What pt. hx questions would you ask when assessing cardiovascular pt.

-Family hx; risk factors; any heart problems

-Pain                     -Sputum

-Gen. appearance; skin color

-V/S; O2 sat

-Cardiac rhythm; heart sounds; lung sounds

-Peripheral pulses & edema

-Calf tenderness

-Jugular veins

-wt; mental status; I/O

3 different coagulation studies performed on cardiac pt. are?

1. PT

2. INR

3. APTT

What coagulation test is done to evaluate & monitor clotting time when on oral anticoagulant therapy like Coumadin?

Normal level?

-Prothrombin Time/ Protime (PT)

-Normal level: 11-12.5 sec.

(Anticoagulant effect: 1.5-2x control)

What coagulation test is another way to express PT results regardless of what chemicals or methods were used to run test?

Normal level?

-International Normalized Ratio (INR)

-Normal level:  2-3.5

What coagulation test is done to evaluate or monitor clotting when on parenteral anticoagulant therapy?

Normal level?

-Partial thromboplastin time (PTT) or actived PTT (APTT)

-Normal level: 30-40 sec.

Why are ABG's performed?

1. Evaluate oxygenation & acid-base balances

2. Cardiac problems can cause decreased circulation to lungs, normal gas exchange is disrupted

3. CO2 ^ & O2 decreases in blood

4. If not treated, acidosis & hypoxemia will cause major problems to vital organs

What are the 3 important electrolytes & their levels & why their significant?

1. Na: 135-145

2. K: 3.5-5.3

3. Cl: 90-110

-Abnormal Na & Cl will result in fluid imbalances & will

^ workload of heart

Why are lipid profiles performed?

-Helps identify pt. @ risk for CAD

What are the 4 lipid profile tests performed?

1. Lipoproteins

2. Apolipoproteins

3. Cholesterol

4. Triglycerides

Lipoproteins have 3 subcategories, what are they & what are their levels?

1. HDL (>40)

2. LDL (<100)

3. VLDL

What are the levels of cholesterol & triglycerides & where are they made?

1. Cholesterol (<200)

2. Triglycerides (<150)

-Made in liver

What do HDL's do?

-Carry cholesterol to liver for excretion, preventing uptake of cholesterol by cells so sometimes called healthy cholesterol

LDL's are sometimes called what & why?

-Bad cholesterol

-LDL's are cholesterol that can be deposited in peripheral tissue such as the blood vessel lining

VLDL's carry small amt. of ________,

but lots of ____________?

1. Cholesterol

2. Triglycerides

Apoliproteins Apo-b & Apo-C II

-Proteins on surface of cholesterol molecules that bind to enzyme that direct cholesterol to site for metabolism

(They are often low or absent in ppl genetically prone to

Define cardiac markers, what they are used for, & what's included in the tests

-It's a blood test for substances released by damaged cells of they myocardium

-Used to dx MI

-Includes Troponin; CPK-MB (F: 5-25 & M:5-55)

(Usually give them Mylanta to see if it was just gas etc.)

What is an electron beamCT

&

what does it detect?

-Xray of coronary artery using electron beam

(less radiation & quicker than CT scan & noninvasive)

-Detects calcified plaque in coronary arteries before s/s

Why would an echocardiogram be ordered?

-US of heart

-Evaluates fx of LV

-Detects tumors & congenital defects

-Detects changes in layers of heart

-How is Trans esophageal ecocardiogram (TEE)

performed?

- Small tube w/ small transducer passed thru mouth into esophagus & images of posterior heart & internal structures are obtained

-Throat's anesthetized so after-care includes: NPO till gag reflex returns

What is an electrocardiogram (ECG/EKG)

&

why are they performed?

-Recording of electrical activity generated by heart muscle

-Used to identify dysrhythmias & detect myocardial damage

What are the variations in ECG?

-Ambulatory or holter monitor

(EKG leads on chest, recording rate & rhythm by battery-powered montior for 24-48 hrs)

&

pt. keeps journal of activities & s/s

What is a stress electrocardiogram & why would test be stopped?

 -Exercise induced stress test that evaluates heart fxn during exercise

 -HR & rhythm; bp; RR monitored continuously

-Stopped if: pt c/o chest pain; has severe dyspnea; ^ bp; confusion; dysrhythmias

-Also used to evaluate CAD & aids in diagnosing ischemic heart disease, cause of chest pain & dysrhythmias

What is a drug stress test?

-Drugs used to stress the heart for clients w/ sedentary lifestyle or w/ phys. disability

-These drugs dilate coronary arteries similar to vasodilation that occurs when exercising

What is a cardiac catherization-coronary

angiogram?

-Flexible catheter inserted in peripheral vessel thru great vessels into heart

-Goes to LT. side of heart by artery to Rt. side by vein

-Can measure (pressure) fluid volume in heart & obtain blood samples to check O2 & CO2 content

-Lt. side of heart dye can be injected into coronary arteries to determine blockage

Possible complications of cardiac catherization-coronary angiogram

-Dysrhythmias

-Allergic reaction

-Breaking of cath.

-Thrombus formation

-Emboli of air or blood

-Hemorrhage

-MI/CVA

Care before & during cardiac cath.

-W/hold food & fluids (NPO)

-Check for allergies to iodine, shellfish, latex, radiographic dye

-IV fluids started & may give sedative

-Insertion site scrubbed w/ betadine

-Heart monitor applied

-Local anesthesia injected @ insertion site

-May feel brief warm sensation when dye's injected

-Report chest discomfort, difficulty breathing, nausea

Measures of care after cardiac cath.

 -Extremity straight for several hours 

-V/s monitored frequently

-Pressure drsg. over site checked often

-Peripheral pulses, color & temp of extremity checked often to check circulation

-Encourage fluids to promote excretion of dye

Why is a heart scan performed?

(Aka: thallium scan or MUGA scan)

-Radioactive chemical injected into bloodstream

-Scanner wil detect areas of damage in myocardium

-Can be used w/ stress test

What are doppler studies

&

what can they detect?

-US of veins or arteries to evaluate bloodflow

-Used on legs & carotids

-Used to help dx thrombosis & arterial occlusive disase

Electrophysiology studies

&

why are they done?

-Flexible wire electrode cath. passed into veins in groin & neck, then into heart (RA, Bundle of His, RV)

-Record heart rhythm

-Dr. can reproduce abn. rhythm by stimulating these areas & then use drugs to evaluate each one's ability to restore normal heart rhythm

-Also ablation can be done to destroy area that produces dysrhythmia

What are the 3 different types of hemodynamic monitoring?

1. Direct bp monitoring

2. Central venous pressure

3. Pulmonary artery monitoring

What is direct bp monitoring?

-Catheter w/ sensor in tip placed in peripheral artery (usually radial)

-Measures syst. & diast. & mean arterial pressures continuously

-Blood for ABG's obtained

What is central venous pressure monitoring?

-Cath. inserted into lg. vein (jugular or subclavian) & advanced to superior vena cava

(IV fluids can be infused thru central line)

-Manometer may be used periodically to measure fluid pressure

-Normal CVP is 4-10 cm H2O

-Used to detect FVD or FVE

What is pulmonary artery monitoring?

-Cath. inserted into pulmonary artery by peripheral vein & thru Rt. side of heart

-Pressure & cardiac output measured to assess LV fx

-Helps in early tx of fluid imbalances

(Prevents Lt. sided HF or promotes its early correction)

What is bp & what does it tell?

-Def.: Force produced by volume of blood within walls of arteries

- Tells us ability of artery to stretch & fill w/ blood & efficiency of heart as pump

-Must take several to compare to find out normal bp range

What factors influence a person's bp?

-Age                 -Time of day

-Body & size                -Disease status

-Diet

-Activity

-Emotions

-Pain

-Position

-Gender

What is HTN?

-Sustained ^ bp

-Systolic:≥140

-Diastolic ≥90

What are the 2 categories of HTN?

1. Essential HTN

-w/o known cause

2. Secondary HTN

-R/t diet, disease, kidney, adrenal tumors, caffeine, stimulants, oral contraceptives, hyperaldosteronism

What ^ risk for HTN?

-Family hx

-Age

-Race

-Obesity

-Excessive ETOH intake

-Inactivity

-Smoking

-Ineffective stress management

What are 3 main causes of ^ bp w/ age?

1. Changes in blood vessels

2. Arteriosclerosis

3. Atherosclerosis

Complications of uncontrolled HTN?

-Enlarged heart

-Heart failure

-Angina/MI

-Acceleration of atherosclerosis

-Damage to eyes, brain, heart, peripheral blood vessels

& kidneys

Common s/s of HTN

-Can be asymptomatic

-HA: throbbing, pounding

-Dizziness

-Fatigue, insomnia

-Nervousness

-Nosebleeds

-Blurred vision

What are common lifestyle modifications

to reduce HTN?

-wt. mgmt.

-Low Na, caffeine, alcohol intake

-Moderate exc.

-Low sat. fats

-Stop smoking

What is accelerated HTN?

-Markedly ^ bp accompanied by hemorrhage & exudate in eye

(If untreated progresses to malignant HTN)

S/s of accelerated HTN

-Confusion               -Ha

-Visual disturbance       -Seizure

-Coma                -Sudden ^ bp

-Chest pain           -Dyspnea

-Moist lung            -Renal failure (<30ml/hr)

-Sudden severe back pain & hypotension=dissecting or ruptured aortic aneurysm

What is malignant HTN & the s/s different from accelerated HTN?

-Dangerously ^ bp accompanied by papilledema

(Swelling of optic nerve @ pt. of entrance into eye)

-S/s: papilledema

How is accelerated & malignant HTN treated?

-Main goal: Decrease bp within 1-2 hrs.

-Potent drugs: Morphine, nitro.

-O2

-Frequent v/s

-Restrict activity

-Neurochecks

What is hypertensive emergency

& its cause & tx?

-Def: Severe type of HTN characterized by

^ systolic bp: >180 & diastolic: >120

-Cause: untreated HTN; noncompliance; abruptly stopping meds

-Tx: Hosp.; IV antihypertensives, then oral regimen; teaching

What are complications of

hypertensive emergency?

-Organ failure

-MI

-HF

-Dissecting aneurysm

-CVA

Stenosis

-Constricted or narrow valve

Insufficiency

-AKA: regurgitation

-Valve does'nt close completely

Pericardial friction rub

-Scratchy, grating sound heard from inflamed pericardial

& epicardial layers rubbing together 

Pericardiocentesis

-Aspiration of fluid from periocardial sac

Pericardial effusion

-Build up of fluid in pericardial sac

Valvotomy

-Cutting thru a valve

Cardiac tamponade

-Life threatening compression of heart from fluid accumulation in pericardial sac

Paradoxical pulse

-Change in pulse during respiration

-s/s of constrictive pericarditis or pericardial effusion

What is arrhythmia

&

most common cause

-Abnormally slow or rapid regular hr

-Irregular pace

-Cause: ischemic heart disease

(Other causes: drugs; elec. imbalances; met. acidosis; hypothalamus disorder)

What are the 6 steps involved in interpreting a cardiac strip?

1. Regularity

2. HR

3. P waves (atrial or vent.; p wave w/ every QRS)

4. P-R intervals

5. QRS complex

6. QT interval

Define the 4 waves/intervals measured during cardiac monitoring

1. P wave: atrial depolarization

2. P-R interval: elec. impulse travel time to AV node

3. QRS wave: Ventricular depolarization

4. T wave: Ventricular repolarization

Normal sinus rhythm

-HR: 60-100 bpm

-Tx.: none

-S/S: none

Sinus bradycardia

-HR: <60 bpm; reg. rhythm, but slow

-Tx: pacemaker; meds

-S/S: vertigo, fatigue

-Causes: ^ICP; heart disorders; dig toxicity; hypothyroidism

Sinus Tachycardia

-HR: 100-150 bpm; reg. but fast

-Tx: ? cause; digoxin; Ca/beta blockers; treat cause

-S/S: Dyspnea; angina; may be asymptomatic

-Causes: Anxiety; fear; pain; fever; shock; hypoxemia; hemorrhage; hyperthyroidism

Premature Atrial Contractions

-HR: 60-100 (depends on underlying rhythm)

-Tx: beta blockers if frequent

-S/S: Usually none; may have palpitations

-Causes: hypoxia; smoking; stress; myocardial ischemia; enlarged atria; elec. disorders; a-fib; HF

Atrial flutter

-Impulse outside SA node

-HR: 250-300 (atrial, vent. slower)

-Tx: Cardioconvert (elec. shock); CA channel blockers; ablation; antiarrhythmic meds

-S/S: usually none

(if vent. rate rapid: angina; palpitations; dyspnea)

-Causes: rheumatic or ischemic disease; HF; HTN; pulmonary edema; post CABG; pericarditis; some meds

Atrial fibrillation

-Impulse from several areas & may be disorganized

-HR: variable; atrial ↑; vent. ↓

-Tx: if unstable: cardioversion; stable: meds,

(ablation as last resort)

-S/S: palpitations; dyspnea; irreg. pulse

-Causes: smoking; >60 y.o.; HF; HTN; pericarditis; pulmonary embolism; post CABG; ischemic heart disease

(Post CABG has no P waves)

Premature Ventricular Contractions

-Ventricles fire prematurely before SA nodes, have different shapes/patterns (bigeminy, trigeminy, quadgeminy)

-HR: varies

-Tx: depends on underlying rhythm & how often you're having PVS'c (frequency)

-S/S: flip flop or fluttering sensation in chest; sweating, pallor, vertigo

-Causes: anxiety, ETOH w/drawal; fatigue; tobacco use

Ventricular Tachycardia

-3 or more PVC's in a row & vent. fires instead of SA node

-HR: 150-250 bpm

-Tx: if no pulse then CPR & defib.; stable: meds

-S/S: CO & LOC ↓

-Causes: MI; cardiomyopathy, myocardial irritability; pacing wires; cardiac caths; digoxin toxicity

Ventricular Fibrillation

-No cardiac output, vent. quivers, needs immediate defibrillation; rhythm: chaotic & extremely irreg.

-HR: none

-Tx: CPR w/ defib.

-S/S: lose consciousness immediately; no peripheral pulses; no bp or pulse

-Causes: hyperkalemia; hypomagnesemia; CAD; MI; electrocution

Supraventricular Tachycardia

(SVT)

-A-fib is the most common type of SVT

-HR: >150

-Tx: vagal maneuver; Ca channel blockers; beta blockers

-S/S: if short term: maybe no s/s; angina, hypotension, syncope, decreased renal output, cardiac output decreased & can lead to HF

-Causes: unknown, COPD, PN

Definition of heart block

-Interferes w/ transmission of impulses from SA node thru AV to ventricles

The three degrees of heart block

&

Asystole caused by MI or hyperkalemia

- 1st degree: delayed impulse ( more room b/w P & QRS)

 - 2nd degree: Type I (wenckebach's): delayed response; time b/w sinus & atrial tissue progressively lengthens

-Type II (Mobitz II): conduction b/w sinus & atrial tissue normal until an impulse is blocked; usually occurs w/ MI or cardiac ischemia

- 3rd degree (Complete block): atrial impulse doesn't go thru; ventricles develop own rhythm

-Asystole: absence of elec. activity (cardiac arrest)

Tx, s/s, causes of heart block

-Tx: pacemaker

-S/S: slow hr (30-40 bpm), fatigue, vertigo

-Causes: some infections & meds; ischemic heart

S/S of arrhythmias

-Dyspnea; vertigo

-Signs of ↓ cardiac output

-Palpitations

-Angina

-Fatigue

-Disoriented

- ↓ bp

-Pale, cool skin

-Changes in LOC

How are arrhythmias diagnosed

&

what common drug therapies are used

-Dx by ECG

-Beta blockers

-Ca channel blockers

-Anticoagulants

-Antidyrhythmias

-Vasopressors

What is defibrillation?

-Life saving procedure that delivers elec. shock to reset hearts rhythm

What is cardioversion?

-Non-emergency shock procedure performed by dr. to stop

non-threatening arrhythmia

-Sedated: short term

-Electrodes applied

Automatic implanted cardiac defibrillator

-Senses hr & arrhythmia & corrects it w/ low energy cardio-conversion

Pacemaker

-Provides electrical stimulates to heart for

brady-dysrhythmias

What are the different

types of pacemakers?

1. Temporary

2. Permanent

3. External

4. Internal

5. Demand (activates w/ pulse set rate)

6. Fixed (set @ certain rate)

Nrsg. care & discharge teaching for client w/ a pacemaker insertion

-Avoid MRI; metal detectors, store entrances, touching running car engines, welders above 130 amps, radio towers

-Avoid equipment w/ strong elec. fields; stereo speakers, remote controlled cars

-Keep cell 6" away from ICD (implantable cardioconvertor defibrillator)

-Carry pacemaker ID card

What is radiofrequency ablation therapy?

-Heated catheter goes in & destroys

arrhythmia producing tissue

Other names for HF

-CHF

-Chronic heart failure

-Cardiac decompensation

-Cardiac insufficiency

-Ventricular failure

What are some facts about HF?

1. Not a disease but abnormal clinical condition

2. Morality ^ in women

3. ^ in Afr. Am.

4. Leading cause of hospilization for elderly

What is HF?

-Ventricles can't pump oxygenated blood

to the systemic circulation

What are some extrinsic & intrinsic factors that lead to the failure of the ventricles?

- CAD

-HTN

-Smoking

-DM

-Obesity

- ^ chol.

-MI

-Valve disorders

-Cariomyopathy; dysrhythmias

What is the #1 cause of HF & why?

1. CAD: b/c w/o O2 the myocardium can't function

-MI: w/o blood supply to myocardium, tissue dies, & can't contract

What is one major cause of lt. sided HF

-HTN b/c it ^ pressure within arteries

Acute HF

(aka: pulmonary edema)

-S/S appear suddenly

- Occurs w/ acute event: MI or acute stress of heart

- Leads to failure of lt. ventricle

-S/s: primarly worsening respiratory

Right-sided HF s/s

-Fatigue

-Anxiety

- Dependent LE edema

-RUQ pain

-Anorexia/GI bloating

- Nausea

-Hepatomegaly

-Heart murmur

- Nocturia

Left sided HF

(think lungs)

-Dyspnea

-Shallow rr ^ to 32-40/min.

-Orthopnea (shortness of breath when lying flat)

-Dry/hacking cough

-Frothy, pink sputum

-Paroxysmal nocturnal dyspnea

-Crackles in lungs

-Fatigue/anxiety

Paroxysmal nocturnal dsypnea definition

-Attacks of severe shortness of breath & coughing that generally occur @ night

Common causes of Right-sided HF

-Atrial septal defect

-Lt. sided HF

-Pulmonary HTN

-Pulmonary valve stenosis

-Cor pulmonale

Common causes of Left-sided HF

-Aortic stenosis

-Cardiomyopathy

-Coarctation of aorta (birth defect)

-HTN

-Heart muscle infection

-MI/infection

-Mitral regurgitation

Which HF is more common?

-Left-sided HF

-Usually rt. & lt. side of heart work together, but one side may fail & may become asychronized which will eventually lead to failure in both sides

Describe the classifications of HF

-Class I: No limitations

-Class II: Slight limitations, no dyspnea @ rest but may have sx w/ normal phys. activity

-Class III: Marked phys. limitations, usually comfortable @ rest, sx w/ phys. activity

-Class IV: can't do normal activity w/o discomfort

s/s even @ rest & sx may ^ w/ acitivity

Common diagnostic test used to diagnose HF

-EKG

-2D echo w/ doppler

-Angiogram

-CXR

-ABG's

What are complications of HF

- ^ liver & spleen = impaired function & cellular death & scarring of these tissues

-Pleural effusion

-Thrombosis & emboli

-Cardiogenic shock

What meds are used for tx of HF

-Diuretics, vasodilators, beta blockers

(^ cardiac output)

-Ace Inhibitors (↓ cardiac hypertrophy)

-Thiazides: ↓ fluid

-Angiotensin II Inhibitors: HTN

What is pulmonary edema

-Fluid in lungs b/c heart's not working properly

What is involved w/ pre-op care for pt. having CV surgery?

-Nurse makes sure pt. understands procedure; anestheologist interviews pt; surgical permits signed; surgical site prepped &/or clipped

-Med. & surgical hx

-Phys. exam; Ht. & wt.; vs; I/O

-Diagnostic test (CXR, EKG, stress EKG, PFT, echo, labs, angiogram results, renal fx, carotid doppler

Top sign for hemorrhage

-Tachycardia

What type of equipment is common for

a pt. to have after CV surgery?

-ET tube

-IV

-Foley

-Pulse ox

-NG tube

-EKG monitor

-Internal monitors for measuring c.o. & blood sampling

-Chest tubes

-Arterial line for pressures & blood sampling

Which type of ulcer do you elevate extremities?

Arterial or Venous

-Venous ulcer

Symptoms of varicose veins

-Legs may feel heavy, tired, achy, & painful

-Varicose veins can cause skin color changes (stasis pigmentation); dry, thinned, skin; skin inflammation; open sores; or bleeding after minor injury

What can develop in varicose veins?

-Superficial thrombophlebitis

(blood clot & inflammation develop in small vein near surface of skin)

-Varicose veins usually not serious, but some can signal a blockage in deeper veins (DVT) which needs tx

What are varicose veins

&

where do they usually develop?

-Twisted, enlarged veins near surface of skin

-Usually develop in legs & ankles

Why do varicose veins develop?

-When you have faulty valves in veins & weakened vein walls.

-When valves don't work properly, blood pools, pressure builds up, & veins become weakened, enlarged, & twisted

(venous insufficiency)