common cardiac problems

troponin

most sensitive indicator of cardiac damage

what does troponin differentiate between?

cardiac vs non-cardiac pain

what happens to troponin levels after MI?

- increases 4-6 hours after MI
- peaks in 10-24 hours
- returns to baseline in 10-14 days

how do you draw blood for troponin lab?

3 sets, 3-6 hours apart

CK-MB lab

- cardiac damage/ischemia
- not as specific as troponin

what happens to CK-MB levels after MI?

- increases 6 hours after MI
- peaks in 18 hours
- returns in 24-36 hours

ESR

erythrocyte sedimentation rate - indicates inflammation

CRP

C-reactive protein - a blood protein that increases in concentration during infections

serum electrolytes

electrical conductivity of heart

BNP/pro-BNP

test Used to access congestive heart failure

lipid panel

series of blood tests (total cholesterol, high-density lipoprotein, low-density lipoprotein, and triglycerides) used to assess risk factors of ischemic heart disease

C-reactive protein (CRP)

- indicates inflammatory illness
- fairly nonspecific
- more sensitive & rapidly responding than ESR
- peaks in 18-72 hrs; failure to normalize may indicate ongoing damage to heart muscle
- not elevated with angina
- useful in monitoring acute inflammation

Erythrocyte Sedimentation Rate (ESR)

- nonspecific indicator of acute or chronic infection, inflammation, tissue infarction
- useful in monitoring chronic inflammation

BNP

- main source is cardiac ventricle
- aids in distinguishing cardiac vs. respiratory cause of dyspnea
- seen often in CHF exacerbations

Pro-BNP

\`more specific to left ventricular dysfunction

normal cholesterol levels

150-200 mg/dL

normal triglyceride levels

40-150 mg/dL

normal LDL levels

< 100 mg/dL

normal HDL levels

\> 40 mg/dL

what do elevated serum lipid levels mean?

high levels of fat in blood

noninvasive procedures & CV disease

- EKG/ECG
- holter monitor
- exercise stress test
- echocardiogram

12-lead EKG

provides information about the electrical conduction of the heart

what is the difference between EKG & telemetry?

EKG gives detailed info of electrical conduction for diagnostic purposes while telemetry is only for monitoring purposes

holter monitor

- test is painless, requires no prep, electrodes must be firmly attached, person continues usual activity
- usually worn for 24 hours
- used to diagnose atrial fib, reasons for fainting or tachycardia

excerise stress/treadmill test

- evaluates heart's response to exercise; use treadmill or exercise bike
- exercise can unmask s/s of CAD or dysrhythmias
- continuous heart monitoring & vital signs are required

echocardiogram

- uses sound waves to create a moving picture of heart
- evaluates valves & chambers of heart
- measures ejection fraction
- no radiation is used
- no prep
- painless
- can be done at bedside

ejection fraction

amount of blood pumped out of the left ventricle with each contraction

what is EF an indication of?

effectiveness of heart "pump"

what are normal EF values?

55-70%

what are low values (under 40) of EJ seen with?

heart failure

bubble study

- done during an ECHO
- fluid/bubbles circulate up to the right side of heart and shows up on echo image

patent foramen ovale

tiny opening between heart's upper chambers and some bubbles will move through hole & appear on left side of heart

trans esophageal echocardiogram (TEE)

probe with an ultrasound transducer is placed down throat with end near heart

where is a trans esophageal echocardiogram done?

vascular lab; invasive

trans esophageal echocardiogram considerations

- NPO for solid food 6 hours before test
- dentures removed
- NPO until gag reflex returns
- temporary sore throat common

3 types of angiography

- contrast
- CT
- MR

contrast angiography

- radiopaque contrast medium injection
- series of x rays taken

contrast angiography nursing care

- check for iodine allergy
- patient teaching: invasive, cannulate vessel
- check extremity for perfusion s/p procedure

CT angiography

- contrast dye is injected and multilayer pictures are taken of vessels
- 3-dimensional

MR angiography

- magnetic resonance
- difference: It does not depend on radiation
- dye used is not iodine

duplex/doppler ultrasound

- combines doppler flow and conventional imaging information; measures speed of flow through vessels; measures diameter of vessel as well as degree of obstruction
- no prep

ankle brachial index (ABI)

- less than 0.9 can indicate PAD
- compares pressure in the ankle to pressure in the arms
- a lower pressure in ankles indicates PAD

how do you calculate ABI?

divide highest pressure in ankle by highest pressure in both arms

venous circulation

carries deoxygenated blood from the extremities back to the heart so it can get replenished with oxygen

arterial circulation

carries oxygenated blood that flows to the extremities

risk factors for arterial diseases

- smoking
- high cholesterol (obesity)
- DM type II
- uncontrolled HTN

types of arterial diseases

- atherosclerosis
- reynaud's disease
- buerger's disease

risk factors for venous diseases

- being cisgender female ( + history of using BC)
- pregnancy
- obesity
- sitting or standing for long periods
- advanced age

types of venous diseases

- varicose veins
- venous insuffiececny
- deep vein thrombosis

VESSEL mnemonic for s/s

Various positions that help alleviate discomfort
Explanation of the pain
Skin (color, temp, nails)
Strength of pulse
Edema
Lesions

arterial various positions

dangling with leg down helps with pain

arterial explanation of problem

- rest pain / sharp pain
- intermittent claudication

arterial skin

- cool
- thin
- dry
- scaly skin
- hairless
- thick toenails

arterial strength of pulse

very poor or even absent

arterial edema present?

no

arterial lesions location

end of toes, top of feet, lateral ankle region

arterial lesions appearance

- very little drainage
- little tissue granulation OR necrotic/black
- deep "punched out" w/ noticeable margins/edges that gives it a round appearance

venous various positions

elevation of legs decreases swelling & helps with blood flow

venous explanation of problem

- heavy, dull, throbbing, achy
- pain is worst when standing or sitting for long periods

venous skin

- warm to touch
- thick, tough skin
- brownish color

venous strength of pulse

present, typically normal

venous edema present?

yes, especially at end of day

venous lesions location

medial parts of lower legs & medial (malleolus) ankle region

venous lesions appearance

- swollen w/ drainage
- granulation present (deep pink to red)
- edges are irregular and depth is shallow

intermittent claudication

leg discomfort, pain or cramping that develops with activity, is relieved with rest, & recurs upon resuming activity

nursing care: PAD assessments

- pulses
- color
- temperature (skin)
- doppler pulses
- pain level
- sensation
- ABI testing

nursing care: PAD interventions to improve circulation

- avoid constrictive clothing, foot wear
- quit smoking (causes vasoconstriction)
- avoid knee-flex position or crossing legs (impedes blood flow)
- take antiplatelet or anticoagulants as prescribed
- medications lower cholesterol and low fat diet
- exercise program

nursing care: PAD interventions to improve pain

per MD/APRN order (meds)

nursing care: PAD interventions for skin integrity

avoid excessive pressure on pressure points of extremities (bony prominsces)

nursing care: PAD surgical/medical intervention

- heparin drips
- percutaneous transluminal angioplasty with or without a stent peripheral artery
- arterial bypass
- amputation (worst case scenario)

nursing care: VAD assessments

- pulses
- color
- temperature (skin)
- pain level
- sensation
- wound assessment

nursing care: VAD preventing venous stasis

- elevate lower extremities above heart level throughout the day (promotes blood return in heart) and avoid standing for long periods of time
- wear elastic compression stockings on affected extremity routinely (make sure they are cleaned & changed daily to prevent infection)

nursing care: VAD wound care

- assess wound for infection and provide wound care per physician's order
- healthy nutrition to promote wound healing

nursing care: VAD avoiding/treating clots

- clot s/s: red, swollen, painful, warm area
- danger signs: dyspnea, chest pain, increased respirations, decrease oxygen sat
- treatment: blood thinners (heparin, warfarin)

nursing care: VAD preventing infection

- monitor CBC (WBC), wound site, proper wound care
- antibiotics if indicated

reynaud's disease

- vasospasm of peripheral arteries mainly to fingers and toes
- fingers or toes start to feel numb or tingle & turn white or bluish
- when cold/stress is removed, they turn a red color with a prickling sensation

reynaud's disease treatment

- calcium channel blockers
- avoidance of triggers

buerger's disease

- blood vessels swell, which can prevent blood flow, causing clots to form
- can lead to pain, tissue damage, & even gangrene
- amputation may be required in some cases
- smoking strongly linked

pericarditis

inflammation of the pericardium

causes of pericarditis

- illness: viral, bacterial infection
- trauma: heart attack, heart surgery, physical injury
- autoimmune: body causes it (lupus)
- unknown: idiopathic

acute pericarditis

pericarditis that lasts for less than 6 weeks (most common)

chronic pericarditis

happens over time & lasts a long time ... about 6 months

pericarditis labs

increased WBC, ESR, CRP

pericarditis mnemonic: FRICTION

* Friction rub pericardial/Fever
Radiating substernal pain to left shoulder, neck or back
* Increased pain when in supine position
* Chest pain that is "stabbing"
Trouble breathing when supine
* Inspiration or coughing makes pain worse
Overall feels very sick and weak
Noticeable ST segment elevation

pericardial effusion

- build up of fluid in pericardium
- may have cough, tachypnea, dyspnea, distant/muffled heart sounds
- can lead to cardiac tamponade (medical emergency)

cardiac tamponade

accumulation of fluid in pericardial sac impairs diastolic filling and reduces CO

cardiac tamponade s/s

JVD, muffled heart sounds, hypotension
( Becks Triad)

pericarditis: nursing care

- bedrest w/ HOB 45 degrees: anxiety reduction
- antibiotics if "bacterial" pericarditis
- NSAIDs (naproxen, high dose ibuprofen, colchicine for recurrent pericarditis)
- prednisone taper (only if NSAIDs ineffective)

endocarditis

inflammation of endocardium (inner layer)

what does endocarditis mainly affect?

- heart valves
- interventricular septum: separates right & left ventricle
- chordae tendineae: fibrous cords of tendons that connect papillary muscle to the tricuspid & bicuspid valves (rupture)

acute infective endocarditis

- affects pt. who have healthy heart valves (high death rate)
- onset is fast & symptoms are very severe

subacute infective endocarditis

- affects people who have a pre-existing condition like rheumatic heart disease, valve problem
- symptoms are subtle & onset slower (several weeks to months to develop)

endocarditis cause

infective: bacteria, virus, or fungi gets into bloodstream & grows on the valve

patients at risk of endocarditis

- history of mitral valve prolapse
- history of rheumatic heart disease
- history of IV drug use
- invasive procedures: implanted device pacemaker, dental work surgery, central line placement
- congenital heart defects

endocarditis s/s

- Petechiae
- Anorexia
- Tired and weak
- High fever & Heart failure
- Osler's Nodes: tender, red lesions on hands & feets
- finGernail changes: splinter hemorrhages that are small, dark lines under the nails
- Embolic events, Erythematous, non-tender nodular lesions on the palms or soles of feet (Janeway lesions)
- Night sweats, New cardiac heart murmur or worsening of one
- Splenomegaly, roth Spots

endocarditis nursing care

- monitor embolic episodes of the spleen, renal, brain, pulmonary status
- signs & symptoms of CHF
- monitor vital signs especially temperature, heart rate, blood pressure, oxygen saturation

endocarditis: monitor spleen embolic

radiating abdominal pain that goes to the left shoulder

endocarditis: monitor renal

flank pain in the groin with possible pus or blood in the urine

endocarditis: monitor brain

changes in neuro status: confusion, speech difficulty

endocarditis: monitor pulmonary

chest pain, SOB, dyspnea, decreased oxygen saturation