Cardio Dysfunction and Delegation
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Which lab test will be most accurate for a client having chest pain that started 3 days ago?
All cardiomyopathies will present as....
What is cardiomyopathy?
heart muscle disease that affects the structural of functional ability of the myocardium
What problem is the most likely to lead to heart transplant?
What's the problem with dilated cardiomyopathy? Solution?
- control CHF
What's the problem with hypertrophic cardiomyopathy? Solution?
Impaired LV filling and obstruction to outflow of the aorta.
- improve ventricular filling and relieve outflow obstruction
- myomectomy-debulks ventricle
What's the solution to restrictive cardiomyopathy?
improve diastolic filling
Person comes in with chest pain...tests to look at?
CK first that indicates injury
CK-MB next and it tells injury is heart specific
Difference between CK-MB and Troponin tests?
CK MB shows injury within 2-3 hrs and will be there for 2-3 days
Troponin shows injury within 4-6 hrs and will be there for 10-14 days
What does BNP dx?
Heart failure....and the higher the number indicates worse failure
BNP leves of normal, suggestion of failure and severe failure
- Normal <100
- possible failure 100-300
- severe HF >900
Which cardiac biomarker test is best for a person who thought they were having indigestion for past 8 days?
Troponin...takes 10-14 days to be out of system
Chest x ray is good to dx.....
if cardiac silhouette is >50% of diameter of chest then cardiomegaly
What test will look for occlussions of heart?
Prior to sending a patient to cath lab check....
- iodine sensitivities
- NPO 6-18 hrs prior
What does a stress test look for? How?
- myocardial ischemia......will show differences in left ventricular wall motion
- thickening before and after exercise are evaluated.
What test is used to assess heart wall motion and valve function in the atria?
Echocardiogram is used is good to use check for....
clots if they have a fib
TEE gives a good view of....
posterior portion of the heart
How quickly do thrombolytics work and how will you know?
within 15 min and they will have no chest pain
What does nuclear cardiography look at? Using?
- wall motion
- myocardial contractial
- myocardial perfusion
3 types of nuclear cardiography
- Technetium Pyrophosphate
- Cardiac Blood pooling imagng
Technetium Pyrophosphate shows......
Hot spots...an accumulation in damaged tissues
cold spots....damaged or ischemic tissue that does not take up thallium
Cardiac Blood Pool Imaging shows
cardiac motion and calculates EF
Who will be a part of Electrophysiology studies....why?
survivors of V tach or V fib
they have an irritable focus, but are having a hard time treating it
Prior to Electrophysiology study the patient will.....
- d/c anti-dysrhythmic meds for several days prior
- NPO 6-8 hrs
How does an electrophysiology studies work???
- arrhythmia will be stimulated off med
- defibrillated to terminate rhythm
- start patient on new regime
- take patient back to lab and stim arrhythmia....
Has the fibrilation threshold been increased???
Good part about thrombolytic therapy and bad part
breaks up systemic clots
but we have good clots that protect us from bleeding
What do I need to know prior to giving a thrombolytic? Why?
Do they have high BP
If they do and I give they are at risk for a hemorrhagic stroke
Nuclear cardiography involves an injection of....
Goal of fibrinolytic therapy
reperfusion of the heart by reversing the thrombotic component of the coronary occlussion in order to limit infarct size
Who is eligible for fibrinolytic therapy?
- onset of chest pain between 3-6 hours previous
- ST elevation
Contraindications for fibrinolytic therapy
- liver failure
- stroke in last 3 months
- surgery in last 3-6 weeks
Goal for fibrinolytic therapy?
door to drug in <30min
Why is tPA the preferred thrombolytic?
big bad bleed happens right away....has a short half life 3-6 min
When giving an IV thrombolytic make sure....
2 IV lines
one dedicated to thrombolytic and the other for fluids
Nursing care after thrombolytic admin
- Resolution of chest pain
- NORMAL ST segment
- Reperfusion arrhythmias
- Wash out phenomenon
- Evidence of re-occlusion of coronary artery
What is wash out phenomenon with thrombolytic and PCTA ? Do what?
an increase in cardiac enzymes 3-4 hours after reperfusion.
do serial cardiac enzyme tests q 6-8 hour for next 24 hours
Once the heart has been reperfused what is expected and common?
have reperfusion arrhythmias like PVC's.
Watch the patient.....dont panic
What does PCTA do? How?
non surgical alternative for treating obstructive CAD
involves dilation of stenotic or occluded coronary artery using a balloon tipped catheter to deploy a stent to open the occluded artery
How long does PCTA take? Pre treatments?
45min - 1.5 hrs
NPO and Versed
Nursing management during a PTCA procedure?
*Patients response to the procedure by watching...
- symptoms of chest pain
- s/s of contrast sensitivity
- anticoagulation status
Prior to letting a person under go PTCA....what do I check? Post care???
do they have any problems with iodine or kidney disease?
- watch BUN and Creatnine levels
- admin lots of fluids to flush dye
After a PTCA make sure.....
- watch for bleeding.....so check under the dressing with eyes and feel
- watch for patient to brady down due to vagal response from pressure at entry site
- check VS
- check distal pulses
- HOB <20
- Legs straight
IF a person bradys down, I give them....
How often do I check under the dressing for a person who just had a PTCA
q 15 min for the first 2 hours
After stent placement the patient becomes diaphoretic, chest pains and has an elevated ST what do I do?
Call Dr. with SBAR...will probably go back to cath lab
What is the GOAL of REPERFUSION?
- to decrease complications from MI-examples
- heart failure
- cardiogenic shock
What is coronary athrectomy?
suck out the placque
What procedure will show blockages to the heart?
Why would a person have a CABG?
- High risk lesions....
- -3 vessel disease with good LV function
- AMI with failed thrombolysis or PTCA
- Cardiogenic shock due to AMI
What is the result of a clogged chest tube?
cardiac tamponade due to accumulation of stuff in the pericardium
What do epicardial pacing wires help with?
regulation of arrhythmias
Why is morphine so good with heart patients?
- MI and stress increases HR, which increases O2 demand even more
- It cuts pain and relaxes the patient which decreases the heart rate
- It decreases VENOUS CAPITOUS which decreases PRE LOAD which decreases the work the L ventricle has to do to contract
POST OP problems in the 1st 24 hours after a CABG
- LO CO
- Hypertension....cuz was hypothermic, causing shivering and vasoconstriction
- Hypovolemia....blood loss or vasodilated
- Neurologic dysfunction
- F&E Imbal-mag and K and clotting
- Renal Dysfunction
How quickly do you rewarm a patient after CABG?
1 degree/hr with bear hugger and watch BP
Describe off pump coronary artery by pass
- no bypass
- use meds to slow down the HR
- do bypass graph with slow heart
shorter recovery and less complications
Who can get a Pacemaker??
Person with brady or tachy HR
How does a pacemaker work?
it senses the ability of the heart to initiate an impuolse. If the intrinsic heart rate is not adequate the pacemaker will fire a pace
What is the result of the pacemaker firing a pace?
depolarization occur seen with a wide QRS....referred to as capture
Have a pacer...MRI or CT scan?
CT only....cuz MRI is with a magnet
Who gets an ICD?
- survivors of sudden cardiac arrest
- people with lethal dysrhtyhmias like V Tach or V Fib
What does an ICD do?
- it senses the patients HR and is able to:
What does the patient do if their ICD fires?
What does the patient do if they have an ICD and they lose consciousness?
- call 911
- defib with external paddles...but dont put pads over the ICD
How often does a person with an ICD get it checked?
q 2-3 months....can do it by phone
2 complications that occur 1 week after AMI
- Papillary muscle rupture
- Ventricular septal rupture
What happens with papillary muscle rupture?
this is what holds the valves, specifically mitral valve in place.
result is cardiogenic shock
What happens with ventricular septal rupture?
- bi-ventricular failure
- L>R shunting=
- chest pain
What causes increase in SVR?
What causes decrease in SVR?
What causes low SVO2?
- lung disease
What causes high SVO2?
Before giving morphine know your patients....
RR and BP
If a person has had nitro x3 and still has chest pain....what next?
IF a person took their nitro at home and they are still uncomfy I should....
- ask to see their bottle
- is it expired?
- is it dark?
- did it make his tongue tingle?
Interventions done by the EMS
When EMS is bringing a person in for chest pain and they run an EKG and dx of STEMI....then what?
- time of onset of symptoms is noted and first medical contact
- hospital alerts cath lab and cardio OR team
- fibrinolytics are considered
Person comes in to ED with chest pains....what happens?
- seen in less than 10min
- O2 sats
- IV access
- Focused history
- Labs-cardiac markers and electrolytes
Goal for time to get a chest x ray for a person who comes in with chest pains
Initial ED general treatment for chest pains
- O2 sat <94% give O2 @ 4L/min
Person comes in to ED with chest pains but have normal or non cardiogenic changes in ST segment or T wave....with no cardiac hx.
- Consider admission
- perform serial cardiac markers
- repeat EKG
Person who came in with chest pains but had normal EKG...but turns to having a bad EKG or troponin is elevated.
consider BB, Clopidogrel, and Glycoprotein III
admit to CICU
What do BB do for a person having a heart attack?
decreases the heart rate, which decreases the hearts O2 requirements
Person comes in to the hospital with chest pains, ST depression, T wave inversion....high risk unstable angina.
- consider BB, Clopidogrel and Glycoprotein III
- Admit to CICU
What do Clopidogrel and Glycoprotein do?
cause platelet inhibition....so platelets cant form and get stuck in an atherosclerotic spot
Person comes in to the ED with STEMI or new BBB (seen as a wide QRS).
Goal time for balloon inflation?
- balloon 90 minutes
- fibrinolysis 30 min
Unstable angina gets
possible PCI....NO thrombolytics
What's the goal of reperfusion?
reestablish blood flow within 90 minutes
Person that has pulmonary edema will look like this
- that look of terror
- feet dangling over the bed-decreases pre load
- increase HR and RR
How does CHF occur?
LV fails causing alveoli to get filled with crackles
How does Pulmonary edema occur?
after HF the lungs alveoli are filled with fluid causing dyspnes, orthopnea, decreased sats....all leading to decreased CO.....causing cardiogenic SHOCK
Goals for pulmonary edema
- increase ventricular function
- decrease pre load
- decrease after load
- Improve gas exchange
- increase CO with dopamine
- give morphine
Sign of CHF
gain more than 3lbs in 48 hours
or 3-5 lbs over a week
How do you distinguish MI from pericarditis?
pericarditis will have inflammation markers
increased ESR, C reactive proteins
Will hear pericardial friction rub
How will you dx pericarditis?
Echo....or chest x ray
Treatment for pericarditis
- treat the pain
- raise HOB to 45
- provide over bed table for support
Complication from pericarditis...describe dx
cardiac tamponade...increase in IVC/SVC pressure. Decreased SV and pt is hypotensive and tachy....decreased CO
Beck's Triad seen in cardiac tamponade
- muffled heart sounds
- paridoxical pulse-SBP increase 10-15 on expiration
Result of rheumatic heart disease
valve dysfunction....causing it to be replaced
S/S or aortic aneurysm
chest or back pain
What is the goal of care for aortic aneurysm?
prevention of rupturing
Goal of treatment for CHF
improve ventricular function
decrease fluid volume.....and pre load
cause vasidilation....decrease preload and afterload
decrease contractility by decreasing HR and after load
increase contractility and CO
How much sodium with HF?
If a person has cardiogenic shock what needs to be done? How?
- dilate coronaries with CCV
- improve contractility with Dopa
- reduce pre load with morphine, nitro, lasix
- reduce afterload with nitro
What is Intra-aortic balloon pump used for?
- person with cardiogenic shock...improves myocardial perfusion
- reduces afterload
- facilitates emptying of the LV
What is the LVAD used for?
a bridge to cardiac transplant
no real pulse
What puts a person on transplant list?
If a person has cardiogenic shock we look at BP to determine what is given
70-100 w/shock signs
70-100 w/out shock signs
- 70-100 w/shock=Dopamine
- 70-100 w/out shock=dobutamine
Who is most likely to have heart disease
african americans and native amerians
Nutritional considerations for people with heart disease
- <10% saturated fat
- <30% of total calories from fat
- <200mg cholesterol/day
- <2g sodium/day
- 50-60% carbs in diet
- 15% protein in diet
- 20-30g fiber/day
- anything with a pine and
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