Cardiovascular: Valvular, Cardiomyopathy,
Aneurysm and Cardiac Surgery
Heart valves at work!
A&P Heart Valves-
Carolyn M Jacobs RN MSN ONC
Click here
Valvular Heart Disease
 Heart contains
 Two atrioventricular valves


Mitral
Tricuspid
 Two semilunar valves

Aortic
Pulmonic

Valvular Disease

Short video-valvular
heart disease
Valvular Heart Disease
 Types of valvular heart disease depend on
 Valve or valves affected
 Two types of functional alterations


1.

Stenosis
Regurgitation
View
HeartPoint:Valves; Flashcards
MD Lecture on valvular disease
Pathophysiology
 Stenosis- narrowed valve, increases afterload
 Regurgitation or insufficiency- increases preload.
The heart has to pump same blood
 **Blood volume and pressures > reduced in front
of affected valve and inc behind affected valve >
results in heart failure
 All valvular diseases have a characteristic murmur
murmurs
Valvular Stenosis and
Regurgitation
Fig. 37-8. Valvular stenosis and regurgitation. A, Normal position of the valve leaflets, or cusps, when the
valve is open and closed. B, Open position of a stenosed valve (left) and position of closed regurgitant valve
(right). C, Hemodynamic effect of mitral stenosis. The stenosed valve is unable to open sufficiently during left
atrial systole, inhibiting left ventricular filling. D, Hemodynamic effect of mitral regurgitation. The mitral valve
does not close completely during left ventricular systole, permitting blood to reenter the left atrium.
Normal function and sound of heart valves
Normal aortic and mitral valves
function

You tube video-good review on heart sounds, S3,
S4
Valvular Heart Disease
 Valvular disorders occur
 in children and adolescents primarily from congenital
conditions
 in adults from degenerative heart disease
 Risk Factors
 Rheumatic Heart Disease MI
 Congenital Heart Defects
 Aging
 CHF
Mitral Valve Stenosis
Pathophysiology





Dec blood flow into LV
LA hypertrophy
Pulmonary pressures inc
Pulmonary hypertension
Dec CO
Fig. 37-9
Fish mouth
Mitral Valve Stenosis
Manifestations
 Primary symptom is DOE
 Later > symptoms of R
heart failure
 A fib common
 MVS murmur (low pitched
rumbling)
 Usually secondary to
rheumatic fever
Mitral Valve Regurgitation
Pathophysiology
 Regurgitation of blood into




LA during systole
LA dilation and hypertrophy
Pulmonary congestion
RV failure
LV dilation and hypertrophyto accommodate inc preload
and dec CO
Manifestations
 Thready pulses
 Cool extremities
 Symptoms of LV failure
 Third heart sound (S3)
 MVR murmur
 *Acute- poorly tolerated:
systolic murmur, shock,
pulmonary edema
 *Chronic-weakness, fatigue,
S3 gallop, holosystolic murmur
Mitral Valve Prolapse
Fig. 37-10. Mitral valve prolapse. In this valvular
abnormality, the mitral leaflets have prolapsed back
into the left atrium. They also demonstrate hooding
(arrow). The left ventricle is on the right.
Mitral Valve Prolapse
Pathophysiology
Manifestations
 Abnormality of mitral valve
 Usually asymptomatic
leaflets, papillary muscles or
chordae
 Etiology unknown
 Most common valvular heart
disease in US
 Female 2x > Male
 Click murmur
 *Atypical chest pain does not
respond to NTG
 Tachydysrhythmias may
develop- SVT
 Risk for endocarditis may be
inc
 heart association guidelines
Mitral Valve Prolapse
 May or may not be present
with chest pain
 If pain occurs, episodes tend to
occur in clusters, especially
during stress
 Pain may be accompanied by
dyspnea, palpitations, and
syncope
 *Does not respond to
antianginal treatment
 MVP murmur (mid-systolic
click)
Click to see video Mitral valve prolapse and consequent
mitral valve regurgitation is seen during TEE examination
in a patient undergoing mitral valve repair.
Aortic Valve Stenosis
Aortic Valve Problems
Pathophysiology
 Inc in afterload
 Incomplete emptying of LA
 LV hypertrophy
 Reduced CO
 RV strain
 Pulmonary congestion
 Poor prognosis when
experiencing symptoms
and not treated- 10-20%
*sudden cardiac death
(SCD)

great YouTube
Aortic Valve Stenosis
Manifestations
Syncope
Angina
Dyspnea
 May be asymptomatic for
many years due to
compensation
 AVS murmur (normal or sofot
S1, systolic mormur, S4 (why)
 Exertional Syncope, Angina,
DOE -classic symptoms
 *Triad > LVF
 Later get signs of RHF
*Nitroglycerin contraindicated
> reduces preload
Bicuspid Aortic Valve
Congenital Heart
Defect
Most Common
Congenital Heart
Disease
Familial
Male>Female
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Aortic Valve Regurgitation
Pathophysiology
 Inc preload- 60% of SV can be






regurgitated
Characteristic Water Hammer
pulse; Corrigan's sign (what is it?)
AVR (Austin Flint Murmur)
Regurgitation of blood into LV
LV dilation and hypertrophy
*Dec CO
Can have Acute onset *life
threatening
Water Hammer pulse
Pulse- “water hammer” -jerky pulse that is full, then
collapses due to aortic insufficiency/regurgitation
(blood ejected into aorta regurgitates back through
aortic valve into L. ventricle ). AKA-called a Corrigan
pulse or a cannonball, collapsing, pistol-shot, or triphammer pulse. (Click to view video)
an abrupt distension and collapse of carotid arteries-sign
indicating aortic incompetence
Aortic Valve Regurgitation
Manifestations
 *Acute: sudden manifestations
cardiovascular collapse
 Left ventricle exposed to aortic
pressure during diastole




Weakness
Severe dyspnea
Chest pain
Hypotension
 Constitutes a medical
emergency

AVR murmur (Austin Flint-Soft or absent S1;
presence of S3 and S4; Soft, high-pitched diastolic
murmur)
Tricuspid and Pulmonic Valve
Disease
Pathophysiology
Manifestations
 Uncommon
 RHF
 Both conditions > inc in
blood volume in R atrium
and R ventricle > Right sided
heart failure
 Tricuspid- Rheumatic, prior
IV drugs; use dopamine
agonist
 Pulmonic- Congenital
Collaborative Care
 Focus on preventing
 Exacerbations of heart failure
 Acute pulmonary edema
 Thromboembolism
 Recurrent endocarditis and recurrent rheumatic fever
 *Treatment depends on valve involved and severity of
disease.
Copyright © 2011, 2007 by
Mosby, Inc., an affiliate of
Elsevier Inc.
Diagnostic Tests
 Echo- assess valve motion and chamber size
 CXR
 EKG
 Cardiac cath- get pressures
Transesophageal
echocardiogram
Medications/diet
 Like Heart Failure
 ACE inhibitors
 Beta Blockers
 Digoxin
 Diuretics
 Vasodilators
 Anticoagulants
 Prophylactic antibiotics
 Low sodium diet
Percutaneous Aortic Valve Replacement
Percutaneous AVR
a) Balloon valvuloplasty; b) Balloon catheter with valve in the diseased valve;
c) Balloon inflation to secure the valve; d) Valve in place
Percutaneous aortic valve replacement (AVR)- new treatment being investigated for select patients with
severe symptomatic aortic stenosis… a percutaneous technique for implanting a prosthetic valve inside
diseased calcific aortic valve… performed in catheterization lab…a catheter is placed through femoral
artery (in the groin) and guided into chambers of the heart. A compressed tissue heart valve is placed on
the balloon-mounted catheter and is positioned directly over the diseased aortic valve. Once in position,
the balloon is inflated to secure the valve in place. *For patients with severe peripheral vascular disease,
surgeons and cardiologists are testing an alternative approach through the left ventricular apex of the
heart.
Collaborative Therapy
 Surgical therapy for valve repair or replacement
 Valve repair typically the surgical procedure of choice.
 Valvular replacement may be required for certain
patients.
Copyright © 2011, 2007 by
Mosby, Inc., an affiliate of
Elsevier Inc.
Mitral Stenosis Therapy
 Surgical
 Mitral Commissurotomy
 Mitral Valve Replacement


Mechanical
Bioprosthetic
Heart Valve
replacement
(Aortic valve, patient
resource,
mechanical,
biological)
Mechanical valve prosthesis- modern tilting disk
variety (for mitral valve); last indefinitely from
structural standpoint; patient requires continuing
anticoagulation due exposed non-biologic surfaces.
Excised porcine bioprosthesis; main advantage of
bioprosthesis is lack of need for continued
anticoagulation-drawback include limited lifespan, on
average from 5 to 10 years (sometimes shorter) due to
wear and calcification. (No immune suppressive agents
required.)
Important-teaching needs for
valve replacement
Ross Procedure
Summary Interventions
 Percutaneous balloon valvuloplasty
 Surgical therapy for valve repair or replacement:
 Valve repair-typically surgical procedure of choice
Open commissurotomy- open stenotic valves
 Annuloplasty- can be used for both
 Valve replacement may be required for certain patients
Heart valve surgery
 Mechanical-need anticoagulant
 Biologic-only last about 15 years
 Ross Procedure
 MedlinePlus: Interactive Health Tutorials (choose
open heart surgery etc)

A patient with mitral stenosis should be on an anticoagulant because atrial
fibrillation is common ?
1. True
2. False
A balloon valvuloplasty would be contraindicated for the elderly.
1. True
2. False
Which can be serious complications of MVP? (may have more than one answer)
1. Mitral insufficiency
2. Sudden cardiac death (SCD)
3. Infectious endocarditis (IE)
4. Cerebral Ischemia
A water hammer pulse is common in aortic stenosis because of aortic
insufficiency ?
1. True
2. False
During the nursing assessment of a patient with an aortic
stenosis, the nurse would expect to find:
1. A systolic murmur.
2. Systolic ejection click.
3. Pericardial friction rub.
4. Brisk, hammering pulses.
Copyright © 2011, 2007 by
Mosby, Inc., an affiliate of
Elsevier Inc.
Nursing Diagnoses
 Activity intolerance
 Excess fluid volume
 Decreased cardiac output
 Ineffective therapeutic regimen management
What Is New?
•Heart valve replacement without need for open heart
surgery.
•Typically, diseased or defective valves replaced with an
artificial valve or a tissue valve (from pig or cow).
•A new, less invasive procedure, known as percutaneous
transcatheter heart valve implantation, involves use of
balloon catheters and large stents…
•New heart valve transported via stent; stent then
expanded to implant the valve.
• For patients not able to undergo open-heart surgery…
percutaneous heart valve implantation may impact
significantly on survival and quality of life. Click for more!
New Cont.
•New technologies…a tiny metallic clip is being studied for
treatment of mitral regurgitation- MitraClip 3D Animation View
video -procedure to correct
•Valves may last a lifetime for older patients, younger
patients may need several replacement procedures over
time.
•One focus of research-create longer-lasting replacement
valves, particularly for patients with congenital heart disease.
Research potential toward this goal: stem cell research and
the use of endothelial cells.
Cardiomyopathy
 Condition in which ventricle has become enlarged,
thickened or stiffened >heart’s ability as pump is
reduced
 3 Types
 Dilated
 Hypertropic
 Restrictive
3 Types
 Dilated
 Hypertrophic
 Restrictive
Cardiomyopathy
 Primary-idiopathic
 Secondary
 Ischemia- from CAD
 Infectious/viral disease
 Exposure to toxins
 Metabolic disorders
 Nutritional deficiencies
 Genetic
Cardiomyopathy
 Primary-idiopathic
 Secondary
 Ischemia- from CAD
 Infectious disease
 Exposure to toxins
 Metabolic disorders
 Nutritional
deficiencies
 Pregnancy
Dilated Cardiomyopathy
 *Most common type
 Diffuse inflammation rapid degeneration
myocardial tissue
 Heart chambers dilate; impaired systolic
function, *atrial enlargement
 40% dev. R & L heart failure; dec. EF
 *Dysrhythmias are common- SVT, A-fib, VT
 Prognosis poor-*need transplant
Dilated Cardiomyopathy
 Factors Causing:
 Genetic predisposition
 May follows infectious endocarditis & viral infections
 Alcohol related
 S&S- (heart failure)
 Fatigue, orthopnea, noctural dyspnea
 Irregular heart rate, pulmonary crackles, S3, S4
 Heart murmurs, sudden cardiac death!
Cardiomyopathy- very large heart,
circular shape, all chambers are
dilated, flabby, myocardium poorly
contractile
Normal weight 350 gms –dilated cardiomegaly-700 gms
Dilated Cardiomyopathy
 Collaborative Care
 *Focus-control heart failure
 Enhance contractility; dec. afterload
 Dx Tests (signs heart failure)
 Doppler ECHO, EKG, heart cath
 Lab (BNP)
 Chest X-Ray
 Diet/Drugs
 Low Na
 HF meds
Dialated Cardiomyopathy
 Diagnostics
 Echocardiogram, CXR, ECG, labs
 Treatment-Control HF
 Diuretics
 Nitrates
 Ace inhibitors
 Beta blockers
 Digoxin
 Amiodarone
 Anticoagulants
Dilated Cardiomyopathy
 Collaborative Care
 Surgical/resynchronizationization therapy

VAD or LVAD

CRT (cardiac resynchronization therapy)

Heart Transplant
Heart Transplant
Heart transplant
(slide show)
Virtual transplant
(try it!)
Click here-YouTube-
Lung machine
Heart-
Hypertrophic Cardiomyopathy
 Massive ventricular hypertrophy
 Rapid, forceful contraction of the
LV
 Impaired relaxation or diastole
 Obstruction to aortic outflow
 Primary defect is diastolic filling
 **HCM most common cause of
SCD in young adulthood
 Genetic
Hypertrophic Cardiomyopathy
 Manifestations
 Dyspnea
 Fatigue-dec CO
 Angina, syncope
 S4 and systolic murmur
 Diagnostics
 Echo- TEE
 Heart cath
*Hypertropic Aortic Stenosis*Note obstruction-aortic
outflow (HCM)
Hypertrophic Cardiomyopathy (HCM)
 Collaborative Care
 Goals
 Improve ventricular filling


*Reduce ventricular contractility
Relieve L. ventricular outflow obstruction
 Diagnostic Tests
 “Forced” apical sound (laterally)
 EKG, ECHO (L. ventricular hypertrophy, abnormal wall
motion)
 Heart cath
 Meds
 Negative inotropes (Ca channel blockers, beta blockers)
 *NO vasodilators, digitalis (usually), nitrates
Hypertrophic Cardiomyopathy
Treatment Goal- improve ventricular filling and
relieve LV outflow obstruction
 Beta blockers
 Calcium channel blockers
 Digoxin- only for A-fib if present
 Antidysrhythmics
 ICD
 AV pacing
Hypertrophic Cardiomyopathy (HCM)
 Collaborative Care
 Surgical/Other Interventions





Cardioverter/defibrillator (At risk patients)
AV pacing if outflow obstruction
Ventriculomyotomy and septal myomectomy
Alcohol septal ablation
Live Search Videos: cardiomyopathy
Hypertrophic Cardiomyopathy
Ventriculomyotomy and myomectomy- incising
the septum muscle and removing some of the
hypertrophied muscle
PTSMA- alcohol induced percutaneous trans
luminal septal myocardial ablation
- inject alcohol into small branch of LAD which
causes ischemia and MI of septal wall.
 Videos: cardiomyopathy
Restrictive Cardiomyopathy
 Least common
 Rigid ventricular walls that impair filling
(impaired diastolic)
 Contraction (systolic) and EF normal
 Prognosis-poor
S&S
 Fatigue, dyspnea, exercise intolerance
 R. sided heart failure
Restrictive cardiomyopathy
Restrictive Cardiomyopathy
 Collaborative Care
 Dx Test
 Chest X-ray (cardiomegaly?, show R. and L atrial enlargement)
 EKG (tachycardia), supraventricular dysrhythmias, AV block
 ECHO wall motion, EMB, CT nuclear imaging
 Medications
 *No specific treatment
 Meds to improve diastolic filling, manage heart failure, dysrhythmia
 Surgical/Other Treatment
 Poor prognosis
 Transplant maybe (depends underlying cause)
Biopsy of heart (EMB)
Restrictive Cardiomyopathy
Treatment
Surgery
 Vad-bridge to transplant
 Heart Transplant
 Myoplasty
 ICD- antiarrhythmics are negative inotropes
 Dual chamber pacemaker
 Hypertrophic
 excision of ventricular septum-myotomy, inject
denatured alcohol in coronary artery that feeds the top
portion of septum.
Restrictive Cardiomyopathy
Treatment
No specific Treatment- goal to improve diastolic
filling
Medications
HF and dysrhythmias
Teaching
Avoid strenuous activity, dehydration, increases in
SVR
High risk for IE
Review-Management Cardiomyopathy
 Vad-bridge to transplant
 Heart Transplant
 Myloplasty
 ICD- antiarrhythmics are negative inotropes
 Dual chamber pacemaker
 *Hypertrophic- excision of ventricular septummyotomy, inject denatured alcohol in coronary
artery that feeds top portion of septum.
 *Transplant
Cardiomyopathy
Nursing Diagnoses
 Decreased Cardiac Output
 Fatigue
 Ineffective Breathing Pattern
 Fear
 Ineffective Role Performance
 Anticipatory grieving
Nursing
 Relieve symptoms
 Prevent complications
 Provide pysch and emotional support
 Teaching Avoid strenuous exercise and dehydration
 Avoid anything increasing the SVR (afterload) makes
obstruction worse
 Chest pain


Rest and elevation of feet for venous return
NO vasodilators like nitroglycerine
Aortic Aneurysms
 Aorta
 Largest artery
 Responsible for
supplying oxygenated
blood to
essentially all vital
organs
 Aneurysm Abnormal dilation of a
blood vessel at a site of
weakness or a tear in the
vessel wall.
 Usually secondary to
atherosclerosis
 Most commonly affect
the aorta
Aortic Aneurysms
 Atherosclerotic plaques deposit beneath the intima
 Plaque formation is thought to cause degenerative
changes in the media
 Leading to loss of elasticity, weakening, and aortic
dilation
 May have aneurysm in
more than one location
 Growth rate
unpredictable
 Larger the aneurysm
greater risk of rupture
 May also involve the
aortic arch or the
thoracic aorta,
 Most (3/4) are found in
abdominal aorta below
renal arteries
 ¼ are found in the
thoracic area
 Dilated aortic wall
becomes lined with
thrombi than can embolize
 Leads to acute ischemic
symptoms in distal
branches
 Important to assess
peripheral pulses
Aortic Aneurysms
 Male>female
 Atherosclerosis Risks:
 Risk increases with age
 Studies suggest strong
genetic predisposition
 Age>60

 *Male gender and smoking
stronger risk factors than
hypertension and diabetes
 Male
 White
 Family Hx AAA
 Smoking
 HTN
 CAD
Aortic Aneurysms
 Usually atherosclerosis
 May also result from
 Trauma
 Infection
 Surgery
 Inflammation
 Infection
 Genetic
 Marfan’s
Types of
Aneursyms
 2 basic classifications-
True and False
 True aneurysm
 Wall of artery forms the
aneurysm
 At least one vessel layer
still intact
Fusiform-Circumferential,
relatively uniform in
shape
Saccular-Pouchlike with
narrow neck connecting
bulge to one side of
arterial wall
Types of Aneurysms
Fusiform-most are
Saccular
fusiform and 98% are below
the renal artery
Types of aneursyms
 False aneurysm (also called pseudoaneurysm)
 Not an aneurysm
 Disruption of all layers of arterial wall

Results in bleeding contained by surrounding
structures
Ascending Aortic Aneurysm
Aortic Arch
Clinical Manifestations
ASH
 Angina
 Swelling
 Hoarseness
 If presses on superior vena cava decreased venous
return can cause distended neck veins edema of head
and arms
Thoracic Aortic Aneurysm
Clinical Manifestations
 Frequently asymptomatic
 Coughing
 Hoarseness
 Difficulty swallowing
 May have substernal, neck, back pain
 Swelling (edema) in the neck or arms
 Myocardial infarction
 Stroke
Abdominal Aortic Aneurysm
Clinical Manifestations
Abdominal aortic aneurysms
 (AAA)
 Often asymptomatic
 Frequently detected


On physical exam
 Pulsatile mass in periumbilical area
 Bruit may be auscultated
Often found when patient examined for unrelated
problem (i.e., CT scan, abdominal x-ray)
Aortic Aneurysm
Clinical Manifestations
 AAA
 May mimic pain associated with abdominal or
back disorders
 Pain correlates to the size
 May spontaneously embolize plaque

Causing “blue toe syndrome” patchy mottling of
feet/toes with presence of palpable pedal pulses
 It can rupture causing shock and death in 50% of
rupture cases

Complications
 Rupture- signs of ecchymosis
 Back pain
 Hypotension
 Pulsating mass
 (rupture triad)
 Thrombi
 Renal Failure
 Death
Aortic Aneurysm- Complications
 Rupture- serious complication related to untreated
aneurysm
 Anterior rupture


Massive hemorrhage
Most do not survive long enough to get to the hospital
 Posterior rupture



Bleeding may be tamponaded by surrounding structures,
thus preventing exsanguination and death
Severe pain
May/may not have back/flank ecchymosis
Turner’s sign and Cullen’s Sign
 Live Search Videos: aortic aneurysm
 http://www.austincc.edu/adnlev4/rnsg2331online/module05/aneurys
m_case_study.htm
Aortic Aneurysm
Diagnostic Studies
 X-rays
 Chest  Abdomen  ECG -to rule out MI
 Echocardiography
 Ultrasound
 CT scan
 MRI
 Angiography
Medical Treatment
 Anti-hypertensives
 Beta blockers,
 Vasodilators
 Calcium channel blockers
 Nipride
 Sedatives
 Niacin, mevocor, statins
 Post-op anti-coagulants
Surgery
 Usually repaired if >5cm
 Open procedure- abd incision, cross clamp aorta,aneuysm
opened and plaque removed, then graft sutured in place
 Pre-op assess all peripheral pulses
 Post-op-check urine output and peripheral pulses
hourly for 24 hours
 Endovascular stents- placed through femoral artery
YouTube - Abdominal
Aortic Aneurysm
Graft Repair
Endovascular graft
procedure
 New approach is
percutaneous femoral
access
 Advantages
 Shorter operative time
 Shorter anesthesia time
 Reduction in use of general
anesthesia
 Reduced groin complications
within first 6 months
 YouTube - Cook's
modular AAA graft an
"engineering
achievement"
Aortic Dissection
 Blood invades or dissects the layers of the vessel wall
Dissecting aneurysms are unique and life threatening. A break or tear in
the tunica intima and media allows blood to invade or dissect the layers
of the vessel wall. The blood is usually contained by the adventitia,
forming a saccular or longitudinal aneurysm.
Aortic dissection occurs when blood enters the wall of
aorta, separating its layers, and creating a blood filled
cavity.
Aortic Dissection
 Often misnamed “dissecting aneurysm”
 Not a type of aneurysm
 Occurs most commonly in thoracic aorta
 Result of a tear in the intimal lining of arterial wall
 Male>Female
 Occurs most frequently between 30’s-60’s
 Acute and life threatening
 Mortality rate 90% if not surgically treated
Aortic Dissection
 As heart contracts, each systolic pulsation ↑ pressure on
damaged area
 Further ↑ dissection
 May occlude major branches of aorta
 Cutting off blood supply to brain, abdominal organs,
kidneys, spinal cord, and extremities
 People with Marfan’s at risk
Aortic Dissection
Manifestations
 Abrupt severe ripping or
tearing pain
 Mild or marked HTN
early
 Weak or absent pulses
and BP in upper
extremeties
 Syncope
Aortic Dissection
Collaborative Care
 Initial goal
 ↓ BP and myocardial contractility to diminish pulsatile forces
within aorta
 Conservative therapy
 If no symptoms
Can be treated conservatively for a period of time
 Success of the treatment judged by relief of pain
 Emergency surgery is needed if involves ascending aorta

Aortic Dissection
Collaborative Care
 Drug therapy
 IV Beta- adrenergic blocker
Esmolol (Brevibloc)
 Other antihypertensive agents
 Calcium channel blockers
 Sodium Nitroprusside
 Angiotensin converting enzyme

Aortic Dissection
Collaborative Care
 Surgical therapy
 When drug therapy is ineffective
or
 When complications of aortic dissection are present
 Heart failure, leaking dissection, occlusion of an
artery
 Surgery is delayed to allow edema to decrease and
permit clotting of blood
 Even with prompt surgical intervention 30-day
mortality of acute aortic dissections remains high
(10%-28%)
Nursing Diagnoses
 Risk for Ineffective Tissue Perfusion
 Risk for Injury
 Anxiety
 Pain
 Knowledge Deficit
Nursing Management
Acute Intervention- Post-op ICU monitoring
 Arterial line
 Central venous pressure (CVP) or pulmonary artery (PA)
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
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catheter
Continuous ECG monitoring
Oxygen administration/Mechanical ventilation
Pulse oximetry/ Arterial blood gas monitoring
Urinary catheter
Nasogastric tube
Electrolyte monitoring
Antidysrhythmic/pain medications
Nursing Management
 Infection
 Neurologic Status
 Peripheral perfusion status
 Renal perfusion status
 Gastrointestinal status
 Ambulatory /Home care
Prevention


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1.Ultrasound
2.Prevent atherosclerosis
3.Treat and control hypertension
4.Diet- low cholesterol, low sodium and no stimulants
5.Careful follow-up if less than 5cm.
Case study
Ms. C. 81 y/o admitted to CCU with SOB; has a hx of mitral valve
regurgitation with left ventricular enlargement. She received 100mg Lasix
IV in ER and her dyspnea improved. She has O2 at 3L/min. She has
crackles bibasilar and monitor is SR rate 94-96 with occ. PVC’s. The only
med ordered is morphine 2-4mg IV as needed for chest pain or dyspnea.
As you go to assess her, you find her in bed at 60 degree angle. She is
pale, has circumoral cyanosis and respirations are rapid and labored.
1. What action should you take first?
A. Listen to breath sounds
B. Ask when the dyspnea started
C. Increase her O2 to 6L minute
D. Raise the HOB to 75-85 degrees
Case study
Ms. C. 81 y/o admitted to CCU with SOB; has a hx of mitral valve
regurgitation with left ventricular enlargement. She received 100mg Lasix
IV in ER and her dyspnea improved. She has O2 at 3L/min. She has
crackles bibasilar and monitor is SR rate 94-96 with occ. PVC’s. The only
med ordered is morphine 2-4mg IV as needed for chest pain or dyspnea.
As you go to assess her, you find her in bed at 60 degree angle. She is
pale, has circumoral cyanosis and respirations are rapid and labored.
1. What action should you take first?
A. Listen to breath sounds
B. Ask when the dyspnea started
C. Increase her O2 to 6L minute (symptoms indicate acute hypoxemia, need to
inc O2 flow, HOB already elevated)
D. Raise the HOB to 75-85 degrees
Case Study-Question 2, 3
 2. Which of these complications are you most
concerned about, based on your assessment?
 A. Pulmonary edema
 B. Cor pulmonale
 C. Myocardial infarction
 D. Pulmonary embolus
 3. Which action will you take next?
 A. Call the physician about client’s condition.
 B. Place client on a non-rebreather mask with FiO2 at 95%.
 C. Assist client to cough and deep breathe.
 D. Administer ordered morphine sulfate 2mg IV.
Case Study-Question 2, 3
 2. Which of these complications are you most
concerned about, based on your assessment?
 A. Pulmonary edema- hx of inc SOB, mitral valve regurgitation, and sx hypoxemia, pink
frothy sputum indicate L. ventricular failure….prioroity
 B. Cor pulmonale
 C. Myocardial infarction
 D. Pulmonary embolus
 3. Which action will you take next?
 A. Call the physician about client’s condition.
 B. Place client on a non-rebreather mask with FiO2 at 95%. (in this
case, priority is still oxygenation, give morphine and call physician still appropriate…)
 C. Assist client to cough and deep breathe.
 D. Administer ordered morphine sulfate 2mg IV.
Case Study questions #4, 5
 4. What additional assessment data are most important
to obtain at this time?




A. Skin color and capillary refill
B. Orientation and pupil reaction to light
C. Heart sounds and PMI
D. Blood pressure and apical pulse
 5. B/P is 98/52, apical is 116, irregular at 110-120 with
frequent multifocal PVC’s. Physician is called and these
orders received. Which one should be done first?




A. Obtain serum dig level
B. Give furosemide 100mg. IV
C. Check blood potassium level
D. Insert #16 french foley catheter
Case Study questions #4, 5
 4. What additional assessment data are most important
to obtain at this time?




A. Skin color and capillary refill
B. Orientation and pupil reaction to light
C. Heart sounds and PMI
D. Blood pressure and apical pulse (Need VS to know changes in CO)
 5. B/P is 98/52, apical is 116, irregular at 110-120 with
frequent multifocal PVC’s. Physician is called and these
orders received. Which one should be done first?
 A. Obtain serum dig level
 B. Give furosemide 100mg. IV
 C. Check blood potassium level (Must know serum K level, low level might be cause of
PVC, know prior to Lasix)
 D. Insert #16 french foley catheter
Question #6, 7, 8
 6. Which order could be assigned to an LVN?
 A. Obtain serum digoxin level
 G. Give furosemide 100mg. IV
 C Check blood potassium level
 D. Insert #16 french foley catheter
 7. While waiting for potassium level, you give morphine sulfate IV to the
patient. A new graduate asks why you are giving the morphine. What is the
best response? It will:
 A. prevent chest pain.
 B. decrease respiratory rate.
 C. make her comfortable if intubation required.
 D. decrease venous return to heart
 8. Her K is 3.1; physician orders KCL 20meq. IV. How this be given?
 A. Utilize a syringe pump to infuse KCL over 10 minutes.
 B. Dilute KCL in 100 ml of D5W and infuse over 1 hour.
 C. Use a 5ml syringe and push KCL over at least 5 minutes.
 D. Add KCL to 1 liter of D5W and give over 8 hours.
Question #6, 7, 8
 6. Which order could be assigned to an LVN?
 A. Obtain serum digoxin level
 G. Give furosemide 100mg. IV
 C Check blood potassium level
 D. Insert #16 french foley catheter (All LVNs trained to insert Foleys)
 7. While waiting for potassium level, you give morphine sulfate IV to the
patient. A new graduate asks why you are giving the morphine. What is the
best response? It will:
 A. prevent chest pain.
 B. decrease respiratory rate.
 C. make her comfortable if intubation required.
 D. decrease venous return to heart (Morphine dec. venous return, dec. ventricular preload)
 8. Her K is 3.1; physician orders KCL 20meq. IV. How this be given?
 A. Utilize a syringe pump to infuse KCL over 10 minutes.
 B. Dilute KCL in 100 ml of D5W and infuse over 1 hour.(only safe way, too fast, > cardiac
arrest; too slow may not correct problem rapidly enough)
 C. Use a 5ml syringe and push KCL over at least 5 minutes.
 D. Add KCL to 1 liter of D5W and give over 8 hours.
Questions #9, 10, 11
 9. After infusing KCL, you give Lasix. Which of nursing action will be most
useful in evaluating if lasix is having desired effect?
 A. Obtain the client’s daily weight
 B. Measure the hourly urine output
 C. Monitor blood pressure
 D. Assess the lung sounds
 10. The physician orders a natrecor 100mcg IV bolus and an infusion of 0.5 mcg/
min. Which assessment data is most important to monitor during the infusion?
 A. Lung sounds
 B. Heart rate
 C. Blood pressure
 D. Peripheral edema
 11. Which nurse should be assigned care for this client?
 A. Float RN who worked on CCU stepdown for 9 years and floated before to CCU
 B. RN from staffing agency, 5 years CCU experience and orienting to CCU today
 C. CCU RN, already assigned to a newly admitted client with chest trauma
 D. New graduate RN who needs experience in caring for client with left ventricular
failure.
Questions #9, 10, 11
 9. After infusing KCL, you give Lasix. Which of nursing action will be most
useful in evaluating if lasix is having desired effect?
 A. Obtain the client’s daily weight
 B. Measure the hourly urine output
 C. Monitor blood pressure
 D. Assess the lung sounds (Major problem-pulmonary edema, lung sounds most important)
 10. The physician orders a natrecor 100mcg IV bolus and an infusion of 0.5 mcg/
min. Which assessment data is most important to monitor during the infusion?
 A. Lung sounds
 B. Heart rate
 C. Blood pressure (natrecor causes vasodilation, diuresis, ck for hypotension)
 D. Peripheral edema
 11. Which nurse should be assigned care for this client?
 A. Float RN who worked on CCU stepdown for 9 years and floated before to CCU
(had
experience with this type patient & on unit)
 B. RN from staffing agency, 5 years CCU experience and orienting to CCU today
 C. CCU RN, already assigned to a newly admitted client with chest trauma
 D. New graduate RN who needs experience in caring for client with left ventricular
failure.
Question #12, 13
 12.Which information would be important to report to the physician?

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

A. Crackles and oxygen saturation
B. Atrial fibrillation and fuzzy vision
C. Apical murmur and pulse rate
D. Peripheral edema and weight
 13. All meds are scheduled for 9 AM. Which would you hold until you
discuss it with the physician?
 A. Furosemide 40mg po bid
 B. Ecotrin 81mg po daily
 C. KCL 10meq three times a day
 D. Captopril 6.25mg po three times a day
 E. Lanoxin .125mg po every other day
Question #12, 13
 12.Which information would be important to report to the physician?
 A. Crackles and oxygen saturation
 B. Atrial fibrillation and fuzzy vision (dysrhythmias, visual disturbances, common side effects of
digoxin toxicity)
 C. Apical murmur and pulse rate
 D. Peripheral edema and weight
 13. All meds are scheduled for 9 AM. Which ones would you hold until you
discuss it with the physician?
 A. Furosemide 40mg po bid
 B. Ecotrin 81mg po daily
 C. KCL 10meq three times a day
 D. Captopril 6.25mg po three times a day
 E. Lanoxin .125mg po every other day

**Hold Furosemide and Lanoxin- low potassium potentiates dig toxicity
Priority Question # 14
 During the initial post-operative assessment of a

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
patient who has just transferred to the post-anesthesia
care unit after repair of an abdominal aortic aneruysm
all of these data are obtained. Which has the most
immediate implications for the client’s care?
A. The arterial line indicates a blood pressure of 190/112.
B. The monitor shows sinus rhythm with frequent
PAC’s.
C. The client does not respond to verbal stimulation.
D. The client’s urine output is 100ml of amber urine.
Priority Question #17
 It is the manager of a cardiac surgery unit’s job to develop a




standardized care plan for the post-operative care of client having
cardiac surgery. Which of these nursing activities included in the
care plan will need to be done by an RN?
A. Remove chest and leg dressings on the second post-operative
day and clean the incisions with antibacterial swabs.
B. Reinforce patient and family teaching about the need to deep
breathe and cough at least every 2 hours while awake.
C. Develop individual plan for discharge teaching based on
discharge medications and needed lifestyle changes.
D. Administer oral analgesisc medications as needed prior to
assisting patient out of bed on first post-operative day.
Priority Question # 16
 These clients present to the ER complaining of acute abdominal




pain. Prioritize them in order of severity.
A. A 35 year old male complaining of severe, intermittent cramps
with three episodes of watery diarrhea, 2 hours after eating.
B. An 11 year old boy with a low-grade fever, left lower quadrant
tenderness, nausea, and anorexia for the past 2 days.
C. A 40 year old female with moderate left upper quadrant pain,
vomiting small amounts of yellow bile, and worsening symptoms
over the past week.
D. A 56 year old male with a pulsating abdominal mass and sudden
onset of pressure-like pain in the abdomen and flank within the
past hour.
Priority Question # 25
 These clients present to the ER complaining of acute abdominal




pain. Prioritize them in order of severity.
A. A 35 year old male complaining of severe, intermittent cramps
with three episodes of watery diarrhea, 2 hours after eating.
B. An 11 year old boy with a low-grade fever, left lower quadrant
tenderness, nausea, and anorexia for the past 2 days.
C. A 40 year old female with moderate left upper quadrant pain,
vomiting small amounts of yellow bile, and worsening symptoms
over the past week.
D. A 56 year old male with a pulsating abdominal mass and sudden
onset of pressure-like pain in the abdomen and flank within the
past hour.