nclex cardio, resp
trop MI
peaks 4-12 hr remains elevated up to 3 weeks
ventricular fibrillation
the rapid, irregular, and useless contractions of the ventricles *emergency care w/ defibrillation needed since rhythm incompatible with life*
aneurysm management
tight blood pressure control and surgical repair. This may be emergency surgery in the event of a dissection.
Aortic stenosis
most significant valvular lesion seen among elderly people. ** It usually leads to left-sided heart failure, left ventricular hypertrophy and cardiomyopathy.
coronary artery disease presentation in women, DM pt, and older adults
often atypical symptoms (ex/ dyspnea, lightheadedness, GI complaints, or pain/discomfort in atypical locations
after MI when can sexual activity be gradually resumed?
when pt can walk up 2 flights of stairs w/o symptoms - nitroglycerin before may prevent angina ***no meds like sildenafil can cause severe hypotension**
prehypertension
120-139/80-89
MI ECG changes
ST segment elevation
heart block
a block or delay of the normal electrical conduction of the heart
Pulmonary valve insufficiency epidemiology
birth defect or pulm HTN
normal BP
<120/80
meds to immediately admin for MI
"M.O.N.A" -Morphine -oxygen -nitrates -aspirin
MI therapeautic tx
"OH BATMAN" - oxygen -heparin -beta blocker -aspirin - thrombolytics - morphine -ace inhibitor - nitroglycerin
diastolic heart failure
(left heart) - left ventricle unable to relax during diastole (usually R/T hypertrophy) - prevents adequate filling of LV - reduced stroke volume - **normal to high LV ejection fraction >50%
systolic heart failure
(left heart) - weakened left ventricle - reduced contraction ability - *reduced LV ejection fraction <40%
Pulmonary stenosis sign
(usually congenital) - Cyanosis dyspnea, fatigue, syncope and findings of right heart failure - Cyanosis, failure to thrive
Mitral valve insufficiency (regurgitation) s/s
(usually result of birth defect) - often asymptomatic. If they do present with symptoms, you may see the following: - Orthopnea, dyspnea, fatigue, weakness and weight loss - Chest pain and palpitations -*Systolic murmur at the apex; high pitched, blowing murmur; may radiate to axilla - Jugular vein distention - Peripheral edema - Hepatomegaly
cardiac tamponade s/s
*medical emergency* classic triad: 1) hypotension 2)muffled heart sounds 3) marked JVD additional: -pulsus paradocus when SBP >10 mm/hg lower on inspiration than expiration - narrowed pulse pressure (indicated poor cardiac output) - tachypnea, tachy, restlessness, lightheaded, decreased LOC *** emergency care required*
classic MI findings
-persistent, - crushing substernal chest pain (may radiate to left arm, jaw, neck, shoulder blades) *some pt report no pain* - sense of impending doom
CK-MB MI
-rises 4-6 degrees within 3-6hrs - peaks at 18-24 hrs - returns to normal in 3-4 days
Pulmonary valve insufficiency s.s
- Dyspnea, fatigue, chest pain and syncope - Peripheral edema may cause discomfort - Possible malnourished appearance **If advanced, the client will present with jaundice with ascites and peripheral edema.
Aortic stenosis sign
- classic triad: dyspnea, syncope, and angina - Fatigue, palpitations and left-sided heart failure may occur with orthopnea, paroxysmal nocturnal dyspnea and crackles in the lungs - systolic murmur that radiates into carotid arteries and heart apex - 4th heart sound
hyperlipidemia management
- diet w/o trans fats and cholesterol - increased whole grains and omega-3 fatty acid foods - increased activity - statins - bile acid sequestrates (colestipol or cholestyramine) - niacin
Tricuspid stenosis s/s
- dyspnea, fatigue, weakness and syncope - Peripheral edema - Client may appear malnourished - Distended jugular vein
CAD lab findings
- elevated homocysteine, CRP, LDH, and trig - reduced HDL
older women s/ MI
- fatigue -N/V -SOB - flu like s/s
left heart failure s/s from earliest to latest
- fatigue and activity intolerance - cough (often dry) - mild wt gain leads to early pulm s/s - SOB/orthopnea - paroxysmal nocturnal dyspnea -tachypnea -crackles -3rd heart sound -cardiac cachexia and muscle weakness - acute pulmonary edema
signs acute pulm edema
- frothy sputum (may be blood tinged) - restlessness, irritability, hostility, agitation, anxiety - prominent crackles through lung fields - diaphoresis - cyanosis
clues silent MI
- heart failure -change in mental status -unexplained abd pain -dyspnea -fatigue
complications of acute HTN crisis
- hypertensive encephalopathy (often 1st sign): severe headache, N/V, seizures, confusion, coma or stroke like symptoms -papilledema - rapid development of angina or MI or pulm edema - new renal insufficiency or failure
post cardiac cath and percutaneous transluminal coronary angioplasty/stent interventions
- maintain heperinization - monitor pt for chest pain, hypotension, coronary artery spasm, and bleeding from cath site - observe for bleeding or hematoma at puncture site -**keep affected leg straight and immobile 6-12 hours** - check distal pulses to detect occlusion - admin IVF and increase fluids (counteract diuretic dye effect) - assess potassium and monitor for arrhythmias - monitor serum creatining
s/s mitral stenosis
- mild asymptomatic hrt murmer - s/ left sided hrt failure (exertion, cough, orthopnea (supine dysnea), paroxysmal nocturnal dyspnea (waking w/ SOB), hx propping up w/ pillows to sleep) - crackles, weakness, fatigue, palp, mild wt gain
CAD pharmacological management
- nitrates (vasodilator) *all nitrates require "nitrate- free" period each 24 hr to prevent tolerance (admin during active period and break during sleep) acute cardiac symptom relief<- short acting nitro sublingual tab or spray anginal episode prevention<--oral isosorbide or transdermal nitro - beta blockers: reduce myocardial O2 demand - antiplatelet agent (81 mg aspirin daily): reduce risk of thrombolitic event - antilipemics: reduce risk of plaque rupture that most often causes MI - oxygen
right heart failure (s/s from earliest to latest)
- significant wt gain - JVD - bilateral dependent peripheral edema - liver engorgement (hepatomegaly w/ abd pain, anorexia, and nausea) - ascites
Aortic insufficiency signs
-Uncomfortable awareness of heartbeat -Palpitations -Dyspnea with exertion -Orthopnea, paroxysmal nocturnal dyspnea and cough -Fatigue and syncope with exertion or emotion *Anginal chest pain unrelieved by sublingual nitroglycerin - Nail beds appear to be pulsating **Quincke's sign - root of nail will flush and then pale when press nail tip - If the right ventricle fails - may show signs of right heart failure with peripheral edema, jugular vein distention and ascites -**High pitched diastolic murmur at the third or fourth intercostal space, left sternal border - Widened pulse pressure - Pulsus bisferiens - a double-beat pulse, palpated over the carotid or brachial artery
LDH MI
-appears 12-24 hour -peaks 28-72 hr - lasts 6-12 days
mitral stenosis mngmt
-diuretics -o2 - ACE inhibitor - beta blocker - low sodium diet - exercise as tolerated
RN interventions hypertensive crisis
-monitoring for end stage organ damage - urine output -LOC -labs BUN, creat, ABG, urinalysis - VS check q5-30 min and continuous cardiac monitoring while titrating IV vasodilators
activitiess and substances known to cause angina (CAD pt should avoid these)
-very cold and very hot weather -alch and caffeine -stimulants such as diet pills, nasal decongestants, and any natural remedy that raises HR or BP
progression toward MI
1) atherosclerotic plaques cause narrowed arteries (coronary artery disease) 2) sudden rupture of unstable plaque causes thrombolitic event 3) sudden worstening stenosis (acute coronary syndrome) 4) occlusion of coronary blood flow to heart muscle distal to blockage (myocardial infarction)
hypertension (stage 1)
140-59/90-99
Systolic blood pressures in legs
20-40 mmHg higher than the brachial artery
hypertension (stage 2)
>160/>100
hypertensive crisis
>180/110
ABCD of Atrial Fibrillation Management
A - anticoagulate with heparin (short-term) or warfarin (long-term) B - beta blocker C - cardioversion (if beta blocker ineffective; or calcium channel blocker) D - digoxin
med for left-sided heart failure tx preferred for diabetic pt
ACE inhibitors- protect the kidneys
management chronic occlusive arterial disease
An arterial-brachial index will be reduced and an arteriography will be performed. Pharmacologic Interventions: Anticoagulants: prevent blood clots Vasodilators Antiplatelet drugs: prevent platelet aggregation Pentoxifylline: promotes blood flow by making blood cells more "slippery" Surgical Interventions: Endarterectomy Femoral-popliteal bypass Sympathectomy Amputation of affected limb for gangrene Laser coronary angioplasty (LTA) Peripheral angioplasty
sinus arrhythmia
Appearance is ALMOST NORMAL: Respiratory - Circulatory interaction Rate INCREASES with INSPIRATION (IN=IN)
Post-op CABG care
I/O restrict fluid (usually 1500-2000mL), daily wt report drainage >100mL/hr from mediastinal and pleural chest tubes
rheumatic endocarditis prevention
ID and tx steptococcal pharyngitis
chronic occlusive arterial disease s/s
Intermittent claudication (predictable pain with walking) which is relieved with rest indicates a mild to moderate obstruction. If the client reports pain at rest, this indicates severe arterial obstruction. The affected limb will present with: Skin: waxy, hairless, cool, pale or cyanotic Weak or absent pulses Paresthesia Non-healing wounds
sign tricuspid stenosis has led to right ventricular failure
Jaundice with severe peripheral edema and ascites
symptom thoracic aorta aneurysm
May be asymptomatic Vague chest pain - may be sudden onset and severe, which may signal a dissecting thoracic aneurysm Dyspnea Distended neck veins
6 P's of acute arterial occlusion/poor perfusion
P allor (or mottling) P ain P aresthesia (numbness or tingling) P allor (cool or cold skin) P ulselessness (distal to the blockage) P aralysis (or weakness or muscle spasm)
acute occlusive arterial disease s/s
Pain is reported in the affected limb, especially with activity or walking. Cyanosis can be observed in the affected limb. The client may report paresthesia. If left untreated, gangrene can occur.
signs cardiomyopathy
Shortness of breath Orthopnea Dyspnea (exertion and paroxysmal nocturnal dyspnea) Fatigue Dry cough (nighttime) Palpitations Peripheral edema Vague chest pain Narrow pulse pressure Irregular rhythms S3 and S4 gallop Murmur
post op CABG s/ cardiac tamponade
Sudden cessation of mediastinal drainage Jugular vein distention (with clear lung sounds) Equalization of right atrial pressure and pulmonary artery wedge pressure Pulsus paradoxus
saccular aneurysm
a sac-like bulge on one side; the outpouching of one wall in a circumscribed area
Pseudoaneurysm
a tear of the full thickness of the arterial wall, leading to a collection of blood contained in the connective tissue. It is often referred to as a "false aneurysm".
premature ventricular contraction
a ventricular contraction preceding the normal impulse initiated by the SA node
ventricular tachycardia
a very rapid heartbeat that begins within the ventricles *emergent care w/ defibrillation* pt may have a pulse or no pulse includes torsade de points rhythm
common aneurysm sites
abdominal aorta (can be seen w. arteriography)
what qualifies as an arrhythmia?
american heart association defines as any change from the normal sequence of electrical impulses, such as atrial fibrillation, bradycardia, tachycardia, conduction disorders, rhythm disorders, ventricular fibrillation, premature contractions and more.
dx acute occlusive arterial disease
arteriography and doppler study
how is HTN diagnosed?
based on avg of 3 or more BP readings, 2 min apart, at each of 3 or more visits (not including initial screening)
dissecting aneurysm
blood accumulates between the tunics of the artery and separates them, usually because of degeneration of the tunica media * active dissection requires EMERGENCYCARE
mitral stenosis
blood flow is obstructed from the left atrium to the left ventricle 2/3 female often caused by rheumatic fever
what is the gold standard of CAD diagnosis
cardiac catheterization with coronary angiography to show areas of narrowing in coronary arteries
mitral stenosis chest XR
cardiomegaly (enlargement)
Rheumatic heart disease surgery
commissurotomy, valvuloplasty, or prosthetic hrt valve
management of all new of symptomatic arrhythmias
continuous cardiac monitoring, IV access for meds, VS and symptom monitoring for any changes pt not tolerating the rhythm (asymptomatic=pt tolerating it well and there's adequate CO. document and report to MD
rheumatic endocarditis typically appears in
crowded living conditions. children 5-15yrs
rheumatic endocarditis
damage to heart from one or more episodes rheumatic fecer; results in damage to hrt (particularly valves) results in valve leakage and/or stenosis; chambers compensate by enlarging *can lead to heart failure*
why stool softener for MI pt
decrease heart workload caused by straining (causes vasal stimulation leading to bradycardia and arrhythmias)
aneurysm etiology
dilation of artery due to weakening of wall- etiology- atherosclerosis
fusiform aneurysm
dilation of the entire circumference of the artery
coronary artery disease(CAD) symptoms
early --> asymptomatic - when significant reduction in cardiac blood flow occurs (>70% narrowing) angina chest discomfort and cardiac symptoms *occur w/ exertion and resolve w/ rest
Tricuspid valve insufficiency signs
early- asymptomatic severe- can lead to right heart failure and poor cardiac output - Dyspnea, fatigue, weakness and syncope - Distended jugular veins - Peripheral edema, ascites and pulmonary edema as blood is backing up from right side of heart into the venous system
hypertension labs
elevated serum creatinine and urine positive for protein
cardiac tamponade management
emergency pericardiocentesis <--*** rapid response
activity level for acute MI event
enforce bedrest (w/ bathroom privilages) to decrease heart workload. slowly increase activity when pt stable
management of moderate arrhythmia symptoms
ex/ lightheadedness, low blood pressure, chest discomfort, dyspnea or other indicators of poor cardiac output - put pt on bedrest - The nurse will conduct a 12-lead ECG, provide oxygen and frequent blood pressure monitoring. -***Call the health care provider immediately or the rapid response team for the rapid intervention, due to impending risk of cardiac arrest
management of severe arrhythmia symptoms
ex/ unresponsive, pulse is absent or very slow or weak, the client has no blood pressure or very low compared to the client's baseline - emergency care needed - ABCDs of basic life support; call code or rapid response team
management of mild arrhythmia symptoms
ex/palpitations and fatigue (a mild reduction in cardiac output.) - The nurse will monitor vital signs, inform the provider, and institute any orders such as oxygen or medication administration.
back pain after abdominal aorta surgery
finding of retroperitoneal hemorrhage
what to do if pt post cardiac cath and percutaneous transluminal coronary angioplasty/stent has hypotension, bradycardia, diaphoresis, and dizziness?
give atropine and lay the pt flat
rheumatic heart disease s/s
hx strep pharyngitis, polyarthritis (numerous warm and swollen joints) fever, chills, malaise, SOB, chest pain. *common findings= - chorea (emotional instability, muscle weakness w. quick uncoordinated jerky movements usually in face feet and hands **INCREASED FALL RISK** - erythema marginatum (ring-like or snake-shaped rash on trunk or extremities) - subq nodules -temp to 104
Rheumatic heart disease labs
increased antistreptolysin O (ASO) titer increased ESR + throat culture for streptococci increased WBC
MI management temp after return to spontaneous circulation
induce hypothermia (target 32-34 celcius) as soon as possible
intervention cardiogenic shock
intra-aortic ballon couterpulsation
atrial flutter
irregular beating of the atria; often described as "a-flutter with 2 to 1 block or 3 to 1 block"
mitral stenosis ECG findings
left artria and right ventricle enlargement
long term management endocarditis w/ abx
long trem IV abx and prophylactic abx prior to dental work or other invasive procedures
MI time frame
may take 3-6 *more than half of sudden deaths from MI occur within 1 hr (females 2x mortality)
pericardiocentesis complications
pneumothorax, arrhythmia, hypotension
atrial fibrillation
rapid, random, ineffective contractions of the atrium
intervention if endocarditis valve infection doesnt respond to abx?
surgery to replace valve
monitoring pulm artery pressure
swan-ganz cath measures left ventricle function
