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Adult Health Test #1
| Question | Answer |
|---|---|
| Central Lines | PICC AND CVL |
| What confirms the placement of a CVL? | X-Ray |
| What technique is used for CVL? | Seldinger technique |
| Central Venous Line | sterile technique at bedside or radiology, SC or IJ vein used. |
| PICC Line | PICC (Peripherally Inserted Cardiac Catheter)- specialty nurse places it, sterile technique used at bedside, uses cephalic or basilic vein, confirm placement by X-Ray. |
| What position should patient be in for removal of CVL? | Supine with head away from insertion site |
| Removal of a CVL | Non-sterile gloves, remove dressing and inspect site, cut sutures, Valsalva Maneuver, remove catheter, apply pressure/dressing (1-5mins for patients not on anticoagulants), inspect catheter tip, and document! |
| What are some Parenteral Nutrition Complications? | Refeeding Syndrome (add Phosphorus), Fluid Volume Overload (mostly PPN), Hyperglcemia (very common), Phlebitis, (heparin or hydrocortisone added to prevent this), Catheter infection, catheter occlusion, CV Thrombosis, and Air Embolism |
| What can catheter infection lead to? | Can lead to osteomyelitis, septic shock, or endocarditis. |
| S/S of Catheter Infection | Erythema, induration, tenderness, and purulence |
| Nursing Management of Parenteral Nutrition Complications | Site care, Glucose control, and May remove/replace |
| Prevention of Catheter Occlusion | Flush ports using positive pressure and fluss PICC with diluted heparin solution. Flush CVL with saline NOT heparin. |
| What do you do for an occluded catheter? | Thrombolytic agents or exchange catheter (Ex: Alteplase) |
| S/S of Central Vein Thrombosis at site | affected side will have swelling in arm, neck, eyes, and head |
| SVC syndrome | Rare, but can happen |
| Tx of CV Thrombosis | removing catheter and/or systemic anticoagulants |
| Air Embolism | 50% mortality rate. Has acute onset with sharp chest pain and hypotension. |
| Nursing Management of Air Embolism | Valsalva maneuver, Patient supine, Occlusive dressing, Trendelenburg on left lateral side (if suspect air embolism), and place patient on 100% non-rebreather O2. |
| Definition of Obesity | Abnormal increase in the proportion of fat cells |
| Primary Obesity | too many calories intake |
| Secondary Obesity | patient has no control over weight gain |
| What is the second leading cause of preventable deaths? | Obesity |
| Goal to decrease obesity | Reduce prevalenc of obesity |
| What percent of Americans are overweight? | 65% |
| Contributing factors to Obesity | Genetics (300 genes may determine weight), Env't (40-50% men/women are inactive), Pyschosocial, and Culture (Qualitative study) |
| Who is considered obese? | BMI (most common measure. uses height and weight), Waist-to-hip (MI risk=WHR), NHANES 1999-2002 |
| Dangers of being obese | Excess weight burdens various organs and joints, Cancer (morbidly obese can cause 1.62X greater risk of all cancers), and Pyschosocial (obese women 3.8X more likely to be depressed). |
| Metabolic Syndrome | group of risk factors that increase your risk for heart disease and other health problems (DM, CVA, etc). |
| What are the five conditions used to diagnose Metabolic Syndrome? | Must have 3 out of 5: Waistline greater than or equal to 40in in men and 35in in women, Triglycerides greater than 150 or on drug Tx, HDL less than 40 in men and 50 in women or drug Tx, SBP greater or equal 130 or DBP greater or equal to 85 or drug Tx |
| What are the five conditions used to diagnose Metabolic Syndrome? | Fasting glucose greater than or equal to 100 or drug Tx. |
| Tx of Metabolic Syndrome | Weight loss, increase physical activity, healthy diet, medications and research (Fatty liver, PCOS, Cholethiasis and Sleep Apnea) |
| Care of Morbidly Obese Patient | Large or thigh cuff, specialty bed, brace for ceramic toilet, skin care (Braeden scale, assess skin folds, keep clean and dry), and provide support (this includes the family. Be sensitive to needs). |
| Management of Obesity | Goals realistic and achievable (family support), diet/exercise, behavioral modifications, medications, surgery |
| Indications for Surgical Therapy for Obesity | When all other medical/dietary treatment has failed |
| Criteria set by NIH for Surgical Therapy for Obesity | BMI greater than 40 or greater than 35 with comorbidities, failed medical management, no psychological contraindications, and less than 60 years old. |
| Vertical Banded Gastroplasty | Restrictive procedure |
| Laparoscopic Adjustable Gastric Banding | Band easily adjusted to increase or decrease restrictive mechanism. |
| Complications of Lap-Band | Slippage or erosion of band, n/v, obstruction, stomach perforation with leak |
| Biliopancreatic Diversion | Removal of 3/4 of intestines and re-routing everything. Most complicated of the current procedures. Used for BMI of greater than 50. |
| Gastric Bypass | Combination of restrictive and malabsorptive. Gold standard. |
| Complications of Gastric Bypass | Leaks, strictures, malnutrition, anemia, dumping syndrome |
| Bariatric Surgery | First 3-6 months: hair thinning/loss, body aches, dry skin, mood changes, fatigue. Improves/resolves medical problems. |
| Post-op care of Bariatric Surgery | Keep HOB 30-45 degree angle, monitor for rapid O2 desaturation, early ambulation prevents DVT (4 hours postop), NGT (very rare. Do NOT touch), Medications (Elixir, No NSAIDS, chewable multivitamin, and crush tabs), turn cough and deep breath. |
| Bariatric Surgery Complications | Dumping Syndrome (avoid sugar to prevent), Anastomotic leak (Life Threatening), and Pulmonary Embolism |
| Diet after Bariatric Surgery | First 24hrs, Sugar free clear liquids (30cc/2hrs). 2 weeks post-op, soft diet and 4-5 small frequent meals. Long term, Discourage drinking carbonated drinks for first 6-8 weeks. It can stretch pouch. |
| What three things must be present in order for oxygenation and ventilation to occur? | 1) Brain must be functioning properly. Brainstem very important! 2) Bellows must be able to breath in and out. 3) Alveolar/Capillary Bed |
| Pulmonary Circulation | Low pressure, low resistance system. Receives full cardiac output. |
| Circulation and Side lying position | allows different areas of the lungs to be oxygenated and perfused. |
| Circulation and Supine position | is not good fro oxygenation or perfusion and can cause pneumonia or other diseases if supine for long periods of time. |
| Circulation during exercise | O2 goes up |
| What area of the lung contains more oxygenation? | The apex of the lung has more oxygenation than perfusion. |
| BNP Nesiritide | is a human B-type natriuretic peptide. If elevated, it could be a sign of CHF. |
| Oxygen | first line medication administration |
| What happens when the alveoli has secretions blocking them? | The blood is shunted to other available alveoli for oxygenation |
| Hemoglobin | The primary carrier of oxygen in the blood. |
| How is the amount of oxygen that is loaded onto hemoglobin expressed? | A percentage of hemoglobin saturation by oxygen SaO2. This is obtained through ABG. |
| What does the Oxyhemoglobin Curve represent? | The relationship of the partial pressure of arterial oxygen (PaO2) and hemoglobin saturation (SaO2) |
| What does a normal Oxyhemoglobin Curve look like? | Curve is depicted as an S-curve rather than a straight line, showing that the percentage saturation of hemoglobin does not maintain a direct relationship with partial pressure of arterial oxygen. |
| Factors causing a shift to the left in the OD curve | Alkalosis, Hypothermia, Hypocarbia, and Decreased 2,3-DPG |
| Factors causing a shift to the right in the OD curve | Acidosis, Hyperthermia, Hypercarbia, and Increased 2.3-DPG. Oxygen is bound to hemoglobin less tight and is delivered to tissues. |
| What occurs with increased 2.3-DPG? | Chronic Hypoxemia, Anemia, and Hyperthyroidism |
| What occurs with decreased 2.3-DPG? | Transfusions, Hypophosphatemia, and Hypothyroidism |
| Rhales | Fine crackles indicating wet lungs |
| Rhonchi | Corse crackles indicating build up of sputum r/t pneumonia |
| Restrictive Ventilation | Atelectasis and Pneumonia(Hard to get CO2 out), pneumothorax (Lung collapses down. Tx with chest tube) , pulmonary edema (Fluid in alveoli), pulmonary fibrosis, ARDS (body can't use O2), and obesity |
| Obstructive Ventilation | Asthma, Chronic Bronchitis, and Emphysema |
| Uncompensated ABG | Respiratory alkalosis and acidosis, metabolic alkalosis and acidosis |
| Partially Compensated ABG | The body is trying to bring the body back in balance. All values will be abnormal. Respiratory Alkalosis and Acidosis, Metabolic Alkalosis and Acidosis |
| Compensated ABG | The body has managed to bring the pH back into a normal range. CO2 and HCO3 will remain out of range. |
| Acute Respiratory Failure | Impairment in oxygenation/or ventilation, Pulmonary system is no longer able to meet the metabolic demands of the body. Failure to maintain adequate gas exchange. |
| Hypercapnia | Too much CO2. Tidal volume, frequency, and dead space. |
| Hypoxemic Failure | Pa02 is less than 60 and FIO2 is greater than or equal to 60%. Physiologic mechanisms: V/Q mismatch, shunt, diffusion limitations, alveolar hypoventilation. Often a combination of mechanisms. |
| Hypoxemia | V/Q mismatch is primary cause. Shunt effect takes place where blood is not oxygenated as it travels through lungs. |
| Tx of Hypoxemia | Removing the obstruction, Reopening (recruiting) atelectatic zones, and preventing closure (derecruitment) of affected lung units. |
| Clinical Indications of Hypoxemia/Hypoxia | Dysrhythmias (tachycardia and irregular rhythms), tachypnea, dyspnea, restlessness, confusion, lethargy, coma, accessory muscle use, and cyanosis. |
| Minute Ventilation | Tidal volume X RR. It controls the PaCO2 level. |
| Hypercapnic Failure | PaCO2 greater than 50 with pH less than 7.35. Abnormalities of airways and alveoli, the CNS, the chest wall, and the neuromuscular system. |
| Clinical indications of Hypercapnia | Dysrhythmias (Tachycardia), Bradypnea, Irritability, Confusion, Inability to concentrate, Somnolence, Coma, Hypotension, Facial Rubor, and Headache. |
| Medical Management of Hypercapnia | Overall goal to promote oxygenation, oxygenation supplementation, treat underlying cause, correct acidosis, medications to treat symptoms (Sodium Bicarb), prevent further complications, and intubate if necessary. |
| Nursing Management of Hypercapnia | Positioning, Nutrition (may have to intervene b/c they don't care about food, they just want to breath!), Monitoring, and Mobilization of secretions (IV fluids help their secretions). |
| Pulmonary Embolus | Emboli lodges in a branch of the pulmonary artery. Tissue is ventilated but not perfused. |
| Source of Pulmonary Embolus | Blood clot, air, fat, amniotic fluid, bone marrow, foreign body, or tumor cell. |
| Symptoms of Pulmonary Embolus | Depend on severity of occlusion. Main problem is V/Q mismatch. |
| S/S of a small embolus | Frequently undetected |
| S/S of Medium Embolus | Pleuritic chest pain, pleural friction rub, low grade fever, tachycardia, dyspnea, cough, decrease in O2 sat, anxiety, and altered mental status. |
| S/S of Large Embolus | Sudden collapse with shock; death occurs in 60% |
| Diagnostics for Pulmonary Embolus | Hx, Symptoms, V/Q scan, Doppler studies, Chest X-Ray, Spiral CT, Pulmonary Angiography (Goal Standard) |
| Medical Management of Pulmonary Embolus | Prevention, Identify high risk patiients (bedrest/postop), oxygenation, anticoagulants, thrombolytics, vena cava filter (standard of care for parapalegic or quadriplegic) , and embolectomy. |
| What is the antidote for IV Heparin? | Protomine Sulfate |
| What is the antidote for Coumadin? | Vitamin K |
| INR | The best and most reliable test |
| PT & INR | Monitor effectiveness of Coumadin |
| PTT | Determines effectiveness of Heparin |
| Nursing Management of Pulmonary Embolus | Close monitoring, pain relief, anxiolytic, bedrest, and education |
| Thoracic Surgery | Opening into the chest cavity for surgery |
| Indications for Thoracic Surgery | Pulmonary surgery, Open heart surgery, Esophageal surgery, Trauma, and Renal surgery |
| Thorascopic Surgery | Less invasive and safer than Thoracic Surgery |
| Post-op Nursing Management of Thoracic Surgery | Optimize O2 and ventilation, Manage pain, Monitor VS, O2, & Lungs, Positioning and early ambulation, Pneumonectomy, and Lobectomy |
| Post-op Nursing Management of Lobectomy | Turn to non-operative side, chest tube commonly placed. |
| Post-op Nursing Management of Pneumonectomy | Turn to back or affected side, no chest tube. |
| Complications of Thoracic Surgery | Respiratory failure, Hemorrhage, Cardiac disturbances, Suture failure, Infection |
| Chest Tube Management of Pneumonectomy and Lobectomy | Milk or strip chest tubes only if clots develop or order to do so. It should have 100-300ml/hr of blood for 2 hours post surgery and then it should decrease. |
| What is the purpose of a chest tube? | To drain air and/or fluid and restore normal intrapleural pressure |
| Thoracentesis | Can be done at the bedside. Explain procedure and obtain informed consent. Place patient in proper position and perform an assessment of vitals. Care of specimens. |
| Aspiration Pneumonia (Ventilator-Associated Pneumonia) | Lung injury related to the inhalation of stomach contents, saliva, foods, or other foreign material into the tracheobronchial tree. |
| Pathophysiology of Aspiration Pneumonia | Oropharyngeal secretions are the most common. |
| What can help with Ventilator Associated Pneumonia Prevention? | Hand washing, HOB at 45, ETT with continuous suction above cuff, Meticulous oral care, and No routine changes of ventilator circuit. |
| Causes/Risk Factors for Nosocomial Pneumonia | Altered consciousness and/or gag reflex (Anesthesia, CNS disorder, Altered anatomy, GI conditions such as Hiatal hernia and vomiting), Prolonged intubation, and Enteral nutrition support. |
| Bronchoscopy | Explain procedure and Obtain informed consent, NPO for 6-12hrs, IV sedation, Assist with suctioning, Care of specimens, NPO after procedure until gag returns, Monitor for laryngeal edema, hemorrhage, and pneumothorax |
| Systemic Inflammatory Response Syndrome | SIRS abormal systemic response to a variety of insults. Inflammatory response that is not localized, but becomes systemic causing damage to vascular endothelium and increase metabolic rate. May be caused by sepsis or any type of shock. |
| Multisystem Organ Dysfunction Syndrome | Results from SIRS; Progressive failure of more than one organ. |
| S/S of SIRS | Temp >100.4 or <97.0, HR>90bpm, RR>20bpm or PCO2<32, WBC>12,000 cells or <4000 cells or greater than 10% immature neutrophils. SIRS is present when 2 or more criteria are met. |
| Progression of Organ Dysfunction | Lungs usually fail first, Renal failure, Altered mental status, GI failure, Liver failure, Late-CV failure, and Death |
| Treatment of SIRS and MODS | Prevention and treatment of infection, Maintenance of tissue oxygenation, Support nutrition and metabolic needs, and Support of failing organs. |
| Acute Respiratory Distress Syndrome | Form of acute respiratory failure involving lung injury, refractory to O2 and usually secondary to another event. 150,000 estimated cases annually. Mortality rate >50%, if septic shock and ARDS 70-90%. |
| Causes of ARDS | Shock, Trauma (Direct or Indirect Lung Injury), Inhalation of noxious substances, Infectious causes, Drug overdose, Hematologic disorders, SIRS/MODS. |
| Injury/Exudative Phase | Blood flow to lungs decreased, Increase in capillary permeability, Pulmonary edema, Surfactant decreased, Alveoli collapse, Altered gas exchange, and Hypoxia. |
| Treatment of ARDS | O2 and PEEP with Oxygenation |
| Injury/Exudative Phase Reparative/Proliferative Phase of ARDS | Inflammation, Fibrosis, Gas Exchange, and Compliance |
| Fibrotic Phase of ARDS | Remodeling, Scarring, Pulmonary Hypertension, Continuing Hypoxia |
| Early S/S of ARDS | Dyspnea, Tachycardia, Cough, Restlessness, Scattered Crackles, Mild Hypoxia |
| Mid S/S of ARDS | WOB, More Severe Hypoxia, Chest X-Ray shows interstitial and alveolar infiltration. |
| Late S/S of ARDS | Refractory Hypoxia, Hypercapnia, Metabolic Acidosis, White Out of Chest X-Ray, and Tissue Hypoxia |
| Management goals for ARDS | PaO2 of 60 on < 60% FIO2, Decrease work of breathing, Maintain airway and ventilation, and Improve oxygen delivery and decrease oxygen consumption. |
| Management of ARDS | Intubation and mechanical ventilation with high PEEP and low tidal volume. Treat underlying problems (Sepsis, them major cause of ARDS), Corticosteroids, Lateral rotation therapy, and Sedation and NMBA's to decrease O2 demand. |
| NMBA's | Work by interfering with nerve impulse transmission b/w the motor endplate and the receptors of the skeletal muscle. Takes effect in 6mins and last 60mins. Do not affect LOC or Pain! Sedation must be given first! Patients must be intubated!! |
| Do patient's on NMBA's feel pain? | Yes, they feel pain and are aware of everything that goes on around them! |
| Nursing Care of Patient's on NMBA's | ABC's first!, Safety, Eye care, Skin care, DVT prophylaxis, ROJM, Provide emotional support, Monitor level of paralysis, Make sure all alarms are activated, Peripheral nerve stimulator, and Comfort Measures. |
| What monitors level of sedation on NMBA? | Bispectral Monitor |
| Sequela of ARDS | Nosocomial Pneumonia, VAP, Stress Ulcers, Renal Failure, and Death usually due to MODS. |
| Indications for an Artificial Airway | Ensure patent upper airway, Decrease/prevent aspiration, Facilitate secretion removal, and Provide a closed system for mechanical ventilation |
| Endotracheal Tubes | May be inserted orally with Laryngoscope or Nasally through blind intubation. Offers more airflow resistance. Not to be left in for >10days. If oral, need block bite to prevent biting tube. Nasal ETT promotes sinus and ear infection. Verified via X-Ray |
| Tracheostomy Tube | Used for long term use. Increase patient comfort. Decreases airway resistance. Improves patient's ability to wean from ventilator. |
| Nursing Role in Intubation | Explain procedure to patient. Gather equipment. Assist with insertion. Check for breath sounds, secure tube, obtain chest x-ray, connect to ventilator/O2. Note size, cm marking at insertion site, note cuff pressure. Suction as needed. |
| Nursing Management of the Intubated Patient | Maintain proper tube placement, Monitor cuff pressure, Monitor and maintain oxygenation, Meticulous oral care, Suctioning, Prevent Injury, and Communication. |
| Indications for Mechanical Ventilation | Respiratory Failure, Impaired gas exchange, Operative procedure, RR>35, PaCO2>50 with pH <7.25, PaO2<55 on supplemental O2. |
| 2 Types of Ventilators | Negative and Positive Pressure |
| Positive Pressure Ventilators | Volume, pressure, air flow, or time cycled or a combination. Variable that ends inspiration is called the cycle |
| Volume-Controlled Positive Pressure Ventilation | Delivers a preset volume of gas to the lungs. Volume is measured in mL (5-10mL per kg of patient's body weight). Ventilator will deliver the volume regardless of the amount of pressure it takes-within preset range. Pressure requ. will vary from Br to Br. |
| 4 Modes of Volume-Controlled Ventilation | Controlled Mandatory Ventilation, Assist-Controlled Ventilation, Synchronized Intermittent Mandatory Ventilation, and Pressure Support Ventilation |
| Adjunct/Maneuvers to VCV | PEEP and CPAP |
| Contolled Mandatory Ventilation | Ventilator delivers preset rate and volume. Not sensitive to the patient's own respiratory efforts. Uncomfortable for awake patient. Usually sedated or chemically paralyzed. Rarely used and must have NMBA drug. |
| Indications for CMV | Apneic or critically ill patients. |
| Assist-Control Ventilation | Has a set tidal volume and a minimal rate (will take over if patient becomes apneic). Sensitive to inspiratory efforts of patient. When patient begins to breath, ventilator delivers a breath at the prescribed setting. |
| Complication of A/C Ventilation | Over-ventilation is a complication. |
| What happens if patient decides to breath more than the ventilator is set to give with A/C Ventilation? | It will assist the patient in extra breaths. |
| Synchronized Intermittent Mandatory Ventilation | Provides a ventilator breath at a prescribed rate and tidal volume, but synchronized to the patient's own ventilatory cycle. Additionally, the patient spontaneously breaths and will pull their own TV on the extra breaths over the ventilator set RR. |
| Complication of Synchronized Intermittent Mandatory Ventilation | Fatigue |
| What mode of Mechanical Ventilation is used as a First Weaning Mode? | SIMV |
| Pressure Support Ventilation | Positive pressure is applied during inspiration. Triggered by spontaneous breath. Patient stops airflow by beginning expiration. Decreases work of breathing to achieve an adequate TV. |
| Indications for Pressure Support Ventilation | It assists in weaning as it improves patient endurance. Can be used as a mode for a spontaneously breathing patient or as an adjunct to another mode. |
| How is PSV measured? | Measured in cm of H2O pressure. Usually greater than or equal to 10cm |
| PEEP | Can be added to a variety of ventilatory modes. Usually set at 5cm buy may go to 20cm (Adjusted to meet oxygenation needs of the patient). |
| Therapuetic results of PEEP | Recruits previously collapsed alveoli, Prevents re-collapse of alveoli, and Improves oxygenation. |
| How is PEEP measured? | Measured in cm of H20 pressure. |
| What patient's should PEEP be used with caution? | COPD and Head Injury Patient's |
| Complications of PEEP | Decreased venous return and Decreased cardiac output (Cause decreased urine output and BP), Increased intracranial pressure, Barotrauma, Pneumothorax with PEEP >10cm, and Subcutaneous emphysema. |
| Continuous Positive Airway Pressure (CPAP) | Positive presure applied continuously during spontaneously breathing. Recruits collapsed alveoli, prevents atelectasis, improves oxygenation. |
| Methods of CPAP? | Can be delivered by nasal or oronasal mask for extubated patients (NIPPV). |
| Indications for CPAP | Sometimes used as a weaning mode for intubated patients. Used for Obstructive sleep apnea and Chronic respiratory failure. |
| Bilevel NIPPV | Provides 2 levels of PAP (IPAP and EPAP). Delivered via mask. Patient must be spontaneously breathing, able to cooperate, and hemodynamically stable. |
| Indications of Bilevel NIPPV | Used in exacerbation of COPD, pulmonary edema, early post-op, and prevention of reintubation. |
| Nursing Management of the Patient on Mechanical Ventilation | Assessment (Breath sounds, Airway, Alarms, Compliance, Ventilator settings, and Emergency equipment), Reassess Q2H and PRN, Suction as needed, and HOB elevated 45 degrees unless contraindicated. |
| Complications of Mechanical Ventilation | Barotrauma, CV (Cardiac Output), GI (Gastric Distension, Vomiting), Nosocomial Pneumonia (VAP), Incorrect ventilator settings. |
| Ventilator Alarms | Don't loose your cool!. Review alarms listed on ventilator. May need assistance from respiratory therapy. |
| What do you do if you can't figure out why the ventilator alarms is going off? | Ventilate the patient with an ambu bag set at 100% FIO2 until problem can be resolved. |
| Thing to look at to know if the patient is ready to wean? | Resolution of underlying problem, Adequate oxygenation and no respiratory acidosis, Stable hemodynamics, Afebrile, Adequate Hgb level, mental and nutritional status. |
| Weaning | Appropriate sedation, Positioning for lung expansion, Importance of nurse coaching and emotional support, Adequate vital capacity measurement, and Negative Inspiratory Pressure of -30cm H20 or less. |
| Weaning Methods | Changing modes from A/C to SIMV. Gradual decrease in SIMV rate (Often extubate at RR< or equal to 5. May add PSV to decrease WOB (Gradual decrease in amount of pressure support). May place patient on CPAP only. T-Piece alternative. |
| T-Piece Alternative | Only O2 is being administered through tracheal tube. |
| Weaning Observations | RR<30, TV, Cardiac Rhythm, BP, WOB, Respiratory Distress, Mental Status, and ABG's and SaO2. |
| Definition of CAD | A type of blood vessel disorder that is included in the general category of atherosclerosis. |
| CAD | Begins as soft deposits of fat that harden with age. Referred to as "hardening of the arteries". Can occur in in any artery in the body. Atheromas (Fatty deposits). |
| Atheromas | Fatty deposits. A preference for coronary arteries. |
| What is CAD also described as? | Arteriosclerotic Heart Disease and Cardiovascular Heart Disease |
| What is the major cause of death in the U.S.? | Cardiovascular Diseases |
| What is the leading cause of cardiovascular disease deaths and deaths in general? | Heart attacks |
| What is the major cause of CAD? | Atherosclerosis |
| Etiology and Pathophysiology | Characterized by a focal deposit of cholesterol and lipid, primarily within the wall of the artery. Endothelial lining altered as a result of inflammation and injury. C-reactive Protein. |
| C-reactive Protein (CRP) | Nonspecific marker of inflammation. Increased in many patients with CAD. Chronic exposure to CRP triggers the rupture of plaques. |
| Fatty Streaks Developmental Stage of CAD | Earliest lesions. Characterized by lipid-filled smooth muscle cells. Potentially reversible. |
| Fibrous Plaque Developmental Stage of CAD | Beginning of progressive changes in the arterial wall. Lipoproteins transport cholesterol and other lipids into the arterial intima. Fatty streaks is covered by collagen forming a fibrous plaque that appears gray or white. Results in vessel lum narrowing. |
| Complicated Lesion Developmental Stage of CAD | Continued inflammation can result in plaque instability, ulcerations, and rupture. Platelets accumulate and thrombus forms. Results in increased narrowing or total occlusion of lumen. |
| Collateral Circulation | Normally some arterial anastomoses (connections) exist within the coronary circulation. There is a greater chance of adequate, collateral circulation developing if the occlusion occurs over a long period of time. |
| What two factors contribute to collateral circulation? | Inherited predisposition to develop new vessels (Angiogenesis). Presence of chronic ischemia. |
| 2 Types of Risk Factors for CAD? | Modifiable and Nonmodifiable |
| What type of people is CAD more present in? | African American women at rates higher than white women. |
| Nonmodifiable Risk Factors for CAD | Things we cannot change. Ex: Age, Gender, Ethnicity, Family History, and Genetic Predisposition. |
| Modifiable Risk Factors for CAD | Things we can change or modify: Elevated serum lipids, HTN, tobacco use, physical inactivity, obesity, diabetes, metabolic syndrome, psychologic states, and homocysteine level. |
| Homocysteine Level | Amino acids bound in the blood. High levels damage the artery. |
| Metabolic Syndrome | Obesity, Elevated Triglycerides, HTN, Increased Lipids, and Elevated Fasting Blood Glucose. Must have at least three of these components to be diagnosed. |
| Health Promotion for CAD | Identification of people at high risk. H.H. (Script and Non-script meds), Presence of CV symptoms (Ever had chest pains), Env't patterns (diet/activity), and Values and beliefs about health and illness (Do they accept Health Care?). |
| Nutritional Therapy: Health promoting behaviors for CAD. | Therapeutic Lifestyle Changes: Should lower LDL and Cholesterol. Omega 3-fatty acids should be increased. |
| Who recommends Therapeutic Lifestyle Changes? | Adult Tx Panel III of the National Heart, Lung, and Blood Institute |
| What is Cholesterol Lowering Drug Therapy? | Drugs that restrict lipoprotein production. Drugs that increase lipoprotein removal. Drugs that decrease cholesterol absorption. |
| What are examples of drugs that restrict lipoprotein production? | Statins, Niacin (Liptior, Crestor, Zocor) |
| What are examples of drugs that increase lipoprotein removal? | Bile acid sequestrants (Cloestid, WelChol, Questran) |
| What are examples of drugs that decrease cholesterol absorption? | Ezetimibe (Zetia) |
| Antiplatelet Therapy | ASA and Clopidogrel (Plavix). Women ages 45 to 60 may not benefit from ASA the same as men. |
| Chronic Stable Angina | Reversible Myocardial Ischemia. This occurs when the O2 demand is greater than the O2 supply. |
| What is the primary reason for Chronic Stable Angina? | Insufficient blood flow caused by narrowin of coronary arteries by atherosclerosis. |
| For ischemia to occur, how occluded does the artery have to be? | The artery is usually 75% or more stenosed. |
| Clinical manifestations of Chronic Stable Angina | Intermittent chest pain occuring over a long period with the same pattern of onset, duration, and intesity of symptoms. Pain usually lasts 3-5mins. Subsides when precipitating factor is relieved. Pain at rest is unusual. |
| What does the EKG look like during Chronic Stable Angina? | Reveals ST segment depression |
| Silent Ischemia | Up to 80% of patients with Myocardial Ischemia are asymptomatic. Associated with DM and HTN. Confirmed by EKG changes. |
| Nocturnal Angina | Occurs only at night but not necessarily during sleep. |
| Angina Decubitus | Chest pain that occurs only while lying down. Relieved by standing or sitting. |
| Prinzmetal's (Variant) Angina | Occurs at rest usually in response to spasm of major coronary artery. Spasm may occur in absence of CAD. May occur during REM sleep. When spasm occurs: Chest pain and marked, transient ST segment elevation. |
| What types of patients is Prinzmetal's Angina usually seen in? | Patient's with a history of Migraine Headaches and Raynaud's phenomenon. |
| How might the pain of Prinzmetal's Angina be relieved? | Moderate Exercise |
| Nursing & Collaborative Management of Chronic Stable Angina | Position patient in reclining position w/ head elevated. MONA. Begin O2. Assess characteristics of pain and evaluate vitals. |
| Goal of Drug therapy for Chronic Stable Angina and Priority Nursing Intervention | Decrease O2 Demand and increase O2 supply. |
| Drug Classes used to treat Chronic Stable Angina | Short-acting nitrates (Sublingual), Long-acting nitrates, Beta Adrenergic Blockers, CCB, and ACE inhibitors. |
| Adverse effects of short acting nitrates | Headache and Flushing |
| Examples of Long acting Nitrates | Nitroglycerine Ointment and Transdermal controlled-release nitroglycerin. |
| What is important about Transdermal controlled-release nitroglycerin? | There should be at least 8hr free per day from the patch. |
| Adverse effects of Transdermal NTG? | Headache and OH |
| Beta Adrenergic Blockers | Reduce O2 demand of heart. Bradycardia, OH, Wheezing, GI, Weigh, and Sexual Side effects. |
| What is important about Beta Adrenergic Blockers? | Do not stop abruptly!! It can cause frequent angina! |
| Calcium Channel Blockers | Used if BB are poorly tolerated, contraindicated, or do not control angina symptoms. They cause coronary and peripheral vasodilation. |
| What drug is used to Tx Prinzmetal's Angina? | CCB |
| S/S of Digoxin Toxicity | N/V/Loss of appetite, diarrhea, blurred vision, halo vision, confusion, and drowsiness. |
| Diagnostic Studies for CSA | H.H., P.E., Labs, EKG, Chest X-Ray, Echocardiogram, Exercise Stress Test, Cardiac Catheterization. |
| Coronary Revascularization | Percutaneous Coronary Intervention, Balloon Angioplasty, and Stent |
| When does Acute Coronary Syndrome develop? | When ischemia is prolonged and not immediately reversible. This is an M.I. |
| ACS encompasses | Unstable angina, Non-ST segment elevation M.I., ST segment elevation. |
| Relationship between CAD, Chronic Stable Angina, and ACS: Etiology and Pathophysiology | Deterioration of a once stable plaque causing a rupture which then causes platelet aggregation resulting in a thrombus. |
| The result of the Thrombus is... | If Partial occlusion of coronary artery: Unstable angina or Non-ST segment elevation M.I.. If total occlusion of coronary artery, ST segment elevation. |
| Unstable Angina | New in onset, occurs at rest, and has a worsening pattern. It is unpredictable and represents and Emergency!! |
| Clinical Manifestations of MI | Result of sustained ischemia (>20mins);causes irreversible myocardial cell death (necrosis). Contractile function is disrupted in areas of myocardial necrosis. |
| What ventricle is affected in MOST MI? | Left Ventricle |
| How long does it take for necrosis of entire thickness to occur? | 4-6 hours |
| What is the altered function of the heart based on after an MI? | The degree of the altered function depends on the area of the heart involved and the size of the infarct. |
| MI Pain | Total occlusion resulting in anaerobic metabolism and lactic acid accumulation resulting in severe immobilizing chest pain not relieved by rest, position change, or nitrate administration. Pain may radiate! |
| How is the MI pain described by patients? | Heaviness, constriction, tightness, burning, pressure, or crushing. |
| Common location of pain from MI | Substernal, Retrosternal, or epigastric areas. |
| Results of SNS during MI | Release of glycogen, diaphoresis, vasoconstriction of peripheral blood vessels, and the skin becomes ashen, clammy, and/or cool to touch. |
| CV effects of MI | Initially,increased HR and BP, then decreased BP (secondary to decrease in CO). Crackles, JVD, Abnormal heart sounds (S3 and murmur) , N/V (results from reflex stimulation caused by severe pain), and Fever. |
| Healing Process of MI (24hrs) | Leukocytes infiltrate the area of cell death. Enzymes are released from the dead cardiac cells. Proteolytic enzymes of neutrophils and macrophages remove all necrotic tissue by 2 or 3 day. Develop collateral circulation. Necrotic zone shown on EKG |
| Healing Process of MI (10-14days) | Scar tissue is still weak and vulnerable to stress |
| Healing Process of MI (6 weeks) | Scar tissue has replaced the necrotic tissue. Area is healed but less compliant. Ventricular modeling occurs in an attempt to compensate, the myocardium will hypertrophy and dilate. |
| Complications of MI | Dysrhythmias, HF, Cardiogenic shock, Papillary muscle dysfunction, Ventricular aneurysm, Acute pericarditis, and Dressler syndrome. |
| Dysrhythmias | Most common complication. Present in 80% of MI patients. Most common cause of death in the prehospital period. Life-threatening dysthythmias seen most often w/ anterior MI, HF, or shock. |
| Heart Failure (HF) | Complications that occurs when the pumping power of the heart has diminished |
| Cardiogenic Shock | Occurs when inadequate oxygen and nutrients are supplied to the tissues because of severe LV failure. Requires aggressive management. |
| Papillary Muscle Dysfunction | Causes mitral valve regurgitation. Condition aggravates an already compromised LV. |
| Ventricular Aneurysm | Results when the infarcted myocardial wall becomes thinned and bulges out during contraction |
| Acute Pericarditis | An inflammation of visceral and/or parietal pericardium. May result in cardiac compression, decrease LV filling and emptying, HF. Pericardial friction rub may be heard on auscultation. Chest pain different from MI. |
| What makes acute pericarditis go away? | Leaning over or sitting on bed. |
| Dressler Syndrome | Characterized by pericarditis with effusion and fever that develop 4-6 weeks after MI. Pericardial chest pain. Pericardial friction rub may be heard on auscultation. Arthralgia. |
| Priority for MI | Danger of death within first 2 hours of MI |
| Collaborative Care: ACS | Emergency management, Emergent PCI, Fibrinolytic therapy, Drug therapy, Nutritional therapy, Coronary surgical revascularization |
| Emergency Management of ACS | Initial interventions and Ongoing monitoring |
| Emergent PCI of ACS | Tx of choice for confirmed MI. Balloon angioplasty and drug-eluting stent(s). Ambulatory 24hrs after procedure. |
| Fibrinolytic Therapy of ACS | Indications and Contraindications. Marker of reperfusion: return of ST segment to baseline. Rescue PCI if thrombolysis fails.Major complication is bleeding!! |
| Drug Therapy of ACS | IV NTG, Morphine Sulfate, BB, ACE inhibitors, Antidysrhythmia drugs, Cholesterol-lowering drugs, and Stool softeners. |
| Nutritional Therapy of ACS | Progress to low-salt, low saturated fat, low-cholesterol diet. |
| Coronary Surgical Revascularization of ACS | Fail medical management, Presence of left main coronary artery or three-vessel disease, Not a candidate for PCI, Failed PCI with ongoing chest pain. |
| 4 Types of Coronary Surgical Revascularization | Coronary Artery Bypass Graft Surgery, Minimally Invasive Direct Coronary Artery Bypass, Off-pump Coronary Artery Bypass, and Transmyocardial Laser Revascularization |
| Coronary Artery Bypass Graft | Requires cardiopulmonary bypass. Uses arteries and veins for grafts. |
| Minimally Invasive Direct Coronary Artery Bypass | Alternative to traditional CABG |
| Off-pump Coronary Artery Bypass | Does not require cardiopulmonary bypass |
| Transmyocardial Laser Revascularization | For patients with advanced CAD who are not surgical candidates or who have failed maximum medical therapy. |
| Nursing diagnoses for Chronic Stable Angina and ACS | Acute pain, Ineffective tissue perfusion (cardiac), Anxiety, and Activity intolerance. |
| Overall Planning goals for Chronic Stable Angina and ACS | Relief of pain, Preservation of myocardium, Immediate and appropriate treatment, Effective coping with illness-associated anxiety, Participation in a rehabilitation plan, and Reduction of risk factors. |
| Health Promotion for Chronic Stable Angina and ACS | Therapeutic lifestyle changes to reduce cardiac risk factors. |
| Acute interventions for anginal attack | Administer O2, EKG, Prompt pain relief first with a nitrate followed by an opioid analgesic if needed, Auscultation of heart sounds, and Comfortable positioning of the patient. |
| Patient teaching teaching for ACS and Chronic Stable Angina | CAD and Angina, Precipitating factors for angina, Risk factor reduction, and Medications |
| Acute Intervention of ACS | Pain relief, Rest and Comfort (Begin cardiac rehab and Balance rest/activity), Anxiety, and Emotional and behavioral reaction. |
| Nursing Management of Coronary Revascularization | ICU for first 24-26hrs. Pulmonary artery cath for measuring CO, other hemodynamic parameters. Intraarterial line for continuous BP monitoring. Pleura/mediastinal chest tubes for drainage. Continuous EKG monitoring for dysrhythmias. |
| Complications related to Cardiopulmonary Bypass | Bleeding and anemia from damage to RBC's and platelets. Fluid and electrolyte imbalances. Hypothermia as blood is cooled as it passes through the bypass machine. |
| Care of ACS patient after surgery is focused on: | Assessing the patient for bleeding, Monitoring fluid status, Replacing electrolytes PRN, and Restoring temperature (e.g., warming blankets) |
| Ambulatory and Home Care of ACS patient after surgery | Patient teaching, Physical exercise, Resumption of sexual activity (Emotional readiness of patient and partner and Physical expenditure) |
| Evaluation of ACS patient after surgery | Relief of pain, Preservation of myocardium, Immediate and appropriate treatment, Effective coping w/ illness-associated anxiety, Participation in rehab plan, and Reduction of risk factors. |
| Sudden Cardiac Death (SCD) | Unexpected death from cardiac causes. Most deaths occur outside hospital. CAD occounts for 80% of all SCD's |
| Etiology and Pathophysiology of SCD | Abrupt disruption in cardiac function, resulting in loss of CO and cerebral blood flow. Death usually within 1 hour of onset of acute symptoms (e.g., angina, palpitations). |
| Most SCD's are caused by: | Ventricular dysrhythmias (e.g., V-TACH) |
| SCD's occur less commonly as a result of: | LV outflow obstruction (e.g., aorta obstruction) |
| Primary risk factors for SCD | Left ventricular dysfunction (EF 30%) and Ventricular Dysrhythmias following MI. |
| Other risk factors for SCD | Male gender (esp. A.A.), Family Hx of premature atherosclerosis, Tobacco use, DM, Hypercholesterolemia, Hypertension, and Cardiomyopathy |
| Sudden Cardiac Death: Nursing & Collaborative Management | Diagnostic workup to rule out MI, Cardiac cath, PCI or CBAG, 24hr monitoring, Exercise stress testing, Signal-avg EKG, EPS, ICD (Implantable cardioverter-defibrillator), Psychosocial adaption. |
| Examples of Psychosocial Adaption | Brush with death, Time bomb mentally, Possible role changes (e.g., occupation and driving restrictions) |
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nbmcabee
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