Cardiac Flashcards Preview

Illness and Patho 1 > Cardiac > Flashcards

Flashcards in Cardiac Deck (513):
0

Peptide secreted by ventricles of the heart in response to excessive stretching of the heart muscles

Brain Natriuretic Peptide

1

What controls the modulation of BNP?

Calcium

2

In a heart failure patient, what would the BNP levels look like?

Elevated

3

System that regulates blood pressure and water balance

Renin Angiotension Aldosterone System

4

The volumetric fraction of blood pumped out of the ventricle with each heartbeat or cardiac cycle

Ejection Fraction

5

What is a normal ejection fraction?

70%

6

What is the danger level of ejection fraction?

<55%

7

The volume of blood pumped from one ventricle with each beat

Stroke volume

8

The stoke volume of the heart increases in response to an increase in the volume of blood filling the heart when all other factors remain constant

Starling's Law

10

The intrinsic ability of the heart to squeeze; the potential of the myocyte to contract

Contractility

11

What is the most accurate measure of how a heart patient is doing?

Ejection fraction

12

Pressure needed to open the aortic valve

Impedance

13

Myocardial fiber stretch, determined by the amount of blood at the end of diastole and by the pulmonary system

Preload

14

The resistance against which the left ventricle must eject its load

Afterload

15

High density lipoproteins that enable the transportation of lipids such as cholesterol

HDL

16

Low density lipoproteins that enable the transportation of lipids such as cholesterol

LDL

17

Stretching the heart too much will cause it to explode

Starling's Law

18

What is the good cholesterol?

HDL

19

What should the HDL levels be?

Greater than 40

20

What should the LDL levels be?

Less than 100

21

Occurs when the kidneys leak small amounts of albumin in the urine indicating protein breakdown and heart disease?

Microalbuminuria

22

Glycerol and a three fatty acid chain that help enable the bidirectional transference of adipose fat and blood glucose from the liver

Triglycerides

23

What should triglyceride levels be?

Lower than 150

24

Protein produced by the liver that rises when there is inflammation throughout the body, especially in the heart

C-Reactive protein

25

A non-protein amino acid which high levels of are linked to cardiovascular disease

Homocysteine

26

What is the left atrial valve?

Mitral

27

What is the normal stroke volume?

50 mL/contraction

28

What is the formula for cardiac output?

CO = HR x SV

29

What is the normal cardiac output?

4-7 L/min

30

What factors affect preload?

Blood volume, muscle fiber length, and tension

31

As preload increases, what also increases?

Oxygen demand

32

What is the right atrial valve?

Tricuspid

33

What factors affect after load?

Blood pressure and the diameter of the blood vessels

34

As after load increases, what decreases?

Cardiac Output

35

What factors influence impedance?

Blood viscosity, arterial constriction, and aortic compliance

36

What are the two major divisions of the circulatory system?

The systemic division and the pulmonary division

37

What are the semilunar valves?

Aortic and pulmonic

38

What does cold air do to systemic vascular resistance?

Increases it

39

What are the non-modifiable risk factors for cardiac disease?

Family history, diabetes mellitus, gender, and age

40

Which gender is at the biggest risk for cardiac disease?

Men until women reach menopause, then it equals out

41

Why do women with cardiac disease fair worse then men?

They have less collateral circulation

42

What is the dominant artery in females?

The right anterior decending

43

Why do older patients with coronary artery disease fair better than younger patients?

They have developed better collateral circulation

44

What values indicate metabolic syndrome?

Fasting glucose > 100, low HDLs, triglycerides > 150, BP >130/85, and waist circumference > 35" (F) or 40" (M)

45

What causes hyperurecemia and gout?

Increased uric acid produced by and excess of meats and alcohol

46

What diseases that occur during pregnancy increase the risk of cardiovascular disease later in life?

Preeclampsia and gestational diabetes

47

What does heavy alcohol intake increase the risk of?

Hypertension, arrhythmias, and heart disease

48

What cardiovascular problems does cocaine cause?

Spasms of the coronary arteries, atherosclerosis, and thrombosis

49

What cardiovascular problems do amphetamines cause?

Acute hypertension, arrhythmias, myocardial infarctions, and cardiomyopathy

50

What history should a patient with dyspnea be asked?

When did you first notice it, what brings it on, how is it relieved, and if they are taking any meds for it

51

What history should a patient with orthopnea be asked?

Number of pillows to sleep and the onset of the symptoms

52

What history should a patient with paroxysmal nocturnal dyspnea be asked?

Ask about sudden onset and termination

53

What history should a patient with a cough be asked?

When was it first noticed, is it productive, is it dry or moist, when did it first occur

54

What does a dry cough indicate?

Cardiac related without heart failure

55

What does a moist cough indicate?

Respiratory causes

56

What does a night cough indicate?

Cardiac related

57

What history should a patient with fatigue be asked?

What activities can no longer be performed, how often do you need to rest, and do you nap during the day

58

What history should a patient with chest discomfort be asked?

Type, location, how often, what precipitates it, and what alleviates it

59

What does a weight increase in a cardiac patient indicate?

Fluid increase

60

What is the most common symptom that brings patients with cardiac problems to the doctor?

Fatigue

61

What is an appropriate BMI range?

18.5 kg/m2 and 24.9 kg/m2

62

Why is BMI not alway accurate?

It doesn't take the weight of muscles into account

63

What does a BMI of over 25 indicate?

The patient is overweight

64

What does a BMI of over 30 indicate?

The patient is obese

65

What does waist circumference indicate?

Central obesity

66

What should a patient's head and neck be evaluated for?

Carotid bruits, JVD, and xanthomas

67

What is an early sign of CHF?

S3 heart sound

68

What does an S4 heart sound indicate?

Hypertension

69

What would a dissecting aorta present as?

Searing, unrelenting back pain

70

What are the mitral and aortic changes related to calcification that occur normally with age?

Murmurs, valve changes, and possibly rhythm changes

71

Fatty deposits around the eyes

Xanthomas

72

What do the decreased number of pacemaker cells that occur with advancing age cause?

Dysrhythmias and a slower heart rate

73

As people age, conduction time increases and what occurs?

PVCs

74

The increase of fat and fibrous tissue in the SA node that occurs with age results in what?

A loss of inherent rhythm

75

What do xanthomas indicate?

Elevated cholesterol levels

76

As people age, how does the left ventricle change?

Increases in size, stiffens, and undergoes fibrotic changes, undergoes hypertrophy

77

What do the changes that occur in the left ventricle with age result in?

Decreased ejection fraction, activity intolerance, and a decrease in diastolic filling

78

As people age, how do the aorta and arteries change?

They thicken and stiffen

79

What do the changes that occur in the aorta and arteries with age result in?

Hypertension, increased SVR, and there is a risk of target organ damage

80

As people age, what happens to their baroreceptors?

They become less sensitive

81

What does the decrease in sensitivity of the baroreceptors cause?

Orthostatic hypothension

82

As people age, what changes does the SA node undergo?

Increases in fat and fibrous tissue

83

What does the lipid panel measure?

Cholesterol, lipoproteins, and triglycerides

84

What causes an increase in lipid panel measurements?

Atherosclerosis

85

What is the emerging risk factor and indicator of metabolic syndrome?

Triglycerides

86

What should a patient's total cholesterol be?

Less than 200 mg/dL

87

What should be Lp(a) levels be?

Less than 30 mg/dL

88

What is a lipoprotein-a?

A modified LDL

89

What c-reactive protein level is normal?

1 mg/dL

90

What c-reactive protein level indicates risk for heart disease?

>3 mg/dL

91

Elevated c-reactive protein levels in patients over 60 indicate which type of drug therapy?

Statins

92

What do high levels of homocysteine cause?

Cell walls become vulnerable to plaque buildup

93

What are high levels of homocysteine treated with?

Dietary sources of B vitamins

94

What does a fasting blood glucose test for?

Metabolic syndrome and diabetes

95

What does creatinine test for?

Chronic renal insufficiency

96

What are ECGs used to evaluate?

Left ventricular hypertrophy

97

What does left ventricular hypertrophy indicate?

Longstanding hypertension

98

What does a patient undergoing an Exercise Treadmill Test have to be watched for?

Rebound effect

99

Why is Chantix a preferred smoking cessation treatment?

It doesn't have nicotine in it

100

How to you know that you are exercising at an appropriate level?

The patient is in a target heart rate and has no chest pain

101

Why is the "Heart Healthy Diet" no longer recommended?

It is too high in sugar

102

Why are soluble fibers good for your diet?

Binds fat in the intestine and helps to lower cholesterol levels

103

Drugs used to lower LDL and triglyceride levels when diet isn't enough

Statins

104

How much does statins lower total cholesterol levels by?

20%

105

Name the statins

Zocor, mevacor, lipitor, crestor, and pravachol

106

What is the action of statins?

They reduce cholesterol synthesis in the liver and increase clearance of LDL from the blood

107

What symptom indicates that statins should be stopped?

Muscle pain

108

In what patients are statins contraindicated?

Patients with liver disease, pregnancy, rhabdomyolysis, and cholestasis

109

What needs to be monitored for patients on statins?

Liver enzymes, total cholesterol levels, CPK levels, and PT

110

When should statins be taken?

In the evening

111

What needs to be avoided by a patient on statins?

Grapefruit

112

Ezetimibe, used in place of or with statins to inhibit absorption of cholesterol through small intestines

Zetia

113

Combo of ezetimibe and simvastatin

Vytorin

114

Lowers LDL and VLDL and increases HDL

Niacin

115

What side effect is associated with niacin?

Flushing

116

What needs to be monitored when a patient is on niacin?

Liver enzymes

117

Combines niacin and lovastatin

Advicor

118

Reduce triglycerides and decreases plaque, inflammation, and clots

Omega-3 Fatty Acids

119

A chronic disease of the arterial system including abnormal thickening and hardening of the vessel walls

Arteriosclerosis

120

What causes the stiffening of arteries in arteriosclerosis?

Smooth muscle cells and collagen fibers migrate to the tunica intima

121

What molecules affect arteriosclerosis?

Cholesterol, lipids, and phospholipids

122

What are the modifiable risk factors for arteriosclerosis?

Obesity, sedentary lifestyle, smoking and stress

123

What diseases exacerbate arteriosclerosis?

Hypertension or poor tissue perfusion

124

What is the leading cause of coronary and cerebrovascular heart disease?

Atherosclerosis

125

How does atherosclerosis occur?

Soft deposits of intra-arterial fat and fibrin in vessel walls harden over time

126

At what point will a patient realize they have atherosclerosis?

Only when a complication occurs

127

How does arteriosclerosis occur?

The artery gets damaged, setting off an inflammatory response and leading to cholesterol flooding the vessel, making it sticky

128

Why does an injured vessel get sticky?

Injured cells produce lower amounts of antithrombic and vasodilating cytokines

129

What are the causes of injuries to arteries that lead to arteriosclerosis?

Elevated blood sugars and hypertension

130

How is a foam cell formed?

LDL is engulfed by macrophages

131

What is the pathophysiology of arteriosclerosis?

Injury, cellular proliferation, macrophage migration, LDL oxidation, foam cell formation, foam cell accumulation leads to a fatty streak, fibrous plaque, and complicated plaque

132

What are the clinical manifestations of arteriosclerosis?

Inadequate tissue perfusion, TIA, superimposed thrombus formation, and tissue infarction

133

What are TIAs associated with?

Exertion, exercise, or stress

134

What is the goal for patients with arteriosclerosis?

Restore tissue perfusion

135

Measure of force applied to walls of the arteries as the heart pumps blood throughout the body

Blood pressure

136

What factors determine blood pressure?

Strength of the contraction, amount of blood pumped into the arteries, viscosity of blood and size and flexibility of arteries

137

Who has smaller arteries?

Women

138

Elevated systolic and/or diastolic blood pressure

Hypertension

139

If a patient has heart disease or diabetes, what is the recommended blood pressure?

<130/90

140

What is the recommended blood pressure for average patients?

<120/80

141

What does an increased blood pressure do to the workload of the heart?

Increases it

142

What does an increased blood pressure do to the physiology of the heart?

Causes it to enlarge and weaken

143

What population in the US is at higher risk for hypertension?

Male african americans and people with diabetes

144

What are the parameters for prehypertension?

120-139/80-89

145

What part of the nervous system regulates blood pressure?

Autonomic nervous system

146

What aspects of blood pressure are controlled by the autonomic nervous system?

Controls vessel diameter and peripheral vascular resistance

147

Which hormones of the autonomic nervous system regulates blood pressure?

Epinephrine and Norepinephrine

148

What does the sympathetic nervous system do in response to lowered blood pressure?

Increases heart rate, speed of conduction, contractility and peripheral vasoconstriction

149

What does the parasympathetic do in response to increased blood pressure?

Decreases heart rate, contractility and conductivity

150

Which hormone controls the parasympathetic nervous system's response to increased blood pressure?

Acetylcholine

151

What do chemoreceptors respond to changes in?

PaO2, PaCO2, and pH

152

What do chemoreceptors do?

Stimulate vasomotor center in the medulla controlling vasoconstriction and vasodilation

153

Where are the baroreceptors located?

Carotid sinus, aorta, and left ventricular wall

154

What are the parameters for Stage 1 hypertension

140-159/90-99

155

What do baroreceptors respond to changes in?

Arterial pressure

156

How do the baroreceptors counteract a rise in arterial pressure?

Through the vagus nerve

157

What do the baroreceptors do?

They slow pulse and cause vasodilation

158

What causes baroreceptors to fail?

Hypertension

159

How does the amount of fluid in the ECF regulate blood pressure?

The increase in Na causes increased blood return to the heart, increased cardiac output, and diuresis

160

What changes does ADH undergo in response to blood volume?

Decreases in response to increased volume, increases in response to decreased volume

161

How does the R-A-A-S regulate blood pressure?

A rise in cardiac output produces diuresis, and stimulates Angiotensin 2 and aldosterone to constrict vessels and promote water retention

162

What are the parameters for Stage 2 hypertension?

>160/>100

163

What does inappropriate secretion of renin increase?

PVR in essential hypertension

164

When blood pressure increases, what should renin do?

Fall

165

Idiopathic hypertension with no known cause

Primary or essential hypertension

166

How many of the cases of hypertension does primary hypertension account for?

92-95%

167

Hypertension caused by a systemic disease process that raises peripheral vascular resistance or cardiac output?

Secondary hypertension

168

Rapidly progressing elevation of blood pressure to >200/>130

Malignant hypertension

169

What are the symptoms of malignant hypertension?

Blurred vision, headaches, dyspnea, and uremia

170

Increased waste products in blood signifying a renal problem

Uremia

171

As we age, which is a better indicator for heart disease and stroke, systolic or diastolic blood pressure?

Systolic Blood Pressure

172

What is the most common form of hypertension in older adults?

Isolated systolic hypertension

173

What type of hypertension does white coat syndrome cause?

Isolated systolic hypertension

174

What diseases cause secondary hypertension?

Renal dysfunction, dysfunction of the adrenal medulla or cortex, primary aldosteronism, pheochromocytoma, Cushing's syndrome, coarctation of the aorta, neurogenic disturbances, and medications

175

Why does a pheochromocytoma cause hypertension?

Excretes lots of epinephrine

176

What does aldosterone do to blood pressure and how?

It promotes sodium and therefore water retention, raising blood pressure

177

What is coarctation of the aorta?

Narrowing of the aorta

178

Chronic hypertensive damage to the walls of systemic blood vessels

Complicated hypertension

179

What accompanies complicated hypertension?

Target organ damage

180

What happens to the vasculature in patients with complicated hypertension?

Formation, dissection, rupture of aneurysms, occlusion, and edema

181

What happens to the renal system in patients with complicated hypertension?

Nephrosclerosis, renal arteriosclerosis, and renal insufficiency and failure

182

What is an early sign of renal damage caused by hypertension?

Protein in urine

183

What happens to the retinas of patients with complicated hypertension?

Impaired vision, retinal vascular stenosis, hemorrhage, and exudation

184

What happens to the brain of patients with complicated hypertension?

TIA, stroke, cerebral thrombosis, aneurysm, hemorrhage, and cognitive decline in the elderly

185

How is primary hypertension treated?

Diuretics, beta blockers, and ACE inhibitors

186

What do beta blockers or ACE inhibitors treat in patients with primary hypertension?

Overstimulation of sympathetic neural fibers in the heart and great vessels

187

What do diuretics treat in patients with primary hypertension?

Increased blood volume, water and sodium retention, and the hormonal inhibition of Na-K transport across cell walls

188

What diuretic should patients with primary hypertension be on?

Spironalactone

189

What should patients with primary hypertension try first for treatment?

Life style modification

190

What diagnostic workups should be done for patients with hypertension?

ECG, urinalysis, blood glucose, Hct, lipid panel, serum K, Ca, creatinine, and BUN

191

What would an ECG show to diagnose hypertension?

Evidence of left atrial and ventricular hypertrophy

192

Why is an urinalysis obtained in patients with hypertension?

To indicate whether there is renal damage from that hypertension

193

What diuretics can be given to patients with hypertension?

HCTZ, Lasix, Bumex, or Aldactone

194

What do calcium channel blockers do?

Interfere with membrane transfer of Ca leading to vasodilation

195

What are the calcium channel blockers?

Amlodipine and Cardizem

196

What do ACE inhibitors do?

Inhibit the enzyme that converts Angiotensin 1 to Angiotensin 2, preventing vasoconstriction

197

What are the ACE inhibitors?

Enalapril, captopril, and prinivil

198

What is a side effect of ACE inhibitors?

Dry, hacking cough, and fluid trapped in lower extremities

199

What do ARBs do?

Block Angiotensin 2 from binding to its receptor, thereby blocking vasoconstriction

200

What are the ARBs?

Losartan, candesartan, and telmesartan

201

What do the aldosterone receptor antagonists do?

Block aldosterone binding at receptor sites in the kidney, heart, blood vessels, and brain, thereby inhibiting water and sodium retention, reducing total plasma volume

202

What are the aldosterone receptor antagonists?

Inspra

203

What do beta blockers do?

Decrease contractility and heart rate, decreasing cardiac output

204

What are the beta blockers?

Metoprolol, atenolol, Coreg, Zebeta

205

What needs to be checked before administering a beta blocker?

Heart rate and blood pressure

206

What do central alpha agonists do?

Prevent uptake of norepinephrine, thereby decreasing vascular resistance

207

What are the central alpha agonists?

Clonidine

208

What do alpha adrenergic agonists do?

Dilate arterioles and veins, decreasing PVR

209

What are the alpha adrenergic agonists?

Minipress

210

What do renin inhibitors do?

Inhibit vasoconstriction and aldosterone production, reducing Na reabsorption and fluid retention

211

What are the renin inhibitors?

Aliskiren

212

What is the best medication for patients with heart disease?

Beta blockers

213

What needs to be monitored when a patient is on antihypertensives?

Vital signs, orthostatic blood pressures, and electrolytes, especially potassium

214

In general, when would you hold an antihypertensive medication?

Systolic < 90, diastolic <60

215

How long should nicotine and caffeine be withheld after administering an antihypertensive?

1 hour

216

What activities should be avoided for patients on antihypertensive medications?

Hot tubs, saunas, alcohol, and exercise

217

How often should home blood pressures be taken?

Once a week

218

What does a patient on antihypertensive meds need to be taught?

Lifetime therapy, orthostatics, sodium restriction, water restriction, and relaxation techniques

219

When does a hypertensive crisis occur?

When patient's hypertension has been poorly controlled, undiagnosed, or if they have abruptly stopped taking their medications

220

What is the treatment for a hypertensive crisis?

IV antihypertensives

221

What are the IV antihypertensives used in a hypertensive crisis?

Nipride, Cardene, and normodyne

222

What types of drugs are the IV antihypertensives?

Potent beta blockers

223

What do IV antihypertensives need to be protected from?

Light

224

How often should the blood pressure of a patient in a hypertensive crisis be monitored?

Every 5 minutes

225

Who is most at risk for heart failure?

African Americans

226

Why is heart failure a major cause of death and disability after a MI?

Because the heart muscle is destroyed

227

General term used to describe several types of cardiac dysfunction that results in inadequate perfusion of tissues with blood borne nutrients

Heart failure

228

What are the types of heart failure?

Left sided, right sided, and high output heart failures

229

What proceeds 75% of heart failure cases?

Hypertension

230

What disease causes heart failure because of pulmonary and aortic stenosis?

Rheumatic heart disease

231

What population is most at risk for endocarditis?

Drug abusers

232

What is the most common dysrhythmia?

Atrial fibrillation

233

Which type of drug attacks the heart muscle?

Mycins

234

What are the causes of heart failure?

Hypertension, CAD, cardiomyopathy, alcohol and drug abuse, valve disease, congenital defects, cardiac infections, dysrhythmias, diabetes mellitus, smoking, family history, hyperthyroidism, and chemotherapy

235

What is the most common type of heart failure?

Left sided heart failure

236

What are the causes of left sided heart failure?

Hypertension, CAD, and valvular disease

237

What are the clinical manifestations of left sided heart failure?

Decreased CO and severe pulmonary congestion

238

Is systolic or diastolic heart failure more common?

Systolic

239

With systolic heart failure, what happens to preload, after load, ejection fraction, and tissue perfusion?

Preload increases, after load increases, ejection fraction decreases and tissue perfusion decreases

240

Left ventricle can't relax enough during diastole, preventing inadequate filling

Diastolic heart failure

241

What happens to the ventricles during diastolic heart failure?

They stiffen

242

With diastolic heart failure, what happens to stroke volume, CO, and ejection fraction?

All remain normal

243

Decreased contractility of the heart, causing the heart to not be able to eject adequate blood

Systolic heart failure

244

What is the sign of systolic heart failure?

Increase pulmonary blood, so crackles in the lungs

245

Who is more at risk for diastolic heart failure?

Older adults and women post MIs

246

What is the sign of diastolic heart failure?

Crackles in the lungs

247

What happens to the coronary vessels of patients with diastolic heart failure?

They don't get perfusion and adequate filling, causing a buildup of lactic acidosis

248

What are the symptoms of left sided heart failure?

Fatigue, weakness, activity intolerance, oliguria, confusion, restlessness, dizziness, tachycardia, palpitations, chest discomfort, arrhythmia, S3 gallop, pallor, pulmonary congestion, dyspnea, orthopnea, tachypnea, cough, and paroxysmal nocturnal dyspnea

249

What arrhythmias are common in patients with left sided heart failure?

Atrial fibrillation, PACs, and PVCs

250

What are the early signs of left sided heart failure?

Coughing at night and S3 gallop

251

Where would adventitious lung sounds be heard in patients with left sided heart failure?

Crackles and wheezes heard from the bases up

252

When would frothy pink-tinged sputum be seen in patient with left sided heart failure?

As it progresses to include pulmonary edema

253

Why does pulmonary pressure increase in patients with left sided heart failure?

The left ventricle fails to eject sufficient blood

254

What are the signs of pulmonary edema?

Crackles, dyspnea at rest, anxiousness, tachycardia, disorientation, and confusion

255

What are the signs of worsening pulmonary edema?

Pink, frothy sputum, cold and clammy, and cyanosis

256

The right ventricle is unable to empty completely, causing increased volume and pressure in the systemic veins

Right sided heart failure

257

What is the most common cause of right sided heart failure?

Diffuse hypoxic pulmonary disease

258

What are the signs of right sided heart failure?

Peripheral edema, JVD, hepatomegaly, splenomegaly, distended abdomen, increases abdominal girth, ascites, nocturnal polyuria, weight gain, anorexia, and nausea

259

Where would peripheral edema be seen in patients with right sided heart failure?

From the lower legs and ascending

260

What causes the anorexia and nausea seen in patients with right sided heart failure?

Liver engorgement

261

Physical changes in the heart that occur with heart failure

Remodeling

262

What are the causes of right sided heart failure?

LV failure, RV MI, pulmonary hypertension, and increased left ventricular filling pressure

263

What remodeling occurs in patients with heart failure?

Enlargement and thinning of the left ventricle, causing contractile dysfunction and mitral valve regurgitation

264

What happens to the use of oxygen, ejection fraction, and CO in patients with remodeling?

Increased use of oxygen, decreased ejection fraction, and reduced CO

265

What hormone contributes to remodeling in patients with heart failure?

Angiotensin 2

266

Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms

Stage B

267

What are the compensatory mechanisms for heart failure?

Increase in catecholamines, increase in CO, tachycardia, increase in oxygen demand, increased stroke volume, increased venous return, more forceful contractions, and arterial vasoconstriction

268

Heart failure patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion

Class 2

269

What are the catecholamines?

Epinephrine and norepinepherine

270

Patients with current or prior symptoms of heart failure

Stage C

271

What does the increase in catecholamines do for patients with heart failure?

Increases heart rate and blood pressure

272

Heart failure patients with no limitations of activity, they suffer no symptoms from ordinary activities

Class 1

273

What system in activated in patients with heart failure due to reduced blood flow to kidneys with decreased CO?

R-A-A-S

274

What does the R-A-A-S do for patients with heart failure?

Vasoconstriction, aldosterone secretion, increase in preload and after load, and ventricular remodeling

275

Patients at high risk for developing heart failure

Stage A

276

What is the immune response to heart muscle injury?

Release of cytokine, interleukins, and endothelin

277

What does endothelin do for patient with heart failure?

Increases peripheral resistance and hypertension, actually worsening the heart failure

278

Patients with refractory end-stage heart failure

Stage D

279

Thickening of the heart muscle to compensate for low output

Hypertrophy of the myocardium

280

Heart failure patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest

Class 4

281

Potent vasoconstrictor that is released with stretching of myocardial fibers

Endothelin

282

What does myocardial hypertrophy do for patients with heart failure?

Increases the force of the contraction

283

Tumor necrosis factor that contributes to ventricular remodeling

Cytokine

284

What is a symptom of myocardial hypertrophy?

Loss of appetite

285

Heart failure patients with marked limitation of activity; they are comfortable only at rest

Class 3

286

Produced by ventricles with fluid overload from heart failure

BNP

287

What system does BNP counteract?

R-A-A-S

288

What does BNP promote?

Vasodilation and diuresis

289

Which sex has a higher concentration of BNP?

Women

290

Secreted by the posterior pituitary as a result of lower cerebral perfusion from low cardiac output

ADH

291

What does ADH do?

Causes vasoconstriction and fluid retention

292

What does ADH do for heart failure?

Worsens it

293

What are the diagnostic tests for heart failure?

Electrolytes, BUN, creatinine, urinalysis, microalbuminuria, Hb, Hct, BNP, ABG, SCG, echocardiogram, chest xray, and a MUGA scan

294

Why are Hb and Hct taken for patients with heart failure?

To see if the heart failure is a result of anemia

295

What type of heart failure would BNP be especially elevated in?

Diastolic failure

296

What are normal levels of BNP?

<100

297

Why is a BNP taken for patients with heart failure?

To differentiate between respiratory symptoms of cardiac versus pulmonary nature

298

Why is an ABG taken for patients with heart failure?

To reveal hypoxia and blood oxygenation

299

What does an ECG reveal for patients with heart failure?

Ischemia, injury to heart, dysrhythmias, and hypertrophy

300

What does an echocardiogram reveal in patients with heart failure?

Ejection fraction, hypertrophy, chamber enlargement, and valvular function

301

What does a MUGA scan reveal in patients with heart failure?

MUGA scans calculate LV ejection fraction and velocity

302

What extra test is done for patients with heart failure who are in critical care?

Pulmonary artery catheter measurements of pressure

303

What do pulmonary artery catheter measurements of pressure show?

Ventricle end diastolic pressures

304

What do chest X-rays reveal for patients with heart failure?

Show shape, size and location of the heart

305

What is the goal of treatment for patients with heart failure?

Reduce after load, reduce preload and improve cardiac contractility

306

What types of drugs reduce after load?

ACE inhibitors, ARBs, and B-type natriuretic peptides

307

What types of drugs reduce preload?

Sodium restriction, fluid restriction, diuretics, and venous vasodilators

308

Which drugs improve cardiac contractility?

Positive inotropic meds, vasodilators, and beta blockers

309

Which population are ARBs less effective in?

African Americans

310

What patients are ARBs good for?

Patients with the cough from ACE inhibitors and those at risk for hyperkalemia

311

What type of diet should patients with heart failure be on?

2-3 grams of sodium/day, 2 L of fluid/day

312

What do patients with heart failure need to monitor closely?

Weight and electrolyte levels

313

How long do loop diuretics take to work?

5 minutes

314

What is a side effect of rapid administration of Lasix?

Ototoxicity

315

How does aldactone spare potassium?

Inhibits reabsorption of sodium in distal tubules in exchange for potassium

316

What is the sign of hyperkalemia?

Peaked T waves

317

Drug used for patients with acute heart failure with dyspnea

Nitrates

318

What do nitrates do for patients with heart failure?

Reverses vasoconstriction, decreases volume of blood returning to the right ventricle, and improves left ventricular function

319

How do nitrates improve left ventricular function?

They increase coronary arteriole blood flow

320

What is the side effect of nitrates?

Head ache

321

Drugs given to decrease preload and after load, reduce anxiety, and slow respirations in patients with heart failure

Morphine sulfate

322

How are morphine sulfates given to patients with heart failure?

IV, in 1-2 mg increments

323

What do beta blockers do for patients with heart failure?

Improves morbidity, mortality, quality of life, and increases ejection fraction

324

How should beta blockers be administered?

Initial doses are low, started slowly and titrated up

325

What do cardiac glycosides do?

Improve cardiac contractility and decrease heart rate

326

Name the cardiac glycosides

Digoxin and digitalis

327

Why are cardiac glycosides used less often?

They increase myocardial oxygen demand

328

What patients are cardiac glycosides used for?

Those in either sinus rhythm or atrial fibrillation with class 3 or 4 heart failure

329

How is IV digoxin given?

Over at least 5 minutes

330

What needs to be assessed before giving IV digoxin?

Apical pulse

331

What teaching needs to take place for patients taking digoxin?

Don't take with antacids, look for hypokalemia, how to take pulse and assess rhythm

332

Why would hypokalemia be very bad for patients on digoxin?

It increases the risk of dig toxicity

333

What are the signs of dig toxicity?

Bradycardia, halo vision, seeing red and yellow lights, dysrhythmias, anorexia, mental status changes, vomiting, and fatigue

334

What is the antidote for digoxin?

Digubine

335

Beta-adrenergic agonist given IV for short-term treatment of acute heart failure to improve contractility and increase cardiac output

Dobutrex

336

Inotropic and vasodilator, phosphodiestrerase inhibitor given IV that enhance calcium entry into heart cells and increases contractility

Milrinone (Primacor)

337

What is the therapeutic range of digoxin?

0.8-2.0 mg/mL

338

How often should a pulse ox be taken on a patient with heart failure?

Every 1-4 hours

339

At what level should oxygen sats be maintained in patients with heart failure?

>90%

340

How often should patients with heart failure do deep breath and cough exercises?

Every 2 hours

341

How often should breath sounds be assessed on patients with heart failure?

Every 4 hours

342

In what position should patients with heart failure be in?

High Fowlers

343

What are the goals for patients with heart failure?

Improve tissue perfusion, improve gas exchange, and increase activity tolerance

344

What are the nursing implications for increasing activity tolerance in patients with heart failure?

Assess cardiovascular response to activity, assess vital signs, alternate periods of rest and activity, avoid activity immediately after meals, teach patients how to minimize oxygen consumption

345

What indicates activity is too much for patients with heart failure?

Any dramatic change in vital signs

346

What is a dramatic change in vital signs?

Change of blood pressure of 20 mmHg or more or increase in heart rate of 20 beats/minute or more

347

How can patients with heart failure minimize oxygen consumption?

Cluster activities to avoid using all of their oxygen reserve

348

What health teaching is needed for patients with heart failure?

Fluid restriction; daily weights and reporting gains of 2-3 pounds or more; sodium restriction; small, frequent meals; report edema and cough; and how to take pulse and blood pressure

349

Acute condition associated with severe heart failure in which the pressure in the lounge is increased from accumulation of blood

Pulmonary Edema

350

Why are patients with pulmonary edema placed in High Fowlers with their legs down?

To decrease venous return

351

How is pulmonary edema treated?

High flow oxygen through a non-rebreather at 10 L, give nitro, diuretics, and morphine

352

What is the side effect of HCTZ?

Decrease in male libido

353

What causes the dry, persistent cough associated with ACE Inhibitors?

Accumulation of kinins in the respiratory tract

354

What do patients taking aldosterone receptor antagonists need to be taught?

Avoid extra potassium, don't use salt substitutes

355

What are the side effects of aldosterone receptor antagonists?

Gynecomastia and progesterone stimulation

356

What do central alpha agonists do?

Decrease systolic and diastolic blood pressure and heart rate

357

What are the side effects of central alpha agonists?

Postural hypotension, sedation, and impotence

358

What is the largest affect of alpha adrenergic agonists on?

Diastolic pressure

359

What diseases, besides heart disease, are alpha adrenergic agonists used for?

Raynaud's disease and BPH

360

What do patients on renin inhibitors need to be monitored for?

Angioedema

361

How is the filling volume and pressure on the right side of the heart assessed?

Jugular venous pressure

362

How are pack-years determined?

Number of packs per day multiplied by the number of years the patient has smoked

363

S3 is what kind of gallop?

Ventricular

364

Which types of ulcers are more common?

Venous

365

Which types of ulcers are more severe?

Arterial

366

Atherosclerotic disease of arteries that perfuse the limbs

Peripheral vascular disease

367

How often does peripheral vascular disease occur in patients over 70?

12-20%

368

What is generally the end result of peripheral vascular disease?

Limb amputation

369

S4 is what kind of gallop?

Atrial

370

What are the symptoms of peripheral vascular disease often mistaken for?

Aging or peripheral neuropathy

371

Distal end of aorta and iliac arteries

Inflow

372

Where do patients with inflow occlusion complain of pain?

Lower back, buttocks, or thighs

373

Intra-inguinal artery segments, below the superficial popliteal

Outflow

374

Where do patients with outflow occlusion complain of pain?

Calves, ankles, and feet

375

Which type of occlusion causes significant damage?

Outflow

376

Where is tissue perfusion altered in patients with occlusions?

Below the level of occlusions

377

What is usually the first symptom of PAD?

Intermittent Claudication

378

What percentage of patients with PAD have intermittent claudication?

15-40%

379

Pain that occurs even while at rest; numbness and burring in the distal portion of extremities that is relieved with dependent position

Rest pain

380

Ulcers; blacked tissue on toes, forefoot, heel with a gangrenous odor

Gangrene/necrosis

381

Where do patients with PAD lose hair?

Lower calf, ankle, and foot

382

Pain, cramping, burning in the legs, usually at calf with ambulation or exercise that subsides at rest

Intermittent Claudication

383

What does the skin of patients with PAD look like?

Dry, scaly, mottled and thickened toenails

384

What color is the skin of patients with PAD?

Cold, gray-blue, or darkened, pallor when elevated and rub or when lowered

385

Painful ulcers on or between toes at pressure points with deep, pale, even edges that won't heal or heal slowly

Arterial ulcers

386

What is Buerger's test?

Capillary refill is greater than 15 seconds, indicating vascular compromise

387

Line of demarcation that will not spread to healthy tissue; causes affected area to wither and die

Dry gangrene

388

Soft tissue swelling due to infection of strep or staph, causing the tissue to die

Wet gangrene

389

Where are arterial (ischemic) ulcers frequently seen?

On the dorsum of the foot

390

What color are arterial ulcers?

Pale, gray, or yellow, possibly with eschar

391

What would the segmental systolic blood pressures of patients with PAD reveal?

Leg pressures are lower than in the upper extremities

392

Where are segmental systolic blood pressure taken?

Thigh, calf, and ankle

393

What would an exercise tolerance test show in patients with PAD?

After 5 minutes on the treadmill, the able pulse pressure will drop and claudication will occur

394

Graphs of arterial flow that detect changes in the volume of an organ, limb, or body by measuring the flow of blood through its veins and arteries

Plethysmography

395

How is the ankle-brachial index determined?

Divide the ankle pressure by the branchial pressure

396

What is a normal ankle-brachial index?

0.9-1.0

397

What test is used to diagnose PAD in diabetics?

Toe-brachial index

398

What ankle-brachial index indicates severe PAD?

0.5-0.75

399

What is the most frequent test done to diagnose PAD?

Dopplers

400

What ankle-brachial index indicates moderate PAD?

0.75-0.9

401

What is the nonsurgical management of PAD?

Exercise, positioning, promoting vasodilation, avoidance of cold, adequate fluids, and drug therapy

402

Test using two forms of ultrasound to show the structure of the blood vessels and the movement of the RBCs through the vessels

Dopplers

403

What ankle-brachial index indicates life-threatening PAD?

Below 0.5

404

What position needs to be avoided in patients with PAD?

Crossed legs

405

How is vasodilation promoted in patients with PAD?

Warmth and avoidance of nicotine and alcohol

406

What do Doppler studies reveal?

Obstruction, speed, and direction of flow in the blood vessels

407

What drugs are used for antiplatelet therapy?

Aspirin or Plavix

408

Suppresses platelet aggregation and acts as a direct arterial vasodilator

Pletal

409

What does pletal treat?

Claudication and improves skin temperature

410

In what patients is pletal contraindicated?

Patients with CHF

411

Dilates the arteries with a balloon catheter; may use a stent to maintain patency

Percutaneous Transluminal Angioplasty

412

What types of of occlusions are percutaneous transluminal angioplasty useful for?

Arterial occlusions that are accessible with the catheter and in patients who are poor surgical risks

413

When should patients with PAD avoid exercise?

If they have rest pain, venous ulcers, or gangrene

414

What is the general care for arterial revascularization?

Check pulses, check for bleeding or occlusion/collapse, don't take blood pressures in the area, know baseline vitals and monitor them, site should be pink and warm, mark the site of the pulse and Doppler, and monitor for pain

415

What type of pain indicates an occlusion in patients with PAD?

Throbbing or burning

416

In what vessels can stents be placed in patients with PAD?

Common Iliac or external iliac arteries

417

What does stent duration in patients with PAD depend on?

Blood viscosity and compliance

418

Heat from laser vaporizes the plaque in arterial occlusions

Laser-assisted Angioplasty

419

What types of occlusions is laser-assisted angioplasty used for?

Small arterial ones

420

Metal burr abrades occlusion to fine particles

Artherectomy

421

What is the risk with any procedure that accesses an artery?

Bleeding and stroke

422

What needs to be monitored with procedures that access arteries?

Bleeding, vitals, H&H, and pulses

423

What are the surgical treatments for inflow occlusions in patients with PAD?

Aortoiliac, aortafemoral, and axillogemoral bypasses

424

What are the surgical treatments for outflow occlusions in patients with PAD?

Femoropopliteal and femorotibial bypasses

425

Which surgeries are generally more successful and have less instance of reocclusion?

Inflow

426

What remains even after outflow surgeries in patients with PAD?

Pain

427

What graphs can be used to treat patients with PAD?

Autogenous, saphenous vein, cephalic, basilic vein or synthetic grafts

428

Surgical removal of the plaque from the artery

Endartectomy

429

What does the success of endartectomies depend on?

Location and extent of arterial blockage

430

Where is the incision of endartectomies?

Inner lining of the diseased artery

431

When do graft occlusions occur after surgical treatment of patients with PAD?

Within the first 24 hours

432

How often do grafts have to be assessed post-op in patients with PAD?

Q15 minutes for 1 hour and then hourly

433

What do normal grafts look like post-op in patients with PAD?

Warm, red, and edema

434

How long do patients with PAD need to be on bed rest post-op?

24 hours

435

What is used for thrombolytic therapy?

t-PA, Integrilin, and Aggrastat

436

How often do platelets need to be monitored after platelet inhibitors are used?

3, 6, and 12 hours after surgery

437

What is the platelet inhibiting drug?

ReoPro

438

Increased tissue pressure within confined space, leading to tissue ischemia and necrosis

Compartment Syndrome

439

Where is the most common site for compartment syndrome?

Forearm or lower leg

440

What is the earliest sign of compartment syndrome?

Progressive pain distal to the injury that is not relieved by analgesics

441

What are the signs of compartment syndrome?

Pain with passive movement, inability to move digits, numbness, tingling, loss of function, pallor, coolness, diminished or absent peripheral pulses

442

What can result from untreated compartment syndrome?

Myoglobinuria and renal failure

443

What is the treatment for compartment syndrome?

Fasciotomy or amputation

444

What is the most common cause of PAD occlusions?

Embolus

445

What are the six p's in assessing for PAD occlusions?

Pain, Pallor, Pulselessnes, Paresthenia, Paralysis, and Poiklothermia

446

What drugs are used to treat PAD occlusions?

Activase, t-PA, ReoPro, and Heparin

447

What is the surgical treatment for PAD occlusions?

Arteriotomy, thrombectomy or embolectomy

448

Inflammatory disease of the peripheral arteries resulting in the formation of nonatherosclerotic lesions

Buerger's Disease

449

Where do the nonatherosclerotic lesions of Buerger's Disease occur?

Digital, tibial, plantar, ulnar, and palmar arteries

450

What occludes or obliterates arteries in Buerger's disease?

Thrombi and vasospasm

451

Who does Buerger's disease occur in most?

Young men who are heavy smokers

452

What causes the symptoms of Buerger's disease?

Slow, sluggish blood flow

453

What are the symptoms of Buerger's disease?

Pain, tenderness, hair loss, rubor, cyanosis, cold sensation, diminished pulses, sharply defined lesions leading to gangrenous lesions

454

How is Buerger's disease treated?

Quit smoking, vasodilators, and sympathectomy

455

Episodic vasospasm in arteries and arterioles of the upper and lower extremities

Raynaud's disease/phenomenon

456

What are the primary diseases of Raynaud phenomenon?

Scleroderma, smoking, pulmonary hypertension, myxedema, or environmental factors

457

What are the signs of Raynaud?

Pallor, numbness, and cold sensation

458

What are the changes in skin color and sensation in Raynaud due to?

Ischemia

459

What is the drug therapy for Raynaud?

Procardia or Dibenzyline

460

Clot of fibrin attached to vessel wall

Thrombus

461

Bolus of matter that is circulating in the blood stream

Embolus

462

Clot of platelets and fibrin formed under high flow

Arterial thrombus

463

Clot of red blood cells and large amounts of fibrin formed under low flow

Venous thrombus

464

What can be an embolus?

Thrombus, air bubble, amniotic fluid, aggregate of fat, bacteria, cancer cells or a foreign substance

465

Previously circulating matter that has lodged and obstructed blood flow, causing ischemia

Lodged embolus

466

Where is a superficial venous thromboembolism located?

Below the knee

467

Where is a deep venous thromboembolism located?

Above the knee

468

What is the main complication of venous thromboemboli?

Pulmonary Emboli

469

What does a superficial VTE look like?

Red streak along the vein coarse that is warm and tender, possibly with edema

470

How is a superficial VTE treated?

Elevate the extremity, moist heat, and NSAIDs

471

When do DVTs occur?

After hip, knee or prostate surgery, with pregnancy, heart failure, immobility, or ulcerative colitis

472

What are the symptoms of a DVT?

Pain with walking, pain in the foot, leg edema, and pressure

473

What are the factors for a DVT?

Virchow's triad - Alterations in blood flow, venous endothelial damage, and hyper coagulable state

474

What can cause alterations in blood flow?

Stasis, turbulence, and varicose veins

475

What can cause venous endothelial damage?

Hypertension or shear stress

476

What can cause a hyper coagulable state?

Hyperviscosity, age, smoking, obesity, pregnancy, trauma, burns, or cancer

477

What are the signs of a DVT?

Calf or groin tenderness or pain, sudden onset of unilateral swelling, Homans' sign, and localized edema and warmth

478

Test to measure fibrin and degradation products to diagnose DVTs or PEs

D-dimer test

479

What are the venous flow studies?

Doppler, ultrasounds, venography, and MRI

480

How accurate are venous flow studies in diagnosing DVTs?

95%

481

How are DVTs managed?

Rest and elevation, warm, moist socks and drug therapy

482

What are the signs of a PE?

Dyspnea and chest pain

483

What is the drug therapy for DVTs?

Anticoagulants Heparin and then warfarin and thrombolytics

484

What does Heparin do for DVTs?

Inhibits fibrin formation

485

What are the types of Heparin?

Unfractioned and low molecular weight

486

When on heparin, what needs to be monitored?

PTT

487

What is the therapeutic level of heparin?

1.5-2X normal control

488

What is the heparin antidote?

Protamine Sulfate

489

When on Coumadin, what needs to be monitored?

PT and INR

490

What is the therapeutic PT/INR?

1.5-2X the control or 12-15 seconds

491

What is the antidote for Coumadin?

Vitamin K

492

What are the types of low molecular weight Heparin?

Lovenox or Fragmin

493

What is different between low molecular weight and unfractioned heparin?

Low molecular weight does not require constant coagulation monitoring

494

When a patient is on Coumadin, how often does their PT need checked?

Every 1-4 weeks

495

How long do thrombolytics take to work?

24 hours

496

How can DVTs be prevented?

Smoking cessation, avoid oral contraceptives, adequate hydration, increased mobility, early ambition, leg exercises, and compression stockings

497

Result of prolonged venous hypertension, stretching veins and damaging valves

Venous Insufficiency

498

What are the risk factors for venous insufficiency?

Prolonged standing, obesity, and pregnancy

499

What is the hallmark of venous insufficiency?

Hemosiderin deposits

500

Wood-like hard deposits of fibrin in dermis and fat from chronic venous disease that has the appearance of an inverted bottle

Lipodermatosclerosis

501

What do venous ulcers look like?

Irregular boarders and a large, shallow base with heavy drainage and only mild pain

502

Where do venous ulcers appear?

In the gaiter region - medial malleolus and lateral malleolus

503

What are the symptoms of venous ulcers?

Leg aches, heaviness, cramps, itchiness and edema

504

What are the goals of managing venous ulcers?

Reduce edema, promote venous return, and prevent stasis

505

Dressings for venous ulcers to assist in return of pooled blood to circulation

Compression dressings

506

Dressing for venous ulcers to control the wound environment and deliver some growth factors for healing

Active Dressings

507

Occlusive dressings for venous ulcers that provide moisture

Interactive dressings

508

What antibiotic is used to treat venous ulcers?

Silvadene

509

How can the edema associated with venous ulcers be managed?

Elevation of the leg above the heart, bed rest, and compression stockings

510

Distended, protruding veins that appear darkened and tortuous

Varicose Veins

511

How are varicose veins managed?

Elastic stockings, elevation, sclerotherapy, surgical removal, and radio frequency to heat the veins

512

Broad spectrum antibiotic that lowers bacterial load to levels acceptable for wound closure without causing pain

Silvadene

513

What is the most sensitive indicator of PAD?

Quality of the posterior tibial pulse