Cardiovascular Concepts Ch 3 Flashcards
(416 cards)
1
Q
What sound is the “Lub”?
A
S1
2
Q
What causes the S1 sound?
A
The closure of the AV (mitral and tricuspid) valves
3
Q
Where does S1 sound the loudest?
A
Apex of the heart
4
Q
Where can you listen for the apex of the heart?
A
Mitral area
5
Q
Where is the mitral area?
A
Midclavicular, 5th intercostal space
6
Q
The midclavicular, 5th intercostal space is called the — —
A
Mitral (apical) area
7
Q
You can listen to the __ at the 5th intercostal, midclavicular space
A
Apex
8
Q
What does the S1 sound mark?
A
The end of diastole and beginning of systole
9
Q
What sound marks the end of diastole?
A
S1
10
Q
What sound marks the beginning of systole?
A
S1
11
Q
The end of diastole and beginning of systole is marked by the closure of…?
A
AV valves (mitral and tricuspid)
12
Q
What does S2 sound like?
A
Dub
13
Q
What does the “dub” sound indicate?
A
S2
14
Q
This sound is caused by the closure of the semilunar valves
A
S2
15
Q
Which are the semilunar valves?
A
Aortic and pulmonic
16
Q
S2 is caused by…
A
Closure of the semilunar valves
17
Q
Where is S2 loudest?
A
At the base of the heart
18
Q
Where can you listen to the base of the heart?
A
Right eternal border, 2nd intercostal space
19
Q
Where can you listen to S2 sounds?
A
Right sternal border, 2nd intercostal space
20
Q
What sound can be heard by listening to the right sternal border, 2nd intercostal space?
A
S2, at the base of the heart
21
Q
S2 marks the end…
A
Of systole and beginning of diastole
22
Q
S2 __ on inspiration
A
Splits
23
Q
Which sound splits on inspiration?
A
S2
24
Q
S2 splits on __
A
Inspiration
25
Wide fixed splitting of S2 is caused by…
Right bundle branch block (RBBB)
26
A right bundle branch block can cause what sound?
Fixed wide splitting of S2 sound
27
What type of BBB causes wide fixed splitting of the S2 sound?
Right
28
What pathology can cause S2 to become louder?
Pulmonary embolism
29
What effect can a pulmonary embolism have on heart sounds?
It can make S2 sound louder
30
Which area is right sternal, 2nd intercostal space?
Aortic area
31
Where is the aortic area located?
Right sternal, 2nd intercostal space
32
Where is the pulmonic area located?
Left sternal, 2nd intercostal space
33
What area is located at the left sternal, 2nd intercostal space?
Pulmonic area
34
Where is Erb’s point located?
Left sternal, 3rd intercostal space
35
What area is located at the left sternal, 3rd intercostal space?
Erb’s Point
36
Where is the tricuspid area located?
Left sternal, 5th intercostal space
37
What area is located at the left sternal, 5th intercostal space?
Tricuspid area
38
What space is located at the misternal, 5th intercostal space?
Mitral (apical) area
39
What causes S3 heart sound?
Rapid rush of blood into a dilated ventricle
40
A rapid rush of blood into a dilated ventricle would cause what sound?
S3
41
When does S3 sound occur?
Early in diastole, right after S2
42
Where is S3 best heard?
At the apex of the heart, mitral area
43
S3 is associated with __ __
heart failure
44
S3 may occur before __
Crackles
45
S3 is also called a ventricular __
Gallop
46
A ventricular gallop sounds like…
“Kentucky”
47
S3 can also be caused by…
PHTN
Cor pulmonale
Mitral, aortic, or tricuspid insufficiency
48
S3 can also be caused by…
PHTN
Cor pulmonale
Mitral, aortic, or tricuspid insufficiency
49
What should you use to listen for S3 sound?
Bell of stethoscope at the apex (mitral area)
50
What is Cor pulmonale?
Pulmonary heart disease/ right ventricular failure
51
What causes S4 sound?
Atrial contraction of blood into a noncompliant ventricle
52
Atrial contraction of blood into a noncompliant ventricle causes what sound?
S3
53
When does S4 sound occur?
Right before S1
54
When can you not hear S4 sound?
In the presence of a fib
55
Why can you not hear S4 during a fib?
No atrial contraction
56
Where is S4 best heard?
Apex of the heart with the bell of stethoscope
57
What is S4 associated with?
Myocardial ischemia
Infarction
HTN
Ventricular hypertrophy
Aortic stenosis
58
What is S4 most associated with?
Aortic stenosis
59
What does an atrial gallop sound like?
“Tennessee”
60
What is the name for the S4 sound?
Atrial gallop
61
What type of gallop makes a “Tennessee” sound?
Atrial gallop
62
An atrial gallop is the __ sound
S4
63
What type of gallop makes the “Kentucky” sound?
Ventricular gallop (S3)
64
What causes a pericardial friction rub?
Pericarditis
65
A pericardial friction rub may be __
Positional
66
What heart sound is associated with pain on deep inspiration?
Pericardial friction rub
67
Murmurs are associated with __ __
Valvular disease
68
Murmurs are also associated with __ __
Septal defects
69
What is the equation for pulse pressure?
Systolic - diastolic pressure
70
What is a normal pulse pressure?
40-60 mmHg
71
Systolic pressure is an indirect measurement of…
Cardiac output and stroke volume
72
__ BP is an indirect measure of CO and SV
Systolic
73
A narrowing of pulse pressure is most often seen in…
Severe hypovolemia or a severe drop in CO (from 120/80 to 100/73)
74
Diastolic BP is an indirect measurement of…
Systemic vascular resistance
75
__ BP is an indirect measurement of systemic vascular resistance
Diastolic
76
A decrease in diastolic pressure __ pulse pressure
Widens
77
A decrease in diastolic pressure __ pulse pressure
Widens
78
What could a decrease in diastolic pressure that widens PP indicate?
Vasodilation, and a drop is SVR
79
A decrease in diastolic pressure that widens pulse pressure may occur in…
Septic shock
80
Diastole is normally __ __ longer than systole
One third
81
When are coronary arteries perfused?
During diastole
82
During diastole, which arteries are perfused?
Coronary arteries
83
Why do heart valves open and close?
Based on pressure changes in the chambers above and below the valve
84
When does a valve open?
When the pressure in the chamber above the valve is greater than the pressure in the chamber below
85
When does a valve close?
When the pressure drops in the chamber above the valve, and the pressure is greater below the valve
86
Systole:
Ejection, high pressure
87
Diastole:
Filling, low pressure
88
Why is diastole 1/3 longer than systole?
Needs time for filling
89
List some general causes of valvular heart disease
CAD, MI
DCM
Degeneration
Bicuspid aortic valve (genetic)
Rheumatic fever
Infection
Connective tissue diseases
90
What is a murmur of insufficiency?
Regurgitation
91
When does a murmurs of insufficiency occur?
When the valve is closed
92
Murmurs of insufficiency (regurgitation) can be ___ or ___
Acute or chronic
93
What type of murmur occurs when the valve is closed?
Insufficiency (regurgitation)
94
What type of murmur occurs when the valve is open?
Stenosis
95
Murmurs of stenosis occur when the valve is __
Open
96
Murmurs of stenosis are a __ problem
Chronic
97
Murmurs of stenosis are NOT __
Acute
98
Murmurs of stenosis develop ___ ___
Over time
99
What do systolic murmurs sound like?
“Lub…shhhb…dub”
100
What types of valve stenosis are the semilunar valves open during systole?
Aortic stenosis
Pulmonic stenosis
101
With aortic and pulmonic stenosis, which valves are open?
Semilunar
102
What types of insufficiency are AV valves closed during systole?
Mitral and tricuspid insufficiency
103
If a patient has a pulmonary artery catheter, mitral insufficiency (regurgitation) will look like what on the monitor?
Large, giant V waves on the pulmonary artery occlusion pressure
104
During mitral and tricuspid insufficiency (regurgitation), what valves are closed during systole?
AV valves (tricuspid and bi/mitral)
105
With mitral and tricuspid insufficiency (regurgitation), AV valves are __ during systole
Closed
106
When is a ventricular septal defect most common?
With an acute MI
107
A ventricular septal defect may result in a __ __
Systolic murmur
108
Where is a ventricular septal defect heard?
Left sternal border, 5th intercostal space
109
List 5 systolic murmurs
Aortic stenosis
Pulmonic stenosis
Mitral insufficiency
Tricuspid insufficiency
Ventricular septal defect
110
What does a diastolic murmur sound like?
“Lub…Dub…shhhb”
111
Semilunar valves are closed during diastole with which 2 murmurs?
Aortic insufficiency (regurgitation)
Pulmonic insufficiency (regurgitation)
112
With aortic and pulmonic insufficiency (regurgitation), what valves are closed during diastole
Semilunar
113
With aortic and pulmonic insufficiency, semilunar valves are ___ during diastole.
Closed
114
AV valves are open during diastole with which diastolic murmurs?
Mitral and tricuspid stenosis
115
With mitral and tricuspid stenosis, which valves are open during diastole?
AV valves
116
With mitral and tricuspid stenosis, AV valves are __ during diastole
Open
117
What is mitral stenosis associated with?
Atrial fibrillation
118
Why is mitral stenosis associated with atrial fibrillation?
D/t atrial enlargement that occurs over time
119
During systole, which valves are open and which are closed?
Open- semilunar (pulmonic and aortic)
Closed- AV (tricuspid, mitral)
120
What does this photo show?
Systole
121
What does this photo show?
Diastole
122
Mitral insufficiency (regurgitation) occurs when…
The mitral valve is closed
123
When is the mitral valve closed?
During systole
124
Mitral stenosis occurs when the mitral valve is __
Open
125
When is the mitral valve open?
During diastole
126
Aortic insufficiency (regurgitation) occurs when the aortic valve is __
Closed
127
When is the aortic valve closed?
During diastole
128
Aortic stenosis occurs when the aortic valve is __
Open
129
When is the aortic valve open?
During systole
130
Does a murmur due to VSD occur during diastole or systole?
During ejection or systole
131
The mitral valve is attached to the left ventricular wall by…
Papillary muscles and the chordae tendineae
132
How does MI lead to acute mitral valve regurgitation?
Ischemia or infarction can affect mitral valve function
133
Papillary muscle dysfunction or rupture is loudest…
At the apex
134
Papillary muscle rupture is a ___ ___
Surgical emergency
135
Papillary muslce rupture and dysfunction are both associated with an __ __
Acute MI
136
What is characteristic of stable angina?
Chest pain with activity
Predictable
Lesions that are usually fixed and calcified
137
Acute coronary syndrome is due to ___-___ thrombosis
platelet-mediated
138
Acute coronary syndrome may result in sudden __ __.
cardiac death
139
What are the 4 types of acute coronary syndrome?
1. Unstable angina
2. Non ST-elevation myocardial infarction
3. ST elevation MI
4. Variant or Prinzmetal's angina
140
What is characteristic of unstable angina?
Chest pain at rest
Unpredictable
May be relived with nitro
Troponin negative
ST depression or T wave inversion
141
ST depression or T wave inversion is characteristic of which types of actue coronary syndrome?
Unstable angina or NSTEMI
142
Chest pain at rest, unpredictable, troponin negative, ST depression or T wave inversion are characteristics of...
Unstable angina
143
Unrelenting chest pain, troponin positive, ST depression or T wave inversion are characteristic of...
NSTEMI
144
What is characteristic of a STEMI?
Troponin positive
ST elevation in 2 or more continuous leads
Unrelenting chest pain
145
Positive troponins, unrelenting chest pain, and ST elevation in 2 or more continuous leads is characteristic of...
STEMI
146
147
What is variant or Prinzmetal's angina?
A type of unstable angina associated with transient ST elevation
148
Transient ST elevation with unstable angina is called...
Variant or Prinzmetal's angina
149
What causes variant or Prinzmetal's angina?
D/t coronary artery spasm with or without atherosclerotic lesions
150
When does variant or Prinzmetal's angina occur?
At rest or could be cyclic (same time each day)
151
What can precipitate variant or Prinzmetal's angina?
Nicotine, ETOH, or cocaine ingestion
152
With variant or Prinzmetal's angina, troponins will be __.
negative
153
How is variant or Prinzmetal's angina treated?
With nitroglycerin, will relieve chest pain and ST will return to normal
154
What can you tell from an EKG during acute chest pain?
STEMI, NSTEMI/UA, or no acute change
155
If someone is having an MI, what are the 7 treatment steps
1. STAT EKG
2. Aspirin
3. Anticoagulation: heparin or lovenox
4. Antiplatelet agent
5. Beta blocker
6. Treat pain
7. Labs
156
What should be given asap if MI is suspected?
Aspirin, and must be chewed
157
What are 4 antiplatelet agents that may be used in treatment of MI
Clopidogrel (Plavix)
Abciximab (Reopro)
Eptifibatide (Integrilin)
Tirofiban (Aggreastat)
158
Clopidogrel (Plavix), Abciximab (Reopro), Eptifibatide (Integrilin), Tirofiban (Aggreastat) are all __ drugs
antiplatelet
159
What is the exception for giving a beta blocker during an MI?
If ACS is d/t cocaine
160
What type of beta blockers should be used during ACS?
Cardioselective BB
161
What is an example of a cardioselective BB?
metoprolol (Lopressor)
162
What is an example of a non Cardioselective BB?
Propanolol (Inderal)
163
What are 3 contraindications to administering a beta blocker for ACS?
Hypotension
Bradycardia
Use of phosphodiesterase-inhibitor drugs
164
What is an example of a phosphodiesterase-inhibitor drug?
sildenafil (Viagra)
165
What is pain treated with for ACS?
Nitroglycerin and morphine
166
What labs might be ordered if suspected ACS?
Cardiac biomarkers
Lipid profile
CBC
Electrolytes
BUN/Cr
PT/PTT
167
Changes in lead II, III and aVF. Where is the location of the CAD/ACS?
Right coronary artery (RCA) and/or inferior LV
168
If the ACS is located in the right coronary artery (RCA) and/or inferior LV, what leads would you see changes?
II, III, aVF
169
If you see changes in leads V1, V2, V3, and V4, where is the location of the CAD?
left anterior descending (LAD), and anterior LV
170
If the ACS/CAD is in the left anterior descending (LAD), and anterior LV, what leads would you see changes?
V1, V2, V3 and V4
171
If you see changes in leads V5, V6, I and aVL, where is the CAD/ACS located?
Circumflex, lateral LV
172
If CAD?ACS is located in the circumflex and lateral LV, what leads would you see changes?
V5, V6, I and aVL
173
Is there are changes in only leads V5 and V6, where is the CAD/ACS?
low lateral LV
174
If the CAD/ACS is in the low lateral LV, where would you see lead changes?
V5 and V6
175
If you see lead changes in lead I and aVL only, where is the CAD/ACS?
high lateral LV
176
If the CAD/ACS is in the high left ventricle, what leads would you see changes?
I and aVL
177
If you see changes in leads V1 and V2 only, where is the CAD/ACS?
RCA, posterior LV
178
If the CAD/ACS is in the RCA and posterior LV, what leads would you see changes?
V1 and V2
179
If you see changes in only leads V3R and V4R, where is the CAD/ACS?
RCA, RV infarct
180
If a patient has CAD/ACS in the RV and RCA, what leads would you see changes?
V3R, V4R
181
A ___ MI is associated with RCA occlusion
Inferior
182
An inferior MI is associated with which artery occlusion?
RCA
183
For an inferior MI, you'll see ST elevation in which leads?
II, III, and aVF
184
For an inferior MI, what leads will have reciprocal changes?
I and aVL
185
An inferior MI is associated with what type of conduction disturbances?
AV
186
What are examples of AV conduction disturbances that are associated with an inferior MI?
2nd degree type 1, 3rd degree AV black, sick sinus syndrome (SSS) and sinus bradycardia
187
2nd degree AV block, 3rd degree AV block, SSS, and SB are all associated with a(n) ___ MI
inferior
188
If tachycardia is associated with an inferior MI, this means...
higher mortality
189
Development of a systolic mumur is associated with an inferior MI d/t...
MVR secondary to papillary muscle rupture
190
Why is the development of a systolic murmur associated with an inferior MI?
posterior papillary muscle has only one source of blood supply, the RCA
191
Use BB and NTG with CAUTION in which type of MI?
Inferior
192
Why are inferior MI associated with RV infarct?
RAC supplies inferior wall of LV and also the RV, so 30% of inferior wall MI patients also have RV infarct
193
What type of EKG will demonstrate ST changes in the RV?
right sided EKG
194
A patient has JVD at 45 degrees, high CVP, hypotension, clear lungs, and bradyarrhythmias. These are signs of what type of MI?
right ventricular infarct
195
What are symptoms of a right ventricular infarct?
JVD at 45 degrees, high CVP, hypotension, usually clear lungs, and bradyarrhythmias
196
Right ventricular infarct will show ST elevation in which leads?
V3R and V4R
197
How is a right ventricular infarct treated?
Fluids and positive inotropes
198
What should be avoided in a patient with a right ventricular infarct?
Preload reducers such as nitrates and diuretics
199
What type of MI is associated with LAD occlusion?
Anterior
200
What artery occlusion is associated with an anterior MI?
LAD
201
An anterior MI will have ST elevation in what leads?
V1-V4
202
This EKG shows what?
Right-sided EKG with evidence of RV infarction
203
An anterior MI will have reciprocal changes (ST depression) in what leads?
II, III, and aVF
204
A patient with an anterior MI may develop what types of heart block?
2nd degree type 2 or a right BBB
205
Why can a patient with an anterior MI develop a RBBB or 2nd degree type 2 block?
The LAD supplies the common bundle of His
206
If a patient with an anterior MI develops a 2nd degree type 2 or RBBB, this is a ___ sign
ominous
207
If a patient with an anterior MI develops a systolic murmur, this could mean...
possible ventricular septal defect
208
Which has higher mortality, inferior or anterior MI?
Anterior, can lead to heart failure
209
A LOW lateral MI will show ST elevation in what lead?
V5 and V6
210
A HIGH lateral MI will show ST elevation in what leads?
I and aVL
211
A lateral MI generally involves which artery?
left circumflex
212
For treatment of STEMI, if symptoms are less than __ hours, goal is reperfusion
12
213
What is the time frame standard for PCI after STEMI?
door to balloon within 90 minutes
214
What is the time-frame standard of fibrinolytic therapy for treatment of MI?
door to drug within 30 minutes
215
What are the 4 criteria for treatment of STEMI by PCI or fibrinolytic therapy
1. ST elevation in 2 or more continuous leads OR new onset LBBB
2. Onset of chest pain <12 hours
3. Chest pain of 30 mins in duration
4. Chest pain unresponsive to SL NTG
216
What should the nurse monitor for post PCI for treatment of acute STEMI
1. Signs of reocclusion
2. Bleeding at sheath site and retroperitoneal
3. Vascular complications
4. Vasovagal reaction during sheath removal
217
How does the RN assess for a vasovagal reaction during sheath removal after PCI for STEMI
Hypotension <90 systolic w/wo bradycardia, absense of compensatory tachycardia
Associated symptoms of pallor, nausea, yawning, diaphoresis
218
How long does nurse hold pressure at sheath site after PCI for STEMI?
Minimum of 20 mins, 30 if on GP IIb/IIIa inhibitors
219
How would a nurse treat a PCI complication of vasovagal reaction during sheath removal?
Give fluids and possible atropine
220
What are symptoms/signs of retroperitoneal bleeding?
Sudden hypotension and severe lower back pain
221
What is treatment for retroperitoneal bleeding?
Fluids, blood products
222
How does RN monitor for vascular complications after PCI?
pulse assessments
223
What are absolute contraindications to fibrinolytic therapy for STEMI
1. Any prior intracranial hemorrhage
2. Known structural cerebral vascular lesion (AV malformation)
3. Known malignant intracranial neoplasm
4. Ischemic stroke within 3 months EXCEPT acture ischemic stroke within 3 hrs
5. Active bleeding
6. Significant closed-head or facial trauma within 3 months
224
How does chest pain relief prove evidence of reperfusion?
D/t fibrinolysis of clot
225
How does resolution of ST elevations show evidence of reperfusion?
due to return of blood flow
226
Why is there marked elevation of troponin/CK-MB after fibrinolytic/PCI for STEMI?
D/t myocardial "stunning" when vessel opens
227
After PCI or fibrinolytic therapy for STEMI, what should the nurse assess for?
Bleeding
Change in LOC (brain bleed)
Reocclusion (chest pain, ST elevation)
228
What is the treatment for NSTEMI?
1. NO emergent reperfusion
2. Same meds as STEMI
3. If high risk score or continued C/P, instability, start GP IIb/IIIa inhibitors such as Integrilin and reopro, and prepare for cardiac cath within 24 hrs
229
What is the most common complication of an acute MI?
Arrhythmias
230
If a patient has a fib after an acute MI, mortality rate...
Increases 10-15% even if returned to NSR
231
What is the goal of PCI with a stent?
Restoration of blood flow distal to a coronary artery lesion with partial or total occlusion
232
What are two most important complications of PCI
Stent thrombosis
Retroperitoneal bleed
233
When is a stent thrombosis most likely to occur?
Within 24 hours of stent placement or sub acutely within the first 30 days
234
What increases a patient's risk of stroke or TIA after PCI
the patient has aortic stenosis
235
List other complications of PCI
coronary artery perforation
distal coronary artery embolization
Intramural hematoma
renal failure
failure of stent deployment
hematoma at sheath site
236
How often in BP measured during PCI sheath removal
every 5-10 mins
237
What should RN do before sheath removal for PCI
baseline vitals and pain medicine
238
What is treatment if patient experiences vasovagal response during sheath removal after PCI
1. Hold nitrates
2. Atropine 0.5mg (even in absence of bradycardia if pt has other symptoms)
3. IV fluid bolus 250 mL NS if pt not immediately responsive to atropine
4. Assess for anxiety/pain as contributing factors
239
What are three ways to achieve hemostasis during PCI sheath removal?
1. Manual pressure for 20-30 mins
2. Mechanical clamp compression using FemoStop or C-clamp
3. Closure device
240
What are signs of coronary artery reocclusion after PCI?
C/P, ST elevation
241
What is a hypertensive emergency (also called htn crisis)?
Elevated BP with evidence of end organ damage (brain, heart, kidneys, retina) that can be related to acute hypertension.
242
What is hypertensive urgency?
Elevated BP WITHOUT signs of acute end organ damage
243
Does hypertensive emergency/urgency require a critical care admission?
HTN emergency does, HTN urgency usually does not
244
What is treatment for hypertensive emergency/crisis?
emergent lowering of BP needed, with nitroprusside (Nipride) or Labetalol
245
Nitroprusside (Nipride) is both a __ and __ reducer
preload and afterload
246
What are signs of nitroprusside toxicity?
Cyanide toxicity secondary to drug metabolite (Thiocyanate).
Signs: mental status changes, restlessness, lethargy, tachycardia, seizures, unexplained metabolic acidosis, especially those with renal impairment when drug used for greater than 24 hrs.
247
Trade names for labetolol
normodyne, trandate
248
Why is intermittent IV doses of labetalol preferred over continuous IV infusion for HTN emergency treatment?
D/t possibility of continuing dose beyond maximum of 300 mg
249
How long does labetalol effect persist after discontinuation of IV
4-6 hours
250
What is the greatest risk of a HTN emergency?
Stroke
251
What are the six Ps?
Pain
Pallor
Pulse
Paresthesia
Paralysis
Poikilothermia
252
What is poikilothermia?
Inability to regulate one's body temperature
253
Loss of hair on toes, legs, and cool dry skin are signs of...
peripheral arterial disease
254
What test can be used to assess for peripheral arterial disease?
Ankle/brachial index
255
What is a normal ankle-brachial index
>0.9
256
How do you get an ankle-brachial index?
divide ankle pressure by brachial pressure on the same side
257
How else can PAD be found?
Doppler ultrasound
Arteriography
258
259
What procedures can be done for PAD?
Embolectomy
Bypass graft
Angioplasty
260
Why should you NOT elevate a patient extremity with PAD
Will decrease perfusion
261
What position can you put the bed in for a patient with PAD?
reverse trendelenburg
262
What medications will a patient with PAD be on?
Thrombolytics (tPA)
Anticoagulants (heparin)
ANtiplatelets (asa, clopidogrel)
vasodilators
263
Signs and symptoms of acute symptomatic CAD
TIA
Monocular visual disturbances
Aphasia
Stroke
264
What is the gold standard for diagnosing acute symptomatic CAD?
angiography
265
What is the risk of having an angiography?
Stroke
266
How else can acute symptomatic CAD be diagnosed?
carotid duplex ultrasound
Computed tomography angiography (CTA)
Magnetic resonance angiography (MRA)
267
How is acute symptomatic CAD treated?
Carotid endarterectomy
Carotid stenting
Aspirin
Statin therapy
268
What is hyperperfusion syndrome after CAD treatments?
When patient has signs and symptoms of a headache ipsilateral to the revascularized carotid artery, focal motor seizures, and/or an intra cerebral hemorrhage
269
What should a nurse monitor for post procedure carotid endarterectomy?
Neuro/motor checks
VS
Bleeding
Hyperperfusion syndrome
270
Why should a nurse pay close attention to VS after carotid endarterectomy?
BP and HR may be labile, such as bradyarrhythmia with HTN, hypotension, bradycarda
271
What is Wolff-Parkinson-White syndrome?
An abnormal conduction pathway exists that allows a reentrant tachycardia pathway to bypass the normal AV node conduction pathway, resulting in supraventricular tachycardia.
272
What age group in WPW syndrome typically seen?
Younger than age 30
273
WPW syndrome typically presents as...
supraventricular tachycardia
274
WPW may also presents as...
pre-excited atrial fibrillation (irregular rhythm, 150 beats/min or greater and wide QRS)
275
What are signs/symptoms a patient may experience during WPW syndrome?
palpitations, dizziness, chest pain, SOB, syncope
276
What does WPW syndrome look like when in sinus rhythm?
short PR interval and presence of a delta wave (seen as a slow rise of the initial upstroke of the QRS)
277
What is this EKG showing?
A delta wave
278
How is WPW syndrome treated?
1. Radiofrequency ablation to eliminate reentrant pathway
2. Synchronized cardioversion or adenosine for SVT
3. For A fib BB, amio, or procainamide IV
279
What should NOT be given to patients with pre-excited atrial fibrillation?
Adenosine, digoxin, or calcium channel blockers
280
Why should adenosine, CCB, and digoxin NOT be given for pre-excited atrial fibrillation?
May enhance antegrade conduction through abnormal pathway by increasing the refractory period in the AV node
281
What can happen if you give a patient with pre-excited atrial fibrillation digoxin, CCB, or adenosine?
V fib
282
QT prolongation may lead to...
torsades de pointes
283
What drugs can cause prolonged QT?
Amiodarone
Quinidine
Haloperidol
Procainamide
284
Which electrolyte problems can lead to prolonged QT?
Hypokalemia
Hypocalcemia
Hypomagnesemia
285
What is treatment for torsades de pointes?
magnesium
286
What does the first initial of a pacemaker mode stand for?
The chamber that is paced
287
What does the second initial of a pacemaker mode stand for?
the chamber being sensed
288
What does the third initial stand for of pacemaker modes?
I = inhibits
D = inhibits and triggers
O = none
289
What does inhibits mean for pacemaker modes?
pacer detects intrinsic cardiac activity and withholds its pacing stimuli
290
What does D (inhibits and triggers) mean for pacemaker modes?
pacer detects intrinsic cardiac activity and fires a pacing stimulus in response
291
Which pacemaker paces both the atria and ventricles, senses both the atria and ventricles, and can inhibit and trigger in response to sensing?
DDD
292
What is the pacemaker code?
A = atrial
V = ventricle
D = dual
293
Which pacemaker paces the ventricle, senses the ventricle, and inhibits pacing in response to sensing?
VVI
294
What are the 3 main pacer malfunctions?
Failure to pace
Failure to capture
Failure to sense
295
What failure to pace?
No spike at all when expected
296
What is failure to capture?
Spikes without a QRS for ventricular pacing
297
What is failure to sense?
Pacing in native beats
298
ICDs can provide __ therapy
tiered
299
What are 3 functions of an ICD
Programmed to shock
Programmed to burst pace
Programmed to provide pacing for bradyarrhythmias
300
When an ICD shocks it will...
defibrillate or synchronized cardiovert
301
When an ICD burst paces it will...
sense tachyarrhythmia, provide a series of beats fast than the tachyarrhythmia, and then suddenly stop (with the hope of recovery of the SA node)
302
If a patient's ICD does not correct a lethal arrhythmia...
shock as usual, but do not place pads directly over the ICD
303
What types of heart failure are there?
Acute
Chronic
Acute exacerbation of chronic
Systolic or diastolic
Right or left sided
Cardiogenic shock
304
What is heart failure in a nutshell?
A clinical syndrome characterized by S/S associated with high intracardiac pressures and decreased cardiac output
305
What is acute decompensated heart failure?
Abrupt onset of symptoms severe enough to warrant hospitalization, typically seen in those with chronic HF
306
What is heart failure with systolic dysfunction?
HF with left ventricular dysfunction, EF is 40% or less
307
What is heart failure with diastolic dysfunction?
EF >50%, but there is a problem with filling. Ejection is okay.
308
HFrEF is ___ heart failure
systolic
309
HFpEF is __ heart failure
diastolic
310
What does BNP stand for?
B-type natriuretic peptide
311
What is BNP?
a peptide released by the ventricle when it is under wall stress in attempts to dilate and decrease ventricular pressure
312
BNP elevates more when the __ ventricle is under stress compared to the __
left, right
313
What can cause BNP to elevate caused by the RIGHT ventricle?
Pulmonary hypertension
Pulmonary embolism
314
What are 4 potential causes of acute decompensated systolic dysfunction?
CAD
Cardiomyopathy
Acute arrhythmia
Valvular dysfunction
315
In acute decompensated systolic dysfunction, what causes EF <40% and high LVEDP?
Wall motion abnormality, LV unable to eject normally
316
In the process of acute decompensated systolic dysfunction, when EF is less than 40% and LVEDP is high, what does this cause?
Pulmonary edema and hypoxemia
317
In the process of acute decompensated systolic dysfunction, when a patient experiences pulmonary edema and hypoxemia, this causes the body to release...
catecholamines which increases systemic vascular resistance
318
In the process of acute decompensated systolic dysfunction, when SVR is increased, if EF continues to decrease what will happen?
CO continues to decrease which causes BP to drop, which the body will increase SVR to compensate for low BP, which starts cycle over again
319
When systolic dysfunction is prolonged and becomes chronic, compensatory ___ lead to ventricular remodeling over time
hormones
320
Explain briefly the pathophysiology of acute decompensated systolic dysfunction
CAD/CM/etc leads to wall motion abnormality/reduced EF, LVEDP increases, pt experiences pulmonary edema/hypoxemia, catecholamines release (norepi) and SVR increases. EF decreases even more which lowers BP. SVR increased compensatory which worsens LV function even more.
321
Briefly explain progressive systolic dysfunction
Persistent systolic dysfunction leads to activation of endogenous neurohormones, these lead to vasoconstriction which causes ventricular remodeling, thus further worsening ventricular function
322
Which endogenous neurohormones are released by persistent systolic dysfunction?
Norepinephrine
Vasopressin
Angiotensin I
323
How does the release of angiotensin I lead to ventricular remodeling?
It converts to angiotensin II which leads to vasoconstriction, and also aldosterone
324
What happens when aldosterone is released in the process of progressive systolic dysfunction?
It leads to Na and water retention causing chamber dilation
325
What drugs are given for progressive systolic dysfunction to block the effects of norepinephrine?
Beta blockers
326
What drugs are given to prevent the effects of angiotensin I in progressive systolic dysfunction?
ACE inhibitors
327
What drugs are given to prevent the effects of angiotensin II in progressive systolic dysfunction?
ARBs
328
What type of conditions can lead to HF with diastolic dysfunction?
Chronic hypertension
Valvular disease
Restrictive or hypertrophic CM
329
What type of conditions can lead to acute decompensated systolic dysfunction?
CAD
CM
Acute arrhythmias
Valvular dysfunction
330
Briefly explain the pathophysiology of HF with diastolic dysfunction
Chronic HTN/etc leads to still LV d/t inability of myofibrils to relax. This causes impaired LV filling which increases LVEDP. Which then causes pulmonary edema
331
What is the primary problem with systolic HF
Ejection/dilated chamber. Filling is okay
332
What is the primary problem with diastolic HF
Filling problem, hypertrophie chamber or septum. Can eject OK
333
What are signs of systolic HF (8)
Dilated LV
PMI shift to left
Mitral valve insufficiency
EF <40%
Pulmonary edema
s3 heart sound
BP normal or low
BNP elevated
334
What are signs of diastolic HF (7)
Normal LV
This ventricular walls/septum
Normal EF
Pulmonary edema
S4 heart sound
BP high
BNP elevated
335
What causes pulmonary edema in systolic HF
due to poor ventricular emptying
336
What causes pulmonary edema in diastolic HF?
d/t high ventricular pressure
337
What drugs are given in systolic HF? (6)
Beta blockers
ACEi/ARBs
Diuretics
Dilators
Aldosterone antagonists
Positive inotropes
338
What drugs are given in diastolic HF? (5)
Beta blockers
ACEi/ARB
CCB
Diuretics (low dose)
Aldosterone antagonists
339
What drugs are contraindicated in diastolic HF?
positive inotropes
340
Why are positive inotropes contraindicated in diastolic HF?
Dehydration worsens filling, tachyarrhythmias decrease filling time and worsen symptoms
341
What type of drugs are contraindicated in systolic HF?
negative inotropes (CCB, and in acute phase BB)
342
What type of cardiomyopathies result in systolic HF?
dilated
343
What type of cardiomyopathy results in diastolic HF?
Idiopathic hypertrophic subaortic stenosis
Hypertrophic cardiomyopathy
Restrictive cardiomyopathy
344
Which type of HF is evident by large heart on imaging?
Systolic
345
What is PMI?
point of maximal impulse
346
Where is PMI normally?
midclavicular line
347
A shift to the left (of PMI) is associated with which type of HF?
Systolic
348
What are causes of right-sided HF?
Acute RV infarct
Pulmonary embolism
Septal defects
Pulmonary stenosis/insufficiency
COPD
Pulmonary HTN
LV failure
349
What are causes of left sided HF?
CAD/Ischemia
MI
CM
FVO
Chronic uncontrolled HTN
AS/Insufficiency
Mitral stenosis/insufficiency
Cardiac tamponade
350
s/s of right-sided HF
hepatomegaly
splenomegaly
dependent edema
venous distention
elevated CVP/JVD
tricuspid insufficiency
abd pain
351
S/S of left-sided HF
Orthopnea, dyspnea, tachypnea
Hypoxemia
Tachycardia
Crackles
Cough with pink, frothy sputum
Elevated PA diastolic/PAOP
Diaphoresis
Anxiety/Confusion
352
What are the 2 types of HF classifications?
AHA
New York Heart Association
353
The AHA stages of HF are classified according to...
HF progression and recommended therapy for each stage
354
How does the New York Heart Association base HF classes?
Based on patient's symptoms and do not suggest treatment
355
The main cause of death in patients with HF is...
sudden death arrhythmia
356
What classes of NYHA are eligible for ICD?
II to IV
357
Stage A of AHA HF Stages
High risk, no evidence of dysfunction
358
Stage B of AHA HF Stages
Heart disorder or structural defect, asymptomatic
359
Stage C of AHA HF Stages
Heart disorder or structural defect, with symptoms (past or present)
360
Stage D of AHA HF Stages
End-stage cardiac disease, with symptoms despite maximal therapy (inotropic or mechanical support)
361
Class I NYHA HF
Ordinary activity does not cause symptoms, although extraordinary activity results in HF symptoms
362
Class II NYHA HF
Comfortable at rest, but ordinary activity results in heart failure symptoms
363
Class III NYHA HF
Comfortable at rest, but minimal activity causes HF symptoms
364
365
Class IV NYHA HF
Symptoms of HF occur at rest, there is severe limitation of physical activity
366
Dilated cardiomyopathy is __ dysfunction
systolic
367
Hypertrophic cardiomyopathy is __ dysfunction
diastolic
368
Systolic dysfunction (DCM) is problems with...
ejecting blood
369
Diastolic dysfunction (hypertrophic CM) is problems with...
filling
370
Dilated cardiomyopathy is...
thinning, dilation, and/or enlargement of LV
371
Mitral valve regurgitation is common with DCM d/t
ventricular dilation
372
Hypertrophic CM has increased risk of... compared to DCM
sudden cardiac death
373
A patient with dilated CM may need a __ or __
VAD or heart txp
374
With hypertrophic cardiomyopathy, there is increased thickening of...
heart muscle and septum inwardly at the expense of the LV chamber
375
Symptoms of hypertrophic CM
Fatigue
Dyspnea
Chest pain
Palpations
S3, S4 heart sounds
Presyncope or syncope
376
Cardiogenic shock is most commonly caused by...
extreme drop in stroke volume secondary to systolic dysfunction
377
List 3 things you might see in a patient with cardiogenic shock
Elevated PAOP with pulmonary symptoms
Elevated SVR d/t compensatory mechanisms
Drop in CO to where organs are not perfusing
378
What does PAOP indicate?
Elevated left ventricular preload
379
What does SVR indicate in cardiogenic shock?
Elevated left ventricular afterload
380
What are s/s of the compensatory stage of cardiogenic shock?
Tachycardia
Tachypnea
Crackles, mild hypoxemia
ABG with resp alkalosis or early metabolic acidosis
Anxiety
Neck vein distention
S3 heart sounds (s4 if there is also an acute MI)
Cool skin
Decreased UOP
Narrow PP
BP maintained but lower than baseline
381
What are s/s of the progressive stage of cardiogenic shock?
Hypotension
Worsening tachycardia, tachypnea, oliguria
Metabolic acidosis
Worsening crackles and hypoxemia
Clammy, mottled skin
Worsening anxiety
382
List 6 etiologies of cardiogenic shock
Acute MI
Chronic HF
CM
Dysrhythmias
Cardiac tamponade
Papillary muscle rupture
383
If a patient has papillary muscle rupture and is in cardiogenic shock, this is a...
life-threatening emergency and requires immediate surgical intervention
384
How is cardiogenic shock treated?
Identify cause
Manage arrhythmias
Reperfusion if MI
Emergent surgery if ruptured pap muscle
Mechanical circulatory support
385
What increases the effectiveness of ECMO?
positive inotropes
386
Give 4 examples of positive inotropes that enhance effectiveness of ECMO
Norepi
Dopamine (4-10 mcg/kg/min)
Dobutamine
Milrinone
387
What should be avoided on ECMO?
Negative inotropic agents
388
When would vasodilators be used for a patient on ECMO?
IN conjunction with IABP and positive inotropic agents (if the pt is in the progressive stage of hypotension)
389
What decreases demand of pump for ECMO
Preload/afterload reduction
Optimized oxygenation
mechanical ventilation
treating pain
IABP for short term support and VAD for long
390
When is a IABP used?
Management of LV failure
Cardiogenic shock
Cardiomyopathies
Pts awaiting heart txp
391
When an IABP inflates, what does this do?
Increases coronary artery perfusion
392
When an IABP deflates, what does this do?
decreases afterload
393
When does an IABP inflate?
at dicrotic notch of the arterial waveform, beginning of diastole
394
When does an IABP deflate?
Right before systole begins
395
IABP deflation is determined by...
a set trigger for deflation, R wave of ECG or upstroke of the arterial pressure wave
396
During cardiopulmonary bypass what is done?
aortic cross clamping and the heart is stopped
397
What are the most common cannula sites for cardiopulmonary bypass?
Aorta and right atrium
398
The longer a patient is on cardiopulmonary bypass the more...
bleeding there is and the more complications there may be postoperatively
399
During a CABG, what can enhance oxygenation by improving blood flow?
Priming with isotonic cystalloids
400
During a CABG, how is circulatory arrest achieved?
During diastole with infusion of a potassium cardioplegic agent, and is reinfused at regular intervals
401
What are 2 very important things to assess for in a patient post op CABG
Tamponade and pericarditis
402
What else should be included in nursing assessment of a post op CABG?
Hemodynamic abnormalities
Arrhythmias
Electrolytes
Bleeding
Pulmonary issuese
Pain/Anxiety
Renal failure
Issues with blood sugar control
GI - ileus
Infection
403
How to maintain patency of post op chest tube
do not allow dependent loops
Milking or stripping not typically indicated, but if clots appear can milk
404
What is removed via a mediastinal chest tube?
Serosanguineous fluid from the operative site
405
What is removed via a pleural chest tube?
Air, blood, or serous fluid from the pleural space
406
Chest tubes should always be...
lower than the patient's chest
407
When should a chest tube be clamped?
Only if you are changing the drainage system or there is a system disconnect
408
What happens when a chest tube is clamped?
The connection to the negative chamber is lost
409
What does chest tube output generally require intervention?
When the output is greater than 100 mL/hr for at least 2 hrs
410
What should the nurse do if a patient's CT output is great than 100 ml/hr for over 2 hrs?
Maintain hemodynamic stability
Correct volume status
Administer blood products
411
What are 3 advantages of a mechanical valve?
Relatively easy to insert
Very reliable
Lasts longer than a biological valve
412
What are 2 disadvantages of a mechanical valve?
High risk of thrombosis
Permanent anticoagulation therapy
413
What is an advantage of a biological valve?
Only short term anticoagulation therapy is needed
414
What is a disadvantage of a biological valve?
Wears down, especially in high pressure systems
415
What are three nursing considerations for post heart valve replacement?
Avoid a drop in preload
Anticoagulation and antiplatelet therapy needed
Anticipate conduction disturbances
416
