Cardiac Nursing – Flashcards
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Preload
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The amount of blood returning to the heart
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Afterload
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The pressure in the aorta and peripheral arteries that the left ventricle has to pump against to get the blood out -referred to as resistance -The resistance the LV has to overcome to get the blood out
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Stroke Volume
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The amount of blood pumped out of the ventricles with each beat
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Cardiac Output
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Heart Rate (HR) x Stroke Volume (SV) -tissue perfusion is dependent on an adequate cardiac output -CO changes according to the body's needs
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Factors that affect cardiac output
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Heart rate and certain arrhythmias Blood volume Decreased contractility (MI, medication, muscle disease)
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What does a patient with decreased CO look like?
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Not perfusing properly LOC decreases chest pain short of breath (wet lung sounds) cold and clamy urinary output decreases weak peripheral pulses
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Which 3 arrhythmias cause no cardiac output?
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1. V-fib 2. pulseless V-tach 3. asystole
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Chronic Stable Angina Patho
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-decreased blood flow to the myocardium causes ischemia and there is temporary pain and pressure in the chest -Usually caused by CAD -Low O2 due to exertion usually brings this pain on -Rest or nitro relieves this pain
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Treatment for Chronic Stable Angina: Nitroglycerin
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-Nitroglycerin (Nitrostat): Sublingual (tablet or spray) -causes venous and arterial dilation -result will decrease preload and afterload -Also causes dilation of coronary arteries which will increase blood flow to the actual heart muscle
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Taking and storing Nitro
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-Take q 5 minutes up to 3 doses -Do not swallow -Keep in a dark, glass bottle and store in a dry, cool place -Might burn or fizz when you take it -Renew 3-5 months and the spray needs to be renewed 2 years -The BP may go down and there may be a headache
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Beta Blocker Examples
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Propranolol (Inderal) Metroprolol (Lopressor/Toprol XL) Atenolol (Tenormin) Carvedilol (Coreg)
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Beta Blockers
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-Decrease BP, HR, and myocardial contractility -Decreases the workload of the heart -Beta Blockers block the beta cells...these are the receptor sites for catecholamines (epi and norepi). So we just decreased the contractility. CO is decreased and we have decreased the workload of the heart. This is a good thing to a certain point because we decreased the workload of the heart, but we could decrease the patient's cardiac output too much with these drugs if we are not careful.
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Calcium Channel Blocker Examples
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Nifedipine (Procardia XL) Verapamil (Calan) Amlodipine (Norvasc) Diltiazem (Cardizem)
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Calcium Channel Blocker Action
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Decrease the BP -They also dilate coronary arteries
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Acetylsalicylic Acid (Aspirin)
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Given so platelets don't stick -Maintenance dose is determined by the doctor (81-325 mg)
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Client Education/Teaching for Chronic Stable Angina
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-Avoid Isometric exercise -avoid overeating -rest frequently -avoid excess caffeine or any other drugs that increase HR -wait 2 hours after eating to exercise -Dress warmly in cold weather (any temp extreme can precipitate an attack) -take nitroglycerin prophylactically -smoking cessation -lose weight -Do everything you can to decrease the workload on the heart
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Cardiac Cath pre-procedure nursing interventions
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-Ask if they are allergic to shellfish or iodine (dye used in procedure) -Check kidney function because you excrete the dye through the kidneys -warn the patient that they will have a hot shot and flushed when dye goes through -palpitations are normal
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Post-procedure Cardiac Cath Nursing Care
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-Monitor VS -Watch puncture site (for bleeding and hematoma) -Assess extremity distal to puncture site (5Ps) -bed rest, flat, leg straight for 4-6 hours -report pain ASAP
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5 P's for circulation/neuro checks
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Pulselessness Pallor Pain Paresthesia Paralysis (also could have skin temp and cap refill)
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major complication post cath
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Bleeding
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what medication should you hold 48 hours before cardiac cath?
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glucophage because it can be bad for the kidneys with the dye and the glucophage
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What does unstable chronic angina lead to?
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Impending MI
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Acute Coronary Syndrome=
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MI, Unstable Angina
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Patho of Acute Coronary Syndrome
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-Decreased blood flow to the myocardium causing ischemia and necrosis -Goal of care is to limit the size -pain can come on at any time (not just exercise) -Rest or Nitro will not relieve the pain
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Signs/Symptoms of Acute Coronary Syndrome
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-Pain: crushing, elephant sitting on chest, jaw -cold/clamy -BP drops -Cardiac output going down -increased WBCs -Increased temp (low grade) -ECG changes- heart is irritated -Vomiting because vagus nerve is stimulated
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Women's Heart Attack Triad of Symptoms
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-fullness in abdomen -chronic fatigue -inability to catch breath
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Elderly main symptom of MI
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shortness of breath (could also have change in behavior)
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STEMI
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Most worrisome patients...get to cath lab for PCI in <90 minutes -ST-Segment Elevation Myocardial Infarction
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NSTEMI
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Non-Elevation ST Segment Myocardial Infarction These patients are usually less worrisome
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3 Lab markers that are checked for MIs
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1. CPK-MB 2. Troponin 3. Myoglobin
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CPK-MB
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Cardiac-specific iso-enzymes Increases when there is damage to cardiac cells Elevates in 3-12 hours and peaks in 24 hours
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Troponin
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Cardiac biomarker with high specificity to myocardial damage -Trop I and Trop T -Elevates within 3-4 hours and remains elevated up to 3 weeks Trop T <0.02 Trop I < 0.03
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Myoglobin
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Not as specific...can be other muscles not specific to just the heart -Increases within 1 hour and peaks in 12 hours -negative results are a good thing
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Which cardiac biomarker is the most sensitive to MI?
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Troponin
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Which biomarker is most helpful when client delays seeking care
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Troponin (it stays elevated for 3 weeks)
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Complication of MI: Major Arrhythmias: What major arrhythmia will put the patient at risk for sudden death?
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D-Fib the V-Fib (worst one!)
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If the first shock does not work, what do we give patient?
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Epinephrine (or might give Lidocaine)
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Amiodarone (Cordarone)
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Anti-arrhythmic used when VFib is resistant to treatment, and also for fast arrhythmias
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What anti-arrhythmic drugs are given commonly to prevent a second episode of VFib?
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Amiodarone and Lidocaine
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What does Lidocaine toxicity cause?
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Neuro changes
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What drug is the first anti-arrhythmic drug of choice?
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Amiodarone
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Important side effect of Amiodarone
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hypotension (and this can lead to more arrhythmias)
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Treatment for Acute Coronary Syndrome
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Drugs for chest pain: -oxygen -aspirin (chewable works fastest) -nitro -morphine Head up position to decrease workload on heart and increase cardiac output
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Treatment for Acute Coronary Syndrome: Fibrinolytics (what is the goal and what are some examples?)
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Goal: to dissolve the clot that is blocking blood flow to the heart muscle. This decreases the size of the infarction -Streptokinase (Strepase) -Alteplase (t-PA) -Tenecteplase (TNKase) (one time push) -Reteplase (Retavase) ASE!!
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How soon should fibrinolytics be administered after the onset of myocardial pain?
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6-8 hours (sooner the better)
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Complications of Fibrinolytic therapy
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Major complication is bleeding -Obtain a good bleeding hx (recent surgery, pregnant, stroke, bleeding ulcer?) -During and after administration we take bleeding precautions
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Absolute Contraindications for Fibrinolytic therapy
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-intracranial neoplasm -intracranial bleed -suspected aortic dissection -internal bleeding
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Bleeding Precautions
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-draw blood when starting IV -Decrease the number of puncture sites -watch for bleeding gums, hematuria, and black stools -use an electric razor, a soft toothbrush, and no IMs -no ABGs (only puncture veins)
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Follow-up therapy and meds with Fibrinolytic therapy
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-Antiplatelets are another important component for fibrinolytic therapy -Acetylsalicylic Acid (Aspirin) -Clopidogrel (Plaxix) -Abciximab (ReoPro IV)...continuous infusion to prevent platelet aggrevation
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PCI (percutaneous Coronary Intervention)
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-Includes all interventions such as PTCA (angioplasty) and stents -Major complication of the angioplasty is a MI -If any problems occur, go to surgery -Anti-platelet medications are given after to keep the stented artery open. IV antiplatelets are given to high-risk patients
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Coronary Artery Bypass Graft (CABG)
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-scheduled or emergency procedure -used with multiple vessel disease -left main artery occlusion (which supplies the entire left ventricle) widowmaker
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Cardiac Rehab Teaching Points
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-smoking cessation -stepped care plan (increase activity gradually) -diet changes: decrease fat, salt, and cholesterol -No isometric exercise-these increase the heart workload -no valsalva -No straining, no suppository -Use Colace (softener)
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When can sex be resumed and what is the safest time of day?
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-Can resume sex when you can go up a flight of stairs or walk around the block without discomfort -morning is the safest time because you are well rested.
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Best exercise for MI patient
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walking
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Teach signs and symptoms of heart failure
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weight gain ankle edema shortness of breath confusion
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Pacemaker (general notes)
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-Cardiac output can decrease if the SA node fires less than 60 BPM -Pacemakers are used to increase the heart rate with symptomatic bradycardia -They depolarize the heart muscle and a contraction will occur (electricity going through the muscle) -Repolarization (ventricles are resting and filling with blood)
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Temporary Pace Maker
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-used in acute or emergency situations like after heart surgeries or an acute MI -used until the client is stable enough for a permanent pacemaker to be inserted. -Can be classified as invasive or noninvasive
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Noninvasive temporary pacing
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-Called transcutaneuos pacing -don't go in the body -2 large electrode pads are applied to the client and turned to the PACING mode. -This is an emergency procedure -The shock will hurt and the patient will need analgesics
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Invasive Temporary Pacemaker
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-has pacing wires that are placed into the heart muscle (transvenous pacing) -wires are connected to a power source outside of the body -Epicardial pacing is when the wires are attached to the epicardium during surgery
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Permanent Pacemakers
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-Used when heart condition is chronic -Electrodes are anchored to the endocardium and attached to a battery source implanted into a subcutaneous pocket (need a little pocket of fat) -a demand pacemaker kicks in only when the client needs it to -a fixed rate fires at a fixed rate constantly -It is ok for the heart rate to increase, but it should never drop below set rate
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Post-Pace maker Procedure Care
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-Monitor the incision -most common complication in early hours is electrode displacement (wires pulled out)...muscles need to grow around the heart -Immobilize the arm -PROM to prevent frozen shoulder -Keep the patient from raising their arm too high
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Signs and Symptoms of Pacemaker Malfunction: Loss of Capture
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-No mechanical event or contraction followed the stimuli -This is caused by: the pacemaker not being programmed correctly, electrodes can dislodge, or the battery may be depleted. Malfunctions can be caught with any signs of decreased CO or decreased HR
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Patient teaching for Pacemakers
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-check pulse daily -ID card -Avoid electromagnetic fields (cell phones, large motors, arc welding, electric substations) -Avoid MRIs -They will set off alarms at the airport -Avoid contact sports
