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CCRN Book > Cardiovascular Concepts Ch 3 > Flashcards

Cardiovascular Concepts Ch 3 Flashcards

1
Q

What sound is the “Lub”?

A

S1

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2
Q

What causes the S1 sound?

A

The closure of the AV (mitral and tricuspid) valves

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3
Q

Where does S1 sound the loudest?

A

Apex of the heart

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4
Q

Where can you listen for the apex of the heart?

A

Mitral area

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5
Q

Where is the mitral area?

A

Midclavicular, 5th intercostal space

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6
Q

The midclavicular, 5th intercostal space is called the — —

A

Mitral (apical) area

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7
Q

You can listen to the __ at the 5th intercostal, midclavicular space

A

Apex

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8
Q

What does the S1 sound mark?

A

The end of diastole and beginning of systole

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9
Q

What sound marks the end of diastole?

A

S1

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10
Q

What sound marks the beginning of systole?

A

S1

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11
Q

The end of diastole and beginning of systole is marked by the closure of…?

A

AV valves (mitral and tricuspid)

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12
Q

What does S2 sound like?

A

Dub

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13
Q

What does the “dub” sound indicate?

A

S2

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14
Q

This sound is caused by the closure of the semilunar valves

A

S2

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15
Q

Which are the semilunar valves?

A

Aortic and pulmonic

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16
Q

S2 is caused by…

A

Closure of the semilunar valves

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17
Q

Where is S2 loudest?

A

At the base of the heart

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18
Q

Where can you listen to the base of the heart?

A

Right eternal border, 2nd intercostal space

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19
Q

Where can you listen to S2 sounds?

A

Right sternal border, 2nd intercostal space

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20
Q

What sound can be heard by listening to the right sternal border, 2nd intercostal space?

A

S2, at the base of the heart

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21
Q

S2 marks the end…

A

Of systole and beginning of diastole

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22
Q

S2 __ on inspiration

A

Splits

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23
Q

Which sound splits on inspiration?

A

S2

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24
Q

S2 splits on __

A

Inspiration

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25
Q

Wide fixed splitting of S2 is caused by…

A

Right bundle branch block (RBBB)

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26
Q

A right bundle branch block can cause what sound?

A

Fixed wide splitting of S2 sound

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27
Q

What type of BBB causes wide fixed splitting of the S2 sound?

A

Right

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28
Q

What pathology can cause S2 to become louder?

A

Pulmonary embolism

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29
Q

What effect can a pulmonary embolism have on heart sounds?

A

It can make S2 sound louder

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30
Q

Which area is right sternal, 2nd intercostal space?

A

Aortic area

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31
Q

Where is the aortic area located?

A

Right sternal, 2nd intercostal space

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32
Q

Where is the pulmonic area located?

A

Left sternal, 2nd intercostal space

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33
Q

What area is located at the left sternal, 2nd intercostal space?

A

Pulmonic area

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34
Q

Where is Erb’s point located?

A

Left sternal, 3rd intercostal space

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35
Q

What area is located at the left sternal, 3rd intercostal space?

A

Erb’s Point

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36
Q

Where is the tricuspid area located?

A

Left sternal, 5th intercostal space

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37
Q

What area is located at the left sternal, 5th intercostal space?

A

Tricuspid area

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38
Q

What space is located at the misternal, 5th intercostal space?

A

Mitral (apical) area

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39
Q

What causes S3 heart sound?

A

Rapid rush of blood into a dilated ventricle

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40
Q

A rapid rush of blood into a dilated ventricle would cause what sound?

A

S3

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41
Q

When does S3 sound occur?

A

Early in diastole, right after S2

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42
Q

Where is S3 best heard?

A

At the apex of the heart, mitral area

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43
Q

S3 is associated with __ __

A

heart failure

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44
Q

S3 may occur before __

A

Crackles

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45
Q

S3 is also called a ventricular __

A

Gallop

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46
Q

A ventricular gallop sounds like…

A

“Kentucky”

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47
Q

S3 can also be caused by…

A

PHTN
Cor pulmonale
Mitral, aortic, or tricuspid insufficiency

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48
Q

S3 can also be caused by…

A

PHTN
Cor pulmonale
Mitral, aortic, or tricuspid insufficiency

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49
Q

What should you use to listen for S3 sound?

A

Bell of stethoscope at the apex (mitral area)

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50
Q

What is Cor pulmonale?

A

Pulmonary heart disease/ right ventricular failure

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51
Q

What causes S4 sound?

A

Atrial contraction of blood into a noncompliant ventricle

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52
Q

Atrial contraction of blood into a noncompliant ventricle causes what sound?

A

S3

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53
Q

When does S4 sound occur?

A

Right before S1

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54
Q

When can you not hear S4 sound?

A

In the presence of a fib

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55
Q

Why can you not hear S4 during a fib?

A

No atrial contraction

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56
Q

Where is S4 best heard?

A

Apex of the heart with the bell of stethoscope

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57
Q

What is S4 associated with?

A

Myocardial ischemia
Infarction
HTN
Ventricular hypertrophy
Aortic stenosis

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58
Q

What is S4 most associated with?

A

Aortic stenosis

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59
Q

What does an atrial gallop sound like?

A

“Tennessee”

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60
Q

What is the name for the S4 sound?

A

Atrial gallop

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61
Q

What type of gallop makes a “Tennessee” sound?

A

Atrial gallop

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62
Q

An atrial gallop is the __ sound

A

S4

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63
Q

What type of gallop makes the “Kentucky” sound?

A

Ventricular gallop (S3)

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64
Q

What causes a pericardial friction rub?

A

Pericarditis

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65
Q

A pericardial friction rub may be __

A

Positional

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66
Q

What heart sound is associated with pain on deep inspiration?

A

Pericardial friction rub

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67
Q

Murmurs are associated with __ __

A

Valvular disease

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68
Q

Murmurs are also associated with __ __

A

Septal defects

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69
Q

What is the equation for pulse pressure?

A

Systolic - diastolic pressure

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70
Q

What is a normal pulse pressure?

A

40-60 mmHg

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71
Q

Systolic pressure is an indirect measurement of…

A

Cardiac output and stroke volume

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72
Q

__ BP is an indirect measure of CO and SV

A

Systolic

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73
Q

A narrowing of pulse pressure is most often seen in…

A

Severe hypovolemia or a severe drop in CO (from 120/80 to 100/73)

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74
Q

Diastolic BP is an indirect measurement of…

A

Systemic vascular resistance

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75
Q

__ BP is an indirect measurement of systemic vascular resistance

A

Diastolic

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76
Q

A decrease in diastolic pressure __ pulse pressure

A

Widens

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77
Q

A decrease in diastolic pressure __ pulse pressure

A

Widens

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78
Q

What could a decrease in diastolic pressure that widens PP indicate?

A

Vasodilation, and a drop is SVR

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79
Q

A decrease in diastolic pressure that widens pulse pressure may occur in…

A

Septic shock

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80
Q

Diastole is normally __ __ longer than systole

A

One third

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81
Q

When are coronary arteries perfused?

A

During diastole

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82
Q

During diastole, which arteries are perfused?

A

Coronary arteries

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83
Q

Why do heart valves open and close?

A

Based on pressure changes in the chambers above and below the valve

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84
Q

When does a valve open?

A

When the pressure in the chamber above the valve is greater than the pressure in the chamber below

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85
Q

When does a valve close?

A

When the pressure drops in the chamber above the valve, and the pressure is greater below the valve

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86
Q

Systole:

A

Ejection, high pressure

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87
Q

Diastole:

A

Filling, low pressure

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88
Q

Why is diastole 1/3 longer than systole?

A

Needs time for filling

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89
Q

List some general causes of valvular heart disease

A

CAD, MI
DCM
Degeneration
Bicuspid aortic valve (genetic)
Rheumatic fever
Infection
Connective tissue diseases

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90
Q

What is a murmur of insufficiency?

A

Regurgitation

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91
Q

When does a murmurs of insufficiency occur?

A

When the valve is closed

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92
Q

Murmurs of insufficiency (regurgitation) can be ___ or ___

A

Acute or chronic

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93
Q

What type of murmur occurs when the valve is closed?

A

Insufficiency (regurgitation)

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94
Q

What type of murmur occurs when the valve is open?

A

Stenosis

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95
Q

Murmurs of stenosis occur when the valve is __

A

Open

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96
Q

Murmurs of stenosis are a __ problem

A

Chronic

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97
Q

Murmurs of stenosis are NOT __

A

Acute

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98
Q

Murmurs of stenosis develop ___ ___

A

Over time

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99
Q

What do systolic murmurs sound like?

A

“Lub…shhhb…dub”

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100
Q

What types of valve stenosis are the semilunar valves open during systole?

A

Aortic stenosis
Pulmonic stenosis

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101
Q

With aortic and pulmonic stenosis, which valves are open?

A

Semilunar

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102
Q

What types of insufficiency are AV valves closed during systole?

A

Mitral and tricuspid insufficiency

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103
Q

If a patient has a pulmonary artery catheter, mitral insufficiency (regurgitation) will look like what on the monitor?

A

Large, giant V waves on the pulmonary artery occlusion pressure

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104
Q

During mitral and tricuspid insufficiency (regurgitation), what valves are closed during systole?

A

AV valves (tricuspid and bi/mitral)

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105
Q

With mitral and tricuspid insufficiency (regurgitation), AV valves are __ during systole

A

Closed

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106
Q

When is a ventricular septal defect most common?

A

With an acute MI

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107
Q

A ventricular septal defect may result in a __ __

A

Systolic murmur

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108
Q

Where is a ventricular septal defect heard?

A

Left sternal border, 5th intercostal space

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109
Q

List 5 systolic murmurs

A

Aortic stenosis
Pulmonic stenosis
Mitral insufficiency
Tricuspid insufficiency
Ventricular septal defect

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110
Q

What does a diastolic murmur sound like?

A

“Lub…Dub…shhhb”

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111
Q

Semilunar valves are closed during diastole with which 2 murmurs?

A

Aortic insufficiency (regurgitation)
Pulmonic insufficiency (regurgitation)

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112
Q

With aortic and pulmonic insufficiency (regurgitation), what valves are closed during diastole

A

Semilunar

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113
Q

With aortic and pulmonic insufficiency, semilunar valves are ___ during diastole.

A

Closed

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114
Q

AV valves are open during diastole with which diastolic murmurs?

A

Mitral and tricuspid stenosis

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115
Q

With mitral and tricuspid stenosis, which valves are open during diastole?

A

AV valves

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116
Q

With mitral and tricuspid stenosis, AV valves are __ during diastole

A

Open

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117
Q

What is mitral stenosis associated with?

A

Atrial fibrillation

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118
Q

Why is mitral stenosis associated with atrial fibrillation?

A

D/t atrial enlargement that occurs over time

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119
Q

During systole, which valves are open and which are closed?

A

Open- semilunar (pulmonic and aortic)
Closed- AV (tricuspid, mitral)

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120
Q

What does this photo show?

A

Systole

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121
Q

What does this photo show?

A

Diastole

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122
Q

Mitral insufficiency (regurgitation) occurs when…

A

The mitral valve is closed

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123
Q

When is the mitral valve closed?

A

During systole

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124
Q

Mitral stenosis occurs when the mitral valve is __

A

Open

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125
Q

When is the mitral valve open?

A

During diastole

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126
Q

Aortic insufficiency (regurgitation) occurs when the aortic valve is __

A

Closed

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127
Q

When is the aortic valve closed?

A

During diastole

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128
Q

Aortic stenosis occurs when the aortic valve is __

A

Open

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129
Q

When is the aortic valve open?

A

During systole

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130
Q

Does a murmur due to VSD occur during diastole or systole?

A

During ejection or systole

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131
Q

The mitral valve is attached to the left ventricular wall by…

A

Papillary muscles and the chordae tendineae

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132
Q

How does MI lead to acute mitral valve regurgitation?

A

Ischemia or infarction can affect mitral valve function

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133
Q

Papillary muscle dysfunction or rupture is loudest…

A

At the apex

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134
Q

Papillary muscle rupture is a ___ ___

A

Surgical emergency

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135
Q

Papillary muslce rupture and dysfunction are both associated with an __ __

A

Acute MI

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136
Q

What is characteristic of stable angina?

A

Chest pain with activity
Predictable
Lesions that are usually fixed and calcified

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137
Q

Acute coronary syndrome is due to ___-___ thrombosis

A

platelet-mediated

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138
Q

Acute coronary syndrome may result in sudden __ __.

A

cardiac death

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139
Q

What are the 4 types of acute coronary syndrome?

A
  1. Unstable angina
  2. Non ST-elevation myocardial infarction
  3. ST elevation MI
  4. Variant or Prinzmetal’s angina
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140
Q

What is characteristic of unstable angina?

A

Chest pain at rest
Unpredictable
May be relived with nitro
Troponin negative
ST depression or T wave inversion

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141
Q

ST depression or T wave inversion is characteristic of which types of actue coronary syndrome?

A

Unstable angina or NSTEMI

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142
Q

Chest pain at rest, unpredictable, troponin negative, ST depression or T wave inversion are characteristics of…

A

Unstable angina

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143
Q

Unrelenting chest pain, troponin positive, ST depression or T wave inversion are characteristic of…

A

NSTEMI

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144
Q

What is characteristic of a STEMI?

A

Troponin positive
ST elevation in 2 or more continuous leads
Unrelenting chest pain

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145
Q

Positive troponins, unrelenting chest pain, and ST elevation in 2 or more continuous leads is characteristic of…

A

STEMI

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146
Q
A
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147
Q

What is variant or Prinzmetal’s angina?

A

A type of unstable angina associated with transient ST elevation

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148
Q

Transient ST elevation with unstable angina is called…

A

Variant or Prinzmetal’s angina

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149
Q

What causes variant or Prinzmetal’s angina?

A

D/t coronary artery spasm with or without atherosclerotic lesions

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150
Q

When does variant or Prinzmetal’s angina occur?

A

At rest or could be cyclic (same time each day)

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151
Q

What can precipitate variant or Prinzmetal’s angina?

A

Nicotine, ETOH, or cocaine ingestion

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152
Q

With variant or Prinzmetal’s angina, troponins will be __.

A

negative

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153
Q

How is variant or Prinzmetal’s angina treated?

A

With nitroglycerin, will relieve chest pain and ST will return to normal

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154
Q

What can you tell from an EKG during acute chest pain?

A

STEMI, NSTEMI/UA, or no acute change

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155
Q

If someone is having an MI, what are the 7 treatment steps

A
  1. STAT EKG
  2. Aspirin
  3. Anticoagulation: heparin or lovenox
  4. Antiplatelet agent
  5. Beta blocker
  6. Treat pain
  7. Labs
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156
Q

What should be given asap if MI is suspected?

A

Aspirin, and must be chewed

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157
Q

What are 4 antiplatelet agents that may be used in treatment of MI

A

Clopidogrel (Plavix)
Abciximab (Reopro)
Eptifibatide (Integrilin)
Tirofiban (Aggreastat)

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158
Q

Clopidogrel (Plavix), Abciximab (Reopro), Eptifibatide (Integrilin), Tirofiban (Aggreastat) are all __ drugs

A

antiplatelet

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159
Q

What is the exception for giving a beta blocker during an MI?

A

If ACS is d/t cocaine

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160
Q

What type of beta blockers should be used during ACS?

A

Cardioselective BB

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161
Q

What is an example of a cardioselective BB?

A

metoprolol (Lopressor)

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162
Q

What is an example of a non Cardioselective BB?

A

Propanolol (Inderal)

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163
Q

What are 3 contraindications to administering a beta blocker for ACS?

A

Hypotension
Bradycardia
Use of phosphodiesterase-inhibitor drugs

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164
Q

What is an example of a phosphodiesterase-inhibitor drug?

A

sildenafil (Viagra)

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165
Q

What is pain treated with for ACS?

A

Nitroglycerin and morphine

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166
Q

What labs might be ordered if suspected ACS?

A

Cardiac biomarkers
Lipid profile
CBC
Electrolytes
BUN/Cr
PT/PTT

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167
Q

Changes in lead II, III and aVF. Where is the location of the CAD/ACS?

A

Right coronary artery (RCA) and/or inferior LV

168
Q

If the ACS is located in the right coronary artery (RCA) and/or inferior LV, what leads would you see changes?

A

II, III, aVF

169
Q

If you see changes in leads V1, V2, V3, and V4, where is the location of the CAD?

A

left anterior descending (LAD), and anterior LV

170
Q

If the ACS/CAD is in the left anterior descending (LAD), and anterior LV, what leads would you see changes?

A

V1, V2, V3 and V4

171
Q

If you see changes in leads V5, V6, I and aVL, where is the CAD/ACS located?

A

Circumflex, lateral LV

172
Q

If CAD?ACS is located in the circumflex and lateral LV, what leads would you see changes?

A

V5, V6, I and aVL

173
Q

Is there are changes in only leads V5 and V6, where is the CAD/ACS?

A

low lateral LV

174
Q

If the CAD/ACS is in the low lateral LV, where would you see lead changes?

A

V5 and V6

175
Q

If you see lead changes in lead I and aVL only, where is the CAD/ACS?

A

high lateral LV

176
Q

If the CAD/ACS is in the high left ventricle, what leads would you see changes?

A

I and aVL

177
Q

If you see changes in leads V1 and V2 only, where is the CAD/ACS?

A

RCA, posterior LV

178
Q

If the CAD/ACS is in the RCA and posterior LV, what leads would you see changes?

A

V1 and V2

179
Q

If you see changes in only leads V3R and V4R, where is the CAD/ACS?

A

RCA, RV infarct

180
Q

If a patient has CAD/ACS in the RV and RCA, what leads would you see changes?

A

V3R, V4R

181
Q

A ___ MI is associated with RCA occlusion

A

Inferior

182
Q

An inferior MI is associated with which artery occlusion?

A

RCA

183
Q

For an inferior MI, you’ll see ST elevation in which leads?

A

II, III, and aVF

184
Q

For an inferior MI, what leads will have reciprocal changes?

A

I and aVL

185
Q

An inferior MI is associated with what type of conduction disturbances?

A

AV

186
Q

What are examples of AV conduction disturbances that are associated with an inferior MI?

A

2nd degree type 1, 3rd degree AV black, sick sinus syndrome (SSS) and sinus bradycardia

187
Q

2nd degree AV block, 3rd degree AV block, SSS, and SB are all associated with a(n) ___ MI

A

inferior

188
Q

If tachycardia is associated with an inferior MI, this means…

A

higher mortality

189
Q

Development of a systolic mumur is associated with an inferior MI d/t…

A

MVR secondary to papillary muscle rupture

190
Q

Why is the development of a systolic murmur associated with an inferior MI?

A

posterior papillary muscle has only one source of blood supply, the RCA

191
Q

Use BB and NTG with CAUTION in which type of MI?

A

Inferior

192
Q

Why are inferior MI associated with RV infarct?

A

RAC supplies inferior wall of LV and also the RV, so 30% of inferior wall MI patients also have RV infarct

193
Q

What type of EKG will demonstrate ST changes in the RV?

A

right sided EKG

194
Q

A patient has JVD at 45 degrees, high CVP, hypotension, clear lungs, and bradyarrhythmias. These are signs of what type of MI?

A

right ventricular infarct

195
Q

What are symptoms of a right ventricular infarct?

A

JVD at 45 degrees, high CVP, hypotension, usually clear lungs, and bradyarrhythmias

196
Q

Right ventricular infarct will show ST elevation in which leads?

A

V3R and V4R

197
Q

How is a right ventricular infarct treated?

A

Fluids and positive inotropes

198
Q

What should be avoided in a patient with a right ventricular infarct?

A

Preload reducers such as nitrates and diuretics

199
Q

What type of MI is associated with LAD occlusion?

A

Anterior

200
Q

What artery occlusion is associated with an anterior MI?

A

LAD

201
Q

An anterior MI will have ST elevation in what leads?

A

V1-V4

202
Q

This EKG shows what?

A

Right-sided EKG with evidence of RV infarction

203
Q

An anterior MI will have reciprocal changes (ST depression) in what leads?

A

II, III, and aVF

204
Q

A patient with an anterior MI may develop what types of heart block?

A

2nd degree type 2 or a right BBB

205
Q

Why can a patient with an anterior MI develop a RBBB or 2nd degree type 2 block?

A

The LAD supplies the common bundle of His

206
Q

If a patient with an anterior MI develops a 2nd degree type 2 or RBBB, this is a ___ sign

A

ominous

207
Q

If a patient with an anterior MI develops a systolic murmur, this could mean…

A

possible ventricular septal defect

208
Q

Which has higher mortality, inferior or anterior MI?

A

Anterior, can lead to heart failure

209
Q

A LOW lateral MI will show ST elevation in what lead?

A

V5 and V6

210
Q

A HIGH lateral MI will show ST elevation in what leads?

A

I and aVL

211
Q

A lateral MI generally involves which artery?

A

left circumflex

212
Q

For treatment of STEMI, if symptoms are less than __ hours, goal is reperfusion

A

12

213
Q

What is the time frame standard for PCI after STEMI?

A

door to balloon within 90 minutes

214
Q

What is the time-frame standard of fibrinolytic therapy for treatment of MI?

A

door to drug within 30 minutes

215
Q

What are the 4 criteria for treatment of STEMI by PCI or fibrinolytic therapy

A
  1. ST elevation in 2 or more continuous leads OR new onset LBBB
  2. Onset of chest pain <12 hours
  3. Chest pain of 30 mins in duration
  4. Chest pain unresponsive to SL NTG
216
Q

What should the nurse monitor for post PCI for treatment of acute STEMI

A
  1. Signs of reocclusion
  2. Bleeding at sheath site and retroperitoneal
  3. Vascular complications
  4. Vasovagal reaction during sheath removal
217
Q

How does the RN assess for a vasovagal reaction during sheath removal after PCI for STEMI

A

Hypotension <90 systolic w/wo bradycardia, absense of compensatory tachycardia
Associated symptoms of pallor, nausea, yawning, diaphoresis

218
Q

How long does nurse hold pressure at sheath site after PCI for STEMI?

A

Minimum of 20 mins, 30 if on GP IIb/IIIa inhibitors

219
Q

How would a nurse treat a PCI complication of vasovagal reaction during sheath removal?

A

Give fluids and possible atropine

220
Q

What are symptoms/signs of retroperitoneal bleeding?

A

Sudden hypotension and severe lower back pain

221
Q

What is treatment for retroperitoneal bleeding?

A

Fluids, blood products

222
Q

How does RN monitor for vascular complications after PCI?

A

pulse assessments

223
Q

What are absolute contraindications to fibrinolytic therapy for STEMI

A
  1. Any prior intracranial hemorrhage
  2. Known structural cerebral vascular lesion (AV malformation)
  3. Known malignant intracranial neoplasm
  4. Ischemic stroke within 3 months EXCEPT acture ischemic stroke within 3 hrs
  5. Active bleeding
  6. Significant closed-head or facial trauma within 3 months
224
Q

How does chest pain relief prove evidence of reperfusion?

A

D/t fibrinolysis of clot

225
Q

How does resolution of ST elevations show evidence of reperfusion?

A

due to return of blood flow

226
Q

Why is there marked elevation of troponin/CK-MB after fibrinolytic/PCI for STEMI?

A

D/t myocardial “stunning” when vessel opens

227
Q

After PCI or fibrinolytic therapy for STEMI, what should the nurse assess for?

A

Bleeding
Change in LOC (brain bleed)
Reocclusion (chest pain, ST elevation)

228
Q

What is the treatment for NSTEMI?

A
  1. NO emergent reperfusion
  2. Same meds as STEMI
  3. If high risk score or continued C/P, instability, start GP IIb/IIIa inhibitors such as Integrilin and reopro, and prepare for cardiac cath within 24 hrs
229
Q

What is the most common complication of an acute MI?

A

Arrhythmias

230
Q

If a patient has a fib after an acute MI, mortality rate…

A

Increases 10-15% even if returned to NSR

231
Q

What is the goal of PCI with a stent?

A

Restoration of blood flow distal to a coronary artery lesion with partial or total occlusion

232
Q

What are two most important complications of PCI

A

Stent thrombosis
Retroperitoneal bleed

233
Q

When is a stent thrombosis most likely to occur?

A

Within 24 hours of stent placement or sub acutely within the first 30 days

234
Q

What increases a patient’s risk of stroke or TIA after PCI

A

the patient has aortic stenosis

235
Q

List other complications of PCI

A

coronary artery perforation
distal coronary artery embolization
Intramural hematoma
renal failure
failure of stent deployment
hematoma at sheath site

236
Q

How often in BP measured during PCI sheath removal

A

every 5-10 mins

237
Q

What should RN do before sheath removal for PCI

A

baseline vitals and pain medicine

238
Q

What is treatment if patient experiences vasovagal response during sheath removal after PCI

A
  1. Hold nitrates
  2. Atropine 0.5mg (even in absence of bradycardia if pt has other symptoms)
  3. IV fluid bolus 250 mL NS if pt not immediately responsive to atropine
  4. Assess for anxiety/pain as contributing factors
239
Q

What are three ways to achieve hemostasis during PCI sheath removal?

A
  1. Manual pressure for 20-30 mins
  2. Mechanical clamp compression using FemoStop or C-clamp
  3. Closure device
240
Q

What are signs of coronary artery reocclusion after PCI?

A

C/P, ST elevation

241
Q

What is a hypertensive emergency (also called htn crisis)?

A

Elevated BP with evidence of end organ damage (brain, heart, kidneys, retina) that can be related to acute hypertension.

242
Q

What is hypertensive urgency?

A

Elevated BP WITHOUT signs of acute end organ damage

243
Q

Does hypertensive emergency/urgency require a critical care admission?

A

HTN emergency does, HTN urgency usually does not

244
Q

What is treatment for hypertensive emergency/crisis?

A

emergent lowering of BP needed, with nitroprusside (Nipride) or Labetalol

245
Q

Nitroprusside (Nipride) is both a __ and __ reducer

A

preload and afterload

246
Q

What are signs of nitroprusside toxicity?

A

Cyanide toxicity secondary to drug metabolite (Thiocyanate).
Signs: mental status changes, restlessness, lethargy, tachycardia, seizures, unexplained metabolic acidosis, especially those with renal impairment when drug used for greater than 24 hrs.

247
Q

Trade names for labetolol

A

normodyne, trandate

248
Q

Why is intermittent IV doses of labetalol preferred over continuous IV infusion for HTN emergency treatment?

A

D/t possibility of continuing dose beyond maximum of 300 mg

249
Q

How long does labetalol effect persist after discontinuation of IV

A

4-6 hours

250
Q

What is the greatest risk of a HTN emergency?

A

Stroke

251
Q

What are the six Ps?

A

Pain
Pallor
Pulse
Paresthesia
Paralysis
Poikilothermia

252
Q

What is poikilothermia?

A

Inability to regulate one’s body temperature

253
Q

Loss of hair on toes, legs, and cool dry skin are signs of…

A

peripheral arterial disease

254
Q

What test can be used to assess for peripheral arterial disease?

A

Ankle/brachial index

255
Q

What is a normal ankle-brachial index

A

> 0.9

256
Q

How do you get an ankle-brachial index?

A

divide ankle pressure by brachial pressure on the same side

257
Q

How else can PAD be found?

A

Doppler ultrasound
Arteriography

258
Q
A
259
Q

What procedures can be done for PAD?

A

Embolectomy
Bypass graft
Angioplasty

260
Q

Why should you NOT elevate a patient extremity with PAD

A

Will decrease perfusion

261
Q

What position can you put the bed in for a patient with PAD?

A

reverse trendelenburg

262
Q

What medications will a patient with PAD be on?

A

Thrombolytics (tPA)
Anticoagulants (heparin)
ANtiplatelets (asa, clopidogrel)
vasodilators

263
Q

Signs and symptoms of acute symptomatic CAD

A

TIA
Monocular visual disturbances
Aphasia
Stroke

264
Q

What is the gold standard for diagnosing acute symptomatic CAD?

A

angiography

265
Q

What is the risk of having an angiography?

A

Stroke

266
Q

How else can acute symptomatic CAD be diagnosed?

A

carotid duplex ultrasound
Computed tomography angiography (CTA)
Magnetic resonance angiography (MRA)

267
Q

How is acute symptomatic CAD treated?

A

Carotid endarterectomy
Carotid stenting
Aspirin
Statin therapy

268
Q

What is hyperperfusion syndrome after CAD treatments?

A

When patient has signs and symptoms of a headache ipsilateral to the revascularized carotid artery, focal motor seizures, and/or an intra cerebral hemorrhage

269
Q

What should a nurse monitor for post procedure carotid endarterectomy?

A

Neuro/motor checks
VS
Bleeding
Hyperperfusion syndrome

270
Q

Why should a nurse pay close attention to VS after carotid endarterectomy?

A

BP and HR may be labile, such as bradyarrhythmia with HTN, hypotension, bradycarda

271
Q

What is Wolff-Parkinson-White syndrome?

A

An abnormal conduction pathway exists that allows a reentrant tachycardia pathway to bypass the normal AV node conduction pathway, resulting in supraventricular tachycardia.

272
Q

What age group in WPW syndrome typically seen?

A

Younger than age 30

273
Q

WPW syndrome typically presents as…

A

supraventricular tachycardia

274
Q

WPW may also presents as…

A

pre-excited atrial fibrillation (irregular rhythm, 150 beats/min or greater and wide QRS)

275
Q

What are signs/symptoms a patient may experience during WPW syndrome?

A

palpitations, dizziness, chest pain, SOB, syncope

276
Q

What does WPW syndrome look like when in sinus rhythm?

A

short PR interval and presence of a delta wave (seen as a slow rise of the initial upstroke of the QRS)

277
Q

What is this EKG showing?

A

A delta wave

278
Q

How is WPW syndrome treated?

A
  1. Radiofrequency ablation to eliminate reentrant pathway
  2. Synchronized cardioversion or adenosine for SVT
  3. For A fib BB, amio, or procainamide IV
279
Q

What should NOT be given to patients with pre-excited atrial fibrillation?

A

Adenosine, digoxin, or calcium channel blockers

280
Q

Why should adenosine, CCB, and digoxin NOT be given for pre-excited atrial fibrillation?

A

May enhance antegrade conduction through abnormal pathway by increasing the refractory period in the AV node

281
Q

What can happen if you give a patient with pre-excited atrial fibrillation digoxin, CCB, or adenosine?

A

V fib

282
Q

QT prolongation may lead to…

A

torsades de pointes

283
Q

What drugs can cause prolonged QT?

A

Amiodarone
Quinidine
Haloperidol
Procainamide

284
Q

Which electrolyte problems can lead to prolonged QT?

A

Hypokalemia
Hypocalcemia
Hypomagnesemia

285
Q

What is treatment for torsades de pointes?

A

magnesium

286
Q

What does the first initial of a pacemaker mode stand for?

A

The chamber that is paced

287
Q

What does the second initial of a pacemaker mode stand for?

A

the chamber being sensed

288
Q

What does the third initial stand for of pacemaker modes?

A

I = inhibits
D = inhibits and triggers
O = none

289
Q

What does inhibits mean for pacemaker modes?

A

pacer detects intrinsic cardiac activity and withholds its pacing stimuli

290
Q

What does D (inhibits and triggers) mean for pacemaker modes?

A

pacer detects intrinsic cardiac activity and fires a pacing stimulus in response

291
Q

Which pacemaker paces both the atria and ventricles, senses both the atria and ventricles, and can inhibit and trigger in response to sensing?

A

DDD

292
Q

What is the pacemaker code?

A

A = atrial
V = ventricle
D = dual

293
Q

Which pacemaker paces the ventricle, senses the ventricle, and inhibits pacing in response to sensing?

A

VVI

294
Q

What are the 3 main pacer malfunctions?

A

Failure to pace
Failure to capture
Failure to sense

295
Q

What failure to pace?

A

No spike at all when expected

296
Q

What is failure to capture?

A

Spikes without a QRS for ventricular pacing

297
Q

What is failure to sense?

A

Pacing in native beats

298
Q

ICDs can provide __ therapy

A

tiered

299
Q

What are 3 functions of an ICD

A

Programmed to shock
Programmed to burst pace
Programmed to provide pacing for bradyarrhythmias

300
Q

When an ICD shocks it will…

A

defibrillate or synchronized cardiovert

301
Q

When an ICD burst paces it will…

A

sense tachyarrhythmia, provide a series of beats fast than the tachyarrhythmia, and then suddenly stop (with the hope of recovery of the SA node)

302
Q

If a patient’s ICD does not correct a lethal arrhythmia…

A

shock as usual, but do not place pads directly over the ICD

303
Q

What types of heart failure are there?

A

Acute
Chronic
Acute exacerbation of chronic
Systolic or diastolic
Right or left sided
Cardiogenic shock

304
Q

What is heart failure in a nutshell?

A

A clinical syndrome characterized by S/S associated with high intracardiac pressures and decreased cardiac output

305
Q

What is acute decompensated heart failure?

A

Abrupt onset of symptoms severe enough to warrant hospitalization, typically seen in those with chronic HF

306
Q

What is heart failure with systolic dysfunction?

A

HF with left ventricular dysfunction, EF is 40% or less

307
Q

What is heart failure with diastolic dysfunction?

A

EF >50%, but there is a problem with filling. Ejection is okay.

308
Q

HFrEF is ___ heart failure

A

systolic

309
Q

HFpEF is __ heart failure

A

diastolic

310
Q

What does BNP stand for?

A

B-type natriuretic peptide

311
Q

What is BNP?

A

a peptide released by the ventricle when it is under wall stress in attempts to dilate and decrease ventricular pressure

312
Q

BNP elevates more when the __ ventricle is under stress compared to the __

A

left, right

313
Q

What can cause BNP to elevate caused by the RIGHT ventricle?

A

Pulmonary hypertension
Pulmonary embolism

314
Q

What are 4 potential causes of acute decompensated systolic dysfunction?

A

CAD
Cardiomyopathy
Acute arrhythmia
Valvular dysfunction

315
Q

In acute decompensated systolic dysfunction, what causes EF <40% and high LVEDP?

A

Wall motion abnormality, LV unable to eject normally

316
Q

In the process of acute decompensated systolic dysfunction, when EF is less than 40% and LVEDP is high, what does this cause?

A

Pulmonary edema and hypoxemia

317
Q

In the process of acute decompensated systolic dysfunction, when a patient experiences pulmonary edema and hypoxemia, this causes the body to release…

A

catecholamines which increases systemic vascular resistance

318
Q

In the process of acute decompensated systolic dysfunction, when SVR is increased, if EF continues to decrease what will happen?

A

CO continues to decrease which causes BP to drop, which the body will increase SVR to compensate for low BP, which starts cycle over again

319
Q

When systolic dysfunction is prolonged and becomes chronic, compensatory ___ lead to ventricular remodeling over time

A

hormones

320
Q

Explain briefly the pathophysiology of acute decompensated systolic dysfunction

A

CAD/CM/etc leads to wall motion abnormality/reduced EF, LVEDP increases, pt experiences pulmonary edema/hypoxemia, catecholamines release (norepi) and SVR increases. EF decreases even more which lowers BP. SVR increased compensatory which worsens LV function even more.

321
Q

Briefly explain progressive systolic dysfunction

A

Persistent systolic dysfunction leads to activation of endogenous neurohormones, these lead to vasoconstriction which causes ventricular remodeling, thus further worsening ventricular function

322
Q

Which endogenous neurohormones are released by persistent systolic dysfunction?

A

Norepinephrine
Vasopressin
Angiotensin I

323
Q

How does the release of angiotensin I lead to ventricular remodeling?

A

It converts to angiotensin II which leads to vasoconstriction, and also aldosterone

324
Q

What happens when aldosterone is released in the process of progressive systolic dysfunction?

A

It leads to Na and water retention causing chamber dilation

325
Q

What drugs are given for progressive systolic dysfunction to block the effects of norepinephrine?

A

Beta blockers

326
Q

What drugs are given to prevent the effects of angiotensin I in progressive systolic dysfunction?

A

ACE inhibitors

327
Q

What drugs are given to prevent the effects of angiotensin II in progressive systolic dysfunction?

A

ARBs

328
Q

What type of conditions can lead to HF with diastolic dysfunction?

A

Chronic hypertension
Valvular disease
Restrictive or hypertrophic CM

329
Q

What type of conditions can lead to acute decompensated systolic dysfunction?

A

CAD
CM
Acute arrhythmias
Valvular dysfunction

330
Q

Briefly explain the pathophysiology of HF with diastolic dysfunction

A

Chronic HTN/etc leads to still LV d/t inability of myofibrils to relax. This causes impaired LV filling which increases LVEDP. Which then causes pulmonary edema

331
Q

What is the primary problem with systolic HF

A

Ejection/dilated chamber. Filling is okay

332
Q

What is the primary problem with diastolic HF

A

Filling problem, hypertrophie chamber or septum. Can eject OK

333
Q

What are signs of systolic HF (8)

A

Dilated LV
PMI shift to left
Mitral valve insufficiency
EF <40%
Pulmonary edema
s3 heart sound
BP normal or low
BNP elevated

334
Q

What are signs of diastolic HF (7)

A

Normal LV
This ventricular walls/septum
Normal EF
Pulmonary edema
S4 heart sound
BP high
BNP elevated

335
Q

What causes pulmonary edema in systolic HF

A

due to poor ventricular emptying

336
Q

What causes pulmonary edema in diastolic HF?

A

d/t high ventricular pressure

337
Q

What drugs are given in systolic HF? (6)

A

Beta blockers
ACEi/ARBs
Diuretics
Dilators
Aldosterone antagonists
Positive inotropes

338
Q

What drugs are given in diastolic HF? (5)

A

Beta blockers
ACEi/ARB
CCB
Diuretics (low dose)
Aldosterone antagonists

339
Q

What drugs are contraindicated in diastolic HF?

A

positive inotropes

340
Q

Why are positive inotropes contraindicated in diastolic HF?

A

Dehydration worsens filling, tachyarrhythmias decrease filling time and worsen symptoms

341
Q

What type of drugs are contraindicated in systolic HF?

A

negative inotropes (CCB, and in acute phase BB)

342
Q

What type of cardiomyopathies result in systolic HF?

A

dilated

343
Q

What type of cardiomyopathy results in diastolic HF?

A

Idiopathic hypertrophic subaortic stenosis
Hypertrophic cardiomyopathy
Restrictive cardiomyopathy

344
Q

Which type of HF is evident by large heart on imaging?

A

Systolic

345
Q

What is PMI?

A

point of maximal impulse

346
Q

Where is PMI normally?

A

midclavicular line

347
Q

A shift to the left (of PMI) is associated with which type of HF?

A

Systolic

348
Q

What are causes of right-sided HF?

A

Acute RV infarct
Pulmonary embolism
Septal defects
Pulmonary stenosis/insufficiency
COPD
Pulmonary HTN
LV failure

349
Q

What are causes of left sided HF?

A

CAD/Ischemia
MI
CM
FVO
Chronic uncontrolled HTN
AS/Insufficiency
Mitral stenosis/insufficiency
Cardiac tamponade

350
Q

s/s of right-sided HF

A

hepatomegaly
splenomegaly
dependent edema
venous distention
elevated CVP/JVD
tricuspid insufficiency
abd pain

351
Q

S/S of left-sided HF

A

Orthopnea, dyspnea, tachypnea
Hypoxemia
Tachycardia
Crackles
Cough with pink, frothy sputum
Elevated PA diastolic/PAOP
Diaphoresis
Anxiety/Confusion

352
Q

What are the 2 types of HF classifications?

A

AHA
New York Heart Association

353
Q

The AHA stages of HF are classified according to…

A

HF progression and recommended therapy for each stage

354
Q

How does the New York Heart Association base HF classes?

A

Based on patient’s symptoms and do not suggest treatment

355
Q

The main cause of death in patients with HF is…

A

sudden death arrhythmia

356
Q

What classes of NYHA are eligible for ICD?

A

II to IV

357
Q

Stage A of AHA HF Stages

A

High risk, no evidence of dysfunction

358
Q

Stage B of AHA HF Stages

A

Heart disorder or structural defect, asymptomatic

359
Q

Stage C of AHA HF Stages

A

Heart disorder or structural defect, with symptoms (past or present)

360
Q

Stage D of AHA HF Stages

A

End-stage cardiac disease, with symptoms despite maximal therapy (inotropic or mechanical support)

361
Q

Class I NYHA HF

A

Ordinary activity does not cause symptoms, although extraordinary activity results in HF symptoms

362
Q

Class II NYHA HF

A

Comfortable at rest, but ordinary activity results in heart failure symptoms

363
Q

Class III NYHA HF

A

Comfortable at rest, but minimal activity causes HF symptoms

364
Q
A
365
Q

Class IV NYHA HF

A

Symptoms of HF occur at rest, there is severe limitation of physical activity

366
Q

Dilated cardiomyopathy is __ dysfunction

A

systolic

367
Q

Hypertrophic cardiomyopathy is __ dysfunction

A

diastolic

368
Q

Systolic dysfunction (DCM) is problems with…

A

ejecting blood

369
Q

Diastolic dysfunction (hypertrophic CM) is problems with…

A

filling

370
Q

Dilated cardiomyopathy is…

A

thinning, dilation, and/or enlargement of LV

371
Q

Mitral valve regurgitation is common with DCM d/t

A

ventricular dilation

372
Q

Hypertrophic CM has increased risk of… compared to DCM

A

sudden cardiac death

373
Q

A patient with dilated CM may need a __ or __

A

VAD or heart txp

374
Q

With hypertrophic cardiomyopathy, there is increased thickening of…

A

heart muscle and septum inwardly at the expense of the LV chamber

375
Q

Symptoms of hypertrophic CM

A

Fatigue
Dyspnea
Chest pain
Palpations
S3, S4 heart sounds
Presyncope or syncope

376
Q

Cardiogenic shock is most commonly caused by…

A

extreme drop in stroke volume secondary to systolic dysfunction

377
Q

List 3 things you might see in a patient with cardiogenic shock

A

Elevated PAOP with pulmonary symptoms
Elevated SVR d/t compensatory mechanisms
Drop in CO to where organs are not perfusing

378
Q

What does PAOP indicate?

A

Elevated left ventricular preload

379
Q

What does SVR indicate in cardiogenic shock?

A

Elevated left ventricular afterload

380
Q

What are s/s of the compensatory stage of cardiogenic shock?

A

Tachycardia
Tachypnea
Crackles, mild hypoxemia
ABG with resp alkalosis or early metabolic acidosis
Anxiety
Neck vein distention
S3 heart sounds (s4 if there is also an acute MI)
Cool skin
Decreased UOP
Narrow PP
BP maintained but lower than baseline

381
Q

What are s/s of the progressive stage of cardiogenic shock?

A

Hypotension
Worsening tachycardia, tachypnea, oliguria
Metabolic acidosis
Worsening crackles and hypoxemia
Clammy, mottled skin
Worsening anxiety

382
Q

List 6 etiologies of cardiogenic shock

A

Acute MI
Chronic HF
CM
Dysrhythmias
Cardiac tamponade
Papillary muscle rupture

383
Q

If a patient has papillary muscle rupture and is in cardiogenic shock, this is a…

A

life-threatening emergency and requires immediate surgical intervention

384
Q

How is cardiogenic shock treated?

A

Identify cause
Manage arrhythmias
Reperfusion if MI
Emergent surgery if ruptured pap muscle
Mechanical circulatory support

385
Q

What increases the effectiveness of ECMO?

A

positive inotropes

386
Q

Give 4 examples of positive inotropes that enhance effectiveness of ECMO

A

Norepi
Dopamine (4-10 mcg/kg/min)
Dobutamine
Milrinone

387
Q

What should be avoided on ECMO?

A

Negative inotropic agents

388
Q

When would vasodilators be used for a patient on ECMO?

A

IN conjunction with IABP and positive inotropic agents (if the pt is in the progressive stage of hypotension)

389
Q

What decreases demand of pump for ECMO

A

Preload/afterload reduction
Optimized oxygenation
mechanical ventilation
treating pain
IABP for short term support and VAD for long

390
Q

When is a IABP used?

A

Management of LV failure
Cardiogenic shock
Cardiomyopathies
Pts awaiting heart txp

391
Q

When an IABP inflates, what does this do?

A

Increases coronary artery perfusion

392
Q

When an IABP deflates, what does this do?

A

decreases afterload

393
Q

When does an IABP inflate?

A

at dicrotic notch of the arterial waveform, beginning of diastole

394
Q

When does an IABP deflate?

A

Right before systole begins

395
Q

IABP deflation is determined by…

A

a set trigger for deflation, R wave of ECG or upstroke of the arterial pressure wave

396
Q

During cardiopulmonary bypass what is done?

A

aortic cross clamping and the heart is stopped

397
Q

What are the most common cannula sites for cardiopulmonary bypass?

A

Aorta and right atrium

398
Q

The longer a patient is on cardiopulmonary bypass the more…

A

bleeding there is and the more complications there may be postoperatively

399
Q

During a CABG, what can enhance oxygenation by improving blood flow?

A

Priming with isotonic cystalloids

400
Q

During a CABG, how is circulatory arrest achieved?

A

During diastole with infusion of a potassium cardioplegic agent, and is reinfused at regular intervals

401
Q

What are 2 very important things to assess for in a patient post op CABG

A

Tamponade and pericarditis

402
Q

What else should be included in nursing assessment of a post op CABG?

A

Hemodynamic abnormalities
Arrhythmias
Electrolytes
Bleeding
Pulmonary issuese
Pain/Anxiety
Renal failure
Issues with blood sugar control
GI - ileus
Infection

403
Q

How to maintain patency of post op chest tube

A

do not allow dependent loops
Milking or stripping not typically indicated, but if clots appear can milk

404
Q

What is removed via a mediastinal chest tube?

A

Serosanguineous fluid from the operative site

405
Q

What is removed via a pleural chest tube?

A

Air, blood, or serous fluid from the pleural space

406
Q

Chest tubes should always be…

A

lower than the patient’s chest

407
Q

When should a chest tube be clamped?

A

Only if you are changing the drainage system or there is a system disconnect

408
Q

What happens when a chest tube is clamped?

A

The connection to the negative chamber is lost

409
Q

What does chest tube output generally require intervention?

A

When the output is greater than 100 mL/hr for at least 2 hrs

410
Q

What should the nurse do if a patient’s CT output is great than 100 ml/hr for over 2 hrs?

A

Maintain hemodynamic stability
Correct volume status
Administer blood products

411
Q

What are 3 advantages of a mechanical valve?

A

Relatively easy to insert
Very reliable
Lasts longer than a biological valve

412
Q

What are 2 disadvantages of a mechanical valve?

A

High risk of thrombosis
Permanent anticoagulation therapy

413
Q

What is an advantage of a biological valve?

A

Only short term anticoagulation therapy is needed

414
Q

What is a disadvantage of a biological valve?

A

Wears down, especially in high pressure systems

415
Q

What are three nursing considerations for post heart valve replacement?

A

Avoid a drop in preload
Anticoagulation and antiplatelet therapy needed
Anticipate conduction disturbances

416
Q
A

CCRN Book (1 decks)

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