Cardiac Part 2 Flashcards
Leading cause of HF
HTN
Left HF S/S
Lung problems Blood tinged frothy sputum S3 Restless Orthopnea (SOB laying down) Nocturnal SOB
2 common causes of RHF
PE - lung clot causes pooling of blood before it gets there, causing increased pressure and pulmonary HTN (RV has to push HARD to get blood to the lungs)
COPD - always have low O2 causing pulmonary HTN (hypoxia is #1 cause of pul HTN)
Pulmonary HTN b/c of increased workload on the R side of the heart
3 ways to diagnose HF
- BNP
- CXR
- Echo
What is BNP?
What do results mean?
What may alter this test?
B-Type Natriuretic Peptide
A substance that the ventricle tissue secretes when there is increased volume and pressure within the heart
Increased amounts are a sensitive indicator of HR and can be positive for HF when the CXR doesn’t show any problems
If a patient is taking nesiritide, turn it off 2 hours before drawing a BNP because this drug is man-made BNP and will give a false high
What will a HF CXR look like?
Enlarged heart
Pulmonary infiltrates / edema
What will an echo do?
Look at the pumping action of the heart muscle
What does a Swan Ganz cath do?
Cath floated to R side of heart and pulmonary artery to rapidly get hemodynamics, CO, and mixed venous blood sample
What is an easy access to get ABG samples?
Art line
NY heart association functional Classification of HF
Classes 1-4, 4 being the most
What are the 4 main drugs used in the management of HF?
ACE
ARB
Dioxin
Diuretics
Drug of choice for HF?
ACE Inhibitors
SE: hypotension, cough, hyperkalemia
How do ACE Inhibitors work?
How do ARBs work?
What do they both do?
So what do we watch for?
Suppress RAAS resulting in arterial dilation and increased stroke volume - prevent angio 1 to 2 conversion
Decrease arterial resistance and decreased BP - block angio 2 receptors
Block aldosterone, resulting in losing Na and water, and retaining K
Watch for S/S hyperkalemia
Standard core measure that a HF patient will be sent home with what? Why?
ACE Inhibitor and/or BB
They decrease the workload of the heart by preventing VC and promoting forward blood flow out of the heart
How does digoxin work?
Usually used for what?
Increased contractility and decreases HR to increase CO and kidney perfusion
A slow HR gives the ventricles more time to fill
Usually used with sinus rhythm or A fib in combo with HF
Often given with the 4 HF drugs
How is the dosing of Digoxin?
Normal level on the body?
Digitalizing dose - large 1st dose
Normal level: 0.5-2
What kind of blood transfusions do HF patients get?
NOT WHOLE BLOOD! If they need a specific component, they will receive that
Ex: Platelet transfusion, RBC transfusion
Early and Late signs of Dig toxicity
What should we monitor while they are on it?
What 2 things will especially put the patient at risk for toxicity?
NCLEX strategy here
Early: Anorexia, N/V
LateL Arrhythmias, Vision changes
Monitor Electrolytes
LOW potassium and dig
NCLEX: ANY E IMBALANCE CAN PROMOTE DIG TOXICITY
Signs that Dig is working?
What to check before we give it?
Increased CO
Apical pulse (5th IC space, left midclavicular line)
What do diuretics do?
When do we give them?
Decrease Preload
In the morning - pee a lot
How does a low sodium diet do for HF?
What should we watch for?
Examples of high sodium foods?
Decreases fluid retention and decreases preload
Na substitutes - contain excessive K
Canned/processed foods and OTC meds
How do pacemakers work in regards to HF?
Increase HR with SYMPTOMATIC bradycardia (HR
Always worry if what happens with the pacemaker?
It drops below the set rate (minimal HR)
- It’s okay for the rate to increase but NEVER decrease
Fixed vs demand pacemaker
Fixed:Fire at a fixed rate constantly
Demand: Only kicks in if the patient needs it
Post op pacemaker care
Most common complication?
What not to move
Why do we do assistive passive ROM?
How high can we raise the arm?
Monitor the incision
Electrode displacement (wires pulled out - wires need time to imbed into the heart muscle)
Immobilize arm - prevent displacement
Frozen shoulder
Not above shoulder height!! Unless wires might come out
Failure to capture
What is happening?
What causes this?
What do we watch for?
Stimulus fired but heart doesn’t react
Not programmed right
Dislodged electrodes
Low battery
Watch for decreased CO or decreased HR
Pacemaker edu
Need a ID bracelet/card?
What to avoid?
Will they set off alarms?
Check HR daily
YES
Avoid electromagnetic fields (use opposite cell ear, large motors)
Avoid MRI
Avoid contact sports
Will set off airport alarms
What is an ICD?
Post op care?
Implantable Cardioverter Defibrillator / Cardiac device
Be be used to pace the heart or defibrillate the patient in V Fib
Same pot op care as pacemaker
Risks for getting pulmonary edema?
IVF really fast
Young and old
Hx of heart or kidney disease
What is happening in pulmonary edema?
When does it usually occur?
Fluid in the lungs, heart can’t more the volume forward
Night time- promotes pooling
S/S Pulmonary edema
Sudden onset Breathless Restless/anxiety SEVERE HYPOXIA Productive cough and pink frothy sputum
How to treat pulmonary edema
High flow oxygen - keep above 90% Furosemide Bumetanide NTG Morphine Nesiritide
How do we give Furosemide?
40 mg IVP slowly over 1-2 min to prevent ototoxicity and hypotension
How do we give Bumetanide?
IVP or continuous infusion
1-2 mg IVP over 1-2 min
Why do we give NTG for pulmonary edema?
Decreases preload and after load to increase CO and promote forward blood flow
Why do we give morphine?
Causes vasodilation to decrease preload and after load
Decrease agitation
Why do we give Nesiritide?
Precaution?
What to remember about this drug?
For short term therapy
Don’t give for more than 48 hours!
Vasodilator veins and arteries and had diuretic effect
DC 2 hours before BNP draw
How to position pulmonary edema patient
Upright with legs dependent (down)
This improves CO and promotes pooling in LE
What happens in cardiac tamponade?
What can cause this?
Blood, fluid, or exudate have leaked into the pericardial sac resulting in compression of the heart and improper filling capabilities
MVA, RV biopsy, MI, pericarditis, hemorrhage after CABG
Hallmark signs of cardiac tamponade?
Other S/S?
Increased CVP and Decreased BP
Muffled/distant heart sounds Distended neck veins with clear lungs Same pressure in all chambers (fluid all around the heart) SHOCK d/t decreased CO Narrowed pulse pressure
Narrow Pulse pressure think:
Widened pulse pressure think:
Narrow: Cardiac tamponade
Widened: Increased ICP
** Need to know the baseline!!!
How to treat cardiac tamponade?
Pericardiocentesis to remove the fluid around the heart
Surgery
If you have atherosclerosis in 1 place, you have it ______
everywhere
What does it mean if you have an arterial occlusion? (numb, pain, cold, pulseless)
MEDICAL EMERGENCY
Hallmark sign of intermittent claudication
PAIN
What does pain at rest mean?
A severe obstruction
When arterial/oxygenated blood can’t get to the tissues, what would we see?
Cold, numb DECREASED PERIPHERAL P Atrophy (decreased muscle tone d/t lack of O2) Bruit (turbulent blood flow) Skin/nail changes Ulcerations
If arterial/oxygenated blood is having trouble getting to the tissue, what’s going to happen if you elevate the extremity?
Increased PAIN!!!! You are making it even hard for the blood to get there!
How are arterial disorders usually treated?
Angioplasty (balloon & stent)
Endarterectomy (remove inner artery lining)
Both increase perfusion
Rule of thumb for extremity placement for arterial / venous insufficiencies
ELEVATE veins
DANGLE arteries
If you don’t know the artery in the question, try to think of where the artery feeds
Ex: Radial feeds hand, carotid feeds head, femoral feeds leg
Ex: Carotid endarterectomy
Think- Replenishing blood flow to the head so think ^LOC
Ex: AAA patient post op has a leg cramp – BAD! perfusion disrupted - DVT - Never delay treatment!! Get a wheelchair and then call MD!
Don’t just assume an answer that has increased perfusion anywhere or that flow will come booming in
Chronic ARTERIAL Insufficiency
Pain: Pulses: Color: Temp: Edema: Skin changes: Ulceration: Gangrene: Compression:
ARTERIAL Insufficiency
Pain: Intermittent claudication
Pulses: Decreased or absent
Color: Pallor w/ elevation, red with lowering
Temp: Cold, numb
Edema: Absent or mild
Skin changes: Thin, shiny, loss of hair over feet/toes, nail thickening
Ulceration: If present, will involve toes
Gangrene: May develop
Compression: Not used
Chronic VENOUS Insufficiency
Pain: Pulses: Color: Temp: Edema: Skin changes: Ulceration: Gangrene: Compression:
VENOUS Insufficiency
Pain: None to aching Pulses: Normal (may be hard to palpate d/t edema) Color: Normal or petechiae or brown Temp: Normal Edema: Present Skin changes: Brown, leathery, scarring Ulceration: If present, will be on sides of ankles Gangrene: None Compression: Used
