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Understanding the Essentials of
CRITICAL CARE Nursing
Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Chapter 6Care of the Patient Experiencing Shock or Heart Failure
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Learning Outcome 1
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Hypvolemia
•Results from decreased circulating volume
•Loss of 15–30 % or more of normal blood volume
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Etiology
•Hemorrhage– GI bleed, trauma, surgery, ruptured aneurysm
•Fluid loss– Vomiting, diarrhea, burns
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Clinical Manifestations
•Hypotension
•Orthostatic
•Tachycardia
•Reduced capillary refill
•Dry mucous membranes
•Poor skin turgor
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Clinical Manifestations (cont.)
•Thirst
•Weight loss
•Oliguria
•Concentrated urine
•Altered mental status
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Diagnostic Criteria
•Reviews laboratory studies for:– Hypernatremia (serum levels above 145
mEq/L)– Increased hematocrit (Hct) due to
hemoconcentration (if patient actively bleeding, Hct may drop)
– Arterial blood gases: metabolic acidosis– Elevated serum lactate (serum lactate greater
than 4 mmol/L)
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Diagnostic Criteria (cont.)
•Reviews laboratory studies for:– Reduced mixed venous oxygen saturation
(SvO2 less than 60%; ScvO2 less than 70%)
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Learning Outcome 2
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Hypovolemic Shock
•In hypovolemic shock, the heart rate is increased
•MAP, CVP/RA, and PAWP are decreased, reflecting a reduced preload
•A reduction in circulating volume may also lead to a reduction in SV and CO/CI
•An elevated SVR may be present, reflecting the vasoconstriction due to compensatory mechanisms
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Learning Outcome 3
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Collaborative Management Goals
•Early identification of hypovolemic shock is the key to successful outcome
•Goal of treatment is to expand intravascular volume
•Restore a normal circulating volume
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Restoration of Volume
•Requires fluid challenges of an isotonic solution through large bore intravenous catheters
•Examples of isotonic crystalloid solutions include 0.9% normal saline and lactated Ringer’s solution
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Restoration of Volume (cont.)
•These isotonic solutions are infused into the vascular space and stay there long enough to expand the intravascular space
•Fluid resuscitation starts with 1 to 2 liters of crystalloid over 10 to15 minutes. Standard, large (i.e., 14- to 16-gauge) peripheral IV catheters or central venous catheters are adequate for most fluid resuscitation
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Restoration of Volume (cont.)
•The advantage of a central venous catheter is that it can be used to monitor CVP
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Nursing Intervention
•Restore normovolemia and improve cardiac output
•Fluid challenge of isotonic solution
•Monitor CVP readings
•Monitor calcium level
•Assess of respiratory compromise
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Prevention and Detection of Life-threatening Complications
•Renal insufficiency
•Cerebral ischemia
•Irreversible shock
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Learning Outcome 4
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Pathophysiology of Heart Failure
•As heart function fails and cardiac output decreases, compensatory mechanisms such as sympathetic nervous system and renin-angiotensin-aldosterone system, are activated
•The role of compensatory mechanisms is to maintain perfusion to the vital organs
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Pathophysiology of Heart Failure (cont.)
•Long-term activation of these mechanisms can be deleterious, leading to:– Increased afterload– Pulmonary edema– Peripheral edema – Chamber dilation and/or hypertrophy—called
remodeling
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Neurohormonal Mechanisms of Heart Failure
•Primary mechanisms are sympathetic nervous system
•Renin-angiotensin-aldosterone system
•Activation of sympathetic nervous system releases norepinephrine = increased vasoconstriction, heart rate, and contractility
•Activation of renin-angiotensin-aldosterone system stimulates aldosterone
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Learning Outcome 5
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Systolic vs. Diastolic HF
Systolic Diastolic
Impaired left ventricular Ventricle is normal size but
contractility hypertrophies
Reduced ejection Loss of left ventricular
fraction (normal 55–75%) diastolic relaxation
Decreased cardiac output Ejection fraction normal
Filling of ventricles impaired
PAWP is elevated
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Learning Outcome 6
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Clinical Manifestations of Heart Failure
•Manifestations occur depending on the location of the failure
•Left-sided heart failure results in respiratory manifestations
•Right-sided heart failure results in peripheral manifestations
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Clinical Manifestations of Heart Failure (cont.)
Left-sided Right-Sided Manifestations ManifestationsDyspnea on exertion Peripheral edemaOrthopnea Abdominal pain and distentionParoxymal noctural Weight gaindyspneaCrackles on Ascitespulmonary auscultation Jugular vein distention
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
End Organ Hypoperfusion Is Manifested By:
Decreased exercise Fatigue
tolerance
Dizziness Syncope
Palpitations Hypotension
Tachycardia Cool extremities
Delayed capillary refill Decreased urinary output
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Learning Outcome 7
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Hemodynamic Findings
•Nurse monitors for trends indicating volume overload or decompensation
•Elevated filling pressures may be elevated in heart failure
•RA/CVP (right filling pressures) is elevated = peripheral edema
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Hemodynamic Findings (cont.)
•PAWP (left filling pressures) is elevated = pulmonary edema
•Cardiac output normal
•Elevated systemic and pulmonary vascular resistance
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Diagnostic/Laboratory Tests
•Laboratory Tests– Sodium– BUN and creatinine– B-type natriuretic peptide
•Diagnostic Tests– Chest x-ray– ECG– Noninvasive cardiac tests– Invasive cardiac tests
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Learning Outcome 8
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Contrasted Hemodynamic Findings of Heart Failure and Hypovolemia
Heart Failure Hypovolemia
RA/CVP is elevated RA/CVP is decreased
PAWP is elevated MAP is decreased
Cardiac output normal CO/CI is reduced
Elevated systemic and SV reduced
pulmonary vascular
resistance
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Learning Outcome 9
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Collaborative Management
•Nurse works with MD to manage symptoms
•Reduce the progression
•Prolong survival
•Pharmacological and nonpharmacologic measures
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Nurse Management/Interventions
•Administer medications as ordered– Ace inhibitors– Beta blockers– Aldosterone antagonists
•Monitor for side effects of ace inhibitors– Dizziness– Hypotension– Cough– Hyperkalemia
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Nurse Management/Interventions (cont.)
•Monitor for fluid volume excess– Administer diuretics– Monitor intake and output– Assess respiratory status
•Monitor for impaired gas exchange
•Monitor for decreased cardiac output– Vasodilators– Inotropes– Digoxin
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Nurse Management/Interventions (cont.)
•Monitor for complications and interventions– Dysrhythmias– Pulmonary edema– Hypercarbia– Cardiogenic shock
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Common Medications Used for Complications
•Venodilators– Morphine sulfate– Nitroglycerin
•Vasodilators– Nesiritide (Natrecor)
•Intravenous inotropics– Dobutamine– Milrinone
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Learning Outcome 10
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Acute Decompensated Heart Failure (Cardiogenic Shock)
•Prevention is linked to early detection and appropriate management
•Patient compliance with lifestyle modifications may decrease occurrence
•Appropriate nurse assessment is crucial
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Nurse Assessment of Decompensated Heart Failure
•Dyspnea at rest•Tachycardia•Reduced oxygen saturation•Crackles on lung auscultation•Hypotension•Worsening cough•New dysrhythmias•Elevation of PAWP•Reduction in CO/CI
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Learning Outcome 11
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Collaborative Management of Acute Decompensated Heart Failure
•Oxygen therapy of 100% nonrebreathing mask
•BIPAP may be appropriate
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Nursing Management
•Assess for complications from CPAP or BIPAP– Air leak around the mask– Facial skin breakdown– Gastric distention– Vomiting and aspiration– Claustrophobia
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Pharmacological Interventions
•Venodilators (morphine and nitroglycerin)•Venodilators reduce preload and PAWP•Morphine sulfate reduces anxiety and
venodilate•Nurse must assess for side effects/adverse
reactions of morphine– Excessive decrease in respiratory rate– Excessive decrease in oxygen saturation– Hypotension– Decreased level of consciousness
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Nitroglycerin
•Clients who do not respond to morphine may be treated with nitroglycerin
•Nitroglycerin Administration– Special tubing to prevent excessive
absorption of the drug– Assess blood pressure, heart rate, respiratory
rate, and oxygen saturation– Assess for side effects: hypotension,
tachycardia, headache
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Other Pharmacological Interventions
•Nesiritide (Natrecor) given IV– Does not increase heart rate– Cannot replace diuretics– Closely monitor the blood pressure
•Intravenous inotropic therapy– Clients who remain in pulmonary edema– Dobutamine and milrinone (Primacor)
•Increase dose of diuretics (IV)
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Understanding the Essentials of Critical Care NursingKathleen Ouimet Perrin
Signs of Cardiogenic Shock
•Cardiac index < 2.0 L/min
•Systolic blood pressure less than 90 mmHg
•PAWP above 19 mm Hg
•Intraaortic balloon pump may be used