1
Q
preload
A
amount of blood returning to the right side of the heart and the stretch in muscle the volume causes
2
Q
_____ is released when we have this preload stretch
A
ANP -> diurese
3
Q
increased preload =
A
increased workload
4
Q
afterload
A
the pressure (resistance) in the aorta and the peripheral arteries that the LV has to pump against to get the blood out
5
Q
diagnosis with increased afterload
A
HTN
6
Q
HTN can lead to… (2), because why?
A
- HF|2. pulmonary edema||- high afterload decreases CO and forward flow -> wears your heart out
7
Q
stroke volume
A
amount of blood pumped out of the ventricles w/ each beat
8
Q
CO = ____ x ____
A
CO = HR x SV
9
Q
____ is dependent on adequate CO
A
tissue perfusion
10
Q
*4 factors that affect CO*
A
- HR|2. certain dysrhythmias|3. blood volume|4. decreased contractility
11
Q
3 potential causes of decreased contractility
A
- MI|- medications|- cardiac muscle disease
12
Q
Medications: preload|- how do medications work to affect preload and increase CO?||- 2 examples
A
- by vasodilating or diuresing to decrease preload||1. Diuretics (furosemide)|2. Nitrates (nitroglycerine)
13
Q
Medications: afterload|- how do medications work to affect afterload and increase CO?||- 4 examples
A
- by vasodilating to reduce afterload||1. ACE Inhibitors (captopril, enalapril, fosinopril)|2. ARBS (valsartan, losartan, irbesartan)|3. hydralazine|4. nitrates
14
Q
Medications: contractility|- how do medications work to affect contractility and increase CO?||- 3 example
A
- by providing an inotropic effect on the heart -> increases contractility ||1. inotropes (dopamine, dobutamine, milrinone)
15
Q
Medications: rate control|- how do medications work to affect HR and increase CO?||- 3 examples
A
- by slowing the rate down to a more controlled, effective pump||1. Digoxin|2. B-blockers (metoprolol, propanolol, atenolol, carvedilol)|3. Ca-Channel blockers (diltiazem, verapamil, amlodipine)
16
Q
Medications: rhythm contol|- how do medications work to affect rhythm and increase CO?||- 1 example
A
- by converting the heart back to a NSR, the heart pumps more effectively and CO increases||1. antiarrythmics (Amiodarone)
17
Q
6 areas affected by decreased CO
A
- brain|2. heart|3. lungs|4. kidneys|5. skin|6. peripheral pulses
18
Q
Decreased CO:|- brain|- heart|- lungs|- kidneys|- skin|- peripheral pulses
A
- brain: LOC decreases||2. heart: chest pain||3. lungs: wet sound/crackles, SOB||4. skin: cold, clammy||5. kidneys: UO decreases||6. peripheral pulses: weak/thready
19
Q
dysrhythmias are no big deal until what?
A
they affect your CO
20
Q
*3 arrythmias that are ALWAYS a big deal + ACTION*
A
- pulseless v-tach|2. v-fib|3. asystole||- CPR!!
21
Q
most common CV disease
A
coronary artery disease
22
Q
CAD includes… (2)
A
- chronic stable angina||- acute coronary syndrome
23
Q
Patho: chronic stable angina
A
- intermittent decreased BF to myocardium leads to ischemia||- this ischemia can lead to temporary pain/pressure in chest
24
Q
CSA:|- what brings on the chest pain?|- what relieves it?
A
- low O2, usually d/t exertion||- rest and/or nitroglycerine sublingual
25
4 medications for CSA
1. nitroglycerine sublingual|2. B-blockers|3. Ca-Channel blockers|4. Aspirin
26
Nitroglycerine:|- action|- route|- use
- causes venous, arterial, and coronary artery vasodilation -\> decreases preload and afterload; and increases blood flow to the myocardium||- sublingual||- used for angina
27
Nitroglycerine:|- how to take?|- swallow?|- burn/fizz?|- expected outcome?
- sublingual: take 1 every 5 minutes x 3 doses for acute angina -\> no help, call 911||- DON'T SWALLOW||- may or may not burn/fizz||- patient WILL get a headache -\> but also their BP will decrease
28
Storing Nitroglycerine:|- store it how?|- renew SL tablets how often?|- spray how often?
- store in a dark, glass bottle in a dry and cool place||- q3-6months||- q2yr
29
After giving nitro, can you leave the pt?
NO: never leave an unstable pt!
30
nitro: home teaching (2)
- take one NTG SL -\> after 5 minutes if chest pain/discomfort is unrelieved or worse, call 911||- take @ home -\> have a BP monitor to check your BP
31
B-blockers:|- use|- action (3)
- prevention of angina||- decrease:|1. BP|2. HR|3. contractility||...therefore, decreasing the workload of the heart
32
What happens to CO when you give B-blockers?
- decreases -\> decreases workload of heart
33
considerations for b-blockers
- good to a certain point to decrease the work/CO on the heart||- but we could potentially decrease CO too much
34
Ca-channel blockers:|- 4 examples|- use|- action
1. nifedipine|2. verapamil|3. amlodipine|4. diltiazem||- prevention of angina||- dilation of the arterial system (coronary arteries) -\> decreasing BP
35
2 benefits of Ca-channel blockers
1. decrease afterload|2. decrease heart's oxygen demand
36
Acetylsalicylic acid (aspirin): use
to keep blood flowing freely
37
general strategy for pt teaching for CSA
do whatever you can to decrease the workload on the heart
38
\*pt teaching: CSA (8)\*
1. rest frequently|2. avoid overeating|3. avoid excess caffeine/drugs that increase HR|4. dress warmly in cold weather|5. take NTG prophylactically|6. quit smoking|7. lose weight|8. reduce stress
39
diet for CSA
- low fat, high fiber
40
CSA: exercise teaching (2)
- wait 2 hr after eating to exercise||- avoid isometric exercise (squeeze/release muscles)
41
Why do CSA pt's need to dress appropriately for the weather?
any temperature extreme can precipitate an attack
42
procedure that may need to be performed in a CSA pt
cardiac catheterization
43
Considerations: pre-cardiac cath (4)
1. assess if allergic to iodine or shellfish (an iodine-based dye is used)||2. assess kidney function: dye is excreted thru kidneys||3. inform pt that the shot will feel hot and that palpitations are normal||4. hold metformin
44
What is often ordered before a cardiac cath if a pt has kidney problems?
- acetylcystine (Mucomyst): helps to protect kidneys
45
considerations: post-cath (4)
1. monitor VS|2. watch puncture site|3. assess extremity distal to puncture site|4. proper positioning
46
watch puncture site for what? (2)
1. bleeding: major complication post-cath||2. hematoma formation: bleeding behind them
47
assess extremity distal to puncture site how often? for what? (5 P's)
- q15m for 1 hr||Pulselessness|Pallor|Pain|Paresthesias|Paralysis
48
\*Positioning post-cath\* (3)
- bedrest||- lie flat||- keep extremity straight for 4-6 hr
49
after cath, report ______ ASAP
PAIN
50
withhold which med after cath? for how long? why?
- metformin||- 48 hr||- worried about kidneys
51
Unstable chronic angina = ....
impending MI
52
Acute Coronary Syndrome (ACS) is another name for..
- MI||- unstable angina
53
ACS:|- patho
- decreased BF to myocardium -\> ischemia and necrosis
54
difference b/n ACS and CSA
ACS:|- pt does not have to be doing anything to bring this pain on||- NTG will not relieve the pain
55
6 general s/s of ACS
1. pain|2. cold/clammy|3. hypoTN|4. decreased CO|5. ECG changes|6. vomiting
56
how might the pain from ACS be described?
- pressure|- elephant sitting on my chest|- pressure radiating to left arm/jaw|- N/V|- pain between shoulder blades
57
3 patients we are most concerned about when considering MI + why?
1. women|2. elderly |3. diabetics||- these patients don't have typical s/s of ACS
58
Women usually present w/.....during an MI (5)
1. GI s/s|2. epigastric complaints|3. pain between shoulder blades|4. aching jaw|5. choking sensation
59
\*classic triad a woman will present w/ when having an MI\*
1. abd fullness|2. chronic fatigue|3. SOB
60
Why are we worried about the elderly?
they might have less or no pain
61
2 most common s/s of ACS in elderly
1. SOB = most common||2. change in behavior
62
why are we worried about diabetics?
can't feel pain properly (neuropathy)
63
Which patient is more severe: STEMI or NSTEMI?|- \*action?\*
STEMI: this indicates that the pt is having a heart attack||- need to get them to the cath lab for PCI in less than 90 minutes
64
3 labs used to diagnoses MI
1. CPK-MB|2. Troponin|3. Myoglobin
65
which lab value is most sensitive and most specific for diagnosing MI?
- troponin
66
CPK-MB:|- increases with..|- elevates how fast?|- peaks when?
- damage to cardiac cells||- within 3-6 hr||- 12-24 hr
67
Troponin: normal levels|- T|- I
- T: \< 0.10||- I: \< 0.03
68
Troponin:|- elevates how fast?|- remains elevated how long?
- within 3-4 hr||- up to 3 weeks
69
Why is troponin the best indicator of an MI?
- it is the most sensitive biomarker to myocardial damage||- it remains elevated for a long time, good for the pt who delayed seeking care
70
why is myoglobin not reliable for diagnosing MI?
it is not cardiac specific
71
One benefit of myoglobin levels
it will elevate first: within 1 hr
72
potential complication of an ACS
major arrythmias
73
\*3 untreated arrythmias that will put the pt at risk for sudden death\*
1. pulseless v-tach|2. v-fib|3. asystole
74
\*priority tx for v-fib\*
DEFIBRILATE!: de-fib the v-fib||- also CPR!
75
\*the first shock doesn't work and the pt remains in v-fib. what are the next 2 actions to take?\*
- epinephrine -\> then amiodarone
76
Amiodarone:|- uses (3)
when:|1. v-fib and|2. pulseless v-tach|...are resistant to tx||3. fast dysrhythmias
77
2 anti-arrythmics commonly given to prevent a 2nd episode of v-fib
1. amiodarone|2. lidocaine
78
#1 antiarrythmic of choice + major S/E
- amiodarone||- hypoTN -\> can lead to further dysrhythmias
79
s/s of lidocaine toxicity
any neuro changes
80
\*order of medications given to pt w/ chest pain when they arrive at the ED\*
1. Oxygen: keep O2 sat \> 90%|2. Aspirin: chewable|3. Nitroglycerine|4. Morphine||\*OANM\*
81
what position should you place pt c/o of chest pain in?
head up: decreases workload and increases CO
82
what other kind of medication will the pt c/o chest pain be given?
thrombolytics
83
thrombolytics:|- goal|- 4 examples
- dissolve the clot that is blocking BF to the heart muscle -\> decrease size of infarction||1. alteplase|2. tenecteplase|3. reteplase|4. streptokinase
84
\*how soon after onset of myocardial pain should thrombolytics be administered?\*
within 6-8 hrs
85
Stroke: ________ is BRAIN
TIME
86
major complication of thrombolytic therapy
bleeding
87
\*4 absolute contraindications for thrombolytic treatment\*
1. intracranial neoplasm|2. intracranial bleed|3. suspected aortic dissection|4. internal bleeding
88
antidote for dabigatran
iadrucizumab
89
3 classes of drugs requiring bleeding precautions
1. thrombolytics|2. antithrombotics|3. acetominophen
90
3 other examples of thrombolytics
1. heparin|2. warfarin|3. enoxaparin sodium
91
\*bleeding precautions (8)\*
watch for:|1. bleeding gums|2. hematuria|3. black stools||use:|4. electric razor|5. soft toothbrush|6. stool softeners|7. lubricant for sex||no:|8. IM injections
92
How to draw blood on a pt on bleeding precautions
- draw blood when starting IVs -\> decrease number of puncture sites
93
any ABGs if a pt is on bleeding precautions?
NO
94
\_\_\_\_\_ are another important follow-up component of thrombolytic therapy
antiplatelets: aspirin, clopidogrel, etc
95
Which type of IV is preferred if you need a TPA for an MI?|- CVL or PIV?
PIV: because if you put in a central line there is an extreme risk for bleeding out
96
2 medical interventions for MI
1. percutaneous coronary intervention (PCI)||2. coronary artery bypass graft (CABG)
97
use of PCI
to open up occluded artery to restore BF
98
PCI includes... (2)
- PTCA (angioplasty)||- stents
99
major complication of PCI
MI (also bleeding from heart cath site, or reocclusion)
100
if any problems occur after PCI, do what?
go to surgery
101
\*pt teaching: post-PCI\*
report any pain! -\> Call HCP STAT, they are reoccluding
102
CABG:|- use (2)
(scheduled or emergent)||- multiple vessel disease||- left main artery occlusion
103
why is the left main coronary artery so important?
- supplies the LV -\> ||- if occluded, think sudden death! (or "widow maker")
104
\*Post-MI: pt teaching -\> NO...(4)\*
NO:|- smoking|- isometric exercises|- valsalva/straining|- suppository meds
105
Give ____ to prevent straining post-MI
docusate
106
Post-MI: exercise teaching (3)
- stepped-care plan (increase activity gradually)|- no isometric exercises|- best exercise: walking
107
Post-MI: diet (4)
1. low fat|2. low salt|3. low cholesterol|4. high fiber
108
Post-MI: sex teaching (2)
- can resume sex when they can walk up a flight of stairs or around the block w/ no discomfort (1 wk-10 days)||- safest time to have sex: morning, when they are well rested
109
teach Post-MI pt s/s of HF (4)
1. increased wt|2. ankle edema|3. SOB|4. confusion
110
5 main causes of HF
1. untreated HTN: #1 causes|2. cardiomyopathy|3. endocarditis|4. MI|5. valvular heart disease
111
S/S of LHF (9)
1. pulmonary congestion|2. pink, frothy sputum|3. dyspnea|4. cough|5. restlessness|6. tachycardia|7. S-3 sound|8. orthopnea|9. nocturnal dyspnea
112
S/S of RHF (5)
1. distended neck veins|2. edema|3. enlarged organs|4. wt gain|5. ascites
113
how can COPD/pulmonary embolus lead to cor pulmonale?
- hypoxia -\> pulmonary HTN -\> increased workload -\> RHF -\> cor pulmonale
114
what is cor pulmonale?
RHF caused by LHF/primary disorder in respiratory system
115
Systolic vs Diastolic HF
- systolic: heart can't contract and eject||- diastolic: heart can't relax and fill
116
4 common ways to diagnose HF
1. B-type natriuretic peptide (BNP)|2. CXR|3. Echocardiogram|4. NY Heart Association Functional Classification
117
NY Functional classification: which is the worst?
- scale of 1-4, 4 being the worst
118
sensitive laboratory indicator of HF
BNP
119
BNP:|- when is it secreted?|- considerations when preparing to draw
- secreted by ventricular tissues when ventricular volumes and pressures in the heart are increased||- discontinue nesiritide 2 hr before drawing BNP
120
a CXR will show (2) in HF
- enlarged ventricles||- pulmonary infiltrates
121
echocardiograms can give you information on.. (2)
1. pumping action/ejection fraction|2. backflow -\> valve disease
122
2 standard medications used for HF
1. ACE inhibitors||2. ARBs
123
drug of choice for HF
ACE inhibitors
124
ACE inhibitor:|- action|- result in (2)
- prevent conversion of angiotensin I to angiotensin II||1. arterial dilation|2. increased stroke volume
125
ARBs:|- action|- result in (2)
- block angiotensin II receptors||1. decreased arterial resistance|2. decreased BP
126
ACE inhibitors and ARBs both block ________ =\> result (3)
- aldosterone: ||1. lose Na|2. lose H2O|3. retain K+ -\>
127
watch for ______ w/ ACE inhibitors/ARBs
hyperkalemia
128
it is a core practice that a pt w/ HF will be sent home on...what (2)?||Why?
1. ACE inhbitor||and||2. B-blocker||- these drugs decrease workload by preventing vasoconstriction (decreasing afterload). This will increase CO and keep blood moving forward.
129
2 other drugs for HF
1. digoxin|2. diuretics
130
Digoxin:|- use|- results (4)
- used when pt is in sinus rhythm or a-fib and has HF||1. increased contractility|2. decreased HR|3. increased CO|4. increased kidney perfusion
131
Important to assess for _____ w/ digoxin
toxicity (especially in elderly pt)
132
normal digoxin levels
0.5 - 2.0
133
we always want to ____ HF pts
diurese
134
s/s of digoxin toxicity (4)
- anorexia|- N/V|- arrythmias|- vision changes: yellow halos
135
before giving digoxin, do what?
assess apical pulse for a full minute. Hold dose if it is \<60
136
where would you check for apical pulse?
5th ICS, MCL
137
most important electrolyte to monitor if a pt is on digoxin
K+
138
\_\_\_\_\_\_\_ + digoxin = toxicity
hypokalemia
139
T/F: any electrolyte can promote digoxin toxicity
TRUE
140
diuretics:|- action|- consideration
- decrease preload||- always give in the morning
141
5 other interventions for HF pt
1. low Na diet|2. bed positioning|3. daily wt|4. report s/s of recurring failure|5. pacemaker
142
low Na diet helps decrease \_\_\_
preload
143
salt substitutes can contain excessive \_\_\_\_
K+
144
position in bed for HF pt
HOB elevated
145
report a wt gain of....
2-3 lb
146
fluid retention, think ____ first
heart problems
147
natural pacemaker
SA node
148
Pacemaker:|- indication
symptomatic bradycardia
149
What do pacemakers do?
depolarize the heart muscle -\> contraction will occur
150
repolarization
- Re = rest: ventricles rest and fill up w/ blood
151
pt w/ pacemaker: always worry if...
HR drops below the set rate
152
post-permanent pacemaker care (4)
1. monitor incision|2. immobilize arm -\> put things close to them|3. assisted passive ROM to prevent frozen shoulder|4. keep pt from raising arm higher than shoulder
153
loss of capture
no contraction follows stimulus -\> decreased CO
154
failure to sense
pacemaker fires at innappropriate times
155
2 s/s of pacemaker malfunction
- any sign of decreased CO||- bradycardia
156
Pacemaker: pt teaching (6)
1. check pulse daily|2. ID card/bracelet|3. avoid electromagnetic fields (cell phones, large motors)|4. avoid MRIs|5. will set off alarm at airport|6. avoid contact sports
157
R/F for pulmonary edema (5)
1. receiving IV fluids very fast|2. very young|3. very old|4. heart dz|5. renal dz
158
when does pulmonary edema usually occur?
at night, when pt goes to bed
159
S/S of pulmonary edema (5)
- pink, frothy sputum|- sudden onset|- breathless|- restless/anxious|- severe hypoxia
160
\*priority nursing action for pulmonary edema\*
- administer high-flow oxygen: titrate to keep O2 sats \> 90%
161
4 medications for pulmonary edema
1. diuretics|2. nitroglycerine|3. morphine|4. nesiritide
162
Diuretics:|- use|- results (2)|- how to give?|- prevent (2)
- reduce preload||1. diuresis|2. vasodilation||- IVP slowly over 1-2 minutes to prevent hypoTN and ototoxicity
163
which diuretic can be given as a continuous IV infusion?
bumetanide
164
result of NTG
decreased afterload
165
results of morpine (2)
- decreased afterload and preload
166
Nesiritide:|- actions (2)|- considerations (2)
1. vasodilates veins/arteries|2. diuretic effect||1. turn off 2 hr before drawing BNP|2. only used for short-term therapy: never longer than 48 hr
167
pulmonary edema: positioning + why? (2)
- upright position, legs down||1. improves CO|2. promotes pooling of blood in legs
168
cardiac tamponade: patho
- blood, fluid, or exudate has leaked into the pericardial sac resulting in compression of the heart||- often seen in MVA, MI, pericarditis, hemorrhage post-CABG
169
2 hallmark signs of cardiac tamponade
1. increased CVP|2. decreased BP
170
other s/s of tamponade (5)
1. narrowed pulse pressure|2. muffled/distant heart sounds|3. distended neck veins|4. pressures in all 4 chambers the same|5. shock
171
tamponade tx
pericardiocentesis
172
T/F: atherosclerosis is often limited to one certain spot
false: if you have it in one place, you have it everywhere
173
hallmark sign of arterial disorder
intermittent claudication: |- only seen w/ arterial problems|- pain relieved w/ rest
174
7 s/s of arterial disorder
- coldness|- numbness|- decreased peripheral pulses|- atrophy|- bruit|- skin/nail changes|- ulcerations
175
Pain at rest means...
severe arterial occlusion: medical emergency
176
leg positioning:|- arterial disorder|- venous disorder
- A: dangle arteries (A points down)||- V: elevate veins (V points up)
177
2 common treatments for aterial disorders
- angioplasty||- endarterectomy
178
how to assess if an angioplasty/endarterectomy was successful?
- look for positive changes in the area that the artery is feeding blood to (brain, abd, leg)
179
Arterial vs. Venous: pain
- A: intermittent claudication (progressing to pain at rest)||- V: none-to-aching pain; depends on dependency of area
180
Arterial vs. Venous: pulses
- A: decreased, may be absent||- V: normal (may be difficult to palpate d/t edema)
181
Arterial vs. Venous: color
- A: pale when elevated, red when lowered||- V: normal (may see petechiae/brown pigment)
182
Arterial vs. Venous: temperature
- A: cool||- V: normal
183
Arterial vs. Venous: edema
- A: absent or mild||- V: present
184
Arterial vs. Venous: skin changes
- A: thin, shiny, loss of hair over foot/toes, nail thickens||- V: brown pigment around ankles, thickening/scarring of skin
185
Arterial vs. Venous: ulceration
- A: will involve toes or areas of trauma on feet (painful)||- V: will be on sides of ankles
186
Arterial vs. Venous: gangrene
- A: may develop||- V: does not develop
187
Arterial vs. Venous: compression
- A: not used||- V: used
NCLEX
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