UNIT 1- CARE OF A CARDIAC PATIENT Flashcards
What is the normal flow of the heart?
- Blood enters from the superior and inferior vena cava
- Right atrium
- Tricuspid valve
- Right ventricle
- Pulmonary valve
- Pulmonary artery
- Lungs
- Pulmonary vein
- Left atrium
- Mitral valve
- Left ventricle
- Aortic valve
- Aorta
What are the coronary arteries of the heart?
- Right coronary artery
- Right (acute) marginal artery
- Left coronary artery
- Circumflex artery
- Left (obtuse) marginal artery
- Left anterior descending artery
- Diagnal arteries
What are the different layers of the heart?
- Endocardium
- Myocardium
- Epicardium (visceral layer of serous pericardium)
- Pericardial cavity
- Parietal layer of serous pericardium
- fibrous pericardium- 1st outer layer and protective layer
Left sided heart results in…
Pulmonary congestion decreased cardiac output
Right sided heart failure results in
generalized edema
What organs will the heart choose to shunt blood too in emergent situations?
- Brain
- Spinal cord
- Lungs
What is preload?
Volume of blood in ventricles at end of diastole (blood left after a contraction)
Preload is increased in….
Hypervolemia
Regurgitation of cardiac valves
What is afterload?
Resistence left ventricle must overcome to circulate blood
Afterload is increased in…
- Hypertension
- Vasoconstriction
Increased afterload increases
Cardiac workload
What is cardiac output?
Amount of blood pumped through the circulatory system in one min.
What determines CO?
Stroke volume and heart rate.
What is acute coronary syndrome?
A condition that occurs when blood flow is decreased or blocked in the heart. Can have unstable angina, NSTEMI, STEMI
How do you know if your patient is having a NSTEMI or a STEMI?
EKG
What is our objective with Advanced Cardiac Support? & how can we do that
Decrease 02 demand and increase 02 supply
1. Decrease physical activity
2. Apply supplemental oxygen
3. Administer medication
What medication can be used to help decrease 02 demand and increase 02 supply and how do they work.
- Beta blockers
- anticoagulants
- Ca channel blockers
- nitrates
- Opiods
- Ace/Arb
These medications can work by
1. Decreasing preload
2. Decreasing Afterload
3. Dilate coronary arteries
4. Reduce contractility
5. Reduce heart rate
6. Prevent further thrombosis
1
What do arteries do as we age?
Harden and calcify which causes impaired blood flow and increased resistence
What is our first intervention when a patient comes in with chest pain?
Nasal cannula to decrease the demand and increase supply of oxygen. Sit up in high fowler if standing.
How do we administer nitro?
Place nitro under tongue for fastest absorption.
works by dilating arteries & Decreasing BP.
Wait 5 mins.
Assess bp, chest pain, admin another dose if chest pain is still present. Can do this 3 times.
If a patient needs nitro what medication must you ask if they are taking before administering.
ED
What should we consider with morphine and advanced cardiac support?
Might have to weigh risk vs. benefit. Since morphine can cause resp depression we need to know rr and o2 sat. Sit the patient wake them up. Make them take good deep breaths. Narcan antidote.
How do beta blockers decrease 02 demand and increase 02 supply?
Block effect of epi and adernaline decrease hr and contactility which will lower bp
How do ACE/ARBs work to decrease o2 demand and increase supply
Vasodilators decrease preload and afterload biggest issue after taking this drug…cough… which is an adverse reaching. May need to treat
Asprin is recommended for patients
49 and over
What is an MI?
Death or necrosis of myocardial cells caused by blood flow blockage
- NSTEMI
- STEMI
What is a NSTEMI?
Partial occlusion or narrowing. You have 12-72 hours after being diagnosed to recieve treatment. Will have necrosis within 12 hours.
Cardiac enzymes will show what in NSTEMI
Elevation
What is a STEMI
Total occlusion. NO blood flow. Emergent. Treatment needs to be within 90 mins. If not helped necrosis will happen within 4-6 hours and blood flow is compromised. CODE STEMI. Cath lab quick. Labs elevated to indicate MI.
How can we tell if the patient is experiencing angina or a MI?
Angina pain is releived with nitro and labs dont show anything
What is hypokinesis?
Worsening contractility or akinesis… no contractility… this happens in areas of necrosis
Time = what
Muscle
1. Once cells have died they are gone
2. The body replaces necrotic cells with scar tissue
3. Hypoxia begins in 10 seconds
4. Damage occurs after 20 mins of 02 deprivation
What are s/s of MI?
- Chest pain/discomfort/pressure
- Elevated blood glucose
- N/V
- Diaphoreisis
- increased HR/BP
- S3/S4 heart sounds
- Peripheral vasoconstriction
- Fever
- SOB
- Dizziness
- AMS
- Dysrthymias
- Pulmonary edema
What are atypical symptoms of MI?
- Any symptom not accompanied by chest pain…
Diabetes and lupus can mask….
MI symptoms
What are descriptions frequently used by patients to describe MI include….
- Squeezing
- Tightness
- Pressure
- Ache
- Crushing
- Burning/heartburn
- Band-like sensation
- Knot in the center of the chest
- Toothache
- Heavy weight on chest (elephant sitting on chest)
Descriptions of MI are generally not described as?
- Sharp
- Knife-like
- Changed w/breathing
- Stabbing
- Like pins and needles
How is a diagnosis of MI made?
- Diagnosis is made with elevated cardiac enzymes plus:
- Typical symptoms
- ST segment changes
- History of cardiac intervention
- EKG- done early looking for ST elevation so we know how much time…
- Cardiac enzymes- late sign. Not a priority. Troponin can take up to 5-6 hours to elevate
- Echocardiogram
- Coronary angiogram
what is collateral circulation?
Alternate or backup blood vessels in your body that can take over when another artery or vein becomes blocked or damaged. This can be good in certain situations.
What will your troponin look like during an MI?
Troponin (T or I)
1. Best indication of knowing if they are having a heart attack
2. Elevates 4-6 hours after injury, peaks at 10-24 hours
3. Level = less than 0.03 ng/ml (I); less than 0.1ng/ml (T)
4. Returns to baseline in 10-14 days
What would our creatine kinase (CK) show in an MI?
This lab will tell us if muscle damage is present but it can not tell us specifically where
1. elevates after 6 hours after injury, peaks at 18 hours
2. Level = 30-170 u/L
3. Returns to normal 24-36 hours following injury
What would our myoglobin (CK-MB) level show up in an MI?
This lab is cardiac specific. Elevates with shock, myocarditis, and this will tell us if the muscle damage was in the heart and how bad.
1. Elevates within 2 hours, peaks at 3-15 hours
2. Level = less than 90
3. Returns to normal 12-24 hours afte injury
Your patient complains of chest pain…. What do we do? (perfect order)
- Rest
- Apply supplemental o2
- Place the patient on a cardiac monitor
- Vital signs
- EKG (looking for ST elevation)
- Ensure adequate IV access- two large bore IV esp. if STEMI
- Draw cardiac enzymes
- Admin meds- nitro x3 if it doent work…morphine
- Get patients ready for repurfusion therapy.
What are the medications given for MI?
- Nitrates (IV/SL nitro)
- Beta blockers (metroprolol)
- Decreases HR and BP… lowering pumping ability so its not working so hard
- Antiplatelet agents (ASA/clopidogrel/eptifibatide)
- Anticoagulants (heparin and enoxaparin)
- PT/INR- theraputic level will be 2 to 3 times the normal level
- Thrombolytic therapy (alteplase)
What is heparin-induced thrombocytopenia (HIT)
- Immune response to heparin- body forms antibodies against heparin
- Platelets activated = increased platelet plugs = inceased r/o thrombosis = decreased ciculating platelets
- Usually occurs 5-10 days into treatment but can occur in as little as 24 hours
What information would cause us to suspect that our patient has HIT?
- Plt <150 or drop of 50% or more from baseline
- Arterial or venous thrombosis
- Acute systemic reactions after admission.
- Treatment STOP heaprin. Can give them argatroban, Iviludin.
Patients with suspected HIT are at huge risk of what…
bleeding out… keep pt on bed rest
What procedures can be done for a patient experiencing a MI?
- Percutaneous coronary intervention (PCI) ** gold standard**
- uses dye so check for shelfish and iodine allergery
- Cardiac bypass- if patinet is not a candidate for the above
Watch for signs of bleeding out after both procedures: low bp, high hr, cold, clammy, decrease pedal pulse, decreased pedal temp. Notify MD immediately and apply major pressure to fermoral artery if PCI was done.
PV assessment is KEY. Compare affected extremity to nonaffected to have baseline
BED REST IMPORTANT AFTER. min OF 6 hours
What is cardiogenic shock?
Inadequate tissue perfusion due to cardiac dyfunction
so you have decreased o2 to cardiac muscle which results in decreased cardiac function and decreased perfusion to the body
What are your biggest symptoms of cardiogenic shock?
1.Tachycardia: Your heart knows something isnt right so its pumping to compensate
2. Hypotension
What is the most common cause of cardiogenic shock?
- Trauma caused by MI due to ischemia and necrosis
Life threatening.
What is the difference between cardiogenic shock vs. hypovolemic shock?
Cardiogenic shock is a pump problem whereas hypovolemic shock is a volume problem. Same symptoms different cause
What is our treament for cardiogenic shock?
- Reperfusion of cardiac muscle
- Find the cause and treat it
- ASA before PCI, Clopidergral after PCI
- Symptom management
Cardiogenic shock treatment vs. hypovolemic shock treatment
Cardiogenic shock tx: Fix our pump so that it can pump out the fluid NEVER BOLUS THIS PATIENT
Hypovolemic shock: Replace fluids.
If our patient is experiencing dysrhymias in cardiogenic shock how are we going ot manage this?
- Antydysrhythmics like amiodarone
If our patient is experiencing hypotension due to cardiogenic shock how do we manage this?
- Postive inotropic and vasopressor agents like norepinephrine and dopamine
- AVOID beta blockers
True or false: we might try a fluid challenage on a patient with cardiogenic shock?
True they can give 250ml fluid challenage to see if it helps or hurts patient
If a patient is experiencing fluid overload during cardiogenic shock how will we manage this?
- Diuretics
- Vasodilators
How long is recovery after an MI?
Several weeks– scar tissue replaces damaged heart muscle
may recommend cardiac rehab for patients after an MI
What lifestyle changes are necessary after an MI
- New medications
- diet modifications
- activity modification
- tobacco cessation.
What procedure is done if a blockage cannot be relieved using PCI?
Cardiac bypass- the surgeion “bypasses” a blockage that connot be opened with PCI.
For this patient we will want to encourage them to cough… since they will be in pain the patients breathing will be shallow and they become more prone to pnemonia.. Coughing helps them open up the airway
Why might a non-diabetic patient who underwent a cardiac bypass procedue recieve insulin?
This procedure is highly stressful on the body. Which increases the bodies blood glucose. Epi which will be produced by the body is a natural insulin antagonist which increases the blood sugar so during the acute phase of this recovery they will be placed on inuslin to help those levels
What is always present after a cardiac bypass to drain excess blood?
Chest tube
What is the blood called that is present immediately after a cardiac bypass and the patient has a chest tube?
Frank blood
What is the blood called after an hour after chest tube insertion called?
Serosanguinous
Drainage from a chest tube should be no more than how many mL/hr
100
When should we see the most drainage from a chest tube?
Immediately after insertion. It should continue to decrease after that
What do we monitor and assess for in a patient with a chest tube?
- We need to make sure to document the amount of drainage each shift. We can do this by marking the collection system and the beginning and end of each shift.
- We look at color, amount, insertiong site
What is an aneurysm?
- When an artery wall weakens causing it to widen abnormally or “balloon out”
What are s/s of a non-ruptured AAA
- Abnormal, back or flank pain
- Pulsating abdomen
- Pain or discoloration of the feet
“STABLE”
What are s/s of a ruptured AAA?
- Severe pain
- Hypotension- r/t bleeding internally
- Pulsatile abdominal mass
- MEDICAL EMERGENCY- poor prognosis if it ruptures
What are our priorties for patients with AAA
- Type and cross ready
- Large bore IV
- Baseline vitals to know where they stand hemodynamically
- Check peripheral pulses
- IF stable get CT.
- NEVER TOUCH A PULSATING MASS IT COULD RUPTURE IT
How is AAA managed?
- Open repair
- Endovascular aneurysm repair- replace diseased part of the aorta
3.
What are complications of a post-op AAA?
- MI
- bleeding
- renal failure
- bowel/ureteral injury
- gi complications
- Leg ischemia
- Graft infection (mortality of 90% with this)
What is a cardiac tamponade?
- A pericardial effusion extends the sac beyond its limits
- The heart is unable to function properly
What are the s/s of a cardiac tamponade?
Becks triad
1. Low BP
2. Muffeled heart sounds (like the heart is inside a water balloon)
3. Distension of jugular veins
Not everyone with cardiac tamponate will show all 3 signs
May also have
1. Tachycardia and SOB
What is our treatment for a cardiac tamponade?
- If having hempdynamic changes we will do a pericardiocentesis
- Percutaneous (at bedside)
- Surgical (more riskY)
- If no hemodynamic changes- conservative management with continous hemodynamic assessment
