment and physical
 Physician must assess the patient rapidly
 Nurse’s obtain the Packet and perform a subjective
assessment for contraindications
 Patient and family are informed of potential risks and
benefits
 Permit is signed.
 Patient must have had labs drawn which include a
cardiac panel, coags, chest x-ray
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Why do we do a CXR?
 Is it diagnostic of an acute MI?
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Normal CXR/Thoracic Aortic
Aneurysym
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More about thrombolytics
 They are administered in an ER or critical care unit
 They dissolve clots anywhere they are located
 Example – Retavase given for an IWMI – patient
reperfused, 24 hours later had a huge bleed into his
shoulder, and then a cerebral bleed. Did not die from
the MI, died from the complications of the
thrombolytic
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Assessments to perform to assess for
abnormal bleeding
 Neuro check
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Pupils
Hand grip strength/foot pushes
Mentation
Cranial nerve check
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Bleeding Symptoms
 Monitor for signs of hypovolemia
 Monitor hematocrit/hemoglobin
 Really watch the biceps muscle under the automatic
blood pressure cuff, notorious for developing
hematomas under these
 Prevention – when b/p stable reduce frequency of the
blood pressure checks
 If bruising, increased pain occurs take manual
pressures
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Did the Thrombolytic Work?
 Chest pain/pressure should subside
 ST elevation should decrease
 Most common sign is ventricular reperfusion
dysrhythmias
 Let them happen- most of the time are self limiting
 If they cause hemodynamic problems treat- otherwise
just be scared but don’t show it
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When do reperfusion dysrhythmias
occur?
 Usually within one to two hours of administration of
the thrombolytic --- Does a thrombolytic always work?
 Nope – patient will complete their MI
 These patients experience much more post MI problems
such as CHF, angina, cardiac failure
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Reperfusion Dysrhythmias
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After the thrombolytic you hang
Heparin?
 Does that make sense to you?
 Why or Why Not?
 Explain the rationale for hanging heparin on a patient
who just received a thrombolytic?
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Basic review of heparin
 Weight based dosing – drug calculations on heparin
will be on this test (just a couple)
 Labs to monitor PT/PTT – (q6 to 8 hours)
 Adjust to parameters on orders
 Usual goal is to keep the Ptt (65-80)
 Heparin is a dedicated line, try not to give any other
meds through this line unless you have checked
compatibility, most don’t mix.
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