CARDIOVASCULAR CASE STUDIES Flashcards by Kelsey Klipfel

Acute episodes lands them in hospital for HF exacerbation
Manage outpatient and edu how manage outpat
Pump failure-chronic inability of heart to work effectively as a pump
Heart not able to maintain adequate cardiac output to meet the metabolic needs of the body
Types
Most heart failure begins with failure of the left ventricle and progresses to failure of both ventricles

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Left-sided heart failure
Right-sided heart failure
High-output failure

Types - HF

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Decreased tissue perfusion from poor cardiac output and pulmonary congestion
Backs up into lungs: s/s of pulm congestion
Often happens first
Systolic heart failure (2/3 of cases)
Diastolic heart failure

Left-sided heart failure

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Heart doesn’t pump adequately; reduced EF: <40% diagnostic HF

Systolic heart failure (2/3 of cases) - Left-sided heart failure

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Heart doesn’t fill adequately

Diastolic heart failure - Left-sided heart failure

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Right ventricle can not empty
Backs up into body: s/s of systemic congestion
Happens if have chronic obstructive disease

Right-sided heart failure

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Cardiac output remains normal but there are increased metabolic needs or hyperkinetic conditions
Normal EF (prob not with pump) - issue is with increase in metabolic needs

High-output failure

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Bert is concerned and he is not sure what caused this problem? What prior medical history puts Bert at risk for heart failure(Select all that apply)?
1. Hypertension
2. Hypothyroidism
3. GERD
4. Aortic valve stenosis

Answer: 1, 4
Why? (Think about plumbing)
What are some other causes of HF?
Smoking (risk factor/contribute), Age, overweight, CAD, following a MI - area heart muscle damaged end up with HF

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Left ventricular failure - backs up into right side after so long of back up
Right ventricular MI (myocardial infarction)
Pulmonary hypertension
Chronic lung disease

Causes of right sided heart failure:

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Hypertension
Coronary artery disease
Valvular disease
Ventricular remodeling after MI - ventricles remodel and reshape after MI around area that have infarct

Causes of left sided heart failure:

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Which question will provide the nurse the best data about any additional risk factors for heart failure? (Select all that apply)
1. “Do you have any chronic lung disorders?”
2. “Have you ever had a heart attack?”
3. “Do you have varicose veins?”
4. “Have you ever had low blood pressure?”

Answer: 1, 2
Chronic goes along with right-sided
Varicose veins - tells having other issues in extremities; HTN is more a risk factor than low BP

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When planning care for Bert the nurse anticipates what diagnostic procedure?
1. Cardiac catheterization
2. Echocardiogram
3. Angiography
4. Exercise electrocardiograpy

Answer: 2
Standard tool for diagnosing HF
ECG - looking at heart rhythm; electrocardiogram

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Imaging:
Lab

Diagnostic assessment - HF

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CXR
Echocardiogram

Imaging:

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Cardiomegaly (enlarged heart) may be present

CXR

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US of the heart
Best tool in diagnosing HF
Looks at structure of the heart
Measures chamber size, ejection fraction and flow
If EF (ejection fraction) <40% then diagnostic of HF
Can look at valves
Can increase EF back up with back meds and lifestyle modifications; can also get lower if not take care of self
Do when have acute exacerbations

Echocardiogram

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BNP (B-type natiuretic peptide)
Electrolytes
BUN and creatinine
H&H
Urinalysis
ABG

Lab

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Will be elevated and used for diagnosing HF
BNP is produced and released by the ventricles when the patient has fluid overload
Natriuretic peptides promote vasodilation and diuresis through sodium loss in the renal tubules

BNP (B-type natiuretic peptide)

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Abnormalities from complications of HF or side effects of drug therapy
Diuretics given for HF; loop: excreting electrolytes and K low - aggressive K protocol

Electrolytes

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Inadequate perfusion of kidneys can result in impairment and elevated levels
Can get kidney disease when not perfusing as well
Diuretics can affect kidneys: want get fluid off - creatinine can get too high and not want damage kidneys

BUN and creatinine

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Could be low secondary to hemodilution

H&H

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Possible proteinuria and high specific gravity
Microalbuminuria - early indicator of decreased compliance of the heart and occurs before the BNP rises

Urinalysis

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Decrease in gas exchange secondary to fluid filled alveoli
May also have obstructive pulm disease

ABG

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Which assessment finding would indicate to the nurse that Bert is experiencing right-sided heart failure?
1.Dyspnea
2.Tachycardia
3.Edema
4.Fatigue

Answer: 3
Systemic effect with right-sided HF

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Does Bert have right or left sided heart failure symptoms? Physical assessment findings: Irregular HR 138; BP of 140/86 Lungs with fine crackles in the bases bilaterally Dyspnea Positive jugular vein distention (JVD) Bilateral 1+ pitting edema of his ankles

Both - often see both in pats

Systemic Congestion Jugular (neck vein) distention Enlarged liver and spleen Anorexia and nausea Dependent edema (legs and sacrum) Distended abdomen Swollen hands and fingers Polyuria at night Weight gain - need weigh every day Increased blood pressure (from excess volume) Decreased blood pressure (from failure)

Symptoms of right sided heart failure

Pulmonary congestion Decreased cardiac output

Symptoms of left sided HF

Hacking cough, worse at night Dyspnea - not lay flat because fluid builds up Crackles/wheezes in lungs Pink, frothy sputum - lot congestion Tachypnea S3/S4 gallop

Pulmonary congestion

Fatigue and weakness Oliguria during day/Nocturia at night Angina - chest pain Confusion and restlessness - hypoxia sign Dizziness Pallor and cool extremities - not good perfusion Weak peripheral pulses Tachycardia - increase CO

Decreased cardiac output

reduce the resistance to left ventricular ejection (afterload) and improve cardiac output Angiotensin-converting enzyme (ACE) inhibitors Angiotensin-receptor blockers (ARBs)

Arterial vasodilators

Enalapril (Vasotec) Fisinopril (Monopril) -pril ACE inhibitors are the first-line drug of choice Monitor for:

Angiotensin-converting enzyme (ACE) inhibitors

May cause dry cough; monitor

ACE inhibitors are the first-line drug of choice

Orthostatic hypotension - safety big concern; be with them when getting up and up slowly Acute confusion Angioedema Poor peripheral perfusion Reduced urine output in patients with low systolic BP Potassium and creatinine levels Start slowly - lower dose and work up because not want BP too low

Monitor for: - ACE; ARBs

Valsartan (Diovan) Irbesartan (Avapro) Losartan (Cozaar) -sartan

Angiotensin-receptor blockers (ARBs)

Reduce preload by decreasing volume and pressure in the left ventricle Up in weight and take extra dose First-line drug of choice in older adults with HF and fluid overload Enhance renal excretion of sodium and water Can be PO, IV push, IV drip Ex. Monitor for:

Diuretics

Loop - Furosemide (Lasix) - excrete K Loop - Torsemide (Demadex) - excrete K Loop - Bumetanide (Bumex) - excrete K Thiazide – Hydrochlorothiazide (HCTZ); Metolazone (Zaroxolyn) - K held onto Potassium-sparing – Spironolactone (Aldactone) - K held onto

Ex. - Diuretics

Dehydration - fluid comes off too fast; may need give back some fluid potassium levels (potassium wasting for potassium sparing) If creatinine level is greater than 1.8 mg/dL, notify health care provider before administering supplemental potassium - look what going on with kidneys; not typ give diuretics

Monitor for:- Diuretics

Reduce preload by decreasing volume and pressure in the left ventricle For HF patients that have persistent dyspnea May be administered IV, orally, topically (paste) Headache is common but the patient will develop a tolerance to this effect Must monitor BP - drops quickly

Venous vasodilators (nitrates)

Reduces venous return Given in acute heart failure to reduce anxiety Decreases preload and afterload Slows respirations and reduces the pain associated with an acute myocardial infarction (MI)

Morphine sulfate

Blocks the sympathetic stimulation, increases contractility and decreases demand of heart; decreases BP Monitor for: Not used in patients with acute HF - go home on it; daily/q12hr Ex.

Beta-adrenergic blockers

BP and HR Slow position changes Start slowly and don’t stop abruptly

Monitor for: - Beta-adrenergic blockers

Carvedilol (Coreg) Metoprolol succinate (Toprol XL) Bisoprolol (Zebeta) -lol

Ex. - Beta-adrenergic blockers

Interferes with calcium ions causing vasodilation to lower blood pressure Monitor for: Verapamil (Calan) Amlodipine (Norvasc) Diff endings

Calcium channel blockers:

BP and HR Slow position changes

Monitor for: - Calcium channel blockers:

Provides symptomatic benefits for patients in chronic HF Inconsistent absorption in GI tract so monitor for toxicity Monitor for:

Digoxin (Lanoxin)

Reduce HR; Increase contractility; slows conduction through AV node; increases filling of the ventricles

Provides symptomatic benefits for patients in chronic HF- Digoxin (Lanoxin)

HR (apical HR check prior to every administration) Digoxin toxicity (anorexia, fatigue, blurred vision, changes in mental status, dysrhythmias) - erratically absorbed Drug levels - not too much of it/too low

Monitor for:- Digoxin (Lanoxin)

Prior to administration what assessment finding would prevent the nurse from administering lanoxin? 1. BP 99/68 2. Apical pulse 48 3. Respiratory rate 28 4. SpO2 89%

Answer: 2 Count for full min then decide if admin apical pulse Apical pulse most accurate noninvasive way of looking at cardiac health Want greater than 60

Which assessment is most important for the nurse to perform prior to the administration of captopril(Capoten)? 1.Apical pulse 2.Blood pressure 3.Respiratory rate 4.Intake and output

Answer: 2 BP med; BP prior to med then reassess BP med; low BP will feel it; too low BP may experience syncope

Which complaint by Bert would be of highest concern after adminstration of captopril? 1.Diarrhea 2.Itching in throat 3.Constant dry cough 4.Dizziness when standing

Answer: 2 Dizziness is safety concern but highest concern is itching - AE of drug induced angioedema: swelling of airway; itching in throat highest concern

When planning care for Bert what should be the priority nursing diagnosis? 1.Fluid volume deficit 2.Ineffective airway clearance 3.Altered nutrition, greater than needs 4.Impaired gas exchange

Answer: 4 Issues with breathing and HF, fluid in lungs (impaired gas exchange), not having airway issues; fluid volume overload

Which intervention should be implemented based on the diagnosis of activity intolerance? 1.Provide 3 large meals daily 2.Provide all activities of daily living (ADLs) for the patient 3.Encourage frequent rest periods 4.Encourage regular aerobic exercise

Answer: 3 Might need take it slow and work back up; encourage get up to prevent comps; cardiac rehab more appropriate

Oxygen Monitor respirations and lung sounds - need baseline assessment early so if have issues later can know if new If dyspnea present, high-Fowler’s position Reposition, cough and deep breathe every 2 hours Drug Therapy Nutrition therapy Fluid restriction Weigh daily Monitor and record intake and output - strict; measuring how doing; base meds Provide periods of uninterrupted rest - cluster care and try not wake up when asleep Assess the patient’s response to increased activity - PT/OT

Nursing interventions - HF

Keep oxygen saturations 90% or greater - Depends on pat and orders; typ order to be on O2

Oxygen

Maximize chest expansion and improve oxygenation Noninvasive

If dyspnea present, high-Fowler’s position

Improve oxygenation and prevent atelectasis Provide frequent rest periods when working

Reposition, cough and deep breathe every 2 hours

To improve stroke volume Big intervention for HF pats Will reduce afterload, reduce preload, and improve cardiac muscle contractility

Drug Therapy

Goal to reduce sodium and water retention Reduce sodium intake: 2 gram/day - teach other ways to avoid salt; BIG

Nutrition therapy

Range from 2 Liters to 3 Liters per day; measuring intake

Fluid restriction

Most reliable indicator of fluid gain or loss; rapid weight gain concerning 1 kg of weight gain or loss equals 1 liter of retained or lost fluid

Weigh daily

The nurse enters Bert’s room and finds him lying in bed in a supine position. His respiratory rate is 32 per minute and he states that his back hurts. Which action should the nurse implement first? 1.Notify the respiratory therapist 2.Assist Bert to turn on his side 3.Elevate the head of Bert’s bed 4.Offer Bert a back massage

Answer: 3 Needs help with breathing; less invasive and see supine and struggling and elevate HOB to see if helps him

The nurse assesses that Bert is becoming increasingly confused and restless, and that he has developed a frothy, productive cough. His vital signs are temperature 98, P 148, R 36, BP 110/64. Which intervention should the nurse implement first? 1.Obtain an oxygen saturation level via pulse oximeter 2.Call the lab to obtain a stat serum potassium level 3.Collect a sputum specimen for culture and sensitivity 4.Initiate suctioning to remove lung secretions

Answer: 1 Increasingly confused and restless - hypoxia Frothy, productive cough - increased fluid in lungs Want assess further and see O2 sat - determines treatment

Left ventricle fails to eject sufficient blood and pressure increases in the lungs With pats with left sided HF; want avoid developing The increased pressure causes fluid to leak across the pulmonary capillaries and into the lung airways and tissues Pink frothy sputum classic pulm edema Confused and restless because low O2 sat

Pulmonary Edema

Bert’s condition worsens and he is transferred to ICU. What are the priorities of care at this time (Select all that apply) 1. Rapid acting diuretics 2. Nitroglycerin 3. Aggressive pulmonary therapy 4. Aggressive IVF replacement 5. Beta blockers

Answer: 1, 2, 3 Not give PO diuretics - IV push and/or drip Not just low O2 therapy on them IVF - IV fluid; want fluid off of them Beta blockers: something to manage HF but not for acute exacerbation

Monitor VS If not hypotensive, put in high Fowler’s position High flow oxygen therapy Aggressive pulmonary therapy - may need this Nitroglycerin (NTG) Administer rapid-acting diuretics IV Morphine Sulfate

Pulm edema interventions

Maintain oxygen saturation above 90%

High flow oxygen therapy

CPAP, BiPAP, or intubation and mechanical ventilation Depends on how pat presenting: get fluid off, how quickly, how breathing, conscious

Aggressive pulmonary therapy - may need this

if systolic BP is greater than 100; too low not give vasodilator

Nitroglycerin (NTG)

IV Furosemide (Lasix) or Bumetanide (Bumex)

Administer rapid-acting diuretics

Reduces venous return (preload) Decreases anxiety - very anxious and confused because hypoxic Reduces work of breathing

IV Morphine Sulfate

Bert is now recovered and on a medical surgical unit preparing for discharge. What statement by Bert indicates to the nurse that further teaching is required? 1.“I must weigh myself once a month and watch for fluid retention” 2.“If my heart feels like it is racing I should call the doctor” 3.“I’ll need to consider my activities for the day and rest as needed” 4.“I’ll need periods of rest and should avoid activity after a meal”

Answer: 1 Weigh daily Racing - increased HR, abnorm heart rhythm

Diet Activity schedule - active and periods rest Drug therapy - why need cont keep taking meds Discharge instructions - need appt before leave hospital because need good follow up so not end up back in hospital Resources and equipment needs - O2; social work; medication regimen: know what take and how take it VERY IMPORTANT TO DECREASE READMISSIONS - follow-up often; still happens but need be educated

Patient teaching for HF

Sodium restriction and fluid restriction - watch Na; teach ways that do not involve salt

Diet

Rapid weight gain (3 lbs in a week or 1-2 lb overnight) Decrease in exercise tolerance lasting 2 to 3 days Cold like symptoms (cough) lasting more than 3-5 days Excessive awakening at night to urinate Development of dyspnea or angina at rest or worsening angina Increased swelling in the feet, ankles, or hands

Notify any of the following symptoms to health care provider - Discharge instructions - need appt before leave hospital because need good follow up so not end up back in hospital

Six months later Bert is back on your unit recovering from an AVR (aortic valve replacement) with an artificial valve. What should be including in his discharge teaching (Select all that apply)? 1. Avoid crowds and sick people 2. Use electric razors for shaving 3. Pre-medicate with antibiotics prior to invasive procedures 4. Avoid heavy lifting for 3-6 months

Answer: 2, 3, 4 Put on blood thinners: INR: 2-3 Not want develop endocarditis Depends on how go in for surgery - may do cardiac cath (have qualify) - bigger surgery

Diagnostic testing: Management depends on which valve is affected and the degree of valve impairment

Vavular heart disease

Echocardiogram – procedure of choice; Echo - look at valves and see what going on with them Transesophageal echocardiogram (TEE) Chest x-ray ECG

Diagnostic testing:

Nonsurgical management: Medications Surgical management: May need Replacement or repair Patients with defective or repaired valves are at risk for infective endocarditis, so they do require prophylactic antibiotic therapy before any invasive procedures

Management depends on which valve is affected and the degree of valve impairment

Infection of the endocardium High mortality rate Early detection is essential to protect pats Causes: Possible ports of entry Key features: Diagnostic assessment: Interventions:

Infective endocarditis

IV drugs use Valve replacements Systemic infection Structural cardiac defects

Causes: - Infective endocarditis

Oral cavity (if dental procedures have been performed) Skin rashes, lesions, abscesses Infections Surgery or invasive procedures, including IV line placement Imp for aseptic technique as a result

Possible ports of entry - Infective endocarditis

Fever associated with chills, night sweats, malaise, fatigue Anorexia and weight loss Cardiac murmur Petechiae (pinpoint red spots) Splinter hemorrhages (black lines or small red streaks on the nail bed)

Key features: - Infective endocarditis

positive blood cultures - couple days to grow out TEE

Diagnostic assessment: - Infective endocarditis

IV antibiotics for 4-6 weeks - drug choice depends on choice of blood cultures; start on broad then to narrow Rest Surgical management if antibiotic therapy is ineffective - replace/repair injured/affected valve - drainage if interventions not work;

Interventions: - Infective endocarditis

CARDIOVASCULAR CASE STUDIES Flashcards

(84 cards)