Cardiac Flashcards
Preload
Afterload
High afterload decreases
Stroke volume is the amount of blood volume pumped with each beat
CO = HR x SV
The amount of blood returning to right side of heart
Afterload is the pressure in the aorta and peripheral arteries that the left ventricle has to pump against
Cardiac output and decreases forward flow
Medications that affect cardiac output:
Preload ( DN)
Afterload (HAAN)
Improve contractility
Rate control (BCD)
Rhythm control
Diuretics(furosemide) and Nitrates(nitroglycerin)
Hydralazine
Ace inhibitors (enalapril,captopril,fosinopril)
ARBS (losartan, irbesartan)
Nitrates
Inotropes (dopamine, dobutamine, milrinone)
Beta blockers(cardevilol,propanolol) Calcium channel blockers( amlodipine,diltiazem,verapamil) Digoxin
Antiarrhythmics (amiodarone)
3 arrhythmias that are always a big deal
Pulseless V-Tach
V-fib
Asystole
Coronary artery disease is
It includes
Most common type of cardiovascular disease
Chronic stable angina and Acute coronary syndrome( unstable angina, MI)
Chronic stable angina
Patho
- what brings this pain?
- what relieves the pain?
Treatment: Medications -Nitroglycerin -Beta blockers -calcium channel blockers -acetylsalicylic acid
Intermittent decreased blood flow is going to the heart which leads to ischemia resulting to pain.
- low oxygen due to exertion
- rest and/or nitroglycerin
Nitroglycerin:
- causes venous and arterial dilation which decreases preload and afterload,also causes CORONARY dilation which increase blood flow to the actual heart muscle
-must be taken sublingually, 1 every 5 mins x 3 doses,if not relieved activate emergency response
-must be kept in dark,glass bottle,dry cool
-HEADACHE is expected
Renew an average of 6 months and 2 years for SPRAY
Beta blockers:
-prevention of angina by decreasing workload on the heart because it blocks beta cells(the receptor sites for catecholamines) norepi and epi
-but we could decrease the cardiac output and
BP too much with these drugs
Calcium blockers:
- cause vasodilation of the arterial system which decreases blood pressure
- 2 benefits are they decrease afterload and increase oxygen to the heart muscle
- they also dilate coronary arteries
Acetlysalicylic acid:
- aspirin, keeps blood going
- dose is determined by primary HCP
Rule:
NEVER LEAVE
Do everything you can
AN UNSTABLE CLIENT
To decrease the workload on the heart
Ranolazine does not increase
has adverse effect of
BP or HR
Chronic constipation
Client teaching for chronic stable angina
Rest frequently Avoid Diet Lose Wait 2 hours Reduce Dress warmly Take nitro
Overeating and excess caffeine and isometric exercises
Diet should be low fat and high fiber
Weight
After eating to exercise
Stress
To avoid precipation of attack especially in cold weather
Nitroglycerin prophylactically
Cardiac catheterization
Pre procedure:
Allergic to and kidney function
Acetylcysteine
Post procedure: V/S Puncture site for Assess 5P's distal to site Extremity should be Major complication Methformin (glucophage)
Must ask if allergic to shellfish or Iodine because a dye is used and also check kidney function because the dye is excreted to the kidneys
Acetylcysteine is prescribed pre procedure to protect the kidneys, hot shot or palpitations are normal
V/S should be monitored
Watch puncture site for bleeding and hematoma formation
Assess for pulselessness,pallor,paresthesia,pain and paralysis(also include skin temp and capillary refill)
Straight and flat for 4 to 6 hours, and bed rest
Hemorrhage
If client is taking methformin(glucophage) must hold for 48 hours because we are trying to protect the kidneys
Acute coronary syndrome (unstable angina,MI)
Patho
S/S: Pain describe as In women they Triad symptoms of women Number 1 sign in elderly
Decreased blood flow to the heart causing ischemia leading to necrosis and pain. The pain will be sudden, it is not caused by client activity. And this pain will not be relieved by nitroglycerin
CRUSHING, an elephant sitting on chest,radiating to left arm and left jaw or pain between shoulder blades
Present with GI signs and symptoms,epigastric discomfort, aching jaw or choking sensation
-Triad-
Indigestion or feeling of fullness
Unusual fatigur
Inability to catch ones breath
Shortness of breathe
STEMI
NON-STEMI
Worry about the
ECG changes in MI
ST Segment Elevation Myocardial infarction
- indicates that the client is having Heart Attack and Goal is ti get them to cath lab in less than 90 minutes
Non-ST segmentt Elevation Myocardial Infarction- these are less worrisome
Worry about the STEMI client
St segment elevation
St segment depression
Abnormal Q wave
T wave inversion
Diagnostic Lab Work in acute coronary syndrome
CPK-MB
- specific
- elevates and peaks
TROPONIN
- specific
- elevates and remains
MYOGLOBIN
- elevates and peaks
- negative
Biomarker most sensitive indicator for MI?
Cardiac specific isoenzyme
Elevates in 3 to 6 hours and peaks 12 to 24 hours
Most specific and most sensitive in detecting cardiac damage
Elevates 3 to 4 hours and remains elevated for up to 3 weeks
Elevates in 1 hour and peaks in 12 hours
Negative result is a good thing
Troponin
Priority treatment for V-fib
If defib does not work?
Amiodarone (cordarone)
- used when
- Important side effect
What antiarrhythmic drugs given to prevent 2nd episode of V-fib?
Lidocaine toxity =
Defibrillation between CPR
Give epinephrine, this is the first medication we give
An anti-arrythmic drug and is used when V-fib and pulseless V-tach are resistant to treatment(defib and vasopressor drugs). This is also the first anti-arrythmic of CHOICE
HYPOTENSION, which could lead to further arrhythmias
Amiodarone and Lidocaine
Any neuro changes
Treatment for acute coronary syndrome
Meds used for chest pain at the ED?
- OANM-must give these meds in order
Thrombolytics (-ase)
- Goal
- how soon after onset of pain
- major complication
- draw blood when starting IV
Oxygen- if less than 90%
Aspirin - chewable is faster
Nitrogylcerin
Morphine
Goal is to restore blood flow by dissolving the clot
Must be given 6 to 8 hours, the sooner the better because TIME IS BRAIN
Bleeding so must do bleeding precautions before and after
To decrease number of Puncture sites
Medical interventions for Acute coronary syndrome
PCI (percutaneous coronary intervention): Includes all intervention such as Major complication of angioplasty This opens up Heart cath site Reocclude
Coronary Artery Bypass Graft (CABG)
Indicated for
Scheduled or
Aka
Left main coronary artery is the
PTCA(percutaneous coronary angioplasty) and stents
MI
The coronary artery
Must monitor for bleeding
Chest pain after procedure means its reoccluding and must notify primary HCP
Multiple vessel disease or Left main coronary artery occlusion.
This can be an emergency procedure or scheduled
Aka open heart surgery
Widowmaker because this artery supplies the Left ventricle
Cardiac rehab in acute coronary syndrome
Smoking Stepped care plan Diet Avoid what exercise Best exercise No "VSS" When can sex be resumed Safest time to have sex
Cessation
Increase activity gradually
Low,low salt,low cholesterol
Isometric exercises because it increases workload
WALKING
No Valsalva, Straining and Suppository (Docusate)
About 1 week to 10 days
In the morning around 8am because during REM sleep is where people usually have an MI
Heart Failure is a complication of
Left sided
Right sided
Cardiomyopathy, valvular heart disease, endocarditis, acute MI and HPN (which is the leading cause of HF)
Blood is not moving forward and will go backward to lungs
Blood is not moving forward to lungs so it backs up to Venous system
S/S of Left HF
Left =Lungs
BROD S-3
S-3 is an
- normal in
- heard using
- kentucky
Blood tinged frothy sputum Restlessness Orthopnea Dyspnea S-3
Extra heart sound
Normal in adults and children but can be Abnormal in the elderly
Heard by using the bell
The sound is described as kentucky
S/S Right HF
“WADEE”
Weight gain Ascites Distended Neck Veins Edema Enlarged organs
Diagnosis of HF
BNP
If on NESIRITIDE?
CXR
Echocardiogram
New york heart association classification
B type natriuretic peptide is secreted by ventricular tissues when there is increase pressure and ventricular volume in heart
Sensitive indicator
If CXR does not indicate a problem, BNP can be Positive
turn it off 2 hours prior to drawing because it might give false positive
Enlarged Heart, pulmonary infiltrates and edema
Looks at the pumping action or ejection fraction of the heart and also give information about backflow and valve disease
Class 1 to 4, the higher the number the worse the HF is
Swan Ganz (Pulmonary Artery)
Arterial Lines
Placed in
ABG and blood pressure
Balloon flotation catheter that can be floated to right side of heart and pulmonary artery
It provides info to rapidly determine hemodynamic pressures and cardiac output
Multiple arteries but most common is radial artery
It allows to collect repeated ABG samples without injury and continuous monitoring of intra artherial blood pressure
Treatment for HF
Medications: Ace inhibitors -DOC -suppresses -Prevents conversion -dilates
ARBS
- maybe used first
- blocks
Beta blockers
- in addition
- relax and decreases
Ace and arbs both block
Client will be sent home with HF while on
Drug of choice for heart failure
Supresses renin angiotensin system (RAS)
Angiotensin I to angiotensin II
Dilates arteries and increases stroke volume
Maybe used first insted of ACE inhibitors due to nagging dry cough with ACE inhibitors
Blocks Angiotensin II receptors and causes decrease artery resistance and decrease BP
Prescribed in addition with ACE inhibitors
Vessels and decreases BP,afterload,Workload
Both block Aldosterone, which decreases Na and H2O, but retaining Potassium, so watch out for Hyperkalemia
Ace inhibitors and beta blockers by preventing vasoconstriction by decreasing afterload
Digoxin given in HF
Used when
Heart rate? “CR”
Heart contraction? “IC”
When the heart is slowed thos gives
C.O will go
Kidney perfusion will go
Sinus rhthym or atfial fib has accompanying chronic HF
Slow it Down (negative chronotropic)
Stronger contraction (positive Inotropic)
Ventricles more time to fill with blood
Up
Up
Troponin I
Troponin T
Less than 0.03 ng/mL
Less than 0.10 ng/mL
Systolic HF
Diastolic HF
Heart cant contract and eject
Ventricles cant relax and fill, they become stiff
Nursing considerations in Digoxin (HF)
Before administering Diurese Whole blood -exception is How to know digoxin is working? S/S for dig toxicity: Early-VAN Late-AV Electrolyte imbalance monitoring Antidote
Check Apical Pulse
We want to always diurese these clients to lessen the pressure of fluid
Must not be given, it can cause pulmonary edema. But an exception is Autologous blood donation like hip surgery
Cardiac Output is increased
Early: vomiting, anorexia and nausea
Late: arrhythmias and vision changes(halo and yellow color)
Any electrolyte imbalance can cause digoxin toxicity but Hypokalemia causes the MOST trouble
Digibind
Diuretics
Action
When to give
Diurese and decreases Preload
Morning
Salt substitutes contain
in HF, report weight gain of
Excessive POTASSIUM
2-3 lbs and weigh daily
PVC ECG readings
Wide QRS and No Pwaves. There is no contraction in the myocardium
Patients with Implantable Cardioverter Defibrillator (ICD) can the significant other be concerned if it delivers shock while having sex?
No, because it is designed to deliver shock at a lower power compared to external defib. It can be felt but will not cause harm
Pacemaker
Natural pacemaker is the
Pacemakers are used to increased heart rate with
Pacemakers may be temporary or permanent ALWAYS worry if the heart rate drops to They maintain a minimal heart rate aka Demand pacemaker kicks in Fixed pacemaker
SA node
SYMPTOMATIC bradycardia
Invasive or non-invasive Below the set rate Set rate Kicks in when it is needed. While a fixed pacemaker fires constantly at a fixed rate
Post procedure fir permanent pacemakers
Incision Most common complication ARM must be Assisted passive ROM Dont raise arm above
Monitor incision site Electrode displacement IMMOBILIZED To prevent FROZEN SHOULDER SHOULDER HEIGHT because wires could be pulled out
Pacemaker fires at inappropriate times
Pacemaker cant cause contraction after stimulus
Reasons why these malfunction happen:
Programmed
Electrodes
Battery
Decreased CO or HR can mean
Client teaching:
Pulse
Id card
Avoid
Failure to Sense
Failure to Capture
May not be programmed correctly
Electrodes may be dislodged
Battery may be depleted
There is a problem
Pulse must be monitored daily
ID csrd or bracelet should be worn
Avoid electro magnetic fields like phones which shoild NOT be carried over the implanted site and must be used on opposite ear, large mofors
-MRI should be avoided because it could turn off the setting or change it. (It wont be pulled out of the body like you imagine)
Pulmonary Edema
(Dont confuse with Pulmonary Embolism)
Patho
S/S Sudden Breathless Severe Hypoxia Cough
Treatment: Oxygen Meds -Diuretics (furosemide and bumetanide) -nitrates -morphine sulfate -nesiritide (turn off 2 hours prior BNP drawing)
Position
Fluid is backing up into LUNGS. The heart is unable to move the VOLUME forward. It usually occurs at Night when the client goes to bed.
Sudden onset
Breathless due to too much fluid going to the lungs
Hypoxia because the lungs cant function well and organ perfusion is decreased. Hypoxia leads to Restlessness or Nervousness( always think Hypoxia first)
Productive cough with pink frothy sputum
Treatment:
High flow oxygen is the PRIORITY nursing action
Must be kept at above 90%
Meds:
Furosemide reduces preload and Bumetanide provide rapid removal of fluid, these can be given IVP SLOWLY
NITROGLYCERIN decreases afterload which then increases CO due to decreased peripheral resistance
Morphine Sulfate decreases afterload and preload. It calms patient,decrease agitation
Nesiritide; iv infusion and for only short term therapy NOT more than 48 hours. Dilates veins and arteries, has diuretic effect
Upright with legs down improves CO and pooling of blood in lower extremeties
Cardiac Tamponade
Patho
Causes:
Accident
Biopsy
MI
S/S: Hallmark signs Muffled Pressure in chambers Shock Narrowed Pulse Pressure
Treatment:
Pericardiocentesis
Surgery
Blood, fluid or exudates have leaked into pericardial sac and compresses the Heart.
Causes can be to motor accidents, right ventricular biopsy, MI or hemorrhage post CABG
Increased CVP and Decreased BP Muffled heart sounds Pressure in 4 chambers will be the same Shock due to decreased CO This is the difference of diastolic and systolic
Pericardiocentesis is the removal of fluid around the heart.inserted in pericardial sac
Narrowed pulse pressure Think:
Widened pulse pressure Think:
Cardiac Tamponade
Increased ICP
Arterial Disorders
Patho
If you have atheroscloris in one place
Acute Arterial Occlusion this is a
Extremity will be
No palpable
Hallmark sign
Treatment:
If you elevate extremity, will pain increase or decrease?
Angioplasty or endarterectomy
Arterial blood is not getting into the tissues which leads to coldness, numbness, decreased Peripheral Pulses(PRIORITY),atrophy, bruit, skin/nail changes and ulcerations
You have it everywhere
Medical Emergency
COLD. And more symptomatic in LOWER EXTREMETIES
Pulse
Intermittent claudication is the hallmark sign but only in artery problems
Treatment:
Increase. We elevate Veins and Dangle Arteries
To increase perfusion
Venous disorders
Veins carry
What can occur in venous disorders?
Could develop
We elevate
Deoxygenated blood
Inflammation and chronic ulcers
DVT
We elevate Veins and dangle Arteries
Chronic arterial insufficiency
Pain Pulses Color Temperature Edema Skin changes Ulceration if present Gangrene Compression
Intermittent claudication, progresses to pain at rest
Decreased or may be absent
Pale when elevated and red when lowering leg
Temperature is COOL
May be mild or absent
Thin, shiny loss of hair over foot or toes, nail thickening
On toes or feet which is painful
Gangrene may develop
Not used
Chronic venous insufficiency
Pain Pulse Color Temp Edema Skin changes Ulceration if present Gangrene Compression
None to aching pain Pulse may be difficult to palpate due to edema May see brown pigmentation or petechia or may be normal Temperature is Normal Edema is present Brown pigmentation, thickening of skin Sides of ankles Does not develop gangrene Conpression is used
