Cardiac Exam 1 Flashcards
What is the standard definition of Heart Failure?
A condition in which the heart is unable to meet the metabolic needs of the body
What are some causes of Heart Failure?
MI, Cardiomyopathy, Valve dysfunction, inflammatory conditions, Pulm HTN. etc
How does the American Hear association stage Heart failure? How many stages of heart failure are there?
Based off of Structure.
4 stages A-D
What is stage A Heart failure? How is it managed?
Pt Has no s/s but is at high risk of HF d/t other medical issues that may cause HF. (DM, HTN, Obesity, Smoker, Inactive, Drug user)
Managed by monitoring the PTs condition, enacting interventions that focus on the prevention of the PT developing HF
What is stage B HF and how is it managed?
- The PT still has no s/s however they do have structural heart disease. (Hx of MI, Valvular diseases, hypotrophy, Chamber dilation, Myopathy)
- Managed using preventative interventions at increased intensity and focus. (Meds such as ACE inhibitors)
What is stage C HF and how is it managed?
- PT does have s/s and has a structural heart disease
- Managed using the same measures as stage B with the addition of meds and interventions to treat the s/s. (Diuretics, Ace inhibitors, Beta-blockers, Diuretics, ARBs,) as well as Surgery and Pacing
What is stage D HF and how is it managed?
- PT has s/s often with little to no exertion along with an advanced structural disease
- Managed using maximum medicinal support (Vasodilators, Cardiac meds) and advanced interventions (LVAD, Cardioversion)
How does the New York Hear association Classify HF and how many Classes do they have?
- They classify based on activity levels
- 4 classes
What is class 1 HF (New York)
- No s.s
- No limitations to activity
What is class 2 HF (New York)
- Mild s/s
- Mild ADL limitations
What is class 3 HF (New York)
- Significant s/s
- marked limitations
- Comfortable only at rest
What is class 4 HF (New York)
- Severe s/s
- Very limited to no activity
What are the four main classifications of HF
- High output
- Low output
- Systolic
- Diastolic
What is high output HF?
when the metabolic needs of the body exceed the ability of the left ventricle to supply enough blood to provide O2 and nutrition.
What is low output HF?
When there is a pump failure within the heart
What is systolic HF? What are some causes?
When a ventricle (mainly the left) fails to pump efficiently.
-Caused by weakening, stiffening, or overstretching of the ventricle
What is Diastolic HF?
When the cause of failure comes from poor filling of the ventricle. Either from valvular dysfunction or a stiff ventricle.
What is preload?
The amount of stretch during diastole. It is determined by the LVEDV. The more passive blood filling into the ventricle the more the stretch and the stronger the contraction will be.
What is afterload?
The amount of pressure (aortic) the LV must overcome to open the aortic valve and pump blood out into the body
How does decreased kidney function affect preload and after load?
If the kidneys are unable to eliminate water from the body, blood volume, and blood pressure will increase causing an increased passive filling and therefore an increased preload.
-Afterload may or may not be increased depending on the extent of the increased BP and volume as well as the extent and type of HF
What is the main point in treating HF?
Controlling the preload and afterload
What is the ejection fraction?
The amount of blood forced from the LV during systole
What is a normal ejection fraction for a healthy adult?
55%-75%
At what % ejection fraction is the pt considered (generally) to have HF?
39% or less
What is a compensatory mechanism? (HF)
The body’s way of making up for the effects of HF
How can HR change as a compensatory mechanism for HF? what system is responsible for the change?
- It can increase to compensate for reduced SV and/or reduced blood volume
- Changed via sympathetic NS
How can SV change as a compensatory mechanism for HF? what system is responsible for the change?
- SV may be increased by sympathetic stimulation.
- This is achieved by the increased venous return and thus an increased ventricular stretch and increased preload/contraction strength
How can arterial vasoconstriction be used as a compensatory mechanism for HF? what system is responsible for the change?
- Sympathetic NS causes arterial vasoconstriction and this increases BP and that increases SV
- Via Rennin Angiotensin Aldosterone system
How can sodium/water retention be used as a compensatory mechanism for HF? what system is responsible for the change?
- Rennin/angio/aldos system causes retention of water and sodium.
- This increases BV and thus Preload/CO
What are the two main amino acid peptides that the body produces during HF?
hANP and hBNP
Are hANP and hBNP compensatory mechanisms?
They work in opposition to them
What triggers the release of hANP and what is its function?
- Atrical stretch
- Promotes Na and H2O excretion
- Decreased Vasopressin
What triggers the release of hBNP? What is its function?
- Ventricular stretching triggers its release.
- Decreased the levels of aldosterone
- Helps to balance vasoconstriction
- Used as a measure of severity of HF
What is “balanced” HF?
When compensatory mech. effectively control the HF (aka compensated HF)
What is unbalanced HF?
- AKA uncompensated HF
- When the compensatory mechanisms fail to control the HF
What occurs when a PT enters uncompensated HF?
Structural changes begin to occur.
-Remodeling=Change in size, shape, and function of the heart
JVD at the sitting angle of _____ is a physical indicator of HF
45 degrees
A majority of the symptoms of Left-sided HF are _____
Respiratory
What are some respiratory assessment findings that are common with Left Ventricular Heart Failure?
-Lung crackles, cough, dyspnea, orthopnea, Pulm Edema, Proximal Nocturnal dyspnea
What is Proximal Nocturnal Dyspnea?
Edema backs up into the lungs when a pt lays down causing dyspnea when lying down.
How is the severity/Progression of orthopnea unofficially/subjectively measured?
Number of pillows you need to sleep
What are some CV assessment findings common to Left Ventricular Heart Failure?
S3, Fatigue, decreased activity tolerance, palpitations, decreased urinary output (oliguria)
What are some assessment findings common in Right Ventricular Heart Failure?
- Dependent Edema
- JVD
- Abdominal Discomfort
- Nocturia
What are some expected findings in a CRX of a heart failure pt?
Structural enlargement, Fluid in the lungs (pulmonary congestion), possibly valvular dysfunction
What is the purpose of a echo-cardiogram?
To measure CO, SV, Preload, Pressure & velocity.
-To visualize the chambers and valves and measure/observe hemodynamics
Hemodynamics can also be measured using what? (non imaging)
CVP
What is a lab use to monitor HF?
hBNP
What hBNP value indicates HF?
Greater than 100
What is the acronym to remember the main medications given to HF PTs?
Always Administer Drugs Before A Ventricle Dies
What are the 7 common drug classifications given to HF PT’s?
Always Administer Drugs Before A Ventricle Dies
- Angiotensin 2 receptor blockers
- Ace inhibitors
- Diuretics
- Beta Blockers
- Anti-Coagulants
- Vasodilators
- Digoxin
What are the two categories of valvular Heart disease?
Stenotic or insufficient
What is a stenotic valvular heart disease.
A disease in which one or more of the hearts valves are stiffened, fused, or calcified
What is an insufficient valvular heart disease?
A disease in which one or more of the hearts valves do not fully close and/or have weak functions
When a valve does not close properly, ______ flow occurs. This ios also know as ____
Retrograde
-Regurgitation
What are the 5 main causes of valvular heart disease?
CMERC
- Congenital defects
- MI
- Endocarditis
- Rheumatic Fever
- Calcium deposits
What are some assessment considerations for valvular heart disease?
- Murmurs will be present and help determine the type.
- Symptoms Depend on the affected valves and the progression of the disease.
- Symptoms may be respiratory or CV or both.
- Pulse may be weak
What are some common findings on a CXR of a pt with valvular heart disease?
- Cardiomegaly
- Fluid in the lungs
What are some common findings on a Echocardiogram of a PT with Valvular Heart disease?
- You are able to visualize the valves in action and see the extent of their dysfunction.
- You can visualize the regurgitation
What may be present on an EKG of a pt with valvular heart disease?
A prolonged QRS complex from hear enlargement.
What two questions need to be asked when assessing a murmur?
- Is blood moving through the valve when it should be?
2. What is the LV doing at the time of the murmur?
What is the main effect of mitral stenosis?
-Reduced blood flow from the LA to the LV d/t the mitral valve being stiff or calcified
What type of s/s are seen in mitral stenosis?
Pulmonary congestion, respiratory s/s, Increased pressure in the LA (causing enlargement), Hypertrophy of the RV
-Dry cough from increased pressure on the bronchials
What type of murmur is present with mitral stenosis?
Diastolic. blood regurgitates from the LV to the LA after systole. Lub Dub Swish
What is the main effect of mitral regurgitation?
The mitral valve does not close fully. Blood regurgitates after LA and LV contractions.
What type of murmur is present during mitral regurgitation?
A systolic murmur. Lub swish Dub Swish
What type of s/s are present in mitral regurgitation?
La dilation, LV hypertrophy
-Respiratory S/S
-Possible sudden death
-
What is the main effect of aortic stenosis?
-increased after-load due to a stiff aortic valve.
What are the s/s of aortic stenosis?
-LV hypertrophy
-Decreased activity tolerance due to poor peripheral perfusion = decreased O2 in tissues
-Respiratory s/s
-Angina from decreased coronary blood flow
-
What type of murmur is present in aortic stenosis?
A systolic murmur
What is the main effect of aortic regurgitation?
-The Aortic valve does not close fully and allows blood to regurgitate into the LV after systole.
What are the s/s of aortic regurgitation?
Respiratory s/s
- LV dilation
- LV hypertrophy
What type of murmur is present in aortic regurgitation?
A diastolic murmur
What are the main types of management for valvular heart disease?
- Drugs
- Self imposed Activity restriction
- NSAD and Fluid restriction for FVE
- Surgery
What are some common drugs used in treatment of Valvular heart disease?
- O2
- Diuretics
- Digoxin
- Calcium Channel Blockers
- Beta Blockers
- Coumadin
What are the two common surgery types of valvular heart disease?
- Total/partial reconstruction
- Total replacement (porcine or mechanical)
What is an Aneurysm?
an excessive localized enlargement of an artery caused by a weakening of the artery wall
What are the five main classifications of Aneurysms?
- Fusiform
- Sacular
- True
- False
- Dissecting
What is a fusiform aneurysm?
-When the localized enlargement affects the entire circumference of the affected artery
What is a sacular aneurysm?
When the aneurysm creates a pouch from an artery but does not affect its entire circumfrence
What is a true aneurysm?
When all layers of the arterial wall are affected
What is a false aneurysm?
When arterial leakage causes a thrombosis that is encapsulated but does not affect all layers of the vessel
What is a dissecting hematoma aneurysm?
When the smooth muscle of an artery is damaged and a false lumin is created that begins to fill with blood. The lumin increases in size causing a traveling split in the vessel wall.
What is the most common type of aneurysm? what %?
What are the other two most common?
AAA 75%
Thorsaic 25%
Cerebral
What are some major contributing factors to aneurysm formation?
- Weak vessel walls
- HTN
Describe the symptoms of aneurysms
- Many can be asymptomatic.
- Most symptoms come from the pressure that the aneurysm places on other vessels or organs
- others are caused when an aneurysm ruptures creating a life threatening situation. (hypovolumeic shock)
What are some symptoms specific to a AAA?
- ABD discomfort
- Bruis heard above umbilicus
- Flank Pain
- Back Pain
- Continuous pain as AAA enlarges
- Increased BP if kidney perfusion is affected
How will the PT describe pain in a ruptured AAA?
- Sudden severe pain
- Pain is radiating
What are some likely physical assessment findings in a ruptured AAA
- Extreme Hypotension (very fast occuring)
- Diaphoretic appearance
- Hematomas from pooling blood
- ABD distention
- Loss of consciousness
- Dizzy
- TachyCardia
What are the three types of thoracic aortic aneurysms?
- Ascending
- Descending
- Arch
What are two common s/s of an ascending aortic aneurysm?
- HF
- Murmurs
What are some s/s of a descending aortic aneurysm?
Respiratory s/s - SOB -Wheezing from tracheal compression - Difficulty swallowing -Vagal nerve compression Spinal compression (causes numbness and tingling)
What are some s/s of an Arch aortic aneurysm?
- Neurological s/s r/t compression of the carotid arteries decreasing blood flow to the brain
- TIA’s
What is the most common cause of a dissecting aneurysm?
HTN
How will a patients BP appear in a traveling dissecting aneurysm? What is some subjective data that is common in this event?
SYS of 100-120
-Ripping, tearing, traveling, severe pain
Describe the interventions for aneurysms?
- Depends heavily on the type, size, and location.
- Interventions range from monitoring and measurement to medications and surgery
You should always perform a _____ assessment below the location of the aneurysm
Neurocirculatory check
What is expended post-op for an aneurysm pt?
- They will be in the ICU for a while
- They will have an arterial line in place to monitor bp
What are the complications of aneurysm surgery?
- High blood pressure
- Poor peripheral perfusion and circulation
- Cyanosis
- Pallor
- Abd Pain
- Low urinary output if renal arteries are compromised
What are the two main types of surgery for an aneurysm?
- Stretch clamp cut
- Grafts
one of the biggest risks from aneurysm repair surgery is _____
Hypovolemia from blood loss
this will lead to increased HR, eventual hypotension, and pt will have weak pulses
If a patient with a chest tube is showing blood in the collection area, what should be done.
Monitor the rate of collection and report
Why are aneurysm repair PT’s at risk for renal failure?
Because the renal arteries can be compromised during surgery.
After aneurysm repain surgery, what should the urine output be?
50ml/hr
Respiratory complications from aneurysm surgery often come from ____
The ventilator
What are some interventions for respiratory complications after aneurysm surgery?
- incentive spirometry
- Get up and walk asap
- O2
What are assessments for a paralytic ileus?
- Are there Bowel tones?
- Last BM
- Are you passing gas?
What causes paralytic ileus?
-Sock to the bowels after their removal and replacement during surgery
What is there a risk for spinal cord ischemia during aneurysm surgery?
-The aorta is clamped and if repair is not fast enough, blood supply to spine will be compromised and can cause ischemia
What is endovascular repair?
The use of a graft to bypass an aneurysm.
-The graft is inserted via a major blood vessel and anchored into the blood vessel with the aneurysm. Blocking off the aneurysm from the blood flow. hopefully the aneurysm clots off and stops increasing in size
What is a peripheral arterial disease?
A disease affecting the function of non-coronary arteries
that leads to disruption of blood flow distal to the affected area reducing perfusion
What is the primary cause of Peripheral arterial disease?
Atherosclerosis
What are some secondary causes of peripheral arterial disease?
- Trauma
- Embolism
- Inflammation
Where are the most common locations of peripheral arterial disease in non-diabetics?
in the femoral or popliteal arteries
Where is the most common location of peripheral arterial disease in diabetics?
-Distal to the knees in the smaller vasculature
Describe the progression of Peripheral arterial disease.
- It’s a slow chronic occlusion of the vessels.
- Over time, as blood flow decreases, ischemia occurs along with increasing pain
- If untreated, Necrosis is possible
What are some risk factors for Peripheral arterial disease?
- Advanced age (over 70)
- Smoking (increases the risk above 50-60 years old)
- Diabetes
- HTN
- Hyperlipidemia
- Overweight
- Family Hx
What subjective assessment findings are common in peripheral arterial disease?
- Claudication
- Pain at rest (advanced)
- Numbness/loss of sensation
What are the key assessments for peripheral arterial disease?
- Neurovascular checks (ALL PULSES)
- Ankle-Brachial index
- Listen for bruits
- Check feet for trauma
- Pain assessment and Hx
- Pallor upon raising the leg to 60 degrees (time how long after lowering that color returns)
- Postoral Pain
What is the Ankle-Brachial index and how is it measured?
A comparison of the BP in the upper and lower extremities
-Done by measuring the systolic BP in all 4 extremities than the highest systolic of the lower is divided by the highest of the lower
What is the normal range for the ankle-brachial index?
What range indicated Peripheral Arterial disease?
- 0 to 1.4
0. 9 or less = positive indication of peripheral Arterial Disease
What may cause a false high/positive in ankle-brachial index readings?
Pts with DM or Pts who are over 70
When assessing the extremities in PTs with Peripheral artery disease, what all needs to be assessed?
-Edema, Color, Ulcerations, Temp (especially temp differences), Nails, Hair distribution (hair loss will be on affected extremity d/t decreased circulation)
