Cardiac 2 Flashcards
(68 cards)
1
Q
What is preload?
A
The initial stretching of cardiac myocytes PRIOR to contraction.
The VOLUME of blood in the ventricles at end of diastole.
2
Q
What is afterload?
A
The resistance to ejection
Pressure that the left ventricle must pump against - affected by the systemic vascular resistance
3
Q
What is Ejection Fraction?
A
The amount (ratio) of blood ejected from the Left Ventricle during systole
(compared to the amount of blood present at the end of diastole)
4
Q
What is a normal Ejection Fraction?
A
50-70%
5
Q
What is HFpEF?
A
Heart failure with preserved ejection fraction
Diastolic Failure
6
Q
What is HFrEF?
A
Heart failure with reduced ejection fraction
Systolic failure
7
Q
What is HFmrEF?
A
Heart failure with midrange Ejection Fraction
8
Q
What will a HIGH EF result in?
A
> 75%
Hypertrophic Cardiomyopathy
9
Q
Heart Failure
Definition
A
- A clinical syndrome resulting from structural or functional cardiac disorders that impairs ability of a ventricle to FILL or EJECT blood
- When the heart is unable to pump enough blood to meet the body’s metabolic demands or needs
- Most cases are chronic and progressive, but can be acute
10
Q
Heart Failure
Complications
A
- Pulmonary congestion
- Systemic congestion
- Hypotension, poor perfusion, cardiogenic shock
- Arrhythmias
- Thromboembolism
- Pericardial effusion
11
Q
Heart Failure
Modifiable Risk Factors
A
- Smoking
- Obesity
- Diabetes (Uncontrolled)
- ETOH
- Poor Diet
- Sedentary Lifestyle
12
Q
Heart Failure
Non-Modifiable Risk Factors
A
- Age > 60
- Male
- African American
- Hispanic
13
Q
What are some ways the heart tries to compensate for an increased oxygen demand in the body?
A
- Sympathetic Nervous System (Increases HR and force of contraction)
- Increased preload (Increased stretch increases force of contraction)
- Myocardial Hypertrophy (Causes increase in cardiac oxygen demand on already stressed heart)
14
Q
Heart Failure
Causes
A
- Coronary Artery Disease
- DM
- HTN
- Pulmonary Arterial Hypertension (PAH)
- Cardiomyopathy: Dilated Cardiomyopathy and Hypertrophic Cardiomyopathy
- Valvular Disorders
15
Q
Systolic Heart Failure
Specific Causes
A
Left ventricular contraction impaired
HFrEF < 40%
- CAD
- Volume Overload: Dilated cardiomyopathy or Valvular Disease regurgitation
- Increased Afterload: Aortic or Pulmonary Stenosis
- Arrhythmias
16
Q
Diastolic Heart Failure
Specific Causes
A
Left ventricular relaxation impaired; lower volume filled = lower volume ejected = HFpEF > 50%
* Hypertrophic cardiomyopathy (smaller ventricular volume)
* Restrictive cardiomyopathy (stiff ventricular walls)
* Myocardial Fibrosis
* Pericardial constriction
17
Q
What is Acute Decompensated Heart Failure (ADHF)?
A
- Sudden, severe onset
- Deterioration of the heart that had been previously working with the help of compensatory mechanisms
18
Q
Acute Decompensated Heart Failure
Clinical Manifestations
A
- Tachypnea
- SOB
- Pulmonary Edema with hemoptysis
- Crackles
- Tachycardia
- Hypotension
- Severe Dyspnea
- Orthopnea
- Use of accessory muscles to breathe
19
Q
What is the most common cause of right sided heart failure?
A
Left Sided Heart Failure
20
Q
Left Sided Heart Failure
Definition
A
- 2/3 of left sided HF is a result of systolic dysfunction
- Left ventricle cannot pump blood out of the heart into systemic circulation effectively
- Results in increased left ventricle end diastolic pressure
- Forces fluid and pressure back into pulmonary circulation
- Increased pulmonary artery pressure
- Results in Pulmonary edema and impaired gas exchange
21
Q
Right Sided Heart Failure
Definition
A
- Right ventricle cannot effectively pump blood into pulmonary circulation
- Elevated pressure in pulmonary system reduces amount of blood entering pulmonary circulation
- Results in fluid backup in systemic circulation
- Frequently caused by Left sided HF
- May also result from chronic lung disease (COPD), cor pulmonale
22
Q
Left Sided Heart Failure
Clinical Manifestations
A
- Pulmonary Congestion
- Crackles/Rales in lungs
- S3 or “ventricular gallop”
- Tachycardia
- Dyspneic on Exertion (DOE)
- SOB
- Orthopnea
- Low O2 sat
- Dry, non-productive cough
- Oliguria
- Paroxysmal Nocturnal Dyspnea
- Fatigue, lethargy
23
Q
Right Sided Heart Failure
Clinical Manifestations
A
- Visceral and peripheral congestion
- Increased CVP
- Jugular Vein Distention
- Peripheral edema
- Hepatomegaly
- Ascites
- Weight Gain
24
Q
Congestive Heart Failure
Definition
A
Both Left and Right Sided Heart Failure
Congestion in:
* lungs (pulmonary edema)
* liver (portal hypertension)
* abdomen (ascites)
25
**Heart Failure**
Assessment
Focus on:
* Effectiveness of therapy
* Patient's self-management
* S&S of increased HF
* Emotional or pyschosocial response
* Health History
* Physical Examination: mental status, lung sounds *(crackles, wheezes)*, heart sounds *(S3)*, fluid status or signs of fluid overload, daily weight, I&Os, assess responses to medications
26
**Heart Failure**
Diagnostics
**Labs**
* BNP, CMP, urinalysis
**Chest XR**
**Echo** *(EF)*
**ECG**
**Presence of comorbities**
26
What causes Paroxysmal Nocturnal Dyspnea (PND) in HF?
* During waking hours, gravity causes fluid to sink to lung bases
* When pt lies down, fluids redistribute throughout the lungs decreasing the amount of alveoli able to participate in gas exchange
* L ventricle cannot handle increased fluid and backs into pulmonary circulation
27
What causes nocturia in HF?
* During day, kidneys are not well perfused due to lower circulating volume
* When pt lies down, kidneys become fully perfused stimulating urine ouput
28
**Heart Failure**
Medical Management
* Oral and IV medications
* Lifestyle modifications
* Supplemental O2
* Surgical interventions: ICD, valve repair, heart transplant
* Education for patient and family
29
**Heart Failure**
Common Medications
* **Diuretics**: decrease fluid volume
* **Angiotensin II Receptor Blockers (ARBs)**
* **Angiotensin Converting Enzyme Inhibitors (ACE-I)**: vasodilation, diuresis, decreases afterload (Watch for hypotension, hyperkalemia, altered renal function, and cough)
* **Beta Blockers**: May be prescribed with ACE-Is. (Takes several weeks for effects, use in caution in asthma patients)
* **Ivabradine**: decreases rate of conduction through the SA Node (monitor for HR and BP)
* **Hydralazine and Isosorbide dinitrate**: alternative to ACE-Is (observe for decreased BP)
* **Digitalis**: Monitor for digitalis toxicity *(especially in hypokalemia)*
30
**ADHF**
Medications Used
**IV medications for hospitalized pts with ADHF**
* **Dopamine** *(vasopressor - ⬆️BP, ⬆️ myocardial contraction; adjunt with loop diuretics)*
* **Dobutamine** *(used for left ventricular failure; ⬆️ cardiac contractility, ⬆️ renal perfusion)*
* **Milrinone** *(⬇️ preload and afterload; causes hypotension and increased risk of dysrhythmias)*
* **Vasodilators** *(IV Nitro, Nitroprusside, Nesiritide, enhances symptom relief)*
31
**Heart Failure**
Gerontologic Considerations
* Atypical signs: fatigue, weakness, somnolence
* Resistant to diuretics d/t decreased renal perfusion
* More sensitive to changes in volume
* Need to monitor males closer for bladder distention and urethral obstruction r/t BPH
32
**Heart Failure**
Patient Goals
* Promote activity and reduce fatigue
* Relieve fluid overload symptoms
* Decrease anxiety or increase patient's ability to manage anxiety
* Encourage the patient to verbalize his or her ability to make decisions and influence outcomes
* Educate patient and family about management of the therapeutic regimen
* Optimize treatment of co-morbidities
33
**Heart Failure**
Nursing Management: Promote Activity Tolerance
* Bed rest for acute exacerbations
* Encourage regular physical activity - build up to 30 min/day
* Exercise training
* Pacing of activities - wait 2 hours after eating for physical activity
* Avoid activities in extreme weather
* Modify activities to conserve energy
* Positioning: elevate head of the bed to facilitate breathing and rest; support arms
34
**Heart Failure**
Nursing Management: Manage Fluid Volume
* Assess for symptoms of fluid overload
* Daily weight
* I&Os
* Diuretic Therapy; timing of meds
* Fluid Intake; fluid restriction
* Maintenance of sodium restriction
35
**Heart Failure**
Nursing Management: Patient Education
* Medications *(what do they do, when to take)*
* Diet: low sodium diet and fluid restriction
* Monitor for signs of excess fluid, hypotension, and disease exacerbation
* Daily weights; report weight gain of > 3lbs/day or > 5lbs/week
* Exercise and activity program
* Stress management
* Prevention of infection
* Know how and when to contact provider
* Include family in education
36
**Pulmonary Edema**
Definition
* Acute vs. chronic
* As Left Ventricle begins to fail, blood backs up into the pulmonary circulation causing pulmonary interstitial edema
* Results in hypoxemia, often severe
37
**Pulmonary Edema**
Clinical Manifestations
* Restlessness
* Anxiety
* tachypnea
* Dyspnea
* Cool and clammy skin
* Cyanosis
* Weak and rapid pulse
* Cough
* Lung congestion *(wet, noisy respirations)*
* Increased sputum production *(may be frothy and blood tinged - late sign)*
* Decreased level of consciousness *(from CO2 buildup)*
38
**Pulmonary Edema**
Management
**Easier to prevent than to treat**
* Early recognition: monitor lung sounds
* Minimize exertion and stress
* Oxygen: Non-Rebreather, CPAP, BiPAP
* Medications: Diuretics, Vasodilators
39
**Pulmonary Edema**
Nursing Management
* Positioning: upright with legs dangling
* Psychological support
* Provide anticipatory care
* Monitor medications
* I&Os
40
**Cardiogenic Shock**
Definition
* Life Threatening/ High Mortality Rate
* Decreased CO leads to inadequate perfusion and initiation of shock
* Commonly occurs following acute MI when a large area becomes ischemic and hypokinetic
* Can occur as a result of end stage HF, cardiac tamponade, pulmonary embolism, cardiomyopathy, and arrhythmias
41
**Thromboembolism**
Important things to know
* Pt with cardiovascular disease are at risk of arterial thromboemboli and venous thromboemboli (VTE)
* Decreased mobility and circulation increase risk
* Intracardiac thrombi can form in pts with A-fib
* Pulmonary embolism - when a blood clot typically from the legs moves to obstruct pulmonary vessels
42
**Pericardial Effusion**
Definition
The accumulation of fluid in the pericardial sac
43
**Cardiac Tamponade**
Definition
The restriction of heart function because of pericardial effusion, resulting in decreased venous return and decreased CO
44
**Pericardial Effusion**
Clinical Manifestations
* Diffused ill-defined chest pain or fullness
* Pulsus paradoxus
* Engorged neck veins *(JVD)*
* Labile or low BP
* SOB
45
**Cardiac Tamponade**
Cardinal Signs
* Sudden chest pain
* Falling systolic BP
* Narrowing pulse pressure
* Rising venous pressure
* Distant heart sounds *(harder to hear through all the fluid)*
46
**Pericardial Effusion and Cardiac Tamponade**
Medical Management
* **Pericardiocentisis**: Puncture of the pericardial sac to aspirate pericardial fluid
* **Percardiotomy**: Under general anesthesia, a portion of the pericardium is excised to permit the exudative pericardial fluid to drain into the lymphatic system
47
When is a 2D echocardiography used?
To diagnose heart conditions like valvular disorders, cardiomyopathy, ventricular dysfuntion
48
What is 3D echocardiography and when is it used?
* Pt is under sedation
* Provides more detailed, 3D view of the heart
* Used to evaluate cardiac chamber volumes, left ventricular wall motion, etc.
* Can also be used to assess the left ventricular ejection fraction more accurately than a 2D echo
49
**Deep Vein Thrombosis and Pulmonary Embolism**
Risk Factors
**Endothelial Damage**
* Central venous catheters
* Dialysis access catheters
* Local vein damage
* Pacing wires
* Repetitive motion injury
* Surgery
* Trauma
**Venous Stasis**
* Age > 65
* Bed rest/immobilization
* Heart failure
* History of variscosities
* Obesity
* Spinal Cord Injury
**Altered Coagulation**
* Cancer
* Elevated Factors II, VIII, IX, XI
* Oral Contraceptive Use/Hormone Replacement Therapy
* Pregnancy
* Withdrawal of anticoagulant medications
50
**Deep Vein Thrombosis**
Clinical Manifestations
**Deep Veins**
* tender
* warmer
* enlarged superficial veins
**Massive Iliofemoral Venous Thrombosis**
* Swelling
* Tense
* Painful
* Cool
**Superficial Venous Thrombosis**
* rarely cause a problem, most dissolve spontaneously
51
**Venous Thromboembolism**
Prevention Measures
* Early ambulation
* Leg exercises
* TED hose, SCDs
* Subcutaneous heparin or LMWH
* Lifestyle changes: weight loss, smoking cessation, regular exercise
52
**DVT**
Medications
* **Heparin**: IV or SubQ, monitor aPTT, *(protamine sulfate is the antidote)*
* **LMWH**: *Enoxaparin, Dalteparin*, SubQ, no monitoring of labs, *(protamine sulfate is the antidote)*
* **Warfarin**: PO, slow onset of action, monitor INR (therapeutic range: 2.0-3.0), *(Vitamin K is antidote)*
* **Factor Xa Inhibitor**: *Fondaparinux*, SubQ, monitor Creatinine
* **Oral Factor Xa Inhibitor**: *Apixaban, Rivaroxaban*, PO, Monitor renal function
* **Thrombolytics**: *Alteplase*, dissolves existing thrombus, monitor CBC, platelets, aPTT
53
**DVT**
Medical Management
* **Medications**
* **Endovascular Management**: Thrombectomy, inferior vena cava filter
54
**DVT**
Nursing Management
* Assess limb pain, edema, temperature, tenderness
* Measure limb circumference
* Monitor labs, bleeding
* Elevate extremity
* TED hose
***SCDs are contraindicated with confirmed DVT*** *(risk of PE)*
55
**Pulmonary Embolism**
Definition
Blood clot gets stuck in artery to the lung, blocking blood flow to the lung
Most often starts in the legs and travels up
56
**Pulmonary Embolism**
Clinical Manifestations
* Dyspnea
* Tachypnea
* Pleuritic Chest Pain
* Anxiety
* Tachycardia
* Syncope
* May cause minimal clinical manifestations
57
**Pulmonary Embolism**
Diagnostics
* Chest XR *(ruling out other things)*
* ECG *(ruling out other things)*
* **MDCTA** *(Multidetector computed tomographic angiography)*: **Definitive diagnostic for PE**
* Pulmonary angiography
* D-Dimer
* ABG/SpO2
* V/Q scan
58
**Pulmonary Embolism**
Medical Management
**Unstable:**
* Thrombolytic Therapy
* Surgical Embolectomy (rare)
* Cardiopulmonary bypass
**Stable:**
* Heparin drip
* LMWH
* Apixaban
59
**Pulmonary Embolism**
Nursing Management
* Monitor labs
* Frequent TCDB: *turn, cough, deep breathing*
* Monitor SpO2
* Encourage Incentive Spirometer Use
* Manage pain and anxiety
* Monitor for complications
60
**After teaching a patient about the use of sublingual nitroglycerin, which statement by the client indicates the teaching has been effective?**
**a.** Taking sidenafil citrate with this medication will be okay
**b.** It helps reduce the plaque formation in my blood vessels
**c.** I will call 911 if I still have chest pain after I finish taking all three doses of my nitroglycerin
**d.** Nitroglycerin will help more blood go into my heart from my arms
**c. I will call 911 if I still have chest pain after I finish taking all three doses of my nitroglycerin**
**Rationale:**
Combining sidenafil and nitro may cause BP to drop excessively leading to cardiovascular collapse.
Nitroglycerin works by relaxing smooth muscle within the walls of blood vessels (particularly veins) which dilates them. It has no effect on plaque.
Nitroglycerin does increase blood supply to the cardiac muscle, but it does not necessarily come from the arms
61
**A patient with an acute deep vein thrombosis (DVT) is on a heparin drip. In anticipation of discharge, the healthcare provider orders warfarin. Which action should the nurse take?**
**a.** Discontinue the heparin drip prior to administrating the warfarin
**b.** Check the patients INR prior to administering the warfarin.
**c.** Clarify the order with the HCP as soon as possible
**d.** Administer the warfarin along with the heparin drip as ordered.
**d. Administer the warfarin along with the heparin drip as ordered**
**Rationale:**
Once a patient has a therapeutic value for aPTT for two days, warfarin is begun for 24 hours at which time heparin is discontinued.
INR is not typically checked while on a heparin drip; aPTT or anti-Xa is used instead
Bridging from a heparin drip to warfarin is common practice so no clarification is needed.
62
**The nurse is caring for a patient with a deep vein thrombosis of the right calf. The patient is receiving an IV heparin drip. What is the priority outcome for this patient? The patient will:**
**a.** Comply with dietary restrictions
**b.** Have the clot dissolved within 72 hours
**c.** Not experience bleeding
**d.** Keep the right leg elevated on two pillows
**c. Not experience bleeding**
**Rationale:**
Heparin will not dissolve blood clots that have already formed, but it may prevent the clots from becoming larger and causing more serious problems
Larger clots can take months to dissolve
Elevating the leg above the heart may help keep blood from pooling, reducing the risk of clot formation but this is not as high a priority as no bleeding
63
**Acute pulmonary edema caused by heart failure is usually a result of damage to which area of the heart?**
**a.** Left atrium
**b.** Right atrium
**c.** Left ventricle
**d.** Right ventricle
**c. Left ventricle**
**Rationale:**
Blood backing up from the Left ventricle causes an increase in fluid in the pulmonary system
Blood backing up from the Right ventricle causes an increase in fluid in the peripheral system
64
**The nurse receives change of shift report on the following four patients. Which patient should the nurse assess first?**
**a.** 46 year old on bed rest who is complaining of sudden onset of shortness of breath
**b.** 77 year old with tuberculosis who has four antitubercular medications due in 15 minutes
**c.** 35 year old who was admitted the previous day with pneumonia and has a temperature of 102
**d.** 23 year old with cystic fibrosis who has pulmonary function testing scheduled
**a. 46 year old on bed rest who is complaining of sudden onset of shortness of breath**
**Rationale**
Possible PE
Fever in an adult is 100.4 (38) or higher. While 102 is high, the possible PE takes precedence
65
**The heart failure patient should have a sodium restriction of less than ___________ mg of sodium daily.**
**a.** < 1000mg
**b.** < 2000mg
**c.** < 3000mg
**d.** < 4000mg
**b. < 2000mg**
**Rationale:**
Following a low sodium diet (< 2g) and avoiding excessive fluid intake are usually recommended, although studies differ regarding the effectiveness of sodium restriction
66
**A patient with possible PE complains of chest pain and difficulty breathing. The nurse finds a HR of 142 bpm, BP of 100/60, and RR of 42. Which action should the nurse take first?**
**a.** Administer anticoagulant drug therapy
**b.** Notify the charge nurse of the patients deteriorating condition
**c.** Prepare for a MDCTA scan
**d.** Elevate the head of the bed to semi-fowlers
**c. Prepare for a MDCTA scan**
**Rationale:**
The scan is needed to confirm the diagnosis of PE before treatment can begin
The is a "possible" PE, an actual diagnosis is needed to start anticoagulants
The head of the bed should be in High Fowler's
67
**What should the nurse recognize as an indication for the use of dopamine in the care of the patient with heart failure?**
**a.** Acute anxiety
**b.** Hypotension and tachycardia
**c.** Peripheral edema and weight gain
**d.** Paroxysmal nocturnal dyspnea
**b. hypotension adn tachycardia**
**Rationale:**
Dopamine is a vasopressor given to increase BP and myocardial contractility
