Week 11 - Cardiac Health Flashcards
Blood Flow through the Heart
Body → Lungs
Right
1. SVC/IVC
2. Right Atrium
3. Tricuspid valve
4. Right ventricle
5. Pulmonary Valve
6. Pulmonary Artery
Left
1. Pulmonary Veins
2. Left Atrium
3. Mitral Valve
4. Left Ventricle
5. Aortic Valve
6. Aorta
Electrical Conduction through the Heart
- Sinoatrial Node
- Atrioventricular Node
- Bundle of His
- R/L Bundle Branches
- Purkinje Fibres
Coronary Vasculature (Arterial Supply to the Heart)
1) Right Coronary Artery (RCA)
2) Left Coronary Artery (LCA)
→Left Circumflex Artery (LCx)
Perfusion
Perfusion: flow of blood through circulatory system to oxygenate cells
& remove waste
Perfusion depends on:
→Sufficient cardiac output
→Sufficient blood pressure to move blood to periphery
→Complementary action of adequate coagulation to prevent hemorrhagic blood loss
- Blood pressure influenced by CO (amount of blood pumped, peripheral
vascular resistance)
Cardiac Output (CO)
- Cardiac Output relies on: 1) Heart
Rate & 2) Stroke Volume
Heart Rate: frequency with which heart pumps, based on electrical stimulation
Stroke volume: volume of blood in the heart when it pumps
Factors impacting CO
1) nervous system
2) fluid volume
3) heart muscle contraction
4) resistance in vessels
Cardiac Assessment
1) Health history - other illness that impact cardiac function
→ risk factors for heart disease
→ medications
→chest pain, exercise tolerance
2) Physical Assessment- vital signs
→ heart sounds
→ perfusion - cap refill, skin colour and temp, edema
→ respiratory assessment
→ other systems (Liver, kidney)
3) Bloodwork, ECG, echocardiogram
→ looks at structure of the heart (ex. size)
Risk Factors for Cardiovascular Disease
Modifiable
- Hypertension (blood pressure)
→Damage to vessels over time
→Left ventricular hypertrophy
Dyslipidemia
→ Blocks vessels, impacts blood flow
- Diabetes (keeping BG w/in normal range)
→Damage to vessels over time
- Lifestyle
→smoking, lack of exercise, obesity
- Sleep apnea
Nonmodifiable
- Age
- Family history/genetics
- Gender-3 to 2 ratio men to
women
In relation to Cardiovascular health, you should watch for:
- Changes in vital signs
- Fatigue
- Changes in breathing (s.o.b., crackles)
- Chest pain- Tissue hypoxia
→Cardiac: squeezing, racing, palpitations, SOB, nausea, shoulder or jaw pain, anxiety, dizziness
Hypertension
- Chronic condition where BP remains consistently elevated above target level
Diagnoses: 2 or more readings following initial screening
- Major risk factor for heart attack & stroke
Primary VS. Secondary Hypertension
Primary Hypertension
- 95% of all cases
- No identifiable cause
Possible contributing factors
→↑SNS activity
→↑ Sodium-retaining hormone
→↑ Sodium intake
→↑ Alcohol consumption
→Diabetes Mellitus
→Obesity
Secondary Hypertension
- 5% of all cases
- Identifiable cause
Contributing Factors
→Kidney disease
→Neurologic disorder
→Drugs: estrogen replacement therapy, corticosteroids etc.
→Pregnancy
Classification of Hypertension
Normal
≤ 120-129 & ≤ 80-84
Pre HPTN
130-139 OR 85-89
HPTN
≥ 140 OR ≥ 90
Stage 1 HPTN
140-159 OR 90-99
Stage 2 HPTN
≥ 160 OR ≥ 100
Signs & Symptoms
-Often asymptomatic “silent killer”
- Severe and symptomatic hypertension can cause:
→Fatigue
→Dizziness
→Dyspnea
→Angina
Diagnosing Hypertension
- Health history, including risk factors, medications
Systems Assessment
1) Neuro- headaches
- hypertensive retinopathy
2) Cardiac
→ chest pain, irregular, bounding pulse
3) Respiratory
→ shortness of breath
4) Gi
→ nausea, vomiting (hypertensive
crisis)
Other Diagnostic Test
- Hematocrit
- Serum K+ & Ca ++
- Serum creatinine (kidney function)
- HDL, LDL & triglycerides
- ECG
- Urinalysis
- Blood glucose
Goals & Nursing Interventions
- Prevention
- Control and maintain BP < 140/90 mm Hg
- In clients with diabetes or renal disease, BP goal is <130/80
- Decrease risk of cardiovascular & renal complications
- Develop and maintain lifestyle modifications, medication adherence
- Patient education
Patient Education
- Knowledge
→self-management, risk factors, managing hypotension - Monitor
→BP tracking, follow-up appointments - Lifestyle
→reduce risk, complications - Medications
→name, dose, side effects, frequency, adherence
Lifestyle Modification
- Maintain
→ healthy body weight (BMI 18.5-14.9) - Eat
→ diet rich in fruits, veg, low-fat dairy products, low in saturated fat, reduced Na+, DASH diet - Reduce
→ sodium intake
→ stress - Quit
→smoking - Moderate
→ alcohol consumption (less than 1-2/day for men, no > 2 for women) - Increase
→ exercise (at least 30 mins/day)
Pharmacological Intervention
Meds target
- Peripheral resistance
- Cardiac output
- RAAS System & fluid volume
- Angiotensin Converting Enzyme
(ACE) Inhibitors - Angiotensin Receptor Blockers
(ARB) - Beta Blockers
→ watch for bradycardia - Calcium Channel Blockers
→ watch for bradycardia - Diuretics
- Vasodilators (hydralazine)
PRILs: Ramipril, Perindopril, Lisinopril
Therapeutic Class: Antihypertensives
Pharmacologic Class: ACE inhibitors
Action:
→vasodilate
→lower BP
Side Effects:
→Drowsiness
→dizziness
→headache
→persistent dry cough
Caution:
→Risk of angioedema (fluid below skin could block airway-emergency)
Nursing Considerations:
→ Monitor for hypotension (hold SBP >90)
→change position slow
→fall risk
→advocate for change in medication if client is having trouble coping
with dry cough SE
→metabolized by liver
→excreted by kidney
Metoprolol, Carvedilol
→ pulse <60, do NOT give, bc it drops BP
Therapeutic Class: Antihypertensives & Anti Dysrhythmics
Pharmacologic Class: Beta Blockers
Action:
→decreases HR/cardiac contractility, lowers BP
→treats dysrhythmias, HF, HTN,
acute MI, CAD
Side Effects:
→Dizziness
→lightheadedness
→hypotension/ortho hypotension
→bradycardia
→dry mouth
Caution:
→May worsen CHF over time, therefore contraindicated in late stage
Nursing Considerations:
→Assess VS prior to admin (hold in HR<60. SBP<90)
→change position slowly
→medication may mask hypoglycemic symptoms—monitor in people
with type 1 or 2 diabetes
Amlodipine, Diltiazem
Therapeutic Class: Antihypertensives & Anti Dysrhythmics
Pharmacologic Class: Calcium Channel Blockers
Action:
→decreases HR/cardiac contractility, cause vasodilation, lowers BP
Side Effects:
→Dizziness
→lightheadedness
→hypotension/orthostatic hypotension
→bradycardia
→peripheral edema
→flushing
→GI upset
→constipation
Caution: Avoid with CHF
Nursing Considerations:
→Risk for hypotension (hold SBP<90, HR<60)
→change position slowly
→monitor I/O due to risk for edema →metabolized by liver
→excreted by kidneys
Furosemide (Lasix)
Therapeutic Class: Antihypertensives
Pharmacologic Class: Loop Diuretic
Action: lower BP by reducing fluid volume
Side Effects:
→ Dehydration
→Dizziness, headache
→hypotension/orthostatic
hypotension
→electrolyte imbalances (hypokalemia, hyponatremia, hypocalcaemia)
Caution:
→Use with caution in kidney disease, monitor kidney function
Nursing Considerations:
→Risk for hypotension
→monitor electrolytes
→daily weights
→I/O
→falls risk with older adults
→monitor kidney function
Hydrochlorothiazide
Therapeutic Class: Antihypertensives
Pharmacologic Class: Thiazide Diuretic
Action: lower BP by reducing fluid volume
Side Effects:
→Dehydration
→dizziness, headache
→ hypotension/orthostatic hypotension
→electrolyte imbalances (hypokalemia, hyponatremia)
Caution:
→Contraindicated with impaired kidney function
Nursing Considerations:
→Risk for hypotension
→monitor electrolytes
→daily weights, I/O
→falls risk with older adults
→monitor kidney function
Spironolactone
Therapeutic Class: Antihypertensives
Pharmacologic Class: Potassium Sparing Diuretic
Action: lower BP by reducing fluid volume
Side Effects:
→Dizziness, headache, →hypotension/orthostatic hypotension,
→electrolyte imbalances (hyperkalemia)
→photosensitivity
→N/V/D
Caution:
→Contraindicated with later stage kidney function
Nursing Considerations:
→Risk for hypotension
→monitor electrolytes
→daily weights
→I/O
→falls risk with older adults
→monitor kidney function
Hypertensive Crisis
- Acute marked increase in BP
- Cause = abrupt stopping of medication, poor management of HTN
Urgency
→ High BP, headache, nosebleed, anxiety
→ Manifests in days → weeks
→ BP > 180/110mm Hg
→ No major organ damage Identified
Emergency
→ Manifests in hours to days
→ BP > 220/140mm Hg
→ Potential organ damage: Intracranial or subarachnoid hemorrhage
→ MI
→ left ventricular failure
→ renal failure
→ retinopathy
→ aortic aneurysm
Nursing Care of a Patient with a Hypertensive Crisis
Goal:
→Decrease BP by 25% in 1 hour
→Achieve 160/100 BP in 2-6 hours
- VS monitoring: Q 5 minutes
- Systems Assessment: S & S of organ damage (remember findings
associated with lack of perfusion!) - Bloodwork: Electrolytes (K, Mg, Cl, Na), urea, creatinine, lipids, glucose
- Initiate IV Access
- Administer IV antihypertensive medications
- Urinalysis
- 12 lead ECG
- I/O
- Administer O2 PRN
- Encourage rest & quiet room
Coronary Artery Disease
- Narrowing or obstruction of the coronary arteries due to atherosclerosis
Atherosclerosis: Buildup of plaque in arterial walls
→Caused by injury to artery walls (due to HTN, diabetes, inflammation,
cholesterol)
→Plaque impacts perfusion=damage to body systems
Progression of Coronary Artery Disease
1) Atherosclerosis: Plaque deposition in arteries
→hardened and thickened walls, restricted blood flow
2) Peripheral Artery Disease
(PAD): Inadequate oxygen supply to the extremities
2) Coronary Artery Disease (CAD): Inadequate oxygen supply to the myocardium
2a. Angina = chest pain due to
inadequate oxygen supply to myocardium
2b. Acute Coronary Syndrome
(ACS): Spectrum of acute myocardial infarction; results in STEMI, NSTEMI, & unstable angina
Risk Factors for CAD
Modifiable
→Lifestyle (smoking, obesity, diet, exercise)
Non-modifiable
→Family history
→Age
→Gender (women after menopause)
→Genetics
→ need to consider other comorbidities (diabetes, dyslipidemia)
Assessment for CAD
1) Health history
2) Labs & diagnostic tests:
Lipid Profile:
→Total cholesterol Normal = < 200 mg/dL
→LDL (“bad”) cholesterol Normal = < 100 mg/dL (high=risk)
→HDL (“good”) cholesterol Normal = ≥ 60 mg/dL (low=risk)
→Triglycerides Normal = < 150 mg/dL
→HbA1C: uncontrolled diabetes, high A1C = increased risk
→BG: uncontrolled diabetes, high BG = increased risk
Nursing Priorities
- Reduce Cholesterol
→Diet, medications - Manage comorbidities (glucose, BP management)
- Health Promotion
→Lifestyle changes (diet similar to diabetic diet-low in sugars, low in
saturated fats, high in fiber)
→ Exercise
→Stress reduction
Statins: Atrovastatin, Rosuvastatin
Therapeutic Class: Antihyperlipidemic
Pharmacologic Class: HMG-CoA reductase inhibitors
Action: decrease LDL/triglycerides
Side Effects:
→Headache, dizziness
→GI upset
→insomnia
→MUSCLE PAIN
Caution:
→Do not take if liver disease present; may increase blood glucose level
Nursing Considerations:
→monitor lipids (**fasting)
→hepatotoxic
Angina’s Mismatch of Supply & demand
Normal physiology
→ Oxygen demand is in balance with supply
→ When oxygen demand ↑, coronary
blood flow will ↑; increasing oxygen
supply, or vice versa
Angina’s Mismatch of Supply & demand
→ Coronary blood flow ↓, & oxygen supply is limited
→ Since heart muscles need oxygen, oxygen demand ↑ during exercise
Results:
→ ↑ Oxygen demand, & ↓ supply =
hypoxia (oxygen deficiency) → MI
or angina
Angina VS. Myocardial Infarction
Angina
→ Ischemia of partial thickness of myocardial muscle
→ Causes chest pain
→ Due to stenosis, vasospasm,
thickening of heart wall
→ Goal: Relieve pain &reduce risk
of disease progression & MI
Myocardial Infarction
→Death of myocardia cells due to prolonged ischemia of full thickness of myocardial muscle
→ EMERGENCY Time is Tissue
→ Due to stenosis, plaque lodge
→ Goal: restore blood flow
Stable VS. Unstable Angina
Stable Angina (exertional angina)
→ due to exertion/stress
→ stable pattern of onset and duration
→ inadequate blood supply
→ treated with stopping/ resting and nitroglycerin
→ will feel the same and last for the same amount of time
→ ST depression and or T wave inversion on ECG, or no changes at rest
Unstable Angina (Pre-infarction angina)
→plaque rupture, prone got thrombogeneis
→ can occur during at rest or very little stress/exertion
→ increased occurrence and severity over time
→ ST depression and T wave changes may occur on ECG
→ treated with nitroglycerin
Variant Angina (rare)
→ chest pain at rest
→ often occurs between midnight adn early morning
→ caused by temp spasms in the coronary arteries, leading to reduced blood flow
→ treatment: nitrates, calcium channel blockers
Signs & Symptoms of Angina
Cardiac
→ Chest pain (pressure, squeezing)
→ irregular rhythm
→ bounding pulse
→ pain can radiate to left arm, jaw, shoulders, and back
Respiratory
→dyspnea
→ shortness of breath
tachypnea
crackles (more common with MI)
Neurological
→ anxiety
→ restlessness
→ dizziness
GI (more common with MI)
→ nausea, vomiting
Integumentary
→flush
→pale
→ diaphoretic
Assessment of Angina
- Health history
- Vital signs
- Bloodwork & diagnostic tests
- Troponin, ECG, stress test, angiogram
Troponin I
- A cardiac biomarker lab value that measures a protein that is specific to the heart muscle; it is released when heart muscle cells are damaged
→Normal=<0.03 ng/mL
→ Elevates 3-6 hrs post MI, peak 12-16 hrs, remains high 5-9 days
- Elevated troponin= MI
Electrocardiogram
- Investigation of cardiac electrical activity, used to identify rhythm
changes that are indicative of an MI - Within 10 minutes of arrival with S&S to rule out Myocardial Infarction
** look at electrocardiogram on slide*
Other Diagnostic Tests
- Exercise Tolerance Test (ETT, or “Stress Test”)
→used to visualize activity of heart during exertion - Coronary Angiogram
→catheter to heart muscle with dye to visualize coronary blood flow (blockages) & identify areas of ischemia
Pharmacological Interventions
- Meds used for vasodilation, prevention/treatment of pain, reduce risk of clotting/atherosclerosis
- Nitrates (short acting: nitroglycerin)
- Nitrates (long acting, extended release, patches, etc.)
- Calcium channel blockers
- Beta Blockers
- Antihyperlipidemics (statins)
- Anti-coagulants (ASA)
Nitroglycerin
Therapeutic Class: Vasodilator (short acting)
Pharmacologic Class: Nitrates
Action: d
→decreases BP
→decrease pre-load and afterload
Side Effects:
→Dizziness
→light headedness, headache, →orthostatic hypotension
→tachycardia
→hypotension
→flushing
Caution: avoid sildenafil (Viagara)→hypotension!
Nursing Considerations:
→health teaching on use
→monitor effects after
use
→Given sublingually to treat chest pain
If someone experiences chest pain…
- Stop activity
- Sit down
- Assess pain
- Assess vitals (BP, pulse)
- Administer nitroglycerin sublingually (1 spray q 5 minutes up to 3 sprays)
→ watch for HYPOtension - Reassess pain
- Reassess vitals
- If pain is unrelieved by 3 consecutive sprays or pain lasts longer than 15 minutes, notify MD
