COTC Nursing 201 Module 3 Cardiac Exam Guide

Circulation/Perfusion Blood flow to al of the tissues of the body Cardiac Concepts Circulation/Perfusion Oxygenation Cardiac Concepts Circulation/Perfusion Oxygenation Oxygenation O2 carried by red blood cells within the vascular system to be delivered to the cells within the body tissues. Quality of blood amount of O2 and nutrients in blood Quantity of blood amount of blood that is able to reach the tissues Cardiac Preload The stretching of muscle fibers in the cardiac ventricles Cardiac Contractility the myocardium's ability to stretch and contract in response to the filling of the heart with blood Cardiac Afterload Pressure that the heart is pushing against; arterial pressure that the left ventricle must overcome to eject blood Contractility of the heart characterized by the force and velocity of contraction; it's often expressed as the ejection fraction Ejection Fraction left ventricular stroke volume/end-diastolic volume resistance the force the heart muscle must counteract; related to afterload Afterload determined by ventricular pressure blood volume in the chamber wall thickness at the time of the aortic valve opening Heart failure pathophysiology Pump failure The heart can't pump enough to meet metabolic demands Types of heart failure left sided right sided high output Left sided heart failure Most Common type formally known as CHF Typically migrates to the right side of the heart but not always. L side of the heart not pumping adaquately 2 types of Left sided heart failure systolic diastolic Systolic heart failure- Left Failing of the heart on the squeeze so it doesn't push enough blood through; left ventricle specifically Diastolic Heart failure-Left Failure of the heart to relax so it doesn't fill enough Typical causes of Left sided Heart failure HTN CAD Valvular disease hx of MI Common Risk factors for Heart failure hx of smoking job hx with respiratory risks high stress job The more the heart has to work... The more the heart wears down Right sided heart failure pathophysiology Right ventricular dysfunction causes blood to back up into the right atrium and venous circulation Right ventricle unable to empty completely Manifestation of Right sided heart failure Distended neck veins Ascites Hepatomegaly Hepatojugular reflux Dependent edema Rapid weight gains Causes of Right sided heart failure primarily caused by left sided heart failure, right ventricular MI, and chronic pulmonary hypertension High output heart failure pathophysiology Cardiac output remains normal or above normal. Cardiac output is good! Metabolic demands are too much for the heart to keep up with. Causes of High output heart failure Caused by increased metabolic needs of hyperkinetic conditions such as: Septicemia Anemia Hyperthyroidism Signs and symptoms of High Output Heart failure Shortness of breath. Tiredness or weakness. Swelling in your feet, ankles, legs, or abdomen. Lasting cough or wheezing. Fast or irregular heartbeat. Dizziness. Confusion. Having to go to the bathroom more often at night. High Output HF caused by anemia treatment blood transfusion High Output HF caused by Hyperthyroidism tx treat the hyperthyroidism High output HF caused by septicemia tx fluids and anti-infectives HF Compensatory Mechanisms Sympathetic Nervous system stimulation Renin-angiotensin system RAS activation Cardiac Remodeling B-type natriuretic peptide BNP Sympathetic nervous system stimulation fight or flight release of beta-1 and beta-2 meant to be short term to dilate everything to reduce pressure for the heart during an emergency. Beta -1 Affects the heart Beta -2 Affects the lungs Alpha counters effects of beta RAS activated by Kidneys to increase perfusion to themselves. Heart doesn't like this increased in pressure and volume. We stop this with drugs Renin-angiotensin System RAS Angiotensin 1 converts to angiotensin 2 accompanied by aldosterone to hold on to fluid and sodium while also constricting vasculature increasing pressure. Cardiac Remodeling Ventricular dilation and hypertrophy like cardiomegaly the ventricular wall swells and stretches out. B-type Naturetic peptide Neurohormone that causes dilation and diuresis Triggered by the heart when it feels overstretched. WE LIKE THIS SYSTEM Left sided heart failure can lead to Breathing and oxygenation issues with weakness. Can lead to pulmonary edema Manifestations of left sided heart failure Weakness Fatigue Dizziness Confusion Pulmonary congestion Breathlessness Oliguria Death hepatojugular reflux sustained distention of jugular veins observed when during phys exam you press just under the liver for 20-30 secs Pulmonary Edema Fluid back up into the lungs from the heart. Characterized by SOB and pink frothy sputum HF Hx and physical get as much info as possible assess for s/s of right or left sided look at potential risk factors look at medical hx for indications Our Goal for treatment with HF To get them back to a reasonable level of function for them to get back to their lives. Psychosocial assessment for HF It's a big diagnosis and can impact all aspects of the patient's life. BNP for HF Created when heart feels stretched, so it is high initially, greater the BNP the greater the heart feels stretched. Treatment is effective if the BNP drops over time Labs for HF BNP Hgb Electrolytes BUN/Creatinine Electrolytes with HF can be low due to increase in retention of fluids by kidneys Hgb with HF Impacted when poor quality of blood forces the heart to have to work harder. We expect lower levels BUN and Creatinine with HF higher than normal due to decrease in renal function due to decreased perfusion imaging for HF Chest xray echocardiogram EKG Echocardiogram Ultrasound of the heart We can see blood flow, valve function, direction of blood flow, and muscle sizes EKG (electrocardiogram) instrument used in measuring the electrical potential during a heartbeat With HF we can use for monitoring and diagnostics Impaired gas exchange related to HF Ventilation Positioning Oxygenation HF Positioning upright sitting to improve gas exchange and for HTN. Basic HF intervention monitor vitals HTN positioning sit upright Fowlers Semifowlers Hypotension positioning Lay patient back Trendelenburg Interventions for decreased cardiac output Nutrition therapy Lifestyle changes medication BiPAP/CPAP Oxygenation for HF Super helpful Increases quality of the blood by increasing O2 Nutrition therapy for HF Weight loss nutritious foods low sodium decrease fluids No fried foods No prepackaged foods Lifestyle changes Keep patients moving, exercises Smoking cessation Nicotiene causes vasoconstriction and trauma to blood vessels Medications for HF Diuretics ACE Inhibitors ARBs Human B-type Natiuretic Peptides Digoxin Beta-adrenergic blockers Inotropic drugs Diuretics Loop Potassium sparing Loop Diuretics furosemide, bumetanide, torsemide dump everything leads Watch K+ Potassium sparing diuretics spironolactone, triamterene, amiloride Holds onto potassium Watch for hyperkalemia ACE inhibitors Angiotensin Converting Enzyme Inhibitor "PRIL" Captopril, Enalapril, Afosiopril Antihypertensive. ACE inhibitors action Blocks Angiotensin converting enzyme in lungs from converting angiotensin I to angiotensin II (powerful vasoconstrictor). ARBs Angiotensin II Receptor Blockers -sartans ACE inhibitors effects Decreases BP, Decreased Aldosterone secretions, Sodium and fluid loss. Check BP before giving (hypotension) *Orthostatic Hypotension ARBs action Blocks the action of angiotensin II by attaching to angiotensin II receptors so the angiotensin can't take hold and becomes neutralized. ACEs and ARBs Work together to counter the RAS system to lower BP by preventing the vasoconstriction and fluid retention. Dilate and Diuresis!!! ARBs Effect Maintain normal BP, Increase cardiac OP, decreased fatigue, SOB, and swelling in CHF Kidneys want Angiotensin II and Aldosterone Causes Vasoconstriction and fluid retention BNP gives us DD Dilation and Diuresis ACEs adverse effect Angioedema Dry hacking cough Heart Wants Dilation and diuresis Signs and symptoms of angioedema Deep firm swelling of the face, lips, tongue, neck. Difficulty speaking or drinking. Distorted face. Hives. Globus in the throat. Anxiety. Angioedema with ACEs Can occur at any time during treatment with these drugs. Scary, listen to your patients and observe for signs and symptoms Beta blockers action decrease heart rate and dilate arteries by blocking beta receptors -olol Inotropic agents Increases stroke volume by increasing cardiac contraction/stimulates effective squeeze Dopamine, epinephrine, digoxin Beta-adrenergic blockers 1. Olol medications 2. Reduce blood pressure by decreasing cardiac output 3. Indernal (Propranolol) non-selective beta blocker 4. Tenormin (atenolol) selective beta blocker 5. Lopressor (metoprolol) selective beta blocker 6. Avoid epinephrine with non-selective beta blockers Beta 2 affected by blocker no blocker bronchodilator with blocker bronchoconstriction-negative effect beta 1 affected by blocker no blocker increased HR with blocker decreased HR Never give a nonselective beta blocker to... a person with respiratory problems. It can kill them cardioselective beta blockers AMEBA Atenolol Metoprolol** Esmolol Bisoprolol** Acebutolol **are usually used in patients with CHF with co-morbid COPD, asthma With Beta blockers monitor for respiratory responses Beta blocker considerations These drugs shut off the stress response so pt will feel tired. This effect dissapates over time. BiPAP/CPAP Positive pressure into chest to increase O2. Increased pressure in chest can decrease BP Heart likes this temporarily in HF because it decreases the workload by impeding venous return. Excess fluid volume with HF Nutrition therapy Meds Risk of pulmonary edema Meds for EFV in HF Diuretics Vasodilators like morphine Nutrition therapy for EFV in HF Decreased sodium and fluids Ischemia is a... Time is tissue issue Activity intolerance with HF Balance activity and rest naps to restore energy Recognize energy limitations Conserve energy Adapt lifestyle to meet energy level Surgical management for HF CABG Cardiac resynchronization therapy/Implantable Cardioverter Defibrillator Balloon Pump Heart transplant Coronary Artery Bypass Graft CABG surgical technique to bring a new blood supply to heart muscle by detouring around blocked arteries implantable cardioverter defibrillator (ICD) Internal Defibrillator an implanted, battery-operated device with rate-sensing leads; the device monitors cardiac impulses and initiates an electrical stimulus as needed to stop ventricular fibrillation or tachycardia cardiac resynchronization therapy (CRT) Pacemaker a treatment for heart failure in which a device paces both ventricles to synchronize contractions Balloon Pump - Acts to divert blood back into the coronary artery on diastole, so that they maintain a better perfusion and so a better LV filling and push - Should increase the BP and C.O. - Be careful that the balloon does not move or cause dysrhythmias, has to be timed to the patient's rhythm LVAD (left ventricular assist device) is used to help with pumping- implanted in abdomen or chest and attached to the heart, while waiting for transplant. HF community based resources Dietician OT PT Nursing Case management Heart transplantation a donor heart is transferred to a recipient Final step, last option We leave part of the atrium and all of the vessels before and after the heart during the transplant Cardiac Catheterization a diagnostic procedure in which a catheter is passed into a vein or artery and then guided into the heart Radial Femoral MAWDS Medications- manage meds Activity-find balance with rest Weight-daily Diet-follow new diet including restrictions Symptoms-teach for symptoms to report Radial approach Cardiac catheterization Goes in through the radial artery Generally seen as safer than femoral Pressure band for site to maintain pressure Acetylcysteine (Mucomyst) antidote for acetaminophen dries up thick mucosal secretions Protects kidneys from contrast dye. Aneurysm Outpouching of blood vessel thinning the wall of the blood vessel Common problem for all types of Aneurysm BP Types of Aneurysm Abdominal Aortic Thoracic Aortic Dissecting Aneurysm Abdominal Aortic Aneurysm AAA A rapidly fatal condition in which the walls of the aorta in the abdomen weaken and blood leaks into the layers of the vessel, causing it to bulge. AAA Pain Quality Usually steady with a gnawing quality Unaffected by movement may last for hours or days AAA Pain location Abdomen Flank Back with expansion or impending rupture AAA visual cue Abdominal mass is pulsatile AAA Complication Most frequent Complication is rupture, which is life threatening Surgery for aneurysms of the core of the body are... dangerous and very risky due to Aortic blood flow being so fast. AAA Pain is caused by The pressure of the aneurism as it pushes out more and more as it grows Thoracic Aortic Aneurysm (TAA) widening or bulging of the upper portion of the aorta that may occur in the descending thoracic aorta, the ascending aorta, or the aortic arch. TAA Rupture Sudden and severe/excruciating pain in back or chest is symptomatic for rupture TAA visual cue Occaisional mass may be visible above the suprasternal notch TAA pain Pain is with growth Pressure makes growth occur pain resolution occurs when surrounding structures adjust to the pressure. TAA Signs and symptoms SOB Hoarseness difficulty swallowing TAA assessment Assess for back pain and manifestation of compression of the aneurysm on adjacent structures Aortic Aneurysms Diagnostics We usually find them as we are looking for something else. Xray CT Aortic Arteriography Ultrasonography