Med-surg 207 Exam 2

Cardiac Diagnostic Testing

Basic Cardiac Anatomy

Four chambers: right/left atrium, right/left ventricle
Valves: tricuspid, pulmonic, mitral, aortic
Septum separates right and left sides

Blood flow through the heart

1. Deoxygenated blood enters right atrium and goes to the right ventricle

2. Through the pulmonary artery to lungs

3. Pulmonary vein to left atrium to left ventricle

4. Through the aorta to the body

Arteries vs veins

arteries carry blood away from the heart (oxygenated)

veins carry blood to the heart (deoxygenated)

Coronary circulation

coronary arteries supply oxygen to the heart muscle
blockage can cause ischemia or infarction
main arteries: left main, LAD, circumflex, RCA

Vasoconstriction

Narrowing of blood vessels
Causes: cold, stress, nicotine, certain medications (vasopressors)

Vasodilation

Widening of blood vessels
Causes: heat, exercise, alcohol, certain meds (nitrates)

Cardiac Diagnostic Labs

Troponin

• #1 blood test

• Most sensitive indicator of myocardial damage

• Differentiates cardiac vs non-cardiac chest pain

• Increase 4-6 hours after MI, peaks in 10-24 hours, returns to baseline in 10-14 days

• Blood draw- 3 sets, 3-6 hours apart

CK-MB

• Increase 6 hours after MI, peaks in 18 hours, returns in 24-36 hours

• “Historically important”

• Not as specific as troponin

C Reactive Protein (CRP)

• Indicates inflammatory illness

• Fairly nonspecific

• More sensitive and rapidly responding than ESR

• Peaks in 18-72 hours; failure to normalize may indicate ongoing damage to heart muscle

• Not elevated with angina

• Useful in monitoring acute inflammation

Erythrocyte Sedimentation Rate (ESR)

• Nonspecific indicator of acute or chronic infection, inflammation, tissue infarction

• Useful in monitoring chronic inflammation

BNP

• Main source is cardiac ventricle

• Aids in distinguishing cardiac vs respiratory cause of dyspnea

• Seen often in CHF exacerbations

Pro-BNP

More specific to left ventricular dysfunction

Serum Lipid Panels

Looks at the levels for certain lipids
- Cholesterol (150-200mg/dL)
- Triglycerides (40-150 mg/dL)
- Lipoproteins (LDL <100 mg/dL and HDL >40-50 mg/dL)

Noninvasive Procedures & CV Disease

EKG/ECG- 12 lead provides information about the electrical conduction of the heart
Holter Monitor: Outpatient monitor is usually worn for 24 hours, used to diagnose atrial fib, reasons for fainting or tachycardia
Exercise Stress/Treadmill test: evaluates the hearts response to exercise, can unmask symptoms of CAD or dysrhythmias
Echocardiogram: Uses sound waves to create a moving picture of the heart, evaluates valves and chambers, measures ejection fraction

Ejection Fraction

Amount of blood pumped out of the left ventricle with each contraction
Indication of the effectiveness of the heart pump
Normal values are 55-70%
Low values under 40% seen with HF

Bubble Study

Done during an ECHO
RN may assist with injection of NS bubbles
Fluid/bubbles circulate up to the right side of the heart and shows up on the echocardiogram image
If there is a tiny opening between heart’s upper chambers (right and left atria), some bubbles will move through that hole and appear on the left side of the heart (patent foramen ovale)

TEE (trans-esophageal ECHO) *invasive

• A probe with an ultrasound transducer is placed down the throat with the end near the heart. This provides improves pictures to be taken

• Done in vascular lab

• Requires an IV, local anesthetic or conscious sedation

• NPO for solid food 6 hours before the test

• Dentures must be removed

• NPO until gag reflex returns

• Temporary sore throat common

Arterial Disorders: Diagnostic tests

Contrast Angiography

• Radiopaque contrast medium injection

• Series of x-rays taken

• Nursing care:

  • Check for iodine allergy

  • Patient teaching: invasive, cannulate vessel

  • Check for extremity for perfusion s/p procedure

CT Angiography

Contrast (dye) is injected & multilayer pictures are taken of vessels
3-dimensional (pictures of blood vessels)

MR Angiography

• Magnetic resonance

• Difference: It does not depend on radiation

• Dye used is not iodine

Duplex/Doppler Ultrasound

• Combines doppler flow & conventional imaging information

  • measures speed of flow through vessels

  • Measures diameter of vessel as well as degree of obstruction

• No prep/additional nursing care

• Determines degree of blood flow

Ankle Brachial Index

• ABIs: less than 0.9 can indicate PAD

• Compares the pressure in the ankle to the pressure in the arms… a lower pressure indicates PAD

• Non-invasive

• Systolic readings

• Right ABI = Highest pressure in the right foot/(divided by)highest pressure in both arms

• Systolic pressure over brachial systolic pressure

Hypertension & Hyperlipidemia

Hypertension

• persistent elevation of SBP >130 or DBP >80

• Classified as primary (essential) or secondary (due to underlying cause)

• Stages: normal, elevated, stage 1, stage 2, crisis

Pathophysiology

• BP=CO x SVR

• Genetic and environmental factors

• Key systems: SNS, RAAS, endothelial function

Risk factors

Non-modifiable: age, gender, race, family history
Modifiable: diet, activity, alcohol, smoking, obesity
Stress and socioeconomic status can also contribute

Nursing Assessment of hypertension

• Silent killer

• Headache

• Blurry vision

• Chest pain

• Nose bleeds

• Ringing in the ears

• Dizzy

Complications to taking blood pressure

• Cardiac system: congestive heart failure (heart muscle becomes enlarged from overworking)

• Brain: stroke (increase pressure weakens blood vessels which can cause a clot to form or for them to rupture)

• Kidneys: renal failure (weakens and narrows the arteries which impairs proper perfusion)

• Eyes: visual changes

• Urogenital: erectile dysfunction

Lifestyle modifications

• Weight loss

• DASH diet

• Sodium restriction

• Moderation of alcohol

• Physical activity

• Smoking cessation

Medications

• First line: thiazide diuretics, ACEs, ARBs, CCBs

• Monitor side effects

• May cause orthostatic hypotension

Hypertensive Crisis

Urgency: no target organ damage; treat with oral meds
Emergency: organ damage; IV antihypertensives

Patient Education

• Self-monitoring and medication adherence

• Understanding side effects

• Lifelong commitment to management

Nursing Interventions for hypertension

• Measure blood pressure in both arms, resting position for 5 minutes

• Ask about family history

• Any sensory changes

• Evaluate blood pressure reading, dietary intake, body mass index

• Educate on DASH diet, limiting sodium, alcohol, caffeine, quit smoking, importance of medication compliance, measure blood pressure regularly

Hyperlipidemia

• Elevated levels of lipids in the blood (cholesterol and triglycerides)

• Major risk factor for atherosclerosis and cardiovascular disease

• Often coexists with hypertension

Pathophysiology

• LDL: bad cholesterol; contributes to plaque buildup

• HDL: good cholesterol; helps remove LDL

• Elevated triglycerides also contribute to CV risk

Risk factors

• Genetic predisposition

• Diet high in saturated fats and cholesterol

• Obesity, sedentary lifestyle, smoking, diabetes

Treatment

• Lifestyle: diet, exercise, weight loss

• Drug therapy: statins, ezetimibe, PCSK9 inhibitors

• Goals: lower LDL, raise HDL, reduce triglycerides

Nursing responsibilities

• Assess lipid levels and cardiovascular risk

• Monitor for medication side effects (statins: myopathy, liver enzymes)

• Educate on diet, exercise, and adherence to therapy

• Encourage routine lipid screening

Vascular & Inflammatory

Vascular

Arterial Risk factors and types of disease

• Risk factors: smoking, high cholesterol, DM type 2, uncontrolled HTN

• Types of disease: atherosclerosis, reynauds disease, buergers disease

Venous risk factors and types of disease

• Risk factors: being cisgender female & using birth control, pregnancy, obesity, sitting or standing for too long, advanced age

• Types of disease: varicose veins, venous insufficiency, DVT

Signs and symptoms of arterial

• Dangling the legs down helps with the pain

• Sharp pain

• Cool, thin, dry, scaly skin, thick toenails

• very poor or absent pulse

• no edema

• location end of toes, top of feet, lateral ankle region

• Appearance is very little drainage, little tissue granulation

Venous signs and symptoms

• Elevation of the legs decreases swelling and helps with blood flow

• Heavy, dull, throbbing, achy pain

• Pain gets worse when standing for long periods

• Warm, thick, tough skin, brownish color

• Pulse is present and normal

• Edema at the end of the day

• Location is medial parts of lower legs

• Appearance: swollen with drainage, granulation present, edges are irregular

Nursing care: peripheral arterial disease

• Assessments: pulses, color, temperature, doppler pulses, pain level, sensation, ABI testing

• Interventions: avoid constrictive clothing, foot wear, quit smoking, avoid knee-flex position or crossing the legs

• Take antiplatelet or anticoagulants, medications lower cholesterol and low fat diet

• Heparin drips

• percutaneous transluminal angioplasty with or without stent

Nursing care: venous disease

• Assessment: pulses, color, temperature, pain level, sensation, wound assessment

• Preventing venous stasis: elevate lower extremities above heart level throughout the day, wear elastic compression stockings

• Wound care: assess for infection

• Avoiding/treating clots:

  • red, swollen, painful, warm area

  • danger signs: dyspnea, chest pain, increased respirations, decrease o2 sat

• Treatment blood thinners (heparin, warfarin)

• Preventing infection: monitor CBC (WBC), wound site, proper wound care, antibiotics

Reynaud’s Disease

• Vasospasm of peripheral arteries mainly to the fingers and toes

• The fingers or toes start to feel numb or tingle and turn white or bluish

• When the cold or stress is removed they turn red

• Treatment: calcium channel blockers, avoidance of triggers (cold)

Buerger’s Disease

• Blood vessels swell, which prevent blood flow, causing clots to form

• Can lead to pain, tissue damage, and even gangrene

• Amputation may be required

• Smoking strongly linked

• Treatment: tobacco abstinence, wound care

Inflammatory

Pericarditis

• Definition: Inflammation of the pericardium layer of the heart

• Causes:

  • illness (viral, bacterial)

  • Trauma: heart attack, heart surgery, physical injury

  • Autoimmune: body causes it

  • Unknown: idiopathic

• Types of pericarditis

  • Acute: last for less than 6 weeks (most common)

  • Chronic: happens over time and lasts a long time (6 months)

• Labs: increase WBC, ESR, CRP

Pericarditis signs and symptoms

Friction rub/ fever
Radiating substernal pain to left shoulder, neck, or back
Increased pain when supine position
Chest pain that is stabbing
Trouble breathing when supine
Inspiration or coughing makes pain worse
Overall feels very sick and weak
Noticeable ST segment elevation

Potential complications

Pericardial effusion
Build up of fluid in pericardium, may have cough, tachypnea, dyspnea, distant/muffled heart sounds, can lead to cardiac tamponade

Pericarditis nursing care

• Bedrest with HOB 45 degrees; anxiety reduction

• Antibiotics if bacterial

• NSAIDS to treat inflammation

  • naproxen

  • high dose ibuprofen

  • Colchicine for recurrent pericarditis

• Prednisone taper

• Pericardiocentesis

Endocarditis

• Definition: inflammation of the endocardium layer of the heart

• Endocarditis mainly affects the heart valves but it can affect the circulation of blood

• interventricular septum: this seperates the right and left ventricles (perforation)

• chordae tendineae: fibrous cords of tendons that connect papillary muscle to the tricuspid and bicuspid valves (rupture)

Causes of endocarditis

Acute infective: affects patients who have healthy heart valves (high death rates). The onset is fast and symptoms are very severe

Subacute infective: affects people who have a pre-exisiting condition like rheumatic heart disease, valve problem. The symptoms are subtle and onset slower (several weeks to month to develop)

Risk factors

Infective: bacteria, virus, or fungi gets into the bloodstream and grows on the valve
Patients at risk:

• history of mitral valve prolapse

• history of rheumatic heart disease

• history of IV drug use

• Invasive procedures: implanted device pacemaker, dental work surgery, central line placement

• Congenital heart defects

Signs and symptoms

Petechaie
Anorexia
Tired and weak
High fever & heart failure
Osler’s Nodes: tender, red lesions on the hands and feet
finGernail changes: splinter hemorrhages that are small, dark lines under the nails
Embolic events, Erythematous, non-tender nodular lesions on the palms or soles of feet
Night sweats, new cardiac heart murmur or worsening of one
Splenomegaly/ roth Spots

Nursing Care

Monitor:

• Embolic episodes of the spleen, renal, brain, pulmonary status

  • Spleen embolic: radiating abdominal pain that goes to the left shoulder

  • Renal: flank pain in the groin with possible pus or blood in the urine

  • Brain: changes in neuro status: confusion, speech difficulty

  • Pulmonary: chest pain, SOB, dyspnea, decreased O2 sat

• Signs and symptoms of CHF

• Monitor vital signs especially temperature, heart rate, blood pressure, O2 sat

Nursing Interventions

• Collecting blood cultures

• Administration of IV antibiotics

  • usually need a central line because patient will be on long term and go home on the antibiotics

  • up to 4-8 weeks

Patient Education

• Who should get prophylactic treatment

  • Prosthetic heart valve

  • History of IE

  • Congenital heart disease

  • Heart transplant patients

• How to take or administer antibiotics

• monitor central line site and how to care for it

• good oral care

• relapse counseling/chemical abuse counseling

Obesity

Epidemiology

• About 40% of adults in the US

• 1 in 10 children become obese as early as ages 2-5

• Highest in the south, among blacks and hispanics, among lower income and less educated

Etiology and Pathophysiology

• The processes leading to and sustaining obese state are complex

  • Body weight beyond physical requirements

  • Abnormal increase and accumulation of fat cells

• Increase in number (hyperplasia) and size (hypertrophy) of adipocytes

  • large increases in lipid storage

  • Preadipocytes are triggered to become adipocytes once storage of exisiting fat cells is exceeded

Classification of Body Weight and Obesity

• Primary obesity

  • Excess caloric intake for body’s metabolic demands

• Secondary obesity

  • Chromosomal and congenital anomalies

  • Metabolic problems

  • CNS lesions and disorders

  • Drugs (corticosteroids, antipsychotics)

• Patient Assessment

  • BMI

  • Waist circumference

  • waist to hip ratio

  • body shape

Genetic/Biologic Basis

• Strong evidence of significant genetic/biologic susceptibility factors that are highly influenced by environmental and psychosocial factors

  • Factors can be considered individually but in reality, they are interrelated

• Research has identified several genes linked to obesity

  • Energy thrifty genes

  • Strong link between FTO gene and BMI

    • People with a certain allele at the FTO gene appear to have an increased appetite, reduced satiety, and higher calorie intake

Physiologic Regulatory Mechanisms

• Research focused on processes that control

  • Eating behavior

  • Energy metabolism

  • Body fat metabolism

Hormones and Peptides that interact with hypothalamus

Adipocytes, pancreas, stomach, colon, small intestine

Physiologic Regulatory Mechanisms

Leptin: suppresses appetite, increases fat metabolism

Ghrelin: regulates appetite by inhibiting leptin, thought to play a part in compulsive eating

Physiologic Regulatory Mechanisms

• Two major consequences of obesity are due to

  • Increase in fat mass

  • Production of adipokines

  • Contribute to insulin resistance, dyslipidemia, and hypertension

  • May disrupt immune factors and predispose to certain cancers

Environmental Factors

• Greater access to food with poor nutritional quality

• Common to underestimate food and caloric intake

• Lack of physical exercise

• Low socioeconomic status

Psychosocial factors

• People use food for many reasons

  • Associations begin in childhood

  • Sense of satiety can be altered

  • Mindless eating

  • Eating is social and often associated with pleasure and fun

Health risks Associated with Obesity

• Health problems occur at higher rates among the obese

  • Increased mortality, especially with increased visceral fat

  • Reduced quality of life

• Most conditions can improve with weight loss

Health risks of Obesity

• Cardiovascular disease

• Diabetes

• GI and liver problems

• Respiratory and sleep problems

• Musculoskeletal problems

• Cancer

• Psychosocial problems

Therapies

• Nutritional therapy

• Exercise

• Behavior modification

• Support groups

• Drug therapy

• Surgery

Drug therapy

• orlistat

  • MOA: blocks fat breakdown and absorption in intestine

  • Inhibits the action of intestinal lipases, resulting in undigested fat excreted in feces

• locaserin

  • selective serotonin agonist

  • suppresses appetite and creates a sense of satiety

• bupropion/naltrexone

  • bupropion is an antidepressant

  • naltrexone is an opioid antagonist

• phenteramine

  • sympathomimetic anorectic

• topiramate

  • antiseizure drug that induces satiety

• liraglutide

  • glucagon-like peptide 1 agonist

  • induces satiety

Bariatric surgery

• Viable option for treating obesity

• Currently only treatment found to have a successful and lasting impact on sustained weight loss for those with extreme obesity

• Criteria for surgery

  • BMI >40mg/m

  • BMI >35mg/m with significant comorbidities

    • Hypertension, type 2 diabetes, heart failure, sleep apnea

• Must be screened for

  • psychologic, physical, and behavioral conditions that have been associated with poor surgical outcomes

  • Illnesses known to reduce life expectancy are not likely to be improved with weight reduction

Restrictive bariatric surgery

• Adjustable gastric banding

  • Limits stomach size with an inflatable band around the fundus of the stomach

    • Connected to a subcutaneous port for adjustments.

    • Band creates sense of fullness

Sleeve Gastrectomy

• 75% of the stomach is removed

  • not reversible

  • Stomach function is preserved

  • Results in elimination of hormones produced in the stomach that stimulate hunger

    • Ghrelin

Combination of Restrictive and Malabsorptive surgery

• Roux-en-Y surgical procedure- gold standard

  • Has low complication rates

  • Excellent patient tolerance

  • Food bypasses 90% of the stomach, duodenum, and a small segment of jejunum

• Dumping syndrome is a complication of the RYGB

  • gastic contents empty too rapidly into small intestine

  • Avoidance of sugary foods is recommended

Maestro Rechargeable System

• Pacemaker-like electrical pulse generator, wire leads, and electrodes implanted in abdomen

  • Sends intermittent electrical pulses to vagus nerve to regulate emptying and signaling feelings of emptiness or fullness to the brain

Metabolic Syndrome

• Group risk factors that increase a person’s chance of developing cardiovascular disease, stroke and diabetes

  • more prevalent in those 60 years of age and older

• Active treatment for

  • triglycerides greater than 150mg/dL

  • HDL cholesterol less than 40 (men) or 50 (women)

  • Blood pressure greater than or equal to 130 systolic and 85 diastolic

  • Fasting glucose greater than or equal to 100 mg/dL

• Etiology and Pathophysiology

  • Insulin resistance related to excessive visceral fat

  • Increased prevalence of coronary artery disease

    • Hypertension

    • Increased risk for clotting

    • Abnormal cholesterol levels