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Critical Care (Cardiac). Megan McClintock, MS, RN. Winter 2012. CCUs or ICUs. RRTs – rapid response teams Pts exhibit subtle changes 6-8 hrs before a cardiac and/or respiratory arrest Critical care nurse, RT, MD or APN PCUs Transition between ICU and general care Critically ill patient

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Critical Care (Cardiac)

Megan McClintock, MS, RN

Winter 2012

ccus or icus
CCUs or ICUs
  • RRTs – rapid response teams
    • Pts exhibit subtle changes 6-8 hrs before a cardiac and/or respiratory arrest
    • Critical care nurse, RT, MD or APN
  • PCUs
    • Transition between ICU and general care
  • Critically ill patient
    • Physiologically unstable
    • At risk for serious complications
    • Requires intensive and complicated nursing support
common problems of icu patients
Common Problems of ICU Patients
  • Venous thromboembolismd/t immobility
  • Skin problems d/t immobility
  • Nutritional deficiencies d/thypermetabolic or catabolic states
    • Start enteral or parenteral nutrition early
  • Anxiety d/t threat to physical health, foreign environment, pain, sleeplessness, immobilization, loss of control, impaired communication
    • Work closely with pts, families, caregivers
    • Encourage caregivers to bring in personal items and photographs
    • Judiciously use antianxiety drugs (ie. Ativan)
    • Judiciously use massage, guided imagery
common problems of icu patients1
Common Problems of ICU Patients
  • Pain d/t medical conditions, immobilization, invasive monitoring devices and procedures
    • Continuous IV sedation (ie. Propofal [Diprivan]) and an analgesic (ie. Fentanyl [Sublimaze]) but include a daily “sedation vacation”
  • Impaired Communication d/t use of sedative or paralyzing drugs, ET tube
    • Always explain what is happening to the patient
    • Use picture boards, notepads, computer keyboards
    • Look directly at the patient
    • Use hand gestures when appropriate
    • Use an interpreter with non-English speaking patients
    • Provide comforting touch
common problems of icu patients2
Common Problems of ICU Patients
  • Sensory-Perceptual Problems d/t delirium
    • Assess for delirium with the Confusion Assessment Method for ICU and the Intensive Care Delirium Screening Checklist
    • Address physiologic factors
    • Use clocks and calendars to help orient the pt
    • Encourage presence of a caregiver
    • May need haloperidol (Haldol)
  • Sensory-Perceptual Problems d/t sensory overload
    • Be cautious with conversations
    • Mute phones
    • Set alarms appropriate to the pt’s condition
    • Limit overhead paging
    • Limit any unnecessary noise
common problems of icu patients3
Common Problems of ICU Patients
  • Sleep Problems d/t noise, anxiety, pain, frequent monitoring, treatment procedures
    • Structure the environment to promote the sleep-wake cycle
    • Cluster activities
    • Schedule rest periods
    • Dim lights at nighttime, open curtains during daytime
    • Limit noise
    • Provide comfort measures (ie. Back rubs)
    • Use benzodiazepines (ie. Temazepam [Restoril]) or zolpidem (Ambien)
  • Give them guidance and support
  • Actively listen
  • Provide them with opportunity to participate in decision making
  • Involve durable power of attorney for health care if pt is incapable of making decisions
  • Give convenient access to the pt
  • Prepare caregivers for the ICU and the pt’s appearance
  • Provide for the option of family presence during invasive procedures and CPR
  • Be culturally aware especially in regards to death and dying
hemodynamic monitoring
Hemodynamic Monitoring
  • Measurement of pressure, flow, and oxygenation within the cardiovascular system
    • Invasive (internally placed)
    • Noninvasive (externally placed)
    • Includes:
      • Systemic and pulmonary arterial pressures
      • CVP – central venous pressure
      • PAWP – pulmonary artery wedge pressure
      • CO/CI – cardiac output/cardiac index
      • SV/SVI – stroke volume/stroke volume index
      • Oxygen saturation
    • Integrating and trending all of this data together provides a picture of the pt’s hemodynamic status
    • Very important to be technically accurate to prevent unnecessary or inappropriate treatment
hemodynamic terminology
Hemodynamic Terminology
  • Cardiac Output (CO) and Cardiac Index (CI)
    • Volume of blood (in liters) pumped by the heart in 1 minute, cardiac index is adjusted for BSA and is a more precise measure of efficiency of the pumping action of the heart
    • Increased with high circulating volume
    • Decreased with low circulating volume or decrease in strength of ventricular contraction
    • CO normal 4-8, CI normal 2.5-4
  • Stroke Volume (SV) and Stroke Volume Index (SVI)
    • Volume of blood (in mL) ejected with each heartbeat, determined by preload, afterload and contractility, SVI is adjusted for BSA
    • Increased with volume overload, inotropy, hyperthermia, meds (ie. Digitalis, dopamine, dobutamine)
    • Decreased with impaired cardiac contractility, valve dysfunction, CHF, beta blockers, MI
    • SV normal 50-100, SVI normal 25-45
hemodynamic terminology1
Hemodynamic Terminology
  • Systemic Vascular Resistance (SVR)
    • Opposition encountered by left ventricle
    • Increased with vasoconstrictors, low volume
    • Decreased with vasodilators, morphine, nitrates, high CO2
  • Pulmonary Vascular Resistance (PVR)
    • Opposition encountered by right ventricle
    • Increased with pulmonary hypertension, hypoxia
    • Decreased with meds (ie calcium channel blockers, aminophylline, isoproterenol, oxygen)
  • Preload, afterload, and contractility determine SV which then determines CO and BP
hemodynamic terminology2
Hemodynamic Terminology
  • Preload
    • Volume in the ventricle at the end of diastole
    • Combination of pulmonary blood filling the atria and stretching
    • Regulated by variability in intravascular volume
    • PAWP will show us left ventricular preload (AKA left ventricular end-diastolic pressure)
    • CVP will show us right ventricular preload (AKA right ventricular end-diastolic pressure)
    • Increased with fluid administration
    • Decreased with diuretics and vasodilation
hemodynamic terminology3
Hemodynamic Terminology
  • Afterload
    • Forces opposing ventricular ejection including systemic arterial pressure, resistance from the aortic valve, mass/density of the blood
    • Resistance the heart has to overcome to send blood to the aorta affected by vasoactivity and blood viscosity
    • SVR shows left ventricular afterload
    • PVR shows right ventricular afterload
    • When afterload is increased, cardiac output is decreased
    • To decrease afterload give vasodilators
hemodynamic terminology4
Hemodynamic Terminology
  • Contractility
    • Strength of contraction
    • If the cardiac output changes but everything else stays the same, then the problem is with contractility
    • When it is increased it increases stroke volume and oxygen demand
    • Increased with meds (ie. Epinephrine, norepinephrine, isoproteronol, dopamine, dobutamine, digitalis)
    • Decreased with heart failure, alcohol, calcium channel blockers, beta blockers, acidosis
  • Frank Starling’s Law – the greater the preload, the greater the myocardial stretch, and the greater the oxygen need which increases CO and SV
arterial lines
Arterial Lines
  • Purpose -
  • Allen’s test
  • Position transducer level with the heart, then zero to negate the pressure applied by the flush
  • Look for a normal waveform – dicrotic notch (systolic pressure) should be after QRS on EKG
  • Correlate with manual BP
cvp monitoring
CVP Monitoring
  • Purpose – to tell us about the right ventricle
  • Placed while in Trendelberg position, CVC is threaded so that the tip rests in the superior vena cava
  • Can give IV fluids and draw venous blood
  • High point of waveform should correlate with R of ECG
pa catheter
PA Catheter
  • Purpose – to tell us about the left ventricle and measure CO
  • Often called Swan-Ganz catheter
  • Proximal port is for CVP and fluids
  • Distal port is for PA and PCWP with balloon inflation (balloon floats the catheter into a pulmonary artery branch vessel – wedge)
  • Thermistor – continuous temperature readings to calculate CO (inject 5-10 mL cold fluid as exhalation begins, take the average of 3 times)
  • Very important that the waveform has not changed or the catheter may be displaced
cvp or right atrial pressure
CVP or Right Atrial Pressure

Normal is 2-6

  • Approximates right ventricular end diastolic pressure (blood in the right atrium)
  • Tells us about right ventricular function and general fluid status
  • Increased with overhydration, increased venous return or right-sided heart failure, straining
  • Decreased with hypovolemia, decreased venous return
map mean arterial pressure
MAP – Mean Arterial Pressure

Normal is 70-100

  • Reflects changes in the relationship between CO and SVR and reflects arterial pressure in vessels perfusing the organs
  • Increased with increased cardiac workload
  • Decreased with decreased blood flow to the organs
  • Can make it increase by administering fluids
pap pulmonary artery pressure
PAP – Pulmonary Artery Pressure

Normal is 20-30 (systolic), 8-12 (diastolic), 25 (mean)

  • BP in the pulmonary artery
  • Increased with left to right cardiac shunt, PA hypertension, COPD, emphysema, PE, pulmonary edema, left ventricular failure
pcwp or pawp pulmonary capillary wedge pressure
PCWP or PAWP – Pulmonary Capillary Wedge Pressure
  • Normal 4-12
  • Approximates left ventricular end diastolic pressure
  • Increased with left ventricular failure, mitral valve problems, cardiac insufficiency, cardiac compression
right ventricular pressure
Right Ventricular Pressure

Normal is 0-5 (diastolic), 20-30 (systolic)

  • Indicates right ventricular function and fluid status
  • Increased with pulmonary hypertension, right ventricular failure, CHF
circulatory assist devices
Circulatory Assist Devices
  • Used to decrease cardiac work and improve organ perfusion
    • Ventricles require support while recovering from acute injury
    • Pt must be stabilized before surgical repair
    • Heart has failed and pt is awaiting cardiac transplant
  • Intraaortic Balloon Pump (IABP) – most commonly used
    • Balloon is placed in the descending thoracic aorta above the renal arteries
    • Balloon fills with helium at start of diastole and deflates before systole (triggered by the ECG), counterpulsation – inflates opposite to ventricular contraction
    • Inflates with every heartbeat
  • Ventricular Assist Device (VAD)
    • Allows more mobility than the IABP
    • Placed internally or externally
    • Shunts blood from left atrium or ventricle to the device and then to the aorta