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PCCIV exam 1 Review

Terms in this set (73)

Preload
Amount of blood returning to the right side of the heart and the muscle strength that the volume causes. ANP is released when we have this stretch
Afterload
The pressure in the aorta and peripheral arteries that the left ventricle has to pump against to get blood out
Pressure referred to as resistance
With HTN - more resistance for left ventricle to pump against - why HTN can eventually lead to HF and pulmonary edema b/c high afterload decreases CO and decreases forward flow and wears out heart
Stroke Volume
Amount of blood pumped out of the ventricles with each beat
CO
HR x SV
Tissue perfusion is dependent on adequate CO
Changes according to the body's need
Factors that affect CO
Heart rate and certain arrhythmias (decr HR = dec CO) (incr HR = decr CO B/c not enough time for ventricle to fill)
Blood volume (less volume - less CO; more volume - more CO)
Decreased contractility (MI, medication, muscle disease)
CO think left ventricle, if not working, pumps back into the lungs
Patho of decreased CO
Poor CO = poor perfusion
LOC Down, client complains of chest pain, shortness of breath and wet lung sounds, cold and clammy skin, urine output down (poor perfusion), and peripheral pulses are weak
Arrhythmias are not a big deal UNTIL they mess with CO
Coronary Artery Disease
Most common type of CV disease
Broad term that includes chronic stable angina and acute coronary syndrome
Chronic Stable Angina Patho
Decreased blood flow to the myocardium - ischemia - temporary pain/pressure in the chest
Low O2 brings on the pain
Rest or sublingual nitroglycerin relieves the pain (vasodilates)
Nitroglycerin (Nitrostat) Sublingual CAD
Treat chronic stable angina
Causes venous and arterial dilation - decreased preload and afterload, also causes vasodilation of coronary arteries which will increase blood flow to the actual heart muscle
Take 1 every 5 min, max of 3 doses
Do not swallow
Keep in dark, glass bottle, cool and dry
Client will get a headache
Renew q3-5 months
Expect a DROP in BP
Beta Blockers CAD
Treat chronic stable angina
Decrease myocardial contractility
Decreases workload of the heart
BP and HR down
Vasodilation
Calcium Channel Blockers CAD
Prevention of angina
Nifedipine, verapamil, amlodipine and diltiazem
Decrease BP, cause vasodilation of arterial system (decrease afterload), dilate coronary arteries
Two benefits: decrease afterload and increase O2 to the heart muslce
Acetlysalicylic acid CAD (aspirin)
Stable Angina
Aspirin
Not to treat pain but to keep the blood flowing by thinning and preventing clots
Dose is determined by physician 81mg (baby aspirin) to 325mg
Client Education/Teaching for chronic stable angina
Rest frequently, avoid overeating (low fat, high fiber diet), avoid excess caffeine or any drugs that increase HR, wait two hours after eating to exercise, dress warmly in cold weather (extremes can precipitate attack), take nitro prophylactically, smoking cessation, lose weight (decrease calories), avoid isometric exercise (make muscles squeeze and increase workload of heart), reduce stress
DO EVERYTHING TO DECREASE WORKLOAD ON HEART
Cardiac Cath
Tx of stabile angina
Most definitive and invasive tx
Pre-procedure cardiac cath
Ask if they are allergic to shellfish or iodine - used in dye
Check kidney fxn because dye is excreted through the kidneys - mucomyst pre procedure if kidney problems - helps to protect kidneys
Hot shot when injecting dye - warm and flushed
Palpitations are normal
Post procedure cardiac cath
Monitor VS
Watch puncture site - BLEEDING and hematoma formation
Assess extremities 5Ps( pulselessness, pallor, pain, paresthesia (sensation), paralysis)
Best rest, flat, leg straight 4-6hrs
Major complication: hemorrhage
Report pain ASAP - hematoma
Hold metformin (glucophage) for 48hrs - worry about kidneys
Unstable Chronic Angina
IMPENDING MI
Patho Acute Coronary Syndrome: MI, Unstable Angina
Decreased blood flow to myocardium - ischemia and necrosis (want to limit the size of infarction)
Client doesnt have to do anything to bring on pain - rest and nitro will NOT relieve pain
S/S Acute Coronary Syndrome, MI unstable angina
Pain - described as crushing, elephant on chest, pressure radiating down to left arm and left jaw, N/V, or pain between shoulder blades
Women present with GI sx: epigastric chronic fatigue
#1 sign in elderly: shortness of breath
Cold/clammy/bp drops, CO down
ECG changes
vomiting = BAD
STEMI
ST segment elevation myocardial infarction - this indicated that client is having a heart attack and the goal is go get them to the cath lab for PCI in less than 90 minutes
WORRY ABOUT THE STEMI CLIENT
NSTEMI
Non elevated ST segment myocardial infarction, these clients are usually less worrysome
Diagnostic Lab work
CPK-MB
Troponin
Myoglobin
CPK-MB
Cardiac specific isoenzyme
increased with damage to cardiac cells
elevates in 3-12 hours and peaks in 24hrs after onset of sx
Troponin
Most specific for cardiac damage/MI and most helpful when care is delayed
Elevates within 3-4hrs and remains elevated for up to three weeks after onset of chest pain
Troponin T <0.10 ng/mL
Troponin I <0.03 ng/mL
Myoglobin
Increased within 1 hour and peaks in 12
Not very specific for MI
Negative results are a good thing
Complications Acute Coronary Syndrome
Major arrhythmias - pulseless v tach, v fib, asystole and bradycardia
Priority tx: de fib and CPR
First vasopressor to give is epinephrine or vasopressor
Anuidaribe, lidocaine
Amiodarone (cordarone)
Anti arrhythmic and is used when V fib and pulseles VT are resistant to tx and also for fast arrhythmias
First anti-arrhythmic of choice
HYPOTN is important side effect - can lead to further arrhythmias
Lidocaine
Decreases irritant to the heart
Lidocaine toxicity: neuro changes
Tx Acute coronary syndrome
Goal: dissolve clot that is blocking blood flow and decrease size of infarction
Medication: streptokinase (Streptase), alteplase (t-PA), tenecteplase (TNKase,one time push), reteplase (Retavase)
Administer within 6-8hrs of myocardial pain onset
Major complication: BLEEDING - get bleeding hx
Contra indictations: intracranial neoplasm, intracranial bleed, suspected aortic dissection, internal bleeding
Decrease puncture sites and no ABGs b/c artery will bleed
Bleeding Precautions
Watch for bleeding gums, hematuria, and black stool
Use electric razor, a soft toothbrush and no IMs
Follow up to Fibrinolytic therapy
Antiplatelets are another important component of fibrinolytic therapy
Acetylsalicylic acid (aspirin), clopidogrel (Plavix), abciximab (ReoPro IV), continuous infusion to inhibit platelet aggregation
Medical Interventions Acute Coronary Syndrome
PCI (percutaneous coronary intervention
Coronary Artery Bypass Graft (CABG)
Cardiac Rehab
PCI
Includes all interventions such as PTCA (angioplasty) and stents, major complication = MI
If problems occur = go to surgery - chest pain post surgery CALL PHYSICIAN
Give antiplatelet medications
Anti platelet medications
Aspirin
Clopidogrel (plavix)
abciximab (ReoPro IV)
eptifibatide (Integrilin IV) - the last two are given to high risk clients who have been stented to keep artery open and those waiting to go to cath lab
CABG
Coronary artery bypass graft - open heart
Can be scheduled or emergency
Used with multiple vessel disease or left main artery occlusion
The left main coronary artery supplies the entire left ventricle: think sudden death or widow maker
Cardiac Rehab
Smoking cessation, stepped - care plan (increase activity gradually), diet change (low fat, low salt low cholesterol), no isometric exercise (increase workload of heart), no valsalva, no straining, no suppository; docusate, sex after you can walk a block or stairs with no discomfort, have sex in the morning when well rested
Best exercise for MI: walking
Teach s/s of heart failure: weight gain, ankle edema, shortness of breath, and confusion
Heart Failure Causes
Complication that can result from problems such as cardiomyopathy, valvular heart disease, endocarditis, acute MI and HTN (leading cause)
Types of HF
Left sided - blood not moving forward into aorta and out to body - backsup to the lungs
Right sided - blood not moving forward into lungs - moves back into venous system
S/S Left sided HF
Pulmonary congestion, dyspnea, cough, blood tinged frothy sputum, restlessness, tachycardia, S3, orthopnea, noctural dyspnea
S/S Right sided HF
Distended neck veins, edema, enlarged organs, weight gain, ascites
Right side can start from L side - pulmonary embolis - pul HTN - increase R side workload - R HF
or hypoxia - right side HTN
Systolic HF
Heart cannot contract and eject
Diastolic HF
Ventricles cannot relax and fill
Dx HF
BNP
Chest X ray
Echocardiogram (looks @ pumping action)
NY Heart association functional classification of person with HF
BNP HF
B-type Natriuretic peptide
Secreted by ventricular tissues in the heart when ventricular volume and pressures in the heart are increased
Sensitive indicator
Can be positive for HR when CXR does not indicate
Turn off nesiritide 2hrs prior to draw
Chest X ray HF
Enlarged heart, pulmonary infiltrates such as fluids and edema
New York Association Functional Classification of Persons with HF
Classes 1-4 (4 is worst)
Tx HF
Standard medication therapy for HR is ACE inhibitors and ARBS
Digitalis (Lanoxin)
Diuretics
Low Na diet
Elevate HOB
Daily weights - report gain of 2-3lbs
Report any recurring s/s
Pacemaker
Ace Inhibitors
Drugs of choice for HF, suppress the angiotensin system (RAS), prevent the conversion of angiotension I to angiotension II, Block aldosterone - lose sodium and water and retain potassium
Result in arterial dilations and increased stroke volume
Can cause dry cough
ARBS HF
Block angiotensin II receptors and cause a decrease in arterial resistance and decreased BP
Block aldosterone - lose sodium and water and retain potassium
HF Ace inhibitors/Beta Blockers
These drugs together in combo decrease the workload of the heart by preventing vasoconstriction (decrease afterload) - this will increase cardiac output and keep blood moving forward out of the heart - we WANT forward flow!
Digitalis (Lanoxin)
Used less today due to risk of drug toxicity, esp in elderly
Used with sinus rhythm or atrial fibrillation and accompanying chronic HR
Often given in combo with ACE inhibitor, ARB, BB or diuretics
Make heart contractions stronger, HR slows (gives ventricles more time to fill), cardiac output up and kidney perfusion up
Normal dig levels: 0.5-2ng/ml
Dig Toxicity/Normal values
Normal dig levels: 0.5-2ng/ml
S/S of toxicity: Anorexia, N/V
Late signs: arrhythmias and vision changes
Hypokalemia + Dig = TOXICITY
Nursing considerations HF
Diuretics = good thing - want to diurese heart failure clients b/c they cannot handle the fluid
Know dig is working b/c CO goes UP
Dont give whole blood to HF pts - can lead to pulmonary edema
Monitor electrolytes - k+ causes most trouble
Diuretics HF
Decrease preload by decreasing volume
Give in the morning
Ex: furosemide (Lasix), hydrochlorothiazide (HCTZ), bumetanide (Bumex), hydrochlorothiazide/triamterene (Dyazide), and spironolactone (aldactone)
Low Na Diet for HF
Decrease fluid retention and decrease preload
Watch salt substitutes - can contain excessive potassium
Canned/processed foods can contains lots of sodium
Pacemaker
Natural pacemaker is SA node - sends output to make heart contract
HR drops to <60 = not enough perfusion CO decreased
Pacemaker used to increase HR w/symptomatic brady
Depolarizes (shock/contract) heart muscle and repolarizes (venticle rest and filling)
Demand and Fixed, invasive or non invasive - know set rate - worry if HR drops below set rate (min HR)
Demand kicks in when needed
Fixed is set at a fixed rate
Ok for HR to increase but never decrease below fixed rate
Post Procedure Care (for permanent pacemakers)
Monitor incision, most common complication post op is electrode displacement - so immobilize arm, assisted passive range of motion to prevent frozen should, keep the client from raising their arms higher than shoulder height
S/S of Pacemaker Malfunction
Possible that no contraction will follow stimulus - called loss of capture - caused by pacemaker not programmed correctly, electrode can dislodge, battery may be depleted
Watch for: any sign of decreased CO or decreased rate
Client Education/Teaching Pacemaker
Check pulse daily, ID card or bracelet, avoid electromagnetic fields (cell phone in opposite ear, large monitors), avoid MRI (turn off pacemaker or change settings), will set off alarm at airport - use wand below waist, avoid contact sports
ICD
Implantable cardiac device (sometimes implantable cardioverter defibrillator)
May be used to pace heart or it might be used to defibrillate people in Vfib
Post op care for ICD is same for pacemaker
ACE inhibitors
Action: blocks conversion of angio I to angio II
Promote vasodilation and diuresis, decrease secretion of aldosterone
Examples: enalapril (vasotec), Fosinopril (Monopril), Captopril (Capoten)
Uses: HF and HTN
Nursing Observation ACE Inhibitors
If drug ends in -pril - most likely ACE I
Watch for hyperkalemia, ortho syncope, HPOTN, and renal dysfunction
Angio-edema-laryngeal swelling can be fatal, dry, non productive cough-reversible when drug is stopped, fall precautions
ARBS
Block effects of angio II (potent vasoconstictor) at the receptor site - can block other things that ACE Is cannot
Decrease BP, Increase CO - used for HTN and HF
Ex: valsartan (Diovan), Losartan (Cazaar), irbesartan (Avapro)
Nursing Considerations ARBS
If drug ends in -sartan most likely an ARB
Watch for hyperkalmeia, HYOTN, and renal dysfunction
Beta Blockers
Block adverse effects from sympathetic NS
Block receptor sites for epi and norepi - so decrease afterload and contracility - decrease BP and HR
ex: propranolol (Inderal), metoprolol (lopressor/troprol xl), atenolol (tenormin), carvedilol)
Uses: Angina, chest pain, HTN, ventricular dysrhythmias and thyroid storm
Nursing Consideration BB
Dont give to asthmatics, dont give to diabetics (blocks sympathetic responses seen in hypoglycemia)
what are indications for IABP?
cardiogenic shock, MI w/ mechanical defects, post op low output syndromes, medical refractory angina, w/ thrombolytic therapy, high risk PCI, weening from bypass, stunned myocardium, drug induced failure, assist CPR
what are some contraindications for IABP?
irreversible brain damage, chronic end stage heart disease not waiting on transplant, AO valve insufficiency, aortic dissection, aortic aneurysm, peripheral vascular disease, aortic regurgitation, bleeding disorder, sepsis, coagulopathy
where in the aorta should the balloon be placed?
above the renal artery and below subclavian artery
What are the goals of CABG?
Improve quality of life
Reduce angina, shortness of breath, fatigue, and dizziness
Resume more active lifestyle
Improve pumping action of heart if it was damaged by MI
Decrease risk of MI
Increased chance of surviva
What is the risk of CABG surgery?
Bleeding
Blood clots
Infection at incision site
PNA
Unable to be removed from vent
Cardiac dysrhythmias/arrhythmias
Loss of toe or foot
What are sternal precautions for CABG patients?
May lift up to 10 lbs for 6-8 weeks after surgery
Pain free ROM is acceptable
Always use pillow when coughing
No driving for 6 weeks, use seat belt and do not sit by airbags if possible
What should the goal for walking with CABG patients?
6 times/day
400 feet each time
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