PCCN EXAM | QUESTIONS & ANSWERS (VERIFIED) | LATEST UPDATE | GRADED A+

1 PCCN EXAM | QUESTIONS & ANSWERS (VERIFIED) | LATEST UPDATE | GRADED A+ What is the function of the cardiovascular system Correct Answer: to drive O2 to the cell so that the cell can make ATP for energy production What is the formula for CARDIAC OUTPUT Correct Answer: Stroke volume x Heart Rate CO = HR X SV ( Preload + Afterload + Contractility) What is the term for the amount of blood that is pumped out of the ventricle each MINUTE? Correct Answer: Cardiac Output ( approximately 4 - 8 LPM ) What is the term for the amount of blood that is pumped out of the ventricle each BEAT? Correct Answer: Stroke Volume What is the term for the number of contractions / minute? 2 Correct Answer: Heart Rate IMPORTANT RELATIONSHIPS TO KNOW Correct Answer: 1. CO DECREASED -> HR INCREASES ( to maintain adequate stroke volume ) 2. CO INCREASED -> HR DECREASES ( as stroke volume decreases ) 3. HR DECREASED -> SV DECREASES and CO DECREASES 4. HR INCREASES ( > 150 ) -> SV DECREASES and CO DECREASES 5. SV DECREASES -> CO DECREASES and HR INCREASES 6. SV INCREASES -> CO INCREASES and HR DECREASES What is the term for the volume of blood ejected from the ventricle per minute adjusted for body size Correct Answer: Cardiac Index What is a normal cardiac index? Correct Answer: Normal = 2.5 to 4.4 L/min/m2 **Always utilize CI values on exam (especially for bigger patients) 3 What is a normal amount (mL/beat) for stroke volume? Correct Answer: 60 to 100 mL What is the term for the end-diastolic volume stretching the ventricle? Correct Answer: Preload ( increased fluid = increased stroke volume ) What is the term for the pressure that the ventricle must OVERCOME in order to eject blood into the circulatory system? Correct Answer: Afterload What is the term for the inotropic state the cardiac muscle Correct Answer: Contractility (how well the heart is contracted) Preload is the function of which part of the circulatory system? Correct Answer: VEINS FUNCTION OF VEINS = PRELOAD 4 What is the RIGHT VENTRICLE PRELOAD assessed by? Correct Answer: CVP (Central venous pressure) (Normal is approx. 2 - 8 mmhg) What is a normal central venous pressure ? Correct Answer: Approximately 2 - 8 mmhg What is the LEFT VENTRICLE PRELOAD assessed by? Correct Answer: PAOP (Pulmonary artery occlusion pressure) / PAW pulmonary artery wedge pressure -Swans ganns in placed wedge pressure (PA) What are the signs and symptoms of an altered preload? Correct Answer: 1. Dehydration (decreased preload) 2. Fluid overload (increased preload) What are some causes of a low preload? Correct Answer: 1. Hemorrhage 2. Dehydration 3. Burns 4. Over-diuresis 5 5. Third spacing (fluid moving into spaces they shouldn't be) What are some causes of high preload? Correct Answer: 1. Hypervolemia 2. Heart failure 3. Renal failure 4. Pulmonary HTN 5. Tamponade 6. Tension pneumothorax (most likely seen in right ventricle preload) What are the venous dilating drugs? Correct Answer: 1. NITRO (given to drop preload) 2. ACE I/ARB 3. Ca-Channel blocker Which venous dilating drug is given to drop the preload amount? Correct Answer: Nitro What are some causes that can alter the vascular space? Correct Answer: 1. Sepsis 2. Neurogenic shock 6 3. Anaphylaxis 4. Warming after cardiac surgery 5. Venous dilating drugs What part of the circulatory system determines the afterload? Correct Answer: Arteries Afterload determines the functions of the __________ Correct Answer: ARTERIES RIGHT VENTRICLE AFTERLOAD is assessed by Correct Answer: PVR (pulmonary vascular resistance) Normal is 20 - 200 dynes /sec/cm2 What is a normal range for pulmonary vascular resistance Correct Answer: Normal is 20 - 200 dynes / sec / cm2 What is the LEFT VENTRICLE AFTERLOAD assessed by? Correct Answer: SVR (systemic vascular resistance) Normal is 800 - 1600 dynes / sec / cm2 7 What is a normal range for systemic vascular resistance Correct Answer: Normal is 800 - 1600 dynes / sec / cm2 What are the S/S of increased afterload? Correct Answer: 1. CVP > 8 2. s/s of fluid overload ** 3. CO < 4 LPM --- 4. signs of cardiogenic shock 5. PA wedge > 12 mmhg 6. EF fraction < 60 % 7. MAP < 60 mmhg --- 8. SVR > 1600 dynes / sec / cm5 9. Decreased urine output --- 10. LV hypertrophy **LEFT VENTRICLE HYPERTROPHY **SYSTEMIC HTN What are the main signs of increased afterload? Correct Answer: Left ventricle hypertrophy Systemic HTN What are the s/s of decreased afterload? 8 Correct Answer: 1. CVP < 4 2. s/s of fluid depletion ** 3. CO < 4 LPM --- 4. PA wedge < 8 mmhg 5. MAP < 60 mmhg (b/c patient is vasodilated) --- 6. SVR < 800 dynes / sec/ cm5 7. decreased urine output --- 8. HR > 90 BPM **common with sepsis What can affect afterload? Correct Answer: 1. Vasodilation 2. Vasoconstriction What are some causes of vasodilation that can affect the afterload? Correct Answer: 1. Nipride ** 2. ACE I / ARB 3. Milirinone 4. Ca - Channel blocker 5. Antihypertensives All arterial dilating drugs 9 What are some causes of vasoconstrictors that can affect the afterload? Correct Answer: 1. Hypertension 2. SNS stimulation 3. Compensatory vasoconstriction (hypothermia, sepsis) 4. Arterial constricting drugs (phenylephrine , norepinephrine, high - dose dopamine, epinephrine, vasopressin) This type of heart failure has reduced LV ejection fraction Correct Answer: systolic heart failure ( HFrEF) Heart failure with ejection fraction EF < 40 % (leads to increasing end-diastolic volume and pressure) How does the hearts anatomy change when a pt has systolic heart failure Correct Answer: Ventricle will dilate with the heart wall thinning large outward bulging of muscle of heart What causes systolic heart failure? Correct Answer: ***USUALLY D/T VOLUME OVERLOAD 1. MI (decreased CO -> fluid retention by kidney) 2. Aortic and mitral regurgitation 10 3. Congenital defects This type of heart failure presents with preserved LV ejection fraction Correct Answer: Diastolic heart failure (HFpER) heart failure with ejection reserved EF < 40% (increased filling pressures due to stiff, non compliant ventricle) How does the hearts anatomy change with diastolic HF? Correct Answer: Ventricles become thickened without the dilation of the chamber What are some causes for diastolic HF? Correct Answer: 1. Chronic HTN 2. Aortic Stenosis 3. Hypertrophic cardiomyopathy Explain the difference between systolic and diastolic's HF heart anatomy change Correct Answer: 1. Systolic HF'S ventricle's dilate with wall thinning 2. Diastolic HF'S ventricle's DOES NOT dilate with wall thickening What is the formula for EF? Correct Answer: Systolic - diastolic = EF 11 Right sided heart failure is caused by Correct Answer: LUNG conditions Which medications are usually given to African American males with HTN & has HF Correct Answer: beta-blocker Which medications are usually given to White peopled with HTN and HF Correct Answer: Diuretics What are the MAIN S/S of HF Correct Answer: 1. Fluid retention 2. SOB ( esp. at rest ) & orthopnea 3. Paroxsysmal nocturnal dyspnea or cough ( esp in new onset of early HF ) 4. Fatigue ( reduction of exercise capacity ) 5. Inadequate peripheral oxygenation 6. Pulmonary and or systemic congestion (edema) 7. Ascites / early satiety 8. Depression/weakness/sluggish (esp in elderly) impending doom S/S OF LEFT SIDED HF Correct Answer: 1. Fatigue 2. Chest pain (if coronary arteries are under-perfused) 12 3. Increased LV - sided volume and pressure ( S3 AND OR S4 GALLOP, increased PAOP & PAD & Pulmonary capillaries ) 4. Crackles, SOB, cough, orthopnea, wheezing, hypoxia, pulmonary edema 5. Increased LAP causing atrial arrhythmias -PAOP = pulmonary artery wedge pressure -Difference between PAD and PAOP < 5 mmhg How does the medication Nitropusside work? Correct Answer: It's an arterio dilator How does a pt with right sided failure present? Correct Answer: 1. Systemic engorgement, poor perfusion 2. Sternal heave, right sided - S3 3. Increased CVP , JVD, Peripheral edema 4. Nausea / anorexia 5. + Abdomino - jugular test How does nitroglycerin work? Correct Answer: decreases preload BNP < 100 Correct Answer: CHF unlikely 13 BNP 100 - 500 with baseline LV dysfunction Correct Answer: Exacerbation of CHF BNP greater than 100 with no baseline LV dysfunction Correct Answer: CHF LIKELY LVHF on EKG Correct Answer: Check leads: V1, V2, V5, V6 -If greater than 35 boxes, there is left ventricular enlargement in QRS in V5 & V6 RVHF on EKG Correct Answer: Check leads V1, V2, V3 QRS is wide and are all positive (when it's supposed to be negative) meaning it's a RBBB OR RHF Appears as bunny ears Best med for HF Correct Answer: nitroglycerine (preferred) bc it decreases preload and afterload and improves CO 14 & lasix adverse effects of ACE inhibitors Correct Answer: 1. Renal impairment 2. Cough ( d/t bradykinen ) 3. Angioedema Which two meds should never be used together? Correct Answer: Ace Inhibitors and ARBs (-sartan drugs) -ARBs are given if you can't use an ACE inhibitor ( esp if pt has cough and angioedema from ACE I When are ARBS contraindicated Correct Answer: if pt has bilateral renal artery stenosis In ACUTE HF situations with HTN , DO NOT GIVE WHICH MEDICATION? Correct Answer: Beta Blockers! What are popular aquaretic drugs and how do they work for HF pt Correct Answer: 1. Conivaptan (Vapirsol) -> IV V2 antagonist 2. Tolvaptan (Samsca) -> PO V2 antagonist 15 - gets rid of pure water and keeps sodium intact , pt will be extremely thirsty Digoxin is mainly given to what type of patients Correct Answer: HF with concomitant atrial fibrilation -it's a positive ionotrope & slows AV conduction -monitor for hypokalemia and hypercalcemia How does Entresto (Sacubitril /Valsartan compound) work with patient's with HF Correct Answer: Prevents break down of BNP, which helps you diurese. (Neprilysin and RAAS inhibition) Chest pain assessment Correct Answer: P : pain, placement, provocation Q : quality (sharp, stabbing, pressure), quantity R : Radiation, relief S : Severity, systems (nausea, sweaty, dizziness) T : Timing ( when it started, how long did it last, what makes it better or worse ) this is the amount of blood leaving the heart in over a minute Correct Answer: Cardiac output this is the amount volume that leaves the heart with each beat ( mL/beat) 16 Correct Answer: Stroke volume Stroke volume consists of which 3 things Correct Answer: Preload Afterload Contractility This the volume of blood in the ventricle at the end of diastole Correct Answer: preload (the stretch of the ventricle) What is the normal preload pressure in the RV and LV Correct Answer: RV : CVP 2- 6 MMHG LV : PAOP 4 - 12 mmhg this is how much the ventricles have to overcome to eject the blood into the next compartment of circulation Correct Answer: Afterload what is the normal afterload pressures in the RV and LV Correct Answer: RV : PVR = ((MAP - PAOP) X 80) / CO PVR Normal is 37 - 250 LV : SVR = ((MAP - RAP) X 80) / CO 17 SVR normal is 900 - 1400 paop = pulmonary artery occlusion pressure rap = right arterial pressure Will an MI increase or decrease preload? Correct Answer: Increase preload Will sepsis increase or decrease preload? Correct Answer: Decrease preload d/t blood in peripheral areas of the body being unable to get to heart Causes of decreases of preload Correct Answer: 1. Hypovolemia 2. Arrhythmia 3. Loss of atrial kick 4. Venous vasodilation What can decrease contractility Correct Answer: 1. Parasympathetic stimulation 2. Negative ionotropic therapies ( beta blockers & ca channel blockers ) 3. Hyperkalemia, acidosis 4. Acidosis 18 What can increase contractility Correct Answer: 1. Sympathetic stimulation 2. Inotropic therapies ( epinephrine, dopamine, dig, calcium ) 3. Hypercalciemia What is being activated for a HF patient in the neurohormornal systems Correct Answer: 1. Adrenergic 2. Renin - Angiotension Aldosterone 3. Hypothalamic - neurohypohphyseal 4. Endothelium What is the end result for the activation of the Neurohormonal Systems Correct Answer: 1. Increased heart rate 2. Increased contractility 3. Vasoconstriction 4. Sodium and H20 retention ***ULTIMATELY INCREASED CO & BP How will left sided heart failure appear? Correct Answer: will see fluid on CXR and hear bibaslar rales 19 Explain a positive hepatojugular reflex Correct Answer: Pushing on the liver on acute pts can cause JVD to appear what is a major cause of HF Correct Answer: ACUTE CORONARY SYNDROME ( poor coronary perfusion ) may need CABG, PCI , Thrombolytics What stops the causes of HF Correct Answer: STATINS -all other drugs block the compensatory mechanisms that makes the patient's symptomatic Which 4 classes of drugs are used for HF? Correct Answer: 1. Vasodilators -A. ACE inhibitors -B. ARBs -C. Hydralazine (selective arteriole dilator) & Isosorbide dinitrate (isordil, sorbitrate) (selective veous dilator) are commonly used together to create same result of ACE inhibitor -D. Nitroglycerin (venous dilator) -E. Ca Channel blockers (not rec for tx, can cause opposite effect) 20 -F. BNP is only avail in IV and not PO (Nesiritide / Natrecor ) increases cardiac output and GFR ( increasing U/O) & increases calcium to increase contractility 2. Diuretics 3. Inotropic agents (positive) -A. Cardiac glycosides : Dig -B. Sympathomimetics: Dobutamine (dobutrex) -C. Phosphodiesterase inhibitors: Amrinone (Inocor) and Milrinone (Primacor) 4. Beta Blockers (negative ionotropic agents) how does diuretics work to help patient's with HF Correct Answer: decreases preload and afterload by reducing water retention it decreases the work of the failing heart muscle, and rec. for all pts who have symptomatic HF How do POSITIVE ionotropic agents work Correct Answer: Increases the force of myocardial contraction enhancing stroke volume -> increasing cardiac output How does cardiac glycosides work? 21 Correct Answer: AKA Dig accumulates Ca to increase contractility & decreasing HR by slowing conduction through the AV node What other devices can help the patient's heart demands descrease Correct Answer: 1. IABP (INTRA-AORTIC BALLOON PUMP) 2. VENTRICULAR ASSIST DEVICES (VAD) half of the deaths from heart failure occurs suddenly and are most likely due to the result of what? Correct Answer: dysrhytmia Treatments for arrhythmia Correct Answer: 1. PO meds 2. Pacemakers 3. ICD (implantable cardioverter defibrilators) 4. Heart transplant 5. Quality of life focus this pacemaker is located in the right atria and spikes before the p wave Correct Answer: Atrial (A) pacing this pacemaker is in the right ventricle and spikes before the QRS complex 22 Correct Answer: Ventricular (V) pacing this pacemaker is in both right sided chambers and spike before the P & QRS complex Correct Answer: Atrial / ventricular (AV) pacing this pacemaker has electrodes in the RA, RV, AND outside of the LV Correct Answer: Biventricular or Cardiac Resynchronization therapy trouble shooting pacing Correct Answer: failure to capture , sense, or to fire What are the 3 types of cardiomyopathy Correct Answer: 1. Dilated (congestive) AKA DCM (most common form -A. Ischemic : MI , alcoholic, DM -B. Non - ischemic (post partum or viral) -C. Stress induced (post partum or viral) 2. Hypertrophic 3. Restrictive cardiomyopathy How will a heart look if it's dilated? Correct Answer: stretched out & stretched out ventricles 23 causes arrhythmias Hypertrophic cardiomyopathy or idiopathic subaortic stenosis Correct Answer: 1. primarily hereditary 2. will look normal on CXR 3. BUT with ECHO, ventricles are smaller and aortic valve is smaller 4. Usually seen in 20 and 30 year olds 5. Tx with alcohol ablation of septum or heart transplant or ICD Restrictive cardiomyopathy Correct Answer: caused by sarcardosis TX for cardiomyopathy Correct Answer: 1. rest heart 2. blood thinners to prevent blood clots 3. antidysrhythmic agents / assistive devices BE CAREFUL WITH THESE DRUGS FOR PT WITH HYPERTROPHIC CARDIOMYOPATHY Correct Answer: 1. Digitalis 2. Diuretics 3. Inotropic agents 24 ** can result in closing ventricular outflow and cause cardiac death Pharmocology mainly used in cardiomyopahty Correct Answer: 1. Digitalis 2. Diuretics 3. Beta blockers , ace inhibitors 4. vasodilators 5. inotropic agents 6. antidysrhythmics 7. anticoagulants main s/s of dilated cardiomyopathy Correct Answer: 1. Arrhythmia (poss ) 2. low amplitude QRS 3. Hypotension 4. pulmonary congestion diltazem (Cardizem) is what type of pharmalogical drug Correct Answer: calcium channel blocker , you know it's effective when HR decreases What will you see with a mag toxicity Correct Answer: + depressed tendon reflexes 25 Torsades Correct Answer: pt needs mag What is given for a pt in SVT Correct Answer: Adenosine potassium abnormalities will result in Correct Answer: depressed or increased T waves What is integrillin used for? Correct Answer: To help stop bleeding or retroperitoneal bleeding What is dig toxicity's antidote? Correct Answer: digibind (digoxin immune fab) Pt on dig that has toxicity will see what? Correct Answer: an aurora nausea, vomiting, abdominal pain, headache, dizziness, confusion, delirium, vision disturbance Lidocaine on an EKG will show Correct Answer: Wide QRS 26 What is below the SA node? Correct Answer: JR How will tension pneumothorax present? Correct Answer: JVD, Elevated HR, BP Dobutrex is used for pt's with Correct Answer: kidney function? A.fib first line of drugs Correct Answer: Cardizem first then admiodarone COPD will cause enlargement in which part of the heart Correct Answer: Right ventricular enlargement What is the antidote for Coumadin? Correct Answer: Vitamin K What is a therapeutic INR for a pt on Coumadin? Correct Answer: 2.5 - 3.5 which test is the most effective to determine an MI Correct Answer: Troponin levels