Cardiovascular

DVT tests

-D-dimer: blood test would confirm the presence of fibrin degradation products from a clot. -Venography: Venography would visualize the clot with contrast. -Venous ultrasound: Venous duplex ultrasound is noninvasive and is the preferred test used to visualize the clot by placing a transducer over the vessels.

Left sided heart failure

-Left sided HF is when left ventricle doesn't pump efficiently and prevents body from receiving O2 rich blood. The blood backs up into your lungs instead, which causes shortness of breath and a buildup of fluid. -Left = lungs (and heart) -Crackles, increased HR, SOB, palpitations, dizzy, lightheaded, confused, restless, dry cough, dyspnea Fatigue, cyanosis, tachycardia Both left- and right-sided heart failure result in low cardiac output. Left-sided heart failure (formerly congestive heart failure) falls into two types: systolic (decreased contractility resulting in pulmonary congestion) or diastolic (inadequate ventricular filling). Interventions for both types of left-sided failure are the same. Right-sided heart failure may be caused by left-sided failure, myocardial infarction, or pulmonary hypertension. High-output heart failure, which is less common than left- and right-sided heart failure, is caused by excessive metabolic needs (sepsis). The nurse cares for a client with severe acute left-sided heart failure. The nurse includes which intervention in the care plan? Select All That Apply Administer dobutamine as prescribed. Inotropic medications are the most powerful way to increase heart contractility. Inotropic agents (dobutamine or milrinone) may be used when diuretics fail to improve clinical status. Reduce stress in the environment. The client needs to reduce physical and emotional stress to improve ventricular pump performance and reduce myocardial workload. Limit fluid intake to 1,500 mL daily. Fluid restriction may be included for clients with severe heart failure, especially when hyponatremia is present. A limit of 1,500-2,000 mL/day is typical. Administer furosemide as prescribed. First-line therapy generally includes a loop diuretic such as furosemide, which will inhibit sodium chloride reabsorption in the ascending loop of Henle. Diuretics reduce circulating blood volume, diminish preload, and lessen systemic and pulmonary congestion. NOT: Elevate the legs higher than the heart. Even though the legs may become edematous with a persistent left-sided failure, elevating the legs will increase venous return to the heart. This may worsen the client's condition. Frequent assessment to monitor changes in pulses, cardiac rhythm, vital signs, and symptoms allows for prompt intervention. Common dysrhythmias for clients with reduced cardiac output include premature atrial contractions, premature ventricular contractions, and paroxysmal atrial tachycardia. Changes in the ST segment may indicate myocardial ischemia from decreased coronary artery perfusion. The nurse cares for a client with left-sided heart failure. Which actions does the nurse implement? Select All That Apply--> all correct Assess peripheral pulses for strength and quality. Decreased strength of peripheral pulses is often found in clients with decreased cardiac output. A further decrease in pulses from baseline may indicate further cardiac failure. Pulsus alternans (changes in pulse strength with alternating beats) indicates severe heart failure. Document rhythm strips every shift. Cardiac rhythm strips should be documented at least every 8 hours and dysrhythmias reported for adequate cardiac management. Administer diuretic therapy as prescribed. Diuretics are commonly prescribed to promote the diuresis of accumulated fluid in clients with fluid volume overload. Assess heart rate every hour. Vital signs should be taken hourly and tachycardia reported. Tachycardia (increased heart rate) can increase myocardial and oxygen demands and may be a compensatory mechanism related to the decreased cardiac output (the decrease in stroke volume). Assessment for this can help in prompt intervention. Provide a low-sodium diet. Decreased systemic blood pressure can lead to stimulation of aldosterone, which leads to renal retention of sodium. A low-sodium diet is often prescribed to minimize water retention.

Corrigan pulse/water hammer pulse

-bounding arterial pulse assoc w/aortic regurgitation -Corrigan pulse is a bounding and forceful pulse with a rapid rise and sudden collapse. This is associated with increased stroke volume and a decrease in peripheral resistance.

Normal QRS complex

0.12 seconds (max)

Normal PR interval time

0.12-0.20 seconds longer time = first degree heart block (AV block)

pitting edema grades

1+= barely detectable with immediate rebound 2+= slight indentation, 15 sec rebound 3+= deeper indentation, 30+ sec rebound 4+= deep indentation, 2-5 minute rebound

Rhythms for cardioversion

1. A-Fib 2. A-Flutter 3. SVT 4. V-tach w/ pulse

Mean Arterial Pressure (MAP)

2 x DBP + SBP /3 normal: 70-105

normal cardiac output

4-8 L/min

Metabolic Syndrome (Syndrome X)

A cluster of conditions that increase the risk of heart disease, stroke, and diabetes. Metabolic syndrome includes high blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol levels.

echocardiogram

An echocardiogram (also called a diagnostic cardiac ultrasound) identifies heart position and size. It also provides information about heart structure and function, including blood flow. It uses harmless high-frequency sound waves (ultrasound) and usually takes about 45 minutes to complete. To alleviate client anxiety, it is important to convey that the procedure is noninvasive and painless.

anterolateral vs anteroposterior AED pad placement

Anterolateral: To the right of the sternum and To the left of the cardiac apex. -One pad should be placed just to the left of the cardiac apex in the anterolateral position. -One pad should be placed just to the right of the sternum, below the clavicle, in the anterolateral position. Anteroposterior: Over the left apex and Under the infrascapular region -The posterior pad should be placed under the infrascapular region in the anteroposterior position. -The anterior pad should be placed over the left apex in the anteroposterior position.

cardiac ablation (catheter ablation)

Cardiac ablation usually uses long, flexible tubes (catheters) inserted through a vein or artery in your groin and threaded to your heart to deliver energy in the form of heat or extreme cold to modify the tissues in your heart that cause an arrhythmia. Catheter ablation is a procedure used to remove or terminate a faulty electrical pathway from sections of the hearts of those who are prone to developing cardiac arrhythmias such as atrial fibrillation, atrial flutter, supraventricular tachycardias and Wolff-Parkinson-White syndrome.

sepsis signs and symptoms

Chills and fever, shaking, rapid breathing and pulse, confusion, and anxiety If shock develops, drop in urine output, bruising, and bleeding and organ failure

Beta-blockers and asthma

Contraindicated in hx of asthma. -Evidenced by new onset of dry, non-productive cough

exercise-induced angina

Exercise-induced angina can be managed properly with an exacerbation plan in place. The plan describes the steps necessary to help in the reduction of angina pain. Once angina pain is noticeable, it is recommended to stop the exercise, as it could cause further injury or pain. It is then recommended to rest and allow the body time to get adequate oxygen to the vessels and heart. After rest, if angina pain persists, it is recommended to take prescribed medications per healthcare provider guidelines. If angina pain persists after rest and medication, it is recommended to notify a healthcare provider for guidance.

Thromboangiitis obliterans (Buerger disease)

Inflammation and thrombosis of the vessels of the distal hands and feet, resulting in ischemia and gangrene. -Smoking related condition

primary hypertension risk factors

Nonmodifiable- Family history Age Modifiable- Dietary factors Sedentary lifestyle Obesity Metabolic syndrome (includes high blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol levels.)

Raynaud Syndrome and Disease

Raynaud syndrome is a vasoconstrictive disorder typically affecting the fingers and toes. It leads to impaired perfusion. An episode can last minutes to hours. Signs and symptoms include diminished peripheral pulses, pallor, numbness in the extremities, brittle fingernails, thin skin, and cyanosis. Vasospasm is believed to be an autoimmune response and is triggered by exposure to cold or stress. It will resolve once the trigger is removed. Clients are taught to avoid triggers such as exposure to cold, smoking, and medications that decrease peripheral circulation. They are also taught to protect their fingertips. A client with Raynaud syndrome is admitted to the hospital. Which clinical manifestations does the nurse expect to assess? Select All That Apply Blue discoloration of fingers An episode is marked by skin color changes. The color begins with white and progresses to blue and purple as blood vessels constrict. Brittle fingernails Chronic vasoconstriction can impede the transport of nutrients to distal tissue. Pale extremities An episode is marked by skin color changes. The color begins with white and progresses to blue and purple as blood vessels constrict. Numbness in the hands Severe vasoconstriction results in reduced sensation in the affected extremities. NOT: Thickening of the skin Thickening of the skin is a sign of scleroderma or connective tissue disorders.

ECG changes in MI

T wave inversion = ischemia ST segment elevation = injury abnormal Q wave = necrosis ST depression = subendocardial infarct

Afterload

The amount of resistance the heart must overcome to open the aortic valve and push the blood volume out into the systemic circulation

pulse deficit

The difference between the rate of an apical pulse and the rate of a radial pulse. Common in A-fib due to low stroke volume bc ventricles don't have time to stretch and fill.

coronary artery disease (CAD)

a condition affecting arteries of the heart that reduces the flow of blood and the delivery of oxygen and nutrients to the myocardium; most often caused by atherosclerosis

secondary hypertension

high blood pressure caused by the effects of another disease (known cause of hypertension) ex: kidney disease Secondary hypertension has identifiable causes, including (but not limited to) medications, renal disease, Cushing syndrome, hyperthyroidism, hyperaldosteronism, pheochromocytoma, obstructive sleep apnea, and coarctation of the aorta (especially in children).

intermittent claudication

pain and discomfort in calf muscles while walking; a condition seen in peripheral arterial disease

Atrial Flutter

-"saw tooth" shaped F waves between QRS of groups of 3:1 or 4:1. Not real P waves. Not measurable -regular rhythm -60-180 bpm -narrow QRS -Atrial flutter is treated with the same medications used for atrial fibrillation, or it resolves spontaneously. Atrial flutter is an abnormal cardiac rhythm characterized by rapid, regular atrial depolarizations at a characteristic rate of 300-600 beats/min. These atrial beats are followed by a regular or irregular ventricular response of about 150 beats/min. Atrial flutter can lead to symptoms of palpitations, shortness of breath, fatigue, lightheadedness, and syncope. Rapid atrial arrhythmias increase the risk of thrombus formation that may travel to the lungs and cause pulmonary embolism. The nurse in the cardiac unit receives a report from the emergency department about a client with mild dyspnea and persistent atrial flutter. Which intervention does the nurse anticipate for treatment? Select All That Apply Administration of heparin as prescribed Administration of IV heparin or subcutaneous enoxaparin is administered for anticoagulation to reduce the risk for systemic embolization for clients with persistent atrial tachycardias. IV diltiazem Administration of an IV calcium channel blocker such as diltiazem or verapamil or a beta blocker such as metoprolol is used to slow the heart rate. Radiofrequency catheter ablation Catheter ablation, the definitive treatment for these symptoms, eliminates the irritable foci generating the abnormal impulses. It may be used electively when other treatments fail to convert the abnormal rhythm, but it is not anticipated until other therapies fail. NOT: Emergent cardioversion Cardioversion, a synchronized counter low-energy shock, may be needed if medications fail to convert the abnormal rhythm to sinus rhythm or slow the rate. Emergent cardioversion is indicated for unstable clients with rapid tachycardia. Carotid massage Carotid massage is an initial intervention that may be attempted when the client arrives for medical care. For atrial flutter that persists, the nurse anticipates medications to slow the rapid rate.

Supraventricular Tachycardia (SVT)

--Supraventricular tachycardia (SVT) is an atrial tachycardia caused by an abnormal impulse above the bundle of His, typically in the atria or near the atrioventricular node (AV). -When intermittent, SVT is termed paroxysmal (PSVT). PSVT may begin with a premature atrial complex due to irritability. The ventricular response (QRS complexes) is rapid and unpredictable but usually regular. It may start and stop suddenly, may occur in healthy individuals, and is the most common arrhythmia in children. -PSVT triggers include excess alcohol consumption, stress or extreme emotions, caffeine, hyperthyroidism, digitalis toxicity, hypokalemia, coronary artery disease, myocardial infarction, cardiomyopathy, or cor pulmonale (right ventricular enlargement due to pulmonary hypertension). -PSVT can lead to symptoms of palpitations, bounding pulse, shortness of breath, fatigue, angina, and lightheadedness. -Treatment focuses on eliminating these factors to restore a tolerable heart rate. -Significant symptoms may indicate the need for vagal maneuvers (carotid massage, Valsalva maneuver) or require AV nodal blocker medications to interrupt the fast rate and restore sinus rhythm. -Other common atrial tachycardias include sinus tachycardia, atrial fibrillation, and atrial flutter. -Regular rhythm, rate: 150-250, narrow QRS, difficult to detect P waves bc buried in QRS. A nurse applies a cardiac monitor to a client with paroxysmal supraventricular tachycardia (PSVT). Which factors can contribute to the development of this rapid rhythm? Select All That Apply Extreme emotions Emotional stress and agitation can trigger an episode of PSVT. Coronary valve disease Coronary valve disease, heart failure, and conditions that lead to atrial stretch can affect the atrial tissue and increase the risk for PSVT. Smoking cigarettes Heavy smoking is a known trigger for PSVT. NOT: Hyperkalemia Hyperkalemia is not associated with PSVT. It is more likely to result in sinus bradycardia or heart block. Hypothyroidism PSVT is more common in hypermetabolic states such as hyperthyroid disease.

Abdominal Aortic Aneurysm (AAA)

-An AAA is defined by a vessel diameter of at least 3 cm. The aortic vessel wall weakens due to hereditary factors, atherosclerosis, trauma, infection, or other disorders. Aneurysms can develop gradually and may be asymptomatic until the vessel diameter enlarges to the point that surrounding structures are compressed. During an AAA repair, a stent graft is placed in the aorta to support the lumen and reduce pressure on the aneurysm sac. -complication: scant urine --> stent graft could block renal arteries

aortic stenosis

-Aortic stenosis refers to the narrowing of the aortic valve. It causes reduced cardiac output and increased left ventricle pressure. It is often asymptomatic until narrowing is pronounced. -Hallmark signs for aortic stenosis are heart failure (dyspnea on exertion symptoms), anginal pain, and syncope. -With exertion, the heart cannot increase cardiac output because of a narrow aortic valve. This can cause syncope due to insufficient perfusion to the brain when it needs the extra oxygen. -Aortic valve stenosis is best heard over the second intercostal space at the right sternal border.

Atrial Fibrillation (A-Fib)

-Atrial fibrillation is an arrhythmia. The normal cardiac pacemaker is not functioning properly, and rapid impulses are transmitted to the atria, resulting in ineffective contractions. -The ventricles contract too rapidly or ineffectively, decreasing cardiac output. Uncontrolled atrial fibrillation occurs when the heart rate is too fast to maintain adequate perfusion. -Immediate intervention is required to restore cardiac output. -Can lead to thrombus formation

Endocarditis - signs and symptoms

-Common signs and symptoms of infective endocarditis include fever, malaise, dyspnea, murmur, weight loss, splinter hemorrhages, Janeway lesions, and Osler nodes. -Infective endocarditis is prevalent among IV drug users as a result of contamination and bacteria entering the bloodstream. -Other risk factors are rheumatic fever, history of heart valve replacement, or dental procedures.

Percutaneous Cardiac Intervention (PCI)

An invasive revascularization procedure done in the acute phase of myocardial infarction by placing a stent (mesh device to keep patency) in an occluded coronary artery. The most common PCI is an angioplasty (balloon) A nurse cares for a client for 4 hours of post-percutaneous coronary intervention (PCI). The nurse includes which assessments to best identify the most common complications of PCI? Select All That Apply Observation of the access site A common complication is hematoma formation at the site where the artery was accessed for the PCI. If a hematoma is noted, additional pressure should be applied to promote hemostasis. Discomfort or pain report A serious complication of PCI is myocardial infarction; frequent assessment for chest pain or pressure, as well as increasing pain at the access site, is indicated. Electrocardiogram tracings Arrhythmias may develop after PCI, and the client should be monitored via telemetry per facility policy. NOT: Pulse oximetry levels Although pulse oximetry is monitored as part of routine vital signs, respiratory complications are not expected with PCI. Because the access site is an artery, any emboli that may develop puts the client at risk for limb ischemia distal to the access site and cannot lead to pulmonary emboli, which originate in the venous system. Current WBC count Infection is a rare complication of PCI; the WBC is not a priority assessment in the first 4 hours.

Digoxin toxicity

-GI effects (anorexia, n/v, abdominal pain) -CNS effects (fatigue, weakness, diplopia, blurred vision, yellow-green or white halos around objects) -Arrhythmias, AV block -Premature ventricular contractions or episodes of ventricular tachycardia are the most common ECG abnormality seen in early digoxin toxicity. -Bradycardia is a late symptom. -Can lead to hyperkalemia, which indicates poor prognosis. -Therapeutic: 0.8-2.0, toxic: >2.4 ng/mL Digoxin is used as a long-term treatment for certain types of HF. The drug affects the transport of sodium to and from cells in the myocardium, resulting in stronger contractions (positive inotrope). Digoxin also delays the electrical impulse from the sinoatrial node and slows conduction through the atrioventricular node, resulting in a slower rate. Digoxin is also used to treat atrial fibrillation. Evidence suggests that digoxin affects baroreceptors in the heart, decreasing vagal tone. These actions can benefit clients with HF symptoms. Electrolyte abnormalities greatly increase the risk for toxicity, so diuretics that can cause imbalances or renal insufficiency can increase risk. Renal functions and possible drug interactions should be reviewed. A client taking spironolactone daily is prescribed digoxin for the treatment of heart failure (HF). Which response by the client indicates an understanding of the medication regimen? Select All That Apply "I should report seeing halos or rings of light." Visual changes are some of the clinical manifestations of digoxin toxicity, and the healthcare provider should be notified. "My radial pulse rate should decrease." Clients are taught to assess heart rate daily before taking a dose of this drug. A decrease in heart rate is expected. Clients are often advised to contact the healthcare provider before taking their dose if their pulse is less than 60 beats/min. "I should seek medical care if I experience palpitations." Palpitations indicate irregular heartbeat or rapid rate and can indicate digoxin toxicity. The cardiac manifestations of digitalis toxicity can include virtually any type of arrhythmia with the exception of rapidly conducted atrial arrhythmias. "Spironolactone may affect my digoxin blood level." In clients taking spironolactone, a potassium-sparing diuretic, hyperkalemia and digitalis toxicity may result even at low serum digoxin levels. This drug may also interfere with tests for measuring digoxin levels in the blood. NOT: "Digoxin toxicity is a rare issue." Digoxin preparations have a narrow window of therapeutic efficacy, and toxicity from digitalis is common.

Atrial Flutter Treatment

-Give anticoagulants (faster the HR, more risk for thrombus) --> IV Heparin or Subcutaneous enoxaparin -treat underlying cause -digoxin (slows rate by enhancing AV block) -Quinidine (supresses atrial ectopic block) -Amiodarone -Calcium Channel Blockers (Cardizem)/Beta Blockers (-olol) -radiofrequency catheter ablation -consider cardioversion --> emergent: Cardioversion, a synchronized counter low-energy shock, may be needed if medications fail to convert the abnormal rhythm to sinus rhythm or slow the rate. Emergent cardioversion is indicated for unstable clients with rapid tachycardia.

Activated partial thromboplastin time (aPTT)

-Normal: 30-40 seconds -aPTT is a lab value that estimates how long it takes (in seconds) for blood to clot. The greater the aPTT value, the longer it takes blood to clot and the greater the risk for bleeding. Although lab reference ranges vary, Mosby's normal value range for this test is 30-40 seconds. -For anti-coagulant therapy, the reference range is 1.5-2.5 times the control value

Pulmonary Capillary Wedge Pressure (PCWP)

-PCWP is used to measure left ventricular failure or the severity of mitral valve stenosis. Both conditions would elevate left arterial pressure, which would elevate the PCWP. -PCWP also provides an indirect measurement for left atrial pressure. -PCWP provides an indirect measure of the left ventricular end-diastolic pressure (the left ventricular preload). An elevated PCWP is indicative of left ventricular heart failure

Prinzmetal angina

-Prinzmetal angina, also known as vasospastic angina, is characterized by recurrent chest pain that often occurs at rest, typically at night. It is caused by vascular smooth muscle vasospasms and leads to narrowing of the coronary arteries and ischemia. It is more common in clients younger than 50 years. It typically has a gradual onset and subsides gradually. Episodes usually last 5-15 minutes but may be longer. -Triggers: emotional stress, cold weather -Smoking a cause? of course, always.

Complications of MI

-Sudden cardiac arrest due to ischemia, left ventricular dysfunction, and electrical instability -Heart failure -decreased CO -dysrhythmias

Ankle-Brachial Index (ABI)

-The formula for ankle brachial index (ABI) is the greatest (systolic) BP of the ankle (measured at the dorsalis pedis or posterior tibial arteries) divided by the (greatest) systolic pressure in the arms. It is measured on both sides. -The normal or acceptable ABI range is 0.9-1.4. A ratio less than 0.9 indicates PVD. -Clinical findings suggesting the presence of PVD include a history of angina with activity, intermittent claudication, and abnormal (weak or absent) pedal pulses.

premature ventricular contraction (PVC)

-The prevalence of PVCs increases with age and in people with underlying structural heart disease. PVCs may also occur in response to electrolyte imbalance, hypertension, heart failure, and cardiomyopathy. Chronic pulmonary conditions such as chronic obstructive pulmonary disease may also cause PVCs. -PVCs do not usually cause symptoms, although some clients may experience palpitations or dizziness if many PVCs occur together. Serious ventricular arrhythmias may develop in someone with frequent PVCs, which may indicate irritability of the heart muscle. -When several PVCs occur together, cardiac output will decrease. When sustained, this pattern can lead to ventricular tachycardia or ventricular fibrillation. -Wide QRS and no visible P wave, PVC occurs before QRS is expected Continue to monitor the client's rhythm. Isolated PVCs are common in people with underlying heart disease. They are not life-threatening but should be monitored closely for rhythm changes. Premature ventricular contractions (PVCs) is an abnormal or wide QRS complex that occurs in the cardiac cycle before the QRS is expected. They are extra heartbeats that initiate in one of the two ventricles of the heart and cause a disruption in the regular heartrate. The client may feel like the heart flutters or skips a beat. PVC frequency may increase with anxiety, stress, alcohol use, stimulant medication, hypoxia, or electrolyte abnormalities. PVCs are common in older adults and clients with underlying heart disease. They may occur sporadically or at regular intervals with predictable patterns. They may occur with every other beat (bigeminy) or every third beat (trigeminy).

Second degree AV block

-The primary concern when a client has second-degree heart block is progression to third-degree block or bradycardia severe enough to decrease cardiac output to a level that impairs vital organ perfusion (a mean arterial pressure of less than 60 mm Hg). -Heart block occurs when no atrial impulse is conducted through the atrioventricular (AV) node into the ventricles. This is why heart block is also called AV block. P waves may be seen, but the atrial electrical activity is not conducted to the ventricles to stimulate the usual QRS complex. -If the client becomes symptomatic for organ dysfunction (experiencing presyncope), the nurse should take immediate action. This would include lowering the head of the bed, ensuring IV access, and notifying the healthcare provider for prescriptions of medications or transcutaneous pacing. -Progressively longer PR intervals

Third degree AV block (complete heart block)

-Third-degree (complete) heart block occurs when the atria and ventricles contract independently. The QRS complex may appear normal or widened, depending on where ventricular electrical conduction occurs. -Third-degree (complete) heart block occurs when there is no communication between the ventricular and atrial conduction systems. The PP and R to R intervals are regular because the rhythm of each chamber is regular; the chambers just don't communicate with each other. The PR intervals vary because the P waves are not "in sync" with QRS. -Finally, the QT interval is prolonged, causing a bradydysrhythmia. -20-55 bpm -usually wide QRS -regular rhythm with "AV dissociation" -P waves are present but dissociated from QRS

Ventricular tachycardia (V-tach)

-Ventricular tachycardia is indicated by wide QRS waveforms, the absence of P waves, and an elevated rate greater than 100 beats/min. -When ventricular tachycardia is intermittent, the client may be awake and alert but have altered mental status, shortness of breath, and chest pain. -Clients in ventricular tachycardia may also be unresponsive. -Sustained ventricular tachycardia is an emergent situation. -A low potassium level can cause ventricular irritability, which may lead to ventricular arrhythmias. -Cardioversion if pulse, pulseless is defibrillation If a client becomes pulseless during synchronized cardioversion, immediate unsynchronized defibrillation should occur. When the client is already hooked up to a defibrillator, the nurse does not delay immediate defibrillation. After the defibrillation, the nurse immediately starts CPR. The nurse cares for a client with unstable ventricular tachycardia (VT) who is undergoing immediate synchronized cardioversion. What is the nurse's priority action when the client becomes pulseless with VT after the initial cardioversion? Initiate unsynchronized defibrillation. The nurse initiates immediate, unsynchronized defibrillation if the client becomes pulseless during synchronized cardioversion. NOT: Prepare to administer magnesium sulfate. Using magnesium sulfate is not the priority action when a client become pulseless during synchronized cardioversion. It may be considered for polymorphic VTs, especially if torsades de pointes is suspected. Initiate transcutaneous pacing. Transcutaneous pacing will not be performed if a client becomes pulseless during synchronized cardioversion. It may be used for a client with symptomatic bradycardia with a pulse, a symptomatic junctional rhythm with a pulse, or symptomatic second- or third-degree heart block with a pulse if other interventions are unsuccessful. Synchronize the precordial shock. If a client becomes pulseless during synchronized cardioversion, is not appropriate to synchronize the shock again. Pulseless VTs and fibrillations require unsynchronized cardioversion.

cardiac catheterization

-a diagnostic procedure in which a catheter is passed into a vein or artery and then guided into the heart -During a cardiac catheterization, the client may feel warmth, flushing, a fluttery feeling, palpitations, or a desire to cough. These symptoms are from the injection of dye and the catheter passage.

Tachydysrhythmias

-abnormally fast cardiac rhythms -Interventions for clients with tachydysrhythmias include the following: --Planning rest periods to minimize fatigue and activity intolerance --Documenting response to antiarrhythmic medications --Monitoring for dyspnea --Instructing the client to report chest discomfort --Offering tools for stress reduction and spiritual support The nurse manager teaches a new nurse how to care for clients with tachydysrhythmias on the cardiac unit. Which response by the new nurse indicates the need for further education? Select All That Apply "Activity intolerance should be reported to the healthcare provider." Clients with tachydysrhythmias are expected to have some intolerance to activity. This is a common symptom resulting from decreased cardiac output. Often, clients are prescribed bed rest until the rhythm resolves. They should have assistance with ambulation. More importantly, the nurse should monitor for changes in this clinical condition and report it, particularly if dyspnea worsens on exertion. "After an ECG is evaluated, I do not need to monitor the rhythm." A client with tachydysrhythmias requires continuous cardiac monitoring until the healthcare provider prescribes discontinuation. "I should assess vital signs every 8 hours." Vital signs should be recorded at least every 4 hours and as needed. OK: "Monitoring serum electrolyte levels is important." Labs routinely monitored for this client include cardiac enzymes and electrolytes. "A focused assessment includes capillary refill and extremity temperature." Best practice when caring for clients with dysrhythmias includes assessment of peripheral circulation.

Myocardial infarction (MI) complications

-pericarditis (presents as a pericardial friction rub) --> cardiac tamponade. May occur within 3 days after MI. Common complications of MI include dysrhythmias and decreased cardiac output. The degree of risk will depend on the size and location of the infarction. Assessment for evidence of heart failure focuses on fluid volume status with the most life-threatening complication of left-sided heart failure being acute pulmonary edema. Often the client will be placed on telemetry after the MI. The nurse should assess apical rate and rhythm in addition to monitoring telemetry because of the high risk for mortality post-MI secondary to dysrhythmias. The nurse cares for a client who was diagnosed with acute myocardial infarction (MI). The nurse incorporates which assessments as part of monitoring for common complications of MI? Select All That Apply Lung auscultation The client may be at risk for left-sided heart failure if the MI affected enough of the left ventricle. The nurse should auscultate the lungs because of the risk for pulmonary edema related to decreased cardiac output and the resulting increase in pulmonary capillary pressures. Apical heart rate Cardiac arrhythmias are the most common complication associated with an MI due to the interruption of the normal cardiac conduction from tissue ischemia and inflammation. Dysrhythmias are a common cause of post-MI mortality and should be assessed for by the nurse. Daily weight Daily weight helps determine if the client is experiencing fluid retention related to decreased cardiac output and the activation of the renin-angiotensin-aldosterone system and antidiuretic hormone release. A gain of more than 3 pounds in 24 hours is evidence of fluid volume excess. NOT: Cognitive assessment Cognitive impairment is not an expected or common complication of MI. An example of a cognitive assessment is the Mini Mental Status Examination. A cognitive assessment is more specific than assessing the spheres of orientation or level of consciousness. Residual urine volumes Residual urine volumes are done to determine if a client has urinary retention, which is not associated with MI.

SIRS (Systematic inflammatory response syndrome) criteria

2/4 of the criteria Temp > 38.5 (101.4F) or < 35 (95 F) Pulse > 90 Resp > 20 WBC > 12,000, < 4000, > 10% bands Sepsis: SIRS criteria + infection

normal BP range

90/60 to 120/80

S3 heart sound

An S3 heart sound can occur normally in people younger than 40 and in athletes. Later in life, it may indicate heart failure (ventricular dysfunction) or fluid overload. The nurse performs auscultation of heart sounds for a client admitted with congestive heart failure. How does the nurse interpret an extra sound with a very low pitch immediately after the second heart sound? Third heart sound (S3) S3 occurs immediately after S2. It has a very low pitch compared to S2 and has been described as a ventricular "gallop." NOT: An aortic valve murmur A murmur due to aortic regurgitation has a high pitch and is described as a decrescendo during early diastole. Split S2 Split S2 is when the pulmonary valve closes slightly after the aortic valve. This normally occurs on inspiration due to the increased pressure in the pulmonary circulation. It may also be caused by septal defects, pulmonary stenosis, or other abnormalities. Split S1 A split S1 occurs when the closure of the mitral valve is slightly delayed. This is caused by a dysfunction in conduction.

intra-aortic balloon pump (IABP)

An intra-aortic counterpulsation device. It may be used as an invasive intervention to improve myocardial perfusion during an acute myocardial infarction, reduce preload and afterload, and facilitate left ventricular ejection. It is also used when patients do not respond to drug therapy with improved tissue perfusion, decreased workload of the heart, and increased cardiac contractility. The IABP works by inflating a balloon inside the descending aorta during diastole to displace blood and increase perfusion to the coronary arteries and improve cardiac output. During systole, the balloon rapidly deflates, reducing aortic volume through a vacuum effect and lessening the workload of the heart (decreased afterload). An IABP is especially useful following MI. Another absolute contraindication for IABP is aortic dissection. The balloon could dissect the aorta completely if inflated inside the aorta. A client arrives in the emergency department with cardiogenic shock from myocardial infarction (MI). The nurse considers which condition to be an absolute contraindication to an intra-aortic balloon pump (IABP)? Severe aortic regurgitation Absolute contraindications to an IABP include significant aortic regurgitation. The degree of aortic regurgitation would be increased by the counterpulsation, pushing blood back into the left ventricle through the aortic valve each time the balloon inflates. NOT: Severe hypertension A hypertensive crisis is not a contraindication to an IABP. Cardiogenic shock is life-threatening, and immediate life-saving intervention takes priority over risk from hypertension. Hypertension is not expected when shock is present. Abdominal aortic aneurysm Abdominal aortic aneurysm is a relative contraindication, and the IABP can be used with caution. Peripheral arterial disease Peripheral vascular disease is a relative contraindication, but the IABP can be used with caution. Vascular complications are the major risk associated with its use.

congestive heart failure (CHF)

Chronic congestive heart failure can easily exacerbate and decompensate. Exacerbations arise from from infections, arrhythmias, hypertension, anemia, hyperthyroidism, hypothyroidism, inadequate diet, and use of nonsteroidal anti-inflammatory drugs. Diabetes is a known risk factor for heart failure. The nurse questions a client with acute exacerbation of heart failure about recent medical history and medication usage. The nurse recognizes that which medications or conditions may contribute to this client's exacerbation of heart failure? Select All That Apply Anemia Anemia, if severe enough, may cause high-output heart failure, where the heart cannot meet the body's oxygen requirements. High-output heart failure is less common than other types of heart failure. Daily ibuprofen use Ibuprofen, a nonsteroidal anti-inflammatory drug, may contribute to retention of sodium and water. The increased workload on the heart may exacerbate heart failure. Daily metformin use Diabetes is a known risk factor for heart failure. The nurse assesses the client for taking antidiabetic medications, including insulin and metformin, when admitting the client with exacerbation of heart failure. Hyperthyroidism Both hyperthyroidism and hypothyroidism place the client at increased risk of exacerbation of heart failure. NOT: Irritable bowel syndrome Irritable bowel syndrome is not known to contribute to heart failure exacerbations.

Chronic hypertension

Chronic hypertension typically does not produce symptoms for many years. Over time, damage to small vessels in the kidneys, heart, brain, and eyes produce changes in normal function of end organs, producing clinical signs that indicate tissue damage. A nurse assesses a client with chronic hypertension. Which signs does the nurse identify as a chronic complication of hypertension? Select All That Apply Dyspnea at rest Dyspnea at rest is associated with congestive heart failure. High blood pressure contributes directly to the development of congestive heart failure by increasing the heart's workload and leading to thickening of the ventricle walls. Protein in urine Proteinuria and albuminuria are early indicators of renal injury, a serious complication that can be caused by chronic hypertension. High pressures damage the kidneys' ability to filter toxins, and evidence of this damage is seen as proteins leak out into the urine. Leg pain when climbing stairs Peripheral artery disease is a complication of hypertension in which plaques in leg arteries and hardened vessel walls compromise blood flow to the legs. The condition causes pain, aching, or heaviness in the legs, feet, and buttocks after activity. NOT: Vomiting Nausea or vomiting may indicate acutely increased intracranial pressure. Although this life-threatening condition may result from severe hypertension, it is not a sign of chronically elevated blood pressure. Weakness Weakness may be an adverse effect of certain medications used to treat hypertension, but it is not commonly associated with chronic hypertension.

Wolf Parkinson White Syndrome (WPW)

WPW syndrome is a congenital condition in which abnormal myocardial conducting tissue or an "accessory pathway" directly connects the atria and ventricles, allowing electrical activity to bypass the atrioventricular node. This results in an unpredictable excitatory state in which rapid atrial rates may result in tachycardia as extra impulses pass to the ventricles. The ultimate risk to the client is development of ventricular fibrillation and sudden cardiac death. Ablation of the accessory pathway tissue is the preferred treatment. Wolff-Parkinson-White (WPW) syndrome is a condition in which there is an extra electrical pathway in the heart that leads to periods of rapid heart rate (tachycardia). WPW syndrome is one of the most common causes of fast heart rate problems in infants and children. The nurse admits a client for telemetry monitoring due to suspected Wolff-Parkinson-White (WPW) syndrome. Which ECG findings does the nurse report as supporting WPW syndrome? Select All That Apply Tachycardia Tachycardia is typical of WPW syndrome because of extra atrial impulses being passed to the ventricles. Widened QRS complex There is a shorter refractory period and greater pre-excitation in WPW syndrome, leading to widening of QRS complexes. Clients with very short refractory periods and rapid atrial fibrillation are at greater risk for degeneration to ventricular fibrillation. Short PR interval A client with WPW will demonstrate a short PR interval because of the bypassing of the atrioventricular node. NOT: Peaked T waves Peaked T waves are not typical of WPW syndrome. They are associated with conditions such as hyperkalemia and sometimes seen in early myocardial infarction. Inverted T waves Inverted T waves are not typical of WPW syndrome, but they can be present in many conditions affecting the myocardium (including ischemia).

DVT interventions

bed rest w/ minimal activity, bedside commode elevate legs up 6-8 inches warm compress intermittently thigh high or anti-embolism stockings, compression devices (if DVT present, only apply these to Unaffected leg) NEVER massage affected limb Promote blood flow Administer Meds (comp-bleeding) - LOW MOLECULAR WT HEPARIN, WARFARIN, ANALGESICS -Thrombolytic therepy- must be initiated within 5 days Research does not support the idea that ambulation increases the risk of developing a pulmonary embolism in clients with a DVT. That said, the current recommendation is to rest the affected limb and avoid frequent ambulation during recovery. Although gentle palpation to assess for pitting edema is acceptable, avoid massaging the affected limb. The most common venous thromboembolism is a DVT. Clients on bed rest for more than 3 days are at increased risk for DVT. When the nurse plans interventions for a client with a deep vein thrombosis (DVT) who has been on anticoagulation therapy for 2 days, which interventions are included? Select All That Apply Elevate the affected leg. Rest and elevation are appropriate nursing interventions when caring for a client with a venous thromboembolism. Wear compression stockings. Graduated compression stockings are recommended for those at risk for or with a resolving DVT. Apply heat to the affected leg. Applying warm, moist heat increases client comfort, promotes healing, and is an appropriate (if underutilized) nursing intervention when caring for a client with a venous thromboembolism. Moist heat decreases overall inflammation, decreasing the damage to the extremity and possibly reducing inflammatory processes and stasis that contribute to the clot itself. Just as recent evidence suggests ambulation is safe after anticoagulation has begun, relieving the pain of the clot is safe after anticoagulation has begun. Additionally, this action keeps circulation going past the clot so that the extremity distal to the clot maintains circulation. Administer pain medication. Treating pain as prescribed is an appropriate nursing intervention when caring for a client with a venous thromboembolism. NOT: Ambulate frequently. Clients should be advised to ambulate as needed, but frequent ambulation does not allow for rest and elevation, which are recommended.

spleen function

it fights invading germs in the blood (the spleen contains infection-fighting white blood cells) it controls the level of blood cells (white blood cells, red blood cells and platelets) it filters the blood and removes any old or damaged red blood cells.

Rhythms for defibrillation

v-tach pulseless v-fib

dysrhythmias

• Normal intrinsic impulses can be altered or interrupted for many reasons, including drugs, increased vagal tone, node tissue damage, congenital defects, and other conditions.• Some dysrhythmias are life-threatening, but not all.• Normally, an impulse is generated by the sinoatrial (SA) node, travels to the atrioventricular (AV) node, and then to the ventricles. If the SA node fails to generate an impulse, the AV node should take over pacemaker function. A nurse educator trains a new nurse on the cardiac unit. Which response by the nurse demonstrates understanding about conduction disturbances? Select All That Apply "The sinoatrial (SA) node is the pacemaker of the heart." The SA node (or sinus node) is the intrinsic pacemaker of the heart. It possesses the highest level of automaticity and is located at the top of the right atrium. "Dysrhythmias can result from myocardial defects." Dysrhythmias can occur due to disturbances from the three mechanisms of the heart: automaticity, conduction, or impulse re-entry. The conduction system, for example, is within the myocardium. A defect in the myocardium can lead to an abnormal heart rhythm. NOT: "Conduction disturbances do not cause death." Dysrhythmias can severely decrease the heart's ability to pump effectively, even causing death. "The most serious complication of a dysrhythmia is myocardial infarction." The most serious complication of dysrhythmia is not myocardial infarct. The most serious complication of a dysrhythmia is asystole, or cardiac death. "Sinus rhythm is initiated by the atrioventricular (AV) node." The sinoatrial node is regulated by the nervous system through the vagus nerve.

septic shock

sepsis and uncontrollable decreased blood pressure

aortic regurgitation

(aortic insufficiency) incompetent aortic valve that allows backward flow of blood into left ventricle during diastole

Hypertensive crisis treatment

*IV ASAP* IV antihypertensive: Nipride, labetalol, nicardipine Monitor BP every 15 min during treatment Assess neurological status Assess ECG Goal: drop MAP by 25%

Dobutamine (Dobutrex)

*class*: beta-adrenergic agonist, inotropic *Indication*: short term management of heart failure *Action*: Dobutamine has a positive inotropic effect (increases cardiac output) with very little effect on heart rate. Stimulates Beta1 receptors in the heart. *Nursing Considerations*: - Monitor hemodynamics: hypertension, ↑HR, PVCs - Skin reactions may occur with hypersensitivity - Beta blockers may negate therapeutic effects of dobutamine - Monitor cardiac output - Monitor peripheral pulses before, during, and after therapy - DO NOT confuse dobutamine with dopamine

atrial fibrillation signs and symptoms

- -quivering -irregularly irregular rhythm -no p-wave, instead chaotic "fib" waves, not measurable -120-180 bpm -narrow QRS -This client has uncontrolled atrial fibrillation, which can result in a low cardiac output. Signs and symptoms of low cardiac output include dizziness, weakness, nausea, fatigue, shortness of breath, and syncope. -digoxin, diltiazem, varapamil -Ca2+ blockers, beta-blocker -anti-coagulants (warfarin) -cardioversion -ablation surgery

First degree AV block

- PRI >5 boxes/.20 sec - Fixed but prolonged PRI (consistent but long) - normally get bradycardia here

endocarditis

-Endocarditis is an infection or inflammation of the endocardium (the inner lining of the heart). -Major risk factors for endocarditis include history of an abnormal, damaged, or artificial heart valve; rheumatic fever; congenital heart defects; implanted medical devices (pacemakers); or heart transplant. -IV drug use, dental surgery, central venous access, and immunosuppression also increase risk. -Endocarditis is most commonly caused by bacteria. Heart valves do not receive a dedicated supply of blood. This results in a blunted immune response to valve infections or damage, so microbes can attach to the surface of a valve and form a vegetation without a significant response from the body.

Torsades de pointes

-Life-threatening ventricular tachycardia resulting from a prolonged QT interval. It is characterized by an irregular change in amplitude of QRS complexes that appear to twist around the ECG baseline. -Torsades de pointes can be caused by hypomagnesemia, so give Mag Sulfate to correct.

mitral stenosis

-Narrowing of the mitral orifice and thickening of the mitral valve leaflets. -The condition impedes blood flow into the left ventricle. -The most common cause of mitral valve stenosis is rheumatic heart disease caused by rheumatic fever, which can develop after a strep infection (strep throat). -Can lead to CHF (right sided) -Heart failure is a common complication of clients with mitral valve stenosis. This is evidenced by jugular vein distention, cold clammy skin, tachycardia, orthopnea, increased arterial pCO2, and a decrease in pO2. Preload should be closely monitored for clients with signs of mitral stenosis. The right ventricle can easily become overloaded, increasing pulmonary pressures and further decreasing cardiac output. The nurse should closely monitor fluid status and avoid rapid fluid replacement. The nurse reviews the medical record for an adult client diagnosed with mitral valve stenosis. Which documented observations or therapies prompt the nurse to contact the healthcare provider (HCP)? Select All That Apply pO2 of 70 mm Hg The arterial blood gas value indicates hypoxia (low blood oxygen) and hypercapnia (high carbon dioxide) despite oxygen therapy. Normal pO2 is 80-100 mm Hg. Mitral valve stenosis can lead to heart failure as evidenced by an increase in pCO2 levels (and a decrease in pO2) due to increased preload and decreased cardiac output. Crackles upon auscultation Rales (crackles) is an indication of pulmonary edema that has developed secondary to the congestive heart failure. Report of cough The report of a new cough is concerning for congestive heart failure from worsening stenosis or an evolving infection. The HCP may prescribe a chest x-ray to evaluate the new symptom. NOT: IV fluid rate 80 mL/hr This fluid rate is appropriate for fluid maintenance. The nurse should question rapid fluid rates or fluid boluses that would worsen fluid overload and lead to pump failure. WBC 5,000 mm3 A total WBC count of 5,000 is within the expected range of 5,000-10,000 for adults. It is not a concern to report to the HCP. Mitral stenosis is a narrowing of the mitral orifice and thickening of the mitral valve leaflets. The condition impedes blood flow into the left ventricle. Blood picks up oxygen in the lungs, re-enters the heart into the left atrium, and then must pass through the narrowed and thickened mitral valve into the left ventricle of the heart. The left ventricle is the main chamber and pumps oxygen-rich blood to the body through the aorta. As blood strains to pass through the mitral valve, pressures rise in the left atrium and then in the lungs, where the blood meets vascular resistance as it backs up. This causes pulmonary congestion and shortness of breath that worsen with activity as oxygen needs increase. If untreated, the pressure and fluid buildup in the lungs increases the workload of the right side of the heart, which has to pump harder to send blood into the lungs to be oxygenated. Over time, right-sided heart failure develops. Complications include secondary pulmonary hypertension, atrial fibrillation, and thrombus. Additional symptoms associated with mitral valve stenosis include chest pain and palpitations. A third heart sound may be heard on auscultation, and clients often have a low oxygen saturation even with supplemental O2. This condition is diagnosed by echocardiography. The most common cause of mitral valve stenosis is rheumatic heart disease caused by rheumatic fever, which can develop after a strep infection (strep throat). s/s: Blood-tinged sputum Symptoms associated with mitral valve stenosis include coughing as cardiac output decreases and pulmonary edema develops. The sputum may be blood-tinged. Edema in the legs Edema in the arms and legs supports a diagnosis for mitral valve stenosis as right-sided heart failure develops and blood "backs up." Fatigue As cardiac output falls, clients report fatigue—especially with activity—as dyspnea worsens with exertion.

Right sided heart failure symptoms

-Peripheral pitting edema (legs and hands common) -Weight gain -JVD (jugular vein distension) -Ascites -Hepatic enlargement -JVD -Parasternal lift -Nausea -Decreased appetite -Cold extremities -Diaphoresis

percutaneous transluminal coronary angioplasty (PTCA)

-cardiac surgery in which an inflatable catheter is used to open a blocked coronary artery -assess for bleeding in angioplasty of iliac artery by measuring abdominal girth

extrinsic vs intrinsic factors of heart failure

-extrinsic: forces external to the heart ex: diet, weight, HTN, CAD, pregnancy, diabetes II, medications (daily ibuprofen use, causes Na and h2o retention) -intrinsic: forces within the heart, genetic in origin ex: dysrhythmias, diabetes I

Tented T wave

-hyperkalemia, also comes with widened QRS complex -Hyperkalemia is associated with bradycardia or heart block

Endocarditis risk factors

-mitral valve replacement (invasive surgery) -hx of rheumatic fever (Clients with a history of acute rheumatic fever often sustain damage to the heart valve tissue and develop lifelong rheumatic heart disease, increasing their risk for bacterial infection.) -IV drug use (esp. w/ shared or contaminated needles)

QT interval duration

0.34-0.43 seconds (prolonged means v-tach)

ECG electrode placement

A standard 12-lead ECG has 10 electrodes: six precordial (for the chest) and four "limb leads" (for the extremities). One lead or electrode (V1) is placed right of the sternum; the other five leads (V2-V6) are placed on specific landmarks left of the sternum.

cardiogenic shock

A state in which not enough oxygen is delivered to the tissues of the body, caused by low output of blood from the heart. It can be a severe complication of a large acute myocardial infarction, as well as other conditions.

implantable cardioverter defibrillator (ICD)

An ICD monitors the heart rhythm and delivers a shock if a life-threatening rhythm is detected. Most also have pacing capability. If after receiving a shock, the client feels no chest pain or other symptoms, they should notify the health care provider. If after the shock, the client experiences chest pain or feels bad, the client should activate emergency medical services immediately upon gaining consciousness and not simply notify the cardiologist. The nurse prepares a client for insertion of an implantable cardiac defibrillator (ICD). The nurse includes what information in preprocedure teaching? Select All That Apply "After insertion, you will be restricted from driving for a while." The specific restrictions on driving vary from state to state and province to province and is also individualized by the healthcare provider based on client risks. "If you decide to stop treatment, the device can be deactivated." Clients may choose to turn the device off for a variety of reasons. Receiving an accidental shock while conscious is painful and frightening, or the client may reach end of life care. "If working properly, you may be unconscious when the device fires." Unconsciousness occurs almost simultaneously with a life-threatening dysrhythmia that would require the delivery of a shock, so if working correctly, the client should not be conscious for the firing of the defibrillator. NOT: "If the device delivers a shock, just notify your cardiologist." This information is over simplified and insufficient. If after receiving a shock, the client feels no chest pain or other symptoms, they should notify the health care provider. If after the shock, the client experiences chest pain or feels unwell, the client should activate emergency medical services immediately upon gaining consciousness and not simply notify the cardiologist. "The device will be implanted under general anesthesia." The procedure is performed under local anesthesia in the electrophysiological laboratory. ICDs are used to prevent sudden death for clients with a history of sustained ventricular tachycardia or ventricular fibrillation. Like pacemakers, these battery-powered devices are placed in the chest under the skin. They deliver a shock in response to detecting lethal arrhythmias. According to the American Heart Association, there is no risk of harm to anyone touching the client when a shock is delivered. It is important for instruction to include reassurance to promote sexual health and to assist clients in resuming usual activity once healed. "A shock may be felt, but it would not harm your spouse." An ICD shock is delivered internally using much less power than external defibrillator pads. It cannot harm a person touching the client because the charge is not sufficient to cause harm.

hepatojugular reflux (HJR)

Assessing the jugular venous pulse is a standard part of a focused cardiovascular assessment, especially for detecting CHF. The hepatojugular reflux test measures jugular vein distention seen in tricuspid regurgitation, heart failure, and other conditions. In this test, the nurse places the client's head at 45 degrees. The nurse observes the jugular pulsations during quiet respirations, then firmly presses the right upper quadrant or center of the abdomen for 30-60 seconds and observes the right jugular pulsations during respirations. If the jugular vein shows a sustained rise (>3 cm), the result is positive. The nurse helps the healthcare provider (HCP) perform a focused assessment for a client with congestive heart failure (CHF). Which is the proper approach when performing a hepatojugular reflux? Elevate head of bed to 45 degrees. The nurse places the client's head at 45 degrees to properly assess jugular filling pressure. NOT: Have the clients hold their breath. Clients should not be allowed to hold their breath during this exam. Compress abdomen for 5-15 seconds. The nurse observes the jugular pulsations during quiet respirations, then firmly presses the right upper quadrant or center of the abdomen for 30-60 seconds. Press left upper quadrant of abdomen. The nurse presses the right upper abdomen to increase pressure in the inferior vena cava.

Bleeding S/S

Bleeding may manifest as decreased blood pressure, increased heart rate, shortness of breath, decreased hemoglobin and hematocrit, and confusion (due to decreased perfusion to the brain).

cardiac tamponade

Compression of the heart caused by fluid collecting in the sac surrounding the heart. Cardiac tamponade puts pressure on the heart and keeps it from filling properly. The result is a dramatic drop in blood pressure that can be fatal. Symptoms include low blood pressure, shortness of breath, and lightheadedness. Emergency treatment is required. Usually, a needle or small tube is used to drain excess fluid. Tx: pericardiocentesis People may experience: Pain areas: in the chest Whole body: low blood pressure, fainting, or lightheadedness Heart: fast heart rate or palpitations Respiratory: fast breathing or shortness of breath Also common: distant heart sounds, swelling in extremities, or wheezing due to heart disease

primary hypertension

High blood pressure, the cause of which is unknown; also known as essential hypertension Major risk factors for primary hypertension (formerly called essential hypertension) include high salt and fat intake, obesity, inactive lifestyle, age, family history, race, excessive alcohol consumption, personality traits or depression, and cardiovascular risk factors such as dyslipidemia and diabetes. Secondary hypertension has identifiable causes, including (but not limited to) medications, renal disease, Cushing syndrome, hyperthyroidism, hyperaldosteronism, pheochromocytoma, obstructive sleep apnea, and coarctation of the aorta (especially in children). A client diagnosed with primary hypertension asks the nurse about risk factors for this condition. The nurse confirms the client's understanding of teaching with which response? Select All That Apply "I may be eating too much dietary sodium." Sodium intake greater than 3,000 mg per day increases risk for hypertension, and reducing sodium intake reduces blood pressure. "Obesity often leads to primary hypertension." Weight gain is associated with higher risk for primary hypertension. "Lack of exercise makes hypertension more likely." Inactivity is a risk factor for the development of primary hypertension. NOT: "Taking too much ibuprofen increases my risk." Nonsteroidal anti-inflammatory medications such as ibuprofin are a risk factor for developing secondary hypertension. "My kidney disease worsened my blood pressure." Acquired renal disease (not congenital) is a known cause for secondary hypertension.

Signs of bleeding

It is important for the nurse to recognize trends in vital signs, laboratory results, and other diagnostic values in order to ensure that rapid treatment of conditions occur. The spleen is very vascular and an injury to the spleen greatly increases the risk of bleeding. Bleeding may manifest as decreased blood pressure, increased heart rate, shortness of breath, decreased hemoglobin and hematocrit, and confusion (due to decreased perfusion to the brain). A nurse cares for a client who is post-operative splenic repair. Which finding does the nurse most likely assess in the client? (See exhibit.) View Exhibits Dizziness The client's medical record indicates that the client has trending hypotension, most likely from bleeding. Dizziness may occur with hypotension due to decreased perfusion to the brain. This is the most likely assessment finding based on the client's medical record. NOT: Right upper abdominal pain The spleen is located in the upper left quadrant, not the right upper quadrant of the abdomen. The client would not likely have pain in the right upper abdomen. Dull headache According to the exhibit, the client is displaying signs of potential bleeding (decreased blood pressure, elevated heart rate, decreasing hemoglobin and hematocrit levels). A dull headache is a presenting symptom of hypertension, not hypotension. Nosebleed Nosebleeds are most often associated with hypertension, due to a sudden increase in the blood pressure and vessel constriction. This is not a finding common to hypotension, which the client is displaying.

Myocardial infraction (MI)

LABS: -troponin: Normal (0-0.4 ng/mL). Rises in 3-4 hours and can be detected for 10-14 days. -Creatine kinase-myocardial band (CK-MB): Normal (3-5% or 5 - 25 IU/L). Starts to elevate 4-6 hours after chest pain -These labs indicate myocardium damage The nurse cares for a client diagnosed with an acute myocardial infarction (MI). The nurse attributes which ECG changes to the pathology of MI? Select All That Apply T wave inversion T wave inversion often develops within 24 hours of the acute event. When the client has had an ST elevation MI, the inversion occurs as the ST elevation resolves. Abnormal Q wave The Q wave appears abnormal when infarction of the ventricle is present and is often seen within hours of an MI. ST elevation When all layers of the myocardium are damaged by the infarction, an elevated ST segment will be seen. NOT: Irregular PR interval An irregular PR interval is seen in second-degree heart block. U wave A U wave is associated with hypokalemia but not with acute MI. When a client has symptoms of a myocardial infarction (MI), the nurse takes steps to increase myocardial oxygen supply while awaiting the arrival of the MRT. Medications commonly used during the initial treatment and evaluation of acute coronary syndromes such as MI include morphine, oxygen, nitroglycerin, and aspirin. These drugs can be recalled by the acronym "MONA." Aspirin is intended to prevent further occlusion of coronary arteries. The other three medications are used to improve coronary artery dilation and reduce oxygen demand. A unit nurse assesses a client with shortness of breath, diaphoresis, and chest pain that radiates down the left arm. After activating the Medical Response Team (MRT), which actions does the nurse perform next? Administer oxygen, initiate an ECG, measure vital signs, and prepare sublingual nitroglycerin. The nurse administers oxygen and prepares nitroglycerin to vasodilate the coronary arteries, thus increasing perfusion and improving myocardial delivery of oxygen. Telemetry monitoring and performing an ECG immediately evaluates the cardiac rhythm, including signs for myocardial infarction such as ST segment elevation. Vital signs should be assessed to evaluate perfusion and an IV started before administering nitroglycerin. NOT: Administer oxygen, check vital signs, and notify the cardiac catheterization team. Notifying the cardiac catheterization team before completely assessing the client and determining the cause of symptoms is premature. Administer oxygen, initiate telemetry, check vital signs, and prepare norepinephrine. Norepinephrine is a catecholamine and would increase oxygen demand, which is not desired when ischemia is suspected. Administer oxygen, start an IV, and administer morphine. Although morphine is used to relieve pain from suspected myocardial infarction, it is administered if nitroglycerin is unsuccessful or contraindicated. The first drug to prepare following administration of oxygen and aspirin is nitroglycerin.

lisinopril

Lisinopril is an ACE inhibitor, which is frequently used to treat heart failure and hypertension. ACE inhibitors improve lung function by increasing alveolar-capillary membrane diffusing capacity and pulmonary vascular function. Side effects include hypotension, acute renal failure, and hyperkalemia. ACE inhibitors occasionally induce life-threatening angioedema. While the risk is low, the wide use of these drugs requires that nurses be alert for reports of asymmetric swelling of nondependent tissue, especially in the face. Face, tongue, lips, and upper airway swelling can lead to rapid airway compromise. At discharge, a client with heart failure due to systolic dysfunction is prescribed lisinopril, an angiotensin-converting enzyme (ACE) inhibitor. Which teaching does the nurse include for this medication? Select All That Apply "Report a persistent cough immediately." ACE inhibitors are known for a common adverse effect of persistent dry cough. This occurs in up to 20% of clients after starting the drug. The cough resolves after discontinuation. ACE inhibitors are also known for inducing life-threatening angioedema. Although the risk is low, the wide use of these drugs requires that all clients are aware of this possible side effect. "It relaxes blood vessels, which lowers blood pressure." Relaxed blood vessels, leading to lower blood pressure, make it easier for the heart to pump. "This drug can make it easier to exercise." Actions on muscle tissue are thought to help with exercise tolerance. While not fully understood, trials have found that therapy with ACE inhibitors significantly improves exercise capacity in patients with heart failure. "This drug may contribute to hyperkalemia." ACE inhibitors affect the kidneys and may cause hyperkalemia, especially when the client takes potassium supplements or has renal disease. NOT: "It is safe to take during pregnancy." ACE inhibitors such as lisinopril carry a black-box warning to discontinue when pregnancy is known. It can contribute to fetal injury and death.

Austin Flint murmur

Murmurs result from blood flow turbulence within heart valves. Murmurs have distinct characteristics depending on the location and severity and are described by intensity and pitch. An Austin Flint murmur is described as low-pitched and rumbling and can be heard during mid-to-late diastole at the apex. This murmur is associated with severe aortic regurgitation, which results in increased left ventricular end diastolic pressure and right-sided heart failure. During a focused cardiac assessment, the nurse assesses the function of valves by auscultating over areas of the chest that provide access to the heart sounds (valves open and closing) that radiate toward these areas. Anatomical locations on the chest correspond with valves and vessels. The nurse assesses the mitral, tricuspid, pulmonary, and aortic areas.

peripheral artery disease (PAD)

PAD is a chronic condition resulting in decreased perfusion to an extremity. Atherosclerosis is the most common cause for artery occlusion, so many clients benefit from interventions aimed at reducing cardiovascular disease. That said, symptoms from the disease such as claudication (extremity cramping pain from exertion that resolves with rest) may benefit from a structured exercise program. Exercise programs should be progressive. The client should start with walking or other mild exercises and increase intensity as tolerated.

implanted pacemaker

Regardless of the cause, when problems with pacer function occur, the nurse prepares temporary external pacing to restore the rhythm until the problem can be fixed. The nurse observes a cardiac monitor for a client with an implanted pacemaker. The nurse notes several regular vertical pacer spikes not followed by QRS complexes. Which does the nurse report to the healthcare provider (HCP)? Failure to capture Failure to capture is when the pacer fires a signal but the heart does not respond with a beat. This is often caused by pacer lead migration on the epicardium. NOT: Lead dislodgement A dislodged pacing catheter or lead can result in various pacer abnormalities, including oversensing and failure to capture. Undersensing Failure to sense is when the pacer cannot find the heartbeat consistently, leading to poorly timed firing by the pacer and an intermittently paced rhythm. Absence of artifact Failure to pace, or discharge, is when the pacer fails to fire a signal when it should. A properly firing pacemaker produces a spike or an artifact. Lack of pacing often leads to bradycardia and hypotension because the heart does not generate an adequate rhythm intrinsically.

Conduction of a normal heart beat (normal sinus rhythm)

SA Node, AV Node, Bundle of His, Bundle Branches, then Purkinje Fibers

sinus tachycardia

Sinus tachycardia is a sinus rhythm with a rate of greater than 100 beats/min. It is regular and narrow and does not generally exceed 160 beats/min. It may occur as part of normal cardiac function related to sympathetic stimulation (exercise) or from lack of parasympathetic tone (dehydration, shock). Unless persistent, sinus tachycardia increases cardiac output and BP. Sinus tachycardia does not usually require treatment for the rhythm. The causes of sinus tachycardia are numerous: fever, emotional stress, anxiety, pain, heart failure, hypoxia, hypovolemia, hyperthyroidism, hypercalcemia, caffeine, nicotine, exercise, and many medications. The nurse looks for a cause and provides support to eliminate that cause. If the nurse suspects dehydration, administration of fluids will decrease the heart rate. For sustained tachycardia, the nurse assesses for signs of decreased perfusion such as fatigue, hypotension, dyspnea, restlessness, and decreased urine output. A wheelchair-bound client is evaluated in the emergency department. The nurse notes sinus tachycardia on the cardiac monitor. Which condition does the nurse suspect as a potential cause of the rapid heart rate? Select All That Apply Acute back pain Unrelieved pain increases heart rate, BP, and oxygen demand. The nurse should ask the client if he or she has pain. Emotional stress Emotional stress stimulates an autonomic response ("fight or flight") that elevates heart rate. Temperature 101.8° F (38.78° C) Fever triggers vasoconstriction and increases the metabolic rate, resulting in increased BP (initially), respiratory rate, and heart rate. Urinary tract infection Infection may cause a rapid sinus rate as the body increases sympathetic tone to promote tissue perfusion. NOT: Distended urinary bladder A full and distended bladder, which commonly occurs in autonomic dysreflexia secondary to spinal trauma, can cause a decrease in pulse rate.

DASH Diet

The DASH diet suggests limits for calories, sodium, and fat. It also encourages avoidance of a sedentary lifestyle. The diet recommends less than 2,300 mg of sodium daily, but people with comorbidities such as diabetes and heart disease should have less. Water is drawn to sodium, which is why thirst worsens when eating salty snacks such as potato chips. Increased sodium intake causes fluid retention, which increases BP because more fluid is in the bloodstream and blood vessels. Decreasing sodium intake can help reduce the amount of excess fluid in the blood, decreasing BP.

Preload

The precontraction pressure in the heart as the volume of blood builds up. Preload is determined by how much the muscles of the heart stretch due to the blood volume that has filled the ventricles at the end of diastole. Preload is decreased by conditions that reduce circulating volume, venous return, or right ventricular volume. The nurse is caring for clients on the cardiac unit. Which conditions affect cardiac output by reducing preload? Select All That Apply Urinary sepsis Tachycardia and hypotension result in reduced preload in sepsis and is treated with IV fluid resuscitation. Upper thoracic spinal cord injury Injuries above the sixth thoracic vertebra lead to spinal shock, decreased vasomotor tone, and decreased preload due to decreased venous return. This condition also decreases afterload due to decreased peripheral vascular resistance. Postpartum hemorrhage Uncontrolled bleeding leads to hypovolemia, which reduces venous return to the heart and thereby reduces preload. NOT: Chronic renal failure Renal failure results in sodium and fluid retention and increases the risk for fluid overload, which increases preload, but during and immediately after hemodialysis, the client is at risk for decreased preload. Sinus bradycardia A slower heart rate increases filling time, which increases the amount of blood that fills the ventricles and increases preload.

varicose veins

Varicose veins are weak-walled, engorged, and tortuous. They often have defective valves that fail to prevent reflux (backflow). Blood pools in the veins, causing enlargement, deformity, and pain. Varicose veins occur more frequently in clients with occupations that involve standing for long periods of time. Supportive treatment includes the "3 Es": elastic compression, elevation, and exercise. The nurse cares for a client with venous insufficiency. What does the nurse teach the client about the condition? "Varicose veins are a result of a familial predisposition." Varicose veins are linked to genetics related to less-elastic veins. NOT: "Sclerotherapy is the only cure for varicose veins." Sclerotherapy is used to treat existing varicose veins, but it is not a cure and does not prevent other varicose veins from developing. "Discomfort is directly related to the size of the varicosities." Pain is not directly related to the size of the varicosities. "Varicose veins are more common in men than in women." Varicose veins are not more common in men. Women have a higher incidence of varicose veins than men do.

pulsus paradoxus (Kussmaul's pulse, paradoxical pulse)

an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg. When the drop is more than 10 mmHg, it is referred to as pulsus paradoxus. A paradoxical pulse (Kussmaul's) is an abnormal decrease in pulse wave amplitude during inspiration (problem with breathing owing to mechanical obstruction, pericardial tumor, pericarditis, aneurysm, etc.

heart failure (HF)

condition in which there is an inability of the heart to pump enough blood through the body to supply the tissues and organs with nutrients and oxygen HF is identified by manifestations of volume overload, inadequate tissue perfusion, and poor exercise tolerance. There are many types of HF, both acute and chronic, and each has a different pathophysiology and treatments. For example, high metabolic demand from a thyroid storm can lead to HF. The nurse teaches a client with newly diagnosed heart failure (HF). Which responses by the client indicate understanding? Select All That Apply "It is a condition, not a disease." HF pertains to ventricular dysfunction. It can result from systolic or diastolic abnormalities. "The heart cannot handle a normal volume of blood." The heart fails when, because of intrinsic disease or structural defects, it cannot handle a normal blood volume or, in the absence of disease, cannot tolerate a sudden expansion in blood volume. "The heart is unable to pump effectively." HF is a physiologic state in which the heart cannot pump enough blood to meet the body's metabolic needs. HF may occur secondary to other diseases that weaken the heart structure or make it difficult for the heart to compensate. NOT: "It results from too much fluid in the heart." Although fluid overload can contribute to HF symptoms, HF may occur despite normal fluid volume when the heart is weakened. "The heart does not have enough oxygen." Even with adequate oxygenation HF can occur. Hypoxia is the term for lack of oxygen, and when tissue is affected, the term ischemia is used.

Inverted or depressed T-wave

tissue ischemia or decreased oxygen to tissues (heart msucle) The nurse cares for a client with pericarditis and notes inverted T waves on the ECG. Which priority intervention by the nurse is most appropriate? Assess the client for chest discomfort. Tissue ischemia may result from pericarditis, including myocardial ischemia. The best action by the nurse is to perform a focused assessment to determine whether the client is having myocardial ischemia. NOT: Notify the healthcare provider. Although the healthcare provider should be made aware of changes to the cardiac rhythm, the nurse must establish whether the client has signs of ischemia, which is a medical emergency. Obtain vital signs, including oxygen saturation. Obtaining vital signs is helpful, but more information is needed as a result of visible changes in the T waves for a client at risk for ischemia. Administer 100% oxygen. Unless the client reports dyspnea or has evidence of hypoxia (low saturation), the best action is to gather more data. Once saturation is assessed, oxygen can be titrated.