502 Exam 1

Cardiac Catheterization- Intervention for MI

Coronary angiography (radiation and contrast dye--dye is nephrotoxic: BUN and Cr*) Coronary revascularization Percutaneous coronary intervention ---Balloon Angioplasty: push fat to sides of artery, place stent--hold walls of artery out -Sometimes stent has Anticoagulation or antiplatelet Meds

Pharmacologic Management for ACS

General treatment measures Oxygen - at least for first 2-3 hours (maybe not) Aspirin 325mg (chew it) and statin drug Nitroglycerine (sublingual or spray) Morphine Sulfate 2-4 mg IV as needed (vasodilator and analgesic) Goal: Get rid of the pain!

HF Assessment

Health and family history Activity tolerance (functional assessment) Vital Signs Fatigue Oxygen Saturation Skin Heart & lung sounds Fluid Status (I&O, Weight, Edema, JVD, Ascites) Are they taking their prescribed medications?

Hypertensive Crisis Types

Hypertensive urgency: BP > 180/120 but no target organ symptoms Hypertensive emergency: BP > 180/120 and target organ symptoms (CNS - hemorrhage, Cardiac - heart failure and MI, Renal failure)

Thrombolytic Therapy for ACS

If no Cardiac Catheterization (interventional radiology) lab is available, dissolve the thrombosis with fibrinolytics (within 30 minutes) Many Contraindications and Cautions! Active Bleeding Trauma within the last 3 months Known Cancer Pregnancy Recent Surgery Monitor Bleeding EKG for reperfusion dysrhythmias (usually PVC, VT, VF) Cardiac Enzymes

HF Nursing Diagnoses

Impaired gas exchange related to preload and alveolar capillary membrane changes Impaired/Decreased cardiac output related to decreased contractility, increased afterload Imbalance (Excess) fluid volume related to decreased renal perfusion Activity intolerance related to oxygen supply/demand imbalance

Implantable Devices for HF

Implantable devices -Internal Cardiac Defibrillators/Cardiac resynchronization therapy -CardioMEMS: remote monitoring of pressure/fluid

Nursing Diagnosis related to HTN

Ineffective health management related to knowledge deficit, complications, and management of hypertension; Anxiety At risk for (potential): Sexual dysfunction, Orthostatic hypotension, fatigue, depression, hypertensive crisis, myocardial infarction, stroke Ineffective tissue perfusion: Cerebral, Cardiovascular, Renal, Retinal

Gradual progressive disease of the coronary arteries

Initial injury to the endothelial cells in the intima (hypertension & hyperlipidemia) Lipoproteins enter the intimal layer (hyperlipidemia) Platelet adhesion & aggregation at the site of injury Progressive narrowing Plaque rupture Occlusion of vessel (hypoxic/ischemic injury)

HF Complications

Pleural Effusion Dysrhythmias Thrombus Hepatomegaly Renal Failure Anemia

HF Primary Causes

Primary Causes: CAD and MI Hypertension (↑ SVR) Pulmonary Hypertension Cardiomyopathy (viral, substance abuse, post partum) Valve disorders Hyperthyroidism Congenital heart disease Rheumatic heart disease Contributing Factors: Diabetes, age, Tobacco use

Normalize Hospital Env.

Promote freedom of movement Maintain child's routine Time structuring Self-care Therapeutic play Schoolwork Friends and visitors

BP/Temp

Proper size cuff Posterial tibial most common for peds Axillary for temp Rectal temp if fever (when precision and accuracy needed) Oral for 5+ but hard for child to cooperate Tympanic unreliable

Decrease oxygen demand

Stop angina-inducing activity! Decrease blood pressure and/or heart rate: -Nitroglycerin, BB, CCB, ACEi, ARB

Etiology of HF

The biggies are hypertension (don't forget right side which pumps again the lungs) and post-myocardial infarction remodeling. Contributing factors/diagnoses: Diabetes, metabolic syndrome, advanced age, and tobacco use. Primary and Secondary causes (should make sense to you)

Anxiety Management

The goal, especially in the peri-infarct period, is decreased anxiety and even a little pharmacologically induced sedation. i. Treatment to promptly resolve ischemic symptoms. Relief of chest pain will do a lot to reduce anxiety; "There, there, you'll be okay" will not. ii. Calm, efficient, empathetic bedside manner - focus on basic concerns first - unit sounds, monitor, etc. iii. Active listening - patient and family.

Metabolic Syndrome

Three or more of CAD risk factors is criteria for metabolic syndrome

Potential Communication Challenges with Older Adults

Time and technology Risks of paternalism and infantilism Relating to the older adult's reality Sensory and cognitive changes Multiple concerns that distract from focus Comorbidities Health literacy

ACS Diagnosis: Cardiac Markers

Troponin (T and I) - Most commonly drawn Radiology: Chest x-ray to assess cardiac enlargement and pulmonary congestion

Paper Doll technique

Use paper doll and show on body outline where equipment will go, have child practice

What's happening to hydrostatic and colloidal osmotic pressure? (In decompensated HF)

a. Sympathetic signs and symptoms: Anxious, Pale, Cyanotic, Cold, And Clammy b. Respiratory signs and symptoms of pulmonary edema: Dyspnea, Orthopnea, Tachypnea, use of accessory muscles, wheezing, coughing, crackles, rhonchi, frothy pink sputum. Acid base status - initially hyperventilation leads to slight respiratory alkalosis; oxygenation status - due to fluid in the alveolar capillary membrane, PaO2 and SaO2 low. Non-respiratory symptoms: Jugular Vein Distention (JVD), Blood pressure (increased or normal early on and decreased later when cardiogenic shock), S3 or S4 heart sounds (fluid volume overload), and increased PaCO2 (later with acidosis).

Ed pt on HTN reportable symptoms

chest pain, shortness of breath, edema, weight gain (think fluid), nose bleeds, headaches, vision changes, dizziness (less common, think target organs)

Features of HF

decreased Cardiac Output (CO), Decreased Blood Pressure (BP), Decreased renal perfusion, poor exercise tolerance, and dysrhythmias.

Stress and HTN

stress increases SNS and cortisol secretion which can lead to tachycardia, inflammation, insulin resistance, central adiposity, platelet aggregation, and poor heath choices (like stress eating or decreased physical activity).

Growth charts x and y

x axis age in weeks y axis variable measured

Infants

-1 mo to 12 mo -rapid growth and dev, double birth weight by 6 mo, triple by 1 yr -eat, sleep, pee/poop, cry -2 mo: track objects, social smile, curiosity, steps, sounds -least invasive to most invasive (keep warm, quiet) -start with respiratory rate, abd. sounds -keep snug and wrapped, unwrap only what needed -nose and mouth last, back (cold), genitals wet when cold -swaddle, held, sucking, soothing tone -communicate with caregiver -carseat safety, safe sleeping env., vaccines, diet -Breastmilk -oral sucrose to decrease pain -buzzy: cold, vibration, helps with pain

Toddlers

-1 yr-3yrs -Physical growth slows down -decreased appetite -walk, stairs, jump -Independent, like routine, control -language increases to two-three word phrases -understand more than they can express -gross motor skills before fine motor skills -dentation -toilet training -pen light, distraction, sing -Head area most invasive (ears, eyes, nose, throat) -don't say all done until actually done -drowning #1 cause of death, heavy objects -picky, variable diet

Preschoolers

-3-5 -long, lean, more coordinated, complex sentences -refine gross motor skills-- skipping -imaginative, egocentric, words matter -Body integrity, bandaids -car accident #1 cause of death -helmet, road safety, safe touch

School agers

-5-12 -growth levels off -lose teeth, school env, cog. growth, concrete thinking, modest -head to toe easier, genitals private, matter of fact -pain management plan ahead of time (count down, tv) -car safety (booster until 11--height based) -smoking, private conversation -helmets, preventing sports injury

Protest Phase of Separation Anxiety

-7-14 mo peak -distress, kick, fight, punch

HTN Meds

-Diuretics: (Hydrochlorothiazide and Lasix) - in general inhibit sodium resorption in the kidney (watch electrolytes) -β- Adrenergic Blockers (olol) - Block β1 cardiac receptors to slow heart rate (monitor heart rate) -ACEi (pril)/ARB (sartan) - Block the effects of the RAAS -CCB (dipine) - Inhibit movement of Calcium across cell membrane resulting in vasodilation -Vasodilators (Nitroglycerine and Hydralazine) - Venous (nitroglycerine) and arterial (Hydralazine) vasodilation and SVR reduction (work fast, monitor closely and frequently)

Target Organ Damage Manifestations

-Encephalopathy (LOC Changes) -Retinopathy (Visual Changes) -Renal insufficiency -Cardiac Decompensation (Chest Pain, MI, Unstable Angina, decreased pulses) headache, nausea, vomiting, seizures confusion and coma, Visual changes, chest pain, dyspnea, faintness, agitation)

Ped Growth Measurements

-Head, chest, abdominal circumference -precision important -Chest and head ratio important -Ab circumference for ill children

Three components of ACS Diagnosis

-Pain -Electrocardiogram -Cardiac Markers

Watch language with Peds

-Stick in arm -IV-- ivy -Flush-- toilet -Dye-- die -CAT scan-- cats -Put you to sleep-- euthanize pet, death

Oral Meds for Peds

-cant take pills, oral solution -oral syringe most common -DO NOT use IV syringe for oral meds (broader tip) -liquid in side and back of cheek so they don't spit it out -hold child to side

Gerontological considerations: risk of hypertension increases with age

1. Increased white coat syndrome 2. Loss of elasticity of arteries 3. Stiff myocardium 4. Possible use of anti-inflammatory medications (prostaglandin inhibitors) for arthritis 5. Decreased Baroreceptor Reflexes leads to increased orthostatic hypotension *Two step method to get highest systolic number**

Modifiable Risk Factors for CAD:

1. Lipids a. Total Cholesterol >200 mg/dL b. Total triglycerides ≥ 150 mg/d c. LDL > 130 d. HDL <40 for men or <50 for women 2. BP ≥ 130/80 mm/Hg 3. Diabetes Mellitus 4. Tobacco Use (p. 702) 5. Physical Inactivity 6. Obesity

Gerontologic considerations

1. Risks can still be reduced! a. Treat Hypertension and hypercholesterolemia b. Smoking Cessation c. Specific considerations for Physical Activity 1. Longer warm up periods 2. Low-level activity 3. Longer rest periods Motivated to change -When hospitalized -When symptoms are not related to aging

Ped HTN considerations

1. The etiology is different (in children, it is usually the result of congenital defects). 2. The symptomology is somewhat different (irritability, head rubbing, waking up screaming) 3. The treatments are somewhat different because of the different etiologies and differences in response to medications. 4. Nursing diagnoses/priorities of care are similar

HTN Lifestyle Modifiers (Simple 7)

1. Weight loss: Most consistent action which demonstrates BP reduction (BMI Goal 18 - 24.9 kg/m2 - 1 Kg weight loss = 1 mm Hg BP reduction) 2. Physical activity: 30 minutes or more of moderate-intensity physical activity on most, and preferably all, days of the week. Strength training at least twice a week. 3. Nutritional therapy: Dietary Approaches to Stop Hypertension (DASH) 4. Limit salt 5. Avoid tabacco 6. Limit alc (2 drinks/day for males and 1 drink/day for females and lighter weight males) 7. Management of psychosocial risk factors and Social Determinates of Health (SDH), Minimize stress

HF Diagnostic Tests Part 1

A. Echocardiogram B. 12 lead and continuous ECG (EKG): C. Chest X-ray: D. Cardiopulmonary Stress test (exercise) and 6 minute walk test: assess activity tolerance

Assess Health Literacy: The Newest Vital Sign

Ask me three: main prob, what to do to manage, why

ACS Diagnosis: Pain

Characteristic Unstable Angina chest pain New Onset at Rest -Unpredictable/Easily provoked -Fatigue, SOB, indigestion, and anxiety (Females) Can progress to Myocardial Infarction (MI) No coronary blood flow leading to necrosis Severe, Immobilizing, Not relieved by Nitro Diaphoretic, Elevated BP and HR, Nausea Fever

Adult Emo. Milestones

Children leave home "Sandwich generation" Significant relationships at work, family, and community Major life changes Find new meaning and purpose "Was the trip worth it?"

Surgery for ACS

Coronary artery bypass graft with internal mammary artery anastomosis or saphenous vein. This is a major surgery involving sternotomy and cardiopulmonary bypass (CPB); if saphenous vein leg incision too. Minimally invasive direct coronary artery bypass and off pump robotic procedures

Health Equity

Culture of Equity - aids in meaningful change Equitable Care - high quality health care for everyone Valuing everyone equally (not the same interventions for all) Strength based approach Builds on strengths, resources, and the ability to recover from adversity Allows one to see opportunities, hope, and solutions rather than just problems and hopelessness Focuses on resilience and thriving

HF Diagnostic Tests Part 11

E. MUGA Scan - (Multigated Acquisition Scan - nuclear medicine) uses a radionucleotide to view the beating/movement of the heart F. Heart Catheterization (percutaneous coronary intervention like in acute coronary syndromes) - assess Cardiac output and overall fluid volume status. G. Sleep study to evaluate for Obstructive Sleep Apnea (OSA): can exacerbate heart failure H. Laboratory values: BNP or NT-proBNP may be elevated but also can be elevated with pulmonary embolism, renal failure and acute coronary syndrome.

Heart Failure with reduced Ejection Fraction (HFrEF):

Ejection fraction < 40% (normally ~ 55-65%) and used to be called Systolic failure

Caregiver and Sibiling Stressors

Emotional Support: -Support groups -Chaplain Social Work Logistical/Practical -Support Housing/Meals -Maintaining home/work Providing information Family-include in rounds (including video conferencing) -Preserving caregiver role -Sibling Support Child Life

Proper BP reading

Empty bladder, relaxed, legs uncrossed, avoid caffeine, smoking and exercise 30 min before, correct cuff size, use avg. of 2+ readings,

Peptides and Cytokines Compensation

Endothelin (local vasoconstrictor) increases afterload and decreases the force of contraction of the heart Proinflammatory cytokines are released by the cardiomyocytes in response to heart damage/injury to the heart and play a role in myocardial remodeling. *Neg Effect**

Adult Cog. Milestones

Fluid intelligence peaks during early adulthood and then declines Think logically to solve new problems Crystallized intelligence improves through middle adulthood and beyond Body of knowledge

Complications of HTN

Heart disease: Coronary artery disease, hypertrophy, and heart failure Cerebrovascular disease: "Brain attack" Transient ischemic attack Stroke: Both thrombotic and hemorrhagic Renal: Nephrosclerosis (elevated proteinuria and creatinine) Peripheral artery disease: Intermittent claudication, Aneurysm, Bruits/Thrills Retinopathy: Blurred vision to blindness

Key Points of Ped Care

Know expected growth and development Establish trust Communicate at developmental level (which may differ from chronological age) Head-to-toe? - never mind! Involve the caregiver (parent, guardian, etc.) Importance of play

CAD Treatment

Know the risk reduction strategies/goals for physical activity, nutrition, and lipid lowering drugs (most commonly Statins are used) and there is a new class of subcutaneous injections called PCSK9 inhibitors. Other drug are also used to lower cholesterol as well as low dose aspirin.

Side effect of HTN Meds

Most patients will require two or more medications to achieve control and most common side effect is orthostatic hypotension (SBP decrease by 20mm/Hg, DBP decrease by 10mm/Hg, or HR increase by 20 beats/minute).

YA Milestones (Emotional)

Move into an adult relationship with parents Peer group becomes less important as determinant of behavior Feel empathetic Have greater intimacy skills Complete their values framework Still may carry some feelings of invincibility Establish their body image

Acute coronary syndrome (ACS)

Myocardium oxygen delivery is not sufficient to meet basic cellular needs - reduced ATP production - cellular death - rupture - release of cardiac enzymes.

Drugs that interfere with therapy (Education opportunity)

NSAIDs, stimulants (legal or otherwise), oral contraceptives, supplements, decongestants, diet pills

Ages and Stages

Neonate: Birth to 28 days Infant: 1 month to 12 months Toddler: 1 year to 3 years Preschool: 3 to 5 years School-ager/Grade schooler/Preteen: 5 to 12 years Adolescent: 12 to 18 years Young adult: 18 to 21 years Young Adult: 18 to 44 years Middle Age: 44 to 64 years Older Adult: Over 60/65 years "Frail" Older Adult

BP Cutoffs

Normal: <120/<80 Elevated: 120-129/<80 1: 130-139/80-89 2: 140-159/90-99 3:>160/>100

Other Non pharmological Interventions for HF

Oxygen (Nasal Cannula, mask, intubation) - how do you evaluate this intervention? Position - High Fowlers with legs supine or dangling off bed is helpful to reduce venous return and increase thoracic cavity to aid in breathing Ultrafiltration/aquapheresis - remove only fluid (not waste products) Dialysis - if fluid and wastes need to be removed Cardiac Rehab - Short bouts of activities with rest periods

Family Centered Care

Philosophy and approach to care that recognizes the family is a constant "Patient- and family-centered care is working "with" patients and families, rather than just doing "to" or "for" them." Core concepts: -Dignity and respect -Information sharing -Participation -Collaboration

Assessments/Interventions for anyone having chest pain

Place patient upright Assess Vital Signs Apply Oxygen to keep O2 Saturation ~93% (check your policy) Continuous EKG monitor Obtain a 12 lead EKG Nitroglycerin and IV Morphine Draw Cardiac Biomarkers (enzymes) Assess heart and Lungs Obtain a chest x-ray

Post Catheterization Complications

Reperfusion Dysrhythmias (usually PVC, VT, VF)--blood starved cells suddenly flooded Re-occlusion Dye reaction (stent doesn't work, pain comes back) Renal Compromise (reaction to dye) Hematoma/Bleeding, Pulmonary embolism, Coronary artery rupture Monitor Cardiac enzymes, EKG, Pain

Activity intolerance r/t weakness and ineffective self-health management r/t new diagnosis/rehabilitation.

Rest and physical activity: Typically, activity limited initially and then gradually increased as patient tolerates it.

DASH Diet

Restricted calories, red meats, and fats High in fresh fruits, vegetables, and whole grain High in poultry, fish and nuts Low-fat dairy Sodium restriction Usual American Diet: 3-4 grams/day Recommend less than 2300 mg/day in the absence of disease For people of middle age, and those with Hypertension, Diabetes, Kidney Disease, and Heart Failure: 1500 mg/day is recommended.

Stressors of Hospitalization and Children's Reactions

Separation from parents and loved ones Fear of the unknown Loss of control and autonomy Bodily injury resulting in discomfort, pain, and mutilation Fear of death Pretty much everything we do in the hospital is in direct contrast to children's expected growth and development

Physical Activity and WL Education

Set the right goals: Realistic, attainable, measurable Shape success: Progressive, short term goals Reward success, but not with food Avoid stimuli that triggers eating Friends and family The little things: Eat slowly - Satiety takes ~ 15 minutes Fill up on vegetables first Control portions - smaller plate

Care for ACS

Stabilization and reperfusion if possible: Since chest pain = ischemia the goal is to get rid of the chest pain. Monitor the patient, Take a good history. Add Aspirin, clopidogril (Plavix) and a statin for an acute MI. May need to add IV nitroglycerin. Morphine, Oxygen, Nitroglycerin, and Aspirin (MONA) will get you going in the right direction until help arrives.

Increase oxygen supply

Supplemental oxygen (if available) Medications: Nitroglycerin (short term) Aspirin and statins (long term) Cardiac catheterization and percutaneous coronary intervention (PCI) including angioplasty and drug eluding stent. Anticoagulants and/or antiplatelet Medications

BP Goal Study

Systolic blood Pressure Intervention Trial (SPRINT) findings released in 2015 show that having a target goal of 120mm/Hg lowers the cardiovascular events by 1/3 and the risk of death by almost 25% for people over 50 years old

Health Literacy

The ability to read, understand, and effectively use basic medical instruction and information Low health literacy contributes to: -Poor adherence -Failure to seek preventive services -Prolonged hospitalizations -High annual health care costs

Decreased CO Management

The goal is good systemic perfusion. i. Absence of crackles; strong pulses, adequate urine output. ii. Aside from assessment, the interventions for decreased cardiac output are mostly collaborative related to medication administration.

Acute Pain Management

The goal is its absence. i. Administer morphine, nitroglycerine, and oxygen. ii. Keep oxygen demand low - meds and gradual activity. Some activities increase oxygen demand more than others. What are they? iii. Assess patient tolerance to gradually (i.e. more home like) increasing activity. How would you do that in the in-patient setting?

Types of ACS

Unstable angina (Precursor to NSTEMI/STEMI but without necrosis) - may need stress test Non-ST segment (NSTEMI) and ST segment elevation myocardial infarction (STEMI): "I think I'm dying." Pain, more persistent than Unstable Angina SNS - Diaphoretic VS and CV and PV assessment findings -Elevated BP and Heart Rate, Cool clammy skin Nausea and vomiting Fever

Ongoing assessment and response to HTN treatment

Vital signs - Rest before taking blood pressure may help Neurologic: Cognitive function, LOC Cardiovascular: Ischemia and pump function, dysrhythmias Pulmonary: Congestion Renal function - Urine output

Growth Charts

WHO and CDC make growth charts WHO: 0-24 mo CDC: 2-20 years -WHO charts identify "ideal growth" based on breastmilk feeding for at least 12 months -Specialty charts for certain conditions (e.g. Trisomy 21)

Compensated and Decompensated HF

a. Compensated: Counter-regulatory mechanisms maintain Cardiac Output (no or few symptoms) b. Decompensated: Counter-regulation cannot maintain Cardiac Output and there is decreased Blood pressure, poor renal perfusion, poor exercise tolerance, and dysrhythmias. (When the effects of the RAAS and SNS are more powerful than the natriuretic and endothelial vasodilators.)

Procedures for ACS

i. If ACS confirmed and patient is a candidate, emergency PCI - angioplasty and stent usually (Goal 90 minutes from ED to intervention). ii. If ACS confirmed and interventional services not available, fibrinolytics to dissolve the thrombosis (Goal 30 minutes from ED to infusion). -Evidence of reperfusion: Diagnostic criteria disappear -Evidence of reocclusion: Diagnostic criteria reappear.

Patient education and chronic disease self-management

i. Timing is everything. iii. Physical activity: guide patients to listen to their, pulse check (though false negative common due to beta blockade), symptom recognition. Walking, jogging, swimming, bicycling, jumping rope. iv. Sexual activity may resume when able to climb two flights of stairs without symptoms. v. Medication management and adherence

Health Promotion

weight management, manage hypertension, flu shot, pneumonia shot, precipitating factors, use sleep apnea aids, and decrease anxiety. What should the patient know about this condition? It is progressive but manageable.

4 Ms

what matters, meds, mentation (dementia, depression, delirium), mobility

Detachment of Separation Anxiety

-chronically ill -difficulty forming relationships -loss of trust

Lowering Cholesterol (Diet)

-less saturated and monounsaturated -more polyunsaturated (nuts, seeds, veggie oils)

Despair Phase of Separation Anxiety

-long term seperation -withdrawn, sade

BP Goal

1. Blood pressure: < 130 mmHg / < 80 mmHg 2. Understand and follow the plan 3. Experience minimal or no unpleasant side effects of therapy or target organ disease 4. Be confident of the ability to manage and cope with the condition

Complications of ACS

1. Dysrhythmias: Ventricular fibrillation and complete heart block. 2. Sudden Cardiac Death OR Acute decompensated heart failure or Cardiogenic Shock

HF Definition

1. Impaired cardiac pumping (Cardiac output) 2. Results in Tissue and cellular hypoperfusion 3. Most common reason for hospital admission in older adults

Other Treatments for HF

1. Ventricular Assist Devices 2. Heart transplant (list of contraindications 34-11) 3. Palliative/Hospice care (usually less than 6 months life expectancy

Percent with HTN

46% off adults in the U.S. have hypertension 48% of people with hypertension are not well controlled

Typical Adult Trajectory

Acute injury with recovery, another acute injury without full recovery, lower baseline -cascade (ex. HTN-- anithypertensives, fall at home, hip fracture, surgery, skin breakdown)

Nursing Diagnosis related to ACS

Acute pain r/t imbalance between oxygen supply/demand, decreased cardiac output r/t altered contractility anxiety related to physiologic threat of death

Chronic stable angina and types

An imbalance in oxygen supply and demand resulting in temporary and reversible ischemia. Types: -Chronic stable -Other anginal events: Silent ischemia, Prinzmetal's angina, and microvascular

HF in General

CO is insufficient to meet the needs of the body (impaired pumping and hypoperfusion) Is progressive with poor prognosis (about half die within 5 years) Impairs functional abilities, cognition, emotional status, and quality of life Most common reason for hospitalization in adults over 65 years old

Collaborative management of CAD

Decrease oxygen demand and/or increase oxygen supply

HF Goals

Decrease symptoms (identify and treat cause), decrease edema (optimize volume status), support oxygenation and ventilation, increase exercise tolerance (maximize cardiac output), adhere to treatments; avoid complications (increase quality of life), identifying precipitating factors, and discharge planning.

Ventricular Compensations for HF

Dilation - High filling pressure and volume over time stretch and eventually overstretch (think about the lack of crossover of muscle fibers leading to excess preload) Hypertrophy - heart muscle increases in size, requires more oxygen, the chamber volume decreases (stroke volume), the ventricle gets stiff and cant stretch/contract, and it's prone to dysrhythmias. Remodeling - The heart becomes more spherical in response to cytokines and inflammation due to the changes in collagen (Fig 34-3)

Other Diagnotics of ACS

Echocardiogram Lipid profile C-reactive protein: muscle breakdown-- elevates Stress test (only detects blockage of 70% or more) Exercise or Pharmacologic stress test and monitor vitals/EKG Other types of angiography which require a dosage of dye (dye load)

Chronic HF Symptoms

Fatigue Cough Dyspnea (Paroxysmal Nocturnal Dyspnea) Orthopnea Tachycardia Edema Nocturia Skin Changes Behavioral Changes Chest Pain Weight Changes

Pharmacological Therapy in combination with lifestyle modifications for people with BP >130/>80 and has known CVD, Diabetes, or chronic kidney disease

Goal to decrease systemic vascular resistance (SVR) and/or reduce blood volume with meds

Adult Physical Milestones

Hearing and vision changes Decrease in strength and flexibility Menopause Aging physical appearance Hair loss, wrinkles Health Cancer, heart disease, stroke risk increases

Health Equity-- HTN

Identifying people at high risk Screening people with limited access Connecting people to a provider

YA Milestones (Physical)

Intimacy vs. isolation Complete physical maturation Attain adult height

Middle/late Adult Milestones

Middle: Generativity vs Self absorption or Stagnation Basic Strengths: Production and Care Late: Integrity vs Despair Basic Strengths: Wisdom

Monitoring for HF

Monitoring: FACES - Fatigue, Activity limitation, Chest congestion/Cough, Edema, and Shortness of Breath. Call the health care provider (reportable symptoms) if: Weight gain > 3 lbs. in 2 days and 3-5 lbs. in one week (from textbook), PND, cough, swelling, nausea, dizziness. Monitor I&O

Decompensated (aka Pulmonary Edema)

Perfusion and Congestion Warm and Dry is Good Wet and Cold is Bad

Neurohormonal Compensation

RAAS: the idea is to increase the preload but chronic activation leads to cardiomyocyte apoptosis, ventricular hypertrophy, and fibrosis. All of which increases workload on the failing heart. SNS is activated by decreased pressure to the baroreceptors. α and β1 receptors are stimulated by epinephrine and norepinephrine which increase the heart rate and force of contraction (a short term solution to a long term problem by increasing oxygen demand of a failing heart) Antidiuretic hormone (vasopressin) is released due to decreased baroreceptor stimulationNeurohormonal

Ice Cream Literacy Test

Read nutrition label for ice cream, answer questions

Management for HTN Crisis

Reduce BP by no more than 25% or in most cases. Then 160/110-100 in hours 2-6, then to normal in 24-48 hours Medications: IV have a rapid onset and require frequent monitoring with non-invasive blood pressure or arterial line (you don't leave your patient and/or usually in the critical care unit). Oral agents are commonly used for hypertensive urgency but do not have a rapid onset.

Assistive devices

Use of Assistive Devices Sensory aids: glasses, hearing aids, large print Adaptive devices: special utensils, elevated toilets Mobility: walkers, wheelchairs Dignity devices: adult briefs, napkins

Orthostatic Hypotension Prevention

i) Avoid sudden postural changes ii) Hot tubs and saunas iii) Prolonged standing

Heart Failure with preserved Ejection Fraction (HFpEF)

relaxing and filling failure: High filling pressure with pulmonary and venous engorgement. Seen commonly with Hypertension, in older adults, women, people with diabetes, and the obese. A stiff and non-compliant ventricle. Used to be called Diastolic failure

Beneficial Counter-regulation Natriuretic peptides (ANP and BNP)

released in response to stretch of the heart which results in increased GFR and excretion of Na+ and water in the urine (inhibits renin) Nitric oxide and prostaglandins - Endothelium releases vasodilators to try to reduce afterload

HF Meds

same as HTN

Silent Killer (HTN)

vague symptoms (fatigue, dizziness, palpitations, angina and dyspnea)

Med Adherence

(1) Report Side Effects (maybe other options to avoid specific side effects (2) Medication Reconciliation with each visit (include over the counter medications) (3) Systems to avoid running out of the medication (plan ahead, automatic refills)

Adolescents

-12-21 -girls hit puberty first -higher level thinking, frontal lobe (impulsivity) -choice of caregiver present -(drunk and distracted) driving -falls (diving accidents) -sexual relationships, drugs and alc, mental health

ACS Diagnosis: EKG

12 lead electrocardiogram Changes? Serial ECG recordings because of rapid changes NSTEMI = ST segment inversion/depression or T wave inversion (ischemia) STEMI = ST segment elevation and pathological Q waves (complete blockage)

Hypertensive Crisis Etiology

Abrupt antihypertensive (antagonist) drug withdrawal. Rebound. Stimulant abuse (cocaine or amphetamines)

YA Milestones (Cog.)

Adult roles and responsibilities Trade, career, higher education Develop new skills, hobbies, and adult interests Fully understand abstract concepts, aware of consequences and limitations Secure autonomy and test decision making skills

Coping for anxiety and emotional reactions

Anger Hostility Anxiety and Fear Denial Dependency Depression Realistic Acceptance