VI. CARDIAC Preload Afterload A. Normal blood flow through the heart: The two major veins that bring blood to the right side of the heart are the superior and inferior vena cava (This blood is deoxygenated)→The blood enters the right atrium→ Then the right ventricle→ From the RV the blood is pumped into the pulmonary artery (this artery carries deoxygenated blood) → Then the blood goes to the lungs where it is oxygenated→ Next through the pulmonary veins (they carry oxygenated blood)→ It then goes to the left atrium → to the left ventricle (the big bad pump)→ It is then pumped into the aorta→ And finally this oxygenated blood is delivered throughout the body through the arterial system where it eventually ties back into the venous system. Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 71 Cardiac
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VI. CARDIAC
Preload
Afterload
A. Normal blood flow through the heart:
The two major veins that bring blood to the right side of the heart are the superior and inferior vena cava (This blood is deoxygenated)→The blood enters the right atrium→ Then the right ventricle→ From the RV the blood is pumped into the pulmonary artery (this artery carries deoxygenated blood) → Then the blood goes to the lungs where it is oxygenated→ Next through the pulmonary veins (they carry oxygenated blood)→ It then goes to the left atrium → to the left ventricle (the big bad pump)→ It is then pumped into the aorta→ And finally this oxygenated blood is delivered throughout the body through the arterial system where it eventually ties back into the venous system.
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B. Cardiac Terms: 1. Preload is the amount of blood _____________ to the right side of the heart and the
muscle ________________ that the volume causes. ____________ is released when we have this stretch.
2. Afterload is the ___________ in the aorta and peripheral arteries that the left ventricle has to pump against to get the blood out.
This pressure is referred to as resistance.
With hypertension there’s even more ________________ for the left ventricle to pump against. That’s why ______________ can eventually lead to HF and pulmonary edema, because high afterload _______________ cardiac output and ________________ forward flow. Plus, it wears your heart out.
3. Stroke volume is the ____________ of blood pumped out of the ventricles with each beat.
C. Cardiac Output: CO = HR x SV
Tissue ____________ is dependent on an adequate cardiac output.
Cardiac output changes according to the body’s __________________.
1. Factors that affect cardiac output:
a. Heart rate and certain arrhythmias
b. Blood ___________
1) Less volume = ___________ CO
2) More volume = ___________CO
c. ______________ contractility
MI, medication, muscle disease
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2. Pathophysiology of decreased CO:
If your CO is decreased, will you perfuse properly? ________
a. Brain: LOC will go_______
b. Heart: Client reports of ________ pain
c. Lungs: Short of breath? ______ Lungs sound ______________
d. Skin: ________ and clammy
e. Kidneys: UO goes _____
f. Peripheral pulses: ____________
Arrhythmias are no big deal UNTIL they affect your cardiac output. g. Three Arrhythmias that are always a big deal:
1) ________________________________________
2) ________________________________________
3) ________________________________________
D. Coronary Artery Disease:
Coronary artery disease is the most common type of cardiovascular disease.
Coronary artery disease is a broad term that includes chronic stable angina and
acute coronary syndrome.
1. Chronic Stable Angina:
a. Pathophysiology:
1) Decreased blood flow to the myocardium→ ischemia or necrosis? → temporary pain/pressure in chest.
2) What brings this pain on? Low ____________usually due
to________________. 3) What relieves the pain? ______________ and/or __________
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b. Tx:
1) Medications:
a) nitroglycerin (Nitrostat®): Sublingual:
Causes venous and arterial ___________________
This result will cause ________________ preload and afterload.
Also causes dilation of _________________ arteries which will increase blood flow to the actual heart muscle (myocardium)
Take 1 every ________ min x ________ doses. Okay to swallow? __________
Keep in dark, glass bottle; dry, cool
May or may not burn or fizz
The client will get a ________________.
Renew how often? An average of every_________ months
Spray? _______ years
After nitroglycerin (Nitrostat®), what do you expect the BP to do? ______________________
What do beta blockers do to BP, P, and myocardial contractility? _______
What does this do to the workload of the heart? _______________
Beta blockers block the beta cells… these are the receptor sites for catecholamines- the epi and norepi. So we just decreased the contractility… So what happened to my CO? _____________. So we have ______________ the workload on my heart. This is a good thing to a certain point, because we decrease the work on the heart, the need for oxygen is decreased, and that decreases angina. But could we decrease the client’s cardiac output (HR and BP) too much with these drugs? ________
*TESTING STRATEGY* RULE: NEVER LEAVE AN UNSTABLE CLIENT.
Algorithm for NTG: Take one NTG SL, after 5 minutes if chest pain/discomfort is unimproved or worsened, activate emergency response.
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c) Calcium Channel Blockers (prevention of angina):
Calcium channel blockers cause vasodilation of the arterial system.
They dilate ____________________arteries.
Two benefits of calcium channel blockers are they ____________ afterload and ________________ oxygen to the heart muscle.
d) acetylsalicylic acid (Aspirin®):
Dose is determined by the physician (81 mg - 325 mg)
c. Client Education/Teaching for Chronic Stable Angina:
Rest frequently
Avoid overeating
Avoid excess caffeine or any drugs that increase HR.
Wait 2 hours after eating to exercise.
Dress warmly in cold weather (any temperature extreme can precipitate an attack).
Take nitroglycerin prophylactically.
Smoking cessation
Lose weight.
Avoid isometric exercise
Reduce stress
*TESTING STRATEGY* DO EVERYTHING YOU CAN TO
DECREASE THE WORKLOAD ON THE HEART.
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d. Cardiac Catheterization:
1) Pre-procedure:
Ask if they are allergic to ___________________________.
Iodine based dye is used during the procedure.
Also we want to check their kidney function because you excrete the dye through the ____________. Many primary healthcare providers order acetylcysteine (Mucomyst ®) pre-procedure especially if they have kidney problems. Mucomyst helps to protect the kidneys.
Hot shot
Palpitations normal
2) Post-procedure:
Monitor VS
Watch puncture site
What are you watching for? _______________ and hematoma formation
Assess extremity distal to puncture site (5-Ps).
Bed rest, flat, leg straight X 4-6 hours
Major complication post cath? ____________________
Report pain ASAP
If the client is on metformin (Glucophage), ______________ this medicine for 48 hours post procedure. We are worried about the _______________.
Unstable chronic angina= Impending MI
The 5 Ps Pulselessness
Pallor Pain
Paresthesia Paralysis
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2. Acute Coronary Syndrome: MI, Unstable Angina:
a. Pathophysiology:
1) Decreased blood flow to myocardium→ ischemia, necrosis or both? ___________
2) Does the client have to be doing anything to bring this pain on?
______________ 3) Will rest or nitroglycerin (Nitrostat®) relieve this pain? _______________
b. S/S:
Pain
May describe pain as ______________________, an elephant sitting on their chest, pressure radiating to the left arm and left jaw, N/V, or pain between their shoulder blades.
_______________ usually present with GI signs and symptoms, epigastric complaints or pain between the shoulders, an aching jaw or a choking sensation.
What is the #1 sign of an MI in the elderly? _________________
Cold/clammy/BP drops
Cardiac output is going ________. ECG changes
Vomiting
You may see the following terms in a test question:
***WORRY ABOUT THE STEMI CLIENT***
STEMI: ST-Segment Elevation Myocardial Infarction-this indicates that the client is having a heart attack and the goal is to get them to the cath lab for PCI in less than 90 minutes.
NSTEMI: Non- ST- Segment Elevation Myocardial Infarction-these clients are usually less worrisome.
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c. Diagnostic Lab Work:
1) CPK-MB:
Cardiac specific _____________________
_________ with damage to cardiac cells
Elevates in _____ hours and peaks in _____ hours
2) Troponin:
Cardiac biomarker with _______ specificity to myocardial damage
Elevates within ________ hours and remains _________ for up to 3 weeks 3) Myoglobin:
Increases within ____ hour and peaks in _____ hours
___________ results are a good thing.
4) Which cardiac biomarker is the most sensitive indicator for an MI? _____________
5) Which enzymes or markers are most helpful when the client delays seeking care? ________________
d. Complications:
Major arrhythmias:
What untreated arrhythmias will put the client at risk for sudden death?
____________________ ____________________ ____________________, plus we are going to add ____________________
Priority treatment for V-Fib: ___________________
If the first shock doesn’t work and the client remains in V-Fib, what is the first vasopressor we give? _________________
Lab values for Troponin Isomers
Troponin T < 0.10 ng/mL Troponin I < 0.03 ng/mL
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amiodarone (Cordarone®) is an anti-arrhythmic and is used when V-Fib and pulseless VT are resistant to treatment, and also for fast arrhythmias.
What anti-arrhythmic drugs are commonly given to prevent a second
episode of V-Fib? ________________ and ___________________.
Lidocaine toxicity: any _________ changes
amiodarone (Cordarone®) is the first anti-arrhythmic of choice.
Important side effect? ____________
This hypotension can lead to further arrhythmias.
e. Treatment:
What drugs are used for chest pain when they get to the ED? _______________________ _______________________ (chewable or tablet?) _______________________ _______________________
Head up position. Why?
Decreases ___________ on the heart and increases ________________.
1) Fibrinolytics:
Goal: Dissolve the clot that is blocking blood flow to the heart muscle→ decreases the size of the infarction.
No isometric exercises-___________________ workload of heart
No Valsalva
No straining; no suppository; docusate (Colace®)
When can sex be resumed? _____________
What is the safest time of day for sex? ___________
Best exercise for MI client? _____________
Teach S/S of heart failure:
Weight __________________
Ankle edema
Shortness of ______________
Confusion
E. Heart Failure (HF):
1. Causes:
HF is a complication that can result from problems such as cardiomyopathy, valvular heart disease, endocarditis, acute MI, and _______________.
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2. Types:
a. Left Side Failure: the blood is not moving forward into the aorta and out to the body…IF it does not move forward, then it will go backwards into the ________.
b. Right Side Failure: the blood is not moving forward into the lungs…IF it does not move forwards then it goes backwards into the ___________ system.
S/S: Distended neck veins Edema
Enlarged organs Weight gain Ascites
Terminology: Systolic heart failure: heart can’t contract and eject. Diastolic heart failure: ventricles can’t relax and fill.
3. Dx:
a. B-type (BNP) natriuretic peptide: Secreted by ventricular tissues in the heart when ventricular volumes and
pressures in the heart are increased
Sensitive indicator
Can be _________ for HF when the CXR does not indicate a problem
If the client is on nesiritide (Natrecor®), turn it off _________ prior to drawing a BNP.
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b. CXR: enlarged ____________________, pulmonary infiltrates
c. Echocardiogram
d. New York Heart Association Functional Classification of Persons with HF:
Classes 1-4 (Class 4 being worst)
4. Tx:
a. Medications: Standard medication therapy for HF is ACE inhibitors and ARBS.
1) ACE Inhibitors:
These are the Drugs of Choice (DOC)for HF
They suppress the Renin Angiotensin System (RAS)
Prevent conversion of Angiotensin I to Angiotensin II
Results in arterial _____________ and ______________ stroke volume.
2) ARBS: Block Angiotensin II receptors, and causes a ________________ in
arterial resistance and decreased BP.
The Swan-Ganz (Pulmonary Artery) catheter is a balloon flotation catheter that can be floated into the right side of the heart and pulmonary artery. It provides information to rapidly determine hemodynamic pressures, cardiac output and provides access to mixed venous blood sampling.
Arterial lines can be places in multiple arteries, but the most common site is the radial artery. It provides continuous intra-arterial blood pressure monitoring and allows for repeated ABG samples to be collected without injury to the client.
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Ace inhibitors and ARBS both block aldosterone. When we block aldosterone, we lose _____________ and ____________ and retain __________________. It is standard practice (a core measure) that a client with HF will be sent home on an ____________________and/or a beta blocker. Why? Because, these drugs in combination ____________ the workload on the heart by preventing vasoconstriction (decreasing afterload). This will increase the cardiac output and keep blood moving ________________ out of the heart. That’s what we want- forward flow.
3) Digoxin (Lanoxin®):
Actions:
Used less today because of the risk of drug toxicity, especially in the elderly.
Used with sinus rhythm or atrial fibrillation and accompanying chronic HF.
Often given in combination with an ACE inhibitor, ARB, beta blocker or
________________.
Contraction? __________________
Heart rate? ____________________
When the heart rate is slowed this gives the ventricles more time to fill with blood.
Cardiac output will go ___________.
Kidney perfusion _______________.
Nursing Considerations:
Would diuresis be a good thing or bad thing for this client? _________
We always want to ____________heart failure clients…they can’t handle the fluid.
Digitalizing dose (loading dose)
How do you know the Digoxin is working? Because the cardiac output goes_____
Normal Dig level= ____to____ ng/ml
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S/S of toxicity:
Early: Anorexia, nausea, and vomiting
Late: Arrhythmias and _________________ changes
Before administering, do what? ________________________
Monitor electrolytes
All electrolyte levels must remain normal, but K+ is the one that causes the most trouble.
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b. Tx:
Since arterial blood is having problems getting to the tissue, if you elevated the extremity would the pain increase or decrease? _____________________
Arterial disorders of the lower extremities are usually treated with either angioplasty or endarterectomy.
We ELEVATE veins
We DANGLE arteries
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ACE inhibitors (angiotensin converting enzyme inhibitor) Actions: Uses: Blocks conversion of angiotensin I to angiotensin II Hypertension and heart failure What they do: promote vasodilation and diuresis, Nursing Observations: decrease the secretion of aldosterone (so the If the drug ends in –pril it is most likely an ACE kidneys will get rid of sodium and water and retain inhibitor. potassium). Watch for hyperkalemia, orthostatic syncope, Examples: hypotension, and renal dysfunction. enalapril (Vasotec®) Angioedema creating laryngeal swelling, can be fosinopril (Monopril®) fatal. Dry, nonproductive cough-reversible when captopril (Capoten®) drug stopped. Fall precautions. ARBs (angiotensin II receptor blockers)
Action: Uses: Blocks effects of angiotensin II (a potent Hypertension and heart failure. vasoconstrictor) at the receptor site (used as an Nursing Considerations: alternative to ACE inhibitors). ACE inhibitors block If the drug ends in –sartan it is most likely an ARB the conversion of AI to AII but AII can also be Watch for hyperkalemia, hypotension, and renal formed by other enzymes that are not blocked by dysfunction.. ACE Inhibitors. What they do: decrease blood pressure, increase CO Examples: valsartan (Diovan®) losartan (Cozaar®) irbesartan (Avapro®) Beta Adrenergic Blockers
Action: Uses: Block adverse effects from sympathetic nervous Angina, chest pain. Hypertension, ventricular stimulation. dysrhythmias and thyroid storm. What they do: block the receptor sites for epi and Nursing Consideration: norepi…so they will decrease afterload and If the drug ends in–lol it is most likely a beta contractility….as a result they decrease the BP and blocker. HR. Don’t give to asthmatics (some beta blockers also Examples: constrict the smooth muscle of the bronchioles). propranolol (Inderal®) Don’t give to diabetics (blocks the sympathetic metoprolol (Lopressor®/Toprol XL®) responses seen in hypoglycemia). atenolol (Tenormin®) carvedilol (Coreg®)
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