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Flashcards in Cardiac Disorders and Hemodynamic Monitoring Deck (135):
1

Cardiac Enzymes

1. CKMD
2. CKMB
3. Troponin

2

CKMD

Indicates muscle damage (could be any muscle damage, not just the heart)

* Creatine kinase

3

CKMB

Muscle band; is the most sensitive but takes longer to rise ( > 5%)

* Creatine kinase

4

Troponin

Cardiac enzyme that is seen in the blood sooner than CKMB
- Rises 4-6 hours
- Enzymes appear, then peak and then suddenly go down. If not then patient is extended their MI and experiencing more cardiac damage
- Troponin is released by the necrotic heart tissue
- Indicates myocardial damage, lasts in blood 10-14 days

5

Lipid Profile

Cholesterol, triglycerides, and lipoproteins are measured to evaluate a patient's risk of developing CAD

6

Lipoproteins

Is important in the diagnosis of MI. Is a little slower at showing up in the blood, one of the last to arrive.

- Tests are done series over 3 days. Person sits around the house 2 days after chest pain, the CKMB will start to diminish after 3 days but the LDH will stay. Will be checked more than once if there is any abnormality.
- Check to see if it’s peaked & now coming down. Don’t want continuous elevation.
- Can also be indicator of an older MI that occurred.

7

Cholesterol

<200 normal (140-200)

** HDL – “good”, transports cholesterol away from the tissue and cells.

** LDL – “bad”, transports cholesterol and triglycerides into the cell.

8

How is a chest x-ray used for cardiac diagnostics?

Shows cardiomyopathy. Also done to check for heart size and congestion.

9

SED Rate

Inflammation 0-15 men, 0-20 women

10

C-reactive protein

Indicator of possible MI, indicates infection

11

Cardiac Diagnostics: BNP

Measures fluid volume

12

Cardiac Diagnostics: Cardiac Stress Test

Shows heart's ability to endure stress. Types of stress testing include:
- Exercise stress testing
- Pharmacological stress testing

13

Cardiac Diagnostics: Radionuclide Imaging

Shows myocardial ischemia and infarction and evaluate lest ventricular function through the use of radioisotopes

14

What does an EKG look like during an acute MI

1. T wave inversion
2. ST elevation
3. Formation of Q wave

15

What does an EKG look like when there is ischemia?

Depression or T wave inversion

16

What does an EKG look like when there is myocardial injury?

ST segment elevation

17

Cardiac Diagnostics: Cardiac Catheterization

Invasion procedure used to measure cardiac chamber pressures and assess patency of coronary arteries

18

Cardiac Diagnostics: Electrophysiologic Testing (EPS)

Invasive procedure used to locate the source of serious dysrhythmias

19

Cardiac Diagnostics: Hemodynamic Monitoring

Invasive measurement of the movement of blood and the pressures being exerted in the veins, arteries, and chambers of the heart

20

What is CAD

Coronary Artery Disease
- Accumulation of plaque causing impaired blood flow to the heart muscle
- In coronary atherosclerosis, blockages and narrowing of the coronary vessels reduce blood flow to the myocardium

21

Clinical Manifestations of CAD

1. May be asymptomatic or lead to angina
2. MI
3. Dysrhythmias
4. Heart failure
5. Sudden death

22

Risk Factors for CAD

1. HTN
2. DM
3. Hyperlipidemia
4. Increased homocysteine level
5. Metabolic syndrome
6. Lifestyle factors: obesity, smoking, inactivity, diet, drug abuse
7. Men or postmenopausal women
8. Age

23

What is Angina Pectoris?

Chest discomfort that occurs when there is a decreased blood oxygen supply to an area of the heart muscle

24

What is the most common cause of angina pectoris?

CAD (obstruction of the arteries due to atherosclerosis)

25

Types of Angina

1. Stable
2. Unstable
3. Intractable or refractory
4. Variant
5. Silent

26

S/Sx of Angina Pectoris

1. Tightness, squeezing, pressure or ache deep in the chest
2. Sudden breathing difficulty (sometimes)
3. Chest pain similar to indigestion
4. A choking feeling in the throat
5. Chest pain that radiates to the jaw, teeth or earlobes
6. Heaviness, numbness, tingling or ache in the chest, arm, shoulder, elbow or hand usually on the left side
7. Pain between the shoulder blades

27

Treatment of Angina Pectoris

Treatment seeks to decrease myocardial oxygen demand and increase oxygen supply
1. Medications
2. Oxygen
3. Reduce and control risk factors
4. Reperfusion therapy may also be done

28

Medications that treat angina pectoris

1. Beta blockers
2. Calcium channel blockers
3. Antiplatelet and anticoagulant agents (aspirin, clopidogrel, ticlopidine)
4. Glycoprotein IIB/IIIa agents
5. Morphine (decreases O2 consumption, decreases anxiety, and lowers HR and BP

29

Acute Coronary Syndrome

Includes unstable angina and myocardial infarction

* An area of the myocardium is permanently destroyed (MI)

30

Unstable Angina

The plaque ruptures but the artery is not completely occluded

31

Clinical Manifestations of ACS/MI: Cardiovascular

1. Chest pain or discomfort
2. Irregular HR
3. New onset murmur
4. Jugular vein distention (JVD)
5. HTN

32

Clinical Manifestations of ACS/MI: Respiratory

1. SOB
2. Dyspnea
3. Tachypnea
4. Crackles
5. Pulmonary edema

33

Clinical Manifestations of ACS/MI: Gastrointestinal

1. Nausea
2. Vomiting

34

Clinical Manifestations of ACS/MI: Genitonurinary

Decreased urinary output

35

Clinical Manifestations of ACS/MI: Skin

1. Cool
2. Clammy
3. Diaphoretic
4. Pale

36

Clinical Manifestations of ACS/MI: Neurologic

1. Anxiety
2. Restlessness
3. Lightheadedness
4. Decreased LOC

37

Diagnostics for ACS/MI

1. Patient history, symptoms
2. ECG
3. Echocardiogram
4. Laboratory tests (creatine kinase and isoenzymes, myoglobin, troponin)

38

Treatment for Acute MI (STEMI)

1. Obtain diagnostic tests including ECG within 10 minutes of arrival
2. Oxygen
3. Aspirin, nitroglycerin, morphine, Beta-blocker (MONA)
4. Angiotensin-converting enzyme inhibitor within 24 hours
5. Evaluate percutaneous coronary intervention, if emergent and indicated should be performed in less than 60 minutes
6. Evaluate for thrombolytic therapy, if indicated should be administered within 3 to 6 hours of the onset of symptoms
7. As indicated: IV heparin or LMWH, clopidogrel or ticlopidine, Glycoprotein IIb/IIIa inhibitor (Repro, Integrilin)
8. Bedrest

39

Pharmacologic Therapy for Acute MI

1. Unfractionated heparin or LMWH (Lovenox) is prescribed along with platelet-inhibiting agents to prevent further clot formation (Also, may be placed on Warfarin)
2. The analgesic of choice for acute MI is morphine administered in IV boluses to reduce pain and anxiety
3. The use of ACE inhibitors decrease mortality rate and prevent remodeling of myocardial cells that is associated with onset of heart failure
4. The purpose of thrombolytics is to dissolve the thrombus in a coronary artery, allowing blood to flow through the coronary again, minimizing the size of the infarction and preserving ventricular function

40

Potential Complications of ACS/MI

1. Acute pulmonary edema
2. Dysrhythmias
3. Heart failure
4. Cardiogenic shock
5. Dressler's syndrome

41

Nursing Interventions for patient with ACS/MI

1. Relieving pain and other s/sx of ischemia
2. Improving respiratory function
3. Promoting adequate tissue perfusion
4. Reducing anxiety
5. Monitoring and managing potential complications
6. Promoting home and community-based care

42

Invasive Coronary Artery Procedures

1. Potential transluminal coronary angioplasty
2. Coronary artery stent
3. Atherectomy
4. Brachytherapy
5. Laser therapy
6. Angio-jet

43

What is the purpose of a percutaneous transluminal coronary angioplasty?

Compresses the plaque against the arterial wall

44

What is the purpose of a coronary artery stent?

Used to maintain an open arterial lumen

45

What is the purpose of an atherectomy?

Shaves the plaque off vessel walls using a rotary cutting head

46

Invasive Coronary Artery Procedures: Possible Complications During the Procedure

1. Dissection
2. Perforation
3. Embolism
4. Hypersensitivity to the contrast dye
5. Dysrhythmias
6. Abrupt closure
7. Vasospasm
8. Acute MI
9. Cardiac arrest

47

Invasive Coronary Artery Procedures: Possible Complications After the Procedure

1. Bleeding at insertion site
2. Retroperitoneal bleeding
3. Hematoma
4. Arterial occlusion

48

The Major Indications for CABG

1. Alleviation of angina that cannot be controlled with medication or PCI
2. Treatment of left main coronary stenosis or multi-vessel CAD
3. Prevention and treatment of MI, dysrhythmias, or heart failure
4. Treatment for complications from an unsuccessful PCI

49

What is a CABG?

Coronary Artery Bypass Graft
- Uses a section of the saphenous vein or internal mammary artery to create a connection between the aorta and the coronary artery beyond the obstruction to allow blood to perfuse the ischemic portion of the heart
- A median sternotomy is used to access the heart

50

Potential Complications of CABG

1. Hypovolemia
2. persistent bleeding
3. cardiac tamponade
4. fluid overload
5. hypothermia
6. hypertension
7. tachydysrhythmias
8. bradycardia
9. cardiac failure
10. MI
11. impaired gas exchange
12. neurologic changes
13. stroke
14. acute renal failure
15. electrolyte imbalance
16. hepatic failure
17. infection

51

Post-Operative Nursing Management of CABG

1. Monitor VS, O2 sat, hemodynamic parameters, HCT and Hgb, electrolytes, auscultate heart and breath sounds, assess skin color, skin temperature, peripheral pulses, and LOC
2. Document cardiac rhythm and waveforms, measure I/O or urine, chest tube and fluids
3. Administer IV fluids, blood products, inotropic, vasodilators, and/or antidysrhythmics as ordered

52

Aneurysms

- An abnormal dilation of a blood vessel
- Most are caused by arteriosclerosis, atherosclerosis, and HTN

53

Saccular Type Aneurysms

Are caused by a traumatic break in the vessel wall rather than weakness

54

Dissecting Type Aneurysms

Develop when a break or tear in the tunica intima and media allows blood to invade or dissect the layers of the vessel wall

55

Aneurysm Treatment

When aneurysms are 5-6 cm in diameter they are surgically excised and replaced with a synthetic fabric graft

56

Arterial Disorders

1. Buergers Disease
2. Raynauds Disease

57

Buergers Disease

(Occlusions)
- A chronic disease of the arteries and veins characterized by pain, color changes, and coldness in the fingers and toes; results from thickening of the walls of blood vessels; cause is unknown, possibly genetic

58

Raynauds Disease

(Spasms)
- Vascular condition in which the fingers become cold and pale when blood vessels are constricted upon exposure to cold; no known cause (occurs secondary to scleroderma, RA)

59

Treatment for Buergers and Raynauds Disease

Key is to increase circulation
1. Calcium channel blockers
2. Nerve block
3. Use gloves
4. Smoking cessation
5. Limit sodium intake
6. Exercise

60

Valvular Disorders

1. Mitral valve prolapse
2. Mitral regurgitation
3. Mitral stenosis
4. Aortic regurgitation
5. Aortic stenosis

61

Mitral Valve Prolapse

- A portion of one or both mitral valve leaflets balloons back into the atrium during systole

62

Medical Management of Mitral Valve Prolapse

Directed at controlling symptoms (avoid caffeine and alcohol)

63

Mitral Regurgitation

- Involves blood flowing back from the left ventricle into the left atrium during systole

64

Medical Management of Mitral Regurgitation

Is the same as for heart failure

65

Mitral Stenosis

- An obstruction of blood flowing from the left atrium into the left ventricle
- Most often cause by Rheumatic Endocarditis

66

Medical Management of Mitral Stenosis

Anticoagulants and heart failure treatment

67

Aortic Regurgitation

- The flow of blood backs into the left ventricle from the aorta during diastole

68

Aortic Regurgitation Treatment

Aortic valvuloplasty or valve replacement

69

Aortic Stenosis

- Narrowing of the orifice between the left ventricle and the aorta

70

Aortic Stenosis Treatment

Surgical replacement of the aortic valve

71

Assessment for Valvular Heart Disorders

1. S/sx of heart failure, such as fatigue, dyspnea on exertion, an increase coughing, hemoptysis, multiple respiratory infections, orthopnea, and PND
2. Dysrhythmias
3. Symptoms such as dizziness, syncope, increased weakness, or angina pectoris

72

Valve Repairs

Valvuloplasty
1. Commissurotomy (open or closed)
2. Annuloplasty
3. Leaflet repair
4. Chordoplasty

73

Valve Replacements

1. Mechanical valves
2. Tissue valves
- Xenograft (from an animal)
- Homograft (from another person)
- Autograft (from self)

74

Tricuspid Valve Disorders

Stenosis obstructs blood flow from the right atrium to the right ventricle
- Regurgitation occurs secondarily to right ventricular dilation, allowing blood to flow back into the right atrium during systole, increasing atrial pressures

75

S/Sx of Tricuspid Valve Disorders

1. Increased CVP
2. JVD
3. Ascites
4. Hepatomegaly
5. Peripheral edema

76

Pulmonic Valve Disorders

- Narrowing of the pulmonary valve, known as valvular pulmonary stenosis (PS) causes the right ventricle to pump harder to get blood past the blockage

77

S/Sx of Pulmonic Valve Disorders

DOE and fatigue are early signs; right-sided heart failure develops

* Regurgitation is a complication of pulmonary HTN, infective endocarditis, pulmonary artery aneurysm, or syphilis. With regurgitation blood is allowed to back flow into the right ventricle during diastole

78

Types of Cardiomyopathy

1. Dilated
2. Hypertrophic
3. Restrictive
4. Unclassified

79

Medical Management of Cardiomyopathy

1. Directed toward identifying and managing possible underlying or precipitating causes
2. Correcting the heart failure with medications
3. A low-sodium diet
4. Exercise/rest regimen
5. Control dysrhythmias
6. Systemic anticoagulation may be used in some cases.

80

Surgical Management of Cardiomyopathy

1. Left ventricular outflow tract surgery
2. Latissimus dorsi muscle wrap
3. Heart transplantation
4. Mechanical assist devices
5. Total artificial hearts

81

Cardiomyopathy Assessment

1. VS
2. Pulses
3. Weight
4. Cardiac and pulmonary auscultation
5. Assessment of JVD
6. Edema

82

Cardiomyopathy Potential Complications

1. Heart failure
2. Dysrhythmias
3. Pulmonary or Cerebral Embolism
4. Valvular dysfunction

83

Nursing Interventions for Cardiomyopathy

1. Improving Cardiac Output
2. Increasing Activity Tolerance
3. Reducing Anxiety
4. Decreasing the Sense of Powerlessness
5. Promoting Home and Community-Based Care

84

Infectious Disease of the Heart

- Any of the layers of the heart may be affected by an infectious process
- Diseases are named by the layer of the heart that is affected
- Diagnosis is made by patient symptoms and echocardiogram
- Blood cultures may be used to identify the infectious agent and to monitor therapy
- Treatment is with appropriate antimicrobial therapy.

85

Rheumatic Endocarditis

- Occurs most often in school-age children, after group A beta-hemolytic streptococcal pharyngitis
- Injury to heart tissue is caused by inflammatory or sensitivity reaction to the streptococci
- Myocardial and pericardial tissue is also affected, but endocarditis results in permanent changes in the valves
- Need to promptly recognize and treat “strep” throat to prevent rheumatic fever

86

Infective Endocarditis

- A microbial infection of the endothelial surface of the heart. Vegetative growths occur and may embolize to tissues throughout the body.
- Usually develops in people with prosthetic heart valves or structural cardiac defects. Also occurs in patients who are IV drug abusers and in those with debilitating diseases, indwelling catheters, or prolonged IV therapy.

87

Myocarditis

- Usually results from viral, bacterial, rickettsial, fungal, parasitic, metazoal, protozoal, or spirochetal infection.
- May also be immune related

88

Pericarditis

Inflammation of the pericardium

89

S/Sx of Pericarditis

1. Friction rub
2. Fever
3. Pain

90

Potential Complications of Pericarditis

1. Pericardial effusion
2. Cardiac tamponade

91

Why is invasive hemodynamic monitoring used?

Used to assess cardiac and circulatory function and the response to interventions in the critically ill patient

92

What are the parameters used for invasive hemodynamic monitoring?

1. HR
2. Arterial BP
3. Central veinous pressure
4. Cardiac output

93

Why is intra-arterial pressure monitoring used?

Used to assess blood volume, monitor the effects of vasoactive drugs, and obtain ABGs

94

Preload

The amount of blood presented to the ventricle just before systole

95

Afterload

The amount of resistance to the ejection of blood from the ventricle

96

Contractility

The force of the contraction

97

Cardiac Output

The quantity of blood pumped by the left ventricle into the aorta each minute

CO = SV x HR

98

Ejection Fraction

The percentage of emptying of the ventricular chamber

99

Central Venous Pressure Monitoring (CVP)

- Measures blood volume and venous return
- Normal range 2-6 mm Hg

100

What does an increased CVP look like?

1. Intravascular volume overload
2. Cardiac tamponade
3. Pericardial effusion
4. Tricuspid valve disease
5. Right ventricular failure

101

What does a decreased CVP look like?

1. Hypovolemia/dehydration
2. Alteration in venous tone

102

Treatment for increased CVP

Diuretic

103

Treatment for decreased CVP

Fluids

104

Complications of CVP

1. Hemorrhage
2. Pneumothorax
3. Vascular erosion
4. Dysrhythmias
5. Infection
6. Fluid overload
7. Hypothermia
8. Embolism
9. Air embolus

105

Indications for CVP Monitoring

1. Administration of fluid/electrolytes/blood
2. Drug therapy
3. Pressure monitoring
4. Insert a pacemaker
5. Parenteral nutrition

106

Pulmonary Artery Pressure Monitoring

- Often called a Swan-Ganz catheter
- Used to evaluate overall cardiac function, especially left heart function
- Inserted into a central vein, then threaded into the right atrium, right ventricle and left in the pulmonary artery
- Normal PA is around 25/10 mm Hg

* Important for left heart function

107

Indications for PA monitoring

1. LV failure or shock after AMI
2. Shock or prolonged hypotension
3. CHF secondary to AMI
4. Unstable Angina
5. Suspected extension of MI
6. Monitor systemic volume requirement

108

Arterial Pressure Monitoring

Internal means of monitoring systemic arterial blood pressure

109

Indications for Arterial Pressure Monitoring

1. Accurate BP reading
2. Obtain ABG
3. Drug Therapy
4. Inaudible BP (stages of shock)
5. Timing for an IABP

110

Complications for Arterial Pressure Monitoring

1. Air embolus
2. Sepsis
3. Paresthesia
4. Thrombosis

111

Mixed Venous Oxygen Saturation (SVO2)

- Measured in the pulmonary artery
- Normal range 60-80%

112

Indications for SVO2 Monitoring

- Early warning of alterations in hemodynamic status
- Monitor changes in cardiorespiratory status

113

Intra-Aortic Balloon Pump (IABP)

- The balloon is inserted in the thoracic aorta
- Reduces cardiac work by decreasing afterload
- Increases coronary blood flow
- Increases cardiac output

114

Indications for IABP

1. Cardiogenic Shock secondary to MI
2. CHF secondary MI
3. Unstable Angina or Arrhythmias
4. Prophylaxis or Post-op Cardiac Surgery
5. Septic Shock
6. Cardiac Contusion

115

Complications for IABP

1. Extremity ischemia
2. Thrombus formation
3. Infection
4. Hemorrhage
5. Renal compromise

116

Heart Failure

- The inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients
- A syndrome characterized by fluid overload or inadequate tissue perfusion
- The term heart failure indicates myocardial disease, in which there is a problem with the contraction of the heart (systolic failure) or filling of the heart (diastolic failure)
- Some cases are reversible
- Most heart failure is a progressive, lifelong disorder managed with lifestyle changes and medications

117

Medical Management of Heart Failure

1. Eliminate or reduce etiologic or contributory factors
2. Reduce the workload of the heart by reducing afterload and preload
3. Optimize all therapeutic regimens
4. Prevent exacerbations of heart failure
5. Medications are routinely prescribed for heart failure

118

Medications Used to Treat Heart Failure

1. Angiotensin: converting enzyme inhibitors (prils)
2. Angiotensin II receptor blockers (tans)
3. Beta-blockers (lols)
4. Diuretics
5. Digitalis

119

Potential Complications of Heart Failure

1. Cardiogenic shock
2. Dysrhythmias
3. Thromboembolism
4. Pericardial effusion and cardiac tamponade

120

Pulmonary Edema

- Acute event in which the LV cannot handle an overload of blood volume. Pressure increases in the pulmonary vasculature, causing fluid movement out of the pulmonary capillaries and into the interstitial space of the lungs and alveoli
- Results in hypoxemia

121

S/Sx of Pulmonary Edema

1. Restlessness
2. Anxiety
3. Dyspnea
4. Cool and clammy skin
5. Cyanosis
6. Weak and rapid pulse
7. Cough, lung congestion (moist, noisy respirations),
8. Increased sputum production (sputum may be pink frothy and blood-tinged),
9. Decreased level of consciousness

122

Management of Pulmonary Edema

1. Prevention!!!!
2. Early recognition: monitor lung sounds and for signs of decreased activity tolerance and increased fluid retention
3. Place patient upright and dangle legs
4. Minimize exertion and stress
5. Oxygen
6. Medications
- Morphine
- Diuretic: furosemide

123

Shock

The failure of the heart as a pump, volume of blood available, vascular delivery of blood
- Inadequate tissue perfusion

124

S/Sx of Shock

1. Low BP
2. Increased HR
3. Cold, clammy skin
4. Change in LOC

125

Types of Shock

1. Hypovolemic
2. Septic
3. Anaphylactic
4. Cardiogenic

126

Cardiogenic Shock

- A life threatening condition with a high mortality rate
- Decreased CO leads to inadequate tissue perfusion and initiation of shock syndrome
- Clinical manifestations: symptoms of heart failure, shock state, and hypoxia

127

S/Sx of Cardiogenic Shock

1. Angina
2. Dysrhythmias
3. Fatigue
4. Feelings of doom
5. Hemodynamic instability

128

Management of Cardiogenic Shock

1. Correct underlying problem
2. Medications
- Diuretics
- Positive inotropic agents and vasopressors
3. Circulatory assist devices
- Intra-aortic balloon pump (IABP)

129

What can increase the risk for Thromboembolism?

Decreased mobility and decreased circulation increase the risk for thromboembolism in patient with cardiac disorders including those with Heart Failure.

130

Pulmonary Embolism

Blood clot from the legs moves to obstruct the pulmonary vessels

131

Treatment for Pulmonary Embolism

1. Anticoagulant therapy

132

Pericardial Effusion

The accumulation of fluid in the pericardial sac

133

Cardiac Tamponade

The restriction of heart function due to this fluid resulting in decreased venous return and decreased CO

134

Clinical Manifestations of Pericardial Effusion and Cardiac Tamponade

1. Ill defined chest pain or fullness
2. Pulsus paradoxus
3. Engorged neck veins
4. Labile or low BP
5. Shortness of breath

135

Cardinal Signs of Cardiac Tamponade

1. Falling systolic BP
2. Narrowing pulse pressure
3. Rising venous pressure
4. Distant heart sounds (muffled)

** EMERGENCY