1
Q
Coronary Artery Disease (CAD) definition
A
atherosclerosis of the coronary artery and heart structures
- disturbs the balance between myocardial oxygen supply and demand
2
Q
Peripheral Vascular Disease (PAD) tx
-(arterial)
A
-more chronic and does not require admission to ICU
3
Q
Peripheral Vascular Dz pathophys
A
- atheroscelrosis
- spasms and inflammation
- trauma
- compression
- thrombus
4
Q
S/S of PAD
A
- intermittent claudication-incr with activity, decr with rest
- Rest pain
- s/s acute occlusion- pain, loss of pulses, pallor, coldness, motor/sensory changes
- Atrophic tissue changes-skin and nail changes
5
Q
How to test for clots/occlusion in PAD
A
- Homan’s sign
- Angiogram
- Doppler *definitive
6
Q
Diagnosis test for PAD:
ANKLE-BRACHIAL INDEX
A
measures the SBP in the arm and in the leg.
arm SBP/leg SBP
7
Q
Ankle-Brachial Index for PAD:
- normal
- mild
- moderate
- severe
A
- 0.9-1.0
-0.71-0.90
-0.41-0.70
-
8
Q
Medical management PAD
-pharmacology
A
- anticoagulants (asprin)
- vasodilators (hydrolazine)
- antiplatelet agents
9
Q
Medical Management PAD
-invasive
A
- PTA/PTI- angioplasty through groin
- stent placement
- bypass surgery
10
Q
PAD nursing management
A
- monitor peripheral arterial pulses
- intervene to maintain skin integrity and pain
11
Q
Nursing management AFTER ANGIOPLASTY
A
- assess dysrhythmias (a-fib)
- renal failure r/t dye. measure urine output
- hematoma r/t puncture
- CANT TAKE METFORMIN IF DIABETIC d/t dye
12
Q
if patient comes to ED with s/s of heart attack, how fast does EKG need to be set up
A
13
Q
Cardiac Enzymes:
Troponin-1
(also troponin-T, less significant)
A
**>0.49
most significant indicator of MI within 12 hrs of chest pain
-most sensitive to myocardial infarction
14
Q
Cardiac Enzymes:
CK-MB
A
0.06-0.10
Increased shows there may be rhabdomyalosis or they could have just ran a marathon
15
Q
Cardiac Enzymes:
BNP
A
> 100
-shows volume overload of ventricles
16
Q
Cardiac Enzymes
change over times
A
peak elevations are typically seen within 12-24 hours,
return to baseline after 5-10 days
17
Q
Imaging studies ordered after MI
A
1) CXR to rule out pnuemonia and check for fluid overload
2) Echocardiogram
3) Cardiac stress testing (treadmill)
4) coronary angiogram/ catheterization right away
18
Q
where is an angioplasty inserted
A
femoral artery
19
Q
PCI
-what is it
A
Angiogram with a stent- stent remains to keep artery open
20
Q
Nursing management AFTER PCI
A
- check for recurrent angina (spasm)
- reperfusion arrhythmia (a-fib)
- renal failure d/t dye
- site care (hematoma)
- peripheral pulses
- check fluids
- NO metformin
21
Q
Cardiovascular symptoms
A
- chest pain
- SOB
- dyspnea on exertion (DOE)
- orthopnea
- wheezing
- syncope
- palpitations
- fatigue
- edema (decreased venous return)
- Intermittent claudication (IC)
- cyanosis
22
Q
OLD CART assessment
A
O- onset of pain
L- location of pain
D- duration of pain
C- characteristics
A-aggravating factors or associated factors
R- Radiating
T- treatments or temporal (has it happened before)
- past medical hx and surgical hx
23
Q
Risk factors:
waist circumference
A
Women: >35
Men: >40
24
Q
what age to cardiovascular changes take place
A
after 30
25
Acute Coronary Syndrome (ACS)
clinical presentations of CAD range from unstable angina to acute MI
26
Stable angina
relieved by rest and Nitro
27
Unstable angina
myocardial infarction
| - pain not relieved by rest, takes more Nitro, or is a new pain
28
Silent Ischemia
No s/s
- low O2 to heart
- See ST elevation on EKG
- Most common in women, DM, and obese
29
Steps to take when 46 y.o male comes in with CP, 6/10 pain radiating to jaw, smoker, BMI 30
- EKG within 10 min
- MONA
- CE-STAT then q8x3- (cardiac enxymes)
30
MONA
M- morphine
O-O2
N- nitro
A- aspirin
31
M- Morphine
morphine decreases cardiac preload and afterload, which lowers O2 demand and ischemic pain
32
O-oxygen
start low and go slow >92%
33
O- oxygen
start low and go slow- >92%
34
N-nitroglycerine
| -if stable angina
0. 4 mg SL Q 5 min up to 3 doses
| - prophylactic patch 0.4 mg on chest wall Q4-6 hr
35
Nitro
| -if NSTEMI
```
multiple SL doses.
if no response start IV drip
-titrate to relieve chest pain and prevent hypotension
-anticoagulant-heparin started
-
```
36
What drug interacts with Nitro
VIAGRA. CANT TAKE
37
why use Nitro with caution if pt has right ventricular infarction?
b/c nitro has a profound effect on preload
38
A- Aspirin
81-650 mg chewable b/c better absorption
39
ST elevation with Positive Troponin?
ST elevation MI
40
ST elevation with Negative Troponin
Unstable Angina-
give nitro
and take cardiac enzymes for 24 hrs
41
Non-St elevation with Positive Troponin
Non-ST elevation MI
42
Non-ST elevation with Negative Troponin
Unstable angina
| -Nitro and CE
43
STEMI
ST elevation MI
| ST elevated >1 small box
44
NSTEMI
Non-ST elevation MI but cardiac enzymes are elevated
45
persistent STEMI pathophys
shows total occlusion of a coronary artery that causes transmural ischemia of the myocardial tissue, causing myocardial necrosis
46
Transmural ischemia
All three layers of the heart are effected
47
MI patho
1) myocardial ischemia- T wave inversion
2) *if not revascularized : myocardial injury- ST elevation
3) * if not revascularized: Myocardial Infarction- Long Q wave
48
EKG Layout
1) Anterioseptal
- vessel
- leads
- s/s
- LAD
- V1-V4
- SICK! Left ventricle failure, cardiogenic shock
49
EKG Layout
2) Inferior
- vessel
- leads
- s/s
- RCA
- II, III, aVf
- bradycardia, AV blocks, N/V
50
EKG Layout
3) Lateral
- vessel
- leads
- s/s
- Circumflex
- I , aVL, V5, V6
- arhythmias, VF, VT, PVC
51
Management of NSTEMI/STEMI
| -within how much time should you treat them
TIME IS TISSUE
| -tissue is best saved within 2 hours of onset of S/S
52
Management of /STEMI
| -Goals for STEMI: PCI angiogram timing
53
Management of NSTEMI/STEMI
| -what to do if PCI takes >120 minutes
give Fibrinolytics within 30 min of arriving to ER
| ST ELEVATION MUST BE PRESENT to use thrombolytic tx
54
What is a fibrolytic?
tPA (intrgralin)
| -used as a clot buster in ER only for ST ELEVATION
55
When can you NOT give fibrolytics?
if pt has a Q wave- this means they had an MI >24 hrs ago and are not a candadit for thrombolytics
56
What to monitor when giving fibrolytics?
MONITOR BLEEDING
| -make sure all IVs are already in!
57
Cardiac Enzymes Diagnosis :Troponin
- indicates
- normal value
-Most significant indicator of MI within 12 hr of CP
-more sensitive than CKMB
-done for 24 hrs
-
58
Cardiac Enzyme Diagnosis: CK-MB
| -indicates
- Creatine Kinase: shows any tissue damage, not heart specific
- MB- cardiac damage
59
Nursing consideration with Cardiac Enzymes
CE's may not be elevated initially and may continue to rise after reperfusion
60
Other Meds to give for MI
ACE inhib
- BB
- Diuretics
- Anticoagulants
- antiplatelets
- vasodilators
- inotropics
- saline therapy
61
MONA (S)
| -S= surveillance
continuous monitoring of:
- arrthythmias
- ventricular aneurysm
- rupture of ventricular septal, papillary muscle, cardiac wall
- pericarditis
- heart failure
62
Rupture of cardiac wall
FATAL- cardiogenic shock
- hypotension
- decompensation fast
63
Monitoring:
- Hemodynamics-
- CVP
- CO
- SCVO2
- preload
- afterload
- oxygen supply and demand
64
Monitoring:
| Echocardiogram
- transthoracic
| - transesophageal
65
Monitoring:
| -Stress test
Non-ST elevation MI
- exercise
- dobutamine
66
systolic HF
decreased contractility during systole (ejection) that lessens the quantity of blood pumped out of the heart
67
SHF:
| how does this affect the Ejection Fraction (EF)
68
S/S of SHF
dyspnea
- exercise intolerance
- fluid volume overload
- JVD
- Edema : systemic
69
SHF causes
- CAD
- HTN
- valve disease
- ETOH
70
patho of SHF
weak heart muscle that cant pump out blood- fluid overload
71
Diastolic Heart Failure
heart muscles unable to relax, stretch, or fill during diastole
72
Diastolic Heart Failure EF
>45% maintained normal
73
DHF changes to the left ventricle
LV becomes thick and stiff
- lowers Left Ventricular End Diastolic Volume
- Highers Left Ventricular End Diastolic Pressure
74
DHF S/S
exercise intolerance
- fatigue
- pulmonary congestion
- pulmonary edema
75
DHF patho
can pump blood out but unable to fill properly- pulmonary back up * thick stiff left ventricle
76
what will you see on a CXR for HF
enlarged heart or pulmonary edema
77
BNP levels in HF
- moderate
- severe
- >100
| - >400
78
HF medical management
| -Inotropes
Dopamine
Doputamine
*these improve C.O
79
HF Meds:
| Dopamine dosing
5 mcg/kg/min increase by 5 Q 10-30 min up to max of 50 mcg
| *increases cardiac contractility
80
HF Meds:
| other
- diuretics
- Vasodilators
- ACE inhibitors -preserve kidney function
- CCB & BB
- Anticoagulants
81
ACE- inhibitors side effects
dry cough and angioedema
| -give ARB if ACE not working
82
Management of HF other than meds
```
monitor BNP
-oxygen
-hemodynamics
-rest and pain control
-emotional support
-nutrition
education
```
83
Cardiomyopathy
disease of the heart muscle
84
Cardiomyopathy
| -Primary
unknown cause
-viral? autoimmune?
Hypertrophic muscle and dilated
85
Cardiomyopathy
| -secondary
-result of systemic dz such as valvular dz, CAD, HTN, ETHO abuse, autoimmune
86
meds to give for impaired contractility
Inotropes
| -DIG, DOPAMINE, DOBUTAMINE, PACEMAKER
87
Meds to give for LV dysfunction
BB
| (CARVEDILOL, ATENOLOL
88
Meds to give for Dysrhythmias
anti-arrhythmic agents (AMIODARONE)
89
Meds for dilated cardiomyopathy
ACE-I
(Lisinopril)
-first line treatment whether symptomatic or asymptomatic
90
Mechanical Circulatory Assist Devices
- IABP: intra-aortic balloon pump
- VAD- ventricular assistant device
used in treatment of heart failure when meds have failed
| -decreases myocardial workload and maintain adequate perfusion to vital organs
91
Indications for Intra Aortic Balloon Pump
| -IABP
- failure to wean off of bypass
- recurrent angina after acute MI
- hemodynamic support for high risk PCI and CABG
- complications from acute MI
- Bridge to definitive therapy (LVAD, heart transplant)
92
IABP
| -what are complications of MI that would call for an IABP
- cardiogenic shock
- papillary muscle dysfunction of rupture with MR
- Ventricular septal rupture
93
Intra-Aortic Balloon Pump Function
Inflates during diastole --> incr. perfusion to coronary artery--> incr. perfusion to kidneys--> displaces blood (decr. afterload, incr. CO)--> improves balance bewteen O2 supply and demand
94
therapeutic effects of IABP
- what increases
- what decreases
1) INCR
- coronary artery BF
- CO
- UO
- improved mentation
2) DECR
-s/s myocardial ischemia (angina, ST changes, ventricular, arrythmias)
-myocardial oxygen demand
HR
95
IABP nursing considerations
- assess perfusion- pulses, temp, calf circumference
- anticoagulation
- balloon rupture
- balloon migration
- timing of IABP
96
IABP balloon migration assessment
- upwards
- downwards
- assess radial pulses and LOC
| - assess U.O , GI s/s
97
what CANNOT do if a pt has IABP
SIT THE PT UP!
98
IABP
| -Timing: what does 8:1 indicate
weaning the pt off device, only for a short amt of time
99
Education IABP
- activity restriction (minimal leg mvmt)
| - s/s report to nurse- pain in back, leg, or chest
100
Ventricular Assist Device (VAD)
| -indications
- partially or completely replace the function of the heart
| - used for failing RV, LV, or both
101
VAD
| -flow rate
flow rate of 1-10 L/min
- decreases V workload
- maintains adequate CO
102
When would a pt need a VAD
- Bridge to recovery
- Bridge to transplantation
- destination therapy
103
what about VAD and pt pulses?
THERE IS NO PULSE OR BP!
| if patient dies this machine continues to run
104
VAD: Bridge to Recovery
Continues to demonstrate persistent HF despite aggressive medical treatement, BUT shows potential for regaining normal heart function if heart is given time to rest
105
Diseases that would use VAD
acute post op myocardial dysfunction
- refactory cardigenic shock after acute MI
- acute viral myocarditis
106
Nursing considerations for LVAD
- pulseless
- heart tones machine like
- Use MAP for BP (no S/DBP)
- rely on basic assessments such as circulation, mentation, UO
- prevent line infection
107
Aortic Aneurysm
localized dilation of the arterial wall that results in an alteration in vessel shape and blood flow (abdominal and thoracic)
108
visible sign of an aortic aneurysm
pulsatile mass in umbilical region- abdominal aneurysm
109
something patients c/o with aortic aneurysm
BACK PAIN!
| -dont press hard on their stomach
110
Aortic Aneurysm Diagnosis
- detected with palpation of umbilical
- fleeting peripheral pulses
- new murmur
- HTN
111
Aortic Aneurysm:
| Diagnosis with procedures
CXR- only helpful if thoracic aneurysm
* **-CT and TTE(Transthoracic echocardiogram): two most helpful tests for rapid dx
- DEFINITIVE- aortogram
112
Aortic Aneurysm Etiology
- Atherosclerosis
- HTN
- Trauma
- Marfans Syndrome
- Pregnancy
113
aortic dissection
column of blood seperates the vascular layers. This creates a false lumen which communicates with the true lumen through a tear in the intima
114
Aortic Dissection S/S
- Sharp pain that radiates to back
- cardiac murmur, HTN, Unequal BP in upper extremities
- Decreased LOC
115
Aortic Dissection
| -Diagnosis
CT ultrasound MRI
116
Aortic Dissection Tx
SURGERY
| -give vasodiator to decrease BP (Nipride drip)
117
Cardiac Tamponade
accumulation of blood in the pericardial sac
118
Cardiac tamponade s/s
decreased CO
PEA or tachycardia
Becks triad
119
Beck's triad (cardiac tamponade)
- neck vein distenstion
- increased CVP
- hypotension
- Muffled heart sounds
120
Cardiac tamponade tx
pericardiocentesis
121
Cardiac tamponade management
surgical repair >5 cm= surgery
122
Nursing management of cardiac tamponade
```
monitor Q1hr
-BP
-Pain
-Vasodilators
-UO
-aortic murmurs
-circulation
-5 P's
A-line: tx HTN with Labetalol (dec. CO)
```
Critical Care Test 2
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