Critical Care Nursing > Topic 4 > Flashcards

Topic 4 Flashcards

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1
Q

Normal Structure Heart

A 
Heart
◦ Mediastinal space
◦ Covered by pericardium
Composed of three layers 
◦ Epicardium
◦ Myocardium 
◦ Endocardium
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2
Q

Coronary Artery Disease (CAD)

A

Progressive narrowing of coronary arteries by atherosclerosis
◦ Coronary heart disease
◦ Atherosclerotic heart disease

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3
Q

Pathophysiology of CAD

A

Injury to epithelial cells in intima
◦ Platelet aggregation
◦ Migration of monocytes
◦ Lipoproteins enter intima
Fatty streak
◦ Monocytes develop into macrophages
◦ Lipid-rich “foam cells” develop Atheroma
Damage to intima
◦ Liberates platelet-derived growth factor
Proliferation of smooth muscle cells Fibrous cap forms
◦ From connective tissue and low-density lipoprotein (LDL)
Fibrous cap often ruptures
◦ Thrombus
◦ Clotting cascade initiated

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4
Q 
Pathophysiology of CAD
Adhesion: 
Activation: 
Aggregation: 
Drugs administered to stop the process?
A
  • Adhesion: platelets bind to receptors
  • Activation: platelets change shape and activate receptors
    ◦ Release: thromboxane A2 and serotonin
    ◦ Activate glycoprotein IIb/IIIa receptors
  • Aggregation: platelets clump together
  • Drugs administered to stop the process
    ◦ Aspirin
    ◦ Glycoprotein IIb/IIIa inhibitors
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5
Q

Risk Factors for CAD
Nonmodifiable factors
Modifiable

A 
- Nonmodifiable factors
Age
◦ Men > 45 years
◦ Women > 55 years
Family history
- Modifiable 
Smoking 
Inactivity 
Overweight
Cholesterol
◦ High LDL
◦ Low levels of HDL
Diabetes Hypertension
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6
Q

History for CAD

A
  • Risk factors
  • Prior hospitalizations
  • Shortness of breath, chest pain
  • Medications
    ◦ Erectile dysfunction meds if considering nitroglycerin
  • Psychosocial history
    ◦ Include stressors
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7
Q

Diagnostic Studies for CAD

A
  • 12-lead electrocardiogram (ECG)
  • Holter monitor
  • Exercise tolerance test (stress test)
    ◦ Exercise to increase demand on heart
    ◦ Stressed via drugs (e.g., adenosine) if patient cannot
    tolerate exercise
    ◦ Monitoring vital signs, ECG
  • Pharmacological stress testing Nuclear stress testing
  • Chest x-ray
  • Echocardiography
    ◦ Ultrasound to visualize cardiac structures
  • Transesophageal echocardiography
  • Multigated blood pool study (MUGA scan)
  • Positron emission tomography (PET scan)
  • Cardiac magnetic resonance imaging
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8
Q

Cardiac Catheterization and Arteriography

A
  • Electrophysiology study Catheter (right or left)
    ◦ Heart pressures (similar to PA catheter)
    ◦ Cardiac output
  • Arteriography
    ◦ Visualize blood vessels
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9
Q

Post-catheterization Care

A
  • Bed rest; head of bed no higher than 30 degrees
  • Monitor bleeding; newer collagen agents for hemostasis may be used
  • Monitor pulses
  • Antiplatelet drugs after the procedure (usually after interventions such as PCI)
  • May be discharged in 6 to 8 hours; depends on diagnosis and procedures done in catheterization laboratory
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10
Q

Laboratory Tests for post cath care

A 
- CBC
◦ Hemoglobin 
◦ Hematocrit
- Sodium 
- Potassium 
- Calcium 
- Magnesium
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11
Q

Cardiac Enzymes

A
  • Troponin I and T
    ◦ As early as 1 hour after injury
    ◦ Normal values less than 0.5 mcg/L for Troponin I
    ◦ Normal values less than 0.1 mcg/L for Troponin T
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12
Q 
Which value, when elevated, places the patient at lowest risk for CAD?
A. Triglycerides
B. Low-density lipoproteins (LDLs)
C. High-density lipoproteins (HDLs)
D. Very-low-density lipoproteins (VLDLs)
A

C. High-density lipoproteins (HDLs)

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13
Q

Cholesterol in CAD Categories

A

◦ HDL is considered good

◦ LDL is considered bad

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14
Q

LDL Target Levels (NIH)

A
  • No CHD and fewer than two risk factors o160 mg/dL
  • No CHD and two or more risk factors o130 mg/dL
  • CAD
    o<100 mg/dL
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15
Q

Treatment for CAD

A
  • Diet: low cholesterol, low salt
  • Exercise: aerobic
  • Weight loss
  • Smoking cessation
  • Management of hypertension and diabetes if present - Medications: lipid-lowering agents
    ◦ Various types: weigh advantages and disadvantages of each
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16
Q

Medications for Hyperlipidemia

A
  • HMG-CoA reductase inhibitors; slow production: most effective
    ◦ Statins
  • Bile acid resins bind and are excreted via bowel.
    ◦ Cholestyramine
    ◦ Colestipol
  • Ezetimibe (Zetia) blocks the absorption of cholesterol in the digestive tract.
  • Nicotinic acid; inhibits LDL synthesis and increases HDL; many side effects
  • Fibric acid derivatives; increase VLDL clearance
    ◦ Gemfibrozil
  • Patients carefully monitored
  • Combination therapy may be needed to reach target goals
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17
Q

Medications Affecting Platelets

A
  • ASA (inhibits thromboxane A2)

- Others: dipyridamole, ticlopidine, and clopidogrel

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18
Q

Types of Angina

A

1) Stable (chronic, exertional) = effort, classic
◦ T-wave inversion on ECG
◦ Treatment: rest and nitroglycerin
2) Unstable (crescendo) = more often and more severe, less relief
◦ May see ST elevation on ECG
◦ Treatment: rest and nitroglycerin; drugs affecting platelets; revascularization
3) Variant = Prinzmetal’s (vasospasms)
◦ ST elevation during pain episodes
◦ Treatment: calcium channel blockers

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19
Q

Angina/Chest Pain

A
  • Myocardial ischemia: the heart’s demand for oxygen is higher than the supply
  • Classic symptom
  • Often midsternal
  • May radiate to arms, jaw, or back
  • ECG changes to the ST segment/T wave
  • ischemia is depressed complete occlusion is elevated
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20
Q

Nursing Diagnoses for angina

A
  • Acute chest pain related to myocardial ischemia
  • Knowledge deficit related to unfamiliarity with disease processes and treatment
  • Activity intolerance related to ischemic changes
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21
Q

Nursing Management: Angina

A
  • Maintain cardiac output
  • Pain relief
  • Self-care; risk-factor modification
  • Medications
  • Postprocedure observation and care following cardiac catheterization, angioplasty, bypass surgery.
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22
Q

Patient Care Outcomes for angina

A
  • The patient will verbalize relief of chest discomfort,
    appear relaxed and comfortable, verbalize an understanding of angina pectoris and its management,
    describe cardiac risk factors and strategies to reduce them, and perform activities within limits of the disease,
    as evidenced by absence of chest pain or discomfort and no ECG changes reflecting ischemia.
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23
Q

Nursing management of the patient with angina is directed toward
A. immediate administration of nitrates.
B. assessment of history of previous anginal episodes.
C. assessment and documentation of chest pain episodes.
D. administration of prophylactic lidocaine for ventricular ectopy.

A

A. immediate administration of nitrates.

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24
Q

Acute Coronary Syndrome (ACS)

A
  • Ischemia with myocardial cell death
  • Imbalance of oxygen supply and demand
  • Includes stable angina, unstable angina or acute myocardial infarction
  • Causes
    ◦ Atherosclerosis
    ◦ Emboli
    ◦ Blunt trauma
    ◦ Spasm
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25
Acute Myocardial Infarction (AMI) Types
◦ Non-ST segment elevation (NSTEMI) ◦ ST segment elevation (STEMI) Collateral circulation (go around it)
26
Assessment of AMI
``` Midsternal chest pain ◦ Severe, crushing, and squeezing pressure ◦ May radiate ◦ Unrelieved with nitrates - Pale and diaphoretic - Dyspnea, tachypnea, and/or hypotension Syncope - Feeling of impending doom - Nausea and vomiting - Dysrhythmias ```
27
Diagnosis of AMI
- Signs and symptoms ◦ Often atypical symptoms in women - 12-lead: ◦ ST elevation followed by Q wave (Q-wave myocardial infarction) ◦ ST depression (non–Q-wave myocardial infarction) - Elevated serum troponin ◦ Troponin I ◦ Troponin T
28
``` Which finding on the ECG is most conclusive for infarction? A. Q waves B. Inverted T waves C. Tall, peaked T waves D. ST-segment depression ```
``` Which finding on the ECG is most conclusive for infarction? A. Q waves B. Inverted T waves C. Tall, peaked T waves D. ST-segment depression ```
29
Nursing Diagnoses for ACS
- Acute Chest Pain | - Poor Tissue Perfusion
30
Nursing Goals: AMI
- Maintain cardiac output - Treat pain - Assess for complications - Increase activity tolerance - Relieve anxiety - Ongoing and discharge teaching
31
Medical Management: AMI
- Pain relief: morphine, nitroglycerin - Oxygen - Prevention of platelet aggregation - Percutaneous Coronary Intervention (PCI) - Fibrinolytic therapy - Medications (nitrates, beta blockers, angiotensin-converting enzyme inhibitors - Autologous bone marrow stem cell treatment to the damaged myocardium.
32
Complications of AMI
- Dysrhythmias - Sudden death - Heart failure - Cardiogenic shock - Ventricular aneurysm or rupture - Papillary muscle dysfunction - Pericarditis - Infarct extension
33
After giving the first dose of morphine to relieve the chest pain of a critical care patient, the next priority action is to A. change the intravenous tubing to maintain a patent infusion line and reduce risk of infection. B. bathe the patient while the analgesic is still in effect. C. assess the patient for pain relief and signs of any adverse effects of the medication. D. initiate administration of oxygen by nasal cannula.
After giving the first dose of morphine to relieve the chest pain of a critical care patient, the next priority action is to A. change the intravenous tubing to maintain a patent infusion line and reduce risk of infection. B. bathe the patient while the analgesic is still in effect. C. assess the patient for pain relief and signs of any adverse effects of the medication. D. initiate administration of oxygen by nasal cannula.
34
Primary Angioplasty
- Get patient to catheterization lab for emergent percutaneous intervention or stenting if facilities are available - Better outcomes than thrombolytics
35
Thrombolytic Therapy
- Time is muscle; 6-hour window - Several thrombolytic agents available, such as: ◦ Tissue plasminogen activator (t-PA) ◦ Streptokinase ◦ Reteplase - Heparin and glycoprotein IIb/IIIa inhibitors
36
Interventional Cardiology
- Variety of procedures ◦ Percutaneous transluminal coronary angioplasty (PTCA) ◦ Intracoronary stenting ◦ Drug-eluting stents
37
PTCA
- Goal to increase blood flow to myocardium - Criteria ◦ Uncompromised collateral flow ◦ Noncalcified lesions ◦ Lesions not on bifurcations of vessels - Balloon catheter is inflated
38
Coronary Stents
- Tubes placed in conjunction with angioplasty to keep vessel patent - Help prevent the restenosis associated with angioplasty - Similar procedure as PTCA - Anticoagulation therapy
39
Surgical Revascularization
- Coronary artery bypass graft (CABG) surgery - Minimally invasive direct coronary artery bypass (MIDCAB) surgery - Transmyocardial revascularization (TMR)
40
CABG Surgery
``` - Provides additional conduits for blood flow ◦ Saphenous vein ◦ Internal mammary artery ◦ Radial artery - Arteries longer patency ```
41
Indications for CABG
- Unstable angina - AMI - Failure of percutaneous interventions
42
Risks Associated with CABG
``` - Increased mortality associated with: ◦ Left ventricle dysfunction ◦ Emergency surgery ◦ Age ◦ Sex (female) ◦ Number of diseased vessels ◦ Decreased ejection fraction with congestive heart failure ```
43
Traditional CABG
- Median sternotomy or sternum split - Excision of pericardium - Cardiopulmonary bypass - Myocardial preservation or cardioplegia - Grafts - Wean bypass; defibrillate if needed - Mediastinal and chest tubes - Epicardial pacing wires - Wire sternum
44
Goals of CABG Surgery
- Increase blood flow to myocardium - Relieve symptoms - Prolong survival - Improve quality of life
45
Minimally Invasive Direct Coronary Artery Bypass Surgery
``` Direct - Port-access coronary artery bypass ◦ Cardiopulmonary bypass ◦ Incisions (ports) - Minimally invasive direct coronary artery bypass surgery ◦ No cardiopulmonary bypass ◦ Heart still beating ◦ One or two bypasses ```
46
Cardiac Surgery Complications
``` - Low cardiac output ◦ Renal impairment ◦ Gastrointestinal dysfunction ◦ Impaired peripheral circulation - Mediastinal bleeding ◦ Infection: very serious if sternal Atrial dysrhythmias Hypovolemia ```
47
Complications of CABG
- Dysrhythmias - Impaired contractility; low cardiac output - Intraoperative myocardial infarction - Pericardial tamponade - Respiratory insufficiency - Pain - Emboli; stroke - AMI - Shock - Death
48
Transmyocardial Revascularization
- Laser channels into ventricle - Goal is to increase perfusion of heart muscle - Relief of symptoms occurs over time - Poor candidates for CABG - Mixed results from clinical trials
49
Enhanced External Counterpulsation
◦ Enhanced external counterpulsation (EECP) is a treatment for angina when the patient is not a candidate for bypass surgery or PCI. ◦ EECP uses cuffs wrapped around the patient’s legs to increase arterial blood pressure and retrograde aortic blood flow during diastole. Sequential pressure, using compressed air, is applied from the lower legs to the upper thighs. ◦ There are no definite data that EECP reduces ischemia; however, treatment reduces angina and improves quality of life.
50
Dysrhythmias
- Radiofrequency catheter ablation - Permanent pacemakers - Implantable cardioverter-defibrillator
51
Radiofrequency Catheter Ablation
- Supraventricular tachycardia - Interrupt electrical conduction or activity - Radiofrequency used - Electrophysiology
52
Temporary and Permanent Pacemakers
``` - Multiprogrammable for: ◦ Rate ◦ Voltage ◦ Sensitivity ◦ Stimulus duration ◦ Refractory period - Intersociety Commission for Heart Disease (ICHD) - Can pace atria, ventricles, or dual chamber Inserted transvenously ```
53
Implantable Cardioverter- Defibrillator (ICD)
- Used to treat survivors of sudden cardiac arrest - Some have built-in pacemakers - Delivers high-energy shock - Patient education - Emergency procedures
54
Heart Failure
- Inability of the heart to generate adequate flow and to meet the metabolic demands of the body 1) Systolic (impaired contractility) 2) Diastolic (impaired filling)
55
Etiology for heart failure
- AMI - Hypertension - Idiopathic; cardiomyopathy - Valvular disease
56
Pathophysiology for heart failure left side
``` - Left heart failure ◦ Decreased pumping action ◦ Failure to meet metabolic demands ◦ Backup of blood from left ventricle ◦ Fluid buildup in lungs ◦ Backflow leads to right heart failure ```
57
Pathophysiology Compensatory mechanisms Right heart failure
``` - Compensatory mechanisms ◦ Renin-angiotensin-aldosterone system ◦ Sympathetic nervous system - Right heart failure ◦ Leads to systemic symptoms ```
58
Pathophysiology (Cont.) | - Brain natriuretic peptide (BNP)
- Brain natriuretic peptide (BNP) ◦ Cardiac hormone ◦ Secreted by ventricular myocytes in response to wall stretch ◦ Normal 100 pg/mL ◦ Plasma concentrations reflect severity of heart failure ◦ In decompensated heart failure, BNP rises ◦ As heart failure is treated, BNP will lower ◦ Good marker for differentiating between pulmonary and cardiac causes of dyspnea
59
Assessment of Heart Failure
- Left-sided failure signs and symptoms - Right-sided failure signs and symptoms - Examination of neck veins - Presence or absence of edema - Perfusion status - Lung sounds - Diagnostic findings ◦ Chest x-ray ◦ Hemodynamic monitoring (pulmonary artery catheter)
60
Assessment Diagnostics Testing (heart failure)
- Echocardiogram - Arterial blood gases - Serum electrolytes - BUN/Creatinine - Complete blood count - B-type natriuretic peptide (BNP) - Hepatic function - ECG
61
Heart Failure Nursing Interventions
``` - Improve pump function ◦ Diuretics ◦ ACE inhibitors ◦ Angiotensin receptor blockers ◦ Beta blockers (carvedilol [Coreg]) ◦ Digoxin ◦ Nesiritide citrate (Natrecor) intravenous for acute decompensation of heart failure ```
62
Heart Failure Treatment to Reduce cardiac workload
◦ Intraaortic balloon pump ◦ Mechanical circulatory support devices (MCSDs) ◦ Biventricular pacing ◦ Nursing interventions, rest, and activity as tolerated. ◦ Cardiac rehabilitation
63
Heart Failure Treatment to Optimization of gas exchange
``` ◦ Airway assessment and degree of respiratory distress ◦ Semi-Fowler positioning ◦ Supplemental oxygen ◦ Continuous positive airway pressure (CPAP) ◦ Diuresis ◦ Control sodium and fluid retention ◦ Daily weights ◦ VTE prophylaxis ```
64
Heart Failure Complications
``` - Pulmonary edema ◦ Dyspnea ◦ Cyanosis ◦ Gurgles ◦ Pink, frothy sputum ◦ Hypoxemia - Cardiogenic shock ```
65
Inflammatory Heart Disease
- Pericarditis—inflammation of the pericardium | - Endocarditis—inflammation of the endocardium
66
Pericarditis Etiology
◦ After a myocardial infarction ◦ Uremia ◦ Cancers - Can lead to infusion, tamponade, and scarring
67
Hallmarks of Pericarditis
- Friction rub - Pulsus paradoxus - Initial ST elevation
68
Pericarditis Assessment
- Relieve pain - Procedures: ◦ pericardiocentesis ◦ pericardial window
69
Endocarditis
- Endocardium continuous with valves - Vegetation - Embolization - Valvular dysfunction
70
Assessment of Endocarditis
- The clinical presentation * High fever and shaking chills * Night sweats, cough, weight loss * General malaise, weakness, fatigue, headache, musculoskeletal complaints * New murmurs * Symptoms of HF * Skin abnormalities - Janeway lesions - Osler nodes
71
Endocarditis - Diagnosis: - Treatment: - Prevention:
- Diagnosis: echocardiogram, transesophageal echocardiography - Treatment: antibiotics, rest - Prevention: antibiotic prescription before treatments (e.g., dentist) ◦ Heart valve ◦ History of endocarditis ◦ Microvascular pressure with regurgitation
72
Vascular Alterations for Aortic aneurysms
``` ◦ Dilation or thinning of wall ◦ Thoracic aortic ◦ Thoracoabdominal aortic ◦ Abdominal aortic ◦ Treat based on size and symptoms ◦ False versus true ```
73
Vascular Alterations for Aortic dissection
``` ◦ Tear of intimal layer of the vessel ◦ Sudden ◦ Sharp ◦ Shifting pain ◦ Marfan syndrome - Surgical Treatment ◦ Open approach ◦ Endovascular approach ```
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