Adult2Exam2

CARDIOVASCULARDISEASELeadingcauseofdeathformales&females,regardlessofrace

-Cardiaccycle:Systole&Diastole

- SystoleisVentricularContraction- DiastoleisVentricularRelaxation

-CO:Howmuchbloodisejectedeveryminute(CO=SVxHR)-SV:Howmuchbloodispumpedw/eachcontraction-Preload:HowmuchmuscleisstretchedafterDiastole-Afterload:TheresistancetheVentricleisejectingagainst

EKG

• Duringprocedure,liestillfor5-10seconds• Nurses&RespiratoryTherapistscandoEKGs

• PartsofanEKG-

o HorizontalAxis:Thetimethatgoesby(eachboxis0.04sec)o VerticalAxis:Amplitude/voltageo Pwave:AtrialDepolarization,notatrialcontractionbcthisistheelectricalactivitytellingtheatriatocontracto QRS:VentricularDepolarization/AtrialRepolarization(hidden)o T:VentricularRepolarizationo UWave:PurkinjeFibersRepolarization(couldbepathological)

SINUSRHYTHMSSinusRhythmmeanstheSAnodeisgeneratingyourimpulse(thepacemaker)

STDEPRESSION:withlowKoriftheyareonDigoxin

ReadingaNormalEKG-NormalHRis60-100(normalsinusrhythm)

-Rhythm:RtoRdistanceshouldmatchupalongstrips(regularrhythm)

-PshouldbeinfrontofeveryQRS

-QRS&Tshouldbepointingsamedirection

ATRIALFIBRILATION

-UncoordinatedAtrialActivity

-Atriumsarejusttwitching-Notpushingbloodintotheventricleliketheyaresupposedto

-NoPattern-RtoRdistancedoesn’tmatchsorhythmisIRREGULAR

-Youcan’tidentifytheP-BetaBlockersaregiventocontrolHR

-Anti-Coagulant(Coumadin)bctheyareatahighriskforclots

ATRIALFLUTTER

-“SawToothWave”betweenR-R

-NodistinguishablePwave

AFibisfaster&morechaoticthanAFlutter

STEMI:“STelevationMI”-Probablymeanstheyarehavingaheartattack

-CouldbefromhighKlevels

CoronaryAtherosclerosis• FormationoffocaldepositsofCholesterol&Lipidsknownasplaquethat

obstructscirculationinCoronaryArterieso CoronaryArteriesprovidebloodsupplytoheartmuscle(myocardium)

• CADincludesAtherosclerosis,AnginaallthewaytoanMI–continuum

AtheromaorPlaque:smoothmusclecellformedfibrouscapovercorefilledw/lipidandinflammatoryfiltrate

NON-MODIFIABLERISKFACTORS• Genetics• FamilyHistory• Ageo Menolderthan45o Womenolderthan55

• Gendero Women:Moredeathsbcnosxo Men:Moresx--seektxearliero After55,bothhaveequalrisk

• Race(AAhashigherincidence)

MODIFIABLERISKFACTORS• ChangingLifestyleorHabits• TakeMedications• Diet• Exercise• Smoking• Stress• Hyperlipidemia/HTN/DM(meds)• Obesity

PATHOPHYSIOLOGYOFCAD• Injurymaybeinitiatedbysmoking,HTN,genetics,etc• Beginsasfattystreaksoflipidsthatdepositonvesselwallwhichdevelopatyoungage

&someofthelesionsadvanceduetootherfactorso Heredity,Smoking,EnvironmentalFactors

• InflammationprocessattractsPlatelets&WBCsandfibrouscapcoversinflammationfiltratesoitisunstable

• Bloodflowcoulddislodgeclot---thisobstructsbloodflowwhichwouldleadtoaMI• Theplaqueisveryunstableandcanruptureanytime.Whenitdoes,athrombosiswill

formandwilloccludethevesselcompletely.

RISKFACTORS

SIGNS&SYMPTOMS• ManypeopleareAsymptomatic

o Dependsonwhereobstructionis&howbigitis• ChestPainduetoIschemiacanoccur• Women&ElderlyusuallyhaveSOB,Nausea,andWeakness• DM/HFmayjustreportSOB

LABS

FastingLipidPanel(FLP)• Needtofastfor12hours• Cholesterol,LDL,HDL,Triglycerides• Olderthan20--checkevery5yrso Abnormalresultcheckmoreofteno IfpthadaCABG

§ Checkafterdischarge§ Thenevery6weeks§ Thenevery4-6months

Nutrient RecommendedIntake

Totalcalories Balanceintake&expendituretomaintaindesirableweight

Totalfat 25%–35%)Saturatedfat <7%

Polyunsaturatedfat Upto10%Monounsaturatedfat Upto20%

Carbohydrate 50%–60%Dietaryfiber 20–30g/day

Protein About15%Cholesterol <200mg/day

MEDICATIONS

NiacinRestrictsLipoprotein

Production

CholesterolAbsorptionInhibitorEzetimibe(Zetia)

-¯cholesterolabsorption

BileAcidSequestrantsCholestyramine(Questran)-­LipoproteinRemoval

FibricAcidDerviativesFenofibrate(TriCor),Gemfibrozil(Lopid)

-RestrictsLipoproteinProduction

HMG-CoAReductaseInhibitors(endin–statin)

-Don’ttakew/LiverDisease

-Takeatnightw/food(morecholesterolmadeatnight)

-RestrictsLipoproteinProduction

PREVENTION• Hyperlipidemia

o TakeMedso LoseWeight(LowFat,LowCholesteroldiet)o ModerateExercise(abletotalk,briskwalking)

§ 30mins/mostdaysoftheweek–­HDLand¯TG• StopSmoking

o CausesVasoconstriction(­BPandHR)o HigherriskfordevelopingClotsdueto

§ ­plateletaggregation§ ­CO2production(carbonmonoxide)

- whichbindstoHGB,insteadofO2- leadstodecreasedO2

• HTN&DM:acceleratesprocessofatherosclerosis;takemeds

AnginaPectoris-StableAnginaisrelievedbyRestorNitro-UnstableAnginaisnotrelievedbyrestornitro&consideredMIw/STEMIornon-STEMI

MedicationsforAngina

NitroglycerinVasodilator/¯Preload&Afterload

• SideEffects:¯BP,Headache• Types:

o Sublingual:every5minupto3x o Patch

§ Writedate/time/initial § Chartwhicharmorchest § Tellptstheycanshower/swim § Putoninam,takeoffpm(tolerance) § PreventsCPbutdoesnotstopanattack

• BeforeGivingNitro---o AssessBPo AskiftheyareonViagara

(bothvasodilate,soBPwilldropquick)UsediftheyhavehadAnginainthepast

Beta-blocker(Metoprolol/Carvedilol)

¯HRandBP• DONTstopabruptly-ReboundHTN• DM-masksHypoglycemiasymptoms

o MonitorBGoften• Don’tusew/SevereAsthmaorCOPD

o Itcancausebronchoconstrictiono WheezingorSOB--callprovider

andswitchmedications

CaChannelBlocker(Amlodipine/Diltiazem/Verapamil)• ¯BP-checkbeforegiving• UsedforHeartCathptso atriskforvasospasms

&thismedhelpsthat

HeparinAnticoagulantPreventDVTorClots

• SUBQ o Needle:5/8&25-30G

• MonitoraPTT o Therapeuticis45-75 o Normalis30

• Antidote:ProtamineSulfat • Watchforbleeding

o ¯BP/¯H&H/­HR • HeparinInducedThrombocytopenia

o HoldPressureLonger o AvoidIMInjection o AvoidContinuousBPCuff

Enoxaparin(Lovenox)Mustgiveairbubbletoptbcitsealsthemedicationinside

tissue

ASA(Aspirin)¯PlateletAggregation

¯RiskforClots• Dose:81mg• SideEffects:

o GIBleeding/GIUpset• AskiftheyhavetakenAspirinthatdaysoyou

don’tgivethemtoomuch

Oxygen(consideredamedication)• GiveO2forCP• 2LNasalCannula&then

CallPhysician• OxygenToxicity–

o N/Vo Coughingo NasalStuffinesso Sub-sternalPain

Assessment• ECG:12lead• Lab:CardiacEnzyme-3sets,every6hrstoseetrends

o TroponinandCK-MB• ChestX-ray:CPcancomefromPulmonaryoriginsothis

istoruleoutdifferentthingso Nometal,Checkforpregnancy

Signs&Symptoms• ChestpainisaHeavySensation

o “Elephantsittingonchest”• PainisusuallybehindSternum

o CanradiatetoNeck,Jaw,ShoulderorRightArm• MaytellyoutheyhaveIndigestion&ChokingSensation• DM--maynotfeelChestPainduetoNeuropathy• Women&Elderly--mayjusthaveSOB&WeaknessorSilent• Mayoccurupon:

o PhysicalExertiono EatingHeavyMealo StressorColdEnvironmentbcVasoconstriction

NursingProcess:AnginaAssessment:COLDSPA–whatweretheydoing,activitylevel,riskfactors,understandingofCPPhysical–vitals,heart,lung,abdomen,peripheralvascular(pulsesandedema)

Interventions:PlaceptinSemi-fowlers,rest;assessO2&vitals,EKGandlabs;teachstressreductionandpreventpain;stopsmoking,watchactivitylevel,carrynitroallthetime,followupappts

Diagnosis:Ineffectivetissueperfusionr/tdecreasedcoronarybloodflowaebptreportschestpain;ABCs,deficientknowledge

Planning/Goals:reserveheartmuscles&treatsignsandsymptoms

CardiacStressTesting

Goalis80-90%ofmaxHR--MaxHR=(220–Age)

ExerciseStressTest:runontreadmill/pedalbicycleorarmcrank;testtakes1-3hrsPharmTest:Vasodilators(Dabutamine,adenosine)o SideEffects:Flushing/Nausea/HA/Dizziness

-Avoidtobacco,caffeine,andalcoholbefore

NursingInterventions-Instructpttofast4hrbeforetest-Cantakemedswsipsofwater-Avoidintenseexercise3hrsbefore-Signedconsentneeded-Drmaysaynottotakemeds(betablockers)-IVSitejustincasetheyhaveMIduringtest

SymptomstoReportCP,dyspnea,dizziness,legcramp,fatiguechangeinEKG,BPorHRchange,pallor,sweat

-Allindicates(+)EKG—STOPTHETEST-Ptneedstreatmentincardiaccath

Post-Test:avoidhotbath/showerfor1-2hrs

MIBITechnetium-99mlabeledmethoxy-

isobutyl-isonitrileTestPerfusioninHeart

IVinjectionofRadioactiveIsotope-notaconcernbcloseradioactivityafterafewhrs

-NOcaffeine12hrsbefore-Don’tsmoke2hrsbefore-Nofood2hrsbefore-Lieonbackw/armsextendedoverhead-Cameraistakingpics-Testwilltake2-3hrs-Fatigueafterisnormal

MyocardialInfarction-AcuteCoronarySyndrome,includesUnstableAngina/nonSTEMI/andSTEMI-InanMI,areasoftheMyocardiumarepermanentlydestroyedresultingindeathofMyocardium-ProfoundimbalancebetweenO2Supply&Demand1. Assessment

1. ChestPain–continuesw/Rest&Nitro2. Dyspnea,Indigestion,Nausea,Anxiety

2. Diagnostic:CardiacEnzymes&Biomarkers(Troponin,CK-MB)1. ECGwithin10minutes

-GoalsofMedtherapy:Preventtissuedeathandpreventcomplications

DrugTherapy(MONA–Morphine,Oxygen,Nitro,Aspirin)

-if3Nitrosdon’twork,callPhysician&getanorderforMorphineIVPush-Cardiacrehab:trytoreturntopre-illnesslifestyle/work;teaching,counseling,interdisciplinaryteam

NitroglycerinVasodilator

MorphineAnalgesic(monitorRR)

ACEInhibitors--Lisinopril(Prinivil)--

¯workloadoftheheart,Helps¯mortalityrate,Preventsremodelingoftheheartmuscle

SideEffects:1. DryCough2. RetentionofK+-(monitorfor¯BP)3. Angioedema-(EMERGENCY)(monitorairway&assessswelling)

BetaBlockersmetoprolol&carvedilol

Thrombolytics(TPA)Mustbegivenwithinfirst6hrstowork

AssessptbeforeContraindicatedinPts:1. MajorRecentSurgery2. PastHemorrhagicStroke

Canalsousetode-clotcentralline

AspirinAntiplateletAgent

Anticoagulants-heparin&enoxaparin(lovenox)

Assessment

Lungs,Heart,Abdomen,IVsite,HR&Rhythm,Appearance,Chestpain,EKG,Respirations-Crackles&Edema–notifythephysician

Tempernarde-accumulationoffluidinPericardialCavity

Diagnosis-ineffective

tissueperfusion-anxiety

InterventionsHelppreventPulmonaryEdema

NeedIVLinetoPushMedsSemi-fowlers/fowlerstogetoxygentoheart

Oxygen-HF--Complication

VitalsQ4HActiveMI-ptneedstoberestinguntilcontrolled

InvasiveCoronaryArteryProcedure--HeartCathetercanbeDiagnosticorInterventional---GoldstandardfordetectingStenosisofCoronaryArtery

GothruFemoralArtery&threadallthewaytoCoronaryArtery• PercutaneousTransluminalCoronaryAngioplasty• CoronaryArteryStent:stentcanbecoatedinmedstohelpdissolve

clot.Afterthey’llbeonAspirinorPlavix(1monthto1year)• Atherectomy:Cutting&ShavingoffPlague

CoronaryArteryBypassGraft--FindveininLeg&GrafttoHeartsoBloodcanFlow--

PreProcedure--

-Assessallergies

-Getsignedconsent

-RenalFunctionbcofDye

-NPOfor8hours

-MaysignEmergencyCAGB(foriftheyhaveMIduringCathLab

&needemergencysurgery)

-Tellptitcantake2hrsormore

-Mayhavebackpainorfeelflushed(dye)(giveanalgesics)

PostProcedure--

-FrequentVSevery15minx4every30minx2every1hourx4

Assess:-siteforbleeding-siteshouldbesoft

(hard&painful=hematoma)-peripheralpulses-remainflatinbed

-keepaffectedlegstraight-analgesicsforpain

PostProcedure---ICUfor1-2days---thenMedSurg

-PtwillhavealotoflinesAssess:Vitals,Heart/LungSound,HeartrhythmLOC,O2Sat

-Assessincisionsites:(bigincisiononchest&smallincisionsonlegs)

-AssessPainandcontrolitAmbulate:ptneedstobemovetochairorambulate25-100ft48

hrsaftertopreventDVT&Atelectasis(ifsxwhilemoving,needtostop&notifysomeone)

-Deepbreathe,CoughandTurn-IncentiveSpirometry–getbaseline&useaftersurgery-MonitorCBCandBMP

Preprocedure:-ProvideInstruction-InformedConsent-DiscontinueMeds(anticoagulants,digoxin,diuretics)

Hypertensionthesilentkiller;sometimesithasnosymptoms;ifleftuntreated,canaffectheart,brain,kidneysandeyes;canleadtoheartattack,strokeandkidneyfailure;1/3ofpatientshaveHTNanddon’tevenknow

PrimaryHTN:(Essential)noknowncause—mostcommonSecondaryHTN:identifiedcause;ex:pregnancyormedications

Patho:BP=COxPRS/S:HA,dizziness,fainting,visionproblems;mostlysymptomaticthoughAssessment/Diagnostic:averageoftwoormorereadingsintwoormorevisitstoPCP;mustbeproperreadings–sitting,armatheartlevel,barearmsandlegsuncrossed;kidneydamage(urinalysisandBUN/creat),FLP,EKGcanalsotellyousomething

HypertensionMedications

Diuretics-moveoutofpositionsslowly-usesiderailsandaskforhelp

-assessforhypotension

Loop--Furosemide(Lasix)--

-checkKlevels

Thiazides---HCTZ---

-cancauseKloss(notasbadasloop)-Takew/foodto¯stomachupset

AldosteroneReceptorBlocker

---Spironolactone---

PotassiumSparingMiloride(midamor)

BetaBlockers

ACEInhibitorsLisinopril(Prinivil)

ARBs-angiotensinIIreceptor

blockers-similartoACEInhibitor

-blocksbinding

Central-AlphaAgonistClonidine(Catapres)

CaChannelBlockerAmlodipine(Norvasc)&Diltiazem(Cardizem)

Discharge:encourageBPchecks–providecufftopt,keepdiaryeducateonposturalhypotension&changingpositionsslowly

HTNCRISES

BPclassification SBP DBPNormal <120 and <80Prehypertension 120-139 or 80-89Stage1HTN 140-159 or 90-99Stage2HTN >160 or >100

HypertensiveEmergency

BP>220/140-thereistargetorgandamage(kidneys,elevatedBUN&creat)

Youcan’tbringBPdowntoofast,bcvitalorganswon’tgetblood–

1. ReduceMAPby25%within1sthr1. Overnext6hrsslowlyreduceBPto160-1002. Thenslowlybringdownovernextfewdays

Treatment:-IVSodiumNitroprusside(Nitropress)-NicardipineHydrochloride(Cardene)

Prehypertension:modifyweight,dietandexerciseStage1

1. BPmeds–diureticsorbetablockers2. physicianvisitseverymonth3. every3-6monthsafterregulated4. Goalisunder140/90&forDMis130/80

Stage2:morefrequentvisits

NursingCare-MeasureBPevery5min----(leaveBPcuffon&setautomatically)

-Oncestable,BPevery10-15min(tomonitorBP&preventfurtherorgandamage)

HypertensiveUrgency--HA,NoseBleeds,Anxiety--UsefastactingOralmeds

TrytonormalizeBPwithin1-2daysNoorgandamageyet

NotasbadasHTNEmergency

NursingCare-MonitorBP-MonitortheHeart-CheckPeripheralVascular-CheckurineoutputforKidneyfunction

TreatmentPOFastActingAnti-hypertensives

-BetaBlocker(Labetalol)-ACEInhibitor(Captopril)

-Alpha2Agonists(Clonidine)

AbdominalAorticAneurysmDamagedmedialayerofthevessel;weakenedspotinarterywall;HTNcausesbulgeinarterialwall- Riskfactors

o Genetico Age&Gender(Caucasianelderlymen4xmorethanwomen)o Tobaccoo HTN(morethanhalfofpeoplewithAAAhaveHTN)o Atherosclerosis(mostcommoncause)

- Signs&Symptoms:o UsuallyNoneo Canfeeltheirheartbeatingintheirabdomen--Maybeabletohearabruit

- Assessment/diagnostic:o Usuallypickedupwithimagingforotherthings

§ Ifsmall,monitorevery6monthstomakesureit’snotgrowingtoomuch- MedicalManagement:

o Meds:controlBPwithoralmedicationo Surgicalintervention:ifbiggerthan2inor5cm,needssurgicalintervention(whenitreaches5.5cm)

§ OpenSurgicalRepair:openincision&sewstentinplace;incisioninabdomen§ Endovasculargrafting:likeheartcath,gointhroughgroinareaandplacestent

• NursingManagement:

Pre-Op:

-MaintainSystolicBP100-120bygivingAnti-hypertensives-AnticipateRupture

-ImpendingRuptureSigns:SevereBack&ConstantAbdominalPain(bigclue)-DropinBP,decreasedHCT

-Getbaselinevitals&detectperipheralpulses

Post-Op:

-Getbaselinevitals-VitalsQ15minx4,Q30minx4andtheneveryhour-Assessincisionsite(nobleeding/hematoma)-Ensureadequatenutrition-Assesspain,colorandtemperatureoflegs,peripheralpulses,I/Oandvolumestatus

HeartFailure-canresultfromHTNandCAD

LEFTSIDEDHF RIGHTSIDEDHF

BacksuptotheLungs BacksuptotheRestofBody(Peripheral&VisceralOrgans)

• Dyspnea–(sitptinHIGHFowlers)• LowO2sats–(mayneedO2)• S3HeartSound–(bclargevolumeoffluidenteringventricles)• AlteredMentalStatus--(bclessbloodflowtobrain)• PulmonaryCrackle• Cough,frothysputum• Alteredmentalstatus• Fatigue

• JVD• Edema–(weightgain)• Ascites• Hepatomegaly• Anorexia• Nausea• Weakness

MedicationsforHeartFailure

Digoxin

¯HR--by­ContractionofMyocardium&¯WorkLoad(Digoxin­EjectionFraction)

NursingCare-AssessHR&Kbefore(Apical<60--hold)(-K+<3.5----hold)

-TellTeleroomyou’repushingDigoxinbcitwill¯HR

EarlySignsofToxicityGIManifestations/HRAbnormalities/VisualDisturbances(diplopia,blurredvision,photophobia,yellow/greenhalos)

SideEffects

-Anorexia,N&V,Diarrhea-Drowsiness,Fatigue,Weakness-Headache-Depression-Bradycardia,Dysrhythmias-VisualDisturbances

ACEInhibitorsLisinopril

BetaBlockersMetoprolol

ARBsValsarten

Hydralazine&IsosorbideDinitrateVasodilator

DiureticsFurosemide

CaChannelBlockerAmlodipine&Diltiazem

Antidote:Digibind

TherapeuticRange:0.8-2.0

Diagnostics

BNPHormonethatregulates

Volume&BPKeyDiagnosticIndicatorinHF

Normal:0-100pg/mLHFPts:around1000pg/mL

ECGEjectionFraction-%ofbloodbeing

pumpedout

Normal:55-65%HFPatients:around10% Procedure:

-Takesabout1hour-LieverystillonLeftside

LifestyleRecommendations SodiumRestriction:(2-3g/day)

FluidRestriction:(1500ml-2L/day)

DailyWeight-everydayatthesametime/sameclothes

-emptybladderbefore-keepdiary

ShouldbeConcerned:-gain2-3lbs/day-5lbsinaweek