2.2 Cardiovascular, Acute Coronary Heart Disease Flashcards

Question

Coronary Artery Bypass Grafting (CABG) Revascularization Prioritize post op nursing interventions

Answer 1

Postop CABG: Know what the patient had done CBP (cardiopulmonary bipass) affects every system- inflammatory response Monitor cardiac output Oxygenation: vent, suction, airway, extubation, O2 Lungs not inflated during procedure (atelectasis Acute pain Dysrhythmias common Temporary pacer (right atrial, left ventricular) Strict I/O- report <30ml/hr x 2hr Chest tube patency, output, air leaks Labs: ABG's, lytes, blood count, coags, renal function Manage IV fluids VS Hemodynamic monitoring Heart sounds: S3/S4, respiratory compromise ``` First several hours is recovery Once stable, recovery is aggressive -early mobilization -pulmonary rehab (inspirex, cough and deep breathing, flutter, ambulation, nebs) -bowel regimen -multimodal pain management -oral care TID with tooth brush -gum chewing -IPC's, SCD's -assess and manage delirium ```

Answer 2

Heart transplant surgery: When mechanical support is not enough Only definitive treatment for end-stage HF Postop care similar to CABG Dysrhythmias common Myocardial stunning common (initial post op HF) Donor heart is denervated- lacks autonomic regulation, HR runs higher 90-110 Infection and rejection are major risks- antirejection meds are critical but increase infection risk

Answer 3

Cardiac output: Amount of blood the heart pumps in 1 minute Cardiac output= heart rate X stroke volume Cardiac index: Index for size, better indicator of cardiac performance Cardiac output adjusted for body size of patient Provides more meaningful data about the heart's ability to perfuse the tissues, therefore is more accurate indicator of the effectiveness of the circulation than CO

Answer 4

Stroke volume includes: preload, afterload and contractility Heart rate X stroke volume = cardiac output Preload: amount of blood remaining in the ventricle. Preload is the end-diastolic stretch on the muscle fibers. Pressure inside the heart just before contraction. Usually volume dependent Afterload: PRESSURE that the ventricular muscles must generate to overcome the pressure in the aorta. Afterload = resistance. Components of afterload: BP, valve compliance (stiff valves, arterial wall compliance (tight arteries) Contractility: inherent ability of the myocardium to contract independent of preload or afterload, velocity and extent of myocardial fiber shortening; quality of the pump. Cannot be directly measured. Influences myocardial oxygen consumption: increased contractility= increased myocardial work= increase O2 consumption. Hear rate: affected by the SNS. Autonomic reflexes trigger heart rate to compensate for changes in cardiac output. Multiple meds are chronotropic, affecting the heart rate. Increasing the heart rate increases cardiac output to the point where it interferes with ventricular filling

Answer 5

Invasive Hemodynamic Monitoring (ART line): Assess cardiovascular function in patients who are critically ill or unstable. Main goal: to evaluate cardiac and circulatory function and the response to interventions. Noninvasive: Pulses, HR, BP, mentation, skin, breath sounds, neck veins. Labs: BNP, ABG, BMP, LFT, lactic acid Invasive: Measure pressures, flow and oxygenation in cardiovascular system Pressure in vessel converted to electrical waveform Parameters include: HR, arterial BP, central venous or right atrial pressure, pulmonary pressures and cardiac output **trends are more significant than individual readings

Answer 6

Mean arterial pressure (MAP): Average pressure in the arterial system during systole and diastole REFLECTS THE PERFUSION PRESSURE Calculate MAP: Systolic pressure + 2x diastole pressure/3 Ex: 120/80 BP 120 + 160 = 280/3 = 93 ``` Normal: Systolic 100-119 Diastolic 60-79 MAP 70-90 <60 is hypoperfusion, not supplying O2 <40 is circulatory collapse ``` **DIASTOLE IS TWICE AS LONG AS SYSTOLE

Answer 7

Dressing: tubing secure/ transparent dressing over insertion site Immobilize: padded splint to immobilize in neutral position (wrist slightly hyper extended) Assess: distal extremity for neurovascular assessments/changes ``` Complication: distal ischemia Thrombus Infection Nerve injury ``` Nursing care: Assess site and distal perfusion Flush lines Maintain dressing and lines **NEVER INFUSE ANYTHING THROUGH ART LINE

Answer 8

Allen's test is used to evaluate ulnar circulation Patient clench fist, apply pressure to both radial and ulnar arteries. Without releasing pressure have patient to unclench fist to relaxed position. Palm should be blanched due to lack of blood flow Release pressure from ulnar artery to observe return of color within 7 seconds If blood flow returns in 7-15 seconds= blood flow impaired If blood flow returns in >15 seconds blood flow is considered inadequate and the radial artery should not be used in this hand

Answer 9

``` Complications: CVC (central line pressure, access by jugular, clavicle) Infection (CLABSI): central line associated bloodstream infection Air emboli Insertion site: -bleeding -hematoma -pneumothorax PA (Pulmonary artery catheterization, access in mid arm) lines: -ventricular dysrhythmias -pulmonary infarction -pulmonary artery rupture -balloon rupture- emboli ``` Nursing care: Verify placement by x-ray prior to infusion Flush line to keep patent Assess distal circulation with limb sites Assess sites for infection, infiltration, phlebitis Strict aseptic technique, scrub the hub Follow protocols for dressing and tubing changes Hold pressure when pulling

Answer 10

Oral contraception | Hormone replacement therapy

Answer 11

``` Risk factor modifications: Smoking cessation Cardiac diet Glycemic control Weight loss ``` Activity guidelines: restrictions and goals ``` Medications ASA/Antiplatelets Beta blockers Nitrates ACE/ARB Statin Diuretics Anticoagulants Antiarrhythmics ``` Multidisciplinary: RN, provider, PT/OT/ST, case manager, social work, cardiac rehab, palliative care Assess capacity for ADL's, mobility , medication management, wound care

Answer 12

``` O2 Supply: Atherosclerosis Anemia Lung disease Dysrhythmias Hypovolemia Valve disorders ``` ``` O2 Demand: Exertion Cardiomyopathy Tachycardia Hypertension Hyperthermia Stress ``` **Myocardial ischemia: insufficient O2 supply= cardiac chest pain

Answer 13

Coronary artery occlusion with stable plaque Platelet aggregation forms a thrombus Coronary vasospasm (Printzmetal's angina) Drop in BP= reduced coronary perfusion pressure Autoregulatory systems fail

Answer 14

Spectrum of myocardial ischemia- injury- infarction- necrosis Not getting enough O2 to heart muscle, supply and demand is off balance Most often due to atherosclerosis Unstable angina Acute myocardial infarction (AMI) -NSTEMI (non ST elevation myocardial infarction) -STEMI (ST elevation myocardial infarction)

Answer 15

CBC- increased WBC r/t inflammation and damaged muscle PT/PTT- baselines before intervention BMP- electrolytes and renal function Liver Function Test ABG's- oxygenation and acid/base balance Assess risk factors: lipid profile, Hgb A1C

Answer 16

Time is muscle. Damage begins within 30 minutes Unstable angina- ischemia: partially occluding thrombus NSTEMI- injury (not full thickness): T wave inverted or ST depressed, enzymes positive, platelet aggregation, early thrombus STEMI- infarction (full thickness): Elevated ST segment, may have Q wave, thrombin rich thrombus, conduction problems can cause life threatening dysrhythmias Necrosis- permanent damage **GOAL: restore blood flow, treat dysrhythmias, stabilize

Answer 17

Morphine: relieves pain, decreases workload O2: keep stats >92% Nitroglycerin: relieves pain, dilates arteries and veins, improves coronary perfusion, reduces workload (usually given first) Aspirin: platelet inhibitor

Answer 18

On arrival: Aspirin ECG Time to PCI or fibrinolytics: 90 min CMS mandate for STEMI Smoking cessation counseling ``` At discharge: Statin Beta Blockers Aspirin ACE/ARB with MI, DM, CHF ```

Answer 19

``` Extension of the original infarct Presents with same s/s as original MI Typically seen 10-14 days after MI Risks is minimized by medication: Aspirin Beta blockers ("olol") ACE ("pril") inhibitors or ARB ("sartan") Revascularization procedures ```

Answer 20

Encephalopathy: Neurologic injury following cardiac arrest Arrest survivors- high risk for hypoxic brain injury and permanent neuro deficits Statistics- up to 80% are comatose, 10-30% have "meaningful neurologic recovery Oxygen and ATP stores that "feed" the brain are used up in about 5 minutes Prevention: Excellent CPR- push hard, push fast Early defibrillation Targeted temperature management or therapeutic hypothermia

Answer 21

Pump Failure: Acute heart failure from muscle wall injury Severity dep on location and size of MI Cardiogenic shock- cardiac output cannot meet O2 demands and organs begin to fail Left HF: Large anterior MI (LV) S/S: crackles, dyspnea, frothy cough, S3 gallop, mentation changes, cough Right HF: Large inferior MI (RV) S/S: JVD, ascites, peripheral edema, hypotension

Answer 22

HF classifications: Acute vs Chronic: Refers to onset and current ability to compensate Left vs Right: One always leads to the other over time Systolic vs Diastolic: Systolic- disease of pumping Diastolic- disease of filling Low output vs High output: Low- cardiac disorder with increased cardiac output High- increased metabolism, cardiac output can't meet demands: hyperthyroidism, sepsis

Answer 23

Monitoring: Labs- BNP, renal, lytes, weights, I/O, BP, HR, breath sounds Education: Meds, diet, daily weights, activity/rests balance, when to call, follow up appointments Medication: Beta blockers ("olol")- reduce O2 demand, workload, HR and BP ACE ("pril")/ARB ("sartan")- vasodilation, reduce O2 demand, workload, remodeling, cardiomyopathy Entresto- combo of ARB and sacubitril, increase natriuretic peptides Diuretics

Answer 24

Blood movement Study of blood flow or circulation Management of volumes and pressures to optimize the delivery of oxygen to all the cells of the body ``` REMEMBER THE CELL The end goal is NOT blood pressure Goal is cellular respiration Cellular respiration is the foundation for life Focus on oxygen delivery to the cell ```

Answer 25

Right: Central Venous Pressure (CVP) Noninvasive- JVD, peripheral edema, weight Left: Pulmonary Capillary Wedge Pressure (PCWP) Noninvasive- lung sounds, BP, urine output (low), weight

Answer 26

Right: Pulmonary vascular resistance (PVR) Elevated PVR = pulmonary hypertension Left: Systemic vascular resistance (SVR) Noninvasive- diastolic blood pressure

Answer 27

Direct, continuous monitoring of systolic, diastolic and mean arterial pressure Easy access for arterial blood samples and ABG's Assess blood volume and response to vasoactive meds Most common placement is radial (femoral and brachial also used) Before placement, check Allen's test

Answer 28

Central Venous Catheter (CVC): Venous access and monitoring central venous pressure Multiple types of CVC access, not all monitor CVP Most common is triple lumen, can read CVP -most common, subclavian, internal jugular, femoral -femoral CVC are not accurate but are useful for trending Purple Power PICCS can be used for CVP monitoring Ports are NEVER used for CVP monitoring ``` Central Venous Pressure (CVP): Pressure in right atrium- ASSESS preload Assesses venous return to the heart- think volume Normal CVP value- 2-6 mmHg (higher in sick people) Increased CVP: -right sided heart failure -volume overload -pulmonary hypertension -cardiac tamponade Decreased CVP: -hypovolemia -shock ```

Answer 29

Pulmonary Artery Catheter (PAC): Placed for detailed assessment for stroke volume and management of shock status High risk- requires meticulous care and monitoring Venous access (right internal jugular most common) -balloon tip "floats" through right ventricle and into pulmonary artery -wedges in small pulmonary artery branch -balloon is then deflated and catheter tip rest there Calculated assessments not directly measured -Cardiac output/index: overall pump function -Systemic Vascular Resistance: left and right, afterload assessment, think constriction (afterload) -Stroke Work Index: left and right, contractility assessment ``` Pulmonary Artery Pressure (PAP): Measured continuously by pulmonary artery catheter Normal PAP 15-30/8-15 Increased PAP -left sided heart failure -increased pulmonary arterial resistance (pulmonary HT, mitral valve disease, hypoxia) Decreased PAP -low circulating blood volume ``` Arterial waveform

Answer 30

PCWP: Reflects left atrial and ventricular pressures Measured when the inflated balloon wedges in the pulmonary vasculature Also called pulmonary artery occlusive pressure and pulmonary artery wedge pressure High risk procedure: Effectively creates a PE Balloon can rupture Can injure the artery Increased PCWP: Left sided heart failure Cardiac tamponade Decreased PCWP: Low circulating blood volume

2.2 Cardiovascular, Acute Coronary Heart Disease Flashcards

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