CV/PV OUTLINE

Quick Reviewo Cardiac Output = the amount of blood pumped in 1 minute (CO = HR x SV)o Stroke Volume = the amount of blood pumped out of the ventricle with each contractiono Preload = the amount of myocardial stretch just before systole caused by the pressure created by the volume of

blood within the ventricle (aka Left ventricular end diastolic pressure, LVEDP)o Afterload = the amount of resistance to the ejection of blood from the ventricleo Atherosclerosis = plaque development. #1 cause of coronary artery disease and can occur in any vessel of the bodyo Angina = Chest pain

Stable is predictable and is fixed with rest and nitroglycerine Unstable isn’t predictable and isn’t fixed with nitro or rest Prinzmetal’s due to coronary artery vasospasm. Something is causing the artery to spasm and clamp

down and slows blood flow, therefore you get the angina Silent goes undetected. Happens a lot in elderly people (because their neurotransmitters are worn down),

diabetics, and womeno Myocardial Infarction = cellular injury and cellular death. There is an inadequate flow of O2 long enough that the

cells begin to starve for nutrients and die… Risk Factors

o Modifiable High Cholesterol

HDL’s are good and you want them to be over 60 mg/dL LDL’s are bad and you want them to be below 100 mg/dL Total triglyceride level you want to be less than 200 mg/dL

Smoking Causes massive vasoconstriction. People who stop smoking reduce their risk of heart disease by

30-50% in the first year and it gets better every year after that HTN

Vasoconstriction causes problems Hyperglycemia

The higher the sugar level in your body the more you’re likely to have vascular injury Obesity Physical Inactivity Stress

Type A personalities are much more prone to heart diseaseo Non-Modifiable

Age- Men more than women younger, after women hit menopause the risk is the same Gender Family History- very strong genetic link to heart disease Ethnicity

o Cultural Aspects White, middle-aged men have the highest incidence of coronary artery disease. African Americans have an early age of onset of coronary artery disease. African American women have a higher incidence and death rate related to coronary artery disease than

white women. African Americans have more severe coronary artery disease than whites. Native Americans <35 yr of age have heart disease mortality rates twice as high as other Americans. Major

modifiable cardiovascular risk factors for Native Americans are obesity and diabetes mellitus. Hispanics have lower death rates from heart disease than non-Hispanic whites

Prevention and treatmento Dieto Exercise

Goal is 30 mins 3-4 times a week. May need to start off slowly and work up to this point. Make sure to teach them S/S of heart problems (i.e. Myocardial Infarction) so if it happens they don’t die..

o Medications Effective, but won’t replace diet and exercise

o Tobacco cessationo Managing HTNo Controlling DMo Managing stress

Lipid Lowering Drugso Statins – most common, goal is to lower LDL and increase your HDLo Niacin- help with minimally elevated cholesterolo Fibric Acidso Cholesterol absorption inhibitorso Bile acid sequestrants

Evaluation of Chest Paino Physical Assessment

Auscultation S/S of Angina

Characteristic ones are dyspnea, chest pain, crushing/stabbing pain, clutching chest. For silent angina they’re N/V/D, diaphoretic and confused

Feeling of indigestion Choking or heavy pressure in sternum May radiate to neck, jaw, shoulders, arms, usually left arm Weakness or numbness in arm, wrists, and hands Shortness of breath, pallor, diaphoresis Dizziness, nausea, and vomiting

o EKG Normals

P wave- atrial contraction QRS wave- ventricular contraction---- ventricles are responsible for pushing out all the blood to

the entire body, so might be a little more important ST segment- where the heart is relaxing, when your heart relaxes, that’s when it feels with blood.

When contracted it is smashed out. If a person has a blockage/vasospasm, the blood stops sudden, doesn’t flow smoothly. Represents the time the heart gets the blood. During the segment it doesn’t get good blood flow.

Specific for heart problems Look for ST depression and/or T wave inversion

o These means ischemia ST elevation

o This means there is infarction and deatho Labs

CK & CKMB CK = creatinine kinase, enzyme that gets spilled from muscle tissue when it’s damaged. You’ll see

a rise during/after muscle injury. So it’s good but not that great cause the damage could be in your leg muscle

CKMB = different form of above that very specific to cardiac tissue. Shows up anywhere from 3-6 hours, and usually lowers itself in 24 hours

Troponin (I & T) Very specific to cardiac tissue. Will nearly always be normal with non-cardiac disorders. The

higher the troponin and the higher the CK the more extensive the tissue damage. Shows up in 3-4

hours, and peaks anywhere from 4-24 hours. She thinks this is the biggie, hence study troponin more…

Myoglobin = shows up early (1-3 hours after cardiac damage). Good for detecting early damage .This might be someone who is having early signs of chest pain. Also cardiac specific

Serial Cardiac Enzymes are when they’ll check your troponin and CK enzymes every 6 hours for 3 times. This is to watch for a trend in the labs to see if they’re getting better or worse.

More Evaluation of Chest Pain = they’ve done the things above and they still think it may be a cardiac problem they will do these slightly more invasive procedures below… But they do the above ones first. They go from least invasive to more and more invasive as they try to figure the problem out.

o Stress Tests Exercise- putting them on a treadmill and making them work Drug induced – These drugs will mimic exercise in the heart. Can be either Persantine valium is used very

commonly but can also use dobutamine tests. Persantine valium is often referred to as PVST = persantine valium stress test .

o Echo Just like a sonogram that you get when your pregnant

o CT Scans Electron Beam tomography (EBT) 64 Slice CT Scan- a ct scan that takes a picture every millisecond. Develops a 3-D picture of the heart

o Coronary Angiography (Cardiac Cath) Take you to the cardiac catheterization lab and they inject meds to highlight your vessels and look at

them. Treatment of Angina

o Primary aim of therapy for myocardial ischemia and angina is to reduce myocardial oxygen consumption. We want to do things to decrease the myocardial oxygen demand…

o Do this by decreasing the BP, decreasing the HR, assist contractility, and decrease left ventricular volume (the more blood that fills into your ventricles the harder the ventricle is going to push to get the blood out).

Medical Managemento Nitrates

Nitroglycerine A vasodilator that works really well on our veins. The bigger the veins are the more they can

hold in them, hence less blood is in the heart. Sublingual Nitro

o Make sure and keep it in the original containero Administration = put it under your tongue. Wait 5 mins and if the chest pain isn’t better

take another pill. Do this 2 more times (for a total of 3 pills every 5 mins) and if it’s still hurting call 911 cause you gonna die…

o Side Effects Flushing, decreased BP, H/A and tachycardia

Don’t take along with Viagra and the like… they shunt all the blood to your Who-Ha, which for a cardiac person, is bad news bears.

o Beta Blockers They help dilate the vessels and slow the HR down and they assist the contractility of the heart. The heart

can do 25% more work without ischemia while on beta blockers. Monitoring

Never stop beta blockers abruptly! If a person has been on it for a while and we withhold that the receptors are nice and irritable (hypersensitive) and you can have severe rebound HTN

Monitor HR, check BP, monitor for bronchospasm, and glucose levels. Remember asthmatics aren’t supposed to have a non-selective beta blocker or a beta2 blocker.

And it can inhibit glycogenolysis in a diabetic so they should carry a fast sugar with them…o Calcium Channel Blocker

They relax the blood vessels. Very good for coronary vasospasm (which can happen with Prinzmetal’s angina or after invasive coronary procedures).

↓ SA node impulse & AV node conduction * Slows HR * Decrease myocardial oxygen demand

Relaxes blood vessels improving coronary perfusion

o Antiplatelets and Anticoagulants Aspirin

Prevents platelet aggregation (or clot formation) 81 mg dose is for prevention. Like you have a family history or high risk. They have no known

problems but they could have a problem in the future 325 mg dose is for someone who has been diagnosed with something

Plavix Very widely used. Acts very similar to aspirin and can be used along with ASA. Very commonly

used after a pt has had a procedure like a bypass, peripherovascular surgery, etc. Concerns with these are bleeding 1st (cause they can’t clot) and GI upset 2nd (can cause ulcers)

Lovenox Low molecular weight heparin. Used all the time.

o Oxygen Increase oxygen delivered to the myocardium ALWAYS initiate O2 at the onset of chest pain!!!

Nursing Interventions for Chest Paino Oxygen first and foremost!!!o Quick assessment of the angina

PQRST (position, quality, radiation/relief, severity, timing) o Vital signso Monitor respiratory statuso 12 lead EKGo Check Labso Nitro!!!

Management of Angina at Homeo Reduce activities that produce chest pain or dyspnea o Avoid temperature extremeso Maintain normal BP o Avoid OTC meds that can ↑BP

Nasal decongestants can raise your blood pressure and HRo Stop smoking!!o Take ASA & β-blockers as prescribedo Carry Nitro at all times!

S/S of Myocardial Infarctiono Sudden onset of chest pain o No response to rest or medicationo Shortness of breath, dyspnea, tachypnea o Nausea & vomitingo ↓ urinary outputo Cool, clammy, diaphoretic, pale skino Anxiety, restlessness, fear

Medical Management of MIo Goals

Minimize myocardial damage Preserve myocardial function Prevent complications Use the following

Thrombolyticso Dissolve thrombi (clots) in coronarieso Restore perfusiono Given IV or Intra-coronary routeo Administer ASAP after onset of symptoms

By the time they get in the hospital door to when they get the drug needs to be a 30 min window. If you’re giving it into the heart itself in the cath lab the window is 60 mins

Streptokinase, activase, t-PAo Risk for these are bleeding cause they break up clogs everywhere in the body!

PTCA Medications

o MONA Morphine –good for pain and vasodilation. Decreases preload and decreases

workload on the heart Oxygen Nitrates – vasodilation. More of an emergency drug, not an everyday thing Aspirin – antiplatelet

o Ace Inhibitors – decrease BP and cardiac workload Prevention of further damage (remodeling). When you have a weak heart the

muscle gets stiff and tends to stretch and become thick and it stays that way. These guys help prevent your heart from becoming thick and stretched…

Increase renal productiono Beta Blockers

Decrease cardiac output Reduce incidence of further attack

Acute Myocardial Infarction Care Improvement Standards Aspirin at arrival Aspirin prescribed at discharge ACE inhibitor/ARB for LVSD prescribed at discharge Adult Smoking Cessation advice/counseling Beta Blocker prescribed at arrival and discharge Thrombolysis within 30 minutes of arrival PCI within 90 minutes of arrival* (Percutaneous coronary intervention )

o ST segment elevation without thrombolyticso Nursing Care

Bed rest Stool Softeners Education

Diet, caffeine, smoking cessation, exercise S/S of recurrent MI TEST QUESTION on when can you have sex again after an MI it’s when you can walk up 3 or 4

miles per hour or up flights of stairs. o Cardiac Rehab

Goals Extend & improve quality of life Limit progression of atherosclerosis

Return client to work and pre-illness lifestyle Enhance psychosocial & vocational status Prevent another cardiac event

Surgical Interventions for CADo Cardiac Catheterization & Coronary Angiography (CCCA)- they’re going in looking for a block

What they do Insert a catheter into the femoral artery up to the aorta and shoot dye in so they can watch

what’s going on in the vessels. They visualize the arteries looking for blockages. Done in the cath lab.

Nursing Interventions Pre-Op

o Give them lots of IV fluid b/c the dye we inject can be toxic to the kidneys so we want to be sure we flush the kidneys out

o Fast for 8-12 hourso Prepare the client for expectations of procedure

They are going to be on a hard table for a while, they’ll be able to hear the physician talking to them, the dye may feel warm, they may feel their heart palpitate or shudder when the catheter is inserted

Random Infoo In a right heart cath they are looking at the inside of the hearto In a left heart cath they are looking at the coronary arteries on the outside of the heart

Post-Opo Assess catheter site for bleeding or hematoma. Make sure and apply a lot of pressure. If

there is a hematoma, take a marker and mark it so you know if it gets bigger or whatever…

o Check peripheral pulses, color, temperature, pain or numbness of affected extremity q 15 min X1 hr

o Monitor for dysrhythmias o Bed rest for 2-6 hrs o Affected extremity straight o HOB no higher than 30°o Encourage fluids to flush out dye

They have to flush out the dye whether they want to or not! o Ensure safety

o Percutaneous Coronary Interventions (PCI)- they’ve found a clot and they go in to remove it PTCA – Percutaneous Transluminal Coronary Angioplasty

Procedureo They take a balloon and center it under the plaque (that they found via angiogram) and

they expand and contract, expand and contract, etc. They’re trying to break up the plaque.

Goalo Getting a plaque that is only causing 20% blockage (so the blood flow thru the vessel is

at 80%). Risk

o Abrupt closure of the vessel due to debris. Watch for dyspnea, dysrhythmias, etc.o Perforation of the vessel

A blockage in the Left main artery can’t be fixed by this procedure Coronary Artery Stent

Sometimes during a PTCA they will place a stent that stays in place after they take the balloon out. The stent helps hold the vessel wall open. If it’s a drug eluding stent then the stent is covered with something that keeps stuff like platelets from sticking to it.

Atherectomy Ather = plaque and ectomy = get rid of They go in and basically shave or bore the plaque away with a device

Transmyocardial revascularization Can be done on a heart that has infracted to the point where there is no blood flow to the area

of the tissue. If the person’s had a massive MI and there is a place that has no blood flow they’ll go in and try this shit.

They take a laser and injure the heart. They bore out little holes into the wall of the damaged heart muscle. The idea is that if they injure the heart muscle angiogenesis will move in and replace vessels and all that have died. They’re trying to get circulation back to that muscle. They’re hoping the dead area will wake back up. Not widely used but has good results

o Coronary Artery Bypass (CABG or ACBP) – open heart surgery Procedure

Surgery where blood vessel from another part of the body is put on the heart to reroute blood from a bigger vessel that works fine down to the place where blood isn’t getting. Say you have a vessel path A,B, and C. B is blocked so they put a vessel from your leg directly from A to C, bypassing B.

They might put a person on a bypass machine making blood go outside to the machine and not back into the heart

Vein choices Best choice is LIMA (just inside your chest wall) Most common choice is greater saphenous vein (cause it’s easy to access, fairly superficial and

there are lots of other vessels in your leg to compensate once it’s gone). It’s in the thigh Patient is a candidate for bypass if:

They have angina that is uncontrolled by medication They have a positive stress test with a blockage that can’t be treated in the cath lab If the main coronary artery (the left one) is occluded more than 60% If they have complications in the cath lab

o Like debris that has caused an abrupt closure, they poked a hole in the vessel on accident

Care of a pt after a Bypass Monitor cardiovascular status

o Look at urinary output (you want 25mL or more an hour)o Labs of potassium and Magnesium are important after

Monitor respiratory status Maintain fluid & electrolyte balance Relieve pain Maintain adequate tissue perfusion Maintain normal body temperature

o Get them in the shower to keep the wounds clean! Bed bath won’t work unless they are fucked up!

Promote home & community-based care Infectious Diseases of the Heart

o Rheumatic Endocarditis Rheumatic Fever

What it is:

o Group A beta-hemolytic streptococcal pharyngitis. Causes inflammation of the lining of the heart. Over time the scarring remains and as they age the endocardium doesn’t work the way it should.

o Preventable with antibiotics The key to preventing it is a throat culture for accurate diagnosis!! You want to

find these guys and treat them quickly! o Mitral Valve is the most common siteo Common in school age children

Recognizing and Preventing Rheumatic Fevero S/S of streptococcal pharyngitis (strep throat)

Fever of 101-104 degrees F) Chills Sore throat (sudden in onset) Redness of throat with exudates Enlarged tender lymph nodes Abdominal pain Acute sinusitis and acute otisis media

o Infective Endocarditis Direct invasion by a microbe causing a deformity of valves

Flu-like symptoms Weight loss Intermittent fever Heart murmur Osler’s Nodules (red inflamed spots on the fingers) and petichiae

Diagnosed by serial blood cultures and Echo Treatment

IV antibiotics for 2-6 weeks (very aggressive). They are usually stuck doing this in an inpatient setting.

Antibiotic therapy for high risk patients before and after dental or surgical procedures. People who have valve problems need antibiotics before they go in for minor surgical procedures. However American Heart Association is showing now that it really doesn’t make that much of a difference.

o Pericarditis (aka Pericardial Effusion) What it is

Inflammation of the membranous sac around the heart Occurs commonly after cardiac surgery, due to infection, with some inflammatory disorders like

Lupus and RA, after trauma, and with connective tissue disorders S/S

Most characteristic symptom is chest pain that may get worse when they lay down Most characteristic sign is a pericardial friction rub. Loud sound that’s said to sound like leather

rubbing against leather. If the effusion develops quickly it can become:

Cardiac tamponade = Emergency situation!!o Muffled and distant heart soundso Fall in systolic pressure 10mmHg when diastolic is going up (narrowing pulse pressure)o Distended neck veins (cause blood is backing up into the next veins)

Emergency pericardiocentesis is used to fix this problem. They stick a needle in the sac around the heart and aspirate the fluid in there…

Valve disorderso Info

Regurgitation = too lose and the valves become floppy

Stenosis = very stiff and tight and don’t allow enough blood to come thru You’re most concerned about the valves on the left side of the heart because the left side of the heart is

responsible for pumping blood out to the rest of the body. o Management of Valve Disorders

Meds Diuretics Cardiac glycosides

o Digixin or whatever the fuck Beta blockers Prophylactic antibiotics

Valve repair or replacement Info

o Done when a valve is too fucked upo Usually requires use of Cardiopulmonary Bypass machineo Care very similar to that of CABGo Valves which are repaired function longer than those which are replaced (cause it’s our

own tissue and we tolerate it better) Types

o Connissurotomy – separation of fused leatlets (for stenosis). Try to make the valve wider by cutting it or using a balloon to expand the valve. Not too invasive. Done a lot on small children and sick people

o Annuloplasty- for regurgitation valve problems. They narrow the diameter of the valve opening.

o Leaflet repair- fuck if I knowo Chordoplasty- they shorten the fibers on the valve so they aren’t as stretchy. For

regurgitative shit. Replacement of valve with prosthesis

o Mechanical Valves These guys always have to be on anticoagulant therapy cause your body wants Not for use in

People of child bearing age Old bastards

Good for use in people who are immunosuppressed because they’re body can’t fight foreign things anyway so might as well put something in there that is foreign.

Most common type is the St. Jude valve and when it opens and closes you can hear it click.

o Tissue Valves = don’t need anticoagulation but not as durable as a mechanical valve Xenografts = valve from a pig or cow, most common Homografts = valve from a human cadaver Autografts = from the patient them self. Used for an aortic valve replacement.

They’ll come over and take pulmonic valve and move it over to your aortic valve cause it’s more important and takes more stress. Then they would put something else in on the pulmonic valve.

Heart Failureo Info

Inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients *When the left side of your heart fails you manifest with pulmonary S/S

The blood isn’t moving forward so it’s backing up into the lungs. It’s the only place for it to go. Once you have it you’ve got it forever, lifelong chronic condition. You want to prevent progression of the

disease.

Most often caused by CAD, but often it’s HTN or valve disorders. 60% of people with heart failure also have CAD

o Types of dysfunction Systolic dysfunction – problems with contraction. Like the water balloon. It fills with too much so often it

gets stretched out. Ejection fraction is less that 40%. It can’t pump out all the blood it fills with. The muscle is so

stretched it isn’t strong enough to get all the blood out Normal EF is around 75-80%

Diastolic Dysfunction – problem is with the heart filling. The heart is stiff and doesn’t move like it should. The muscle is so thick and stiff it doesn’t stretch to fill. Like a coffee cup, stiff and hard, you can’t fill it with more fluid than it’s going to hold no matter how hard you try.

o Left Sided Heart Failure (the most common b/c the left side of the heart has the most workload b/c it’s pumping blood to the entire body)

Pulmonary Congestion – dyspnea, cough, crackles, low O2 saturation, S3 heart sound Dyspea on exertion Orthopnea- hard to breathe when they lay down Paroxymal nocturnal dyspnea (PND)

o The client has been sitting up or walking around all day and all this fluid has accumulated in their extremities. When they lay down the fluid moves into their lungs and they have a hard time breathing

Confusion, anxiety, and restlessness due to lack of oxygen Pulmonary Edema

Main goal is to get the extra fluid off/out of their body Prevention is key

o Need a thorough lung assessmento Recognition of early stages

Dry hacking cough, fatigue, weight gain, worsening edema, degree of dyspneao Right Sided Heart Failure

S/S The problems are systemic Jugular vein distention Dependent edema in the feet, ankles and legs (BIG SIGN) Hepatomegaly- enlarged liver Ascites- look like your preggers Weakness, anorexia, and weight gain

Heart Failure Diagnostic Findingso Pulmonary and peripheral assessmento BNP (B type natriuretic peptide) very specific to heart failure.

Normal value is less than 200, but you only treat it when it gets up to 800o Echocardiogram

Functional Classes of Heart Failureo Class 1 – been diagnosed but are functionally fineo Class 2 – have symptoms with ordinary activityo Class 3 – symptoms with minimal activity o Class 4 – persistent symptoms even at rest

Medical Managemento Ace Inhibitors stop heart remodellingo ARBS are used if the person can’t tolerate an ACEo Beta Blockers are good drugs for you

o Digoxin – cardiac glycoside used for systolic heart failure, a-fib and flutter. Dig and diuretics are your main drugs for heart failure. It regulates the heart rate and assists the contraction. Very similar to what the beta blockers do.

Dig Toxicity Fatigue, depression, malaise, N/V, anorexia, changes in heart rhythm (PVC’s are premature

ventricular contractions). Halo vision is also a big sign, they see green halo’s around lights Risk increases with hypokalemia, oral antibiotics, CCB’s, quinidine, and amiodarone If their potassium is low they’re more likely to have a digoxin toxicity

Always call the doctor before you hold digoxin, even if the levels are super duper high. Also, if the pulse is less than 60 then call the doctor before you give it. Listen to the apical pulse for 60 seconds, every time, even if there is a heart monitor, always. Bitch.

o Diureticso Calcium channel blockerso Anticoagulantso Low sodium Diet b/c water follows salt. If they are eating a lot of salt they will retain a lot of fluid

Nursing management of Heart Failureo I & O – super importanto Daily weight – a 2-4 lb gain a day is super not good. o Lung assessmento Look for edemao Look for pressure ulcers cause they are all fat from fluid therefore more likely to get these o Monitor electrolytes (potassium and magnesium)

Dysrhythmias Atrial Fibrillation

o Info Rapid, disorganized atrial twitching. Most common dysrhythmia Hard to see the P wave. It can be either inconsistent or absent

B/c the atria are fluttering. They’re not making a strong enough beat to show up on the EKG QRS’s aren’t evenly spaced apart Acute (Paroxymal)(it just shows up and goes away) or Chronic

o Causes Old age, CAD, HF, valve disorders, hyperthyroidism, post open heart surgery (cause they cut you open and

touch your heart and your heart hates that shit and gets pissed off and flutters for a few days), idiopathic, low potassium and low magnesium. The higher the HR the worse your pt will feel b/c the CO is bad.

o S/S They say my hearts racing or they feel palpitation Often their O2 sats drop (cause CO is lousy) Some people are walking around with a-fib and they don’t even know it. BP is usually low (because CO is low)

o Complications of A-Fib Decreased atrial kick Mural thrombi

Clots along the wall of the heart Atrial Flutter (similar to a-fib)

o Info Regularly irregular rate Saw-tooth appearance Risk of mural thrombi again

Treatment of these two bastards… (a flutter and a fib)

o Goal is to convert them back to a regular rhythmo Meds

Cordarone and Digoxin are used We know they are at an increased risk of clots so you put them on Coumadin or whatever the fuck the dr

orders. Cardioversion is when they shock the shit balls out of you to shock your heart into a normal rhythm. If they’re heart is still all kinds of fucked up they will put in a pacemaker

o Nursing care Oxygen, watch vitals, get an EKG STAT motha fucka! Notify the doc, try to keep them calm, and use bed

rest for an acute onset Labs are also very important

o Pacemaker Placement Placed for

Bradycardia, dysrhythmias, and heart failure Types

Temporary or permanent Permanent are most common

o Most of them will have a little box up in their left subclavian area. Has leads that are implanted in the heart to stimulate it to beat.

o Complication of pacemaker Infection

Can’t shower for a week cause water could get into pocket and fuck their shit up Bleeding and hematoma after insertion Hemothorax Dysrhythmias Dislocated leads – to help prevent this they put arm in a sling for like 12-24 hours afterward and they

remain in bed after night Hiccupping Cardiac Tamponade if they nick the pericardial sack

o Nursing Care for Pacemakers Monitor rhythm Monitor vitals Chest X-ray Bedrest HOB 30° Do not get wet for 7 days Carry information at all times Pacemaker checks Avoid strong EM fields

Peripheral Vascular Diseaseo #1 Sign is Intermittent Claudication!

Pain in extremities with exercise; relieved by rest (this is the definition of intermittent claudication. There is something that is causing a blockage that is keeping the blood from where it needs to go)

Persistent pain @ rest indicates severe ischemia Lowering extremity to dependent position ↑ perfusion Pain of Int. Claud. Occurs one joint level below disease process

o Calf pain may reflect femoral or popliteal artery ischemiao Pain in hip or buttocks may be ischemia in abdominal aorta or iliac arterieso There is something that is causing a blockage that is keeping the blood from where it

needs to go Skin & temperature changes

o Cool & paleo White or blanched appearance when elevatedo Rubor – reddish bluish discoloration in dependent position (over-reaction)o Cyanosis – blueo Gangrenous changes

Edema – unilateral or bilateralo Loss of hair, brittle nails, dry, shiny, scaly skin, ulcerations (very difficult to heal b/c of

lack of blood), bruits (vibrating sound/feel b/c of obstruction)o Pulse changes

Presence or absence; 0 to +4 scale; Doppler to detect flow (If you don’t feel a pulse somewhere ALWAYS check with a Doppler!!!)

Ankle-brachial index (ABI) Ankle-bradial Index

Systolic BP ankle ÷ Systolic BP brachialo Risk Factors

Nicotine use Hyperlipidemia (causes plaques to form) Hypertension Diabetes Stress Sedentary lifestyle/Obesity

o Nursing Interventions for Arterial Insufficiency Lower extremity to increase perfusion (let gravity get blood to where it needs to go) Exercise program (when appropriate) Avoid extreme cold No nicotine Avoid stress No constrictive clothing; no crossing legs (causes a tourniquet effect) Medication for pain & vasodilation Protective shoes; foot care; meticulous hygiene Proper nutrition

o Management of Peripheral Vascular Disease Exercise program Weight reduction Smoking cessation Medications

Trental, Pletal (makes blood more slippery), ASA, Ticlid, Plavix Antihypertensives Diabetes medications Lipid lowering agents

o Surgical Interventions for PVD Angioplasty Surgical bypass grafts

Aorto-iliac (AIBP) Aorto-femoral (AFBP) Femoral-popliteal (Fem-Pop)

o Post Operative Care for Vascular Procedures Maintain adequate circulation

Monitor pulse of affected extremity (if a pulse is absent call the physician right away!) Compare to other

o No pulse may indicate thrombotic occlusion of graft

Monitor color & temperature of affected extremity Monitor VS, mental status, urinary output Monitor with doppler every hour for 8 hours then every 2 hours for 24 hours Monitor for Bleeding Avoid leg crossing & prolonged extremity dependence Extremity elevation to reduce edema

Venous Insufficiencyo Info (don’t see this as often and not as much of a problem. Blood just isn’t moving back up, just hanging out in one

place. Can be uncomfortable, but not a life or death situation. Edema is present and it turns your skin turn brown) Chronic venous stasis Edema Brownish discoloration Pain

o Management Elevating extremities Foot pumping Avoid crossing legs Avoid constrictive clothing Compression stockings (good for venous insufficiency, but if they’re not a good fit and too tight on the

legs, could cause a tourniquet effect) Careful assessment

Raynaud’s Diseaseo Patho

Intermittent episodes of vasoconstriction of small arteries of feet & hands, causing color and temperature changes

o S/S Color change – white, blue, red

White = start to lose of blood flow Blue = loss of blood, no O2 to the tissues causes cyanosis, hence blue coloration Red = return of blood flow, most painful.

Numbness, tingling, & burning. Think of how it feels when your hands get cold and you go to the sink for some warm water to heat them up. If the water you use is too hot it burns like crazy. Same basic concept/sensation.

Involvement tends to be bilateral & symmetrico Management

Avoid stimuli that provoke vasoconstriction Avoid stress Avoid smoking Minimize exposure to cold Handle sharp objects carefully Give prescribed vasodilators Avoid decongestants Sympathectomy

Deep Vein Thrombosis (DVT)o Info (remember, immobility is the most common cause of these guys)

Virchow’s triad (3 Things that contribute to development of DVTs) Venous stasis Vessel wall injury Altered blood coagulation

Deep veins Superficial veins

o Assessment and Prevention of DVT Recognition of high risk client Thorough lower extremity assessment

Limb pain Heaviness Swelling, redness, warmth Tenderness Difference in leg circumference Venous Doppler (use this to diagnose) Remember, you’ll have a regular pulse because it’s a venous problem, not arterial

Prevention Anticoagulants, Intra vena cava filter Also things like foot pump exercises, early ambulation, lovenox, etc.

o Treatment for DVT Comfort Measures

Bed rest Elevation Compression stockings Analgesics

Modes of anticoagulant therapy IV heparin infusion followed by Coumadin

o PTT every 6 hrso INR (international normalized ratio) 2-3o Coumadin

LMWH – low molecular weight heparino Lovenox/Coumadin – outpatiento PT/INR for Coumadin

Thrombolytic therapyo Nursing Management for Anticoagulant Therapy

Bleeding Antidote for heparin is protamine sulfate Antidote for Coumadin is Vit K or fresh frozen plasma

Thrombocytopenia Heparin-induced thrombocytopenia. The body has an allergic reaction to the heparin and will

have massive clotting all over the body. Severe ischemia and may cause amputation Drug interactions

Coumadin is tricky; pay attention to drugs that ↑ or ↓ efficacyo Patient Education while taking Anticoagulants

Adhere to PT/INR monitoring as directed Avoid OTC meds without medical advice (like stuff you get at Walgreens, or your dealer, whichever one…) Avoid ETOH Do not stop unless directed Consider wearing ID band Always alert caregiver before any medical treatment (dental, or any major or minor treatment/surgery) Report any bleeding – blood in urine, stool, excessive bruising, epistaxis Avoid excessive amounts of foods high in Vitamin K

o Greenfield Vena Cava Filter Traps blood clots as they travel up the vena cava preventing them from reaching the lungs. The cone-

shaped design allows blood to flow around the captured clot Abdominal Aortic Aneurysm (AAA)

o Info

Most commonly formed due to HTN and atherosclerosis, strongest vessel in our body and becomes worn down. Remember, an aneurysm is like a balloon-filled bulge in an artery caused by weakening of the artery wall.

o Risk Factors Genetic predisposition Smoking/tobacco use Hypertension

o S/S Many asymptomatic “Feel my heartbeat in my abdomen” Abdominal mass/pulsation Bruit in abdomen

o A CT scan is the most common way to detect them. Then with an ultrasound, then arterialgram. Watch H&H very carefully. If it ruptures they’ll become pale and have dysrhythmias

o AAA Repair Open procedure

Aneurysm is resected (is that a word? I don’t know, and spell check is no help) and a graft is sewn in place

Major surgery Extended recovery

Endovascular AAA Repair – looks like a sleeve to protect the aneurysm, used for the small ones and for people too sick to undergo the major surgery. Can’t do surgery if the aneurysm is at or above the renal arteries…

Aortic graft is placed inside the aorta Accessed via catheters place in bilateral groins Quick recovery

o Nursing Management of AAA Severe abdominal or back pain?? Could be expanding or growing. Watch BP & H/H Post-op:

Intense monitoring of CV, renal, pulmonary, and neuro status Assess bowel sounds- indicates when they can start eating. “home free” Early ambulation, IS

Review Questions from Wolfe on the Discussion Board (And thank John Stell for answering all of these so you don’t have to)What are the primary sign and primary symptom of pericarditis?...muffled heart sounds upon auscultation, JVD, narrowing pulse pressure.What is pulse pressure? Difference between the systolic pressure and diastolic pressure.Name some clients who would be at risk for developing a-fib/a-flutter?...previous hx of CAD, cardiac arrhythmias, post-op CABG...probably more?What is a common sign of a cardiovascular event in the elderly?Dyspnea; atypical s/sx due to degeneration of nerve fibers.What are the major side effects of thrombolytics? Increased bleeding risk, absolute contraindication in those with concurrent hemorrhagic CVA or hx of the same.How does morphine decrease preload? Decreases pain and anxiety...relaxes vessels causing vasodilation and subsequent decrease in preload??What do you need to assess in a patient that has just had a cardiac cath?...bleeding at the site of the catheterization, increase the pt's fluid intake to flush out dye.What are the risk factors of PTCA? Not sure :/...cardiac irritability? Risk of embolus if unable to "capture" any debris that may be

inadvertently dislodged during procedures...I think. Need to read up on it more.Do you elevate or dangle legs for peripheral arterial disease? peripheral venous disease? Dangle for PAD - gravity assists in circulating the poor arterial circulation; elevate for PVD, which will also facilitate gravity to help blood flow back to the heart.What is involved in the care of a client immediately following pacemaker placement?....hmm, also need to read up on it. Monitor for dysrhythmias?A client with ascites is more likely to have ________ heart failure?Right sided heart failure...back up of fluid into systemic circulation (including ascites) is the hallmark sign

Group Case Study things…1

A female client, 57 years of age, is admitted to the emergency department (ED) with a diagnosis of heart failure. She was discharged from the hospital 10 days ago and comes in today stating, "I just had to come to the hospital today because I can't catch my breath and my legs are as big as tree trunks." After further questioning you learn she is strictly following the fluid and salt restriction ordered during her last admission. She reports she has been gaining 1 to 2 lbs every day since her discharge.1A) What error in teaching most likely occurred when the pt was discharged 10 days ago?There may have been an error in medication compliance or regimen. The patient should be on a diuretic along with the fluid and sodium restriction. The diuretic should be taken at the same time everyday, and not discontinued just because she "feels better". She may also be on ACE inhibitors, Beta blockers, or CCB. Also pt. teaching over which foods are high in sodium, ie... pickles, processed foods. Not to just avoid "table salt". Also patient should know that foods can increase fluid intake as well, such as melons, grapes, and ice. Pt. should have been taught to notify her physician of the weight gain or any swelling in her arms and legs, prior to becoming symptomatic. Also encourage periods of rest between ADL's. Also report daily weight, would have helped her figure this out earlier.1B)The client had been taking furosemide (Lasix) 40mg PO daily. The doctor changes her dose to 80mg IV push twice daily. Identify several strategies you would use to monitor effectiveness of this medication.Monitor Strict I/O, Monitor patients weight daily at the same time everyday, monitor for peripheral edema, Auscultate lung sounds for diminished crackles and decreased shortness of breath. Also you need to monitor serum electrolytes of this patient during diuretic therapy, especially potassium

2Your client is a 70 yr-old retired bus driver who has just been admitted to your floor with a right leg DVT. He has a 48-pack-year smoking history but states he quit 2 years ago. He has had pneumonia several times and has frequent bouts of A-fib. His history includes two previous DVTs. Two months ago he began experiencing shortness of breath on exertion and noticed swelling of his right lower leg that became progressively worse until it involved his thigh to groin. His wife brought him in because of complaints of increasingly severe leg pain. A Doppler study indicated probable thrombus of the external iliac vein extending distally to the lower leg. He is admitted for bed rest and heparin therapy. His lab values are PT 12.4 second and INR 1.11 (Both low: we prefer for the INR to be 2.5-3.0) PTT 25 seconds(also low) H/H 13.3 & 38.9, cholesterol 206 mg/dl. BMP is normal. 2A) Identify problems in this client's history that represent his personal risk for DVT.Increased age, previous occupation, history of smoking, previous DVT’s, SOB, Swelling of lower right leg, history of pneumonia and frequent bouts of A-fib. The high cholesterol is also an issue. We know his blood flow isn’t good, so that will make him at an increased risk for stasis of blood2B) Based on his history, this client should have been taking an important medication. What is it, and why should he be on it?Coumadin as antiplatelet therapy, Digoxin to treat dysrhythmias and to prevent clotting. Once you’ve had more than one DVT the physician most likely will prescribe Coumadin for several years to life…2C) What are the most important assessments you should make during his physical assessment?Any signs of complications from anticoagulation therapy such as: Unusual bleeding ( nosebleed, bleeding gums, red or cola colored urine, black bowel movements, skin ulcers) bruises. Lung sounds, pedal pulses, limb pain, swelling, redness, warmth, and difference in leg circumference, tenderness to touch, respiratory rate, 02 sats and heart rate.2D) What is the most serious complication of DVT?Pulmonary Embolism

3

You are assigned a 76 year-old female client. Two nights before her admission to your cardiac unit, she awoke with heavy substernal pressure accompanied by epigastric distress. The pain was reduced somewhat when she rolled onto her side but did not completely subside for about 6 hours. The next night she experienced the same chest pressure. The following morning her husband brought her to the ER and she was hospitalized to rule out a myocardial infarction (MI)3A) What steps will be taken to evaluate if her chest pain is due to a cardiac problem?EKG, Lab work: Calcium, Magnesium and Potassium levels as well as CK levels, WBC and Triponin levels. Check O2 sats. Auscultate heart sounds, Extensive health history including medication list and previous cardiac issues.3B) What interventions should we begin immediately?Vital signs, Oxygen if needed, get order for aspirin or Nitro, blood tests: CK triponin and get EKG.A thorough assessment and health history are performed. Her vitals are 132/86, 88, 18, and 97.9. She has moderate edema of both ankles and peripheral pulses are 1+. She has a soft systolic murmur. She denies any discomfort at this time. She has no history of smoking or alcohol use, good general health except for osteoarthritis of her hands, knees, and spine. She takes Protonix, ibuprofen for joint and bone pain, and some "herbs". 3C) Why are we concerned about her murmur and edema?We are concerned that her murmur and edema are related due to the possiblity of mitral valve dysfunction. This maybe the result of ischemia to the papillary muscles resulting in acute mitral insufficiency. Which in turn could lead to congestive heart failure. Additional possibility of symptoms could be aortic stenosis, the contributing factors could be her age. Her age could cause calcific aortic stenosis, causing CHF and coronary symptoms.3D) What other sources, besides cardiac ischemia, might be responsible for her chest pain/abdominal discomfort? (think of a couple)The herbal supplements maybe a contributory factor in her symptoms either masking them or exererbating them. She might have a hiatal hernia in addition to her GERD. She may have been misdiagnosed with GERD, since she was taking Protonix on admission. Her cardiac issues maybe worse than orginally thought if her GERD was misdiagnosed and the cardiac portion of her disease was missed. AT 76 yrs old, her peripheral pulses are at 1+, her edema is moderate (2+?), her ejection fracture may be down or she could have PVD. In our 70's we start getting calicum deposits in our peripheral vasculature. She takes very little medication and would be considered to be in good health with her age. Treatment suggestions (not that we would offer one to a Dr. without being asked!) would be digixon and lasix to help contractility and fluid retention.

4A 46 year old male client with a history of familial hyperlipidemia presents to the medical clinic. He states he used to smoke 2 packs of cigarettes a day but has cut back to 1 pack a day over the past 2 months. He has recently begun walking his dog twice a day because "it's good for the dog and my doctor says it's good for me too." However, he states he cannot make it as far as he used to. He complains of pain to his right calf that starts after only a couple minutes of walking. Once he goes inside and sits down the pain goes away.4A) What is the medical term for this symptom?Intermittent claudication4B) What disease process is this an indicator of? Peripheral Artery Disease4C) Name some symptoms of progression of this disease?- Cyanosis, gangrenous changes, loss of hair, ulcerations and with severe ischemia pain persists at rest4D) What interventions can be used to assist him? (Don't forget teaching!)No nicotine (very important), proper nutrition, avoid extreme cold, wear protective shoes, encourage moderate exercise. Need to find things that keep the blood flowing and prevent worsening of the disease. However, at the same time, we have to keep their pain in mind. So we may need to teach them foot pump exercises, stretches, etc. Something that won’t cause overwhelming discomfort.

5A 68 year old female client is three days post-op bypass. She has done well today by walking in the hall twice, showering, and sitting up in the chair for meals. She has had no arrhythmias and is 98% on 2LNC. She has had very few complaints.

At 1430 you are called to her room. She complains "I can't catch my breath." You note that her respirations are labored and she is tachypnic with a rate of 32.5A) What should you do next?Apply oxygen. Check ALL vitals and pulses. Inform the doctor of situation. Stay in the room to make sure she’s ok. Her safety is of your highest concern. You note an irregular rhythm with absence of a P-wave on the monitor. Her heart rate is 143 beats per minute. She states "My heart is racing. I'm scared." 5B) What rhythm do you believe she is in? Atrial Fibrillation5C) What complications may arise if she maintains this rhythm?If the heart is in atrial fibrillation then the blood can pool in the left atrium which can form a clot. The clot can then be pumped into the left ventrical and travel out of the heart and into other areas of the body, such as the brain. The clot could then get stuck and cause a stroke. Remember the term mural thrombi. Could also be at risk for DVTs, basically anything having to do with a clot getting stuck and causing problems she’s at risk for.5D) What interventions can be used to alleviate this rhythm? Check all vitals and pulses, call doc and inform him of situation, suggest EKG, labs (Mg, K, Ca, PT/INR) and meds: Coradone or Digoxin to convert back to a regular rhythm, Beta Blockers and CCB, and Coumadin to prevent clot formation along the wall of the atriaAfter 24 hours cardiovert or pacemaker (extreme)5E) What do you tell your patient?Explain to her that her heart rate is irregular (HR 143) and that you are going to call the doctor. Keep her informed to help with the anxiety b/c the increased HR will be making her feel bad.

Things she labeled “Additional Info from the Lecture”

First off, I hope you kind of got a feel for what questions will be like. They will be similar to those from the first test. You will be asked to prioritize, meaning: which intervention should be performed first, which patient should you go take care of first, what assessment are you most concerned about, etc.

Ok, I know AAA was the last thing we covered and we were so, so ready to go. Just realize that we are concerned when a person's pain is worsening. That makes us fear that the aneurysm is expanding and rupture may be near. We are going to watch the H/H, BP, mental status, skin tone, etc. very closely. If we see a drop in the H/H and BP we fear that there is a leak and immediate surgery is our only hope.

On a similar note, I feel like I covered how we care for surgical patients while they are still in the hospital. However, I don't think I emphasized home care very well at all. This pretty much goes for all the surgeries we talked about CABG, Valve Replacement, Peripheral Bypasses, AAA, and even Cardiac Cath to some extent. We really have to teach these people to continue their ambulation and I.S. Really want to avoid blood clots and pneumonia/atelectasis. They will be restricted on how soon they can drive. One reason is because they will be on pain meds and won't be with it enough to drive. But, maybe even more than that, they don't want to be at risk of having and accident and the steering wheel or airbag goes flying into their incision. They could suffer major, major damage. Another thing is that they have to watch lifting. With open hearts, our fear is that they will pull those sternal wires apart. With AAAs and peripheral bypasses we are worried that the stress of lifting and straining will pop their incision, or even worse, their new graft open.

Also, I don't remember how much I said about restrictions for those people who have permanent pacemakers. I remember talking about welding, using a chainsaw, jack-hammer etc. Did I talk about avoiding heavy magnetic fields. One big issue is that they WILL NOT be able to have MRIs anymore. We definitely don't want to run the risk of the pacemaker getting sucked out of their chest. As far as airport security goes, they will need to have a card showing that they have a pacemaker. They will set off the airport security. I don't believe that it will affect the pacemaker function as long as the wand isn't held over the pacemaker site for an extended period of time.