2016 Student RN - · PDF fileWhat they do:

VI. CARDIAC

Preload

Afterload

A. Normal blood flow through the heart:

The two major veins that bring blood to the right side of the heart are the superior and inferior vena cava (This blood is deoxygenated)→The blood enters the right atrium→ Then the right ventricle→ From the RV the blood is pumped into the pulmonary artery (this artery carries deoxygenated blood) → Then the blood goes to the lungs where it is oxygenated→ Next through the pulmonary veins (they carry oxygenated blood)→ It then goes to the left atrium → to the left ventricle (the big bad pump)→ It is then pumped into the aorta→ And finally this oxygenated blood is delivered throughout the body through the arterial system where it eventually ties back into the venous system.

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B. Cardiac Terms: 1. Preload is the amount of blood _____________ to the right side of the heart and the

muscle ________________ that the volume causes. ____________ is released when we have this stretch.

2. Afterload is the ___________ in the aorta and peripheral arteries that the left ventricle has to pump against to get the blood out.

This pressure is referred to as resistance.

With hypertension there’s even more ________________ for the left ventricle to pump against. That’s why ______________ can eventually lead to HF and pulmonary edema, because high afterload _______________ cardiac output and ________________ forward flow. Plus, it wears your heart out.

3. Stroke volume is the ____________ of blood pumped out of the ventricles with each beat.

C. Cardiac Output: CO = HR x SV

Tissue ____________ is dependent on an adequate cardiac output.

Cardiac output changes according to the body’s __________________.

1. Factors that affect cardiac output:

a. Heart rate and certain arrhythmias

b. Blood ___________

1) Less volume = ___________ CO

2) More volume = ___________CO

c. ______________ contractility

MI, medication, muscle disease

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2. Pathophysiology of decreased CO:

If your CO is decreased, will you perfuse properly? ________

a. Brain: LOC will go_______

b. Heart: Client reports of ________ pain

c. Lungs: Short of breath? ______ Lungs sound ______________

d. Skin: ________ and clammy

e. Kidneys: UO goes _____

f. Peripheral pulses: ____________

Arrhythmias are no big deal UNTIL they affect your cardiac output. g. Three Arrhythmias that are always a big deal:

1) ________________________________________

2) ________________________________________

3) ________________________________________

D. Coronary Artery Disease:

Coronary artery disease is the most common type of cardiovascular disease.

Coronary artery disease is a broad term that includes chronic stable angina and

acute coronary syndrome.

1. Chronic Stable Angina:

a. Pathophysiology:

1) Decreased blood flow to the myocardium→ ischemia or necrosis? → temporary pain/pressure in chest.

2) What brings this pain on? Low ____________usually due

to________________. 3) What relieves the pain? ______________ and/or __________


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b. Tx:

1) Medications:

a) nitroglycerin (Nitrostat®): Sublingual:

Causes venous and arterial ___________________

This result will cause ________________ preload and afterload.

Also causes dilation of _________________ arteries which will increase blood flow to the actual heart muscle (myocardium)

Take 1 every ________ min x ________ doses. Okay to swallow? __________

Keep in dark, glass bottle; dry, cool

May or may not burn or fizz

The client will get a ________________.

Renew how often? An average of every_________ months

Spray? _______ years

After nitroglycerin (Nitrostat®), what do you expect the BP to do? ______________________

b) Beta Blockers (for prevention of angina):

Examples: propranolol (Inderal®), metoprolol (Lopressor®/Toprol XL®), atenolol (Tenormin®), carvedilol (Coreg®)

What do beta blockers do to BP, P, and myocardial contractility? _______

What does this do to the workload of the heart? _______________

Beta blockers block the beta cells… these are the receptor sites for catecholamines- the epi and norepi. So we just decreased the contractility… So what happened to my CO? _____________. So we have ______________ the workload on my heart. This is a good thing to a certain point, because we decrease the work on the heart, the need for oxygen is decreased, and that decreases angina. But could we decrease the client’s cardiac output (HR and BP) too much with these drugs? ________

*TESTING STRATEGY* RULE: NEVER LEAVE AN UNSTABLE CLIENT.

Algorithm for NTG: Take one NTG SL, after 5 minutes if chest pain/discomfort is unimproved or worsened, activate emergency response.


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c) Calcium Channel Blockers (prevention of angina):

Examples: nifedipine (Procardia XL®), verapamil (Calan®), amlodipine (Norvasc®), diltiazem(Cardizem®)

What do these do to the BP? ____________

Calcium channel blockers cause vasodilation of the arterial system.

They dilate ____________________arteries.

Two benefits of calcium channel blockers are they ____________ afterload and ________________ oxygen to the heart muscle.

d) acetylsalicylic acid (Aspirin®):

Dose is determined by the physician (81 mg - 325 mg)

c. Client Education/Teaching for Chronic Stable Angina:

Rest frequently

Avoid overeating

Avoid excess caffeine or any drugs that increase HR.

Wait 2 hours after eating to exercise.

Dress warmly in cold weather (any temperature extreme can precipitate an attack).

Take nitroglycerin prophylactically.

Smoking cessation

Lose weight.

Avoid isometric exercise

Reduce stress

*TESTING STRATEGY* DO EVERYTHING YOU CAN TO

DECREASE THE WORKLOAD ON THE HEART.


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d. Cardiac Catheterization:

1) Pre-procedure:

Ask if they are allergic to ___________________________.

Iodine based dye is used during the procedure.

Also we want to check their kidney function because you excrete the dye through the ____________. Many primary healthcare providers order acetylcysteine (Mucomyst ®) pre-procedure especially if they have kidney problems. Mucomyst helps to protect the kidneys.

Hot shot

Palpitations normal

2) Post-procedure:

Monitor VS

Watch puncture site

What are you watching for? _______________ and hematoma formation

Assess extremity distal to puncture site (5-Ps).

Bed rest, flat, leg straight X 4-6 hours

Major complication post cath? ____________________

Report pain ASAP

If the client is on metformin (Glucophage), ______________ this medicine for 48 hours post procedure. We are worried about the _______________.

Unstable chronic angina= Impending MI

The 5 Ps Pulselessness

Pallor Pain

Paresthesia Paralysis


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2. Acute Coronary Syndrome: MI, Unstable Angina:

a. Pathophysiology:

1) Decreased blood flow to myocardium→ ischemia, necrosis or both? ___________

2) Does the client have to be doing anything to bring this pain on?

______________ 3) Will rest or nitroglycerin (Nitrostat®) relieve this pain? _______________

b. S/S:

Pain

May describe pain as ______________________, an elephant sitting on their chest, pressure radiating to the left arm and left jaw, N/V, or pain between their shoulder blades.

_______________ usually present with GI signs and symptoms, epigastric complaints or pain between the shoulders, an aching jaw or a choking sensation.

What is the #1 sign of an MI in the elderly? _________________

Cold/clammy/BP drops

Cardiac output is going ________. ECG changes

Vomiting

You may see the following terms in a test question:

***WORRY ABOUT THE STEMI CLIENT***

STEMI: ST-Segment Elevation Myocardial Infarction-this indicates that the client is having a heart attack and the goal is to get them to the cath lab for PCI in less than 90 minutes.

NSTEMI: Non- ST- Segment Elevation Myocardial Infarction-these clients are usually less worrisome.


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c. Diagnostic Lab Work:

1) CPK-MB:

Cardiac specific _____________________

_________ with damage to cardiac cells

Elevates in _____ hours and peaks in _____ hours

2) Troponin:

Cardiac biomarker with _______ specificity to myocardial damage

Elevates within ________ hours and remains _________ for up to 3 weeks 3) Myoglobin:

Increases within ____ hour and peaks in _____ hours

___________ results are a good thing.

4) Which cardiac biomarker is the most sensitive indicator for an MI? _____________

5) Which enzymes or markers are most helpful when the client delays seeking care? ________________

d. Complications:

Major arrhythmias:

What untreated arrhythmias will put the client at risk for sudden death?

____________________ ____________________ ____________________, plus we are going to add ____________________

Priority treatment for V-Fib: ___________________

If the first shock doesn’t work and the client remains in V-Fib, what is the first vasopressor we give? _________________

Lab values for Troponin Isomers

Troponin T < 0.10 ng/mL Troponin I < 0.03 ng/mL


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amiodarone (Cordarone®) is an anti-arrhythmic and is used when V-Fib and pulseless VT are resistant to treatment, and also for fast arrhythmias.

What anti-arrhythmic drugs are commonly given to prevent a second

episode of V-Fib? ________________ and ___________________.

Lidocaine toxicity: any _________ changes

amiodarone (Cordarone®) is the first anti-arrhythmic of choice.

Important side effect? ____________

This hypotension can lead to further arrhythmias.

e. Treatment:

What drugs are used for chest pain when they get to the ED? _______________________ _______________________ (chewable or tablet?) _______________________ _______________________

Head up position. Why?

Decreases ___________ on the heart and increases ________________.

1) Fibrinolytics:

Goal: Dissolve the clot that is blocking blood flow to the heart muscle→ decreases the size of the infarction.

Medications: streptokinase (Streptase®), alteplase (t-PA®), tenecteplase

(TNKase®, one time push), reteplase (Retavase®)

How soon after the onset of myocardial pain should these drugs be administered? Within _____________ hours

Brain attack? __________ IS BRAIN.

Major complication: _________________


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Obtain a _______________ history.

Absolute contraindications:

Intracranial neoplasm, intracranial bleed, suspected aortic dissection, or internal bleeding

During and after administration, we take ___________________ precautions.

Draw blood when starting IVs, decrease the number of _____________

sites. What about ABGs? ______________

Follow-Up Therapy: Antiplatelets are another important component of

fibrinolytic therapy.

acetylsalicylic acid (Aspirin®), clopidogrel (Plavix®), abciximab (ReoPro®) (continuous IV infusion to inhibit platelet aggregation)

2) Medical Interventions:

a) PCI (Percutaneous Coronary Intervention):

Includes all interventions such as PTCA (angioplasty) and stents

Major complication of the angioplasty is a _________.

Don’t forget client may bleed from heart cath site, or they could reocclude.

If any problems occur→ go to ___________________.

Chest pain after procedure: call the physician at once→ re- occluding!

Anti-platelet medications:

Aspirin

clopidogrel (Plavix®) Given to high risk clients who have

abciximab (ReoPro®) been stented to keep artery open and those waiting to go to cath lab

eptifibatide (Integrilin®)

Bleeding Precautions: Watch for bleeding gums, hematuria and black stools. Use an electric razor, a soft toothbrush, and No IMs.


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b) Coronary Artery Bypass Graft (CABG):

Can be scheduled or emergency procedure

Used with multiple vessel disease or left main coronary artery occlusion.

The ______________ main coronary artery supplies the entire left

ventricle.

Left main coronary artery occlusion… Think: __________________ or Widow Maker.

3) Cardiac Rehabilitation:

Smoking cessation

Stepped-care plan (increase activity gradually)

Diet changes- _____fat, _____salt, _____cholesterol

No isometric exercises-___________________ workload of heart

No Valsalva

No straining; no suppository; docusate (Colace®)

When can sex be resumed? _____________

What is the safest time of day for sex? ___________

Best exercise for MI client? _____________

Teach S/S of heart failure:

Weight __________________

Ankle edema

Shortness of ______________

Confusion

E. Heart Failure (HF):

1. Causes:

HF is a complication that can result from problems such as cardiomyopathy, valvular heart disease, endocarditis, acute MI, and _______________.


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2. Types:

a. Left Side Failure: the blood is not moving forward into the aorta and out to the body…IF it does not move forward, then it will go backwards into the ________.

S/S: Pulmonary congestion Dyspnea Cough Blood tinged frothy sputum Restlessness Tachycardia S-3 Orthopnea Nocturnal dyspnea

b. Right Side Failure: the blood is not moving forward into the lungs…IF it does not move forwards then it goes backwards into the ___________ system.

S/S: Distended neck veins Edema

Enlarged organs Weight gain Ascites

Terminology: Systolic heart failure: heart can’t contract and eject. Diastolic heart failure: ventricles can’t relax and fill.

3. Dx:

a. B-type (BNP) natriuretic peptide: Secreted by ventricular tissues in the heart when ventricular volumes and

pressures in the heart are increased

Sensitive indicator

Can be _________ for HF when the CXR does not indicate a problem

If the client is on nesiritide (Natrecor®), turn it off _________ prior to drawing a BNP.


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b. CXR: enlarged ____________________, pulmonary infiltrates

c. Echocardiogram

d. New York Heart Association Functional Classification of Persons with HF:

Classes 1-4 (Class 4 being worst)

4. Tx:

a. Medications: Standard medication therapy for HF is ACE inhibitors and ARBS.

1) ACE Inhibitors:

These are the Drugs of Choice (DOC)for HF

They suppress the Renin Angiotensin System (RAS)

Prevent conversion of Angiotensin I to Angiotensin II

Results in arterial _____________ and ______________ stroke volume.

2) ARBS: Block Angiotensin II receptors, and causes a ________________ in

arterial resistance and decreased BP.

The Swan-Ganz (Pulmonary Artery) catheter is a balloon flotation catheter that can be floated into the right side of the heart and pulmonary artery. It provides information to rapidly determine hemodynamic pressures, cardiac output and provides access to mixed venous blood sampling.

Arterial lines can be places in multiple arteries, but the most common site is the radial artery. It provides continuous intra-arterial blood pressure monitoring and allows for repeated ABG samples to be collected without injury to the client.


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Ace inhibitors and ARBS both block aldosterone. When we block aldosterone, we lose _____________ and ____________ and retain __________________. It is standard practice (a core measure) that a client with HF will be sent home on an ____________________and/or a beta blocker. Why? Because, these drugs in combination ____________ the workload on the heart by preventing vasoconstriction (decreasing afterload). This will increase the cardiac output and keep blood moving ________________ out of the heart. That’s what we want- forward flow.

3) Digoxin (Lanoxin®):

Actions:

Used less today because of the risk of drug toxicity, especially in the elderly.

Used with sinus rhythm or atrial fibrillation and accompanying chronic HF.

Often given in combination with an ACE inhibitor, ARB, beta blocker or

________________.

Contraction? __________________

Heart rate? ____________________

When the heart rate is slowed this gives the ventricles more time to fill with blood.

Cardiac output will go ___________.

Kidney perfusion _______________.

Nursing Considerations:

Would diuresis be a good thing or bad thing for this client? _________

We always want to ____________heart failure clients…they can’t handle the fluid.

Digitalizing dose (loading dose)

How do you know the Digoxin is working? Because the cardiac output goes_____

Normal Dig level= ____to____ ng/ml


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S/S of toxicity:

Early: Anorexia, nausea, and vomiting

Late: Arrhythmias and _________________ changes

Before administering, do what? ________________________

Monitor electrolytes

All electrolyte levels must remain normal, but K+ is the one that causes the most trouble.

(_____________________+_______________________=______________________)

4) Diuretics:

Examples: furosemide (Lasix®), hydrochlorothiazide (HCTZ®), bumetanide (Bumex®), hydrochlorothiazide/triamterene (Dyazide®), spironolactone (Aldactone®)

Action: Decreases _____________________________ Nursing Considerations:

When do you give diuretics? ______________________

b. Low Na Diet:

Decrease _________________________________.

Watch salt substitutes.

Salt substitutes can contain excessive ____________________________.

Canned/processed foods & OTC meds can contain a lot of _________________.

c. Elevate head of bed

d. Weigh daily and report a gain of ___________

e. Report signs and symptoms of recurring failure.

*TESTING STRATEGY* Fluid retention-think Heart Problems 1st.

*TESTING STRATEGY* Any electrolyte imbalance can promote Digoxin toxicity.


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f. Pacemaker: Your “natural” pacemaker is the SA node or sinus node.

It sends out impulses that make the heart ___________________.

If your heart rate drops to 60 or below, cardiac output can ____________________.

Pacemakers are used to increase the heart rate with symptomatic bradycardia.

Pacemakers depolarize the heart muscle and a contraction will occur (electricity goes through the muscle).

Repolarization (ventricles are resting and are filling up with blood).

Pacemakers may be temporary (invasive or non-invasive) or permanent.

Most permanent pacemakers are demand, but you can also see fixed pacemakers.

Always worry if the heart rate drops below the set rate.

Any pacemaker will maintain a certain minimal heart rate depending on the

settings, in other words the ________________.

A demand pacemaker kicks in only when the client needs it to.

Fixed rate pacemakers fire at a ______________ rate constantly.

It’s okay for the rate to increase but never ___________________.

Always worry if the rate ___________ below the set rate.

Post-Procedure Care (for permanent pacemakers):

Monitor the incision.

Most common complication post-op? Electrode __________________

Immobilize arm.

Assisted passive range of motion to prevent frozen _______________

Keep the client from raising the arm higher than shoulder height.


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S/S of Malfunction:

It’s possible that no contraction will follow the stimulus.

This is called __________________.

What causes this?

The pacemaker may not be ___________________ correctly.

Electrodes can _________________.

Battery may be _______________.

Watch for any sign of decreased CO or decreased _________________.

Client Education/Teaching:

Check __________________ daily.

ID card or bracelet

Avoid electromagnetic fields (cell phones, large motors).

Avoid MRIs.

Are they going to set off alarms at airport? _______

Avoid contact sports.

ICD – Implantable Cardiac Device

May be used to pace the heart, or it might be used to defibrillate people in V-Fib.

Post-op care for an ICD is the same as for a pacemaker.

F. Pulmonary Edema:

1. Who is at risk?

Any person:

receiving IV fluids really ___________________

the very young and the very old

any person who has a history of ____________ or _______________ disease

ICD- May also see referred to as Implantable Cardioverter Defibrillator


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2. Pathophysiology:

Fluid is backing up into the _______________. The heart is unable to move the volume _________________.

Pulmonary edema usually occurs at ______________, when the client goes to ___________________.

3. S/S:

Sudden onset

Breathless

Restless/anxious

Severe ___________________________

Productive cough (pink frothy sputum)

4. Tx:

a. Oxygen:

The priority nursing action is to administer high flow oxygen. Monitor oxygen sat and titrate to keep above ________%.

b. Medications:

1) Diuretics:

furosemide (Lasix®)

Causes diuresis and vasodilation which traps more blood out in the arms and legs and reduces _______________ and ___________

40 mg IV push slowly over 1-2 minutes to prevent __________________ and ototoxicity

bumetanide (Bumex®)

Can be given IV push or as a continuous IV infusion to provide rapid fluid _________

1-2 mg IV push given over 1-2 minutes

2) nitroglycerin (Nitro-Bid®) IV:

Vasodilation: ____________ afterload

Decreased afterload = increased CO because the heart is pumping against less pressure, and more blood can be moved _____________.


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3) Morphine (Morphine Sulfate®):

2 mg IV push for vasodilation to decrease preload and afterload

4) Nesiritide (Natrecor®):

IV infusion; short term therapy; not to be given more than 48 hours

Vasodilates veins and arteries and has a diuretic effect

c. Positioning:

_________________ position; legs down

Improves ______________________________

Promotes ______________________ of blood in lower extremities

d. Prevention:

Prevention when possible:

Check ________________________, and

Avoid fluid volume __________________.

G. Cardiac Tamponade:

1. Pathophysiology:

_____________________, fluid, or exudates have leaked into the pericardial sac resulting in compression of the heart.

This can happen if the client has had a motor vehicle collision, right ventricular biopsy, an ___________, pericarditis, or hemorrhage post CABG.

2. S/S:

Decreased cardiac output

CVP will be _______________.

BP will be dropping.

Hallmark signs for cardiac tamponade

________________ CVP

__________________ BP

Remember to turn the Natrecor ® infusion off 2 hours before drawing a BNP level.


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Heart sounds will be muffled or distant.

Neck veins _________________

Pressures in all 4 chambers are the same

Shock

Narrowed pulse pressure (from the baseline)

What is the pulse pressure? It’s the difference between the ________________ and the ______________________ pressure.

3. Tx:

Pericardiocentesis to remove _________________________ from around the heart

Surgery

H. Arterial Disorders:

1. General Information: a. Pathophysiology:

If you have atherosclerosis in one place, you have it everywhere.

It is a medical emergency if you have an acute arterial _______________ (numb, pain, cold, no pulse).

Client will report numbness and pain

The extremity will be cold

No palpable pulse

More symptomatic in ______________________ extremities

Intermittent claudication- hallmark _________________.

Arterial blood isn’t getting to the ______________________→coldness, numbness, decreased peripheral pulses, atrophy, bruit, skin/nail changes, and ulcerations.

Pain at rest means _________________ obstruction.

Narrowed pulse pressure think: Cardiac Tamponade Widened pulse pressure think: Increased Intracranial Pressure


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b. Tx:

Since arterial blood is having problems getting to the tissue, if you elevated the extremity would the pain increase or decrease? _____________________

Arterial disorders of the lower extremities are usually treated with either angioplasty or endarterectomy.

We ELEVATE veins

We DANGLE arteries


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ACE inhibitors (angiotensin converting enzyme inhibitor) Actions: Uses: Blocks conversion of angiotensin I to angiotensin II Hypertension and heart failure What they do: promote vasodilation and diuresis, Nursing Observations: decrease the secretion of aldosterone (so the If the drug ends in –pril it is most likely an ACE kidneys will get rid of sodium and water and retain inhibitor. potassium). Watch for hyperkalemia, orthostatic syncope, Examples: hypotension, and renal dysfunction. enalapril (Vasotec®) Angioedema creating laryngeal swelling, can be fosinopril (Monopril®) fatal. Dry, nonproductive cough-reversible when captopril (Capoten®) drug stopped. Fall precautions. ARBs (angiotensin II receptor blockers)

Action: Uses: Blocks effects of angiotensin II (a potent Hypertension and heart failure. vasoconstrictor) at the receptor site (used as an Nursing Considerations: alternative to ACE inhibitors). ACE inhibitors block If the drug ends in –sartan it is most likely an ARB the conversion of AI to AII but AII can also be Watch for hyperkalemia, hypotension, and renal formed by other enzymes that are not blocked by dysfunction.. ACE Inhibitors. What they do: decrease blood pressure, increase CO Examples: valsartan (Diovan®) losartan (Cozaar®) irbesartan (Avapro®) Beta Adrenergic Blockers

Action: Uses: Block adverse effects from sympathetic nervous Angina, chest pain. Hypertension, ventricular stimulation. dysrhythmias and thyroid storm. What they do: block the receptor sites for epi and Nursing Consideration: norepi…so they will decrease afterload and If the drug ends in–lol it is most likely a beta contractility….as a result they decrease the BP and blocker. HR. Don’t give to asthmatics (some beta blockers also Examples: constrict the smooth muscle of the bronchioles). propranolol (Inderal®) Don’t give to diabetics (blocks the sympathetic metoprolol (Lopressor®/Toprol XL®) responses seen in hypoglycemia). atenolol (Tenormin®) carvedilol (Coreg®)


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Chronic Arterial vs Chronic Venous

Symptom

Chronic Arterial Insufficiency Chronic Venous Insufficiency

Pain Intermittent claudication (progresses to pain at rest)

None to aching pain, depending on dependency of area

Pulses Decreased or may be absent Normal (may be difficult to palpate due to edema)

Color Pale when elevated, red with lowering of leg

Normal (may see petechiae or brown pigmentation with chronic condition)

Temperature Cool Normal

Edema Absent or mild Present

Skin Changes Thin, shiny, loss of hair over foot/toes, nail thickening

Brown pigmentation around ankles, possible thickening of skin, scarring may develop

Ulceration If present, will involve toes or areas of trauma on feet (painful)

If present, will be on sides of ankles

Gangrene May develop Does not develop

Compression Not used Used


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2016 Student RN - · PDF fileWhat they do: