Risk for decreased cardiac output: validation of a proposal for nursing diagnosis.

AIM: To verify the content validity of the nursing diagnosis risk for decreased cardiac output (RDCO). BACKGROUND: DCO is a phenomenon that is not restricted to individuals or environments that specifically focus on cardiovascular care. It is not only prevalent in cardiovascular care units, but also in post-anaesthesia units and non-cardiac care units among individuals with non-cardiogenic disorders. A significant decrease in cardiac output is a life-threatening situation, demonstrating the need for developing a risk nursing diagnosis for early intervention. The development of this diagnosis requires the construction of a diagnosis label, a definition of the diagnostic concept and the risk factors associated with the diagnosis. METHODS: The research was carried out in two methodological stages based on the Fehring diagnosis content validation model. The quantitative analysis consisted of the calculation of the weighted mean of the values attributed by experts to each risk factor, the level of agreement/disagreement between the experts regarding the operational definitions of risk factors and the index of diagnostic content validity (DCV). RESULTS: The label 'risk for decreased cardiac output' was considered representative of a nursing diagnosis defined as 'at risk of developing a health status characterized by an insufficient quantity of blood pumped by the heart to meet physical metabolic demands'. Critical risk factors (DCV ≥ 0·7) were myocardial dysfunction (0·887), blood loss (0·875), increase in intrapericardial pressure (0·825), condition that leads to changes in cardiac rhythm and/or electrical conduction (0·812), deficient fluid volume (0·725), plasma loss (0·712), ineffective tissue perfusion (0·712) and electrolyte imbalance (0·7). CONCLUSIONS: The research identified eight risk factors with valid content for assessment of RDCO. IMPLICATIONS FOR NURSING PRACTICE: The identification of risk factors for DCO assists nurses to intervene early and minimize the consequences of a deficient cardiac function.

Identification of Low Cardiac Output Syndrome at the Bedside: A Pediatric Cardiac Intensive Care Unit Survey.

BACKGROUND: Low cardiac output syndrome is a transient constellation of signs and symptoms that indicate the heart's inability to supply sufficient oxygen to tissues and end-organs to meet metabolic demand. Because the term lacks a standard clinical definition, the bedside diagnosis of this syndrome can be difficult. OBJECTIVE: To evaluate concordance among pediatric cardiac intensive care unit nurses in their identification of low cardiac output syndrome in pediatric patients after cardiac surgery. METHODS: An anonymous survey was distributed to 69 pediatric cardiac intensive care unit nurses. The survey described 10 randomly selected patients aged 6 months or younger who had undergone corrective or palliative cardiac surgery at a freestanding children's hospital in a tertiary academic center. For each patient, data were presented corresponding to 5 time points (0, 6, 12, 18, and 24 hours postoperatively). The respondent was asked to indicate whether the patient had low cardiac output syndrome (yes or no) at each time point on the basis of the data presented. RESULTS: The response rate was 46% (32 of 69 nurses). The overall Fleiss k value was 0.30, indicating fair agreement among raters. When the results were analyzed by years of experience, agreement remained only slight to fair. CONCLUSIONS: Regardless of years of experience, nurses have difficulty agreeing on the presence of low cardiac output syndrome. Further research is needed to determine whether the development of objective guidelines could improve recognition and facilitate communication between the pediatric cardiac intensive care unit nurse and the medical team.

Extending the horizon in chronic heart failure: effects of multidisciplinary, home-based intervention relative to usual care.

BACKGROUND: The long-term impact of chronic heart failure management programs over the typical life span of affected individuals is unknown. METHODS AND RESULTS: The effects of a nurse-led, multidisciplinary, home-based intervention (HBI) in a typically elderly cohort of patients with chronic heart failure initially randomized to either HBI (n=149) or usual postdischarge care (UC) (n=148) after a short-term hospitalization were studied for up to 10 years of follow-up (minimum 7.5 years of follow-up). Study end points were all-cause mortality, event-free survival (event was defined as death or unplanned hospitalization), recurrent hospital stay, and cost per life-year gained. Median survival in the HBI cohort was almost twice that of UC (40 versus 22 months; P<0.001), with fewer deaths overall (HBI, 77% versus 89%; adjusted relative risk, 0.74; 95% CI, 0.53 to 0.80; P<0.001). HBI was associated with prolonged event-free survival (median, 7 versus 4 months; P<0.01). HBI patients had more unplanned readmissions (560 versus 550) but took 7 years to overtake UC; the rates of readmission (2.04+/-3.23 versus 3.66+/-7.62 admissions; P<0.05) and related hospital stay (14.8+/-23.0 versus 28.4+/-53.4 days per patient per year; P<0.05) were significantly lower in the HBI group. HBI was associated with 120 more life-years per 100 patients treated compared with UC (405 versus 285 years) at a cost of 1729 dollars per additional life-year gained when we accounted for healthcare costs including the HBI. CONCLUSIONS: In altering the natural history of chronic heart failure relative to UC (via prolonged survival and reduced frequency of recurrent hospitalization), HBI is a remarkably cost- and time-effective strategy over the longer term.

Maintaining hope in transition: a theoretical framework to guide interventions for people with heart failure.

Theoretical frameworks provide a structure for the planning and delivery of nursing care and for research. Heart failure (HF), a condition of increasing prevalence in communities internationally, is responsible for high rates of morbidity, mortality, and great societal burden. The HF illness trajectory can be unpredictable and uncertain. Markers of transition, such as functional decline and increasing dependence, can signal the need for transition to a more palliative approach. This transition challenges clinicians to deliver information and interventions and to support patients and their families not only in relation to their physical status but also in the social, psychological, and existential dimensions. This article describes a theoretical framework, Maintaining Hope in Transition, informed by transition theory, to assist patients to cope with a diagnosis of HF and to guide development of nursing interventions. Transition theory provides a useful context to assist clinicians, patients, and their families adjust to the challenges inherent in a diagnosis of HF and negotiating the illness trajectory. Key factors acknowledged in the Maintaining Hope in Transition framework that determine its utility in models of care for HF patients are (1) acknowledging the changing of life circumstances, (2) restructuring reality, (3) dealing with vulnerability, (4) achieving normalization, and (5) resolving uncertainty. It is likely that incorporation of these factors in care planning, information, and interventions can facilitate patients' and their families' abilities to negotiate the HF illness trajectory, particularly in the advanced stages.

Update on complications of pediatric cardiac surgery.

Management of the pediatric patient after congenital heart disease surgery requires a multidisciplinary team approach. All members of the team must understand the risk factors, pathophysiology, and management of common postoperative problems such as low cardiac output, pulmonary hypertension, and chylothorax to assure early recognition and intervention.

Hospital cost effect of a heart failure disease management program: the Specialized Primary and Networked Care in Heart Failure (SPAN-CHF) trial.

BACKGROUND: Determine the effect on hospitalization cost of a heart failure disease management (HFDM) program delivered within a diverse provider network as demonstrated in the SPAN-CHF randomized controlled trial. METHODS: The SPAN-CHF trial was a prospective randomized assessment of the effectiveness of HFDM delivered for 90 days across a diverse provider network in a heterogeneous population of 200 patients. Baseline clinical and demographic data were obtained on each patient, mortality was monitored, and hospitalizations were tracked for 90 days. Cost estimates for each hospitalization were based on a subsample of patients seen at Tufts-New England Medical Center for whom hospitalization costs were calculated. Heart failure disease management program costs were estimated using a programmatic budget model. Hospital utilization and cost data were combined to estimate medical costs for intervention and control groups. RESULTS: Heart failure disease management had a favorable effect on heart failure hospitalization, which was partially offset by noncardiac hospitalizations. The relative odds of at least one all-cause hospitalization during the intervention period trended less for the intervention group compared with the control group (0.76 [95% CI 0.38-1.51]). The point estimate of the differential hospitalization cost between control and intervention groups was a reduction in cost of $375 per patient. The net effect including the costs of the program was an increase of $488 per patient for the intervention group compared with the control group. The program would have been cost saving if HFDM costs had been 24% lower. CONCLUSION: The HFDM intervention, administered over 90 days to patients hospitalized for heart failure, succeeded in reducing the rate of heart failure hospitalizations, although this effect was partially offset by an increase in non-heart failure hospitalizations. The resulting modest reduction in all-cause hospitalization costs was exceeded by the cost of the intervention. Thus, although the reduction in heart failure may be interpreted as an improvement in health status, it could not be considered cost saving.

Managing beyond an uncertain illness trajectory: palliative care in advanced heart failure.

A lack of comprehensive and effective palliative care is clearly evident in a number of studies describing the end of life for patients with advanced heart failure. These patients have been portrayed as experiencing a wide array of poorly managed symptoms. The primary rationale for the lack of care has been the uncertain illness trajectory that characterizes living with advanced heart failure. Nurses must manage care beyond the illness trajectory from an emphasis of palliative care as each of these patients may face significant illness burden and even sudden death. The purpose of this paper is to: discuss the current status of palliative care for patients with advanced heart failure; explain the basic pathophysiology and resulting signs and symptoms of advanced heart failure; describe pharmacological and non-pharmacological symptom management strategies for patients with advanced heart failure.

Telecardiology: one-lead electrocardiogram monitoring and nurse triage in chronic heart failure.

We investigated a home-based intervention based on telecardiology in patients with chronic heart failure (CHF). Two hundred and thirty CHF patients, aged 59 years (SD 9), in stable condition and with optimized therapy were enrolled. The programme consisted of trans-telephonic follow-up and electrocardiogram (ECG) monitoring followed by visits from a paramedical and medical team. The patient could call the centre when required (tele-assistance), while the team could call the patient at prescheduled times (telemonitoring). During the first 12 months, there were 3767 calls (873 ad hoc and 2894 scheduled calls). There were 648 events, including 126 episodes of asymptomatic hypotension and 168 episodes which were not due to cardiological symptoms. No actions were taken by the nurse after 2417 calls (64%). A change in therapy was suggested after 418 calls, hospital admission in 62 patients, further investigations for 243 patients and a consultation with the general practitioner in 41 patients. A total of 2303 one-lead ECG recordings were received (10 per patient); 126 recordings (6%) were diagnosed as pathological in comparison with the baseline one. The one-lead ECG recording was used for titration of beta-blockers in 79 patients (mean dosage 38 mg vs 42 mg, P<0.01). Home telenursing could be an important application of telemedicine and single-lead ECG recording seems to offer additional benefit in comparison with telephone follow-up alone.

Advance-practice nursing in heart-failure management: an integrative review.

The number of patients with heart failure (HF) is predicted to escalate into the next decade, whereas the number of cardiac specialists who are skilled in evidence-based recommendations in HF practice will struggle to provide available, quality care. The advance-practice nurse, whose focus is HF management, may be an important key to improving access to this growing aggregate. This integrative review indicates the positive cost-to-benefit ratio for the advance-practice nurse's collaboration in HF management. Other measurable nursing outcomes have yet to scratch the surface, thereby inviting studies into areas that will promote the patient's quality of life.

Agreement and clinical utility of 2 techniques for measuring cardiac output in patients with low cardiac output.

BACKGROUND: The reliability of cardiac output obtained with the bolus technique is a problem. OBJECTIVES: To compare measurements of cardiac output measured with bolus and continuous techniques in patients with low cardiac output and to determine if measurements obtained with the continuous technique increased the number of subsequent clinical decisions. METHODS: In 60 intensive care patients, a nurse recorded a single continuous cardiac output measurement and then obtained the mean of 3 consecutive bolus determinations. The medical records of these 60 patients (experimental group) for the next 48 hours and of 60 other patients with regular or mixed venous oximetry catheters (control group) were reviewed to assess the occurrence of cardiac output events and the frequency of clinical decisions based on the events. RESULTS: Mean cardiac output was 4.46 L/min by the continuous technique and 5.20 L/min by the bolus technique (P = .011) for the experimental group. Median bias between the 2 types of measurements was -0.10 L/min (P = .79). Twenty-three of the pairs (38%) had an absolute percent difference greater than 15%. Of these, 18 (78%) had a higher bolus reading. Treatment decisions per 48 hours were 9.9 for the experimental group and 8.6 for the control group (P = .014). Median length of stay was 2 days less in the experimental group (P = .02), and mean highest cardiac output was 0.81 L/min higher (P = .009). CONCLUSIONS: Measurements of cardiac output determined with the continuous technique may be more precise than measurements determined with the bolus technique. Continuous cardiac output information increases the number of treatment decisions and actions that may shorten hospital length of stay.

Nursing diagnoses, indicators, and interventions in an outpatient cardiac rehabilitation program.

This study identified two nursing diagnoses used in an outpatient cardiac rehabilitation program. The indicators and interventions for these diagnoses were also identified. We feel that nurses in cardiac rehabilitation programs will find these diagnostic labels to be clinically useful. The indicators may also help nurses decide when to use the diagnostic labels. The interventions will provide direction on how to treat these nursing diagnoses. The use of nursing diagnoses in this setting helps clarify nursing's unique role in a multidisciplinary team providing services to participants in outpatient cardiac rehabilitation programs.

IV inotropic agents: dopamine, dobutamine, and amrinone.

Three commonly used IV inotropic agents--dopamine, dobutamine, and amrinone--have been discussed in this article. Knowledge of their common mechanisms of action, individual actions, dosages, methods of preparation, precautions, and side effects can only help critical care nurses maintain or improve the quality of care given to patients receiving these medications.

Postoperative perfusion deficits.

The three keys to successful recovery of the critically ill postoperative patient are: (1) in-depth preoperative assessment and risk evaluation; (2) review of intraoperative course and evaluation of risk for perfusion deficit; and (3) diligent postoperative monitoring for early onset of perfusion deficit. Complications arise when metabolic demands exceed the body's ability to supply essential nutrients. The choice of treatment modality is related to the cause of perfusion deficits. Decreased preload and afterload is treated with fluid and vasopressor therapy. Increased preload is best managed by diuretics and venous dilation. Afterload reduction is accomplished with vasodilator therapy and decreases in sympathetic stimulation. Contraction is enhanced with inotropic therapy and management of preload and afterload within normal ranges. Metabolic demands are best managed with tight control of the patient's hemodynamic profile, oxygen consumption, and environmental stimuli. The challenge of managing the critically ill postoperative patient is great, but the rewards of successful recovery are tremendous.

Management of heart failure in cardiac surgical patients: amrinone and other pharmacologic agents.

The pharmacologic treatment of heart failure and low cardiac output syndrome in the cardiac surgical patient continues to be a challenge in the nursing management of these patients. While the catecholamines have been of proven inotropic benefit over the years, their inherit risks of increased myocardial oxygen consumption, tachyphylaxis and poor tolerance in many patients have lead to the search for other medications to augment cardiac performance. Amrinone, the only drug available for use in the U.S. from the class of phosphodiesterase inhibitors, acts as both an inotrope and vasodilator to increase cardiac output without an increase in myocardial oxygen consumption. This paper reviews pharmacological management of heart failure in the cardiac surgical patient and nursing considerations specific to amrinone and combination inotropic therapy management.

The phenomenon of "stunned" myocardium: implications for coronary care nurses.

In recent years, the use of thrombolytic therapy for the treatment of acute myocardial infarction has become the standard of care. A new phenomenon known as "stunned" myocardium has been described with the use of this treatment. Stunned myocardium refers to tissue that has been reperfused before of necrosis, but that remains dysfunctional. Stunned myocardium can regain its contractile function at any time from several hours to two weeks following reperfusion. It is important for nurses to understand this phenomenon and to incorporate this knowledge in the care of patients in the coronary care unit. Mechanisms that cause stunned myocardium are poorly understood. Some theories include: (a) reduction of ATP levels, (b) coronary artery microvascular spasm or plugging, (c) cytotoxic injury from oxygen-derived free radicals and (d) abnormalities of calcium flux. Nurses need to understand the response of stunned myocardium to various cardiac drugs when caring for post-myocardial infarction patients exhibiting heart failure. It is important to be aware that contractile function may not be optimal for up to two weeks after reperfusion.

The nursing diagnosis of decreased cardiac output.

This descriptive study validated the nursing diagnosis of decreased cardiac output in a critical-care population. A cardiac output assessment tool was developed. Nursing interventions associated with decreased cardiac output were identified and classified as independent, collaborative, and dependent.

Decreased cardiac output: a nursing diagnosis.

Controversy exists regarding whether "Decreased Cardiac Output" is really a nursing, or instead, a medical diagnosis. These authors clarify the importance of this diagnosis for nursing care.

Low cardiac output following cardiac surgery: critical thinking steps.

Patients often experience low cardiac output following cardiac surgery and as many as 90% of patients experience a decreased left ventricular ejection fraction (LVEF) and cardiac index (CI). Causes may vary from volume depletion to global myocardial dysfunction. Critical thinking skills, combined with diligent patient monitoring and a knowledge of cardiovascular physiology and pharmacology are required for prompt recognition and treatment of low cardiac output following cardiac surgery.

Decreased cardiac output: case for a collaborative diagnosis.

The nursing diagnosis Cardiac Output, Alteration in: Decreased (COAD) continues to be challenged as an appropriate nursing diagnostic category. Two areas of concern are the interdependent interventions associated with this physiologic diagnosis and the potential misuse of the diagnosis due to incomplete refinement of the diagnostic category. A new conceptual framework is suggested for dealing with physiologic diagnostic categories and ways to refine the definition, the etiologies, and the defining characteristics of COAD for use as a collaborative diagnosis are discussed.

Assessing and treating decreased cardiac output.

The compensatory pathophysiological mechanisms for a decreased cardiac output are explored via three case studies. The assessments and nursing interventions appropriate to these patients are included in separate tables. Evaluation and decision making about the patient's clinical status and responses are major nursing responsibilities that require astute assessment and skilled intervention to lead to optimal patient outcomes.