Week 2 recorded cardio vascular part 2 Flashcards
What is Heart Failure?
A physiological state where cardiac output is
insufficient to meet the needs of the body.
Heart failure can be a problem with structure or
function of the heart.
Causes of Heart Failure:
▶ Coronary Artery Disease (CAD)
▶ Atherosclerosis
▶ Tobacco
▶ Elevated Lipids
▶ Diet
▶ Sedentary
▶ Uncontrolled Hypertension
▶ Myocardial Infarction
▶ Renal Dysfunction
▶ Volume Overload
▶ Cardiomyopathy
▶ Diabetes Mellitus
▶ Heart Valve Disorders
Cardiac Output (CO)
▶ Volume of blood pumped throughout the body per minute.
▶ Heart Rate X Stroke Volume = CO (Liters / Minute)
▶ Normal CO necessary to maintain tissue perfusion.
▶ TIME IS TISSUE: Decreased perfusion = cellular death (Infarction)
▶ Cellular Death and Cardiogenic Shock
▶ Preload =
▶ Afterload=
Volume of blood in ventricles at end of diastole.
▶ Volume of blood received back to the heart.
▶ Preload is the amount ventricles stretch at end of diastole.
▶ Relaxation and filling phase.
▶ AV valves (mitral and tricuspid) are wide open
▶ Afterload = Resistance left ventricle must overcome to eject and
circulate blood.
▶ Afterload is the squeeze.
▶ Pressure opens semilunar valves (pulmonic and aortic) to push
blood out through circulation. Right to lungs, left to peripheral.
▶ Affected by Systemic Vascular Resistance (SVR)
Preload
▶ To increase preload (which will increase stroke volume and cardiac output):
▶ To decrease preload:
Preload
▶ To increase preload (which will increase stroke volume and cardiac output):
▶ ie. Hypovolemic Shock
▶ IV Fluids
▶ Stimulate SNS
▶ To decrease preload:
▶ ie. Fluid Overload in HF
▶ Diuretics
▶ Vasodilation
Afterload
▶ To increase afterload:
▶ To decrease afterload:
Afterload
▶ To increase afterload:
▶ ie. Aortic Stenosis
▶ ie. Pulmonary HTN
▶ Increase Vasoconstriction
▶ To decrease afterload:
▶ Vasodilators to decrease vascular resistance.
Ejection Fraction
Ejection Fraction
Measurement in percentage of total blood volume that the
left ventricle pumps out with each contraction
The right side Heart failure
The right ventricle plays
a supporting yet
important role in
circulation.
▶ Sends deoxygenated
blood into the lungs for
oxygenation and then
back to the left side of
the heart.
▶ Systolic failure.
▶ A contraction problem
The left ventricle failure
The left ventricle is the
powerhouse of the heart.
▶ Sends oxygenated blood
out to the peripherals.
▶ Diastolic failure.
▶ A relaxation problem
Acute =
decompensated =
heart=
failure=
Acute = Sudden in onset, severe
▶ Decompensated = Deterioration of a structure or system previously
working with the help of compensatory mechanisms
▶ Heart = Organ that functions to circulate blood and perfuse tissue.
▶ Failure = A state of insufficiency or declined performance leading to
dysfunction of a body system (cardiovascular) or organ (heart)
Acute Decompensated Heart Failure (ADHF)
Acute Decompensated Heart Failure (ADHF)
▶ Increased Respiratory Rate
▶ Fluid Shift and Interstitial Edema
▶ Tachypnea and SOB
▶ Pulmonary Edema with Hemoptysis
▶ Crackles
▶ Tachycardia
▶ Hypotension
▶ Severe Dyspnea
▶ Orthopnea
▶ Use of Accessory Muscles to Breathe
What is Pulmonary Edema?
▶ aka Pulmonary Congestion
▶ Liquid Accumulation
▶ Tissue
▶ Alveoli
▶ Concerns:
▶ Impaired Gas Exchange
▶ Acute Respiratory Failure
ventilatory Support
▶ Nasal Cannula
▶ 6L Max up to 44% FIO2
▶ Simple Face Mask
▶ 10L Max up to 60% FIO2
▶ Non-Rebreather Mask
▶ 15L Max up to 100% FIO2
▶ VapoTherm
▶ 40L Max with 100% FIO2
▶ BiPap
▶ Rate 10-12 breaths per minute, 100% FIO2.
▶ Endotracheal (ET) Intubation
▶ Full Ventilatory Support for those unable to maintain airway
Chest X-Ray:
Fluid in lungs
Enlarged Heart
▶ Fluid in lungs - Pulmonary Edema
▶ Enlarged Heart - Pulmonary Arterial Hypertension
▶ Air Between Lung/Chest Wall - Pneumothorax
▶ Infiltrates (blood, pus) - Pneumonia
BNP (brain natriuretic peptide)
aka B-type natriuretic peptide
▶ Hormone secreted by cardiomyocytes in the heart
ventricles in response to stretching caused by
increased ventricular blood volume.
▶ Normal Range = <100 pg/mL
What other labs would be important?
▶ Cardiac Biomarkers
▶ Troponins
▶ CK-MB
▶ Myoglobin
▶ Renal Function
▶ BUN and Serum Creatinine
▶ Electrolytes
▶ Especially Potassium, Magnesium
HF Medications: Why? Priority Assessments?
▶ Loop Diuretic - Fluid excretion and elimination
▶ Furosemide
▶ Nitroprusside - Vasodilation, rapid onset
▶ Severe HF
▶ ACE Inhibitor - Vasodilator - reduce BP cardiac workload
▶ Lisinopril
▶ Angiotensin Receptor Blockers - decrease BP and cardiac workload
▶ Valsartan
Hydralazine - Vasodilator - decrease BP
▶ Digitalis - increase cardiac contractility and LV function
▶ Digoxin
▶ Beta Blockers - directly block negative effects of SNS on
failing heart by decreasing HR to allow left ventricle time
to fill more completely.
▶ Carvedilol
what About Morphine?
▶ Morphine - It’s not just for pain…..
▶ Vasodilator properties
▶ Decrease dyspnea
▶ Decrease anxiety
▶ Decrease cardiac workload
Nursing Diagnosis
▶ Impaired Gas Exchange
▶ Decreased Cardiac Output
▶ Excess Fluid Volume
▶ Activity Intolerance
Peripheral Arterial Occlusive Disease (PAD)
▶ Hallmark Sign: Intermittent Claudication
▶ Elevation Pallor and Dependant Rubor
▶ Symptomatic Claudication
▶ Pentoxifylline and Cilostazol
▶ Antiplatelets
▶ Statins
PAD Management
▶ Radiologic Intervention
▶ Balloon Angioplasty
▶ Stent
▶ Stent graft
▶ Atherectomy
▶ Surgical Management
▶ Bypass Graft (50% or more occlusion)
Critical Limb Ischemia
▶ Severe obstruction
▶ Pain at rest
▶ Non Healing wounds
▶ Gangrene
Medication Review: Preventing or
Reducing Blood Clots
▶ Unfractionated Heparin (Protamine Sulfate)
▶ aPTT
▶ Low-Molecular-Weight Heparin
▶ Enoxaparin
▶ Longer Half Life
▶ Oral Anticoagulants
▶ Warfarin (Vitamin K)
▶ INR
▶ Thrombolytic Therapy
▶ Alteplase
▶ Factor Xa and Direct Thrombin Inhibitors
▶ Rivaroxaban (Xarelto)
▶ Apixaban (Eliquis)
▶ Direct Thrombin Inhibitor
▶ Dabigatran (Pradaxa)
Upper Extremity Arterial Occlusive Disease
▶ Coolness and Pallor
▶ Stent or Stent Graft
▶ Percutaneous Transluminal Angioplasty (PTA)
▶ Bilateral BP Comparison
Aortic Aneurysms
▶ Aneurysm
▶ Abdominal
▶ Thoracic
Dissecting Aorta
▶ Dissection
▶ Severe pain
▶ Nausea and vomiting
▶ Tearing feeling
▶ Pulsating abdomen
Arterial Embolism and Thrombosis
Acute Vascular Occlusion
Acute Arterial Occlusion
Arterial Embolism and Thrombosis
Acute Vascular Occlusion
▶ Arterial Emboli
▶ Acute Thrombosis
Acute Arterial Occlusion
▶ Iatrogenic Causes
▶ IV Drug Use
▶ Trauma
Raynaud’s Phenomenon
▶ Microvascular vasoconstriction
▶ Coolness, pain, pallor
▶ Avoid stimuli
▶ Calcium channel blockers
Venous Thromboembolism (VTE)
▶ Deep Vein Thrombosis
▶ Pulmonary Embolism
Chronic Venous Insufficiency /
Postthrombotic Syndrome
▶ Obstruction of valves
▶ Reflux of blood
▶ Superficial or deep veins
▶ Prolonged venous pressure
▶ Increased risk of infection / injury
▶ Treatment:
▶ Leg elevation
▶ Compression stockings
The Six P’s of Acute Arterial Occlusion
▶ Pain
▶ Pallor
▶ Poikilothermia
▶ Pulselessness
▶ Paresthesia
▶ Paralysis
Why are these symptoms occurring?
Varicose Veins
▶ Abnormally dilated and tortuous
▶ Primary (no deep vein involvement)
▶ Secondary (obstruction of deep veins)
▶ Ligation and Stripping
▶ Micro Phlebectomy
lymphatic Disorders
▶ Lymphangitis
▶ Lymphadenitis
▶ Lymphedema
▶ Elephantiasis
What laboratory test would
you ensure is ordered for DVT?
D-Dimer: Measures a substance in the
blood released when a blood clot
dissolves.
What is the normal D-dimer value?
250 ng/mL
What diagnostic test will you
request from the physician to
confirm the presence of a DVT?
Venous Ultrasound RLE
Ultrasound uses high frequency sound waves to
create pictures and measure the amount of
blood flow through your veins.
What are the three main goals of
treatment?
▶ Stop the clot from growing larger.
▶ Prevent clot from breaking off and moving to the lungs.
▶ Decrease the risk of having another clot.
DVT Medications: Why? Priority Assessments?
▶ Anticoagulation:
▶ Heparin Subcutaneous x 5 days
▶Normal vs. Therapeutic Level
▶q 6 hours initially
▶Reversal Agent
▶ Warfarin PO
▶Normal vs. Therapeutic Level
▶Bridge Therapy
▶Reversal Agent
Warfarin LEVEL
▶ Test: INR
▶ Normal Range: 1 or less
▶ Therapeutic Range: 2.0 - 3.5
▶ Reversal Agent: Vitamin K
Heparin test and level
Test: aPTT
▶ Normal Range: 20 - 39 seconds
▶ Therapeutic Range: 30 - 100 seconds
▶ Reversal Agent: Protamine Sulfate
Let’s recap the risk factors for a DVT/PE
▶ Sedentary Lifestyle
▶ Recent sedentary behavior
▶ Travel
▶ Prolonged bed rest
▶ Surgery
▶ Heart Failure
▶ Birth Control or Hormone Supplementation
▶ Smoking
▶ Obesity
▶ Pregnancy
▶ Cancer
▶ Genetic Clotting Disorders
