Alterations in Cardiac Function - Chapter 32
Stenosis
failure of the valve to open completely results in extra pressure work for the heart
Hypertrophic Cardiomyopathy
thickened ventricular muscle mass -Genetic Abnormality = ATHLETE*** -Asymptomatic or dyspnea and angina *slow progression
ACS after 5-7 Days
turns yellowish and soft with a rim of red vascular connective tissue
How do you check ortheostatic BP ?
wait 5 min pt lying 5 min later sit up check bp 5 min later have pt stand up and check bp and HR (need HR*)
Mechanisms of Coronary Atherosclerosis
Lipoproteins being eaten by macrophages which causes and inflammatory response. Low density lipoproteins = greater risk of atherosclerosis High density lipoproteins = transport cholesterol from peripheral tissue back to the liver = clearing them away from the atherosclerotic plaques
NSTEMI - NonSTEMI
Patients presenting with symptoms of unstable angina and no ST elevation on the ECG *NO ST elevation and Biomarkers = NSTEMI
STEMI
Patients with chest pain and evidence of acute ischemia on the electrocardiogram St-segment = elevation = medical emergency = immediate intervention=acute perfusion therapy *Chest pain(BIOMARKERS) and ST-segment elevation =STEMI
A client comes to the emergency room exhibiting signs and symptoms of right-sided heart failure. Upon X-ray it is determined that he has 250ML of fluid in the pericardial cavity. Which disease should the nurse suspect this client to be suffering?
Pericardial effusion
A client was in car accident client while not wearing a seatbelt and has sustained multiple rib fractures. During assessment, the nurse is having a hard time hearing heart sounds, and the client reports chest pain/pressure repeatedly. This client may be experiencing:
Pericardial effusion
Chronic Coronary Syndromes
-Slow Progression (due to stable atherosclerotic plaques) -STABLE angina -Ischemic cardiomyopathy: Due to prolong ischemia the myocardium starts to change (the cellular aspect changes) heart gets bigger and left ventricle gets bigger changes the shape of heart and it effects cardiac output = heart failure
Sudden Cardiac Death (SCD)
**Unexpected death from cardiac causes within 1 hour of symptom onset** Use of external defibrillators and CPR has increased survival **Lethal dysrhythmia (such as ventricular fibrillation) is usually the primary cause**
Restrictive Cardiomyopathy
*rarest form Stiff, fibrotic, rigid, noncompliance ventricle with impaired diastolic filling *Associated with AMYLOIDOSIS -Decreased CO = left sided failure -exercise intolerance dyspnea and weakness
Four clients were admitted to the emergency department with severe chest pain. All were given preliminary treatment with aspirin, morphine, oxygen, and nitrates and were monitored by ECG. Which client most likely experienced myocardial infarction?
80-year-old woman whose pain was not relieved by nitrates or rest; the ECG showed ST-segment elevation with inverted T waves and abnormal Q waves; levels of cardiac markers subsequently rose Explanation: The chest pain of myocardial infarction does not respond to rest or to nitrates. Ischemic injury to the myocardium alters the ECG patterns, often elevating the ST segment and inverting T waves. Abnormal Q waves indicate necrosis. Cardiac markers are released in response to myocardial injury; rising levels indicate damage to the heart. The other clients have angina of varying severity.
Endocardial and valvular structures may be damaged by?
=murmurs -Inflammation and scarring -Calcification -Congenital malformations
While studying the heart the nursing instructor teaches about pericarditis. Which of the following does she tell the student best defines this disease?
It is an inflammatory process.
The nursing instructor teaches the students that when a client is suffering from pericarditis he/she will have a friction rub. The student asks the instructor what a friction rub is. What would be her best response?
An audible medical sign that is high-pitched and results from the rubbing and friction between the inflamed pericardial surfaces.
A patient who complains of chest pain with activity and explains that it is going away with rest is presenting with
Angina
CONSEQUENCES (Sequelae) Of Coronary Heart Disease
Angina pectoris Myocardial Infraction Dysrhythmias Heart Failure Sudden Cardia Death
Door-balloon time
Anyone who is experience a STEMI has to have coronary intervention within 90 MINUTES (now even exploring less than 60 min)
What causes Coronary Heart Disease?
Atherosclerosis and possible microcirculation abnormalities.
Coronary artery bypass grafting (CABG) is a treatment modality for which of the following disorders of cardiac function?
Atherosclerosis and unstable angina
Atherosclerosis
Causes narrowing of the arterial lumen that can lead to ischemia through: -Thrombus Formation -Coronary Vasospasm -Endothelial cell dysfunction
The nursing student correctly identifies which of the following as major risk factors for coronary artery disease?
Cigarette smoking Elevated LDL Diabetes Abdominal obesity
Coronary Artery Disease (CAD)
Disorders of myocardial blood flow due to stable or unstable coronary atherosclerotic plaques.
A client with heart failure has just had an automatic defibrillator installed in her chest wall. When the nurse is performing follow-up assessments in the coming months, which finding is most likely the result of a complication?
Fever and diaphoresis
Cardiomyopathy
Functional Impairment: Dilated Hypertrophic Restrictive
Nearly everyone with pericarditis has chest pain. With acute pericarditis, the pain is abrupt in onset, sharp, and radiates to the neck, back, abdomen, or sides. What can be done to ease the pain of acute pericarditis?
Have the client sit up and lean forward
Chronic Ischemic Cardiomyopathy
Heart failure develops insidiously due to progressive ischemic myocardial damage and remodeling Typically have history of angina or MI Appears to be a consequence of slow, *progressive apoptotic death of myocytes from chronic ischemia*- gradual hear failure (treatment = beta blocker) Scattered throughout the myocardium
Sympathetic nervous system activation leads to increased myocardial workload by increasing:
Heart rate Contractility Blood pressure -All things that increase the myocardial oxygenation demand
The health care provider is discussing major risk factors for coronary artery disease (CAD) with a client. The most important information for the provider to include would be:
History of cigarette smoking and elevated blood pressure
The nurse working in the emergency room triages a client who comes in with complaints of chest pain, shortness of breath, sweating and elevated anxiety. The physician suspects a myodardial infarction. The client is given a nitrate, which does nothing for his pain. Which of the following medications should the nurse suspect the doctor will order next for the pain?
Morphine Explanation: morphine is the drug of choice and is usually indicated if chest pain is unrelieved with oxygen and nitrates.
Elevated biomarkers and chest pain has what?
Myocardial Infraction *have to make biomarkers = must be elevated biomarkers on blood work w. chest pain= myocardial death MI
Serum Marker Changes
Myoglobin, troponin, lactate dehydrogenase, and creatine kinase Increased CK-MB and troponin I and T Troponin = most sensative as well as CK-MB troponin I and T =if elevation of these = MI *******Cardiac biomarkers that we use to determine if pt has had an MI
ACS after 1-2 weeks:
Necrotic Tissue progressively degraded and cleared away
ACS by 6 weeks:
Necrotic tissue replaced by tough fibrous scared tissue= tissue is dead
A nurse is assessing a client diagnosed with severe mitral valve stenosis. The nurse anticipates the assessment will include:
Orthopnea Explanation: The symptoms of mitral valve stenosis are those of pulmonary congestion, including nocturnal paroxysmal dyspnea and orthopnea. Atrial tachycardia and atrial fibrillation develop in 30% to 40% of clients with mitral valve stenosis. Transient ischemic attacks occur more frequently in persons with mitral valve prolapse.
A client who is experiencing angina at rest that has been increasing in intensity should be instructed to do which of the following?
See the doctor for evaluation immediately. Explanation: Angina that occurs at rest, is of new onset, or is increasing in intensity or duration denotes an increased risk for myocardial infarction and should be seen immediately using the criteria for acute coronary syndrome (ACS).
What do you use for checking if pt has had a heart attack is having one or going to have one?
Serial biomarker = do three of them every 8 hrs for tropin and CK-MB of I and II = if they are decreasing then send pt home no longer rising is good -great for monitoring an acute MI
What causes chronic occlusion of coronary vessel?
Stable angina
Stable Atherosclerotic Plaques
Stable atherosclerotic plaques produce fixed obstruction of coronary blood flow with myocardial ischemia occurring during periods of increased metabolic need, such as in stable angina. THEY HAVE: -More collagen and fibrin -Stable Cap
Any of the coronary heart syndromes may participate in what?
Sudden Cardiac Death and Associated Dysrhythmias
Which of the following patients is at the greatest risk of developing rheumatic heart disease?
Teenager with untreated strep throat
The nurse is preparing to auscultate for a mitral valve stenosis murmur Where is the best location to place the stethoscope?
The apex of the heart Explanation: The murmur of mitral valve stenosis is heard during diastole when blood is flowing through the constricted valve; it is characteristically a low-pitched, rumbling murmur best heard at the apex of the heart. The other locations would not be effective.
A client has just been admitted to the cardiac intensive care unit with a diagnosis of infective endocarditis. His wife appears distraught and asks the nurse what caused this to happen to her husband. What would be the nurse's best response?
The most common cause is a staph infection. Explanation: Staphylococcal infections have now emerged as the leading cause of infective endocarditis, with streptococci and enterococci as the other two most common causes. Informing the client's wife about the drug abuse connection infers that you think he is a drug addict and is not therapeutic. Parasites are never the cause and telling the patient to focus on her husband also is not appropriate as this is a genuine concern for her.
A client has been diagnosed with aortic stenosis and asks the nurse what this means. The most appropriate response would be:
The valve opening is narrowed and produces increased resistance to blood flow out of the left ventricle and into the aorta.
Which serum biomarker is highly specific for myocardial tissue?
Troponin
A client with a suspected MI is brought to the emergency department by ambulance. The nurse caring for this client would expect to receive an order for which laboratory test to confirm a diagnosis of MI?
Troponin Level The troponin assays have high specificity for myocardial tissue and have become the primary biomarker for the diagnosis of myocardial infarction (MI).
What does it mean if you have no biomarkers and no ST elevation?
UNSTBLE ANGINA!
A patient who complains of chest pain with activity and explains that it is NOT going away with rest is presenting with
Unstable Angina
Vulnerable (Unstable) Atherosclerotic Plaques
Unstable atherosclerotic plaques tend to fissure or rupture, causing platelet aggregation and potential for thrombus formation with production of a spectrum of acute coronary syndromes of increasing severity, ranging from unstable angina, to non-ST-segment elevation myocardial infarction, to ST-segment elevation myocardial infarction. THEY HAVE: -Large Lipid Core -Thin Cap -High Shear Stress due to BP
ACS after 18-24hrs
area of infarction becomes paler than surrounding tissues
What causes Myocardial Ischemia?
-Coronary Vasospasm -Hypoxemia -Low perfusion pressure from volume depletion or shock -Myocardial griding : coronary artery that is a congenital issue it runs under the muscle compressing the corenary artery causeing ischemic pain
Aortic Regurgitation
-Diastolic -Incompetent aortic valve allows blood to leak back from the aorta into the left ventricle -Causes: abnormal aortic valve or aortic root dilation -Leads to left ventricle hypertrophy and dilation with eventual left-sided heart failure High-pitched blowing murmur during ventricular diastole; high systolic blood pressure; diastolic blood pressure usually low; palpitations
Mitral Stenosis
-Diastolic -Increased pressure of Left atrium = enlargement and hypertrophy of LA -Tight valve -Pulmonary hypertension/congestion Diagnostic: Low pitched murmur, rumbling diastolic murmur; open snap
Mitral Valve Prolapse
-Displacement (ballooning) of the mitral valve leaflets into the left atrium during ventricular systole -Women affected more than men -Typically asymptomatic Diagnostic: Midsystolic click or systolic murmur; palpitations; rhythm abnormalities; dizziness; fatigue; dyspnea; chest pain; or depression and anxiety ***SQUAT OR SQUEEZE = hear the murmur better
What can coronary perfusion be altered by?
-Stable atherosclerotic plaque -Acute platelet aggregation and thrombosis -Vasospasms -Failure of autoregulation by the microcirculation Poor perfusion pressure
Mitral Regurgitation
-Systolic -Backflow of blood from the left ventricle to the left atrium -Left atrium and ventricle dilate and hypertrophy due to extra volume -due to valve not closing properly Diagnostic: blowing murmur, high pitched, chronic weakness and fatigue
Aortic Stenosis
-Systolic -Results in obstruction of aortic outflow from the left ventricle -Left ventricle hypertrophy -Crescendo-decrescendo = murmur during ventricular systole = syncope, angina, dyspnea -Calcium built up
What happens if there is an increased plaque vulnerability?
-There is an active inflammation within the plaque -Large Lipid core within a thin cap -*Endothelial denudation (erosion) with superficial platelet adherence -*Fissured or ruptured cap -Severe stenosis due to high shear stress
Acute Coronary Syndrome (ACS)
-acute changes in plaque morphology and thrombosis -UNSTABLE angina= Tissue isn't dead just deprived of oxygen -Myocardial Infraction=tissues is dead Chest pain usually more severe and lasts longer than typical angina Plaque rupture with acute thrombus development Unstable angina—occlusion is partial MI—occlusion is complete leading to infraction of tissue ECG and biomarkers used for diagnosis
Angina Pectoris
1. Chest pain associated with intermittent myocardial ischemia - Burning, crushing, squeezing, choking or referred pain (to jaw or left arm) also can have paresthesia (hands and toes feel numb/tingling) 2. Inefficient cardiac pumping = pulmonary congestion & SOB 3. No permanent myocardial damage because it is just ischemia can be reverse
Why do patients get dysrhythmias?
Because electrical signals cannot pass through dead tissue (the cardiac tissue is dead) 1. Ventricular arythmias V-FIB = #1= lethal causes pts to die 2. Ventricular tachycardias = can lead to VFIB which causes death
A client is admitted to the intensive care unit suspected of having infective endocarditis. Which of the following tests is the most definitive diagnostic procedure that is done and used to guide treatment for this type of client?
Blood culture
3 Patterns of Angina Pectoris
1. Stable/Typical/Classic Angina: stenotic atherosclerotic coronary vessels; generally predictable and detected by similar stimuli each time; relived by rest and nitroglycerin 2. Unstable Agina: may progress acute ischemia or MI 3. Prinzmetal or Varient Angina: unpredictable attacks of anginal pain; Onset of symptoms is unrelated to physical or emotional exertion, heart rate, or other obvious causes of increased myocardial oxygen demand; Characterized by VASOSPAMS, atherosclerosis-induced hypercontractility, abnormal secretion of vasospastic chemicals by local mast cells, and abnormal calcium flux across vascular smooth muscle; Treatment: CALCIUM CHANNEL-BLOCKING drugs
Pericardial Effusion
Accumulation of noninflammatory fluid in the pericardial sac Composition of usual fluids Serous=yellow Serosanguineous=pink Chylous=milky Blood
ST-elevated myocardial infarction is accompanied by severe, crushing pain. Morphine is the drug of choice used to treat the pain of STEMI when the pain cannot be relieved with oxygen and nitrates. Why is morphine considered the drug of choice in STEMI?
Action decreases metabolic demands of the heart. Explanation: Although a number of analgesic agents have been used to treat the pain of STEMI, morphine is usually the drug of choice. It usually is indicated if chest pain is unrelieved with oxygen and nitrates. The reduction in anxiety that accompanies the administration of morphine contributes to a decrease in restlessness and autonomic nervous system activity, with a subsequent decrease in the metabolic demands of the heart. Morphine does not cause a feeling of depression to the client.
Rheumatic heart disease
Acute inflammatory disease that follows infection with group A β-hemolytic streptococci -Damage due to immune attack -Fever, sore throat, ROUND RED RASH -Dancing (involuntary) movements of hands *have to do 3 set of blood cultures to diagnose it
A father experienced the onset of chest pain and dies suddenly. The family asks, "What caused him to die so suddenly?" The health care provider's reply that is most appropriate would be, "There's a high probability that your loved one developed an acute heart attack and experienced:
Acute ventricular arrhythmia Explanation: Sudden death from an acute myocardial infarction in an adult is usually caused by fatal (ventricular) arrhythmias. Hypertrophic cardiomyopathy is the most common cause of sudden cardiac death in the young, since the disorder can be inherited as an autosomal dominant trait. Troponin is normally present in cardiac muscle; serum levels of troponin enzymes are diagnostic and will elevate within 3 hours of the acute event. Myocarditis is inflammation of the heart muscle and conduction system without evidence of myocardial infarction.
When a client suffers from a pericardial effusion which of the following are considered to be factors that will influence what effects it will have on cardiac function?
Amount of fluid Rapidity with which it accumulates The elasticity of the pericardium
A child's history of a recurrent sore throat followed by severe knee and ankle pain has resulted in a diagnostic workup and a diagnosis of rheumatic fever. What are the treatment priorities for this child?
Antibiotics and anti-inflammatory drugs Explanation: A diagnosis of rheumatic fever (RF) necessitates the use of antibiotics (usually penicillin) and anti-inflammatory drugs. These measures supersede the importance of pain control and oxygen therapy. Cardiac catheterization, corticosteroid therapy, pacemakers, and ?-adrenergic blockers are not common treatment modalities for RF.
When an acute MI occurs, many physiologic changes occur very rapidly. What causes the loss of contractile function of the heart within seconds of the onset of an MI?
Conversion from aerobic to anaerobic metabolism Explanation: The principal biochemical consequence of MI is the conversion from aerobic to anaerobic metabolism with inadequate production of energy to sustain normal myocardial function. As a result, a striking loss of contractile function occurs within 60 seconds of onset. None of the other answers occur.
A patient who experienced an ST elevation myocardial infarction (STEMI) received fibrinolytic therapy with streptokinase. Which of the following manifestations alerts the nurse to a developing complication?
Decreased level of consciousness
Dialated Cardiomyopathy
Dilation of one or both ventricular chambers Related to: -Alcohol Toxicity=heart failure -Pregnancy -GENETIC abnormality *slow progression
Angina pectoris is a chronic ischemic CAD that is characterized by a symptomatic paroxysmal chest pain or pressure sensation associated with transient myocardial ischemia. What precipitates an attack of angina pectoris?
Emotional Stress
Infective Endocarditis
Infection of endocardial structure *most common bacterial Streptococcus & Staphylococcus Acute=IV drug users = poor prognosis Subacute = predisposing risk factors typically present (low grade fever) **3 set of blood cultures && Dukes Criteria to diagnose! Bacterial infections = 2 weeks to develop Fungal = over a month to develop
A client has just been told that he has an infection of the inner surface of the heart. He is also told that the bacteria has invaded his heart valves. What term is used for this disease process?
Infective Endocarditis Explanation: Infective endocarditis is a serious and potentially life-threatening infection of the inner surface of the heart. Pericarditis involves an inflammatory response of the pericardium. Myocardial infarction is a heart attack while cardiomyopathy is a heart disorder that is confined to the myocardium and can sometimes represent myocardial changes that occur with a variety of systemic disorders.
A client who has suffered a myocardial infarction is being treated in the emergency room. His pain remains severe even though he was given nitrates and oxygen. The physician now orders morphine for the pain. What method should the nurse to administer the morphine?
Intravenous Explanation:It is given intravenously because of the rapid onset of action, and it does not elevate enzyme levels.
CHD -Coronary Heart Disease
Ischemic heart disease and coronary artery disease. Insufficient delivery of oxygenated blood to the myocardium due to ATHEROSCLEROTIC ARTERIES
Treatment of ACS
MONA! Morphine -decreases pain and vasodialator improves blood flow to myocardia O-oxygen N-nitrates - casodialate coronary artery A-asprin
Lipid Lower Therapy
Mainstay of therapy for patients with atherosclerotic heart disease because they prevented the formation of atherosclerosis and stabilizes the plaques by making them less prone to rupture (ex. aspirin , statin)
A client is admitted for observation due to abnormal heart sounds, pulmonary congestion, nocturnal paroxysmal dyspnea, and orthopnea. Upon auscultation a low-pitched, rumbling murmur, best heard at the apex of the heart, is also heard. Which condition does the client likely have?
Mitral Valve Stenosis Explanation: Pulmonary Congestion + low-pitched rumbling murmur
Antibodies directed against the M protein of certain strains of streptococcal bacteria seem to cross-react with glycoprotein antigens in the heart, joint, and other tissues to produce an autoimmune response resulting in rheumatic fever and rheumatic heart disease. This occurs through what phenomenon?
Molecular mimicry Explanation: It is thought that antibodies directed against the M protein of certain strains of streptococci cross-react with glycoprotein antigens in the heart, joint, and other tissues to produce an autoimmune response through a phenomenon called molecular mimicry. None of the other answers are correct.
A client with a long history of stable angina suddenly experiences substernal pain that radiates to the left arm, neck, and jaw. He describes the pain as severe and feels as if he is suffocating. He has taken nitroglycerin and not experienced any relief. The client is most likely experiencing:
Onset of STEMI Explanation: The onset of STEMI involves abrupt and significant chest pain. The pain typically is severe, often described as being constricting, suffocating, and crushing. Substernal pain that radiates to the left arm, neck, or jaw is common, although it may be experienced in other areas of the chest and back. Unlike that of angina, the pain associated with MI is more prolonged and not relieved by rest or nitroglycerin.
A client is at high risk for the development of rheumatic heart disease. The most important information for the nurse to provide would be:
Prompt diagnosis and treatment of streptococcal infections
A preventative measure to decrease the risk of developing rheumatic heart disease includes which of the following?
Prompt diagnosis of streptococcal infections with a throat culture
Cardiac tamponade and pericardial effusion can be life-threatening when the pericardial sac _______ and ______ the heart.
fills rapidly; compresses Explanation: Rapid accumulation of effusion fluid or blood in the pericardial sac causes cardiac tamponade, resulting in compression of the heart. This leads to cardiac standstill or failure. Pericardial sac thickening due to inflammation can restrict the heart, rather than allow stretching. Rupture of the sac is pathologic, resulting in heart expansion. A friction rub sound (rubbing between the inflamed pericardial surfaces) is characteristic of acute pericarditis. Constrictive pericarditis causes scar tissue formation that contracts and interferes with filling.
Cardiac Tamponade
fluid accumulation in the pericardial sac is sudden it can lead to external compression of the heart chambers= impaired filling Manifestations include: Reduced stroke volume = HR will increase Compensatory increases in heart rate Pulsus paradoxus= systolic BP will drop by 10mmHg on insperation Hypotension, distended neck veins and muffled heart sounds―called Beck's triad = BEKS triad with caria tamponade***** Treatment: pericardiocentesis - drain fluid ; or pericardio window
Acute Pericarditis
idiopathic and presumed viral Uncomplicated form resolves spontaneously = antinflammatory treatment Complicated forms involve pericardial effusion, or persistent/recurrent inflammation; requires hospitalization Typically presents as chest pain that is RELIVED BY LEANING FORWARD; fever, leukocytosis, malaise, and tachycardia; FRICTION RUB***
Regurgitation
inability of a valve to close completely results in extra volume work for the heart
Acute occlusion
plaque disruption and thrombus formation and results in UNSTABLe angina and MI
Asymptomatic MI
silent MI : they don't know they have it EKG has a deep Q wave = old infraction
