Cardiac
VI. CARDIAC
Cardiac
VI. CARDIAC
A. Normal blood flow through the heart:
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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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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:
B. Cardiac Terms:
1. Preload is the amount of blood _____________ to the heart.
1. Preload is the amount of blood _____________ to the heart.
2. Afterload is the ___________ in the aorta and peripheral arteries that the left
2. Afterload is the ___________ in the aorta and peripheral arteries that the left
ventricle has to pump against to get the blood out.
ventricle has to pump against to get the blood out.
•
That pressure is referred to as resistance.
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That pressure is referred to as resistance.
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The resistance the LV has to overcome to get the blood out
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The resistance the LV has to overcome to get the blood out
3. Stroke volume is the ____________ of blood pumped out of the ventricles with each
3. Stroke volume is the ____________ of blood pumped out of the ventricles with each
beat.
beat.
C. Cardiac Output:
•
Tissue ____________ is dependent on an adequate cardiac output.
•
Cardiac output changes according to the body’s __________________.
1. Factors that affect cardiac output:
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CO = HR x SV
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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 arrthymias
a. Heart rate and certain arrthymias
b. Blood ___________
b. Blood ___________
c. ______________ contractility
c. ______________ contractility
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MI, medication, muscle disease
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Cardiac
CO = HR x SV
Cardiac
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C. Cardiac Output:
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MI, medication, muscle disease
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2. Pathophysiology of decreased CO:
2. Pathophysiology of decreased CO:
If your CO is decreased, will you perfuse properly? ________
a. Brain: LOC will go_______
a. Brain: LOC will go_______
b. Heart: Client complains of ________ pain
b. Heart: Client complains of ________ pain
c. Lungs: Short of breath? ______
c. Lungs: Short of breath? ______
d. Skin: ________ and clammy
d. Skin: ________ and clammy
e. Kidneys: UO goes _____
e. Kidneys: UO goes _____
f. Peripheral pulses: ____________
f. Peripheral pulses: ____________
Arrhythmias are no big deal UNTIL they affect your cardiac output.
Arrhythmias are no big deal UNTIL they affect your cardiac output.
(1) ________________________________________
(1) ________________________________________
(2) ________________________________________
(2) ________________________________________
(3) ________________________________________
(3) ________________________________________
D. Chronic Stable Angina:
D. Chronic Stable Angina:
1. Pathophysiology:
1. Pathophysiology:
a. Decreased blood flow to myocardium→ ischemia or necrosis?→ temporary
a. Decreased blood flow to myocardium→ ischemia or necrosis?→ temporary
b. Usually caused by CAD
b. Usually caused by CAD
c. What brings this pain on? ____________________________
c. What brings this pain on? ____________________________
d. What relieves the pain? ______________ and/or __________
d. What relieves the pain? ______________ and/or __________
pain/pressure in chest ________________
pain/pressure in chest ________________
2. Tx:
2. Tx:
a. Medications:
a. Medications:
1) Nitroglycerin (Nitrostat ® ): Sublingual
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If your CO is decreased, will you perfuse properly? ________
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Cardiac
Cardiac
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1) Nitroglycerin (Nitrostat ® ): Sublingual
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Causes venous and arterial ___________________
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Causes venous and arterial ___________________
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This result will cause ________________ preload and afterload.
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This result will cause ________________ preload and afterload.
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Also causes dilation of _________________ arteries which will increase
blood flow to the actual heart muscle (myocardium)
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Also causes dilation of _________________ arteries which will increase
blood flow to the actual heart muscle (myocardium)
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Take 1 every ________ min x ________ doses.
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Take 1 every ________ min x ________ doses.
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Okay to swallow? __________
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Okay to swallow? __________
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Keep in dark, glass bottle; dry, cool
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Keep in dark, glass bottle; dry, cool
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May or may not burn or fizz
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May or may not burn or fizz
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The client will get a ________________.
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The client will get a ________________.
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Renew how often? _________ months
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Renew how often? _________ months
Spray? _______ years
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Spray? _______ years
After Nitroglycerin (Nitrostat®), what do you expect the BP to do? _____
2) Beta Blockers:
After Nitroglycerin (Nitrostat®), what do you expect the BP to do? _____
*TESTING STRATEGY*
RULE: NEVER LEAVE AN UNSTABLE CLIENT.
Cardiac
Cardiac
*TESTING STRATEGY*
RULE: NEVER LEAVE AN UNSTABLE CLIENT.
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2) Beta Blockers:
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Examples: Propranolol (Inderal®), Metoprolol (Lopressor®/Toprol XL®),
Atenolol (Tenormin®), Carvedilol (Coreg®)
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Examples: Propranolol (Inderal®), Metoprolol (Lopressor®/Toprol XL®),
Atenolol (Tenormin®), Carvedilol (Coreg®)
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What do beta blockers do to BP, P, and myocardial contractility? _______
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What do beta blockers do to BP, P, and myocardial contractility? _______
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What does this do to the workload of the heart? _______________
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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? Decreased So we have
Decreased the workload on my heart. This is a good thing to a certain
point because we decreased the workload on the heart, but could we
decrease the client’s cardiac output (HR and BP) too much with these
drugs? YES
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? Decreased So we have
Decreased the workload on my heart. This is a good thing to a certain
point because we decreased the workload on the heart, but could we
decrease the client’s cardiac output (HR and BP) too much with these
drugs? YES
3) Calcium Channel Blockers:
3) Calcium Channel Blockers:
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Examples: Nifedipine (Procardia XL®), Verapamil (Calan®), Amlodipine
(Norvasc®), Diltiazem(Cardizem®)
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Examples: Nifedipine (Procardia XL®), Verapamil (Calan®), Amlodipine
(Norvasc®), Diltiazem(Cardizem®)
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What do these do to the BP? ____________
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What do these do to the BP? ____________
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They also dilate ____________________arteries.
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They also dilate ____________________arteries.
4) Acetylsalicylic Acid (Aspirin):
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4) Acetylsalicylic Acid (Aspirin):
Dose is determined by the physician (81 mg-325 mg)
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Dose is determined by the physician (81 mg-325 mg)
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b. Client Education/Teaching:
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Avoid isometric exercise (exercises that make your muscles squeeze/tense
up).
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Avoid isometric exercise (exercises that make your muscles squeeze/tense
up).
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Avoid overeating.
•
Avoid overeating.
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Rest frequently.
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Rest frequently.
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Avoid excess caffeine or any drugs that increase HR.
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Avoid excess caffeine or any drugs that increase HR.
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Wait 2 hours after eating to exercise.
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Wait 2 hours after eating to exercise.
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Dress warmly in cold weather (any temperature extreme can precipitate an
attack).
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Dress warmly in cold weather (any temperature extreme can precipitate an
attack).
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Take nitroglycerin prophylactically.
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Take nitroglycerin prophylactically.
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Smoking cessation
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Smoking cessation
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Lose weight.
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Lose weight.
*TESTING STRATEGY*
DO EVERYTHING YOU CAN TO DECREASE
WORKLOAD ON THE HEART.
c. Cardiac Catheterization:
1) Pre-procedure:
•
Cardiac
Cardiac
b. Client Education/Teaching:
c. Cardiac Catheterization:
1) Pre-procedure:
Ask if they are allergic to ___________________________.
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Iodine based dye is used during procedure.
Ask if they are allergic to ___________________________.
Iodine based dye is used during procedure.
•
Also we want to check their kidney function because you excrete the dye
through the ____________.
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Also we want to check their kidney function because you excrete the dye
through the ____________.
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Hot shot
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Hot shot
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Palpitations normal
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Palpitations normal
2) Post-procedure:
2) Post-procedure:
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Monitor VS.
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Monitor VS.
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Watch puncture site.
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Watch puncture site.
What are you watching for? ___________________
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What are you watching for? ___________________
Assess extremity distal to puncture site (5-Ps).
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The 5 Ps
Pulselessness
Pallor
Pain
Paresthesia
Paralysis
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*TESTING STRATEGY*
DO EVERYTHING YOU CAN TO DECREASE
WORKLOAD ON THE HEART.
Assess extremity distal to puncture site (5-Ps).
The 5 Ps
Pulselessness
Pallor
Pain
Paresthesia
Paralysis
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Bed rest, flat, leg straight X 4-6 hours
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Bed rest, flat, leg straight X 4-6 hours
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Report pain ASAP.
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Report pain ASAP.
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Major complication post cath? ___________________
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Major complication post cath? ___________________
Unstable chronic angina= Impending MI
Unstable chronic angina= Impending MI
E. Acute Coronary Syndrome: MI, Unstable Angina:
E. Acute Coronary Syndrome: MI, Unstable Angina:
1. Pathophysiology:
1. Pathophysiology:
b. Does the client have to be doing anything to bring this pain on? ______________
b. Does the client have to be doing anything to bring this pain on? ______________
c. Will rest or Nitroglycerin (Nitrostat®) relieve this pain? _______________
c. Will rest or Nitroglycerin (Nitrostat®) relieve this pain? _______________
2. S/S:
2. S/S:
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Pain
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Pain
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Cold/clammy/BP drops
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Cold/clammy/BP drops
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Cardiac output is going ________.
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Cardiac output is going ________.
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↑WBC’s
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↑WBC’s
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↑temp
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↑temp
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ECG changes
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ECG changes
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Vomiting
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Vomiting
Due to inflammation
Cardiac
a. Decreased blood flow to myocardium→ ischemia/necrosis or both? ___________
Cardiac
a. Decreased blood flow to myocardium→ ischemia/necrosis or both? ___________
Due to inflammation
You may see the following terms in a test question:
You may see the following terms in a test question:
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.
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.
***WORRY ABOUT THIS CLIENT***
***WORRY ABOUT THIS CLIENT***
NSTEMI: Non-Elevation ST Segment Myocardial Infarction-these clients are usually less
worrisome.
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NSTEMI: Non-Elevation ST Segment Myocardial Infarction-these clients are usually less
worrisome.
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3. Diagnostic Lab Work:
3. Diagnostic Lab Work:
a. CPK-MB:
a. CPK-MB:
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Cardiac specific _____________________
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Cardiac specific _____________________
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_________ with damage to cardiac cells
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_________ with damage to cardiac cells
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Elevates in _____ hours and peaks in _____ hours
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Elevates in _____ hours and peaks in _____ hours
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Cardiac biomarker with _______ specificity to myocardial damage
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Has two specific isomers called Troponin _____ and _____
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Elevates within ________ hours and remains _________ for up to 3 weeks
Cardiac
c. Myoglobin:
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Increases within ____ hour and peaks in _____ hours
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___________ results are a good thing.
b. Troponin:
Troponin
Isomers
T < 0.20
I < 0.03
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Cardiac biomarker with _______ specificity to myocardial damage
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Has two specific isomers called Troponin _____ and _____
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Elevates within ________ hours and remains _________ for up to 3 weeks
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Increases within ____ hour and peaks in _____ hours
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___________ results are a good thing.
d. Which cardiac biomarker is the most sensitive indicator for an
d. Which cardiac biomarker is the most sensitive indicator for an
e. Which enzymes or makers are most helpful when the client delays seeking care?
e. Which enzymes or makers are most helpful when the client delays seeking care?
MI?_____________
MI?_____________
________________
________________
4. Complications:
4. Complications:
Major arrhythmias:
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Troponin
Isomers
T < 0.20
I < 0.03
c. Myoglobin:
Cardiac
b. Troponin:
Major arrhythmias:
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What untreated arrhythmias will put the client at risk for sudden death? ________
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What untreated arrhythmias will put the client at risk for sudden death? ________
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If the first shock doesn’t work and client remains in V-Fib, what is the first
vasopressor we give? _________________
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If the first shock doesn’t work and client remains in V-Fib, what is the first
vasopressor we give? _________________
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Amiodarone (Cordarone®) is an anti-arrhythmic and is used when V-Fib is
resistant to treatment, and also for fast arrhythmias.
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Amiodarone (Cordarone®) is an anti-arrhythmic and is used when V-Fib is
resistant to treatment, and also for fast arrhythmias.
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What anti-arrhythmic drugs are commonly given to prevent a second episode of
V-Fib? ________________ and ___________________.
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What anti-arrhythmic drugs are commonly given to prevent a second episode of
V-Fib? ________________ and ___________________.
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Lidocaine toxicity: _________ changes
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Lidocaine toxicity: _________ changes
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Amiodarone (Cordarone®) is the first anti-arrhythmic of choice.
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Amiodarone (Cordarone®) is the first anti-arrhythmic of choice.
Important side effect? ____________
Important side effect? ____________
This hypotension can lead to further arrhythmias.
This hypotension can lead to further arrhythmias.
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5. Treatment:
•
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5. Treatment:
What drugs are used for chest pain when they get to the ED?
_____________
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What drugs are used for chest pain when they get to the ED?
_____________
_____________ (chewable or tablet?)
_____________ (chewable or tablet?)
_____________
_____________
_____________
_____________
Head up position and why?
•
Head up position and why?
Decreases ___________ on heart and increases ________________.
Decreases ___________ on heart and increases ________________.
a. Fibrinolytics:
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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®)
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Medications: Streptokinase (Streptase®), Alteplase (t-PA®), Tenecteplase
(TNKase®) (one time push), Reteplase (Retavase®)
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How soon after the onset of myocardial pain should these drugs be
administered? _____________
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How soon after the onset of myocardial pain should these drugs be
administered? _____________
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Brain attack? __________ IS BRAIN.
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Brain attack? __________ IS BRAIN.
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Major complication: _________________
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Major complication: _________________
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Obtain a____________________ history.
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Obtain a____________________ history.
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Absolute contraindications:
•
Absolute contraindications:
Intracranial neoplasm, intracranial bleed, suspected aortic dissection,
internal bleeding
Cardiac
Goal: Dissolve the clot that is blocking blood flow to the heart muscle→
decreases the size of the infarction.
Cardiac
•
a. Fibrinolytics:
Intracranial neoplasm, intracranial bleed, suspected aortic dissection,
internal bleeding
•
During and after administration we take ___________________ precautions.
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During and after administration we take ___________________ precautions.
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Draw blood when starting IVs, decrease the number of _____________ sites.
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Draw blood when starting IVs, decrease the number of _____________ sites.
Bleeding Precautions: Watch for bleeding gums, hematuria and black stools.
Use an electric razor, a soft toothbrush, and No IM’s.
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Bleeding Precautions: Watch for bleeding gums, hematuria and black stools.
Use an electric razor, a soft toothbrush, and No IM’s.
Follow-Up Therapy: Antiplatelets are another important component of
fibrinolytic therapy.
•
Acetylsalicylic Acid (Aspirin®), Clopidogrel (Plavix®), Abciximab
(ReoPro IV®) (continuous infusion to inhibit platelet aggregation)
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Follow-Up Therapy: Antiplatelets are another important component of
fibrinolytic therapy.
Acetylsalicylic Acid (Aspirin®), Clopidogrel (Plavix®), Abciximab
(ReoPro IV®) (continuous infusion to inhibit platelet aggregation)
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b. Medical Interventions:
b. Medical Interventions:
1) PCI (Percutaneous Coronary Intervention):
1) PCI (Percutaneous Coronary Intervention):
•
Includes all interventions such as PTCA (angioplasty) and stents
•
Includes all interventions such as PTCA (angioplasty) and stents
•
Major complication of the angioplasty is a _________.
•
Major complication of the angioplasty is a _________.
Don’t forget client may bleed from heart cath site.
•
Don’t forget client may bleed from heart cath site.
If any problems occur→ go to ___________________.
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If any problems occur→ go to ___________________.
Chest pain after procedure: call the doctor at once→ re-occluding!
Anti-platelet medications:
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Aspirin
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Aspirin
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Clopidogrel (Plavix®)
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Clopidogrel (Plavix®)
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Abciximab (ReoPro IV®)
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Abciximab (ReoPro IV®)
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Eptifibaride (Integrilin IV®)
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Eptifibaride (Integrilin IV®)
Given to high risk clients who have
been stented to keep artery open
those waiting to go to cath lab
2) Coronary Artery Bypass Graft (CABG)
Given to high risk clients who have
been stented to keep artery open
those waiting to go to cath lab
2) Coronary Artery Bypass Graft (CABG)
•
Can be scheduled or emergency procedure
•
Can be scheduled or emergency procedure
•
Used with multiple vessel disease
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Used with multiple vessel disease
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_________artery occlusion which supplies the entire left ventricle
•
_________artery occlusion which supplies the entire left ventricle
c. Cardiac Rehabilitation:
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Anti-platelet medications:
•
Cardiac
Cardiac
•
Chest pain after procedure: call the doctor at once→ re-occluding!
c. Cardiac Rehabilitation:
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Smoking cessation
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Smoking cessation
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Stepped-care plan (increase activity gradually)
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Stepped-care plan (increase activity gradually)
•
Diet changes- _____fat, _____salt, _____cholesterol
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Diet changes- _____fat, _____salt, _____cholesterol
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No isometric exercises-___________________ workload of heart
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No isometric exercises-___________________ workload of heart
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No valsalva
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No valsalva
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No straining; no suppository; Docusate (Colace®)
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No straining; no suppository; Docusate (Colace®)
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When can sex be resumed? _____________
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When can sex be resumed? _____________
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What is the safest time of day for sex? ___________
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What is the safest time of day for sex? ___________
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Best exercise for MI client? _____________
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Best exercise for MI client? _____________
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Teach S/S of heart failure:
•
Teach S/S of heart failure:
Weight __________________
Weight __________________
Ankle edema
Ankle edema
Shortness of ______________
Shortness of ______________
Confusion
Confusion
d. Pacemaker:
•
d. Pacemaker:
The heart has a “natural” pacemaker called the SA node (sinoatrial node).
•
The heart has a “natural” pacemaker called the SA node (sinoatrial node).
This sends out impulses that make the heart _____________________.
•
This sends out impulses that make the heart _____________________.
What happens to cardiac output if your natural electrical system malfunctions
and the heart rate drops below 60?
•
What happens to cardiac output if your natural electrical system malfunctions
and the heart rate drops below 60?
Cardiac output can ___________________.
Cardiac output can ___________________.
•
Pacemakers depolarize the heart muscle and a contraction will occur
(electricity going through the muscle).
•
Repolarization (ventricles are resting and are filling up with blood).
1) Temporary:
•
Pacemakers are used to increase the heart rate with symptomatic bradycardia.
•
Pacemakers depolarize the heart muscle and a contraction will occur
(electricity going through the muscle).
•
Repolarization (ventricles are resting and are filling up with blood).
1) Temporary:
•
Used in ____________ situations
•
Used in ____________ situations
•
After heart surgery
•
After heart surgery
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Acute MI
•
Acute MI
•
Until the client is stable enough for a permanent pacemaker to be inserted
•
Until the client is stable enough for a permanent pacemaker to be inserted
•
Can be classified as invasive or noninvasive:
•
Can be classified as invasive or noninvasive:
•
•
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Noninvasive temporary pacing, called transcutaneous pacing
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Noninvasive temporary pacing, called transcutaneous pacing
Two large electrode pads are applied to client and turned to the
_________ mode.
Two large electrode pads are applied to client and turned to the
_________ mode.
This is an _______________ procedure.
This is an _______________ procedure.
Is it going to hurt? ___________, the client will need _____________.
Is it going to hurt? ___________, the client will need _____________.
Invasive temporary pacemaker has pacing wires that are placed into
the heart ___________ (transvenous pacing).
•
Invasive temporary pacemaker has pacing wires that are placed into
the heart ___________ (transvenous pacing).
Wires are connected to power source _______________ the body.
Wires are connected to power source _______________ the body.
Epicardial pacing is when the wires are attached to the epicardium
during surgery.
Epicardial pacing is when the wires are attached to the epicardium
during surgery.
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Cardiac
Pacemakers are used to increase the heart rate with symptomatic bradycardia.
Cardiac
•
2) Permanent Pacemakers:
2) Permanent Pacemakers:
•
Used when heart condition is ____________
•
Used when heart condition is ____________
•
Electrodes are anchored to the endocardium and attached to a battery
source implanted into a subcutaneous “pocket.”
•
Electrodes are anchored to the endocardium and attached to a battery
source implanted into a subcutaneous “pocket.”
•
A demand pacemaker kicks in only when the client needs it to.
•
A demand pacemaker kicks in only when the client needs it to.
•
Fixed rate fires at a ________rate constantly.
•
Fixed rate fires at a ________rate constantly.
It’s ok for the rate to increase but never _______________.
It’s ok for the rate to increase but never _______________.
Always worry if the rate _______ below set rate.
Always worry if the rate _______ below set rate.
Post-Procedure Care:
•
Monitor the incision.
•
Monitor the incision.
•
Most common complication in early hours? Electrode displacement
•
Most common complication in early hours? Electrode displacement
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Immobilize arm.
•
Immobilize arm.
•
PROM to prevent frozen ____________
•
PROM to prevent frozen ____________
•
Keep the client from raising their arm too high.
•
Keep the client from raising their arm too high.
Cardiac
Cardiac
Post-Procedure Care:
S/S of Malfunction:
•
S/S of Malfunction:
It’s possible that no mechanical event or contraction follows the
stimuli.
•
This is called _________________.
•
•
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It’s possible that no mechanical event or contraction follows the
stimuli.
This is called _________________.
What causes this?
•
What causes this?
The pacemaker may not be ____________ correctly.
The pacemaker may not be ____________ correctly.
Electrodes can _______________.
Electrodes can _______________.
Battery may be _____________.
Battery may be _____________.
Any sign of decreased CO or decreased ____________
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Any sign of decreased CO or decreased ____________
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Client Education/Teaching:
Client Education/Teaching:
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Check _________________daily.
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Check _________________daily.
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ID card
•
ID card
•
Avoid electromagnetic fields (cell phones, large motors, arc
welding, electric substations).
•
Avoid electromagnetic fields (cell phones, large motors, arc
welding, electric substations).
•
Avoid MRI’s.
•
Avoid MRI’s.
•
Are they going to set off alarms at airport? _______
•
Are they going to set off alarms at airport? _______
•
Avoid contact sports.
•
Avoid contact sports.
F. Heart Failure (HF):
F. Heart Failure (HF):
1. Causes:
2. Types:
a. Left Side Failure: the blood is not moving forward into the aorta and out to my
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
•
HF is a complication that can result from problems such as cardiomyopathy,
valvular heart disease, endocarditis, acute MI, and _______________.
2. Types:
a. Left Side Failure: the blood is not moving forward into the aorta and out to my
body…IF it does not move forward, then it will go backwards into the ________.
•
b. Right Side Failure: the blood is not moving forward into the lungs…IF it does
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.
not move forwards then it goes backwards into the ___________ system.
•
S/S:
Enlarged organs
Edema
Weight gain
Distended neck veins
Ascites
•
S/S:
Enlarged organs
Edema
Weight gain
Distended neck veins
Ascites
•
New Terminology: Systolic heart failure: heart can’t contract and eject.
Diastolic heart failure: ventricles can’t relax and fill.
•
New Terminology: Systolic heart failure: heart can’t contract and eject.
Diastolic heart failure: ventricles can’t relax and fill.
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HF is a complication that can result from problems such as cardiomyopathy,
valvular heart disease, endocarditis, acute MI, and _______________.
Cardiac
•
1. Causes:
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3. Dx:
3. Dx:
a. Pulmonary artery catheter (Swan Ganz catheter):
a. Pulmonary artery catheter (Swan Ganz catheter):
•
A type of central line that measures pressures inside the heart
•
A type of central line that measures pressures inside the heart
•
Helps to determine the cause of _____________ cardiac output
•
Helps to determine the cause of _____________ cardiac output
•
Killer complications: ____________embolus, ____________infarction
•
Killer complications: ____________embolus, ____________infarction
b. A-line:
b. A-line:
•
Measures __________________________continuously on a monitor
•
Measures __________________________continuously on a monitor
•
NEVER put medicine in an A-line.
•
NEVER put medicine in an A-line.
•
A-lines are placed in what artery? ___________________
•
A-lines are placed in what artery? ___________________
•
Allen’s test- a check for alternative circulation.
•
Allen’s test- a check for alternative circulation.
Apply pressure to client’s ulnar and radial arteries at the same time, ask
client to open and close hand, hand should blanch, release the pressure
from the ulnar artery while continuing to compress the radial artery and
assess the color in the extremity distal to the pressure point- pinkness
should return within 6 seconds (indicating the ulnar artery is sufficient to
provide hand with adequate circulation if radial artery is occluded with Aline). This is considered a positive Allen’s test.
Cardiac
Cardiac
Apply pressure to client’s ulnar and radial arteries at the same time, ask
client to open and close hand, hand should blanch, release the pressure
from the ulnar artery while continuing to compress the radial artery and
assess the color in the extremity distal to the pressure point- pinkness
should return within 6 seconds (indicating the ulnar artery is sufficient to
provide hand with adequate circulation if radial artery is occluded with Aline). This is considered a positive Allen’s test.
•
You do have to be careful with an A-line because if you do not have the
connections secure on your pressure tubing or if you do not have the
stopcocks in the proper positions your client could bleed out.
•
You do have to be careful with an A-line because if you do not have the
connections secure on your pressure tubing or if you do not have the
stopcocks in the proper positions your client could bleed out.
•
Check ____________ circulation while in place.
The 5-Ps: Pulselessness, Pallor, Pain, Paresthesia, Paralysis
•
Check ____________ circulation while in place.
The 5-Ps: Pulselessness, Pallor, Pain, Paresthesia, Paralysis
c. BNP: B-type natriuretic peptide:
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c. BNP: B-type natriuretic peptide:
•
Secreted by ventricular tissues in the heart when ventricular volumes and
pressures in the heart are increased
•
Secreted by ventricular tissues in the heart when ventricular volumes and
pressures in the heart are increased
•
Sensitive indicator
•
Sensitive indicator
•
Can be _________ for HF when the CXR does not indicate a problem
•
Can be _________ for HF when the CXR does not indicate a problem
•
If the client is on Natrecor, turn it off _________ prior to drawing a BNP.
•
If the client is on Natrecor, turn it off _________ prior to drawing a BNP.
d. CXR: enlarged ____________________, pulmonary infiltrates
d. CXR: enlarged ____________________, pulmonary infiltrates
e. Echocardiogram
e. Echocardiogram
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f. New York Heart Association Functional Classification of Persons with HF:
•
f. New York Heart Association Functional Classification of Persons with HF:
Classes 1-4 (Class 4 being worst)
•
4. Tx:
Classes 1-4 (Class 4 being worst)
4. Tx:
a. Medications:
a. Medications:
1) Digitalis (L anoxin ® )
1) Digitalis (L anoxin ® )
Actions:
Actions:
•
Used with atrial fibrillation and HF
•
Used with atrial fibrillation and HF
•
Contraction? __________________
•
Contraction? __________________
•
Heart rate? ____________________
•
Heart rate? ____________________
Cardiac output will go ___________.
•
Kidney perfusion _______________.
Nursing Considerations:
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? _________
•
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.
•
We always want to ____________heart failure clients…they can’t handle
the fluid.
•
Digitalizing dose-loading dose
•
Digitalizing dose-loading dose
•
How do you know the Digoxin is working? Because the cardiac output
goes_____
•
How do you know the Digoxin is working? Because the cardiac output
goes_____
•
S/S of toxicity?
•
S/S of toxicity?
Normal Dig level=
____to____ ng/ml
Normal Dig level=
____to____ ng/ml
Early: Anorexia, nausea, and vomiting
Early: Anorexia, nausea, and vomiting
Late: Arrhythmias and _________________ changes
Late: Arrhythmias and _________________ changes
•
Before administering do what? ________________________
•
Before administering do what? ________________________
•
Monitor electrolytes
•
Monitor electrolytes
All electrolytes levels must remain normal, but K+ is the one that
causes the most trouble.
All electrolytes levels must remain normal, but K+ is the one that
causes the most trouble.
(_____________________+_______________________=______________________)
(_____________________+_______________________=______________________)
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Cardiac
•
Cardiac
When the heart rate is slowed this gives the ventricles more time to fill
with blood.
2) Diuretics:
2) Diuretics:
•
Examples: Furosemide (Lasix®), Hydrochlorothiazide (HCTZ®),
Bumetanide (Bumex®), Hydrochlorothiazide/Triamterene (Dyazide®)
•
Examples: Furosemide (Lasix®), Hydrochlorothiazide (HCTZ®),
Bumetanide (Bumex®), Hydrochlorothiazide/Triamterene (Dyazide®)
•
Action: Decrease _____________________________
•
Action: Decrease _____________________________
•
Nursing Considerations:
•
Nursing Considerations:
Aldactone may be given to decrease aldosterone levels.
Aldactone may be given to decrease aldosterone levels.
When do you give diuretics? _____________________
When do you give diuretics? _____________________
3) ACE inhibitor/ARBs and/or a Beta Blocker:
3) ACE inhibitor/ARBs and/or a Beta Blocker:
•
(See next page for examples)
These drugs will decrease the workload in the heart, prevent
vasoconstriction (decreasing afterload) which will increase cardiac outputkeeping the blood moving forward out of the heart.
Cardiac
Cardiac
(See next page for examples)
•
b. Low Na Diet:
b. Low Na Diet:
•
Decrease _________________________________.
•
Decrease _________________________________.
•
Watch salt substitutes.
•
Watch salt substitutes.
Salt substitutes can contain excessive ____________________________.
•
Salt substitutes can contain excessive ____________________________.
Canned/processed foods & OTC’s can contain a lot of _________________.
•
c. Miscellaneous Information:
•
Canned/processed foods & OTC’s can contain a lot of _________________.
c. Miscellaneous Information:
Elevate head of bed.
•
10” blocks under the head of the bed
Elevate head of bed.
10” blocks under the head of the bed
•
Weigh daily (report gain of ______ to ______ lbs).
•
Weigh daily (report gain of ______ to ______ lbs).
•
Report S/S of recurring failure.
•
Report S/S of recurring failure.
*TESTING STRATGY*
Fluid retention-think Heart Problems 1st.
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These drugs will decrease the workload in the heart, prevent
vasoconstriction (decreasing afterload) which will increase cardiac outputkeeping the blood moving forward out of the heart.
*TESTING STRATGY*
Fluid retention-think Heart Problems 1st.
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ACE inhibitors
ACE inhibitors
(angiotensin converting enzyme inhibitor)
Actions:
Blocks conversion of angiotensin I to angiotensin II
What they do: promote vasodilation and diuresis,
decreases the secretions of aldosterone (so the
kidneys will get rid of sodium and water and retain
potassium).
Examples:
Enalapril (Vasotec®)
Fosinopril (Monopril®)
Captopril (Capoten®)
(angiotensin converting enzyme inhibitor)
Uses:
Hypertension and heart failure
Nursing Observations:
If the drug ends in –pril it is most likely an ACE
inhibitor.
Watch for hyperkalemia, orthostatic syncope,
hypotension, and renal dysfunction.
Angioedema-laryngeal swelling, can be fatal
dry, nonproductive cough-reversible when drug
stopped.
Fall precautions.
Actions:
Blocks conversion of angiotensin I to angiotensin II
What they do: promote vasodilation and diuresis,
decreases the secretions of aldosterone (so the
kidneys will get rid of sodium and water and retain
potassium).
Examples:
Enalapril (Vasotec®)
Fosinopril (Monopril®)
Captopril (Capoten®)
ARBs
(angiotensin II receptor blockers)
ARBs
(angiotensin II receptor blockers)
Beta Adrenergic Blockers
Action:
Block adverse effects from sympathetic nervous
stimulation.
What they do: block the receptor sites for epi and
norepi…so they will decrease afterload and
contractility….as a result they decrease the BP and
HR.
Examples:
Propranolol (Inderal®)
Metoprolol (Lopressor®/Toprol XL®)
Atenolol (Tenormin®)
Carvedilol (Coreg®)
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Action:
Blocks effects of angiotensin II (a potent
vasoconstrictor) at the receptor site (used as an
alternative to ACE inhibitors) ACE inhibitors block
the conversion of AI to AII but AII can also be
formed by other enzymes that are not blocked by
ACE Inhibitors
What they do: decrease blood pressure, increase
CO
Examples:
Valsartan (Diovan®)
Losartan (Cozaar®)
Irbesartan (Avapro®)
Uses:
Hypertension and heart failure.
Nursing Considerations:
If the drug ends in –sartan it is most likely an ARB
Watch for hyperkalemia, hypotension, and renal
dysfunction..
Cardiac
Uses:
Hypertension and heart failure.
Nursing Considerations:
If the drug ends in –sartan it is most likely an ARB
Watch for hyperkalemia, hypotension, and renal
dysfunction..
Cardiac
Action:
Blocks effects of angiotensin II (a potent
vasoconstrictor) at the receptor site (used as an
alternative to ACE inhibitors) ACE inhibitors block
the conversion of AI to AII but AII can also be
formed by other enzymes that are not blocked by
ACE Inhibitors
What they do: decrease blood pressure, increase
CO
Examples:
Valsartan (Diovan®)
Losartan (Cozaar®)
Irbesartan (Avapro®)
Uses:
Hypertension and heart failure
Nursing Observations:
If the drug ends in –pril it is most likely an ACE
inhibitor.
Watch for hyperkalemia, orthostatic syncope,
hypotension, and renal dysfunction.
Angioedema-laryngeal swelling, can be fatal
dry, nonproductive cough-reversible when drug
stopped.
Fall precautions.
Beta Adrenergic Blockers
Uses:
Angina, chest pain. Hypertension, ventricular
dysrhythmias and thyroid storm.
Nursing Consideration:
If the drug ends in–lol it is most likely a Beta
Blocker.
Don’t give to asthmatics (some beta blockers also
constrict the smooth muscle of the bronchioles)
Don’t give to diabetics (block the sympathetic
responses seen in hypoglycemia).
Action:
Block adverse effects from sympathetic nervous
stimulation.
What they do: block the receptor sites for epi and
norepi…so they will decrease afterload and
contractility….as a result they decrease the BP and
HR.
Examples:
Propranolol (Inderal®)
Metoprolol (Lopressor®/Toprol XL®)
Atenolol (Tenormin®)
Carvedilol (Coreg®)
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Uses:
Angina, chest pain. Hypertension, ventricular
dysrhythmias and thyroid storm.
Nursing Consideration:
If the drug ends in–lol it is most likely a Beta
Blocker.
Don’t give to asthmatics (some beta blockers also
constrict the smooth muscle of the bronchioles)
Don’t give to diabetics (block the sympathetic
responses seen in hypoglycemia).
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G. Pulmonary Edema:
G. Pulmonary Edema:
1. Pathophysiology:
•
1. Pathophysiology:
Heart isn’t pumping strong, so cardiac output goes down, and fluid backs up into
the __________.
•
2. S/S:
•
Severe hypoxia
•
Severe hypoxia
•
When does this usually occur? ___________________
•
When does this usually occur? ___________________
•
Sudden onset
•
Sudden onset
•
Breathless
•
Breathless
•
Restless/anxious
•
Restless/anxious
•
Productive cough (pink frothy sputum)
•
Productive cough (pink frothy sputum)
Cardiac
Cardiac
2. S/S:
3. Tx:
a. Medications:
3. Tx:
a. Medications:
1) Furosemide (Lasix®)
1) Furosemide (Lasix®)
•
Causes diuresis and vasodilation which traps more blood out in the arms
and legs and reduces _________ and __________
•
Causes diuresis and vasodilation which traps more blood out in the arms
and legs and reduces _________ and __________
•
40 mg IV push over 1-2 minutes to prevent ______________ and
ototoxicity
•
40 mg IV push over 1-2 minutes to prevent ______________ and
ototoxicity
2) Bumetanide (Bumex®)
2) Bumetanide (Bumex®)
•
Can be given IV push or as continuous IV to provide rapid fluid _______
•
Can be given IV push or as continuous IV to provide rapid fluid _______
•
1-2 mg IV push given over 1-2 minutes
•
1-2 mg IV push given over 1-2 minutes
3) Nitroglycerin IV (Nitro-Bid IV®)
3) Nitroglycerin IV (Nitro-Bid IV®)
•
Vasodilation; _________afterload
•
Vasodilation; _________afterload
•
Decreased afterload = increased CO because the heart is pumping against
less pressure and more blood can be moved______________.
•
Decreased afterload = increased CO because the heart is pumping against
less pressure and more blood can be moved______________.
4) Digoxin (Lanoxin®)
•
4) Digoxin (Lanoxin®)
Used to get the blood moving in a ____________ direction
•
5) Morphine (Morphine Sulfate®)
•
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Heart isn’t pumping strong, so cardiac output goes down, and fluid backs up into
the __________.
Used to get the blood moving in a ____________ direction
5) Morphine (Morphine Sulfate®)
2 mg IV push for vasodilation to decrease preload and afterload
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2 mg IV push for vasodilation to decrease preload and afterload
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6) Nesiritide (Natrecor®)
6) Nesiritide (Natrecor®)
•
Infusion; short term therapy; not to be given more than 48 hours
•
Infusion; short term therapy; not to be given more than 48 hours
•
Vasodilates veins and arteries and has a diuretic effect
•
Vasodilates veins and arteries and has a diuretic effect
7) Milrinone (Primacor®)
7) Milrinone (Primacor®)
•
Continuous infusion
•
Continuous infusion
•
Vasodilates veins and arteries
•
Vasodilates veins and arteries
8) Dobutamine (Dobutrex®)
•
8) Dobutamine (Dobutrex®)
Increases cardiac output
•
b. Positioning:
•
b. Positioning:
_________________ position, legs down
•
c. Prevention:
Promotes _____________________ of blood in lower extremities
c. Prevention:
Prevention when possible:
•
Prevention when possible:
Check ___________________
Check ___________________
Avoid fluid volume ______________.
Avoid fluid volume ______________.
H. Cardiac Tamponade:
H. Cardiac Tamponade:
1. Pathophysiology:
1. Pathophysiology:
•
_______________, fluid, or exudates have leaked into pericardial sac.
•
_______________, fluid, or exudates have leaked into pericardial sac.
•
This can happen if the client has had a motor vehicle collision, right ventricular
biopsy, _____________, pericarditis, or hemorrhage post CABG.
•
This can happen if the client has had a motor vehicle collision, right ventricular
biopsy, _____________, pericarditis, or hemorrhage post CABG.
2. S/S:
2. S/S:
•
Decreased cardiac output
•
Decreased cardiac output
•
CVP will be _____________.
•
CVP will be _____________.
•
BP will be dropping.
•
BP will be dropping.
•
Heart sounds will be muffled or distant.
•
Heart sounds will be muffled or distant.
•
Neck veins ____________
•
Neck veins ____________
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Promotes _____________________ of blood in lower extremities
_________________ position, legs down
Improves __________________________
Cardiac
Improves __________________________
•
Increases cardiac output
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•
Pressures in all 4 chambers are the same
•
Pressures in all 4 chambers are the same
•
Shock
•
Shock
•
Paradoxical pulse (pulsus paradoxus)
•
Paradoxical pulse (pulsus paradoxus)
This is when the BP is greater than 10 mm Hg higher on expiration than
on inspiration.
This is when the BP is greater than 10 mm Hg higher on expiration than
on inspiration.
Narrowed pulse pressure (from the baseline)
•
•
Narrowed pulse pressure (from the baseline)
What is the pulse pressure? It’s the difference between the __________
and the ________________.
What is the pulse pressure? It’s the difference between the __________
and the ________________.
3. Tx:
•
Pericardiocentesis to remove _______________ from around the heart
•
Pericardiocentesis to remove _______________ from around the heart
•
Surgery
•
Surgery
Cardiac
Cardiac
3. Tx:
I. Arterial Disorders:
I. Arterial Disorders:
1. General Information:
1. General Information:
a. Pathophysiology:
a. Pathophysiology:
•
If you have atherosclerosis in one place you have it everywhere.
•
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).
•
It is a medical emergency if you have an acute arterial ____________ (numb,
pain, cold, no pulse).
•
More symptomatic in __________ extremities
•
More symptomatic in __________ extremities
•
Intermittent claudication- hallmark ________
•
Intermittent claudication- hallmark ________
•
Arterial blood isn’t getting to the_________ → coldness, numbness,
decreased peripheral pulses, atrophy, bruit, skin/nail changes, and ulcerations.
•
Arterial blood isn’t getting to the_________ → coldness, numbness,
decreased peripheral pulses, atrophy, bruit, skin/nail changes, and ulcerations.
•
Rest pain means _____________obstruction.
•
Rest pain means _____________obstruction.
b. Tx:
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b. Tx:
•
Since arterial blood is having problems getting to the tissue, if you elevated
the extremity the pain would increase or decrease? ______________
•
Since arterial blood is having problems getting to the tissue, if you elevated
the extremity the pain would increase or decrease? ______________
•
Arterial disorders if the lower extremities are usually treated with either
angioplasty, endarterectomy.
•
Arterial disorders if the lower extremities are usually treated with either
angioplasty, endarterectomy.
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2. Types if Arterial Disorders:
2. Types if Arterial Disorders:
a. Buerger’s Disease:
a. Buerger’s Disease:
1) S/S:
1) S/S:
•
Inflammation of ____________ and ______________.
•
Inflammation of ____________ and ______________.
•
Men
•
Men
•
Heavy smoking, cold, emotions
•
Heavy smoking, cold, emotions
Causes vasoconstriction of vessels
Causes vasoconstriction of vessels
Lower extremities/sometimes fingers.
•
•
2) Tx:
Lower extremities/sometimes fingers.
2) Tx:
•
Avoid cause.
•
Stop smoking.
•
Stop smoking.
•
Avoid cold.
•
Avoid cold.
•
Hydration
•
Hydration
•
Bypass surgery
•
Bypass surgery
•
Wear shoes that fit well; avoid any trauma to feet.
•
Wear shoes that fit well; avoid any trauma to feet.
•
Gangrene→ amputation
•
Gangrene→ amputation
b. Raynaud’s Disease:
b. Raynaud’s Disease:
1) S/S:
1) S/S:
•
This occurs in the __________ client.
•
This occurs in the __________ client.
•
Happens in fingers (bilaterally, usually in fingers tips)
•
Happens in fingers (bilaterally, usually in fingers tips)
•
Turns white, blue, red
•
Turns white, blue, red
•
Gets cold, upset, smokes
•
Gets cold, upset, smokes
•
Painful, can cause ulceration
•
Painful, can cause ulceration
2) Tx:
•
Cardiac
Avoid cause.
Cardiac
•
2) Tx:
Avoid the cause.
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Avoid the cause.
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J. DVT (Deep Venous Thrombosis):
1. Pathophysiology:
•
Blood stasis, vessel injury, blood coagulation.
•
The blood can get to the tissue, it just can’t get away.
J. DVT (Deep Venous Thrombosis):
Normal Lab Values:
(may vary with institutions):
PTT: 21-35 seconds.
PT: 11.0-13.0
INR: 2-3.5
1. Pathophysiology:
2. S/S:
Blood stasis, vessel injury, blood coagulation.
•
The blood can get to the tissue, it just can’t get away.
2. S/S:
•
Edema
•
Edema
•
Tenderness
•
Tenderness
•
Warmth
•
Warmth
3. Tx:
3. Tx:
Anticoagulant drugs: Heparin, Fibrinolytics, warfarin (Coumadin®), clopidogrel
(Plavix®), Aspirin, enoxaparin (Lovenox®), or dipyridamole (Persantine®).
These drugs either prevent aggregation or prevent the clot from getting
bigger.
•
Cardiac
Cardiac
•
Anticoagulant drugs: Heparin, Fibrinolytics, warfarin (Coumadin®), clopidogrel
(Plavix®), Aspirin, enoxaparin (Lovenox®), or dipyridamole (Persantine®).
These drugs either prevent aggregation or prevent the clot from getting
bigger.
•
Limit foods with Vitamin ____.
•
Limit foods with Vitamin ____.
•
Surgery
•
Surgery
•
Bed rest
•
Bed rest
•
Elevate- to increase blood return; _______________ pooling.
•
Elevate- to increase blood return; _______________ pooling.
•
TED hose- to ____________ venous return; decrease pooling
•
TED hose- to ____________ venous return; decrease pooling
•
•
Used with SCD’s many times
Used with SCD’s many times
With a known clot TED’s or SCD’s may not be used
With a known clot TED’s or SCD’s may not be used
Warm, moist heat-_________________inflammation
•
Warm, moist heat-_________________inflammation
Never cold on a vein= excessive vasoconstriction
Never cold on a vein= excessive vasoconstriction
Never hot on a vein= excessive vasodilation
Never hot on a vein= excessive vasodilation
Prevention is the key!
•
Prevention is the key!
We __________ and __________ the client.
We __________ and __________ the client.
Also for prevention we put on SCD’s and get the client to do isometric exercises
Also for prevention we put on SCD’s and get the client to do isometric exercises
*TESTING STRATEGY*
Never delay treatment.
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•
Normal Lab Values:
(may vary with institutions):
PTT: 21-35 seconds.
PT: 11.0-13.0
INR: 2-3.5
*TESTING STRATEGY*
Never delay treatment.
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