NURSING DIAGNOSIS OF LEFT VENTRICULAR FAILURE IN ACUTE MYOCARDIAL INFARCTION by Alfred Bobby Miller A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science College of Nursing The University of Utah December 1979
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NURSING DIAGNOSIS OF LEFT VENTRICULAR FAILURE
IN ACUTE MYOCARDIAL INFARCTION
by
Alfred Bobby Miller
A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements
for the degree of
Master of Science
College of Nursing
The University of Utah
December 1979
THE UNIVERSITY OF UTAH GRADUATE SCHOOL
SUPERVISORY COMMITTEE APPROVAL
of a thesis submitted by
Alfred Bobby Miller
I have read this thesis and have found it to be of satisfactory quality for a master's degree.
f1ut ell 1f11 i
! ) i /�/C' (;�
, Dale Maeona K. Jacobs Chairman. Supervisory Commillcc
I have read this thesis and have found it to be of �atisfactory quality for.
a master's degree.
d ' A:' FM.7 /1 77 . / / v. . . P / ,.. " '\ .. / ' I ' , ' 4,'
Dale
Member, Supen isory Commillcc
THE UNIVERSITY OF UTAH GRADUATE SCHOOL
FINAL READING APPROVAL
To the Graduate Council of The University of Utah:
I have read the thesis of Alfred Bobby Miller in its
final form and have found that (I) its format, citations, and bibliographic style are
consistent and acceptable; (2) its illustrative materials including figures, tables, and
charts are in place; and (3) the final manuscript is satisfactory to the Supervisory
Committee and is ready for submission to the Graduate School.
Dale
Member. Supervisory Commiltee
Approved for the Major Department .""
)
Approved for the Gradu3te Council
ABSTRACT
A new mode of therapy has recently been advocated for the treatment
of left ventricular failure (L VF) due to acute myocardial infarction (AMI).
This therapy involves the use of vasodilator drugs., Current literature
places little emphasis on the clinical findings of the effects of vasodilators.,
This is especially true of nursing literatureo
Registered nurses (RN) i.n coronary care units (CCU) throughout the
country are responsible for the monitoring and administration of vaso
dilator therapy., The majority of RNs use hemodynamic measurements as
their only data to administer vasodilators. It is a well-known fact that
electronic equipment utilized to obtain hemodynamic measurements can
produce inaccurate data., Several medical studies exist which document
the relationships between clinical findings and hemodynamic measurements
during L VF due to AML
Providing adequate care requires the RN to acquire appropriate
skills and be capable of correlating these skills with all available data"
The investigator theorized that a properly prepared RN could assess,
diagnose and place patients, with LVF due to AMI, into clinical and
hemodynamic subsets for purposes of management.,
A continuous measurement experimental design as described by
Drew (1976) was utilized., The subject population consisted of 30 patients
with AMI. The investigator utilized multiple assessments on each subject
while providing a continuous measurement of the subjects' clinical progress
throughout medical therapy 0
The majority of subjects (23) did not require hemodynamic
monitoring. Correlation of clinical and hemodynamic subsets for those
subjects who were monitored is not consistenL A significant percentage
(26.6%) of the subject population were less than 50 years of age 0 Therapeutic
regimes could not be compared because of the physicians' reluctance to
record appropriate data.
Appropriately prepared RNs are capable of performing cardio
vascular assessments while obtaining a sound clinical data base upon which
to arrive at a nursing diagnosis. Utilizing the subset classification system,
the RN could begin management of patients with LVF due to AMI on a regular
basis. This may reduce the number of fatalities due to L VF c
v
TABLE OF CONTENTS
Page
ABSTRACT 0 ••• ix
LIST OF TABLES .. viii
ACKNOWLEDGMENTS. • ix
NURSING DIAGNOSIS OF LEFT VENTRICULAR FAILURE IN ACUTE MYCARDIAL INFAR CfION . .,. ,. ,. 1
pharmacology and physical diagnosis enabled the nurse to perform a
complete and accurate cardiopulmonary assessment. Several advantages
to nursing involvement in the constant and. in -depth management of patients
are apparent: 1) a sound basis for evaluation of nursing care is provided
in the charted records, 2) immediate identification of problems in educa-
tional preparation or misinterpretation of data is possible which allows
for corrective feedback, and 3) a source of highly reliable physiological
data is readily available to the physician (Silverman, 1971) 0
A conspicuous omission in the Silverman (1971) report was that the
author did not convey whether nurses were included in the decision making
process of formulating a plan for therapy 0 The RNs were trained and
utilized to gather and report data utilized to gather and report data utilized
by the physician, however? no other involvement of the RN is reportedo
Hemodynamic Monitoring of Cardiopulmonary Function
Hemodynamic monitoring of patients with left ventricular failure
(LVF) associated with AMI became common practice only in the 1970so
Many studies (Awan et ala ~ 1976; Chatterjee et ala? 1972; Chiariello
et aL, 1976; Cohn, 1973; Franciosa et aL, 1972; Parmley et {iI., 1974;
Rowe & Henderson, 1974; Ziesche & Franciosa, 1977) have been conducted
13
utilizing the balloon -tipped flow directed catheter (Swan -Ganz) and record-
ing devices to describe the effects of various medications on the hemo-
dynamics of the cardiopulmonary system. The primary focus of these
studies has been to manipulate the pulmonary artery pressure (PAP),
pulmonary wedge pressure (PWP), cardiac output (CO) and cardiac index
(CI) ~ The authors generally agree that these parameters can be desirably
altered with the use of vasodilator therapy ~ and for patients experiencing
acute LVF associated with AMI, desired values for the PWP are commonly
between 15-18 mm Hg. with the CI greater than 2.2 l/min/m2 (Forrester
et al o , 1976, 1977). The major criticism of these studies is that they are
hemodynamically oriented while providing the reader with little or no
clinical findings which may be useful to assess the hemodynamic response
obtained.
Subset Classification: Clinical and Hemodynamic
As nursing becomes more sophisticated, professional nurses are
seeking greater responsibilities 0 Gordon (1976) describes nursing diagnosis
as:
Description of actual or potential health problems, which nurses, by virtue of their education and experience, are capable and licensed to treaL (po 1299)
The registered nurse who functions in the role of diagnostician must be
knowledgeable of the physiologic reasons for clinical symptoms usually
seen following acute myocardial infarction and must be knowledgeable
14
the hemodynamic response of the cardiovascular system 0
Gordon (1976) states that the end product of nursing diagnosis is
the placement of the patient in one or more diagnostic categories for the
purpose of determining therapy. She did not attempt to broaden this
concept into specific specialty fields of nursing.
Several studies have attempted to classify the degree of loss of
LVF in AMI on the basis of clinical and hemodynamic parameters (Chatter-
jee & Parmley, 1977; Forrester et al.q 1976, 1977) 0 The patients in such
studies were clinically categorized on the basis of physical assessment
and invasive hemodynamic measurements 0 Forrester et al. (1976, 1977)
categortzed the hemodynamic responses and clinical findings commonly
found in patients experiencihg AML In Forrester's et a1.. (1977) scheme,
both hemodynamic and clinical findings are divided into four subsets with
a parallel relationship existing between the corresponding subseL
A sample of the classification system as utilized by Forrester
et a10 (1977, po 139) is as follows~
Subsets
Hem odynam ic
HI) PWP less than 18 mm Hg 0
and CI greater than 2 02 l/min/m2
H2) PWP greater than 18 mm Hg.
H3) CI less than 202 l/min/m2
Cli.nical
Cl) No pulmonary congestion or peripheral hypoperfusion
C2) Pulmonary congestion present
C3) Peripheral hypoperfusion present
H4) PWP greater than 18 mm Hg 0
and CI less than 2.2 1/min/m2
C4) Both pulmonary congestion and peripheral hypoperfusion present
The study by Chatterjee and Parmley (1977) does not include subsets
equivalent to the clinical and hemodynamic classifications of Forrester
et a10 (1977). Forrester et a10 (1977~ p. 137) report that by utilizing
their classification system, patterns may be established which aid in the
prognosis and treatment following AMI. The authors further report that
15
even with accurate equipment nothing can substitute for the bedside cHnical
examination.
Forrester et a1. (1977) with the use of clinical subsets, were able
to predict the hemodynamic subset with approximately 83% accuracy.
This means that 83% of the time the actual hemodynamic measurement
corresponded with that predicted by the clinical finding" Terms for the
study used in the clinical subset classification scheme were carefully
defined" Peripheral hypoperfusion was defined as the presence of:
1) decreased skin temperature, 2) mental confusion, and 3) oliguria in
conjunction with arterial hypoperfusion or sinus tachycardia with the
patient breathing room air before sedation. Mental state p skin tempera-
ture and color were determined subjectively. Oliguria was defined as
urine output of less than 40 cc/hr" Arterial hypoperfusion was indicated
if the systolic blood pressure was less than 100 mm Hg 0 and sinus
tachycardia was defined as a heart rate of more than 125 beats/minute.
Pulmonary congestion was considered present if auscultatory findings
16
revealed rales over the posteriobasal chest and radiographic findings were
positive for pulmonary congestiono
Forrester et aL (1977) also discuss several classes of medica-
tions utilized for therapy in patients and identify their effects on CO
and PWPo The hemodynamic effects of the drug classes are as follows:
Class
Inotropics Diuretics Vasodilators Beta -adrenegic
blockers
CO PWP
Unchanged or Increased Unchanged or Decreased Unchanged Decreased Increased Decreased Decreased Unchanged or Increased
Utilizing the above guidelines, medical therapy was tailored to the patient's
subset classification 0 For example, if a patient is assigned to clinical
subset C4 and hemodynamic subset H4, the patient will have a decreased
CI and an increased PWP Q Vasodilators would be the medication of choice
as these medications increase CD and decrease PWP 0 The author s contend
that in patients with AMI, prime consideration should be given to correcting
the abnormal hemodynamics Q
The studies by Forrester et aL (1976, 1977) are complete when
considering the factors of hypoperfusion and pulmonary congestiono These
studies demonstrate that it is possible to interrelate clinical findings and
hemodynamic responses in patients with L VF due to AML
Sodium Nitropruss ide Therapy
It has been this investigator i s experience that the major vasod)l
currently used in the treatment of LVF associated with AMI is sodium
nitroprusside (SNP). Of the many studies related to the use of vasodi-
1ators two are of prime importance to the nursing management of SNP
therapy 0
Moskowitz (1975) discusses vasodilator therapy in general with a
specific section related to SNP.. The author reports hemodynamic changes
associated with SNP therapy as increased CO and decreased PWP 0 Infor
mation relevant to nursing implications contributed by Moskowitz are:
1) an emphasis for careful history taking, 2) the need for continuous
monitoring of hemodynamics to maintain the PWP between 15 -18 mg Hgo
without inducing hypotension, 3) patient activities that may potentiate the
effects of SNP, and 4) precautions utilized in preparation of SNP for intra
venous infusion. Unfortunately, the report is not primarily concerned
with associated changes in the clinical findings and is therefore narrow
in scope 0
Ziesche and Franciosa (1977) in their article also do not provi.de
the reader with useful clinical data by which to assess SNP therapy.
Their major contribution is concerned with the administration of SNP.
They provide information in a clear concise manner which enables the
reader to understand the administration and evaluation of SNP utilizing
hemodynamic measurements.. Included in their report is a cornplete
reference table for the titration scheduling of SNP dosage (Ziesche &
Franciosa, 1977, p. 101)0
17
The literature on left ventricular failure and SNP therapy reveals
that a core of valuable information is available to the RN involved in the
care and management of the patient with LVF associated with AMI.
Clinical data may be utilized as the RN desires, however ~ it has been
the experience of this investigator that the majority of RNs use only bits
and pieces of clinical informationo An extensive review of literature
revealed no centralized, succinct report on the synthesis of clinical
and hemodynamic data designed for and by RNs. Thus~ it may be diffi
cult to arrive at a nursing diagnosis and determine appropriate therapy
for patients undergoing treatment of LVF due to AMI.
Although most of the available literature on clinical and hemo
dynamic responses to vasodilator therapy is physician oriented, it can be
understood by the professional nurse 0 By synthesiz ing information con ~
cerning the pathophysiology of AMI, clinical signs and symptoms of LVF
and the involved hemodynamics, the professional nurse can arrive at a
nursing diagnosis 0 Utilizing a classification system such as that pre =
pared by Forrester et al. (1977) the RN could manage patients with L VF
associated with AMI within more complete parameters 0
Conceptual Framework
18
The professional registered nurse must possess an adequate under
standing of the relationship between clinical findings and the hemodynamic
function of the myocardium to adequately assess the pathophysiology of
acute myocardial infarction. The RN must also possess understanding of
the physiological effects of vasodilators on this relationship. The follow
ing discussion is based on the model in Figure 1 designed by the investi
gator which depicts a relationship between key factors associated with
vasodilator therapy and management 0 The arrows serve as a guide to
direct the reviewer's attention toward the clinical and hemodynamic
aspects of the pathophysiology that occurs during AMI, L VF and vaso
dilator therapy. The relationships within the model have been explained
in the review of literature. Each of the four parts of Figure 1 relate to
one of the four clinical and hemodynamic subsets suggested by Forrester
et a 1. (1 977) •
19
The clinical findings and hemodynamic alterations associated with
acute myocardial infarction (AMI) are attributed to the extent of myocardial
damage during the infarction process (Netter~ 1974)0 The patient with an
uncomplicated AMI (see Figure I-A) may exhibit few or no abnormal
clinical findings from the infarction process"
SNP reduces the impedence against which the heart must eject blood
during systole.. This results in a larger volume of blood ejected without
an increase in myocardial workload (see Figure 1 =D)~ therefore, myo=
cardial oxygen consumption remains the same or improves due to reduced
workload. This decreases the possibility of injury or necrosis to the myo
cardium adjacent to the infarction site in the ventricle (Armstrong~ Walker,
Burton & Parker, 1975; Chatterjee et aL, 1973; Chiariello et aL, 1976;
Hemodynamic Subjects. Only seven subjects required hemodynamic
monitoring during the study, however, initial planning required ten sub
jects in this category., The sporadic occurrence of these subjects rendered
it impossible to obtain the required data. By using multiple hemodynamic
assessments it was possible to accomplish 33 assessments on the 7 subjects
obtained., If a single assessment had been made~ 7 would not constitute a
clinically significant number for analYSiS" Multiple assessments also
allowed the investigator to assess the subject over the acute phase of the
medical regime. When compared with Forrester et al. (1977), who
accomplished only one assessment per subject, this produces a more
clinically significant evaluation of the medical regime. By utilizing multiple
assessments the 33 assessments obtained would be significant for clinical
analysis.
Table 4 summarizes the placement of subjects within the four hemo
dynamic subsets. The difference in numbers of the hemodynamic measure
ments between the two studies (33 vs. 200) does not allow for statistical
comparison. This investigator reports a relatively even distribution of
subjects within the hemodynamic subset classification system.
Table 5 demonstrates a comparison of the clinical and hemodynamic
subsets of all subjects who were hemodynamically monitored. The clinica 1
subset did not correlate with the hemodynamic subset on 19 comparisons
(57%). The discrepancy in correlation between clini.cal and hemodynamic
subset classification is due in large part to the MPWP which were less
37
Table 4
Hemodynamic Subsets with Number of Hemodynamic Measurements
Subsets Total Patient # I II III IV Assessments
14 1 1 2 4
17 1 1 2
22 3 1 5 9
24 2 2
26 4 4
28 2 2 1 2 7
30 1 4 5
Total 7 9 8 9 33
Table 5
Cornparison Matrix of Clinical and Hemodynamic Subset Classification
Hemodl:namic Subsets Total Clinical Subsets I II III IV Assessments
I 1 1 2
II 19 7 8 1 3 38
III
IV 13 1 7 5 26
Total 33 7 9 8 9 66
38
than 18mm Hg in 13 comparisons.
Table 6 classifies the raw data secured from subjects who were
hemodynamically monitored. It displays the range and average of the
cardiac index (CI) and the mean pulmonary wedge pressure (MPWP). This
data indicates that hemodynamic monitoring was appropriate in all but one
subject. Raw data for all subjects from which subset classifications were
made is displayed in Appendix E.
Progress Notes. Physician Progress Notes were reviewed for the
following data: 1) time of day, 2) recording of hemodynamic measurements,
3) clinical findings, and 4) planned therapeutic regimes. Progress notes
for comparison purposes, were deficient in three areas: 1) they consistently
failed to provide the time of clinical assessment, 2) hemodynamic measure
ments were recorded on only 2 occasions, and 3) a recorded planned thera
peutic regime was not consistently available. Thus, it was not possible
to perform a significant comparison of the investigator's therapeutic
regime with that of the physicians.
Discussion
Since no study utilizing mUltiple clinical assessments of subjects who
have developed left ventricular failure due to acute myocardial infarction
with subsequent assignment to clinical and hemodynamic subsets could be
found, this study could not be compared with similar studies 0
39
Table 6
Classification of Hemodynamic Measurements by Range and Average
Total Patient # CI (L/min/m2) MPWP (mm Hg) Measurements
14 Range 1 .. 79-2.15 13-26 4 Average 1.99 21025
17 Range 2.03-2.54 20-22 2 Average 2.28 21
22 Range 1.83 -2 .56 12-16 9 Average 2.116 14.25
24 Range 2.65-2.75 14 ... 15 2 Average 2.7 14.5
26 Range 2.45-206 19-25 4 Average 2.51 22
28 Range 1.6-2022 12-27 7 Average 2.1 20.14
30 Range 1014-2.02 15-21 5 Average 106 19
Summary Range 1.14-2.75 12-27 33 Average 2.11 18.63
40
Limitations
Certain aspects of the study posed limitations that had not been
anticipated. The time frame for the study did not allow a large patient
population. The methodology for performing hemodynamic measurements
was not controlled. In an attempt to limit internal bias, the investigator
decided it would be more appropriate not to know the hemodynamic
measurements prior to completing a cardiopulmonary assessmenL This
placed the responsibility for hemodynamic measurements upon the nursing
staff of the CCU. It was subsequently determined that each RN did not
accomplish the hemodynamic measurements with the same technique.
For example, some R Ns did not calibrate the transducer at each measure ~
menL This may have introduced error into recorded values for hemo~
dynamic measurements. This may have attributed to some of the differ
ences when clinical and hemodynamic subsets did not correlate (see Table
5).
The investigator utilized both subjective and objective data when
assigning subjects to clinical and hemodynamic subsets. The subjective
data may have resulted in some internal bias when assigning subjects to
subsets a
1m plications
Cardiopulmonary assessments in conjunction with hemodynamic
measurements are not routinely performed by nursing 0 If the professional
RN were to assume this function on a regular basis the number of fatalities
41
due to left ventricular failure might be reduced. Since the advent of SNP
therapy, nursing has been accomplishing the management of SNP therapy
on the basis of hemodynamic measurements alone. Nursing has not
taken into account the {X)ssibility of equipment malfunction or improper
technique while accomplishing hemodynamic measurements, and sub-
sequently used clinical data to expand the data base on which critical
judgments are made. The opportunity to improve nursing care is both
pos sible and neces sary to improve patient care 0
In clinical settings where hemodynamic monitoring is accomplished
expectations of the R N are high 0 Experience and the study results has
shown that the highly skilled RN, is capable of and can achieve competence
in performing cardiopulmonary assessments and hemodynamic measure-
ments. However, to achieve the desired level of competence there needs
to be a planned course of instruction with expected skills to be demon-
strated 0 A logical method to provide incentive to learn advanced skills
would be a clinical ladder in which the clinical unit defined competencies
to be achieved at each leveL The most advanced level could require the
RN perform a complete and accurate cardiopulmonary assessment in
conjunction with hemodynamic measurement.
The RN who achieves this level would then be considered clinically
competent to administer and manage patients receiving vasodilator therapy
for left ventricular failure due to acute myocardial infarction.
ISR:
42
R ecommenda tions
The pertinence of clinical data could be increased if the following
gUidelines had been included in the methodology: 1) that the physicians
who participated utilized the same recording technique as the investigator,
and 2) that all RNs accomplished hemodynamic measurements utilizing
the same technique 0
These guidelines would have provided to the investigator a more
valid and reliable data base of clinical informationo Future studies,
embodying these recordings, would provide a core of clinical data useful
for determining the extent to which the competent, highly skilled R N is
capable of managing patients with left ventricular failure 0
APPENDIX A
PHYSICIAN NOTIFICATION
Dr"
Your cooperation and permission are requested in a study designed to increase the effectiveness of nursing care provided in the coronary care unit" has been contacted and has consented to participate in this study"
The study involves the patient receiving a cardiopulmonary assess =
ment consisting of auscultation of the heart and lungs with palpation of the trunk and peripheral pulses" The number of assessments conducted will be determined by the severity of the patient's conditiono
This study is being conducted by Alfred Be Miller, RN and is being supervised by Dr. Frank Yanowitz, M .. D 0 and Dr" Steven Klausner, MoD" of the Cardiology Department of LDS Hospital 0 This study has been reviewed by the University of Utah Review Committee for Research with Human Subjects and the LDS Hospital Research and Human Rights Committee" These committees have determined that the patient will be at Low or No Risk during the study.. A copy of the study proposal is on file with each committee ..
Questions can be directed to Alfred B" Miller, RN or Dr. Yanowitz 9
MoDo and Dr 0 Klausner, M"D"
Thank you for your cooperation 0
Alfred B" Miller J RN Principal Investigator
Permis sion is granted , denied --------------~ -------------
Dr. --------------------------------------
APPENDIX B
PATIENT INFORMATION
1. Name 2. Number --------------------------3. Age ---- 4. Sex 5. Race ----- 6. Weight __ kgo
The amount of blood ejected by the heart expressed in liters/minute ..
The cardiac output divided by the body surface area, expressed in liters/minute/M2, used to normalize cardiac output for body size ..
Pulmonary Artery The pressure in the pulmonary artery, expressed in Pressure: mm Hg"
Pulmonary Wedge The pressure in the pulmonary capillary, expressed Pressure: in mm Hg", usually reflective of left atrial pressure ..
Systemic Vascular The resistance to blood flow in the systemic system Resistance: throughout the cardiac cycle, calculated as mean
Subsets:
Cardiopulmonary Assessment:
arterial pressure - mean right atrial pressure cardiac output
(MAP - RAP) d . W d' h CO an express In 00 unlts, w en
MAP = RAP CO x 80 it is expressed as dynes sec/CMS .
Classification of the physiological state of left ventri ~ cular function. Clinical subsets are defined as the data obtained from the history, physical examination and rc'utine laboratory findings.. Hemodynamic subsets are defined using measured hemodynamic parameters such as CO, CI, PAP, and PWP" In the acute patient, clinical and hemodynamic subsets should correlate to justify their use in directing therapeutic decisions.
Clinical evaluation based on history, physical examina-> tion and routine laboratory findings ..
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Name
Birthdate
Birthplace
High School
College 1967 -1969
1970-1971
University 1973-1974
1976-1979
Degree 1973
1974
Professional Organizations
Professional Positions
VITA
Alfred Bobby Miller
February 27, 1937
Danville, Pennsylvania
Coal Township High School Shamokin, Pennsylvania
Merced Jr" College Merced, California
Minot State College Minot, North Dakota
University of North Dakota Grand Forks, North Dakota
University of Utah Salt Lake City ~ Utah
A 8 S 0 ~ Merced Jr. College Merced, California
B. S. N.l University of North Dakota Grand Forks, North Dakota
American Association of Critical Care Nurses
Assistant Director of Nursing for Critical Care~ Memorial Hospital of South Bend, Indiana, 1978-Staff Nurse, Coronary Care Unit, LDS Hospital, Salt Lake City, Utah~ 1975=1978; United States Air Force 9