Unit 9 Adult Cardiac Output

Chapters 24 & 25

Cardiac System Risk Factors

Valve Defects

Coronary Artery Disorders

Rheumatic Fever

Developmental

Microbiological

Cardiac Tamponade

Chemical

Chemotherapy

Other Precipitating Factors: Anemia, Electrolyte Imbalance, Dysrhythmias 

Valve Defects

Normal valves function to maintain a unidirectional flow of blood through the cardiac chambers by passively opening and closing in response to variant pressure gradients

Coronary Artery Disorders

Results when decreased blood flows causing inadequate delivery of oxygen and nutrients to the myocardium

Rhematic Fever

Can develop into heart disease that affects valves as evidenced by a new heart murmur, cardiomegaly, pericarditis, and heart failure

Other causes to Rheumatic Fever

Malnutrition, overcrowding, poor hygiene, and lower socioeconomic status, primarily a disease of developing world

Rheumatic Fever/Streptococcal Pharyngitis Signs and Symptoms

Sore throat that can start very quickly

Pain when swallowing

Fever

Red and swollen tonsils, sometimes with white patches or streaks of pus

Petechiae (tiny, red spots) on the roof of the mouth (the soft or hard palate)

Swollen lymph nodes in the front of the neck

Rheumatic Fever Negative Rapid Strep Test

Can be followed with a throat culture but it is usually not necessary for adults since they are not at risk following a strep throat infection

Positive Rapid Strep Test/Throat Cultures Positive For Streptococcal Pharyngitis

Must adhere to prescribed antibiotic treatment

1st line: Penicillin or amoxicillin

Developmental

Cardiac anomalies – most involve the inappropriate communication of blood between chambers of the heart and include cyanotic & acyanotic disorders

Cyanotic

Acyanotic

Microbiological

Infective endocarditis acute type: normal heart valves are attacked by highly virulent organisms (staph aureous) causing severe damage

Subacute infective endocarditis: defective heart valves are invaded by organisms such as strep that are part of the normal flora of the mouth

Pericarditis: inflammation of the pericardium

Infective Endocarditis Acute Type

Normal heart valves are attacked by highly virulent organisms (staph aureous) causing severe damage

Subacute infective endocarditis

Defective heart valves are invaded by organisms such as strep that are part of the normal flora of the mouth

People at risk of infective endocarditis

Older adults, people with prosthetic heart valves or cardiac device

Staphylococcal Endocarditis

Common among adults who use illicit IV drugs

Hospital-aquired infective endocarditis

Occurs most often in patients with debilitating disease or indwelling catheters and in patients who are receiving hemodialysis or prolonged IV fluid or antibiotic therapy

Clinical Manifestations of Infective Endocarditis

Fever and a heart murmur

Fever may be intermittent or absent, especially in patients who are receiving antibiotics or corticosteroids

Small, painful nodules (Olser nodes) may be present in pads of fingers or toes

Irregular, red or purple, painless flat macules (Janeway lesions) may be present on palms, fingers, hands, soles, and toes

Hemorrhages with pale centers (Roth spots) caused by emboli may be observed in fundi of the eyes.

Splinter hemorrhages (i.e., reddish-brown lines and streaks) may be seen under the proximal half of fingernails and toenails.

Petechiae may appear in conjunctiva and mucous membranes

Infective Endocarditis Complications

Heart failure - may result from perforation of a valve leaflet, rupture of chordae, blood flow obstruction due to vegetations, or intracardiac shunts from dehiscence of prosthetic valves

Definitive Diagnosis of Infective Endocarditis

Made when a microorganism is found in two separate blood cultures and there is evidence of vegetation on imaging of the heart

1 Aerobic Culture

1 Anaerobic Culture

2 hours apart, from different venipuncture sites over 24-hours

Obtained before admission/administration of any antibiotics

Infective Endocarditis

Elevated white blood cell count, normal: 4500 - 11000

Anemia

Positive rheumatoid factor

Elevated erythrocyte sedimentation rate (ESR):

m < 50 years, 0-15

m > 50 years, 0-20

f < 50 years, 0-20

f > 50 years, 0-30

Elevated C-reactive protein, normal: < 1mg

Erythrocyte Sedimentation Rate (ESR)

Increased in tissue destruction, whether inflammatory or degenerative; during menstruation and pregnancy; in acute febrile diseases; and other conditions

Prevention of Infective Endocarditis

Poor dental hygiene can lead to bacteremia, particularly in the setting of a dental procedure, practice good dental care.

Report fevers of more than 7 days duration to primary provider

Do not self medicate with antibiotics or stop taking before the prescribe dosage has been complete

Medical Management of Infective Endocarditis

Intravenous antibiotic therapy for 2 to 6 weeks

Dosage is increased if unsuccessful with current dosage

May need psychosocial support due to being confined to their IV for so long at home/hospital

Signs of improvement in health: regaining of an appetite, less fatigue

Nursing Management of Ineffective Endocarditis

Monitor temperature to gage the effectiveness of treatment but keep in mind a fever may be a result of medication.

Administer antibiotics, antifungal, or antivirals as prescribed

Ensure rest between activities

If shivering or piloerection occurs— stop the interventions that provoke this

Piloerection

This is like goosebumps, the hair on your skin contracts due to stimulation of the sympathetic nervous system or the cold

Pericarditis

Inflammation of the pericardium, etiology of this can be infectious or noninfectious. May occur 10 days to 2 months post acute myocardial infarction.

Causes of Pericarditis

Chart 24-7 Chapter 24

Clinical Manifestations of Pericarditis

May be asymptomatic

Chest pain, pain beneath the clavicle, in the neck, or in the left trapezius (scapula) region

Pain may worsen with deep inspiration

Mild fever

Increased white blood count, erythrocyte sedimentation rate, and c-reactive protein levels

Anemia

Nonproductive cough or hiccup

Dyspnea

Assessment/Diagnostic Findings of Pericarditis

CT imaging may be the best for determining size, shape, and location of pericardial effusions, and may also guide pericardiocentesis 

MRI may detect inflammation and adhesions

12-lead ECG may show concave St elevations in many if not all leads, may show depressed PR segments or atrial arrhythmias 

Pericardial Friction Rub

Diagnostic of pericarditis, creaky or scratchy sound at the end of exhalation

Assess by placing the diaphragm of stethoscope tightly against the patient’s thorax and auscultating the left sternal edge in the 4th intercostal space

May best be heard when sitting and leaning forward

Pericardial Friction Rub While Holding Breath

Will be heard and is performed when there is difficulty differentiating between a pleural friction rub

Medical Management of Pericarditis

Bedrest until fever, chest pain, and fraction rub have subsided 

Analgesics and NSAIDs- aspirin, indomethacin, ibuprofen for acute phase

Corticosteroids as an alternatives when NSAIDs are contraindicated

Colchicine may be prescribed if the pericarditis is severe as an additive therapy

Pericardiocentesis

A procedure in which some pericardial fluid is removed, rarely is necessary. It may be performed to assist in identification of the cause or relieve symptoms, especially if there are signs and symptoms of heart failure or tamponade.

Nursing Management for Pericarditis

Reassure that pain is not due to a heart attack

Leaning forward or sitting position may relieve pain

Activity restriction until pain and fever subsides. Will be reinstated if these reoccur.

Be alert to signs and symptoms of cardiac tamponade

Monitor for heart failure

Hemodynamic instability or pulmonary congestion = treated as if they had heart failure

Pericarditis Complications

Cardiac Tamponade, Pleural Effusion

Cardiac Tamponade

Life threatening compression of the heart due to fluid within the pericardial sac

Chemical

ETOH abuse = decreased cardiac output

Chemotherapy

Can be toxic to tissue

Other Precipitating Factors

Anemia, electrolyte imbalance, dysrhythmias

Cardiac Clinical Manifestations

Dizziness, Confusion, Fatigue, Exercise Intolerance, Cool Extremities, Oliguria

Cardiac System Diagnostic Testing

a. Routine Chemistry: SMA6, 12, 18

b. BUN & Creatinine to assess kidneys

c. lipid profile, cholesterol

d. c-reactive protein: inflammation

e. cardiac enzymes, troponin, CKMB,

f. B-type Natriuretic Peptide (BNP) — increased with Heart Failure

g. serum digoxin level: 0.5 - 2

Routine Chemistry

SMA6, 12, 18

BUN & Creatinine

Assess kidneys

BUN: 8 - 20

Creatinine: M/ 0.6 - 1.2 F/ 0.4 - 1

Lipid Profile/Cholesterol

LDL: > 100, At Risk For Coronary Artery Disease/ >70 

HDL: Males/ > 40, Females/ > 50

Total: 200

Triglycerides: 150

C - Reactive Protein

< 1

Inflammation Indicator, elevated when inflammed

Cardiac Enzymes

Troponin I: < 0.35

CKMB

Both rise when there is myocardial damage

Troponin

Usually a one time draw

Begins to rise in a few hours

Remains elevated for weeks

Usually we use troponin I, troponin T can be elevated due to skeletal muscle damage making it not as cardiac focused

Creatine Kinase Myocardial Band (CKMB)

Serial - 1st one is stat then done every 8 hours x 3 to capture the rise of CK-MB levels

Begins to increase in a few hours - peaks in 24 hours

Returns to normal in 3-4 days

B-type Natriuretic Peptide (BNP)

< 100

Increased with Heart Failure:

Serum Digoxin Level

0.5 - 2

Chest X Ray

to determine size, contour, and position of heart

Electrocardiogram (ECG/EKG)

to determine electrical conduction system of heart

Hemodynamic Monitoring Central Venous Pressure (CVP)

Pressure on the vena cava or right atrium

Used to assess right ventricle function

Increased central venous pressure indicates right ventricle damage

Pulmonary Artery Pressure Monitoring

Used to assess left ventricle function

Diagnoses the etiology of shock

Evaluates responses to fluids & meds

PCWP (pulmonary artery capillary wedge pressure) when increased indicates left ventricle damage

Multilumen Catheter

Enters right atrium via venous catheter and travels to right ventricle and pulmonary artery pressure readings is obtained along the way

Echocardiogram

Noninvasive ultrasound test to examine size, shape and motion of cardiac structures

Transesophageal Echocardiogram

Thread a small transducer through mouth into esophagus

Provides clearer images because ultrasound waves are passing through less tissue

This method of echocardiography is superior in assessing vegetations and perivalvular complications

Cardiac Stress Test

Used to evaluate the heart and vascular system during exercise

Nuclear Stress Test

Refers to stress testing performed in combination with a nuclear imaging test, such as a SPECT or PET scan.

More expensive

Require more time

Exposed to small amount of radioactive substance

PET

Thallium

Muga

Spect

Cardiac Catheterization & Angiography

Determine pressures & oxygen saturation in the heart, outlines heart and blood vessels, can have right or left sided done

Pre-Catheterization Nursing Interventions

NPO FOR 8-12 hours

Patient will be lying on hard table for 2 hours

Patient will experience certain sensations: palpitations, feeling of warmth, feeling of voiding

Post-Cath Nursing Interventions

Assess puncture site for bleeding

Assess affected extremity q15m for 1-2h after that q1-2h until stable: PULSE, TEMP, COLOR, PAIN, NUMBNESS

Report ABNORMAL FINDINGS to MD

Assess for dysrhythmia

Assess for vasovagal reaction (low HR, hypotension, nausea, syncope)

Femoral Artery Catheterization

Patient remains supine with affected leg straight

Head of bed elevated <= 30 degrees for several hours

Increase oral fluid to increase urinary output to flush out dye

Assess for chest discomfort & report immediately

Assist patient out of bed 1st time

Assess and check orthostatic vital signs

Vasovagal Nursing Interventions

Raise legs above head: Trendellenberg

Intravenous Fluid

Atropine sometimes

Congestive Heart Failure aka Heart Failure

Heart’s inability to pump blood to meet the needs of tissues for oxygen and nutrients

Increases with age

May be referred to in terms of left or right sided

Congestive Heart Failure aka Heart Failure Pathophysiology

Decreased cardiac muscle contractibility, valve problems, systemic hypertension

Conditions that worsen Congestive Heart Failure

Increased metabolic rate, hypoxia, anemia, acidosis, dysrhythmias

Atherosclerosis

Is the primary cause of heart failure, coronary artery disease is found in 60% of patients with heart failure

Heart Failure Cycle

A decrease in blood ejected from the ventricle stimulates the sympathetic nervous system, stimulating the release of renin, causing fluid retention & vasoconstriction, the purpose of this compensatory response is to maintain or increase contractility to maintain cardiac output, but because this response increases preload and afterload, the heart must work harder as well

Shortness of breath (dyspnea) during Heart Failure

At rest, while sleeping, and during activity. May come on suddenly and wake you up. You often have difficulty breathing while lying flat and may need to prop up the upper body and head on two pillows. You often complain of waking up tired or feeling anxious and restless.

Why shortness of breath occurs?

Blood "backs up" in the pulmonary veins (the vessels that return blood from the lungs to the heart) because the heart can't keep up with the supply. This causes fluid to leak into the lungs.

Persistent coughing or wheezing

Produces white or pinked blood tinged mucus

Why persistent coughing or wheezing occurs

Fluid builds up in the lungs 

Buildup of excess fluid in body tissues (Edema)

Swelling in the feet, ankles, legs or abdomen or weight gain. You may find that your shoes feel tight.

Why buildup of excess fluid in body tissues (Edema) occurs?

As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing fluid to build up in the tissues. The kidneys are less able to dispose of sodium and water, also causing fluid retention in the tissues.

Tiredness, fatigue

A tired feeling all the time and difficulty with everyday activities, such as shopping, climbing stairs, carrying groceries or walking.

Why tiredness and fatigue occurs?

The heart can't pump enough blood to meet the needs of body tissues. The body diverts blood away from less vital organs, particularly muscles in the limbs, and sends it to the heart and brain.

Lack of appetite, nausea

A feeling of being full or sick to your stomach.

Why a lack of appetite and/or nausea occurs?

The digestive system receives less blood, causing problems with digestion

Confusion, impaired thinking

Memory loss and feelings of disorientation. A caregiver or relative may notice this first

Why confusion or impaired thinking occurs?

Hypoxia

Increased heart rate

Heart palpitations, which feel like your heart is racing or throbbing

Why an increased heart rate occurs?

To compensate for the loss in pumping capacity, the heart beats faster

Left Sided Heart Failure

Left ventricle is unable to pump blood to meet oxygen needs

Therefore, there is a back up of blood in the left atrium and into the pulmonary veins

Fluids move into alveoli from pulmonary capillary bed causing pulmonary congestion & edema

Left Sided Heart Failure Causes

Myocardial Infarction (increased workload on healing tissue), Hypertension, Rheumatic Heart Disease

Usually results in hypertrophy of left ventricle causing poor contractibility

Signs & Symptoms of Left Sided Heart Failure

Dyspnea: early due to fluid in alveoli which interferes with gas exchange, at rest or with exertion

Paroxysmal Nocturnal Dyspnea: night, fluid in feet/ legs re-absorbed and left ventricle can’t empty extra volume

Orthopnea: (difficulty breathing while lying flat) needs several pillow to lie down

Cough: moist, frothy, blood tinged with

Crackles/Rales: fill up the lungs

Fatigue, Anxiety, Restlessness, Tachycardia

Increased pulmonary capillary wedge pressure indicating decreased left ventricle function

Paroxysmal Nocturnal Dyspnea

Night, fluid in feet/legs re-absorbed and left ventricle can’t empty extra volume

Orthopnea

(Difficulty breathing while lying flat) needs several pillow to lie down

Right Side Heart Failure Causes 

By left sided heart failure

Results from weakened right ventricle, cannot pump blood effectively to lungs

Causes venous congestion in systemic circulation: peripheral edema, hepatomegaly, splenomegaly

Signs & Symptoms of Right Side Heart Failure

Peripheral edema: secondary to increased pressure in venous system, dependent edema (legs, sacrum, pitting edema, (pitting is obvious with retention of 10 lbs of fluid)

Weight gain: secondary to fluid retention

Generalized edema: anasarca

Distended neck veins: due to increased venous pressure on superior vena cava (jugular vein distension)

Ascites, anorexia & nausea: from venous engorgement on abdomen

Nocturia: increased renal perfusion is promoted by periods of rest (increased urine at night)

Heart Failure Core Measures

JCAHO Heart Failure Core Measures

Discharge instructions regarding activity, diet, follow-up, medications, symptoms worsening, and weight monitoring documented.

Left ventricular function assessment documented.

ACE inhibitors prescribed at discharge for left ventricle systolic dysfunction if no documented contraindication

Adult smoking cessation advice/counseling provided if patient has smoked in 12 months

Heart Failure Management Goals

1. Promote rest to decrease workload of heart

1. Increase force of efficiency of cardiac contraction

2. Eliminate edema & congestion

3. Assess hemodynamic status

Interventions for Heart Failure

Encourage rest (organize care to decrease oxygen demand)

Positioning high fowlers (legs dependent decrease venous return to the heart to decrease preload, pulmonary congestion

O2

STRICT intake and output

Daily weights

Promote tissue perfusion (position changes, TEDS, deep breathing & leg exercises)

Pharmacological management (diuretics, vasodilator, digitalis)

Medication Chart

Part of your preparation for ADULT CARDIAC included creating a medication comparison chart

This may be worked on independently or collaboratively but REMEMBER you are responsible for cardiac meds and common actions