Cardiac pathologies

Question 1

What are the precautions for a Sternotomy?

Answer 1

• No lifting 10lbs below waist and 5lbs above waist for 6-8 weeks.
• No pushing with arms in sit to stand.
• No pulling/pushing more than 5 lbs.
• Teach splinting a pillow over insertion:
o Creates counter pressure for pain relief while they stand, and it keeps the arms busy so that they don’t break sternal precautions and push down on bed when getting up into sitting or into standing

Question 2

What are the precautions for a Thoracotomy?

Answer 2

No lifting 10 lbs above waist.

Question 3

What is Arteriosclerosis

Answer 3

The thickening, hardening and stiffening of arterial walls.
• Results in a loss of elasticity which restricts blood flow to tissues.
• Common in smaller sized arteries.

Question 4

What is Artherosclerosis?

Answer 4

Slow progressive condition, that causes narrowing of arteries due to a build up of plaque (atheroma).

Question 5

What is Atheroma?

Answer 5

o An accumulation of degenerative material in the inner layer of an artery wall
o Made up of cholesterol, lipids, calcium etc.
o Plaque buildup within the vessel wall (the intima)

Question 6

What is Right sided heart failure

Answer 6

Blood backs up in systemic circulation resulting in systemic hypertension and edema

Question 7

What are the common causes of R sided heart failure?

Answer 7

▪ Left sided heart failure
▪ Right ventricle infarct
▪ Pulmonary Hypertension
➢ Due to the following: COPD, ARDS, interstitial lung disease, cystic fibrosis, pulmonary embolism
➢ Cor Pulmonale: the enlargement and failure of the right side of the heart due to chronic severe pulmonary hypertension

Question 8

What are the S/S of R sided heart failure?

Answer 8

▪ Peripheral edema (systemic – upper and lower extremity)
▪ Pitting edema
▪ Shortness of breath
▪ Weakness/fatigue
▪ Jugular venous distension
▪ Liver damage and enlarged spleen
➢ Ascites
▪ Decreased blood flow in periphery
▪ Kidney and brain issues due to decreased perfusion

Question 9

What is L sided heart failure?

Answer 9

o Blood backs up in the pulmonary circulation leading to pulmonary congestion

Question 10

What are the causes of L sided heart failure?

Answer 10

(1) Diastolic dysfunction
➢ Left ventricle does not relax completely
➢ Ventricles become stiff and have trouble filling
➢ Results in high ventricular pressure and pulmonary edema
➢ Due to: ischemic heart disease, mitral valve regurgitation, stenosis, hypertrophic cardiomyopathy
(2) Systolic dysfunction
➢ Weak left ventricular contraction: CAD, dilated cardiomyopathy
➢ Increased resistance downstream: aortic stenosis, systemic hypertension

Question 11

What are the S/S of L sided heart failure?

Answer 11

▪ Pulmonary edema
▪ Dyspnea - due to pulmonary edema
▪ Increased work of breathing
▪ Orthopnea - SOB when lying down flat because of increased venous return)
▪ Paroxysmal nocturnal dyspnea (PND) - SOB when sleeping
▪ Pink, frothy sputum
▪ Tachypnea
▪ Lightheartedness
▪ Lethargy
▪ Cyanosis (if severe)
▪ Kidney and brain issues due to decreased perfusion
▪ On auscultation: crackles

Question 12

What is an aneurysm?

Answer 12

Localized abnormal dilation of the wall of a blood vessel.

Question 13

What is the difference between a true and a false aneurysm?

Answer 13

(1) True:
o There is circumferential dilation of the vessel wall and involves all three layers of the artery wall
o The vessel walls stretch outwards resulting in weakening and risk of rupture
(2) False aneurysm/pseudoaneurysm:
o There is a breach in the vessel wall and blood leaks completely out of the vessel but is confined next to the vessel by the surrounding tissue
o The blood-filled cavity will eventually clot enough to seal the leak or rupture causing blood to leak out into the surrounding tissue
o Often occurs as a result of trauma (e.g. cardiac catheterization)

Question 14

What are the S/S of an aneurysm?

Answer 14

vary based on the location of the aneurysm and whether it has ruptured or not:
o E.g.: AAA - abdominal aortic aneursym
▪ Pain In the back, abdomen or groin that may be prolonged and not relieved by position change or rest
o A ruptured aneurysm usually produces sudden, severe pain and other symptoms such as LOC or shock depending on the location and amount of bleeding that occurs

Question 15

What is a dilated cardiomyopathy?

Answer 15

• Most common type.
• Occurs mostly in adults 20-60 years old.
• More common in males vs. females.
• Issue often starts in left ventricle.
o Left ventricle chamber dilates (becomes thin and weak) and the heart cannot contract normally which can result in heart failure
• Heart has trouble pumping = systolic dysfunction.
• Risks: third trimester, alcohol, myocarditis (inflammation of myocardium).

Question 16

What is a hypertrophic cardiomyopathy?

Answer 16

• Heart muscle cells enlarge (usually starts within left ventricle) which causes the walls of the ventricle to thicken.
• Thickening of ventricle walls makes chambers smaller and they cannot hold as much blood which results in decreased cardiac output and heart failure.
• Abnormalities in filling = diastolic dysfunction.
• Signs and symptoms: sudden chest pain, SOB, dizziness.

Question 17

What is Cardiac tamponade?

Answer 17

Compression of the heart due to blood or fluid buildup in the pericardial sac.

Question 18

What are the causes of cardiac tamponade?

Answer 18

• Malignant disease.
• Cardiac surgery (puncture wound through the heart during a procedure).
• Post MI.
• TB.

Question 19

What are the s/S of Cardiac Tamponade?

Answer 19

• Jugular vein distension.
• Hypotension.
• Muffled heart sounds.
• Cyanosis.
• Decreased LOC.
• Shock.

Question 20

What is Infective Endocarditis?

Answer 20

• Inflammatory destruction of heart tissue (endocardium) - usually heart valves.
• Causes: usually bacterial infection.
• Signs and symptoms: fever, chills, weakness, murmur.
• Treatment: prevention is key; high dose of antibiotics.

Question 21

What is Aortic stenosis?

Answer 21

▪ Calcification due to age or lipid accumulation
▪ The most common valvular abnormality
▪ Can cause left systolic dysfunction = Left sided heart failure
▪ Signs and symptoms: SOB especially during exercise, angina, syncope, heart murmur, left ventricular hypertrophy

Question 22

What is aortic insufficiency?

Answer 22

Acute AI episode can result rapid increase in left ventricle pressure → increased left atrium pressure → pulmonary edema

Question 23

What is mitral stenosis?

Answer 23

▪ Most cases are due to heart problems secondary to rheumatic fever; less common = calcification
▪ Signs and symptoms: SOB on exertion, orthopnea, paroxysmal nocturnal dyspnea (PND), angina

Question 24

What is mitral insufficiency

Answer 24

Signs and symptoms:
➢ In mild cases patients are asymptomatic
➢ Severe cases can result in arrhythmias, syncope, fatigue, light-headedness, TIA, SOB

Question 25

What is angina?

Answer 25

Myocardial oxygen does not meet demand causing chest pain, resulting in transient, reversible ischemia. Angina is not a heart attack but is indicative of underlying coronary heart disease and is a sign of an increased risk of having a heart attack.

Question 26

What are the 3 types of angina and be able to explain each one

Answer 26

3 Overall patterns: (1)Stable: • Predictable • Occurs only when heart has to work harder than normal (e.g. exercise) • Relieved by rest (2) Unstable: • Unpredictable, more serious than stable angina • Can occur during exercise or at rest • Not relived by rest • Usually due to atherosclerosis (3) Prinzmetal: • Often occurs at rest Narrowing is caused by coronary vasospasm rather than directly by atherosclerosis (where plaque buildup causes blockage

Question 27

What is the difference between ischemia and infraction?

Answer 27

Ischemia: decreased blood flow to heart tissue which leads to angina. Infarction: the end point of ischemia that results in necrosis of heart tissue; develops distal to occlusion of an artery.

Question 28

What is a myocardial infraction most common?

Answer 28

Most frequent location for myocardial infarction is the left ventricle due to occlusion of left coronary artery.

Question 29

What are the risk factors for a myocardial infraction?

Answer 29

``` Non-modifiable risk factors: • Age, gender (M>F), family history. Modifiable risk factors: • Smoking. • Diabetes. • High cholesterol. • Hypertension. • Obesity (>1.0 waist-to-hip ratio). • Left ventricular hypertrophy - The most common cause of LVH is high blood pressure. Thus, antihypertensive treatments, that cause LVH to regress, decrease the rates of adverse cardiovascular events making it a modifiable risk factor. ```

Question 30

What are the S/S of MI

Answer 30

* Chest pain. * Dyspnea. * Rapid pulse. * Profuse sweating. * Release of troponin and creatine kinase (evidence of tissue damage).

Question 31

What are the treatments for MI?

Answer 31

Lifestyle modifications to decrease risk factors: diet, exercise, weight loss, smoking cessation. • Medical management: o Thrombolytic agents, angioplasty, coronary artery bypass graft (CABG), medications

Question 32

What is arterial insufficiency?

Answer 32

Pathologic conditions of blood vessels that supply extremities and major abdominal organs.

Question 33

What are the S/S for Arterial insufficiency?

Answer 33

occur distal to site of narrowing or obstruction: • Pain • Minimal swelling • Cool to touch • Pallor • Diminished or absent pulse (distinguishing feature from venous insufficiency) • Delayed healing, ulceration and gangrene • Shiny, thin, hairless skin

Question 34

What is intermittent claudication?

Answer 34

results in decreased blood flow to muscles used during exercise.

Question 35

What are the S/S of Intermittent claudication?

Answer 35

• Symptoms of claudication: pain, cramp, ache, fatigue – can be experienced when exercising. o The most common site is the calf muscles while walking • Alleviated by rest. • When exercising, encourage patients to exercise to the point of claudication pain and then stop at the onset of cramping and rest before resuming. o Do not push patients to exercise through intermittent claudication pain • Exercise has been shown to improve walking endurance in patients with intermittent claudication from peripheral arterial disease.

Question 36

What is Thombophlebitis

Answer 36

* Phlebitis: inflammation of a vein, usually in the legs. * When associated with the formation of blood clots (thrombosis). * Partial or complete occlusion of a vein by a thrombus with secondary inflammation. * Can be superficial or deep.

Question 37

What are the risk factors of DVT?

Answer 37

* Venous stasis (e.g. prolonged sitting/immobilization). * Venous damage. * Hypercoagulability. * Trauma/surgery. * Pregnancy. * Obesity. * Cancer. * Smoking. * Genetic susceptibility.

Question 38

What are the S/S of DVT

Answer 38

* Dull ache. * Tightness/pain in calf and tenderness on palpation. * Swelling. * May have a fever. * Pain with dorsiflexion. * Can become a pulmonary embolism (thrombo-embolism).

Question 39

How do we treat DVT?

Answer 39

Heparin and warfarin are both anticoagulants used to treat blood clots. They help to prevent the formation of more blood clots or stop the existing clot from getting any larger. o Heparin: ▪ Provides an immediate response/rapid onset ▪ Is an injection/IV use o Warfarin (Coumadin): ▪ Generally used for long-term treatment or as a long-term prophylaxis ▪ An oral medication ▪ Slower onset and takes up to 72 hours to become effective

Question 40

How do we test for DVT?

Answer 40

* Appropriate test = Homan’s sign (calf pain on passive dorsiflexion of foot). * Rapid screening with doppler ultrasonography.

Question 41

What are the S/S of pulmonary embolism?

Answer 41

``` Bloody sputum; • Dyspnea; • Increased respiratory rate and work of breathing; • Cyanotic; • Tachycardia; • New chest pain; • Decrease oxygen saturation; • Ventilation/perfusion scan used for diagnosis (shows area of poor perfusion in lungs). ```

Question 42

What treatments can be done for PE?

Answer 42

(1) Education: o Prevention is key: ▪ Early bed exercises and mobilization post operatively ▪ Compression stockings (2) Appropriate treatment once PE suspected: o Deep and segmental breathing o Oxygenation o Where there is a suspected/diagnosed PE all mobility orders should go through the physician due to potential significant V/Q mismatch. Mobilization is halted until adequate anti-coagulation is achieved and mobility orders are received from doctor

Question 43

What is orthostatic hypotension?

Answer 43

Orthostatic hypotension from bed rest occurs as a result of decreased venous tone, which will lead to a pooling of blood in the LE upon standing. The pooling of blood in the LE will reduce the amount of blood returning to the heart decreasing ventricular filling and ultimately decreasing cardiac output: • Results in a drop in BP with resultant dizziness. • To compensate for the decrease in cardiac output, the sympathetic system would stimulate an increase in heart rate. • Diagnosis made when there is a drop in BP measured: SBP >20 mmHg OR DBP >10 mmHg when a person assumes a standing position

Question 44

What are the S/S for orthostatic hypotension?

Answer 44

Dizziness, light headedness, fatigue, blurred vision, muscle weakness, syncope.

Question 45

What is the treatment for orthostatic hypotension?

Answer 45

* Optimal position is supine if patient demonstrates signs. * If severe, use tilt table with progressive vertical positioning to assist with standing. * Tolerance can be improved by medications, regular physical activity, being upright and compression stockings.