Exam 1: Cardiac and Perfusion

ppt 3

Left sided HF S/S

think LUNGS

-paroxysmal nocturnal dyspnea

-cough

-crackles

-wheezes

-blood tinged sputum

-tachypnea

-tachycardia

-exertional dyspnea

-fatigue

-cyanosis

-restlessness

-confusion

-orthopnea

Right sided HF S/S

Think REST of the body

-enlarged liver and spleen

-ascites

-increased peripheral venous pressure

-distended JVD

-anorexia

-complaints of GI distress

-weight gain

-dependent edema

-fatigue

Acute Coronary Syndrome: primary cause

Atherosclerosis

-Angina occurs when the O2 demand is greater than the oxygen supply

·      The heart is working hard (high oxygen demand) but there is poor perfusion to the myocardium (low oxygen supply)

§  Lipids accumulate causing a fatty streak

§  The endothelial lining of the arteries is damaged

Acute Coronary Syndrome: RF

§  Smoking

§  Hyperlipidemia

§  HTN

§  Toxins

§  Diabetes

§  Localized inflammatory process

Acute Coronary Syndrome: S/S

§  Palpitations

§  Diaphoresis

§  Anxiety Nausea

§  Angina (chest pain)

·      Women confuse chest pain for indigestion

·      Men will describe it as an elephant on the chest

·      Both genders will complain of arm pain

  Non-ST Elevated Myocardial Infarction (NSTEMI):

§  This is considered Ischemia

·      Ischemia means it is lacking O2 NOT tissue death

§  It is reversible

§  Releases cardiac enzymes if damaged

how will an NSTEMI strip look like?

ST Depression and/or T wave inversion indicating ischemia

NSTEMI and STEMI- dx and labs

12 lead EKG

myoglobins

creatine kinase MB

Troponin I or T

Myoglobins

• earliest marker of injury to cardiac/skeletal muscle

§  No longer evident after 24hrs

creatine kinase - MB

§  Peaks around 24hrs after onset of chest pain

§  No longer evident after 3 days

Troponin I or T

§  If there is any POSITIVE+ value, it means there is cardiac tissue damage and should be reported

Unstable Angina & NSTEMI MEDS:

o   MONA – Morphine, O2, Nitroglycerine, Aspirin

o   give heparin to prevent clot formation of microemboli

o   DAPT (dual anti platelet therapy) – ex. Aspirin, clopidogrel, ticagrelor

o   PCI (percutaneous coronary intervention) – within 12-72 hrs.

§  This refers to cardiac cath with stent placement

o   Notify PCP ASAP if there are any changes in ST segment

o   ST-Elevated Myocardial Infarction (STEMI):

§  Infarction – Classic heart attack

§  ST segment is elevated = pt is dying

§  Extensive heart damage

§  This is the only one with an ST elevation

·       Tissue is dead and more tissue is continuing to die

§  STEMI MEDS:

·      PCI (percutaneous coronary intervention) – within 90 mins.

o   This refers to cardiac cath with stent placement

·      TPA if PCI is not available

o   TPA = tissue plasminogen activator = thrombolytic therapy = breaks up existing clots

o   PRIORITY NURSING INTERVENTIONS FOR ALL CLIENTS WITH ANGINA:

§  FOR UA, NSTEMI, STEMI

·      12-LEAD ECG

·      Serial cardiac biomarkers

·      Vitals and O2 monitoring HOURLY

·      Continuous ECG monitoring

·      MONA

·      Monitor UOP

·      Maintain bed rest

·      Limit activity for 12-24hrs.

·      Monitor and treat Anxiety

when do STEMI pts go for stent placement

§  goes to cardiac cath lab for stent placement right away; these interventions are happening during transport and procedure preparation

when do NSTEMI and UA pts go for stent placement

will go to cardiac cath within 72h; these interventions are happening until they go to the cath lab

o   ACS Procedures: Angiography/Cardiac Catheterization:

·      This is an invasive procedure

·      Evaluates presence & degree of coronary artery blockage

·      Threads a catheter through a peripheral artery into the heart to visualize coronary arteries

·      Contrast is used to see blockage

use of contrast nursing care

o   Assess for allergies: especially contrast dye \n o Perform baseline assessment \n o Withhold food/fluids 6-12 hrs before \n o Assess baseline lab values: cardiac biomarkers & creatinine

o Teach about procedure \n o Give sedative & other drugs

§  Post Angiography Site Care:

·      Monitor vitals

·      Assess for bleeding

·      Assess for hematomas

·      Assess neurovascular checks (5 P’s – Pain, Paresthesia, Pallor, Pulse, Paralysis)

o   Check every 15 min for the 1st hour (4 times)

o   Check every 30 min for the 2nd hour (2 times)

o   Check every hour for the next 4 hours (4 times)

o   Check every 4 hours

·      Bed Rest

o   Pt must lay flat, supine

o   Extremity must be straight for the prescribed time

o   Pt cannot walk

o   Pt cannot sit up to eat

ACS MEDS - drug action - Vasodilators – Nitroglycerin -

o   Prevents coronary artery vasospasm

o   Reduces preload and afterload, decreasing myocardial oxygen demand

o   Decreases BP

ACS MEDS - nursing action - Vasodilators – Nitroglycerin -

o   Monitor for orthostatic hypotension

o   Teach pt headaches are common

o   Withhold drug if pt is taking phosphodiesterase inhibitor for erectile dysfunction within the last 24-48hrs – can cause severe hypotension

o   Educate to take 1 tablet every 5 mins x 3

o   If chest pain continues after first dose and 5 mins have passed, take 2nd tablet and call 911

o   When taking this medication pt should be sitting down

ACS MEDS - drug action - Analgesic – Morphine

o   Pain relief (chest pain)

o   Decreased O2 consumption (Reduces the demand for O2)

o   Calms anxiety

ACS MEDS - nursing action - Analgesic – Morphine

o   Monitor for decreased RR

o   Monitor for hypotension

o   N/V

ACS MEDS - drug action - Betablockers – Metoprolol (end in LOL)

o   Antidysrhythmic & antihypertensive

§  decrease O2 demand by reducing afterload and slowing HR

o   Acute MI:  decrease infarct size

§  improves short- and long-term outcomes

ACS MEDS - nursing action - Betablockers – Metoprolol (end in LOL)

o   Monitor for bradycardia and hypotension

o   Hold if apical pulse < 60

o   Monitor asthma & heart failure pts

o   Monitor for decreased LOC, crackles, chest discomfort

o   Check heart rate before admin

§  60 or less hold med call pcp

ACS MEDS - drug action - Thrombolytic Agent – Alteplase

o   Breaks up clots in the blood

ACS MEDS - nursing action - Thrombolytic Agent – Alteplase

o   Monitor for bleeding

o   Monitor labs – PTT and PT

o   Not indicated for pts with NSTEMI

o   Indicated for pts with STEMI and PCI is not an option

ACS MEDS - drug action - Antiplatelet Agents – Aspirin, Clopidogrel (Plavix)

o   Prevent platelets from sticking together

o   Aspirin should be given with nitro on onset of symptoms due to its ability to prevent vasoconstriction

ACS MEDS - nursing action -Antiplatelet Agents – Aspirin, Clopidogrel (Plavix)

o   Monitor for tinnitus (toxicity)

§  Ringing of the ears

o   Watch out for bleeding

ACS MEDS - drug action - Anticoagulants – Heparin and Enoxaparin

o   Prevent clot growth

o   Prevent new clot formation

ACS MEDS - nursing action - Anticoagulants – Heparin and Enoxaparin

o   Monitor for bleeding

o   PT/ INR, PTT, CBC

§  Platelet count comes from CBC

o   Thrombocytopenia & Anemia

o   Risk for bleeding and bruising

ACS MEDS - drug action - Lipid Lowering Statin – Atorvastatin (end in STATIN)

o   Block synthesis of cholesterol and increase LDL receptors in liver

o   Decreases LDL

o   Decreases triglycerides

Increases HDL (in small amounts

ACS MEDS - nursing action - Lipid Lowering Statin – Atorvastatin (end in STATIN)

o   Monitor liver enzymes and creatine kinase

§  Will be decreased

§  if muscle weakness or pain occurs

o   Give at night

ACS – Nutrition

·      NPO except water until stable

·      Low sodium diet

·      Low saturated fat diet

·      Low cholesterol diet

·      No Fast food

·      No Canned food

·      No prepackaged food

ACS - exercise

·      Low Impact activity

ACS - nursing considerations

Administer stool softener

o   Prevent straining

o   Drink plenty of water

o   Include fiber in diet

Coronary Artery Bypass Graft (CABG)

o   Surgical procedure to restore vascularization of the myocardium & improve client quality of life

o   Most effective when EF is less than 50%

o   Open chest procedure

o   ICU monitoring

CABG - Pre-Op Nursing Considerations

o   Informed consent

o   Discontinue meds prior to sx (educate pt)

o   Meds to continue until morning of sx (educate pt)

CABG - PRE-OP - Discontinue meds prior to sx

§  Diuretics - 2-3 days prior to sx

§  Aspirin and other anticoagulants – 1 week prior to sx

CABG - PRE-OP - continue meds prior to sx

§  Potassium supplements

§  Antidysrhythmic

§  Antihypertensives

§  Insulin

CABG - Post-Op Nursing Considerations:

o   ICU for 24-36 hours

o   Monitor hemodynamics – tight BP control

§  Arterial line for BP monitoring

·      Hypotension

o   Can be due to the graft collapsing

·      Hypertension

o   Can be due to bleeding at graft or suture sites

o   ECG for heart rhythms

o   Epicardial pacing wire for emergency pacing

o   Chest tube care

o   Endotracheal / Mechanical vent care

o   Foley cath

o   NGT for gastric decompression

o   Splinting for coughing and deep breathing

o   Early mobility

CABG - Complications - Pulmonary

·      Atelectasis

·      Pneumonia

·      Pulmonary Edema

CABG - Complications - Pulmonary - prevention

·      Early Ambulation

·      Turning

·      Deep breathing exercises

CABG - Complications - Pulmonary - recognize cues

·      Abnormal lung sounds

·      Unequal lung sounds

·      Crackles

CABG - Complications - Pulmonary - interventions

·      Administer O2

·      Notify PCP

·      Potentially prepare for chest tubes/ diuretics

CABG - Complications - hypothermia

·      Vasoconstriction

·      Metabolic acidosis

CABG - Complications - hypothermia - prevention

·      Monitor Temp

·      Keep pt warm

CABG - Complications - hypothermia - recognizing cues

·      Decreased capillary refill

·      Cool extremities

·      HTN

CABG - Complications - hypothermia - intervention

·      Check ABG’s

·      Bear hugger

·      Warming blanket

·      Warming fluids

CABG - Complications - heart (decreased cardiac output)

·      Dysrhythmias – AFIB

·      Cardiac Tamponade (Causes restrictive pressure around heart which reduces its ability to pump = decreased cardiac output)

·      Hypovolemia

·      Left Ventricular Failure

·      Myocardial Infarction (MI)

CABG - Complications - heart - Dysrhythmias – AFIB Intervention

§  Administer BB soon after sx

CABG - Complications - heart - cardiac tamponade Intervention

§  Sternotomy or pericardiocentesis

CABG - Complications - heart - hypovolemia Intervention

§  Carefully replace fluids, colloids

CABG - Complications - heart - left ventricular failure Intervention

§  Vasopressors and positive inotropes

CABG - Complications - heart - MI Intervention

§  Call MD

§  MONA

CABG - Complications - Electrolyte Disturbances

·      K and Magnesium depletion

CABG - Complications - Electrolyte Disturbances - recognizing cues

§  Fatigue

§  Muscle cramps

§  Tingle

§  Numbness

§  Heart palpitations

CABG - Complications - Electrolyte Disturbances - intervention

o   give K + and Mag replacements

§  SAFETY for IV potassium- how fast can we give K+?

§  10 mEq/hr

§  Must use IV pump

§  Must be on cardiac monitor

§  NEVER PUSH IV

CABG - Complications - neuro deficits

·      CVA (stroke) from transient HTN

·      hypotension

·      blood clot

CABG - Complications - neuro deficits - recognizing cues

§  balance issues

§  eyesight issues

§  facial droop

§  arm weakness

§  speech difficulties

CABG - Complications - neuro deficits - interventions

o   Protect airway

o   Call MD

o   Code stroke

pacemakers indication

o   Help control abnormal heart rhythms with low-electrical pulses to prompt heart to beat at normal rate

transcutaneous pacemaker

●Fully external

●Symptomatic bradycardia when pt is unresponsive to atropine

●Painful d/t large amount of electricity

●Temporary

epicardial pacemaker

●Pulse generator outside of body

●Leads threaded through chest directly to heart

●Common after open-heart surgery

●Temporary

endocardial (transvenous) pacemaker

●Pulse generator implanted under skin/muscle

●Wires threaded through a large vein and lodged into the wall of the heart

●Permanent (pulse generator will be changed as needed)

●*Some also function as a defibrillator

  Implantable Cardioverter/Defibrillator (ICD):

o   CONTAINS AN INTERNAL GENERATOR TO DELIVER SHOCK IF NEEDED

§  For pt’s with ventricular dysrhythmias who are at risk of needing D-FIB

§  Ventricular Tachydysrhythmias

§  MI with left ventricular dysfunction

§  For pts who survive sudden cardiac death / ventricular dysrhythmias

§  Stronger shock – will feel like a blow to the chest

pacemaker on demand

 pacemaker will deliver electricity when the HR falls below a predetermined rate

fixed pacemaker

the pacemaker will deliver electricity at a fixed rate (less common)

reasons to put a pacemaker in

§  Symptomatic bradycardia

§  Complete heart block

§  Sick sinus syndrome

§  Cardiac arrest

§  Atrial tachydysrhythmias

pacemaker spikes

expected

§  shows when electricity is being sent to the heart

pacemaker - ECG Monitoring For Malfunction - failure to sense

·      Doesn’t sense pt HR

·      Causes inappropriate/random firing

pacemaker - ECG Monitoring For Malfunction - failure to capture

§  due to leads not connected appropriately

§  Electricity is not caught by the heart

§  Leads to bradycardia or asystole

pacemaker - ECG Monitoring For Malfunction - failure to pace

§  battery issue

§  Pacemaker is not sending electricity

Pacemaker Complications

o   Infection- Endocarditis

o   Hematoma Formation

o   Pneumothorax

o   Atrial Or Ventricular Septum Perforation

o   Lead Misplacement

o   Hiccups

Pacemaker Complications - why do hiccups occur?

§  Pacemaker is sitting low in the heart – near the diaphragm (tickling the diaphragm)

Pacemaker FACTS - pt education

-Regular pacemaker function checks

-Report any signs of infection at incision site

-Keep incision dry for 4 days after implantation, or as ordered.

- AVOID LIFTING arm on pacemaker side above shoulder until approved by cardiologist.

-Avoid close proximity to high-output electric generators

-Monitor pulse and tell your HCP if heart rate drops below predetermined rate.

-Always wear a Medic Alert ID device

-Always carry your pacemaker information card and a current list of drugs.

Pacemaker MYTHS - pt education

Okay to resume boxing / bar fights

All pacemakers are MRI safe

Microwave ovens interfere with pacemaker function.

Travel is restricted

Aneurysm definition

o   Weakness in a section of a dilated artery that causes a widening or balloon in the wall of the blood vessel

aneurysm RF

o   Male

o   Atherosclerosis (most common cause)

o   Hypertension

o   Smoking

o   Hyperlipidemia

o   Genetics

o   Age (loss of elastin in artery walls causes stiffening/thickening, & progressive fibrosis; more prone to aneurysms & higher mortality rate), etc.

aneurysm types

saccular

fusiform

aneurysm types - saccular

affect only one side of the artery

aneurysm types - fusiform

Affect the complete circumference of the artery

aneurysm - recognizing cues for thoracic aortic aneurism

§  Severe back pain (most common)

§  Hoarseness

§  Cough

§  SOB

§  Difficulty swallowing

§  Decrease in urinary output d/t hypovolemic shock

aneurysm - recognizing cues for Abdominal Aortic Aneurism:

§  Constant gnawing

§   abdominal pain

§  flank or back pain

§  pulsating abdominal mass (do not palpate)

aneurysm - recognizing cues for Iliac Aortic Dissection: (EMERGENCY)

§  Sudden tearing, ripping, stabbing abdominal or back pain

§  Hypovolemic shock

·      Decreased BP

·      Tachycardia

Aneurism Nursing Care: (PRIORITY)

o   Assess ABC - circulation!!

o   Vitals Q15 min

o   Decrease SBP to 100 to 120mm Hg with b-blockers or CCB

o   Monitor UOP

o   Prepare for emergency surgery for rupturing aneurysm

Aneurism Complication: rupture

§  Can result in massive hemorrhage, shock & death

§  Treatment is resuscitation & immediate surgical repair

§   Older clients with > 6 cm aneurysm & hypertension have greater risk of death

Aneurism Complication: thrombus

§  Can form inside aneurysm, emboli can dislodge causing ischemia

§  Assess circulation distal to aneurysm (pulses, color, & temperature)

Aortic Aneurysm Repair

o    Graft

§  Report graft rupture or occlusion:

·      Absent pulses, coolness of extremities, signs of hypovolemia (hypotension, decreased UOP)

§  Implement general post op nursing care – ex. turning, deep breathing, splinting