Med/Surg 3- Ch. 14 (Cardiovascular Disorders)
Paroxysmal Nocturnal Dyspnea
Refers to attacks of severe shortness of breath and coughing that generally occur at night. It usually awakens the person from sleep, and may be quite frightening. - pt might have the urge to "get some air" (go to the window)
MUSCLE
TIME IS ...
Atherosclerotic heart disease
There is strong link between vascular inflammation and the development of .... - C-reactive Protein
RAAS (renin-angiotensin-aldosterone system)
What is activated during HF which results in fluid overload?
PQRSTU Pain Assessment
What is the FIRST assessment you would complete if a patient mentions they are having chest pain? - do determine if it could be from cardiac cause or if it is MUSK or GI in nature
30
When HF is so bad that the EF is <___% the patient may experience ventricular dysrhythmias such as (VT/ VF) - LIFE-THREATENING - tx: antidysrhythmics and/or ICD
the CAUSE of HF
When a patient is experiencing heart failure it is best to target the medical interventions to treat....
Digoxin
When a patient with HF experiences atrial fibrillation they will likely be given which medication? - helps with symptoms relief (tolderable) - works synergistically with beta-blockers
100
When the BNP is greater than ____ the Dyspnea is likely r/t Heart Failure rather than pulmonary failure
Arteriosclerosis
hardening of the artery walls
Dyskinetic
scar tissue moves in the opposite direction to the normal contractile myocardium
Acute Coronary Syndrome (ACS)
sudden symptoms of insufficient blood supply to the heart indicating unstable angina or acute myocardial infarction - angina pectoris (caused by myocardial ischemia)
remodeling
when healthy tissue is replaced with scar tissue
PATHOLOGICAL Q-WAVE (ELEVATED)
*INDICATES ISCHEMIC INJURY AND MYOCARDIAL NECROSIS*
INVERTED T-WAVE
*INDICATIVE OF ISCHEMIA OR INFARCTION*
STEMI: MANAGEMENT
*Initially tx post-STEMI: * - Often Heparin Bolus is given and followed by a Heparin drip (Goal: get PT T time between 50-70 seconds for ~48 hrs/ til revascularization has occurred) - fibrinolytic/thrombolytic therapy (Alteplase) is often given in combo with Heparin, OR percutaneous coronary intervention is performed (ex. stent placement) *New Arrhythmia tx Post-STEMI : * - Amiodarone - Beta-Blockers - Vasodilators (ACE-I / Angiotensin receptor blockers) can stop or limit the ventricular remodeling which can lead to HF
MI: Nursing Management
*Main Goal: maintain a balance between myocardial oxygen supply and demand * ~~ Oxygen ~~ Medications *Prevent complications* ~~ Monitor the effectiveness of tx ~~ Encourage bed rest ~~ Continuous cardiac monitoring & assessment ~~ Monitor for & tx depression *Provide patient and family education* ~~ Risk factor reduction ~~ management of angina ~~ when to call for help ~~ Medications ~~ resumption of physical & sexual activities ~~ referral to cardiac rehabilitation
Ventricular septal wall rupture
*Rare but lethal complication of an Acute MI* - occurs in less than 4% of all MIs - most pt will also have S&S of Cardiogenic Shock - S&S: ~~~ *Severe chest pain* ~~~ *Syncope* ~~~ *Hypotension* ~~~ *Sudden Hemodynamic Deterioration* (caused by shunting of blood from high pressure left ventricle to the low pressure right ventricle) ~~~ *Holosystolic murmur* (throughout systole) often accompanied by a thrill (palpated or auscultated along left sternal border) *MEDICAL & SURGICAL EMERGENCY*
Endocarditis
- *inflammation on the endothelial surface of the heart* (specifically thrombotic-fibrin vegetations on the cardiac valves) - *Valve leaflets, chordae, chamber walls, paraprosthetic tissue, implanted shunts, conduits, and fistulas may be affected* - AKA bacterial endocarditis (older) & infectious endocarditis (IE- newer) - Approximately 75% of patients have a pre-existing structural abnormality of the involved cardiac valve. - *Involvement of right heart valves is highly suspicious for intravenous drug abuse (IVDA)*
Cardiovascular Disease (CVD)
- A general term for all diseases of the heart and blood vessels - leading cause of death in U.S.
Hypertrophic Cardiomyopathy (HCM)
- AFFECTS THE HEART MUSCLE myocardial sarcomere) - an *genetically inherited condition* in which there is an enlargement of the heart muscle, especially the muscle between the two ventricles - leading cause of sudden death in athletes
Dilated Cardiomyopathy
- AKA congestive cardiomyopathy - characterized by gross dilation of both muscles but does not have muscle hypertrophy
Pericarditis
- After an MI damaged epicardium becomes rough, inflamed, and it irritates pericardial lining adjacent to it and this precipitates _________. - Pain is the most common symptom - pericardial friction rub (most common initial finding) - produced a pericardial effusion (friction rub may disappear after effusion occurs) - may appear as ST elevation on 12-lead EKG in all upright leads - can occur as a late complication of an MI which is known as Dressler's Syndrome
Zone of infarction
- Area of myocardium that was completely deprived of oxygen during an MI, resulting in cell death - evidence of this zone is seen as new *pathological Q waves* which are a reflection of a lack of depolarization from the cardiac surface involved in the MI - after healing this are is replaced with scar tissue
Endocarditis: Assessment & Diagnostics
- Blood cultures - Chest X-ray (infiltrates/ pneumonia/ enlarged heart/ enlarged pulmonary vessels) - Echocardiogram/ TEE (visualized vegetations on the heart valves)
Pulmonary Arterial Hypertension (PAH): Medical Management
- Calcium Channel Blockers - Endothelial Receptor Antagonists - PDE-5 Inhibitors (erectile Dysfunction med) - Nitric Oxide (vasodilate) - Prostacyclins (vasodilate) - Anticoagulants - Oxygen Therapy - Diuretics *Heart & Lung transplant is the last option* (for those which medical management does not succeed)
Coronary Artery Disease (CAD)
- Cause: atherosclerosis occurring in the coronary vessels - AKA Coronary Heart Disease because other cardiac structures will become involved by the disease process - More risk factors you have, the greater risk you have (p. 291)
NSTEMI (non-ST elevation myocardial infarction)
- Definitive diagnosed by matching clinical S&S to some of the cardiac biomarkers (TROPONIN) - these patients do not receive fibrinolytic therapy - they go to cath lab (they can be diagnosed with CAD here and also receive interventional procedures done - they usually receive the GP2B or the 3A inhibitor therapies (ex. PLAVIX / BERLINTA)
CAD Risk Equivalents
- Diabetes - Chronic Kidney Disease - Peripheral Arterial Disease - Cerebral Vascular Disease
Acute HF
- HF with acute onset and no compensatory mechanisms - pulmonary edema, low CO, or cardiogenic shock - S&S are caused by tissue hypoperfusion and organ congestion, they are progressive
Endocarditis: Complications
- Heart Failure (most frequent and most frequent cause of death) - embolic (2nd most common)
Cardiac Asthma
- this is not a form of asthma but rather a type of coughing or wheezing that occurs with left sided heart failure - Bronchospasm due to congestion of the bronchial mucosa (interstitial edema causes airway narrowing)
Low-Density Lipoprotein (LDL)
- High ____ levels trigger inflammation of the vascular system - the inflammation causes injury to vessel walls which allows _____ to move below the endothelial surface - After which WBCs migrate to and enter the lining of the vessel wall too - they unite with and internalize the ____ cholesterol which results in foam cells (marker cells of atherosclerosis)
Myocardial Infarction (Acute MI)
- IRREVERSIBLE cell death of myocardium due to ischemia (decrease or complete lack of blood flow) - may be a STEMI or acute NSTEMI - 3 methods of vessel blockage: ~~~ plaque rupture from atherosclerosis ~~~ new thrombosis/ clot in the coronary artery ~~~ spasm of the coronary artery
Endocarditis: Medical Management
- Long term IV antimicrobial agents (4-6 weeks) - cardiac surgery (maybe, to repair damaged valves)
Coronary Artery Disease (CAD) / Coronary Heart Disease (CHD)
- The biggest contributor to cardiovascular system-related morbidity and mortality - caused by atherosclerosis - the more risk factors present, the more likely the pt is to experience his disorder
Ventricular Hypertrophy
- a compensatory mechanism of HF which helps increase the force of contraction to help the ventricle overcome increased afterload - when no longer helpful, it remodels to resemble a round bowl (dilated ventricle) which has poor contractility and poor stretch, it is enlarged without hypertrophy
Ventricular Aneurysm
- a non-contractile, thinned left ventricular wall resulting from an acute transdermal infarction, often from acute left anterior descending artery occlusion with a wide area of infarcted myocardium - Hypokinetic, Akinetic, Dyskinetic COMPLICATIONS: - Acute HF - Systemic Emboli/ blood clots - Angina / chest pain - V. Tach PROGNOSIS: - depends on the size of the aneurysm, degree of left ventricular dysfunction, and severity of coexisting coronary artery disease
Hypokinetic
- a reduction in movement/ poor contraction
Heart Failure
- a response to cardiac dysfunction - condition is which the heart cannot pump blood at the volume necessary to meet the body's needs - so any condition that impairs the ventricles to either fill or eject the blood can cause it ~~ *CAD with resulting necrotic damage to the left ventricle is the underlying cause in most patients* ~~ valve dysfunction ~~ infection (like endocarditis) ~~ Cardiomyopathy ~~ Uncontrolled HTN
Systolic Dysfunction Heart Failure
- an abnormality of the heart muscle, marked by decreased contractility during systole/ ejection - these patients have S&S of HF combined with below normal ejection fraction (EF<50%) - BNP tends to be higher than with diastolic HF
Pericardial friction rub
- best heard with a stethoscope at the left sternal border - most common initial finding of pericarditis - disappears after pericardial effusion occurs
C-reactive protein (CRP)
- blood test used to measure the level of inflammation in the body - also indicates risk for other conditions that lead to cardiovascular disease such as *DM, HTN, & obesity * - *the higher the high-sensitivity value, the greater the risk for a coronary event*
MI: Complications
- can arise from either an electrical issue or from a pumping issue of the heart - Electrical: (arrhythmias/ dysrhythmias) ~~~ Bradycardia ~~~ Bundle Branch Blocks ~~~ Heart Blocks - Pumping: ~~~ Acute Heart Failure ~~~ Pulmonary edema ~~~ Cardiogenic Shock ~~~ Rupture of papillary muscles (new murmur heard) ~~~ Ventricular Aneurysm (non-contractile, thinned left ventricular wall resulting from an acute transdermal infarction, often from acute left anterior descending artery occlusion with wide area of infarcted myocardium) ~~~ Ventricular septal wall rupture (rare but LETHAL) ~~~ Papillary muscle rupture (Complete or partial ) ~~~ Cardiac Wall Rupture -> Cardiac Tamponade ~~~ Pericarditis-> friction rub-> pericardial effusion ~~~ Heart Failure (must be monitored very closely)
Variant angina (Prinzmetal's angina)
- caused by obstruction from an intense vasoconstriction of a coronary artery - can occur with or without atherosclerotic lesions - commonly occurs when pt is at rest - often cyclic (occurring at the same time each day)
Unstable Angina
- chest pain at rest or chest pain of increasing frequency which is not relieved with rest and/or Nitro - may awaken the person from sleep (red flag) - indication that the atherosclerotic plaque is unstable - can signal that there's been a plaque rupture and thrombus formation which can lead to MI
S&S of MI in WOMEN
- classic symptoms may be more mild - nausea - vomiting - sweating / cold sweats - SOB - sudden fatigue - lightheadedness - epigastric pain - jaw/ left or right arm/ upper mid back pain
Cardiomyopathy: Nursing Management
- differs with type but generally... - achieve a stable fluid balance - monitor affects of pharmacological therapies - safety increase mobility - provide them with patient and family education
Cardiomyopathy (CMP)
- disease of the heart muscle that leads to generalized deterioration of the muscle and its pumping ability - *Extrinsic:* caused by external factors (HTN) - *Intrinsic:* myocardial diseases w/o identifiable external causes Categories: - Hypertrophic - Dialated - Restrictive
PDE-5 Inhibitor
- this drug helps the pulmonary vessels to vasodilate and decreases vascular smooth muscle cell proliferation - can be used to treat pulmonary hypertension - ex. Sildenafil (Viagra ) & Tadalafil (Cialis)
Pulmonary Arterial Hypertension (PAH)
- disease of the small pulmonary arteries - largest subdivision of PH - characterized by vascular proliferation and remodeling *Pathophysiology: * (1) Endothelial dysfunction and vasoconstriction (2) Vascular remodeling (scar tissue formation) (3) Thrombosis (4) Development of lesions that irreversible obliterate the pulmonary arterioles *Diagnosis:* - very difficult, often considered a diagnosis of exclusion (meaning all other theories have been exhausted) *Findings:* - EARLY: fatigue, SOB, reduced CO - elevated venous pressure - palpable right ventricular heave - enlarged liver (Hepatomegaly) - fluid in the abdomen (Ascites) - peripheral edema - prominent pulmonic component to the second heart sounds/ blowing murmur from the tricuspid regurg - pulmonary edema (suggests left ventricular dysfunction/ possible non-cardiac problem such as ARDS) - LATE: ~~ syncope (the result of hypotension from low CO) ~~ Angina
Pulmonary Hypertension: Nursing Management
- focus on lowering the PAP - administer and monitor effects of medications - treat pain - provide patient and family education
Endocarditis: Nursing Management
- focused on resolving the infection - preventing complications ~~ thorough cardiac and respiratory assessments ~~~ look for SOB, chest pain, hemoptysis, S&S acute HF, cardiac murmurs, changes in LOC, visual changes, or headaches: report these findings immediately ~~~ concerned about emboli ~~ Evaluate liver and kidney function - providing pain meds - individualized patient education ~~~ how to admin IV abx for 4-6 weeks through PICC
Right Ventricular Heart Failure
- ineffective right ventricular contractile function - can result from and acute condition such as... ~~ Pulmonary Embolis ~~ right ventricular myocardial infarction - MOST COMMONLY CAUSED BY LEFT SIDED HF
Left Ventricular Heart Failure
- left ventricle isn't pumping properly - results in low CO state which results in a vasoconstriction of the arterial bed and can increase systemic vascular resistance (HIGH AFTERLOAD) - Created congestion and edema in the pulmonary circulation - Pt will have one of the following.. ~~ decreased exercise tolerance ~~ fluid retention ~~ discover during examination of non-cardiac problems
Heart Failure: Nursing Management
- monitor EKG (for dysrhythmias) - Respiratory assessment (crackles) - Give O2, diuretics, vasodilators, morphine (if not hypotensive to decrease hyperventilation and help with anxiety) - daily weights - restrict activity during periods of breathlessness / bedrest with the HOB elevated - reposition frequently while on bedrest - gradually increase activity w/ patient's tolerance - Monitor VS closely - if HF is severe: be prepared for intubation and mechanical ventilation - administer medications and monitor for effectiveness and for toxicity - I&O, monitor nutritional status - encourage small frequent meals - fluid restrictions - educate the patient and family
Silent Ischemia
- objective evidence of ischemia is observed (such as electrocardiographic changes with a stress test), but patient reports no pain/ angina symptoms
Papillary Rupture
- occurs when infarct happens near the mitral valve - results in ineffective valve closure and regurg into the left atrium during V. Systole - Partial ~~~ may result in mitral regurg ~~~ can be stabilized with aggressive medical management - Complete ~~~ Catastrophic ~~~ precipitated severe acute mitral regurgitation, cardiogenic shock, and a VERY HIGH RISK OF DEATH
Health Factor Goals
- optimal blood lipids - optimal blood pressure - optimal glucose levels
Pulmonary Hypertension
- progressive - ultimately fatal disease of the pulmonary vasculature - occurs b/c progressive narrowing of the small pulmonary vessels which increases the pulmonary vascular resistance
Chronic HF
- pt is HYPERvolemic, they have Na and water retention, they have structural heart chamber changes (like dilation/ hypertrophy) - ongoing process - can be made tolerable with medications and diet and reduce activity level - deterioration to acute can be precipitated bu the onset of dysrhythmias, acute ischemia, sudden illness, d/c of medications,
NYHA Class IV Heart Failure
- pt is symptomatic at rest - they are candidates for palliative care (goal: symptom management to relieve suffering in combination to tx of medical problem)
Restrictive Cardiomyopathy
- rarest of the cardiomyopathies - usually has no known cause - heart muscle hardens, restricting the expansion of the heart, thus limiting the amount of blood it can pump to the rest of the body (decreased compliance)
Endocarditis (IE)
- results from a bacterial or fungal organism in the bloodstream that successfully colonizes the cardiac endothelium - It is fatal if not treated. - Bacterial organisms, typically *streptococci, staphylococci, and enterococci, are the most common pathogens*. - After the vegetations have colonized, bacteria multiply at a rapid rate inside a protective platelet-fibrin casing that sequesters the infection.
Pericardiocentesis
- surgical puncture to aspirate fluid from the sac surrounding the heart - needle is inserted into the pericardial space and then blood/fluid is drained to relieve the pressure surrounding the heart which is preventing it from bleeding normally
Valvular Heart Disease (VHD)
- term describing the structural and functional abnormalities of single or multiple cardiac valves - The result is an alteration in blood flow across the valve. - The two types of valvular lesions: ~~~ Stenotic (stiff) ~~~ Regurgitant (back flows) - In the past, in the United States, most valvular lesions were rheumatic in origin (direct result of group A beta-hemolytic streptococcal pharyngitis). As a result of aggressive treatment of "strep throat," this has become a rare problem. - Valve lesions are now more commonly related to *congenital disorders and older patients* - low CO is a common finding,
Diastolic Dysfunction Heart Failure
- the heart muscle is unable to relax, stretch, or fill during diastole - caused by left ventricular dysfunction - EF is normal (50% or greater) - BNP tends to be lower than w/ systolic HF - definitive diagnosis is made using a doppler echocardiography (ultrasound of heart)
NO (NSTEMI)
Is the ST segment of an EKG elevated with every acute MI?
High-Density Lipoprotein (HDL)
- this type of cholesterol can enter the damaged vessel lining and helps to efflux cholesterol from the endothelial cells and returns it to the circulation - helps to minimize the number of foam cells in the artery wall
Angina symptom equivalents
- unexpected SOB - cold sweat - sudden fatigue, nausea, or lightheadedness - indigestion like pains
Nitric Oxide
- vasodilator - helps to ventilate the lung units - used to treat pulmonary hypertension
Penumbra (Zone of Ischemia)
- very outer edge of the zone of injured myocardium after an MI - targeted area for priority interventions (goal: to save viable muscle) - this is the area surrounding the infarcted zone - the tissue is injured but still potentially viable - they do not fully repolarize because of the deficient blood supply and this is recorded on the EKG as the elevation of the ST segment
YES
Is unstable angina a medical emergency?
Heart Attack (MI)
A mature atherosclerotic plaque or atherosclerosis that has been present for a while has a liquid center that is covered in a fibrous cap. If ruptured that liquid pours out and can cause a coronary thrombosis resulting in a ... - unknown what makes the capsule rupture
Secondary
A patient shows up to the ER with angina upon vigorous activity. Labs revealed the patient has elevated cholesterol, triglycerides, and troponin levels. For this patient what level of CAD prevention will the RN focus on?
Dyspnea
difficult or labored breathing/ SOB
Primary
A 50 year old woman presents to your office with diabetes mellitus type 2, she has no other indications of having CAD. Since being diagnosed with DM she has strived to eat better and loose weight. However the RN understands that DM is a risk equivalent for CAD. For this particular patient, what level of CAD prevention will the RN encourage? (primary/ secondary/ tertiary?)
Pulmonary Hypertension
A female patient is on Viagra (a PDE-5 Inhibitor), what condition can the experienced RN assume this medication is intended to treat?
Plavix/ Berlinta
A patient with unstable angina or non-ST elevated MI (NSTEMI) will receive duel anti-platelet therapy upon admission which may consist of Aspirin & ..... - they may also go to the cardiac cath lab to open up the occluded vessel - if no invasive measures are indicated for pt then they will likely go for stress test
Orthopnea
difficulty breathing when lying down flat
MEN
CAD, specifically MI is the PRIMARY CAUSE OF HF in ...
Protective; Pathogenic
HDL is a ______ factor, whereas LDL is ______________
Coronary Artery Disease (CAD)
If a patient has Diabetes or Chronic kidney disease you can assume they also have ___ ___ ____ or at the very least you are going to tx them as if they already do. - b/c they are risk equivalents
right ventricular HF
If left untreated pulmonary hypertension progresses to ___ ____ ___ & death
12-lead EKG
If you feel that your patient is potentially having cardiac pain you should immediately get an .... - look for ST-segment elevation OR LBBB (INDICATIVE OF MI)
ANGINA
In the critical care unit in order to get ______ under control, you would ... - give supplemental oxygen - Nitro drip / sublingual - Analgesics (morphine) - maintain calm environment - attempt to alleviate fear/ anxiety (increases cardiac workload) - educate the patient and family
2 hours/ 120 minutes
Myocardial tissue can best be salvaged within the first __ hours or the first ____ minutes after the onset of angina symptoms
CAD
NON-MODIFIABLE RISK FACTORS: - Age - Sex - Family hx - Race MODIFIABLE RISK FACTORS: - elevated serum lipids - HTN - cigarette smoking - pre-diabetes and DM - diet high in saturated fat, cholesterol, & calories - elevated Homocysteine level - metabolic syndrome - obesity - physical inactivity - postmenopausal (modification is controversial)
Akinetic
Non contractile scar tissue
Cardiac Wall Rupture
PEAK TIMES: - Within 24 hours of MI - between the 3rd and 5th post-infarction days (as leukocyte scavenger cells work to remove the necrotic debris and there is thinning of the myocardial wall) RESULTS: - onset is usually very sudden and catastrophic - there may be bleeding to the pericardial sac which results in CARDIAC TAMPONADE, CARDIOGENIC SHOCK, PULSLESS ELECTRICAL ACTIVITY, OR DEATH - SURVIVAL OF THIS COMPLICATION IS RARE - If this occurs in the hospital the patient needs an emergency pericardiocentesis to relieve the tamponade until sx repair can be attempted
Autonomic Neuropathy
Patients that have had DM type 2 for more than 10 years have developed _____ _____ which DECREASES ABILITY TO FEEL CHEST PAIN
Hypertension
Precursor to heart failure in both men and women - primary precursor for women
cardiac enzymes
When the heart muscle (myocardium) is damaged it releases chemical biomarkers known as ___ ____ - these are measured to determine the presence and/or degree of cardiac injury - Creatinine Kinase Muscle Brain (CKMB) - Troponin I / Troponin T - if the coronary artery is opened using either fibrinolytic therapy (ex. TPA) or Percutaneous catheter intervention (ex. cardiac stent placement) the biomarkers / ___ ___ exhibit a more rapid rise and dramatic fall
1/3
_/_ of patients having a heart attack DO NOT REPORT PAIN / ANGINA - DO NOT RELY ON THE PRESENTS OF CHEST PAIN
Depression
___ is a risk factor for developing CAD and it can also impede the recovery following an acute MI - S&S ~~ Fatigue ~~ changes in appetite ~~ sleep disturbances
Heart Disease
____ _____ is responsible for 1/3 of female deaths in the U.S. - this is important to remember since they often present with atypical S&S
Modifiable
_____ Risk Factors: - Elevated serum lipids - HTN - smoking cigs - DM/ Pre-DM - diet high in saturated dat, cholesterol, & calories - Elevated homocysteine level - metabolic syndrome - Obesity - Physical Inactivity - Postmenopause (controversial)
NONmodifable
________ Risk Factors: - age - sex - family hx - race
Stable Angina
chest pain that occurs when a person is active or under severe stress - goes away after 5 minutes of rest or after Nitro
Atherosclerosis
condition in which fatty deposits called plaque build up on the inner walls of the arteries