B28 exam 3 - class notes

Cardiac index is specific:

more specific to patient's size

Right atrial pressure is measured on :

end exhalation to ensure that pulmonary changes do not skew the numeric value

Stages of Shock (Sole Table 12-2 p 257)

Stage I: Initiation Stage II: Compensatory Stage III: Progressive Stage IV: Refractory

Aortic Stenosis - causes

Degenerative Rheumatic damage Idiopathic Congenital

Normal central venous pressures range between:

2 and 6 mm Hg

What is normal value RAP/CVP?

2 to 6 mm Hg

When is CVP monitoring indicated?

Measure right heart filling pressure Estimate fluid status Guide volume resuscitation Assess ScvO2 Administer large volume fluid resuscitation or meds that are irritants Access to place transvenous pacemaker

Factors Affecting Preload

Blood / fluid volume Venous return Compliance Medications Venous dilators ↓preload Venous constrictors ↑ preload

HTN pathophysiology - 3 major organ systems affected by high BP

CNS -papilledema -encephalopathy Cardiovascular system -Heart failure -Pulmonary edema -Myocardial ischemia, AMI Renal system -Acute renal failure -Hematuria, proteinuria

CARDIOGENIC SHOCK meds INCREASE contractility

Digoxin Dobutamine Milrinone DO NOT GIVE b-blockade Ca++ channel blockers

Complications of RAP/CVP

Infection Pneumothorax or hemothorax Carotid puncture Heart perforation Dysrhythmias

Coronary arterydisease risk factors - modifiable and non-modifable

Modifiable-smoking, obesity, sedentary, hypertension, hyperlipidemia, diabetes Non modifiable-Age, male, African American, family history

Hemodynamics

measure pressure in the heart and vascular system

Shock is anything:

that causes inadequate tissue perfusion

How is Allen's test is preform?

ulnar and radial arteries are checked

mitral valve prolapse findings

usually asymptomatic atypical CP dizzy palpitations atrial tachycardia common in females

SHOCK Stage I: Initiation

Early Stage Compensatory mechanisms are effective Cellular changes only

Measured values are used to guide:

fluid replacement and assess the status of the right ventricle

What labs are frequently drawn on a patient with CAD?

CRP

what are causes of mitral valve prolapse?

FVO congenital

What port is used to measure CVP?

the distal port is used to measure CVP

Cardiac Tamponade-Diagnosis

FAST-scan Pericardiocentesis 16 or 18G needle, 6in or longer Blood from sac does not clot unless heart has been penetrated Remove as little as 15-20ml improves CO

Abnormal heart sounds - S3-after S2

Fluid overload/poor compliance Occurs after S2 "ken-tuk-e"

Aortic Stenosis - findings

Narrowing pulse pressure Fatigue Angina Syncope Systolic murmur

Afterload-Measured with PVR/SVR

Pressure or resistance against flow Related to lumen size and viscosity -Systemic vascular resistance SVR or SVRI Force overcome by the left ventricle upon contraction -Pulmonary vascular resistance Force overcome by the right ventricle upon contraction Example = opening door against wind

Discuss normal arterial waveform components:

#1 - Upstroke representing systolic pressure #2 - Dicrotic notch representing aortic valve closure #3 - End-diastolic pressure

Annuloplasty

-A prosthetic ring is used to resize the opening -purse string sutures are used to reduce and gather excess tissue - Used for either stenosis or regurgitation

Cardiogenic Shock Signs & Symptoms

-AMS -increased HR -decreased BP -Tachypnea -decreased Cardiac Output -Cardiac Index (based on hight and weight) -Angina -Narrow Pulse Pressure Dysrhythmias -increased Right Atrial Pressure, Pulmonary Artery Pressure, Pulmonary Artery Occlusion Pressure, Systemic Vascular Resistence -Cool pale skin Left Ventricular failure - S3, crackles, dyspnea, hypoxemia Right Ventricular failure - JVD, edema, spleen, liver

Cardiac Output-Measured directly with PA catheter

-Cardiac output is the volume of blood ejected from heart/min -CO = HR × Stroke volume (volume of blood ejected with each beat) 4 to 8 L/min CI 2.5-4.2 L/mi/m2 -Stroke volume is affected by preload, afterload and contractility -Ejection fraction—fraction of blood ejected with each beat Normal 60% to 70%

Effects of Aging on the vascular system

-decrease elasticity & compliance -increase arterial pressure -increase systemic HTN -increase Left Ventricular hypertrophy -decrease HR -Fibrosis of cardiac structures

Sepsis-Within 3 hours

1. Measure lactate level 2. Obtain blood cultures prior to administration of antibiotics 3. Administer broad spectrum antibiotics 4. Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L

Acute coronary syndrome (ACS)

1. Unstable angina 2. Myocardial Infarction -Non ST segment elevation myocardial infarction (NSTEMI) -ST segment elevation myocardial infarction (STEMI)

NSTEMI

30% of M Complete occlusion of minor coronary artery or partial occlusion of major Partial thickness damage of heart muscle ECG-ST segment depression in 2 or more leads or T wave inversion (no Q wave formation)

Sepsis-Within 6 hours

5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg 6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings according to Table 1. 7. Re-measure lactate if initial lactate elevated.

STEMI

70 % of MI Complete occlusion of major coronary artery Full thickness damage of heart muscle ECG-ST segment elevation in 2 leads progresses to Q wave and T wave inversion

Afterload-Measured with PVR/SVR

Pressure or resistance against flow Related to lumen size and viscosity Systemic vascular resistance SVR or SVRI Force overcome by the left ventricle upon contraction Pulmonary vascular resistance Force overcome by the right ventricle upon contraction Example = opening door against wind

Pressure = flow × resistance What can affect pressure?

Pressure—force exerted on the liquid mm Hg Flow: amount of fluid moved over time L/min or mL/min Resistance: opposition to flow

Valvular heart disease - nonsurgical treatment

Provide periods of rest Pace activities Medications Diuretics, ACE inhibitors, vasodilators - reduce preload and afterload Anticoagulant Therapy - prevention of clots and emboli Antibiotics - prophylactic endocarditis prior to dental work and invasive procedures

Myocardial infarction - What is it? Risk factors? Manifestations?

Sustained ischemia leading to irreversible myocardial cell death >20 min) Extension of untreated CAD Risk factors-same as for ACS Manifestations-same as for ACS plus feeling of impeding doom, intractable pain Atypical symptoms in older adults and women

Three types of angina

Stable angina-Trigger precedes pain, follows predictable pattern, relieved by rest and nitrates Prinzmetal's or atypical angina-caused by vasospasm with or without CAD, tx with calcium channel blockers and nitrates Unstable angina-increasing frequency and duration, pain unpredictable, risk for MI (considered Acute Coronary Syndrome)

Manifestations of angina

chest pain Fatigue, dyspnea, diaphoresis, nausea/vomiting, changes in HR, BP, lung sounds Silent ischemia-Up to 80% with myocardial ischemia are asymptomatic (HTN, DM).

What is the best understanding of mixed venous oxygen saturation by the nurse? a. An overall picture of oxygen delivery and oxygen consumption b. The amount of oxygen attached to each hemoglobin molecule c. The amount of oxygen perfusion taking place within the myocardium d. The amount of oxygen the lungs are able to mix with the blood

ANS: a Clinical determination of mixed venous oxygen saturation can be measured hemodynamically and provides a picture of the overall oxygen utilization by organs and tissues. Mixed venous oxygen saturation is the percentage of hemoglobin saturation in the central venous circulation, and it provides an assessment of the amount of oxygen used by the tissues.

When checking a patient's pulmonary artery occlusion pressure, the nurse inflates the balloon as ordered, not inflating the balloon for more than 8 to 10 seconds. The patient asks the rationale behind the nurse's actions. Which statement should the nurse make? a. "Prolonged inflation can obstruct blood flow, resulting in ischemia." b. "Prolonged inflation increases the risk of catheter balloon rupture." c. "Prolonged inflation increases the likelihood of thermistor damage." d. "Prolonged inflation will reduce tension on the pulmonary artery wall."

ANS: a Prolonged inflation of the pulmonary artery catheter balloon will compromise blood flow forward of the balloon, risking pulmonary infarction. Overinflation with a high volume of air in the balloon, rather than prolonged inflation, can lead to balloon rupture. Balloon inflation does not influence thermistor damage. Prolonged inflation will increase tension on the pulmonary artery wall.

The nurse is caring for a patient who is being monitored with a central venous catheter. In preparing to record a right atrial pressure reading, what is most important for the nurse to keep in mind when recording an accurate value? a. Record the pressure at the end of expiration. b. Low pressures indicate ventricular dysfunction. c. High pressures are likely to indicate hypovolemia. d. Zero referencing is not needed before every recording.

ANS: a Right atrial pressures are measured at the end of expiration to ensure that pleural pressure changes do not skew the numerical value. Low pressures are generally indicative of hypovolemia, while high pressures are likely to indicate right ventricular dysfunction. Zero referencing is necessary to ensure accurate measurement and should be performed after any position change.

The nurse is educating a new RN on preparing a patient for assessment of cardiac output using an esophageal monitor. Which statement by the new RN indicates that teaching was effective? a. "The procedure involves a thin probe inserted into the esophagus." b. "Patients require deep sedation provided by an anesthesia provider." c. "The procedure immediately assesses right ventricular performance." d. "There are no absolute contraindications for the procedure."

ANS: a The procedure involves insertion of a thin silicone probe into the distal esophagus. The probe is easily placed similarly to an orogastric or nasograstric tube, so patients require little to no sedation. The procedure provides an immediate assessment of left ventricular performance. There are several contraindications to the procedure, including esophageal stricture and esophagegeal varices (see Box 8-9).

The nurse needs to obtain a cardiac output measurement from a patient who has just had a pulmonary artery catheter inserted. What are important interventions for ensuring accurate pressure and cardiac output measurements? Select all that apply. A. Ensure rapid injection of fluid through the injectate port. B. Zero reference the transducer system at the phlebostatic axis. C. Inflate the pulmonary artery catheter balloon with 5 mL air. D. Use lactated Ringer's solution for the injectate.

ANS: a, b To ensure accurate measurement, zero referencing of the transducer system is a priority action. Rapid injection of the appropriate solution will ensure more accurate readings. Inflating the pulmonary artery catheter balloon with 5 mL of air is likely to result in rupture of the balloon, as this volume of air is too high. Normal saline or 5% dextrose in water solutions are used for obtaining thermodilution cardiac output measurements.

What is the best position for the nurse to place the patient in to obtain a right atrial pressure measurement? a. Left side-lying with the head of the bed elevated 30 degrees b. Prone, lying on the abdomen with slight head elevation c. Right side-lying with the head of the bed elevated 30 degrees d. Supine, either flat or with the head of the bed no more than 60 degrees

ANS: d Accurate assessment of a hemodynamic measure is best accomplished with the patient in a supine position with the head of the bed elevated slightly but no more than 60 degrees. The measurement can be obtained in the lateral position, but it is technically difficult because the patient must be positioned at a 30-degree lateral position for this method to be accurate. Hemodynamic measurements are not assessed in the prone position.

A 45-year-old male is visiting the wellness clinic and has been newly diagnosed as a stage I hypertensive patient. His blood pressure assessment over the past 6 months has consistently been 145/92 mm Hg. The patient asks, "What is blood pressure?" What is the best response by the nurse? a. "A complex measurement that should be discussed only with your physician." b. "A measurement that should be 120/80 mm Hg unless complications are present." c. "A measurement that takes into consideration the amount of blood your heart is pumping and the size of the vessel diameter the heart must pump against." d. "The amount of pressure exerted on the veins by the blood."

ANS: c The contractile force of the heart is the driving pump behind blood flow through the cardiovascular system. The ease of blood flow is a measurement of diameter of the vessel (resistance) and the volume and viscosity of blood through the cardiovascular circuit. It is within the scope of practice of a nurse to educate the patient about blood pressure. Blood pressure values may have a wide range dependent upon the pumping action of the heart, vessel diameter, and blood volume. Variations can be tolerated, but trends that remain high should be evaluated further. Blood pressure measurement is a reflection of pumping action of the heart, vessel diameter, and blood volume.

What is the best action by the nurse to level and zero a hemodynamic monitoring system transducer? a. Level the air-fluid interface of the zeroing transducer at the height of the patient's mattress. b. Position the air-fluid interface of the zeroing transducer at the fifth intercostal space,midclavicular line. c. Position the air-fluid interface of the zeroing transducer at the phlebostatic axis (fourth intercostal space, midaxillary line). d. Level the air-fluid interface of the zeroing transducer at the second intercostal space, anterior-axillary line.

ANS: c To obtain accurate hemodynamic values, the transducer system must be positioned at the level of the atria and pulmonary artery, commonly termed the phlebostatic axis (fourth intercostal space, midaxillary line). The transducer must be leveled at the phlebostatic axis. The transducer must be placed at the level of the fourth intercostal space, midaxillary line.

The nurse is orienting a new RN to the ICU. The nurse begins to review orders recently entered by the cardiologist and to explain their rationale to the new RN. Medication orders include dobutamine (Dobutrex) 400 mg in 250 mL 5% dextrose in water titrated to keep cardiac index >2 L/min/m2. Which statement by the new RN indicates that teaching has been effective? a. "The cardiac index is the amount of blood pumped out by a ventricle per minute." b. "The cardiac index is the amount of blood ejected with each ventricular contraction." c. "The cardiac index is the pressure created by the volume of blood in the left heart." d. "The cardiac index is the measurement specific to the patient's size or body area."

ANS: d Cardiac index is cardiac output individualized to a patient's body surface area or size. Cardiac output is the amount of blood pumped out by a ventricle per minute. The amount of blood ejected with each ventricular contraction is stroke volume. The pressure created by the volume of blood in the left heart is pulmonary artery occlusive pressure.

What is the best action by the nurse to accurately record a thermodilution cardiac output (CO)? a. Place the patient prone, enter the computation constant, and obtain four successive measurements. b. Place the patient prone, elevate the backrest 30 degrees, and obtain three successive measurements. c. Place the patient supine, enter the computation constant, and obtain one value with the head of the bed elevated at 45 degrees. d. Position the patient supine, obtain three values within 10% of each other, and calculate the average cardiac output.

ANS: d Position the patient supine, obtain three values within 10% of each other, and calculate the average cardiac output. The average of three cardiac output measurements, all within 10% of each other, is obtained to accurately assess a cardiac output. To obtain accurate cardiac output measurements, a patient must be in the supine position with a backrest elevation of 0 to 30 degrees. Three successive measurements are taken and the average cardiac output calculated.

HEMODYNAMIC DADA PVR

Amount of resistance RV must overcome to eject blood 20 - 120 dynes/sec/cm PVRI 69-177 dynes/sec/cm/m2

Hemodynamic Data-Sole p 137 SVR

Amount of resistance heart pumps against 700-1500 dynes/sec/cm SVRI 1680-2580 dynes/sec/cm/m2

CARDIOGENIC SHOCK HEART RATE - how to DECREASE

Antidysrhythmic Vagal maneuver Cardioversion Defibrillation

Hemodynamic Monitoring Invasive modalities

Arterial pressure monitoring Pulmonary artery pressure monitoring Right atrial pressure monitoring

Methods of invasive monitoring include:

Arterial pressure monitoring, considered to be the most accurate method of monitoring blood pressure. Provides a continuous analysis of arterial pressure. Pulmonary artery pressure monitoring, accomplished using a flow directed catheter, is used to measure pressures in the pulmonary artery and the left side of the heart. Right atrial pressure monitoring, also known as central venous pressure monitoring or CVP, is used to estimate central venous blood/fluid volume and right heart function. / CVP MONITORING

CARDIOGENIC SHOCK HEART RATE - how to INCREASE

Atropine Epinephrine Pacemaker

Factors Affecting Afterload

Blood / fluid volume Compliance of vessels Arterial vasoconstriction Flow patterns Infection / sepsis Medications

Several factors influence cardiac output by influencing concepts associated with the hemodynamic status of the patient:

Blood Pressure: Factors that influence blood pressure within the cardiovascular system include preload. Increasing preload, or filling pressures of the ventricle, maximizes cardiac muscle fiber stretch, optimizing cardiac output. Increasing fluid volume is one way to increase preload. Venous vasoconstriction is another. Cardiac Output: Sympathetic nervous system activity enhances cardiac performance by shortening conduction time through the AV node, increasing heart rate and stroke volume, leading to enhanced cardiac output. Peripheral Vascular Resistance: Hormonal influences, including the release of norepinephrine, increases heart rate and contractility, causing vasoconstriction, which increases systemic vascular resistance. Factors that increase systemic vascular resistance have the ability to decrease cardiac output.

shock classifications

Cardiogenic-Pump failure of heart failure Distributive-Widespread vasodilatation and capillary permeability (septic, neurogenic) Obstructive-Mechanical blockage in the heart or great vessels (emboli) Hypovolemic-fluid loss

Acute coronary syndrome (ACS)-Manifestations

Chest pain-may radiate to L shoulder, neck or arm Epigastric pain Dyspnea Tachycardia and hypotension Cool, pale skin Atypical in elderly patients and women

Pericardial Effusion

Collection of fluid between pericardial layers Threatens cardiac function Pus, blood, serum, lymph or combo Tolerated better if occurs over time Can cause cardiac tamponade

SHOCK Stage III: Progressive

Compensatory mechanisms begin to fail Profound hypo perfusion Systemic vasodilation Vital organs become hypoxic Classic signs and symptoms of shock manifest Anaerobic metabolism, lactic acidosis Cellular edema/dysfunction

Contractility-Can't really measure but EF helps

Contractility is the strength of myocardial fiber shortening during systole, the force of ventricular contraction that propels blood forward. Optimizing preload influences contractility by ensuring maximal stretch of myocardial fibers. Discuss: What physiological conditions could alter contractility?

Acute Coronary Syndrome - Diagnostics

Electrocardiogram (EKG or ECG) Serial: Q 6 - 8 H, X 3 - 4; baseline, pre / post intervention, symptoms Looking for changes primarily in ST and t waves. Identify area of the heart affected. Ischemia / injury / infarction - changes on EKG? EKG changes correlated to vessel and area of the heart fed-Sole (2013), page 311, Table 12 - 6 Collateral circulation may limit the amount of damage. Echocardiography - surface / transcutaneous, transesophageal (TEE). Nuclear testing Stress testing - physical (treadmill, bike) or chemical (dobutamine, Thallium) Coronary angiography - renal function, hydration, intervention

Preload-Measured with CVP/RAP

Degree of muscle fibers stretch before systole Volume of blood in ventricle prior to contraction Frank-Starling law Increased stretch = increased volume Stretch is within physiological limits Example = balloon CVP (right heart) 2-6 mm Hg PAOP/PCWP/PAWP (left heart) 8-12 mm Hg

Angina - management

Diagnostics-history, ecg, echocardiogram, coronary angiography Medical management-nitroglycerine acutely, prevention-nitroglycerine, beta blockers, calcium channel blockers, aspirin Lifestyle modification

CAD-Management

Diagnostics-serum cholesterol, lipid panel, C-reactive protein levels (inflammation), blood glucose Medical management-Risk factor management and medications to reduce cholesterol, hypertension, etc. Surgical management-not until progresses (ACS and MI)

What is RAP/CVP measuring?

Direct measurement of pressure in right atrium

The Pericardium

Double-layered fibroserous membrane surrounding the heart - Anchors the heart to surrounding structures Space between layers is filled with pericardial fluid - Lubricates heart muscle - Helps to cushion the heart

Acute Coronary Syndrome-Complications (from decreased myocardial perfusion)

Dysrhythmias Pericarditis Papillary muscle dysfunction/valvular dysfunction Myocardial rupture Left ventricular aneurysm Heart failure / Cardiogenic shock

NSTEMI on a EKG

EKG can be normal, or depressed ST, or inverted T-wave

aneurysm classification

Fusiform aneurysm- involve the entire circumference of the vessel Saccular aneurysm- involve only a portion of the vessel, congenital malformations Aortic dissection- weakening of the medial layer of the aorta (dissecting aneurysm)

Aneurysm-Treatment

Goal is to prevent dissection / rupture Medical Aneurysm < 5 cm Risk factor modification Serial ultrasound / MRI / CT to assess size / growth Q 6 months. Endovascular graft Cath lab procedure Criteria: single vessel involvement, "smaller" aneurysm, no bifurcation Surgical Aneurysm > 5 - 6 cm Other structures involved such as renal or iliac artery (ies) Comorbidities: HTN, DM, known vascular disease Rapid expansion: 0.5 cm or more in 6 months, dissect or rupture

Valvular heart disease - Nursing Considerations

Health History: activity intolerance, dyspnea, palpations, respiratory infections, rheumatic heart disease, endocarditis, heart murmur Assess: VS, skin color, clubbing, edema, JVD, lung sounds, heart sounds, murmur; timing, grade and characteristics Cardiac rhythm interpretation Medications Patient Education Post surgical-bleeding, stroke, AKF, dysrhythmias

CardiovascularAssessment

Heart sounds New murmurs Abdominal bruit S/S Heart failure Pulmonary edema

When is an arterial line is Indicated?

Hemodynamic instability Assess efficacy of vasoactive meds Frequent BP monitoring Frequent ABG analysis

Aneurysm medications

IV beta blockers Sodium nitroprusside Calcium channel blockers Direct vasodilators are avoided such as hydralizine Post-operative anticoagulant therapy

Nursing care assessment - Aortic balloon pump What are some potential complications?

Infection Dissection of Aorta Emboli Limb ischemia Kidney damage / failure

Acute Coronary Syndrome - Nursing implications

Interventions-Assessment, inpatient management, pre and post operative care, education, medication management Diagnoses- RC-? Pain Decreased cardiac output Risk for bleeding Ineffective coping Fear

Angina-nursing implications

Interventions-teaching re meds, lifestyle changes, activity tolerance, etc Diagnoses- -RC-? -Activity intolerance -Pain -Decreased cardiac tissue perfusion

Components of Invasive Hemodynamic Monitoring

Invasive catheter Noncompliant pressure tubing Transducer and stopcocks Flush system Bedside monitor

SHOCK Stage IV: Refractory

Irreversible Inadequate tissue perfusion Unresponsive to therapy Severe acidosis SIRS Multiple organ dysfunction Death

NSTEMI - labs

Labs-CK-MB, and troponin elevated but not as much as with STEMI

Mitral Valve Prolapse (MVP)

Leaflets prolapse or bulge into the left atrium during systole May or may not have regurgitation, usually benign

Accuracy in Hemodynamic Monitoring

Level = phlebostatic axis Fourth intercostal space, midaxillary line Approximate level of right atrium Zero reference Negate atmosphere pressure Zeroing stopcock is leveled at phlebostatic axis and "zeroed" Dynamic response testing Square wave test

What are nursing responsibilities for an arterial line?

Level, zero, waveform test Neurovascular check Q 2hr Neutral position Assess waveform/ cuff correlation Hold pressure for 5' when DC NO medications!!! Alarms set at all times Check connections

To validate the accuracy of invasive hemodynamic monitoring values, the following processes need to occur:

Level/Zero referencing: To zero reference or eliminate the effect of atmospheric pressure on the fluid-filled monitoring system, the transducer system must be "zeroed" at the level of the phlebostatic axis. Zero referencing can be accomplished supine or with the HOB elevated up to 45 degrees. Dynamic response testing verifies that the transducer system accurately reflects displayed pressures

What steps are done to get accurate hemodynamic monitoring readings?

Level= phlebostatic axis Zero referencing - zeroing stopcock dynamic response testing - square wave test

Cardiac Tamponade

Life threatening Caused by fluid (usually blood) in the pericardial sack Decreases CO because of decreased venous return Caused by penetrating chest trauma but can be after blunt trauma or after heart surgery

Acute coronary syndrome - Management

Lifestyle changes Pharmacologic intervention Hemodynamic support Cardiac cath Myocardial revascularization Transmyocardial revascularization Rehabillitation/support

Causes of Cardiogenic Shock

MI Myocardial contusion Cardiomyopathy Myocarditis Severe HF Dysrhythmias Valvular disease Structural disorders Ventricular septal rupture

Aneurysm nursing interventions

Medical tx-patient education/compliance and follow up and monitor for extension of aneurysm Surgical tx Monitoring prior to surgery-BP, pain, organ function Patient education Post op care-site, BP, organ perfusion

CARDIOGENIC SHOCK Preload Manipulation decrease

Morphine- it vasodilates NTG Diuretics ACE - I ARB DO NOT GIVE: -crystalloids -colloids -blood -blood products

Angina patho:

Myocardial ischemia Patho-not enough flow to meet demand so heart muscle goes into anaerobic metabolism w lactic acid build up

Ongoing treatment drugs for ACS

Nitrates Beta blockers Calcium channel blockers Platelet aggregation inhibitors Anticoagulation Pain management. Cardiac catheterization - examine vessels, guide treatment

Hemodynamic Monitoring Noninvasive modalities

Noninvasive blood pressure Assessment of jugular venous pressure-Sole p 138 Assessment of serum lactate levels

Aneurysm

Outpouching or widening of arterial wall Underlying cause - atherosclerosis and degradation of connective tissue Common to have clots in / around the aneurysm

Acute Coronary Syndrome-Surgical intervention

Percutaneous Coronary Intervention (PCI), Percutaneous Transluminal Coronary Angioplasty (PTCA), Intracoronary stent Coronary Artery Bypass Graft Intra aortic balloon pump (temporary) Ventricular assist devices (temporary) Pacemaker Internal defibrillator

Cardiac Tamponade-Manifestations

Pulsus paradoxus-decrease in systolic BP during inspiration Decreased R atrial pressure JVD Most common-hypotension, muffled heart sounds, and elevated venous pressure (Beck's triad)

Aneurysm nursing diagnoses

RC-Decreased CO, shock Risk for ineffective tissue perfusion Risk for injury Anxiety

What are common insertion sites for arterial pressure monitoring?

Radial artery Brachial artery Femoral artery

Arterial Pressure Monitoring sites

Radial artery Allen's test prior to insertion to verify collateral circulation in the extremity Issues related to predictability of Allen's test Brachial artery Femoral artery

Valvular heart disease - Surgical Interventions

Reconstruction or repair of a heart valve Can be used for: - stenosis or regurgitation of mitral & tricuspid valve - mitral valve prolapse - aortic stenosis Valve Replacement -Indicated when manifestations of valve dysfunction develop -Mechanical vs. Biological Transcatheter Aortic Valve Replacement for the treatment of Aortic Stenosis (TAVR) for patients who can't tolerate surgical replacement

Unstable angina treatment

Requires immediate treatment MONA Morphine - dilates coronary arteries as well Oxygen Nitroglycerin-not to inferior wall/r vent or phosphodiesterases in 24 hours Aspirin

RAP/CVP Monitoring

Right atrial pressure (RAP)—catheter in right atrium Proximal port of pulmonary artery catheter Central venous pressure (CVP)—catheter in superior or inferior vena cava Triple lumen Values similar and terms interchanged

Acute coronary syndrome (ACS)-risk factors

Risk factors-same as CAD Patho-occlusion of coronary artery w plaque rupture and clot formation

Myocardial infarction (MI) two types

STEMI and NSTEMI

Acute Coronary Syndrome-Labs

Serum cardiac enzymes -Creatine kinase (CK or CPK), CK MB-Increases in 2 - 6 hours, usually peak within 24 hours -Troponin-Increases in 1 - 6 hours, remains elevated 5 - 14 days -Lactic dehydrogenase (LDH)-Increases in 6 - 12 hours, peak 48 - 72 hours Cholesterol / lipid profile Non - specific to cardiac C - reactive protein (CRP) - with inflammatory process Homocysteine - amino acid used as indicator of CAD Myoglobin

SHOCK Stage II: Compensatory

Symptoms become apparent Measures to increase CO to restore tissue perfusion and oxygenation -Neural-baroreceptors cause vasoconstriction/increased HR -Endocrine-RAAS -Chemical-chemoreceptors increase RR and depth -Sympathetic nervous system-catecholamines -Glycogenolysis and gluconeogenesis -Bronchodilation

Systemic Vascular Resistance

Systemic vascular resistance (SVR)-770-1500 dynes/sec/cm-5 Peripheral vascular resistance Diameter of blood vessels Can use body surface area to determine Systemic Vascular Resistance Index (SVRI)-more accurate measurement 1680-2580 dynes/sec/cm-5/m2 Arterial BP = CO × SVR

Aneurysm-Manifestations

THORACIC -Most common symptom is deep, diffuse chest pain -occurs Ascending and arch Symptoms: hoarseness, dysphagia. -Descending Symptoms: chest and / or back pain. ABDOMINAL -Most often found between renal arteries and bifurcation. -Symptoms-Abdominal / back pain, pulsatile abdominal mass, neurovascular changes to lower extremities.- leg feeling cold

CAD-Nursing Implications

Teaching, Teaching, Teaching-meds, smoking cessation, diet, exercise, stress reduction, control of diabetes, cholesterol and hypertension, when to seek treatment Nursing Diagnoses -RC-? -Knowledge deficit -Ineffective management of -therapeutic regimen -Non compliance

Aortic Dissection

Tear in the intimal lining of the aorta, causes blood flow diversion Pain is sudden, sharp, and shifting; distal ischemic symptoms Can lead to rupture - Grey Turner's sign (bruising of flanks-retroperitoneal) Surgical emergency

CARDIOGENIC SHOCK Afterload Manipulation

decrease Systemic Vascular Resistence NTP NTG Hydralazine ACE-I ARB IntraAortic Ballon Pump - (this is temporary) placed before surgery and taken out after patient is stable DONT GIVE phenylephrine norepinephrine epinephrine vasopressin

What are complications of an a-line?

Thrombosis Embolism Blood loss infection

NSTEMI treatment

Tx-NO THROMBOLYTICS Low risk-drug therapy Mod to high risk-PCI or CABG

STEMI - Treatment

Tx-percutaneous coronary intervention (PCI) (same as PCR and PTCA) in 90 min, thrombolytics (streptokinase, tenecteplase, alteplase)-see contraindications

When is pulmonary artery pressure monitoring needed?

When we want to see left ventricular function

Nursing Implications RAP/CVP

Zero/balance Waveform analysis Respiratory variation and PEEP Patient position Head of bed between 0 and 60 degrees Correlate values with assessment Monitor for complications

Which part of the hemodynamic monitoring system to we use to level the system?

Zeroing stopcock

CAD manifestations

asymptomatic, ischemia when 70% occluded

inflammation of coronary artery walls leads to:

atherosclerosis which occludes vessel

Equipment necessary for monitoring arterial blood pressure invasively includes

pressurized flush system with transducer and arterial catheter.

Monitoring methods include both invasive and noninvasive methods. Of the noninvasive methods,

routine blood pressure monitoring is common. Need right-sized equipment for accuracy. Measuring jugular venous distention (see Figure 8-8) provides an estimate of intravascular volume. Jugular venous distention occurs when central venous pressure is elevated. Serum lactate levels can provide information regarding end-organ perfusion.

Mitral Stenosis - causes

#1 Rheumatic heart disease Calcium accumulation Thrombus

Mitral Regurgitation - cause

#1 Rheumatic heart disease Infective endocarditis Congenital

Aortic Regurgitation - causes

#1 Rheumatic heart disease Infective endocarditis Marfans HTN

The patient has a rhythm but no pulse or blood pressure. The nurse interprets the possible causes of this condition to include: (select all that apply) a. cardiac tamponade b. drug overdose c. hypernatremia d. hypovolemia e. tension pneumothorax

ANS: a, b, d, e This is a definition of pulseless electrical activity, or PEA. Causes of PEA include hypovolemia, hypoxia, cardiac tamponade, tension pneumothorax, drug overdose, pulmonary embolism, acidosis, massive myocardial infarction, hyperkalemia or hypokalemia, hypoglycemia, trauma, and hypothermia.

Valvular heart disease - What is it?

Any disease process that involves one or more of the heart valves Interferes with the blood flow to and from the heart Caused by acute condition or congenital Rheumatic heart disease is the MOST common cause of valvular disease Aortic stenosis is most common, then mitral regurgitation, aortic regurgitation and mitral stenosis

A 67-year-old female is admitted to the emergency department complaining of midback pain and shortness of breath for the preceding 2 hours. She also complains of nausea and states that she vomited twice before coming to the hospital. She denies any chest discomfort or arm pain. The nurse prepares to the treat the patient for a diagnosis of: a. flu symptoms b. anxiety attack c. myocardial infarction d. osteoporosis

ANS: C Women are more likely to have atypical signs and symptoms of acute myocardial infarction (AMI), such as shortness of breath, nausea and vomiting, and back or jaw pain.

A nurse is admitting a client who has a suspected myocardial infarction (MI) and a history of angina. Which of the following findings will help the nurse distinguish angina from an MI? a. Angina can be relieved with rest and nitroglycerin b. The pain of an MI resolves in less than 15 min c. The type of activity that causes an MI can be identified d. Angina can occur for longer than 30 min

ANS: a Angina can be relieved by rest and nitroglycerin. Pain associated with an MI usually lasts longer than 30 min and requires opioid analgesics for relief. There is no specific type of activity that causes an MI. It can occur following rest. The pain of angina usually occurs for 15 min or less.

The nurse is caring for a patient with a diagnosis of acute myocardial infarction (AMI). Which medication should the nurse anticipate administering to the patient to reduce platelet aggregation? a. aspirin b. lidocaine c. nitroglycerin d. oxygen

ANS: a Aspirin blocks synthesis of thromboxane A2, thus inhibiting aggregation of platelets.

A nurse is caring for a client who asks why her provider prescribed a daily aspirin. Which of the following is an appropriate response by the nurse? a. aspirin reduces the formation of blood clots that could cause a heart attack b. aspirin relieves the pain due to myocardial ischemia c. aspirin dissolves clots that are forming in your coronary arteries d. aspirin relieves headaches that are caused by other medications

ANS: a Aspirin decreases platelet aggregation that can cause a myocardial infarction. One aspirin per day is not sufficient to alleviate ischemic pain. Aspirin does not dissolve clots. Other medications can cause headaches, but one aspirin per day is not administered as an analgesic.

The nurse is caring for a patient admitted with severe sepsis. The physician orders include the administration of large volumes of isotonic saline solution as part of early goal-directed therapy. Which of the following best represents a therapeutic end point for goal-directed fluid therapy? a. central venous pressure >8 mm Hg b. heart rate >60 beats/min c. mean arterial pressure >50mm Hg d. serum lactate level >6mEq/L

ANS: a Early goal-directed therapy includes administration of IV fluids to keep the central venous pressure at 8 mm Hg or greater. Additional therapeutic end points include a heart rate at less than 110 beats/min and a mean arterial blood pressure at 65 mm Hg or greater. Serum lactate levels are elevated in sepsis; target levels should be <2.2 mEq/L.

The nurse educator is presenting a lecture on crystalloid fluid replacement therapy in shock states. Which statement by a nurse indicates that the teaching has been effective? a. Lactated Ringer's should not be infused if lactic acidosis is severe. b. 3 mL of crystalloid is administered to replace 10 mL of blood loss c. Administration of colloids is preferred over crystalloids d. Solutions of 0.45% normal saline are used routinely in shock

ANS: a LR solutions contain lactate, which the liver converts to bicarbonate. If liver function is normal, this will counteract lactic acidosis. However, LR should not be infused if lactic acidosis is severe. To replace every 1 mL of blood loss, 3 mL of crystalloid is administered. There is no evidence to support colloid administration being more beneficial than crystalloid administration in shock states. Hypotonic solutions such as 0.45% normal saline are not administered in shock states as these solutions rapidly leave the intravascular space, causing interstitial and intracellular edema.

Abnormal heart sounds - s4 before S1

Atria contract forcefully against ventricles full of blood Occurs before S1 "ten-ne-see"

A restrained patient's status after a motor vehicle crash includes dyspnea, dysphagia, hoarseness, and complaints of severe chest pain. Upon assessment you note that the patient has weak femoral pulses. Which of the following complications and related diagnostic test should be considered? a. Aortic dissection and aortogram b. Cardiac tamponade and pericardiocentesis c. Liver laceration and focused assessment with sonography for trauma (FAST) d. Pulmonary contusion and chest x-ray

ANS: a Signs of aortic disruption include weak femoral pulses, dysphagia, dyspnea, hoarseness, and severe pain. A chest x-ray study may demonstrate a widened mediastinum, tracheal deviation to the right, depressed left mainstem bronchus, first and second rib fractures, and left hemothorax. The diagnosis is confirmed by an aortogram. Cardiac tamponade presents with pulsus paradoxus and decreased cardiac output with poor venous return; a pericardiocentesis is the treatment of choice. Depending on the severity of the liver laceration, the pateint will present with right upper quadrant abdominal pain and tenderness and hypotension. FAST is used to diagnosis hepatic injury and intraabdominal bleeding. Pulmonary contusion will present primarily with signs and symptoms of poor oxygenation, and a chest x-ray may not be helpful in diagnosing this condition.

The patient presents to the emergency department with severe substernal chest discomfort. Cardiac enzymes are elevated, and his ECG shows ST-segment depression in V2 and V3. The nurse anticipates a diagnosis of: a. non-Q-wave myocardial infarction (MI). b. pulmonary embolism. c. Q-wave myocardial infarction (MI). d. right ventricular infarction.

ANS: a The non-Q-wave MI usually results from a partially occluded coronary vessel, and it is associated with ST-segment depression in two or more leads, along with elevated cardiac enzymes.

Your patient was a passenger in a motor vehicle crash yesterday and suffered an open fracture of the femur. His condition was stable until an hour ago, when he began to complain of shortness of breath. His heart rate is 104 beats/min, respiratory rate is 30 breaths/min, BP is 90/60 mm Hg, and temperature is now 38.4°C. You suspect that he: a. has a fat embolism. b. has developed metabolic acidosis. c. is developing systemic inflammatory response syndrome (SIRS). d. is experiencing early multiple organ dysfunction syndrome (MODS).

ANS: a These are classic signs and symptoms of a fat embolism. The history of a long-bone fracture adds to the evidence of a fat embolism. The patient may develop metabolic acidosis associated with poor oxygenation from the fat emboli. SIRS possibly progressing to MODS would also be a consequence of the fat emboli.

An adult patient suffered an anterior wall myocardial infarction (MI) 4 days ago. Today the patient is experiencing dyspnea and sitting straight up in bed. The nurse's assessment includes bibasilar crackles, an S3 heart sound with a heart rate of 125 beats/min. The nurse anticipates a diagnosis of: a. heart failure b. papillary muscle rupture c. pericarditis dterm-64. pulmonary embolism

ANS: a These are classic signs of fluid overload and heart failure. Presence of a heart murmur, not the S3, might alert the nurse to a papillary muscle rupture. The patient with pericarditis may have chest pain and a pericardial friction rub. The patient with a pulmonary embolism has symptoms including difficulty in breathing, cyanosis, chest pain and possibly death.

A trauma patient with a fractured forearm complains of extreme, throbbing pain at the fracture site and paresthesia in the fingers. Upon further assessment, you note that the forearm is extremely edematous, and you are now having difficulty palpating a radial pulse. You notify the physician immediately because you suspect: a. compartment syndrome. b. fat emboli. c. Hypothermia. d. rhabdomyolysis.

ANS: a These signs and symptoms are characteristic of late signs of compartment syndrome. Fat emboli are associated with long-bone fractures and typically manifest pulmonary symptoms. These signs and symptoms are characteristic of compartment syndrome, not hypothermia. Rhabdomyolysis is associated with a crush injury and compartment syndrome. A clinical sign that may be noted by the nurse is dark tea-colored urine.

When obtaining report on a trauma pateint, which question would be helpful in determining potential injuries associated with the mechanism of injury? Select all that apply. a. Was the patient wearing a seat belt? b. Where was the patient in the car? c. Where are the family members? d. Was fluid resuscitation initiated?

ANS: a, b When obtaining report on a trauma patient, several questions should be asked to help determine potential complications associated with the mechanism of injury. It is especially important to ask where the patient was sitting in the car and whether he or she was wearing a seat belt. Asking the distance of a fall assists with understanding of complications from blunt forces. Information concerning the initiation of fluid resuscitation is helpful in determining tissue perfusion needs but may not provide insight into possible complications associated from the mechanism of injury. Information about the family is important for communication but does not assess etiology of injury.

The patient presents to the emergency department after having crushing chest pain for the past 5 hours. The ECG and laboratory work confirm suspicions of an acute myocardial infarction (AMI). Which findings would be the most conclusive that the patient is having an AMI? (select all that apply) a. ECG changes with ST-elevation b. elevated CK-MB isoenzymes c. elevated serum troponin levels d. elevated urinary myoglobin level

ANS: a, b, c ST-segment elevation and elevated cardiac enzymes are seen in Q-wave MI. Serum Troponin may assist in diagnosis of AMI.

A nurse educator is reviewing the use of cardiopulmonary bypass during surgery for coronary artery bypass grafting with a group of nurses. Which of the following statements should the nurse include in the discussion? select all that apply a. the client's demand for oxygen is lowered b. motion of the heart ceases c. rewarming of the client takes place d. the client's metabolic rate is increased e. blood flow to the heart is stopped

ANS: a, b, c The use of cardiopulmonary bypass reduces the client's demand for oxygen, which reduces the risk of inadequate oxygenation of vital organs. Motion of the heart ceases to allow for placement of the graft near the affected coronary artery. The core body temperature is lowered for the procedure, and rewarming then occurs through heat exchanges on the cardiopulmonary bypass machine. Metabolic rate is decreased and blood flow to the heart is maintained.

The nurse is orienting a new RN to airway management and intubation in the critical care unit. Which statement by the new RN indicates that teaching has been effective? (select all that apply) a. this is done to protect the patient from aspiration b. this is done to protect the patient from gastric distension c. this is done to provide a means for keeping the airway patent d. this is done to provide a route for medication

ANS: a, b, c, d all answers are correct

Which interventions are appropriate to consider in the management of the geriatric trauma patient? Select all that apply. a. Ask the patient if he or she has fallen recently. b. Obtain a detailed medical history. c. Administer intravenous fluids rapidly to maintain blood pressure. d. Frequently assess for signs of acute delirium. e. Observe for signs of infection, primarily elevated temperature. f. Obtain a detailed list of current medications.

ANS: a, b, d, f Geriatric trauma patients provide unique challenges related to changes in phsyiology associated with aging. Obtaining a fall history is important because falls are the primary mechanism of traumatic injury in the older adult. Obtaining a complete past and current medical history, including a list of current medications, is essential. Older patients are at a higher risk of fluid overload becauses of age-related changes in the cardiovascular system. Fluid resuscitation should be monitored closely to avoid complications of overresuscitation. Monitor the patient for acute delirium, as delirum increases morbidity and mortality of the older trauma patient. The immune system is less responsive with aging, thus placing this patient at higher risk of infection and less pronounced changes in body temperature when infection is present. Brain mass decreases with aging; thus, changes in neurological exam may progress gradually.

A nurse educator is reviewing expected findings in a client who has right-sided valvular heart disease with a group of nurses. Which of the following findings should the include in the discussion? select all that apply a. dyspnea b. client report of fatigue c. bradycardia d. pleural friction rub e. peripheral edema

ANS: a, b, e Dyspnea, fatigue, and peripheral edema is a manifestation of right-sided valvular heart disease. A normal or rapid pulse and an irregularly irregular rhythm are manifestations of right-sided valvular heart disease. A pleural friction rub is a manifestation of pleurisy or pneumonia

To maintain the patient's airway, which interventions are appropriate to implement with a trauma patient who sustained a spinal cord injury? Select all that apply. a. Avoid hyperextension of the neck. b. Observe respiratory pattern. c. Insert an oral airway if patient is alert. d. Elevate the head of bed 30 degrees. e. Observe depth of ventilation. f. Maintain complete spinal immobilization.

ANS: a, b, e, f Maintaining a patent airway is an essential intervention in the care of the trauma patient. When the patient has a spinal cord injury, additional precautions are needed, including the following: (1) avoid hyperextension or rotation of the neck; (2) maintain spinal immobilization; (3) observe ventilatory effort, rate, depth, and effectiveness of breathing; (4) monitor motor and sensory function; and (5) anticipate the need for intubation and mechanical ventilation. Oral airways should not be inserted in an awake patient, as it will cause an airway obstruction. The patient's head of bed should remain flat, and spinal precautions should be taken.

The nurse is assessing a patient for suspected alcohol withdrawal and identifies which signs and symptoms as suspicious? Select all that apply. a. Irritable, confused, hallucinations b. Nausea, vomiting, diarrhea c. Hypotension and tachycardia d. Low body temperature f. Seizures g. Somnolent, difficult to arouse

ANS: a, b, f Signs and symptoms of alcohol withdrawal include irritability, agitation, confusion, hallucinations and delusions, insomnia, anxiety and tremors, nausea, vomiting, diarrhea, diaphoresis, tachycardia and hypertension, fever, and seizures.

A nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. The nurse should recognize which of the following data as risk factors for this condition? a. surgical repair of an atrial septal defect at age 2 b. measles infection during childhood c. hypertension for 5 years d. weight gain of 10 lb in past year e. diastolic murmur present

ANS: a, c, e A history of congenital malformations is a risk factor for valvular heart disease, hypertension places a client at risk. A murmur indicates turbulent blood flow, which is often due to valvular heart disease. Having a streptococcal infection or rheumatic fever during childhood is a risk factor. A sudden weight gain of 10lb could indicate fluid collection related to left-sided valvular heart disease

After receiving handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis. Vital sign assessment notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2)96% on 45% oxygen via Venturi mask, temperature 101.5° F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the last hour. Given this report, the nurse obtains orders for treatment that include which of the following? (select all that apply) a. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is <5 mm Hg. b. Increase supplemental oxygen therapy to 60% Venturi mask. c. Administer 40 mg furosemide (Lasix) intravenously as needed if the urine output is less than 30 mL/hr. d. Administer acetaminophen (Tylenol) 650 mg suppository per rectum as needed to treat temperature >101° F.

ANS: a, d Fluid volume resuscitation is a priority in patients with severe sepsis to maintain circulating blood volume and end organ perfusion and oxygenation. A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient's CVP of 2 mm Hg and hourly urine output of 10 mL/hr. There is no evidence to support the need to increase supplemental oxygen. Administration of furosemide (Lasix) in the presence of a fluid volume deficit is contraindicated. The fever may need to be treated.

The primary indication for the use of adenosine is: a. sustained atrial flutter b. sustained narrow-complex supraventricular tachycardia (SVT) c. sustained ventricular tachycardia (VT) d. symptomatic atrial fibrillation

ANS: b Adenosine is the initial drug of choice for the diagnosis and treatment of supraventricular dysrhythmias. Adenosine does not convert supraventricular rhythms that do not involve the sinoatrial or atrioventricular (AV) node, such as atrial fibrillation, atrial flutter, atrial tachycardia, or VT.

The patient is in ventricular tachycardia (VT) and is unresponsive to conventional treatment (epinephrine or vasopressin). Which drug is the most appropriate to use next? a. adenosine b. amiodarone c. atropine d. dopamine

ANS: b Amiodarone is a unique antidysrhythmic medication, possessing some characteristics of all groups of antidysrhythmic drugs. It reduces membrane excitability, and by prolonging the action potential and retarding the refractory period, it facilitates the termination of VT and ventricular fibrillation (VF). Adenosine is the initial drug of choice for the diagnosis and treatment of supraventricular dysrhythmias. Atropine is used to increase the heart rate by decreasing the vagal tone. The indication for dopamine is symptomatic hypotension in the absence of hypovolemia.

A nurse is completing discharge teaching with a client who had a surgical placement of a mechanical heart valve. Which of the following statements by the client indicates understanding of the teaching? a. I will be glad to get back to my exercise routine right away b. I will have my prothrombin time checked on a regular basis c. I will talk to my dentist about no longer needing antibiotics before dental exams d. I will continue to limit my intake of foods containing potassium

ANS: b Anticoagulant therapy with warfarin (coumadin) is necessary for the client following placement of a mechanical heart valve; the client's prothrombin time will be checked on a regular basis. Following surgery for heart valve replacement, The client will be on activity limitation for 6 weeks; antibiotic therapy is recommended prior to dental work; and dietary recommendations include limiting foods containing sodium

The nurse is caring for a patient in shock. Which is a priority action by the nurse? a. ensure adequate cellular hydration b. maintain adequate tissue perfusion c. prevent third-spacing of fluids d. support mechanical ventilation

ANS: b Care of a patient in shock is directed toward correcting or reversing the altered circulatory component and reversing tissue hypoxia. Restoring circulating intravascular volume is the priority in improving tissue perfusion and oxygen delivery.

The patient is unconscious with a pulse but is not breathing. The nurse calls for help and tries to ventilate the patient but cannot. The next step would be to: a. administer lidocaine b. reposition the head c. turn the patient to his side d. wait for the anesthesiologist e. call for an emergency cricothyrotomy kit

ANS: b If the nurse has trouble ventilating the patient, the patient's head should be repositioned because an improperly opened airway is the most common cause of inability to ventilate. Lidocaine is an antidysrhythmic drug that suppresses ventricular ectopic activity. The airway must be opened first. During a code, the patient is positioned on his or her back, and the airway is opened. The cricothyrotomy kit is not considered until attempts to open the airway with conventional means fail. An open airway is essential. The nurse cannot wait.

Which hemodynamic values should the nurse anticipate in a patient who is in the initial stages of septic shock state? a. low heart rate; high blood pressure b. high heart rate; low right atrial pressure c. high PAOP; low cardiac output d. high SVR; normal blood pressure

ANS: b In septic shock, inflammatory mediators damage the endothelial cells that line blood vessels, producing profound vasodilation and increased capillary permeability. Initially this results in a high heart rate, hypotension, and low SVR, and subsequently in low right atrial pressure.

The nurse explains to the new RN that angiotensin-converting enzyme inhibitors (ACE inhibitors) should be started within 24 hours of acute myocardial infarction (AMI). Which statement by the new RN indicates that teaching has been effective? a. ACE inhibitors are started within 24 hours to prevent hibernating myocardium." b. ACE inhibitors are started within 24 hours to prevent myocardial remodeling." c. "ACE inhibitors are started within 24 hours to prevent myocardial stunning." term-31d. "ACE inhibitors are started within 24 hours to prevent tachycardia."

ANS: b Myocardial remodeling is a process mediated by angiotensin II, aldosterone, catecholamine, adenosine, and inflammatory cytokines; it causes myocyte hypertrophy and loss of contractile function in the areas of the heart distant from the site of infarctions. ACE inhibitors should be ordered.

A nurse is caring for a 72yr old client who is to undergo a percutaneous balloon valvuloplasty. The client's daughter asks the nurse to explain the expected outcome of this procedure. Which of the following responses should the nurse give? a. This will improve blood flow in your mother's coronary arteries b. This will permit your mother to resume her activities of daily living c. This will prolong your mother's life d. This will reverse the effects to the damaged area

ANS: b Surgery is indicated for older adult clients when manifestations interfere with activities of daily living. A valvuloplasty improves blood flow through a heart valve by opening the fused commissures and allowing valve leaflets greater mobility. It does not improve blood flow in the coronary arteries. Surgical interventions can improve the client's quality of life, but they will not necessarily prolong life. It does not reverse the damage that has already occurred to the valve

A nurse is caring for a client who is 4hrs postoperative following coronary artery bypass grafting (CABG) surgery. He is able to inspire 200 ml with the incentive spirometer, then refuses to cough because he is tired and it hurts too much. Which of the following actions should the nurse take? a. allow the client to rest, and return in 1 hr b. administer IV bolus analgesic, and return in 15 min c. document the 200ml as an appropriate inspired volume d. tell the client that he must try to cough of he does not want to get penumonia

ANS: b providing adequate analgesia and returning in 15 min will reduce pain and improve coughing effectiveness turning, coughing, and deep breathing should be performed every 2hrs to promote oxygenation and circulation 200ml is not an adequate inspired air volume to promote effective oxygenation d - this intervention is non-therapeutic communication

A cardiac arrest alert is called by a nursing unit. The nursing supervisor responds as part of the code team. What action does the nurse anticipate that the nursing supervisor will take? a. Assist with manual ventilation b. Manage crowd control c. Direct the code d. Obtain blood gases

ANS: b One job of the supervisor is to limit the number of people in the code to only those necessary and those there for learning purposes. This approach decreases crowding and confusion. The respiratory therapist usually assists with ventilation of the patient before and after intubation. The person who directs the code is usually a physician experienced in code management, such as an intensivist or emergency department physician. The respiratory therapist usually obtains blood samples for arterial blood gas analysis.

A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following findings pose an immediate concern? select all that apply a. Trace of bloody drainage on dressing b. Capillary refill of affected limb of 6 seconds c. Mottled appearance of the limb d. Throbbing pain of affected limb that is decreased following IV bolus analgesic e. Pulse of 2+ in the affected limb

ANS: b, c Capillary refill greater that 2 - 4 seconds is outside the expected reference range and should be reported to the provider. Mottled appearance of the affected extremity is an unexpected finding and should be reported to the provider. A trace of bloody drainage on the dressing is an expected finding and does not require immediate concern. Pain that is decreased following IV bolus analgesia is an expected finding. Pulse of 2+ in the affected extremity is an expected finding.

A 55-year-old trauma patient hit the steering wheel and has a cardiac contusion. Which are potential complications of the injury? Select all that apply. a. Flail chest b. Dysrhythmias c. Hypotension d. Myocardial ischemia

ANS: b, c, d A flail chest is commonly associated with rib fractures, which are not present in this patient. Cardiac contusions present with signs and symptoms of ineffective heart functioning, including dysrhythmias, decreased cardiac output (i.e., hypotension), and myocardial ischemia that may progress to infarction.

Which statements related to the management of unstable angina are true? a. Aspirin is given at the onset of each chest pain episode. b. calcium channel blockers help to reduce symptoms c. Early revascularization (e.g., angioplasty) may be helpful. d. It is best treated with rest and nitroglycerin.

ANS: b, c, d Unstable angina can be treated by conservative management or early intervention with percutaneous intervention or surgical revascularization. Conservative intervention for the patient experiencing angina includes the administration of nitrates, beta-adrenergic blocking agents, and/or calcium channel blocking agents. Angioplasty, stenting, and bypass surgery are approaches to revascularization. Rest and nitroglycerin are treatments for stable angina. Aspirin is not a typical treatment for unstable angina.

Prevention of hypothermia is crucial in caring for trauma patients. Which treatments are appropriate for preventing hypothermia? Select all that apply. a. Administer cool humidified oxygen. b. Cover the patient with an external warming device. c. Leave the patient's clothing on, even if wet. d. Warm fluids and blood products before or during administration. e. Warm the room in the emergency department and critical care unit.

ANS: b, d, e Oxygen should be warm and humidified to prevent hypothermia. External warming devices are effective in preventing or treating hypothermia. All of the patient's clothes should be removed so that the body can be inspected. Wet clothing increases the risk of hypothermia. After clothing is removed, the patient is warmed. Warming fluids and blood products reduces the risk of hypothermia. Warming the temperature in the rooms where care is provided is a strategy for preventing hypothermia.

A nurse is presenting a community education program on recommended lifestyle changes to prevent angina and myocardial infarction. Which of the following changes should the nurse recommend be made first? a. diet modification b. relaxation exercises c. smoking cessation d. taking omega-3 capsules

ANS: c According to the airway, breathing, and circulation (ABC) priority-setting framework, the first change the nurse should recommend the clients take is to stop smoking. Nicotine causes vasoconstriction, elevates blood pressure, and narrows coronary arteries. The nurse should recommend changing the diet to decrease consumption of sodium and saturated fat; The nurse should recommend using relaxation exercise to cope with stress. The nurse should recommend taking omega-3 capsules to increase consumption of good cholesterol; however, there is another change the clients should plan to make first.

A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client's lower back. Which of the following findings should the nurse suspect? a. Retroperitoneal bleeding b. Cardiac tamponade c. Bleeding from the incisional site d. Heart failure

ANS: c Bleeding is occurring from the incision site and then draining under the client. The nurse should assess the incision for hematoma, apply pressure, monitor the client, and notify the provider. Retroperitoneal bleeding is internal bleeding. Cardiac tamponade includes manifestations of bleeding in the pericardial sac, which is internal. Heart failure does not include findings of blood underneath the client's lower back.

The patient, who is being treated for hypercholesterolemia, complains of hot flashes and a metallic taste in the mouth. The nurse educates the patient that this is a side effect of: a. bile acid resins b. clopidogrel c. nicotinic acid d. statins

ANS: c Common side effects of nicotinic acid include metallic taste in mouth, flushing, and increased feelings of warmth.

Poor patient outcomes after a traumatic injury are associated with: a. chest tube placement for treatment of a hemothorax. b immediate decompression of a tension pneumothorax. c. massive transfusions of blood products. d. intraosseous cannulation for intravenous fluid administration.

ANS: c Current evidence suggests that patients receiving massive blood transfusions have poorer outcomes. Although a chest tube may be necessary in the treatment of trauma patients, it is not associated with poor patient outcomes. Immediate decompression of a tension pneumothorax is also not associated with poor patient outcomes. Intraosseous cannulation for intravenous fluid administration has not been shown to have adverse patient outcomes.

Which of the following statements about the management of dysrhythmias is true? a. cardioversion is used to treat pulseless VT b. CPR is not needed if drugs are administered to stimulate the cardiac rhythm c. if intravenous (IV) access is unavailable, some medications can be given through the endotracheal tube (ETT) d. patients with a permanent pacemaker cannot be defibrillated

ANS: c Medications that can be administered through the ETT until an IV access is established are epinephrine, lidocaine, vasopressin, and atropine. However, intraosseous administration is preferred over the endotracheal route. During an emergency, cardioversion is used to treat patients with VT or supraventricular tachycardia (SVT) who have a pulse but are developing symptoms related to a low cardiac output, such as hypotension and decreased level of consciousness. CPR is essential to ensure adequate circulation and to provide circulation for medications that are administered. Patients with a permanent pacemaker or implantable cardioverter-defibrillator (ICD) can be defibrillated if needed. Placing the paddle or adhesive defibrillator pads near the generator is avoided.

If pericardial tamponade is suspected during a code, which procedure should the nurse anticipate and prepare for? a. elective cardioversion b. emergency insertion of a chest tube c. needle inserted into pericardial sac to aspirate fluid d. needle inserted into third intercostal space to decompress the lungs

ANS: c Pericardiocentesis, or needle aspiration of pericardial fluid, is performed to alleviate the pressure around the heart. Elective cardioversion is used to treat atrial flutter and atrial fibrillation. Emergency insertion of a chest tube is done to treat a pneumothorax. Emergency thoracostomy is done to treat a tension pneumothorax.

The nurse admits a patient to the coronary care unit in cardiogenic shock. The nurse anticipates administering which medication in an effort to improve cardiac output by increasing the contractile force of the heart? a. dopamine (intropin) b. phenylephrine (neo-synephrine) c. dobutamine (dobutrex) d. nitroprusside (nipride)

ANS: c Positive inotropic agents such as dobutamine (Dobutrex) are given to increase the contractile force of the heart in cardiogenic shock. Dopamine (Intropin) is used primarily in low cardiac output states to restore vascular tone and increase blood pressure, but not in cardiogenic shock. Neo-Synephrine would be contraindicated in cardiogenic shock, as the vasoconstriction it produces would exacerbate cardiac ischemia. Nitroprusside (Nipride), used for preload and after load reduction, can improve cardiac performance in shock states by its reduction of systemic vascular resistance.

The patient with an implanted cardioverter-defibrillator (ICD) develops sustained ventricular fibrillation (VF) and loses consciousness. The responding nurse should: a. avoid touching the patient in case the ICD fires b. call the code team but tell them that the patient cannot be defibrillated c. initiate a code and prepare to defibrillate the patient d. prepare to administer adenosine intravenously

ANS: c Regardless of the ICD, resuscitation efforts are administered, including defibrillation if needed. There is no danger to personnel if the ICD discharges while staff members are touching the patient. However, the shock may be felt and has been compared to the sensation of contact with an electrical outlet. Adenosine is indicated for supraventricular tachycardia (SVT).

A 72-year-old patient fractured his pelvis in a motor vehicle crash 2 days ago. He suddenly becomes anxious and short of breath. His respiratory rate is 34 breaths/min, and he is complaining of midsternal chest pain. His oxygen saturation drops to 75%. You suspect: a. cardiac tamponade. b. myocardial infarction. c. pulmonary embolus. d. tension pneumothorax.

ANS: c The patient's history and respiratory signs and symptoms indicate pulmonary embolus. The patient's signs and symptoms do not suggest a cardiac tamonade; however, given the patient's age, he may be evaluated for a possible myocardial infarction. His mechanism of injury and his 2 days postinjury make a tension pneumothorax less likely.

A nurse on a cardiac unit is reviewing the laboratory findings of a client who has a diagnosis of myocardial infarction (MI) and reports that his dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the MI occurred 14 days ago? a. CK-MB b. Troponin I c. Troponin T d. Myoglobin

ANS: c The troponin T level will still be evident 10-14 days following an MI. Troponin I levels are no longer evident after 7-10 days. The creatinine kinase MB levels are no longer evident after 3 days. Myoglobin levels are no longer evident after 24hrs.

The patient is experiencing nausea and shortness of breath and is pale and diaphoretic. Although the patient's usual heart rate is 86 beats/min, it is now 62 beats/min. Carotid and radial pulses are palpable, and the blood pressure is 82/56 mm Hg. Which drug would the nurse prepare to administer? a. adenosine b. epinephrine c. atropine d. amiodarone

ANS: c This patient is demonstrating symptomatic bradycardia. Administer atropine, 0.5 mg IV every 3 to 5 minutes to a total dose of 3 mg. Atropine is used to increase the heart rate by decreasing the vagal tone. Adenosine is the initial drug of choice for the diagnosis and treatment of supraventricular dysrhythmias. Epinephrine is used to treat VF or pulseless VT that is unresponsive to initial defibrillation, asystole, and pulseless electrical activity (PEA). IV amiodarone is indicated for treatment and prophylaxis of recurring VF and unstable VT refractory to other treatment.

A nurse is completing the admission physical assessment of a client who has a history of mitral valve insufficiency. Which of the following findings should the nurse expect? a. S4 heart sounds b. petechiae c. crackles in lung bases d. splenomegaly

ANS: c crackles in the lung bases is an expected finding in a client who has pulmonary congestion due to mitral valve insufficiency. An S3 heart sound is an expected finding in a client who has mitral valve insufficiency. An S4 heart sound is an expected finding for a client who has aortic stenosis. Petechiae is an expected finding in a client who has infective endocarditis. Hepatomegaly, not splenomegaly, is an expected finding in a client who has left-sided heart valve damage.

The nurse is caring for a patient with hypovolemia. Which large volume crystalloid solution should the nurse anticipate the health care provider to order? (select all that apply) a. 5% dextrose b. albumin c. lactated ringer's (LR) d. normal saline

ANS: c, d LR solution and 0.9% normal saline are isotonic solutions that are commonly infused to treat hypovolemia. Solutions of 5% dextrose in water and 0.45% normal saline are hypotonic and are not used for fluid resuscitation. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema. A systematic review of 30 randomized controlled trials found no benefit in giving colloids (e.g., albumin) over crystalloids and recommended against the administration of colloids in most patient populations.

A nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following findings should the nurse expect? a. Rubor of the affected leg when elevated b. 3+ dorsal pedal pulse in left foot c. Thin, peeling toenails of left foot d. Report of intermittent claudication in the affected leg

ANS: d A client who has peripheral artery disease might report that numbness or burning pain in the extremity ceases with rest (intermittent claudication). Reddening (rubor) of a leg affected by PAD occurs when it is placed in a dependent position. Pulses are decreased or absent in the feet and toenails are thickened in cases of PAD

Spinal cord injury causes a loss of sympathetic output, resulting in distributive shock with hypotension and bradycardia. Although blood pressure may respond to fluid resuscitation, what other therapy may be required to compensate for loss of sympathetic innervation? a. Colloids b. Glucocorticoids c. Proton pump inhibitors d. Vasopressors

ANS: d Blood pressure may respond to IV fluids, but vasopressor therapy is often required to compensate for the loss of sympathetic innervation and resultant vasodilation. Colloid administration alone will not provide necessary vascular tone to support perfusion. Glucocorticoids are given in the early stages of spinal cord injury to reduce edema associated with injury and to improve outcomes. Proton pump inhibitors may be given to prevent stress ulcers.

The nurse is caring for a patient with possible distributive shock. Which should the nurse look for on assessment? a. blood loss and actual hypovolemia b. decreased cardiac output c. third-spacing of fluids into peritoneal space d. vasodilation and relative hypovolemia

ANS: d Distributive shock presents with widespread vasodilation and decreased systemic vascular resistance that result in a relative hypovolemia. Blood loss is associated with hypovolemic shock. Decreased cardiac output is a primary cause of cardiogenic shock. Primary internal sequestration of fluids that causes internal fluid loss is associated with hypovolemic shock.

The nurse is caring for a patient in neurogenic shock. Which should the nurse assess for? a. tachycardia b. hypertension c. hypoventilation d. vasodilation

ANS: d In neurogenic shock, there is an interruption of impulse transmission or blockage of sympathetic outflow, resulting in vasodilation, inhibition of baroreceptor response, and impaired thermoregulation. Interruption of sympathetic nerve innervation would result in bradycardia. Interruption of sympathetic nerve innervation would result in hypotension. Hypoventilation is not a physiological mechanism.

The nurse is caring for a patient who has blood pooling in the capillary bed and arterial blood pressure too low to support perfusion of vital organs. Which symptoms should the nurse assess for? a. acute respiratory distress syndrome (ARDS) b. disseminated intravascular coagulation c. increased cerebral perfusion pressure d. multisystem organ failure and/or dysfunction

ANS: d Maldistribution of blood flow refers to the uneven distribution of flow to various organs and pooling of blood in the capillary beds. This impaired blood flow leads to impaired tissue perfusion and a decreased oxygen supply to the cells, all of which contribute to multiple organ failure. Damage to the type II pneumocytes leads to ARDS. Consumption of clotting factors may cause DIC. Low arterial blood pressure leads to decreased cerebral perfusion pressure.

The nurse is working in the emergency department when a patient arrives who has experienced chest trauma. Which condition should the nurse be the most concerned with for this patient? a. Cardiac tamponade b. Flail chest c. Hemothorax d. Pulmonary contusion

ANS: d Pulmonary contusion as a result of blunt chest trauma increases the risk for development of pneumonia, acute lung injury, and/or ARDS. Cardiac tamponade is life threatening if untreated, but it is not a common complication after blunt chest trauma. Flail chest and hemothorax may result with blunt chest trauma, but they are not common causes of death.

The trauma patient presenting with left lower rib fractures develops left upper quadrant tenderness, hypotension, and referred pain to the left shoulder. You suspect: a. bowel obstruction. b. cardiac tamponade. c. pulmonary contusion. d. splenic injury.

ANS: d Splenic injury occurs most often as a result of blunt trauma to the abdomen. However, penetrating trauma to the left upper quadrant of the abdomen or fracture of the anterior left lower ribs also contributes to splenic injuries. The patient may present with left upper quadrant tenderness, peritoneal irritation, and/or referred pain to the left shoulder (Kehr's sign). Hypotension or signs of hypovolemic shock may also be noted. The patient's injury and associated signs and symptoms suggest an injury to the spleen rather than cardiac, bowel, or pulmonary injury.

A nurse is teaching a client who has angina about a new prescription for metoprolol. Which of the following statements by the client indicates understanding of the teaching? a. I should place the tablet under my tongue b. I should have my clotting time checked weekly c. I will report any ringing in my ears d. I will call my doctor if my pulse rate is less than 60

ANS: d The client is advised to notify the provider if bradycardia (pulse rate less than 60) occurs. Lopressor is administered orally, not sublingually. Lopressor does not affect bleeding or clotting time. The client should have CBC and blood glucose checked periodically. Ringing in the ears is not an adverse effect of the medication. Dry mouth and mucous membranes can occur.

The primary priority for the critical care nurse with regard to the trauma patient is which of the following? a. Decrease the patient's risk for multiple organ dysfunction syndrome. b. Ensure adequate fluid resuscitation. c. Increase the physiological reserve of the trauma patient. d. Provide adequate oxygenation and tissue perfusion.

ANS: d The priority is to maintain adequate oxygenation and tissue perfusion through effective fluid resuscitation and management of the patient's airway and breathing. Decreasing the patient's risk for MODS is achieved by ensuring tissue perfusion and oxygenation. Increasing physiological reserve is not an initial priority in the management of the trauma patient.

A patient is complaining of midsternal chest discomfort radiating down the right arm. The discomfort has been present for about 5 minutes. The patient is also asthmatic and allergic to calcium channel blockers. The nurse anticipates an order from the health care provider for which medication? a. isoptin b. metoprolo c. nifedipine d. nitroglycerin sublingual

ANS: d These are symptoms of angina. Administration of nitrates is indicated as a first-line treatment.

The nurse is caring for a patient who has symptoms of an acute myocardial infarction (AMI). Which lab should the nurse prepare to draw in order to detect myocardial necrosis? a. CK b. CK-MB c. potassium d. troponin I

ANS: d Troponin I has a greater specificity than other tests in the diagnosis of acute myocardial infarction (AMI) at 7 to 14 hours after the onset of chest pain.

Hypertensive Urgency

Acute elevation of BP SBP>180 OR a DBP > 110 No end-organ damage ... yet!! Goal → Control BP over several days to weeks

Collaborative Management

Admit to ICU Assist with art line insertion & monitoring Anticipate lab/diagnostic workup Hemodynamic monitoring Appropriate IV drug therapy Provide psychological support Patient education

Hypertensive Emergency

Aka Malignant Hypertension Severe HTN with evidence of acute or ongoing damage of a target organ SBP >180 OR DBP >120 mm Hg OR a MAP >150 mm Hg Goal → BP should be lowered aggressively over minutes to hours

Pulses Alternans

Alternating strong and weak pulse pressures during a sinus rhythm. Need arterial waveform-amplitude of the systolic beat differs with every other beat. No changes are apparent on electrocardiograms or in diastolic filling time. Indicates severe ventricular failure, aortic and mitral valve stenosis, hypertrophic and congestive cardiomyopathy, effusive pericarditis, and instances in which general anesthesia is used.

Normal heart sounds

S1 - occurs due to the closure of the tricuspid and mitral valves, "lub" S2 - occurs due to the closure of the aortic and pulmonic valves, "dub"

Hypertensive emergencies - risk factors

Essential HTN -Renal disorders -Glomerulonephritis -Pyelonephritis -SLE -Renal artery stenosis Endocrine disorders -Pheochromocytoma -Cushing's Syndrome -Primary aldosteronism -Renin - secreting tumors CNS Disorders -CVA, IICP, AD -Head injury Pregnancy -Eclampsia Drugs -BCP's -Abrupt withdrawal of - clonidine -Cocaine or other sympathomimetic drug intoxications

Mitral Stenosis - findings

Fatigue Dyspnea Hemoptysis A-fib Diastolic murmur

Mitral Regurgitation - findings

Fatigue Dyspnea Orthopnea A-Fib Systolic murmur

HTN Treatment Goals

Controlled reduction of BP without the development of hypotension Reduce MAP by no more than 25% within minutes to 1 hour. Followed by the reaching a goal BP of 160/100 mm Hg within 2 to 6 hours.

Assessment/Diagnostics

Differentiate elements of an advanced cardiac assessment, including: -Jugular venous distention -Pulsus alternans/ paradoxus -Hemodynamic readings -Diagnostic tests Electrocardiography Exercise tolerance test Chest X-ray Echocardiography TEE Heart scans Cardiac cath/arteriography MRI EPS

Cardiovascular Manifestations of Hypertensive Emergencies

Discrepancy of BP >20 mm / Hg in both arms -Dissecting aneurysm Angina Symptoms CHF -Pulmonary edema -JVD -Peripheral edema -Extra heart sounds

Jugular Vein Distension

Found under physical assessment of the adult in ATI HOB 45 degrees, turn head away and palpate radial pulse (if it is pulsing with the radial pulse you are looking at the carotid artery, not JVD) Should not be able to see jugular vein distension at 45 degrees

Renal Manifestations Hypertensive Emergencies

Hematuria Oliguria Proteinuria ↑BUN / Cr

Advanced Cardiac Assessment

History Inspection Auscultation Palpation

Nursing Interventions

Monitor BP Continuous ECG monitoring Q1 hour neuro assessment initially, then q4h when condition stabilizes -Report changes Monitor UOP Q1H, notify HCP if < 0.5 ml/kg/hour. Administer anti-hypertensive medications, titrating them to achieve desired BP WITHOUT rapid BP reduction.

Hypertension

Normal <120AND <80 Pre-hypertension 120 - 139 OR 80 - 89 Stage 1 140 - 159 OR 90 - 99 Stage 2 ≥ 160 OR ≥ 100

Other IV Drugs Used to Treat Hypertensive Emergencies Vasotec (enalapril)

ONSET (mins.) 15-30 DURATION (mins.) 6-12 Nursing Implications / Considerations: Monitor for ↓BP, avoid use w AMI, Disease recommended to treat: used in LV disfunction, CHF

Other IV Drugs Used to Treat Hypertensive Emergencies Labetalol

ONSET (mins.) 5-10 DURATION (mins.) 3-6hrs Nursing Implications / Considerations: Avoid in acute HF and asthma Disease recommended to treat: -Acute pulmonary edema - acute aortic dissection - eclampsia

Other IV Drugs Used to Treat Hypertensive Emergencies Fenoldopam

ONSET (mins.) <5 DURATION (mins.) 30 Nursing Implications / Considerations: Hypersensitivity to sulfites Disease recommended to treat: AKD, Ischemic CVA

Other IV Drugs Used to Treat Hypertensive Emergencies Hydralazine

ONSET (mins.)10-30 DURATION (mins.) 2-6 hrs Nursing Implications / Considerations: Avoided in CAD Disease recommended to treat: Eclampsia

Sodium Nitroprusside

Potent arterial & venous vasodilator Onset within seconds, duration 1 - 2 minutes Side effects: ↑'s ICP, N/V, headache, muscle spasms, flushing, thiocyanate / cyanide toxicity Recommended use for Acute pulmonary edema and aortic dissection. USE cautiously with CAD. Needs to be covered with opaque bag Need to monitor thiocyanate and cyanide levels

Pulsus Paradoxus

Pulsus paradoxus is the term used to describe an exaggerated blood pressure variation with the respiratory cycle. This can be found in cardiac tamponade or during COPD/asthma exacerbations.

HTN Pathophysiology -Disruption in one of 4 intrinsic mechanisms

RAAS Auto regulation Sympathetic nervous system Antidiuretic hormone

CNS Manifestations of Hypertensive Emergencies

Rapid onset Blurred vision Papilledema SBP>180 OR DBP >120 Headaches Restlessness Confusion Motor / sensory deficits

What is Hypertensive Crisis???

Severe ↑ in BP Two categories Hypertensive Urgency Hypertensive Emergency AKA ..... Malignant Hypertension

Murmurs

Turbulence of blood flow Rumbling, blowing, harsh or musical Graded based on loudness I-VI, VI being loudest BIG worry if accompanies acute MI-papillary muscle rupture mitral valve-valve incompetence

Disorders of Heart Valves - stenosis

Valve becomes stiff Leaflets "stick" together Valve cannot open fully or valves may be stuck open Types -Aortic -Mitral

Disorders of Heart Valves - regurgitation

Valve is incompetent or insufficient Leaflets do not close completely Causes a backflow of blood Types -Aortic -Mitral

Aortic Regurgitation - findings

Widening pulse pressure Fatigue Orthopnea - can't breath when laying flat Angina Diastolic murmur

Other IV Drugs Used to Treat Hypertensive Emergencies Nitroglycerin

onset: 2 - 5 duration: 5 - 10 NI/considertion: Can cause reflex tachycardia disease recommended to treat: Acute myocardial ischemia