Cardiac Flashcards
preload
amount of blood returning to the right side of the heart and the stretch in muscle the volume causes
_____ is released when we have this preload stretch
ANP -> diurese
increased preload =
increased workload
afterload
the pressure (resistance) in the aorta and the peripheral arteries that the LV has to pump against to get the blood out
diagnosis with increased afterload
HTN
HTN can lead to… (2), because why?
- HF|2. pulmonary edema||- high afterload decreases CO and forward flow -> wears your heart out
stroke volume
amount of blood pumped out of the ventricles w/ each beat
CO = ____ x ____
CO = HR x SV
____ is dependent on adequate CO
tissue perfusion
*4 factors that affect CO*
- HR|2. certain dysrhythmias|3. blood volume|4. decreased contractility
3 potential causes of decreased contractility
- MI|- medications|- cardiac muscle disease
Medications: preload|- how do medications work to affect preload and increase CO?||- 2 examples
- by vasodilating or diuresing to decrease preload||1. Diuretics (furosemide)|2. Nitrates (nitroglycerine)
Medications: afterload|- how do medications work to affect afterload and increase CO?||- 4 examples
- by vasodilating to reduce afterload||1. ACE Inhibitors (captopril, enalapril, fosinopril)|2. ARBS (valsartan, losartan, irbesartan)|3. hydralazine|4. nitrates
Medications: contractility|- how do medications work to affect contractility and increase CO?||- 3 example
- by providing an inotropic effect on the heart -> increases contractility ||1. inotropes (dopamine, dobutamine, milrinone)
Medications: rate control|- how do medications work to affect HR and increase CO?||- 3 examples
- by slowing the rate down to a more controlled, effective pump||1. Digoxin|2. B-blockers (metoprolol, propanolol, atenolol, carvedilol)|3. Ca-Channel blockers (diltiazem, verapamil, amlodipine)
Medications: rhythm contol|- how do medications work to affect rhythm and increase CO?||- 1 example
- by converting the heart back to a NSR, the heart pumps more effectively and CO increases||1. antiarrythmics (Amiodarone)
6 areas affected by decreased CO
- brain|2. heart|3. lungs|4. kidneys|5. skin|6. peripheral pulses
Decreased CO:|- brain|- heart|- lungs|- kidneys|- skin|- peripheral pulses
- brain: LOC decreases||2. heart: chest pain||3. lungs: wet sound/crackles, SOB||4. skin: cold, clammy||5. kidneys: UO decreases||6. peripheral pulses: weak/thready
dysrhythmias are no big deal until what?
they affect your CO
*3 arrythmias that are ALWAYS a big deal + ACTION*
- pulseless v-tach|2. v-fib|3. asystole||- CPR!!
most common CV disease
coronary artery disease
CAD includes… (2)
- chronic stable angina||- acute coronary syndrome
Patho: chronic stable angina
- intermittent decreased BF to myocardium leads to ischemia||- this ischemia can lead to temporary pain/pressure in chest
CSA:|- what brings on the chest pain?|- what relieves it?
- low O2, usually d/t exertion||- rest and/or nitroglycerine sublingual
4 medications for CSA
- nitroglycerine sublingual|2. B-blockers|3. Ca-Channel blockers|4. Aspirin
Nitroglycerine:|- action|- route|- use
- causes venous, arterial, and coronary artery vasodilation -> decreases preload and afterload; and increases blood flow to the myocardium||- sublingual||- used for angina
Nitroglycerine:|- how to take?|- swallow?|- burn/fizz?|- expected outcome?
- sublingual: take 1 every 5 minutes x 3 doses for acute angina -> no help, call 911||- DON’T SWALLOW||- may or may not burn/fizz||- patient WILL get a headache -> but also their BP will decrease
Storing Nitroglycerine:|- store it how?|- renew SL tablets how often?|- spray how often?
- store in a dark, glass bottle in a dry and cool place||- q3-6months||- q2yr
After giving nitro, can you leave the pt?
NO: never leave an unstable pt!
nitro: home teaching (2)
- take one NTG SL -> after 5 minutes if chest pain/discomfort is unrelieved or worse, call 911||- take @ home -> have a BP monitor to check your BP
B-blockers:|- use|- action (3)
- prevention of angina||- decrease:|1. BP|2. HR|3. contractility||…therefore, decreasing the workload of the heart
What happens to CO when you give B-blockers?
- decreases -> decreases workload of heart
considerations for b-blockers
- good to a certain point to decrease the work/CO on the heart||- but we could potentially decrease CO too much
Ca-channel blockers:|- 4 examples|- use|- action
- nifedipine|2. verapamil|3. amlodipine|4. diltiazem||- prevention of angina||- dilation of the arterial system (coronary arteries) -> decreasing BP
2 benefits of Ca-channel blockers
- decrease afterload|2. decrease heart’s oxygen demand
Acetylsalicylic acid (aspirin): use
to keep blood flowing freely
general strategy for pt teaching for CSA
do whatever you can to decrease the workload on the heart
*pt teaching: CSA (8)*
- rest frequently|2. avoid overeating|3. avoid excess caffeine/drugs that increase HR|4. dress warmly in cold weather|5. take NTG prophylactically|6. quit smoking|7. lose weight|8. reduce stress
diet for CSA
- low fat, high fiber
CSA: exercise teaching (2)
- wait 2 hr after eating to exercise||- avoid isometric exercise (squeeze/release muscles)
Why do CSA pt’s need to dress appropriately for the weather?
any temperature extreme can precipitate an attack
procedure that may need to be performed in a CSA pt
cardiac catheterization
Considerations: pre-cardiac cath (4)
- assess if allergic to iodine or shellfish (an iodine-based dye is used)||2. assess kidney function: dye is excreted thru kidneys||3. inform pt that the shot will feel hot and that palpitations are normal||4. hold metformin
What is often ordered before a cardiac cath if a pt has kidney problems?
- acetylcystine (Mucomyst): helps to protect kidneys
considerations: post-cath (4)
- monitor VS|2. watch puncture site|3. assess extremity distal to puncture site|4. proper positioning
watch puncture site for what? (2)
- bleeding: major complication post-cath||2. hematoma formation: bleeding behind them
assess extremity distal to puncture site how often? for what? (5 P’s)
- q15m for 1 hr||Pulselessness|Pallor|Pain|Paresthesias|Paralysis
*Positioning post-cath* (3)
- bedrest||- lie flat||- keep extremity straight for 4-6 hr
after cath, report ______ ASAP
PAIN
withhold which med after cath? for how long? why?
- metformin||- 48 hr||- worried about kidneys
Unstable chronic angina = ….
impending MI
Acute Coronary Syndrome (ACS) is another name for..
- MI||- unstable angina
ACS:|- patho
- decreased BF to myocardium -> ischemia and necrosis
difference b/n ACS and CSA
ACS:|- pt does not have to be doing anything to bring this pain on||- NTG will not relieve the pain
6 general s/s of ACS
- pain|2. cold/clammy|3. hypoTN|4. decreased CO|5. ECG changes|6. vomiting
how might the pain from ACS be described?
- pressure|- elephant sitting on my chest|- pressure radiating to left arm/jaw|- N/V|- pain between shoulder blades
3 patients we are most concerned about when considering MI + why?
- women|2. elderly |3. diabetics||- these patients don’t have typical s/s of ACS
Women usually present w/…..during an MI (5)
- GI s/s|2. epigastric complaints|3. pain between shoulder blades|4. aching jaw|5. choking sensation
*classic triad a woman will present w/ when having an MI*
- abd fullness|2. chronic fatigue|3. SOB
Why are we worried about the elderly?
they might have less or no pain
2 most common s/s of ACS in elderly
- SOB = most common||2. change in behavior
why are we worried about diabetics?
can’t feel pain properly (neuropathy)
Which patient is more severe: STEMI or NSTEMI?|- *action?*
STEMI: this indicates that the pt is having a heart attack||- need to get them to the cath lab for PCI in less than 90 minutes
3 labs used to diagnoses MI
- CPK-MB|2. Troponin|3. Myoglobin
which lab value is most sensitive and most specific for diagnosing MI?
- troponin
CPK-MB:|- increases with..|- elevates how fast?|- peaks when?
- damage to cardiac cells||- within 3-6 hr||- 12-24 hr
Troponin: normal levels|- T|- I
- T: < 0.10||- I: < 0.03
Troponin:|- elevates how fast?|- remains elevated how long?
- within 3-4 hr||- up to 3 weeks
Why is troponin the best indicator of an MI?
- it is the most sensitive biomarker to myocardial damage||- it remains elevated for a long time, good for the pt who delayed seeking care
why is myoglobin not reliable for diagnosing MI?
it is not cardiac specific
One benefit of myoglobin levels
it will elevate first: within 1 hr
potential complication of an ACS
major arrythmias
*3 untreated arrythmias that will put the pt at risk for sudden death*
- pulseless v-tach|2. v-fib|3. asystole
*priority tx for v-fib*
DEFIBRILATE!: de-fib the v-fib||- also CPR!
*the first shock doesn’t work and the pt remains in v-fib. what are the next 2 actions to take?*
- epinephrine -> then amiodarone
Amiodarone:|- uses (3)
when:|1. v-fib and|2. pulseless v-tach|…are resistant to tx||3. fast dysrhythmias
2 anti-arrythmics commonly given to prevent a 2nd episode of v-fib
- amiodarone|2. lidocaine
1 antiarrythmic of choice + major S/E
- amiodarone||- hypoTN -> can lead to further dysrhythmias
s/s of lidocaine toxicity
any neuro changes
*order of medications given to pt w/ chest pain when they arrive at the ED*
- Oxygen: keep O2 sat > 90%|2. Aspirin: chewable|3. Nitroglycerine|4. Morphine||*OANM*
what position should you place pt c/o of chest pain in?
head up: decreases workload and increases CO
what other kind of medication will the pt c/o chest pain be given?
thrombolytics
thrombolytics:|- goal|- 4 examples
- dissolve the clot that is blocking BF to the heart muscle -> decrease size of infarction||1. alteplase|2. tenecteplase|3. reteplase|4. streptokinase
*how soon after onset of myocardial pain should thrombolytics be administered?*
within 6-8 hrs
Stroke: ________ is BRAIN
TIME
major complication of thrombolytic therapy
bleeding
*4 absolute contraindications for thrombolytic treatment*
- intracranial neoplasm|2. intracranial bleed|3. suspected aortic dissection|4. internal bleeding
antidote for dabigatran
iadrucizumab
3 classes of drugs requiring bleeding precautions
- thrombolytics|2. antithrombotics|3. acetominophen
3 other examples of thrombolytics
- heparin|2. warfarin|3. enoxaparin sodium
*bleeding precautions (8)*
watch for:|1. bleeding gums|2. hematuria|3. black stools||use:|4. electric razor|5. soft toothbrush|6. stool softeners|7. lubricant for sex||no:|8. IM injections
How to draw blood on a pt on bleeding precautions
- draw blood when starting IVs -> decrease number of puncture sites
any ABGs if a pt is on bleeding precautions?
NO
_____ are another important follow-up component of thrombolytic therapy
antiplatelets: aspirin, clopidogrel, etc
Which type of IV is preferred if you need a TPA for an MI?|- CVL or PIV?
PIV: because if you put in a central line there is an extreme risk for bleeding out
2 medical interventions for MI
- percutaneous coronary intervention (PCI)||2. coronary artery bypass graft (CABG)
use of PCI
to open up occluded artery to restore BF
PCI includes… (2)
- PTCA (angioplasty)||- stents
major complication of PCI
MI (also bleeding from heart cath site, or reocclusion)
if any problems occur after PCI, do what?
go to surgery
*pt teaching: post-PCI*
report any pain! -> Call HCP STAT, they are reoccluding
CABG:|- use (2)
(scheduled or emergent)||- multiple vessel disease||- left main artery occlusion
why is the left main coronary artery so important?
- supplies the LV -> ||- if occluded, think sudden death! (or “widow maker”)
*Post-MI: pt teaching -> NO…(4)*
NO:|- smoking|- isometric exercises|- valsalva/straining|- suppository meds
Give ____ to prevent straining post-MI
docusate
Post-MI: exercise teaching (3)
- stepped-care plan (increase activity gradually)|- no isometric exercises|- best exercise: walking
Post-MI: diet (4)
- low fat|2. low salt|3. low cholesterol|4. high fiber
Post-MI: sex teaching (2)
- can resume sex when they can walk up a flight of stairs or around the block w/ no discomfort (1 wk-10 days)||- safest time to have sex: morning, when they are well rested
teach Post-MI pt s/s of HF (4)
- increased wt|2. ankle edema|3. SOB|4. confusion
5 main causes of HF
- untreated HTN: #1 causes|2. cardiomyopathy|3. endocarditis|4. MI|5. valvular heart disease
S/S of LHF (9)
- pulmonary congestion|2. pink, frothy sputum|3. dyspnea|4. cough|5. restlessness|6. tachycardia|7. S-3 sound|8. orthopnea|9. nocturnal dyspnea
S/S of RHF (5)
- distended neck veins|2. edema|3. enlarged organs|4. wt gain|5. ascites
how can COPD/pulmonary embolus lead to cor pulmonale?
- hypoxia -> pulmonary HTN -> increased workload -> RHF -> cor pulmonale
what is cor pulmonale?
RHF caused by LHF/primary disorder in respiratory system
Systolic vs Diastolic HF
- systolic: heart can’t contract and eject||- diastolic: heart can’t relax and fill
4 common ways to diagnose HF
- B-type natriuretic peptide (BNP)|2. CXR|3. Echocardiogram|4. NY Heart Association Functional Classification
NY Functional classification: which is the worst?
- scale of 1-4, 4 being the worst
sensitive laboratory indicator of HF
BNP
BNP:|- when is it secreted?|- considerations when preparing to draw
- secreted by ventricular tissues when ventricular volumes and pressures in the heart are increased||- discontinue nesiritide 2 hr before drawing BNP
a CXR will show (2) in HF
- enlarged ventricles||- pulmonary infiltrates
echocardiograms can give you information on.. (2)
- pumping action/ejection fraction|2. backflow -> valve disease
2 standard medications used for HF
- ACE inhibitors||2. ARBs
drug of choice for HF
ACE inhibitors
ACE inhibitor:|- action|- result in (2)
- prevent conversion of angiotensin I to angiotensin II||1. arterial dilation|2. increased stroke volume
ARBs:|- action|- result in (2)
- block angiotensin II receptors||1. decreased arterial resistance|2. decreased BP
ACE inhibitors and ARBs both block ________ => result (3)
- aldosterone: ||1. lose Na|2. lose H2O|3. retain K+ ->
watch for ______ w/ ACE inhibitors/ARBs
hyperkalemia
it is a core practice that a pt w/ HF will be sent home on…what (2)?||Why?
- ACE inhbitor||and||2. B-blocker||- these drugs decrease workload by preventing vasoconstriction (decreasing afterload). This will increase CO and keep blood moving forward.
2 other drugs for HF
- digoxin|2. diuretics
Digoxin:|- use|- results (4)
- used when pt is in sinus rhythm or a-fib and has HF||1. increased contractility|2. decreased HR|3. increased CO|4. increased kidney perfusion
Important to assess for _____ w/ digoxin
toxicity (especially in elderly pt)
normal digoxin levels
0.5 - 2.0
we always want to ____ HF pts
diurese
s/s of digoxin toxicity (4)
- anorexia|- N/V|- arrythmias|- vision changes: yellow halos
before giving digoxin, do what?
assess apical pulse for a full minute. Hold dose if it is <60
where would you check for apical pulse?
5th ICS, MCL
most important electrolyte to monitor if a pt is on digoxin
K+
_______ + digoxin = toxicity
hypokalemia
T/F: any electrolyte can promote digoxin toxicity
TRUE
diuretics:|- action|- consideration
- decrease preload||- always give in the morning
5 other interventions for HF pt
- low Na diet|2. bed positioning|3. daily wt|4. report s/s of recurring failure|5. pacemaker
low Na diet helps decrease ___
preload
salt substitutes can contain excessive ____
K+
position in bed for HF pt
HOB elevated
report a wt gain of….
2-3 lb
fluid retention, think ____ first
heart problems
natural pacemaker
SA node
Pacemaker:|- indication
symptomatic bradycardia
What do pacemakers do?
depolarize the heart muscle -> contraction will occur
repolarization
- Re = rest: ventricles rest and fill up w/ blood
pt w/ pacemaker: always worry if…
HR drops below the set rate
post-permanent pacemaker care (4)
- monitor incision|2. immobilize arm -> put things close to them|3. assisted passive ROM to prevent frozen shoulder|4. keep pt from raising arm higher than shoulder
loss of capture
no contraction follows stimulus -> decreased CO
failure to sense
pacemaker fires at innappropriate times
2 s/s of pacemaker malfunction
- any sign of decreased CO||- bradycardia
Pacemaker: pt teaching (6)
- check pulse daily|2. ID card/bracelet|3. avoid electromagnetic fields (cell phones, large motors)|4. avoid MRIs|5. will set off alarm at airport|6. avoid contact sports
R/F for pulmonary edema (5)
- receiving IV fluids very fast|2. very young|3. very old|4. heart dz|5. renal dz
when does pulmonary edema usually occur?
at night, when pt goes to bed
S/S of pulmonary edema (5)
- pink, frothy sputum|- sudden onset|- breathless|- restless/anxious|- severe hypoxia
*priority nursing action for pulmonary edema*
- administer high-flow oxygen: titrate to keep O2 sats > 90%
4 medications for pulmonary edema
- diuretics|2. nitroglycerine|3. morphine|4. nesiritide
Diuretics:|- use|- results (2)|- how to give?|- prevent (2)
- reduce preload||1. diuresis|2. vasodilation||- IVP slowly over 1-2 minutes to prevent hypoTN and ototoxicity
which diuretic can be given as a continuous IV infusion?
bumetanide
result of NTG
decreased afterload
results of morpine (2)
- decreased afterload and preload
Nesiritide:|- actions (2)|- considerations (2)
- vasodilates veins/arteries|2. diuretic effect||1. turn off 2 hr before drawing BNP|2. only used for short-term therapy: never longer than 48 hr
pulmonary edema: positioning + why? (2)
- upright position, legs down||1. improves CO|2. promotes pooling of blood in legs
cardiac tamponade: patho
- blood, fluid, or exudate has leaked into the pericardial sac resulting in compression of the heart||- often seen in MVA, MI, pericarditis, hemorrhage post-CABG
2 hallmark signs of cardiac tamponade
- increased CVP|2. decreased BP
other s/s of tamponade (5)
- narrowed pulse pressure|2. muffled/distant heart sounds|3. distended neck veins|4. pressures in all 4 chambers the same|5. shock
tamponade tx
pericardiocentesis
T/F: atherosclerosis is often limited to one certain spot
false: if you have it in one place, you have it everywhere
hallmark sign of arterial disorder
intermittent claudication: |- only seen w/ arterial problems|- pain relieved w/ rest
7 s/s of arterial disorder
- coldness|- numbness|- decreased peripheral pulses|- atrophy|- bruit|- skin/nail changes|- ulcerations
Pain at rest means…
severe arterial occlusion: medical emergency
leg positioning:|- arterial disorder|- venous disorder
- A: dangle arteries (A points down)||- V: elevate veins (V points up)
2 common treatments for aterial disorders
- angioplasty||- endarterectomy
how to assess if an angioplasty/endarterectomy was successful?
- look for positive changes in the area that the artery is feeding blood to (brain, abd, leg)
Arterial vs. Venous: pain
- A: intermittent claudication (progressing to pain at rest)||- V: none-to-aching pain; depends on dependency of area
Arterial vs. Venous: pulses
- A: decreased, may be absent||- V: normal (may be difficult to palpate d/t edema)
Arterial vs. Venous: color
- A: pale when elevated, red when lowered||- V: normal (may see petechiae/brown pigment)
Arterial vs. Venous: temperature
- A: cool||- V: normal
Arterial vs. Venous: edema
- A: absent or mild||- V: present
Arterial vs. Venous: skin changes
- A: thin, shiny, loss of hair over foot/toes, nail thickens||- V: brown pigment around ankles, thickening/scarring of skin
Arterial vs. Venous: ulceration
- A: will involve toes or areas of trauma on feet (painful)||- V: will be on sides of ankles
Arterial vs. Venous: gangrene
- A: may develop||- V: does not develop
Arterial vs. Venous: compression
- A: not used||- V: used
