Exam 2 - CARDIAC
Will resolve with rest/stop or with medication Nitro
Stable angina
What is the difference between stable and unable angina?
Stable can be resolved with rest & nitro where unstable is not.
What is some teaching for patient who underwent CABG?
Sternal precautions. No driving for the first month. No lifting over 5 lbs. Do not reach up or upper body exercises until cleared. Cardiac rehab after 1 month. Walk as tolerated but MUST walk. No intercourse for 1 month.
"SALI" had a "LAD" a "LAD, she CIRCUMcisid, RCA-real cute aint she!
S-Septal - Lad (V1,V2) A-Anterior - LAD (V1-V4) L-Lateral - Circumflex (I, AvL, V5, V6) I-Inferior - RCA (right coronary artery) (II, III, AvF)
"ST" elevation in at least 2 contiguous leads with a "T" wave inversion. elevated troponin (all 3 times), usually caused by abrupt blockage or rupture of plaque leading to thrombus formation. Generally only have 90 minutes to treat.
STEMI - "ST" Elevated Myocardial Infarction
No pain but will only see it on a routine EKG.
Silent angina
Goes into the R-Atrium if normal conduction otherwise it will go into R-Ventricle and is a permanent placement.
Single Chamber
S/S: JVD, fluid overload, hepatomegaly, splenomegaly, distended abdomen, nausea, anorexia, polyuria, dependent edema (hands, feet, fingers), weight gain and increased BP.
Right sided heart failure
Why do we use heparin?
To help reduce clot formations
Why would we give a patient heparin who is having a MI?
To prevent clot formation. *Must stop 30 min before cath lab*
Usually attached like AED pad
Transcutaneous
Which is placed through a peripheral site into left/right ventricle with direct contact to the endocardium?
Transvenous
True or False: All types of angina/chest pain are caused as a result of decreased oxygen supply.
True
True or False: Widened "P" & "QRS" can be normal for a patient with a pacemaker.
True
What are the modified risk factors for MI -
Weight, stress, diet, blood pressure, tobacco use, and physical inactivity.
What is the time frame to give TPA--clot buster?
Within 30 minutes of onset of symptoms but not more than 6 hours.
What medications will no longer work on the heart after a transplant?
Digoxin and atropine
What is treatment for heart failure?
Digoxin, morphine, nitrates, ACE/ARB's, dobutamine, milirone. labs, diuretics (lasix), low sodium diet, LVAD, transplant, pacemaker
What are some causes for decreased preload?
Diuretics, Nitrates, loss of blood/fluids
What are some issues you can encounter with the function of a pacemaker?
Failure to sense - not sensing a beat, failure to pace - malfunction of generator, and failure to capture - lacks depolarization.
What are some diagnostics to differentiate between typical angina vs USA vs ACS?
H&P, EKG, Lab-cardiac enzymes (Troponin), CRP, stress test, and or cardiac cath.
What is the biggest post-procedure complication from cath lab?
Hematoma - due to not applying pressure correctly or for long enough.
S/S: Fatigue, SOB, Oliguria, pulmonary congestion, crackles in lungs, pink frothy sputum, tachycardia, palpitations, decreased pulses, & cool extremities
Left sided heart failure
Hardening or stiffening of valve causing decreased in cardiac output - narrowing of mitral leaflets.
Mitral Stenosis
Leaky/flopping valve causing the blood to flow backwards. S/S: Systolic murmur, fatigue, chronic weakness, dyspnea on exertion, orthopenea, anxiety, atypical chest pain, and palpitations
Mitral regurgitation
What are some discharge instructions for a patient with a pacemaker?
Monitor for infection/bleeding. No lifting over head, no rough housing, most are not MRI compatible, can not "wand" over. Monitor HR - reporting if it is consistently 5 above or below where set.
MI Treatments: Medications - MONA
Morphine, Oxygen, Nitro, & Aspirin. ALWAYS use Nitro first and if not helping then low dose of morphine.
No "ST" elevation but will see depression with "T" wave inversion. Usually starts with stable angina. Usually caused by vasospasm, spontanous dissection, or sluggish blood flow usually from narrowed artery. Troponin may not be elevated initially. Not usually CAD related.
NSTEMI - Non ST Elevated Myocardial Infarction
What are some causes for increased preload?
Increased blood/fluids
What is the biggest risk with CABG/open heart?
Infection due to multiple lines/tubes/drains.
What are some complications from implantation of pacemaker to watch for?
Infection, pneumothorax, perforated heart, stimulated phrenic nerve causing uncontrolled hiccuping.
What are some causes for decreased afterload?
Nitrates, CCB, ACE
The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? 1-BP 2-Airway patency 3-Oxygen flow rate 4-Level of consciousness
2- Airway patency
Which is the worst of the MI - SALI - Septal, Anterior, Lateral, or Inferior?
Anterior - it affects the entire L-Ventricle causing ventricular dysrhythmias.
Leaky/floppy valve causing blood to flow backwards from aorta to left ventricle. S/S: usually asymptomatic or will complain of dyspnea.
Aortic regurgitation
Siffening/narrowing of aortic valve leaflets. S/S Dyspnea, crackles, angina, syncope, systolic murmur, & peripheral cyanosis.
Aortic stenosis
What are some indications for a pacemaker?
Arrhythmia, bradycardia, tachycardia, complete heart block, SSS-Sick sinus syndrome, and hypertrophic cardiomyopathy.
A client is having frequent PVC's. The nurse would place priority on assessment of which information? 1- Causative factors such as caffeine 2- Sensation of fluttering or palpitations 3- BP and oxygen saturation 4-Precipitating factors- such as infection
3- BP & Oxygen saturation - PVC's can cause hemodynamic compromise - decreasing CO.
P-waves and QRS complexes are regular. PR interval is 0.16 seconds. Overall heart rate is 64 bpm. Which action would the nurse take? 1-Check vital signs 2-Check lab test results 3-Monitor for any rhythm change 4-Notify provider
3- Monitor for rhythm changes
The nurse is watching the cardiac monitor and notices rhythm suddenly changed. No P-waves, QRS are wide, and the ventricular rate is regular but more than 140 bpm. The nurse determines that the client is experiencing which kind of dysrhythmia? 1- Sinus tachycardia 2- Ventricular fibrillation 3- Ventricular tachycardia 4- PVC's
3- Ventricular tachycardia
Sharp spike before the P-wave
Atrial pacemaker spike
Goes into R-Atrium, R-ventricle, & L-ventricle. Usually only used with severe HF patients.
Bi-Ventricular
What are some other risks with CABG/open heart? (Besides infections)
Bleeding (due to vasoconstriction causing increased BP then cardiac tamponade) Drainage (about 100 ml/hr but notify provider if more than 150 ml/hr) Stroke (heart blood clot goes straight to brain) AKI- due to anesthesia
The nurse is assessing a client w/ HF. Which assessment data are the best indicator for fluid balance? A- BP 144/79 B-Urine OP 200 ml in last 4 hours C-Wt increase of 9lb in the past week D- Generalized edema in the lower extremities
C
Provider prescribed Warfarin for a client with A-Fib. Which client statement indicates that additional education is needed? A- I have to go to clinic once a week to have my levels checked B - If my stools turn black I need to call my provider C-I'm glad I don't have to change my diet because salads are my favorite food D- I need to stop taking my herbal supplement
C- I'm glad I don't have to change my diet because salads are my favorite foods.
The nurse is assessing clients cardiac rhythm and notes HR-64, regular rhythm, PR interval 0.20 sec, QRS-0.10. How will the nurse document this rhythm? A- SInus tachycardia B- Sinus bradycardia C- Normal sinus rhythm D-Sinus arrhythmia
C- Normal sinus rhythm.
Upon entering clients room, the nurse finds the client unresponsive. In what order will the nurse provider care? A-Begin chest compressions B-Check carotid pulse C-Notify Rapid response D-Get the crash cart/AED E- Provide rescue breaths
C- Rapid response D- Crash cart/AED B- Check carotid pulse A- Chest compressions E- Rescue breaths
Greater saphenous vein is harvested for transplant and can be used for 2 or more bypasses. Most common open heart surgery.
CABG - Coronary Artery Bypass Graft
Fluid accumulation rapidly in the pericardium and causes a sudden decreased in cardiac output. S/S: JVD, paradoxical pulse, tachycardia, muffled heart sounds, & hypotension. It is an emergency!
Cardiac Tamponade
This is how well the heart "snaps" back to shape/size.
Contractility
A client in sinus bradycardia- HR 45 bpm and BP 82/60 reports dizziness. Which intervention would the nurse anticipate will be prescribed? A-Administer digoxin B- Defibrillate client C-Continue to monitor D- Prepare for transcutaneous pacing
D- Will provide temporary measure to increase HR and perfusion
A clients rhythm suddenly changes on the monitor. No P-waves; instead there are fibrillatory waves before each QRS complex. How would the nurse interpret the rhythm? 1- A-Fib 2- Sinus tachycardia 3- V-Fib 4- Ventricular tachycardia
1- Atrial fibrillation - quiver comes before the QRS
A client has a frequent burst of ventricular tachycardia on the monitor. Which factor is the highest priority with regard to this dysrhythmia? 1- it can develop into V-Fib 2- it is almost impossible to convert to a normal rhythm 3- It is uncomfortable for client, giving sense of impending doom 4-It produces a high cardiac output with cerebral and myocardial ischemia
1- It can develop into V-fib which can be life threatening
Client with HF. Suddenly develops extreme dyspnea, tachycardia, & lung crackles. Nurse asks another nurse to contact physician and prepares which priority interventions? SATA 1 - Administer oxygen 2- Insert foley catheter 3- Administer furosemide 4-Administer Morphine IV 5-Transport pt to the coronary care unit 6- Place client in low fowlers side lying-position
1- Oxygen 2- Foley catheter 3- Administer furosemide 4 - Administer morphine IV
A client's ECG strip shows atrial and ventricular rates of 110 bpm. PR interval is 0.14 sec, QRS measures 0.08 seconds, and the PP and RR intervals are regular. How would the nurse interpret this rhythm? 1- SInus tachycardia 2-SInus bradycardia 3- SInus dysrhythmia 4- Normal sinus rhythm
1- SInus tachycardia
The client has developed A-Fib with a ventricular rate of 150 bpm. Which associated findings would the nurse anticipate in the assessment? SATA 1- Syncope 2- Dizziness 3- Palpitations 4- Hypertension 5- Flat neck veins
1-Syncope 2- Dizziness 3- Palpitations
Cardiac output compensation: what are the 3?
1. Activate the sympathetic nervous system 2. Increase the preload 3. Gain muscle
Client w/ MI suddenly become tachycardic showing signs of air hunger, begins coughing pink-frothy sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? A- Stridor B- Crackles C- Scattered rhonchi D- Diminished breath sounds
2 - Crackles
Client with MI is developing cardiogenic shock. Which potential condition would the nurse anticipate and monitor the client for to detect cardiogenic shock? 1- Pulsus paradoxus 2- Ventricular dysrhythmias 3- Rising diastolic BP 4- Falling CVP
2 - Ventricular dysrhythmias
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no ekg complexes on screen. What is the priority nursing action? 1 - Call code 2- Check clients status 3- Call provider 4- Document lack of complexes
2 - check on clients status
The nurse is caring for a client who has just had implantation of automatic internal cardioverter-defibrillator. Which assessment is the nursing priority? 1- Anxiety level of client and family 2-Activation status and settings of the device 3-Presence of medicalert card for the client to carry 4-Knowledge of restrictions on post-discharge physical activity
2- Activation status and settings on the device
The nurse is assisting to defibrillate a client in V-Fib. Which intervention is priority after placing the pads on the clients chest and before discharging the device? 1-Ensure client has been intubated 2- Set defibrillator to "synchronize" mode 3-Administer amiodarone bolus 4- Confirm the cardiac rhythm
4- Confirm the cardiac rhythm
A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? 1. Notify my provider if my feet/legs start to swell 2.Notify my provider if my pulse rate decreases below 60 3. Avoid grapefruit will be a challenge since I usually drink it every morning 4. My spouse told me since I have this problem we are going to stop walking the mall every morning.
4- Patient should continue normal activity as they can tolerate.
Patient on cardiac monitor - Nurse receives call from monitor tech stating there are no ECG complexes and alarm is sounding- What is first action by nurse? A- Suspend the alarm B-Call emergency response team C- Press record button to get ECG strip D- Assess client and check lead placement
D- Assess client and check lead placement
The nurse is conducting an admission assessment on a male client. Which assessment data does the nurse identify as a risk factor for CV-Disease? SATA A- BMI of 26, B-BP 160/66, C- Triglycerides 140, D- Mod exercise 20-30 min weekly, E- Exposure to second hand cigarette smoke, F- HX of streptococcal tonsillitis, G- Family hx of CV Disease
A,D,E,G
The nurse is caring for a client who is experiencing occasional PVC's. What assessment data are most concerning to the nurse? A- Potassium 4.8 B- Magnesium 2 C- Heart rate 90 D- Hx of smoking
D- Hx of smoking
Plaque in the coronary artery ruptures resulting in platelet aggregation creating thrombus or embolism formation
Acute Coronary Syndrome "ACS"
Resistance the ventricle will need to overcome to eject blood through the semi-lunar and into system. It affects the blood volume leaving the heart.
Afterload
The nurse is caring for a client with heart failure who is prescribed spironolactone. Which client statement requires further education? A-I may need to take this drug every other day according to lab values B- I need to take potassium supplements with this medication C- I will try my best to not use table salt on my food D- This medication will cause me to urinate more often
B- I need to take potassium supplements with this medication - it is already potassium sparing.
Which statement by pt needs immediate action by nurse? A-Allergies are flared up so I took some benadryl last night B-I was nervous last night but I remembered to take my warfarin C- I am hungry. I haven't eaten anything since I went to bed last night D- I dont know what I'll due if they find a blockage in my heart
B- Increased bleeding risk
The nurse is caring for a client immediately following a cardiac catheterization. Which assessment data require immediate nursing intervention? A- BP 146/70 B- Hematoma at insertion site C- Client reports headache pain D- Client reports extreme thirst
B- Increased risk for bleeding
Client with hx of DM2 is admitted with chest pain and scheduled for cardiac cath. Which medication would need to be withheld for 24 hours before procedure and 48 hours after the procedure? A-Glipizide B-Metformin C- repaglinide D-Regular insulin
B- held due to injection of contrast during procedure
A client is diagnosed with L-HF. Which client assessment findings will the nurse anticipate? SATA A- Peripheral edema B- Crackles in both lungs C-Tachycardia D-Ascites E-Tachypnea F-S3 gallop
B-Crackles C-tachycardia E- Tachypnea F-S3 gallop
What are some options for PCI - Percutaneous Coronary Intervention?
Balloon, arthrectomy, or stent.
Goes into R-Atrium & R-Ventricle-synthesize both ensuring it is working like it should. It is a permanent placement
Dual Chamber
Diagnostic & labs for heart failure?
Echo, xray, hemodynamic monitoring, EKG. Labs - BUN/Creatinine/BMP, Creatinine clearance/microalbumin/ BNP / and ABG"S
Threaded onto the epicardial surface - post open heart surgery
Epicardial
What are some causes for decreased contractility?
Hypoxia & acidemia
MI Care: INFARCTIONS - What does it stand for?
I- IV access N-Narcotics F-facilities for d-fib/crash cart A-Aspirin R-Rest C-Converting enzyme inhibitors (ACE) T- Thrombolytics I- IV Beta Blockers O - Oxygen N- Nitrates S- Stool softners - avoid vagel response
What are some causes for increased afterload?
Levophed and or vasopressin
Area of myocardium is permanently destroyed. Usually a result from plaque rupture, occulsion, or vasospasm of a vessel. Chest pain longer than 30 minutes unrelieved by rest & nitro.
MI- Myocardial Infarction
S/S are Decreased cardiac output, cool/clammy skin, decreased BP, SOB, dizziness, and chest pressure
MI- Myocardial infarction
What are the capabilities of pacemakers?
Pace, sense, & respond
Device that controls electrical impulses that stimulates the myocardium for contraction and overall heart function
Pacemaker
How do you treat cardiac tamponade?
Pericardiocentesis
Usually placed in L-Subclavian, electrodes directly to endocardium. Pre-programmed before implantation.
Permanent pacemaker
Myocardial fiber stretch at the end of diastole but just before contraction. It can affect the blood volume coming into the heart.
Preload
What are some causes for increased contractility?
Sympathetic stimulation and positive iontropic drugs.
Will not be relieved with rest/stop or with Nitro
Unstable angina
Occurs anytime, reversible SVT elevation on EKG. Usually caused by stress/tobacco/drugs.
Variant angina
Sharp spike before the QRS
Ventricular pacemaker spike
Before giving a patient Nitro what should you make sure they are not on?
Viagra/Cialis
