1. Decreased Cardiac Output Medical Surgical Nursing II Spring Charnelle Lee

2.  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. Decreased Cardiac Output

3.  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 The Heart

4.  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 heart muscle perfusion

5. Ischemia Decrease in blood flow with decrease in tissue oxygenation and nutrition Cells can be saved. With restoration of perfusion Infarction Cellular death which results in wall damage, long term scar tissue formation Cells in this state are not usable anymore Alterations in Coronary Perfusion

6. 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

7. 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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12. 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 12

13. 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 13

14. Angina/ MI and the EKG  Angina  Ischemic  No change  T wave inversion  ST depression  MI  Injury pattern  ST elevation in continguous leads  ST depression in leads opposite injury 14

15. Cardiac Equivalents  Shortness of breath  Nausea  Sweating  Fatigue  Lightheadedness  Arm Heaviness 15

16. 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

17. Normal EKG 17

18. Cardiac Biomarkers  CPK-MB  Troponin I  Troponin II  Will be elevated  Rapid rise and fall in those treated with PCI/Thrombolytics 18

19. 12 Lead EKG – Tool of great importance  Identifies area of infarction  Inferior Wall  Anterior Wall  Lateral Wall  Posterior Wall 19

20. Physical Assessment – Rapid focused  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 20

21. 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 21

22. MONA  Simple pneumonic to remember for treatment of the cardiac patient  Morphine  Oxygen  Nitro  Aspirin  Not necessarily in that order though 22

23. 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  Pain – is it better or decreased  Take vitals  Note EKG – are the ST changes improved  Hang nitroglycerin drip – titrate to patient chest pain 23

24. Nitroglycerin Drip Correction on this slide  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 24

25. Controlling Nitro induced side effects  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 25

26. Nitro not given if  Systolic is less than 90 mm/hg  Viagra has been taken  Put reason for this here 26

27. Morphine  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 27

28. 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 28

29. Anxiety  Maintain calm  Display competence  Answer questions simply –  Medicate with ativan prn if ordered  Family presence sometimes helps relieve patient anxiety 29

30. 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 30

31. 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 31

32. The patient is having an MI -  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 32

33. 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 33

34. Why do we do a CXR?  Is it diagnostic of an acute MI? 34

35. 59-35 Normal CXR/Thoracic Aortic Aneurysym

36. 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 36

37. Assessments to perform to assess for abnormal bleeding  Neuro check  Pupils  Hand grip strength/foot pushes  Mentation  Cranial nerve check 37

38. 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 38

39. 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 39

40. 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 40

41. Reperfusion Dysrhythmias 41

42. 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? 42

43. 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. 43