Cardiac Review

Front 1

p wave

Back 1

depolarization of the atria

Front 2

qrs

Back 2

depolarization of the ventricle

Front 3

t

Back 3

ventrical repolarization

Front 4

hypovolemic shock

Back 4

decreased blood volume

Front 5

cardiogenic shock

Back 5

failure of the cardiac muscles to pump

Front 6

cvp

Back 6

5 15 mmhg

Front 7

pericarditis

Back 7

s/s pain, chills, anxiety, fatigue, abd pain, sob
decrease pluse pressure abnormal drop in systolic during insperation, tacycardia, increased temp , pericordal friction rub, increased cvp, restlesness
ekg w/increased st segment

Front 8

cardiac tamponade s/s

Back 8

increase r, and resp, palor , hypotension, distended neck veins

Front 9

post op aneurysms

Back 9

flat in bed, vs, cvp, urine output check for blood in pee, bs for ischemia, abd girth

Front 10

ursing interventions for Jugular Vein Distention
JVD seen in what kind of HF
NDx for JVD

Back 10

HOB elevate 45 degrees
Measure at highest point of distention
If > 3-5 cm (1-2") above sternal angle, indicates central venous pressure (CVP) is > normal
Seen in right sided heart failure
NDx: decreased cardiac output

Front 11

describe Pulsus Alternans

Back 11

Strong beat followed by a weak beat
May be felt with palpation or heard on BP auscultation
May be seen with acute MI or with decreased left ventricular function (CHF)

Front 12

Describe Pulsus Paradoxus

Back 12

Drop in systolic pressure that is greater than 10 mm Hg during inspiration
May indicate advanced CHF, cardiac tamponade, or severe COPD

Front 13

S3-When is it heard, with whom, what does it indicate, what diagnosis does it support
What is it caused by

Back 13

Heard best with the bell
May be normal in children and young adults
Caused by vibrations of ventricular wall caused by rapid ventricular filling
Indicates CHF or Fluid overload
Suppports NDx: Decreased cardiac output

Front 14

S4-When is it heard, with whom, what does it indicate, what diagnosis does it support
What is it caused by

Back 14

Heard best with the bell
May be normal in children and young adults
Caused by increased resistance or decreased ventricular compliance
Frequently develops in acute MI and CAD

Front 15

Describe Pulmonary Artery Pressure of A SWAN

Back 15

pulmonary artery Pressure: (yellow tubing, port) reflects right ventricular function, pulmonary vascular status, indirect left ventricular status
a. PAWP- (pulmonary artery wedge pressure)
I. Occludes flow in branch of PA
ii. reflects LV end-diastolic pressure (function)
iii. Complications: Rupture of PA
b. Pulmonary Artery pressure
i. reflects resistance of pulmonary vasculature and LV end diastolic pressure
ii. Elevated with pulmonary vascular constriction i.e. PE, ARDS, LV failure, Pulmonary hypertension

Front 16

Describe CVP and describe what is occuring when it is low and when it is high.
What should the nurse check-Assess

Back 16

entral Venous pressure of a SWAN (blue tubing, port)
reflects pressure of blood in right atrium or vena cava end-diastole
Low CVP: hypovolemia or vasodilation
High CVP: Right ventricular failure, mechanical ventilation, hypervolemia
check breath sounds, HR, RR, JVD, U/O
May be referred to as Right atrial pressure

Front 17

what are the signs and symptoms when a CVA device's catheter is damaged. What is the cause and what are the nursing actions?

Back 17

S/S-Leakage from catheter or insertion site. Swelling in chest area
Cause: external: scissors, penetration with a needle,
Internal: rupture by use of smaller than 10 mL syringes, pinch-off syndrome

Nursing actions:
monitor for pin holes, leaks, wet dressing
External: clamp proximal to damage
Internal: stop infusion

Front 18

what are the signs and symptoms when a CVA device has an Air embolus in it. What is the cause and what are the nursing actions?

Back 18

ir Embolus
S/S-Chest pain, anxiety, Increased HR, drop in BP, drop in O2 sat, loud churning over precordium.
Cause: Air entering central circulation usually via the central line
Nursing Actions:
clamp the central line
position pt on left side in trendelenburg
Notify the MD stat
Monitor VS and O2 sat
Obtain peripheral IV access

Front 19

what are the signs and symptoms when a CVA device becomes infiltrated. What is the cause and what are the nursing actions?

Back 19

S/S-Stinging/burning pain, redness, warmth and swelling along catheter. Leaking of fluid at catheter insertion site
Cause: catheter misplaced out of vessel. Catheter rupture due to vigorous flushing
Nursing actions: Stop infusion, do not use catheter until placement is verified by x-ray
Notify MD
determine cause

Front 20

Acute Coronary Syndrome
Myocardial Infarction

Back 20

Acute coronary syndrome (ACS) is an umbrella term which includes:

1. angina which is Ischemia of the myocardium and is reversible

a. stable angina-occurs predictably with exertion

b. unstable angina-increasing frequency, possibly at rest

2. NSTEMI (non-ST segment elevation myocardial infarction) may be either ischemia or injury

3. STEMI (ST segment elevation myocardial infarction)

Front 21

efinition
•Acute Myocardial Infarction (AMI):

Back 21

Acute Myocardial Infarction (AMI): Rapid development of Myocardial Necrosis

•Rupture of plaque

•Platelet adhesion & thrombus formation

•Occlusion of coronary artery

•Resulting in reduction of oxygenated blood supply to myocardium

Front 22

Acute Coronary Syndrome
Precipitating Stressors

Back 22

–Anything that increases O2 demand

•increases in preload, afterload, contractility

•stress, physical exertion, increased metabolism

–Anything that decreases O2 delivery

•anemia-There must be adequate hemoglobin to carry the oxygen
•vasoconstriction (hypertension), vasospasms

•narrowed arterial lumen-commonly a result of atherosclerosis

Front 23

ACS
Pharmacology
Thrombolytic Therapy
Name drugs and action

Back 23

Thrombolytic Therapy
•T-PA (Alteplase, Activase, Retavase), Tenecteplase (TNK) Anistrplase (Eminase) .

–Action: a tissue plasminogen activator and enzyme which binds to fibrin in a thrombus and converts plasminogen to plasmin which digests fibrin and dissolves the clot.

•ST elevation > 1 mm in 2 or more contiguous leads. (search for new LBBB that obscures ST-segment)

•Improves survival rate if given w/12 hours

•Risks outweigh benefits over 12 hours & 75 y/o.

Front 24

ACS
Pharmacology
Thrombolytic Therapy
Contraindications
Extreme caution

Back 24

-PA (Alteplase, Activase, Retavase), Tenecteplase (TNK) Anistrplase (Eminase) .

–Contraindications: Active or internal bleeding, severe uncontrolled hypertension, intracranial or intraspinal surgery or trauma within 2 months, stroke.

–Extreme caution: recent major surgery, organ biopsy, or trauma, recent GI or GU bleeding, hypertension (systolic BP above 180 and/or diastolidc BP above 110, - high likelihood of left heart thrombus, pregnancy or recent childbirth, septic thrombophlebitis, advanced age, anticoagulants

Front 25

ACS
Pharmacology
Thrombolytic Therapy
Adverse reactions

Back 25

•T-PA (Alteplase, Activase, Retavase), Tenecteplase (TNK) Anistrplase (Eminase) .

–Adverse reactions:

•bleeding

•reperfusion arrhythmias

•hypotension

Front 26

ACS
Pharmacology
Thrombolytic Therapy
–Nursing care:

Back 26

•T-PA (Alteplase, Activase, Retavase), Tenecteplase (TNK) Anistrplase (Eminase) .

–Nursing care:

•monitor for reperfusion ventricular arrhythmias

•have antiarrythmics at bedside

•avoid rough handling including too-frequent BP monitoring

•avoid use of razors & toothbrushes

•establish separate IV site

•obtain appropriate clotting studies

•baseline assessment

•maintain strict bedrest

•monitor frequently for pain and signs of bleeding

•apply pressure dressing to any recently invaded site

•watch for hematuria, hematemesis, bloody stool

•do neuro checks every hour

Front 27

ACS
Pharmacology
Antithrombotics
GP IIb/IIIa
–action:

Back 27

P IIb/IIIa-receptor agonists (Eptifibatide, tirofiban, abciximab, Integrilin)

–action: decreases platelet aggregation by reversibly antagonizing the binding of fibrinogen to the glycoprotein IIb/IIIa binding site on platelet surfaces.

–May give in addition to aspirin and unfractionated heparin and in whom a PCI (heart catheterization and angioplasty) is anticipated.

Front 28

Nitrates
Nursing interventions:

Back 28

Nursing Interventions:

--In the hospital setting may give every 5 minutes times three for pain relief or as IV

–IV nitroglycerin-- titrate to pain control, but do not substitute for narcotic analgesics

–Monitor BP and HR frequently (before, during , after administration)

•Instruct patients to take ONE nitroglycerin dose sublingually in response to chest discomfort/pain. If chest discomfort /pain is unimproved or worsening 5 minutes after one nitroglycerin, the patient should call 911 immediately

–Caution patient to rise slowly & avoid alcohol

–advise patient to keep tablets in dark container, with cotton removed and replace q 6 mo.

–Explain difference between sublingual and PO medications

–If continuous therapy is planned with oral or topical form, a nitrate-free interval should be incorporated.

Front 29

ACE Inhibitors
Angiotensin-converting enzyme inhibitor
Adverse effects
Precautions

Back 29

Precautions: pt with renal or hepatic impairment, hypovolemia, hyponatremia, elderly patients, concurrent diuretic therapy.

•Adverse reactions: angiodema, cough, hypotension, proteinureia, neutropenia. ARBs (Angiotensin II receptor antagonists) should be administered to patients intolerant of ACE inhibitors

Front 30

ACE Inhibitors
Angiotensin-converting enzyme inhibitor
Nursing interventions:

Back 30

Nursing interventions

–monitor BP and HR

–monitor weight & fluid status

–monitor creatinine and electrolytes

–assess urine protein prior to and periodically during therapy

–monitor WBC with differential to assess for neutropenia

Front 31

Surgical Treatment
•PCI (percutaneous coronary intervention
(percutaneous transluminal coronary angioplasty)

explain

Back 31

urgical Treatment
•PCI (percutaneous coronary intervention
(percutaneous transluminal coronary angioplasty).
Alternative therapy to thrombolytics (if door time to inflation of balloon less than 90 minutes
decreased risk of bleeding
greater coronary patency when stents and GB IIb/IIIa therapy used, than thrombolytics
instant knowledge of underlying disease

Front 32

urgical Treatment
•PCI (percutaneous coronary intervention
(percutaneous transluminal coronary angioplasty)
Advantages

Back 32

dvantages:

1. There is greater coronary patency when stents & GB IIb/IIIa therapy used, than thrombolytics

2. There is instant knowledge of underlying disease

–Indicated with

•patients who do not fit criteria for thrombolytic therapy

•persistent ischemia

•cardiogenic shock

•failed thrombolysis

Front 33

urgical Treatment
•PCI (percutaneous coronary intervention
(percutaneous transluminal coronary angioplasty)
Process

Back 33

•PCI (percutaneous coronary intervention
(percutaneous transluminal coronary angioplasty)
Process Process

•insertion of catheter into femerol artery then up through the aorta

•coronary arteriography- inject dye into coronary arteries to identify blockages

balloon tipped catheter inflated several time at blockage to compress plaque and open artery

stent (mesh scafold) opened to keep artery open

dye injected again to view opened blockage

Front 34

–Nursing Interventions
pre-cath
•post cath

Back 34

Nursing Interventions

•pre-cath

–base-line assessments

–mark pedal pulses & document

–NPO or clear liquid breakfast

–permit

–allergies

–foley or void

•post cath

–VS, pedal pulses, check dressing according to institutional protocol, assess site.

–Immobilize extremity

–hold pressure on artery when lines pulled

–keep flat

–encourage fluids

–PO when awake

–monitor for signs of decreased myocardial perfusion.

Front 35

CABG
describe

Back 35

(coronary artery bypass graft): emergent or urgent CABG indicated in patients in whom angioplasty fails or develop papillary muscle rupture-further discussed in Cardiac Trauma lecture.

Front 36

Which medication is commonly given to patients in whom a PCI is expected?

Back 36

glycoprotein IIb/IIIa inhibitors

Front 37

Activity

Back 37

Initial bedrest—generally 12-24 hours—then BSC (bedside commode), with assisted bathing and light ambulation

•Avoidance of valsalva maneuver

•Should not be on bedrest more than 24 hours if free of recurrent ischemic discomfort, CHF, or serious dysrthymias.

•Activity slowly accelerate as tolerated

•Initiate cardiac rehabilitation prior to discharge

Front 38

Discharge
Exercise prescription
Smoking cessation
Support groups:
Arrange for follow-up within -__ weeks of discharge

Arrange for cardiac

Back 38

xercise prescription

•ideally 30 minutes daily but at least 3-4 X week

•walking, jogging, or other aerobic activity

•may be spread out over 2-3 segments during the day

Smoking cessation--risk of recurrent events decreases 50% at 1 year of cessation

Diet: Low fat

Support groups: ie. Mended Hearts

Arrange for follow-up within 2 weeks of discharge

Arrange for cardiac rehabilitation

Front 39

Complications after surgical treatment

Back 39

Arrhythmia's

–major cause of mortality

–monitor electrolyte disturbances –

•VF (ventricular fibrillation) within first 48 hours

•If ventricular arrythmias occur later, further workup is indicated.

•Recurrent ischemia may be d

Front 40

complications after surgical treatment
•Heart failure:

Back 40

Heart failure:
If enough myocardium is infarcted the heart cannot pump adequately and cardiac output is reduced.
•Cardiogenic shock: defined as systolic BP less than 90 mm Hg in the presence of organ hypoperfusion. Inotropes (dopamine & dobutamine) or intraaortic balloon pump.

•Acute mitral regurgitation: 2ndary to necrosis or rupture of LV papillary muscle. Echocardiogram confirms.

Front 41

The teaching plan for a client with angina includes the action of antianginal drugs. The nurse teaches that these drugs

Back 41

Antianginal drugs act by decreasing myocardial oxygen demand. This is accomplished by decreasing heart rate, decreasing preload, decreasing contractility, and decreasing afterload

Front 42

The nurse cautions the client receiving isosorbide dinitrate for treatment of angina to be aware of the occurrence of

Back 42

tolerance.

Tolerance is a common problem with the use of longer acting organic nitrates. Clients are often instructed to remove the transdermal patch for 6-12 hours each day in order to delay development of tolerance to the drug.

Front 43

The nurse prepares discharge teaching for a client receiving isosorbide dinitrate for treatment of angina. What information must the nurse include?

Back 43

Avoid alcohol consumption

Alcohol intake has additive vasodilation effect. Concurrent use may cause severe hypotension and cardiovascular collapse.

Front 44

nurse, assessing a client's cardiovascular status, simultaneously palpates the radial pulse while listening to the apical pulse. The nurse notes the radial pulse falls behind the apical pulse and recognizes this as an indication of which of the following?

Back 44

Weak, ineffective contractions of the left ventricle

Simultaneously palpating the radial pulse while listening to the apical pulse allows detection of a pulse deficit which is seen when the radial pulse falls behind the apical pulse, indicating weak, ineffective contractions of the left ventricle.`

Front 45

While assessing a client's heart sounds, the nurse notes a murmur which is clearly heard. Which of the following grades will the nurse document this murmur as?

Back 45

rade III

Murmurs are graded according to the following scale:
I = barely heard
II = quietly heard
III = clearly heard
IV = loud
V = very loud
VI = loudest, may be heard with stethoscope off the chest.

Front 46

A nursing student is learning cardiac assessment. The student correctly identifies the first heart sound as which of the following?

Back 46

Closure of the atrioventricular valves

Closure of the atrioventricular (AV) valves at the onset of contraction produces the first heart sound (characterized by "lub" sound). Closure of the semilunar valves at the onset of relaxation produces the second heart sound (characterized by the "dub" sound). S3 and S4 are extra heart sounds identified as gallops.
Assessment;

Front 47

Premature ventricular contractions (PVCs) Ectopic focus in ventricles
Nursing implications

Back 47

ursing implications:
• Assess perfusion of PVC-Pulse deficit—pulse may not be felt with PVC
• Do PVC’s occur with activity or increase with exertion?
• Are PVC’s associated with client c/o angina
• Document rhythm strip with estimate of frequency and type
• No treatment required if infrequent and asymptomatic.
• Advise patient against stimulant use (caffeine, nicotine) consider aminophylline, dopamine, epinephrine
• Monitor ECG continuously during lidocaine or amiodarone administration; may monitor lidocaine blood levels and observe for neurological side effects.

Front 48

Atrial Fibrillation
Nursing Implications:

Back 48

Assess need for Oxygen supplement
• Assure patient has patent IV access
• Document Rhythm Strip, vital signs
• Monitor anticoagulant administration and related symptoms

Front 49

Atrial Flutter
Pharmacological and medical management

Back 49

Pharmacological and medical management
• Synchronized cardioversion
• Meds to slow heart rate-beta blockers and calcium channel blockers

Front 50

Supraventricular Tachycardia (SVT)
Pharmacological and medical management:

Back 50

• Vagal maneuvers: bear down like straining at stool, gag or vomit
• MD”s only-carotid sinus massage-periorbital pressure
• Oxygen therapy
• Meds:
o Adenosine, med given fast as you can shoot it in, and flush fast
o Verapamil
o Procainamide
o Propranolol
o Esmolol
• Synchronized Cardioversion
• Ablation if frequently recurrent

Front 51

Sinus Bradycardia
Pharmacological and medical management:

Back 51

Pharmacological and medical management:
• Administer Atropine per protocol

Front 52

Sinus Bradycardia
Nursing Implications:

Back 52

ursing Implications: No treatment required unless patient is symptomatic
• Place patient in head flat position if respiratory status permits—Brings BP up
• Assess need for oxygen supplement
• Assure patent has patent IV access
• Document rhythm strip, vita signs, and patient activity prior or during the brady event

Front 53

Normal Sinus Rhythm

Back 53

Rate 60-100
• Regular
• Consistent P waves – smooth and rounded
• 1 P wave/QRS
• PRI 0.12-0.20 & QRS 0.12 or below (0.6-0.10)
• Normal-no treatment
• Identification NSR – Every part is normal
• All waves are positive in lead 2

Front 54

ECG rhythm analysis

Back 54

• Step 1. Determine Rate
• P-waves = atrial and R waves = ventricular
• 6 second method= #R’s X 10
• Memorize sequence 300, 150, 100, 75, 60, 50, 43, and sequence with large boxes between two consecutive complexes for rate
Step 2. Determine regularity
Step 3 Assess P wave morphology (smooth and rounded=sinus not origination)
Step 4. Assess P to QRS relationship (?1 P wave/QRS)
Step 5. Determine interval durations (PRI & PRS)-
Measure with calipers or count small squares
Step 6. Identify abnormalities= ectopic (premature) beats, deviation of the ST segment above or below baseline and abnormalities in waveform shape and duration

Front 55

chf When do pts call primary care provider

Back 55

. Weight gain of more than 3 lbs. Lasting longer than 2 consecutive days
2. Increased swelling of the ankles, legs, or stomach
3. Increased SOA, especially when lying flat
4. Extreme fatigue
5. Very fast heartbeat (above 120 bpm)
6. Very slow heartbeat (below 50 bpm)
7. Irregular Heart rhythm such results from the heart skipping beats
8. Chest pain or discomfort when exercising that gets better with rest
9. Nausea or lack of appetite
10. Difficulty with speech, sudden weakness in the arms or legs, or lack of appetite
11. Fainting or loss of consciousness

Front 56

Tx of Pulmonary Edema

Back 56

Oxygen to keep PO2 greater than 60, CPAP or ET with vent, HOB raised, Oximeter, I&O, Foley for accurate O,

Front 57

Meds to treat Pulmonary Edema

Back 57

Edema Morphine Sulfate (Relieves anxiety and decreases pain, sedative
Vasodilator decreases afterload, loop diuretics (Furosemide is a venous dilator), Vasodilators nitroprusside or nitroglycerine decrease afterload,
Dopamine and Dobutamine, Aminophylline used cautiosuly to reduce bronchospasm and decrease wheezing.

Front 58

Cardiomyopathy: Dilated

Back 58

Dilated-chambers are dilated-ventricular contraction is impaired-Extensive interstitial fibrosis or scarring. Progressively worse and die within 2 years.

Front 59

Cardiomyopathy: hypertrophi

Back 59

Decreased compliance of left ventricle and hypertrophy of the ventricular muscle mass, decreases filling small end-diastolic volumes and decreases cardiac output- 1/2 are genetically transmitted in an autosomal dominant pattern--most common cause of sudden cardiac death in young athletes. Sx: dyspnea, angina, syncope, fatigue, dizziness, palpitations, dysrhythmias

Front 60

Inflammatory Cardiac Disorders
pericardial effusion: other symptoms of pericardial effusion

Back 60

pericardial effusion: other symptoms of pericardial effusion Distant muffled heart sounds another symptom
Beck's triad-Seen with pericardial effusion-
1. hypotension
2. distended neck veins
3. muffled heart sounds