Exam II (Cardiac Structural & Inflammatory Disease)

what is preload

amount of stretch at the end of diastole in ventricles (stretch = pressure)

what conditions can lead to less volume

hypovolemia, dehydration, bleeding out

what is cardiac output (and what is the normal)

volume of blood ejected per heartbeat ; end of ventricular diastole

--> 4-8 L/min or 100%

what is afterload

how hard the heart must squeeze to pump blood

what can increase and decrease afterload

increase: CAD, HTN

decrease: cardiac meds (beta-blockers, antihypertensives, etc)

what is the electrical conduction for the heart

SA node , AV node, Bundle of His, Purkinje Fibers

what are common diagnostic exams for functional/structural heart issues

BP, cholesterol levels, echocardiogram, stress test

what do we check with BP

if its hyper/hypo (HTN = "silent killer" and hypo: lightheaded, dizzy, vision changes, decreased perfusion) --> orthostatic BP important!

which organ is affected by HTN/hypoTN the quickest

KIDNEYS; check BUN and creatinine

what are we looking for with cholesterol (and the different types)

high = plaque build up ; LDL (loser/bad), HDL (happy/good), triglycerides (can indicate fatty liver disease; produced in liver)

what does hypercholesterolemia and total cholesterol mean

hypercholesterolemia: high cholesterol levels in the blood

total cholesterol: all cholesterol levels together

- can indicate risk for cardiovascular disease

- high cholesterol in arteries = artery narrowing = increased pressure

what are the two types of echocardiogram

transesophageal (TEE) and transthoracic (TTE)

- TTE = commonly called "echo"

what are the two types of stress test

exercise (treadmill)

nuclear (given med that mimic exercise on treadmill)

- nuclear is done if pt cannot or unsafe to exercise

- anything weird on EKG = STOP

what diagnostic test do we do for the conductive part of heart

electrocardiogram (EKG - ECG): typically 12-lead

telemetry: continuous monitoring; usually

what is the patho of coronary artery disease (CAD)

patho: atherosclerotic plaque build up in the coronary arteries

- leads to atherosclerosis (hardening of BV)

- increase risk for thrombus

what is the etiology of CAD

modifiable: cholesterol lvls, BP management, smoking, weight management

non-modifiable: age, gender, race, genetics

what medications do CAD people take (SE, medication administration, cautions)

STATINS (decrease cholesterol levels)

SE: rhabdo!! (muscle pain = early sign)

MA: given at night

cautions: do not drink alcohol, check liver labs

what other heart issue does CAD cause

Acute Coronary Syndrome (ACS)

how does CAD cause ACS

CAD = narrowing of arteries ; this leads to lack of nutrients to coronary arteries

- lack of nutrients to coronary arteries = prolonged ischemia (cardiac tissue death)

- chest pain = tissue death!!

what is unstable and stable angina

stable angina: chest pain that is relieved w/ rest and/ or nitro

unstable angina: not relieved with rest or meds

what are the 3 types of ACS

unstable angina, NSTEMI, STEMI

what is the difference between NSTEMI and STEMI

NSTEMI: no ST elevation

STEMI: ST elevation

- both are deadly!

what are S/S of ACS (assessment)

chest pain! (OPQRST)

did meds help?

feeling of impending doom

diaphoresis/pale/cold/clammy

- atypical sx in women/elderly/diabetics

how do we treat all chest pain

as a cardiac issue until ruled out!

what test do we do for chest pain?

EKG AND TROPONIN!!

what are we looking for with EKG and troponin

EKG: ST elevation? (NSTEMI or STEMI)

Troponin: cardiac tissue death (will see elevation); determines if cardiac event is M.I or unstable angina

when can we give a thrombolytic for chest pain?

withing 1hr of sx onset; pretty uncommon!

what are the steps when someone comes in with chest pain

1. EKG and Troponin levels

(if both positive; cath lab or CABG or thrombolytic) and meds

2. if NO troponin elevation: recheck q3hrs

3. NO troponin elevation again: echo/stress testing

what is surgical management with a ACS

percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG)

What is PCI and nursing interventions after

Cath Lab; placing a stent or cleaning out arteries to restore blood flow (IV contrast used)

- PCI CANNOT be done for occulsions >90%

AFTER

- frequent groin checks (puncture site, bleeding?, pulses present?)

- leg immobilization after procedure

what does a unsuccessful PCI or multivessel disease mean

2-3 vessels are >50% occluded and pt sees continuous chest pain unrelieved w/ meds --> treatment is now a CABG

what is a coronary artery bypass graft (CABG) and what is the prep for it?

restore BF by going around occluded artery

- surgical prep and chest tube prep

what is post CABG care

use a pillow against their chest to help splint their incision

lifitng restrictions (<10-15lbs for 6-8 weeks)

encourage resp. exercise (IS, deep breathing, cough)

monitor incision site

cardiac rehab (diet, PT, specialized care)

what are complications of ACS/ ACS interventions

reperfusion dysrhythmias (most common)

heart failure

cardiogenic shock

pericarditis

what are medications used for ACS

nitro, aspirin, oxygen, morphine, beta blockers

what is the goal of nitroglycerin and what to monitor

vasodilater; (topical, SL, IV) wants to increase BF to ischemic areas of the heart

monitor: decrease in BP (increased HR in response), HA, dizziness

given q5mins for 3x; do NOT give if sys BP is <90

what is the goal of aspirin and what to monitor

anticoagulant (may use more than 1 agent)

goal: decrease platelet activation, decrease stickiness to prevent clotting

monitor: increased bleeding

what is the goal for oxygen and what to monitor

goal: increase O2 to heart muscle to decrease ischemic injury

monitor: respiratory status

what is the goal of morphine and what to monitor

goal: decrease pain, decrease anxiety, and decrease O2 demand on the heart

monitor: decreased HR, decrease BP, nausea, and resp. depression

what is the goal of beta-blockers and what to monitor

goal: decrease myocardial O2 demand by slowing down HR; prevents Vtach

monitor: decrease HR, dizziness

what are the inflammatory heart disease

acute pericarditis, infective endocarditis

what is the patho of acute pericarditis

many different reasons; idiopathic (pericardial effusion) /infective/acute M.I/CA/trauma

what is the etiology of acute pericarditis

inflammation of the pericardial sac --> results in the collection of fluid

- leads to increased external pressure on the heart and decreased CO

what are the S/S of acute pericarditis

weak pulses, distant heart sounds, friction rub, JVD, SOB

how can we differentiate chest pain between acute pericarditis verus other cardiac issue?

1. obv EKG and troponin... BUT;

changing positions (specifically fowler's and leaning over a bedside table) these two will help decrease CP in those with pericarditis

how do we diagnosis acute pericarditis

echocardiogram (TEE/TTE)

pericardiocentesis: used for fluid analysis (infection?)

how do we medically treat acute pericarditis

medical management: ABX, steroid (anti-inflammatory)

surgical management: pericardiocentesis (receive pressure off heart), surgical window (opening incase for re-accumulation)

what is a HUGH complication of pericarditis

cardiac tamponade; too much fluid putting extensive pressure on the heart

what are the S/S of cardiac tamponade

BECKS TRIAD: hypoTN, JVD, muffled heart sounds

other: CP, palpitations, SOB

how do we treat cardiac tamponade

manage sx; need a surgical solution (pericardiocentesis/pericardial window)

- watch for re-accumulation! (friction rub comes back)

what is the patho of infective endocarditis

stasis of BF in the heart allow for bacteria to settle on heart valves

- any damage to natural heart vavles or prosthetic put pt at higher risk for infection

what is the etiology of infective endocarditis

bacterial colonization on the heart valve; can be viral/bacterial/fungal

- bacterial MOST common (strep or staph)

- dental work

- IV drug use (MOST COMMON)

S/S of infective endocarditis

splinter hemorrhages in nails (swollen nodules on finger tips)

splenomegaly

Osler's Nodes

Janeway's lesions

flu like sx

heart murmur

how do we dx someone w/ infective endocarditis

blood cultures: need 2-3 (+) from 2-3 sites (can take a couple of days to come back)

Echo: looking for vegetation present

what is the medical management of infective endocarditis

pt w/ hx of it: prophylactic tx

Long-term ABX (via IV): 3-6 months

- usually go home w/ PICC line (unless known drug abuser)

- vancomycin ABX

what do you have to monitor with giving vancomycin

Liver and eyes (toxic!!)

red-man syndrome!

what are the surgical management for infective endocarditis

valve replacement (only AFTER ABX therapy)

what can be a complication of infective endocarditis

risk for embolism ! (bacterial growth broken off)

what are important patient teaching with infective endocarditis

ABX prior to dental or invasive procedure

no sharp objects in mouth

what is the patho of valvular heart diseases

abnormal thickening of valve: between atrium and L ventricle (MVP)

stenosis: narrowing

regurgitation: incomplete closure of valve

what is the most common valvular heart disease

mitral valve prolapse (MVP!!)

what is the etiology of valvular heart diseases

congenital or acquired

acquired: ENDOCARDITIS, rheumatic heart disease, calcification (aging))

what are the S/S of ONLY aortic valve stenosis

TRIAD: CP, syncope, dyspnea

what are GENERAL S/S of any valve disease

murmurs, SOB, crackles, mimicking heart failure (fluid overload - edema)

how do we dx valvular disease?

echo (TTE/TEE)

cardiac monitor (EKG, Tele, Holter = outpatient "tele")

what is the medical plan for valvular disease

diuretics (furosemide, spironolactone (watch for HYPERkalemia)

blood thinners (warfarin/rivaroxaban/apirxaban)

antihypertensives (beta-blockers)

what is the surgical plan for valvular disease

mitral valve repair (cords or leaflets)

valve replacement (mechanical, porcine/bovine, cadaver)

- mechanical valve needs lifetime anticoagulants

what is important teaching about valvular disease

dental safety (prophylactic ABX so no endocarditis)

anticoagulant therapy = long term (if mechanical)

what are post op instructions for AFTER valve replacements

monitor for S/S of infection

no lifting heavy objects

encourage periods of rest (decrease cardiac O2 demand)

ease circulation: supine position in bed (easier for blood flow through the heart)

what is our vascular disorder?

abdominal aortic aneurysm (AAA); dilation of arterial wall

- thoracic AA: 25%

abdominal AA: 75%

what causes AAA

atherosclerosis

smoking

HTN

HLD

!! trauma !!

AAA S/S

usually asymptomatic however...

severe lower back pain

"tearing sensation"

diminished/absent pedal pulses

what do you immediately do if you suspect a AAA or a ruptured one

check VS (BP) immediately! (HTN makes it worse!) and get to CT!!

what is the medical plan for AAA

un-ruptured: stent graft repair

ruptured: emergency surgical repair (clip)

- if ruptured 90% mortality rate

what is the nursing plan and evaluation for AAA

nursing plan: frequent VS, and CMS assessments. renal function monitoring and preparing for surgery

Evaluation: want strong peripheral pulses and UOP >30 ml/hr