Exam 2 Flashcards
Heart Failure
Inability of the heart to pump sufficient blood to meet the demand of the body
Signs of Heart Failure
Exercise intolerance, very fatigued with activity, most cases are related to MI damage and chronic HTN
Clinical Manifestations of Heart Failure
Fatigue, Dyspnea, Orthopnea, PND, Tachycardia, Edema, Nocturia, Behavioral changes, chest pain, weight cahnges
Classifying Left Ventricular Failure
Left ventricle has weak pump, backs up into the left atrium and into the lungs
Causes: HTN, CAD, Vascular Disease
Classifying Right Ventricular Failure
Right ventricle weak, unable to pump into the lungs, symptoms come from back up into the systemic system, edema!
Causes: LV Failure, RV infarct, Pulmonary HTN
Bi-Ventricular Failure
Usually RV secondary to LV failure
Acute vs Chronic Failure
Acute= immediate, usually LV, following acute MI Chronic= Long term, less immediate
Systolic vs Diastolic Failure
Systolic = Reduced ejection fraction Diastolic= decreased filling
Low output vs High Output Failure
Low= Reduced pumping, more common High= fever, hyperthyroidism, pregnancy
Compensatory mechanisms for Heart Failure
Increased HR and Increased SV (to maintain output)
Arterial vasoconstriction (to increase perfusion and BP)
Sodium and H2O retention (non-therapeutic)
Myocardial hypertrophy
Diagnosing Heart Failure
CXR= show cardiomegaly, fluid in lungs ECHO= EJ calculation Angiography= visualize heart PA Catheter= Evaluate pressure EKG= conduction abnormalities
B-type natriuretic peptide (BNP)
Plasma levels may correspond to the severity of underlying cardiac dysfunction, provides prognostic information, elevated plasma BNP indicates a high risk of morbidity and mortality in patients with chronic heart failure or acute coronary syndrome. Should be <100.
Functional Classifications of Heart Failure
Class 1=No limitation
Class 2= Slight limitation
Class 3= More severe
Class 4= Inability to carry on any activity
ACE Inhibitors
Reduce workload of heart, increase renal function
Diuretics
Pulling off fluid, many will also have K+ replacements
Beta Blockers
Overall longevity, make the heart work less
Aldactone
Potassium sparing diuretic
Digoxin
No longer top drug, lowers work of the heart, can have toxic levels and nasty side effects
Nitrates
Dilate blood vessels
Rational Polypharmacy
Balancing beneficial and adverse drug effects and monitoring how such drug regimens affect each patient with heart failure
Focus of Heart Failure Therapy
Improve survival, relieve symptoms
Clinical Manifestations of Acute LV heart failure
Respiratory distress; crackles, increased HR, S3 gallop rhythm, restlessness
Pulmonary Edema
Life threatening LV failure; given IV diuretics, MSO4, NTG, Nitroprusside (dilates blood vessels), position in high fowlers, oxygen, and foley catheter
Rheumatic Carditis
Affects 40% of patients with RF, group A beta-hemolytic streptococci (basic strep throat), Impairs pumping function, muscle tissue, pericardium, and valves.
basically Inflammation of cardiac valves related to strep throat
Valvular Heart Disease
Congenital or acquired dysfunctions, valvular stenosis, insufficiency or regurg
Mitral Stenosis
Usually from rheumatic carditis, valve is thickened by fibrosis and calcification. Sx: Dyspnea with exertion, fatigue, orthopnea, neck vein distention
PE: diastolic murmur
Mitral Regurgitation
Caused by RHD, LA and LV dilate and hypertrophy, may be symptom free for decades; common complaints are anxiety, chest pain, and palpitations. Other Sx include fatigue, weakness, and dyspnea, and orthopnea
PE: holosystolic murmur
Mitral Valve Prolapse
Valvular leaflets enlarge and prolapse into the LA during systole, usually benign and asymptomatic
PE: Systolic Click
Familial occurence usually, associated with marfans syndrome- cardiac disease, visual problems, very long arm span, most common in young to middle aged thin women
Aortic Stenosis
Increased resistance to ejection during systole, leading to LV failure and eventually RV failure. Sx: dyspnea, angina, syncope. PE= systolic murmur
Most common in aging populations, majority men
Aortic Regurgitation
Creates dilation of LV, asymptomatic for many years untilc LV failure occurs, usually from non-RHD: endocarditis, congentital, HTN, marfans syndrome, men Sx: DOE, orthopnea, PND
PE= Diastolic Murmur - second intercostal space on right side
Cardiomyopathy
Enlarged cardiac muscle, decreased pumping, irreversible, often unknown etiology, could be etoh,
Dilated Cardiomyopathy
Damage myofibrils, decreased CO
Sx: fatigue, DOE, gallop rhythms
More common in men of middle age
Hypertrophic Cardiomyopathy
LVH with obstruction in LV outflow, abnormal stiffness of LV, genetic usually, often cause of sudden death in young athletes, gallop rhythms, a.fib
Restrictive Cardiomyopathy
Rarest, LV filling is restricted, Sx: dyspnea, fatigue, right sided HF, gallop rhythms
Infective Endocarditis
Infection of valves and endothelial surface of heart cause by direct invasion of bacteria, usually r/t valve replacements, structural cardiac defects, or IV drug abuse. Sources: Oral cavity, skin lesions, infections, invasive procedures.
Patient with the following should receive antibiotics before dental procedures
Prosthetic cardiac valves
Previous bacterial endocarditis
Certain congenital cardiac malformations
Cardiac transplantation
The following no longer require antibiotics prophylaxis
Rheumatic Valve Dysfunction Mitral valve prolapse Previous CABG Heart Murmurs Cardiac Pacemakers and defibs
Infective Endocarditis 2
pt c/o chills, fever, flu like symptoms PE=new onset of murmur Oslers nodes and Janeways lesions petechiae Splinter hemorrhages arterial embolic complications
CO: SV X HR
4-6L/min is normal
HR
60-100 beats/min is normal
SV
73ml/contraction is normal
Preload
5-12 mmHg is normal
Cancer is…
The second leading cause of death in the US. Cancer accounts for nearly one-quarter of all deaths in the US.
Highest Estimated new cases in males and females
Prostate for males
Breast for females
Second for both is lung and bronchus
Highest estimated deaths related to cancer
Lung and bronchus cause the most deaths, followed by prostate and breast
Cancer disparity between african americans and whites
African americans are 10% -20% less likely to survive cancer, this is due to less likely to recieve cancer diagnosis at and early stage, unequal access to medical care, and tumor characteristics not related to early detection
Individual Actions to Prevent Cancer
- Maintain healthy weight
- Physical Activity
- Consume healthy diet with plants
- Limit alcohol consumption
- Stop smoking
- Limit sun exposure
- Protect yourself from toxic substances
CAUTION
Change in bowel/bladder habits A sore Unusual bleeding/discharge Thickening/Lump Indigestion or swallowing issues Obvious change in wart or mole Nagging cough/hoarseness
Unmodifiable Risk Factors for Cancer
Family history, Age, Gender, Impaired immunity
Prognostic Factors for Cancer
Performance status: Karnofsky Scale, ECOG Scale, Staging: TMN Classification, Grading
Karnofsky Scale
A person’s functional status, their ability to care for themselves and carry out normal activities of daily living. 100 = highest living 0= dead
TMN Classification
T=The extent of the primary tumor
N= Lymph Node presence?
M= Distance Metastasis?
Subscripts: X= unknown, 0= none, 1-4 =extent of disease
Grading
Looks at characteristics and behavior of cancer cells. If it looks and behaves more like normal cells they are usually less aggressive.
Ploidy
Chromosome number and appearance. Normal human ploidy = 23. Cancer can cause addition or loss of a chromosome. More or less than 23= aneuploidy = more malignant
Shock
A conditions in which systemic blood pressure is inadequate to deliver oxygen and nutrient to support vital organs and cellular function
Inadequate tissue perfusion leads to…
if untreated cell death will happen
it can lead to anaerobic metabolism which leads to build up of lactic acid and metabolic acidosis
3 optimally performing components needed to ensure adequate tissue perfusion:
Adequate cardiac pump
Effective and intact vasculature
Sufficient blood volume
Mean Arterial Pressure
Average pressure at which blood moves through the circulatory system, normal = 70-110 mm Hg, need a minimum of 60 mm Hg for perfusion of coronary arteries, kidneys, and brain
MAP
CO X Peripheral vascular resistance
Calculated MAP
Diastolic BP + 1/3 Pulse Pressure
Baroreceptors
Respond to dropping BP, stimulate SNS, epinephrine and norephinephrine released from adrenals, increase HR and vasoconstriction
Chemoreceptors
Respond to changes in oxygen and carbon dioxide concentrations
Kidneys role in RP regulation
Vasoconstriction, retention of sodium and water, ADH for further water retention, increased blood volume and BP, takes hours and days to respond
Compensatory stage of Shock
BP=Normal HR= >100 bpm RR= >20 Skin= Cold Clammy Urinary Output= Decreased Mentation= Confused Acid Base Balance= Respiratory Alkalosis
Medical Management of Compensatory stage
Identify and treat cause of shock, support successful physiologic adaptations, replace fluid, meds
Nursing Management of Compensatory Stage
PREVENT BP DROP! Ongoing systematic assessment Urinary output Skin Lab Values: Sodium and blood glucose increase
Progressive Stage of Shock
BP= Systolic 150 RR= Rapid, shallow, crackles Skin= Mottled, petechiae Urinary Output= 0.5 ml/kg/hr Acid Base Balance= Metabolic Acidosis
Progressive Stage Prosnosis
All systems on the verge of failure: Kidneys, liver, GI, Resp, CV, Heme
Medical Management of Progressive Stage of Shock
Fluids and Meds
Restore intravascular volume
Support pumping of the heart
Improve competence of vascular system
Nursing Management of Progressive Stage of Shock
Understand Shock Significance of Changes ASSESS Prevent complications- aseptic technique Promote rest and comfort Support family
Irreversible Stage of Shock
BP= Requires support HR= Erratic and asystole RR= Intubation Skin= Jaundice Urinary Output+ Anuric, dialysis Mentation= Unconsious Acid Base Balance= Profound acidosis
Irreversible Stage Diagnosis
Only made retrospectively, continue intervening until no response to treatment, nursing management is focus on comfort and support to patient and family
Management Strategies of Shock
Fluid Replacement
Vasoactive meds- restore vasomotor tone and improve cardiac function
Nutritional support
Fluid Replacement in Shock
Crystalloid Fluids- electrolytes move freely between intravascular and interstitial spaces
Colloidal Fluids- large molecule fluids
Blood components
Crystalloid Fluid
Isotonic (Expand ECF volume)
0.9% Normal Saline
Lactated Ringer’s
Colloids Fluid
Albumin
Dextran
Vasoactive Meds
Inrease cardiac contactility, Regulate HR, Reduce myocaridla resistance, Initiate vasoconstriction
All work by stimulating alpha- and/or beta- adrenergic receptors
Nursing Management of Vasoactive Meds
VS at least q15 mintues
Administer through central venous catheter
Always use IV pump and monitor closely
Titrate dosage based on patient parameters
NEVER stop abruptly
Nutritional Support for Shock
Glycogen stores depleted in first 8 hours of shock, even with people with large fat stores, muscle is selectively broken down as an energy source, loss of skeletal muscle greatly prolongs recovery time, >3000 kcal/day high protein, enteral and parenteral
Hypovolemic Shock
Hemorrhage, Trauma, Surgery, Dehydration, Burns
Cardiogenic Shock
Coronary (MI), Non-coronary (Cardiomyopathies, valve damage, cardiac tamponade, dysrhythmias)
Circulatory Shock
Septic Shock: Sepsis and hypotension Immunosuppression Extremes of age Malnourishment Chronic Illness Invasive procedures
SIRS
Systemic Inflammatory Response Syndrome
Physiological alterations and organic dysfunctions seen with bacterial infections
Sepsis
Systemic infection occurs in 1-2:100 hospitalized patients
55% in critical care units
Circulatory Shock: Neurogenic Shock
Massive Vasodilation Spinal cord injury Spinal anesthesia Depressant Action of meds Glucose deficiency
Circulatory Shock: Anaphylactic
Vasodilation and capillary leakage PCN sensitivity Transfusion reaction Bee sting allergy Latex Sensitivity Food Allergies
EKG’s
Graphic representations of the ELECTRICAL activity within the heart. They can tell about electrical function: Rhythm disturbances, and conduction disturbances.
EKG’s cannot…
tell about mechanical function: Structural disorders and perfusion disorders
The sodium pump: Polarization
Steady State, “Chillin”, K+ inside the cell, Na+ outside the cell “Ready State”
The sodium pump: Deplorization
by an electrical impulse, sodium rushes into the cell, potassium rushes out, stimulates the contraction “Discharge State”
The sodium pump: Repolarization
Potassium goes back in and sodium comes back out “recovery state”
What do you need in order for the heart to function properly?
Good electrical system
Good blood flow system
Good muscular system
Inherent Rates of the heart
Sinus Node: 60-100 beats/min
AV junction: 40-60 beats/min
Ventricles: 20-40 beats/min
Pacemaker Rule
Pacemaker site with the fastest rate will generally control the heart. SA node should always trump the others paces because it should be fastest.
“Irritability”
A site along the conduction pathway becomes irritable and speeds up, thus overriding higher pacemaking sites for control of the heart. Magnesium is a critical electrolyte to have stable to prevent arrhythmias.
“Escape Mechanism”
The normal pacemaker slows down or fails, and a lower pacing site assumes pacemaking responsibility.
Rule of electrical flow
Electricity flowing toward positive electrode produces upright pattern. Negative to positive electrode - lead two.
Artifact
looks funny on the EKG strip. can be muscle tremors, patient movement, or lose electrodes on the patient’s chest, or it can be an electrical interference
Digoxin
Anti-arrhythmia, increases force of contraction, increasing output and slowing heart rate
Sudden Arrthythmic Death Syndrome (SADS)
Sudden death in healthy individuals, genetic (long QT syndrome, Marfans) vs. Acquired (Meds). If someone has exercise related fainting, its the best predictor. DxL Cardiac MRI Rx: Implantable defibrillators
Ventricular Tachycardia
Life Threatening
Pulseless or pulse
Pulseless patients need to be defibrillated
Sustained or unsustained
Stable or unstable
Unstable: SBP 120, Chest pain, Heart failure
Meds: Amiodarone, anti-arrythmics, vasopressors
Pulseless VT
DEFBRILLATE
Stable VT
Amiodarone, Procainamide, CV
Torsade de Pointe
Mg, BB, Amiodarone
Ventricular Fibrillation
Ventricle quivering, this is the worst possible heart rhythm, completely chaotic activity, never a pulse, clinically dead, need to be defibrillated
V Fib Treatment
Early Defib
Oxygen, CPR, Intubation, Epinephrine, Vasopressin
Prevent Re-Fib: Amiodarone, rocainmide, BB, Lidocaine
Adjust metabolic imbalances
Idioventricular Rhythm
Slow slow slow, dying heart, sinus tach to sinus to sinus brady, to junctional to idioventriculars
atropine is used to speed up a little.
Asystole
Not a healthy rhythm, harder to get out of than Vfib, Barely ANY electrical activity
Prophylactic Surgery
Preventative
Example of removing both breasts if they are at risk for breast cancer
Diagnostic Surgery
To see what kind of surgery to do
Example of Biopsies
Curative Surgery
Removing all cancerous cells, thyroid cancer example, can use this for a lot of solid tumors
Control Surgery
Clean out as much as we can, while preserving function, give chemo. Look again, take out more, reduce tumor mass so chemo will be more effective.
Palliative Surgery
Diverting around the tumor, keeping patient more comfortable, and not be so sick
“Second Look” Surgery
After chemo, go in and take another look, and clean out more
Reconstructive/Rehabilitative
Example of breast reconstruction after mastectomy
Communicating Cancer Diagnosis to the Patient
Nursing responsibilities: Be aware, be there, listen, ask questions for the patient, try to structure meeting time with physician (Family present, privacy)
Goals of Treatment
Cure, Control (Goal is to slow down the growth, and keep patient more comfortable), Palliation (Bony metastasis, reduce pain, and increasing strength of the bone)
Teletherapy
None invasive, position might be uncomfortable but no pokes or anything
Brachytherapy
source of radiation is implanted into the tumor or area around the tumor
Teletherapy part 2
External beam radiation, most common, go everyday, emitted from a source external to the body, linear accelerator, not radioactive, just like having an xray
Brachytherapy part 2
Emitted form a source placed within the body or body cavity, sealed source placed within or near tumor (Wires, ribbons, tubes, needles, seeds, capsules)
Sodium Iodide (I 131)
Hyperthyroidism (Cure) Thyroid carcinoma (Cure, control, and palliation)
Sodium Phosphate (P 32)
Myeloproliferative Disorders
- Polycythemia vera
- thrombocytosis
- Too many RBC
Strontium Chloride (Sr 89)
Painful bony metastasis (Palliation)
Starting cancer Therapy
Determining appropriateness, need tissue diagnosis, not all tumors are radiosensitive
Need to know position of the tumor in relation to other organs, don’t want to radiate the heart or other important organs.
