Cardiac Alterations Study Guide

What is Primary Hypertension?

(essential or idiopathic) elevated BP W/O an identified cause ,and it accounts for 90% to 95%

What are the most widely used lipid lowering drugs?

- (Statins): You will give A LOT of these during your career as a nurse. • Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute renal failure and death in some patients who have taken statin medications. What is Myopathy & Rhabdomyolysis and what do we teach our patients? BEAKS DOWN SKELTAL MUSCLE LET DOTOR KNOW ABOUT MUSCLE TENDERNESS

Risk Factor Modification

7. What are the goals for lipid management? LOW-DENSITY LIPOPROTEIN (LDL) LESS THEN 100 MG TRIGLYCERIDES LESS THAN 150 MG (HDL)-GREATER THAN 40 MG 8. What is the recommended BP? LESS THAN 140/90 M/M PT WITH DIABETIES/RENAL INSUFFICIENCY BP LESS THAN 130/80 9. Exercise Therapy • Walking is the BEST exercise for PAD. • What are the instructions for walking? The patients should "walk to the point of DISCOMFORT

If someone has > 200 cholesterol, they are at risk for CAD and treated. What is tried first?

CALORIC RESTRICTION DECREASE DIETERY FAT INCREASE EXERCESES

Page 777: What is a CARDIAC CATHETERIZATION w/ a PCI (balloon angioplasty)? •

CATHETER IS SERTED IN TO CORONARY ARTERY THEN INFLATED TO COMPRESSED/VESSEL DILATION The patient should NOT have chest pain after this procedure, but we do monitor the patient for this. If they have chest pain, it may be an MI or collapse of the vessel or stent!

Bile Acid Sequestrants: (LOWERS LIPIDS

Can interfere w/ the absorption of many drugs. What should we teach our patients about these? COULD HAVE GI ISSUES, HEART BURN,NAUSEA,STMOCH PAIN,CONSTAPATION INTERFERS WITH DIGOXIN,THIAZIDE WARFARIN SOME ANTIBOTICS(PENICILLIN)

• What are the best types of OILS for CAD? (P. 769) Cholesterol Lowering Drug Therapy (P. 768-771)

POLYUNSATURATED (PRIMERY) MONOUNSATURATED

VENOUS

Peripheral Venous Disease is caused by problems with blood flow to the veins and a back-up of fluid that causes edema. There are 3 things that can lead to problems with blood flow to the veins & back-up of fluid: • Venous Thrombosis(Clot) formation from inflamed veins • Defective (Bad Valves) • Lack of skeletal muscle contractility (when we walk, do leg exercised and 'pump" our feet, Flexion & Contraction) we are contracting our muscles and pushing blood through the veins. • That's why leg exercises & ROM is SOOOO important for all new surgical patients and patients on bed rest. Etiology: There are 3 factors (Virchow's triad) that can lead to a thrombus (Blood Clot). Please know what causes these 3 Factors & think about teaching & ways to prevent them from occurring. 1. Venous Stasis: Blood pools & at risk for clotting 2. Endothelial damage= DAMAGE TO ENDOTHELIUM OF THE VEIN MAY BE CAUSED BY DIRECT ( TRAMA,BURNS FRACTURES) INDIRECT(CHEMO, SEPTIS) 3. Hypercoagulability of Blood (What are interventions to make blood less ANTI- COAGUALTE DRUGS /AMBULATION /

Risk Factors for CAD (P. 761-766) the same as for hypertension!!!

Please know non-modifiable & MODIFIABLE RISK FACTORS!!!! MEN WOMEN OVER 65 MORE DEATH IN WOMEN AFRICAN AMERICAN WOMEN HIGH RISK FAMILY HISTORY • Please commit these Elevated Serum Lipids to memory: - Cholesterol UNDER 200MG/DL - LDL=LESS THAN 160MG GOOD- HDL=MORE THEN 40 MEN/WOMEN 50 MG - Triglycerides= LESS THEN 150 MG

Nursing Management (P. 810-811)

Please study NCP 35-1: These interventions are exactly what we do in nursing for heart patients!! Excess Fluid Volume (Fluid Overload), Impaired Gas Exchange & Activity Intolerance are the issues you will see the most with your patients in clinical. These interventions are RIGHT-ON! This is EXACTLY what you do to take care of a HF patient!

Pacemakers: Ch. 36

Read about permanent pacemakers page 835 and the PCGTG page 836. 1. Why do some people need permanent pacemakers? ACQUIRED AV BLOCK SECOND-DEGREE AV BLOCK THIRD-DEGREE AV BLOCK A-FIB W SLOW VENTRICULAR RESPONCE BUNDLE BRANCH BLOCK CARDIOMYOPATHY/DILATED/HYPERTROPHIC HF SA NODE DYSFUNCTION TACHYDYSRHYTHMAIS (VENTRICULAR TACHYCARDIA) What is the purpose for pacemakers? ELECTONIC DEVICE USED TO PACE THE HEART WHEN NORMAL PATHWAYS ARE DAMAGE 2. What is the teaching regarding pacemakers? MAINTAIN FOLLOW UP CARE REPORT ANY S/S OF INFECTION TO SITE KEEP INCISION DRY FOR 4 DAYS AVOID DIRECT BLOW TO PACEMAKER AVOID HIGH -OUT PUT ELECTRIC GENERATION OR LARGE MAGNETS (MRI) MICROWAVES ARE SAFE AVOID ANTITHEFT DEVICE /DOORWAYS MAYSET OFF METAL DETECTOR HAND HELD NOT DIRECTLY ON MONITOR PULSE/FOR DROPING BELOW PREDETERMINE RATE CARRY PACEMAKER INFO CARD/LIST OF MEDICATION MEDIC ALERT ID BRACELET ALL TIMES • When can they move their arm up? WHEN DOCTOR SAYS IT OK TOO

10. Which of these drugs should the nurse monitor Liver Enzymes?

STATIN = LIVER DAMAGE

Chapter 34: Coronary Artery Disease (CAD)

The 2 main causes of cardiac problems (perfusion problems) are: • Hypertension • Atherosclerosis CAD is caused by atherosclerosis. In Atherosclerosis, cholesterol and lipids (fats) get under the lining of the blood vessels and narrow the vessel. How does cholesterol & lipids get into the lining? By damage to the wall of the vessel. This damage causes INFLAMMATION which is measured by a LAB TEST called C-REACTIVE PROTEIN.

5. What is Secondary Hypertension?

is elevated BP with specific cause that often can be identified and corrected accounts for 5%-10% hypertention in adults

7. Why is Hypertension called the "Silent Killer?"

silent killer = asymptomatic until it becomes sever & targerts organs

What are ANTIPLATELET DRUGS

how do they work? (P. 34-12) • What do we teach our patients about these drugs? = Antiplatelet Therapy "slippery-slidey" Prevent platelets from "sticking together" ASA Plavix Anticoagulants Prevent the blood from "coagulating" (clotting) by inhibiting clotting factors Coumadin (PT/INR) NORMAL 1.0 ON COUMADON -2.0-3.0 INR CHEAK LAB BE FORE GIVEDN ANTIDOT - (Vitamin K) Heparin (APTT) ON Lovenox What should they watch for? ORTHOSTATIC HYPERTENTION BLEED IN GUMS AND URINE,STOOL

8. Complications: Just read this: Hypertension causes "Organ Damage." Here's what all that pressure does:

• All that pressure damages the lining of our blood vessels and causes CAD (Coronary Artery Disease) & PAD (Peripheral Artery Disease) • Left Ventricular Hypertrophy: Left ventricle has to pump so hard against narrowed vessels that it can get out of shape & the heart can begin to fail (Heart Failure)! • Heart Failure: Because the heart becomes damaged, it can't pump out enough blood to the rest of the body & blood backs up into the lungs or back out the right atrium to the rest of the body (edema). (SOB, Fatigue, PND= Paroxysmal Nocturnal Dyspnea) • Speeds up the process of atherosclerosis (plaque in the arteries). - These "plaques" can break off and cause MI & Stroke - Cause lack of blood extremities & it HURTS when you walk (intermittent claudication) - All that pressure can weaken vessels & cause aneurysms (out-pouching of the vessels or bifurcations where the vessel splits apart! • The atherosclerosis further narrows vessels and now even less blood gets to vital organs. - Kidney damage - Retinal Damage

Echocardiogram (P. 730)

• An Echocardiogram is the # 1 diagnostic test used for HF What is it and what does it show? ULTRASOUND WAVES IN PLACED IN FOUR POSITIONS ON THE CHEST ABOVE HEART SOUND WAVES BOUNCED OFF THE HEART ALSO RECORDS DIRECTION & FLOW OF BLOOD THROUGH THE HEART TRANSFORMS IT TO AUDIO & GRAPHIC DATA MEASURESE VALVULAR ABNORMALITIES(IV DYE TO ADD TO IT) • If you can Google an Echocardiogram and see one live, it's pretty neat!

Now read everything on pages 754- 756

• Blood Pressure Measurement PT SHOULD NOT OF SMOKED,EXERCISED, CAFFINE W/IN 30 MIN SIT W NO LEGS CROSS ON SKIN /RELAX/DONT TALK DO BOTH ARM • Safety Alert (different pressures on different arms, which result do you use?) •YOU USE HIGHER OF RESULTS

CAD & Atherosclerosis is often referred to as the SAME thing.

• CAD is "clogging" of ARTERIES in the HEART (Coronary Arteries) caused by ATHEROSCLEROSIS & Hypertension! • PAD (Peripheral Arterial Disease) is "clogging" of ARTERIES in the rest of the body caused by ATHEROSCLEROSIS & Hypertension!

Drug Therapy (P. 885)

• How do the following drugs treat VTE? You will give A LOT of these in the hospital!!! WARFARIN(COUMADIN) (V-K ANTAGONIST T. 38-9 Anticoagulants? : What lab test monitors for therapeutic levels? INR= Warfarin (Coumadin) (Vitamin K ANTAGONIST) Heparin Lovenox: do we do any lab test to monitor this? NOT REQUIRED Arixtra: do we do any lab test?NOT REQUIRED

3. NOW TURN TO PAGE 741: Read the classification of Hypertension

• Normal BP is SBP <120 and DBP < 80 • What are the parameters for: - Pre-hypertension 120-39 or 80-89 - Stage 1 140-159 or 90-99 - stage 2 >160- or >100

What damages the vessel & causes INFLAMMATION?

• Tobacco • Hyperlipidemia (lots of fats in the blood; also called Dyslipidemia) • Hypertension • Diabetes (High blood glucose sets off inflammation) • Lots of homocystein in the blood (amino acid that causes fatty deposits in lining of vessels) • Infection Cholesterol & lipids really LOVE to get into the lining of our HEART or Coronary Arteries!!!! CAD = Coronary Artery Disease

GERONTOLOGICAL CONSIDERATIONS

• What are the OLDER ADULT cardiovascular changes regarding Hypertension? MORE LIKLY TO HAVE WHITE COAT EFFECT LOSS OF TISSUE ELASTICITY INCREASED COLLAGAN COONTENT & STIFFNESS OF MYOCARDIUM INCREASED PERPHERAL VASCULAR RESISTANCE DECREASE IN ADRENERGIC RECEPTOR SENSITIVITY DECREASE RENAL FUNCTION DECREASE RENIN RESPONSE TO SODIUM & WATER DEPLETION

Venous Thromboembolism: (P. 884)

• What are the S/S of a VTE (P. 884) & Chronic Venous InsufficiencySURROUND VEIN TENDER TO TOUGH REDDEND/WARM FIRM SUBQS • How do we prevent VTEs? BEING ACTIVE /REPOSTIONING OFTON • What is hospital VTE Prophylaxis? CHANGE POSITION EVERY2 HRS/\SCDS/,STOCKINGS Must make sure also doesn't have PAD. 2. ELEVATION 3. Elastic Stockings, SCD 4. Avoid standing or sitting for long periods of time 5. Lotion; Non irritating MOIST dressings for stasis ulcers Diet: ↑ Protein, A, C, Zinc HELP HEAL

Chronic Venous Insufficiency & Venous Leg Ulcers P. 891

• What is Chronic Venous Insufficiency and what do we teach our patients? VEIN&VALVES DAMAGED COMMON IN OLD .POOLING BLOOD FLOW IN LEG EDEMA • What is that brownish discoloration on the leg ENZMES BREAK DOWN RBC CAUSE RELEASE OF HEMOSIDERIN & what is "stasis dermatitis?"(ECZEMA) ITCHNESS /HIGHER SKIN TEMP IN ANKLE (p. 892 Fig: 38-12)

Varicose Veins: (P. 890)

• What is the Nursing Management for Varicose Veins & what do we teach our patients? DONT CROSS LEGD COULD PREVIOUS VTE SPIDER VEIN

Know Drug Alert- Anticoagulant Therapy: (P. 889) & Read Table 38-12 P. 889

• What is the antidote for Warfarin in case of uncontrolled bleeding? VITAMIN K

Please know Patient & Care-giver Teaching Guide for Heart Failure (T 35-14, P. 813)

• What should we tell them regarding weight? WEIGHT GAIN 3 LBS IN 2 DAYS 3-5 LBS IN WK • What do we teach them regarding s/s of worsening Heart Failure WEIGHT GAIN DIFFICULTY BREATHING,ESPECIALLY W OR LYING ON BACK WAKE UP BREATHLESS FREQUENT DRY ,HACKING COUGH FATIGUE,WEAKNESS EDEMA NAUSEA.AMDOMEN SWELLING DIZZYNESS OR FAINT • You know the best way to learn? Teach someone else! Why don't you go over the Patient & Family Teaching Guide with your family (Read it aloud) and teach them about CHF! • Also that Aurora Patient Education Packet is really good & has A LOT of what we learned about today in class! • I promise you, they may have really good questions & you'll learn the content better too!!

Know this about the drugs: All will be addressed in class.

• When do we hold a dose? • What do we teach about antihypertensives and orthostatic hypotension? WHEN ON THEM MOVE SLOWLY • Which diuretics should we encourage Potassium (K+) rich foods which should we caution about Potassium (K+)? THIAZIDE decrease k+/potassium-sparing diuretics increase K+ • How do Beta blockers work? HOW does that affect our body? How does this affect people with respiratory problems? Betablockers: "LOL" ATENALOL, UP SNS= RELEASE EPINOPHRINE BP UP ,PULSE UP INCREASE BRONCIOLS INCREASE GLUCOSE / BLOCK IT NOW WHAT ↓HR: UP Pulse: HOLD < 50 DOWN O2 demand DECREASE MIDICARDION O2 DEMANDS Avoid w/ Asthma, COPD Don't Stop Abruptly • What are the "pril" antihypertensives and how they work on the body to lower the BP? ACE INHIBITOR= INHIBITS ANGIOTENSIN l to angiotensin ll ACEI "prils" (CAPRTIPRILS) ARBS "Sartans" (anidema) Interrupt RAAS RENIN - ANGIOTENSION-ANGIOTENTIONll constrictis- ACE block aldosterone- retain water !!Orthostatic BP Change!! ACEI: Cough up K+ / No Salt Subs Angioedema • What are the "sartans" how they work on the body to lower the BP? prevents action of A-ll produce vasodilation • Why would you give a "sartan" over a "pril?" DUE TO A COUGH • What are MAIN side effects of all BP meds and what do we teach our patients about them? DIZZNESS FATIGUE, ORTHOSTIC HYPERTENTION

What is the difference between ANTICOAGULANTS and Antiplatelet drugs? •

How do these drugs work in our body? • What is the difference between Coumadin= LONG TERM INTERFERS WITH VITAMIN K Heparin =SHORT TERM •What are the different Lab tests and what are the different Antidotes for each drug? (PT/INR) NORMAL 1.0 ON COUMADON -2.0-3.0 INR CHEAK LAB BE FORE GIVEDN ANTIDOTES VITAMIN K

Collaborative Care (P. 892-893)

How does compression help? KEEP EDEMA DOWN AND SOME HELP CIRCULATE BLOOD SCD, When should you NOT use compression on a leg? IF PAD PRESENT OR ANKLE- BRACHIAL INDEX LESS THAN 0.9 What is the Nursing Management & what type of dressing is used? Moist or dry? MOIST IS BASIC WOUND CARE (ULCLER) DRY INTAKED SKIN DRY

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Myocardial Ischemia can be caused from either: INCREASE Demand for O2 (Mowing the lawn, having sex, going up a lot of steps) OR DECREASE Decreased Supply of O2 (Atherosclerosis narrows arteries and they can't supply enough O2 during demand- mowing lawn or increasing physical activity) Artery is usually occluded up to 75% before angina will occur.

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2. Please Read the PCTG P. 767; T. 34-3

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1. What are the Healthy People Goals for Hypertension ( Green BOX: P. 738)

...maintain a healthy weight reduce salt & sodium intake increase level of physical exercise limit consumption of alcohol to moderate level monitor blood pressure & know if blood pressure is high ,low,normal,or borderline for hypertention if orderd, take medication to control blood pressure

MI P. 777-8

1. What is an MI? (Also known as Acute Coronary Syndrome (ACS)= ISCHEMIA IS PROLONG NOT IMMEDIATE /REVERSIBLE/ENCOMPRESSESS SECTRUM OF UNSTABLE ANGINA/ MYOCARDIAL CELL DEATH (NECROSIS) MOSTLY LIKLY FROM THROMBUS FORMATION - How is Unstable Angina related to having an MI? WITH CHEST PAIN IT SYMPTOM NOT RELEVED BY REST - What symptoms do women typically present with Unstable Angina & an MI= FATIGUE SOB INDIGESTION ANXIETY - Why is an MI in the LAD (Left Anterior Descending) Artery known as the "widow maker?" BECAUSE WOMEN HUSBAND DIE DUE TO THIS ARTERY (MOST OFTON) 2. What are the Clinical Manifestations of an MI? (P. 779) SEVER ,IMMOBILIZING CHEST PAIN,NOT RELIVED BY REST ,POSITIONING,OR NITRATE ADMINISRATIONS (HEAVINESS,PRESSURE,TIGHTNESS,BURNING,CONSTRICTION,CRUSHING RADIATE TO JAW NEAK ARMS & BACK 3. What are the complications of an MI? (P. 779) CAUSE SCAR TISSUE DYSRHYTHMIAS= MOST COMMON (TACHYCARDIA/BRADYCARDIA VENTRICULAR FIBRILLATION HF CARDIOGENIC SHOCK= OXYGEN & NUTRITION PAPILLARY MUSCLE DYSFUNCTION VENTRICULAR ANEURYSM = WALL IS THIN BULGES OUT DURING CONTRACTION PERICARDITIS=INFLAMMATION OF THE VISCERAL /PARIETAL PERICARDIUM DECRESS VENTRCULAR FILLING & EMPTYING DRESSLER SYNDROME= PERICARDITIS W EFFUSION & FEVER THAT DEVELOPS 4-6 WKS AFTER MI 4. What are the Serum Cardiac Markers for an MI? CERTAIN PROTEINS,RESLESED IN BLOOD FROM NECROTIC HEART MUSCLE AFTER MI(CARDIAC ENZYME & TROPONIN IMPOTENT TO FOR DIAGNOSIS 5. Which ones is SPECIFIC to the Heart Muscle? CARDIAC ENZYME & TROPONIN 6. If someone has an MI, what are the PRIORITY Nursing Interventions? (T: 34-13) ASESSS= ABC ADMINISTER O2 INSERT TWO IV ASSESS PAIN /MEDICATION FOR PAIN (MORPHINE) CONTINUOUS ECG MONITORING /IDENTIFY UNDERLING RHYTHM GET BASELINE BLOOD WORK ( CARDIAC MARKERS) PORTIBLE CHEST X-RAY ASPRIN • What is Fibrinolytic Therapy? TREATMENT TO DESOLVE CLOTTS (P. 783) As you read answer: • Within what time period must they receive fibrinolytic therapy after an MI? GIVE SOON AS POSSIBLE IN THE FIRST 6 HRS • What are the EXPECTED side effects of Fibrinolytics? LOSEN OTHER CLOTTS/BLEEDING ,MINOR/MAJOR • When is it contraindicated (T. 34-14)? ACTIVE BLEEDING(EVEN MENSTRATION) HISTORY OF ANEURYSM OR ARTERIOVENOUS MALFORMATION PREVIOUS CEREBRAL HEMORRHAGE RECENT ISCHEMIC STROKE CLOSED HEAD/FACIAL TRAUMA WITH IN 3 MONTH AORTIC DISSECTION • What is the Major Complication of Fibrinolytics, what is normal & what is the SAFETY ALERT? (P. 783)!!!! MAJOR BLEEDING INCREASE HR CHANGE IN CONSCIOUSNESS BLOOD IN URINE OR STOOL (STOP TAKING IT ) What is a Coronary Bypass Graft Procedure? PLACE MENT OF NEW VESSELS

Nursing Implementation & PCGTG T: 38-5; (P. 878-880)

11. What should we use to keep the patient's extremities warm? BLANKETS,IN CREASE ROOM TEMP 12. Why are heating pads wrong for these people? THEY MIGHT NOT FEEL IT BEING TOO HOT 13. On a client with PAD, what color would their leg be if you raised it up? BLUISH GRAY What color would it be if you lowered it? PINK Any idea why patients with PAD feel more comfortable dangling their leg down? LESS PAINFUL 14. What is an important point about positioning extremities of people w/ PAD? CIRCULATION ,BLOOD FLOW

Beurger's Disease & Reynaud's Phenomena

15. What is the difference between Thromboangiitis Obliterans (Buerger's Disease)= MEN GET THIS BECOUSE THEY SOMKE /MAY HAVE BAC INFECTIONTHER UNDER 40 EFECT LIMBS LEGSFEET HANDS ARMS TX QUIT SMOKING ,ANTIBOTICS & Reynaud's Phenomena? WOMEN 15 -40 YR CAUSE COULD BE PIANOLISST.TYPIEST PEOPLE WHO USE FINGER TIP LOT TX CALCIUM BLOCKERS ASSOCIATED WITH LUBAS,RA What is a VERY important Risk factor that these patients must give up???? SMOKING Put on gloves and remove ice from the refrigerator. Which of these patients should be instructed to do this? RYNAUDS If a patient with Buerger's disease keeps smoking, what WILL happen? THEY WILL LOSS THER LIMBS

Collaborative Care HF (P. 803-804)

2. What position should we put our patients with heart failure in? HIGH FOWLER POSITION /FEET HORIZONTAL IN BED OR DANGLING AT THE BEDSIDE HELP DECREASE VENOUS RETURN BECAUSE OF POOLING OF BLOOD IN THE EXTREMITIES INCREASES THORACIC CAPACITY(IMPROVED VENTILATION)

Drug Therapy (P. 806-808)

3. How do the following drugs help in HF? I'll go over these in class. • Diuretics • Beta-blockers • ACEI (What are the major side effects of ACEI? COUGH (P. 807) Sound familiar????? • ARBS • Aldactone: This is not used as a diuretic in HF. What is it used for.= BLOCKS HARMFUL NEUROHORMONAL EFFECTS OF ALDOSTERONE ON HEART BLOOD VESSELS • Vasodilators:= - Nitrates • Positive Inotropes (What is Digoxin Toxicity? Low levels of potassium in the body increase the risk of digitalis toxicity(INHANCES THE DRUG) Why is Hyperkalemia a concern) = CAN CAUSE A DYSRHYTHMIAS DIGOXIN IMMUNE FAB ANTITOT

Nutritional Therapy

3. What % of fat intake should come from our calories? 25-35% Read T. 34-5 Nutritional Therapy

...Nutritional Therapy: (P. 808)

4. What kinds of foods are high in Na+ (Sodium)? CANNED SOUPS ,PROCESSED MEATS,CHEESE,FROZEN MEALS LIMIT MILK PRODUCTS 5. People with moderate to severe HF- Class III & IV (New York Heart Association P. 803 T. 35-5)are on fluid restrictions. How do we help them with thirst? (ORAL CARE ICE CHIPS GUM,HARD CANDY ICE POPS) 6. What are the instructions for monitoring their weight? DAILY WEIGHT

Nutritional Therapy

9. : What is the recommended diet? HIGH IN FRUITS& VEGS WHOLE GRAIN LOW CHOLESEROL,SALTS,SAT FATS

What are major sources of Saturated Fat?

ANIMAL FAT (BACON,LARD,EGG YOLK,DAIRY FAT,OILS COCNUT,PALM BUTTER CREAM CHESS SOUR CREAM

NCP: 38: P. 878-879. Ineffective Tissue Perfusion's interventions are really good!

ASESS EXTREMITY EVERY 15 MIN THEN HR COLOR,TEMP,CAPILLARY REFILL ,PRESENCE PERIPHERAL PULSE.SENSATION& MOITOR DISCOMFORT WITH EXERCESE & REST PROVIDE WARMTH ENCOURAGE PT TO EXERCISE TO ENHANCE O2 PROPER FEET CARE/ MAINTAIN SKIN INTEGERTY TEACH ABOUT CURCULATION ISSUES=SMOKING,CONSTRICTING CLOTH EXPOSURE TO COLD,CROSSING LEGS ADMINISTER ANTIPLATELET OR ANTICOAGULANT MEDICATION PROMOTE CIRCULATION/PAIN FREE WALKING

Page 732 • What is the nursing care after a PCI? (Same as for Cardiac Cath & Coronary Angiography)

ASSESS CIRCULATION TO EXTREMITY USED FOR CATHETER INSERTION CHECK PERIPHERAL PULSE ,COLOR, SENSATION OF EXTREMITY EVERY 15 MIN/1HR OBSERVE PUNCTURE SITE FOR HEMATOMA & BLEEDING MOITOR VITALS & ECG ASSESS BP HR DYSRHYTHMIAS SIGNS OF PULMONARY EMBOLI

Page 771: ANGINA: CHEST PAIN!!!!!

Angina is PAIN usually from a narrowing of the Coronary Arteries d/t Atherosclerosis. What causes the PAIN is that the arteries can't supply enough blood (OXYGEN) to the heart muscle because they are narrowed. ANGINA = Myocardial Ischemia (not enough OXYGEN to the heart) occurs and it HURTS!

Chronic Stable Angina, Unstable Angina & Printzmetal (P. 771-773)

As you do your readings, think about: 1. What is the difference between Stable (pg. 772) & Unstable Angina (UA pg. 778)? • What do we teach patients about monitoring for unstable angina? UNPRIDCTABLE HAPPENS AT REST /EMERGANCY 2. What do we teach clients about preventing an attack of Stable Angina? DONT BE TO ACTIVE TAKING MEDICATION PREVENT IN MORING T WAIT 30 -1 HR BEFORE MOVING 3. How long does Stable Angina usually last?(5-15MIN ) STOP THE EVENT/ACTIVITY 4. How long does Stable Angina last? UNTIL YOU REST 5-15 MIN 5. What is Printzmetal Angina and what is the main drug we give for it? IT OCCURS AT REST RESPOSE TO SPASM OF MAJOR CORONARY ARTERY FROM INCREASE OF INTRACELLULAR CALCIUM (RARE FORM OF ANGINA TX CALCIUM CHANNEL BLOCKERS & NITRATES

Niacin:(LOWERS LIPIDS)

Cause flushing. What might prevent this? TAKING ASPRIN OR NSAID 30 MIN BEFORE DRUDS MAY PREVENT FLUSHING TAKE W FOOD

VASCULAR DISORDERS CH. 38 Peripheral Artery Disease of the Lower Extremities (P. 874)

Clinical Manifestations (P. 874) 1. What is the classic PAD symptom of Intermittent Claudication? MUSCLE ACHE OR PAIN THAT FROM CONSISTENT LEVEL OF EXERCISE RESOLVES IN 10 MIN OR LESS WITH REST 2. What is parasthesia?=NUMBNESS OR TINGLING IN THE TOES OR FEET /RESULT OF NERVE TISSUE ISCHEMIA 3. What is the physical appearance of a limb with PAD? THIN AND SHINY & TAUT HAIR LOSS OCCURS ON THE LOWER LEGS LOSS OF PULSE ON PEDAL POPLITEAL • Elevation pallor= BLANCHING OF THE FOOT /FROM LEG ELEVATION • Dependent rubor= DEVELOPS WHEN LIMB IS IN A DEPENDENT POSITION • CRT= • Pulses= FELT ON FEMORAL PRESENT PEDAL POPLITEAL ABSENT 4. What is "rest pain" HAPPEN FOREFOOT,TOES AGGRAVATED BY LIMB ELEVATION /INSUFFICIENT BLOOD FLOW MORE OFFTON AT NIGHT CARDIAC OUT TEND TO DROP DURING SLEEP/LIMB AT LEVEL OF HEART

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Clinical Manifestations of Chronic HF (P. 801-802) 1. What are the s/s of Chronic HF? FATIGUE,LIMITATION OF ACTIVITY, CHEST CONGESTION/COUGH,EDEMA& SOB Heart Failure Labs & Diagnostic Studies: CHEAK CARDIAC ENZYMES BNP BNP • B-type Naturetic Peptide is a protein released by our heart in response to the stretch of the fibers. • If the Heart muscle gets too stretched and fluid in the heart backs up, BNP is released to promote vasodilation of the arteries so better profusion occurs? • Did you know that BNP levels are drawn on our Heart Failure patients? • We use BNP levels to assess how bad of HF our patient is in!!!! • If someone has a BNP of 1400, is he in HF? (See page 804, T. 35-7) YES !! BNP HIGHLY IMPROBABLE<100PG HF PROBABLE 100-500PG HIGHLY PROBABLE >500PG

10. Know the Lifestyle Modifications to help control BP:

DASH Eating Plan (Make a menu for your family!!!) - What kinds of foods are emphasized= fruits,vegs,fat-free or low- fat milk milk products,whole grains,fish,poultry,beans,seeds,& nuts avoided= sodium < 2300mg (canned soups,frozen dinner) 4200mg men 3300mg women Dietary Sodium Reduction: How much Na+ should healthy adults have & how much for African-Americans, people with hypertension, DM & Kidney disease? sodium>1500mg per day What is Fish Oil/ Omega-3 Fatty Acids= docosahexaenoic acid(DHA) & Eicosapentaenoic acid (EPA) DECREASE BP LOWER BLOOD TRIGLYCERIDE LEVELS HELPS PREVENT SECONDERY CARDIOVASCULAR DISEASE Moderate Alcohol Consumption: How much? MEN= 2 DRINKS DAY LIGHT WEIGHTS M/W 1 DRINK DAY 12 OZ EXCESSIVE MORE THE 3 DRINKS DAY COULD CAUSE CIRRHOSIS SECONDARY HYPERTENTION Physical Activity •SMOKING! NOT!!!! •Management of Psychosocial Factors

Heart Failure CH. 35

DO NOT FREAK! I WILL NOT TEST YOU ON ANYTHING IN PURPLE! I JUST WANTED TO EXPLAIN SOME OF THE TERMS YOU WILL SEE IN YOUR READING AND BE TAUGHT IN 3RD SEMESTER. Before you read sections of Chapter 35, here is an explanation of the following: Terms: • CO= Cardiac out-put • SVR= (Think "RESISTENCE") Systemic Vascular Resistance (Force that the Heart must pump AGAINST to get the blood out! (If your AORTA is clogged with plaque from atherosclerosis or if it is constricted from hypertension, you will have a ↑ SVR • PRE-LOAD: amount of blood returning to heart (We give diuretics (Lasix, Thiazides) & put people on low Na+ diets to DECREASE Pre-Load. • AFTERLOAD: amount of resistance the Heart has to pump against to get the blood out. A thickened AORTA from atherosclerosis and hypertension leads to INCREASED Afterload. We put people on ACEI & ARBS to decrease After-load. • ACEI & ARBS DILATE BLOOD VESSELS • ACEI also prevents remodeling of the heart muscle (ie: thickening or stretching out)

Now skip to page 751 & read Patient & Caregiver Teaching related to Drug Therapy Know about what to teach about:

DRUGS MAY DECRESE OVER TIME - Orthostatic Hypotension = PT FEEL DIZZY,WEAK,FAINT MOVING UP RIGHTT - Sexual Dysfunction= MAJOR REASON MEN STOP /CHANGE MEDS - Frequent Voiding from diuretics= TAKE EARLY IN THE DAY /PREVENT FREQUENCY AT NIGHT

What are good sources of Omega 3 Fatty Acids and AHA's and what are good sources for that?

FATTY FISH TWICE WEEK SAMON&TUNA TOFU,SOYBEAN,CANOLA,WALNUT

What are good sources of Monounsaturated Fats? (See picture page 769

FISH OIL OIL (CANOLA,PEANUT,OLIVE) AVOCADO NUTS(ALMONDS,PEANUTS) OLIVES(GREEN& BLACK)

We will go over important points about the following drugs in class:

GOAL LESS THEN 140/90 Diuretics= risk hypokalemia THIAZIDE LOOP DIURETICS= moitor orthostatic hypotension POTASSIUM SPARING ALDOSTERONE RECEPTOR BLOCKER B-Adrenergic Blockers = reduces BP decrease renin secretion could cause bronchospasm, monitor pulse&BP bronchospasm /asthma ACEI: Angiotensin Converting Enzyme Inhibitor= vaso constricton Asprin & NSAIDS reduce drug effects may cause COUCH ARBS: Angiotensin II Recepter Blockers= increase vasodilation ,salt &water excretion MAY NOT WORK 3-6 WKS GIVE WHEN PEOPLE GET COUGH FROM ACE Calcium Channel Blockers= block movment of extracellular calcium into cells, causing vasodilation & decreased heart rate ,contractility & SVR CAUTION W HEART FAILURE DONT EAT GREATFRUIT

o What is "White Coat" hypertension? If someone has this, what should the nurse have him do?

HYPERTENTION DUE TO STRESS GOING TO DOCTOR MOITOR BP AT HOME

...PCGTG: Anticoagulant Therapy (P. 890; T. 38-13)

INR GREATER THEN 3.0 GOOD What do we teach our patients about? • S/S of Bleeding BLACK STOOL, COFFIE -GROUND VOMIT • Special instructions regarding shaving, brushing teeth USE ELECTIRIC SHAVER & BRUSH LIGHTLY • Food & drugs that interfere with Warfarin (Coumadin) GREENS INTERFER ANY THING HIGH VITAMIN K • What's the deal with Vitamin K and Coumadin, anyway? VITAMIN K IS ANTODITE FOR COUMADIN • Can people on Coumadin eat a lot of leafy green salads? NO HIGH IN VITAMIN K

Interventional Radiology

If a vessel is severely or completely occluded, they do a Femoral-Popliteal Bypass (Fem-Pop) to REVASCULARIZE. • Please see the picture of a Fem-Pop on page 877 & read the nursing care after a Fem-Pop under Acute Intervention P. 878-879 ASESS EXTREMITY EVERY 15 MIN THEN HR COLOR,TEMP,CAPILLARY REFILL ,PRESENCE PERIPHERAL PULSE.SENSATION& MOVEMENT ANY CHANGES CONTACT DR.

...

Important Points The heart is a PUMP that pumps out blood to the body. During a HEARTBEAT the heart contracts and squirts out (ejects) blood from the ventricles (big pumping chambers) and then it relaxes and the ventricles fill. So really the Heart is a pump. It pumps out blood to the rest of the body. In Heart Failure, the main problem is a PUMP failure. If you have atherosclerosis or hypertension, the heart has to work really hard to pump adequate blood (Cardiac Output = CO) through these narrowed vessels. All this work can damage the walls of the heart ("pump") and make them "stretchy-outy" or thick (hypertrophy). This can affect the cardiac output and blood can back-up! SYSTOLIC FAILURE: (p. 798) If the ventricles become stretched-out, the "pump" is not as effective so there is less cardiac output (meaning less blood to the body & its organs (kidneys, retina...). • In systolic dysfunction, the left ventricle has a hard time pumping out blood through the AORTA. This is because its walls are damaged (stretched out) and it doesn't have enough elasticity to generate enough pressure to pump out adequate blood through the AORTA. • Ejection Fraction (EF) is the percentage of blood that's pumped out of a filled ventricle with each heartbeat. Normal ejection fraction (EF) is 55% or greater.

1. What are the Healthy People goals for the Prevention of Heart Disease (CAD) (P. 766)

MATAIN A HEALTHY WEIGHT REDUCE SODIUM PHYSICAL ACTIVITY AVOID USE /EXPOSURE TO TOBACCO LIMIT DAILY ALCOHOL INTAKE 12 OZ BEER/4 OZ WINE/1 OZ HARD LIQUID

ORTHOSTATIC HYPOTENSION: (Last paragraph on p. 754-755)

USUALLY, HOLD BP Med before getting up to ambulate for the first time... UNLESS VERY HYPERTENSIVE What is it? HYPOVOLUME / LOW BLOOD PRESSURE How do we monitor for it?MESURE BP LYING,SITTING,STANDING ORTH What causes it? DRUGS,ACUTE ILLNESS,BED REST, (Did you know that Loop diuretics (Lasix), Thiazide diuretics and ACEI or ARBs are BIG culprits???? Do you know why? LOWER BLOOD PRESSURE • Home BP monitoring= MONITOR BP/WHITE COAT EFFECT DONT SMOKE,EXERCISE DRINK CAFFINE 30 MIN BEFORE FIRST THING IN MORING/BEFORE MEDS/ AT NIGHT BEFORE BED 2 READ EACH TIME/1 MIN INBETWEEN PCGTG T: 33-14 Please Teach someone about Hypertension by using the • Patient compliance

Nursing Implementation (P. 812-813) 1.

What are Core Measures for HF (T. 35-15)?

Diagnostic Studies (874-875) 5.

What is a Doppler? ULTRASOUND DETERMINE DEGREE OF BLOODFLOW 6. What is the Ankle-Brachial Index?(ABI) USING HAND HELD DOPPLER /MOITIOR BYPASS GRAFT PATENCY NORMAL (ABI) =0.91 TO 1.30 DCRESS WITH PAD

. Some patients in HF have SO MUCH FLUID RETENTION that they are on a FLUID RESTRICTION

What is the assessment (It's the "as evidenced by" symptoms.) and interventions for the following: • Fluid Overload (Excess Fluid Volume) DIURETICS I&OS MOITOR BREATH SOUNDS/POTASSIUM DAILY WEIGHT RESPITORY MOITOR STATUS OF(CVP,MAP,PAWP EDEMA • Impaired Gas Exchange MONITOR RATE,RHYTHM,DEPTH BREATH SOUNDS MONITOR INCREASE RESTLESSNESS,ANXIETY, OXYGEN /ADMINISTER.MONITOR SEMI-fOWER • Activity Intolerance REST& ACTIVITY(CALM) MONITOR PATIENT O2 CONTACT=OT/PT GOALS • Decreased Cardiac Output CHEAK PULSE,EDEMA,CAPILLARY REFILL COLOR,TEMP. MOITOR FLUID BALACE DAILY WEIGHT I&OS MOITOR DYSRHYTHMIAS ,SOB,FATIGUE,TACHYPNEA,ORTHOPNEA

Drug Therapy: Nitrates (P. 773-776)

What is the teaching regarding fast and long-acting Nitroglycerine? SHORT ACTING UNDER TOUGNE=3 MIN UNCHANGES SYMPTOMS IN 5 MIN GO TO HOSPITAL & LONG ACTING PATICH (NITRATES) • How can you tell if the nitroglycerine pills are inactive? SHOULD CAUSE A TINGLING SENSATION NO SENSATION OUT DATED • When should a patient call the EMS? IF IN FIVE MIN DOSENT WORK CALL (EMS) • What's the deal with Viagra & Nitroglycerine? Can you give Nitroglycerin if someone has taken Viagra? (NO) What can happen if you do this? there blood pressure becomes TOO LOW!! • What is the difference between short & long acting Nitrates? TABLET UNDER TOUNGE/PATCH • Can they be given together? YES • Which one would you give for a sudden onset of chest pain? FAST ACTING /UNDER TOUNGE • What are the main side effects of Nitrates & what do we teach our patients to do to relieve this? HR UP HEADACHES DIZZINESS FLUSHING MAY OCCUR ORTHOSTATIC HYPOTENSION • Where should you apply Nitroglycerin ointment? PLACED ON SKIN OVER FLATE MUSCULAR AREA FREE OF HAIR & SCAR

2. Ethnicity: (Pink BOX: P. 739) • Which ethnic group has the highest prevalence of Hypertension?

african American ,highest prevalence of hypertention in the world get at a young age then whites african women have higher incidence of hypertention then men higher morality rate related to hypertention than whites black& whites living in the southeasthern united states have higher incidence of hypertention african American produce less RENIN dont respond well to angiotensin inhibitors african american &asians have a higher risk of angioedema & converting enzyme inhibitor than whites Mexicans American lower level of awarness of hypertention & its treatments then other group les likely to recieve treatment for hypertention then whites & aferican americans mexican americans & native Americn lower rates of adequate blood pressure control then whites & afterican americans

6. What are the Risk Factors for Hypertension? (P. 742 T. 33-4)

age =SBP rises progressively with increase age alcohol= excessive alcohol intake is strongly associated w hypertention cigarette smoking = risk for hypertention & cardiovascular disease diabetes= could effect other organs too elevated serum lipids = increase cholesterol & triglycerides prime risk factor in atherosclerosis hyperlipidemia common in people with hypertention excess dietary sodium= high sodium gender= men have it more in young adult hood women after 55 menapuse family history= parent/siblings obesity= weight gain Ethnicity=african American 2x higher than in whites sedentary lifestyle= reguler physical activity can help control weight help decrese risk socioeconomic status=lower socioeconomic groups less educated stress=

Clinical Manifestations & Complications (P. 743)

blood vessels in various organs & tissues or to the increase work load of the heart symptoms secondary = fatigue,reduced activity,dizziness,palpitations,angina & dyspnea complications= targets organ disease occurring in the heart heart (hypertensive heart disease ) brain (cerebrovascular disease) peripheral vasculature (peripheral vascular disease) kidneys (nephrosclerosis ) eyes= (retinal damage)

When is BP the Highest? Lowest? Who are "Non-Dippers" and what does that mean?

bp highest in the moring gradualy decrease at night some people with hypertention dont show a normal nocturnal dip in bp referred as nondoppers

9. Ambulatory BP Measuring (P. 745):

white coat