Designing Providing Care for Adults with Acute Cardio Disorders (Part 2)

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Designing Providing Care for Adults with Acute Cardio Disorders (Part 2)
2014-09-08 20:20:00
Cardio Day Two
Cardio Day 2
Cardio Day 2
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  1. Most common cause of HF, caused by weak pump, increased afterload, cardiomyopathy, or valvular problems
    Systolic Dysfunction
  2. Hallmark sign of systolic dysfunction:
    • LOW ejection fraction
    • (systole = contracting)
  3. Diastolic Dysfunction results when there is:
    • impaired filling!
    • (Diastole = relaxation)
  4. What is a key cause of Diastolic Dysfunction?
    • Left Ventricular Hypertrophy
    • (ejection fraction is not affected)
  5. Normal EF
  6. Risk Factors for Heart Failure:
    CAD, HTN, DM, Tobacc, Obesity, Hyperlipidemia
  7. Causes of HF
    Any disruption in normal mechanisms regulating Cardiac Output

    •    -preload (hypervolemia, afib)
    •    -afterload (HTN, athersclerosis, smoking, hypothermia, anything leading to vasoconstriction)
    •    -contractility 
    •    -HR (anything causing tachycardia, BBB, bradycardias)
    •    -Metabolic State (hyperthyroidism, infection with high fevers, sepsis, etc)
  8. Blood Flow Forward through the heart:
    Enters through inferior and superior vena cava -> right atrium of the heart ->tricuspid valve (When the ventricle is full, the tricuspid valve shuts. This prevents blood from flowing backward into the atria while the ventricle contracts) -right ventricle -> blood leaves the heart through the pulmonic valve -pulmonary artery -> lungs -The pulmonary vein -left atrium -> mitral valve -left ventricle (When the ventricle is full, the mitral valve shuts. This prevents blood from flowing backward into the atrium while the ventricle contracts.) -blood leaves the heart through the aortic valve -aorta -body
  9. Blood Flow Backwards Starting at the Left Ventricle:
    • Left Ventricle <- Mitral Valve <- Left Atrium <- Pulmonic Vein <- lungs <- Pulmonary Artery <- Pulmonic Valve <- Right Ventricle <- Tricuspid Valve <- Right Atrium <- Inferior/Superior Vena Cava
  10. All symptoms of Heart Failure come from:
    the backlog of blood flow (once the left side fails, it will back up to the right side of the heart)
  11. Most common cause of RV failure
    Left Ventricular Failure
  12. Right Ventricular Failure occuring alone when pt has COPD, Pulmonary HTN, or RV infarction...this is called:
    Cor Pulmonale (very rare!!!)
  13. Occlusion must be ____ for PCI or CABG
  14. Assessment findings on pt with HF
    Crackles in lungs, Gallop at Mitral Valve, Thrills felt at PMI (apex), Signs of fluid rentention, hypoactive bowel sounds, Palpation of liver, Edema of legs, Decreased MAP (<70), diminished pedal pulses
  15. S/S of LEFT Sided HF
    • Pulmonary Edema
    • Fatigue
    • PND (paroxysmal noturnal dyspnea)
    • Crackles, Dry Cough
    • Hypoxia, Resp Alkalosis/Acidosis
    • S3 gallop "A-slosh-ny" (mitral valve)
    • Labored Breathing
    • Orthopnea (elevated head at night)
    • Tachycardia
    • Nocturia
  16. S/S of RIGHT sided HF
    • Peripheral Edema on Legs
    • JVD (jugular venous distention)
    • Weight Gain
    • Constipation
    • Distended Abdomen
    • Enlarged Liver, Ascites, RUQ Pain
    • Loss of Appetite/Full Very Fast
  17. Hemodynamic changes seen in HF
    Preload- increased bc elevated CVP and Pulmonary Pressures

    Cardiac Output- decreased
  18. NYHA Functional Classification of Heart Disease
    • Class 1: No limitation of activity
    • Class 2: slight limitation, no sx at rest
    • Class 3: marked limitation, sx with activity
    • Class 4: inability to carry on any activity without discomfort, has sx at rest
  19. No limitation of physical Activity (which NYHA class???)
    Class 1
  20. Slight Limitation of physical activity, no sx at rest, ordinary activity results in sx (which NYHA classification of Heart Disease)
    Class 2
  21. Marked limitation of physical activity, Comfortable at rest, Sx with activity (which NYHA class)
    Class 3
  22. Inability to carry on any physical activity without discomfort, has sx at rest, discomfort increased with any activity (which NYHA class??)
    Class 4
  23. Priorities of Nurse when patient in distress from HF
    • Stay with pt when they "can't breathe"
    • Reassure Pt
    • Get orders from Doctor
    • Administer meds as prescribed
    • Monitor BP
    • Nitro -- helps preload by dilating veins 
    • Wait for lasix to start working BEFORE nitro
  24. Normal SVR
  25. ACC/AHA Classifications of HF
    A= high risk for developing LV dysfunction, but without structural ht disease or sx of HF

    B= LV dysfunction or structural ht disease who have not developed sx yet of HF

    C= LV dysfunction or structural ht disease with current sx of HF

    D= refractory end-stage HF requiring specialized interventions
  26. S/S of Acute Pulmonary Edema (Acute Decompensated Heart Failure)
    • Agitation
    • Pallor/Cyanosis (very late sign)
    • Cool, clammy skin
    • Severe Dyspnea
    • Wheezing/Coughing (gurgling)
    • Blood Tinged sputum (capillaries are pushed so high in lungs)
    • Tachycardia and BP drops
  27. Normal BNP
  28. Diagnostic Tests for HF
    • Chest X-Ray (shows fluid)
    • Labs:
    •    Serum Chemistries, Cardiac Enz, LFT
    •   Keep at potassium level around 4
    • BNP (norm = <100; HF= >500)
    • Weight (I/O...want output to be > than intake)
    • 12-lead EKG
    • Echocardiogram (shows Ejection Fraction)
    • Cardiac Cath
    • Arterial Blood Gas
  29. Complications of HF
    • Pleural Effusion (lungs can't expand)
    • Dysrhthmias- AFib, VTach, VFib, Sudden Cardiac Death
    • LV Thrombus- recommend coumadin <20% EF
    • Hepatomegaly
    • Renal Failure
  30. Collaborative Treatment for Acute Decompensated HF (acute pulmonary edema)
    Intravascular Volume Reduction- loop diuretics, ultrafiltration

    • Afterload reduction- vasodilators 
    • Nipride, IV Natrecor

    • Preload Reduction (venous dilators)
    • High Fowler's position, IV Nitro

    • Improve Pumping Ability: +inotropic drugs
    • Digoxin, Dobutamine, Milrinone, Dopamine

    • Improve Gas Exchange-
    • Oxygen, Mechanical Ventilation
    • Reduce Anxiety (morphine, calm reassurance)
  31. S/S of CHRONIC Heart Failure
    • Fatigue
    • Dyspnea, PND, Orthopnea
    • Dry, Hacking Cough
    • Tachycardia
    • Edema
    • Nocturia
    • Behavioral Changes
    • Chest Pain
    • Weight Changes
  32. Collaborative Treatment of CHRONIC HF
    • Pharmacologic methods
    • (diuretics, vasodilators, +inotropes, betablockers)

    • Cardiac Resynchronization Therapy
    • (Biventricular Pacemaker)
  33. Pharmacologic measures to treat CHRONIC HF
    • Diuretics:
    •    Lasix, Aldactone

    • Vasodilators:
    •    ACE inhib, Nitrates, AngiotensinII Receptor Blockers

    • Positive Inotropes:
    •    Digoxin

    • Beta Blockers:
    •    Coreg (Carvedilol) or Metoprolol
  34. Nursing care of Pt with HF
    Strict I/O (no order needed)

    Daily Weights (no order needed)

    Reduced Sodium Diet (2G/day)

    Fluid Restriction

    Monitoring electrolyte and fluid balance

    • Pt/Family Education--
    •    Wt monitoring every morning > call dr if greater than 3 lbs over 2-5 days
    •     Monitor Pulses
    •     Monitor for Hypokalemia (cramps in legs)
  35. Pt/Family Education for Pt with HF
    • Diet
    • Activity level
    • Discharge Meds
    • Follow up appointments
    • Daily Weight Monitoring
    • Symptom Management
    • Smoking cessation
    • EF < 40% give ACE inhib
  36. Core Measures for HF patients:
    LVEF documentation at admission

    ACEI/ARB given for LVEF <40%

    Smoking Cessation

    • Discharge instructions:
    •    Diet, Activity, Weight, Sx management, Med list
  37. Prolonged QRS duration on an ECG represents:
    Left Bundle Branch Block (CRT may be needed)
  38. Types of Heart Valve Disorders
    Stenosis- valve opening is small due to thickened valve leaflets...forward flow of blood is impeded

    Regurgitation- valve does not close properly to seal off the heart chamber...causes backward sloshing
  39. If you hear a murmur during Systole, it is ____
  40. If you hear a diastolic murmur r/t Pulmonic Valve it is ____
  41. When blood cannot get out of LA easily...pressure in the LA backs up into pulmonary veins/capillaries...pulmonary edema occurs
    Mitral Stenosis
  42. Biggest Cause of Mitral Stenosis:
    Rheumatoid Fever (type a beta-hemolytic strep)
  43. Early and Late Sx of Mitral Stenosis:
    Early: Exertional Dyspnea, Fatigue, Weakness

    Late: peripheral edema, ascites, liver engorgment

    Diastolic Rumbling Murmur is heard at apex!
  44. Mitral Stenosis usually occurs in these people:
    elderly or people that lived in 3rd world country
  45. When blood sloshes back into the left atrium during ventricular systole...LA overdistends bc blood is going backward
    Mitral Regurgitation
  46. Any time you have Left Atrial enlargement, you are at risk for:
    Atrial Fibrilation
  47. Sx of Mitral Regurgitation
    Left Sided HF symptoms
  48. Holosystolic murmur at apex that radiates to axilla and back is found in:
    Mitral Regurgitation
  49. Treatment of Mitral Regurgitation:
    ACE inhib, Low Sodium Diet, Diuretics, Rest 

    Promote Vasodilation > forward blood flow
  50. Priority for Acute Sudden Mitral Regurgitation:
    Get to OR right away!!! Emergency...person will be heading to cardiogenic shock...dysfunctional papillary muscle
  51. When is a mitral valve click heard?
    Mitral Regurgitation and Mitral Valve Prolapse
  52. When the tight aortic valve causes an obstruction to the ejection of blood from the left ventricle, causing decreased CO and increased myocardial workload
    Aortic Stenosis
  53. What type of murmur will be heard in pt with aortic stenosis?
    Systolic Murmur (radiating to carotids) and S4 gallop
  54. Sx of Aortic Stenosis
    • Angina
    • Syncope
    • CHF
    • Ventricular arrhthmias = severe
  55. Treatment of Aortic Stenosis
    opening the valve with balloon valvuloplasty or valve replacement
  56. When blood in the aorta sloshes back into the left ventricle during diastole because it didn't close properly
    Aortic Regurgitation
  57. In order to eject all of the extra blood that is in it, the LV ______ its total stroke volume during aortic regurgitation
    increases SV
  58. The prolonged ejection fracture period during Aortic Regurgitation causes the LV to ______ which leads to ______
    dilate and hypertrophy...leading to heart failure
  59. What type of murmur will be heard during AORTIC REGURGITATION
    diastolic murmur (Austin Flint)
  60. Aortic Regurgitation will have a _____ pulse pressure, and ______ pulse
    Widened; Water-hammer
  61. Assessment findings in pt with aortic regurgitation
    Dyspnea, LV failure, Diaphoresis
  62. Collaborative Care of Valvular Heart Disease
    Hx (of congenital heart defects, murmurs, etc)

    Chest X Ray (look for enlargements and calcium around valves)

    Echocardiogram ("gold standard test" determining severity)

    Cardiac Catheterization (looks at coronary arteries)

    Prophylactic Antibiotic Therapy (high risk of endocarditis....amoxicillin during dental)

    Treatment of HF

    Balloon Valvuloplasty (moves the blocking factors out of the way...done on pts that are not good surgical candidates)


    Prosthetic Valve Replacement Surgery
  63. Types of valves used during a prosthetic valve replacement surgery
    • Mechanical- usually metal and lasts longer)
    •    (ex: St. Jude's)
    •    Assessmentwill hear a normal crisp "click"
    •    Treatmentlong term anticoagulation (Coumadin)

    • Biologic Tissue Valves- lasts about 10-15 yrs
    •    Bovine (cows)
    •    Porcine (pigs)
    •    Human Cadaver

  64. The AHA recommends _______ one hour before any dental/surgical procedure for people that are known to have valve disease and must adhere to strict prophylactic antibiotic program
    Amoxicillin 2 gm PO
  65. Nursing Care in Valvular Heart Disease
    • Prophylactic Antibiotic Therapy
    • Monitor for heart blocks
    • Anticoagulation Therapy
    •    -INR 2-3 (Atrial Fib)
    •    -INR 2.5-3.5 (Mechanical Valve Prosthesis)
    • Pt teaching -Medic Alert ID!
  66. Group of diseases affecting the structure and/or function of the heart....can be primary or secondary...but all result in heart failure
  67. 3 types of Secondary Cardiomyopathy (due to another disease process)
    • Dilated- systolic HF
    • Hypertrophic-diastolic HF
    • Restrictive-diastolic HF
  68. Primary diagnostic test for Cardiomyopathy
  69. Most common type of Cardiomyopathy characterized by inflammation, ventricular dilation, impaired systolic function (LOW EF), and stasis of blood
    Dilated CMP
  70. Causes of Dilated CMP
    Cardiotoxic agents, genetics, CAD, HTN, ischemia, myocarditis, valvular heart disease, pregnancy
  71. Dilated Cardiomyopathy puts patients at high risk for:
    Arrhythmias and Death
  72. Idiopathic CMP that is more common in men ages 30-40 or athletes
    Hypertrophic CMP
  73. Hypertrophic patients are at a very high risk for _____
    Sudden Cardiac Death
  74. Characteristics of Hypertrophic CMP
    • Massive vulnerability hypertrophy
    • Rapid, foreveful contraction of the LV
    • Impaired relaxation (diastolic, dysfunction)
    • Obstruction to aortic outflow
  75. HCM Collaborative Treatment
    • Reduction of LV contractility and relief of LV outflow obstruction
    •    -Beta Blockers
    •    -Calcium Channel Blockers
    •    -Digoxin is contraindicated

    Implantable cardioverter-defibrillator (can shock the heart out of ventricular  arrhythmias)


    Alcohol-induced Septal Ablation
  76. Reasons / Education for Implantable Cardioverter Defibrillator (ICD)
    •Prevents sudden death

    •Contains defibrillator & pacemaker

    •Senses heart rhythm & detect changes in rate

    •Treats by pacing or shocking to return rhythm to normal

    •Medic Alert Bracelet needed
  77. When myocardial fibrosis, hypertrophy, and infiltration cause impaired diastolic filling and stretching
    Restrictive CMP
  78. Causes of Restrictive CMP
    Amyloidosis (protein), Sarcoidosis, Radiation durying that test!
  79. Sx of Restrictive CMP
    Fatigue, exervise intolerance, dyspnea, angina, syncope, palpitations, HF
  80. Treatment of Restrictive CMCP
    HF sx and arrhythmias

    Avoid strenuous activities, dehydration, and increase in SVR
  81. Pt/Family Teaching for pt with CMP
    • Medications, Low  Na Diet, Fluid intake-increased (preven dehydration)
    • Weight management
    • Avoid stimulants:
    •    (caffeine, ETOH, Diet pills, OVT med)
    • Balance activity and rest
    • Stress Reduction
    • Report S/S of HF
    • Family to learn CRP
    • Prophylactic...antibiotics for endocarditis preventions
  82. Inflammation of fibro-serous sac that surrounds the heart
  83. Cause of Pericarditis
    Infections, Open Heart Surgery, Acute MI, Cancer, Autoimmune Diseases like Lupus
  84. Assessment findings in pt with Pericarditis
    Pericardial friction rub, chest pain worse with lying and inspiration

    Pain may be relieved by sitting up and leaning forward or by Aspirin, NSAIDS or Prednisone
  85. What is the only treatment to be done on pt with Pericardial Effusion
    Pericardiocentesis (done at bedside or OR with echo)...the more fluid in sac, the more pressure on the heart
  86. Signs of Cardiac Tamponade
    Pulsus Paradoxus- listen to SBP on inspiration and expiration (greater than 10 mm Hg drop with inspiration)



    JVD (caused by heart's inability to fill)

    Muffled Heart Sounds (bc of all fluid)

    Narrowing Pulse Pressure


    Signs of decreased CO

  87. Systematic, inflammatory disorder that usually is the result of a strep through
    Rheumatic Fever
  88. Complications from Rheumatic Fever:
    Can cause either valve stenosis or reguritation!! (treat with antibiotics and anti-inflammatory agents)
  89. Infection occurring on the valve, walls of the heart chambers and arteries, or on tissue surrounding artificial valves and create debris (vegetation)...
    • Ineffective Endocarditis 
    • (think vegetations)
  90. Infective Endocarditis most often occurs with these things:
    Known valvular heart disease or artificial valves, IV device placement, IV drug abusers, infections, or dialysis
  91. Assessments of Pt with Infective Endocarditis:
    103-104 fever with chills, delerium, new murmur, heart failure, LOC changes, malaise arthralgia
  92. Manifestations of Endocarditis -> leads to valvular heart disease
    • New/changed murmur
    • Vegetations on heart valves (can break off and cause emboli)
    • Splinter hemorrhage
    • Petechia
    • Osler's nodes
    • Janeway's lesions- nodules on joints
    • Emboli to other organisms
  93. Dx Tests for Endocarditis

    Blood Culture and sensitivity to identify organism

    WBC differential


    Chest X ray

    12-lead EKG

    Cardiac Cath
  94. Nursing Priority when treating infective endocarditis:
    always give urine culture before you start antibiotics!
  95. IV Antibiotic therapy will be given _____ weeks in order to totally clear up the infection and endocarditis...
    6-8 weeks
  96. Why must a Central IV line or PICC be inserted to treat infective endocarditis
    Because they will go home on antibiotic therapy managed by home health
  97. Treatments for Infective Endocarditis
    •IV Antibiotic therapy will be given for 6-8 weeks weeks in order to totally clear up the infection

    •Central IV line or PICC must be inserted because they will go home on antibiotic therapy managed by home health

    •Repeat Blood cultures & sensitivity

    •Surgical repair or replacement of valve

    •Antibiotic Prophylaxis – dental, respiratory, skin, GI, & GU procedures
  98. Type of low blood flow shock due to either
    systolic or diastolic dysfunction resulting
    in compromised CO.
    Cardiogenic Shock
  99. Causes of Cardiogenic Shock
    MI, CMP, blunt cardiac injury, severe HTN or pulmonary HTN, myocardial depression d/t metabolic disorders, cardiac tamponade

    Mortality is HIGH!!! – 50-85%
  100. Signs of Cardiogenic Shock
    •Tachycardia, low BP, narrowed pulse pressure

    •Decreased cap. refill,  possible CP

    •Increased SVR

    • •Decreased CI
    •    < 2.1L/min/m2

    • Tachypnea, crackles, cyanosis

    •Increased PAWP

    • •Peripheral
    •    – pallor, cool, clammy

    • •Renal
    •    – Na & water retention, decreased U/O

    • •Cerebral
    •    – Anxiety, confusion, agitation
  101. Diagnostics of Cardiogenic Shock
    • Elevated cardiac markers: BUN, BG
    •    elevated lactase and base deficit occurs in ANY shock

    CXR- pulmonary infiltrates/congestion

    EKG- dysrhythmias

    Echo- LV dysfunction

    Continuous cardiac monitoring and pulse ox

    Hemodynamic monitoring
  102. Collaborative Care of Cardiogenic Shock
    • Oxygen and Ventillation
    • –Increase Hemoglobin – transfuse prn
    • –Increase arterial oxygen saturation
    •    *give oxygen, mechanical ventilation

    • Restore Myocardial Blood Flow
    • –Urgent cardiac catheterization
    • –Thrombolytics
    • –PCI w/ stent
    • –Emergent CABG or valve replacement
    • Optimize CO and Reduce Myocardial Workload:
    • –Drug Therapy – Keep MAP 60-65 mm Hg
    •    •Sympathomimetics – CAUTION!!!
    •    •Vasodilators
    •        – NTG IV
    •    •Diuretics
    •    •Beta Blocker

    • Circulatory Assist Device
    • Intra-aortic Balloon Pump
    • Ventricular Assist Device
  103. Large balloon-tipped catheter inserted in femoral artery and positioned in the aorta
    just distal to the aortic arch...Inflates
    during diastole to improve coronary & cerebral perfusion....Deflates
    during systole to decrease SVR & LV workload (Balloon is inflated with helium)
    • IABP
    • (intra-aortic balloon pump)
  104. Longer term support to assist or replace work of LV or both ventricles (BiVAD)
    Ventricular Assist Device (VAD)
  105. VADs (ventricular assist devices) are used for:
    –Continuation of cardiopulmonary bypass with failure to wean after CABG

    –Bridge to heart transplant….buying them time until they can get a replacement

    –“Destination therapy”…buy them quality of life
  106. How are VAD (ventricular assessment devices) surgically implanted most often? (USED FOR EF at 10-15%)
    žBi-Ventricular support connections are most often: Right atrium to Pulmonary artery and left ventricle to ascending aorta