PCCN Review – Cardiac with Complete Rationale

Under the Fontaine classification for peripheral vascular disease, intermittent claudication occurs at: -Stage I -Stage II -Stage III -Stage IV Correct Answers Stage II Stage I disease (pathological arterial changes) produces no symptoms. Stage II is representative of a 75% occlusion and the patient will exhibit intermittent claudication. Stage III represents 90-95% occlusion and the patient will have pain at rest. Stage IV is a 99-100% occulsion that will result in necrosis if not treated. Which of the following nursing actions would be important in the care of a patient with occlusive disease of the terminal aorta and a nonhealing wound on the left foot? -Elevate the legs -Place the patient in Fowler's position -Maintain normothermia -Fluid restriction Correct Answers Maintain normothermia Patients with peripheral vascular disease are often hypothermic because of poor blood circulation. The nurse should provide proper alignment without impeding circulation and monitor the patient's peripheral pulses for presence and quality. The color and temperature of the extremity should be monitored and results charted. In a patient with cardiogenic shock, an undesirable outcome would produce: -Increased cardiac output -Increased systemic vascular resistance -Decreased ventricular preload -Decreased pulmonary artery pressures Correct Answers Increased systemic vascular resistance A primary goal in cardiogenic shock is to improve the pumping action of the heart (improve myocardial contractility), reduce the workload of the heart, reduced O2 demand and improve cardiac output. If possible, systemic vascular resistance should be decreased and the left ventricule augmented with an inotrope. Nitoprusside will reduce preload and afterload. The cardiac workload and the myocardial O2 demand should decrease. Marvin has heard the staff talking about his mitral valve regurgitation; they also mentioned that it could be mitral valve stenosis. He asks you how you can tell the difference just by listening to his heart. Your best answer is: -"Mitral stenosis produces a high-pitched murmur and mitral valve regurgitation produces a low-pitched murmur." -"Mitral stenosis produces a murmur during systole and mitral valve regurg produces a murmur during diastole." -"Mitral stenosis murmurs do not radiate their sound, whereas mitral valve regurg murmurs will radiate towards the left arm. " -"There is no difference between the presentation of mitral valve stenosis and the presentation of mitral valve regurg." Correct Answers Mitral stenosis murmurs do not radiate their sound, whereas mitral valve regurg murmurs will radiate towards the left arm. Mitral valve stenosis presents with a low-pitched murmur that can be heard during diastole and that does not radiate. Mitral valve regurgitation presents with a high-pitched murmur that is hearding during systole that may radiate to the left arm. If severe, both conditions present with symptoms of pulmonary edema, low cardiac output, and heart failure. If your patient's temporary pacemaker is not sensing, your first action should be to: -Place patient on their right side -Increase the mA output -Check the sensitivity control for proper setting -Immediately turn off the pacemaker and notify the physician Correct Answer Check the sensitivity control for proper setting The first step is to check the sensitivity control. Even though most of these pacemakers have a cover, the dial may have been moved and indicate that a fixed rate is set. If the pacer continues to fire, it may cause R-on-T phenomenon and cause ventricular tachycardia or fibrillaation. If the patient has an adequate rhythm, you can turn off the paver and notify the physician. If the patient has a non-sustaining rhythm, try positioning the patient on the left side to see if the wire will come in contact with the myocardium. You can also try turning up the mA level. Either way, the physician must be notified and vital signs carefully monitored until the physician can reposition the electrodes. A diastolic murmur will occur as a result of regurgitant blood flow over which of the following valves? -Mitral and aortic -Mitral and tricuspid -Pulmonic and aortic -Tricuspid and pulmonic Correct AnswersPulmonic and aortic During ventricular diastole, both the aortic and pulmonic valves close. If a valve is incompetent, the blood will flow backwards through the valve, creating turbulent blood flow-- that is, a murmur. Blood flow that moves forward through the stenotic valves can also dause a diastolic murmur. The valves involved are the: -Mitral and aortic -Mitral and tricuspid -Pulmonic and aortic -Tricuspid and pulmonic Correct Answers Mitral and tricuspid During diastole, the tricuspid and mitral valves close just prior to systole. If the valve is stenotic, it will not close completely. When the atria contract, a murmur is heard as blood goes through this narrow opening. Sid is a 30 year old male who lost control of his motorcycle while riding in the rain. At the time of the accident, he was wearing a helmet and protective gear. Sid suffered a fractured left femur, a fractured rib, a cervical sprain, and road rash on his face and neck. He is admitted with a BP of 84/44, HR 100, RR 26 and shallow, T 98.4'F. His 12 lead EKG shows ST elevation in the anterior leads. His CXR shows a normal cardiac silhouette and no inflitrates. His H/H is 9.0/32. MB is 18%. Sid is restless and compains of pain in the chest and left leg. Which condition would you anticipate? -Systolic dysfuntion -Hypovolemic shock-Pulmonary hypertension -Pulmonary edema Correct Answers Systolic dysfuntion The injuries to the patient's chest may have caused a pulmonary artery laceration or a cardiac contusion (the latter condition is more likely). His BP is low and the EKG shows ST-segment elevation in the anterior leads. If the myocardium is contused, it will react the same way as if an MI had occurred. The ST elevation may be the result of a physiologic insult to a coronary artery, and an area of the myocardium may be ischemic. If so, the pumping function of the myocardium will be compromised and may need additional support with inotropes. The patient may undergo angiography and/ or surgery. Volume replacment may be necessary. This patient is probably in the first stage of cardiogenic shock. Four days ago, Gert, who is 70 years old, was admitted to your unit status post laparotomy for an unknown abdominal mass. During surgery, Gert had minimal blood loss and an uneventful course. The patient's history includes smoking since she was 15 (unknown number of ppd), DM, a permanent pacemaker, an anterior MI, and a right-sided stroke 20 years ago with no deficits. Three days ago, Gert had a hypotensive episode; her BP dropped to 82/48, HR 70. The doctor ordered dobutamine and the BP increased until the MAP was 72. Today, Gert remains on the dobutamine gtt at 2 mcg/kg/min. Her BP is 108/60, MAP 76, HR 70. Attempts at weaning have failed-- her BP drops precipitously if the dobutamine dosage is lowered. What do you think is the cause Gert's inital hypotensive episode? -Hypovolemic shock -Previous MI -Rapid rewarming postoperatively -Cell mediated response Correct AnswersCell mediated response Approximately 24 hours after a surgical procedure, the release of inflammatory cell mediators can lead to casodilation. Gert has a permanent pacer, but apparently her heart rate cannot compensate for the drop in BP. The caridac output did not increase as a result of the reduced systemic resistance. Her pacer did not allow the HR to climb above 70. The dobutamine acted on the pump and increased the heart's contractility. Gert also has a history of a previous MI. Four days ago, Gert, who is 70 years old, was admitted to your unit status post laparotomy for an unknown abdominal mass. During surgery, Gert had minimal blood loss and an uneventful course. The patient's history includes smoking since she was 15 (unknown number of ppd), DM, a permanent pacemaker, an anterior MI, and a right-sided stroke 20 years ago with no deficits. Three days ago, Gert had a hypotensive episode; her BP dropped to 82/48, HR 70. The doctor ordered dobutamine and the BP increased until the MAP was 72. Today, Gert remains on the dobutamine gtt at 2 mcg/kg/min. Her BP is 108/60, MAP 76, HR 70. Attempts at weaning have failed-- her BP drops precipitously if the dobutamine dosage is lowered.