2410 exam 3

Recognizing patients experiencing impaired perfusion: Subjective

- Pain ( OLDCARTS)

• due to impaired blood flow to the myocardium or pulmonary emboli. ( usually sign of MI NOT HF)

• pt. will report a precipitating event, such as physical exertion, exposure to cold temperatures, or emotional stress

- Dyspnea on exertion (DOE)

- Orthopnea - discomfort in breathing while lying flat.

• How many pillows do you need?

- Paroxysmal nocturnal dyspnea (PND)

- Dizziness or fainting (Syncope & Near-Syncope)

• headache, numbness, and confusion

Recognizing patients experiencing impaired perfusion: Objective

- Edema

- decreased CO, tachycardia, dyspnea, hypertension

- Capillary refill greater than 2 seconds indicates poor perfusion + Clubbing

- JVD are expected

- reduced urine output

- elevated BNP

- Pale mucous membranes, rubor, diaphoresis, cool skin, cyanosis, pallor, no hair on legs.

- Ankle-brachial index (compare BP in arm to ankle to assess for perfusion problems)

- Gallops, murmurs, rubs.

Left-sided heart failure

HF ( HEAVY FLUID)

- Fluid backs up into the Lungs (Left Side)

- inability of the LV to empty adequately during systole or fill adequately during diastole.

- Usually from MI, CAD, ACS

- ↓ EF < 45% == (Normal is 55-60%)

• (<30% = implantable cardioverter defibrillator (IDC) candidate)

LSHF clinical manifestations

- Pulmonary edema

- Dyspnea or Orthopnea

- Pulmonary congestion (Crackles), dry cough

- Blood tinged sputum- pink

- Cyanosis, confusion, restlessness, tachycardia

- S3 heart sound gallop

- Weakness

- Elevated pulmonary capillary wedge pressure

Right-sided heart failure

HF ( HEAVY FLUID)

- Fluid RIGHT backs up into the body. ( Right SIDE)

- Right ventricle doesn't empty effectively

- Most common cause is left-sided heart failure, causes right ventricle to work harder

- Other causes COPD, Smoking, or Obstructive Sleep Apnea

- Pulmonary hypertension (Cor pulmonale) may result

RSHF clinical manifestations

- Peripheral edema

- Weight gain early

• 3 ib IN 1 DAY Report

- JVD

- Fatigue

- Hepatomegaly

- Abdominal ascites (bloating )

- Nausea/ Anorexia- feeling like they don’t wanna eat.

- fluttering or prominent pulsations

- murmus

- Increased peripheral venous pressure

Diagnostics/Labs used to determine heart failure

- BNP ↑

- Hypo/hyperkalemia are sometimes side effects of some cardiac medications

- BUN/ creatinine ↑

- LOW H&H: HF resulted from anemia

- Urinalysis and ABGs

- Chest x-rays

- Echocardiogram

- EKG (ECG)

- Invasive hemodynamic monitoring:

BNP

- hormone secreted by cardiomyocytes in heart ventricles in response to fluid overload/stretching,

• 100- 300 suggest HF

• > 300; mild HF

• > 600; Moderate HF

• > 900; Severe HF

- BNP can also indicate pulmonary embolism, renal failure, and acute coronary syndrome.

EKG (ECG) with HF

Can show dysrhythmias, acute infarction, myocardial ischemia, old MI injuries

Invasive hemodynamic monitoring: with HF

swan ganz catheter

- ↑ Central venous pressure (CVP) OVER 8 NOT Great

- ↑ pulmonary wedge pressure (PAWP)

- ↑ pulmonary artery pressure (PAP)

- ↓ CO

- ↓ venous oxygen saturation (SvO2)

Nursing implications: HF

- ** Furosmide/ Burosmide Priority

- HOB elevated

- Oxygen ( high flow mask)

- Push Morphine+ Furosmide

- End NA+ & fluids

- Look for clearer lung sounds + decreased HR

- Question ANY IV fluids *

Nutritional teaching HF

-Restrict fluid intake (1000 mL)

- Restrict sodium

- Dash diet

- No foods high in K+ ( Green leafy vegetables)

HF home management

-Diet (low NA+ Fluids) - No packaged foods or OTC medicine

-Risk for falls ( change position slowly)

-BP & BNP ( should not be increasing)

-Elevate the legs

-Daily weights (report gain. weight of 3 lb in 1 days)

-Stocking or Ted hose

DR BEDS

ACE inhibitors- Lisinopril

1st choice

- for left ventricular dysfunction, lower BP and increase blood to the heart (does not affect HR)

- Blocks RASS system

- hypotension, Cough, Hyperkalemia, angioedema (AIRWAY Risk) & renal insufficiency

ARBS- Losartan

2nd Choice

- Lower BP ( does not affect HR)

- prevent vasoconstriction

- Promote afterload reduction and vasodilation

- Blocks RASS system

- ARBs do not typically cause a cough

- hyperkalemia- avoid green leafy veggies

betablockers

- decrease cardiac output, HR, and BP

- s/e: bradycardia, bronchospasms, Bad for HF, Blood sugar masking.

- Aruptly stopping can cause rebound hypertension, tachycardia, or rebound angina

Diuretics

- Furosemide (Lasix) & Hydrochlorothiazide promote fluid excretion.

- WATCH FOR HYPOKALEMIA***

- s/s include irregular pulse, muscle weakness

- Consume foods high in potassium (orange juice, bananas)

- spironolactone: avoid foods high in K+

Nitrates

- vasodilator prevents coronary artery vasospasm, reduces preload & afterload, decreases cardiac 02 demands

- s/e: orthostatic hypotension, HEADACHE, nausea & vomiting

- avoid drugs that treat erectile dysfunction, no viagra!

Digoxin

- reduce preload and afterload, reduces HF symptoms, increases myocardial O2 consumption & slowing of HR

- s/e: abdominal pain, anorexia, nausea & vomiting, visual disturbances (yellow or green vision)

- monitor serum K+, Mg, and Ca+, renal & hepatic function

- therapeutic digoxin level: 0.5 - 2ng/mL, draw immediately before next dose is due

- Does not affect BP

Endocarditis causes

disease of the endocardial layer of the heart & heart valves. Impacts aortic and mitral valves.

- dental work, systemic infections, surgery, IV drug use, central venous catheters)

Endocarditis: Clinical manifestations

- Fever, malaise, fatigue

- Roth spots - eye exam

-Osler nodes- OW! painful

-Murmurs

- Janeway's lesions (just jane, not painful)

-Anemia/ Anorexia

-Nail bed hemorrhages

-Emboli

Endocarditis Diagnostics

- Positive Blood Cultures definitive diagnosis: staph/ strep

- ECG - ST elevation (diffusion & widespread)

- Echo: look for change in valve moment

- Labs: elevated CRP, troponins, leukocytosis

- Tx: long term antibiotics

Rifamin for prosthetic valves, if doesn't work- surgery

Pericarditis Clinical manifestations

- inflammation of the sac surrounding the heart

- Precordial pain - sharp, severe, worse with inspiration and often radiating down the shoulder

- Hear a Friction/Rub

- dyspnea with hiccups

Pericarditis: Cardiac tamponade - EMERGENCY

- can lead to Cardiac tamponade

Becks TRIAD

- JVD

- Muffled heart tones/ distant heart sounds

- Hypotension

N/A: Auscultate blood pressure for pulsus paradoxus TX: IV fluids

Echocardiograms

Ultrasound of the heart

- Best tool for DIAGNOSING HEART FAILURE

Transthoracic Echocardiogram (TTE)

- Evaluates size, shape, and motion of heart and measures ejection fraction.

- Noninvasive test takes up to 1 hr.

- Lie on left side and remain still

Transesophageal Echocardiogram (TOE)

- Passed through mouth into esophagus to provide images of heart

- Informed consent; NPO for 6 hr prior

- may be sedated

- Monitor for return of gag reflex; keep HOB at 45.

Stress test

- Pre:

• Consent signed

• Wear comfortable clothes

• Fast for 2-4 hrs before

• hold b-blockers for 24 hours before the test

• avoid caffeine-containing foods 24 hours before the test

- Intra

• Apply 12 lead

• Report Chest pain, SOB, or dizziness

- Post

• Check BP

Acute Coronary Syndrome

spectrum of conditions resulting from thrombus formation in the coronary arteries

- Range from unstable angina, NSTEMI, STEMI

• unstable angina: No necrosis

• NSTEMI: partial necrosis

• STEMI: Transmural necrosis- ST elevation AKA heart attack

Acute Coronary Syndrome MONA

- Morphine sulfate (priority in managing pain for ACS!)

- Oxygen

• administer at 2-4L/min

- Nitrates

• Sublingual Can repeat every 5 minutes x 3

• Can have side effects- hypotension (Contraindicated), severe headache (have some Tylenol on hand)

- Aspirin

• relieve acute pain and restore coronary blood flow

• Administered with Nitroglycerin at the onset of chest pain.

• There is a risk for bleeding and bruising

Acute Coronary Syndrome EKG

- OBTAIN 12 LEAD ASAP TO DETERMINE IF PATIENT HAD MI

- ST depression & T wave inversion = Ischemia/ Unstable Angina

- ST elevation = Injury/ NSTEMI

- ST elevation + widened & deep Q wave = Infarction/ STEMI

- Pathologic Q waves often accompanies STEMI, indicative of COMPLETE CORONARY OCCLUSION

Ischemia

lack of blood flow

Infarction

death of tissue; no blood flow

Acute Coronary Syndrome Chest Pain

- report chest pain that is not relieved by rest or nitroglycerin.

• heavy/ dull

• jaw/ arm/ shoulder

- CALL 911

- IMPLEMENT MONA

- obtain 12 LEAD EKG

- lasting > 20 minutes is highly suggestive of MI

Unstable angina

- new in onset, worse at rest.

- first clinical sign of CAD.

- unpredictable and must be treated immediately

- ST depression and/or T wave inversion

Lasts more than 20 minute

Stable angina

- occurs intermittently over a long period

- provoked by physical exertion, stress, or emotional upset.

- resolved by resting, calming down, using sublingual nitroglycerin

- pt describe a pressure, heaviness, or discomfort in the chest.

lasts less than 15 minutes

Cardiac cath lab

if the patient has chest pain + ST elevation, take them straight to the cardiac cath lab to confirms diagnosis and extent of heart

Reperfusion- cath lab

- uses PTCA for door-to-balloon to restore coronary perfusion in cases of MI

• TX FOR Acute Coronary Syndrome

- pharmacological interventions used only for STEMI include

• thrombolytic agents (alteplase, reteplase & tenecteplase) to dissolve clot and open artery

-high risk for stroke

Percutaneous Transluminal Coronary Angioplasty (PTCA)

- balloon/stent to restore coronary artery blood flow when arteries are narrowed or clogged.

- a femoral introducer/sheath

• Complications: hematoma, pseudoaneurysm, infection over femoral artery, kidney injury from contrast dye. Ask about allergies to iodine/shellfish

Cath lab Pre

- Check for allergies to iodine or shellfish

- Assess for underlying kidney disease( expect Dialysis)

- Patients will need hydration pre & post-procedure

- Consent must be obtained prior to the procedure

- Mark pulse sites

Cath lab Post

- Monitor site for bleeding (bruising on back, side or perineum) & chest pain

- **will see TACHYCARDIA & DECREASED URINE OUTPUT FIRST**

- Frequent neurological assessments; mentation, hand grasps

• signs of stroke

- Leg needs to remain straight and immobilized (no restroom)

Cardiogenic Shock (Pericardial Tamponade)

life-threatening; heart suddenly can't pump enough blood to meet your body's needs

- BECKS TRIAD:

• JVD

• Muffled or distant heart sound

• Low blood pressure

Hypertension Assessment

- Palpate pulses at major sites ( Radial, Dorsal)

- Assess blood pressure in both arms

- Check temperature differences in lower extremities

- Capillary refill

- Assess for bruit with Doppler or stethoscope

- Check for family history of Coronary Artery Disease (CAD)

- Ask about life stressors

Hypertension Risk factors

smoking, obesity, sedentary lifestyle, genetics, age, poor diet

Low HDL + High LDL , Diabetes

Hypertension Signs/symptoms

-Often labeled the "silent killer" due to lack of symptoms

- (Most common symptom is Headache)

-Fatigue, palpitations, angina, dizziness, SOB

HF PADS

Hypertension Common medications

- Diuretics

- Adrenergic inhibitors

- Directvasodilator

- Calcium channel blocker

- ACE inhibitors

- ARBs

Hypertension: Medication regimen compliance

- Take BP at home

- Follow-up with PCP every 3 months

- Restrict sodium intake

- Don't suddenly stop drugs

Peripheral Arterial Disease: risk factors

- Atherosclerosis, CVD, Diabetes, Hypertension, high cholesterol, Smoking

- African Americans are affected more than any other group

Peripheral Arterial Disease: Signs/symptoms

- Cool to touch, white, hairless & Shiny, pulseless, report more pain.

- Very little drainage, Little tissue granulation (pale/very light pink) OR necrotic/black

Peripheral Arterial Disease: Nursing implications

- Meds, surgery,( revascularization), put a stint. Improve blood flow!

- palpate posterior tibial pulse

- (DON'T USE HEATING PAD), CMS checks

Peripheral Arterial Disease: Teaching – diet, exercise, positioning

- Prevention depends on disease process ( hypertension, high cholesterol) Lifestyle + pt. Education ( Smoking cessation)

- DASH diet, avoid alcohol, nicotine & caffeine

- Exercise- Promotes collateral circulation

- Feet should not be elevated above the heart.

Peripheral Arterial Disease: Home care management

- Exercise regimen

- Always wear shoes to avoid injury

- Use mild soap and room temp water to wash feet/legs

- Avoid alcohol and tobacco

- Apply lubricating lotion to dry areas of legs/feet

pregnancy induced cardiomyopathy

- Monitor for cardiac decompensation 24-48 hours after birth * HIGH RISK AT THIS TIME!!

• Difficulty Breathing - Orthopnea

• Cough - crackles in lung bases

• Irregular pulse

• Edema

• JVD

• Tachypnea

• Cyanosis - low O2 saturation

- Oxygen saturation - optimal positioning (elevate HOB)

- Avoid Valsalva maneuver - use stool softeners**

**ACE inhibitors/ ARBs should not be used

Bleeding/clotting Assessment

- Blood in urine/stool

- Low blood count

- Embolus (Pulmonary)

- Drug therapy (Plavix)

- Joint problems

- Ascites

- Warfarin History

- Skin: Pallor/ Petechiae

- Lethargy/ Fatigue

- Yellow/Jaundice

BLED JAW SLY

Bleeding s/s (hypocoagulation)

- Bleeding gums/nose

- Oozing blood from IV site,

- Blood in stools, emesis, or urine,

- Skin: pallor (too much blood loss), petechiae, purpura

- Hematomas, hemoptysis, , hypotension

- Orthopnea

- Tachypnea, tachycardia

BOB SHOT

Conditions resulting in hypo-coagulation

- Aplastic anemia (body doesn't make enough blood cells

- Thrombocytopenia (decreased platelets)

- Idiopathic thrombocytopenic purpura (platelets greatly reduced)

- Hemophilia (Factor VIII deficiency)

- HIT

Thrombocytopenia (decreased platelets) Contributing factors

- Platelet disorders (ITP, HIT, DIC)

- Leukemia

- Aplastic Anemia

-Trauma

-Enlarged spleen

-Liver disease

-Ethanol use

-Toxins/ drugs (chemotherapy,/Aspirin)

-Sepsis (hepatitis C virus, HIV, cytomegalovirus)

PLATELETS

ITP (idiopathic thrombocytopenic purpura)

Own body attacks platelets and blood can't clot -> leads to bleeding.

* emotional disease (lots of fatigue)

- TX: corticosteroids (e.g., prednisone, methylprednisolone) are used initially to treat ITP

Hemophilia

NO coagulation to stop bleeding.. Love to bleed.

* Hereditary

- Decreased clotting factors

• Deficiency of factor VIII (Von willbrand )

- often caused by liver failure + vitamin k deficiency

Clinical Manifestation of Hemophilia

- Easy bruising (Ecchymosis)

- Hematomas

- Prolonged bleeding after cut or surgery

- GI bleed, nose bleeds, hematuria

-Hemarthrosis- bleeding in jounts/muscles- may need joint replacement of hip/knee

Hemophilia Treatments

- A-B-C's: stop the bleeding

1. Factor VIII infusions (most common)

2. Desmopressin (DDAVP)

hemophilia education

- medical alert bracelet

- Avoiding contact sports

- home administration of factor VIII

- bleeding interventions

- NO MI Injection

- no aspirin

Liver clotting factors

- liver plays a function in formation of Vitamin K

- labs:

• ↑ PT/INR, & PTT time

•. ↓ platelets, H&H

Conditions resulting in hyper-coagulation

- polycythemia

- sickle cell anemia

- factor V Leiden

- DVT

- surgeries

factor V Leiden

- Hormones- it increases your risk for thrombus.

- S/S ( VTE, DVT/ Thrombosis, possible fetal loss )

Hyper Coagulation Contributing factors

- History of blood clots

- Chronic heart failure & AFIB

- Genetics

- Central Venous Catheter

- Overweight

- Smoking

- Cancer

polycythemia

- Blood disorder

• Overproduction of RBCs

- ↑ RBC's, WBC's, Platelets

- look for dizziness, HTN, petechiae, enlarged spleen

- comp. include DVT, stroke, myocardial infarction, and angina pectoris.

polycythemia: management

ABCs

- Aspirin may be used to decrease clots

- Blood letting (Phlebotomy= TAKE BLOOD OUT; TOO MUCH RBC)

- Chemotherapy sometimes prescribed but may also lead to leukemia

- Hydroxyurea may be prescribed. Helps lower blood counts.

sickle cell: management

- affects the shape of all RBC’s, which carry O2 around the body

- Oxygen

- Pain medication (Morphine) !

- Medication Hydroxyurea

- Hydration! 250 mL/hr x 4 hours

- Packed RBCs ( watch for iron toxicity)

- Prevent infections

sickle cell : teaching

- warm compresses, no sports, avoid sick kids!

- Maintain hydration

- Avoid high altitudes

- Keep current on all immunizations

- take folic acid supplements

DIC S/S

- DIC has both bleeding and thrombotic

• Acute: Bleeding episodes (ecchymoses, petechiae, purpura, blood oozing from oral mucosa, sites of trauma, catheters and IV lines,

• Chronic: thromboembolism, tissue hypoxia, infarctions

* kidney damage and oliguria, leading to failure.

Lab values associated with DIC

- D-Dimer-confirms diagnosis: increased

- PT/PTT prolonged

- Thrombin prolonged

- Fibrin split products elevated

- Fibrinogen Levels decreased

- Platelets Reduced

- Decreased Hemoglobin

DIC Treatment

- O2, IV fluids, TX w/ blood thinner initially

- Fresh frozen plasma

• Platelet transfusions

• RBC transfusions

Virchow's triad

DVT CAUSES:

Pulmonary embolism (triad = blood stasis, endothelial damage, hypercoagulation)

Warfarin (Coumadin)

( not safe during pregnancy)

- prevents synthesis of factor VII, IX,X

- Prevents Venous thrombosis & PE

- prevents A Fib

- LABS: monitor INR for therapeutic PT/INR 2-3

• (2.5-3.5 w/high risk embolism)

- antidote: vitamin K

-Complications: Hemorrhage, Hepatitis, Toxicity

Heparin

( safe during pregnancy)

-- Stroke, PE, DVT

- monitor aPTT therapeutic (46- 70 seconds)

• 30 mins before next dose or q4hr if continuous

- PT/INR- The higher the # the higher the chance of bleeding

- monitor platelet count q2-3days: HIT

- antidote: protamine sulfate

- Complications: - Toxicity, Hemorrhage, Epidural/spinal hematoma, HIT

LMW Enoxaparin/Lovenox

- prevent angina, ST elevation in MI. SubQ

- Labs: Heparin anti-Xa to titrate doses, therapeutic range 0.5-1 unit/mL

- Antidotes: protamine sulfate

- Complications: Neurologic damage, HIT, Toxicity

HIT Signs & Symptoms

- Venous thrombosis

- Pulmonary embolism

- Thrombosis to hands and feet

HIT Risk Factors

longer use of heparin, post-surgical thrombo-prophylaxis, being female, exposure to unfractionated heparin.

HIT labs + tx

- Evident by low platelets

- Monitor platelets esp. in first month

- Stop heparin if < 100,000

• tx anticoagulation therapy i.e. agatroban