Cardiac- Beerman

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NurseFaith
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282352
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Cardiac- Beerman
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2014-09-07 22:22:14
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Cardiac Day One
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Cardiac Beerman
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  1. Leading cause of death in the US
    • Coronary Artery Disease
    • (over 60 million people have CAD)
    • (kills 10x more women than breast cancer)
  2. Cause of Coronary Artery Disease
    Atherosclerosis ("hard fatty streaks")
  3. Pt Hx when presenting with cardiac issues consists of:
    • History of Present Illness
    •    (analysis of chest discomfort or presenting symptoms, also recent symptoms...PQRST method!)

    Past history of cardiac problems & evaluations

    • Risk Factors
    •     (cultural/ethnic factors, Family Hx)

    • Medications they are on
    • Allergies
  4. Analysis of Chest Pain using this method:
    PQRST

    • P- precipitating events
    • Q- quality of pain (tightness, dull, sharp?)
    • R- radiation of pain? (neck, jaw, arms)
    • S- severity of pain (rate on pain scale, but MI doesn't always present as a "10")
    • T- timing (how long does it last, start?)
  5. Risk factors for CAD
    • Nonmodifiable:
    • Age
    • Gender
    • Ethnicity
    • Family Hx 
    • Modifiable:
    • Abnormal serum lipid levels
    • Hypertension
    • Tobacco use
    • Inactivity
    • Obesity
    • Diabetes
    • Metabolic Syndrome
    • High Homocysteine
    • Psycological states
  6. Cultural/Ethnic Factors affecting CAD:
    Caucasian- men have highest incidence of CAD

    African American- earlier onset, women have higher incidence, mortality, and severity of CAD

    Native American- <35 yrs old has double mortality of other Americans (Obesity and DM are major risk factors)

    Hispanic- lower mortality rates
  7. 3 ways that CAD may present:
    Angina Pectoris

    • Acute Coronary Syndrome
    •    -unstable angina
    •    -non-STEMI
    •    -STEMI

    Sudden Cardiac Death
  8. All symptoms of CAD are the result of:
    ishchemia
  9. When lack of oxygen is temporary and reversible, but causes pain:
    STABLE angina
  10. When lack of oxygen is prolonged ____ results which presents in what 3 ways?
    Acute Coronary Syndrome

    • 1- Unstable Angina
    • 2- Non-ST elevation myocardial infarction
    • 3- ST-elevation myocardial infarction
  11. Ischemia may result when the heart muscle:
    Has an increased demand/need for oxygen

    OR

    Has a decreased supply of oxygen
  12. Factor that could increase the heart's demand for oxygen
    Exercise
  13. Factors that could cause a decreased supply of oxygen to the heart:
    Stimulants/Drugs, Impairments of airway exchange, Hypovolemia
  14. The myocardium becomes cyanotic within ____
    the 1st 10 seconds of coronary occlusion.....

    Anaerobic metabolism begins > the byproduct of anaerobic metabolism is lactic acid > this acid irritates nerve fibers in the myocardium > pain occurs
  15. Angina is a syndrome due to _____ , but damage to cells is _____
    Ischemia, Reversible
  16. Myocardial Infarction means that there has been _______ which has caused cell _____
    sustained ischemia, dead (forever and ever)
  17. Chest discomfort which occurs intermittently over a long period of time with the same pattern of onset, duration and intensity of symptoms
    Stable Angina
  18. Stable angina lasts for how long?
    5-15 minutes, but stops when the precipitating factor is relieved
  19. EKG changes indicating Stable Angina
    ST depression
  20. What are the "4 E's" that precipitate angina?
    • Exercise
    • Emotion
    • Eating a large meal
    • Extreme Temperatures

    (also strong stimulants like cocaine, amphetamines, tobacco, sex, circadian rhythm)
  21. Why do many people have early morning angina?
    Most of the cortisol in the body is released in the morning
  22. Angina due to spasm of a major coronary artery
    Prinzmetal's Angina (variant angina)

    Occurs at REST
  23. Prinzmetal's Angina is usually seen in people with:
    Raynaud's disease
  24. EKG change related to Prinzmetal's Angina
    ST elevation (disappears spontaneously)
  25. When there is a change in the established pattern of angina or a new onset of symptoms occurs, it is considered:
    UNSTABLE angina

    *Emergency! (often means the atherosclerotic plaque has been deteriorated or changed)
  26. Treat a Non-STEMI like ____ because occlusion to the coronary artery is incomplete
    Unstable Angina
  27. Non-Stemi has a ____ plaque
    Stable
  28. A STEMI has an _____ plaque
    Unstable Plaque
  29. S/S of MI
    Sustained pain not relieved by anything

    Can occur at rest/active

    Statistically more common in early morning

    Possible radiation to the jaw, neck, arm, back but primarily substernal

    N/V

    Cool, clammy skin with ashen color

    Feeling of impending doom

    Denial that anything bad will happen

    BP initially goes by but may crash once damage is done to the heart
  30. How do women present differently than men with s/s of MI?
    SOB/crippling fatigue may be first symptom

    Pain may not be as distinct as it is for men (may be described as dull or more like GI pain)

    Frequent radiation into jaw and shoulder
  31. How do diabetics/elderly commonly present MI s/s?
    They many not have pain due to neuropathy.... "silent ischemia"

    SOB, decreased LOC, etc
  32. Any unexpected death from cardiac source:
    • Sudden cardiac death
    • (accounts for 50% of all deaths from CV sources)
  33. Sudden Cardiac Death is usually caused by
    Acute Ventricular Arrhythmia

    ***If people survive give anti-arrhythmic meds and implantable ICD needed long term
  34. The _______ is divided into 2 branches and perfuses the ANTERIAL WALL
    Left Coronary Artery
  35. The artery between the left atrium and ventricle that Perfuses the Lateral Wall of the heart
    Circumflex Artery
  36. Artery that Perfuses the INFERIOR WALL of the heart
    Right Coronary artery
  37. Stage of circulation when blood is filling into the coronary arteries:
    • Ventricular Diastole
    • (anything that increases HR puts at risk for angina because the heart doesn't have time to rest and fill completely)
  38. Complications of MI
    Arrhythmias are #1 (80% of people have them, number 1 cause of death)

    Heart Failure

    Cardiogenic Shock

    Papillary muscle dysfunction --> mitral regurgitation

    Pericarditis--> infarcted area inflamed

    Dressler's Syndrome--> antigen/antibody reaction

    Ventricular Septal Defect

    Ventricular Aneurysm
  39. Priority of MI patient
    PUT ON MONITOR! (monitor rhythm and HR)
  40. Sx of Heart Failure:
    • Respiratory symptoms
    •    SOB, sitting up to breath, crackles
  41. S/s of cardiogenic shock:
    • low BP
    • low MAP (norm = 70-92)
    • cold, clammy, diaphoretic
  42. If you hear a new murmur on a pt, they likely have:
    papillary muscle dysfunction (mitral regurgitation)....they may be going into cardiogenic shock
  43. S/s of Pericarditis
    • Friction Rub
    • (due to cytokines being released)
  44. Syndrome when the body is trying to get rid of the infarcted heart tissue (antigen/antibody reaction)
    Dressler's Syndrome
  45. Hole in the ventricular septum causing a very loud murmur and palpable THRILL
    Ventricular Septal Defect (VSD)
  46. When the ventricle that is affected is dead and won't contract (balloons out)...sometimes gets clots in it and puts pt at risk for emboli
    Ventricular Aneurysm
  47. Patient assessment of a pt presenting with MI
    • Pain
    • Color/Temp = low grade fever, cool, ashen color
    • BP/HR= will tell us how hard heart is working
    • Lung Sounds- listen for crackles
    • Heart Sounds- Gallops, Murmurs, Thrills
    • N/V
    • Cardiac Rhythm
  48. When heat is having difficulty/abnormal ventricular filling, a ____ will be heard
    S3 gallop -- "A-slosh-ny"

    *Turn pt on lateral recumbant position
  49. Sound heard due to the thickened heart muscle...atrium is trying to pump against resistant ventricle (caused by prolonged blood pressure)
    S4 gallop -- "A-Stiff-Heart"
  50. Physician Orders for a pt presenting with MI s/s
    Vital Signs STAT, then HR/BP every 15 min

    Continuous pulse ox

    ECG STAT and every 8 hours x2

    Cardiac Isoenzymes STAT & every 8 hrs x2

    CBC and CMP STAT

    Portable CXR now

    NPO except meds

    IV access (INT) x2
  51. How often are EKG's required for MI patient?
    Every 8 hours to fully see changes

    (may take several hours before MI s/s are seen)

    Don't be fooled if EKG looks ok in ER!!!
  52. T-wave inversion represents:
    Ischemia
  53. ST segment Elevation (>1mm) represents:
    Severe Injury
  54. An elevation of _____ on 2 consecutive leads is diagnostic indicator of MI
    ST segment
  55. To measure ST elevation, start at this point:
    • J-point
    • (.06-.08 after end of QRS segment)
  56. Significant Q wave changes on ECG represents:
    Necrosis of heart

    (if Q wave shows up .04 seconds or 25% of R wave depth WITHOUT STsegment or Twave changes...indicates Old MI)
  57. Abnormal Q wave measurements:
    .04 seconds or 25% of R-wave depth
  58. Serum Cardiac Markers (Enzymes)
    • Troponin (norm = <.4)
    • CK-MB (norm= 0-5)
    • Myoglobin
  59. Most sensitive muscle protein...Blood levels rise in few hours and stay up for weeks
    • Troponin
    • (normal = <.4)
  60. Cardio-sepcific isoenzyme that goes up in a few hours after MI, peaks in 24 hours, and returns in 2-3 days
    • CK-MB
    • (norm=0-5)
  61. Least specific cardiac enzyme that increases in 1-3 hours, peaks within 12 hours
    Myoglobin
  62. Diagnostic Tests for MI
    • EKG
    • Enzymes
    • Stress Test
    • Cardiac Cath (coronary angiography)
    • Echocardiogram (tells us ejection fraction, ishemia, infarct)
  63. Normal Ejection Fraction:
    >60%
  64. Everyone presenting with chest discomfort or s/s of MI will get:
    ASPIRIN! (acts as anti-platelet until MI discovered)
  65. Treatment of Angina:
    "ABCDE" (ASA, ACE inhib, Anti-anginal meds; Beta blockers, BP control; Cholesterol management, Cigarette Cessation; Diabetes control, Diet management; Exercise and Education)

    OR

    Nitrates, Beta Blockers, Calcium Channel Blockers, Anti-platelet/Anticoagulation therapy, Ranexa (anti-anginal), Oxygen
  66. Types of Anti-platelet and Anticoagulation Therapy:
    • Aspirin
    • Thienopyridines (Plavix, Effient)
    • IV Heparin or SQ LMWH
    • Lovenox
    • Fragmin
    • Glycoprotein llb/llla agents
  67. Treatments of Severe CAD and history of MI
    Percutaneous Coronary Intervention (angioplasty) -- STENTS

    Myocardial Revascularization (Coronary Artery Bypass Surgery...CABG) -- new vessels around blockages to promote bloodflow
  68. Total Treatment of MI
    • Rapid Diagnosis and Treatment to save muscle
    • Chew ASA or give heparin
    • Establish IV access
    • IV morphine 2-4 mg every 3-5 min for pain
    • Oxygen (2-4 L/min)
    • Cardiac Monitor
    • IV nitro
    • IV amiodarone drip (if arrhythmias)
    • Frequent VS
    • Complete Bed Rest!!!
    • Emotional Support

    "MONA"-- morphine, oxygen, nitro, aspirin
  69. MONA stands for:
    Morphine, oxygen, nitro, aspirin
  70. Medications used for MI
    • Nitrates (IV while in ER/ICU)
    • Antiarrhythmic Drugs
    • Morphine
    • Beta Blockers
    • ACE inhib (captopril, ramipril, enalapril)
    • Anti-dyslipidemic meds (statins)
    • Stool Softeners
    • Anti-anxiety meds
    • Anti-platelet agents (includes IV Glycoprotein IIb/IIIa inhibitors (to inhibit and block the final pathway for platelet aggregation)
    • IV Access
    • Oxygen
  71. Nursing Care for pt with recent MI
    • -Med Admin
    • -Monitoring for complications
    • -Monitoring/Titration for desirable drug effect and adverse reactions
    • -Prioritization of care delivery
    • -Pt/Family education and emotional support
  72. Goal of Emergent Percutaneous Coronary Intervention (PCI)
    Door to Balloon within 90 minutes!
  73. Advantages to PCI for MI pt
    Early ambulation, discharge, and return to work
  74. Complications of PCI
    • Coronary dissection (causes acute closure)
    • Plaque dislodgement
    • Coronary Spasm
    • Restenosis (insetnt--closes off inside stent)
  75. Clot Busters (Fibrinolytic Therapy)
    Tissue Plasminogen activator or STREPTOKINASE

    (if done in first hour or two, can stop infarction and save muscle...dissolves clot and re-establishes blood through coronary artery...pt selection is critical! Follow clot busters with PCI)
  76. Goal of Clot Busters
    Give within 30 min arrival!

    (make sure you have all IV access ready in case of complications)
  77. Complications from Clot Buster
    BLEEDING!
  78. Hospital Discharge process for post-MI pt
    • Education!
    •    -patho
    •    -recovery procedure
    •    -low fat, low salt diet
    •    -proper use of nitro (sitting down)
    •    -how to check pulse
    •    -important of exercise routine
    •    -resuming ADL
    •    -resuming sexual activity
    • Follow-up appointments with Doctors
    • List of Medications and reasons for taking them
    • Other written instructions
    • Cardiac Rehab Phase II
  79. Core Measures for a patient that has had an acute myocardial infarction:
    • ACEI on discharge for LVEF <40%
    • Beta Blockers
    • Statin prescribed if LDL >100 (lipid profile done within 24hrs admission)
    • Aspirin given on arrival/prescribed at discharge
    • Smoking Cessation Info
    • Thrombolytics received within 30 min OR PCI received within 90 min of hospital arrival
  80. Procedure that redirects blood through a graft from aorta to coronary artery just beyond the obstruction
    CABG (bypass)
  81. Vein used from lower leg that is grafted on heart and attached proximally to aorta and distally to the coronary artery below the obstruction
    Saphenous Vein
  82. Graft of choice used in a CABG and attached to the coronary artery below the area of obstruction...has a superior patency rate (longer than saphenous vein)
    Internal Mammary Artery
  83. Pt undergoing CABG are put in cardioplegia (heart stopped) by using ____
    Hyperkalmic Solution
  84. Functions of Cardiopulmonary Bypass Machine
    Extracorpeal Circulation (blood bypasses the heart so that it can be still during surgery)

    Maintains adequate hemodynamics and metabolic conditions during surgery

    Allows surgeons to work on bloodless field

    Hypothermia used to reduce oxygen requirements
  85. Complications during CABG
    Ischemic Myocardial injury

    Heart Failure

    Arrhythmias

    Limb Ischemia

    Excessive Bleeding (over 200cc/hr...ANYTHING OVER 100 IS TOO MUCH)

    Hyper/Hypovolemia

    Respiratory Complications/Infections
  86. Nursing Care following CABG
    People usually in ICU for 24-48 hours...can go home in 5-7 days

    Assess S/S of angina (indication of grafts closing)

    Deep Breathing, ROM, Dressing changes, support hose to decrease swelling at site of vein removal, should be no more than 100cc blood/ hour from chest tube!!!

    Watch urine output carefully (renal perfusion) -- we want over 30ml/hr...give lasix if not!!!

    Foley cath, hemodynamic monitoring, arterial line

    Assess neuro status, strict I/O, give narcotics for pain

    Watch for shivering, warming blanket prn

    Teach family how loved ones will look/feel after surgery
  87. Amount of blood in ventricles at the end of diastole, affected by venous return to the heart
    Preload
  88. Resistance against which the left ventricle must pump; affected by BP, Systematic Vascular Resistance, and Aortic Valve
    Afterload
  89. Force opposing movement of blood created mostly in small arteries and arterioles
    SVR (Systemic Vascular Resistance)
  90. What does vasoconstriction do to the SVR?
    Increase SVR
  91. Volume of blood ejected from heart with each contraction
    Stroke Volume
  92. Volume of blood ejected from heart per minute (SV*HR)
    Cardiac Output
  93. Normal cardiac output
    4-8 Liters/min in resting adults

    Affected by HR, Contractility, Pre/afterload
  94. CO/BSA = ?
    Cardiac Index
  95. Normal Cardiac Index (CI)
    2.2-4 Liters/min
  96. What is involved/ What is the purpose of Hemodynamic Monitoring?
    Done to monitor cardiovascular function and blood volume

    -place catheters in vascular system and hook them up to transducer and monitor! (invasive)

    -we can measure wave forms to see how the heart is functioning

    -Done for critically ill patients with heart or fluid volume problems
  97. Indicates the driving or perfusion pressure to the organs
    Mean Arterial Pressure
  98. Formula for MAP
    [SBP +2 (DBP)]/3
  99. Normal MAP
    • 70-92 mm Hg
    • (when you get below 60 your organs are at RISK!!!)
  100. A low MAP indicates
    low perfusion which leads to ischemia
  101. Pressure in the right atrium and in the great veins as they enter the right atrium...indicator of circulating blood volume and right-heart pumping strength
    Central Venous Pressure
  102. The CVP reading is dependent on:
    The volume of blood entering the great veins, pumping of Right Ventricle, and the degree of Vasoconstriction in the vascular system
  103. Normal CVP
    2-8 mm Hg
  104. A high CVP indicates
    Hypervolemia or poor RV contraction
  105. A low CVP indicates
    Hypovolemia
  106. Nursing intervention related to high CVP
    slowing down rate of IV fluids OR give diuretic
  107. Nursing intervention related to low CVP
    increase the rate of fluid (pt probably dehydrated)
  108. Pressure that reflects left ventricular function
    Pulmonary Artery Pressure
  109. Normal PAP
    15-30 / 4-12 mm Hg
  110. A high PAP indicates:
    LV is failing as a pump and blood is backing up into pulmonary bed (or hypervolemic state)
  111. A low PAP indicates:
    hypovolemia
  112. Normal PAWP (Pulmonary Artery Wedge Pressure)
    6-12 mm Hg
  113. Why is PAWP a great indicator of Left Ventricular function?
    Because during diastole the mitral valve is open, and the pressure in the pulmonary capillaries is the same as the pressure in the left ventricle
  114. Cardiac Output can be determined at bedside using:
    • swan-ganz catheter
    • (normal cardiac output = 4-8 L)
  115. If the left ventricle is failing, the ___ will be low
    Cardiac Output
  116. Cardiac output adjusted for the patient's size
    Cardiac Index (must determine pt surface area)

    ***no matter how large/small, CI should be 2.2-4L
  117. Catheter used to do all hemodynamic monitoring except arterial BP
    Swan-Ganz Catheter

    (CVP, PAP, PAWP, CO)
  118. Normal Strove Volume
    60-100
  119. Systemic Vascular Resistance formula:
    (MAP-CVP/CO) * 80
  120. Normal SVR
    800-1200
  121. PAWP and CO are _____ related
    • Inversely 
    • (PAWP will go UP if heart cannot pump blood, CO will go DOWN)
  122. Maintenance of Hemodynamic Catheters:
    -attached to bag of saline which is under pressure...serves as flush

    -when attached to transducer, only 3cc of saline per hour (prevention of clots in cath)

    -change every 7 days!
  123. Referencing for Transducer and Flush Set Up
    Position stopcock nearest transducer at phlebostatic axis (midaxillary line and 4th ICS)
  124. Complications of PA Catheters
    • Infection/Sepsis
    • Air Embolus
    • Pulmonary Infarction
    • PA rupture
    • Ventricular Arrhythmias
  125. Perform _____ before insertion of catheter to monitor Arterial Blood Pressure
    Allen's Test
  126. Key Nursing role when monitoring Arterial Blood Pressure:
    • Monitor for hemorrhage, infection, thrombus, neurovascular changes, loss of limb
    • HOURLY!!!!

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