Rehab Test #2 - Cardiac, Pulmonary Flashcards
(32 cards)
Atherosclerosis
Narrowing of arteries
Endothelial lining altered as a result of inflammation and injury
Injury allows deposit of cholesterol and lipid within the intimal wall of the artery
Begins as soft deposits of fat that harden with age
Plaque becomes unstable, ruptures, platelets aggregate leads to thrombus formation
Angina
When the heart’s supply of oxygen rich blood is insufficient to meet the heart muscle’s metabolic demands the heart muscle “aches” - this is called angina pectoris, or chest pain.
Classifications of Angina
Class I
Ordinary physical activity does not cause angina strenuous activity only.
Class II
Angina occurs with walking or climbing stairs rapidly or up hill.
Class III
Marked limitation in ordinary daily activity
Class IV
Anginal symptoms may be present at rest
Myocardial Infarction
Myocardial infarction (MI) occurs when there is sustained ischemia to heart muscle which results in myocardial cell death (necrosis).
Heart Failure
Heart failure (HF) is a pathologic state in which the heart is unable to pump blood in sufficient amounts to meet the body’s metabolic needs (decreased CO).
Systolic
Diastolic
As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing congestion in the tissues
Major causes: Chronic hypertension Myocardial infarction Other causes Valve deficiency Atrial fibrillation/flutter Aging of the myocardium Diabetes
Left-sided heart failure
Pulmonary edema
Coughing
Dyspnea
Right-sided heart failure
Jugular vein distention
Ascites - abnormal accumulation fluid in the abdominal (peritoneal) cavity.
Pedal edema
Patient Education for Heart Failure
Daily weights Acronym FACES F - fatigue A - limitation of activities C - chest congestion/ cough E - dependent edema S - shortness of breath According to the American Heart Association and the American College of Cardiology (2005) treatment of chronic heart failure should be directed at reducing the effects of the: Renin-angiotensin-aldosterone system (RAAS) Sympathetic nervous system (SNS)
Medications Used for HF
Diuretics Agents that inhibit the RAAS ACE inhibitors (ACEI) Angiotensin II receptor blockers (ARBs) Aldosterone antagonists Agents that inhibit the SNS Beta-blockers Others Cardiac glycosides, B-type natriuretic peptides, vasodilators (BiDil)
ER management of HF
Start IV Administer O2 2-4 liters via NC Nitrogylcerin SL and ASA Morphine for pain Continous ECG, BP and O2 sat monitoring Emergent PCI Treatment of choice for confirmed MI Balloon angioplasty + stent(s) placement
Statins - prevent heart attack
Mechanism of action: Decrease the rate of cholesterol production in the liver by inhibiting hydroxymethylglutaryl coenzyme A reductase (HMG-CoA reductase). May also decrease inflammation as well.
Drug effects: Decrease LDL cholesterol by 25-63%
Examples: atorvastatin (Lipitor), rosuvastatin (Crestor), simvastatin (Zocor), pravastatin (Pravachol)
Adverse effects: GI disturbance such as dyspepsia, cramps, flatulence, constipation, abdominal pain (mild and transient) Hepatotoxicity (0.5-2%) Myopathy (5-10%) Rhabdomylosis (rare) Contraindication Pregnancy category X
Nursing implications:
Initial effects 2 weeks, maximal effects 4 to 6 weeks, reversal of effects upon withdrawal.
Monitor LFT, CPK levels
Assess for C/O weakness, muscle aches
Patient education
Most effective when taken at bedtime
Educate patient to immediately report muscle pain/weakness
Keep follow up appointments
Antianginal Drugs Controller drugs
Beta-blockers, calcium channel blockers, and long-acting nitrates provide baseline prophylaxis or protection against acute angina attacks
Antianginal Drugs Rescue drugs
Sublingual (SL), translingual spray, and intravenous (IV) nitroglycerin is used to treat acute anginal pain
Nitrates
Mechanism of action/drug effects: Dilates vessels, especially veins, by relaxing vascular smooth muscle. Reduces preload. Also, dilates coronary arteries which improves blood flow through coronary vasculature. Examples: nitroglycerin (Nitro-Bid, Nitrostat) isosorbide dinitrate (Isordil) isosorbide mononitrate (Imdur)
Indications: Stable, unstable, and vasospastic angina \ Contraindications: Hypotension, erectile dysfunction drugs (e.g. Viagra)
Adverse effects:
Headache
Orthostatic hypotension
Reflex tachycardia
Do NOT Combine ED Drugs and NTG!
Sublingual Nitroglycerin - for angina
Tablet should be held under tongue until dissolved. Avoid eating, drinking, or smoking until tablet is dissolved.
Acute anginal attacks:
Advise patient to sit down
Relief should occur within 5 minutes
If no relief after first dose call 911
May be repeated every 5 minutes for 3 doses
Beta-Blockers - for angina and heart failure
Mechanism of action:
Prevent stimulation of beta receptors in the heart whichdecreases heart rate and contractility. Also prevents release of renin.
Drug effects:
Decreased myocardial oxygen demand
Examples:
propranolol (Inderal)
metoprolol (Lopressor)
Indications:
Prevention/prophylaxis of stable angina
Contraindications: Bradycardia, AV block, asthma Adverse effects: Dizziness (10%) Bradycardia (3%), heart block Mask signs/symptoms of hypogylcemia in diabetics Bronchoconstriction (3%) Constipation
Nursing implications:
Assess for contraindications
Assess vital signs – hold and notify MD for HR less than 60
Patient education:
Inform patient they are for long-term prevention, not immediate relief
Change positions slowly, avoid time in hot tubs, saunas which result in vasodilation
Monitor glucose closely if diabetic
Do not abruptly stop (rebound angina)
Calcium Channel Blockers (CCB) - for angina
Mechanism of action:
Prevents influx of calcium ion across cell membrane of vascular smooth muscle. Dilation of peripheral and coronary arteries.
Drug effects:
Decreased afterload decreases workload of the heart and therefore, myocardial oxygen demand.
Examples:
diltiazem (Cardizem), verapamil (Calan)
Indications:
Prevention/ prophylaxis of stable, variant angina
Adverse effects: Dizziness (4%) Hypotension (4%) Constipation (9%) Peripheral edema (2%)
Nursing implications:
Monitor vital signs
Patient education:
Avoid hazardous activities while dizzy
Change positions slowly
Increase fluid and fiber intake to prevent constipation unless otherwise instructed by provider.
Diuretics (Loop Diuretics) - for heart failure
Mechanism of action:
Decreases Na, Cl, and K reasborption in thick ascending limb of the loop of Henle in the nephron which results in profound diuresis.
Drug effects:
Reduced blood volume decreases venous pressure (preload) and atrial pressure (afterload). Reduce cardiac dilation. Reduced pulmonary and peripheral edema.
Examples:
furosemide (Lasix)
Indications:
Acute and chronic HF
Dosages and Routes:
Oral: 20-80 mg/daily or BID
Adverse effects:
Hypokalemia (↑ risk of Digoxin toxicity)
Severe hypotension
Nursing implications:
Assess patient’s fluid volume status, vital signs, labs
Patient education:
Avoid taking late in the afternoon due to nocturia.
Eat foods rich in potassium (bananas, oranges, potatoes, tomatoes, meats, fish, wheat bread, legumes). K+ supplement may be necessary
Signs of hypokalemia include weakness, leg cramps.
ACE inhibitor - for heart failure
Mechanism of action:
Inhibits ACE which prevents the conversion of angiotensin I to angiotensin II (a powerful vasoconstrictor). Also reduces aldosterone secretion. Suppress degradation of kinins (vasodilator).
Drug effects: Arteriolar and venous dilation results in reduced preload, afterload, pulmonary congestion/pedal, and increased cardiac output. ↑ kinins reduces cardiac remodeling. Examples: lisinopril (Prinvil), captopril (Capoten), enalapril (Vasotec) Indications: Cornerstone of HF therapy Adverse effects: Hypotension (0.9-6.7%) Cough (9%) Hyperkalemia Angioedema
Beta Blocker - for heart failure
Mechanism of action:
Protect heart from excessive sympathetic stimulation
Drug effects:
Improve LV ejection fraction (1-3 months), slow the progression of HF, reduce need for hospitalization, and prolong survivial.
Examples:
Carvedilol (Coreg), bisoprolol, sustained-release metoprolol (Toprol XL)
Dosages and routes:
Start low and go slow. Excessive beta blockade can reduce contractility.
Contraindications:
Heart block
Adverse effects:
Fluid retention/ worsening HF
Bradycardia/ heart block
Hypotension
Cardiac Glycosides
Oldest group of cardiac drugs
Comes from the foxglove plant
Digoxin (Lanoxin) is the only cardiac glycoside available in the U.S.
No longer used as first-line treatment
Mechanism of action:
Inhibits the sodium-potassium adenosine triphosphatase pump. This causes an accumulation of calcium within the myocytes. ↑Ca++ augments contractile force by facilitating the interaction of myocardial actin and myosin.
Drug effects:
Positive inotropic effect on the heart increases the force of ventricular contraction which increases cardiac output. Increased CO, can reverse all the overt manifestations of HF.
The sodium-potassium-adenosine triphosphate pump keeps the kids (K+) in the house (cell)……
The sodium-potassium-adenosine triphosphate pump keeps the neighbors (Na+) and their cats (Ca++) out of the house (cell)
Digoxin inhibits the sodium-potassium adenosine triphosphate pump…this allows the neighbors (Na+) and their cats (Ca++) into the house (cell) and the kids (K+) out on the streets (vessels)
Indications:
Second-line heart failure, atrial fibrillation
Precautions:
Lasix (secondary to risk of hypokalemia)
Adverse effects:
Digoxin toxicity
Cardiac dysrhythmia
Digoxin (Lanoxin)
Signs of dig toxicity include anorexia, nausea, vomiting, yellow tinge to vision, halos
Very narrow therapeutic window.
Drug levels must be monitored
0.5 to 0.8 ng/mL (old upper limit 2 ng/mL)
Low potassium levels increase its toxicity. Electrolyte (serum K) levels must be monitored (normal range 3.5 – 5 mEq / L)
Identify diagnoses appropriate for cardiac rehabilitation
Chronic, stable angina Stable heart failure Post angioplasty Post MI Post CABG Post heart transplant Not had a cardiac event but are at risk because of unfavorable risk factor Stable heart disease, deconditioned by another serious illness
Delineate the phases of cardiac rehabilitation
Phase 1:
Initiated while the patient is still in the hospital
Phase 2:
A supervised ambulatory outpatient program spanning 3–6 months
Phase 3:
A lifetime maintenance phase in which physical fitness and additional risk-factor reduction are emphasized.
