1. Chapter 13 Cardiovascular Therapeutic Management Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.

2. 2  Identify the signs of perfusion in a patient undergoing fibrinolytic therapy. (continued) Objectives

3. 3 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Describe the functions of a temporary pacemaker and an implantable cardioverter- defibrillator. (continued) Objectives

4. 4 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Outline the nursing management of a patient undergoing cardiac surgery and cardiac interventional procedures.  List the most important categories of cardiovascular drugs, their intended actions, and major significance. Objectives (continued)

5. 5 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Temporary Pacemakers  Electronic devices used to initiate the heartbeat when the heart’s intrinsic rhythm cannot effectively generate a rate adequate to support cardiac output  Uses  Temporarily  Supportively  Prophylactically  Permanently  Duration – until the condition responsible for the rate or conduction disturbance resolves.

6. 6 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Indications  Bradydysrhythmias  Tachydysrhythmias  Causes  Drug toxicity  Acute MI  Acute Coronary Syndromes  Following cardiac surgery

7. 7 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Pacemaker System  Simple electrical circuit consisting of a pulse generator and a pacing lead with one, two or three electrodes.  Pulse generator is designed to generate an electrical current that travels through the pacing lead and exits through an electrode (exposed portion of the wire) that is in direct contact with the heart.  The electrical current initiates a myocardial depolarization.  The current returns to the pulse generator to complete the circuit.  Power source is a 9-volt alkaline battery

8. 8 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Pacing Lead Systems FIGURE 13-1 The Components of a Temporary Bipolar Transvenous Catheter. A, Singlechamber temporary (external) pulse generator. B, Bridging cable. C, Pacing lead. D, Enlarged view of the pacing lead tip. (A, Courtesy Medtronic Inc., Minneapolis, Minn.)

9. 9 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Routes for temporary pacing  Transcutaneous  Epicardial  Transvenous (endocardial) Pacemaker System

10. 10 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Pacing Routes  Transcutaneous use of two large skin electrodes  One placed on the anterior chest the other on the posterior chest  These are connected to an external pulse generator  Rapid, noninvasive procedure  First line intervention that nurses can initiate in the ACLS algorithm – for the treatment of symptomatic bradycardia  Used as an emergency short- term therapy until the situation resolves or another route of pacing can be established

11. 11 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Epicardial Pacing  Insertion of temporary epicardial pacing wires is a routine procedure during most cardiac surgical cases  Ventricular and in some case atrial pacing wires are loosely sewn to the epicardium.  The terminal wires are pulled through the skin before the chest is closed.  These are removed several days after surgery by gentle traction at the skin surface with minimal bleeding risk

12. 12 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Transvenous Pacing http://rnbob.tripod.com/transven. htm  Temporary – transvenous endocardial pacing is accomplished by advancing a pacing electrode wire through the subclavian or internal jugular and into the right atrium or right ventricle.  Insertion  Fluoroscopy  Through a pacing swan  Through a central line cordis

13. 13 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.

14. 14  Three-letter pacemaker code  The first letter designates which chamber is paced  The second letter designates which chamber is sensed  The third letter indicates the pacemaker’s response to the sensed event  Five-letter pacemaker code  The fourth letter designates programmability  The fifth letter designates dysrhythmia control (continued) Pacemaker Terminology

15. 15 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Synchronous pacing modes  DDD pacing  VVI pacing  Asynchronous pacing modes  Ignores the patient’s intrinsic heartbeat Pacemaker Terminology (continued)

16. 16 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Rate  Output: milliamps  Pacing threshold  Sensitivity control  Sensitivity threshold  AV interval control Pacemaker Settings

17. 17 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Pacing artifact is a spike seen on the electrocardiogram (ECG) tracing as the pacemaker delivers the pacing stimulus  Pacing artifacts  Atrial artifact  Ventricular artifact  Dual-chamber (both atrial and ventricular) pacing artifact Pacing Artifacts

18. 18 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Pacing Artifacts FIGURE 13-2 Pacing Examples. A, Atrial pacing. B, Ventricular pacing. C, Dual-chamber pacing. Each asterisk represents a pacemaker impulse.

19. 19 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Pacemaker malfunctions  Failure to pace  Failure to capture  Sensing abnormalities Undersensing Undersensing Oversensing Oversensing Pacemaker Malfunctions

20. 20 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Failure to Pace FIGURE 13-3 Pacemaker Malfunction: Failure to Pace. A, Patient with a transvenous pacemaker is turned onto the left side. Immediately, there is a failure to pace (i.e., loss of pacer artifacts on the electrocardiogram). The patient’s heart rate is extremely low without pacemaker support. B, The nurse turns the patient onto the right side, the transvenous electrode floats into contact with the right ventricular wall, and pacing is resumed. (From Kesten KS, Norton CK: Pacemakers: patient care, troubleshooting, rhythm analysis, Baltimore, 1985, Resource Applications.)

21. 21 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. The RN is caring for a patient with a temporary pacemaker. While observing the patient’s ECG rhythm, the RN notes unexplained pauses in the patient’s rhythm. The RN suspects the patient is experiencing: A. failure to capture. B. generator failure. C. undersensing. D. oversensing. Question

22. 22 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. D. Oversensing. Oversensing occurs as a result of inappropriate sensing of extraneous electrical signals that leads to unnecessary triggering or inhibition of stimulus output, depending on the pacer mode. Oversensing results in unexplained pauses in the ECG tracing as the extraneous signals are sensed and inhibit pacing. Answer

23. 23 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Failure to Capture FIGURE 13-4 Pacemaker Malfunction: Failure to Capture. Atrial pacing and capture occur after pacer artifacts (spikes) 1, 3, 5, and 7. The remaining pacer artifacts fail to capture the tissue, resulting in loss of the P wave, no conduction to the ventricles, and no arterial waveform. Each asterisk represents a pacemaker impulse.

24. 24 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Undersensing FIGURE 13-5 Pacemaker Malfunction: Undersensing. After the first two paced beats, a series of intrinsic beats occur; the pacemaker unit fails to sense these intrinsic QRS complexes. These pacer artifacts do not capture the ventricle because they occur during the refractory period of the cardiac cycle. Each asterisk represents a pacemaker impulse.

25. 25 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Medical management  Determine pacing route based on situation  Place transvenous or epicardial lead(s)  Determine pacing rate and mode and evaluate patient’s response to pacing Medical Management

26. 26 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Nursing priorities for the patient connected to a temporary pacemaker focus on:  Preventing pacemaker malfunction  Protecting from microshock  Monitoring for complications  Providing patient education Nursing Management

27. 27 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Nursing Care of the patient with an emergent pacemaker  Continuous ECG monitoring – patent IV access (two sites at least)  Set monitor on pacing to sense pacer energy or spikes  Assess vitals regularly depending on patient status  Assess perfusion – check a radial pulse while watching the monitor. Does the pacer spike generate a pulse  Reassure the patient  Provide pain medication/sedation for a patient with transcutaneous pacing  Prepare for transfer or for transvenous pacing/permanent pacer insertion depending on the setting.

28. 28 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Which of the following interventions should be implemented to minimize the incidence of microshock in the patient with a temporary pacemaker? A. Unplug all electric equipment around the patient B. Ensure all the pacing connections are tight C. Wear gloves when handling pacing wires D. Suspend the pulse generator away from the patient Question

29. 29 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. C. Wear gloves when handling pacing wires The possibility of microshock can be minimized by wearing rubber gloves when handling the pacing wires and by proper insulation of terminal pins of pacing wires when they are not in use. Answer

30. 30 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Myocardial Perforation  Very rare but can occur  Symptoms Rhythmic hiccoughs Rhythmic hiccoughs Cardiac Tamponade Cardiac Tamponade

31. 31 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Patient education temporary pacemakers  Instruct the patient to not handle the exposed portion of the lead wire.  Notify the nurse if the dressing over the insertions site becomes soiled, wet, or dislodged.  Done use any electrical devices brought in from home that could interfere with pacemaker function.  Restrict movement of the affected extremity to avoid displacement.

32. 32 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. http://missinglink.ucsf.edu/lm/pac emaker_module/index.htm

33. 33 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Permanent pacemakers  Cardiac resynchronization therapy  Atrial dysrhythmia suppression  Medical management  Nursing management  Monitoring for complications  Patient education Permanent Devices

34. 34 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Implantable device capable of:  Identification and termination of life-threatening ventricular dysrhythmias  Primary prevention of sudden cardiac death (SCD)  Treatment of refractory rhythms (continued) Implantable Cardioverter Defibrillator (ICD)

35. 35 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  ICD system contains:  Sensing electrodes to recognize the dysrhythmias  Defibrillation electrodes or coils to deliver a “shock” and pacing impulses  Generator to provide the electrical energy for shocks and for backup pacing, cardioversion, or defibrillation (continued) Implantable Cardioverter Defibrillator (ICD) (continued)

36. 36 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. ICD System FIGURE 13-6 A, Placement of an implantable cardioverter defibrillator (ICD) with a transvenous lead system in the pectoral region of the upper chest. Pacing, cardioversion, and defibrillation functions are all contained in a lead (or leads) inserted into the right atrium and ventricle. B, An example of a dual-chamber ICD (Medtronic Gem II DR) with tiered therapy and pacing capabilities. C, Tiered therapy is designed to use increasing levels of intensity to terminate ventricular dysrhythmias. (Courtesy Medtronic Inc., Minneapolis, Minn.)

37. 37 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  ICD insertion  Leads may be placed epicardial or endocardial  Generators are smaller and can now be implanted without major surgery Implantable Cardioverter Defibrillator (ICD) (continued)

38. 38 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Evaluation of patient’s dysrhythmias and cardiac function  Cardiac diagnostic procedures  Decisions about placement, route, and type of therapy needed  ICD programming  Insertion programming, testing, and threshold measurements  Follow-up monitoring to determine function performance and battery life Medical Management

39. 39 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Nursing priorities for the patient with an ICD focus on:  Monitoring for ICD-associated complications  Providing patient education Nursing Management

40. 40 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Goal:  Lysis of the acute thrombus  Opening the obstructed coronary artery  Restoring blood flow to the affected tissue (continued) Fibrinolytic Therapy

41. 41 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Fibrinolysis FIGURE 13-7 Thrombus Formation and Site of Action of Medications Used in the Treatment of Acute Myocardial Infarction. A, Site of action of antiplatelet agents such as aspirin and glycoprotein IIb/IIIa inhibitors. B, Heparin bonds with antithrombin III and thrombin to create an inactive complex. C, Fibrinolytic agents convert plasminogen to plasmin, an enzyme responsible for degradation of fibrin clots.

42. 42 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Inclusion criteria  12 hours or less after onset of chest pain  Persistent ST-elevation on ECG  Bundle branch block with a history suggestive of AMI  Exclusion criteria  Patients who have stable clots from recent surgery, trauma, or stroke Fibrinolytic Therapy (continued)

43. 43 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  No more than 12 hours from onset of chest pain (less if possible)  ST-segment elevation on electrocardiogram or new-onset left bundle branch block  Ischemic chest pain unresponsive to sublingual nitroglycerin  No conditions that might cause a predisposition to hemorrhage Fibrinolytic Therapy Selection Criteria

44. 44 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Clot specific  t-PA (alteplase)  r-PA (reteplase)  TNKase (tenecteplase)  Non–clot specific  SK (streptokinase)  Outcomes Fibrinolytic Agents

45. 45 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Invasive evidence  Can be directly observed under fluoroscopy in the cardiac catheterization laboratory  Noninvasive evidence  Cessation of chest pain  Reperfusion dysrhythmias, primarily ventricular rhythms  Elevated ST segments return to baseline  Early and marked peaking of creatine kinase Evidence of Reperfusion

46. 46 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Nursing priorities for the patient receiving fibrinolytic therapy focus on:  Identifying candidates for thrombolytic therapy  Observing for clinical signs of reperfusion  Monitoring for signs of bleeding  Providing patient education Nursing Management

47. 47 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Indications  Trials demonstrate an advantage for catheter interventions over drug therapy  Surgical backup less often required  Availability of cardiac surgical services on site still recommended (continued) Percutaneous Coronary Interventions (PCI)

48. 48 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Percutaneous transluminal coronary angioplasty (PTCA)  Use of balloon-tipped catheter to dilate the stenotic area  Balloon pressure stretches the vessel wall, fractures the plaque, and enlarges the vessel (continued) Percutaneous Coronary Interventions (PCI) (continued)

49. 49 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. PTCA FIGURE 13-8 Percutaneous Transluminal Coronary Angioplasty (PTCA) is used to open a stenotic vessel occluded by atherosclerosis.

50. 50 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Atherectomy  Directional atherectomy  Rotablator  Transluminal extraction catheter  Coronary stents  Stent thrombosis  Drug-eluting stents Percutaneous Coronary Interventions (PCI) (continued)

51. 51 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Atherectomy Devices FIGURE 13-9 Atherectomy Devices. A, Directional coronary atherectomy catheter. B, Rotational atherectomy catheter.

52. 52 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Acute complications  Coronary spasm  Coronary thrombosis  Coronary dissections  Bleeding  Hematoma  Retroperitoneal bleed  Late complications PCI Complications

53. 53 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Nursing priorities for patients after PCI are directed to:  Monitoring for recurrent angina  Protecting kidney function  Monitoring the femoral access site Assessing for bleeding Assessing for bleeding Hemostatic devices Hemostatic devices  Monitoring peripheral pulses  Promoting ambulation  Providing patient education Nursing Management

54. 54 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Percutaneous balloon valvuloplasty  Aortic  Mitral Percutaneous Valve Repair

55. 55 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Coronary artery bypass surgery (CABG)  Improved quality of life and relief of symptoms  Type of graft  Saphenous vein graft  Internal mammary artery graft  Right gastroepiploic artery graft  Radial artery graft Cardiac Surgery

56. 56 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. CABG FIGURE 13-11 Saphenous Vein Graft.

57. 57 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. CABG FIGURE 13-12 Internal Mammary Artery Graft.

58. 58 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Mechanical valves  Caged-ball valve  Tilting-disk valve  Bi-leaflet valve  Biological (tissue) valves  Porcine (aortic valve) heterograft  Homograft Valvular Surgery

59. 59 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Artificial Valves FIGURE 13-13 Prosthetic Valves. A, The St Jude Medical mechanical heart valve is a mechanical central-flow disk. B, In the Hancock II porcine aortic valve, the flexible Delrin stent and sewing ring are covered in Dacron cloth. (A, Courtesy St Jude Medical, Inc., copyright 1993, St Paul, Minn; B, from Eagle K, et al, editors: The practice of cardiology, ed 2, Boston, 1989, Little, Brown.)

60. 60 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Minimally invasive cardiac surgery  Heart transplantation Cardiac Surgery

61. 61 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Heart Transplant FIGURE 13-14 Heart Transplant Surgical Procedure. (Modified from Hurst JW, et al: Hurst’s The Heart, ed 7, New York, 1990, McGraw-Hill.)

62. 62 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Intravascular fluid deficit  Third spacing  Myocardial depression  Coagulopathy  Pulmonary dysfunction  Hemolysis  Hyperglycemia  Hypokalemia  Hypomagnesemia  Neurological dysfunction  Hypertension Physiological Effects of Cardiopulmonary Bypass

63. 63 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Nursing priorities for the patient after cardiac surgery are directed toward:  Optimizing cardiac output Heart rate Heart rate Preload Preload Afterload Afterload Contractility Contractility  Temperature regulation  Controlling bleeding  Maintaining chest tube patency (continued) Nursing Management

64. 64 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Nursing priorities for the patient after cardiac surgery are directed toward:  Recognizing cardiac tamponade  Promoting early extubation  Assessing for neurological complications  Preventing infection  Preserving kidney function  Providing patient education Nursing Management (continued)

65. 65 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. The RN is caring for a postoperative cardiac surgery patient who develops muffled heart sounds, pulsus paradoxus, decreased BP and cessation of chest tube output. The RN suspects the patient has developed: A. cardiac tamponade. B. graft occlusion. C. acute respiratory failure. D. heart failure. Question

66. 66 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. A. Cardiac tamponade. Cardiac tamponade may occur after surgery if blood accumulates in the mediastinal space, impairing the heart’s ability to pump. Signs of tamponade include elevated and equalized filling pressures (e.g., CVP, PADP, PAOP), decreased cardiac output, decreased blood pressure, jugular venous distention, pulsus paradoxus, muffled heart sounds, sudden cessation of chest tube drainage, and a widened cardiac silhouette on chest x-ray films. Answer

67. 67 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Many of these procedures can be accomplished without a median sternotomy, by means of a series of holes, or ports, in the chest and small thoracotomy incisions  May be performed without cardiopulmonary bypass  OPCAB and MIDCABG Minimally Invasive Cardiac Surgery

68. 68 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Indications for use of intraaortic balloon pump (IABP)  Left ventricular failure after cardiac surgery  Unstable angina refractory to medications  Recurrent angina after myocardial infarction  Complications of acute myocardial infarction Cardiogenic shock Cardiogenic shock Papillary muscle dysfunction/rupture Papillary muscle dysfunction/rupture Ventricular septal rupture Ventricular septal rupture  Refractory ventricular dysrhythmias (continued) Intraaortic Balloon Pump

69. 69 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Balloon inflates in diastole concurrent with aortic valve closure  Augments diastolic coronary arterial blood flow  Increases myocardial oxygen supply  Balloon deflates just prior to the opening of the aortic valve  Decreases resistance of left ventricular ejection Intraaortic Balloon Pump (continued)

70. 70 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Intraaortic Balloon Pump Function FIGURE 13-15 Mechanisms of Action of the Intraaortic Balloon Pump. A, Diastolic balloon inflation augments coronary blood flow. B, Systolic balloon deflation decreases afterload.

71. 71 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Nursing priorities for the patient being treated with an IABP include:  Preventing dysrhythmias  Preventing peripheral ischemia  Monitoring for balloon complications  Monitoring balloon-catheter position  Preventing complications  Providing psychological support  Weaning patient from IABP Nursing Management

72. 72 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Antidysrhythmic drugs  Class 1A, 1B, 1C: affect sodium channels  Class II: blocks beta-receptors  Class III: slows repolarization and prolongs duration of the action potential  Class IV: blocks calcium channels  Unclassified antidysrhythmics  Side effects Effects of Cardiovascular Drugs

73. 73 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc. Treatment of Atrial Fibrillation  Conversion/mainten ance of sinus rhythm  Control of ventricular rate  Prevention of thromboembolism

74. 74 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Alpha receptors  Vasoconstriction of arterioles in vessels of skin, muscles, kidneys, and intestines  Beta 1 receptors  Cardiac: increased heart rate, contractility, and conduction  Beta 2 receptors  Vasodilation of arterioles in bronchi  Bronchodilation Effects of Adrenergic Receptors

75. 75 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Cardiac gylcosides  Sympathomimetics  Dopamine  Dobutamine  Epinephrine  Norepinephrine  Phosphodiesterase inhibitors Inotropic Drugs

76. 76 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Direct smooth muscle relaxants  Sodium nitroprusside  Nitroglycerine  Calcium channel blockers  ACE inhibitors  B-type natriuretic peptide  Alpha-adrenergic blockers  Dopamine receptor agonists Vasodilator Drugs

77. 77 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  Vasopressin Vasopressors

78. 78 Copyright © 2012, 2008, 2004, 2000, 1996, 1992 by Mosby, an imprint of Elsevier Inc.  ACE inhibitors  Angiotensin receptor blockers  Beta blocker  Aldosterone antagonist  Inotropes Pharmacological Management Heart of Failure