Dilated Cardiomyopathy

Significant dilation of the ventricles without hypertrophy and systolic dysfunction.

Cardiomyopathy

Disease of the heart muscle that is associated with cardiac dysfunction.

Three types:

1. Dilated Cardiomyopathy (DCM)

2. Hypertrophic Cardiomyopathy (HCM)

3. Restrictive or constrictive Cardiomyopathy

Two major groups of cardiomyopathies

- Primary (genetic)

- secondary (secondary to influence of amyloidosis, Fabry's disease, sarcoidosis, and scleroderma)

The most common cardiomyopathy

Dilated Cardiomyopathy

(5 out of 8 cases per 100,000 people per year)

Conditions that can cause Dilated Cardiomyopathy

- Pregnancy

- Heavy alcohol intake

- Viral infection (the flu)

- Chemotherapeutic meds

- Doxorubicin

- Chagas disease

Restrictive Cardiomyopathy

Characterized by diastolic dysfunction caused by rigid ventricular walls that impair diastolic filling and ventricular stretch.

Hypertrophic Cardiomyopathies

A rare autosomal dominant condition in which the heart muscle asymmetrically increases in size and mass, especially along the septum. The increased thickness of the heart muscle reduces the size of the ventricular cavities and causes the ventricles to take a longer time to relax after systole.

Normal sodium range (Na⁺)

135-145 mEq/L

Potassium normal range (K⁺)

3.5-5.0 mEq/L

Chloride normal range (Cl^-)

95-105 mEq/L

Calcium normal range

4.5-5.5 mEq/L

Magnesium normal range

1.5-2.5 mEq/L

Fasting glucose normal range

70-110 mg/dL

WBC normal range

5000-10,000 microliter

OR

4,500-11,500/mm³

Normal RBC count range

4.5-5.3 million

Normal hemoglobin (Hb)

13.0-18.0 g/100 mL (men); 12-16 (women)

Normal hematocrit (Hct) range

37-49% (men); 36-46% (women)

Normal platelet count range

150,000-400,000/mm3

Normal BUN range

5-25 mg/dL

Normal serum creatinine range

0.5-1.5 mg/dL

Normal digoxin therapeutic range

0.5-2.0 ng/mL

Normal Dilantin therapeutic range

10-20 mcg/mL

Theophylline therapeutic range

10-20 mg/mL

Shock

A clinical syndrome that results from inadequate tissue perfusion creating an imbalance between the delivery of and requirement for oxygen and nutrients that support cellular function.

Physiologic responses common to all types of shock

- Hypoperfusion of tissues

- Hypermetabolism

- Activation of inflammatory response

Biochemical mediators

i.e. Cytokines - cause local regulatory mechanisms to activate, communicating the need for oxygen and nutrients.

How do the kidneys help regulate blood pressure?

They release renin, which causes vasoconstriction, leading to the release of aldosterone, causing retention of sodium and water. Hypernatremia stimulates release of ADH, which causes the kidneys to retain water in order to raise blood volume and BP.

Stages of Shock

Stage 1: Compensatory Stage

Stage 2: Progressive Stage

Stage 3: Irreversible Stage

Compensatory Stage

- BP remains within normal limits

- Vasoconstriction, increased HR, and increased heart contractility maintain cardiac output

- SNS stimulated, which releases catecholamines (epinephrine and norepinephrine)

- Blood shunting to vital organs

- Skin cool and pale, bowel sounds hypoactive, and urine output decreases

Clinical signs/symptoms of Compensatory Stage of shock

- Normal BP

- Metabolic acidosis

- Increased respiratory rate

- Possible change in affect, anxiety, or confusion

Medical management for compensatory stage of shock

- Correct underlying cause

- Support physiologic processes

- Fluid replacement and medication therapy

Nursing mangement for compensatory stage of shock

- Early intervention

- Systematic assessment

- Identify cause, administer IV fluids/oxygen

Progressive Stage of shock

Mechanisms that regulate BP can no longer compensate, and the MAP falls below normal.

Clinical signs/symptoms of Progressive Stage of shock

- Shallow, rapid respirations

- Decreased SaO2, increased CO2 levels

- Possible lung collapse

- Pulmonary edema, diffusion abnormalities/shunting, and alveolar collapse

- Dysrhythmias, chest pain, MI

- Impaired mental status, behavior changes, mood changes

- Decreased renal function

- Decreased liver metabolism and phagocytic functions

- GI ischemia

Medical management of Progressive Stage of shock

- Depends on type, cause, and degree of compensation

- Support respiratory system

- Optimize intravascular volume

- Improve competence of vascular system

- Support pumping action of the heart

Nursing managment of Progressive Stage of shock

- Assessment skills and understanding of shock and changes in assessment data.

- Early intervention vital to patient survival

- Close monitoring (ECG, ABGs, labs, mental status changes)

- Rapid administration of medications/fluids

- Mechanical ventilation, dialysis, and intra-aortic balloon pump

-Collaboration with multidisciplinary team-members

Irreversible Stage of shock

The point along the continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive.

Nursing managment for Irreversible Stage of shock

- Focus is on carrying out prescribed treatments, etc

- Prevent complications/protect from injury

- Offer brief explanations to patient regarding what is happening

- Inform family that patient is not likely to survive

- Make sure advance directives are in place

- Provide opportunities for family to see and touch patient

- De-briefing

Isotonic crystalloid solutions

They have the same concentration of electrolytes as the ECF and can be given without altering the concentrations of electrolytes in the plasma.

Ex: 0.9% sodium chloride (normal saline)

Lactated Ringers solution (contains lactate ion)

Hypovolemic shock

Characterized by decreased intravascular volume, occurring with a reduction by 15-30%, or 750-1500 mL in a 70-kg (154-lb) person.

Causes of hypovolemic shock

- External fluid losses:

• Traumatic blood loss

- Internal fluid shifts:

• Severe dehydration
• Severe edema
• Ascites

Medical management for Hypovolemic Shock

- Restore intravascular volume to reverse sequence of events leading to inadequate tissue perfusion

- Redistribute fluid volume

- Correct underlying cause of fluid loss as quickly as possible

Risk factors for Hypovolemic shock caused by external fluid losses

• Trauma
• Surgery
• Vomiting
• Diarrhea
• Diuresis
• Diabetes Insipidus

Risk factors for hypovolemic shock caused by internal fluid shifts

• Hemorrhage
• Burns
• Ascites
• Peritonitis
• Dehydration

Nursing management for hypovolemic shock

• Primary prevention
• Safe administration of fluids/medications
• Documentation of administration and effects
• Monitoring for complications and side effects of treatment
• Reporting effects and complications immediately

Cardiogenic Shock

Occurs when the heart's ability to contract and pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues.

Causes of Cardiogenic Shock

• Coronary
• Non-Coronary

Coronary Cardiogenic Shock

Most often seen in patients with acute MI resulting in damage to a significant portion of the left ventricular myocardium.

Non-coronary Cardiogenic Shock

Related to conditions that stress the myocardium (severe hypoxemia, acidosis, hypoglycemia, tension pneuomothorax) as well as conditions that result in ineffective myocardium function (cardiomyopathies, valvular damage, cardiac tamponade, dysrhythmias)

Cardiac manifestations of cardiogenic shock

• Angina
• Dysrhythmias
• Fatigue
• Feelings of doom
• Signs of hemodynamic instability

Goals of Medical Management of Cardiogenic Shock

• To limit further myocardial damage
• Preserve healthy myocardium
• Improve cardiac function by increasing cardiac contracility, decreasing ventricular afterload, or both

First line treatment for Cardiogenic Shock

• Oxygen administration (nasal cannula)
• Pain management (analesics)
• Hemodynamic monitoring (ABGs, BP, HR)
• Lab marker monitoring (CK-MB, BNP)
• Fluid replacement
• Pharmacologic therapy (Dobutamine, IV Nitro, Dopamine, Vasorestrictive meds, antiarrhythmics)

Nursing Management of Cardiogenic Shock

• Preventing cardiogenic shock
• Monitor hemodynamic status
• Administer meds and fluids
• Maintain intra-aortic balloon counterpulsation
• Enhance safety/comfort

Pulmonary Hypertension

Characterized by elevated pulmonary arterial pressure and secondary right heart ventricular failure.

Conditions that increase the risk for pulmonary hypertension

• Collagen vascular disease
• Congenital heart disease
• Anorexigens
• Chronic use of stimulants
• Portal hypertension
• HIV infection

Clinical manifestations of pulmonary hypertension

• Dyspnea (main symptom)
• Substernal chest pain
• Weakness
• Fatigue
• Syncope
• Hemoptysis
• Signs of Right-Sided Heart Failure
• Pain in RUQ of abdomen

Goals of medical management for pulmonary hypertension

• Primary goal - manage underlying condition, if known
• Individualized therapy
• Diuretics, oxygen, anticoagulants, digoxin, exercise training
• May require supplemental oxygen while exercising

Nursing management for pulmonary hypertension

• Identify patients at high risk (COPD, PE, congenital heart disease, mitral valve disease)
• Be alert for signs/symptoms, administer medications, instruct about use of home O2 therapy.
• Address emotional and psychosocial aspects of therapy

Cor pulmonale

A condition that results from pulmonary hypertension which causes right side of heart to enlarge because of increased work required to pump blood against high resistance through pulmonary vascular system.

Pulmonary Embolism (PE)

The obstruction of the pulmonary artery or one of its branches by a thrombus that originates somewhere in the venous system or the right side of the heart.

Risks for Pulmonary Embolism

• Trauma
• Surgery
• Pregnancy
• Heart failure
• Age over 50 years
• Hypercoagulable states
• Prolonged immobility

Symptoms of Pulmonary Embolism

• Depend on size of thrombus and area of pulmonary artery occluded
• Dyspnea (most frequent)
• Chest pain (sudden and pleuritic)
• Anxiety, fever, tachycardia, apprehension
• Tachypnea

Initial diagnostic workup for Pulmonary Embolism

• Chest x-ray
• ECG
• Pulse oximetry
• ABG analysis
• V/Q scan
• Pulmonary angiography* (most effective)

Prevention of DVT

• Active leg exercises
• Early ambulation
• Use of anti-embolic stockings

Nursing management for Pulmonary Embolism

• Minimize risk
• Preventing thrombus formation
• Assess for potential PE
• Monitor thrombolytic therapy
• Manage pain
• Manage oxygen therapy
• Relieve anxiety
• Monitor for complications
• Provide postoperative nursing care
• Promote home care

Three branches of the left coronary artery

1. Left main coronary artery
2. Left anterior descending artery
3. Circumflex artery

Blood supply for right side of the heart

1. Right coronary artery
2. Posterior descending artery

Three physiologic characteristics of types of specialized electrical cells, nodal cells and Purkinje cells

• Automaticity
• Excitability
• Conductivity

Automaticity

Ability to initiate an electrical impulse

Excitability

Ability to respond to an electrical impulse

Conductivity

Ability to transmit an electrical impulse from one cell to another.

Depolarization

Positively charged intracellular space and negatively charged extracellular space.

Repolarization

Resting state

Cardiac Output

The total amount of blood ejected by one of the ventricles in liters per minute.

Cardiac Output in a resting adult

4-6 L/minute

Stroke Volume

The amount of blood ejected from one of the ventricles per heartbeat.

Average resting Stroke Volume

About 60-130 mL

Baroreceptors

Specialized nerve cells located in the aortic arch and in both right and left internal carotid arteries

Preload

The degree of stretch of the ventricular cardiac muscle fibers at the end of diastole.

Afterload

Resistance to ejection of blood from the ventricle.

Contractility

The force generated by the contracting myocardium, enhanced by circulating catecholamines, sympathetic neuronal activity, and certain medications.

Ejection fraction

The % of end-diastolic blood volume that is ejected with each heartbeat.

Three major effects of estrogen

1. Increase in HDLs
2. Reduced LDLs
3. Dilation of blood vessels

Brain (B-Type) Natriuretic Peptide

A neurohormone that helps regulate BP and fluid volume, secreted from the ventricles in response to increased preload with resulting elevation in ventricular pressure.

C-Reactive Protein

A protein produced by the liver in response to systemic inflammation. It is used as an adjunct to other tests to predict CVP risk.

Homocysteine

An amino acid is linked to the development of atherosclerosis because it can damage the endothelial lining of arteries and promote thrombus formation.

Telemetry

The transmission of radio waves from a battery-operated transmitter to a central bank of monitors.

Cardiac stress testing

Non-invasive way of determining:

1. The presence of CAD
2. The cause of chest pain
3. Functional capacity of the heart after MI or heart surgery
4. Effectiveness of antianginal or antiarrhythmic medications
5. Occurrence of dysrhythmias
6. Specific goals for a physical fitness program

Contraindications for stress testing

• Severe aortic stenosis
• Acute myocarditis or pericarditis
• Severe hypertension
• Suspected left main CAD, HF, and unstable angina

Procedure for exercise stress test

• Patient walks on treadmill, pedals on stationary bicycle, or uses an arm crank
• Exercise intensity increases according to established protocols
• ECG, BP, skin temperature, physical appearance, pain, and symptoms are monitored
• IF patient experiences signs of myocardial ischemia, further testing is indicated

Nursing Interventions for Exercise Stress Testing

• NPO x4 hrs before procedure
• Avoid tobacco/caffeine
• Meds may be taken with sips of water
• Clothing should be suitable for exercise (loose clothing, sneakers with rubber soles)
• Describe test, ask if any questions, assess for understanding and consent
• After test, monitor x10-15 minutes

Pharmacologic stress testing

Used for patients who are phyiscally disabled or deconditioned. Uses two vasodilators (dipyridamole and adenosine) IV to mimic effects of stress.

Nursing interventions for pharmacologic stress testing

• NPO x4 hours before test
• Avoid chocolate, caffeine, tea, carbonated beverages, etc
• STop taking aminophylline, theophylline, or dipyridamole 24-48 hours before procedure
• Instruct to report any other symptoms during the test.
• Takes approximately 1-3 hours, depending if imaging used

Nursing responsibilities before cardiac catheterization

• NPO x8-12 hours
• Friend or family member needs to drive
• Hard table for at least 2 hours
• IV meds to maintain comfort
• Occasional heart palpitations
• Flushed feeling caused by dye
• Encouraging patient to express fears/anxiety and providing education and reassurance

Nursing responsibilities after cardiac catheterization

• Observing catheter access site for bleeding/hematoma
• Evaluate color, temperature, capillary refill
• Screen for dysrhythmias
• Maintain bed rest for 2-6 hours
• Report chest pain and bleeding promptly
• Monitor for contrast agent-induced nephropathy
• Ensure patient safety

Hemodynamic monitoring

• CVP
• Pulmonary artery pressure
• Intra-arterial BP monitoring

Central venous pressure monitoring

A measurement of the pressure in the vena cava or right atrium. It reflects the filling pressure of the right ventricle (preload).

Normal CVP

2 to 6 mm Hg

Most common problem that can cause elevated CVP

Hypervolemia or right-sided heart failure

Nursing interventions for CVP monitoring

• Obtain pressure readings
• Influse IV fluids, administer medications, and draw blood specimen

Dysrhythmias

Disorders of the formation or conduction of the electrical impulses within the heart.

Chronotropy

Rate of impulse formation

Dromotropy

Conduction velocity

Inotropy

Force of myocardial contraction

Sinus bradycardia

SA node creates an impulse slower than normal.

Sinus tachycardia

Sinus node creates impulse at faster-than-normal rate.

Treatment for sinus tachycardia

• Vagal maneuvers or administration of adenosine
• Beta-blockers and CCBs
• Procainaminde, amiodarone, and sotalol (in wide QRS tachycardia)
• Catheter ablation of SA node if persistent, inappopriate sinus tachycardia unresponsive to other treatment

Premature Atrial Complex (PAC)

A single ECG complex that occurs when an electrical impulse starts in the atrium before the next normal impulse of the sinus node.

Causes of PACs

• Caffeine
• Alcohol
• Nicotine
• Stretched atrial myocardium
• Anxiety
• Hypokalemia
• Hypermetabolic states (pregnancy)
• Atrial ischemia, injury, or infarction

Atrial Flutter

Occurs because of a conduction defect in the atrium and causes a rapid, regular atrial rate, between 250-400 bpm.

Medical management of atrial flutter

• Vagal maneuvers
• Administration of adenosine, IV, followed by 20 mL saline flush and elevation of arm with IV line

Signs and symptoms of atrial flutter

• Chest pain
• Shortness of breath
• Low blood pressure

Atrial fibrillation

An uncoordinated atrial electrical activation that causes a rapid, disorganized, and uncoordinated twitching of atrial musculature.

Risk factors for Atrial Fibrillation

• Increased age
• Male gender
• Increased BMI
• Systolic BP > 160 mm Hg
• Hypertension
• PR interval > 160 msec
• Clinically significant heart murmur (grade 3+)
• Heart failure

Premature Junctional Complex

An impulse that starts in the AV nodal area before the next normal sinus impulse reaches the AV node.

Causes of PJC

• Digitalis toxicity
• Heart failure
• Coronary artery disease

Premature Ventricular Complex (PVC)

An impulse that starts in a ventricle and is conducted through the ventricles before the next normal sinus impulse.

Causes of PVCs

• Caffeine
• Alcohol
• Nicotine
• Cardiac ischemia or infarction
• Increased cardiac workload
• Digitalis toxicity
• Hypoxia
• Acidosis
• Electrolyte imbalance (esp. hypokalemia)

Ventricular Tachycardia

Three or more PVCs in a row, at rate > 100 bpm.

Management of symptomatic ventricular tachycardia

• Antiarrhythmic medications
• Antitachycardia pacing
• Cardioversion (for monophasic VT)
• Implantable Cardioverter defibrillator

Ventricular fibrillation

A rapid, disorganized ventricular rhythm that causes ineffective quivering of the ventricles.

First-Degree Atrioventricular Block

When all the atrial impulses are conducted through the AV node into the ventricles at a rate slower than normal.

Second-Degree Atrioventricular Block, Type I

There is a repeating pattern in all but one of a series of atrial impulses conducted through the AV node into the ventricles.

Second-Degree Atrioventricular Block, Type II

When only some of the atrial impulses are conducted through the AV node into the ventricles.

Third-Degree Atrioventricular Block

No atrial impulse is conducted through the AV node into the ventricles. Two impulses stimulate the heart: one stimulates the ventricles, represented by the QRS complex, and one stimulates the atria, represented by the P wave.

Medical management of conduction abnormalities

• Increasing the heart rate to normal
• Maintain normal cardiac output
• If stable with no symptoms, no treatment may be necessary

Electrical cardioversion

The delivery of a "timed" electrical current to terminate a tachydysrhythmia.

Defibrillation

Used in emergency situations as the treatment of choice for ventricular fibrillation and pulseless VT.

**Not used if patient conscious with a pulse**

Pacemaker

An electronic device that provides electrical stimuli to the heart muscle.

Complications of pacemaker use

• Most common - dislodgement of pacing electrode
• Pacemaker malfunction
• Exposure to strong electromagnetic fields (household appliances, microwaves, electronic tools)
• Triggering antitheft devices
• Infection

Electrophysiology Study

(EP Studies) are invasive procedures used to evaluate and treat various dysrhythmias that have caused cardiac arrest or other similar symptoms.

What are uses for EP Study?

• Identifying impulse formation and propagation through the cardiac electrical conduction system
• Assessing the function or dysfunction of the SA and AV nodal areas
• Identifying location and mechanisms of dysrhythmogenic foci
• Assessing effectiveness of antiarrhythmic medications and devices for the patient with a dysrhythmia
• Treating certain dysrhythmias through the destruction of causative cells

Maze Procedure

An open heart surgical procedure for refractory atrial fibrillation involving small transmural incisions throughout the atria which build scar tissue to prevent reentry conduction of the electrical impulse.

**Used ONLY for patients undergoing cardiac surgery for something else**

Atherosclerosis

An abnormal accumulation of lipid and fibrous tissue in the lining of arterial and blood vessel walls leading to blocked/narrowing causing ischemia.

Causes of vascular injury associated with inflammation

• Smoking
• Hypertension
• Hyperlipidemia
• Other factor

Atheromas

Plaques that protrude into the lumen of vessels obstructing blood flow.

Clinical manifestations of atherosclerosis

• Angina pain
• Left arm weakness/numbness
• Jaw pain/numbness
• Indigestion
• Shortness of breath
• Feeling of doom

Non-modifiable risk factors for CAD

• Family history of CAD
• Increasing age (esp > 45 years)
• Gender (male > female)
• Race (African Americans > Caucasians)

Modifiable Risk Factors for CAD

• Hyperlipidemia
• Smoking/tobacco use
• Hypertension
• Diabetes
• Metabolic syndrome
• Obesity
• Physical inactivity

Metabolic syndrome

A major risk factor for CAD and includes three of the following conditions:

1. Insulin resistance
2. Central obesity (waist >35"-women, >40"-men)
3. Dyslipidemia
4. Blood pressure > 130/85 mm Hg
5. Proinflammatory state (high C-Reactive protein)
6. Prothrombotic state (high fibrinogen level)

C-Reactive Protein

Inflammatory marker for cardiovascular risk. Produced by the liver in response to stimulus such as tissue injury.

Angina pectoris

Syndrome characterized by episodes or paroxysms of pain or pressure in the anterior chest, caused by insufficient coronary blood flow.

Factors associated with angina pectoris

• Physical exertion
• Exposure to cold
• Eating a heavy meal
• Stress/heavy emotion

Objectives of medical management for angina pectoris

• To decrease oxygen demand of the myocardium
• To increase the oxygen supply

Standard treatment for angina pectoris

Nitrates (nitroglycerin)

How does nitroglycerin work to decrease angina pain?

• Dilates primarily veins, causing venous pooling of blood throughout the body, which reduces preload
• Relax the systemic arteriolar bed, lowering blood pressure and decreasing afterload

Action of Beta Blockers to control angina pain

• Reduce myocardial oxygen consumption by blocking beta-adrenergic sympathetic stimulation to the heart
• Reduces heart rate
• Slows conduction of impulses through the conduction system
• Decreases blood pressure
• Reduces myocardial contractility

Actions of Calcium Channel blockers to reduce angina pain

• Decrease SA node automaticity and AV node conduction, decreasing HR
• Decreases strength of myocardial contractions
• Increase myocardial oxygen supply by dilating the smooth muscle wall of coronary arterioles
• Decrease myocardial oxygen demand by reducing systemic arterial pressure and the workload of left ventricle

Potential complications of angina pectoris

• ACS or MI
• Dysrhythmias and cardiac arrest
• Heart failure
• Cardiogenic shock

Major patient goals associated with angina pectoris

• Immediate and appropriate treatment
• Prevention
• Reduction of anxiety
• Awareness of disease process
• Understanding the prescribed care
• Adherence to self-care plan
• Absence of complications

Acute Coronary Syndrome (ACS)

An emergent situation characterized by acute onset of MI that results in myocardial death, if definitive interventions do not occur promptly.

Spectrum of Acute Coronary Syndrome

• Unstable angina
• NSTEMI
• ST-segment elevation MI (STEMI)

Main presenting symptom with ACS

Chest pain that occurs suddenly and continues despite rest and medication

Diagnosis of ACS

• Presenting symptoms
• ECG (12 lead)
• Labs (cardiac biomarkers)

Troponin

Protein found in myocardial cells that regulates the myocardial contractile process.

**An increase indicates myocardial damage**

CK-MB

Cardiac-specific isoenzyme whose increase indicates acute MI.

Goals of medical management for ACS

• To minimize myocardial damage
• To preserve myocardial function
• To prevent complications

Cardiac rehabilitation

An important continuing care program for patients with CAD that targets risk reduction by providing patient and family education, offering individual and group support, and encouraging physical activity and physical conditioning.

Percutaneous Transluminal Coronary Angioplasty (PTCA)

Procedure involving a balloon-tipped catheter used to open blocked vessels and resolve ischemia.

Complications of PCI procedures

• Coronary artery dissection
• Perforation
• Abrupt closure
• Vasospasm
• MI
• Serious dysrhythmias
• Cardiac arrest

Major indications for CABG

• Alleviation of angina that cannot be controlled with medication or PCI
• Treatment for Left main coronary artery stenosis or multivessel CAD
• Prevention of and treatment for MI, dysrhythmias, or heart failure
• Treatment for complications from an unsuccessful PCI

Complications of CABG

• Hemorrhage
• Dysrhythmias
• MI

Preoperative Nursing Management for Patients undergoing CABG

• Baseline assessments
• Hx and physical exam
• Chest X-ray/labs/type-and-cross
• Cognitive status assessment
• Assess for conditions adding risk for complication
• Blood glucose levels (diabetic patients)
• Psychosocial assessment
• Coping mechanisms
• Support systems

Intraoperative Nursing Managment for cardiac surgery

• Assessments
• Patient safety and comfort
• Chest tubes inserted

Post-operative nursing management for cardiac surgery

• Hemodynamic stability
• Recovery from general anesthesia
• Cardiopulmonary status
• Wound care
• Pain management
• Progressive activity
• Nutrition

Complications following cardiac surgery

• Decreased cardiac output
• Fluid volume/electrolyte imbalance
• Impaired gas exchange
• Impaired cerebral circulation

Tricuspid valve

Valve that separates right atrium from right ventricle

Bicuspid valve (mitral valve)

Valve that separates the left atrium from the left ventricle

Mitral valve prolapse

A deformity involving the mitral valve leaflets stretching into the atrium during systole.

Typical first sign of Mitral Valve Prolapse

Mitral click (extra heart sound)

Medical management for symptomatic mitral valve prolapse

• Eliminate caffeine/tobacco products/alcohol
• Antidysrhythmics (not usual)
• Prophylactic antibiotics NOT recommended prior to dental procedures
• If patient does not respond to nitrates, CCBs or Beta-Blockers are used

Nursing management for Mitral Valve Prolapse

• Education regarding risk minimization
• Avoid caffeine and alcohol
• Explain need to inform PCP about any symptoms
• Read labels, avoid products containing:
• Ephedrine
• Pseudoephedrine
• Epinephrine
• Explore diet, activity and lifestyle factors that may correlate with symptoms
• Discuss pregnancy - patients without regurgitation or symptoms okay for pregnancy

Mitral regurgitation

Back-flow of blood back from the left ventricle into the left atrium during systole.

Causes of mitral regurgitation

Developed countries:

• Degenerative changes
• Ischemia

Developing countries:

• Rheumatic heart disease

Myxomatous changes

Symptoms of mitral regurgitation

• Usually asymptomatic
• Manifests as severe heart failure
• Dyspnea
• Fatigue
• Weakness
• Palpitations
• Shortness of breath on exertion
• Cough from pulmonary congestion

Assessment findings for mitral regurgitation

• High-pitched,  blowing murmur at apex
• HR may be regular or irregular
• ECG - to diagnose and monitor progression
• TEE - best images available for mitral valve

Medical management for mitral regurgitation

• Afterload reduction (arterial dilation) using ACE inhibitors or ARBs
• Restricting activity levels

Mitral stenosis

An obstruction to blood flow from the left atrium into the left ventricle, often caused by rheumatic endocarditis.

First symptom of mitral stenosis, often

Dyspnea on exertion (DOE)

Prevention of mitral stenosis

• Minimizing risk
• Treatment of bacterial infections/strep infections

Medical management

for

mitral stenosis

Anticoagulants

Cardioversion

Beta-blockers or CCBs

Digoxin

Avoid strenuous activity, competitive sports, and pregnancy

Aortic regurgitation

Flow of blood back into the left ventricle from the aorta during diastole.

Medical management of aortic regurgitation

• Avoid physical exertion, competitive sports, and isometric exercise
• First line meds - vasodilators (CCBs and ACE inhibitors)
• Hydralazine
• Treatment of choice - aortic valve replacement or valvuloplasty

Aortic stenosis

Narrowing of the orifice between the left ventricle and aorta

Risk factors for degenerative changes of the aortic valve

• Diabetes
• Hypercholesterolemia
• Hypertension
• Low HDL levels
• Untreated bacterial infections causing rheumatic endocarditis

Clinical manifestations of aortic regurgitation

• Exertional dyspnea
• Orthopnea
• PND
• Pulmonary edema
• Dizziness and syncope caused by decreased blood flow to the brain
• Angina pectoris caused by increased oxygen demand of hypertrophied LV and decreased blood supply
• Low pulse pressure (<30 mm Hg)

Assessment findings with aortic stenosis

• Loud, rough systolic murmur over aortic area
• Low-pitched, crescendo-decrescendo, rough, rasping, and vibrating
• ECG, CMR imaging, and CT scanning to diagnose and monitor progression

Prevention of aortic stenosis

• Focused on controlling risks:
• Treating diabetes
• Hypertension
• Cholesterol
• Triglycerides
• Avoiding tobacco products

Medical management for aortic stenosis

• Medications for dysrhythmias or LV failure
• Surgical replacement of aortic valve
• One- or Two-balloon percutaneous valvuloplasty procedures with or without transcatheter aortic valve implantation

Nursing responsibilities for valvular heart disorders (general)

• Education (dx, procedures, nature of disease)
• Instruct to report new sx or changes
• Minimize r/f infective endocarditis
• Measure vitals (BP, HR, RR), compare with baseline
• Collaborate with patient to develop medication schedule, and educate about name/dosing of meds
• Take daily weight, report gain of >3 lbs/day or >5 lbs/week

Valvuloplasty

Repair of cardiac valve (rather than replacement)

Annuloplasty

Repair of the valve annulus

Mechanical valves

Bileaflet, tilting-disk, or balloon-and-cage design. Used for patients with renal failure, hypercalcemia, endocarditis, or sepsis who require valve replacement.

Significant complications assocated with mechanical valves

• Thromboemboli
• Long-term use of anticoagulants

Types of tissue valves

1. Bioprostheses

2. Homografts

3. Autografts

Why would a bioprosthesis be indicated over mechanical valves?

• Women of childbearing age - cannot use anticoagulants
• Patients over 70 years of age
• Patients with history of peptic ulcer disease
• Patients who cannot tolerate LT anticoagulant use

Homografts

Human valves obtained from cadaver tissue donations and used for aortic and pulmonic valve replacement

Autografts

Obtained by excising the patient's own pulmonic valve and a portion of the pulmonary artery for use as the aortic valve.

Indictions for autografts

• Children
• Women of childbearing age
• Young adults
• Patients with history of peptic ulcer disease
• People who cannot tolerate anticoagulation

Nursing responsibilities for valve replacement and valvuloplasty

• Assist patient/family to prepare fo the procedure and reinforce explanations
• Provide psychosocial support
• Assess for signs/sx for heart failure and emboli
• In the ICU - assess V/S every 5-15 min and PRN until recovery from anesthesia or sedation, then 2-4 hrs.
• Meds gradually reduced until no longer necessary
• Pain assessments q 1-4 hrs
• Education to prevent infective endocarditis

Cardiomyopathy

Disease of the heart muscle that is associated with cardiac dysfunction.

Classifications of Cardiomyopathy

1. DIlated Cardiomyopathy

2. Hypertrophic Cardiomyopathy

3. Restrictive Cardiomyopathy

Dilated Cardiomyopathy

Significant dilation of the ventricles without simultaneous hypertrophy and systolic dysfunction.

Main conditions causing Dilated Cardiomyopathy

• Pregnancy
• Heavy alcohol intake
• Viral infection (flu)
• Chemo meds
• Chagas disease

Restrictive Cardiomyopathy

Characterized by diastolic dysfunction caused by rigid ventricular walls that impair diastolic filling and ventricular stretch.

Causes of restrictive cardiomyopathy

• Amyloidosis
• Other infiltrative diseases

Signs and symptoms of Restrictive Cardiomyopathy

• Dyspnea
• Nonproductive cough
• Chest pain

Hypertrophic Cardiomyopathy

A rare autosomal dominant condition involving asymmetrical increases in heart mass and size, especially along the septum.

Signs and symptoms of cardiomyopathy

• S/Sx of heart failure
• PND, cough, orthopnea
• Fluid retention, peripheral edema, nausea
• Chest pain, palpitations, dizziness, syncope with exertion
• With HCM, sudden cardiac death may occur

Goals of nursing management of cardiomyopathy

• Improvement or maintenance of cardiac output
• Increased activity tolerance
• Reduction of anxiety
• Adherence to self-care program
• Increased sense of power with decision making
• Absence of complications

Infective endocarditis

A microbial infection of the endothelial surface of the heart which develops in people with prosthetic heart valves, cardiac devices, or structural defects

Primary presenting symptoms for infective endocarditis

• Fever
• Heart murmur

Onset of infective endocarditis

• Insidious
• Signs and symptoms develop from toxic effects of infection

Confirmation of diagnosis of infective endocarditis

• Three sets of blood cultures from different venipuncture sites
• MO found in 2 separate cultures.

Objective of medical treatment for infective endocarditis

To eradicate invading organisms through adequate doses of an appropriate antimicrobial agent

Surgical interventions for infective endocarditis

• Valve debridement or excision
• Debiredment of vegetation
• Debridement and closure of an abscess
• Closure of a fistula

Nursing management for infective endocarditis

• Monitor temperature
• Administer meds (abx, antifungals, antivirals)
• Rest periods between activities
• Antipyretics/NSAIDs
• Assess heart sounds
• LT IV antimicrobial therapy

Myocarditis

An inflammatory process involving the myocardium that can cause dilation, thrombi on the heart wall, infiltration of circulating blood cells around the coronary vessels and between muscle fibers, and degeneration of the muscle fibers themelves.

Symptoms of acute myocarditis

• Depend on the type of infection, degree of myocardial damage, and capacity of myocardium to recover
• Asymptomatic, may resolve on its own
• Mild to moderate symptoms - may seek medical attention
• Fatigue, dyspnea, syncope, palpitations, occasional discomfort
• Flulike symptoms

Pericarditis

An inflammation of the pericardium.

Causes of pericarditis

• Idiopathic/nonspecific
• Infection
• CT disorders
• Sarcoidosis
• Hypersensitivity
• Disorders of adjacent structures (MI, dissecting aneurysm, pleural/pulmonary disease)
• Neoplastic disease
• Radiation therapy
• Trauma
• Renal failure/uremia

Most characteristic symptom of pericarditis

Chest pain or pain located in the clavicle, neck or left trapezius region.

Objectives of pericarditis management

• To determine cause
• To administer therapy
• Symptom relief
• Detect signs and symptoms of cardiac tamponade

Nursing management of pericarditis

• Pain management (analgesics, positioning, and psychological support)
• Reassurance that pain not from MI
• Minimize complications
• Monitor for heart failure

Current definition of heart failure

A clinical syndrome characterized by signs and symptoms of fluid overload or inadequate tissue perfusion.

Heart failure (in general)

Indicates myocardial disease in which impaired contraction of the heart or filling of the heart may cause pulmonary or systemic congestion.

Left-sided heart failure

Pulmonary congestion that occurs when the LV cannot effectively pump blood out of the ventricle into the aorta and the systemic circulation.

Signs of heart failure - congestion

• Dyspnea
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Cough
• Pulmonary crackles
• Weight gain
• Abdominal bloating/discomfort
• Jugular vein distention
• Sleep disturbance

Right-sided Heart Failure

Congestion in the peripheral tissues and the viscera predominates, because the heart cannot eject blood effectively and cannot accommodate all of the blood that normally returns to it from the venous circulation.

Systemic clinical manifestations of Right-Sided HF

• Edema of lower extremities
• Hepatomegaly
• Ascites
• Weight gain

Overall goals of management for HF

• To relieve symptoms
• To improve functional status and quality of life
• To extend survival

Major goals for nursing management of HF

• Promoting activity and reducing fatigue
• Relieving fluid overload symptoms
• Decreasing anxiety
• Increasing patient's ability to manage anxiety
• Encouraging patient to verbalize his/her ability to make decisions/ influence outcomes
• Education about management of therapeutic regimens

Pulmonary Edema

The abnormal accumulation of fluid in interstitial spaces and alveoli of the lungs

Clinical manifestations of pulmonary edema

• Restlessness/anxiety
• Sudden onset of breathlessness
• Sense of suffocation
• Tachypnea/noisy breathing
• Pale/cyanotic skin
• Tachycardia/JVD
• Incessant coughing
• Confusion/stupor

Prevention of pulmonary edema

• Recognize symptoms (dyspnea, heart sounds, peripheral edema)
• Hacking cough, fatigue, weight gain, development or worsening edema
• Decreased activity tolerance

Clinical management of pulmonary edema

• Reducing volume overload
• Improving ventricular function
• Increasing oxygenation

Pulsus paradoxus

A systolic blood pressure that is markedly lower during inhalation

Most important factor that determines resistance in the vascular system

Vessel radius

Intermittent claudication

A muscular, cramp-like pain, discomfort, or fatigue in the extremities consistently reproduced with the same degree of fagitue in the extremities or activity and relieved by rest.

Ankle-Brachial Index (ABI)

The ratio of the systolic blood pressure in the ankle to the systolic blood pressure in the arm, which is an indicator of arterial disease and degree of stenosis.

Most common direct results of atherosclerosis

• Stenosis of lumen
• Obstruction by thombosis
• Aneurysm
• Ulceration
• Rupture

Risk factors associated with atherosclerosis

• Nicotine use
• Diet
• Hypertension
• Diabetes
• Hyperlipidemia
• Stress
• Sedentary lifestyle
• Elevated C-reactive protein
• Hyperhomocysteinemia

Nursing management for atherosclerosis

• Improving peripheral arterial circulation
• Walking/grade isometric exercises
• Rest until pain subsides
• Increasing endurance
• Promoting vasodilation and preventing vascular compression
• Application of warmth to promote arterial flow
• Avoid exposure to cold
• Adequate clothing
• Hot water bottle or heating pad, using caution
• Cease tobacco use
• Relief of pain
• Analgesics (hydrocodone/APAP, oxycodone, Percocet, etc)
• Maintaining tissue integrity
• Avoid trauma
• Wear sturdy, well-fitting shoes
• No lotion between toes
• Neutral soaps
• Carefully trim nails
• Good nutrition

Hallmark symptom of Peripheral Artery Disease (PAD)

Intermittent claudication

Factors that increase pain with PAD

• Elevating extremity
• (Placing in dependent position decreases pain)
• Sleeping in reclining chair to keep feet down

Drugs approved for treatment of intermittent claudication

• Pentoxifylline
• cilostazol
• Antiplatelets:
• Aspirin
• Plavix
• Statins

Indications for surgery with PAD

Reserved for treatment of severe and disabling claudication or when a limb is at risk for amputation because of tissue necrosis.

Nursing responsibilities for care of patients with PVD

• Maintaining circulation - check pulses, Doppler, CMS checks every 15 minutes until stable
• Monitoring/managing potential complications - Urine output, CVP, mental status, pulse rate, and volume
• Avoid leg crossing
• Graduated compression or anti-embolic stockings
• Severe edema of extremity, pain, and decreased sensation of toes or fingers can indicate compartment syndrome

Aneurysm

A localized sac or dilation formed at a weak point in the wall of the artery.

Major cause of aneurysms

Atherosclerosis (thoracic aortic aneurysm)

Symptoms of aneurysm

• Asymptomatic
• Pain may be most prominent symptom
• Constant, boring pain, usually just when patient supine
• Dyspnea, cough, hoarseness, stridor, or weakness
• Aphonia
• Dysphagia

Most important diagnostic indication of abdominal aortic aneurysm

A pulsatile mass in the middle and upper abdomen

Dissecting aorta

A tear in the intima which degenerates, causing a dissection

Causes of dissecting aorta

• Poorly controlled HTN
• Blunt chest trauma
• Cocaine use

Symptoms of dissecting aorta

• Sudden onset of pain, tearing or ripping
• May be mistaken for MI
• Sweating/tachycardia
• BP elevated or markedly different from one arm to the other

Raynaud's phenomenon

A form of intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of the fingertips and toes.

Classic clinical picture of Raynaud's

• Pallor brought on by sudden vasoconstriction
• Skin becomes cyanotic because of pooling of deoxygenated blood during vasospasm
• Hyperemia due to vasodilation causing rubor
• White, blue, red color change
• Numbness, tingling and burning pain

Medical management of Raynaud's

• Avoid stimuli (cold, tobacco)
• CCBs
• Sympathectomy (interrupting sympathetic nerves by removing sympathetic ganglia or dividing their branches)

Nursing management for Raynaud's

• Educate patient to avoid cold/stimuli
• Stress management
• Wear sweater inside offices with A/C
• Advise that complications are rare
• Handle sharp objects carefully to avoid injury

Complications of Venous Thrombosis

• Chronic venous occlusion
• Pulmonary emboli
• Valvular destruction
• Venous obstruction

Clinical manifestations of DVT

• Nonspecific
• Phlegmasia cerulea dolens where entire extremity becomes swollen, tense, painful and cool to the touch
• Severe and sudden venous HTN leading to tissue ischemia
• **Venous gangrene occurs in 40-60% of cases**

Contraindications to Anticoagulation Therapy

• Hx of noncompliance
• Bleeding
• Hemorrhagic disorders
• Aneurysms
• Severe trauma
• Alcoholism
• Recent/impending surgery of eyes, spine, brain
• Severe hepatic or renal disease
• Recent cerebrovascular hemorrhage
• Infection
• Open ulcerative wounds
• Hazardous occupations
• Recent childbirth

How often should graduated compression stockings be worn?

At all times except at night. Should be reapplied in the morning before getting out of bed.

Nonselective debridement

The application of isotonic saline dressings of fine mesh gauze to the ulcer, which removes debris adhering to the gauze when removed (AKA wet-to-dry dressing)

Enzymatic debridement

The application of enzyme ointments to ulcerous tissue but not normal tissue, via saline-soaked gauze with loose bandage.

Calcium alginate dressings

When absorption of exudate is needed. They need to be changed every week or when the exudate seeps through. Not for dry or nonexudative wounds.

Foam dressings

Ex: Lyofoam, Allevyn

For exudative wounds, because they absorb exudate into the foam, keeping the wound moist.

Hyperbaric Oxygen (HBO)

Placing the patient into a chamber that increases barometric pressure while the patient is breathing 100% oxygen.

How does Hyperbaric Oxygen work?

• Edema in wound decreased because of vasoconstriction caused by 100% oxygen.
• Leukocytes can phagocytize and kill bacteria more efficiently
• Increases diffusion of oxygen to the hypoxic wound, enhancing epithelial migration and improving collagen production

Two most common adverse effects of Hyperbaric Oxygen

1. Middle ear barotrauma

2. Confinement anxiety

Lymphangitis

An acute inflammation of the lymphatic channels, from a focus of infection in an extremity.

Lymphedema

Tissue swelling in the extremity caused by an increased quantity of lymph from obstruction of lymphatic vessels.

Goal of therapy for lymphedema

To reduce and control edema and prevent infection

Complications of lymphedema

• Flap necrosis
• Hematoma
• Abscess
• Cellulitis

Cellulitis

Occurs when an entry point through normal skin barriers allows bacteria to enter and release their toxins in the subcutaneous tissues.

Systemic signs of cellulitis

• Swelling
• Localized redness
• Pain
• Fever/chills
• sweating
• Regional lymph nodes tender and enlarged

Nursing mangement for cellulitis

• Elevate affected area 3-6 inches above heart level
• Apply warm, moist packs to site every 2-4 hours
• Use caution with warm packs if diabetes
• Education to avoid recurrent episode

Primary Hypertension

AKA essential hypertension - high BP from unidentified cause

Usual causes of secondary hypertension

• Renal parenchyma disease
• Narrowing of renal arteries
• Hyperaldosteronism
• Medications (prednisone, Epogen)
• Coarctation of the aorta
• Pregnancy

Glomerular Filtration Rate (GFR)

Flow rate of filtered fluid through the kidney, indicating renal function

Hypertensive emergency (crisis)

A situation in which blood pressures are extremely elevated and must be lowered immediately to halt or prevent damage to target organs.

The body's major extracellular buffer system

Sodium bicarbonate-carbonic acid buffer system

Signs and symptoms of metabolic acidosis

• Headache
• Confusion
• Drowsiness
• Increased RR and depth
• Nausea
• Vomiting
• Peripheral vasodilation
• Decreased cardiac output if pH < 7.0

Common causes of metabolic alkalosis

• Vomiting
• Gastric suction with loss of hydrogen and chloride ions
• Loss of potassium (diuretic therapy)
• Excessive alkali ingestion (antacids containing bicarbonate)

Aim for treatment of acute and chronic metabolic alkalosis

Correcting underlying acid-base disorder

Pulmonary diffusion

The process by which oxygen and carbion dioxide are exchanged from areas of high concentration to low concentration at the air-blood surface.

Pulmonary perfusion

The actual blood flow through the pulmonary vasculature

V/Q Imbalance