Exam 1

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Exam 1
2011-08-24 18:01:53
Nursing CV System CAD ACS HF

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    • 1. P
    • 2. R
    • 3. T
    • 4. Q
    • 5. PR interval
    • 6. ST Segment
    • 7. S
    • 8. QT interval
    • 9. QRS interval
  1. Blood Flow through the heart
  2. Electrical Impulse Pathway
    • SA Node --> RA/LA --> AV Node--> Bundle of His----> Purkinje Fibers
    • 1. Right Coronary Artery
    • 2. Left Coronary Artery
    • 3. Circumflex Artery
    • 4. Left anterior descending artery or anterior interventricular artery
  3. Polarization
    • Resting membrane potential with no electrical activity
    • Myocardial cell is negatively charged
  4. Depolarization
    • SA Node is stimulated
    • Na+ enters and K+ leaves cardiac cell
    • Cell becomes positively charged
  5. Repolarization
    • Cardiac Muscle contracts
    • Na/Ca channels close and Na/K pumps open and cell goes back to resting potential
    • Ca and Na leave cell and K reenters (Polarization)
  6. Cardiac Output
    • Amount of blood the ventricles pump out in a minute (4-8 liters/min)
    • CO= SV x HR
  7. Factors affecting HR
    Autonomic Nervous System
  8. Factors affecting Stroke Volume
    • Preload
    • Contractility
    • Afterload
  9. Preload
    -Factors affecting preload
    • Volume of blood in the ventricles at the end of diastole
    • -Hydration increases preload
    • -Diuretics decrease
  10. Contractility
    -Factors affecting
    • Degree that the cardiac muscle contracts- increased contractility increases stroke volume
    • Epinephrine and norepinephrine increase
  11. Afterload
    -Affecting Factors
    • Amount of peripheral resistance that the LV must pump against
    • LV Size, LV wall tension, Arterial BP
    • Mital valve disease decreases afterload because some blood reurgitates bact into the RA so there is less resistance.
  12. BP Formula
    BP= CO x SVR (systemic vascular resistance)
  13. Pulse Pressure
    -Affecting Factors
    • SBP-DBP
    • Increased by exercise, atherosclerosis of large arteries
    • Decreased by heart failure or hypovolemia
  14. Mean Arterial Pressure (MAP)
    -Min requirement
    • Average pressure within the arterial system
    • MAP= (SBP+2DBP)/3
    • >60mmHg to perfuse and sustain vital organs
  15. Troponin
    -What abnormal value means
    • Enzyme associated with the heart used for diagnosing MI
    • -<0.03 ng/ml
    • -Increases 4-6 hours after MI
    • -More reliable because it peaks faster and stays at that level for 2 weeks
  16. CK-MB
    • Heart blood test
    • - 0-3ng/ml
    • -Increases after MI
    • -Returns to normal after 2-3 days
  17. BNP
    -Abnormal Value
    • Heart function blood test
    • - <100 pg/ml
    • - If > than 100 then Ventricular Heart Failure
  18. ANP
    -Abnormal Value
    • Heart function blood test
    • - 22-77 pg/ml
    • - if > than 77 then atrial heart failure
  19. C-Reactive Protein
    -Abnormal Value
    • Heart function blood test
    • - <1mg/dL
    • - if >3 then acute MI
  20. Homocysteine
    • -An end product of AA metabolism- can breakdown endothelial walls
    • - 3.7-12.9 micromole/L
    • - >13 means CAD
    • - detects CAD when lipids are normal
  21. Triglycerides
    • - <160 mg/dL
    • - >400 mg/dL = CAD
  22. Total cholesterol
    -Value and abnormal value
    LDL Value and abnormal value
    HDL Value and abnormal value
    • - <200 mg/dL if >200 = CAD
    • - <100mg/dL if >160 = CAD
    • - >40mg/dL if <40 = CAD
  23. Phospholipids
    131-276 ng/mL
  24. Hypokalemia
    -What it causes
    -ECG changes
    • -Ventricular Dysrhythmias (also increases digoxin toxicity) -weakens cardiac muscle by not allowing repolarization
    • - Flat or inverted T wave, ST depression
  25. Hyperkalemia
    -What it causes
    -ECG changes
    • - Ventricular dysrhythmias, asystole, causes decreased depolarization and early repolarization
    • -Tall peaked T waves, wide QRS, prolonged PR interval or flat P wave
  26. Hyponatremia
    -What causes it
    -What it indicates
    • Occurs with overuse of diuretics
    • May indicate water excess and HF
  27. Hypocalcemia
    -What it causes
    -ECG changes
    • - Ventricular dysrhythmias, cardiac arrest
    • -Prolonged ST
  28. Hypercalcemia
    -What it causes
    -ECG changes
    • - Tachy or Bradycardia, Cardiac arrest
    • -Wide T waves
  29. Hypomagnesium
    -What it causes
    -ECG changes
    • -Ventricular tachycardia, V-fibrillation
    • -Tall T wave with depressed ST
  30. Hypermagnesium
    -What it causes
    -ECG changes
    • -Muscle weakness, hypotension, bradycardia
    • -Prolonged PR interval, wide QRS
  31. Holter Monitor
    • Portable heart monitor.
    • Electrodes placed on chest and activity recorded for 24-48 hours
    • Have pt keep log of all activities
  32. Transthoracic Echocardiogram
    • TTE
    • Transducer placed on chest wall to assess heart valves, and degree of contraction
    • To diagnose Endocarditis, thrombus on valves, or disruption of prosthetic heart valves
    • -No lotions, oils or powders on chest area, (No dietary restrictions)
  33. Dobutamine Echocardiogram
    -Nursing considerations
    • Given for patients who cannot exercise.
    • Dobutamine IV drip increased every 5 minutes to mimic exercise by increasing BP and HR. Determines if the heart is getting enough O2 during activity.
    • -Pt must be NPO except for H2O 4 hr prior to test.
    • -No Smoking 4 hrs prior
    • -No lotions oils powders on chest
    • -Monitor VS before during and after
    • -Monitor for S/S of distress
  34. Transesophageal Echocardiogram
    -Nursing considerations
    • Ultrasound transducer is swallowed and better images are produced with the probe closer to the heart. Light sedation and anesthesia required
    • -NPO 6-8 hrs prior
    • -No smoking 6 hrs prior
    • -Remove dentures, use bite block
    • -Sedative and throat locally anesthetized
    • -Monitor VS, O2 Sat, prn suctioning
    • -After test do not feed until gag reflex returns- Start with a small sip of water
  35. Nuclear Cardiology
    -What test reveals
    -Nursing responisibilities
    • Radioactive isotopes are injected IV, Radioactive sensitive camera follows movement of isotopes similar to CT.
    • -Myocardial contractility; Myocardial perfusion; Acute cell injury; Arterial plaque build up
    • -Shellfish or iodine allergy?; During test pt must lie on back with arms overhead for 20 min. (Pain meds?) ; Scands are repeated minutes and hours after initial scan
  36. Magnetic Resonance Imaging
    -What it detects
    -Nursing Responisibilities
    • Multiple plane images
    • -Cardiac tissue integrity, aneurysms, ejection fraction, cardiac output, patency of coronary arteries
    • -No medical implants or jewelry allowed, give anti-anxiety meds if needed.
  37. Cardiac Catheterization
    -How to check left and right side
    -Nursing responsibilities during
    -Nursing responisibilities after
    • A catheter is advanced into the heart chambers to monitor pressures and release dyes.
    • -To check Right side catheter is inserted into femoral vein or cephalic vein in arm; to monitor left side catheter is placed in a femoral or brachial artery
    • -Written consent needed; iodine or shellfish allergy?; NPO 6-18 hrs prior; Pre-meds?; warn of hot flashes and fluttering sensation; have pt cough or deep breathe when insertion; monitor ECG;

    -Monitor VS, cath insertion site, pedal pulse on insertion side q15 min for an hour then q4hr til stable; do not allow pt to get OOB for 6hr post; check for bleeding; do not allow leg to bend post procedure for 6 hrs in case of thrombus risk.
  38. Coronary Angiography
    • Cardiac catheter that extends into coronary arteries.
    • -Dyes injected directly into coronary arteries
    • -Balloon angioplasty can be done during this time and a stent can be placed
  39. Stents
    Drug eluting stents
    Complications of stents
    • Devices used to expand coronary arteries where there are blockages. Glycoprotein inhibitor IV given to prevent closure of stent
    • Coated with paclitaxel to prevent overgrowth of the intimal
    • Stent closure, Vascular injury, MI, stent embolization
  40. Coronary artery disease
    -Potential complications
    • Blood vessel disorder mainly caused by atherosclerosis
    • -Chronic stable angina, acute coronary syndrome, sudden cardiac death
  41. Atherosclerosis
    Soft deposits of fat accumulated within the intimal wall of the artery that hardens with age... found primary in coronary arteries
  42. 3 Stages of CAD
    • Fatty Streak
    • Fibrous Plaque
    • Complicated Lesion
  43. Nitric Oxide
    • A naturally occurring vasodilator and anti-inflammatory produced by endothelium lining the arterial walls.
    • -Atherosclerosis prevents production.
  44. Fatty Streak
    • Injuries to endothelium (smoking, HTN, toxins) cause inflammation.
    • Monocytes turn into macrophages and go to injured site of arterial endothelium.
    • Macrophages ingest lipids and create Foam cells
    • An accumulation of lipids and foam cells creates a yellow tinged area in the muscle cell called a Fatty Streak
  45. Fibrous Plaque
    Smooth muscle cells and fibroblasts accumulate around fatty streak and encapsulate the lipids creating a Fibrous Plaque
  46. Complicated Lesion
    • If lipids and fibrous plaques increase the artery may become occluded and possibly rupture called a Complicated lesion (unstable plaque)
    • -May lead to thrombus formation
  47. Thrombus Formation in Atherosclerosis
    • If thrombus leaks into fibrous plaque- plaque growth will increase
    • If thrombus forms outside plaque- blood flow may be occluded or it may break off and become an emboli
  48. Statins
    • For high cholesterol
    • To be taken at night time
    • -Pravastatin, Simvastin
  49. Lipid Lowering Dietary Choices
    • Omega-3- reduce triglycerides
    • Nicain- Increase HDL
    • Soy and red yeast rice- Decrease LDL and total Chol
    • Garlic- decrease LDL and total Chol
  50. HDL/LDL
    • HDL is good- it carries lipids away from arteries to the liver for metabolism
    • LDL-bad- attracted to arterial walls
  51. Chronic Stable Angina
    • O2 demands of the heart are greater that the amound supplied by coronary arteries--> leads to myocardial ischemia---> angina (chest pain)
    • -Caused by athersclerosis (75% artery occluded)
    • -Emotional stress can increase demands by 25% too
    • Onset: exertion or emotional stress
  52. Result of Chronic Stable Angina
    • Within 10 seconds of occlusion contractility stops and anaerobic metabolism begins leading to lactic acid build up which causes pain to myocardial nerves and fibers and can cause pain in left shoulder and arm
    • Cardiac cells die in 20 minutes (irreversible) after occlusion so must treat/rest quickly.
    • 4-6 hours occlusion causes necrosis to entire thickness of mycocardium
  53. Description of Pain associated with Chronic Stable Angina
    • Intermittent pain over long period
    • Pattern of onset, duration, intensity
    • Feels like: pressure on chest, constrictive, squeezing, heavy, choking, burning sensation
    • Location: Substernal, neck, jaw, arms, shoulders, between shoulder blades
    • Duration: 5-15 minutes (shorter when rest or medicated)
  54. Treating Chronic Stable Angina
    • Rest
    • NTG- nitroglycerine
    • Since pain usually happens around same time take meds on regular schedule prior to pain onset
  55. Chronic Stable Angina ECG changes
    ST Depression and/or T wave inversion
  56. Silent Ischemia Chronic Stable Angina
    • No pain is felt.
    • Occurs in diabetics- neuropathy decrease pain sensaton
    • -Use a holter monitor to detect ischemia
  57. Nocturnal Angina
    • Occurs only at night
    • Not always when asleep or in recumbent position
  58. Angina Decubitus
    • Occurs when lying down
    • Pain is relieved by standing or sitting
  59. Prinzmetal's Angina
    • Occurs at Rest or REM sleep
    • Common in patients with Hx of migraines, raynauds phenomenon
    • CAD may not be present
    • Triggered by smoking, histamine, angiotension, ephinephhrine (Increased myocardial O2 demand)
    • Pain relieved by moderate exercise, or with drugs (Calcium channel blockers, nitrates)
  60. Prinzmetal's Angina ECG Changes
    ST elevation
  61. Percutaneous Coronary Intervention
    • Coronary angiography with ballod angioplasty/stents
    • -Not for patients with three vessel CAD or left main CAD
  62. Chronic Stable Angina Drugs
    • Beta-adrenergic blockers- Decreases HR, BP and Contractility
    • Calcium Channel Blocker-HR and BP control, decreases coronary artery spasms
    • Ace inhibitors- Arterial vasodilation, Decrease BP, afterload, and myocardiac O2 consumption
  63. Acute Coronary Syndrome
    • Includes- Unstable Angina, Non-ST elevation myocardial infarction (NSTEMI), ST elevation myocardial infarction (STEMI)
    • Plaque Ruptures --> blood and platelet aggregate --> thrombus (complicated lesions)--> prolonged ischemia--> irreversible damage
  64. Unstable Angina
    -ECG changes
    • Sudden intense chest pain that worsens within hours to weeks.
    • Requires immediate attention
    • Onset: at rest or minimal activity
  65. Unstable Angina Symptoms
    • Pain Unrelieved by rest or NTG
    • N/V
    • Cold Sweat
    • Sudden SOB (no chest pain for >65 yo)
    • Fever
    • Initial Increased BP and HR, then decreased due to decreased CO
    • Women have prodromal symptoms- Fatigue, SOB, idigestion, anxiety
  66. Myocardial Infarction
    • Sustained Ischemia--> irreversible myocardial cell death
    • -Usually involves LV myocardial cell death after 20 min of ischemia. 4-6 hrs of ischemia= heart muscle necrosis
    • -Onset: any time. More common in morning
  67. MI Pain
    • Severe, Immobilizing pain
    • Not relieved by rest, change of position, or NTG
    • -Described as- persistent, heaviness, pressure, tightness, burning, constriction, crushing.
    • -Those who don't feel pain c/o discomfort, weakness, SOB
    • -Diabetics have silent MI (neuropathy)
    • Pain Location- substernal, retrosternal, epigastric, radiates to jaw, neck, back, arms
  68. MI Symptoms
    • 100.4 temp first 24 hrs after MI (can last a week)
    • Skin-ashen, cold, clammy
    • Increased BP and HR then drop due to low CO
    • Decreased Urine output (low CO)
    • SOB
    • Epigastric discomfort
    • Possible N/V
    • Diaphoresis
    • Syncope (fainiting)
    • ALOC
    • Crackles and ronchi
    • Peripheral Edema
    • Jugular Vein distention
    • RV dysfunction
    • Pulmonary edema