C
Decreased Cardiac Output
NANDA-I
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Demonstrate adequate cardiac output as evidenced by blood pressure, pulse rate and rhythm within normal parameters for client; strong peripheral pulses; maintained level of mentation, lack of chest discomfort or dyspnea, and adequate urinary output; an ability to tolerate activity without symptoms of dyspnea, syncope, or chest pain
• Remain free of side effects from the medications used to achieve adequate cardiac output
• Explain actions and precautions to prevent primary or secondary cardiac disease
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Recognize primary characteristics of decreased cardiac output as fatigue, dyspnea, edema, orthopnea, paroxysmal nocturnal dyspnea, and increased central venous pressure. Recognize secondary characteristics of decreased cardiac output as weight gain, hepatomegaly, jugular venous distention, palpitations, lung crackles, oliguria, coughing, clammy skin, and skin color changes. EBN: A nursing study to validate characteristics of the nursing diagnosis decreased cardiac output in a clinical environment identified and categorized related client characteristics that were present as primary or secondary (Martins, Alita, & Rabelo, 2010).
• Monitor and report presence and degree of symptoms including dyspnea at rest or with reduced exercise capacity, orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough, distended abdomen, fatigue, or weakness. Monitor and report signs including jugular vein distention, S3 gallop, rales, positive hepatojugular reflux, ascites, laterally displaced or pronounced PMI, heart murmurs, narrow pulse pressure, cool extremities, tachycardia with pulsus alternans, and irregular heartbeat. EB: These are symptoms and signs consistent with heart failure (HF) and decreased cardiac output (Jessup et al, 2009). In a study of primary care clients, breathlessness during exercise, limitations in physical activity, and orthopnea were the three most significant symptoms most often associated with HF (Devroey & Van Casteren, 2011).
• Monitor orthostatic blood pressures and daily weights. EB: These interventions assess for fluid volume status (Jessup et al, 2009). EB: The extent of volume overload is key to deciding on appropriate treatment for HF (Lindenfeld et al, 2010).
• Recognize that decreased cardiac output that can occur in a number of non-cardiac disorders such as septic shock and hypovolemia. Expect variation in orders for differential diagnoses related to the etiology of decreased cardiac output, as orders will be distinct to address primary cause of altered cardiac output. EB: A study of left ventricular function in patients with septic shock identified that 60% developed reversible left ventricular dysfunction that could successfully be hemodynamically supported with IV vasoactive medications (Vieillard-Baron et al, 2008). Obtain a thorough history. EB: It is important to assess for behaviors that might accelerate the progression of HF symptoms such as high sodium diet, excess fluid intake, or missed medication doses (Jessup et al, 2009).
Administer oxygen as needed per physician’s order. Supplemental oxygen increases oxygen availability to the myocardium. EB: Clinical practice guidelines cite that oxygen should be administered to relieve symptoms related to hypoxemia. Supplemental oxygen at night or for exercise is not recommended unless there is concurrent pulmonary disease. Resting hypoxia or oxygen desaturation may indicate fluid overload or concurrent pulmonary disease (Jessup et al, 2009).
• Monitor pulse oximetry regularly, using a forehead sensor if needed. CEB: In a study that compared oxygen saturation values of arterial blood gases to various sensors, it was found that the forehead sensor was significantly better than the digit sensor for accuracy in clients with low cardiac output, while being easy to use and not interfering with client care (Fernandez et al, 2007).
• Place client in semi-Fowler’s or high Fowler’s position with legs down or in a position of comfort. Elevating the head of the bed and legs in down position may decrease the work of breathing and may also decrease venous return and preload.
• During acute events, ensure client remains on short-term bed rest or maintains activity level that does not compromise cardiac output. In severe HF, restriction of activity reduces the workload of the heart (Fauci et al, 2008).
• Provide a restful environment by minimizing controllable stressors and unnecessary disturbances. Schedule rest periods after meals and activities. Rest helps lower arterial pressure and reduce the workload of the myocardium by diminishing the requirements for cardiac output (Fauci et al, 2008).
Apply graduated compression stockings or intermittent sequential pneumatic compression (ISPC) leg sleeves as ordered. Ensure proper fit by measuring accurately. Remove stocking at least twice a day, then reapply. Assess the condition of the extremities frequently. Graduated compression stockings may be contraindicated in clients with peripheral arterial disease (Kahn et al, 2012). EB: A study that assessed effects of ISPC on healthy adults found that there were significant increases in cardiac output, stroke volume, and ejection fraction due to increased preload and decreased afterload (Bickel et al, 2011); EBN: A study that assessed use of knee-length graduated compression stockings found they are as effective as thigh-length graduated compression stockings. They are more comfortable for clients, are easier for staff and clients to use, pose less risk of injury to clients, and are less expensive as recommended in this study (Hilleren-Listerud, 2009). EB: Graduated compression stockings, alone or used in conjunction with other prevention modalities, help promote venous return and reduce the risk of deep vein thrombosis in hospitalized clients (Sachdeva et al, 2010).
• Observe for and report chest pain or discomfort; note location, radiation, severity, quality, duration, associated manifestations such as nausea, indigestion, and diaphoresis; also note precipitating and relieving factors. Chest pain/discomfort may indicate an inadequate blood supply to the heart, which can further compromise cardiac output. EB: Clients with decreased cardiac output may present with myocardial ischemia. Those with myocardial ischemia may present with decreased cardiac output and HF (Jessup et al, 2009; Lindenfeld et al, 2010).
• Recognize the effect of sleep disordered breathing in HF. EB & CEB: A study assessing effects of OSA physiology on left sided cardiac function found that the increase in negative intrathoracic pressure found in OSA led to a decrease in left ventricular systolic performance (Orban et al, 2008). A study that assessed effectiveness of nasal cannula oxygen supplement for nocturnal obstructive sleep apnea found that 75% of HF clients had sleep apnea, and those who exhibited central sleep apnea had significantly reduced episodes when wearing nasal oxygen during sleep (Sakakibara et al, 2005). Sleep-disordered breathing, including obstructive sleep apnea and Cheyne-Stokes with central sleep apnea, are common organic sleep disorders in clients with chronic HF and are a poor prognostic sign associated with higher mortality (Brostrom et al, 2004).
• Monitor intake and output. If client is acutely ill, measure hourly urine output and note decreases in output. EB: Clinical practice guidelines cite that monitoring I&Os is useful for monitoring effects of diuretic therapy (Jessup et al, 2009). Decreased cardiac output results in decreased perfusion of the kidneys, with a resulting decrease in urine output.
Note results of electrocardiography and chest radiography. CEB: Clinical practice guidelines suggest that chest radiography and electrocardiogram are recommended in the initial assessment of HF (Jessup et al, 2009).
Note results of diagnostic imaging studies such as echocardiogram, radionuclide imaging, or dobutamine-stress echocardiography. EB: Clinical practice guidelines state that the echocardiogram is a key test in the assessment of HF (Jessup et al, 2009).
Watch laboratory data closely, especially arterial blood gases, CBC, electrolytes including sodium, potassium and magnesium, BUN, creatinine, digoxin level, and B-type natriuretic peptide (BNP assay). Routine blood work can provide insight into the etiology of HF and extent of decompensation. EB: Clinical practice guidelines recommend that BNP or NTpro-BNP assay should be measured in clients when the cause of HF is not known (Jessup et al, 2009). A study assessed hyponatremia as a prognostic indicator in clients with preserved left ventricular function and found that hyponatremia at first hospitalization is a powerful predictor of long-term mortality in this group (Rusinaru et al, 2009). Serum creatinine levels will elevate in clients with severe HF because of decreased perfusion to the kidneys. Client may be receiving cardiac glycosides, and the potential for toxicity is greater with hypokalemia; hypokalemia is common in heart clients because of diuretic use (Fauci et al, 2008).
• Gradually increase activity when client’s condition is stabilized by encouraging slower paced activities or shorter periods of activity with frequent rest periods following exercise prescription; observe for symptoms of intolerance. Take blood pressure and pulse before and after activity and note changes. Activity of the cardiac client should be closely monitored. See Activity Intolerance.
Serve small, frequent, sodium-restricted, low saturated fat meals. Sodium-restricted diets help decrease fluid volume excess. Low saturated fat diets help decrease atherosclerosis, which causes coronary artery disease. Clients with cardiac disease tolerate smaller meals better because they require less cardiac output to digest. EB: A study that compared cardiac event-free survival between clients who ingested more or less than 3 grams of dietary sodium daily found that those who were NYHA class III or IV clients benefited the most from dietary intake less than 3 grams daily (Lennie et al, 2011); EB: A study that compared HF symptoms with dietary sodium intake found that those with sodium intakes greater than 3 grams per day had more HF symptoms (Son et al, 2011). Emphasis on use of unsaturated fats and less use of saturated fats in the diet is recommended to reduce cardiovascular risk. Polyunsaturates are beneficial to vascular endothelial function, while saturated fats impair vascular endothelial function (Hall et al, 2009; Willett et al, 2011).
• Serve only small amounts of coffee or caffeine-containing beverages if requested (no more than four cups per 24 hours) if no resulting dysrhythmia. CEB: A review of studies on caffeine and cardiac arrhythmias concluded that moderate caffeine consumption does not increase the frequency or severity of cardiac arrhythmias (Hogan, Hornick, & Bouchoux, 2002; Myers & Harris, 1990; Schneider, 1987).
Monitor bowel function. Provide stool softeners as ordered. Caution client not to strain when defecating. Decreased activity, pain medication, and diuretics can cause constipation. The Valsalva maneuver which can be elicited by straining during defecation, cough, lifting self onto the bedpan, or lifting self in bed can be harmful (Moser et al, 2008).
• Have clients use a commode or urinal for toileting and avoid use of a bedpan. Getting out of bed to use a commode or urinal does not stress the heart any more than staying in bed to toilet. In addition, getting the client out of bed minimizes complications of immobility and is often preferred by the client (Winslow, 1992).
• Weigh client at same time daily (after voiding). EB: Clinical practice guidelines state that weighing at the same time daily is useful to assess effects of diuretic therapy (Jessup et al, 2009). Use the same scale if possible when weighing clients. Daily weight is also a good indicator of fluid balance. Increased weight and severity of symptoms can signal decreased cardiac function with retention of fluids.
Provide influenza and pneumococcal vaccines prior to discharge for those who have yet to receive them. EB: Clinical practice guidelines and a Scientific Statement cite that HF hospitalizations are more likely during influenza and winter season, and that having the immunization minimizes that risk (Lindenfeld et al, 2010; Riegel et al, 2009).
• Assess for presence of anxiety and refer for treatment if present. See Nursing Interventions and Rationales for Anxiety to facilitate reduction of anxiety in clients and family. EB: A clinical practice guideline recommends that non-pharmacological techniques for stress reduction are a useful adjunct for reduction of anxiety in HF clients (Lindenfeld et al, 2010). A study that assessed the relationship between anxiety and incidence of death, emergency department visits, or hospitalizations found that those with higher anxiety had significantly worse outcomes than those with lower anxiety (De Jong et al, 2011).
Refer for treatment when depression is present. EBN: A study on combined depression and level of perceived social support found that depressive symptoms were an independent predictor of increased morbidity and mortality, and those with lower perceived social support had 2.1 times higher risk of events than nondepressed clients with high perceived social support (Chung et al, 2011). A qualitative study that described experiences of clients living with depressive symptoms found that negative thinking was present in all participants, reinforcing depressed mood; multiple stressors worsened depressive symptoms; and depressive symptoms were reduced by finding activities from which to distract (Dekker et al, 2009). A study that assessed health-related quality of life found that baseline depression along with perceived control were strongest predictors of physical symptom status (Heo et al, 2008).
Refer to a cardiac rehabilitation program for education and monitored exercise. EB & CEB: Clients with HF should be referred for exercise training when deemed safe, to promote exercise expectations, understanding, and adherence (Lindenfeld et al, 2010). A systematic review of outcomes of exercise based interventions in clients with systolic HF found that hospitalizations and those for systolic HF were reduced for clients in an exercise program and quality of life was improved (Davies et al, 2010). In a study to assess effects of exercise in HF clients, exercise tolerance and left ventricular ejection fraction increased with exercise training (Alves et al, 2012).
Refer to HF program for education, evaluation, and guided support to increase activity and rebuild quality of life. CEB: A study assessing the 6-month outcomes of a nurse practitioner–coordinated HF center found that readmissions, length of stay, and cost per case were all significantly reduced, while quality of life was significantly improved (Crowther et al, 2002).
Critically Ill
Observe for symptoms of cardiogenic shock, including impaired mentation, hypotension with blood pressure lower than 90 mm Hg, decreased peripheral pulses, cold clammy skin, signs of pulmonary congestion, and decreased organ function. If present, notify physician immediately. Cardiogenic shock is a state of circulatory failure from loss from cardiac function associated with inadequate organ perfusion with a high mortality rate. CEB: In a study the defining characteristics of decreased cardiac output were best indicated by decreased peripheral pulses and decreased peripheral perfusion (Oliva & Monteiro da Cruz Dde, 2003).
If shock is present, monitor hemodynamic parameters for an increase in pulmonary wedge pressure, an increase in systemic vascular resistance, or a decrease in stroke volume, cardiac output, and cardiac index. Hemodynamic parameters give a good indication of cardiac function (Fauci et al, 2008).
Titrate inotropic and vasoactive medications within defined parameters to maintain contractility, preload, and afterload per physician’s order. EB: Clinical practice guidelines recommend that intravenous inotropic drugs might be reasonable for HF clients presenting with low BP and low cardiac output to maintain systemic perfusion and preserve end-organ performance (Jessup et al, 2009). By following parameters, the nurse ensures maintenance of a delicate balance of medications that stimulate the heart to increase contractility, while maintaining adequate perfusion of the body.
When using pulmonary arterial catheter technology, be sure to appropriately level and zero the equipment, use minimal tubing, maintain system patency, perform square wave testing, position the client appropriately, and consider correlation to respiratory and cardiac cycles when assessing waveforms and integrating data into client assessment. EB: Clinical practice guidelines recommend that invasive hemodynamic monitoring can be useful in acute HF with persistent symptoms when therapy is refractory, fluid status is unclear, systolic pressures are low, renal function is worsening, vasoactive agents are required, or when considering advanced device therapy or transplantation (Jessup et al, 2009).
Observe for worsening signs and symptoms of decreased cardiac output when using positive pressure ventilation. EB: Positive pressure ventilation and mechanical ventilation are associated with a decrease in preload and cardiac output (Lukacsovitis, Carlussi, & Hill, 2012; Yucel et al, 2011).
Recognize that clients with cardiogenic pulmonary edema may have noninvasive positive pressure ventilation (NPPV) ordered. EB: Clinical practice guidelines for HF state that continuous positive airway pressure improves daily functional capacity and quality of life for those with HF and obstructive sleep apnea (Lindenfeld et al, 2010) and is reasonable for clients with refractory HF not responding to other medical therapies (Jessup et al, 2009). A systematic review of NPPV for cardiogenic pulmonary edema found that use of NPPV significantly reduced mortality and intubation, while decreasing ICU stay by 1 day (Vital et al, 2009).
Monitor client for signs and symptoms of fluid and electrolyte imbalance when clients are receiving ultrafiltration or continuous renal replacement therapy (CRRT). Clients with refractory HF may have ultrafiltration or CRRT ordered as a mechanical method to remove excess fluid volume. EB: Clinical practice guidelines cite that ultrafiltration is reasonable for clients with refractory HF not responsive to medical therapy (Jessup et al, 2009).
• Recognize that hypoperfusion from low cardiac output can lead to altered mental status and decreased cognition. EB & CEB: A study that assessed an association among cardiac index and neuropsychological ischemia found that decreased cardiac function, even with normal cardiac index, was associated with accelerated brain aging (Jefferson et al, 2010). A study that assessed the relationship between hypoperfusion and neuropsychological performance found that among stable geriatric HF clients, executive functions of sequencing and planning were altered (Jefferson et al, 2007).
Geriatric:• Recognize that elderly clients may demonstrate fatigue and depression as signs of HF and decreased cardiac output (Lindenfeld et al, 2010).
If client has heart disease causing activity intolerance, refer for cardiac rehabilitation. EBN: A study that assessed clients’ acceptance of a cardiac rehabilitation program found knowledge and perceived quality of life had increased significantly, and anxiety and depression had been reduced at the end of the program and at 6 month follow-up (Muschalla, Glatz, & Karger, 2011).
• Observe for syncope, dizziness, palpitations, or feelings of weakness associated with an irregular heart rhythm. CEB & EB: Dysrhythmias, particularly atrial fibrillation and ventricular ectopy, and both non-sustained and sustained ventricular tachycardia are common in clients with HF (Hunt et al, 2005; Lindenfeld et al, 2010).
• Design educational interventions specifically for the elderly. EB: Many elderly HF clients have low levels of knowledge about HF self-care and have limitations in function and cognition, low motivation, and low self-esteem. They require skilled assessment of educational level and ability to be successful with self-care (Strömberg, 2005).
Home Care:• Some of the above interventions may be adapted for home care use. Home care agencies may use specialized staff and methods to care for chronic HF clients. CEB: A study assessing HF outcomes over a 10-year period between a multidisciplinary home care intervention and usual care found significantly improved survival and prolonged event-free survival and was both cost- and time-effective (Ingles et al, 2006).
Continue to monitor client closely for exacerbation of HF when discharged home. CEB: Home visits and phone contacts that emphasize client education and recognition of early symptoms of exacerbation can decrease rehospitalization (Gorski & Johnson, 2003).
• After acute hospitalization, the majority of HF clients education is performed, including social support of others, with each session focused on assessment of current knowledge, client learning priorities, and barriers to change (Lindenfeld et al, 2010).
• Assess for signs/symptoms of cognitive impairment. EBN: Impaired cognitive function can affect 25-50% of HF clients and is associated with poorer HF self-care. Etiology of this phenomenon may be poorer regional blood flood to areas of the brain (Riegel et al, 2009).
• Assess for fatigue and weakness frequently. Assess home environment for safety, as well as resources/obstacles to energy conservation. Instruct client and family members on need for behavioral pacing and energy conservation. EBN: Fatigue and weakness limit activity level and quality of life. Assistive devices and other techniques of work simplification can help the client participate in and respond to the health care regimen more effectively (Quaglietti et al, 2004).
• Help family adapt daily living patterns to establish life changes that will maintain improved cardiac functioning in the client. Take the client’s perspective into consideration and use a holistic approach in assessing and responding to client planning for the future. Transition to the home setting can cause risk factors such as inappropriate diet to reemerge.
• Assist client to recognize and exercise power in using self-care management to adjust to health change. EBN: Identified self-care behaviors, barriers to self-care, interventions to promote self-care, and evaluation of effects of self-care are important to maintain the heart failure client’s quality of life and functional status and to reduce mortality from the syndrome (Riegel et al, 2009). Refer to care plan for Powerlessness.
Institute case management of frail elderly to support continued independent living.
As the client chooses, refer to palliative care for care, which can begin earlier in the care of the HF client. Palliative care can be used to increase comfort and quality of life in the HF client before end-of-life care (Buck & Zambroski, 2012).
If the client’s condition warrants, refer to hospice. EB & CEB: End-of-life discussions should occur with clients and family as end-stage heart failure becomes refractory to therapy (Hunt et al, 2005; Lindenfeld et al, 2010). The multidisciplinary hospice team can reduce hospital readmission, increase functional capacity, and improve quality of life in end-stage HF (Coviello, Hricz, & Masulli, 2002).
• Identify emergency plan in advance, including whether use of cardiopulmonary resuscitation (CPR) is desired. Encourage family members to become certified in cardiopulmonary resuscitation if the client desires. EB: A study that assessed the client’s perspective on end-of-life care found that the three most important issues ranked included avoidance of life support if there was no hope of survival, provider communication and reduced family burden (Strachan et al, 2009);
Client/Family Teaching and Discharge Planning:
• Begin discharge planning as soon as possible upon admission to the emergency department (ED) with case manager or social worker to assess home support systems and the need for community or home health services. Consider referral for advanced practice nurse (APN) follow-up. Support services may be needed to assist with home care, meal preparations, housekeeping, personal care, transportation to doctor visits, or emotional support. CEB: A study to assess degree of social support as a predictor of heart failure readmission demonstrated that those without someone living with them had a greater readmission rate in a dose-dependent response, but no correlation to death was found (Rodriguez-Artalejo et al, 2006). Clients often need help on discharge.
• Include significant others in client teaching opportunities. Include all six areas of discharge instructions for heart failure hospitalizations: Daily weight monitoring/reporting, symptoms recognition/reporting/when to call for help, smoking cessation, low-sodium diet, medication use and adherence, and regular follow-up with providers. EB: A scientific statement cites social support from family and friends as being positively associated with better medication adherence and self-care maintenance, and lower readmission rates (Riegel et al, 2009). Failure to understand and comply with educational instructions is a major cause of HF exacerbation and hospital readmissions (Jessup et al, 2009). Clinical guidelines recommend that hospitalized heart failure clients be given basic instructions prior to discharge to facilitate self-care and management at home (Jessup et al, 2009).
• Teach importance of performing and recording daily weights upon arising for the day, and to report weight gain. Ask if client has a scale at home; if not, assist in getting one. EB: Clinical practice guidelines suggest that daily weight monitoring leads to early recognition of excess fluid retention, which, when reported, can be offset with additional medication to avoid hospitalization from heart failure decompensation (Jessup et al, 2009). Daily weighing is an essential aspect of self-management. A scale is necessary. Scales vary; the client needs to establish a baseline weight on the home scale.
• Teach types and progression patterns of heart failure symptoms, when to call the physician for help, and when to go to the hospital for urgent care. EB: Inability to recognize or adequately interpret symptom worsening heart failure is common among heart failure clients. Early symptom recognition and early self-help measures or professional evaluation and treatment lead to improved outcomes (Riegel et al, 2009).
• Teach importance of smoking cessation and avoidance of alcohol intake. Help clients who smoke stop by informing them of potential consequences and by helping them find an effective cessation method. EB: Smoking has vasoconstrictor and pro-inflammatory properties that impede effective cardiac output. Discontinuation of smoking leads to reduced adverse consequences, including decreased mortality in HF (Riegel et al, 2009). Smoking cessation advice and counsel given by nurses can be effective and should be available to clients to help stop smoking (Rice & Stead, 2008).
• Teach the direct benefits of a low-sodium diet. EB: A scientific statement and clinical guidelines on heart failure recommend a 2-3 gram/day sodium diet for most stable heart failure clients, and less when heart failure severity warrants (Jessup et al, 2009; Lindenfeld et al, 2010; Riege et al, 2009). Sodium retention leading to fluid overload is a common cause of hospital readmission (Fauci et al, 2008).
Teach the client importance of consistently taking cardiovascular medications, and include actions, side effects to report. EB: A scientific statement cited that adherence to medications ranges from 5% to 90%. In one study 88% adherence was required in heart failure clients to achieve event-free survival. The study cited as reasons for non-adherence, depression, cost, attitudes about taking medication, worrying about or feeling side effects including those on sexual function, receipt of conflicting information about medications from different prescribers, and lack of understanding about discharge instructions (Riegel et al, 2009). Evidence-based guidelines state that taking medication as directed can help prevent HF decompensation, and rehospitalization, and decrease morbidity (Jessup et al, 2009).
• Instruct client and family on the importance of regular follow up care with providers. EB: Post discharge support can significantly reduce hospital readmissions and improve health care outcomes, quality of life, and costs (Hernandez et al, 2010; Jessup et al, 2009).
• Teach stress reduction (e.g., imagery, controlled breathing, muscle relaxation techniques). CEB: A study that assessed effects of relaxation or exercise in heart failure clients versus controls found that those who participated in regular relaxation therapy or exercise training reported greater improvements in psychological outcomes, with the relaxation group significantly improving depression and the exercise training group more improving fatigue (Yu et al, 2007).
Refer to an outpatient system of care. EB: Systems of care such as disease management, telemonitoring, and telehealth promote self-care, facilitating transitions across settings (Riegel et al, 2009).
• Provide client/family with advance directive information to consider. Allow client to give advance directions about medical care or designate who should make medical decisions if he or she should lose decision-making capacity. EB: Heart failure guidelines recommends that clients and families be educated about end-of-life options prior to client decline, and with a change in clinical status (Jessup et al, 2009).
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Risk for decreased Cardiac tissue perfusion
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Be aware that the most common cause of acute coronary syndromes (ACS) [unstable angina (UA), non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI)] is reduced myocardial perfusion associated with partially or fully occlusive thrombus development in coronary arteries (Anderson et al, 2011; Antman et al, 2008).
• Assess for symptoms of coronary hypoperfusion and possible ACS including chest discomfort (pressure, tightness, crushing, squeezing, dullness, or achiness), with or without radiation (or originating) in the back, neck, jaw, shoulder, or arm discomfort or numbness; SOB; associated diaphoresis; dizziness, lightheadedness, loss of consciousness; nausea or vomiting with chest discomfort, heartburn or indigestion; associated anxiety. EB: These symptoms are signs of decreased cardiac perfusion and acute coronary syndrome such as UA, NSTEMI, or STEMI. A physical assessment will aid in assessment of the extent, location and presence of, and complications resulting from a myocardial infarction. It will promote rapid triage and treatment. It is also important to assess if the client had a prior stroke (American Heart Association, 2011a; Anderson et al, 2011).
• Consider atypical presentations for women, and diabetic clients of ACS. EB & CEB: Women and diabetic clients may present with atypical findings. A systematic review of differences showed that women had significantly less chest discomfort and were more likely to present with fatigue, neck pain, syncope, nausea, right arm pain, dizziness, and jaw pain (Coventry, Finn, & Bremner, 2011).
• Review the client’s medical, surgical, and social history. EB: A medical history must be concise and detailed to determine the possibility of acute coronary syndromes, and to help determine the possible cause of cardiac symptoms and pathology (Anderson et al, 2011).
• Perform physical assessments for both CAD and non-coronary findings related to decreased coronary perfusion including vital signs, pulse oximetry, equal blood pressure in both arms, heart rate, respiratory rate, and pulse oximetry. Check bilateral pulses for quality and regularity. Report tachycardia, bradycardia, hypotension or hypertension, pulsus alternans or pulsus paradoxus, tachypnea, or abnormal pulse oximetry reading. Assess cardiac rhythm for arrhythmias; skin and mucous membrane color, temperature and dryness; and capillary refill. Assess neck veins for elevated central venous pressure, cyanosis, and pericardial or pleural friction rub. Examine client for cardiac S4 gallop, new heart murmur, lung crackles, altered mentation, pain to abdominal palpation, decreased bowel sounds, or decreased urinary output EB: These indicators help to assess for cardiac and non-cardiac etiologies of symptoms and differential diagnoses (Anderson et al, 2011; Antman et al, 2008).
Administer oxygen as ordered and needed for clients presenting with ACS to maintain a PO2 of at least 90%. EB: Hypoxemia can be under-recognized in the first 6 hours of ACS treatment. Maintaining a SaO2 level of 90% or more may decrease the pain associated with myocardial ischemia by increasing the amount of oxygen delivered to the myocardium (Anderson et al, 2011). EB: Advanced Cardiac Life Support guidelines recommend administering oxygen if the oxygen saturation is less than 94% (O’Connor et al, 2012). A Cochrane review found there was limited evidence to recommend use of oxygen with acute coronary syndrome, more studies are needed (Cabello et al, 2010).
Use continuous pulse oximetry as ordered. EB: Prevention and treatment of hypoxemia includes maintaining arterial oxygen saturation over 90% (Anderson et al, 2011).
Insert one or more large-bore intravenous catheters to keep the vein open. Routinely assess saline locks for patency. Clients who come to the hospital with possible decrease in coronary perfusion or ACS may have intravenous fluids and medications ordered routinely or emergently to maintain or restore adequate cardiac function and rhythm.
Observe the cardiac monitor for hemodynamically significant arrhythmias, ST depressions or elevations, T wave inversions and/or q waves as signs of ischemia or injury. Report abnormal findings. EB: Arrhythmias and electrocardiogram (ECG) changes indicate myocardial ischemia, injury and/or infarction (Anderson et al, 2011; Antman et al, 2008).
• Have emergency equipment and defibrillation capability nearby and be prepared to defibrillate immediately if ventricular tachycardia with clinical deterioration or ventricular fibrillation occurs. EB: Life-threatening ventricular arrhythmias require defibrillation (Anderson et al, 2011).
Perform a 12-lead ECG as ordered, to be interpreted within 10 minutes of emergency department arrival and during episodes of chest discomfort or angina equivalent. EB: A 12-lead ECG should be performed within 10 minutes of emergency department arrival for all clients who are having chest discomfort. Electrocardiograms are used to identify the area of ischemia or injury such as ST depressions or elevations, new left bundle branch block, T wave inversions, and/or q waves and guide treatment (Anderson et al, 2011; Antman et al, 2008).
Administer aspirin as ordered. EB: Aspirin has been shown to prevent platelet clumping, aggregation, and activation that leads to thrombus formation, which in coronary arteries leads to acute coronary syndromes. Contradictions include active peptic ulcer disease, bleeding disorders, and aspirin allergy (Anderson et al, 2011; Antman et al, 2008).
Administer nitroglycerin tablets sublingually as ordered, every 5 minutes until the chest pain is resolved while also monitoring the blood pressure for hypotension, for a maximum of three doses as ordered. Administer nitroglycerin paste or intravenous preparations as ordered. EB: Nitroglycerin causes coronary arterial and venous dilation, and at higher doses arterial dilation, thus reducing preload and afterload and decreasing myocardial oxygen demand while increasing oxygen delivery (Anderson et al, 2011).
• Do not administer nitroglycerin preparations to clients who have received phosphodiesterase type 5 inhibitors, such as sildenafil, tadalafil, or vardenafil, in the last 24 hours (48 hours for long-acting preparations). EB: Synergistic effect causes marked exaggerated and prolonged vasodilation/hypotension (Anderson et al, 2011; Antman et al, 2008).
Administer morphine intravenously as ordered every 5 to 30 minutes while monitoring blood pressure when nitroglycerin alone does not relieve chest discomfort. EB: Morphine has potent analgesic and antianxiolytic effects and causes mild reductions in blood pressure and heart rate that reduce myocardial oxygen consumption. It increases venous capacitance in pulmonary edema associated with decreased coronary perfusion and resultant myocardial dysfunction (Anderson et al, 2011; Antman et al, 2008).
Assess and report abnormal lab work results of cardiac enzymes, specifically troponin Is, chemistries, hematology, coagulation studies, arterial blood gases, finger stick blood sugar, elevated C-reactive protein, or drug screen. Abnormalities can identify the cause of the decreased perfusion and identify complications related to the decreased perfusion such as anemia, hypovolemia, coagulopathy, drug abuse or hyperglycemia. Elevated cardiac enzymes are indicative of a myocardial infarction (Anderson et al, 2011).
• Assess for individual risk factors for coronary artery disease, such as hypertension, dyslipidemia, cigarette smoking, diabetes mellitus, or family history of heart disease. Other risk factors including sedentary life style, obesity, or cocaine or amphetamine use. Note age and gender as risk factors. EB: Certain conditions place clients at higher risk for decreased cardiac tissue perfusion (Anderson et al, 2011).
Administer additional heart medications as ordered including beta blockers, calcium channel blockers, ACE inhibitors, aldosterone antagonists, antiplatelet agents, and anticoagulants. Always check the blood pressure and pulse rate before administering these medications. If the blood pressure or pulse rate is low, contact the physician to see if the medication should be held. Also check platelet counts and coagulation studies as ordered to assess proper effects of these agents. EB: These medications are useful to optimize cardiac function including blood pressure, heart rate, myocardial oxygen demand, intravascular fluid volume and cardiac rhythm (Anderson et al, 2011; Antman et al, 2008).
Administer lipid-lowering therapy as ordered. EB: LDL-C equal to or over 100 mg/dL requires use of LDL lowering drug therapy to prevent progression and possibly cause regression of coronary artery plaques (Anderson et al, 2011). A systematic review of statin use in primary prevention of cardiovascular disease showed reductions in all-cause mortality, major vascular events, and revascularizations (Taylor et al, 2011).
Prepare client with education, withholding meals and/or medications, and intravenous access for cardiac catheterization and possible PCI with door to balloon time of under 90 minutes if STEMI is suspected. EB & CEB: Door to balloon time of under 90 minutes was associated with improved client outcomes (Antman et al, 2008; McNamara et al, 2006).
Prepare clients with education, withholding meals and/or medications, and intravenous access for noninvasive cardiac diagnostic procedures such as 2D echocardiogram, exercise or pharmacological stress test, and cardiac CT scan as ordered. EB: Clients suspected of decreased coronary perfusion should receive these diagnostic procedures as appropriate to evaluate for coronary artery disease (Anderson et al, 2011; Antman et al, 2008).
Maintain bed rest or chair rest as ordered by the physician. EB: Anti-ischemic therapy includes minimizing myocardial oxygen demand in the early hospital phase (Anderson et al, 2011).
• For further medical and nursing interventions used in care of client with an acute coronary event, refer to the reference by Anderson et al (2011).
Request a referral to a cardiac rehabilitation program. EB: Cardiac rehabilitation programs are designed to limit the physiological and psychological effects of cardiac disease, reduce the risk for sudden cardiac death and reinfarction, control symptoms and stabilize or reverse the process of plaque formation, and enhance psychosocial and vocational status of clients (Anderson et al, 2011; Smith et al, 2011).
Geriatric:• Consider atypical presentations for the elderly of possible ACS. CEB: Elderly may present with atypical signs and symptoms such as weakness, stroke, syncope, or change in mental status (Anderson et al, 2007).
Ask the prescriber about possible reduced dosage of medications for geriatric clients considering weight and creatinine clearance. EB: Geriatric clients have reduced pharmacokinetics including reduced muscle mass, renal and hepatic function, and reduced volume of distribution (Anderson et al, 2011).
• Consider issues such as quality of life, palliative care, end-of-life care, and differences in sociocultural aspects for clients and families when supporting them in decisions regarding aggressiveness of care (Anderson et al, 2011).
Client/Family Teaching and Discharge Planning:
Provide information about provider follow-up. EB: Current recommendations suggest that high-risk clients should be seen within 2 weeks and within 2 to 6 weeks for lower risk clients (Antman et al, 2008).
• Teach the client and family to call 911 for symptoms of new angina, existing angina unresponsive to rest and sublingual nitroglycerin tablets, or heart attack. Do not use friends or family for transportation where 911 is available, unless the delay is expected to be longer than 20 to 30 minutes. EB & CEB: Morbidity and mortality from myocardial infarction can be reduced significantly when symptoms are recognized and EMS activated, shortening time to definitive treatment (Anderson et al, 2011).
• Upon discharge, instruct clients on symptoms of ischemia, when to cease activity, when to use sublingual nitroglycerin, and when to call 911. EB: Degree and extent of myocardial ischemia is related to duration of time with inadequate supply of oxygen-rich blood (Anderson et al, 2011).
• Teach client about any medications prescribed. Medication teaching includes the drug name, its purpose, administration instructions such as taking it with or without food, and any side effects to be aware of. Instruct the client to report any adverse side effects to his/her provider.
• Upon hospital discharge, educate clients and significant others about discharge medications, including nitroglycerin sublingual tablets or spray, with written, easy to understand, culturally sensitive information. Clients and significant others need to be prepared to act quickly and decisively to relieve ischemic discomfort (Anderson et al, 2011).
• Provide client teaching related to risk factors for decreased cardiac tissue perfusion, such as hypertension, hypercholesterolemia, diabetes mellitus, tobacco use, advanced age, and gender (female). EB: Those with two or more risk factors should have a 10-year risk screening for development of symptomatic coronary heart disease. Client education is a vital part of nursing care for the client. Start with the client’s base level of understanding and use that as a foundation for further education. It is important to factor in cultural and/or religious beliefs in the education provided (Anderson et al, 2011).
• Instruct the client on antiplatelet and anticoagulation therapy about signs of bleeding, need for ongoing medication compliance, and INR monitoring. EB: A review of client education literature showed a need to prioritize education domains, standardize educational content, and deliver that content efficiently (Wofford, Wells, & Singh, 2008.)
• After discharge, continue education and support for client blood pressure and diabetes control, weight management, and resumption of physical activity. EB: Reduction of risk factors aids as secondary prevention of coronary artery disease (Anderson et al, 2011). ATP III recommends continued efforts to optimize weight and use of regular physical activity (National Institutes of Health, 2011).
Provide influenza vaccine prior to discharge (Anderson et al, 2011; Antman et al, 2008).
• Stress the importance of ceasing tobacco use. Tobacco use can cause or worsen decreased blood flow in the coronaries. Effects of nicotine include increasing pulse and blood pressure and constricting of blood vessels. Tobacco use is a primary factor in heart disease. EBN: Smoking causes vasoconstriction, which can lead to atherosclerotic disease (American Heart Association, 2012c; Anderson et al, 201; Smith et al, 2011).
• Upon hospital discharge, educate clients about low sodium, low saturated fat diet, with consideration to client education, literacy and health literacy level. EB: Reduction of risk factors aid as primary and secondary prevention of coronary artery disease (Anderson et al, 2011). ATP III guidelines recommend that saturated fats be kept to less than 7% of calories and cholesterol under 200 mg/day when LDL is above goal (http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm). A Cochrane review recommended that there be a permanent reduction in saturated fats and replacement with unsaturated fats to decrease atherosclerosis (Hopper et al, 2012).
• Teach the importance of exercise. Exercise helps control blood pressure and weight, which are the most important controlled risk factors for cardiovascular disease (Smith et al, 2011).
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