VI. CARDIAC 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. B. Cardiac Terms: 1. Preload is the amount of blood RETURNING to the heart. 2. Afterload is the PRESSURE in the aorta and peripheral arteries that the left ventricle has to pump against to get the blood out. That pressure is referred to as resistance. The resistance the LV has to overcome to get the blood out 3. Stroke volume is the AMOUNT of blood pumped out of the ventricles with each beat. C. Cardiac Output: CO = HR x SV Tissue PERFUSION is dependent on an adequate cardiac output. Cardiac output changes according to the bodys NEEDS. 1. Factors that affect cardiac output: a. Heart rate and certain arrthymias

b. Blood PRESSURE DECREASE c. DECREASED contractility MI, medication, muscle disease 70 Hurst Review Services 2. Pathophysiology of decreased CO: If your CO is decreased, will you perfuse properly? NO a. Brain: LOC will go DOWN b. Heart: Client complains of CHEST pain c. Lungs: Short of breath? YES d. Skin: COLD and clammy e. Kidneys: UO goes DOWN f. Peripheral pulses: WEAKER Arrhythmias are no big deal UNTIL they affect your cardiac output. (1) PULSELESS (2) VTACH (3) VFIB D. Chronic Stable Angina: 1. Pathophysiology: a. Decreased blood flow to myocardium ischemia or necrosis? temporary pain/pressure in chest. b. Usually caused by CAD c. What brings this pain on? LOW OXYGEN d. What relieves the pain? REST and/or NITROGLYCERINES 2. Tx: a. Medications: 1) Nitroglycerin (Nitrostat): Sublingual Causes venous and arterial DILATION This result will cause DECREASE preload and afterload. Also causes dilation of CORONARY arteries which will increase blood flow to the actual heart muscle (myocardium) Hurst Review Services 71 Take 1 every 5 min x 3 doses. Okay to swallow? NO Keep in dark, glass bottle; dry, cool May or may not burn or fizz The client will get a HEADACHE. EXPECT IT TO OCCUR

Renew how often? 3-5 months Spray? 2 years After Nitroglycerin (Nitrostat), what do you expect the BP to do? DROP 2) Beta Blockers: Examples: Propranolol (Inderal), Metoprolol (Lopressor/Toprol XL), Atenolol (Tenormin), Carvedilol (Coreg) What do beta blockers do to BP, P, and myocardial contractility? DECREASE What does this do to the workload of the heart? DECREASE 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? Decreased So we have Decreased the workload on my heart. This is a good thing to a certain point because we decreased the workload on the heart, but could we decrease the clients cardiac output (HR and BP) too much with these drugs? YES 3) Calcium Channel Blockers: Examples: Nifedipine (Procardia XL), Verapamil (Calan), Amlodipine (Norvasc), Diltiazem(Cardizem) What do these do to the BP? DECREASE They also dilate CORONARY arteries. 4) Acetylsalicylic Acid (Aspirin): Dose is determined by the physician (81 mg-325 mg) *TESTING STRATEGY* RULE: NEVER LEAVE AN UNSTABLE CLIENT. 72 Hurst Review Services b. Client Education/Teaching:

Avoid isometric exercise (exercises that make your muscles squeeze/tense up). Avoid overeating. Rest frequently. 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. c. Cardiac Catheterization: 1) Pre-procedure: Ask if they are allergic to IODINE/SHELLFISH. Iodine based dye is used during procedure. Also we want to check their kidney function because you excrete the dye through the KIDNEY. Hot shot Palpitations normal 2) Post-procedure: Monitor VS. Watch puncture site. What are you watching for? BLEEDING Assess extremity distal to puncture site (5-Ps). The 5 Ps Pulselessness Pallor Pain Paresthesia Paralysis *TESTING STRATEGY* DO EVERYTHING YOU CAN TO DECREASE WORKLOAD ON THE HEART. Hurst Review Services 73 Bed rest, flat, leg straight X 4-6 hours Report pain ASAP. Major complication post cath? HEMORRHAGE Unstable chronic angina= Impending MI

E. Acute Coronary Syndrome: MI, Unstable Angina: 1. Pathophysiology: a. Decreased blood flow to myocardium ischemia/necrosis or both? BOTH b. Does the client have to be doing anything to bring this pain ON? NO c. Will rest or Nitroglycerin (Nitrostat) relieve this PAIN? NO 2. S/S: Pain Cold/clammy/BP drops Cardiac output is going DOWN. WBCs Due to inflammation temp ECG changes Vomiting You may see the following terms in a test question: 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. ***WORRY ABOUT THIS CLIENT*** NSTEMI: Non-Elevation ST Segment Myocardial Infarctionthese clients are usually less worrisome. 3. Diagnostic Lab Work: a. CPK-MB: Cardiac specific ENZYMES INCREASE with damage to cardiac cells Elevates in 3-12 hours and peaks in 24 hours b. Troponin: Cardiac biomarker with specificity to myocardial damage Has two specific isomers called Troponin T and I Elevates within 3-4 hours and remains ELEVATED for up to 3 weeks c. Myoglobin: Increases within 1 hour and peaks in 12 hours NEGATIVE results are a good thing.

d. Which cardiac biomarker is the most sensitive indicator for an MI? TROPONIN e. Which enzymes or makers are most helpful when the client delays seeking care? TROPONIN 4. Complications: Major arrhythmias: What untreated arrhythmias will put the client at risk for sudden death? VFIB If the first shock doesnt work and client remains in VFib, what is the first vasopressor we give? EPINEPRINE Amiodarone (Cordarone) is an anti-arrhythmic and is used when V-Fib is resistant to treatment, and also for fast arrhythmias. HYPOTENSION What anti-arrhythmic drugs are commonly given to prevent a second episode of V-Fib? AMIODARONE and LIDOCANE. Lidocaine toxicity: ANY NEURO changes Amiodarone (Cordarone) is the first anti-arrhythmic of choice. Important side effect? HYPOTENSION This hypotension can lead to further arrhythmias. Troponin Isomers T < 0.20 I < 0.03 5. Treatment: What drugs are used for chest pain when they get to the ED? OXYGEN ASPIRIN (chewable or tablet?)CHEWABLE NITROGLYCERINE MORPHINE Head up position and why? DECREASE WORKLOAD ON HEART Decreases WORKLOAD on heart and increases CARDIAC OUTPUT. a. Fibrinolytics:

Goal: Dissolve the clot that is blocking blood flow to the heart muscle decreases the size of the infarction. 30 MINS. Medications: Streptokinase (Streptase), Alteplase (tPA), Tenecteplase (TNKase) (one time push), Reteplase (Retavase) How soon after the onset of myocardial pain should these drugs be administered? 6-8 HOURS Brain attack? TIME IS BRAIN. Major complication: BLEEDING Obtain a BLEEDING history. BLEEDING STROKES, PREGNANCY, POST OP. QUESTIONS RELATED TO BLEEDING. Absolute contraindications: Intracranial neoplasm, intracranial bleed, suspected aortic dissection, internal bleeding During and after administration we take BLEEDING precautions. Draw blood when starting IVs, decrease the number of PUNCTURE sites. Follow-Up Therapy: Antiplatelets are another important component of fibrinolytic therapy. Acetylsalicylic Acid (Aspirin), Clopidogrel (Plavix), Abciximab (ReoPro IV) (continuous infusion to inhibit platelet aggregation) Bleeding Precautions: Watch for bleeding gums, hematuria and black stools. Use an electric razor, a soft toothbrush, and No IMs. b. Medical Interventions: 1) PCI (Percutaneous Coronary Intervention): Includes all interventions such as PTCA (angioplasty) and stents Major complication of the angioplasty is a MYOCARDIAL INFARCTION.

Dont forget client may bleed from heart cath site. If any problems occur go to SURGERY. Chest pain after procedure: call the doctor at once reoccluding! Anti-platelet medications: Aspirin Clopidogrel (Plavix) Abciximab (ReoPro IV) Given to high risk clients who have been stented to keep artery open those waiting to go to cath lab Eptifibaride (Integrilin IV) 2) Coronary Artery Bypass Graft (CABG) Can be scheduled or emergency procedure Used with multiple vessel disease LEFT MAIN artery occlusion which supplies the entire left ventricle c. Cardiac Rehabilitation: Smoking cessation Stepped-care plan (increase activity gradually) Diet changes- LOW fat, LOW salt, LOW cholesterol No isometric exercisesINCREASE workload of heart No valsalva No straining; no suppository; Docusate (Colace) When can sex be resumed? YES What is the safest time of day for sex? MORNING Hurst Review Services 77 Best exercise for MI client? WALKING. Teach S/S of heart failure: Weight GAIN Ankle edema Shortness of BREATH Confusion d. Pacemaker: The heart has a natural pacemaker called the SA node (sinoatrial node). This sends out impulses that make the heart CONTRACT.

What happens to cardiac output if your natural electrical system malfunctions and the heart rate drops below 60? Cardiac output can Pacemakers are used to increase the heart rate with symptomatic bradycardia. Pacemakers depolarize the heart muscle and a contraction will occur (electricity going through the muscle). Repolarization (ventricles are resting and are filling up with blood). RESTING!! 1) Temporary: Used in EMERGENCY situations After heart surgery Acute MI Until the client is stable enough for a permanent pacemaker to be inserted Can be classified as invasive or noninvasive: Noninvasive temporary pacing, called transcutaneous pacing Two large electrode pads are applied to client and turned to the PACING mode. This is an EMERGENCY procedure. Is it going to hurt? YES, the client will need ANALGESICS. Invasive temporary pacemaker has pacing wires that are placed into the heart CHAMBER (transvenous pacing). Wires are connected to power source OUTSIDE the body. Epicardial pacing is when the wires are attached to the epicardium during surgery. 2) Permanent Pacemakers: Used when heart condition is CHRONIC Electrodes are anchored to the endocardium and attached to a battery source implanted into a subcutaneous pocket.

A demand pacemaker kicks in only when the client needs it to. Fixed rate fires at a FIXED rate constantly. Its ok for the rate to increase but never DECREASED. Always worry if the rate DROPS below set rate. Post-Procedure Care: Monitor the incision. Most common complication in early hours? Electrode displacement Immobilize arm. PROM to prevent frozen SHOULDER Keep the client from raising their arm too high. S/S of Malfunction: Its possible that no mechanical event or contraction follows the stimuli. This is called LOSS OF CAPTURE. What causes this? The pacemaker may not be PROGRAMMED correctly. Electrodes can DISLODGED. Battery may be DEPLETED. Any sign of decreased CO or decreased RATE Hurst Review Services 79 Client Education/Teaching: Check PACEMAKER daily. ID card Avoid electromagnetic fields (cell phones, large motors, arc welding, electric substations). Avoid MRIs. Are they going to set off alarms at airport? YES Avoid contact sports. IMPLANTABLE CARDIAC DEVICE SPEED UP SLOW RYTHM, SPEED DOWN FAST RYTHM F. Heart Failure (HF): 1. Causes: HF is a complication that can result from problems such as cardiomyopathy, valvular heart disease, endocarditis, acute MI, and HYPERTENSION. 2. Types:

a. Left Side Failure: the blood is not moving forward into the aorta and out to my bodyIF it does not move forward, then it will go backwards into the LUNGS. S/S: Pulmonary congestion Dyspnea Cough Blood tinged frothy sputum Restlessness Tachycardia S-3 Orthopnea Nocturnal dyspnea b. Right Side Failure: the blood is not moving forward into the lungsIF it does not move forwards then it goes backwards into the VENOUS system. S/S: Enlarged organs Edema Weight gain Distended neck veins Ascites New Terminology: Systolic heart failure: heart cant contract and eject. Diastolic heart failure: ventricles cant relax and fill. 3. Dx: a. Pulmonary artery catheter (Swan Ganz catheter): A type of central line that measures pressures inside the heart Helps to determine the cause of DECREASED cardiac output Killer complications: AIR embolus, PULMONARY infarction b. A-line: Measures BLOOD PRESSURE continuously on a monitor NEVER put medicine in an Aline. A-lines are placed in what artery? RADIAL Allens test- a check for alternative circulation. Apply pressure to clients ulnar and radial arteries at the same time, ask

client to open and close hand, hand should blanch, release the pressure from the ulnar artery while continuing to compress the radial artery and assess the color in the extremity distal to the pressure point- pinkness should return within 6 seconds (indicating the ulnar artery is sufficient to provide hand with adequate circulation if radial artery is occluded with Aline). This is considered a positive Allens test. You do have to be careful with an A-line because if you do not have the connections secure on your pressure tubing or if you do not have the stopcocks in the proper positions your client could bleed out. Check ALTERNATE circulation while in place. The 5-Ps: Pulselessness, Pallor, Pain, Paresthesia, Paralysis c. BNP: B-type natriuretic peptide: Secreted by ventricular tissues in the heart when ventricular volumes and pressures in the heart are increased Sensitive indicator Can be POSITIVE for HF when the CXR does not indicate a problem If the client is on Natrecor, turn it off 2HOURS prior to drawing a BNP. d. CXR: enlarged HEART, pulmonary infiltrates e. Echocardiogram f. New York Heart Association Functional Classification of Persons with HF: Classes 1-4 (Class 4 being worst) 4. Tx: a. Medications: 1) Digitalis (Lanoxin) Actions:

Used with atrial fibrillation and HF Contraction? Heart rate? ___________________ When the heart rate is slowed this gives the ventricles more time to fill with blood. Cardiac output will go DOWN. Kidney perfusion INCREASED. Nursing Considerations: Would diuresis be a good thing or bad thing for this client? GOOD THING We always want to DIURESE heart failure clientsthey cant handle the fluid. Digitalizing dose-loading dose .5-2 How do you know the Digoxin is working? Because the cardiac output Goes INCREASE S/S of toxicity? Early: Anorexia, nausea, and vomiting Late: Arrhythmias and VISION changes Before administering do what? CHECK APICAL PULSE Monitor electrolytes All electrolytes levels must remain normal, but K+ is the one that causes the most trouble. (HYPOKALEMIA + DIGOXIN = TOXICITY_) Normal Dig level= ____to____ ng/ml 2) Diuretics: WILL DECREASE PRELOAD Examples: Furosemide (Lasix), Hydrochlorothiazide (HCTZ), Bumetanide (Bumex), Hydrochlorothiazide/Triamterene (Dyazide) Action: Decrease PRELOAD Nursing Considerations: Aldactone may be given to decrease aldosterone levels. When do you give diuretics? MORNING

3) ACE inhibitor/ARBs and/or a Beta Blocker: (See next page for examples) These drugs will decrease the workload in the heart, prevent vasoconstriction (decreasing afterload) which will increase cardiac outputkeeping the blood moving forward out of the heart. b. Low Na Diet: Decrease PRELOAD. Watch salt substitutes. Salt substitutes can contain excessive POTASSIUM. Canned/processed foods & OTCs can contain a lot of SODIUM. c. Miscellaneous Information: Elevate head of bed. 10 blocks under the head of the bed Weigh daily (report gain of 2 to 3 lbs). Report S/S of recurring failure. *TESTING STRATGY* Fluid retention-think Heart Problems 1st. 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: decreases the secretions 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-laryngeal swelling, can be fatal

Fosinopril (Monopril) dry, nonproductive cough-reversible when drug Captopril (Capoten) 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: norepiso they will decrease afterload and If the drug ends inlol it is most likely a Beta contractility.as a result they decrease the BP and Blocker. HR. Dont give to asthmatics (some beta blockers also Examples: constrict the smooth muscle of the bronchioles)

Propranolol (Inderal) Dont give to diabetics (block the sympathetic Metoprolol (Lopressor/Toprol XL) responses seen in hypoglycemia). Atenolol (Tenormin) Carvedilol (Coreg) G. Pulmonary Edema: 1. Pathophysiology: Heart isnt pumping strong, so cardiac output goes down, and fluid backs up into the LUNGS. 2. S/S: Severe hypoxia When does this usually occur? NIGHT Sudden onset Breathless Restless/anxious Productive cough (pink frothy sputum) 3. Tx: a. Medications: 1) Furosemide (Lasix) Causes diuresis and vasodilation which traps more blood out in the arms and legs and reduces PRELOAD and AFTERLOAD 40 mg IV push over 1-2 minutes to prevent HYPERTENSION and ototoxicity 2) Bumetanide (Bumex) Can be given IV push or as continuous IV to provide rapid fluid INTAKE. 1-2 mg IV push given over 1-2 minutes 3) Nitroglycerin IV (Nitro-Bid IV) Vasodilation; DECREASED afterload Decreased afterload = increased CO because the heart is pumping against less pressure and more blood can be moved FORWARD. 4) Digoxin (Lanoxin) Used to get the blood moving in a FORWARD direction 5) Morphine (Morphine Sulfate)

2 mg IV push for vasodilation to decrease preload and afterload Hurst Review Services 85 6) Nesiritide (Natrecor) Infusion; short term therapy; not to be given more than 48 hours Vasodilates veins and arteries and has a diuretic effect 7) Milrinone (Primacor) Continuous infusion Vasodilates veins and arteries 8) Dobutamine (Dobutrex) Increases cardiac output b. Positioning: UP RIGHT position, legs down Improves BLOOD FLOW Promotes POOLING of blood in lower extremities c. Prevention: Prevention when possible: Check LUNG SOUNDS Avoid fluid volume EXCESS/OVERLOAD. H. Cardiac Tamponade: 1. Pathophysiology: BLOOD, fluid, or exudates have leaked into pericardial sac. This can happen if the client has had a motor vehicle collision, right ventricular biopsy, MI , pericarditis, or hemorrhage post CABG. 2. S/S: Decreased cardiac output CVP will be . BP will be dropping. Heart sounds will be muffled or distant. Neck veins dilated Pressures in all 4 chambers are the same Shock Paradoxical pulse (pulsus paradoxus) This is when the BP is greater than 10 mm Hg higher on expiration than on inspiration. Narrowed pulse pressure (from the baseline)

What is the pulse pressure? Its the difference between the SYSTOLIC and the DIASTOLIC. 3. Tx: Pericardiocentesis to remove FLUID from around the heart Surgery I. Arterial Disorders: 1. General Information: a. Pathophysiology: If you have atherosclerosis in one place you have it everywhere. It is a medical emergency if you have an acute arterial OCCLUSION (numb, pain, cold, no pulse). More symptomatic in LOWER extremities Intermittent claudicationhallmark PAIN ARTERIAL PROBLEMS Arterial blood isnt getting to the TISSUE coldness, numbness, decreased peripheral pulses, atrophy, bruit, skin/nail changes, and ulcerations. Rest pain means SEVERE obstruction. b. Tx: Since arterial blood is having problems getting to the tissue, if you elevated the extremity the pain would increase or decrease? Arterial disorders if the lower extremities are usually treated with either angioplasty, endarterectomy. 2. Types of Arterial Disorders: a. Buergers Disease: 1) S/S: Inflammation of ARTERIES and VEINS. Men Heavy smoking, cold, emotions Causes vasoconstriction of vessels Lower extremities/sometimes fingers. 2) Tx: Avoid cause. Stop smoking.

Avoid cold. Hydration THINS OUT BLOOD Bypass surgery Wear shoes that fit well; avoid any trauma to feet. Gangrene amputation

b. Raynauds Disease: 1) S/S: This occurs in the FEMALE client. Happens in fingers (bilaterally, usually in fingers tips) Turns white, blue, red Gets cold, upset, smokes Painful, can cause ulceration VASOCONSTRICTION 2) Tx: Avoid the cause. J. DVT (Deep Venous Thrombosis): 1. Pathophysiology: Blood stasis, vessel injury, blood coagulation. The blood can get to the tissue, it just cant get away. 2. S/S: Edema Tenderness Warmth HOMANS SIGN 3. Tx: Anticoagulant drugs: Heparin, Fibrinolytics, warfarin (Coumadin), clopidogrel (Plavix), Aspirin, enoxaparin (Lovenox), or dipyridamole (Persantine). These drugs either prevent aggregation or prevent the clot from getting bigger. Limit foods with Vitamin K /GREEN LEAFY VEGETABLES. Surgery Bed rest Elevate- to increase blood return; DECREASE pooling. TED hose- to INCREASE venous return; decrease pooling Used with SCDs many times With a known clot TEDs or SCDs may not be used

Warm, moist heat- DECREASE inflammation Never cold on a vein= excessive vasoconstriction Never hot on a vein= excessive vasodilation Prevention is the key! We AMBULATE and HYDRATE the client. Also for prevention we put on SCDs and get the client to do isometric exercises *TESTING STRATEGY* Never delay treatment. Normal Lab Values: (may vary with institutions): aPTT: 30-40 seconds. PT: 11.0-12.5 seconds INR: 1.3-2.0