Adult Health-Cardiovascular







Atropine- given to increase HR; symptomatic bradycardia (hypotension, CP, or syncope)
Adenosine- given to decrease HR (SVT, PSVT) rapid 1-2 secs followed by 20mL saline
bolus
MIDCAB (minimally invasive direct cardiac artery bypass)
o Incision between the ribs (very painful), short recovery
o Cough, deep breathe while splint chest with pillow, and use incentive spirometer
MI (Myocardial Infarction)-Monitor Troponin (normal <0.5 mcg/L)
o Report NEW development of
 New Pulmonary congestion (Xray), new S3 heart sound, crackles, JVD
post MI-all can signal HF
 Possible heart failure or cardiogenic shock
o Dysrhythmia (V-fib-Sudden death) most common complication-PUT ON
CARDIAC MONITOR 1st
o MI in women
 elderly/DM have GI problems as main sxs (N/V, belching, indigestion,
diaphoresis, dizzy, fatigue)
Angina Pectoris (brought on by Myocardial Ischemia)
o Causes
 Physical exertion (sexual activity, exercise)
 Intense emotion (anxiety, fear)
 Temp extremes (usually cold exposure)
 Smoking
 Stimulants (cocaine, amphetamines)
 Coronary Artery narrowing (atherosclerosis, coronary artery spasm)
PAD (HTN, DM, Hyperlipidemia, and Smoking)
o SXS: intermittent claudication (palpate post tibial/dorsalis pedis pulses
quality), skin atrophy with hair loss (poor perfusion), poor wound healing,
weak/absent pulse, bruit on auscultation, cool skin, and prolong cap refill, pain
increases when elevate legs, ulcer/gangrene distal to body
o Teach: Lower extremities BELOW heart level, exercise, skin care (lotion), warm
(socks, light blanket). No tight clothes/stress
o RX: vasodilators, antiplatelets (increase BF/prevent blood clots)
Chronic Venous Insufficiency
o SXS: Chronic edema/inflammation leads to brownish thick skin (leathery) on
extremities and venous leg ulcers (inside ankle)
o Teach: Wear compression stockings for healing/prevent ulcer recurrence








Pacemaker
o Assess function 1st (place on cardiac monitor), mechanical capture (palpate
pulse compare w/ cardiac monitor), and VS.
o Avoid lifting arms above shoulder until HCP clears, carry ID card/notify airport
personnel, wear medical bracelet, AVOID MRI, and avoid cell phone over pacer.
CAN USE MICROWAVE
Air embolism
o Complication of CVC (central venous catheter)
 SXS: respiratory distress (dyspnea, hypoxemia, sense of impending doom)
 RX: Apply occlusive dressing, administer oxygen, position LT lateral
Trendelenburg (promote air pooling in heart instead of lungs), monitor
status, and notify HCP
Abdominal Aortic Aneurysm Repair-Hemodynamic stability #1
o SXS of graft leakage
 Ecchymosis of groin/penis/scrotum/perineum, increased abd girth,
tachycardia, weak/absent peripheral pulse, low H&H, pain in pelvis,
back, or groin, decreased urine
o SXS arterial/graft occlusion
 Pedal pulse decreased from baseline, absent pulse w/ painful cool, or
mottled extremity >2 days PO
o PreOP: Assess character/quality of peripheral pulses for baseline used PO and ID
emergent complication (Embolization/Graft Occlusion
o PO: monitor renal status (BUN/Creatinine/Urine output)  comp: kidney injury
 Causes: hypotension, prolonged aortic clamping, blood loss, embolization
Endovascular Abdominal Aortic Aneurysm Repair
o Femoral Artery entry
o PO: monitor groin puncture site (bleeding/hematoma), peripheral pulses, fluid
intake/urine output, and kidney fx
Thoracic Aortic Aneurysm
o SXS: dysphagia (difficulty swallowing) pressure on esophagus
Mitral Valve Prolapse
o Teach: stay hydrated, avoid caffeine/alcohol, exercise regularly, and reduce stress
o RX: Beta Blocker (palp/CP) **Nitrates not effective**
IVC filter
o Notify team prior to MRI, promote physical activity, AVOID crossing legs, and
report leg pain/selling/numbness
Raynaud Phenomenon
o Teach: avoid smoking/caffeine/cocaine (vasoconstricting), stress reduction (Yoga,
tai chi), and layer clothes (gloves)

Ventricular Paced rhythm- pacer spike before QRS

Atrial Pacing- pacer before P wave
o Clients experiencing sinoatrial node dysfunction (A-Fib, bradycardia, heart
block)

Atrioventricular Paced Rhythm-Two spikes; 1st before p wave and 2nd before QRS
o Client with bradycardia, heart block, or cardiomyopathy

Third-degree AV block/Complete Heart Block-disassociated P waves and QRS
complex
o RX: Temp/Perm pacing

Ventricular tachycardia (HR 100-250)
o RX: CPR and defibrillation

Supraventricular Tachycardia (HR 150-250) No P wave
o RX: Vagal maneuvers, IV Adenosine; Possible synchronized cardioversion (if
hemodynamically unstable and meds not effective)

Asystole-No electrical activity
o SXS: no pulse or RR, unresponsive
o RX: 1st CPR, 2nd advance cardiac life support measures (Epi, trach), and treat
reversible cause

Sinus Bradycardia (HR <60)
o ASSESS: dizziness, syncope, CP, and hypotension
 RX(if sxs): Atropine or Transcutaneous Pacing (if med ineffective)

2nd degree Av Block Type 1
o Associated with MI or meds (BB, digoxin)
o SXS: hypotension, dizziness, SOB
o RX: Atropine or Temp pacing

PSVT (HR 150-220)
o SXS: hypotension, palp, dyspnea, angina
o RX: Vagal maneuver (Valsalva, cough, carotid massage), Adenosine rapid 1-2
secs followed by 20mL saline bolus, Cardioversion if vagal/meds unsuccessful

Ventricular Fibrillation-lethal dysrhythmia **IF NOT TREATED WILL NOT
RECOVER**
o Clients with Myocardial infarction, myocardial ischemia, HR, cardiomyopathy
o SXS(leads to): unresponsiveness, pulseless, and apneic state
o RX: CPR, Defibrillation, and drug therapy (Epi, Vasopressin, Amiodarone)

Atrial Fibrillation- IRREG; fibrillatory waves instead of P waves (P wave not
visible)
o Common dysrhythmia post cardiac surgery
o Clots from aorta  r/f stroke
o RX: Rate control (<100 bpm)CCB (diltiazem, verapamil)/BB(metoprolol)
/Digoxin, Anticoagulation

Aortic Stenosis
o SXS: exertional dyspnea, CP, and syncope; decreased ejection fraction/narrow
pulse pressure, and weak thread peripheral pulse
Mitral Valve Regurgitation
o Backflow of blood from LT ventricle
o Asymptomatic but report NEW sxs:
 HF (pulmonary edema; dyspnea, orthopnea, wt gain, cough, fatigue)
Coronary Arteriogram (angiogram)
o Teach: NPO 6-12 hours, feel warm/flushed while dye injected, will lie flat,
home same day, and will receive sedation medication (NOT GENERAL
ANESTHESIA)
Chronic HF
o SXS: RT/LT sided failure (systemic/pulmonary)
 Crackles, adventitious lung sounds on inspiration (pulm congestion),
JVD, and pitting edema
o Teach: No NSAIDS, daily weight (same time/same clothes/same scale),
diuretics in AM
Decompensated HF (acute)
o SXS: Pulmonary edema (orthopnea/paroxysmal nocturnal dyspnea,
anxiety/restless, tachypnea >30/min, pink/frothy sputum, and crackles)
o RX: furosemide, O2 therapy, vasodilator (nitro, nesiritide) decrease preload, +
inotropes (dopamine, dobutamine)-ONLY IF OTHER MEDS FAIL
HF
o fluid overload **ASSESS/AUSCULTATE BREATHING PRIORITY**
o exacerbation  ASSESS BNP
o Teach: weigh daily, restrict sodium/fluid intake, know how to take pulse
o RT side (systemic): peripheral edema, JVD, increased abd girth (hepatomegaly,
splenomegaly), and ascites











Hypertensive crisis EMERGENCY!!!
o **GOAL=Lower MAP by no more than 25% or maintain MAP of 110-115**
 Normal MAP 70-105  SBP + DBP x 2 divided by 3
 Lower BP slowly; if too fast can cause decrease perfusion to brain, heart,
kidneys
o >180/120, cause end organ damage (hemorrhagic stroke, kidney injury, HF,
papilledema, aortic dissection, or retinopathy)
o SXS: severe HA, confusion, N/V, and seizure **PRIOTITZE NEURO
ASSESSMENT- LOC (low LOC=hemorrhagic stroke) CRANIAL NERVES
o RX: IV nitrates or Antihypertensive (nitroprusside, labetalol, nicardipine), and
continuous cardiac monitor (BP, telemetry, and urine output)
Hypertension
o Risk factor
 African American
 DM
 Frequent stress
 Smoking of 1 pack of cigarette daily
 Hyperlipidemia
o DASH diet-eliminate/reduce sodium, sugar, cholesterol, trans/saturated fat
o Fresh fruit/veggies/whole grains daily
o Fat-free or low-fat dairy product
o Choose meats lower in cholesterol (fish, poultry)
o Alternate protein sources (legumes) instead of red meat
o Limit sweet, food high in sodium (chips, frozen meals, canned foods),
sugary beverage to occasional treat
Synchronized cardioversion
o Convert tachyarrhythmias (SVT, V-Tach) with pulse to stable cardiac rhythm
 Shock delivered at R wave **TURN ON SYNC FEATURE**
 If shock at T wave (no sync on) BAD!!!! Leads to lethal
arrythmia V-Fib
Hypovolemic Shock
o SXS: change in LOC, tachypnea, tachycardia w/ thread pulse, cool, clammy skin,
hypotension, and oliguria (decreased urine output <0.5 ml/kg/hr)
Hypervolemic Shock **Elevated CVP (normal 2-8 mmHg)**
o SXS: crackles, JVD, peripheral (pedal) edema, increased diluted urine output,
bounding peripheral pulses, S3 heart sound, and tachypnea/wt gain
Pericarditis
o Sharp pleuritic pain aggravated during inspiration and cough **RELIEVED SIT
UP LEAN FORWARD** , pericardial friction rub (expected finding-leathery,
high pitched, grating sound), ST-segment elevation-resolves on own
o RX: NSAIDs and Aspirin








o Complication: Cardiac tamponade (hypotension, muffled heart sound, &
neck vein distention (beck triad) TX: Pericardiocentesis
CABG
o Teach: notify HCP if redness/swelling/drainage at site, no lifting >5lbs until
cleared, take daily shower no bath, no drive 4-6 wks, and resume sexual activity
if can walk 1 block or walk 2 flights of stair with no exertion.
Aortic Dissection
o Preop: **PRIORITY** r/f aortic rupture; maintain normal BP/decrease HR (IV
BB ie Labetalol, Metoprolol, Propranolol)
Adequacy of tissue perfusion (shock syndrome/organ dysfunction)
o ASSESS: LOC, urine output, cap refill (<3 sec), peripheral sensation, skin
color, extremity temperature, and peripheral pulses.
Pericardial effusion**R/F CARDIAC TAMPONADE**
o SXS cardiac tamponade: narrow pulse pressure, hypotension, JVD, pulsus
paradoxus, and muffled/distant heart tone, dyspnea, tachycardia, and
tachypnea
o RX: Emergency Pericardiocentesis
Cardiac Nuclear Stress Test
o Teach: Do not eat/drink/smoke day of, No caffeine/decaffeinated drinks 24 hours
prior, No BB/nitrates/dipyridamole
DVT
o Asses: thorough neurovascular assessment of extremities (DP/PT pulses, temp,
cap refill, and circumference calf/thigh)
o Teach prevent: adequate fluid/limit caffeine/alcohol, elevate legs when sitting w/
dorsiflex feet, exercise (walk/swim), no smoking, and can travel but if >4 hours
compression socks/walk hourly/exercise calf & foot muscles
Mediastinal Chest tube
o Decreased drainage  ASSESS HEART SOUNDS (R/F cardiac tamponade),
if no cardiac tamponade troubleshoots for possible occlusion and contact HCP
Cardiomyopathy-r/f cardiogenic shock
o RX: O2, ECG, cardiac enzyme test, and interventions to decrease workload



Infective Endocarditis
o Causes formation vegetation on valves/endocardial surface  Embolization
 Stroke-paralysis one side
 Spinal cord ischemia-paralysis to both legs
 Ischemia to extremities-pain, pallor, and cold foot or arm
 Intestinal infarction-abdominal pain
 Splenic infarction-left upper quadrant pain
o RX: IV antibiotics for 4-6 weeks
Holter monitor
o Keep diary of activities and any symptoms experience
o Do not bathe or shower
o Engage in normal activity to stimulate condition so monitor can record
Murmurs
o Turbulent BF across diseased or malformed cardiac valve
 Musical, blowing, or swooshing sound between normal heart sounds
 Auscultated at:
 Aortic 2nd ICS, RT SB
 Pulmonic  2nd ICS LT SB
 Tricuspid  5th ICS LT SB
 Mitral  5th ICS at MCL; Apex/Maximal impulse/Apical Pulse
Mitral Valve Stenosis
murmur/Point of
maximal impulse or
apical pulse
Bruit (auscultate)periumbilical/epigastri
c
Pharm-Cardio

Cardiac Meds (Assess Safety)
o BB  monitor HR/BP
o ACE  monitor K+/BP
o ASA  monitor platelet/signs of bleeding
o Statins monitor for muscle pain
o Loop diuretic (furosemide)monitor VS/K+/BUN/creatinine
 Prevent hypokalemia, hypotension, and kidney injury

B-blockers-Metoprolol, Bisoprolol, Carvedilol, Propranolol
o Assess BP, HR
o DO NOT STOP ABRUPTLY
o Useful for Chronic HF NOT ADHF
o SE:
 Brady
 hypotension,
 bronchospasms,
 depression,
 impotence
o Propranolol
 Nonselective BB bronchoconstriction NO asthma client

Statins- Atorvastatin, Rosuvastatin, Simvastatin
o Lower cholesterol; reduce r/f atherosclerosis/CAD
o Notify HCP
 muscle aches
 myopathy (muscular weakness)
 obtain blood sample for Creatine kinase level (CK)
 if myopathy CK >10x normal  Med D/C
 AVOID Grapefruit w/ Simvastatin
o Take with evening meal or bedtime
o Monitor
 LFTs before starting statin therapy
 Hepatoxicity
o Contraindication;
 Salt substitutes
 High in K+ (must be approved by HCP)
o Therapeutic response:
o Decrease in
 LDL (<100)


Total cholesterol (<200)
Triglyceride (<150)

ARBS (Valsartan, Losartan)
o No OTC cold medicationslead to Hypertensive crisis
 Phenylephrine
 Pseudoephedrine
o No high sodium antacids
o No appetite suppressants
o Contraindication:
 Pregnancy-BBW  Cardiac defect/death of fetus

Ace Inhibitors- Enalapril, Lisinopril, Captopril
o Assess BP, K+
o DO NOT lower HR ok to give if bradycardia
o Adjust dose for clients with renal impairment (creatinine:0.2-1.3)
o AE:
 Angioedema
 Common in African American
 Place patient on -sartan (ARBS)
 Dry cough
 Hyperkalemia
 Symptomatic hypotension(orthostatic)
 GET UP SLOWLY
o Contraindication;
 Salt substitutes
 High in K+ (must be approved by HCP)
 Pregnancy-BBW
 Cardiac defect/death of fetus

CCB- Nifedipine, Amlodipine, Felodipine, Nicardipine
o Vasodilator used to treat hypertension/stable angina
o AE: **Teach to watch for**
 Dizziness
 Flushing
 HA
 Peripheral edema
 Leg elevation
 Constipation
 Increase fluid intake, fruits/veggies, high fiber foods, exercise
 Initial orthostatic hypotension
Change position slowly
o Non-dihydropyridine CCB (Diltiazem/Verapamil)
 Decrease HR, Hold w/ bradycardia
o AVOID Grapefruit juice severe hypotension


Thiazide Diuretics- Hydrochlorothiazide, Chlorothiazide
o Potassium wasting
o Treat hypertension/Edema
o Contraindication:
 Licorice root
 Hypokalemia
o Major SE:
 Hypokalemia muscle cramps
 Hyponatremia altered mental status/seizures
 Hyperuricemia precipitate/worsen gout
 Hyperglycemia adjust diabetic meds

Antiplatelets – Clopidogrel, Aspirin, Ticagrelor, Prasugrel
o Assess
 Bruising
 tarry stools
 platelets (normal 150,000-400,000)
o Contraindication:
 Ginkgo
 PUD
 Active bleeding
 ICP

Amiodarone
o Antidysrhythmic
o Use to treat life-threatening arrythmias if other tx failed
o Toxic adverse effects
 Pulmonary toxicity **LIFE THREATENING**
 Dry cough
 Pleuritic CP
 Dyspnea

Adenosine
o Treat SVT
o Intervention:
 Administer rapidly over 1-2 seconds (antecubital space)
 Followed with 20 mL saline flush
 Repeat boluses of 12mg may be given twice if persists

Monitor
 ECG continuously
 Flushing/dizziness/CP/palpitations during/after admin

Apixaban, Rivaroxaban, Dabigatran
o Anticoagulant; factor Xa inhibitor
o Teach:
 Increased r/f bleeding
 Bruising, blood in urine, black tarry stool
 Bleeding precautions
 Use of NSAID (Indomethacin, IBU, Meloxicam) increase
bleeding
 Swallow capsule w/ full glass of water
 Keep capsule in original container
 Stopping med increases R/F stroke

Digoxin (Therapeutic range 0.5-2)
o Teach:
 Check HR prior to admin if <60 or skipped beats hold, call HCP
 Report
 Visual changes
 N/V, anorexia, abdominal pain
 Lethargy, confusion, weakness
 Dizziness/lightheaded bradycardia/heart block

Nitrites- Nitroglycerin, Isosorbide
o Cause vasodilation/relaxation of smooth muscle
o IV Assess client for Hypotension decrease or D/C infusion
 Dizziness
 Lightheaded
o Contraindication:
 Sildenafil
o Teach:
 Packaged in light-resistant bottle with metal cap
 Away from light/heat sources (never in car)
 Keep in original container
 Lose potency in 6 months replace!
 Call EMS if pain not improved 5 minutes after 1st tablet
 Rotate sites for nitroglycerin patches
o Worn for 12-14 hours
o Upper body/arms



Meds that cause Orthostatic Hypotension
o Antihypertensive
 BB (metoprolol)
 Alpha blockers (terazosin)
o Antipsychotic
 Olanzapine
 Risperidone
o Antidepressant
 SSRI
o Diuretics
 Furosemide
 Hydrochlorothiazide
o Vasodilator
 Nitroglycerin
 Hydralazine
o Narcotics
 Morphine
Unfractionated heparin
o Keeps current clot from getting bigger
o Prevents new clots from forming
o Administered more than 6 hours after any surgery
o aPTT therapeutic value 1.5-2 times normal or 46-70 secs
Milrinone
o Increases heart contractility/promote vasodilation
o Home infusion through central line
 Teach:
 Ensure infusion pump at home
o Instruct family basic pump troubleshoot
 Evaluate medication effectiveness
 Monitor central line insertion site for infection
 Change dressings (available dressing kits)
 Monitor weight daily (scale at home)
 Monitor BP (BP cuff)
 R/F falling  hypotension

Thrombolytic
o Contraindication:
 Prior intracerebral hemorrhage,
 Cerebrovascular lesion (Arteriovenous malformation, aneurysm)
 Ischemic stroke within 3 months
 Aortic dissection
 Active bleeding
 Head trauma within 3 months

Alpha Agonist- Clonidine, Methyldopa
o Decrease sympathetic response decrease peripheral vascular
resistance/vasodilation
o Clonidine-HIGH POTENT antihypertensive
 DO NOT STOP ABRUPTLY Rebound Hypertensive crisis
 SE:  3 D’s
 Dizziness
 Drowsiness
 Dry mouth

Digoxin for children
o Hold digoxin if pulse
 <90-110 for infant/young child
 <70 for older child
o Admin oral fluid side/back of mouth
o Do not mix drug w/ food or liquids
o If missed dose, do not give extra dose. Stay on same schedule
o If more than 2 doses missed notify HCP
o If child vomits, DO not give second dose
o N/V, slow pulse rate  toxicity NOTIFY HCP
o Give water or brush teeth after admin

Warfarin
o Contraindication:
 Aspirin
 NSAIDS
 Alcohol
o Taken 3-6 months after PE
o INR regularly