Week 4 vavlular and Vascular Lecture Flashcards
What does stenosis mean in valvular disease?
-Valve opening is narrowed
-blood can’t move forward properly
What is regurgitation in valvular disease?
valve fails to close properly and there is blood backflow
What side of the heart do valve disorders more frequently occur?
Left side of heart
(Lt receives from lungs, pumps out to body)
what are commonly heard upon ascultation with valvular disease?
murmurs
What is Mitral Stenosis?
Blood can’t move well from left atrium to L ventricle (narrow)
In mitral stenosis where does blood back up to and what does it cause ?
L atrium and lungs
atrial enlargement/hypertrophy
pulmonary congestion
What is a later stage of mitral stenosis and what does it cause?
back up to R ventricle
Rt sided HF
What are the major symptoms of mitral stenosis?
- SOB
- dyspnea upon exersion
- hemoptysis
- A fib
- stroke (emboli due to blood stasis from afib)
- eventually Rt sided HF (backs up into system- edema, JVP)
What is mitral regurgitation?
-valve doesn’t close properly
- blood flows back to Lt atrium and then goes back into Lt ventricle so there’s too much blood in there
What can mitral regurgitation result in?
Shock
dyspnea
What can mitral regurgitation lead to?
Rt. sided HF (JVP, peripheral edema)
What is mitral prolapse?
valve leaflets enlarge and prolapse into the atrium
Mitral prolapse is usually asymptomatic but patients can eventually feel what symptoms?
- chest pain
- exercise intolerance
- dysrhythmias
What is aortic stenosis?
Obstruction of blood flow between left vent and aorta (not atrium)
What does Aortic stenosis cause?
L vent hypertrophy
decreased CO
What are the classic symptoms of Aortic stenosis?
syncope
angina
dyspnea upon exertion
What med should we be cautious to give to people with aortic stenosis and why?
Nitro
b/c preload has to be maintained in order to force the valve open
When is surgery done for someone with aortic stenosis?
When the valve is less than 1cm = <1 cm
what is aortic regurgitation?
valve doesn’t close completely
blood backs up from the aorta (not atrium) to Lt vent
What part of the heart mechanics does aortic regurgitation impact?
pumping action - ineffective
b/c Lt. vent. hypertrophies
What are the signs of aortic regurgitation ?
low CO
hypotension (low BP)
Shock
PROFOUND DYSPNEA
angina
What are the 5 points of data we collect (Assessment) for someone with valvular heart disease?
- family HX
- crackles - pulmonary congestion
- murmurs - heart sounds/pulses
- peripheral edema (pulses)
- decreased CO - perfusion to organs such as kidneys
What are the 3 main PMHX things we should ask about in someone with valvular heart disease?
- previous rheumatic fever
- previous endocarditis
- hx of IV drug abuse
What are the 4 diagnostic tests for valvular heart disease and what do they test for?
- Echocardiography (structure & movment of heart) - ultrasound of heart
- Exercise tolerance test (determines severity)
- Chest xray (atrial and vent. enlargement)
- EKG (dysrhythmias)
What are 5 non-surgical interventions for someone with valvular heart disease?
- drug therapy and rest
- prevent exaacerbations of PE, thromboembolsim and endocarditis
- anticoagulant therapy (warfarin)
- antidysrhythmic drugs or cardioversion (if Afib)
- treat HF if it develops
What are 4 procedural/surgical interventions for people with valvular heart disease
- balloon valvuloplasty
- TAVR (transcatheter aortic valve replacement)
- Valve repair
- Valve replacement
What’s a major concern for someone with a mechanical valve?
Thromboembolism
- life long anticoagulants and blood monitoring
What are we worried about with biologic valve?
calcification
What valve cannot be replaced with a biologic valve and why?
Aortic valve
b/c increase pressure
Which kind of valve replacement requires anticoagulants for life, Mechanical or biologic?
Mechanical valve only
what do we teach people with valvular disease?
- exercise plan to increase cardiac tolerance
- REST between activity
- Fluid overload - wt gain, perf. edema, crackles to lungs
- less salt - avoid caffeine
- O2 if needed
- prophylactic antibiotics b/f invasive surgery/diagnostic procedure/dentist
- no smoking
- mechanical valve = anticoags for life
- take meds
What is Cardiogenic shock?
HEART CAN’T PUMP d/t damage
emergency
What is Cardiogenic shock most often associated with?
acute MI
what is the big difference between cardiac shock compared to other shock?
RAPID fluid replacement can CAUSE FURTHER DAMAGE
What is the goal for someone with cardiogenic shock?
- restore blood flow to myocardium
- allow perfusion
What is infective endocarditis?
-Infection of heart valves and/or endocardial surface of the heart
- vegetations form
What is infective endocarditis caused by?
Bacteria (staph, strep) in blood stream
Viruses
Fungi
what conditions predispose someone to developing infective endocarditis?
- Prior endocarditis
- damaged valves
- IV drug use
- Hospital aquired bacteremia
- Rheumatic heart disease
How do infecting organisms enter the body leading to infective endocarditis?
-Oral cavity
-Skin rashes /lesions/abscesses
- infections (cutaneous, GI, GU)
- surgery or invasive procedures (IVs, CVADS)
Symptoms of infective endocarditis
- Low grade fever- infection
- Malaise - body fighting
- Chills - temp reg issues
- anorexia - GI affected
- back pain
- Headache
- weight loss
- Myalgia
- heart murmurs
Vegetations can fragment and migrate. What two types of embolism does it cause?
- Organ embolization
- Vascular embolization
Which embolization is more painful when a vegetation fragments or migrates?
organ embolization
What parts of the body/organs are affected in organ embolization?
Brain
Spleen
Kidneys
Lungs
GI tract
arms and leg vessels
What type of skin issues does Vascular embolization cause?
-Splinter hemorrhages (nails)
-Petichia
-Janeaway’s lesions (hands/feet)
-Roth’s spots (eyes)
What 2 lab assessments do we use for infective endocarditis?
-Blood cultures
-CBC might show increased WBC
What diagnostics are used for infective endocarditis?
echocardiogram - shows how well heart chambers are pumping
1. standard thoracic (ultrasound)
2. transesophageal echocardiogram (esophagus)
What do we monitor in people with infective endocarditis?
- fever
- decreased perfusion (LOC, low urine output)
- complications from vegetations (LOC, dyspnea, pain)
What types of emboli can form with vegetations?
- cerebral emboli
- pulmonary emboli
- renal emboli
What should patients do who have infective endocarditis ?
-avoid excessive fatigue
-rest before and after activity
-physical/emotional rest
What are the 2 things to determine with infective endocarditis?
- Cause (IV drug use, dental visit, procedure, valve disease)
- damage (bloodwork, CXray, ECG, EKG)
What are the 4 things to teach patients with Infective endocarditis?
- prophylactic antibiotics before dentist or surgery
- maintain good oral hygene
- avoid people with infections
- valve replacement maybe
What is acute pericarditis?
-inflammation of pericardial sac
what are the 6 causes of acute pericarditis?
- autoimmune disease
- bacterial
- idiopathic
- post MI
- radiation
- Viral
Symptoms of acute pericarditis
- sharp chest pain - increases with breathing
- worse pain when lying flat- better sitting forward
- *pericardial friction rub - high pitched grating sound
What is the hallmark sign of acute pericarditis?
pericardial friction rub
What are 2 complications of acute pericarditis?
- pericardial effusion - fluid btwn visceral & fibrous layer
- pressure on pulmonary tissue & laryngeal nerve) - Cardiac tamponade - intrapericardial pressure = decreased CO = hypotension
- neck veins and jugular veins distended - blood not moving forward * bad
What bad sign will we see when cardiac tamponade is present?
distended jugular veins and neck veins
How do we correct acute pericarditis?
- high dose inflammatories
- bedrest with HOB up (Tripod)
- manage pain & anxiety
- pericardiocentesis if cardiac tamponade
when someone has acute pericarditis and we have to give high dose inflammatories, what do we need to do to ensure patient safety?
- monitor for GI bleeds
- meds to protect GI tract & decrease gastric irritants
What does Rheumatic Carditis result from??
Results from lack of proper treatment of
1. strep
2. scarlet fever
What does Rheumatic carditis damage?
- endocardium - causes valvular mitral and aortic sentosis or regurgitiation
- Pericardium becomes thickened = pleural effusion
What is rheumatic carditis characterized by?
Aschoff bodies - small nodules in myocardium- replaced by scar tissue
What symptoms/signs do we see with rheumatic carditis?
- tachycardia
- enlarged heart
- murmurs - pericardial friction rub and pain
- ECG changes
- evidence of strep
What are the 3 things we do to treat rheumatic carditis?
- antibiotics
- rest
- treat symptoms
What 2 things do we teach people with rheumatic carditis?
- at risk of reinfection for rest of life
- need prophylactic antibiotics before any invasive or dental procedures
what heart issues require prophylactic antibiotics before invasive or dental procedures?
- rheumatic carditis
- Infective endocarditis
- Valvular disease
what do we want to ask someone about who may have/has CAD?
- comorbidities
- chest pain
- extremity pain
- dyspnea
- fatigue
- palpitations
- weight gain
what are the 8 things we look for in patients with valvular heart disease?
- confusion
- cyanosis
- dizziness
- dyspnea
- fatigue & weakness
- fainting
- hemoptysis
- palpitations
What vitals will we see in a patient with valvular heart disease?
- decreased CO - lower BP
- increased RR
- Fever
- Thready pulse
- irregular pulse
What do we auscultate for in someone with valvular heart disease?
- dysrhythmias
- murmurs
What do we assess lungs for in someone with valvular heart disease?
crackles, wheezes, hoarseness
What does a transesophageal echocardiography monitor?
progression of heart disease
What does cardiac catheterization monitor?
- pressure changes in the chambers
- quantifies the size of valve openings
What do we assess for in PVD regarding
1. General appearance
2. Pedal pulses
3. Assess pain
- 5p’s, pitting edema, skin & tonails, ulcerations, drainage, skin temp
- Pedal pulses. Use doplar if can’t find them
- Pain - dull ache, burning when active, pain at rest, intermittent pain
What tests are used for PVD?
- angiography - catheter into artery
- doppler ultrasound
- MRA - magnetic imagine angiogram
- Segmental blood pressures
What is the main cause of PAD?
atherosclerosis
What is claudication?
Muscle pain from lack of oxygen triggered by activity and relived by rest
Are there symptoms in stage 1 of PAD?
no-asymptomatic
no claudication
pp decreased (unnoticed)
What is stage 2 of PAD?
claudication
- muscle pain
- cramping when exercising
- relieved with rest
What is stage 3 PAD?
Pain at rest
- relieved when extremities are dependent
What is stage 4 PAD?
Necrosis/gangrene
- ulcers and black tissue (toes, heel)
- gangrenous odor
What are 5 typical signs of PAD?
1.Shiny hairless skin cool to touch
2.Skin taught and thin,
3.Thick, brittle nails
4.Diminished/absent pedal pulses
5. Prolonged cap refill
What are 3 symptoms of PAD when it’s at it’s severe stage?
1.Pallor when leg elevated and
redness when dependent (dependent rubor)
2.Cold gray-blue or dark gangrenous
3.Pain at rest
How does MRA help diagnose PAD?
contrast die used to see blood flow through arteries
How does segmental systolic BP measurement help diagnose PAD?
compares the BP between thigh and brachial.
The bigger the difference - the worse it is
How does ABI (ankle-brachial index help diagnose PAD?
divide the ankle pressure by brachial pressure.
If <.9 then PAD is present
How does exercise tolerance test help diagnose PAD?
measures pressures when pain OCCURS - while walking
How does Plethysmography help diagnose PAD?
tracings of arterial blood flow in the limb
Where are PAD ulcers usually found?
tips of toes and lateral malleolus
Are PAD ulcers cool or warm to the touch?
cool
What’s the FISRT thing we check if patient has arterial ulcers?
Pedal pulses!!!
What are 4 risk factor modifications for PAD?
- manage blood glucose
- control BP
- smoke cessation
- lower cholesterol
What medications are given for PAD?
- antiplatelets (ASA) OR Clopidogrel (Plavix)
- Pentoxifylline (Trental) - increase RBC flexibility
Patients should not have grapefruit juice with which PAD medication?
Plavix
Heart disease and PAD have the same dietary suggestions. What are the 4 dietary considerations?
- Healthy weight
- low salt
- low fat
- low cholesterol
What is the most important exercise people with PAD can do and why?
WALKING!
increases collateral circulation
What is the walking regime recommended for PAD?
30-40 min/day
3-5x a week
walk until discomfort then rest then resume
If patients with PAD have pain at night, how should they position their legs?
dependent, below the heart by dangling over the bed
What are the 4 interventions for PAD?
- balloon angioplasty with stent insertion - open artery & stent inserted
- arthrectomy - drill like
- aortoiliac and aortofemoral bypass - graft vein placed to bypass the block
- Femoropopliteal or femorotibial graft
After a PAD intervention procedure, what symptoms call for immediate physician intervention?
- change in VS
- any changes in perfusion
- changes in sensation or pain
- signs of bleeding
- compartment syndrome
- hematoma
- thrombosis/embolization
What are 3 things the nurse should focus on for the patient post - PAD intervention procedure?
- move around as soon as possible
- aggressive pain management
- careful wound assessment - low healing
Discharge teaching for PAD
- Inspect feet/legs daily
- protect feet from trauma - shoes
- change positions often
- control infection - clean & moisturize feet
- Cover ulcers with sterile dressing
- Rest pain means it’s getting worse
- good nutrition/exercise/stop smoking
What is acute arterial Ischemia?
Sudden blockage in arterial blood supply
- can lead to gangrene in a few hours
How do we monitor for acute arterial ischemia?
5 P’s
pulse
pallour
pain
paresthesia
paralysis
What can PVD lead to?
DVT and PE
What are 5 cues of DVT?
1/Unilateral leg Edema
2.Pain, sense of fullness
3.Hot to touch
4. Systemic temp
5. Positive Homen’s – unreliable test
What are the 3 diagnositc tests used with PVD?
- venous duplex ultrasonography - blood flow
- Impedance Plethysmography - assess blood flow
- D-Dimer blood test - coagulation, Fibrin, fragments
What drugs are used for DVT?
tPA through femoral vein into clot
What meds are used for PVD?
anticoags
- unfractioned heparin or low molecular weight heparin
- warfarin (vitamin K antagonist)
DOAC - rivaroxaban/apixaban
- similar to warfarin
- do not need frequent blood tests
What are 2 Intervention procedures for DVT?
Thrombectomy - remove clot
Inferior Vena Cava Filtration - a net to catch clots- temporary
What are important teachings for anticoag therapy?
- bleeding >15 min call EMS
- no NSAIDS or ASA - risk of bleeding
- Meds same time daily
- blood work
- signs of bleeding
- avoid high risk for bleed activities - sports, soft toothbrush, electric shaver
- limit alcohol
- medic alert bracelet
- let health care providers know about anticoag drugs - and dentist too
- don’t quickly change food - Vit K increase too fast
What do we teach patients about PVD?
- compression bandages
- Damp-dry dressings to ulcers
- balanced diet
- prevent infection
- daily walking
- Avoid standing/sitting too long
- Reduce swelling- elevate legs
- good shoes
What is Aortic Aneurysm ?
Out pouching or dilation
of the arterial wall
usually caused by
atherosclerosis
What are the 2 types of aortic aneurysm?
Abdominal
Thoracic
What are symptoms of Abdominal aortic aneurysm? (AA)
- pulsating mass left of midline
- Audible Bruits
- Pain in back
- epigastric pain
- GI issues (bowel)
What are the symptoms of a thoracic aneurysm?
- chest pain that radiates across chest to intrascapular area
- often asymptomatic but can have trachea issues
How do we diagnose abdominal or thorasic aortic aneurysm?
- CT scan
- Ultrasound
size & location
Which type of aortic aneurysm (anterior or posterior) has a poor prognosis and why?
Anterior b/c fast bleed into abdominal cavity
Which type of aortic aneurysm (anterior or posterior) has a better prognosis and why?
Posterior b/c bleeds into retroperitoneal space
- tamponaded by surrounding organs
What are 2 non-surgical interventions for aortic aneurysm?
- monitor growth <5cm
- maintain BP WNL
What is EVAR (endovascular graft procedure )with aortic aneurysm?
stents placed via femoral artery
What are 3 important things to monitor after an EVAR?
- bed rest - leg straight 4-6 hrs
- peripheral pulses and groin site
- Ischemic complications - emoboli
What is Aortic dissection?
Tearing of the inner layer of the aorta. Vessel layers separate. life threatening
What are signs of someone experiencing Aortic dissection?
- sudden severe excruciating chest, back, jaw pain (aortic arch)
- decreased CO
- decreased LOC, weak corotid & temporal pulses
- Pain in back and abdomen & legs (descending aorta)
What are 3 complications of Aortic dissection?
- cardiac tamponade
- aortic rupture
- occlusion of blood supply to organs ie) kidneys
what is the goal of aortic dissection intervention?
prevent rupture and progression of dissection
Which vitals should someone post DVT monitor everyday ?
HR
BP
