Exam 3 Flashcards
Where does the heart lie?
obliquely in the mediastinal space and sits behind sternum to the left of the chest
What are the housing units for blood?
Chambers
What chamber receives de-oxygenated blood from the body via the SVC and IVC?
RA
What chamber sends de-oxygenated blood to the lungs through the pulmonic artery?
RV
What chamber receives oxygenated blood from the lungs?
LA
What chamber sends oxygenated blood to the body through the aorta/aortic arch?
LV
What is the order of the valves?
Tricuspid –> Pulmonic –> Bicuspid –> Aortic
What artery does the blood go through to get to the lungs?
Pulmonic
What is the responsibility of the chordae tendonae?
Prevent the tricuspid and mitral valves from everting backward so blood doesn’t regurgitate
What is the responsibility of the septum?
Prevents de-oxygenated blood from mixing with oxygenated blood
What is the order of the membrane layers from inside out?
Endocardium –> Myocardium –> Epicardium –> Pericardium
What is the correct order of the vasculature?
Arteries –> Arterioles –> Capillaries –> Venules –> Veins
Name the membrane layer:
-For continuous closed system of endothelium (continuous lining with the arteries, veins, and capillaries of the body)
-First inner layer
Endocardium
Name the membrane layer:
-Thin fibrous outer layer of the heart
-Rests on top of the heart
Epicardium
Name the membrane layer:
-Double-walled membranous sac that encloses the heart
-Has pain receptors and mechanoreceptors that can feel pain
-Fluid-filled sac that the heart sits inside of
Pericardium
How much fluid is usually found in the pericardial sac?
10-30 mLs
What is the purpose of the pericardial sac?
prevent friction during every heart beat
What are the 3 types of pericardium?
1) Visceral
2) Parietal
3) Pericardial space
Which pericardium lays against the heart?
Visceral
What kind of muscle are the arterioles made out of?
smooth muscle
What kind of walls do the arteries have?
thick elastic walls
What kind of walls do the capillaries have?
thin walls
What kind of walls do the veins have?
large diameter, thin walls
What is the job of the arteries?
Carrying oxygenated blood (except pulmonary artery)
Where does the pulmonary artery go to?
Lung
What happens at the capillaries?
Exchange of cellular nutrients, waste, and end products
What are the jobs of the arterioles?
1) Become capillary beds where diffusion takes place
2) Help control arteriole BP & bloodflow
True or False:
Arterioles are sensitive to local changes to conditions in the body
True
What is the job of the venules?
Collect de-oxygenated blood from the capillaries to send to the veins to go back to the heart
What is the job of the veins?
Return blood back to the RA
True or False:
Veins contain valves to maintain bloodflow in the correct direction
True
What are the major arteries?
Aorta and pulmonary artery
What are the major veins?
SVC and IVC
What side of the heart does the pulmonary circulation go to
right and carries de-o2 blood to the lungs
What side of the heart does the systemic circulation go to
Left – to the body & projects o2 blood out into the system
Where does the pulmonary vein go to?
the LA
The heart’s ability to beat spontaneously and repetitively
Rhythmicity
What 2 systems are the heart controlled by?
Electricity and automaticity
Hearts ability to respond to stress or excitability
Irritability
During diastole where the heart can receive another signal and regain responsiveness
Relative refractory period
What is the absolute refractory period?
-Systolic contraction
-No response can be sent to ventricle during contraction
-Ventricle must relax before receiving another signal
What prevents the heart muscle from responding to a new stimulus while contracting
Refractoriness
Hearts ability to transmit electrical impulses
Conductivity
Ability of heart to spontaneously depolarize and repolarize
Automaticity
Ability of heart fiber muscles to contract (shorten)
Contractility
Ability of heart fiber muscles to stretch/relax
Extensibility
What is the initiation of an action potential?
Conduction
What is the pathway of electrical conduction of the heart?
1) Conduction
2) SA node
3) Internodal pathways
4) AV node
5) Bundle of HIS
6) Right & Left Bundle Branches
7) Purkinje fibers
What is the refractory period?
Resting period between charges or stimulus or contraction
What is depolarization also known as?
Contraction
What is the natural pacemaker of the heart?
SA node
What is the intrinsic rate of the SA node?
60-100 bpm
Where is the SA node located?
upper portion of RA
What is the gatekeeper of the heart?
AV node
What is the job of the AV node?
-Junction where chambers meet
-Slows down conduction of signal briefly before going through ventricles to give them time to fill to max capacity
What is the intrinsic rate of the AV node?
40-60 bpm
What is the intrinsic rate of the purkinje fibers?
20-40 bpm
What is sympathetic control?
“Fight or flight”
-Increases HR, BP, RR
What sx will you see with sympathetic control?
1) Increased VS
2) Hair standing up on skin
3) Pupils dilated
4) Perspiration
5) Decreased GI motility
6) Widened bronchioles
What regulates the SNS?
Adrenaline (epi and norepi)
What is parasympathetic control?
“Rest and digest”
-Slowing down of body systems
-Signals slow along current at AV node
What are the sx you see with PNS?
-SLUDD
-Pupils constrict back to normal size (mediated by CN 10 – vagus nerve)
What does SLUDD stand for?
-Salivation
-Lacrimation
-Urination
-Digestion
-Defaction
Where are baroreceptors located?
Carotid arch
What are baroreceptors?
Area of regulation for the heart
-Respond to changes in volume and pressure
What happens when there is less volume in the heart/less arterial pressure?
Baroreceptors will send signal to SNS & it will kick in to increase HR and RR to maintain CO
True or False:
Baroreceptors have a slower response time
False- chemoreceptors are slower
Where are chemoreceptors located?
Carotid arch
What do chemoreceptors respond to?
Changes in…
-Arterial oxygen
-CO2
-Plasma pH
What do chemoreceptors do?
-Need other systems to kick in to help mediate this
-Stimulates vasomotor center in brain to increase cardiac activity
What do ionotropes do?
Help make contractility better, more effective, and stronger
What is Starling’s Law?
The more you stretch the muscle fibers, the bigger the push will be when the heart contracts
What is stroke volume?
The amount of blood ejected from the LV with each beat
What is the average stroke volume?
50-100 mLs
What effects stroke volume?
1) Preload
2) Afterload
3) Contractility
The volume of blood in the ventricles at the end of diastole right before the next contraction
Preload
Resistance the LV must work against to pump the blood into the system
Afterload
What can increase resistance (afterload)?
-HTN
-Narrowing of the vessels
What is the force needed to effect preload and afterload called?
Contractility
(The force needed to overcome resistance against it and the force needed to push out the volume)
What is contractility influenced by?
-The quantity of blood returned to RA
-NS activation (epi & norepi)
-Vascular resistance
-Viscosity of blood
What is the formula for CO?
CO = SV x HR
The amount of blood pumped from each ventricle per minute
CO
What is the avg CO?
4-8L at rest
What adjusts CO to body size?
Cardiac index
The ability to respond to increased demand for CO
Cardiac reserve
What is the avg cardiac index?
2-4 L/min/meter
Percentage of end diastolic blood volume that is ejected during systole (lets us know LV function during pumping phase)
EF
What happens to the heart as it ages?
1) Increased collagen
2) Decreased ability to stretch or contract
3) Decreased stress response
4) Blunted HR response
5) Thick stiffened valves
6) Changes in conduction
7) Decreased receptors
8) Less vascular elasticity
9) Decreased baroreceptor function
What does OLD CARTS stand for?
-Onset
-Location
-Duration
-Character
-Aggravating factors
-Relieving factors
-Timing
-Severity
True or False:
Long term use of corticosteroids increases susceptibility to illness
True
What happens if you chronically use cold meds that contain low-doses of aspirin?
Low-dose aspirin will begin acting as blood thinner
True or false:
Mag citrate can cause HTN
False– it can cause electrolyte imbalances
What questions need to be asked when assessing cognitive-perceptual patterns?
1) Snore?
2) How many hrs of sleep?
3) # of pillows they sleep with (d/t SOB or reflux)
What does it mean if someone has chest pain when lying down?
Sign of acid reflux
What kind of BP needs to be done for someone with a mechanical valve or defibrillator?
Manual BP
What type of assessment do you always complete prior to any interventions?
Across the room assessment – gray, diaphoresis, SOB
What does a BP measure?
pressure exerted by blood against vessel walls
What are the different types of BP?
1) Manual
2) Invasive
3) Autonomic
4) Doppled
5) Orthostatic
True or false:
You only get diastolic when you dopple a BP
False – you only get systolic
What is an invasive BP?
-Arterial BP
-Transducer in the artery
***Risk for infection & only for really sick pts
What fraction of systolic BP is pulse pressure?
1/3
What happens to pulse pressure in athletes & those with arthosclerosis?
Increases
When is MAP typically evaluated?
With critical patients to see organ perfusion
What is the ideal MAP?
-At least 60
- 70-110 is best
How do you take orthostatic BP?
-Laying down, then sitting, then standing
- 2-5 mins in between each
How is orthostatic hypotension dx?
BP needs to increase by 20
What does APE TM stand for?
-Aorta
-Pulmonic
-Erbs Point
-Tricuspid
-Mitral
Where is S1 heard the loudest?
Apex
Where is S2 heard the loudest?
Base
What does the “lub” sound of the heart represent?
Atrioventricular valves closing
What does the “dub” heart sounds represent?
Semilunar valves closing
What does S3 heart sounds represent?
Ventricular overload
- seen in those < 40, pregnancy, CHF
What does S4 heart sounds represent?
Decreased LV compliance
-More likely to be pathologic (HTN, CAD, cardiomyopathy)
What are the RFs for heart disease?
1) Elevated lipid levels
2) HTN
3) Tobacco use
4) Sedentary lifestyle
5) Obesity
6) Stressful lifestyle
7) DM
8) Metabolic syndrome
What are the cues to CV problems?
1) Fatigue
2) Fluid retention
3) Irregular heartbeats/palpitations
4) Dyspnea
5) Pain
6) Calf tenderness
7) Syncope
8) Altered neuro
9) Leg pain
10) Chest pain
What is fatigue a sign of r/t Cv problems?
Sign of poor perfusion
True or False:
Compression socks can have counter-effects if grade is too strong or chronic use
True
What immediate intervention can be done if someone says that they feel their “heart caught in their throat”?
Drink water to flush out – sign of palpitation
If someone reports pain in their neck during a CV assessment, what important question should you ask?
If they have had dental work done recently
What are the cardiac lab biomarkers?
1) Troponin
2) Copeptin
3) Creatinine-Kinase (& CKMB)
4) C-reactive protein
5) Homocysteine
6) BNP
7) Lipids
When do you get troponin levels?
In acute coronary syndrome
-When someone comes in complaining of chest pain
True or false:
Troponin is the most accurate result because it is based on gender
False – high sensitivity troponin is the most accurate because it is based on gender
What lab test:
-Specific to muscles (kidneys and heart)
-Takes longer to peak
-Used for someone who has already had an MI
CKMB
What lab test:
-Inflammation marker not specific to heart
-Elevated levels means that somewhere in the body is inflammed
C-reactive protein
Name the lab:
-Elevated with protein breakdown
-Don’t run in pts with acute MI
-Can be done at annual appointments to check for predisposition if family hx present
Homocysteine
Name the lab:
-For CHF or pt that says they have extra fluid in them or suspicion of CHF
-Helps distinguish if dyspnea is caused by cardiac or respiratory problems
BNP
When dose creatinine-kinase show and peak?
Shows in 3-6 hrs, peaks in 12-24 hrs
What is a loop recorder?
-Metal in skin that monitors electrical heart activity
-Stores data, does not shock you
What does a 12-lead ECG do?
Takes pictures of the electrical activity in the heart
What does a cardiac CT show?
1) Anatomy
2) Coronary Circulation
3) Blood vessels
What does a chest x-ray show?
Any enlargement/bogginess
What diagnostic test determines your EF?
Echocardiogram
What are the diagnostic tests of CV disease?
1) ECG
2) Chest X-ray
3) Cardiac event monitor/loop recorder
4) Exercise stress test vs MUGA scan
5) Cardiac CT
6) Electrophysiology study
7) Cardiac Cath w/ coronary angiography
8) echocardiogram
What are interventional invasive studies for CV disease?
1) Cardiac Cath
2) Electrophysiology study
Name the interventional invasive study:
-Left-sided
-Arterial access
-Through aortic valve into LV
-Coronary angiography
Cardiac Cath
Name the interventional invasive study:
-Try to manipulate electrical activity
-Induces dysrhythmias
-Goal = determine the best tx
Electrophysiology study
What are the classes of cardiac meds?
1) Antiplatelets
2) Antianginals
3) Antihypertensives
4) anticoagulants
5) Anithrombolytics
6) Antidiuretics
7) Antiarrhythmics
8) Statins
What are the antiplatelet meds?
1) ASA
2) Plavix
3) Brilinta
What do antianginals do?
vasodilate
What are the antianginal meds?
1) Nitroglycerin
2) Ca+ channel blockers
3) Beta Blockers
What do antihypertensive meds do?
Decrease metabolic oxygen demand to decrease HR & BP
What are examples of antihypertensive medications?
1) Beta blockers
2) Ca+ channel blockers
3) ACE inhibitors
4) ARBs
What do anticoagulants do?
Thin the blood to get past the clot
What are examples of anticoags?
1) Warfarin
2) Heparin
What do antithrombolytics do?
“Clot busters”
-Breaks up clot
-Breaks up fibrinogen
-Increases risk of bleeding
What is an example of an antithrombolytic?
tPA –> tissue plasminogenic activator
What are examples of antiarrhythmics?
1) Digoxin
2) Adenosine
3) Ca+ channel blockers
What happens to HR and MAP if preload is decreased?
-Increased HR
-Decreased MAP
What are S&S of decreased preload?
1) Pallor
2) Altered mental status
3) Diaphoretic
How do you tx decreased preload?
-Fluids
-Reverse trendelenberg
What is normal preload value?
MAP > 60
What happens to EF and BNP in increased preload?
-Decreased EF
-Increase BNP
What are S&S of increased prelaod?
-HF
-Aortic/pulmonic stenosis
-Edema
-Crackles
-Dyspnea
-Fatigue
How do you tx increased preload?
-Diuretics
-Supplemental O2
What is the patho of CAD
Narrowing of a coronary artery d/t plaquing (atherosclerosis)
What does CAD lead to?
-Decreased perfusion
-HTN
-Angina***
-MI
What are the RFs of CAD?
1) Middle-aged white men
2) Men > 45, Women > 55
3) First degree relative
4) Fatty diet
5) HTN
6) Obesity
What are the diagnostic tests for CAD?
1) ECG
2) Lipids
How do you treat CAD?
1) Diet
2) Exercise
3) Lipid-lowering meds
4) Antiplatelets
What are the 3 stages of CAD?
1) Fatty streak
2) Fibrous plaques
3) Complicated lesion
How does CAD lead to ischemia?
1) Plaque gets under lumen & narrows it
2) Increases afterload
3) Causes shearing which tears the lumen open and cholesterol leaks into lumen
4) No oxygenated blood going into nearby organ
5) Ischemia results
What are the 2 factors of collateral circulation?
1) Hereditary
2) Ischemia
What happens in the body in the presence of slow, progressive, long-term ischemia?
-Body will try to build little vessels around the side to try to bypass occlusion and get O2 to organs
-Hereditary factor
What happens with anaerobic oxygenation?
-Seen in slow ischemia
-Lactic acid will build up
-Can cause angina
Define the following (ischemia v infarction):
-Reversible
-Increased O2 demand not being met
-Cells are viable under anaerobic respirations (about 20 mins)
-Can put in a stent to try and remove clot
Ischemia
Ischemia or Infarction:
-Irreversible
-Tissue death d/t lack of blood supply
Infarction
How long do people experiencing infarcts have before the area around the clot becomes necrotic and causes tissue death?
4-6 hrs
True or False:
Men at greater risk of developing CVD and women at greater risk of MI
False – Men > risk for MI, women > risk for CVD
What are modifiable RFs for MI?
-Metabolic syndromes
-Homocysteine
What are risky total cholesterol levels?
> 200 mg/dL
What are risky triglyceride levels?
> 150 mg/dL
What are risky LDL levels?
> 130 mg/dL
What are risky HDL levels?
< 40-50 mg/dL
What kind of dietary changes need to be made in instances of MI?
-Decrease fat and cholesterol intake
-Increase whole grains
-Increase fruits
-Increase veggies
-Increase fiber
Niacin is good to manage cholesterol, but what does it increase the risk of developing?
Rhabdomyelosis
True or false:
Angina is a sx, not a dx
True
What is angina a manifestation of?
Ischemia
What diagnostic tests are done for angina?
1) EKG –> rules out MI
2) Labs –> troponin or CKMB
3) Chest x-ray
What are the 2 types of angina?
-Chronic stable
-Unstable
What are the 2 types of chronic stable angina?
1) Prinzmetal’s
2) Microvascular
How do you treat angina?
1) ONAM
2) IR/Surgical
3) Cath lab/PCI
4) CABG
What is the “A” of ABCDEF of angina tx?
-Antiplatelet/anticoags (aspirin)
-Antianginals (nitro)
-ACE inhibitors (lisinopril)
What is the “B” of ABCDEF of angina tx?
1) Beta blockers (metoprolol)
2) BP control (hydrochlorothiazide)
What is the “C” of ABCDEF of angina tx?
-Cardiac rehab
-Ca+ channel blockers (cardizem)
- Cholesterol management (atorvastatin)
What is the “D” of ABCDEF of angina tx?
-Diet
-DM managment (metformin)
-Depression screening
What is the “E” of ABCDEF of angina tx?
-Education
-Exercise
What is the “F” of ABCDEF of angina tx?
-Flu/COVID vax
-Pneumonia vax
How long is ischemia reversible for?
20 min
What pts do we see “silent angina” in?
Diabetic neuropathy (d/t decreased sensation)
What are the atypical S&S women experience with angina?
1) Mid epigastric pain that feels like GERD
2) Dyspnea
3) Nausea
4) Fatigue
Why does angina/ischemia occur?
body senses increased O2 demand, but body can’t meet this
Name the type of angina:
-Intermittent over a long period of time
-Repeated onset, duration & intensity of pain
-Often r/t exertion or stress
-Sx aren’t always chest pain, may feel chest pressure/heaviness that radiates
-Could also have indigestion
-No ST elevation
-May see ST depression and/or t-wave inversion
Chronic
Name the type of angina:
-Occurs at rest
-Alcoholics, chronic smokers, Raynaud’s
-Chest pain that occurs d/t coronary spasms
Prinzmetal’s
Name the type of angina:
-Small distal branches of coronary arteries
-More common in women
-Provoked by exercise
Microvascular
Unstable angina, Non-STEMI or STEMI:
-New onset chest pain
-ST elevation or T-wave inversion
Unstable angina
Unstable angina, Non-STEMI or STEMI:
-Partial blockage (still time to intervene)
-May or may not have EKG changes
Non-STEMI
Unstable angina, Non-STEMI or STEMI:
-Complete occlusion
-ST elevation on EKG
-Cath Lab ASAP
STEMI
What is the nurse’s responsibility pre-op for a balloon angioplasty (cardiac cath)
Assess for dye allergy
What does a cardiac cath assess for?
Coronary artery patency
What education needs are necessary for pts getting cardiac cath?
-DAPT (for 12 months, aspirin for life)
-Bedrest for 2-4 hrs post-op
What is the patho of acute coronary syndrome?
MI, prolonged ischemia not immediately reversible (> 20 min) d/t partial or complete arterial blockage (> 70-80%)
What are the classes of ACS?
1) Unstable angina
2) NSTEMI
3) STEMI
What is tx for ACS?
-NAM (specifically nitro)
True or False:
Nitro is given to pts with lateral MI
False- pts with lateral MI are already hypotensive and cannot receive nitroglycerin because their BP will bottom out
What is the patho of an MI?
1) Thrombus formation
2) Blockage of blood flow
3) Infarction beyond occlusion
4) Necrosis
If an MI occurs at the inferior wall, what vessel is involved and what area of the heart is affected?
Right coronary artery
LV
If an MI occurs at the anterior wall, what vessel is involved and what area of the heart is affected?
Left descending artery
LV
If an MI occurs at the lateral wall, what vessel is involved?
Left circumflex artery
What areas do the inferior wall (right coronary artery) perfuse?
-RA
-RV
-LV
-SA node
-AV node
What areas do the anterior wall (Left descending artery) perfuse?
-LA
-LV
-RV
-Septum
-Bundle Branches
What areas doses the lateral wall (left circumflex artery) perfuse?
-LA
-LV
-Septum
What is the presentation of MI?
Chest pain:
-Unrelieved by rest, position, or nitrates
-Crushing, heavy, pressure, tight, burning, constriction
-Duration > 20 min
-SOB
-Anxiety d/t “air hunger
-Radiating pain to either arm, back, neck, or jaw
-Anxiety
-Dysrhythmias
-SNS stim
What is the tx for an MI?
1) ONAM
2) Thrombolytics, PCI
3) Fibrinolytic therapy
4) DAPT
What is the process of cardiac deterioration?
1) Myocardial ischemia
2) Decreased O2 supply
3) Cellular hypoxia (d/t lactic acid build up)
4) Altered cell membrane integrity (d/t increased troponin)
5) Decreased contractility, CO, & arterial pressure
6) Baroreceptors stimulated
7) SNS response
8) Increased contractility & peripheral vasconstriction
9) Increased afterload and HR
10) Decreased diastolic filling & coronary perfusion
11) Increased myocardial O2 demand
What kind of IVs need to be placed in someone w/ an MI?
- 2 large bore 18G IVs in AC
What are complications of an MI?
1) Dysrhythmias
2) HF
3) Cardiogenic shock
4) Papillary muscle dysfunction
5) Ventricular wall aneurysm
6) Ventricular septal wall rupture
7) Pericarditis
8) Dressler’s Syndrome
What is the most common dysrhythmia resulting from an MI?
A-fib
What are S&S of HF post-MI?
-Edema/wt gain
-SOB
-Racing HR
-Restlessness/agitation
What is cardiogenic shock?
The body can’t get enough oxygen or nutrients, and can’t sent them to tissues so the organs fail
**Can be lethal
What does papillary muscle dysfunction cause?
Mitral valve regurgitation & puts extra stress on LV = decreased CO
What is a major concern with ventricular wall aneurysm?
Infarcted ventricular wall bulges out
-If thrombosis present, clot can break off and cause stroke on next contraction
How long after a MI does pericarditis occur?
2-3 days
When is pericarditis felt/what education needs to be provided to pt?
-Common
-May feel chest pain, but not MI
-Chest pain is felt with deep breaths & feels differently than MI
What is Dressler’s Syndrome?
Pericarditis w/ pleural effusion and fever
What will a pt w/ Dressler’s Syndrome c/o?
Chest and joint pain
True or False:
Dressler’s Syndrome is the most common cause of death post-MI because people think they have the common cold
True
How long after an MI does Dressler’s Syndrome usually occur?
1-3 weeks
What is the daily tx for a pt post-MI?
1) Nitrates
2) Morphine
3) Beta blockers
4) ACE inhibitors
5) ARBs
What do nitrates do to help post-MI?
Dilators – decreased pre and afterload
What do beta blockers do to help post-MI?
decrease O2 demand by decreasing HR and BP
What do ARBs do to help post-MI?
reduce LV dysfunction & slows progress of HF
What classes of medications will a post-MI pt go home on?
1) Ca+ channel blockers
2) Anti-dysrhythmics
3) Lipid-lowering agents
4) Stool softeners
5) ASA/antiplatelets
What is the etiology (cause) of sudden cardiac death syndrome?
1) Acute ventricular dysrhythmia
2) LV dysfunction
3) Structural heart disease
What are S&S of sudden cardiac death?
1) Dizziness/lightheadedness
2) Chest racing
*** Reported by family
What is the initial care for sudden cardiac death?
CPR
What is the post-care of sudden cardiac death syndrome?
1) Hypothermia protocol
2) Dx cause
3) ICP (implanted cardioverted defibrillator)
What are hypothermia protocols?
Ice under axilla or groin, cooling fluids
Why do we do hypothermia protocols in pts with sudden cardiac death?
1) Prevent cerebral edema
2) Preserve neuro function
When is coronary revascularization done?
Surgical intervention for CAD
1) When PCI can’t be done
2) Failed PCI
3) Failed med managment
4) Left main coronary artery disease
5) Tricuspid valve disease
What is the most common vessel used in CABG and why?
Internal Mamillary Artery – best patency
What vessels can be used in CABG?
1) IMA
2) Saphenous veins
3) Radial artery
4) Gastroepiploic
What problem can be seen with the use of saphenous veins in a CABG?
Hyperplastic cells – cells lose patency
** pts take statins and antiplatelets to maintain patency
Why is the radial artery not ideal to use in a CABG?
Prone to spasming & causes chest pain
-In effected arm, pt will experience paresthesia, impaired sensation, and changes of pulse strength
Which vessel still has good patency even after 10 years of use in a CABG?
Gastroepiploic
What does the pt need to be on doing into surgery?
Heparin d/t increased risk for clots
What is a cardiopulmonary bypass graft (CPB)?
Pt’s blood is diverted from the heart to a machine that:
1) Oxygenates blood
2) Returns blood to patient
3) Pumps blood through circulatory system
What can the use of a CPB result in?
1) Cooling of pts blood (hypothermia)
2) Systemic inflammation
3) Damage to RBCs and platelets
4) F/e imbalances (d/t amt of K+ received)
What medication does a pt receive post-op of a CPB?
Protamine sulfate (to reverse anticoag)
What are the respiratory post-op concerns of a CPB?
Atelectasis and pulmonary infection (pnemonia)
What amount of chest tube drainage is concerning?
> 100 mL/hr
What is the biggest post-op complication of cardiopulmonary bypass?
Cardiac tamponade (collection of fluid sitting on top of heart d/t surgery)
What CV complications may occur after CPB?
-Narrowed pulse pressure
-JVD
-Increased HR
-Muffled heart tones
Why is it important to closely monitor UO post-op of CPB?
Helps determine CO & if kidneys were adequately perfused in intraop
Will pts have a NG tube post-op of CPB?
Yes
What is the purpose of a chest tube?
1) Remove air or fluid from pleural space
2) Pneumothorax
3) Pleural effusion
What is the tx goal of a chest tube?
Re-establish negative pressure within the pleural space
What large amts of drainage post op of CPB is concerning?
> 1500 mL
What are breath sounds like prior to a chest tube?
Diminshed/absent
What kind of dressing needs to be placed when chest tube is removed?
Vaseline gauze & dry dressing
What is the patho of HF?
Inability of heart to meet the body’s O2 demands
-Insufficient CO d/t cardiac injury
-Decreased perfusion, impaired gas exchange, f/e imbalances, decreased functional ability
How do you dx HF?
1) BNP
2) CXR
3) ECHO
4) EKG
What will BNP show in a pt w/ HF?
Fluid
What will CXR show in a pt w/ HF?
Big, boggy heart
What will an echo show in a pt w/ HF?
EF < 50%
What will an EKG show in a pt w/ HF?
No STEMI
What diseases is HF associated with?
CAD, HTN, MI
What are the stages of HF?
1) Compensated
2) Acute decompensated (exacerbation)
What are the types of HF?
1) Left side (preserved EF or Reduced EF)
2) Right sided
3) Biventricular
What do primary contributing factors of HR do?
Interfere with pumping, the bloodflow through the heart, or w/ filling
What are examples of primary contributing factors of HF?
-Valvular disorders
-Cardiomyopathy
-Myocarditis
-CAD
-Pulmonary HTN
What do precipitating factors of HF do?
Increase metabolic O2 demand/workload of the heart
What are examples of precipitating factors of HF?
1) Anemia
2) Metabolic syndromes
3) Smoking
4) Sleep apnea
5) PEs
5) Fluid overload
7) Dysrhythmias
8) Toxins (drugs, alcohol, chemo)
What is the most common cause of right-sided HF?
Left-sided HF
What is L sided HF?
Inability to empty/fill adequately & altered EF
What is R sided HF?
Inability to pump effectively
What is Biventricular HF?
Inability of both ventricles to pump efficiently
What is the EF of preserved EFHF?
41-49%
What pts do we see preserved EFHF in?
-Managed HTN
-Managed DM w/ cardiac hx
-Obese
-Females
What is the EF of pts w/ reduced EFHF?
< 40%
What is the patho of PEFHF?
Inability of ventricles to relax and fill –> decreased CO
What is the patho of REFHF?
Impaired contractile function (cannot eject blood), dilated LV (blood backs up into pulmonary circulation)
What are the sx of reduced EFHF?
Pulmonary edema & congestion
What is the typical cause of reduced EFHF?
Previous heart attack
What are the S&S of LSHF?
1) Decreased BP & CO
2) Decreased renal perfusion
3) Dyspnea
4) Exercise intolerance
5) Weakness and fatigue
6) Dysrhythmias
7) Nocturia
8) Orthopnea (esp when lying down)
9) Tachycardia
What are the S&S of Right sided HF?
1) Fatigue
2) Anxiety & depression
3) RUQ pain
4) Anorexia/GI bleeding
5) Nausea
6) Wt gain/edema – most common
What BNP level is diagnostic of HF?
< 100 pg/mL
What are the classifications of CHF?
Systolic and diastolic
What are CMs of CHF?
1) Blood in phlegm or sneezing
2) Dysrhythmias (a-fib, ventricular)
3) Nocturia
4) Cardiorenal syndrome
5) Pleural effusion
6) Hepatomegaly
7) Angina
What does the WBC, RBC, H&H look like in a pt with CHF?
-Normal WBC
-Decreased RBC & H&H
What does CMP look like it pt with CHF?
-Altered K+, Na+, Cl-, liver labs
-Decreased GFR
What is the first line tx for CHF?
ACE inhibitors
What is the worst side effect of ACEs in CHF?
Angioedema
What is the drug therapy for CHF?
1) ACEs
2) ARBs
3) NARI
4) Beta blockers
5) Diuretics (alter volume/preload)
**all of these decrease afterload
What are the body’s compensatory mechanisms for CHF?
-SNS
-RAAS
-Ventricular remodeling (dilation/hypertrophy)
***For dilation, remember Starling’s Law
What does ventricular hypertrophy effect?
Preload
What are counter-regulatory mechanisms for CHF?
1) ANP/BNP
2) Counter-effects of SNS & RAAS (vasodilation, diuresis, Na+ excretion, decreased BP & blood volume)
4) Nitric oxide
What does nitric oxide do?
helps relax smooth muscles to help with vasodilation
What is it called when there is less compliance in the lungs r/t interstitial edema and alveolar edema?
Acute decompensated HF
What is it called when fluid moves into the alveoli & inhibits gas exchange in the alveolar/capillary interface?
Pulmonary edema
What are the CMs of ADHF?
1) anxiety
2) severe dyspnea & tachypnea
3) cough
4) JVD
5) clammy/pale skin
6) Orthopnea
7) hypoTN
8) decreased UOP
How does oxygen need to be given in ADHF?
Via facemask
What bed position does someone with ADHF need to be in?
High fowlers
What is the drug therapy for ADHF?
1) Diuretics
2) Vasodilators
3) Morphine
4) Positive ionotropes
