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M/S Critical Care

Quiz 2 - Cardiac

Question	Answer
Non-modifiable risk factors?	Gender, heredity, inc age, family hx, ethnicity
Modifiable risk factors?	HTN, smoking, elevated lipids, DM, physical inactivity, stress, excessive ETOH, inflam (CRP); Metabolic Syndrome -- central obesity (women < 35 in, men < 45 in), glucose intolerance, dyslipidemia, HTN
Cardiac assessment?	Inspect, palpate, auscultate; Begin with peripheral observations and move in toward precordium -- pulse and BP, extremities, neck vessels, precordium
Assessing jugular vein distention?	HOB at 45 degree angle; right sided heart failure/issues = JVD; right ventricle not moving forward or inc capillary pressure affecting right ventricle
Inspect precordium?	Note contour, pulsations, lifts, heaves, retractions; Apical pulse may be visible in some circumstances
Place stethoscope for aortic valve?	B/w 2nd and 3rd ICS, right sternal border
Place stethoscope for pulmonic valve?	B/w 2nd and 3rd ICS, left sternal border
Place stethoscope for Erb's point?	B/w 3rd and 4th ICS, left sternal border
Place stethoscope for tricuspic valve?	B/w 3rd, 4th, 5th, and 6th ICS, left sternal border
Place stethoscope for mitral valve?	B/w 5th and 6th ICP, midclavicular line
Place stethoscope for apex of heart?	5th intercostal space, midclavicular line
Forceful of displaced movement of apex?	May be d/t ventricular hypertrophy or inc CO
Palpate precordium?	Use palmar surface or hands or fingertips; Note pulsations, thrills, lifts, heavies;
Stethoscope auscultation parts?	Diaphragm for S1 and S2; Bell for S3 and S4
Auscultation of heart?	All 5 areas -- diaphragm = firm pressure, bell = light pressure, systematic approach; Rate -- 60-100 BPM; Rhythm -- normal reg; Pitch -- S2 higher pitched than S2 heart sound
S1?	Produced by mitral and tricuspid valve closure -- louder at apex, synchonized with carotid pulse
S2?	Produced by aortic and pulmonic valve closure -- louder at base, may be split during deep inspiration
Normal cardiac findings?	BP and pulse WNL; peripheral pulses bilaterally; JVD & edema absent; apical pulse at 5th ICS, MCL and 2-3 cm diameter; S1 loudest at apex, S2 loudest at base; No murmurs, S3 or S4
Abnormal heart sound -- S3? (Just after S2)	"Ken-tuck-y"; Low pitched, distant thunder, heard best will bell; Rapid filling of L ventricle during diastole; Normal -- children and young adults; Abnormal -- adults persists when sits up, fluid overload (CHF, mitral/tricuspid regurgitation)
Abnormal heart sound -- S4? (Just before S1)	"Ten-ness-ee"; Soft, low pitched, heard best with bell; Normal (physiologic) occur in adults w/no CV disease, following exercise; Abnormal -- atrial contraction filling stiff, noncompliant vent (L vent hypertrophy and systolic OL d/t aortic stenosis, HTN)
Gallop?	All 4 sounds; Horse running along; Post MI, acute decompensated HF, ventricles not handling it well
Heart sounds and timing of cardiac cycle?	S1 -- Isometric contraction, systole ejection, atria filling; S2 -- isometric relaxation, diastole rapid filling, AV valves open, vent filling passively, AV tricuspid and mitral valves closing; S3 -- ventricular gallop; S4 -- atrial gallop
Normal ejection fraction?	60-65%; What's left in ventricle after ejection
Heart murmurs?	Blowing, swooshing sound; Occurs w/turbulent blood flow in heart or great vessels; May be innocent/normal -- suspect abnormal until proven otherwise
Heart murmurs intensity?	Grade I -- very faint; II -- audible, barely; III -- easily heard; IV -- loud; V -- loud w/ a thrill; VI -- audible w/o stethoscope, with a thrill
Cardiac enzymes labs?	1) CK-MB 2) Troponin 3) Myoglobin
Cardiac enzyme -- CK-MB?	Released when heart muscle dies, rise 4-8 hrs, peak 15-24 hrs, stays 2-3 days, 3 draws
Cardiac enzyme -- Troponin?	Protein, myocardial specific, risk 3-6 hrs, peak 12-48 hrs, stays 5-10 days
Cardiac enzyme -- Myoglobin?	Protein released when muscle tissue dies, not cardiac specific but can help r/o if not inc; within 1 hr
Serum lipid profile labs?	Cholesterol, triglycerides, LDL, HDL
Serum lipid profile -- total cholesterol?	< 200; LDL bad stuff, deposits in vessels -> plaque, < 130; HDL good stuff, sweeps vessels and picks up LDL and back to liver, > 40; Triglycerides < 150
Electrolytes labs?	K, Mg, Na, Ca
Drug level labs?	Digoxin 0.5-2 ng/mL; positive inotrope; S/s toxicity -- green halos, N/V
Coagulation studies labs?	PT -- 10-20 sec; PTT -- 30-45 sec; INR -- A-fib 2-3, mechanical valve 2.5-3.5
CBC with ESR labs?	Low hgb?
B-type natriuretic peptide labs?	Released by body when ventricles stretch; can tell when pt in HF; kidneys ditch Na and H20; > 100 HF, > 400 cardiac
TSH labs?	Low = A-fib, lipid deposition
BUN/creatinine labs?	Liver affected by heart
Diagnostic tests?	EKG; Hemodynamic monitoring -- arterial line, central venous pressure, pulmonary artery catheter; Cardiac imaging and angiography; Blood studies
EKG?	Electrical activity of heart -- detects abnormal rhythms; May show MI in progress/past; 12-lead, cont 3 or 5 lead tracing; Pt must lie still in 12-lead; Cont tracing -- apply leads to clean, dry, non-hairy skin, monitor skin condition
Holter monitoring?	Monitor worn by pt and EKG tracing recorded cont over 24 hrs or more; Nursing interventions -- prepare skin, apply electrodes/leads, instruct pt resume normal daily activity and keep documenting activity and symptoms, no bath/shower during monitoring
Invasive hemodynamic monitoring types?	1) Intra-arterial blood pressure 2) Central venous pressure 3) Pulmonary artery catheter; 2 complications -- bleeding and thrombus formation
Intra-arterial blood pressure?	Cont arterial pressure monitoring -- systolic, diastolic, mean arterial pressures; Usually radially artery
Central venous pressure?	Measures filling pressures on right side of heart;
Pulmonary artery catheter?	Assess pressures in right atrium, right ventricle, pulmonary artery; Indirectly measure and/or calculate left vent pressures, preload, afterload, pulmonary and systolic vascular resistance
Removing an ART line?	Get gloves, dressing; Turn off ART alarm and flush; Hold for 5 min at least
Transducer location?	Usually seen in bed next to pt but level to phlebostatic access is key!
Indications for PA catheter?	Ask yourself if we need detailed info from PA catheter? If so.. CHF/Pulmonary Edema; MI, cardiac tamponade; Post open-heart; Shock -- cardiogenic or septic; Trauma, severe burns; ARDS; Neuro or renal pts
Nursing responsibility with hemodynamic monitoring?	Assist w/insertion; Monitor insertion site; Interpret waveforms; Record hourly readings (per protocol or order); Perform CO measuresa and wedge pressure per protocol or order; Maintain system -- troubleshoot; Prevent complications
PA catheter waveforms?	Right atrium -- pressures low, 0-10 mm Hg; Right ventricle -- 25 mm Hg systolic and 0 mm Hg diastolic; Pulmonary artery -- systolic the same, diastolic little higher, *we want to see at all times; Pulmonary capillary wedge -- 10 mm Hg
Hemodynamic parameters -- right atrial pressure?	CVP; high = overload, right ventricle b/c high inc pulmonary vascular pressure; low = dehydration, volume not going to right side of heart, need to improve volume
Hemodynamic parameters -- wedge pressure?	PAWP (PAOP); high = overload, left vent not moving volume forward and inc pressure; low = dehydration, no volume to left side of heart
Hemodynamic parameters -- cardiac output?	SV x HR; 4-8 liters/min
Hemodynamic parameters -- cardiac index?	2.2-4.0 liters/min/mm^2; CO divided by BSA; more specific to pt
Chest x-ray?	Gives info on size of heart; Position of heart; Condition of lungs; Usually routinely done (inexpensive); Often old films avaiable for compare; Nursing interventions -- explain purpose and procedure, remove jewelry
Cardiac cath?	Dx exam of heart and great vessels; Catheter into heart and surrounding vessels -- radiographic contrast injected for visual; Right vs left; Therapeutic -- Percutaneous Coronary Intervention (PCI) w/ angioplasty or stent placement, Athrectomy, laser tx
Coronary circulation?	Coronary arteries perfuse during diastole, aortic valve open; Right coronary artery to right side of heart, left coronary artery to left side, most problems here
Cardiac cath preprocedure?	Informed consent; Allergy to seafood, iodine, radiopaque dye; NPO 6-8 hrs -- sips w/meds; Baseline vitals, quality/presence of peripheral pulses; Start IV; Preprocedure med; Usually right femoral artery
Cardiac cath pt teaching?	Need to lie still and quiet on hard exam table; May feel warm, flushed feeling when dye injected; Palpations of fluttery feeling as catheter advanced
Coronary stent placement?	Keep vessel open; Heparin during procedure, reversal with Protamine; 20 min - hemostasis
Cardiac cath postprocedure?	Monitor VSs, cardiac rhythm, peripheral pulses, color, sensation, warmth of affected extremity -- bedrest, HOB
Affected extremity straight?	Few hours if device used; 6 hrs if nothing
Mucomyst?	Protect kidneys from dye; Protect liver from Tylenol OD
Hematoma?	Bleeding into deeper tissue plains; If occurs, can compress femoral nerve/infection; New/expanding ones, report to physican
Cardiac cath -- closure devices?	AngioSeal -- collagen based plug; Perclose -- suture based closure; FemoStop -- mechanical compression
Cardiac cath -- when to notify physican?	Bleeding -- sig oozing, bleeding, hematoma formations; Change in LOC; Chest pain, inc HR, hypotension, bradycardia, rhythm change; Inc pain at puncture site; Cool, pale, cyanosis, numb/tingling, loss peripheral pulses in extremity or change in quality
Additional cardiac imaging tests?	1) Cardiac stress test (treadmill) 2) Radionuclide testing 3) Echocardiogram 4) Electrophysiology Study (EP)
Cardiac stress test (treadmill)?	Studies heart during activity -- detects/eval CAD; May be used with radionucleotide testing; Pt should wear comfy shoes; Watching for s/s ischemia -- ST segment depression; 12-lead EKG + echocardiogram + BP cuff
Pt unable to tolerate exercise?	Pharmacologic agent to stress heart and inc contractility -- Dobutamine or dilate coronary arteries -- dipyridamole; Dipyridamole hold caffeine and theophylline products 12 hrs before
Echocardiogram?	Transducer emits and records sound waves; Can record direction and blood flow through heart; Measure wall motion, valvular and structural abnormalities, cardiac fx; May be done in combo w/stress testing
Echocardiogram nursing interventions?	Explain procedure; Advise pt to lie still (usually on left side) and breathe normally
Lethal arrhythmias?	V-tach and V-fib; Asystole
Sinus rhythm?	60-100 BPM; Regular rhythm -- R to R, P to P same distance; P wave before QRST; PR interval .12-2.0; Sinus tachy = 150-160; Sinus brady = < 60 (Atropine pushed quickly!)
Atrial fibrillation?	Irregular; No P waves at all; # 1 priority is rate too fast so no fill time = lose atrial kick; Expect Ca channel blockers - Verapamil + beta blocker; Worry about blood clots; New onset-48 hrs not likely to form clots, Coumadin prevention
Ventricular tachycardia?	Run of PVCs = 3 or more; QRS wide and bizzare; T wave of opposite polarity; Cornerstone -- really good CPR; Amiodarone drug of choice -- very large half life, can cause pul fibrosis, pul fx test, thyroid testing, corneal deposits, eye testing
Ventricular fibrillation?	Pulseless, unresponsive if true V-fib; Ventricles quivering; CPR, code team, code card
Asystole?	Nothing; Might have one idioventricular complex
Defibrillation?	Emergency situation -- pulseless V-tach and v-fib, rapid defib most successful; Electric current delivered to heart to depolarize myocardium; Monophasic vs Biphasic
Monophasic defibrillation?	Usually starts at 360 joules for pulseless v-tach, v-fib
Biphasic defribrillation?	Usually 150-200 joules (depends on brand); Bounces energy back and forth, can use less energy
Compression only BLS?	Don't need airway but keeps circulation going -- 100 x min, depth of 2 cm)
Synchronized cardioversion?	Shock "synchronized" to deliver shock on "R" wave of QRS -- must turn ON synchronize!; Indicated for hemodynamically unstable v-tach of SVT -- lower energy compared to defib; Emergent or non-emergent -- Sedation and airway management
Synchonized cardioversion different from AED?	Lower energy used; Shock synchronized -- may put pt in v-fib, one nurse before AND after
Pacemaker therapy?	Temp (transvenous, epicardial, transcutaneous) or permanent; TV -- into right atrium, ventricle or swann/PA catheter; Epi -- after bypass/valvular surgery, attach to outside; TC -- through skin, patches
Permanent pacemaker?	Battery operated generator/sensing mechanism placed in subq pocket at shoulder in right or left subclavian area; Lead wires introduced intravenously (cephalic or subclavian vein) to right side of heart; One, two, or three leads
Biventricular pacing?	Both ventricles at the same time; Find venous outflows and thread catheter here
Temporary pacer?	ST helps regulate heart; Temp assistance until permanent pacer can be placed; Microshock -- touching bare wire + metal bed/pole can put pt in lethal dysrhythmia
Indications for pacemakers?	Sinus node dysfunction; Some types of heart block; Tachydysrhythmias; Cardiac resynchronization therapy (CRT) for HF; Temp transcutaneous pacing (external pacer) may be done for asystole or severe bradycardia
Permanent pacemaker post-op care?	Monitor EKG, HR -- pacing impulses (pacer strikes) and "capture"; VSs, LOC, CXR; Observe dressing/insertion site for indications of bleeding/infection; Minimal arm and shoulder activity -- arm in sling as ordered
Pt teaching for permanent pacemaker insertion?	Monitor for s/s failure -- pt take own pulse; Advise medic alert bracelet and carry ID; Incision care -- s/s infection, no baths/swimming x 1wk; Activity -- do not raise arm above head x 1 wk or more; Precautions -- elec gen, security, MRI, cell, earbuds
Implantable cardioverter/defibrillator used to treat?	Ventricular tachycardia, ventricular fibrillation
Implantable cardioverter/defibrillator?	Constantly monitors heart rhythm; Programmed deliver "tiered" tx -- antitachycardia pacing -> cardiovert -> defibrillation; May also have pacemaker fx for bradycardia
Nursing care post ICD implant?	Incision for redness, swelling, infection; Cardiac rhythm; Pt teaching -- alert bracelet, sit/lie down if shocks, record "shocks", call if light-headed, fatigue, palpitations, SOB, beeping tones, if unconscious rescuers wear rubber gloves, no H2O
Risk factors for sudden cardiac death r/t ICD?	Male, esp Af Amer, family hx early cardiac death, smoking, DM, hypercholesterolemia, HTN, ejection fraction < 40%, hx ventricular arrhythmias
Coronary artery disease -- atherosclerosis?	Focal deposit of cholesterol and lipids within intima of artery; Stages -- fatty streak, fibrous plaque, complicated lesion; Progressive -- narrowing and pt develop angina, s/s imbalance in supply of O2 and demand by myocardial tissue
Types of angina?	Stable -- predictable pattern; Unstable -- unpredictable, at rest, inc severity, new onset; Prinzmetal -- c/b arterial spasm, manage w/calcium channel blocker
Acute coronary syndrome?	Unstable angina -- high risk MI; Non-ST elevation MI (NSTEMI) -- not candidate for thrombolytics, may go to cath lab, tx medically; ST elevation MI (STEMI) -- goal to reperfuse
Components of patho of MI?	1) Ischemic conditions 2) Cellular death 3) Tissue changes
Patho of MI -- ischemic conditions?	After 8-10 sec affected myocardium -> cyanotic, cooler; Anaerobic metabolism -> acidosis; K+, Ca++, Mg+ leak = suppress impulse conduct; Cells lose contractility = diminished pumping; Myocardial cells release cathcholamines = dys, inc FFAs & glucose
Patho of MI -- cellular death?	After 20 min of ischemia -> irreversible cell death and tissue necrosis, release CK-MB and troponins
Patho of MI -- tissue changes?	Severe inflammatory response -- degradation, proliferation of fibroblasts, scar tissue; 24 hrs -- infiltration of leukocytes and scavenger neutrophils; 10-14 days -- weak, mushy collagen matrix formed; 6 weeks -- scar tissue replaces necrotic area
Care of MI patient?	Goal is three-fold -- limit cardiac size, rapidly inc myocardial blood and O2 supply, red myocaridal O2 demand; Time = muscle! Golden hour -- 1st 60 min
MI, coronary occlusion, heart attack pain?	Sudden onset, substernal, crushing, tightness, severe, unrelieved by nitro, may radiate to: back, neck, jaw, shoulder, arm
MI, coronary occlusion, heart attack other s/s	Dyspnea, syncope (dec BP), N/V, extreme weakness, diaphoresis, denial common, inc HR
MI, coronary occlusion, heart attack treatment?	O2, IV, meds, monitor; Dietary restrictions -- dec Na, cholesterol, caffeine; Surgery? Pacemaker?
MI diagnostic tests?	12 lead EKG, cardiac enzymes/troponin/myoglobin, hemodynamic monitoring, CXR, echocardiogram, TEE, coronary angiogram, nuclear imaging, treadmill testing
Common 12 lead EKG changes from MI?	Elevated ST segment, inverted T wave; Tall R wave, ST depression
MI collaborative care?	1) ABCs, cardiac monitoring, assess chest discomfort, VSs, IV access 2) O2 per order (24-48 hrs) 3) Administer meds 4) Other meds
MI O2 per order?	Keep sats > 90%; Semi-fowler position enhances tissue oxygenation
MI administer meds?	1) ASA (chew) 2) Nitroglycerin 3) IV morphine sulfate 4) Beta adrenergic blockers 5) Heparin 6) Glycoprotein IIB/IIA inhibitors
MI meds -- ASA?	Inhibits platelet activation; May also use other antiplatelet meds (Ticlid, Plavix)
MI meds -- Nitroglycerin?	Dilates vascular smooth muscle; Reduces cardiac O2 demand; HOLD if SBP < 90
MI meds -- IV morphine sulfate?	(Small increment doses) relieves pain/anxiety, vasodilates, dec myocardial O2 demands, dec HR
MI meds -- Beta adrenergic blockers?	Block action of cathcholamines
MI meds -- Heparin?	Inhibit further clot formation, prevent reocclusion after thrombolytic therapy/PTCA
MI meds -- Glycoprotein IIB/IIA Inhibitors?	abciximab (ReoPro), epitfibatide (Integrilin), tirofiban (Aggrestat); Monitor for bleeding
MI -- other meds?	Diuretics; Lipid lowering -- simvastatin (Zorcor) or atorvastatin (Lipitor) to red cholesterol levels and inflammation; Stool softener -- prevent valsalva
MI ongoing care?	Monitor I&O, assess RR, heart/breath sound for s/s HR; Activity -- as tolerated, inc gradually, monitor for complications (dysrhythmia, chest pain, change in VSs); Diet -- NPO if nauseated, progress to low Na/fat as tolerated
MI complications?	Dysrhythmia (MOST COMMON), HF, cardiogenic shock, ventricular aneurysm, ventricular septal rupture, cardiac wall rupture, papillary muscle rupture, pericarditis
Reperfusion therapy?	Percutaneous coronary intervention (PCI) -- angioplasty, stent; Fibrinolytic tx -- recombinant plasminogen activator (rTA, reteplase), tissue plasminogen activator (tPA, alteplase), TNK-tPA, tenecteplase, streptokinase; Cononary Artery Bypass Graft (CABG)
Before fibrinolyic therapy?	Tx start no more than 4-6 hrs after chest pain onset (goal door to needle < 30 min); Rapid screening -- no cond cause hemorrhage, stroke, recent sx, bleeding disorder; Institution protocol -- blood draws/IV first, open artery and pain relief is goal
Following fibrinolytic therapy?	Monitor for bleeding -- major = turn off infusion, call phys; Goal is reperfusion -- resolution of ST seg elevation, chest pain relief, rising CK-MB, reperfusion dysrhythmias; Reocclusion may occur -- Heparin drip to prevent
CABG surgery?	Off pump CABG -- w/o use of cardiopulmonary bypass, done on beating heart; MIDCAB left anterior small thoracotomy -- video assisted, for proximal disease of LAD/RCA using LIMA, radial, saphenous veins, pharmacological measures to slow heart (BB)
Pre-op cardiac surgery?	Conset; Teach about procedure, TCDB, IS
Post-op cardiac surgery ICU?	Close monitoring 12-24 hrs; A-line BP, cont EKG, pulse ox; PA catheter, body temp; Paced HR < 70 (wires from surg); Pleural/mediastinal tubes; Early extubation within 6 hrs; After 24 hrs go to tele/step down -- ambulate q4 x day at least (pain meds!)
Post-op cardiac surgery complications?	Pulmonary -- TCDB, IS; Neuro -- LOC, VSs; Dysrhythmias -- atrial fibrillation may occur 2nd/3rd day post sx; Infection -- incisions, s/s pneumonia, UTI, endocarditis
Post-op cardiac surgery teaching?	ID risk factors; Home care and rehab; Meds; Comm resources and support (Mended Hearts); ID/modify risk factors for CAD -- Diet (dec sat fat, cholesterol, inc complex carbs), activity (walking, cardiac rehab); Meds; Psychosocial
Heart failure?	Syndrome when heart unable to function as effective pump; Most common dx hospitalized pts > 65; Inc freq in US; Causes -- CAD, ischemia, HTN, DM, valvular heart disease, MI, infection
Left sided heart failure s/s?	Paroxysmal nocturnal dyspnea, elevated pulmonary capillary wedge pressure, cough, crackles, wheezes, blood tinged sputum, restlessness, confusion, orthopnea, tachycardia, exertional dyspnea, cyanosis
Right sided heart failure s/s?	Fatigue, inc peripheral venous pressure, ascites, enlarged liver and spleen, distended jugular veins, anorexia and complaints of GI distress, swelling in hands and fingers, dependent edema
Heart failure -- decreased CO?	Causes release of neurohormones; Na+ and H2O retention = activate renin-angiotensin-aldosterone system; Inc sympathetic tone -- epi/NE; Initial response compensatory -- eventually damage to heart, ventricular remodeling, dec SV
Patho of heart failure?	Myocardial insult -> myocardial dysfunction -> reduced system perfusion -> sympathetic system activation and renin-angiotensin-aldosterone system activation -> altered gene expression and apoptosis -> remodeling
New York Heart Association Classification of HF?	Class I: Minimal, no limitations; Class II: Mild, slight limitations; Class III: Moderate, markedly limited activity; Class IV: Severe, unable to perform ADLs w/o symptoms
HF Staging System?	Stage A - D; earlier tx SLOWS progression
Stage A?	Pts at risk d/t co-morbidities; HTN, DM, CAD; Treat w/ ACE inhibitor
Stage B?	No s/s, have developed structural heart disease; Treat w/ ACE inhibitors and BB
Stage C?	Structural disease + s/s; Treat w/ diuretics, ACE inhibitors, BB, ARB's
Stage D?	Marked symptoms of HF; Frequent trips to ED, repeat ICU pts
Heart failure diagnostics?	1) EKG 2) CBC 3) Serum creatinine/BUN 4) BNP 5) Electrolytes 6) Thyroid levels 7) Hemodynamic monitoring 8) Serum albumin 9) Echocardiogram 10) CXR 11) ABG's
HF diagnostics -- EKG?	Indicators of ischemia, hypertrophy, dysrhythmia
HF diagnostics -- CBC?	Anemia -- dec O2 carrying capacity
HF diagnostics -- Hemodynamic monitoring?	RA pressure inc in RV failure; PAP and PAWP inc in LV failure
HF diagnostics -- Serum albumin?	Decreased -- volume overload
HF diagnostics -- CXR?	Hypertrophy
HF diagnostics -- ABG's?	Hypoxia
HF management?	Remove cause, if possible -- sx of structural abnormalities, medical tx of HTN and endocarditis, treat infections, manage arrhythmias; Unable to treat cause, control HF -- reduce WL of heart, manipulate HR, contractility, preload, afterload
Nursing interventions for acute HF?	Monitor VSs, heart sounds, cardiac rhythm, pulse ox; O2 -- high Fowler's; Resp assess -- lung sounds, O2 sat, ABGs; I&O -- foley for accurate output; Labs -- electrolytes; Meds -- ACEI/ARBs, BB, diuretics, inotropic meds, vasodilators, bronchodilators
Treatment goals for HF?	Red intravascular volume, dec venous return, dec afterload, improve gas exchange, improve cardiac function, dec anxiety
ACE inhibitors and ARBs?	ACEI -- enalapril (Vasotec), forsinopril (Monopril), ramipril (Altace); ARBs -- valsartan (Diovan), irbesartan (Avapro), iosartan (Cozaar); Both can cause hypotension, orthostatic; Monitor for hyperkalemia
Beta-adrenergic blockers?	carvedilol (Coreg), metroprolol (Lopressor), bisoprolol (Zebeta) approved for mgt chronic HF; Drug titrated upward while pt monitored -- BP, pulse, activity tol, orthopnea; Resting HR b/w 55-60, slight inc w/exercise; Pt weigh daily, report worsening HF
Diuretics?	Loop -- Lasix, Bumex; Thiazide -- Hydrochlorothiazide (HCTZ, HydroDIURIL), diuresis onset more gradual; K+ sparing -- spironolactone (Aldactone), watch for hyperkalemia, teach pt avoid high K+ foods
Venous vasodilators?	Nitrates -- isosorbide (Isorbid), Nitroglycerin (ER, buccal, IV, oint, SL, transdermal, transmucosal, translingual spray; HA, tolerance, do not use w/erectile dys meds); Digoxin -- symptomatic relief, teach s/s toxicity, monitor dig and K+ levels
HF instructions?	Encourage pts verbalize feelings about lifestyle changes; Discuss/ID risk factors; Meds -- indications, when to take, SEs, when to call doc; Diet -- low sodium, fat, cholesterol; Fluid restriction -- spread throughout day
HF instructions -- daily?	Rest balanced w/activity; Weigh w/o clothes at same time; Take meds as prescribed; Take pulse (if on Digoxin)
HF instructions -- call the doctor if?	Weight gain 3 lbs in 2 days or 3-5 lbs in 1 week; Experience SOB, palpitations, persistant cough, drop in urine output; Pulse < 60 on Digoxin, signs of toxicity
HF complications?	Pleural effusion; Pericardial effusion, tamponade; Thrombus -- may embolize, risk of stroke; Hepatomegaly; RF; Cardiogenic shock; Acute decompensated HF -- Pulmonary Edema
Pulmonary Edema in HF -- 2 stages of patho?	Inc L heart pressure -> pulmonary interstitial edema -> inc lymphatic flow; Fluid moves from interstitium into alveoli -> diffusion abnormalities
S/s pulmonary edema?	Extreme dyspnea, tachypnea, resp distress; Pink, frothy sputum; Agitated, restlessness, diaphoretic; Skin is cold, ashen, may be cyanotic
Collaborative management of pulmonary edema?	Diuretics -- dec preload and red vol overload; Morphine -- dec preload, relieve anxiety/pain; Vasodilators -- red afterload; Nitrates -- red preload and dilate coronary arteries; Inotropic meds -- improve contractility
Cardiogenic shock?	Clinical syndrome -- inadequate tissue perfusion = cellular hypoxia; Leads to -- accumulation of metabolic waste, cellular degeneration, eventual organ failure
Causes of cardiogenic shock?	MI w/resulting pump failure; Rate, rhythm, efficiency of pump impaired; Usually L ventricle; May result from cardiac tamponade; May result from HF; May result from valvular dysfunction
Cardiac output equation?	CO = SV X HR; Dec CO results from low stoke volume if HR can't compensate
Physical assessment for cardiogenic shock?	Skin cool, moist, pale; BP <90 systolic or 30 mm Hg < baseline; Tachy; Weak, thready pulses; Dec CO/CI; Inc PAWP, RAP, SVR; Neuro -- LOC, restless; Renal -- UOP <30 cc/hr; Pul -- dyspnea, tachypnea, low pulse ox, congest (resp alk 1st -> met & resp acid)
Management of cardiogenic shock?	Adminster O2 as prescribed -- prepare for intubation and mech vent; IV morphine -- dec pul cong and relieve pain; Diuretics, nitrates -- cont BP monitoring; Vasopressors, (+) inotropes -- maintain organ perfusion
ADHF/Cardiogenic Shock meds -- inotropic agents?	Inc contractility; dobutamine (Dobutrex), milrinone (Primacor)
ADHF/Cardiogenic Shock meds -- vasoconstrictors?	Inc BP and MAP; dopamine (Intropin), nonepinephrine (Levophed), phenylephrine
ADHF/Cardiogenic Shock meds -- vasodilator?	Inc myocardial perfusion; nitroglycerin, nitroprusside
Nursing Interventions of ADHF/Cardiogenic Shock?	Assist w/insertion of pul artery catheter; Treat cause -- PTCA, CABG, thrombolytic tx; Prepare for IABP insertion; Anti-dys agents -- dys result from A/B alterations, ischemia, MI -> dec CO; Pacing or cardioversion
Intraaortic Balloon Pump (IABP)?	Temp mechanical circulatory assist device 1:1, 1:2, 1:3; Supports failing circulation -- MI, shock, AHF; Diastole -- inflates, assist coronary bloodflow; Systole -- deflates, dec afterload & improve cardiac circulation; "Counter pulsation device"
Nursing care for IABP?	Leg straight, restrain leg; HOB < 30 deg; Check pulse in affected leg and L wrist; Clot risk; Immobility risk; Monitor UOP; Check site for infection
Types of Valvular Heart Disease?	1) Aortic valve stenosis 2) Aortic valve regurgitation 3) Mitral valve stenosis 4) Mitral valve regurgitation
Aortic valve stenosis?	Exertional dyspnea, fatigue, exercise intolerance, syncope, angina, HF, systolic murmur
Aortic valve regurgitation?	Fatigue, dyspnea, palpitations, angina, diastolic murmur
Mitral valve stenosis?	Dyspnea, fatigue, orthopnea, paroxysmal noctural dyspnea, hemoptysis, A-fib, diastolic murmur
Mitral valve regurgitation?	Weakness, fatigue, palpitations, dyspnea, low CO w/pulmonary congestion, systolic murmur
Diagnostics of valvular heart disease?	H&P, CXR, EKG, Echo, Cath
Nonsurgical management of valvular heart disease?	BBs, diuretics, digoxin; Anticoag, antiarrhythmics (A-fib); Vasodilators (regur valves, improves CO); Nitrates (caution in pt w/aortic stenosis); Prophylactic ABX (no longer recomm); Fluid balance (Na restrict, diuretics); Pt education
Surgical management of valvular heart disease?	Reparative -- percutaneous transluminal balloon valvuloplasty, open commissurotomy, mitral annuloplasty; Replacement -- prosthetic valves; *Sx only definitive tx of aortic stenosis -- recommended when angina, syncope, dyspnea on exertion occurs
Types of prosthetic valves?	1) Mechanical 2) Biologic (tissue, pig, cow, human); Pros/cons -- anticoagulant tx, durability
Pre-op care of prosthetic valve sx?	Teaching -- post-op pain, incision care, prevent complications, CCU environment; Anticoagulation -- INR 2.5-3.5
Post-op patient teaching of prosthetic valve sx?	Incision care; Adequate rest; Meds -- diuretics, ABX, antidysrhythmics, anticoagulants; Oral care -- soft toothbrush; Prophylactic ABX before invasive procedures
Predisposing factors for cardiac inflammations/infections?	Cardiac sx; Cardiac defects -- Valvular disease, prosthetic valves, rheumatic heart dis, congenital heart dis; Pacemakers; Cardiomyopathy; IV drug abuse; Invasive procedures involving mucous membranes
S/s infective endocarditis?	New/changing heart murmur; Fever, chills, weakness, fatigue, anorexia; Arthralgias, wt loss, HA; Valvular manifestations
Valvular manifestations of infective endocarditis?	Splinter hemorrhages, petechia in conjunctivae, lips, buccal mucosa, palate, ankles, feet, antecubital, popliteal areas; Osler's nodes, Janeway's lesions, Roth's spots
Diagnostic tests of infective endocarditis?	Blood culture to determine organism; WBC, ESR, CRP; Duke criteria -- + blood cultures, new/changes murmur, echo reveals intracardiac mass or vegitation
Treatment of infective endocarditis?	ABX sensitive to organism -- weeks of therapy, watch for s/s relapse; Valvular sx if compromise s/s
Nursing interventions of infecive endocarditis?	VSs; Signs of HF -- rest balanced w/activity to prevent thrombus formation, antiembolism stockings; Signs vegitative embolization -- splenic, renal, CNS, pulmonary; D/c teaching -- meds, ABX, prevent future infection
Pericarditis?	ID and treat cause; NSAIDs, analgesia -- ABX if infectious, corticosteroids if NSAIDs not effective, avoid ASA/anticoagulants -> inc risk tamponade; Rest -- high Fowler's, upright/leaning forward; Complications -- pericardial effusion, cardiac tamponade
Pericardial effusion?	Escape of fluid into pericardial sac; Slow or rapid; Normally < 50 cc in sac; Can cause dec CO and venous return
Cardiac tamponade?	Compression of heart; S/s -- fullness in chest, pulsus paradoxus, falling arterial BP (narrowing PP), rising venous pressure (inc JVD), distant heart sounds; Notify doc immediately!
Management of tamponade?	Pericardiocentesis; Cont hemodynamic monitoring; Pts at risk -- RF or MI; Monitor for -- pericardial pain, friction rub, dysrhythmias; Maintain adequate CO; Administer NSAIDs, anti-anxiety meds
Cardiomyopathy?	Disease of heart muscle; 3 categories -- hypertrophic, restrictive, dilated; Similar s/s of HF, management similar to HF
Hypertrophic obstructive cardiomyopathy?	Genetically inhereted autosomal dominant; Stiff, non-compliant, hypertrophied L ventricle -- also upper septum w/aortic valve obstruction and mitral regurg; Assoc w/SCD -- ICD dec risk SCD, ETOH ablation of intraventricular septum to dec wall size
Dilated cardiomyopathy?	Gross dilation of ventricles; Ischemic, idopathic (may be genetic link), other causes; Poor contraction, dec CO, dysrhythmia, blood pooling/thrombi, refrectory HF
Restrictive cardiomyopathy?	Myocardial fibrosis -> ventricular wall rigidity, impaired filling, diastolic HF; Idopathic, infiltrative -- amyloidosis, sarcoidosis, radiation; Mgt w/ BB to slow HR, diuretics, low Na+ diet
Cardiomyopathy medications?	ACE inhibitors; BB; Antiarrhythmics, Anticoagulants, ABX -- risk for IE, prophylactic prior to dental/certain sx procedures; DCM -- inotropic agents to improve contract, diuretics, ACE/ARBs; HOCM -- BBs, CCBs, antiarrhythmics
Medications to avoid with cardiomyopathy?	Preload reducers and meds that inc contractility
Treatment of cardiomyopathy?	Biventricular pacemaker -- improves CO in DCM and HOCM, LV EF < 35%, QRS > 0.12 mm; Automatic implantable cardiac defibrillator (AICD) -- HOCM, SCD, impaired systolic fx; Cardiac transplant for end-stage disease
Complications of cardiomyopathy?	HF, dysrhythmias, infective endocarditis, embolism
Hypertensive crisis?	Severe, abrupt elevation in BP -- DBP > 140 mm Hg, HA, dizziness, blurred vision, change in LOC; Causes -- exacerbation of chronic HTN, preeclampsia, pheochromocytoma, drugs, necrotizing vasculitis, head injury, acute aortic dissection
Hypertensive crisis interventions?	Semi-Fowler's position, O2; Meds -- IV nitroprusside (Nitropress), nicardipine (Cardene); Monitor BP, watch for cardiovascular/neuro complications

Created by: teenie0731

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