Cardiac Flashcards
What do arteries carry?
Oxygenated blood
What do veins carry?
Deoxygenated blood
What is the one artery that carries deoxygenated blood?
Pulmonary artery
What is the one vein that carries oxygenated blood?
Pulmonary vein
What delivers deoxygenated blood into the RA?
Inferior and superior vena cava
What carries oxygenated blood from the LV to the body?
Aorta
Preload
Amount of blood returning to the right side of the heart and the muscle stretch that the volume causes.
What is released with the stretch of preload?
ANP
Afterload
Amount of pressure in the aorta and peripheral arteries that the left ventricle has to pump against to get the blood out
Stroke volume
Amount of blood pumped out of the ventricles with each beat
CO formula
HR * SV
How does tachycardia decrease CO?
When you heart beats too fast, the ventricles don’t have enough time to fill
S/S of decreased CO
Decreased LOC Chest pain SOB, wet lung sounds Cold/clammy Decreased UOP Weak pulses
LV = ?
CO
Coronary artery dz includes what?
Chronic stable angina and acute coronary syndrome
Patho of chronic stable angina
Decreased blood flow to the myocardium leads to ischemia which causes temporary pain and pressure in the chest
What causes pain with stable angina?
Low O2, usually due to exertion
What relieves the pain caused by stable angina?
Rest, nitro
What are the 3 arrhythmias that are a big deal because they decrease CO?
Pulseless v tach
V fib
Asystole
*They’ll need CPR
How does nitro work?
Causes venous and arterial dilation which decreases preload and after load. Dilation of coronary arteries will increase blood flow o the myocardium
Decreases BP
How to take nitro
1 every 5 minutes x 3 doses (Take one, after 5 min if pain is still there or worse, activate emergency response) May or may not burn/fizz Do not swallow, put under tongue *Never leave unstable client
How to store nitro
In the dark, glass bottle, dry, cool
Don’t mix, don’t open bottle often
How often do you renew nitro?
Every 3-5 months
Spray every 2 years
What is the main SE caused by nitro?
HA-don’t call doc cause you expect this, not life threatening
Examples of Ca channel blockers for angina
Nifedipine, verapamil, amlodipine, diltiazem
If you take nitro prophylactically, what should you do after taking?
Sit down for a while bc BP will decrease
How do Ca channel blockers work?
Decrease BP by causing vasodilation of the arterial system. They decrease after load and increase the oxygen to the heart muscle
Average aspirin dose for angina
81-325mg
-Keeps blood flowing from keeping platelets from sticking together, doesn’t treat pain directly, will result from increased oxygen with increased blood flow
Client education for chronic stable angina
Wait 2 hours after eating to exercise
Dress warmly in cold weather (warm or cold temp extremes can cause an attack)
Take nitro prophylactically
Stop smoking
Avoid isometric exercise (make muscles squeeze and tense up, increases workload of heart)
Cardiac Catheterization
Procedure used to diagnose heart dz, most definitive, also most invasive
What do you ask the client if they’re allergic to pre cardiac cath?
Iodine/shellfish
-Iodine based dye is used
What function do you check before cardiac cath?
Kidneys, that’s how they excrete the dye. Acetylcysteine (mucomyst) is ordered to help protect the kidneys
Hot shot
Warn, while injecting dye, iodine causes warmth and flushing, palpitations are also normal
What do you watch the puncture site for post heart cath?
Bleeding/hematoma formation
Positioning post heart cath
Bed rest, flat, leg straight for 4-6 hours
How do you assess extremity distal to puncture site post heart cath?
5 P’s
- Pulselessness
- Pallor
- Pain
- Paresthesia
- Paralysis
Major complication of heart cath
Hemorrhage
Is pain normal after heart cath?
No, could mean hemorrhage, report immediately
How med do you stop 48 hours before heart cath?
Metformin. We are worried about the kidneys
Unstable chronic angina = ?
Impending MI
Patho of unstable angina
Decreased blood flow to myocardium leads to ischemia and necrosis. Client doesn’t have to be doing anything to bring this pain on, nitro will not relieve the pain
S/S of unstable angina/MI
Pain-crushing, elephant sitting on chest, pressure radiating to the left arm and left jaw, in between shoulder blades
N/V-Acute pain stimulates vomiting center in brain, when they vomit the vagus nerve is stimulated-decreased HR and CO
Cold/clammy
BP drops-CO is decreasing
ECG changes
Common time for MI
Morning, coming out of dreams, getting up leads to increased HR and BP
Pain for women for MI
GI s/s, epigastric pain or pain between shoulders, aching jaw, choking sensation
1 sign of MI in elderly
SOB, acute behavior change
STEMI
ST segment elevation MI indicates the client is having a heart attack and the goal is to get them to the cath lab for PCI in less than 90 minutes
CPK-MB
Cardiac specific isoenzyme
Increases with damage to cardiac cells
Elevates 3-12 hours and peaks in 24 hours
Troponin
Cardiac biomarker with high specificity to myocardial damage
Elevates within 3-4 hours and remains elevated for up to 3 weeks
Normal lab values for Troponin T
Normal lab values for Troponin I
Myoglobin
Increases within 1 hour and peaks in 12 hours
Negative results are a good thing
Which cardiac biomarker is the most sensitive indicator for an MI?
Troponin
Which enzymes or markers are most helpful when the client delays seeking care?
Troponin
Priority treatment for V-Fib
Defibrillate, do CPR in between shocks until you get an effective heart beat
If the first shock doesn’t work and the v fib client remains in v fib, what is the first vasopressor we give?
Epi
Amiodarone
Anti-arrhythmic, used in v fib or pulseless v tach when shocks and epi do not work, and also for fast arrhythmias
What anti arrhythmic drugs are commonly given to prevent a second episode of v fib?
Amiodarone and lidocaine (decreases irritability of heart)
Sign of lidocaine toxicity
Neuro changes
Important SE of amiodarone?
Hypotension, can lead to further arrhythmias
What drugs are used for chest pain when the client gets to the ED?
O2
Aspirin (165-325, chewable, if not given before arrival)
Nitro
Morphine
What position do you keep the MI patient in?
Head up, decreased workload on the heart and increases CO
Goal of fibrinolytics
Dissolve clot that is blocking blood flow to the heart muscle which decreases the size of the infarction
Fibrinolytic meds
Streptokinase, alteplase, tenecteplase, reteplase
How soon after the onset of myocardial pain should these drugs be administered?
Within 6-8 hours, sooner the better
Door to drug time for fibrinolytic?
30 minutes
Time is what?
Brain
Major complication of fibrinolytic?
Bleeding
Which fibrinolytic are people allergic to most often?
Streptokinase, will have to treat them for their allergy also but still give it
Absolute contraindications of fibrinolytic therapy
Massive hemorrhage, intracranial neoplasm, intracranial bleed, pregnancy, suspected aortic dissection, internal bleeding
Bleeding precautions
Watch for bleeding gums, hematuria and black stools, electric razor, soft toothbrush, no IMs, no ABGS-too much bleeding
Draw blood when for bleeding precautions?
When starting IV, decrease amount of puncture sites
Follow up therapy of fibrinolytic
Antiplatelets (acetylsalicylic acid, clopidogrel
Where do you give fibrinolytic?
Peripheral site you can compress in case of hemorrhage (not a place like jugular, you can hold pressure on that)
PCI
Percutaneous coronary intervention. Incledes PTCA (angioplasty) and stents. Can be done in any artery in body, not just heart
What are you trying to do with PCI
Open up coronary artery, restore blood flow to heart
Major complication of angioplasty
MI. Don’t forget the client may bleed from the heart cath site, or they could re occlude
If any problems occur during PCI?
Go to surgery.
Chest pain after PCI?
Call doc at once, they are re occluding
Anti platelet meds
Aspirin, clopidogrel, abciximab, eptifibatide
When is a CABG indicated?
Multiple vessel dz or left main coronary artery occlusion
Left main coronary artery
Supplies blood to the entire left ventricle
Left main coronary artery occlusion-think what?
Sudden death, widow maker
Activity after CABG
Increase gradually, no isometrics, no valsalva (vagal nerve stimulation will bottom out their HR), no straining/suppository/docusate
Diet after CABG
Low fat, low salt, low cholesterol
When can sex be resumed after CABG?
When they can walk around the block or up a flight of stairs with no discomfort (usually within 1 week to ten days)
What is the safest time for sex after CABG?
Morning when the client is well rested
Best exercise for MI client
Walking
Left side heart failure
The blood is not moving forward into the aorta and out to the body, if it doesn’t move forward, it goes backward into the lungs
S/S of left side heart failure
Blood tinged frothy sputum Restlessness/tachycardia S-3 Nocturnal dyspnea/orthopnea Pulm congestion/dyspnea/cough
Right side heart failure
The blood is not moving forward into the lungs, it it doesn’t more forward into the lungs, it goes backwards into the venous system
S/S of right side heart failure
Distended neck veins Edema Enlarged organs Weight gain Ascites
BNP for diagnosis of heart failure
Secreted by the ventricular tissues in the heart when ventricular volumes and pressures in the heart are increased
Sensitive indicator
Can be positive for HF when the CXR doesn’t indicate a problem
*If client is on nesiritide, turn off for 2 hours prior to drawing a BNP
What can cause right side heart failure
PE, hypoxia #1 cause of pulm htn, workload of right side of heart is increased
Left sided heart failure
What do you look at on a CXR to diagnose heart failure
Enlarged heart, pulmonary infiltrates
What can diagnose heart failure besides CXR and BNP
Echo
Swan-Ganz catheter
Balloon flotation catheter is inserted into the right side of the heart and pulmonary artery. It provides info to rapidly determine hemodynamic pressures, CO and provides access to mixed venous blood sampling
DOC fo rHF
ACE inhibitors
Most common site for arterial line
Radial artery
A lines purpose
Continuous intra-arterial BP monitoring and allows for related ABG samples to be collected without sticks
ACE inhibitor action
Suppress renin angiotensin system, prevents conversion of angiotensin I to angiotensin II
Results in arterial dilation and increased stroke volume
ARBS
Block angiotensin II receptors and causes a decrease in arterial resistance and BP
May be used before ACE inhibitors due to the SE of nagging dry cough of ACE inhibitors
ACE inhibitors and ARBs both block aldosterone. What do you monitor the client for?
Hyperkalemia
Why is it standard practice for HF client to be sent home on ACE inhibitor and/or beta blocker?
In combination they decrees the workload on the heart by prevention vasoconstriction (decreasing after load)
This increases CO and keeps blood moving forward out of the heart
Digoxin
Makes contractions stronger, decreases HR. When the HR is slowed, this gives the ventricles more time to fill with blood, CO and kidney perfusion will increase
Why is digoxin used less today?
High risk of toxicity, especially in elderly
IS diuresis a good thing or bad thing for HR client?
Good, we always want to diaries them, they can’t handle fluid
Normal Dig level?
0.5-2 ng/mL
How do you know dig is working?
CO goes up
LOC goes up, skin is warm/dry, clear lungs, not SOB, palpable/increase pulses, increased UOP, no chest pain
Is it smart to give HF client whole blood?
No, throw them into pulmonary edema
S/S of dig toxicity
Early: anorexia, n/v
Late: arrhythmias and vision changes (not just halos around lights, any changes)
What do you do before administering dig?
Check the apical pulse
5th intercostal space, left midclavicular line, can move around in some people
First few doses of dig are what?
Larger than maintenance dose they’ll be sent home on. Digitalizing (loading) dose builds them up on the drug
Which electrolytes do you monitor with dig?
All, but K is the one that causes the most trouble
Decreased K + Dig = toxicity
Diuretics
Decreases preload by increasing diuresis
When do you administer diuretics?
In the morning
Low Na diet with HF client
Decreases preload, watch salt substitutes bc they can contain excessive K, OTC meds can also have a lot of salt
Weigh HF client daily, report what?
Gain of 2-3 lbs
Fluid retention, think what first?
Heart problems
Natural pacemaker
SA node/sinus node
Sends out impulses that make the heart contract
When are pacemakers used?
To increase HR with symptomatic bradycardia
What do pacemakers do to the heart muscle to make a contraction occur?
Depolarize them, electricity goes through the muscle
Repolarization
Ventricles are resting and are filling up with blood
Set rate of pacemaker
Always know the set rate, and worry if it drops BELOW the set rate
Demand pacemaker
Kicks in only when the client needs it to, when the demand is turned on
Fixed rate pacemaker
Fire at a fixed rate constantly
Is it okay for a pacemaker rate to increase?
Yes, but never decrease
Post-procedure care for permanent pacemakers
Immobilize arm
Assisted passive range of motion to prevent froze shoulder
Keep client from raising arm higher than shoulder height
*Can also be implanted in abdomen
Most common complication of pacemaker placement post op?
Electrode displacement, monitor the incision
S/S of pacemaker malfunction
Loss of capture
This is when no contraction follows the stimulus
Cause of loss of capture
Could not be programmed correctly
Electrodes can dislodge
Battery may be depleted
What do you watch for when monitoring for loss of capture?
Decreased CO or rate
Client teaching for pacemaker
Check pulse daily
ID card
Avoid electromagnetic fields (cell phones on opposite ear, large motors)
Avoid MRIs
Avoid contact sports
They will set off alarms at airport-shouldnt go through machines, be patted down-dont use want above waist, it is a magnet
ICD
Implantable cardiac device
May be used to pace the heart or to defibrillate people in V-Fib
Post op care for ICD placement
Same as for a pacemaker
Who is at risk for pulmonary edema?
Any person receiving IV fluids really fast, the very young and very old, any person with a history of heart or kidney dz
When does pulmonary edema usually occur
At night when the client goes to bed. During the day the fluid is in your extremities
S/S of pulmonary edema
Sudden onset Breathless Restless/anxious Severe hypoxia Productive cough (pink frothy sputum)
Tx for pulmonary edema
Oxygen-high flow, titrate to keep sats above 90%
Furosemide for treatment of pulmonary edema
Causes diuresis and vasodilation which traps more blood out in the arms and legs and reduces preload and afterload
40mg IV push slowly over 1-2 minutes to prevent hypotension and ototoxicity
Bumetanide for tx of pulm edema
Can be given IV push or as cont IV infusion to provide rapid fluid removal
1-2 mg IV push given over 1-2 minutes
Nitro for tx of pulm edema
Vasodilation decreases afterlaod, which lead to increased CO because the heart is pumping against less pressure, and more blood can be moved forward
Morphine for tx of pulm edema
2 mg IV push for vasodilation to decrease preload and afterload
Nesiritide for tx of pulm edema
IV infusion, short term therapy, not to be given for more than 48 hours
Vasodilates veins and arteries and has a diuretic effect
Positioning for pulm edema
Upright with legs down to improve CO and promote pooling or blood in lower extremities
Prevention of pulm edema
Check lung sounds and avoid fluid volume excess
Cardiac tamponade
Blood, fluid, or exudates have leaked into the pericardial sac resulting in compression of the heart
Can happen if the client has had a motor vehicle collision, right ventricular biopsy, an MI, pericarditis, or hemorrhage post CABG
S/S of cardiac tamponade
Decreased CO CVP increases bc heart is squeezed BP drops bc CO is dropping Heart sounds muffled or distant Distended neck veins Pressures in all 4 chambers are the same Shock Narrowed pulse pressure from baseline
Hallmark sign of cardiac tamponade
Increasing CVP with decreasing BP
Pulse pressure
Difference between systolic and diastolic pressures
Narrowed pulse pressure think what?
Cardiac tamponade
Widened pulse pressure think what?
Increased intracranial pressure
Tx of cardiac tamponade
Pericardiocentesis or sx
Pericardiocentesis
Removes blood from around the heart
Doc inserts needle into pericardial space to remove fluid
If you have atherosclerosis in one place, what does this mean?
You have it everywhere
Acute arterial occlusion
Numb, pain, cold, no palpable pulse
More symptomatic in lower extremities
Medical emergency
Hallmark sign of acute arterial occlusion
Intermittent claudication
Bruit
Turbulent blood flow
Patho of acute arterial occlusion
Arterial blood isn’t getting to the tissue which leads to coldness, decreased peripheral pulses, atrophy, burst, skin/nail changes, ulcerations
Pain at rest means what?
Severe arterial obstruction
Since arterial blood is having problems getting to tissues with acute arterial occlusion, will elevating the extremity increase or decrease the pain?
Increase, dangle affected limb to increase perfusion
How to treat vein problems?
Elevate
How to treat arterial problems?
Dangle
How do you treat arterial disorders of the lower extremities?
Angioplasty or endarterectomy to enhance perfusion
How do you know if a carotid endarterectomy was a success?
Carotids feed brain, therefore the LOC should go up
Shiny hair, increased temporal pulses, or follow verbal commands. Which is correct?
Most important is brain (LOC) so follow verbal commands
Abdominal aortic aneurism how do you know if it was successful?
Check pulse from waste down, starting at femoral, should feel warmer as you go, monitor UOP
Dissecting aorta major complaint
Severe burning back pain, with each beat the aorta is tearing apart so pulsatile back pain
Small pain in leg when walking after heart surgery
Lean against wall, take weight off of it, wheel to room, elevate leg, then call doc
