Exam 1 (3/1) Flashcards
components of a cardiac assessment
gather health history:
Chest pain/discomfort
Pain/discomfort in other areas of the upper body
SOB/dyspnea
Peripheral edema, weight gain, abdominal distention
Palpitations
Unusual fatigue, dizziness, syncope, change in LOC
gather past health, family and social history: Medications Nutrition Elimination Activity, exercise Sleep, rest Self-perception/self-concept Roles and relationships Coping and stress
Physical assessment: General appearance Skin and extremities Pulse pressure Blood pressure; orthostatic changes Arterial pulses Jugular venous pulsations Heart inspection, palpation, auscultation Assessment of other systems
Lab tests for the heart
Biomarkers—cardiac enzymes (CK, CK-MB, trop)- from myocardial cells r/t prolonged ischemia or trauma.
BUN—Blood urea nitrogen (and creatine)– kidneys
Lipids monitored in the development of CAD
Brain (B-type) natriuretic peptide- a neurohormone that helps regulate BP and fluid volume.
C-reactive protein- Liver Inflammation noted with atherosclerosis.
Homocysteine— atherosclerosis
age related changes in the cardiac system
Loss of function of the cells leading to slower heart rate
Size of heart increases due to hypertrophy
Reduced volume of blood
Reduced strength of contraction
Valves stiffen
Backflow of blood creates heart murmurs
cardiac tests
-Exercise stress test:
Pt walks on treadmill with intensity progressing according to protocols
ECG, V/S, symptoms monitored
Terminated when target HR is achieved
- Echocardiogram:
Noninvasive ultrasound test that is used to:
Measure the ejection fraction
Examine the size, shape, and motion of cardiac structures - Transthoracic endocardiogram
- Transesophageal endocardiogram
- Chest X-Ray (CXR)
- Fluoroscopy: moving images on xray
What is an (ECG)?
12 lead ECG:
graphic representation of the electrical currents of the heart
diagnose dysrhythmias, conduction abnormalities, and chamber enlargement, as well as myocardial ischemia, injury, or infarction
All ECG’s:
Monitor more than one ECG lead simultaneously
Monitor ST segments (ST-segment depression is a marker of myocardial ischemia; ST-segment elevation provides evidence of an evolving MI)
Provide graded visual and audible alarms (based on priority, asystole merits the highest grade of alarm)
Interpret and store alarms
Trend data over time
Print a copy of rhythms from one or more specific ECG leads over a set time (called a rhythm strip)
What are cardiac enzymes? What are the expectations and concerns related to these?
Myocardial cells that become necrotic from prolonged ischemia or trauma release specific enzymes
These substances leak into the interstitial spaces of the myocardium and are carried by the lymphatic system into general circulation. As a result, abnormally high levels of these substances can be detected in serum blood samples
Heart catheterization
Invasive procedure used to diagnose structural and functional diseases of the heart and great vessels
Right Heart Cath: Pulmonary artery pressure and oxygen saturations may be obtained; biopsy of myocardial tissue may be obtained
Left Heart Cath: Involves use of contrast age
Post procedure care: Observe cath site for bleeding, hematoma Peripheral Neurovascular assessment Evaluate temp, color, and cap refill of affected extremity Screen for dysrhythmias Maintain bed rest 2 to 6 hours Instruct patient to report chest pain, bleeding Monitor for contrast-induced nephropathy Ensure patient safety
age-related changes in cardiac system
Loss of function of the cells leading to slower heart rate
Size of heart increases due to hypertrophy
Reduced volume of blood
Reduced strength of contraction
Valves stiffen
Backflow of blood creates heart murmurs
Causes of Heart failure
causes: coronary artery disease, hypertension, cardiomyopathy, valvular disorders, renal dysfunction, diabetes, atherosclerosis
patho: body activates compensatory hormines, structure of heart changes leading to low CO
Manifestions of Heart Failure
RIGHT SIDED: viscera & peripheral conjestion JVD dependent edema hepatomegaly ascites (accumulation of fluid in abdomen) weight gain LEFT SIDED: pulmonary congestion "crackles" S3 or "ventricular gallops" dyspnea on exertion low O2 sat dry nonproductive cough oliguria (small amount of urine only)
Management of Heart Failure
Angiotensin-converting enzyme (ACE) inhibitors: vasodilation; diuresis; decreases afterload; monitor for hypotension, hyperkalemia, and altered renal function; cough
Angiotensin II receptor blockers: prescribed as an alternative to ACE inhibitors; work similarly
Hydralazine and isosorbide dinitrate: alternative to ACE inhibitors
Beta-blockers: prescribed in addition to ACE inhibitors; may be several weeks before effects seen; use with caution in patients with asthma
Diuretics: decreases fluid volume, monitor serum electrolytes
Digitalis: improves contractility, monitor for digitalis toxicity especially if patient is hypokalemic
IV medications: indicated for hospitalized patients admitted for acute decompensated HF
Milrinone: decreases preload and afterload; causes hypotension and increased risk of dysrhythmias
Dobutamine: used for patients with left ventricular dysfunction; increases cardiac contractility and renal perfusion
Nursing Process with HF
Assessment: Focus on: -Effectiveness of therapy -Patient’s self-management -S&S of increased HF -Emotional or psychosocial response Health history Physical Exam Mental status lung sounds: crackles and wheezes heart sounds: S3; fluid status or signs of fluid overload daily weight and I&O assess responses to medications
Diagnosis:
Activity intolerance related to decreased CO
Excess fluid volume related to the HF syndrome
Anxiety-related symptoms related to complexity of the therapeutic regimen
Powerlessness related to chronic illness and hospitalizations
Ineffective family therapeutic regimen management
Planning:
-Goals-
-Promote activity and reduce fatigue
-Relieving fluid overload symptoms
-Decrease anxiety or increase the patient’s ability to manage anxiety
-Encourage the patient to verbalize his or her ability to make decisions and influence outcomes
-Educate the patient and family about management of the therapeutic regimen
-interventions-
activity intolerance:
Bed rest for acute exacerbations
Encourage regular physical activity; 30 to 45 minutes daily
Exercise training
Pacing of activities
Wait 2 hours after eating for physical activity
Avoid activities in extreme hot, cold, or humid weather
Modify activities to conserve energy
Positioning; elevation of the head of bed to facilitate breathing and rest, support of arms
Fluid volume excess:
Assessment for symptoms of fluid overload
Daily weight
I&O
Diuretic therapy; timing of meds
Fluid intake; fluid restriction
Maintenance of sodium restriction
Potential complications: Hypotension poor perfusion cardiogenic shock Dysrhythmias Thromboembolism Pericardial effusion cardiac tamponade
Heart failure pt education & end of life considerations
-education-
Medications
Diet: low-sodium diet and fluid restriction
Monitoring for signs of excess fluid, hypotension, and symptoms of disease exacerbation, including daily weight
Exercise and activity program
Stress management
Prevention of infection
Know how and when to contact health care provider
Include family in education
-end of life-
HF is a chronic and often progressive condition:
Need to consider issues related to the end of life
When palliative or hospice care should be considered
Pulmonary edema Patho
Acute event results in LV failure
As LV begins to fail, blood backs up into the pulmonary circulation, causing pulmonary interstitial edema
Results in hypoxemia, often severe
manifestations of Pulmonary edema
restlessness, anxiety, dyspnea, cool and clammy skin, cyanosis, weak and rapid pulse, cough, lung congestion (moist, noisy respirations), increased sputum production (sputum may be frothy and blood tinged), decreased level of consciousness
Management of pulmonary edema (fluid in the lungs)
Easier to prevent than to treat
Early recognition: monitor lung sounds and for signs of decreased activity tolerance and increased fluid retention
Minimize exertion and stress
Oxygen; nonrebreather
Medications: Diuretics (furosemide), vasodilators (nitroglycerin)
Nursing Management:
Positioning the patient to promote circulation- Positioned upright with legs dangling
Providing psychological support- Reassure patient and provide anticipatory care
Monitoring medications- I&O
Risk factors of Peripheral Areterial Occlusive Disease (PAD)
Modifiable: Nicotine, diet Hypertension Diabetes Obesity Stress Sedentary lifestyle C-reactive protein Hyperhomocysteinemia
Non-modifiable
Age
Gender
Familial predisposition and genetics
Manifestations of PAD
Intermittent claudication (aching, cramping, fatigue/weakness)
Occurs with activity, relieved with rest
Pain is due to critical ischemia
Persistent, aching, boring (rest pain)
Usually worse at night
Nursing Prosess for PAD
Assessment:
Health history
- Intermittent claudication
- Location of the pain (persistent in forefoot)
Physical assessment
- Skin (blue color (rubor) and cool/pale)
- Pulses (you cant feel it so use a doppler)
Diagnosis:
Ineffective Tissue Perfusion
Diagnostic evaluation:
Doppler Ultrasound
Magnetic Resonance Angiography
Angiography-
- confirms location of an obstruction or aneurysm
-Allergy to contrast:
- normal-sensation of warmth, local irritation at injection site
- Allergy reaction may be immediate or delayed—Dyspnea, nausea and vomiting, sweating, tachycardia, and numbness of the extremities
any reactions should be reported to the interventionalist immediately
Treatment generally includes epinephrine, antihistamines, and/or corticosteroids
Planning: Medical Management -Low-fat diet -Controlled exercise -Medication -Antilipemics -Anti-hypertensives Surgical/Radiologic Interventions -Angioplasty -Atherectomy -Stent grafts
Implementation: Lower extremities below the level of the heart Promote vasodilation Application of warmth Smoking cessation Stress reduction Encourage walking Relieve pain (analgesics) Maintain tissue integrity
Evaluation: Extremities warm to touch & improved color Walks further & with less pain Reports less pain Absence of injury or ulceration
Educate: lower the extremity below the heart, encourage moderate exercise, don’t be on extremity for too long
Venous Insufficiency
Chronic venous stasis: Edema Altered pigmentation Pain Stasis dermatitis
Prevention: Application of graduated compression stockings Pneumatic compression devices Early ambulation Subcutaneous heparin or LMWH Lifestyle changes Weight loss Smoking cessation Regular exercise
Varicose veins
Dilated, tortuous veins: Dull aches Muscle cramps Muscle fatigue lower legs Nocturnal cramps
Prevention:
Avoid activities that cause venous stasis (wearing socks that are too tight at the top or that leave marks on the skin, crossing the legs at the thighs, and sitting or standing for long periods)
Elevate the legs 3 to 6 inches higher than heart level
Encourage to walk 30 minutes each day if there are no contraindications
Wear graduated compression stockings
Overweight patients should be encouraged to begin weight reduction plans
Leg Ulcers
Venous insufficiency can result from obstructed venous valves
Edema, altered pigmentation, pain, stasis dermatitis
Assessment: H & P
Diagnosis: Impaired skin integrity
Plan: Restoration of skin integrity
Interventions Medication - antiseptic agents, oral antibiotics, topical agents GCS, elastic wraps, Unna boots Debridement Dressings Hyperbaric oxygen Negative pressure wound therapy
Lymphangitis
inflammation or infection of the lymphatic channels
Hemolytic streptococcus
Red streaks
Treat with antibiotics
Lymphadenitis
tissue swelling related to obstruction of lymphatic flow
Hemolytic streptococcus
Red streaks
Treat with antibiotics
Cellulitis
S&S: localized swelling or redness, fever, chills, sweating
Treat with oral or IV antibiotics based on severity
Nursing interventions:
Elevate affected area
Warm, moist packs to site every 2 to 4 hours
Educate regarding prevention of recurrence
Reinforce education about skin and foot care
look for points of entry
Lymphedema and elephantiasis
Tissue swelling due to increase lymph that results from obstruction of lymphatic vessels
- Exercise
- GCS
- Manual lymphatic drainage
- Diuretics
- Surgery
Venous Thromboemolism (VTE) preventiosn risk factors
Endothelial damage (trauma, surgery, central venous or dialysis catheters, pacing wires, local vein damage, repetitive motion injury) Venous stasis (bed rest/immobilization, obesity, spinal cord injury, age >65) Altered coagulation (cancer, pregnancy, oral contraceptives, sepsis, polycythemia, protein C or S deficiency, factor V leiden defect)
Manifestation VTE
Swelling Throbbing pain Warm skin Red or darkened skin Swollen veins that are hard/sore when touched
Nursing Process for VTE
Planning: Decrease Venous Congestion Medical/Nursing Management: Anti-gravity activities Graduated compression stockings Encourage walking Maintain tissue integrity
Diasgnosis:
Ineffective Tissue Perfusion
Duplex Ultrasonography
Contrast Phlebography (Venography)
Implementation
Elevate extremities above the level of the heart
Discourage standing or sitting for prolong periods
Discourage constrictive clothing
Avoid crossing legs
evaluation: decreased edema
Management of VTE
Elevate extremity, GCS, SCDs
Warm, moist packs
Anticoagulants:
Monitor lab values
Monitor for bleeding
Know how to reverse anticoagulation effects
Encourage walking AFTER anticoagulation therapy has been started
Prophylactic medication- heparin, enoxaparin
DVT
Prevention: Identify high-risk patients—Endothelial damage (trauma, surgery, central venous or dialysis catheters, pacing wires, local vein damage, repetitive motion injury), venous stasis (bed rest/immobilization, obesity, spinal cord injury, age >65), altered coagulation (cancer, pregnancy, oral contraceptives, sepsis, polycythemia, protein C or S deficiency, factor V leiden defect. GCS Early ambulation Leg exercises Prophylactic medication Heparin, Enoxaparin
Management: Elevate extremity, GCS, SCDs Warm, moist packs Anticoagulants Monitor lab values Monitor for bleeding Know how to reverse anticoagulation effects Encourage walking AFTER anticoagulation therapy has been started
Hypertension categories
Primary or essential (95%)
secondary (5%)
gestational
