ATI- Med Surge - Cardiac Diseases
Angina, MI, Heart Failure, PVD, ATI unit 4 Ivy Tech Community College Northeast Campus - Fort Wayne IN School of Nursing
Terms in this set (50)
MI vs Angina
Angina pectoris is a warning sign of an impending acute MI
4 major S/Sx differences between Angina and MI
MI risk factors (10)
1. male gender
2. postmenopausal women
4. tobacco use
6. metabolic disorders (diabetes mellitus, hyperthyroidism)
7. methamphetamine or cocaine use
8. stress (life, work, physical exercise, sexual activity)
9. increased risk in older adults that are physically inactive, have one or more chronic diseases (hypertension, heart failure, DM) or have lifestyle (smoking, and diet) habits that contribute to atherosclerosis.
10. atherosclerotic changes related to aging predispose the heart to poor blood perfusion and oxygen delivery
MI subjective Data (4)
2. chest pain (substernal or precordial)
-pain can radiate down the shoulder or arm, or may present as jaw pain
-pain can be described as crushing or aching pressure
MI objective Data (5)
1. Pallor, cool, clammy skin
2. tachycardia and or heart palpitations
5. decreased LOC
MI lab tests (7)
3. Troponin I or T
5. Stress Test
6. Thallium Scan
7. Cardiac Catheterization
MI medications (7)
3. Beta Blockers
4. thrombolytic agents
5. Antiplatelet agents
7. Glycoprotein IIB/IIA inhibitors
MI Nursing Education
1. mont. s/sx of infection (fever, redness, incisional drainage)
2. avoid straining, strenuous exercise, or emotional stress
3. ed on subling nitro
4. smoking cessation
5. encourage compliance with diet and exercise
Heart Failure 4 Classifications
New York Heart Association's functional
Class I: Client exhibits no symptoms with activity.
Class II: Client has symptoms with ordinary exertion.
Class III: Client displays symptoms with minimal exertion.
Class IV: Client has symptoms at rest.
Low-output heart failure
-can initially occur on either the left or right side of the heart.
-Left-sided heart (ventricular) failure results in inadequate left ventricle (cardiac) output
and consequently in inadequate tissue perfusion.
Right-sided heart (ventricular) failure results in?
results in inadequate right ventricle output and systemic venous congestion (peripheral edema).
-An uncommon form of heart failure
-cardiac output is normal or above normal.
3 Risk Factors for Left-sided heart (ventricular) failure
■Coronary artery disease, angina, MI
■Valvular disease (mitral and aortic)
3 Risk Factors for Right-sided heart (ventricular) failure
■Left-sided heart (ventricular) failure
■Right ventricular MI
■Pulmonary problems (COPD, ARDS)
4 Risk Factors for High-output heart failure
■ Increased metabolic needs
■ Septicemia (fever)
5 -- Risk Factors for Cardiomyopathy
■ Coronary artery disease
■ Infection or inflammation of the heart muscle
■ Various cancer treatments
■ Prolonged alcohol abuse
Risk for Older Adults and Heart Failure?
Systolic blood pressure is elevated in older adults, putting them at risk for coronary
artery disease and heart failure.
8 Subjective and Objective Data for Left-sided failure
■Dyspnea, orthopnea (shortness of breath while lying down), nocturnal dyspnea
■Displaced apical pulse (hypertrophy)
■S3 heart sound (gallop)
■Pulmonary congestion (dyspnea, cough, bibasilar crackles)
■Frothy sputum (can be blood-tinged)
■Altered mental status
■Symptoms of organ failure, such as oliguria (decrease in urine output)
8 Subjective and Objective Data for Right-sided failure
■Jugular vein distention
■Ascending dependent edema (legs, ankles, sacrum)
■Abdominal distention, ascites
■Nausea and anorexia
■Polyuria at rest (nocturnal)
■Liver enlargement (hepatomegaly) and tenderness
heart muscle becomes enlarged, thick or rigid. In rare cases, the muscle tissue in the heart is replaced with scar tissue.
4 types of Cardiomyopathy
The main types of cardiomyopathy are:
•Arrhythmogenic right ventricular dysplasia
Other types of cardiomyopathy sometimes are referred to as "unclassified cardiomyopathy."
5 Manifestations of Cardiomyopathy
■ Fatigue, weakness
■ Heart failure (left with dilated type, right with restrictive type)
■ Dysrhythmias (heart block)
■ S3 gallop
■ Cardiomegaly (enlarged heart)
6 Lab tests Heart Failure
1. Human B-type natriuretic peptides (hBNP)
2. Hemodynamic monitoring
4. Transesophagageal echocardiography (TEE)
5. A chest x-ray can reveal cardiomegaly and pleural effusions
6. Electrocardiogram (ECG), cardiac enzymes, electrolytes, and ABGs are used to assess factors contributing to heart failure and/or the impact of heart failure.
7 Medications Heart Failure
1. Diuretics are used to decrease preload.
-Loop diuretics, such as furosemide (Lasix), bumetanide (Bumex)
-Thiazide diuretics, such as hydrochlorothiazide (Hydrodiuril)
-Potassium-sparing diuretics, such as spironolactone (Aldactone)
2. Afterload-reducing agents help the heart pump more easily by altering the resistance to contraction. These include:
-Angiotensin-converting enzyme (ACE) inhibitors, such as enalapril
(Vasotec), captopril (Capoten)
-Angiotensin receptor II blockers, such as losartan (Cozaar)
3.Inotropic agents, such as digoxin (Lanoxin), dopamine, dobutamine (Dobutrex), and milrinone (Primacor), are used to increase contractility and thereby improve cardiac output.
-Nitroglycerine (Nitrostat) and isosorbide mononitrate (Imdur) prevent coronary artery vasospasm and reduce preload and afterload, decreasing myocardial oxygen demand.
5.Human B-type natriuretic peptides (hBNP)
- hBNPs, such as nesiritide (Natrecor), are used to treat acute heart failure by causing natriuresis (loss of sodium and vasodilation).
-Anticoagulants, such as warfarin (Coumadin), can be prescribed if the client has a history of thrombus formation.
7 Patient Teaching Heart Failure
☐ Take medications as prescribed.
☐ Take diuretics in the early morning and early afternoon.
☐Maintain fluid and sodium restriction - a dietary consult can be useful.
☐Increase dietary intake of potassium (cantaloupe or bananas) if the client is taking potassium-losing diuretics, such as loop and thiazide diuretics.
☐Check weight daily at the same time and notify the provider for a weight
gain of 2 lb in 24 hr or 5 lb in 1 week.
☐Schedule regular follow-up visits with the provider.
☐Get vaccinations (pneumococcal and yearly influenza vaccines).
PERIPHERAL ARTERIAL DISEASE (PAD)
PAD results from atherosclerosis that usually occurs in the arteries of the lower extremities and is characterized by inadequate flow of blood. Tissue damage occurs below the arterial obstruction.
-caused by a gradual thickening of the intima and media of the arteries, ultimately resulting in the progressive narrowing of the vessel lumen. Plaques may form on the walls of the arteries, making them rough and fragile.
-is actually a type of arteriosclerosis, which means "hardening of the
arteries," and alludes to the loss of elasticity of arteries over time, due to thickening of their
examples of PADs
Buerger's disease, subclavian steal syndrome, thoracic outlet syndrome, Raynaud's disease and Raynaud's phenomenon, and popliteal entrapment are examples of PADs.
8 PAD risk factors
-Older adult clients have a higher incidence of PAD (rate of occurrence is increased
in men over 45 and in women who are postmenopausal) and have a higher
mortality rate from complications than younger individuals.
3 PAD subjective Data
-Burning, cramping, and pain in the legs during exercise (intermittent claudication)
-Numbness or burning pain primarily in the feet when in bed
-Placing legs at rest in a dependent position relieves pain.
11 PAD Objective Data
-Bruit over femoral and aortic arteries
-Decreased capillary refill of toes (greater than 3 seconds)
-Decreased or nonpalpable pulses
-Loss of hair on lower calf, ankle, and foot
-Dry, scaly, mottled skin
-Cold and cyanotic extremity
-Pallor of extremity with elevation
-Ulcers and possible gangrene of toes
4 PAD Diagnostic Procedures
-Exercise tolerance testing
-Segmental systolic blood pressure measurements
2 PAD Medications
- Antiplatelet medications - Aspirin, clopidogrel (Plavix), Pentoxifylline (Trental)
-Statins - Simvastin (Zocor), atorvastatin (Lipitor)
6 PAD patient edication
-Instruct clients to avoid crossing their legs or raising legs above the level of the heart.
-Encourage clients to sit with legs in dependent position to allow gravity to facilitate arterial blood flow to the lower extremities.
-Instruct clients to wear loose clothing.
-Instruct clients on wound care if revascularization surgery was done.
-Discourage smoking and exposure to cold temperatures.
-Instruct clients about foot care (keep feet clean and dry, wash with mild soap and warm water, pat skin dry, especially between the toes, apply moisturizing lotions and powder if desired, wear good-fitting shoes and a clean pair of cotton socks each day, never go barefoot, cut toenails straight across or have the podiatrist cut nails).
Shock is identified by 4 underlying cause
-Cardiogenic - pump failure or heart failure
-Hypovolemic - a decrease in intravascular volume of 10 to 15% or more
-Obstructive - mechanical blockage in the heart or great vessels
-Distributive - widespread vasodilation and increased capillary permeability
All types of shock progress through the same stages and produce 4 similar effects on body systems.
- Initial - no visible changes in client parameters; only changes on the cellular level
-Compensatory - measures to increase cardiac output to restore tissue perfusion and oxygenation.
-Progressive - compensatory mechanisms begin to fail
-Refractory - irreversible shock and total body failure
Risk Factors for Cariogenic Shock
- cardiac pump failure due to:
MI, heart failure, cardiomyopathy, dysrhythmias, and valvular rupture or stenosis
-Older adult clients are more at risk for MI and cardiomyopathy.
Risk Factors for Hypovolemic Shock
- excessive fluid loss from:
-diuresis or vomiting/diarrhea, or blood loss secondary to surgery, trauma, gynecologic/obstetric causes, burns and diabetic ketoacidosis.
-Older adult clients are more prone to dehydration due to decreased fluid and protein intake and the use of medications, such as diuretics. It will not take as much in the way of fluid losses through vomiting/diarrhea for older adult clients to become dehydrated.
Risk Factors for Obstructive Shock
- blockage of great vessels, pulmonary artery stenosis, pulmonary embolism, cardiac tamponade, tension pneumothorax, and aortic dissection are among the causes
Distributive Shock is divided into three types
1. Septic - endotoxins and other mediators causing massive vasodilation; most common cause is gram-negative bacteria
-Urosepsis is more frequent in older adult clients. This may be due to an inability to recognize early symptoms of a urinary tract infection due to
decreased sensation of urethral burning and awareness of urinary urgency.
-Many older adult clients live in extended care facilities where urinary
catheters are used, increasing the likelihood of urosepsis.
2. Neurogenic - loss of sympathetic tone causing massive vasodilation; trauma, spinal shock, and epidural anesthesia are among the causes
3. Anaphylactic - antigen-antibody reaction causing massive vasodilation; allergens inhaled, swallowed, contacted, or introduced IV are causes
Shock - 11 Subjective Data
Symptoms can include:
Shock - 12 Objective Data
1. Hypoxia, tachypnea progressing to greater than 40/min, hypocarbia
2. Skin may be pale, mottled or dusky in color, cool, diaphoretic, warm, flushed with fever (distributive shock), and exhibit a rash (anaphylactic and septic shock)
3. Angioedema (anaphylactic)
5. Blood pressure may be within the expected reference range during the initial stage, but can increase during the progressive stage and then drop to less than 50 to 60 mm Hg
6. Tachycardia progressing to greater than 140/min
7. Pulse that is weak, thready, or bound with distributive shock
8. Decreased cardiac output
9. Central venous pressure is decreased in hypovolemic shock
10. Central venous pressure is increased with increased systemic vascular resistance in cardiogenic shock
11. Decreased urine output
Shock - 6 Laboratory Tests
1. ABGs - decreased tissue oxygenation (decreased pH, decreased PaO2, increased PaCO2)
2. Serum lactic acid - increases due to anaerobic metabolism
3. Serum glucose and electrolytes - serum glucose can increase during shock
4. Cardiogenic shock
-Cardiac enzymes - creatine phosphokinase, troponin
5. Hypovolemic shock
-Hgb and Hct - decreased with hemorrhage, increased with dehydration
6. Septic shock
-Cultures - blood, urine, wound
-Coagulation tests - PT, INR, aPTT
Shock - Diagnostic Procedures
1. Hemodynamic monitoring
- Arterial line insertion - Needed for continuous blood pressure monitoring and access to withdraw ABG sample and other blood work
2. Pulmonary artery catheter insertion
- A pulmonary artery catheter is inserted to measure cerebrovascular pressure, pulmonary artery pressures, and cardiac output. Continuous hemodynamic monitoring is important to manage fluids and dosage of inotropic medications
Diagnostic Procedures - Cardiogenic and obstructive shock
3. Computerized tomography (CT)
4. Cardiac catheterization
5. Chest x-ray
Hypovolemic shock - miscellaneous diagnostic procedures
Investigate possible sources of bleeding
1. Blood in nasogastric drainage or stools
3. CT scan of abdomen
Shock - 17 Nursing Actions
1. Oxygenation status (priority)
2. Vital signs
3. Cardiac rhythm with continuous cardiac monitoring
4. Urine output - hourly, report if less than 30 mL/hr
5. Level of consciousness
6. Skin color, temperature, moisture, capillary refill, turgor
7. Explain procedures and findings to the client and family while providing reassurance.
8. Place the client on high-flow oxygen, such as a 100% nonrebreather face mask.
9. If the client has COPD, insert a 2 L/min nasal cannula and increase the oxygen flow as needed.
10. Be prepared to intubate the client. Have emergency resuscitation equipment ready.
11. Maintain patent IV access.
12. For hypotension, place the client flat with his legs elevated to increase venous return.
13. If change in status occurs, notify the primary care provider of the findings.
14. Initiate orders to intervene during shock, including transfer to the intensive care unit, surgery, other specialty unit, or diagnostic area.
15. Prepare for and carry out hemodynamic monitoring.
16. Monitor cerebrovascular pressure, pulmonary artery pressures, cardiac output, and pulse pressure.
17. Titrate continuous IV drips to maintain hemodynamic parameters as prescribed.
Shock - 12 meds
1. Inotropic agents
• Milrinone lactate (Primacor)
• Dobutamine (Dobutrex)
• Dopamine hydrochloride (Intropin)
• Norepinephrine (Levophed)
3. Pituitary Hormone
• Vasopressin (Pitressin Synthetic)
4. Opioid analgesics
• Morphine sulfate
• Fentanyl (Sublimaze)
5. Proton-pump inhibitors
• Pantoprazole (Protonix)
• Low-molecular weight heparin, enoxaparin sodium (Lovenox)
7. Isotonic crystalloids or colloids (including blood products)
• 0.9% sodium chloride in water) or lactated Ringer's solution
• Sodium nitroprusside (Nipride)
• Diphenhydramine (Benadryl)
• Epinephrine (Adrenaline)
• Hydrocortisone (Solu‑Cortef)
• Methylprednisolone (Solu‑Medrol)
11. Antibiotics sensitive to cultured organism(s)
• Vancomycin (Vancocin)
12. Activated protein C
• Drotrecogin alfa (activated) (Xigris)
Disseminated Intravascular Coagulation (DIC)
DIC is a complication of septic shock. Thousands of small clots form within organ capillaries (liver, kidney, heart, brain), creating hypoxia and anaerobic metabolism. As a result of massive, multiple clot formation, platelets and other clotting factors such as fibrinogen are depleted and the client is at increased risk for hemorrhage. The client can develop diffuse petechiae and ecchymoses, and blood can leak from membranes and puncture sites.
4 Nursing Actions - Disseminated Intravascular Coagulation (DIC)
1. Administer platelets and clotting factors and other blood products as prescribed.
2. Monitor the client's hemodynamic levels.
3. Assess the client for further signs of bleeding.
4. Apply pressure to leaking IV/central line/arterial line sites.