Cardiac Disorders and Hemodynamic Monitoring Flashcards
1
Q
Cardiac Enzymes
A
- CKMD
- CKMB
- Troponin
2
Q
CKMD
A
Indicates muscle damage (could be any muscle damage, not just the heart)
- Creatine kinase
3
Q
CKMB
A
Muscle band; is the most sensitive but takes longer to rise ( > 5%)
- Creatine kinase
4
Q
Troponin
A
Cardiac enzyme that is seen in the blood sooner than CKMB
- Rises 4-6 hours
- Enzymes appear, then peak and then suddenly go down. If not then patient is extended their MI and experiencing more cardiac damage
- Troponin is released by the necrotic heart tissue
- Indicates myocardial damage, lasts in blood 10-14 days
5
Q
Lipid Profile
A
Cholesterol, triglycerides, and lipoproteins are measured to evaluate a patient’s risk of developing CAD
6
Q
Lipoproteins
A
Is important in the diagnosis of MI. Is a little slower at showing up in the blood, one of the last to arrive.
- Tests are done series over 3 days. Person sits around the house 2 days after chest pain, the CKMB will start to diminish after 3 days but the LDH will stay. Will be checked more than once if there is any abnormality.
- Check to see if it’s peaked & now coming down. Don’t want continuous elevation.
- Can also be indicator of an older MI that occurred.
7
Q
Cholesterol
A
<200 normal (140-200)
** HDL – “good”, transports cholesterol away from the tissue and cells.
** LDL – “bad”, transports cholesterol and triglycerides into the cell.
8
Q
How is a chest x-ray used for cardiac diagnostics?
A
Shows cardiomyopathy. Also done to check for heart size and congestion.
9
Q
SED Rate
A
Inflammation 0-15 men, 0-20 women
10
Q
C-reactive protein
A
Indicator of possible MI, indicates infection
11
Q
Cardiac Diagnostics: BNP
A
Measures fluid volume
12
Q
Cardiac Diagnostics: Cardiac Stress Test
A
Shows heart’s ability to endure stress. Types of stress testing include:
- Exercise stress testing
- Pharmacological stress testing
13
Q
Cardiac Diagnostics: Radionuclide Imaging
A
Shows myocardial ischemia and infarction and evaluate lest ventricular function through the use of radioisotopes
14
Q
What does an EKG look like during an acute MI
A
- T wave inversion
- ST elevation
- Formation of Q wave
15
Q
What does an EKG look like when there is ischemia?
A
Depression or T wave inversion
16
Q
What does an EKG look like when there is myocardial injury?
A
ST segment elevation
17
Q
Cardiac Diagnostics: Cardiac Catheterization
A
Invasion procedure used to measure cardiac chamber pressures and assess patency of coronary arteries
18
Q
Cardiac Diagnostics: Electrophysiologic Testing (EPS)
A
Invasive procedure used to locate the source of serious dysrhythmias
19
Q
Cardiac Diagnostics: Hemodynamic Monitoring
A
Invasive measurement of the movement of blood and the pressures being exerted in the veins, arteries, and chambers of the heart
20
Q
What is CAD
A
Coronary Artery Disease
- Accumulation of plaque causing impaired blood flow to the heart muscle
- In coronary atherosclerosis, blockages and narrowing of the coronary vessels reduce blood flow to the myocardium
21
Q
Clinical Manifestations of CAD
A
- May be asymptomatic or lead to angina
- MI
- Dysrhythmias
- Heart failure
- Sudden death
22
Q
Risk Factors for CAD
A
- HTN
- DM
- Hyperlipidemia
- Increased homocysteine level
- Metabolic syndrome
- Lifestyle factors: obesity, smoking, inactivity, diet, drug abuse
- Men or postmenopausal women
- Age
23
Q
What is Angina Pectoris?
A
Chest discomfort that occurs when there is a decreased blood oxygen supply to an area of the heart muscle
24
Q
What is the most common cause of angina pectoris?
A
CAD (obstruction of the arteries due to atherosclerosis)
25
Types of Angina
1. Stable
2. Unstable
3. Intractable or refractory
4. Variant
5. Silent
26
S/Sx of Angina Pectoris
1. Tightness, squeezing, pressure or ache deep in the chest
2. Sudden breathing difficulty (sometimes)
3. Chest pain similar to indigestion
4. A choking feeling in the throat
5. Chest pain that radiates to the jaw, teeth or earlobes
6. Heaviness, numbness, tingling or ache in the chest, arm, shoulder, elbow or hand usually on the left side
7. Pain between the shoulder blades
27
Treatment of Angina Pectoris
Treatment seeks to decrease myocardial oxygen demand and increase oxygen supply
1. Medications
2. Oxygen
3. Reduce and control risk factors
4. Reperfusion therapy may also be done
28
Medications that treat angina pectoris
1. Beta blockers
2. Calcium channel blockers
3. Antiplatelet and anticoagulant agents (aspirin, clopidogrel, ticlopidine)
4. Glycoprotein IIB/IIIa agents
5. Morphine (decreases O2 consumption, decreases anxiety, and lowers HR and BP
29
Acute Coronary Syndrome
Includes unstable angina and myocardial infarction
* An area of the myocardium is permanently destroyed (MI)
30
Unstable Angina
The plaque ruptures but the artery is not completely occluded
31
Clinical Manifestations of ACS/MI: Cardiovascular
1. Chest pain or discomfort
2. Irregular HR
3. New onset murmur
4. Jugular vein distention (JVD)
5. HTN
32
Clinical Manifestations of ACS/MI: Respiratory
1. SOB
2. Dyspnea
3. Tachypnea
4. Crackles
5. Pulmonary edema
33
Clinical Manifestations of ACS/MI: Gastrointestinal
1. Nausea
| 2. Vomiting
34
Clinical Manifestations of ACS/MI: Genitonurinary
Decreased urinary output
35
Clinical Manifestations of ACS/MI: Skin
1. Cool
2. Clammy
3. Diaphoretic
4. Pale
36
Clinical Manifestations of ACS/MI: Neurologic
1. Anxiety
2. Restlessness
3. Lightheadedness
4. Decreased LOC
37
Diagnostics for ACS/MI
1. Patient history, symptoms
2. ECG
3. Echocardiogram
4. Laboratory tests (creatine kinase and isoenzymes, myoglobin, troponin)
38
Treatment for Acute MI (STEMI)
1. Obtain diagnostic tests including ECG within 10 minutes of arrival
2. Oxygen
3. Aspirin, nitroglycerin, morphine, Beta-blocker (MONA)
4. Angiotensin-converting enzyme inhibitor within 24 hours
5. Evaluate percutaneous coronary intervention, if emergent and indicated should be performed in less than 60 minutes
6. Evaluate for thrombolytic therapy, if indicated should be administered within 3 to 6 hours of the onset of symptoms
7. As indicated: IV heparin or LMWH, clopidogrel or ticlopidine, Glycoprotein IIb/IIIa inhibitor (Repro, Integrilin)
8. Bedrest
39
Pharmacologic Therapy for Acute MI
1. Unfractionated heparin or LMWH (Lovenox) is prescribed along with platelet-inhibiting agents to prevent further clot formation (Also, may be placed on Warfarin)
2. The analgesic of choice for acute MI is morphine administered in IV boluses to reduce pain and anxiety
3. The use of ACE inhibitors decrease mortality rate and prevent remodeling of myocardial cells that is associated with onset of heart failure
4. The purpose of thrombolytics is to dissolve the thrombus in a coronary artery, allowing blood to flow through the coronary again, minimizing the size of the infarction and preserving ventricular function
40
Potential Complications of ACS/MI
1. Acute pulmonary edema
2. Dysrhythmias
3. Heart failure
4. Cardiogenic shock
5. Dressler's syndrome
41
Nursing Interventions for patient with ACS/MI
1. Relieving pain and other s/sx of ischemia
2. Improving respiratory function
3. Promoting adequate tissue perfusion
4. Reducing anxiety
5. Monitoring and managing potential complications
6. Promoting home and community-based care
42
Invasive Coronary Artery Procedures
1. Potential transluminal coronary angioplasty
2. Coronary artery stent
3. Atherectomy
4. Brachytherapy
5. Laser therapy
6. Angio-jet
43
What is the purpose of a percutaneous transluminal coronary angioplasty?
Compresses the plaque against the arterial wall
44
What is the purpose of a coronary artery stent?
Used to maintain an open arterial lumen
45
What is the purpose of an atherectomy?
Shaves the plaque off vessel walls using a rotary cutting head
46
Invasive Coronary Artery Procedures: Possible Complications During the Procedure
1. Dissection
2. Perforation
3. Embolism
4. Hypersensitivity to the contrast dye
5. Dysrhythmias
6. Abrupt closure
7. Vasospasm
8. Acute MI
9. Cardiac arrest
47
Invasive Coronary Artery Procedures: Possible Complications After the Procedure
1. Bleeding at insertion site
2. Retroperitoneal bleeding
3. Hematoma
4. Arterial occlusion
48
The Major Indications for CABG
1. Alleviation of angina that cannot be controlled with medication or PCI
2. Treatment of left main coronary stenosis or multi-vessel CAD
3. Prevention and treatment of MI, dysrhythmias, or heart failure
4. Treatment for complications from an unsuccessful PCI
49
What is a CABG?
Coronary Artery Bypass Graft
- Uses a section of the saphenous vein or internal mammary artery to create a connection between the aorta and the coronary artery beyond the obstruction to allow blood to perfuse the ischemic portion of the heart
- A median sternotomy is used to access the heart
50
Potential Complications of CABG
1. Hypovolemia
2. persistent bleeding
3. cardiac tamponade
4. fluid overload
5. hypothermia
6. hypertension
7. tachydysrhythmias
8. bradycardia
9. cardiac failure
10. MI
11. impaired gas exchange
12. neurologic changes
13. stroke
14. acute renal failure
15. electrolyte imbalance
16. hepatic failure
17. infection
51
Post-Operative Nursing Management of CABG
1. Monitor VS, O2 sat, hemodynamic parameters, HCT and Hgb, electrolytes, auscultate heart and breath sounds, assess skin color, skin temperature, peripheral pulses, and LOC
2. Document cardiac rhythm and waveforms, measure I/O or urine, chest tube and fluids
3. Administer IV fluids, blood products, inotropic, vasodilators, and/or antidysrhythmics as ordered
52
Aneurysms
- An abnormal dilation of a blood vessel
| - Most are caused by arteriosclerosis, atherosclerosis, and HTN
53
Saccular Type Aneurysms
Are caused by a traumatic break in the vessel wall rather than weakness
54
Dissecting Type Aneurysms
Develop when a break or tear in the tunica intima and media allows blood to invade or dissect the layers of the vessel wall
55
Aneurysm Treatment
When aneurysms are 5-6 cm in diameter they are surgically excised and replaced with a synthetic fabric graft
56
Arterial Disorders
1. Buergers Disease
| 2. Raynauds Disease
57
Buergers Disease
(Occlusions)
- A chronic disease of the arteries and veins characterized by pain, color changes, and coldness in the fingers and toes; results from thickening of the walls of blood vessels; cause is unknown, possibly genetic
58
Raynauds Disease
(Spasms)
- Vascular condition in which the fingers become cold and pale when blood vessels are constricted upon exposure to cold; no known cause (occurs secondary to scleroderma, RA)
59
Treatment for Buergers and Raynauds Disease
Key is to increase circulation
1. Calcium channel blockers
2. Nerve block
3. Use gloves
4. Smoking cessation
5. Limit sodium intake
6. Exercise
60
Valvular Disorders
1. Mitral valve prolapse
2. Mitral regurgitation
3. Mitral stenosis
4. Aortic regurgitation
5. Aortic stenosis
61
Mitral Valve Prolapse
- A portion of one or both mitral valve leaflets balloons back into the atrium during systole
62
Medical Management of Mitral Valve Prolapse
Directed at controlling symptoms (avoid caffeine and alcohol)
63
Mitral Regurgitation
- Involves blood flowing back from the left ventricle into the left atrium during systole
64
Medical Management of Mitral Regurgitation
Is the same as for heart failure
65
Mitral Stenosis
- An obstruction of blood flowing from the left atrium into the left ventricle
- Most often cause by Rheumatic Endocarditis
66
Medical Management of Mitral Stenosis
Anticoagulants and heart failure treatment
67
Aortic Regurgitation
- The flow of blood backs into the left ventricle from the aorta during diastole
68
Aortic Regurgitation Treatment
Aortic valvuloplasty or valve replacement
69
Aortic Stenosis
- Narrowing of the orifice between the left ventricle and the aorta
70
Aortic Stenosis Treatment
Surgical replacement of the aortic valve
71
Assessment for Valvular Heart Disorders
1. S/sx of heart failure, such as fatigue, dyspnea on exertion, an increase coughing, hemoptysis, multiple respiratory infections, orthopnea, and PND
2. Dysrhythmias
3. Symptoms such as dizziness, syncope, increased weakness, or angina pectoris
72
Valve Repairs
Valvuloplasty
1. Commissurotomy (open or closed)
2. Annuloplasty
3. Leaflet repair
4. Chordoplasty
73
Valve Replacements
1. Mechanical valves
2. Tissue valves
- Xenograft (from an animal)
- Homograft (from another person)
- Autograft (from self)
74
Tricuspid Valve Disorders
Stenosis obstructs blood flow from the right atrium to the right ventricle
- Regurgitation occurs secondarily to right ventricular dilation, allowing blood to flow back into the right atrium during systole, increasing atrial pressures
75
S/Sx of Tricuspid Valve Disorders
1. Increased CVP
2. JVD
3. Ascites
4. Hepatomegaly
5. Peripheral edema
76
Pulmonic Valve Disorders
- Narrowing of the pulmonary valve, known as valvular pulmonary stenosis (PS) causes the right ventricle to pump harder to get blood past the blockage
77
S/Sx of Pulmonic Valve Disorders
DOE and fatigue are early signs; right-sided heart failure develops
* Regurgitation is a complication of pulmonary HTN, infective endocarditis, pulmonary artery aneurysm, or syphilis. With regurgitation blood is allowed to back flow into the right ventricle during diastole
78
Types of Cardiomyopathy
1. Dilated
2. Hypertrophic
3. Restrictive
4. Unclassified
79
Medical Management of Cardiomyopathy
1. Directed toward identifying and managing possible underlying or precipitating causes
2. Correcting the heart failure with medications
3. A low-sodium diet
4. Exercise/rest regimen
5. Control dysrhythmias
6. Systemic anticoagulation may be used in some cases.
80
Surgical Management of Cardiomyopathy
1. Left ventricular outflow tract surgery
2. Latissimus dorsi muscle wrap
3. Heart transplantation
4. Mechanical assist devices
5. Total artificial hearts
81
Cardiomyopathy Assessment
1. VS
2. Pulses
3. Weight
4. Cardiac and pulmonary auscultation
5. Assessment of JVD
6. Edema
82
Cardiomyopathy Potential Complications
1. Heart failure
2. Dysrhythmias
3. Pulmonary or Cerebral Embolism
4. Valvular dysfunction
83
Nursing Interventions for Cardiomyopathy
1. Improving Cardiac Output
2. Increasing Activity Tolerance
3. Reducing Anxiety
4. Decreasing the Sense of Powerlessness
5. Promoting Home and Community-Based Care
84
Infectious Disease of the Heart
- Any of the layers of the heart may be affected by an infectious process
- Diseases are named by the layer of the heart that is affected
- Diagnosis is made by patient symptoms and echocardiogram
- Blood cultures may be used to identify the infectious agent and to monitor therapy
- Treatment is with appropriate antimicrobial therapy.
85
Rheumatic Endocarditis
- Occurs most often in school-age children, after group A beta-hemolytic streptococcal pharyngitis
- Injury to heart tissue is caused by inflammatory or sensitivity reaction to the streptococci
- Myocardial and pericardial tissue is also affected, but endocarditis results in permanent changes in the valves
- Need to promptly recognize and treat “strep” throat to prevent rheumatic fever
86
Infective Endocarditis
- A microbial infection of the endothelial surface of the heart. Vegetative growths occur and may embolize to tissues throughout the body.
- Usually develops in people with prosthetic heart valves or structural cardiac defects. Also occurs in patients who are IV drug abusers and in those with debilitating diseases, indwelling catheters, or prolonged IV therapy.
87
Myocarditis
- Usually results from viral, bacterial, rickettsial, fungal, parasitic, metazoal, protozoal, or spirochetal infection.
- May also be immune related
88
Pericarditis
Inflammation of the pericardium
89
S/Sx of Pericarditis
1. Friction rub
2. Fever
3. Pain
90
Potential Complications of Pericarditis
1. Pericardial effusion
| 2. Cardiac tamponade
91
Why is invasive hemodynamic monitoring used?
Used to assess cardiac and circulatory function and the response to interventions in the critically ill patient
92
What are the parameters used for invasive hemodynamic monitoring?
1. HR
2. Arterial BP
3. Central veinous pressure
4. Cardiac output
93
Why is intra-arterial pressure monitoring used?
Used to assess blood volume, monitor the effects of vasoactive drugs, and obtain ABGs
94
Preload
The amount of blood presented to the ventricle just before systole
95
Afterload
The amount of resistance to the ejection of blood from the ventricle
96
Contractility
The force of the contraction
97
Cardiac Output
The quantity of blood pumped by the left ventricle into the aorta each minute
CO = SV x HR
98
Ejection Fraction
The percentage of emptying of the ventricular chamber
99
Central Venous Pressure Monitoring (CVP)
- Measures blood volume and venous return
| - Normal range 2-6 mm Hg
100
What does an increased CVP look like?
1. Intravascular volume overload
2. Cardiac tamponade
3. Pericardial effusion
4. Tricuspid valve disease
5. Right ventricular failure
101
What does a decreased CVP look like?
1. Hypovolemia/dehydration
| 2. Alteration in venous tone
102
Treatment for increased CVP
Diuretic
103
Treatment for decreased CVP
Fluids
104
Complications of CVP
1. Hemorrhage
2. Pneumothorax
3. Vascular erosion
4. Dysrhythmias
5. Infection
6. Fluid overload
7. Hypothermia
8. Embolism
9. Air embolus
105
Indications for CVP Monitoring
1. Administration of fluid/electrolytes/blood
2. Drug therapy
3. Pressure monitoring
4. Insert a pacemaker
5. Parenteral nutrition
106
Pulmonary Artery Pressure Monitoring
- Often called a Swan-Ganz catheter
- Used to evaluate overall cardiac function, especially left heart function
- Inserted into a central vein, then threaded into the right atrium, right ventricle and left in the pulmonary artery
- Normal PA is around 25/10 mm Hg
* Important for left heart function
107
Indications for PA monitoring
1. LV failure or shock after AMI
2. Shock or prolonged hypotension
3. CHF secondary to AMI
4. Unstable Angina
5. Suspected extension of MI
6. Monitor systemic volume requirement
108
Arterial Pressure Monitoring
Internal means of monitoring systemic arterial blood pressure
109
Indications for Arterial Pressure Monitoring
1. Accurate BP reading
2. Obtain ABG
3. Drug Therapy
4. Inaudible BP (stages of shock)
5. Timing for an IABP
110
Complications for Arterial Pressure Monitoring
1. Air embolus
2. Sepsis
3. Paresthesia
4. Thrombosis
111
Mixed Venous Oxygen Saturation (SVO2)
- Measured in the pulmonary artery
| - Normal range 60-80%
112
Indications for SVO2 Monitoring
- Early warning of alterations in hemodynamic status
| - Monitor changes in cardiorespiratory status
113
Intra-Aortic Balloon Pump (IABP)
- The balloon is inserted in the thoracic aorta
- Reduces cardiac work by decreasing afterload
- Increases coronary blood flow
- Increases cardiac output
114
Indications for IABP
1. Cardiogenic Shock secondary to MI
2. CHF secondary MI
3. Unstable Angina or Arrhythmias
4. Prophylaxis or Post-op Cardiac Surgery
5. Septic Shock
6. Cardiac Contusion
115
Complications for IABP
1. Extremity ischemia
2. Thrombus formation
3. Infection
4. Hemorrhage
5. Renal compromise
116
Heart Failure
- The inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients
- A syndrome characterized by fluid overload or inadequate tissue perfusion
- The term heart failure indicates myocardial disease, in which there is a problem with the contraction of the heart (systolic failure) or filling of the heart (diastolic failure)
- Some cases are reversible
- Most heart failure is a progressive, lifelong disorder managed with lifestyle changes and medications
117
Medical Management of Heart Failure
1. Eliminate or reduce etiologic or contributory factors
2. Reduce the workload of the heart by reducing afterload and preload
3. Optimize all therapeutic regimens
4. Prevent exacerbations of heart failure
5. Medications are routinely prescribed for heart failure
118
Medications Used to Treat Heart Failure
1. Angiotensin: converting enzyme inhibitors (prils)
2. Angiotensin II receptor blockers (tans)
3. Beta-blockers (lols)
4. Diuretics
5. Digitalis
119
Potential Complications of Heart Failure
1. Cardiogenic shock
2. Dysrhythmias
3. Thromboembolism
4. Pericardial effusion and cardiac tamponade
120
Pulmonary Edema
- Acute event in which the LV cannot handle an overload of blood volume. Pressure increases in the pulmonary vasculature, causing fluid movement out of the pulmonary capillaries and into the interstitial space of the lungs and alveoli
- Results in hypoxemia
121
S/Sx of Pulmonary Edema
1. Restlessness
2. Anxiety
3. Dyspnea
4. Cool and clammy skin
5. Cyanosis
6. Weak and rapid pulse
7. Cough, lung congestion (moist, noisy respirations),
8. Increased sputum production (sputum may be pink frothy and blood-tinged),
9. Decreased level of consciousness
122
Management of Pulmonary Edema
1. Prevention!!!!
2. Early recognition: monitor lung sounds and for signs of decreased activity tolerance and increased fluid retention
3. Place patient upright and dangle legs
4. Minimize exertion and stress
5. Oxygen
6. Medications
- Morphine
- Diuretic: furosemide
123
Shock
The failure of the heart as a pump, volume of blood available, vascular delivery of blood
- Inadequate tissue perfusion
124
S/Sx of Shock
1. Low BP
2. Increased HR
3. Cold, clammy skin
4. Change in LOC
125
Types of Shock
1. Hypovolemic
2. Septic
3. Anaphylactic
4. Cardiogenic
126
Cardiogenic Shock
- A life threatening condition with a high mortality rate
- Decreased CO leads to inadequate tissue perfusion and initiation of shock syndrome
- Clinical manifestations: symptoms of heart failure, shock state, and hypoxia
127
S/Sx of Cardiogenic Shock
1. Angina
2. Dysrhythmias
3. Fatigue
4. Feelings of doom
5. Hemodynamic instability
128
Management of Cardiogenic Shock
1. Correct underlying problem
2. Medications
- Diuretics
- Positive inotropic agents and vasopressors
3. Circulatory assist devices
- Intra-aortic balloon pump (IABP)
129
What can increase the risk for Thromboembolism?
Decreased mobility and decreased circulation increase the risk for thromboembolism in patient with cardiac disorders including those with Heart Failure.
130
Pulmonary Embolism
Blood clot from the legs moves to obstruct the pulmonary vessels
131
Treatment for Pulmonary Embolism
1. Anticoagulant therapy
132
Pericardial Effusion
The accumulation of fluid in the pericardial sac
133
Cardiac Tamponade
The restriction of heart function due to this fluid resulting in decreased venous return and decreased CO
134
Clinical Manifestations of Pericardial Effusion and Cardiac Tamponade
1. Ill defined chest pain or fullness
2. Pulsus paradoxus
3. Engorged neck veins
4. Labile or low BP
5. Shortness of breath
135
Cardinal Signs of Cardiac Tamponade
1. Falling systolic BP
2. Narrowing pulse pressure
3. Rising venous pressure
4. Distant heart sounds (muffled)
** EMERGENCY
