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Flashcards in MS2 - Cardiac - Concepts Deck (36):
0

Ejection fraction

% of blood pumped out of left ventricle with each contraction
- EF < 50% - heart failure
- EF < 40% - medicare report - CMS (core measures)

1

What chest x-ray shows for cardiac

Is heart enlarged?

3

Therapeutic Lifestyle Changes Diet

Total fat (incl. sat fat calories): 25-35% of total daily calories
Saturated fat: <200 mg
Plant stanols or sterols (e.g., margarines, nuts, seeds): 2 g
Dietary fiber: 10-25 g of soluble fiber
Total calories: Only enough calories to reach or maintain a healthy weight
Physical activity: at least 30 min of moderate-intensity activity on most, and preferably, all days of the week

4

Echocardiogram shows?

Structures and blood flow

5

What is preload?

- work or load imposed on the heart before contraction begins
- amount of blood returning to the heart for the heart to manage

6

What is afterload?

- pressure that left ventricle must exert to get the blood out of the heart and into the aorta
- higher afterload -> harder for heart to eject blood -> lower stroke volume
- increased afterload and preload can increase blood pressure

7

Pulse pressure

- Difference between the systolic and diastolic pressures
- force that heart generates each time it contracts

8

Optimum LDL:HDL ratio

Below 3:1 (or, in whole numbers, 3.0)

9

Optimum ratio of total cholesterol to HDL

Optimum ratio is below 3.5:1, but goal is to keep ratio below 5:1

10

Troponin I and T

- Used as a marker to detect MI
- Rises 4-6 hours after injury
- Peaks in 10-24 hours
- Troponin I stays elevated for 4-7 days
- Troponin T stays elevated for 10-14 days

11

CK-MB

- Marker that can be used to detect MI but tends to not be used
- Rises later and returns to normal sooner than troponin
- Rises in 6 hours
- Peaks in 18 hours
- Returns to normal in 24-36

12

Risk factors for heart disease

Nonmodifiable:
Age>65
Gender: Male (over 65, same risk for both)
Ethnicity (white)
Genetics

Modifiable:
High serum lipids (>200 at risk and should be treated)
Hypertension
Smoking
Inactivity
Obesity
Stress (type A personality more likely)
Diabetes
Metabolic syndrome

13

Interventions to reduce risk factors for heart disease

Nutritional therapy - cholesterol <7% daily calories, 10-25 g of soluble fiber
Reduce salt intake (strict salt restriction more for HTN)
More small, frequent meals
At least 30 min of physical activity daily
Seek help for stress - stress reduction techniques
Avoid tobacco
Diabetes management
Goal BMI 18.5 to 24.9
Drugs for lipids, anti-platelet therapy (statins - e.g. simvastin, atrovastin; beta blockers, ACE inhibitors)

14

Symptoms of an MI – including in women and elderly

Pain - severe, immobilizing chest pain
- Not relieved by rest, position change, or nitrate administration is hallmark of MI
- Persistent and unlike any other pain - heaviness, pressure, tightness, burning, constriction, or crushing
- Common locations: substernal, retrosternal, epigastric (pt may think epigastric pain is indigestion) - pain may radiate to neck, lower jaw, and arms or back
- Can happen any time, but usually early morning hours
- Last 20+ mins and more severe than anginal pain

Other
- May have "discomfort," weakness, or shortness of breath
- Some women may experience atypical discomfort, SOB, or fatigue
- Diabetes: silent (asymptomatic) because of cardiac neuropathy, may have dyspnea
- Older: change in mental status (confusion), SOB, pulm edema, dizziness, dysrhythmia

15

MONA or ONAM and why

O = Oxygen
N = Nitroglycerin
A = Aspirin
M = Morphine

MONA is in order to remember but ONAM is in order given -- increase oxygen first, then administer nitrates to vasodilate, then aspirin to decrease platelet aggregation, then morphine to reduce pain and anxiety (which can also decrease O2 demand) - though morphine is usually only given if nitrates don't work or pt is having anxiety.

16

Improvement of chest pain in MI

To address pain: NTG, morphine, supplemental O2 as needed to eliminate or reduce chest pain
Relief is pain indicates reperfusion of tissue
Aspirin, heparin
PCI (percutaneous coronary intervention) or thrombolytics or CABG surgery

17

Post CABG assessments

- Assessing for bleeding (e.g., chest tube drainage, incision sites), hemodynamic monitoring, checking fluid status, replacing electrolytes as needed, and restoring temperature (e.g., warming blankets)
- Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in first 3 days after CABG - postop afib happens 20-50% of pts - B-Adrenergic blockers should be restarted as soon possible
- Caring for surgical sites (chest incision usually closed with Dermabond and does not require dressing)
- Pts may have some cognitive dysfunction - 40% of pts after surgery, can become permanent
- Assessing pain, respiratory complications, and preventing venous thromboembolism
- Older pts, high risk of dysrhythmias, stroke, infection

18

Difference between angina and a MI

- MI lasts longer, more fatalities, can happen at any time (though usually early morning)
- Serum cardiac markers present in MI
- Can treat angina at home
- Damage reversible with angina, damage permanent with MI
- Nausea more common with MI (due to severe pain)
- Angina more predictable, has precipitating factors (MI precipitated by prolonged ischemia)

19

Difference between stable and unstable angina

- Chronic stable angina is long-term - can lead to unstable angina (significant change to pattern of angina)
- Unstable angina is unpredictable and an emergency - stable angina is predictable and can be treated at home
- UA increasing frequency, minimal to no exertion - pain is more intense vs chronic stable
- Women's symptoms for UA may include fatigue (most prominent), SOB, indigestion, anxiety
- Pain for stable not relieved by nitro - wait 5 min, take another, up to 3, then wait 5 and call EMS if pain not relieved or worsens
- Pain for UA - take nitro, wait 5 mins - if not relieved call EMS asap

20

Cardiac Cath teaching and post-cath nursing care

- Inform patient about feeling of warmth when dye is injected, and possible fluttering sensation of heart as catheter is passed
- Pt may be instructed to cough or take a deep breath when dye is injected, and pt is monitored by ECG throughout procedure
- Pt will remain supine for 8 hours, and cannot flex leg used for procedure

After procedure:
- Frequently assess circulation to extremity used
- Check neurovascular status (E.g. periph pulses, etc)
- Adequate IV and fluids to flush dye - monitor I&O because dye is osmotic
- Give finger foods to eat since they are lying down
- Observe puncture site for hematoma and bleeding
- Place compression device over arterial site to achieve hemostasis if indicated
- Monitor vital signs and ECG
- Assess for hypo or hypertension, dysrhythmias, and signs of pulm emboli

21

Cardiac Markers for MI

Troponin I and T
- Rises 4-6 hours after injury (2-3 hours newer assays)
- Peaks in 10-24 hours
- cTnI elevated 4-7 days, cTnT 10-14 days
- cTnI Neg 2.3 ng/mL

CK-MB
- Cardiospecific enzyme released in presence of myocardial tissue injury - rises later and lowers sooner vs troponin
- Increase 4-6 hr after MI, peak 18 hr, return to baseline 24-36 hr
- >4-6% of total creatine kinase (CK) highly indicative of MI

Myoglobin
- Protein that is sensitive for myocardial injury - serum concentrations rise 30-60 min after MI
Norm ranges:
Male: 15.2-91.2 mcg/L
Female: 11.1-57.5 mcg/L

22

Complications of MI

- Dysrhythmias most common - afib (AF) occurs in 20-50% of patients
- Heart failure
- Cardiogenic shock - occurs less often with rapid and early treatment
- Papillary muscle dysfunction (auscultate murmur at cardiac apex) - echocardiogram confirms diagnosis
--- papillary muscle rupture rare and life-threatening - causes mitral valve regurgitation --> dyspnea, pulmonary edema, decreased CO - rapid deterioration by patient - treat with nitroprusside (Nipride) and/or IABP therapy, immediate cardiac surgery
Ventricular aneurysm - infarcted myocardial wall is thin and bulges out during contraction - can develop within days, weeks or months
Pericarditis - inflammation of visceral and/or parietal pericardium - may result in cardiac tamponade, decreased ventricular filling and emptying, and HF - occurs 2 or 3 days after an acute MI - sitting in forward position often relieves pain - can also use NSAIDs, aspirin, corticosteroids

23

Prioritization and Delegation

Cardiac Cath:
LPNs can administer meds before/after procedure, assess neurovascular status for first 15 mins for first hour, check for bleeding at insertion site (Q15 min for first hour), report changes to RN
UAP can take vital signs and report increases/decreases, can report complaints of chest pain, SOB, or other signs of distress. Can assist with oral hygiene, hydration, meals, and toileting.

24

Side effects of Lasix

- F&E imbalances (hyponatremia, hypokalemia)
- Hypercholesterolemia, hypertriglyderidemia
- Sexual dysfunction
- Hypotension
- Ototoxicity
- Possible allergic reaction if sensitive to sulfa-type drugs

25

Nursing interventions for ACE inhibitors

- Observe for acute renal failure (reversible)
- Routine renal function tests
- Bed rest 3 hours after first dose (first-dose syncope)
- Hypotension and hyperkalemia may occur
- Skipping doses or d/cing drug can result in rebound HTN
- Angioedema, a rare adverse effect, can develop suddenly and can be life threatening – allergic reaction involving edema of the face and airways
- Cough may be attributed to ACEI but also can be exacerbation of HF – important to know exact cause of cough and other side effects before stopping ACE inhibitor therapy

26

Patient teaching for heart failure

- Avoid using salt when preparing foods or adding salt to meals
- Small, frequent meals
- Weigh yourself at the same time each day, preferably in the morning using the same scale and wearing the same or similar clothes
- Report to HCP: weight gain of >3 lbs in 2 days or 3-5 lbs in one week; frequent dry hacking cough esp when lying down; fatigue or weakness; swelling of ankles, feet or abdomen; dizziness or fainting; difficulty breathing esp when lying flat; nausea w/ab swelling, pain, tenderness
- Avoid extremes of heat and cold
- Know s/s of worsening heart failure – FACES (Fatigue, limitation of Activities, chest Congestion/cough, Edema, and Shortness of breath)
- Flu and pneumonia vaccines
- Increase walking and other activities gradually
- After exertion, plan rest period; shorten working hours or plan rest around work
- Know S/S of internal bleeding (bleeding gums, increased bruises, blood in stool or urine)
- BP control, smoking cessation, weight reduction if needed

27

NYHA heart failure classification with examples of activities for each

Class I
- No limitation of physical activity. Ordinary physical activity does not cause fatigue, dyspnea, palpitations, or anginal pain.
- E.g., no dypsnea with ordinary activity
Class II
- Slight limitation of physical activity. No symptoms at rest. Ordinary physical activity results in fatigue, dyspnea, palpitations, or anginal pain.
- E.g., dyspnea while shopping
Class III
- Marked limitation of physical activity but usually comfortable at rest. Less than ordinary physical activity causes fatigue, dypsnea, palpitations, or anginal pain.
- E.g., dyspnea while brushing teeth
Class IV
- Inability to carry on physical activity without discomfort. Symptoms of cardiac insufficiency or of angina may be present even at rest. If any physical activity is undertaken, discomfort is increased.
- E.g. dyspnea while watching TV

28

Right-sided vs left-sided heart failure

Right-sided:
- RV heaves, murmurs, jugular venous distention
- Edema (e.g., pedal, scrotum, sacrum), weight gain, ascites, anarsca (massive generalized body edema)
- Hepatomegaly (liver enlargement)
- Right upper quadrant pain
- Anorexia and GI bloating
- Nausea
Left sided:
- LV heaves, pulsus alternans (alternating pulses strong, weak)
- PMI displaced inferiorly and posteriorly (LV hypertrophy)
- Decreased PaO2, slight increased PaO2 (poor O2 exchange)
- Crackles (pulmonary edema)
- S3 and S4 heart sounds
- Pleural effusion
- Changes in mental status
- Restlessness, confusion
- Dyspnea
- Shallow respirations up to 32-40/min
- Paroxysmal nocturnal dyspnea
- Orthopnea (shortness of breath in recumbent position
- Dry hacking cough
- Nocturia
- Increased BUN, creatinine
- Frothy, pink-tinged sputum (advanced pulm edema)
Both:
- Increased heart rate (early clinical sign of HF)
- Anxiety, depression, fatigue

29

Ejection Fraction (EF)

- Hallmark of systolic failure is decrease in left ventricular ejection fraction (EF)
- EF defined as amount of blood ejected from LV with each contraction
- Normal EF is 55-60%
- Patients with systolic HF generally have an EF of less than 45% - it can be as low as 10%

30

Symptoms of decreased cardiac output

- Decreased urinary output
- Change in mental status
- Chest pain
- Fatigue
- Dizziness
- Syncope
- Weakness
- Dysrhythmias
- Hypotension

31

Difference between systolic and diastolic heart failure

Systolic:
- Decrease in left ventricular EF (generally <45%)
- Caused by impaired contractile function (such MI), increased afterload, cardiomyopathy, mechanical abnormalities
- Ventricle not emptied properly
- Most common cause of heart failure
- Occurs in about 2/3 of people with heart failure
Diastolic:
- Heart failure with normal EF
- Result of LV hypertrophy, myocardial ischemia, valve disease, cardiomyopathy
- Ventricle not filled properly
- About 1/3 of people with heart failure
- Commonly seen in older adults and women

32

Normal duration of PR interval

0.12 - 0.20 seconds (3-5 small boxes)

33

What does abnormal duration of PR interval mean?

- Longer Duration = delayed progression of electrical impulses through heart (HEART BLOCK)
- Shortened Duration = impulse is originating in a ectopic pacemaker

34

What does elevated ST segment indicate?

MI, hyperkalemia

35

Duration for ST segment

Duration of 0.20 or less = 5 boxes or less

36

QRS

0.04-0.10 seconds <0.12

1.5-2 small boxes