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Nursing Care of the Adult (or
anyone) experiencing shock
Donna Roberson, PhD, APRN, BC
Sharon Cherry,MPH,CNE Assistant
Lecturer
Four Classes of Shock as
proposed by Dr. Alfred Blalock in
1934
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Hypovolemic
Vasogenic (Septic)
Cardiogenic
Neurogenic
• Hypovolemic most
common type resulting
from a loss of circulating
blood volume
• Hallmark Clinical
Indicators of shock are
hypotension, tachycardia,
decreased urine output
and altered mental status
What is shock?
• Syndrome of low blood flow and/or
abnormal blood flow patterns
• Results in imbalance between oxygen and
nutrient delivery and consumption on the
cellular level
• Five types
– Low blood flow
– Mal-distribution of flow
Low Blood Flow Shock
• Hypovolemic
• Cardiogenic
Maldistribution of Blood Flow
• Septic
• Neurogenic
• Anaphylactic
Shock
• Key factor in any type of Shock is
inadequate tissue perfusion
• Adequate fluid replacement in shock
victims should be indicated by urine
outputs of 0.5 to 1ml/kg/hour
• Watch liver failure for increasing acidosis
when LR fluids are utilized. The liver may
not be able to convert lactate to
bicarbonate thus increasing lactic acidosis
Clicker Question
• Prepare Clickers
Stages of Shock
• Initial
– May not have signs and symptoms
– Lactic acid accumulates due to anaerobic
metabolism, liver cannot excrete (no oxygen)
• Compensatory
– Neural, hormonal and biochemical
mechanisms
– Signs and symptoms seen
– Reversible stage with treatment
Compensatory Stage of Shock
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Increased Heart Rate
Slightly decreased Blood Pressure
Pale cool skin
Increased Blood Glucose
Second Stage of Shock
• Progressive stage
– Compensatory mechanisms fail
– Third spacing seen – to the extreme
– Without aggressive treatment, MODS
• Respiratory – increased work, crackles,
tachypneic
• Cardiac – output falls, ischemia (distal
first), dysrrhythmias, MI, complete failure
Refractory Stage Third stage can
be irreversible
• Profound Hypotension and Hypoxemia
• Accumulation of waste products
throughout system
• Cerebral ischemia occurs
• Total, multiple organ failure
• Recovery unlikely
Hypovolemic Shock
• Medical Stressors
leading to
Hypovolemic Shock
• Hemorrhage
• Burns
• Severe vomiting and
diarrhea
• Peritonitis
• Nursing Interventions
• Initiate Intravenous
therapy with NS or
Lactated Ringers
• Be prepared to
administer Blood
products PRBC’s and
Platelets
• Prepare patient for
Surgery
Burns can lead to Hypovolemic
Shock
Hypovolemic Shock
• Blood Replacement
• Crystalloids eg, 0.9%
Saline or Ringers
Lactate
• Colloids eg, Albumin
• Positive indicators
urine output > 0.5 to
1mL/kg/hr, heart rate
and mental status
WNL
Hypovolemic Shock
• Patient has bleeding
in lung
• Knife removed in
surgery
Hypovolemic Shock
• Loss of circulating vascular volume
• Compounding problem
– Decreased circulating volume – decreased
venous return – decreased stroke volume –
decreased cardiac output – decreased
oxygen and nutrients to cells – decreased
tissue perfusion – impaired metabolism
Hypovolemic Shock
• GSW to chest
• Hemothorax
• Note bleeding and
collapsed lung
Hypovolemic Shock
• This young women
was in a high speed
collision
• Stop sign impaled into
abdomen
• Patient survived with
removal of stop sign
and right colon
Clicker Question
Hypovolemic Shock
• GSW to chest
• Hemothorax
• Note bleeding and
collapsed lung
Tissue Perfusion altered
• Children playing with
a machete
• Patient taken to OR
• Do you see the
possibilities of more
that one type of shock
• Patient survived
Open Chest CPR Patient Died in
the Emergency Department
Blount Abdominal Trauma
• Bleeding of liver and
laceration of liver is noted
on the right side of this
CT scan
• Emergent surgery
• What type of shock is this
patient at risk for?
• What nursing
interventions are needed
prior to surgery?
TENSION PNEUMOTHORAX
• Chest Trauma
• High speed air bag
deployed
• Pt with low BP and Sats
of 91% on 100%
nonrebreather bag
• Combative and agitated
• Can lead to Cardiogenic
Shock of a noncoronary
nature
Hemodynamic criteria for
Cardiogenic Shock
• Sustained
hypotension systolic
pressure less than 90
for 30 min
• Reduced cardiac
index less than 2.2
L/min/m2
• Pulmonary capillary
pressure greater than
15 mm Hg
Cardiogenic Shock: Patient with
enlarged heart (echocardiogram)
• Myocardial Infarction
• End-stage Heart
Failure
• Cardiac Tamponade
• Pulmonary Embolism
• Cardiomyopathy
• Dysrhythmias
Clicker Question
Cardiogenic Shock from Myocardial
Ischemia
Cardiogenic shock: EKG Presentation note
ST segment elevation This was a result of
Pericarditis and pericardial tamonade
Clicker Question
Septic Shock
• Systemic inflammatory response to
infection (usually bacterial) that has moved
into the blood stream
• High mortality rate
• Bacteria release endotoxins
• Systemic Inflammatory Response
Syndrome (SIRS)
Patients at risk for Sepsis
• Immunocomprised ( AIDS, Cancer,
Alcoholism, Diabetes)
• Invasive procedures
• Indwelling medical devices
• Increased number of resistant organisms
• Increased older population
Septic Shock
• Medical Stressors leading
to Septic shock
• Blood Stream Rank 1st
• Lungs 2nd
• Urinary tract infections
3rd
• Gram Negative
Organisms Most common
cause of septic shock
• eg,pseudomonas,
acetobacter, E coli,
Salmonella
• Gram Positive Organisms
• Fluid rescuitation with
CVP of 15 is adequate
• Antimicrobial agents
• Inotropic agents
• Vasopressors
• Watch for bleeding
abnormalities decreased
platelets
• Assess for DIC
Other Gram Negative Bacteria
• There are many groups of Gram-Negative
bacteria such as Cyanobacteria, Spirochaetes,
Green-Sulphur and Green Non-Sulphur Bacteria
and Proteobacteria etc. Out of which,
proteobacteria is one of the major group of
known Gram-Negative bacteria (it includes
bacteria like E-coli, Salmonella, Pseudomonas,
Moraxella, Helicobacter, Stenotrophomonas,
Legionella, Acetic Acid Bacteria etc.).
Systemic Inflammatory Response
Syndrome (SIRS) in response to
Sepsis
• Temperature greater than 38 or less than
36
• Heart rate greater than 90
• Respiratory rate greater than 30
• PaCO2 less than 32
• WBC count greater than 12000 or less
than 4000 or greater than 10% immature
bands
Multiple organ dysfunction
syndrome in response to Sepsis
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Cardiovascular Hypotension
Respiratory Hypoxemia
Renal Increased Creatinine
Hematologic Thrombocytopenia
Metabolic lactic acidemia
Neurologic Altered LOC
Hepatic elevated liver function tests
• Septic shock
– 6-10 liters of crystalloids, 2-4 liters of colloids
– Invasive monitoring (ICU patient)
– Vasopressors and inotropics added if fluid fails
– Ventilator
– ANTIBIOTICS – broad spectrum until cultures
back, then specific agents
– Xigris – administered over 96 hours, boosts
activated protein C (unknown action – possibly
anti-inflammatory)
Clicker question
Specifics to Type
• Cardiogenic
– Diagnostic tests (caths) and supportive
pumps (IABP or VAD)
– Medications – diuretics, ACEI, Beta-blockers,
nitrates, (+) inotropes
Cardiogenic Shock Angioplasty Left
Descending Coronary Artery Stenosis
Neurogenic Shock
• Medical Stressors leading to
Neurogenic shock
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Spinal Cord injury
Severe Pain
Epidural Block
Spinal Anesthetics
• Treat hypotension and
bradycardia
• Administer medications as
ordered Ephedrine and
possible need for Vaspressin if
patient has used ACE
inhibitors
• Keep HOB elevated 30 after
spinal or epidural anesthesia
• Immobilize spine with injury
• Lovenox needed during period
of inactivity and SCD’s
Neurogenic Shock
• Occurs after spinal cord injury at T5 or
above
• Massive vasodilation without sympathetic
nervous system compensation (ex. SCI)
• Pooling with bradycardia and hypotension
• Also may have hypothalmic dsyfunction
– Temperature deregulated
• poikilothermia
Neurogenic Shock
• Usually begins within 30 minutes of injury
and can last weeks
• Also caused by spinal anesthesia and
BZDs
• Diagnosed based on cause and VS
• Treatment
Distributive Shock or Neurogenic
Shock C-5 Burst Fracture Before and
after repair
Distributive Shock (Neurogenic
Shock)
• Cervical Spine disk 2
fracture
• Hangman Fracture
from look of a
hanging
• Caused by fall or
MVA
• Type of Shock nurse
would assess for?
• Neurogenic shock
– Stabilize spine
– Support hypotension – volume, neosynephrine (alpha adrenergic agonist)
– Keep warm
– Methylprednisolone (Solu-medrol) prevents
secondary cord injury from inflammatory
mediators
Clicker question
Anaphylactic Shock
• Medical Stressors leading
to Anaphylactic shock
• Insect bites
• Vaccines
• Adverse reactions to
medications or foods
• Intravenous Epinephrine
• Inhalation bronchodilators
• Colloidal fluid
replacement eg, Albumin
• Benadryl
• Corticosteroids
• H2 blockers eg, Tagamet
• Assess for Respiratory
failure
Anaphylactic Shock
• Medical Stressors leading
to Anaphylactic shock
• Insect bites
• Vaccines
• Adverse reactions to
medications or foods
• Intravenous Epinephrine
• Inhalation bronchodilators
• Colloidal fluid
replacement eg, Albumin
• Benadryl
• Corticosteroids
• H2 blockers eg, Tagamet
• Assess for Respiratory
failure
Anaphylactic Shock
• Life-threatening hypersensitivity to a
substance (bee stings, medications, food)
• Massive vasodilation, vasoactive
mediators released and increased
capillary membrane permeability
• Laryngeal edema, hypotension,
wheezing/stridor, skin changes – death!
• c/o dizziness, chest pain, difficulty
swallowing or breathing, anxiety
Clicker Question
• Prepare Clickers
Presentation
• Young, healthy people can compensate up
to a point
• HR elevated, narrowed pulse pressure,
hypotensive
• Tachypneic, decreased UO, increased
specific gravity, pallor, cool/clammy
• Confused, anxious
Presentation
• Hypotension despite fluid support
• Cardiac dysfunction, respiratory failure,
oliguria, confusion, GI bleeds
• Systolic BP <90 or more than 40mmHg
below baseline (inadequate for perfusion
of major organs)
• One or more organs fail – multiple organ
dysfunction syndrome (MODS)
Typical Interventions
(collaborative)
• Oxygen/airway (have intubation tray
ready)
• Stabilize spine (as indicated)
• IV – at least 2 #18 or bigger bore
– Prepare to give crytalloids like NS or LR
• Stop obvious bleeding
• Assess for worsening cardiac and
respiratory function
Collaborative Management
• Requires immediate action by nurse (or
family, or rescue, etc.)
• Protocols are established in areas that see
this type of shock
• Usually administer epinephrine (subq, IV,
IM). Benadryl (IV, IM, PO), steroids also
given
• Anti-venom for insect stings
• IV support and monitoring
• Anaphylactic shock
– Prevention
– Epinephrine #1, Benadryl, Tagamet
– Airway preservation
– Nebulizers with Alupent or Albuterol
– Fluid replacement with colloids (prevent 3rd
spacing)
Diagnostic Interventions
• Monitor dropping hemoglobin and hematocrit, electrolytes
• FAST(Focused abdominal sonographic technique) can be done at
the bedside of the trauma pt
• CT scans (Computed tomography scan)
• EGD
• Chest Radiographs
• Angiography
• Nuclear Medicine Scanning
• ABG’s
• Coagulation studies
• Electrolyte Studies
Treatment Interventions
• Preserve and replace volume
– Blood, plasma expanders, albumin
– Crystalloid’s first choice of fluid for resuscitation (Normal Saline
or Lactated Ringers
Diagnostics
• Cardiac enzymes –
troponin levels
• EKG, Chest Xray and
echocardiogram
• See page 1800!
Treatment
• Correct underlying
cause
• Hypovolemic
– Fluid replacement
– Crystalloids – NS, LR (used for most shock)
– Blood- PRBC (all if Hgb <12) and as indicated
– Colloids- AKA plasma expanders
• hespan (all)
• Albumin –
• Dextran –
• Renal – acute failure, increased BUN/crt,
requires hemodialysis
• GI – ulcers, bleeding, paralytic ileus
• Hematologic – DIC
• Hepatic – liver failure, enzymes increase
Clicker Question
• Prepare Clickers
Clicker question
Clicker question
• Prepare to administer vasopressives
• Prepare to insert Foley and NG
• Monitor and use protocols to treat
dysrrhthmias
• Keep warm (septic may use cooling
blankets)
• Daily weights – TPN after enteral feedings
fail
A word about positioning
• Pay attention to research studies
– Consider sample size, methods to measure
• Most agree, positioning does not impair
tissue perfusion.
• Old-timers – firmly believe in
Trendelenburg positioning to increase
cerebral blood flow
– Not used with cord injuries
• Shock position– flat on back, elevate legs
12 inches (not for cord injuries), cover
Clicker question
• Prepare Clickers
• End of Shock Lecture
How can the nurse assess for
Heart Failure?
• Listen for Heart sounds and Lung Sounds
• Assess pulses
• Assess BP
Heart Failure: The heart’s inability
to pump enough blood through the
body
DRG Heart Failure
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DRG 127 - Substantiating Congestive Heart Failure
SIGNS/SYMPTOMS/CONDITIONS
Shortness of breath
Fatigue with exertion
Orthopnea
Paroxysmal nocturnal dyspnea
Tachycardia
Tachypnea
Pulmonary rales (fine crackles)
Edema of lower extremities
Jugular vein distention
Gallop on cardiac auscultation
Heart Failure
• COMMON TREATMENT
• Medical treatment includes oxygen,
nitroglycerin, diuretics, vasodilators, ACE
inhibitors, ARB (Angiotensin receptor
blocker), hydralazine, digoxin, betablockers or anticoagulation. Patients are
educated and encouraged to restrict
dietary salt and fluid intake.
Heart Failure
• Systolic dysfunction – inability to move
blood forward through the heart
• Diastolic dysfunction – inability to move
blood out of heart (poor right or left
ventricular filling)
• Physiologic state in which inadequate
tissue perfusion results from cardiac
dysfunction
Heart Failure
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TESTS
• Chest x-rays may indicate presence of alveolar
edema, interstitial infiltrates, pleural effusion or
congestive heart failure
• Echocardiogram shows left ventricle dysfunction,
diastolic dysfunction or ejection fraction of <50%
• Gated pool studies reveal moderate-to-severe
left ventricular dysfunction or ejection fraction of
<50%
• Cardiac Catheterization findings reveal left
ventricular dysfunction or ejection fraction of
<50%
Diagnostic test for Heart Failure
• Chest x-rays may indicate presence of alveolar edema,
interstitial infiltrates, pleural effusion or congestive heart
failure
• Echocardiogram shows left ventricle dysfunction,
diastolic dysfunction or ejection fraction of <50%
• Gated pool studies reveal moderate-to-severe left
ventricular dysfunction or ejection fraction of <50%
• Cardiac Catheterization findings reveal left ventricular
dysfunction or ejection fraction
Presentation
• Tachycardia, hypotension and narrow pulse
pressure
• Tachypneic, adventitious breath sounds
• Cyanosis, pallor, cool/clammy skin, decreased
capillary refill time
• Increased central venous pressures
• Decreased cardiac output
• Oliguria
• Altered Mentation
Assessment findings:
The patient’s heart is weaker
• Blood and fluid back up into the lungs
• Fluid builds up into the feet, ankles and
legs
• Patients experience tiredness and SOB
Nursing Care of the Adult
with Cardiovascular
Complications
Donna W. Roberson, PhD(c), APRN, BC
Anemias
• Deficiency in red blood cell mass and
hemoglobin content.
• Deficiency occurs from
– blood loss
– reduced production
– excessive hemolysis
Manifestations
• Mild (Hgb 10-14 g/dL) –
– none, slight fatigue, pale mucous membranes,
DOE
• Moderate (Hbg 6-10g/dL) –
– increased fatigue, palpitations, dyspnea,
diaphoresis
• Severe (Hbg <6 g/dL) –
– pallor, jaundice, glossitis, tachycardia,
murmurs, cardiac symptoms, HA, vertigo,
decreased concentration, organomegaly,
bone pain, cold intolerance, lethargy
Etiology
• Decreased Erythrocyte Production
– Iron deficiency anemia (IDA)
– Thalassemia and thalassemia trait
– Pernicious anemia (vitamin B12 deficiency)
– Folic acid deficiency anemia
– Aplastic anemia
– Anemias of leukemia/cancer
– Anemia of chronic disease (ACD)
• Blood Loss – trauma, hemorrhage, GI,
menstrual
• Increased Erythrocyte Destruction
– Hemoglobin abnormalities (SSC, G6PD
deficiency)
– Trauma – prosthetic valve, hemodialysis and
other extracorporeal circulation, autoimmune
disorder, infections and toxins
Morphology
• Size – consider diameter of cell
– RDW
• Weight – how heavy the cell is
– MCV
• Chromicity – how pretty and red the cell is
– MCH, MCHC
• Normochromic, normocytic – normal color,
size and weight
Normal Red Blood Cell
Production
• Erythropoietin produced by the kidney
regulates cell production.
• Mature erythrocytes form from adequate
– caloric intake
– Iron
– folic acid
– vitamin B12
– erythropoietin
Normal laboratory values
• Reticulocyte count 0.5-2%
Hgb 12-18
Hct 37-52%
MCV 80-95
MCH 27-31
MCHC 32-36
RDW 11-14.5%
Serum Ferritin >10
TIBC 250-420
• The normal adult requires 20 mg of iron
per day to produce HgB.
• About 10 mg comes from degraded HgB.
• Most can absorb 1mg of iron per 10mg
ingested (in duodenum)
IDA
• Most common anemia
• Very young, poor diet, women, absorption
problems (lactose intolerance, celiac
sprue), cancer
• *repeated blood draws (decreases
recycling of iron from Hbg)
• Microcytic, hypochromic
Presentation
• Fatigue, pallor, glossitis
• Worsens as stored iron is depleted
Diagnosis
• History and physical
• CBC with differential, serum ferritin, serum
iron, TIBC, hemoccult, hemoglobin
electrophoresis (peripheral smear)
Thalassemia and Thalassemia Trait
• Genetic disorder of decreased erythrocyte
production
• Common in Mediterranean ancestry,
equatorial Asia and Africa
• AKA Thalassemia major and minor (trait)
• Microcytic, hypochromic
• Thalessemia results in severe deficiencies
and death
Megaloblastic Anemias
• Cobalamin (B12 deficiency)
– dietary deficits, loss of intrinsic factor,
hyperactive gut disorders
• Folic Acid deficiency
– Inadequate oral intake of folate-rich foods
(ETOH abusers, pregnancy)
– Impaired absorption
• Macrocytic normochromic cells
• Pernicious anemia – intrinsic factor is
not secreted by the gastric mucosa
–Erroneously used for all Cobalamin
deficiency Anemias
• prolonged use of PPI in high doses
(atrophy)
• Destroyed parietal cells (autoimmune)
Presentation
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Fatigue
Sore tongue
Anorexia, N/V
Abd pain
Peripheral paresthesias
Confusion
Death if not corrected
Diagnosis
• CBC with diff, peripheral smear
• B12 and folate levels
• Gastric exam (r/o cancer, check for
atrophy)
Schilling test
• NPO 8-12 hrs, no B vitamins 3d before, no
laxatives 1d before
• Collect small urine sample
• Radioactive B12 (po capsule) in radiology
• May eat
• RN gives 1mg B12 IM 1-2hrs after
radioactive dose (saturates liver so
capsule can be absorbed in sm. intestines)
• 24 hour urine (lab decides if iced or not)
Anemia of Chronic Disease
• microcytic to normocytic and
normochromic cells
• chronic depletion of RBC (none for
recycling)
• Chronic state of over-iron utilization or
bone marrow failure (cancers/chemo,
infections, rheumatoid arthritis, lupus,
diabetes, COPD, etc.)
Aplastic Anemia
• All blood components are low
• Congenital (Fanconi syndrome)
• Acquired
– Idiopathic
– Chemical exposure
– Meds
– Pregnancy
– Radiation
– Infections
Care regimens – Medical and
Nursing
• Diet and nutrition
• Based on deficiency, encourage foods
high in need (tends to be the same foods
for iron and folate)
• Examples: spinach, liver, raisins, cast iron
cooking pots, green leafy vegetables,
yeast, dried beans, nuts
• Absorptive disorders interfering
• Educate and support restrictive diet
Examples: assist in determining irritating
foods - limit diary, teach label reading to
avoid glutens
Supplementation - IRON
• Expect improved S&S 5-7d
– ½ labs corrected labs in 3 weeks
– normal by 2 months.
– Iron stores refilled 4-6 months (if successful.)
• Biggest complaint – constipation and
heartburn
• Normal – tarry, dark looking stools
Iron
• ferrous sulfate – 300 -325mg body
absorbs 65mg
• ferrous gluconate – 325mg body absorbs
38mg
• ferrous fumarate – 325mg body absorbs
106mg
• iron dextran –IV or IM monthly – use Ztrack to prevent skin staining (test dose)
Cobalamin and Folic Acid
• Vitamin B12
– 1000mg IM daily for 2 weeks
– Then weekly until normal hematocrit
– Then monthly for life
• Folic acid – usually give with multivitamin
since malnutrition typical root of problem
– 1-5mg daily
Erythropoietin
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ACD (not BM cancers)
EPO, Procrit, Epogen
Refrigerated
Never shaken
Subq at room temperature
Monitor labs
Preventative care
• Balanced diet – particularly menstruating
women
• Use of COC for planned amenorrhea (also
called chemical menopause)
• Substance abuse counseling
• Care for those with chronic illnesses or
prolonged infections
• Management includes nutritional
counseling
Protective care
• Support use of supplements – problem
shooting for GI c/o
• Allow ventilation of concerns, offer support
groups- use of the internet
• Encourage routine health screens by age
– new onset of anemia over age 50 presumed
cancer until proven otherwise!
Anemia due to blood loss
• Volume replacement and PRBCs
• Correct underlying cause
– Pressure, cautery
– COC
• Chronic losses – iron, diet
Hemolytic Anemia
• Overdestruction of RBCs
• Defects of cell causes destruction by
spleen and liver (Sickle Cell)
• Autoimmune disorder
• Jaundice from elevated bilirubin as RBCs
destroyed
• In all cases, ensure renal protection from
large RBC bits (ATN)
Polycythemia
• Overproduction of RBCs
• Causes thickened blood – problems?
• Blood letting, hydration, BM suppression
Coagulation disorders
platelets nl 150k-400k
excess - thrombocytosis
deficit - thrombocytopenia
10k-20k results in hemorrhage from
minor trauma
< 10k results in spontaneous
hemorrhage
Immune thrombocytopenia
purpura (ITP)
acute - usually children/young adults
follows a viral event
chronic - usually women (20-50),
unknown precipitating factor
Platelets coated with antibodies and
destroyed as an immune response by
spleen after only 1-3 days
Manifestations of ITP
Purpura, ecchymoses and petechiae
Epistaxis
Menorrhagia
Hematuria
GI bleeds
Secondary thrombocytopenia
anemias, ETOH abuse, viral
infections (Mono), AIDS, heparin,
Coumadin, sulfonamides, digoxin,
Lasix, MSO4, Tagamet
ASA and NSAIDS interfere with
platelet function but not production
Diagnostics and treatment
CBC - H/H and plt count
bleeding times prolonged in ITP
treat with plt transfusion - warming
increase counts by 28%
expect a rise in count by 8-10k per
unit given. Can recheck plt count in
15 mins. after tx
Disseminated intravascular
coagulation
 state of both clotting and hemorrhage
inappropriate thrombin response
causes diffuse clotting, clotting factors
are consumed and the fibrinolytic
system is activated. Clots are
dissolved, but no clotting factors are
available, therefore hemorrhage
occurs.
Clinical picture
causes include trauma, obstetrics
complications, hemolytic
reactions, shock, sickle cell crisis,
MI, PE, and others
Skin - purpura, ecchymoses,
petechiae, cyanosis of
extremities, bleeding from
wounds
More
GI- ABD distention, blood in stool and
vomitus, frank hemorrhage
Resp/CV – shock symptoms
GU - hematuria, oliguria, renal failure
CNS - confusion, coma, seizures
Diagnostics
PT & INR/PTT increased
Plt decreased
plasma fibrinogen decreased
decreased clotting factors
Treatment
heparin used when organ function is
impaired
Heparin contraindicated in
shock/active bleeding
nursing care - promote hemostasis,
tissue perfusion, manage pain, gas
exchange and anxiety
Heart failure
• Many still call it Congestive Heart Failure
(CHF)
• Systolic failure -pump fails
– Decreased ejection fraction (EF)
– Decreased contractility
– Increased afterload
– cardiomyopathy
• Diastolic heart failure (DHF) – ventricles
fail to fill
– Venous engorgement with S&S (criterion 1)
– Normal EF (criterion 2)
– Abnormal diastolic function (criterion 3)
• Can have both!
• To distinguish between SHF & DHF –
must have measure of EF
Treatment
• Similar medications, different doses and
reasons
• SHF – improve inotropic function and
improve remodeling of LV with Beta
blockers. Digoxin still used. No use for
calcium channel blockers
• DHF – Beta blockers used to decrease
HR, increase diastole, improve response
to exercise *smaller doses than SHF
DHF – improve venous congestion
• Fluid and sodium restriction
• Dialysis
• Nitrates (nitroprusside, long acting oral
agents)
• Diuretics- spironolactone, loops
• ACEI and ARBs
DHF – increasing diastole
• Beta blockers, calcium channel blockers
• Digoxin only used in those with atrial
fibrillation or very short term in the acute
period
Cardiomyopathy
• Disease of the myocardium resulting in
impaired function
• Primary
– Unknown
• Secondary
– Dilated, hypertrophic, or restrictive
Dilated Myopathies
• ETOH, cocaine, doxorubicin, genetic,
HTN, idiopathic, ischemia, etc.
• c/o fatigue, palpitations, SOB/DOE, cough
• PE enlarged heart, decreased contractility,
valve failure, arrhythmias, decreased CO
• Diagnostics – Xray, EKG, cath
Dilated Management
• Treat underlying cause
• ACEI, diuretics, anticoagulants, cardiac
transplant
• Teach family CPR, how to access EMS
• No ETOH, limited sodium
Hypertrophic Myopathies
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Asymmetric enlargement without dilation
Genetic, stenosis or HTN cause
c/o exertional dyspnea, fatigue, angina
Syncope seen in those with aortic outflow
obstruction
• PE SVT, fib, tachy, S3 or S4
• Primary diagnostic tool – EKG with
increased QRS, also may get cath
Hypertrophic Management
• Improve ventricular filling
• Support patient/family
• Relieve symptoms
Restrictive Myopathies
• Fibrotic changes in the myocardium
prevent ventricular filling
• c/o angina, syncope, fatigue, DOE
*hallmark sign
• PE DHF signs and symptoms
• Diagnosis – EKG shows tachy at rest, CT
or MRI
Restrictive management
• No treatment other than DHF therapies
• Nursing supportive
• Cardiac transplant
– Recipient/donor matching based on body
size, heart size and ABO type
– Maximum out-of-body time 6 hours
– Place recipient on cardiopulmonary bypass
– Start immunosuppressives in OR
• Nursing care focused on
• Acute
– Operative recovery
– Teaching about medications and diet
• Long term
– Ongoing support of lifestyle changes
– Monitor for rejection, lymphoma and
vasculopathy
Heart Blocks
 1st degree AV Prolonged PR interval
 2nd degree AV
Type I (Wenckebach) AV node problem
Lengthened PR, some P have no QRS
Type II (Bundle Branch Block) His-Purkinje
problem
Ratios of Ps with QRS 3:1, 2:1
Poorer prognosis, requires temporary pacemaker
 3rd degree AV complete
No relation between P and QRS
Junctional rhythm common with HR 20-40
Ventricular disturbance
• PVCs – indicates electrical irritation across
myocardium
– Bigeminy, Trigeminy possible
– Couplets lead to v-tach
• Ventricular Tachycardia – run of 3 or more
PVCs
• Wide, aberrant QRS pattern
• Rate 100-250
• Leads to v-fib if not interrupted
• Ventricular fibrillation
• Asystole – flat line or occasional P, assess
in different leads to make sure not V-fib
Treatment for AV Block
• Internal pacemaker – takes the place of
the SA node
• Wide variety available – on demand,
preset, responsive to exercise, etc.
• Complications – infection, bleeding, failure
to capture, failure to sense, battery failure
Nursing care of pacemakers
• Administer pre-pacer antibiotic
• Monitor for infection – small incision
anterior chest or abdomen
• Reassurance – fear big problem
• Teach how to assess pulse *family too
• Avoid magnetic fields and electrical
generators (Microwaves are safe)
• Medic alert
Treatment of Ventricular
Dsyrhthmias
• Automatic Internal Cardio-Defibrillator
(AICD) also ICD
• Lead inserted through subclavian vein to
endocardium.
• Pulse generator – upper chest or
abdomen
• Lead senses v-tach or v-fib, cues pulse
generator
• 25-joule shock delivered
• Recycles and can continue to work
Nursing Care
• Similar to pacers
• Reassurance – fear of arrest, fear ICD
won’t work properly
• Sexuality
• Anxiety – patient and family
Revascularization of the
Myocardium
• Treats post-MI ischemia and failed
medication management of CAD
• CABG, RIMA, LIMA, saphenous veins
• Traditional method
– Open sternum incision, bypass, heart stopped
– Long leg(s) incision
– Chest tubes
– External pacing wires
– Cordis
• Requires at least 2 days ICU in specialty
care unit.
• Usually 24-48 hrs ventilator support
• Pain management
• Monitor CT drainage (2-4 CTs usual)
• EKG, cardiac output, pulmonary pressures
Robotics!
• Minimally Invasive Direct CABG
– MIDCAB for short
– Used for LAD or single vessel bypass
• Several, small intercostal incisions
• Harvested LIMA used on heart slowed by
calcium channel blockers or beta blockers
Nursing Care of MIDCABG
•
•
•
•
Usually 2 CTs
Nitro drip
Pain management
No bypass used, so quicker recovery,
shorter LOS
• *Teaching for both centers on lifestyle
changes
Reduce Risk of Coronary Artery
Disease and Heart Failure
• Keep LDL cholesterol below
100
• Keep HDL Cholesterol above
40 in men and above 50 in
women
• Keep Triglycerides another fat
in the blood below 150
• Keep BP 130/80 or below
• Keep Blood Glucose under
control
• Limit alcohol intake and quit
smoking
• Dietary mg Foods low in
saturated fats and low in salt
General Care Principles
• Identify patients at risk
• Careful history and examination
• Report early signs, prepare to act with
supportive measures (IV, blood,
medications, etc)
• Protect and support function