11/2/2018

1

Saving the Life of Your

Cardiac Patient

Presented byMartha Baker PhD RN CNE, CENP, ACNS-BC

Instructor, Clinical Coordinator

Ozarks Technical Community College

Springfield, MO

Cardiac Disorders by

Physiological Disturbance

Damage to hear Muscle

Ischemia ASHD, Infarction,

Embolism

Cardiomyopathies

Tumors,

Trauma,

Collagen diseases

Cardiac Disorders by

Physiological Disturbance

Inflow Abnormalities

Fluid Loss Dehydration, Shock

Hemorrhage

-- Fluid Overload CHF

--Obstruction of blood flow

Thrombosis of Vena Cava

Constrictive pericarditis,

11/2/2018

2

Cardiac Disorders by

Physiological Disturbance

Outflow abnormalities

Valvular stenosis or regurgitation

Hypertension Arterial, Pulmonary

Congenital problems (esp abnormal

shunts)

Cardiac Disorders by

Physiological Disturbance

Excessive demands on the heart due non-cardiac

problems

Anemia

Fever

Anxiety

Hypertension

Obesity

Cardiac Disorders by

Physiological Disturbance

Disturbances of rate, rhythm and conduction

Disturbances of SA node

Disturbances of the atria

Disturbances of AV node

Disturbances of the ventricles

11/2/2018

3

Setting Priorities

Which of the Cardiac Disorders Creates Greatest

Risk To Patients

Unstable Angina

Acute Coronary Syndrome -- Acute Myocardial

Infarction

Hear Failure - Acute Pulmonary Edema

Lethal Arrhythmias

Coronary Artery Disease

• Leading cause of death in the US

• 64% of women and 50% of men who have had and

MI are not aware of it

• Average age is 64.5 years for men, 70.3 years for

women

• Every 25 seconds a person in US has coronary event

• Leading cause of premature permanent disability in

US

• 452,000 people die each year-1 in 4 of all deaths

• Many people die before reaching the hospital – 95%

of sudden cardiac death is due to Vfib 1 in 7.4

people– AED placement

11/2/2018

4

Unstable AnginaOccur at rest or with exertion with severe

activity restriction

• Increase in number of attacks & intensity

• Pain longer than 15 min and poorly

relieved by rest or nitroglycerin q 5min

X 3

• Medical emergency – call 911

• Indication of atherosclerotic plaque

instability

Angina Interventions

• Assess pain

• Bed rest

• O2 3L/nc

• Nitroglycerin sl

• Obtain 12 lead EKG

• Provide continuous cardiac monitoring

11/2/2018

5

ACUTE CORONARY

SYNDROMES

• CORONARY ARTERY DISEASE

• Myocardial Infarction

• ST-elevation MI (STEMI-probable

muscle injury)

• Non-ST-elevation MI (NSTEMI-

ischemia can possibly have no

myocardial injury-depends on

multiple factors)

Myocardial Infarction

• Tissue can be salvaged within first 2 hours of angina symptoms

• 6 hours after infarction - region appears blue and swollen

• 48 hours – gray with yellow streaks as neutrophils invade tissue to remove necrotic cells

• 8-10 days – granulation at edges of necrotic tissue

• Over 2-3 months – necrotic area develops into shrunken, thin, firm scar (Ventricular Remodeling)

• Decreased LVF = HF

11/2/2018

6

Myocardial Infarction Interventions

• Pain Management = if there is pain= ischemia

• Nitroglycerin (decrease preload and afterload)

• Morphine Sulfate

• Oxygen

• ASA (325mg chewed immediately)

• Ineffective Tissue Perfusion

Myocardial Infarction Interventions

Emergency Care of Patient with

Chest Discomfort

• ABCs – Defibrillate if needed

• ECG monitoring

• Description of pain

• VS

• Vascular access

• Consult chest pain protocol

Myocardial Infarction Interventions

Emergency Care of Patient with Chest

Discomfort

• 12 lead ECG

• Notify physician

• Pain relief & ASA

• O2

• Remain calm

• Assess VS & intensity of pain 5 min after

each med

• Notify physician if VS deteriorate or pain

not relieved after 3 doses of nitrogylcerin

11/2/2018

7

Myocardial Infarction Intervention

Identify and manage dysrhythmias

• Inferior MI = bradycardias, Second degree AV

block due to ischemia of AV node

• Anterior MI = PVC caused by ventricular

irritability , Ventricular Tachycardia, Ventricular

Fibrillation Third degree block or BBB is serious

as indicates large portion of LV involved

Myocardial Infarction Intervention

Monitor and manage heart failure

• Inadequate organ perfusion due to decrease

cardiac output

• Drug therapy

• IV nitrates

• Diuretics

• Beta blockers

• Positive inotropes –dobutamine & dobutrex

Myocardial Infarction Interventions

• Percutaneous Transluminal Coronary

Angioplasty (PTCA)

• Stents

• Arthrectomy

• Pre-procedure Care-• NPO

• Antiseptic scrub

• Baseline VS

• Report any CP

11/2/2018

8

Myocardial Infarction Interventions

PTCA – Post procedure Care-

• Bleeding from insertion site

• Plavix for 6-9 mo

• Bed rest

• Encourage fluids

• Reaction to dye

• Dysrhythmias

• Hypotension

Cardiogenic Shock – S/S

• Hypotension – lower than 90 systolic MAP

below 60 = poor myocardial infusion

• Diastolic X 2 + systolic/3 = MAP

• Urinary output less than 30 ml/hr (Oliguria)

• Cold, clammy skin

• Poor peripheral pulses

• Tachycardia

• Pulmonary congestion

• Tachypnea

• Disorientation

• Continued chest discomfort

Cardiogenic Shock – Interventions

• Morphine

• O2

• Prepare for intubation and

mechanical ventilation

11/2/2018

9

Cardiovascular Pharmacology

• Positive Inotropic (IV administration)

• Dopamine

• Dobumtamine

• Primacor

• Produce positive inotropic effect –increase

strength of muscular contractions

• Short-term management of HF

• Increase CO – Decrease preload

• N/I – administer with IV pump only• - Stop if BP drops or dysrhythmias occur

• -Monitor for relief of HF

Cardiovascular Pharmacology

• Antianginal

• Nitrates (Nitroglycerin, Nitro-Bid,

Nitrostat)

• Isosorbid Mononitrate (Imdur)

• Produce vasodilation

• Used for Angina

• Decrease preload and afterload –

reduce myocardial O2 consumption

• Contraindicated – significant

hypotension

• N/I – Monitor VS (BP)• Give according to guidelines for SL

• Wear gloves for topical preparation

Cardiovascular Pharmacology

• Antidysrhythmic

• Class I – Sodium channel blockers (Norpace, Rhythmol,

Dilantin)

• Class II – B-Blockers (Olol, Ilol, Alol Family)

• Class III – Potassium channel blockers (Amiodarone,

Betapace, Tikosyn, Corvert)

• Class IV – Calcium Channel Blockers (Dipine Family,

Diltiazem (Cardizem),

• Suppress dysrhythmias by inhibiting abnormal pathways

of electrical conduction through heart

• N/I – Monitor VS, continuous cardiac monitoring

• Do not administer with food-altering absorption

• Use pump for IV

11/2/2018

10

Lethal Arrhythmias

• Ventricular Tachycardia

• Ventricular Fibrillation

• Asystole

• Third Degree Block

Ventricular Dysrhythmias

Ventricular Tachycardia – “V tach”

• Tx: stable: vagal maneuver, Adenosine

• Tx: unstable

ACLS

• Synchronized shock – 100 J

• CPR – Immediately begin chest compressions

followed by respirations (30:2) for 2 min.

• Rhythm – Check rhythm and shock if indicated

• Epinephrine – 1mg IV/IO q 3-5 min

• Antiarrythmic – Amiodarone, Lidocaine,

Magnesium

• Medications

Ventricular Tachycardia

11/2/2018

11

Ventricular Dysrhythmias

Ventricular Fibrillation – “V fib”

• Electrical chaos in ventricles

• Caused by: CAD, MI, Hypokalemia,

Hypomagnesemia, Hemorrhage

• Tx: ABC – BLS

ACLS (SCREAM)

• Shock – 200j upon identification (300j/360j)

• CPR – Immediately begin chest compressions

followed by respirations (30:2) for 2 min.

• Rhythm – Check rhythm and shock if indicated

• Epinephrine – 1mg IV/IO q 3-5 min

• Antiarrythmic – Amiodarone, Lidocaine, Mg

• Medications

Ventricular Fibrillation

Coarse

Ventricular Fibrillation

“fine”

11/2/2018

12

Ventricular Dysrhythmias

• Ventricular Asystole –• Complete absence of any ventricular rhythm

• No QRS complex, NO pulse, NO BP

• Caused by: Myocardial Hypoxia, Heart failure,

severe hyperkalemia

• Tx: ABC - BLS

• ACLS

• PROBLEM SEARCH – Hs/Ts

• EPINEPHRINE - 1 mg IV/IO q3-5 min

Asystole

Atrioventricular Blocks

Third-Degree Heart Block

• None of sinus impulses conduct to

ventricles

• Atrial & Ventricular rhythms regular but

independent of each other

• NO communication going on

11/2/2018

13

Third Degree Heart Block

Pacemakers

Temporary

Transcutaneous

Transvenous

Heart Failure

ALL About CARDIAC OUTPUT

Preload -The amount of force stretching the

cardiac muscle before contraction. (Like a child

filling a balloon with water, a little stretch and

springiness is good, too much pressure stretch

has the potential for disaster)

Afterload - Pressure against which the heart

must push to move blood. (Peripheral vascular

resistance slight resistance is good, yet too

much brings trouble) Integral to afterload is the

size of the ventricular chamber doing the

pushing. (Smaller is BETTER!)

11/2/2018

14

Heart Failure

ALL About CARDIAC OUTPUT

Contractility =The strength of the muscle fibers

in the heart chambers. Dependent on the supply

of oxygen and glucose TO the cardiac muscle

fibers. (Ischemia drastically cuts function)

Reflective of the presence of influencing

medications.

Heart rate =

Not too fast. (Tachycardia tires heart muscle

causing cardiomegaly ~ BAD)

Not too slow. (Bradycardia decreases needed

perfusion)

Heart Failure

• Nearly 5.1 million Americans live with heart

failure (often referred to as Congestive Heart

Failure or CHF)

• 550,000 new cases diagnosed each year.

• Of those hearing these words applied to

them for the first time, nearly half will die of

complications related to this condition within

the first 5 years after diagnosis, bringing the

annual death rate to nearly 325,000 cases in

the United States each and every year.

Heart Failure

• Sudden death is common in patients with

CHF, occurring at a rate of six to nine times

that of the general population. Deaths from

heart failure have decreased on average by

12 percent per decade for women and men

over the past fifty years.

• All treatment for heart failure emergencies

converge on restoring the maximum amount

of function to the cardiovascular system, at

the least expense to other organs and

tissues.

11/2/2018

15

Heart Failure Emergencies

• ABC's

• Airway Check and secure

• Breathing Monitor

• Circulation Start advanced life support if

needed

Heart Failure Emergencies

LMNOP's:

• Lasix - Reduce fluid congestion

• Morphine - Decrease stress on

myocardium

• Nitroglycerin - Insure cardiac

circulation

• Oxygen - Oxygen to heart and brain

• Positioning - Sit person up to avoid

lungs filling with fluid

Medical Therapies

for Heart Failure

~The Fab Four~• Diuretics help reduce fluid buildup in the lungs

and peripheral edema.

• ACE Inhibitors lower blood pressure and

reduce the strain on the heart. (These

medications also may reduce the risk of a future

heart attack)

• Beta-blockers slow heart rate and lower blood

pressure to decrease the cardiac workload.

• Digoxin makes the heart beat stronger and

pump more blood.

11/2/2018

16

One essential medical regimen for heart

failure sufferers in acute crisis is the ability

to shift fluid by the means of diuretics

Generic name: Furosemide

Classification: Diuretic

Mechanism of action: Inhibits reabsorption of sodium

and water in the kidney

Effect: Begins approx. 10 minutes after administration

and lasts up to 6 hours.

Result: Lowers preload pressures.

Uses: Emergency treatment of congestive heart failure

(i.e. cardiogenic pulmonary edema) in persons with

normal or high blood pressures.

Dosing: IV = 20-40+mg injected slowly over 1 to 2

minutes.

Precautions: Dehydration, hypotension, electrolyte

imbalances, may precipitate renal failure.

Contraindications: Hypotension, Sulfa allergy.

Keys to Good Patient Care

Good Observation Skills

LOOK AT YOUR PATIENT!!!!!!

ASSESSMENT -----ASSESSMENT

ASK QUESTIONS --- TELL

SOMEONE

Patient Assessment

• What am I looking for–

• Patient decline

• Changes in Vital signs

• B/P

• O2 saturation decline

• Respiratory Status

• Pulse rates –slow or fast

• Changes in lung sounds

• Changes in cardiac rhythm (lethal)

• Changes in level of consciousness

11/2/2018

17

Failure to Rescue

Essentially when the nurse fails to see

signs and symptoms in a patient that

leads to physiological compromise or

death.

What steps do we need to take to

prevent failure to rescue????

Early Warning System

MEWS Scoring

• Patient Score 1-2 – Perform

Assessment q 2 hours –inform charge

nurse

• Patient Score 3 –Perform hourly

assessments and inform the charge

nurse –Physician should be notified

• Patient Score 4 or more – Assessments

every ½ hour- Physician is called and

Rapid Response is called.

11/2/2018

18

QUESTIONS??????