Med Surg 2- Cardiac Exam Flashcards
Preload
Stretch just before systole
Afterload
blood ejected from ventricle
S1
mitral/tricuspid closing
S2
aortic/pulmonic closing
Cardiac cath performed for R side
PE, vagal response
Cardiac cath performed for L side
MI, stroke, bleeding
Cardiac cath perform for L and R side
edema, cardiac tamponade, hematoma
Cardiac cath post-op
bed rest, watch insertion site, VS, bleeding, pulses (pedal)
Troponin
protein released when heart is damaged
0-0.04
increased means that there is damaged muscle
BNP
released by ventricles in response to fluid overload
Over 900 is severe!
HF RF
CAD, HTN, smoking, obesity, sleep apnea
HF Compensatory mechanisms
Sympathetic NS, RAS activation, BNP increased, myocardial hypertrophy
HF labs
hypovolemia, check K, increased BNP, urinalysis (protein in urine), ABG’s (hypoxemia)
HF DX
Echo- shows blood flow, how the heart is doing
CXR- fluids
L sided HF
used to be called congestive HF, affects the lungs!
L sided HF causes
HTN, CAD, valvular disease
not all types have fluid accumulation
L sided HF S/S
dyspnea, fatigue, weakness, arm heaviness, CP, palpitations, cough worsened at night, tachypnea, cyanosis, pulmonary congestion
L sided HF severities
Severe L HF leads to pulmonary edema (crackles, dyspnea at rest, confusion)
Pink, frothy sputum is a life-threatening emergency!
R sided HF
R ventricle can’t empty completely
R sided HF causes
L ventricular failure, R ventricle MI, pulmonary HTN
R sided HF s/s
Peripheral edema, increased abd girth/ascites, dependent edema, hepatomegaly, JVD, weight gain
R sided HF interventions
Take a daily weight in the morning
O2, Is, TCDB, sit pt up with pillows underneath arms, reposition frequently, never massage pt’s legs
ACE and ARBS
Lisinopril, Valsartan
Lowers BP
major s/s to stop is swollen lips, can cause coughing
Get pt up slowly due to hypotension, avoid pregnancy
Beta Blockers
Lowers HR and BP
Start slowly for HF and don’t stop abruptly
Calcium CB
Nifedipine, Cardizem
Lowers HR and BP
Digoxin
Lowers HR
Therapeutic levels -.5-2.0
Hypokalemia leads to toxicity
s/s- blurred vision, mental changes, fatigue, anorexia
Dilators- Nitroglycerin
Lowers BP
Common s/s is headache, low NP
NO Viagra
Diuretics
Lasix, Spironolactone
Lowers BP
Spironolactone SPARES K, furosemide WASTES K
HF education
Diet- low sodium, 2L fluid/day
Risk for falls, change positions slowly
BP and BNP should not increase
Elevate legs with pillows
Daily Weights in morning
Sex only if 2 flights of stairs no SOB
Stockings daily
No canned/packaged foods or OTC
Acute pulmonary edema
LV fails to eject sufficient blood, increased pressure in lungs
fluid leaks across pulmonary capillaries (lungs airway)
Acute pulmonary edema s/s
crackles, dyspnea, SOB, tachycardia, cough with frothy, blood-tinged sputum, confused, cyanotic, agitating, increased RR, lethargic
Acute pulmonary edema interventions
High Folwer’s with feet dangling, hemodynamic monitoring, IVF’s, foley
Acute pulmonary edema meds
morphine sulfate
sublingual nitro q5min, max 3 doses
furosemide/ bumetanide IV push over 1-2 min
VS q30min-1hr
Cardiomyopathy
chronic disease of heart
Dilated, hypertrophic, restrictive
Cardiomyopathy s/s
orthopnea, crackles, edema, dyspnea on exertion, nocturnal dyspnea, a-fib in som
Cardiomyopathy interventions
palliative care, possible heart transplant, digoxin, diuretics, vasodilators, ACE
Cardiac Tamponade
fluid accumulation in pericardium that puts pressure on heart, sudden decrease in cardiac output
Medical emergency!
Cardiac Tamponade s/s
JVD, paradoxical pulse, tachycardia, muffled heart sounds, hypotensions
Pericardiocentesis
removes fluids and relieves pressure on the heart
Mitral Stenosis
narrowing of valve L-side
rheumatic fever!
Mitral Stenosis s/s
orthopnea, dyspnea on exertion, dry cough, palpitations, paroxsymal nocturnal dyspnea
Mitral Regurgitation
opening/valve that doesn’t flow, blood goes back into atrium
Mitral Regurgitation causes
mitral valve prolapse, rheumatic heart disease, MI, endocarditis
Mitral Regurgitation s/s
fatigue, extra heart sound, chronic weakness, anxiety, A-fib, RR changes
Mitral valve prolapse
valve leaflets enlarge and prolapse into L atrium during systole
confirmed by echo
Mitral valve prolapse s/s
Most people asymptomatic
CP, palpitations, exercise intolerance, late systolic murmur at apex
Aortic stenosis
narrowing of aortic valve, disrupts flow from L ventrilce
disease of “wear and tear”
can develop R sided HF
Aortic regurgitation
backflow into L ventricle, results from rheumatic conditions
Aortic regurgitation s/s
Can be asymptomatic for years
dyspnea, angina, tachycardia, palpitations, fatigue, syncope on exertion, orthopnea, murmur
Aortic regurgitation DX
CXR, echo, ECG
Aortic regurgitation meds
Prophylactic antibiotic, diuretics, beta blockers, digoxin, O2
Aortic regurgitation management
Nonsurgical- drug therapy, rest, anticoagulant
Surgical- heart valve replacement, autograft
Endocarditis
Inflammation INSIDE the heart
Endocarditis causes
Dirty needles, dental visits, heart surgery, untreated strep throat
Endocarditis s/s
Clos in heart/brain, development HF, splinter hemorrhages (clots under fingernails)
Lungs have fluid (crackles)
Overheated (fever)
Too little O2/cardiac output, clubbing fingers
Roth spots (in retina), Osler’s nodes (palms/soles), Janeway lesions (nontender red spots)
Endocarditis treatment
Antibiotics (PICC)- penicillin, cephalosporins
Valve repair/replacement/drain
Chordae tendineae
Endocarditis education
Monitor for infection- temp for 6 wks
Oral care
Let all providers know (dentist)
Dentist- antibiotics
Endocarditis DX
Blood cultures, echo, TEE, new murmur,
Pericarditis
inflammation OUTSIDE the heart
Pericarditis causes
Acute exacerbations
Heart attack
Autoimmune disorders
Infection
Renal failure
Pericarditis s/s
oppressive pain aggravated by breathing (inspiration), coughing, or swallowing, pain in L side of neck/shoulder worse lying down or inhaling
Acute: increased WBC, ST elevation, A-fib
Chronis- s/s of R sided HF
Pericarditis treatment
treat cause!
NSAIDs, steroids if no relief in 48-72hrs
Sit up/forward
Pericardiocentesis
HTN
chronic high BP, usually 140/90
Malignant/HTN crisis- emergency!
HTN causes
Stress, smoking, sedentary lifestyle
Obesity, oral BC
Diet, disease
African men and age
HTN s/s
Achy had/ abd bruit
Blurred vision
Chest pain
Dizziness
HTN crisis- morning headaches, uremia, blurred vision, dyspnea
semi-fowler’s, BP q5-10min, EKG, IV meds, O2
HTN DX
Echo, ECG, EKG, urinalysis- protein, RBC, BUN, creatinine, increased BNP and cholesterol
HTN education
Diet- low sodium/calories/cholesterol
Reduce alc and caffiene
Exercise- walking 30min/day
Stop smoking/alc
Stress reduction
HTN meds
HTN crisis- labetalol, calcium channel blockers, dilators, ICU
anticoagulants, lovastatin (no grapefruit)
Arteriosclerosis
thickening/hardening of arterial wall associated with aging
Atherosclerosis
type of arteriosclerosis with plaque formation within arterial wall, leading RF of cardiovascular disease
Arteriosclerosis monitoring s/s
monitor BP in both arms, palpate major sites of body, extremity temp, long cap. refill, bruit, cholesterol
Arteriosclerosis meds
statins, ezetimibe (lower cholesterol), combo drugs, PCSK9 inhibitors
PAD
alters natural flow of blood through arteries/veins, plaque unstable more lower extremities
PAD s/s
Stage 1- bruit/aneurysms, pedal pulses absent
Stage 2- claudication: muscle pain, cramping/burning during exercise relieved by rest
Stage 3- pain resting at night, pain relieved putting extremity in dependent position
Stage 4- ulcers/blackened tissue on toes
PAD DX
Labs- lipids, HDL/LDL
MRA- best assess blood flow
ABI, Doppler, stress test
PAD interventions
gradually/slowly increase exercise, warmth/heat (NOT DIRECT), prevent long cold exposure, no smoking/alc/tight clothes
PAD management
HANG FEET DOWN
Non-surgical- axillofemoral bypass
Surgical- Angioplasty with stents
Post-op- warmthness/redness/edema expected, pain 1st sign of occlusion
Nurse check pulses before transfer to another floor!
PAD meds
anticoagulants, antiplatelets
reduce MI/stroke, vascular death
Acute Arterial Insufficiency
embolus most common cause
Thrombectomy or Embolectomy
Acute Arterial Insufficiency s/s
6 P’s
Acute Arterial Insufficiency drugs
TPA (clot bluster), 1:1, watch adverse signs
Acute Arterial Insufficiency management
monitor for compartment syndrome –> fasciotomy
Varicose Veins
distended, protruding veins that appear darkened and tortuous, can be caused by vein wall weaking/dilating
Varicose Veins treatment
compression socks, exercise, elevation, surgical removal of veins
Abd Aortic Aneurysm s/s
asymptomatic; pain steading gnawing may last for days or hours in abd/flank/back, abd mass pulsatile
Abd Aortic Aneurysm management
monitor growth of aneurysm, maintain normal BP to reduce risk of rupture, frequent US/CT to monitor size
Resection of aneurysm- high mortality risk!
Abd Aortic Aneurysm post-op
VS, don’t raise bed higher than 45 to decrease pressure, watch occlusion/rupture, renal failure b/c they clamp off kidneys during surgery
Thoracic Aortic Aneurysm s/s
back pain, SOB b/c aorta can’t pump blood, hoarseness/difficulty swallowing, sudden excruciating back/chest pain = rupture!
Thoracic Aortic Aneurysm interventions
managing rupture (hypovolemic shock, give fluids), BP/HR
Thoracic Aortic Aneurysm repair
watch VS, complications, cardiac dysrhythmia, resp. distress
Aortic Dissection
EMERGENCY- sudden tear in aortic intimia, opening way for blood to enter aortic wall
Pain-tearing/ripping/stabbing
IV fluids, beta blockers, eliminate pain, going to surgery
Normal Sinus rhythm
60-100
Continue to monitor, document
Supraventricular tachycardia
100-280
Sustained- CP, palpitations, SOB, anxiety, syncope
Nonsustained- asymptomatic, occasional palpitations
Treatment- adenosine (N/V, bradycardia, pauses), follow with NS bolus
Sinus Bradycardia
Less than 60
Causes- meds, hypoglycemia, blockage causing MI
S/S- cyanotic, cool, clammy, SOB, dizziness, CP, confusion
Interventions- O2, fluids, atropine, possible pacemaker, IVF
Sinus Tachycardia
Greater than 100
Causes- caffeine, stress, anxiety, meds, pain, electrolyte imbalance
S/S- chest pressure/pain, SOB, dizziness leading to syncope, dehydration
Interventions- O2, treat underlying
A-Fib
Atria quivering, increased risk stroke/clots
RF- HTN, TIA
Causes- congestive HF, mitral valve, rheumatic heart disease, CAD
S/S- palpitations, anxiety, CP, dizzy, SOB
Interventions- cartizem (prevent CP), anticoag, cardioversion
Ventricular Tachycardia
140-180, fatal 3-5 min, spikt tombtone EKG
Pulse- O2, assessments, EKG, cardioversion, amiodarone
Pulseless- CPR, shock, epinephrine, lidocaine IV (treats arrythmia)
Ventricular Fibrillation
Tombstone EKG, fatal 3-5 min
Causes- MI< trauma, overdose, electrolyte imbalance
S/S- pulseless, not awake
Interventions- CPR, epinephrine, defibrillation
Asystole
flatline
Interventions- check pt 1st, CPR, epinephrine
DVT
clot in a deep vein
DVT s/s
Calf pain/cramping
One sided swelling
Wwarm and red, localized edema
SOB and chest pain -call doctor
DVT treatment
Don’t walk, elevate
Surgery- thrombectomy, IVC fiter
DVT education
Calf exercises
Hydration
Ambulate
No long sitting
Ted hose/SCDs
DVT meds
Heparin- PTT 20-40sec
Antidote protamine sulfate
Complications- bleeding, walk with assistance
Lovenox
Coumadin- INR 0.8-1.1
Antidote Vitamin K
No leafy greens b/c of vit. K
DVT DX
US, doppler, elevated D-Dimer
Buerger’s Disease
caused by smoking!
recurring inflammation of intermediate and small arteries/veins of extremities
results in thrombus/ vessel occlusion
Buerger’s Disease s/s
Black fingers/toes, claudication in feet and lower extremities worse at night, decreased pulses, cool/cyanotic in dependent positons, gangrene
Buerger’s Disease education
Avoid cold, stop smoking, drugs for vasodilation
Chronic Venous Insufficiency
result of prolonged venous HTN that stretches veins and damages valves
can lead to leg edema, ulcers, dermatitis
Chronic Venous Insufficiency treatment
elevate legs 4-5times/day q20 min, wear compression socks, don’t cross legs sitting or standing
CAD
included chronic stable angina, acute coronary syndromes
Development
Fatty Streak- can happen at age 15
Raised Fibrous Plaque- can happen at age 30
Complicated Lesion stage
Ischemia
insufficient O2 is supplied to meet requirements of myocardium
Infarction
Necrosis or cell death that occurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage to tissue
Angina s/s
substernal chest pain, radiates to Larm (Rarm in women), relieved by NTG or res, lasting less than 15 minutes
Stable angina
chronic stable angina, classic angina
Paroxysmal, occurs with physical exertion
Relieved by rest or nitroglycerin
Stable angina
preinfarction(cell death) angina or new onset
More prolonged and severe
Needs to be treated immediately
Chest pain when resting
Variant angina
Prinzmetal’s angina, vasospastic angina
Occurs at rest
Result of spasm
MI s/s
substernal chest pain/pressure, radiates to L-arm, pain or discomfort in jaw, back, shoulder or abd, longer than 30 minutes, N/V, clutching of sternal/substernal chest, SNS stimulation, elevated temp, JVD, crackles, women gastro pain
MI lab
troponin, chest x ray, echo, EKG, stress test
MI goals
decrease pain, decrease myocardial oxygen demand, and increase perfusion (Myocardial oxygen supply)
MI interventions
pg. 757, Morphine, Oxygen, Nitroglycerin(3 times q5 min, no Viagra), Aspirin 325 mg chewable tablets as first med given (take 3 if at home and having)
NSTEMI
non ST elevated heart attack
Can have ischemia
Slightly elevated troponin
STEMI
ST elevated MI, emergency!
Rupture of fibrous atherosclerotic plaque leading to platelet aggregation and thrombus formation at the site of rupture
Thrombus causes an abrupt 100% occlusion to coronary artery- emergency!
Heart catheterization
MI RF
AA/Hispanic, sex, hyperlipidemia, smoking, stress, HTN, physical inactivity, metabolic syndrome, obesity- women waist greater than 35 inches, men greater than 40 inches, DM
PTCA/Stent
Reopen the clotted coronary artery and restore perfusion
Goal-> performed within 90 min of acute STEMI
Post op- bleeding, cardiac monitor
Complications- acute closure of artery, bleeding- apply pressure and call RR, pain, ST elevation, hypotensions, dysrhythmia
CABG
pg. 769 open heart surgery!
Occluded coronary arteries are bypassed with the pt own venous or arterial blood vessels or synthetic grafts
Indicated when pt does not respond well to medical management of CAD
CABG pre-op
shower with chlorhexidine, antibiotics q1hr before surgery, BG less than 200, VS/labs, EKG, consent, echo
CABG post-op
intubated in ICU afterwards, ventilator 3-6 hours, mediastinal tubes, pleural chest tubes, pacer wires (decrease arrhythmias), cardiac tamponade huge compilation (HTN, JVD, muffled heart sounds), pain control
CABG complications
arrhythmia. F&E imbalance, bleeding, hypotension/ hypertension, hypothermia, confused, (check LOC 30-60 min until awake then q2-4 hours), respiratory problems
Cardiac rehab
Phase 1- diagnosis during admission, activity tolerance, education
Phase 2- after discharge 4-6wks, education/support/diet/exercise
Phase 3- maintain cardio stability and long-term conditioning
CABG discharge
prevent further risks, anxiety, meds (nitro, beta blockers, ASA, ACE), exercise/cardiac rehab, no sex 4-6wks, NSAIDS increase chance of MI/stroke, activity should be tapered (intermidite claudication), diet, RF
Cardiogenic shock pg. 733 chart, 765 drug alert/critical rescue
heart muscle isn’t healthy, can’t get perfusion b/c heart can’t pump as well (impaired)
Necrosis of more than 40% of Lventricle
Cardiogenic shock s/s
Tachycardia, hypotension, BP <90 or 30 less than pt baseline, urine output less than 30mL/hr, cool, clammy, SOB, hyperventilation, decreased pulses, confusion, restless/agitated, pressure/chest pain, pulmonary congestion
Cardiogenic shock interventions
elevate legs to get blood back at heart, ABC’s, fluid replacement- use PA catheter for PAWP, Vasopressor- constrict to pump blood (Dopamine, Dobutrex), HCO3 if ph <7.3 (buffers the acid), treat arrhythmias quickly, diuretics PRN, balloon pump to help the aorta do its job
Digoxin
decreases heart rate by increases myocardial contractility
Given for heart failure, A-FIb
RF dig toxicity- hypokalemia, advanced age, imparired renal function
s/s- N/V, diarrhea, anorexia, syncope, bradycardic, diaphoresis, hypotension, mental status changes, blurred vision, diplopia
Monitor potassium
Normal digoxin level 0.5-2
Nitrates
Vasodilation dilation, decreases blood pressure
Mechanism of action- vasodilation, reduces preload and afterload, decreases myocardial oxygen demand
Give for CP, MI, angina
S/s- Orthostatic hypotension, dizziness, headache
Routes
PO- regular management
Sublingual- needs to be dissolved (Can take 3 times q5 min)
Transdermal- clean/hairless skin, take off when defibrillating, take off patch after 12-14 hours, rotate sites
IV- Slow infusion then titrate until pain is gone, check B/P every 3-5 minutes
Do not give to people on Viagra
Take on first onset of chest discomfort
Call 911 if no relief after 3 doses
Pg 775
Beta-Blockers
block epinephrine and norepinephrine
Assess HR and BP before giving
Decreases stress on heart
First choice for treatment for stable angina
Drug interactions
Nitrates, anti-diabetics, antacids, antidysrhythmics, calcium channel blockers, anti-hypertensives
Calcium channel blockers
allows heart to relax
Allows blood vessels relax
Give to patients with Afib and CAD
Decreases afterload and increased myocardial oxygen supply, decreases angina
Helps relax heart and increase perfusion
Heparin
prevents blood clots, thrombus formation,
Monitor PTT, normal 25-35
Antidote protamine sulfate
Always follow heparin protocol
Get lab values, PTT q6hr, CBC you want platelets, tell provider critical labs
IV pump must be used for infusion
Watch s/s of bleeding, stop infusion
Coumadin
prevents blood clots/PE
Monitor INR 0.8-1.1, PT 11-12.5
Expected INR to be higher b/c you’re thinning their blood
Antidote vitamin K
Discharge instructions- assess bleeding/bruising, electric razor, hold pressure if bleeding, help when walking, take at same time everyday, tell dentist about med, don’t stop abruptly
Avoid NSAIDs, oral contraceptives, antidepressants, herbs - ginger, garlic, ginseng, St. John’s wort, ginkgo, high-fat and vitamin K-rich foods
