Unit VIII Acutely Ill Clients with Cardiac Disorders

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Unit VIIIAcutely Ill Clients withCardiac
Disorders

• Wendy DuFour, RN, MN,CCRN
• Assistant Professor of Nursing
• Los Angeles Valley College

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HYPERTENSION

• The force exerted by the blood against the walls
  of the blood vessel and must be adequate to
  maintain tissue perfusion during activity and
  rest.
• Arterial blood pressure
• Cardiac output X Systemic vascular resistance

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Systemic Vascular Resistance

• Force opposing the movement of blood within the
  blood vessels.
• The width or radius of the small arteries and
  arterioles determines vascular resistance.
• If the vessels become smaller, SVR goes ? also
  known as________
• If the vessels become larger, SVR goes ?.

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Hypertensive Crisis

• Severe and abrupt elevation in BP
• Diastolic BP 120-130 mm Hg.
• Concern is organ damage to heart, brain,kidneys,
  and aorta.
• Usually more common in non-compliant or
  undermedicated HTN persons.
• May be caused by illicit drug use such as cocaine
  or crack use.

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Hypertensive Crisis Management

• ??Blood pressure IV Nitroprusside
• Monitor for hypotension
• Prevent damage
• Cause of crisis
• Patient education
• Medication management

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Anti-hypertensives

• Diuretics
• Adrenergic Inhibitors
• Central-acting antagonists
• Peripheral acting antagonists
• 8 blockers
• ß blockers
• Combined
• Direct vasodilators
• Angiotensin-Converting Enzyme Inhibitors
• Angiotensin II Receptor Blockers
• Calcium Channel Blockers
• Lewis table 32-8

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Anti-hypertensives

• Duiretics- inhibit NaCl reabsorption within the
  kidney. Some may or may not spare K.
• Nursing implications
• Adrenergic Inhibitors- all work on peripheral
  sympathetic tone and response.
• Nursing implications

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Anti-hypertensives

• Direct Vasodilators- work specifically on central
  venous or arterial tone.
• Nursing implications
• Angiotensin Inhibitors- inhibit or block action
  of angiotensin.
• Nursing implications
• Calcium Channel Blockers- block movement of
  extracellular calcuim into cells. What does
  calcium do?
• Nursing implications

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Remember this

• Heart Rate (HR) X Stroke Volume(SV)
• CARDIAC OUTPUT (CO)
• IF YOUR CLIENT HAS AN ALTERATION IN ANY OF THE
  ABOVE, HR OR SV, THEN THE CO WILL BE AFFECTED

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SOME BASICS

• Normal heart rate-
• Factors influencing changes in heart rate
• Intact SA Node
• Autonomic Nervous System
• Stimulation
• Norepinephrine
• Epinephrine
• Vagal
• Compensation

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SOME BASICS cont.

• Pathologic Conditions-
• Such as
• Immune Response
• Shock
• Hypovolemic
• Septic
• Cardiogenic
• Chapter 65 Lewis, Chapter 54, Morton

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ITS EKG TIME!!

• You know more than you think you do.
• Components of a Normal EKG
• Pwave, QRScomplex, STsegment, Isoelectrical
  Line
• Atrial Depolarization
• Ventricular Depolarization, Atrial Repolarization
• Ventricular Repolarization

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Normal Values

• PR Interval .12-.20ms
• QRS .06-.12ms
• QT Interval
• Heart Rates
• 60-100 Normal Sinus Rhythm
• 40-60 Sinus Bradycardia
• 100-150 Sinus Tachycardia

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ABNORMAL EKGS

• Not originating from the SA node
• Originating in the SA node but then unable to
  travel normal pathway
• Atrial fibrillation
• Atrial flutter
• Blocks 1st, 2nd degree type I II,
• 3rd degree

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ABNORMAL EKGS

• Ventricular irritability
• Ventricular Tachycardia
• Ventricular Fibrillation
• Also known as Sudden Death
• May have Implantable Cardiac Defibrillator (ICD)
• Goal is to shock and restart the heart and a
  normal conduction sequence (hopefully)

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Nursing Management of Patients with Dysrhythmias

• Assessment
• ABCs
• What is the patients current status?
• Vital signs
• How do I help them?
• Keep Calm!!!!!
• Activate EMS
• CPR
• Teaching if stable

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Angina vs Infarction

• Angina- In cardiac patients, caused by ischemia
  or decreased oxygen to the tissues resulting in a
  buildup of lactic acidosis.
• Ache or Dull pressure
• May radiate up neck or down L arm
• Relieved by NTG (SL) or by rest
• Confused with Indigestion
• Review 33-12 for other causes

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Angina vs. Infarction cont.

• Myocardial Infarction
• Crushing unrelieved sub-sternal chest pain
• Requires IV drip of NTG that may or may not
  relieve CP
• Responds to Morphine
• Feeling of Impending Doom
• S S of decreased Cardiac Output
• Can lead to Cardiogenic Shock
• Arrhythmias

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Acute Myocardial Infarction (AMI)

• Severe, immobilizing chest pain not relieved by
  rest, medication, or position change.
• Due to ischemia from lack of oxygen to a specific
  area of myocardial tissue.
• May be caused by a blood clot
• May be caused by an atherosclerotic plaque

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Nursing Management of AMI

• Assessment
• Subjective
• Pain- where, when, type, how long?
• Nausea or other concerns?
• Objective
• VS
• Rapid physical assessment focusing on Cardiac and
  Respiratory systems
• Head to Toe

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Nursing Management of AMI

• Nursing Diagnosis
• Decreased Cardiac Output
• Ineffective tissue perfusion
• Acute Pain Alteration in comfort
• Anxiety
• Altered coping
• Altered level of consciousness
• Activity intolerance
• Powerlessness
• Knowledge deficit

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Nursing Management of AMI

• Plan
• Prevent complications of altered cardiac output
• Maintain safety
• Increase knowledge
• Decrease pain
• Lewis pg 826-27

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Interventions for AMI

• ABCs
• MONA
• Interpret Lab data
• Troponin
• BMP
• CBC
• Coags
• Drugs Morphine, Heparin, Nitrates, ASA, Dopamine
  (blood pressure support)

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Nursing Management of AMI

• Preparing client for Cardiac Cath
• Remember the dye used is nephrotoxic.
• Check labs such as_____
• Consents for catheterization, angioplasty and
  possible surgery.
• Education! How will this help them with their
  pain and the AMI.

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Nursing Care Post Angioplasty

• Risk for Bleeding
• Risk for Arrythmias
• Altered urinary output
• Fluid volume deficits
• Decreased cardiac output
• Potential for injury
• Impaired physical mobility
• Knowledge deficit

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Cardiomyopathy

• Disease of the heart muscle that affects the
  functional ability of the heart
• Primary or Idiopathic- unknown origin
• Secondary- from heart disease
• Dilated- most common form
• Restrictive
• Hypertrophic - most common cause of sudden death
  in healthy young people.

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Collaborative Management of Cardiomyopathy

• Goal is to improve ventricular filling which
  leads to improved cardiac output.
• ?contractility (force)
• Relieving LV outflow obstruction.
• Beta blockers or CA channel blockers
• Antiarrythmias medications or
• Implantable cardiac defibrillators
• Long term treatment may include heart
  transplantation.

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Pacemakers Defibrillators(ICD)

• Support of conduction abnormality
• Initiate stimulus
• Maintain normal cardiac output
• Does not help in contractility.
• Single chamber, dual chamber, and biventricular

• Treatment of life-threatening arrhythmias
• Has shown to improve cardiac mortality rates.
• Has pacemaker built in.
• Can be single or bi- ventrical.

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Nursing Care and Management

• Nursing Diagnosis-______
• Goal is to prevent lead dislodgement.
• Nursing education is key!
• Pain management
• Impaired physical mobility
• Anxiety- altered coping
• Caregiver role strain

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Inflammatory and Valvular Heart Disease

• Infective endocarditis- an infection of the
  endocardial surface of the heart.
• May be called Bacterial Endocarditis.
• Lewis table 36-4, 36-5
• Tends to effect the heart valves.
• Strep or Staph are the main culprits.
• Stroke is common
• Congestive Heart Failure
• Pulmonary Edema

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Inflammatory and Valvular Heart Disease

• Nursing assessment to include
• subjective data- What brought them to seek
  medical attention?
• C/O joint pain, fatigue, night sweats,
• Objective data-
• VS, Integumentary, Respiratory, Cardiovascular,
  Labs, Echo, EKG, Chest X-ray
• Nursing Diagnosis- see Lewis pg. 891

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Nursing Diagnoses

• Alteration in Comfort
• Decreased Cardiac Output
• Impaired physical mobility
• Self care deficit
• Impaired tissue perfusion
• Altered level of consciousness

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Goals

• Improve cardiac output.
• Increase comfort.
• Prevent hazards of immobility.
• Increase knowledge.
• Return client to optimal level of functioning.

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Treatment of Endocarditis

• Antibiotics- in hospital and possibly at home.
• Supportive therapies for comfort, pain, decreased
  cardiac output, impaired gas exchange,
  hyperthermia.
• Patient education and family support.

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Acute Pericarditis

• Inflammation of the pericardial sac.
• Present much like AMI patient.
• More noticeable with each breath.
• Pericardial Friction rub
• Complications may include pericardial effusion-
  an accumulation of excess fluid in the
  restrictive pericardial sac- Tamponade

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Acute Pericarditis

• Assessment
• Subjective
• Pain where, when, intensity, type
• SOB due to pain?
• Medical Hx
• Objective
• Vital Signs
• Evidence of compensation or decompensation
• Cardiac and Respiratory Assessment
• Echocardiogram
• Labs

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Acute Pericarditis cont.

• Nursing Diagnosis
• Decreased cardiac output
• Impaired tissue perfusion
• Pain
• Anxiety
• Impaired physical mobility

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Acute Pericarditis cont.

• Medical Treatment drain fluid
• Surgery or
• Bedside procedure
• Pain management
• Nursing Goal maintain adequate cardiac output
  and monitor for complications

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Valvular Disease

• Aortic and Mitral most common
• Restrictive and Insufficient
• Restrictive stenosis
• Insufficient regurgitation
• Congenital-
• Aortic tri-valve instead of bi-valve
• Mitral valve prolapse 20 of the population
• Men Aortic most common
• Women Mitral most common

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Valvular Disease

• Restrictive- a valve that does not open
  completely and allow for emptying
• Insufficient- a valve that does not close
  completely allowing for back flow of blood.
• How does this effect Cardiac Output?

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Evaluation of Goals

• How do you do that?
• Look to measurable goals.
• Was it realistic?
• Did it happen? Why or why not?
• Make new goals
• Reevaluate

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Evaluation of Medications

• How do you know if it is working?
• Remember to make measurable goals.
• Documentation is important.