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foxyt14
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241420
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Cardio
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2013-10-27 13:45:29
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N172
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N172-Anemia, CAD, HTN, CHF, PVD
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  1. CBC #s
    • Plasma =55%
    • Blood cells =45% (RBC, WBC, Platelets)
  2. Cardiac Output
    amount of blood pumped by the ventricle in 1 min
  3. Stroke Volume
    amount of blood ejected from the ventricle with each heart beat
  4. How do you calculate the cardiac output?
    Stroke volume x Hr= Should be 4-8 L/min
  5. 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
  6. Preload
    amount of blood (stretch) in the ventricles at the end of diastole, and before the contraction
  7. Afterload
    amount of peripheral resistance against which the left ventricle must pump
  8. Contractility
    Starling's Law...

    The greater the fibers are stretched, the greater the force of contraction
  9. What determines the amount of stretch placed on myocardial fibers?
    preload
  10. Definition of anemia
    a deficiency in the number of RBC's or hemoglobin and/or the volume of packed RBC's (hematocrit)
  11. What can cause anemia?
    • bad diet
    • hereditary conditions
    • bone marrow diseases
    • bleeding states
    • renal disease
    • malignancy
    • chronic diseases
  12. What causes anemia by inadequate/defective RBC production?
    • person is missing substrates needed for production of RBC...
    • iron
    • folic acid
    • v. B 12
    • Erythropoietin
  13. What causes anemia by loss of RBC's?
    Acute or Chronic blood loss

    • gastritis
    • menstrual flow
    • hemorrhoids
    • bleeding ulcers
  14. What causes anemia by increased destruction by hemolysis?
    • Sickle cell anemia
    • Hemolytic anemia
  15. What is Hemolytic anemia? (2)
    • autoimmune problem
    • or
    • can be caused by drugs, toxins, trauma to RBC (less than 19-20gauge needle for blood transfusion)
  16. Subjective data you would collect relevant to anemia
    • PMH
    • Meds list
    • Surgeries?
    • Blood transfusions?
    • General health
    • Nutrition status
    • Activity/Rest patterns
  17. Objective data you would collect relevant to anemia
    • bruising
    • petechiae
    • echymosis
    • bleeding gums
    • enlarged lymph nodes, spleen, liver
    • SOB
    • Tachy/Palpitations
    • Dizzy
    • Pallow with nails and mucous membranes
    • Clubbing
  18. What is an objective sign of V. B12 deficiency?
    smooth, sore, bright red tongue
  19. With mild anemia you will see
    • mild fatigue
    • palpitations
    • exertional dyspnea
  20. With moderate anemia you will see
    • Fatigue
    • Bounding pulse
    • dyspnea
    • roaring ears
  21. What does hemoglobin values tell you?
    it is a measurement of the gas carrying capacity of RBC's
  22. Normal Hgb values....M/F
    • M=13-18
    • F=12-16g/dl
  23. What is the clinical manifestation of low Hgb?
    adequate O2 isn't being delivered to tissues around the body
  24. What do hematocrit values tell you?
    the percentage of RBC's to total plasma volume
  25. Normal Hct values (M/F)
    • M-40-54%
    • F-38-47%
  26. What is the Red Blood Cell count?
    # of RBC's per cubic mm of blood
  27. Normal RBC values (M/F)
    • M-4.5 to 6
    • F-4 to 5
  28. 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
  29. What's MCV (Mean Corpuscular Volume)?
    The average (mean) size of a RBC
  30. What is the normal MCV size?
    82-98
  31. What will happen to the MCV if you have a patient with.....
     V. B12 anemia and Folic Acid deficiency?
    or
    Iron deficiency Anemia?
    Increase in MCV

    Decrease in MCV
  32. What does the serum Iron test tell you?
    How much iron is circulating in the blood
  33. What does the Ferritin Level test tell you?
    the total iron stores in the body
  34. Where is iron stored in the body?
    • spleen
    • liver
    • bone marrow
  35. What does Schillings Test do?

    Differentiates?

    How?
    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
  36. 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
  37. Dietary interventions for anemia.....encourage foods like
    • Liver
    • Muscle meats
    • Green Leafy vegetables
    • Eggs
    • Strawberries
    • Cantaloupe
    • Legumes
    • Whole Grains
  38. Oral iron supplements are used to....

    Name 3
    to replenish serum iron and iron stores.

    Ferrous Sulfate, Fumarate and Gluconate
  39. What is iron used for?
    Iron is an essential component of Hgb and subsequently oxygen transport
  40. When do you give parental iron supplements?
    Name it-

    How?

    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
  41. 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)
  42. What will increase oral iron absorption?
    Vitamin C....so drink OJ or eat tomatoes
  43. What is used to increase the production of RBC's?
    Epogen/Procit
  44. 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
  45. 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)

    Cobalamin
  46. If the B12 deficiency is due to poor diet, how will the patient take the supplement?
    Orally
  47. 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**
  48. How does a person have a lack of intrinsic factors causing anemia?
    the parietal cells of the stomach don't make enough
  49. How often does a person receive parental B12 injections?
    monthly...for the rest of their life.
  50. How can a person take Folic Acid Supplements?
    orally or parentally
  51. What is folic acid needed for?
    RBC production
  52. Large doses of folic acid may mask....
    V. B12 deficiency
  53. Patient teaching for folic acid supplements
    Urine may be dark yellow
  54. What is given for immediate improvement in blood cell counts and manifestations of anemia?
    Blood transfusion
  55. Nursing interventions for ANEMIA
    • *Correct physiologic status deficits (chemo)
    • help with activity intolerance
    • encourage self care
    • *monitor tachy/dysrhythmias/dyspnea/
    • diaphoresis/pallor/respiratory rate
  56. Interventions for Sickle Cell Anemia
    • PREVENTION
    • Alleviate PAIN (hypoxia causes pain)
    • Put on O2
    • Get immunizations
  57. What's the medication hydrea do for Sickle Cell Anemia?
    • It decreases painful flare ups
    • AND
    • it decreases their need for blood transfusions
  58. Patient teaching for hydrea?
    wear special gloves when handling....it can be absorbed through the skin/hands!!
  59. What do baroreceptors do?
    monitor changes in BP and transmit this info to the brainstem
  60. If baroreceptors sense increase in BP....
    SNS will be inhibited and there will be a decrease in HR, force of contractions and cause vasidilation
  61. 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
  62. Whats vascular endothelium?
    • a single layer that lines blood vessels and produces vasoactive substances....
    • nitric oxide
    • endothelin
  63. What does nitroc oxide do?
    It is a relaxing factor and helps to maintain low arterial tone at rest
  64. What does endothelin do?
    It is an extremely potent vasoconstrictor
  65. 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!!
  66. What's the effect of Angiotensin II?
    potent vasoconstrictor
  67. What does ADH do to increase BP?
    • increases serum sodium osmolarity
    • water follows salt
    • increase in ECF
    • increased BP
  68. How does the sympathetic nervous system increase BP?
    • it causes the release of epinephrine which....
    • increases CO and HR and myocardial contractility

    Increased BP
  69. Natriuretic Peptides (ANP & BNP)

    Comes from where?
    Causing?
    How?
    • Cardiac Cells
    • Decreased BP

    works against ADH, resulting in excretion of sodium in the urine with diuresis which reduces blood volume
  70. What do prostaglandins do?
    Cause vasodilation
  71. What's the number 1 disease of old age?
    Hypertension
  72. Pathophysiology of PRIMARY HTN
    • GENETICS
    • excessive sodium intake....w/ a sensitivity to sodium
    • high plasma renin....more Angio II converted
    • Stress
    • Insulin Resistance/Hyperinsulinism
  73. Why is HTN called the silent killer?
    cuz there are no symptoms till the disease has become sever and target organs are affected
  74. Symptoms of HTN
    • dizzy
    • fatigue
    • reduced activity tolerance
    • palpitations
    • angina
    • dyspnea
  75. Target organs of HTN
    • heart
    • brain
    • peripheral vasculature
    • kidney
    • eyes
  76. What are the results of hypertensive heart disease?
    • CAD
    • lft ventricular hypertrophy
    • heart failure
  77. HTN causes PVD....what are the results?
    • aortic aneurysm/dissection
    • intermittent claudication
  78. HTN causes Cerebral Vascular Disease....what are the results
    • atherosclerosis
    • stroke
    • encephalopathy
  79. HTN causes Nephrosclerosis...what is the result?
    End Stage Renal Disease
  80. How does HTN affect the eyes?
    • retinal damage...
    • blurred vision
    • retinal hemorrhage
    • loss of vision
  81. 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
  82. 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
  83. #1 Nursing diagnosis for HTN is
    Deficient Knowledge....didn't know I had the disease!!
  84. What's the DASH Diet?
    Low sodium and Low Fat consumption
  85. Psychosocial factors that increase CVD....
    • low socioeconomic status
    • social isolation
    • lack of support
    • stress
    • depression/hostility
  86. Blood Pressure goal for a person with HTN
    130/85
  87. Goal of drug therapy for HTN
    • reduce systemic vascular resistence
    • decrease volume of circulating blood
  88. Who shouldn't get ACE Inhibitors?
    African Americans and old people....renin issues
  89. Side effects of HTN meds
    • orthostatic hypotension
    • sexual dysfunction
    • frequent urination
    • dry mouth
  90. 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
  91. HTN is common in people over
    60 years old
  92. 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
  93. What may happen if you decrease a chronically hypertensive older persons BP too much?
    can cause perfusion deficits
  94. Why do older people get postural or orthostatic hypotension?
    impaired baroreceptors
  95. How do you start a person on BP meds?
    • Titrate up
    • Do orthos....

    If the HR + 15, or the SBP drops 15, or the DBP drops 10 they have orthos
  96. Major causes of CAD
    • atherosclerosis
    • cholesterol/lipids in artery walls
  97. Non modifiable risk factors for CAD
    • age
    • gender
    • ethnicity (white middle aged male)
    • genetics/family history
  98. Modifiable risk factors for CAD
    • Elevated Serum Lipids
    • HTN
    • Smoking
    • Level of physical activity
    • Obesity
    • DM
    • Metabolic Syndrome
    • Psychological States
    • Homocysteine Levels
  99. How do you decrease the levels of homocysteine?
    If you eat eggs, meats, cheeses....eat it with broccoli or salad
  100. What do "statin" meds do?

    Name 3
    reduce cholesterol synthesis in the liver

    • Simvastatin
    • Atorvastin
    • Pravastatin
  101. What does Niacin do for cholesterol?
    inhibits synthesis and secretion of VLDL And LDL
  102. What does Tricor do for cholesterol?
    decreases hepatic synthesis of VLDL and reduces triglycerids
  103. What does Cholestyramine do for cholesterol?
    increases conversion of cholesterol to bile acids for elimination

    ANAL LEAKAGE
  104. What does Zetia do for cholesterol?
    inhibits intestinal absorption
  105. What is anti platelet therapy for cholesterol?
    81mg of aspirin for people over 40....unless contraindicated due to GI bleed or hemorrhagic stroke
  106. Good dx test to say  if person is having an MI or Angina?
    Troponin....levels return to baseline after 10-14 days.
  107. What is the test used to see if cardiac muscle was affected in an MI
    Myoglobin

    Levels are normal after 24 hrs
  108. Best diagnostic test for CAD to determine the extent of the disease and what interventions are best
    Cardiac Catheterization/Coronary Angiography

    DANGEROUS!
  109. 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
  110. What is a Percutaneous Coronary Intervention?
    When a stent is put in an artery to open it up
  111. What causes angina?
    • decrease in oxygen supply OR
    • an increased demand for oxygen
  112. What can cause a decreased oxygen supply?
    • atherosclerosis
    • anemia
    • hypoxemia
    • PNA
    • Asthma
    • COPD
    • Hypovolemia (decreased perfusion of tissues)
  113. What can cause an increased demand for oxygen?
    • Anxiety
    • HTN
    • Hyperthermia
    • Hyperthyroidism
    • Physical Exertion
    • Substance Abuse....cocaine/ephedrine
  114. 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
  115. 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****
  116. 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
  117. 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
  118. What is the goal of angina interventions?
    reduction of frequency in episodes
  119. What is the anti platelet therapy for a person who has CAD and angina?
    Plavix

    Not aspirin
  120. What does nitro do?
    vasodilator
  121. What's the name of the long acting nitrate that comes in a transdermal patch and ointment?
    Isordil
  122. How do Beta Blockers work?
    Names?
    Remember....
    decreases BP and HR, which decreases workload and O2 demands

    "lol"

    Propanolol, Metropolol, Atenolol

    Hold if HR is below 50bpm
  123. How do Calcium Channel Blockers work?
    Names?
    decreases contractility and causes vasidilation of smooth muscles in vessels

    • "ine"
    • Amlodipine, Felodipine
  124. How do ACE Inhibitors work?
    Names?
    prevents A1 from converting to A2, which in turn blocks vasoconstriction

    • "pril"
    • Lisinopril, Enalapril, Benazepril
  125. Describe unstable angina
    • New onset
    • Occurs at rest or has a worsening pattern
    • Unpredictable
    • Increasing frequency
    • Easily provoked by minimal/no exertion (sleep)
  126. Unstable angina will do 1 of 2 things....
    progress to an MI or return to stable lesion
  127. Describe a MI
    • Sever immobilizing chest pain that is unrelieveable
    • Usually occurs in the AM
    • N/V
    • Ashen grey skin
    • Cold/Sweat
  128. What heals the heart?
    • Inflammation
    • Neutrophils and macrophages remove dead tissues (in 4 days)
  129. 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
  130. How long does it take the heart to heal after an MI?
    6 weeks

    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
  131. Complications from an MI
    • HEART FAILURE
    • Dysrhythmias
    • Cardiogenic Shock
    • Papillary Muscle Dysfunction
    • Ventricular Aneurysm
    • Pericarditis
  132. What is Papillary Muscle Dysfunction?
    valve dysfunction causing regurgitation
  133. What is a common manifestation of chronic HF?

    What's it caused by?
    Dyspnea

    Caused by increased pulmonary pressure related to interstitial and alveoli edema
  134. Orthopnea
    SOB when patient is recumbant
  135. 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
  136. What may be the first sign of heart failure?
    dry hacking cough
  137. What is one of the body's first mechanisms of compensation to a decrease in CO?
    Increase heart rate....TACHYCARDIA
  138. What do diuretics do?
    Decrease fluid volume and decrease preload
  139. ACE Inhibitors cause
    • vasodilation
    • decrease both pre and afterload
  140. Vasodilators cause a decrease in

    Name one
    afterload

    Apresoline
  141. Beta Blockers cause...
    decrease in contractility and HR and a decrease in afterload
  142. Positive Inotropes cause...
    Increase in contractility and CO
  143. Nocturnal Angina
    occurs at night...and you don't have to be sleeping
  144. Angina Decubitus
    occurs if recumbent and is relieved by standing/sitting
  145. Prinzmetal's Angina
    Coronary artery spasm that occurs at rest and is relieved with activity
  146. Triggers for Prinzmetal Angina
    • Increase in O2 demand
    • Tobacco Smoke
    • Increase histamine
  147. What do you treat Prinzmetal Angina with?
    Calcium Channel Blockers and Nitrates
  148. Prinzmetal angina has nothing to do with.....but is a problem with
    atherosclerosis

    Coronary artery spasm
  149. What is the name of the angina commonly seen in women?

    What area is affected?
    Microvascular angina

    small branches of distal coronary arteries

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