ADH Exam 2

gold standard testing for PAD

invasive digital angiography

primary cause of PAD

atherosclerosis

risk factors of PAD

smoking, diabetes, obesity, HTN, high cholesterol, increased age, family hx

s/s of PAD

painful cramping in legs after activity, leg numbness or weakness, coldness, sores on legs, delayed wound healing, hair loss on legs, shiny skin, no pulse or weak pulse

management of PAD

reduction of modifiable risk factors, walk through the pain, arterial bypass

cilostazol

cilostazol

medication for intermittent claudication

vasodilates and interferes with platelet aggregation

PAD

inadequate blood flow to the extremities → deprives the extremities of oxygen and nutrition

angina pain

chronic anginal pain does not change with positioning or breathing and is rarely described as sharp or stabbing

precipitating factors of angina

physical exertion, strong emotions, extreme temperatures, tobacco use, sexual activity, stimulants

silent ischemia

absence os any symptoms, increased prevalence in patient’s with diabetes because of neuropathy, confirmed by ECG changes

Prinzetal’s (variant) angina

rare, occurs at rest, pain can occur during REM sleep

pain can be relieved by moderate exercise, SL nitro, or it can disappear on its own

microvascular angina

AKA syndrome X

pain occurs in the absence of CAD, more common in postmenopausal women, pain is brought on my physical exertion, inconsistent response to nitrates

sl ntg administration

every 5 minutes up to 3 times

sit down and place the ntg tablet under the tongue and allow it to dissolve, it should cause a tingling sensation when administered

sl ntg patient teaching

should always be easily accessible, store away from light and heat

once opened, they should be replaced every 6 months

nursing priotity actions for angina

position pt upright and apply supplemental oxygen

assess vitals

obtain 12-lead ECG

provide pain relief - ntg followed by an opioid if needed

assess heart and breath sounds

stages of CAD

fatty streak

fibrous plaque

complicated lesions

non-modifiable risk factors of CAD

age, male, african american, native american, family hx, genetic predispositions

modifiable risk factors of CAD

elevated BP, tobacco use, physical inactivity, obesity, diabetes, metabolic syndrome, elevated cholesterol

mitral stenosis

blocks blood flow from the left atrium to the left ventricle is impaired

s/s of mitral stenosis

a-fib, exertion dyspnea, loud S1, murmur, fatigue, palpitations, hoarsness, chest pain

mitral valve prolapse (MVP)

leaflets bulge back into the left atrium

s/s of mitral valve prolapse

most are asymptomatic

murmur, dysthymia

mitral regurgitation

backward flow of blood from the left ventricle to the left atrium

acute MR

occurs when the papillary muscle ruptures after an MI, IE, or trauma

cardiac emergency

s/s of acute MR

severe SOB, pallor, crackles, hypotension, peripheral edema, JVD, ascites, poor tissue diffusion

s/s of chronic MR

ventricular hypertrophy

weakness, fatigue, palpitations, progressive dyspnea, pallor, peripheral edema, DOE, PND

aortic stenosis

obstruction of flow from the left ventricle to the aorta

LV hypertrophy

causes of aortic stenosis

congenital, degenerative, RF

s/s of aortic stenosis

angina, dyspnea, syncope, HF

aortic regurgitation

backward flow of blood into the left ventricle from the aorta

causes of aortic regurgitation

RF, congenital, syphilis

s/s of aortic regurgitation

decreased exercise tolerance, CHF, angina, dizziness, palpitations, water hammer pulse, murmur, PND

tricuspid stenosis

decreased blood flow between the right atrium and right ventricle

right ventricle hypertrophy

causes of tricuspid stenosis

RF and IVDA

s/s of tricuspid stenosis

peripheral edema, ascites, hepatomegaly, murmur

pulmonary stenosis

blocks blood flow from the right ventricle to the pulmonary vein

valvuloplasty

repair of the cardiac valve

can be done percutaneously or surgically

prosthetic valve replacement

done when valve repair is not an option

mechanical valve

require lifelong anticoagulation therapy due to high thrombus risk

lasts longer

tissue valve

less durable

anticoagulation therapy for the first 3 months

septal defects

causes oxygenated blood to be shunted from the left side of the heart to the right side

cardiomyopathy

a disorder of the heart muscle associated with mechanical and/or electrical dysfunction

all types result in impaired CO

dilated cardiomyopathy

irreversible dilation of the ventricles without hypertrophy

common cause of HF and heart transplant

floppy heart

s/s of heart failure

dyspnea, fatigue, weight gain, volume overload, arrhythmias, PND, orthopnea

causes of DCM

alcohol, cocaine, CAD, genetic, HTN, metabolic disorders, muscular dystrophy, myocarditis, pregnancy, valve disease

hypertrophic cardiomyopathy

hypertrophied, non dilated left ventricle that leads to obstruction of left ventricular outflow

inherited

most common cause of sudden death in young athletes

enlarged, thickened heart

s/s of HCM

usually asymptomatic

dyspnea, chest pain, fatigue, palpitations, dizziness, pre-syncope, syncope, sudden death

restrictive cardiomyopahty

diastolic dysfunction and impaired ventricular fulling

can occur after a heart transplant

stiff, rigid heart

s/s of RCM

dyspnea, orthopnea, nonproductive cough, chest pain, peripheral edema, fatigue, hepatomegaly, JVD, weight gain

arrhythmogenic right ventricular cardiomyopathy (ARVC)

disease of the right ventricle = ventricular tachycardia and right sided heart failure

arrhyhmia-prone heart

s/s of ARVC

usually persistent in early childhood

palpitations, syncope, surpraventricular and ventricular arrhythmias, right sided heart failure, ventricular tachycardia

stress-induced (takotsubo) cardiomypoathy

acute, reversible left ventricular dysfunction commonly precipitated by profound emotional, psychological, or physical distress

predominately in white, post menopausal women

stressed heart

s/s of takotsubo cardiomyopathy

similar to STEMI

life threatening arrhythmias, pulmonary edema, heart failure, cariogenic shock, sudden death, substernal chest pain, and SOB

types of surgical interventions for cardiomyopathy

septal myectomy, alcohol septal ablation, mechanical circulation supprt (IABP, ECMO, VAD, TAH)

septal myectomy

removal of part of the thickened septum

generally used for younger patients with obstructive HCM

alcohol septal ablation

destruction of the hypertrophied septum by injection of alcohol into the artery that supplies blood into the area

in rare occurrences it can cause a permanent heart block which them requires a pacemaker to be put in

types of mechanical circulation support (MCS)

intra-aortic balloon pump counter-pulsation (IABP)

extracorporeal membrane oxygenator (ECMO)

ventricular assist devices (VAD)

total artificial hearts (TAH)

extracorporeal membrane oxygenator (ECMO)

uses a pump to circulate flow though an oxygenator outside the body to provide both cardiac and respiratory support by artificially removing the carbon dioxide and re-oxygenate RBCs

allows time for the heart and lungs to recover

ventricular assist devices

support a failing heart by generating blood flow to the systemic circulation and unloading the ventricle

cyclosporine or tacrolimus

anti-rejection medications for heart transplant

needed for life

contraindications for a heart transplant

irreversible pulmonary hypertension

infection

pericardium

outer layer of the heart

myocardium

the middle, thickest layer of the heart

endocardium

the innermost layer of the heart

rheumatic heart disease

permanent damage to the heart valves following RF

infective endocarditis

serious infection of the endocardium

risk factors for infective endocarditis

prosthetic heart valve, structural cardiac defect, implantable device, pervious episode of endocarditis, immunosuppression, IVDA

s/s of infective endocarditis

anorexia, myalgia, fever, chills, weight loss, back/joint pain, night sweats, heart murmur

treatment for infective endocarditis

antibiotic therapy

myocardiits

inflammation of myocardium

can be acute or chronic

commonly from viral infections

s/s of myocarditis

fever, myalgias, fatigue, dyspnea, ventricular arrhythmia, cariogenic shock, S3 gallop, tachycardia, JVD, edema, orthopnea, palpitations

s/s of pericardits

chest pain - persistent, sharp; aggravated by deep inspiration, coughing, lying down, or turning; relief usually by leaning forward or sitting

friction rub - diagnostic, louder at the end of exhalation (to differentiate a pericardial and pleural friction rub, have the pt hold their breath, the pericardial friction rub will continue)

mild fever, high WBC, anemia, nonproductive cough, dyspnea

valvular heart disease diagnostic studies

hx, physical, CT of chest, CXR, echo, heart cath, ECG

where bile is made

liver

function gallbladder

storage and concentration of bile

bile breaks down:

fat

cholecystitis

caused by inflammation of the gallbladder, usually associated with gallstones or the repeated occurrence of gallstones

acute cholecystitis

usually develops in association with gallstones

obstruction of the cystic duct by a stone leads to an inflammatory response → the bile is trapped then reabsorbed which causes chemical irritation of the gallbladder

chronic cholecystitis

repeated episode of acute attacks

stones are almost always present

can lead to pancreatitis from backup of bile into pancreas

s/s of cholecystitis

pain that radiates to the right shoulder, pain that occurs after a large or high-fat meal, anorexia, n/v, dyspepsia, flatulence, feeling of abdominal fullness, rebound tenderness, jaundice, fever

cholecystectomy

gallbladder removed

cholelithiasis

gallstones - formed when bile in the gallbladder hardens into stone-like material

causes of cholelithiasis

increased cholesterol in bile, increased bile salts

risk factors for cholelithiasis

obesity, multipara women, weight fluctuations, rapid weight loss, estrogen therapy, DM, CF, blood disorders, Chron’s, gastric bypass

cholecystectomy patient education

must walk after surgery to relieve the gas, no heavy lifting, use a heating pad to relieve pain, prevent retching, low-fat diet, take fat soluble vitamin supplements (A, D, E, K)

cholangitis

infection of the bile duct

the exocrine pancrease

releases digestive enzymes (amylase, trypsin, lipase)

amylase

breaks down carbs into glucose

trypsin

breaks down protein into amino acids

lipase

breaks down fats into fatty acids and glycerol

elevated amylase, trypsin, and lipase:

pacreatits

without amylase, trypsin, and lipase:

the body cannot absorb fat-soluble vitamins

endocrine pancreas

insulin, glucagon, and somatostatin

somatostatin

protective mechanism that doesn’t allow for too much or too little release of insulin or glucagon

chronic pancreatitis

destruction of the pancreas

alcoholism accounts for 70-80%

acute pancreatits

caused by obstruction (usually gallstone

possible causes of acute pancreatitis

idiopathic, gallstones, ethanol, trauma, stenosis, mumps, autoimmune, scorpion sting, hyperlipidemia, hypercalcemia, ERCP, drugs

s/s pancreatits

severe abdominal pain, pain 24-48 hrs after a heavy meal, pain after alcohol consumption, pain unrelieved by antacid use, n/v, board like or rigid abdomen (possible sign of peritonitis), fever, jaundice, confusion, agitation

laying in a fetal position makes the pain worse → they like to sit in the orthopnic position

ecchymosis (cullens and grey turners)

signs of internal bleeding

elevated HR, hypotension, cold clammy skin, central cyanosis

diagnosis of acute pancreatits

elevated serum amylase and lipase

elevated WBC

hypocalcemia

hyperglycemia

elevated bilirubin

abdominal x-ray, abdominal ultrasound, abdominal CT