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- Plasma =55%
- Blood cells =45% (RBC, WBC, Platelets)
amount of blood pumped by the ventricle in 1 min
amount of blood ejected from the ventricle with each heart beat
How do you calculate the cardiac output?
Stroke volume x Hr= Should be 4-8 L/min
What affects the stroke volume? What is the result?
preload, afterload and contractility
If they are increased there is more workload for the myocardium...resulting in increased cardiac output
amount of blood (stretch) in the ventricles at the end of diastole, and before the contraction
amount of peripheral resistance against which the left ventricle must pump
The greater the fibers are stretched, the greater the force of contraction
What determines the amount of stretch placed on myocardial fibers?
Definition of anemia
a deficiency in the number of RBC's or hemoglobin and/or the volume of packed RBC's (hematocrit)
What can cause anemia?
- bad diet
- hereditary conditions
- bone marrow diseases
- bleeding states
- renal disease
- chronic diseases
What causes anemia by inadequate/defective RBC production?
- person is missing substrates needed for production of RBC...
- folic acid
- v. B 12
What causes anemia by loss of RBC's?
Acute or Chronic blood loss
- menstrual flow
- bleeding ulcers
What causes anemia by increased destruction by hemolysis?
- Sickle cell anemia
- Hemolytic anemia
What is Hemolytic anemia? (2)
- autoimmune problem
- can be caused by drugs, toxins, trauma to RBC (less than 19-20gauge needle for blood transfusion)
Subjective data you would collect relevant to anemia
- Meds list
- Blood transfusions?
- General health
- Nutrition status
- Activity/Rest patterns
Objective data you would collect relevant to anemia
- bleeding gums
- enlarged lymph nodes, spleen, liver
- Pallow with nails and mucous membranes
What is an objective sign of V. B12 deficiency?
smooth, sore, bright red tongue
With mild anemia you will see
- mild fatigue
- exertional dyspnea
With moderate anemia you will see
- Bounding pulse
- roaring ears
What does hemoglobin values tell you?
it is a measurement of the gas carrying capacity of RBC's
What is the clinical manifestation of low Hgb?
adequate O2 isn't being delivered to tissues around the body
What do hematocrit values tell you?
the percentage of RBC's to total plasma volume
What is the Red Blood Cell count?
# of RBC's per cubic mm of blood
Clinical significance of high/low RBC
closely related to Hgb/Hct
Will increase in response to need for more oxygen and decrease with blood loss or bone marrow suppression
What's MCV (Mean Corpuscular Volume)?
The average (mean) size of a RBC
What is the normal MCV size?
What will happen to the MCV if you have a patient with.....
V. B12 anemia and Folic Acid deficiency?
Iron deficiency Anemia?
Increase in MCV
Decrease in MCV
What does the serum Iron test tell you?
How much iron is circulating in the blood
What does the Ferritin Level test tell you?
the total iron stores in the body
Where is iron stored in the body?
What does Schillings Test do?
measures V. B12 absorption with and without intrinsic factor.
It is used to differentiate between mal-absorption and pernicious (v. B12 ) anemia
Patient infests radioactive V. B12 and assess if it was absorbed by the GI tract
If a person is in fluid overload what happens to the HCT
it will be low....mainly seen with isotonic solutions like Lactated Ringers or NS
Dietary interventions for anemia.....encourage foods like
- Muscle meats
- Green Leafy vegetables
- Whole Grains
Oral iron supplements are used to....
to replenish serum iron and iron stores.
Ferrous Sulfate, Fumarate and Gluconate
What is iron used for?
Iron is an essential component of Hgb and subsequently oxygen transport
When do you give parental iron supplements?
What do they need to be told?
- Iron Dextran
- Only for severe anemia
- Z-track (stains skin) or orally diluted through a straw (stains teeth)
*Causes constipation and stools will be black
Patient teach for patient on Iron supplements
- Have your hemoglobin checked in 4-6 weeks to determine efficacy
- Take supplements between meals to increase absorption (most don't cuz it is irritating to GI)
What will increase oral iron absorption?
Vitamin C....so drink OJ or eat tomatoes
What is used to increase the production of RBC's?
What is important to monitor for a patient on Epogen/Procrit?
- Increased BP
- Monitor Hgb and Hct twice a week
- Monitor for cardiovascular events if Hgb increases too rapidly
Why is V. B12 important?
Name the supplement.
B12 is necessary to convert folic acid from its inactive form to it's active form.
**All cells rely on folic acid for DNA production (RBC production)
If the B12 deficiency is due to poor diet, how will the patient take the supplement?
If the B12 deficiency is due to a lack of intrinsic factors or mal-absorption syndrome how will the patient take the supplement?
Parentally or intranasally
*They will be on this for the rest of their life**
How does a person have a lack of intrinsic factors causing anemia?
the parietal cells of the stomach don't make enough
How often does a person receive parental B12 injections?
monthly...for the rest of their life.
How can a person take Folic Acid Supplements?
orally or parentally
What is folic acid needed for?
Large doses of folic acid may mask....
V. B12 deficiency
Patient teaching for folic acid supplements
Urine may be dark yellow
What is given for immediate improvement in blood cell counts and manifestations of anemia?
Nursing interventions for ANEMIA
- *Correct physiologic status deficits (chemo)
- help with activity intolerance
- encourage self care
- *monitor tachy/dysrhythmias/dyspnea/
- diaphoresis/pallor/respiratory rate
Interventions for Sickle Cell Anemia
- Alleviate PAIN (hypoxia causes pain)
- Put on O2
- Get immunizations
What's the medication hydrea do for Sickle Cell Anemia?
- It decreases painful flare ups
- it decreases their need for blood transfusions
Patient teaching for hydrea?
wear special gloves when handling....it can be absorbed through the skin/hands!!
What do baroreceptors do?
monitor changes in BP and transmit this info to the brainstem
If baroreceptors sense increase in BP....
SNS will be inhibited and there will be a decrease in HR, force of contractions and cause vasidilation
If baroreceptors sense a decrease in BP....
the SNS will be activated and the HR will increase, increase in force of contraction and vasoconstriction occurs
Whats vascular endothelium?
- a single layer that lines blood vessels and produces vasoactive substances....
- nitric oxide
What does nitroc oxide do?
It is a relaxing factor and helps to maintain low arterial tone at rest
What does endothelin do?
It is an extremely potent vasoconstrictor
How does the renals and endocrine system regulate BP?
- causes sodium and water retention
- increases ECF volume
- increases venous return to the heart
- increases stroke volume
- increases CO.....add it all up and get increased BP!!
What's the effect of Angiotensin II?
What does ADH do to increase BP?
- increases serum sodium osmolarity
- water follows salt
- increase in ECF
- increased BP
How does the sympathetic nervous system increase BP?
- it causes the release of epinephrine which....
- increases CO and HR and myocardial contractility
Natriuretic Peptides (ANP & BNP)
Comes from where?
- Cardiac Cells
- Decreased BP
works against ADH, resulting in excretion of sodium in the urine with diuresis which reduces blood volume
What do prostaglandins do?
What's the number 1 disease of old age?
Pathophysiology of PRIMARY HTN
- excessive sodium intake....w/ a sensitivity to sodium
- high plasma renin....more Angio II converted
- Insulin Resistance/Hyperinsulinism
Why is HTN called the silent killer?
cuz there are no symptoms till the disease has become sever and target organs are affected
Symptoms of HTN
- reduced activity tolerance
Target organs of HTN
- peripheral vasculature
What are the results of hypertensive heart disease?
- lft ventricular hypertrophy
- heart failure
HTN causes PVD....what are the results?
- aortic aneurysm/dissection
- intermittent claudication
HTN causes Cerebral Vascular Disease....what are the results
HTN causes Nephrosclerosis...what is the result?
End Stage Renal Disease
How does HTN affect the eyes?
- retinal damage...
- blurred vision
- retinal hemorrhage
- loss of vision
Interventions for HTN
- Health Promotion
- decrease sodium and calories
- DASH Diet
- >3 alcoholic drinks/day
- 30 min/day moderate exercise on most days
- NO TOBACCO
Once a person has Target Organ Disease, Clinical Cardiovascular Disease or Diabetes Mellitus, then....
they are given drugs and implementing lifestyle changes.....EVEN IF THEY ARE ONLY PREHYPERTENSIVE
#1 Nursing diagnosis for HTN is
Deficient Knowledge....didn't know I had the disease!!
What's the DASH Diet?
Low sodium and Low Fat consumption
Psychosocial factors that increase CVD....
- low socioeconomic status
- social isolation
- lack of support
Blood Pressure goal for a person with HTN
Goal of drug therapy for HTN
- reduce systemic vascular resistence
- decrease volume of circulating blood
Who shouldn't get ACE Inhibitors?
African Americans and old people....renin issues
Side effects of HTN meds
- orthostatic hypotension
- sexual dysfunction
- frequent urination
- dry mouth
In order for people to stay on HTN meds we must help them....
minimize the unpleasant side effects of their meds and monitor their BP periodically
HTN is common in people over
60 years old
When taking an older persons BP, make sure....
- look at their BP trend
- Palpate the brachial pulse until it disappears
- pump the cuff 20 higher
What may happen if you decrease a chronically hypertensive older persons BP too much?
can cause perfusion deficits
Why do older people get postural or orthostatic hypotension?
How do you start a person on BP meds?
If the HR + 15, or the SBP drops 15, or the DBP drops 10 they have orthos
Major causes of CAD
- cholesterol/lipids in artery walls
Non modifiable risk factors for CAD
- ethnicity (white middle aged male)
- genetics/family history
Modifiable risk factors for CAD
- Elevated Serum Lipids
- Level of physical activity
- Metabolic Syndrome
- Psychological States
- Homocysteine Levels
How do you decrease the levels of homocysteine?
If you eat eggs, meats, cheeses....eat it with broccoli or salad
What do "statin" meds do?
reduce cholesterol synthesis in the liver
What does Niacin do for cholesterol?
inhibits synthesis and secretion of VLDL And LDL
What does Tricor do for cholesterol?
decreases hepatic synthesis of VLDL and reduces triglycerids
What does Cholestyramine do for cholesterol?
increases conversion of cholesterol to bile acids for elimination
What does Zetia do for cholesterol?
inhibits intestinal absorption
What is anti platelet therapy for cholesterol?
81mg of aspirin for people over 40....unless contraindicated due to GI bleed or hemorrhagic stroke
Good dx test to say if person is having an MI or Angina?
Troponin....levels return to baseline after 10-14 days.
What is the test used to see if cardiac muscle was affected in an MI
Levels are normal after 24 hrs
Best diagnostic test for CAD to determine the extent of the disease and what interventions are best
Cardiac Catheterization/Coronary Angiography
Serum CK-MB test for CAD is a good dx test to tell you...
if there is heart damage or brain damage from a MI
What is a Percutaneous Coronary Intervention?
When a stent is put in an artery to open it up
What causes angina?
- decrease in oxygen supply OR
- an increased demand for oxygen
What can cause a decreased oxygen supply?
- Hypovolemia (decreased perfusion of tissues)
What can cause an increased demand for oxygen?
- Physical Exertion
- Substance Abuse....cocaine/ephedrine
Clinical manifestations of angina
- chest pain/discomfort/pressure
- burning in epigastric area
- constricting, squeezing chest
- heavy choking/suffocating
- *occurs in chest and neck...may radiate to back and arms
Describe Stable Angina
- Predictable with a pattern of onset, duration and intensity
- Pain lasts 5-15 min and ends when precipitating factors are relieved
- No pain while resting
- Controlled by routine meds
***RELIEVED BY REST****
Nursing Care for Angina
- Administer O2
- Take VS (Increase in HR/BP?)
- Do EKG (shows dysrhythmias/cardiac fxn)
- Relief of pain by nitrate
- Auscultation of heart sounds (do you hear a gallop?)
- Place pt in position of comfort
How does a person take nitrates?
q 5 min x 3.....if it doesn't work call rapid response
Or if not at hospital.....take on way to hospital
What is the goal of angina interventions?
reduction of frequency in episodes
What is the anti platelet therapy for a person who has CAD and angina?
What does nitro do?
What's the name of the long acting nitrate that comes in a transdermal patch and ointment?
How do Beta Blockers work?
decreases BP and HR, which decreases workload and O2 demands
Propanolol, Metropolol, Atenolol
Hold if HR is below 50bpm
How do Calcium Channel Blockers work?
decreases contractility and causes vasidilation of smooth muscles in vessels
- Amlodipine, Felodipine
How do ACE Inhibitors work?
prevents A1 from converting to A2, which in turn blocks vasoconstriction
- Lisinopril, Enalapril, Benazepril
Describe unstable angina
- New onset
- Occurs at rest or has a worsening pattern
- Increasing frequency
- Easily provoked by minimal/no exertion (sleep)
Unstable angina will do 1 of 2 things....
progress to an MI or return to stable lesion
Describe a MI
- Sever immobilizing chest pain that is unrelieveable
- Usually occurs in the AM
- Ashen grey skin
What heals the heart?
- Neutrophils and macrophages remove dead tissues (in 4 days)
Why is the first 2 weeks after an MI a vulnerable time?
the myocardium is still weak, but the persons activity level is starting to increase. Myocardium cant handle it....need a balance in activity and rest
How long does it take the heart to heal after an MI?
But...you will see the part of the hard that was hypoxic wont work. Other parts of the heart try to compensate which will cause hypertrophy and result in eventual heart failure
Complications from an MI
- HEART FAILURE
- Cardiogenic Shock
- Papillary Muscle Dysfunction
- Ventricular Aneurysm
What is Papillary Muscle Dysfunction?
valve dysfunction causing regurgitation
What is a common manifestation of chronic HF?
What's it caused by?
Caused by increased pulmonary pressure related to interstitial and alveoli edema
SOB when patient is recumbant
Paroxysmal Nocturnal Dyspnea
occurs when patient is asleep related to reabsorption of fluid from dependent body areas while patient is recumbent.
They wake up in a panic feeling like they are suffocating.....seek relief by sitting up
What may be the first sign of heart failure?
dry hacking cough
What is one of the body's first mechanisms of compensation to a decrease in CO?
Increase heart rate....TACHYCARDIA
What do diuretics do?
Decrease fluid volume and decrease preload
ACE Inhibitors cause
- decrease both pre and afterload
Vasodilators cause a decrease in
Beta Blockers cause...
decrease in contractility and HR and a decrease in afterload
Positive Inotropes cause...
Increase in contractility and CO
occurs at night...and you don't have to be sleeping
occurs if recumbent and is relieved by standing/sitting
Coronary artery spasm that occurs at rest and is relieved with activity
Triggers for Prinzmetal Angina
- Increase in O2 demand
- Tobacco Smoke
- Increase histamine
What do you treat Prinzmetal Angina with?
Calcium Channel Blockers and Nitrates
Prinzmetal angina has nothing to do with.....but is a problem with
Coronary artery spasm
What is the name of the angina commonly seen in women?
What area is affected?
small branches of distal coronary arteries