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CV/PV OUTLINEQuick ReviewCardiac Output = the amount of blood pumped in 1 minute (CO = HR x SV)Stroke Volume = the amount of blood pumped out of the ventricle with each contractionPreload = the amount of myocardial stretch just before systole caused by the pressure created by the volume of blood within the ventricle (aka Left ventricular end diastolic pressure, LVEDP)Afterload = the amount of resistance to the ejection of blood from the ventricleAtherosclerosis = plaque development. #1 cause of coronary artery disease and can occur in any vessel of the bodyAngina = Chest painStable is predictable and is fixed with rest and nitroglycerineUnstable isn’t predictable and isn’t fixed with nitro or restPrinzmetal’s due to coronary artery vasospasm. Something is causing the artery to spasm and clamp down and slows blood flow, therefore you get the anginaSilent goes undetected. Happens a lot in elderly people (because their neurotransmitters are worn down), diabetics, and womenMyocardial Infarction = cellular injury and cellular death. There is an inadequate flow of O2 long enough that the cells begin to starve for nutrients and die…Risk Factors ModifiableHigh CholesterolHDL’s are good and you want them to be over 60 mg/dLLDL’s are bad and you want them to be below 100 mg/dLTotal triglyceride level you want to be less than 200 mg/dLSmokingCauses massive vasoconstriction. People who stop smoking reduce their risk of heart disease by 30-50% in the first year and it gets better every year after thatHTNVasoconstriction causes problemsHyperglycemiaThe higher the sugar level in your body the more you’re likely to have vascular injuryObesityPhysical InactivityStressType A personalities are much more prone to heart diseaseNon-ModifiableAge- Men more than women younger, after women hit menopause the risk is the sameGenderFamily History- very strong genetic link to heart diseaseEthnicityCultural AspectsWhite, middle-aged men have the highest incidence of coronary artery disease.African Americans have an early age of onset of coronary artery disease.African American women have a higher incidence and death rate related to coronary artery disease than white women. African Americans have more severe coronary artery disease than whites.Native Americans <35 yr of age have heart disease mortality rates twice as high as other Americans. Major modifiable cardiovascular risk factors for Native Americans are obesity and diabetes mellitus.Hispanics have lower death rates from heart disease than non-Hispanic whitesPrevention and treatmentDietExerciseGoal is 30 mins 3-4 times a week. May need to start off slowly and work up to this point. Make sure to teach them S/S of heart problems (i.e. Myocardial Infarction) so if it happens they don’t die..MedicationsEffective, but won’t replace diet and exerciseTobacco cessationManaging HTNControlling DMManaging stressLipid Lowering DrugsStatins – most common, goal is to lower LDL and increase your HDLNiacin- help with minimally elevated cholesterolFibric AcidsCholesterol absorption inhibitorsBile acid sequestrantsEvaluation of Chest PainPhysical AssessmentAuscultationS/S of AnginaCharacteristic ones are dyspnea, chest pain, crushing/stabbing pain, clutching chest. For silent angina they’re N/V/D, diaphoretic and confusedFeeling of indigestionChoking or heavy pressure in sternumMay radiate to neck, jaw, shoulders, arms, usually left armWeakness or numbness in arm, wrists, and handsShortness of breath, pallor, diaphoresisDizziness, nausea, and vomitingEKGNormalsP wave- atrial contractionQRS wave- ventricular contraction---- ventricles are responsible for pushing out all the blood to the entire body, so might be a little more importantST segment- where the heart is relaxing, when your heart relaxes, that’s when it feels with blood. When contracted it is smashed out. If a person has a blockage/vasospasm, the blood stops sudden, doesn’t flow smoothly. Represents the time the heart gets the blood. During the segment it doesn’t get good blood flow. Specific for heart problemsLook for ST depression and/or T wave inversionThese means ischemiaST elevationThis means there is infarction and deathLabs CK & CKMBCK = creatinine kinase, enzyme that gets spilled from muscle tissue when it’s damaged. You’ll see a rise during/after muscle injury. So it’s good but not that great cause the damage could be in your leg muscleCKMB = different form of above that very specific to cardiac tissue. Shows up anywhere from 3-6 hours, and usually lowers itself in 24 hoursTroponin (I & T)Very specific to cardiac tissue. Will nearly always be normal with non-cardiac disorders. The higher the troponin and the higher the CK the more extensive the tissue damage. Shows up in 3-4 hours, and peaks anywhere from 4-24 hours. She thinks this is the biggie, hence study troponin more…Myoglobin = shows up early (1-3 hours after cardiac damage). Good for detecting early damage .This might be someone who is having early signs of chest pain. Also cardiac specificSerial Cardiac Enzymes are when they’ll check your troponin and CK enzymes every 6 hours for 3 times. This is to watch for a trend in the labs to see if they’re getting better or worse. More Evaluation of Chest Pain = they’ve done the things above and they still think it may be a cardiac problem they will do these slightly more invasive procedures below… But they do the above ones first. They go from least invasive to more and more invasive as they try to figure the problem out.Stress TestsExercise- putting them on a treadmill and making them workDrug induced – These drugs will mimic exercise in the heart. Can be either Persantine valium is used very commonly but can also use dobutamine tests. Persantine valium is often referred to as PVST = persantine valium stress test . EchoJust like a sonogram that you get when your pregnantCT ScansElectron Beam tomography (EBT)64 Slice CT Scan- a ct scan that takes a picture every millisecond. Develops a 3-D picture of the heartCoronary Angiography (Cardiac Cath)Take you to the cardiac catheterization lab and they inject meds to highlight your vessels and look at them. Treatment of AnginaPrimary aim of therapy for myocardial ischemia and angina is to reduce myocardial oxygen consumption. We want to do things to decrease the myocardial oxygen demand…Do this by decreasing the BP, decreasing the HR, assist contractility, and decrease left ventricular volume (the more blood that fills into your ventricles the harder the ventricle is going to push to get the blood out). Medical ManagementNitratesNitroglycerine A vasodilator that works really well on our veins. The bigger the veins are the more they can hold in them, hence less blood is in the heart. Sublingual NitroMake sure and keep it in the original containerAdministration = put it under your tongue. Wait 5 mins and if the chest pain isn’t better take another pill. Do this 2 more times (for a total of 3 pills every 5 mins) and if it’s still hurting call 911 cause you gonna die…Side EffectsFlushing, decreased BP, H/A and tachycardiaDon’t take along with Viagra and the like… they shunt all the blood to your Who-Ha, which for a cardiac person, is bad news bears.Beta Blockers They help dilate the vessels and slow the HR down and they assist the contractility of the heart. The heart can do 25% more work without ischemia while on beta blockers.MonitoringNever stop beta blockers abruptly! If a person has been on it for a while and we withhold that the receptors are nice and irritable (hypersensitive) and you can have severe rebound HTNMonitor HR, check BP, monitor for bronchospasm, and glucose levels. Remember asthmatics aren’t supposed to have a non-selective beta blocker or a beta2 blocker. And it can inhibit glycogenolysis in a diabetic so they should carry a fast sugar with them…Calcium Channel BlockerThey relax the blood vessels. Very good for coronary vasospasm (which can happen with Prinzmetal’s angina or after invasive coronary procedures). ↓ SA node impulse & AV node conduction* Slows HR* Decrease myocardial oxygen demandRelaxes blood vessels improving coronary perfusionAntiplatelets and Anticoagulants AspirinPrevents platelet aggregation (or clot formation)81 mg dose is for prevention. Like you have a family history or high risk. They have no known problems but they could have a problem in the future325 mg dose is for someone who has been diagnosed with somethingPlavix Very widely used. Acts very similar to aspirin and can be used along with ASA. Very commonly used after a pt has had a procedure like a bypass, peripherovascular surgery, etc. Concerns with these are bleeding 1st (cause they can’t clot) and GI upset 2nd (can cause ulcers) LovenoxLow molecular weight heparin. Used all the time. OxygenIncrease oxygen delivered to the myocardiumALWAYS initiate O2 at the onset of chest pain!!!Nursing Interventions for Chest PainOxygen first and foremost!!!Quick assessment of the anginaPQRST (position, quality, radiation/relief, severity, timing) Vital signsMonitor respiratory status12 lead EKGCheck LabsNitro!!!Management of Angina at HomeReduce activities that produce chest pain or dyspnea Avoid temperature extremesMaintain normal BP Avoid OTC meds that can ↑BPNasal decongestants can raise your blood pressure and HRStop smoking!!Take ASA & β-blockers as prescribedCarry Nitro at all times! S/S of Myocardial InfarctionSudden onset of chest pain No response to rest or medicationShortness of breath, dyspnea, tachypnea Nausea & vomiting↓ urinary outputCool, clammy, diaphoretic, pale skinAnxiety, restlessness, fearMedical Management of MIGoalsMinimize myocardial damagePreserve myocardial functionPrevent complicationsUse the following ThrombolyticsDissolve thrombi (clots) in coronariesRestore perfusionGiven IV or Intra-coronary routeAdminister ASAP after onset of symptomsBy the time they get in the hospital door to when they get the drug needs to be a 30 min window. If you’re giving it into the heart itself in the cath lab the window is 60 minsStreptokinase, activase, t-PARisk for these are bleeding cause they break up clogs everywhere in the body! PTCAMedicationsMONAMorphine –good for pain and vasodilation. Decreases preload and decreases workload on the heartOxygenNitrates – vasodilation. More of an emergency drug, not an everyday thingAspirin – antiplateletAce Inhibitors – decrease BP and cardiac workloadPrevention of further damage (remodeling). When you have a weak heart the muscle gets stiff and tends to stretch and become thick and it stays that way. These guys help prevent your heart from becoming thick and stretched…Increase renal productionBeta BlockersDecrease cardiac outputReduce incidence of further attackAcute Myocardial Infarction Care Improvement StandardsAspirin at arrivalAspirin prescribed at dischargeACE inhibitor/ARB for LVSD prescribed at dischargeAdult Smoking Cessation advice/counselingBeta Blocker prescribed at arrival and dischargeThrombolysis within 30 minutes of arrivalPCI within 90 minutes of arrival* (Percutaneous coronary intervention )ST segment elevation without thrombolyticsNursing CareBed restStool SoftenersEducationDiet, caffeine, smoking cessation, exerciseS/S of recurrent MITEST QUESTION on when can you have sex again after an MI it’s when you can walk up 3 or 4 miles per hour or up flights of stairs. Cardiac RehabGoalsExtend & improve quality of lifeLimit progression of atherosclerosisReturn client to work and pre-illness lifestyleEnhance psychosocial & vocational statusPrevent another cardiac eventSurgical Interventions for CADCardiac Catheterization & Coronary Angiography (CCCA)- they’re going in looking for a blockWhat they doInsert a catheter into the femoral artery up to the aorta and shoot dye in so they can watch what’s going on in the vessels. They visualize the arteries looking for blockages. Done in the cath lab. Nursing InterventionsPre-OpGive them lots of IV fluid b/c the dye we inject can be toxic to the kidneys so we want to be sure we flush the kidneys outFast for 8-12 hoursPrepare the client for expectations of procedureThey are going to be on a hard table for a while, they’ll be able to hear the physician talking to them, the dye may feel warm, they may feel their heart palpitate or shudder when the catheter is insertedRandom InfoIn a right heart cath they are looking at the inside of the heartIn a left heart cath they are looking at the coronary arteries on the outside of the heartPost-OpAssess catheter site for bleeding or hematoma. Make sure and apply a lot of pressure. If there is a hematoma, take a marker and mark it so you know if it gets bigger or whatever…Check peripheral pulses, color, temperature, pain or numbness of affected extremity q 15 min X1 hrMonitor for dysrhythmias Bed rest for 2-6 hrs Affected extremity straight HOB no higher than 30°Encourage fluids to flush out dyeThey have to flush out the dye whether they want to or not! Ensure safetyPercutaneous Coronary Interventions (PCI)- they’ve found a clot and they go in to remove itPTCA – Percutaneous Transluminal Coronary AngioplastyProcedureThey take a balloon and center it under the plaque (that they found via angiogram) and they expand and contract, expand and contract, etc. They’re trying to break up the plaque.GoalGetting a plaque that is only causing 20% blockage (so the blood flow thru the vessel is at 80%).Risk Abrupt closure of the vessel due to debris. Watch for dyspnea, dysrhythmias, etc.Perforation of the vessel A blockage in the Left main artery can’t be fixed by this procedureCoronary Artery StentSometimes during a PTCA they will place a stent that stays in place after they take the balloon out. The stent helps hold the vessel wall open. If it’s a drug eluding stent then the stent is covered with something that keeps stuff like platelets from sticking to it.AtherectomyAther = plaque and ectomy = get rid ofThey go in and basically shave or bore the plaque away with a deviceTransmyocardial revascularization Can be done on a heart that has infracted to the point where there is no blood flow to the area of the tissue. If the person’s had a massive MI and there is a place that has no blood flow they’ll go in and try this shit. They take a laser and injure the heart. They bore out little holes into the wall of the damaged heart muscle. The idea is that if they injure the heart muscle angiogenesis will move in and replace vessels and all that have died. They’re trying to get circulation back to that muscle. They’re hoping the dead area will wake back up. Not widely used but has good resultsCoronary Artery Bypass (CABG or ACBP) – open heart surgeryProcedureSurgery where blood vessel from another part of the body is put on the heart to reroute blood from a bigger vessel that works fine down to the place where blood isn’t getting. Say you have a vessel path A,B, and C. B is blocked so they put a vessel from your leg directly from A to C, bypassing B. They might put a person on a bypass machine making blood go outside to the machine and not back into the heartVein choicesBest choice is LIMA (just inside your chest wall)Most common choice is greater saphenous vein (cause it’s easy to access, fairly superficial and there are lots of other vessels in your leg to compensate once it’s gone). It’s in the thighPatient is a candidate for bypass if:They have angina that is uncontrolled by medicationThey have a positive stress test with a blockage that can’t be treated in the cath labIf the main coronary artery (the left one) is occluded more than 60% If they have complications in the cath labLike debris that has caused an abrupt closure, they poked a hole in the vessel on accidentCare of a pt after a BypassMonitor cardiovascular statusLook at urinary output (you want 25mL or more an hour)Labs of potassium and Magnesium are important afterMonitor respiratory statusMaintain fluid & electrolyte balanceRelieve painMaintain adequate tissue perfusionMaintain normal body temperatureGet them in the shower to keep the wounds clean! Bed bath won’t work unless they are fucked up!Promote home & community-based careInfectious Diseases of the HeartRheumatic EndocarditisRheumatic FeverWhat it is:Group A beta-hemolytic streptococcal pharyngitis. Causes inflammation of the lining of the heart. Over time the scarring remains and as they age the endocardium doesn’t work the way it should. Preventable with antibioticsThe key to preventing it is a throat culture for accurate diagnosis!! You want to find these guys and treat them quickly! Mitral Valve is the most common siteCommon in school age childrenRecognizing and Preventing Rheumatic FeverS/S of streptococcal pharyngitis (strep throat)Fever of 101-104 degrees F)ChillsSore throat (sudden in onset)Redness of throat with exudatesEnlarged tender lymph nodesAbdominal painAcute sinusitis and acute otisis mediaInfective EndocarditisDirect invasion by a microbe causing a deformity of valvesFlu-like symptomsWeight lossIntermittent feverHeart murmurOsler’s Nodules (red inflamed spots on the fingers) and petichiaeDiagnosed by serial blood cultures and EchoTreatmentIV antibiotics for 2-6 weeks (very aggressive). They are usually stuck doing this in an inpatient setting. Antibiotic therapy for high risk patients before and after dental or surgical procedures. People who have valve problems need antibiotics before they go in for minor surgical procedures. However American Heart Association is showing now that it really doesn’t make that much of a difference. Pericarditis (aka Pericardial Effusion)What it isInflammation of the membranous sac around the heartOccurs commonly after cardiac surgery, due to infection, with some inflammatory disorders like Lupus and RA, after trauma, and with connective tissue disordersS/SMost characteristic symptom is chest pain that may get worse when they lay downMost characteristic sign is a pericardial friction rub. Loud sound that’s said to sound like leather rubbing against leather. If the effusion develops quickly it can become:Cardiac tamponade = Emergency situation!!Muffled and distant heart soundsFall in systolic pressure 10mmHg when diastolic is going up (narrowing pulse pressure)Distended neck veins (cause blood is backing up into the next veins)Emergency pericardiocentesis is used to fix this problem. They stick a needle in the sac around the heart and aspirate the fluid in there… Valve disordersInfo Regurgitation = too lose and the valves become floppyStenosis = very stiff and tight and don’t allow enough blood to come thruYou’re most concerned about the valves on the left side of the heart because the left side of the heart is responsible for pumping blood out to the rest of the body. Management of Valve DisordersMedsDiureticsCardiac glycosidesDigixin or whatever the fuckBeta blockersProphylactic antibioticsValve repair or replacementInfoDone when a valve is too fucked upUsually requires use of Cardiopulmonary Bypass machineCare very similar to that of CABGValves which are repaired function longer than those which are replaced (cause it’s our own tissue and we tolerate it better)TypesConnissurotomy – separation of fused leatlets (for stenosis). Try to make the valve wider by cutting it or using a balloon to expand the valve. Not too invasive. Done a lot on small children and sick peopleAnnuloplasty- for regurgitation valve problems. They narrow the diameter of the valve opening. Leaflet repair- fuck if I knowChordoplasty- they shorten the fibers on the valve so they aren’t as stretchy. For regurgitative shit.Replacement of valve with prosthesis Mechanical Valves These guys always have to be on anticoagulant therapy cause your body wants Not for use inPeople of child bearing ageOld bastardsGood for use in people who are immunosuppressed because they’re body can’t fight foreign things anyway so might as well put something in there that is foreign.Most common type is the St. Jude valve and when it opens and closes you can hear it click. Tissue Valves = don’t need anticoagulation but not as durable as a mechanical valveXenografts = valve from a pig or cow, most commonHomografts = valve from a human cadaverAutografts = from the patient them self. Used for an aortic valve replacement. They’ll come over and take pulmonic valve and move it over to your aortic valve cause it’s more important and takes more stress. Then they would put something else in on the pulmonic valve. Heart FailureInfoInability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients*When the left side of your heart fails you manifest with pulmonary S/SThe blood isn’t moving forward so it’s backing up into the lungs. It’s the only place for it to go. Once you have it you’ve got it forever, lifelong chronic condition. You want to prevent progression of the disease.Most often caused by CAD, but often it’s HTN or valve disorders. 60% of people with heart failure also have CADTypes of dysfunctionSystolic dysfunction – problems with contraction. Like the water balloon. It fills with too much so often it gets stretched out.Ejection fraction is less that 40%. It can’t pump out all the blood it fills with. The muscle is so stretched it isn’t strong enough to get all the blood outNormal EF is around 75-80%Diastolic Dysfunction – problem is with the heart filling. The heart is stiff and doesn’t move like it should. The muscle is so thick and stiff it doesn’t stretch to fill. Like a coffee cup, stiff and hard, you can’t fill it with more fluid than it’s going to hold no matter how hard you try.Left Sided Heart Failure (the most common b/c the left side of the heart has the most workload b/c it’s pumping blood to the entire body)Pulmonary Congestion – dyspnea, cough, crackles, low O2 saturation, S3 heart soundDyspea on exertionOrthopnea- hard to breathe when they lay downParoxymal nocturnal dyspnea (PND)The client has been sitting up or walking around all day and all this fluid has accumulated in their extremities. When they lay down the fluid moves into their lungs and they have a hard time breathingConfusion, anxiety, and restlessness due to lack of oxygenPulmonary EdemaMain goal is to get the extra fluid off/out of their bodyPrevention is keyNeed a thorough lung assessmentRecognition of early stagesDry hacking cough, fatigue, weight gain, worsening edema, degree of dyspneaRight Sided Heart FailureS/SThe problems are systemicJugular vein distention Dependent edema in the feet, ankles and legs (BIG SIGN)Hepatomegaly- enlarged liverAscites- look like your preggersWeakness, anorexia, and weight gainHeart Failure Diagnostic FindingsPulmonary and peripheral assessmentBNP (B type natriuretic peptide) very specific to heart failure. Normal value is less than 200, but you only treat it when it gets up to 800EchocardiogramFunctional Classes of Heart FailureClass 1 – been diagnosed but are functionally fineClass 2 – have symptoms with ordinary activityClass 3 – symptoms with minimal activity Class 4 – persistent symptoms even at restMedical ManagementAce Inhibitors stop heart remodellingARBS are used if the person can’t tolerate an ACEBeta Blockers are good drugs for youDigoxin – cardiac glycoside used for systolic heart failure, a-fib and flutter. Dig and diuretics are your main drugs for heart failure. It regulates the heart rate and assists the contraction. Very similar to what the beta blockers do. Dig ToxicityFatigue, depression, malaise, N/V, anorexia, changes in heart rhythm (PVC’s are premature ventricular contractions). Halo vision is also a big sign, they see green halo’s around lightsRisk increases with hypokalemia, oral antibiotics, CCB’s, quinidine, and amiodaroneIf their potassium is low they’re more likely to have a digoxin toxicityAlways call the doctor before you hold digoxin, even if the levels are super duper high. Also, if the pulse is less than 60 then call the doctor before you give it. Listen to the apical pulse for 60 seconds, every time, even if there is a heart monitor, always. Bitch.DiureticsCalcium channel blockersAnticoagulantsLow sodium Diet b/c water follows salt. If they are eating a lot of salt they will retain a lot of fluidNursing management of Heart FailureI & O – super importantDaily weight – a 2-4 lb gain a day is super not good. Lung assessmentLook for edemaLook for pressure ulcers cause they are all fat from fluid therefore more likely to get these Monitor electrolytes (potassium and magnesium)DysrhythmiasAtrial FibrillationInfoRapid, disorganized atrial twitching. Most common dysrhythmiaHard to see the P wave. It can be either inconsistent or absentB/c the atria are fluttering. They’re not making a strong enough beat to show up on the EKGQRS’s aren’t evenly spaced apartAcute (Paroxymal)(it just shows up and goes away) or ChronicCausesOld age, CAD, HF, valve disorders, hyperthyroidism, post open heart surgery (cause they cut you open and touch your heart and your heart hates that shit and gets pissed off and flutters for a few days), idiopathic, low potassium and low magnesium. The higher the HR the worse your pt will feel b/c the CO is bad. S/S They say my hearts racing or they feel palpitationOften their O2 sats drop (cause CO is lousy)Some people are walking around with a-fib and they don’t even know it. BP is usually low (because CO is low)Complications of A-FibDecreased atrial kickMural thrombiClots along the wall of the heartAtrial Flutter (similar to a-fib)InfoRegularly irregular rateSaw-tooth appearanceRisk of mural thrombi againTreatment of these two bastards… (a flutter and a fib)Goal is to convert them back to a regular rhythmMedsCordarone and Digoxin are usedWe know they are at an increased risk of clots so you put them on Coumadin or whatever the fuck the dr orders. Cardioversion is when they shock the shit balls out of you to shock your heart into a normal rhythm. If they’re heart is still all kinds of fucked up they will put in a pacemakerNursing careOxygen, watch vitals, get an EKG STAT motha fucka! Notify the doc, try to keep them calm, and use bed rest for an acute onsetLabs are also very importantPacemaker PlacementPlaced forBradycardia, dysrhythmias, and heart failureTypesTemporary or permanent Permanent are most commonMost of them will have a little box up in their left subclavian area. Has leads that are implanted in the heart to stimulate it to beat. Complication of pacemakerInfectionCan’t shower for a week cause water could get into pocket and fuck their shit upBleeding and hematoma after insertionHemothoraxDysrhythmiasDislocated leads – to help prevent this they put arm in a sling for like 12-24 hours afterward and they remain in bed after nightHiccuppingCardiac Tamponade if they nick the pericardial sackNursing Care for PacemakersMonitor rhythmMonitor vitalsChest X-rayBedrest HOB 30°Do not get wet for 7 daysCarry information at all timesPacemaker checksAvoid strong EM fieldsPeripheral Vascular Disease#1 Sign is Intermittent Claudication!Pain in extremities with exercise; relieved by rest (this is the definition of intermittent claudication. There is something that is causing a blockage that is keeping the blood from where it needs to go)Persistent pain @ rest indicates severe ischemiaLowering extremity to dependent position ↑ perfusionPain of Int. Claud. Occurs one joint level below disease processCalf pain may reflect femoral or popliteal artery ischemiaPain in hip or buttocks may be ischemia in abdominal aorta or iliac arteriesThere is something that is causing a blockage that is keeping the blood from where it needs to goSkin & temperature changesCool & paleWhite or blanched appearance when elevatedRubor – reddish bluish discoloration in dependent position (over-reaction)Cyanosis – blueGangrenous changesEdema – unilateral or bilateralLoss of hair, brittle nails, dry, shiny, scaly skin, ulcerations (very difficult to heal b/c of lack of blood), bruits (vibrating sound/feel b/c of obstruction)Pulse changesPresence or absence; 0 to +4 scale; Doppler to detect flow (If you don’t feel a pulse somewhere ALWAYS check with a Doppler!!!)Ankle-brachial index (ABI)Ankle-bradial IndexSystolic BP ankle ÷ Systolic BP brachialRisk FactorsNicotine useHyperlipidemia (causes plaques to form)HypertensionDiabetesStressSedentary lifestyle/ObesityNursing Interventions for Arterial InsufficiencyLower extremity to increase perfusion (let gravity get blood to where it needs to go)Exercise program (when appropriate)Avoid extreme coldNo nicotineAvoid stressNo constrictive clothing; no crossing legs (causes a tourniquet effect)Medication for pain & vasodilation Protective shoes; foot care; meticulous hygieneProper nutritionManagement of Peripheral Vascular DiseaseExercise programWeight reductionSmoking cessationMedicationsTrental, Pletal (makes blood more slippery), ASA, Ticlid, Plavix Antihypertensives Diabetes medicationsLipid lowering agentsSurgical Interventions for PVDAngioplastySurgical bypass graftsAorto-iliac (AIBP)Aorto-femoral (AFBP)Femoral-popliteal (Fem-Pop)Post Operative Care for Vascular ProceduresMaintain adequate circulation Monitor pulse of affected extremity (if a pulse is absent call the physician right away!)Compare to otherNo pulse may indicate thrombotic occlusion of graftMonitor color & temperature of affected extremityMonitor VS, mental status, urinary outputMonitor with doppler every hour for 8 hours then every 2 hours for 24 hoursMonitor for BleedingAvoid leg crossing & prolonged extremity dependenceExtremity elevation to reduce edemaVenous InsufficiencyInfo (don’t see this as often and not as much of a problem. Blood just isn’t moving back up, just hanging out in one place. Can be uncomfortable, but not a life or death situation. Edema is present and it turns your skin turn brown)Chronic venous stasisEdemaBrownish discolorationPainManagementElevating extremitiesFoot pumpingAvoid crossing legsAvoid constrictive clothingCompression stockings (good for venous insufficiency, but if they’re not a good fit and too tight on the legs, could cause a tourniquet effect)Careful assessmentRaynaud’s DiseasePathoIntermittent episodes of vasoconstriction of small arteries of feet & hands, causing color and temperature changesS/SColor change – white, blue, redWhite = start to lose of blood flowBlue = loss of blood, no O2 to the tissues causes cyanosis, hence blue colorationRed = return of blood flow, most painful. Numbness, tingling, & burning. Think of how it feels when your hands get cold and you go to the sink for some warm water to heat them up. If the water you use is too hot it burns like crazy. Same basic concept/sensation.Involvement tends to be bilateral & symmetricManagementAvoid stimuli that provoke vasoconstrictionAvoid stressAvoid smokingMinimize exposure to coldHandle sharp objects carefullyGive prescribed vasodilatorsAvoid decongestantsSympathectomy Deep Vein Thrombosis (DVT)Info (remember, immobility is the most common cause of these guys)Virchow’s triad (3 Things that contribute to development of DVTs)Venous stasisVessel wall injuryAltered blood coagulationDeep veinsSuperficial veinsAssessment and Prevention of DVTRecognition of high risk clientThorough lower extremity assessmentLimb painHeavinessSwelling, redness, warmthTendernessDifference in leg circumferenceVenous Doppler (use this to diagnose)Remember, you’ll have a regular pulse because it’s a venous problem, not arterialPreventionAnticoagulants, Intra vena cava filterAlso things like foot pump exercises, early ambulation, lovenox, etc. Treatment for DVTComfort MeasuresBed restElevationCompression stockingsAnalgesicsModes of anticoagulant therapyIV heparin infusion followed by CoumadinPTT every 6 hrsINR (international normalized ratio) 2-3CoumadinLMWH – low molecular weight heparinLovenox/Coumadin – outpatientPT/INR for CoumadinThrombolytic therapyNursing Management for Anticoagulant TherapyBleedingAntidote for heparin is protamine sulfateAntidote for Coumadin is Vit K or fresh frozen plasmaThrombocytopeniaHeparin-induced thrombocytopenia. The body has an allergic reaction to the heparin and will have massive clotting all over the body. Severe ischemia and may cause amputationDrug interactionsCoumadin is tricky; pay attention to drugs that ↑ or ↓ efficacyPatient Education while taking AnticoagulantsAdhere to PT/INR monitoring as directedAvoid OTC meds without medical advice (like stuff you get at Walgreens, or your dealer, whichever one…)Avoid ETOHDo not stop unless directedConsider wearing ID bandAlways alert caregiver before any medical treatment (dental, or any major or minor treatment/surgery)Report any bleeding – blood in urine, stool, excessive bruising, epistaxis Avoid excessive amounts of foods high in Vitamin KGreenfield Vena Cava FilterTraps blood clots as they travel up the vena cava preventing them from reaching the lungs. The cone-shaped design allows blood to flow around the captured clotAbdominal Aortic Aneurysm (AAA)InfoMost commonly formed due to HTN and atherosclerosis, strongest vessel in our body and becomes worn down. Remember, an aneurysm is like a balloon-filled bulge in an artery caused by weakening of the artery wall. Risk FactorsGenetic predispositionSmoking/tobacco useHypertensionS/SMany asymptomatic“Feel my heartbeat in my abdomen”Abdominal mass/pulsationBruit in abdomenA CT scan is the most common way to detect them. Then with an ultrasound, then arterialgram. Watch H&H very carefully. If it ruptures they’ll become pale and have dysrhythmiasAAA RepairOpen procedureAneurysm is resected (is that a word? I don’t know, and spell check is no help) and a graft is sewn in placeMajor surgeryExtended recoveryEndovascular AAA Repair – looks like a sleeve to protect the aneurysm, used for the small ones and for people too sick to undergo the major surgery. Can’t do surgery if the aneurysm is at or above the renal arteries…Aortic graft is placed inside the aortaAccessed via catheters place in bilateral groinsQuick recoveryNursing Management of AAASevere abdominal or back pain?? Could be expanding or growing. Watch BP & H/HPost-op: Intense monitoring of CV, renal, pulmonary, and neuro statusAssess bowel sounds- indicates when they can start eating. “home free”Early ambulation, ISReview Questions from Wolfe on the Discussion Board (And thank John Stell for answering all of these so you don’t have to)What are the primary sign and primary symptom of pericarditis?...muffled heart sounds upon auscultation, JVD, narrowing pulse pressure.What is pulse pressure??Difference between the systolic pressure and diastolic pressure.Name some clients who would be at risk for developing a-fib/a-flutter?...previous hx of CAD, cardiac arrhythmias, post-op CABG...probably more?What is a common sign of a cardiovascular event in the elderly?Dyspnea; atypical s/sx due to degeneration of nerve fibers.What are the major side effects of thrombolytics??Increased bleeding risk, absolute contraindication in those with concurrent hemorrhagic CVA or hx of the same.How does morphine decrease preload??Decreases pain and anxiety...relaxes vessels causing vasodilation and subsequent decrease in preload??What do you need to assess in a patient that has just had a cardiac cath?...bleeding at the site of the catheterization, increase the pt's fluid intake to flush out dye.What are the risk factors of PTCA??Not sure :/...cardiac irritability? Risk of embolus if unable to "capture" any debris that may be inadvertently dislodged during procedures...I think. Need to read up on it more.Do you elevate or dangle legs for peripheral arterial disease? peripheral venous disease??Dangle for PAD - gravity assists in circulating the poor arterial circulation; elevate for PVD, which will also facilitate gravity to help blood flow back to the heart.What is involved in the care of a client immediately following pacemaker placement?....hmm, also need to read up on it. Monitor for dysrhythmias?A client with ascites is more likely to have ________ heart failure?Right sided heart failure...back up of fluid into systemic circulation (including ascites) is the hallmark signGroup Case Study things…1A female client, 57 years of age, is admitted to the emergency department (ED) with a diagnosis of heart failure.? She was discharged from the hospital 10 days ago and comes in today stating, "I just had to come to the hospital today because I can't catch my breath and my legs are as big as tree trunks."? After further questioning you learn she is strictly following the fluid and salt restriction ordered during her last admission.? She reports she has been gaining 1 to 2 lbs every day since her discharge.1A) What error in teaching most likely occurred when the pt was discharged 10 days ago?There may have been an error in medication compliance or regimen. The patient should be on a diuretic along with the fluid and sodium restriction. The diuretic should be taken at the same time everyday, and not discontinued just because she "feels better". She may also be on ACE inhibitors, Beta blockers, or CCB. Also pt. teaching over which foods are high in sodium, ie... pickles, processed foods. Not to just avoid "table salt". Also patient should know that foods can increase fluid intake as well, such as melons, grapes, and ice. Pt. should have been taught to notify her physician of the weight gain or any swelling in her arms and legs, prior to becoming symptomatic. Also encourage periods of rest between ADL's. Also report daily weight, would have helped her figure this out earlier.1B)The client had been taking furosemide (Lasix) 40mg PO daily. The doctor changes her dose to 80mg IV push twice daily. Identify several strategies you would use to monitor effectiveness of this medication.Monitor Strict I/O, Monitor patients weight daily at the same time everyday, monitor for peripheral edema, Auscultate lung sounds for diminished crackles and decreased shortness of breath. Also you need to monitor serum electrolytes of this patient during diuretic therapy, especially potassium2Your client is a 70 yr-old retired bus driver who has just been admitted to your floor with a right leg DVT.? He has a 48-pack-year smoking history but states he quit 2 years ago.? He has had pneumonia several times and has frequent bouts of A-fib.? His history includes two previous DVTs.? Two months ago he began experiencing shortness of breath on exertion and noticed swelling of his right lower leg that became progressively worse until it involved his thigh to groin.? His wife brought him in because of complaints of increasingly severe leg pain.? A Doppler study indicated probable thrombus of the external iliac vein extending distally to the lower leg.?? He is admitted for bed rest and heparin therapy.? His lab values are PT 12.4 second and INR 1.11 (Both low:? we prefer for the INR to be 2.5-3.0)?PTT 25 seconds(also low)?H/H 13.3 & 38.9, cholesterol 206 mg/dl.? BMP is normal. 2A)? Identify problems in this client's history that represent his personal risk for DVT.Increased age, previous occupation, history of smoking, previous DVT’s, SOB, Swelling of lower right leg, history of pneumonia and frequent bouts of A-fib. The high cholesterol is also an issue. We know his blood flow isn’t good, so that will make him at an increased risk for stasis of blood2B)? Based on his history, this client should have been taking an important medication.?? What is it, and why should he be on it?Coumadin as antiplatelet therapy, Digoxin to treat dysrhythmias and to prevent clotting. Once you’ve had more than one DVT the physician most likely will prescribe Coumadin for several years to life…2C)? What are the most important assessments you should make during his physical assessment?Any signs of complications from anticoagulation therapy such as: Unusual bleeding ( nosebleed, bleeding gums, red or cola colored urine, black bowel movements, skin ulcers) bruises. Lung sounds, pedal pulses, limb pain, swelling, redness, warmth, and difference in leg circumference, tenderness to touch, respiratory rate, 02 sats and heart rate.2D)? What is the most serious complication of DVT?Pulmonary Embolism3You are assigned a 76 year-old female client.?? Two nights before her admission to your cardiac unit, she awoke with heavy substernal pressure accompanied by epigastric distress.? The pain was reduced somewhat when she rolled onto her side but did not completely subside for about 6 hours.? The next night she experienced the same chest pressure.? The following morning her husband brought her to the ER and she was hospitalized to rule out a myocardial infarction (MI)3A)? What steps will be taken to evaluate if her chest pain is due to a cardiac problem?EKG, Lab work: Calcium, Magnesium and Potassium levels as well as CK levels, WBC and Triponin levels. Check O2 sats. Auscultate heart sounds, Extensive health history including medication list and previous cardiac issues.3B)? What interventions should we begin immediately?Vital signs, Oxygen if needed, get order for aspirin or Nitro, blood tests: CK triponin and get EKG.A thorough assessment and health history are performed.? Her vitals are 132/86, 88, 18, and 97.9.? She has moderate edema of both ankles and peripheral pulses are 1+.? She has a soft systolic murmur.? She denies any discomfort at this time.? She has no history of smoking or alcohol use, good general health except for osteoarthritis of her hands, knees, and spine.? She takes Protonix, ibuprofen for joint and bone pain, and some "herbs".?3C)? Why are we concerned about her murmur and edema?We are concerned that her murmur and edema are related due to the possiblity of mitral valve dysfunction. This maybe the result of ischemia to the papillary muscles resulting in acute mitral insufficiency. Which in turn could lead to congestive heart failure. Additional possibility of symptoms could be aortic stenosis, the contributing factors could be her age. Her age could cause calcific aortic stenosis, causing CHF and coronary symptoms.3D)? What other sources, besides cardiac ischemia, might be responsible for her chest pain/abdominal discomfort? (think of a couple)The herbal supplements maybe a contributory factor in her symptoms either masking them or exererbating them. She might have a hiatal hernia in addition to her GERD. She may have been misdiagnosed with GERD, since she was taking Protonix on admission. Her cardiac issues maybe worse than orginally thought if her GERD was misdiagnosed and the cardiac portion of her disease was missed. AT 76 yrs old, her peripheral pulses are at 1+, her edema is moderate (2+?), her ejection fracture may be down or she could have PVD. In our 70's we start getting calicum deposits in our peripheral vasculature. She takes very little medication and would be considered to be in good health with her age. Treatment suggestions (not that we would offer one to a Dr. without being asked!) would be digixon and lasix to help contractility and fluid retention.4A 46 year old male client with a history of familial hyperlipidemia presents to the medical clinic.? He states he used to smoke 2 packs of cigarettes a day but has cut back to 1 pack a day over the past 2 months.? He has recently begun walking his dog twice a day because "it's good for the dog and my doctor says it's good for me too."? However, he states he cannot make it as far as he used to.? He complains of pain to his right calf that starts after only a couple minutes of walking.?? Once he goes inside and sits down the pain goes away.4A)? What is the medical term for this symptom?Intermittent claudication4B)? What disease process is this an indicator of??Peripheral Artery Disease4C)? Name some symptoms of progression of this disease?- Cyanosis, gangrenous changes, loss of hair, ulcerations and with severe ischemia pain persists at rest4D)? What interventions can be used to assist him? (Don't forget teaching!)No nicotine (very important), proper nutrition, avoid extreme cold, wear protective shoes, encourage moderate exercise. Need to find things that keep the blood flowing and prevent worsening of the disease. However, at the same time, we have to keep their pain in mind. So we may need to teach them foot pump exercises, stretches, etc. Something that won’t cause overwhelming discomfort. 5A 68 year old female client is three days post-op bypass.? She has done well today by walking in the hall twice, showering, and sitting up in the chair for meals.? She has had no arrhythmias and is 98% on 2LNC.? She has had very few complaints.?At 1430 you are called to her room. She complains "I can't catch my breath."? You note that her respirations are labored and she is tachypnic with a rate of 32.5A)? What should you do next?Apply oxygen. Check ALL vitals and pulses. Inform the doctor of situation. Stay in the room to make sure she’s ok. Her safety is of your highest concern. You note an irregular rhythm with absence of a P-wave on the monitor.? Her heart rate is 143 beats per minute.? She states "My heart is racing.? I'm scared."?5B)? What rhythm do you believe she is in???Atrial Fibrillation5C)? What complications may arise if she maintains this rhythm?If the heart is in atrial fibrillation then the blood can pool in the left atrium which can form a clot. The clot can then be pumped into the left ventrical and travel out of the heart and into other areas of the body, such as the brain. The clot could then get stuck and cause a stroke. Remember the term mural thrombi. Could also be at risk for DVTs, basically anything having to do with a clot getting stuck and causing problems she’s at risk for.5D)? What interventions can be used to alleviate this rhythm??Check all vitals and pulses, call doc and inform him of situation, suggest EKG, labs (Mg, K, Ca, PT/INR) and meds: Coradone or Digoxin to convert back to a regular rhythm, Beta Blockers and CCB, and Coumadin to prevent clot formation along the wall of the atriaAfter 24 hours cardiovert or pacemaker (extreme)5E)? What do you tell your patient?Explain to her that her heart rate is irregular (HR 143) and that you are going to call the doctor. Keep her informed to help with the anxiety b/c the increased HR will be making her feel bad. Things she labeled “Additional Info from the Lecture”First off, I hope you kind of got a feel for what questions will be like.? They will be similar to those from the first test.? You will be asked to prioritize, meaning:? which intervention should be performed first, which patient should you go take care of first, what assessment are you most concerned about, etc.?Ok, I know AAA was the last thing we covered and we were so, so ready to go.? Just realize that we are concerned when a person's pain is worsening.? That makes us fear that the aneurysm is expanding and rupture may be near.? We are going to watch the H/H, BP, mental status, skin tone, etc. very closely.? If we see a drop in the H/H and BP we fear that there is a leak and immediate surgery is our only hope.On a similar note, I feel like I covered how we care for surgical patients while they are still in the hospital.? However, I don't think I emphasized home care very well at all.? This pretty much goes for all the surgeries we talked about CABG, Valve Replacement, Peripheral Bypasses, AAA, and even Cardiac Cath to some extent.? We really have to teach these people to continue their ambulation and I.S.? Really want to avoid blood clots and pneumonia/atelectasis.? They will be restricted on how soon they can drive.? One reason is because they will be on pain meds and won't be with it enough to drive.? But, maybe even more than that, they don't want to be at risk of having and accident and the steering wheel or airbag goes flying into their incision.? They could suffer major, major damage.? Another thing is that they have to watch lifting.? With open hearts, our fear is that they will pull those sternal wires apart.? With AAAs and peripheral bypasses we are worried that the stress of lifting and straining will pop their incision, or even worse, their new graft open.Also, I don't remember how much I said about restrictions for those people who have permanent pacemakers.? I remember talking about welding, using a chainsaw, jack-hammer etc.? Did I talk about avoiding heavy magnetic fields.? One big issue is that they WILL NOT be able to have MRIs anymore.? We definitely don't want to run the risk of the pacemaker getting sucked out of their chest.? As far as airport security goes,? they will need to have a card showing that they have a pacemaker.? They will set off the airport security.? I don't believe that it will affect the pacemaker function as long as the wand isn't held over the pacemaker site for an extended period of time. ................
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