Adults and Older Adults Exam 1

Pathophysiology and risk factors of DVT/ PE

1. Pathophysiology: Formation of a thrombus in deep veins that can dislodge and travel to the lungs causing PE

2. Risk Factors:

   1. Immobility, surgery, and trauma

   2. Malignancy

   3. Pregnancy, obesity

   4. Age

   5. Genetics: factor V mutation, prothrombin gene mutation

Pathophysiology and risk factors of dyslipidemia

1. Pathophysiology: Abnormal lipid levels leads to atherosclerosis

2. Risk factors:

   1. Diet

   2. Sedentary lifestyle

   3. Smoking, alcohol use

   4. Genetics: familial hypercholesterolemia

Pathophysiology and risk factors of atherosclerosis

1. Pathophysiology: endothelial injury leading to inflammation which increases inflammation and increases LDL disposition, causing plaque buildup and arterial narrowing

2. Risk factors:

   1. Hypertension, smoking, hyperlipidemia, diabetes

   2. Chronic inflammation

   3. Genetics: familial hypercholesteremia

Pathophysiology of hypertension

1. Pathophysiology: increased systemic vascular resistance and/or chronic cardiac output leading to endothelial injury and remodeling causing organ damage

Pathophysiology and risk factors of acute coronary syndrome (ACS)

1. Pathophysiology: Rupture/ erosion of atherosclerotic plaque causing platelet aggregation and thrombus formation leading to coronary blood flow restriction

2. Risk factors:

   1. Hypertension, smoking, hyperlipidemia, diabetes

   2. Chronic inflammation

Pathophysiology and risk factors of heart failure (systolic and diastolic heart failure)

1. Pathophysiology: inability of heart to pump effectively leading to decreased cardiac output and fluid overload

2. Systolic HF (HFrEF): impaired contractility, dilated cardiomyopathy

3. Diastolic HF (HFpEF): impaired relaxation/filling, hypertension, hypertrophy, aging, restrictive cardiomyopathy

4. Causes: hypertension, MI, heart disease, valvular disease, arrythmias, toxins

5. Genetic influences: Hypertrophic cardiomyopathy, dilated cardiomyopathy

Pathophysiology and risk factors of cardiogenic shock

1. Pathophysiology: severe left ventricle dysfunction leading to inadequate tissue perfusion causing hypotension and multiorgan failure

2. Causes: acute MI, severe HF, valvular disease, myocarditis

3. Risk factors: prior cardiac disease, advanced age, diabetes

What is primary hypertension

• 90-95% multifactorial

• Genetic predisposition: polymorphism affecting RAAS, sodium transport, sympathetic tone

• Environmental: high salt intake, obesity, stress, smoking, sedentary lifestyle

What is secondary hypertension

• Due to underlying conditions

• Renal disease, renal artery stenosis

• Endocrine

What is stable angina

• Type of ACS

• Predictable, exertional chest pain relieved by rest/ nitro.

• Caused by fixed atherosclerotic plaque

What is unstable angina

• Type of ACS

• Chest pain at rest or increasing in frequency

• Plaque rupture with non-occlusive thrombus

What is a myocardial infarction (MI)

• Type of ACS

• Complete or near-complete thrombolytic occlusion causing myocyte ischemia and necrosis

Describe the following sinus dysrhythmias and their causes: normal sinus Rythm (NSR), sinus bradycardia, sinus tachycardia, sinus arrythmia

NSR: Hear rate 60-100 bpm, regular rhythm, p wave before every QRS

• Healthy heart

Sinus bradycardia: HR <60 bpm, regular rhythm

• Vagal stimulation, athletic conditioning, hypothyroidism, medications, hypothermia

Sinus tachycardia: HR > 100 bpm, regular

• Fever, pain, anxiety, hypovolemia, anemia, hyperthyroidism, stimulants

Sinus arrythmia: HR varies with respiration, usually benign

• Often normal in children/ young adults; respiratory influence

Describe the following atrial dysrhythmias and their causes: premature atrial contractions (PAC), atrial flutter, atrial fibrillation

PAC: Early P wave, may be hidden in previous T wave

• Stress, caffeine, alcohol, nicotine, hypoxia

Atrial flutter: Rapid, regular atrial rate with sawtooth P waves

• Heart disease, COPD, hyperthyroidism, post-surgery

Atrial fibrillation: Chaotic atrial activity, irregularly irregular ventricular response

• Hypertension, CAD, valvular disease, HF, alcohol, age >65

Describe the following ventricular dysrhythmias and their causes: premature ventricular contractions (PVC), ventricular tachycardia, ventricular fibrillation

PVC: Early, wide, bizarre QRS, no preceding P wave

• Hypoxia, electrolyte imbalance, stimulants, MI, heart failure

VT: 3_ PVCs in a row, rapid rate, may be sustained or non-sustained

• MI, cardiomyopathy, electrolyte imbalances, hypoxia

VF: Chaotic ventricular activity, no cardiac output

• MI, untreated VT, electrolyte imbalances, electrical shock

Describe the following heart blocks/AV abnormalities and their causes: 1st degree AV block, 2nd degree AV block, 3rd degree AV block

1st degree: PR interval > 0.20 seconds, every atrial impulse conducted

• Medications, ischemia

2nd degree (type 1 Wenckebach): PR interval progressively lengthens until a QRS in dropped

• Inferior MI, medications, high vagal tone

2nd degree (type 2 Mobitz): Intermittent non-conducted P waves, PR constant

• Anterior MI, conduction system disease, more dangerous

3rd degree (complete): No atrial impulses conducted, atria and ventricles beat independently

• Severe conduction disease, MI, medications, degenerative disease

Describe the following dysrhythmias and their causes: supraventricular tachycardia (SVT), torsades de pointe, asystole

SVT: Rapid HR 150-200 bpm, narrow QRS, sudden onset/offset

• Stress, caffeine, stimulants, structural heart disease

Torsades de Pointes: Polymorphic VT, twisting QRS around baseline

• Prolonged QT interval, electrolyte imbalance, medications

Asystole: Flatline, no electrical activity

Signs/ symptoms of DVT

• Unilateral leg swelling/ edema

• Warmth, redness, tenderness along vein

• Calf pain

Signs/ symptoms of PE

• Sudden onset dyspnea, tachypnea

• Chest pain

• Tachycardia, hypoxia

• Anxiety, restlessness

• Cough

What are early and late signs of hypertension

Early:

• No symptoms

Late:

• Headache

• Dizziness, blurred vision

• Chest pain, dyspnea

• Neurological symptoms if stroke

Labs measured when DVT/PE are suspected: D-dimer, INR, aPTT

D-dimer: detects clot degradation

• Range: < 0.5 ug/mL FEU

INR: monitors extrinsic pathway (used for warfarin)

• Range: 0.8 - 1.2

aPTT: monitors intrinsic pathway (used for heparin)

• Range: 25-35

Normal values for HDL, LDL, cholesterol, triglycerides

HDL: >40

LDL: <100

Total cholesterol: <200

Triglycerides: <150

Labs measured when MI is suspected: troponin, CK-MB

Troponin: protein released when myocardial cells are damaged

• Range: <0.04 ng/mL

CK-MB: Indicates recent myocardial cell damage

• Range: 0 - 3 ng/mL

Normal P wave, PR interval, QRS, QT interval times

P wave:  =<0.12

PR interval: 0.12-0.20

QRS:  =<0.12

QT interval: 0.36-0.44

Primary assessments DVT

• Assess: unilateral leg swelling, pain, tenderness, erythema, warmth, measure calf/leg circumference

• Vitals, HR, signs of PE

• Labs: D-dimer

• Priority: prevent embolization, immobilize affected limb, anticoagulation

Primary assessments PE

• Assess: sudden dyspnea, tachypnea, pleuritic chest pain, tachycardia, hypoxia, anxiety

• Vitals: continuous pulse ox, ECG, ABG

• Labs: D-dimer

• Priority: airway, anticoagulation or thrombolysis

Primary assessments hypertension

• Assess: BP in both arms, orthostatic if dizzy, target organ systems

• Priority: identify hypertensive emergency

Primary assessments stable/unstable angina

• Assess: chest pain characteristics, vitals, ECG, pain relief

• Labs: troponin, CK-MB, BMP, CBC, coagulation panel

• Priority: ABCs, apply oxygen, continuous ECG

Primary assessments dysrhythmias

• Assess: telemetry rhythm, pulses, BP, LOC, chest pain, electrolytes, medication history

• Priority: unstable → immediate synchronized cardioversion/ ACLS. Stable: pharmacological therapy and monitoring

Primary assessments cardiogenic shock

• Assess: hypotension, cold/clammy skin, weak pulses, altered mental status, PE

• Priority: airway, restore perfusion, rapid communication with provider

Primary assessments heart failure

• Assess: weight, I&O, lung sounds, JVD, peripheral edema, BNP, oxygenation

• Priority: oxygen, diuretics, fluid/sodium restriction, monitor renal function and electrolytes

What to monitor for Heparin

• Monitor aPTT

• Check platelet counts doily

• Protamine is antidote

What to monitor for Warfarin

• Monitor IRN

What to monitor for fibrinolytics (tPA)

• Used for massive PE of STEMI when PCI not available

• Major bleeding risk and many contraindications

Teachings for patients on anticoagulants

• Bleeding precautions: use soft toothbrush, electric razor, avoid contact sports, report signs: uncontrolled bleeding, black tarry stools, blood in urine, severe headache, sudden weakness

• For warfarin: maintain consistent vitamin K intake

• For heparin: rotate sites, signs of HIT (new bruising, bleeding, platelet drop)

• Avoid NSAIDs

Indications for statins and best time to use them

• Indication: lowers LDL, reduces cardiovascular risk

• Best given at night

Nurse teachings and diet when taking statins

Teaching:

• Report muscle pain/ weakness, dark urine, jaundice, fatigue

Diet:

• Heart healthy food, reduce saturated and trans fats, increase fiber, fish, fruits, veggies, and whole grains

Teachings, medications and side effects for hypertension

Teachings:

• Lifestyle: Low-sodium diet, weight reduction, regular moderate exercise, limit alcohol, stop smoking, med adherence

• Monitor BP

• Report severe headache, visual changes, chest pain, syncope

1. ACE inhibitors: cough, hyperkalemia, angioedema, monitor renal function and K+

2. ARBs: similar to ACE but less cough

3. Beta-blockers: bradycardia, fatigue, bronchospasm in airway

4. Calcium channel blockers: peripheral edema, constipation

5. Diuretics: electrolyte imbalances, dehydration, gout exacerbation

6. Nitrates: headache, hypotension

Define afterload

Force with which the ventricles of the heart contract

Define cardiac output

Amount of blood pumped out of the heart in 1 minute

Define preload

Amount of stretch in the ventricle before it contracts

Define stroke volume

Force with which the ventricles of the heart contract

Define systemic filling pressure

Force that returns blood to the heart

Define baroreceptors

Pressure sensors in the aortic arch and carotids sinus

What causes a decrease in cardiac output

Decreased heart rate