Nursing 405 EXAM 1 REVIEW Cardiovascular Assessment History, Inspection, Palpation, Auscultation -Type A personalities, Previous history of MI,

I, CAD, HTN, hyperlipidemia, COPD, ETOH, respiratory ds, OHS/CABG, stents, diets high in Na and fat, cocaine/amphetamine use. -Look at lists of home meds: Are they taking what they are actually prescribed to? -Make inferences: Lopressor, ASA, Nitro, Cardizem..they have probably previously had a cardiac event! -Watch for sudden cessation of certain meds which can cause rebound SE CHEST PAIN: -Ischemic heart, most frequent symptom of patients with CAD -Can also indicate aortic stenosis, cardiomyopathy, anemia -TRIGGERS: The 4 Es Exercise, Emotion, Eating, Environment -Myocardial Ischemia causes: anxiousness, substernal pain, may radiate to arms/neck/jaw, N/V?, -Pain may be relieved by MONA(Morphine, O2, Nitro, ASA). If pain is relieved? Highly suggestive of CAD -Pts on Viagra/Cialis cannot have nitrates! Potent vasodilation, BP will bottom out -N/V? When SA node is blocked, pacemaker is lost, inferior MIpt will brady down, hypotensive. -Levines sign when patient is grabbing their chest in pain -CP NOT affected by: Movement, Positioning, Breathing (stand on their head, still hurts, MI for sure) -Non-classic signs of MI diabetics: neuropathy, elderly: confusion, syncope, SOB, GI sxs, patients recovering from anesthesia, cardiac transplant pts: no innervations to new heart? No pain, will show other sxs. Women over the age of 60 lose NATURAL hormones which prevent MI, HRT doesnt work, SOB, fatigue, flu-like sxs NON-CHEST PAIN OPTIONS OF MI: -If you tell pt to hold their breath and the pain goes away, it is PULMONARY -SHORTNESS OF BREATH, leads to overexertion, LVHF, SOB at rest, MI -COUGH early symptoms of LVHF, nocturnal orthopnea (3-4 pillows, sleep sitting up) -Pink & Frothypulmonary edema, broken capillaries AFTER 30 MINUTES, THE ISCHEMIC HEART UNDERGOES PERMANENT IRREVERSIBLE, IRREPARABLE DAMAGE!! KNOW THIS: Ischemia (decreased blood flow and O2) acidosis decreased contractility LVHF -LVHF: Pt. will manifest with SOB, Increased RR, S3 heart sounds, Crackles (S3-temporary, S4-permanent) -Fatigue: Decreased CO = Decreased O2 to tissues -Fluid Retention: weight gain with no increase in intake. 1 kilogram = 2.2 lbs = 1 liter of fluid -BE ABLE TO DISTINGUISH: - RVHF: Ascites(fluid in abdomen), JVD, hepatomegaly, increased CVP -LVHF: crackles, moist/productive cough, S3, increased PCWP (pulm cap wedge pressures) -Dizziness, syncope, decreased cerebral blood flow = decreased LOC -Palpitations: heart feels like its fluttering, associated with tachydysrhythmias. These people have resting HRs in the 100s normally (caffeine, amphetamines, nicotine, stress, bronchodilators), tachy ventricular dysrhythmias are more lethal than tachy atrial dysrhythmias. -Fever, sweats, chills: may not have fever until a few days post-MI. Diaphoresis w/ AMI and severe aortic regurg -GI complaints: more when supine, watch certain foods, take GI meds for reflux like protonix, nexxium, pepcid, N/V especially with inferior wall MI, anorexia/N/V can be sxs of digoxin toxicity as well -Changes in weight: CHF fluid retention, dig toxicity, cardiac cachexia (no energy to eat, digest food) -Normal EF: 60-70% Morbid Obesity (5 feet tall and wide), Obstructive Sleep Apnea, Vascular Problems (extremity pain, numbness) KNOW DIFFERENCE BETWEEN ARTERIAL vs VENOUS DISEASE: -Arterial: Intermittent claudication ischemic pain with activity, subsides with REST and lowering extremity. Pain at rest associated w/ SEVERE arterial ischemia/gangrene? MUST get blockage fixed or else loss of extremity -Venous: aching, cramping, heaviness, subsides with activity and elevation of extremity, assess for edema, swelling and tenderness almost EXCLUSIVELY associated with DVT. -Inspect skin for cyanosis, pale (anemia), jaundice (RVHF, hepatomegaly & blocked ducts), clubbing, diaphoresis -Arterial vascular ischemia: occurs mostly with atherosclerosis, skin is hairless, thin, ulcerations, pulses, pain. -OR.sudden onset as with EMBOLUS. Look for 6 Ps, A-fib patients MUST be anti-coagulated!! JUGULAR VENOUS DISTENTION: Should not be greater than 3cm above the sterna border at a 30 degree angle.

-Below sternal border =5cm, add measure of 8cm (ex), actual JVD est. is 13cm = CVP reading, fluid volume status -Hepatojugular reflex: pushing on liver causes distention of jugular veins Indication of RVHF -Kussmaulss sign: Increase in JVD with deep inspiration. -Seen with RVHF, RV MI, or constrictive pericarditis PALPATION: peripheral pulses and temperature, cap refill, PMI (pt.max impulse) diffuse and shifts L or R with HF/hypertrophy, thrills in renal pts(bruits w/ renal & carotid arterial stenosis), hepatosplenomegaly, H-J reflex AUSCULTATION: Know APETM! Ape to man (aortic, pulmonic, erbs point, tricuspid, mitral) -Stenosis: old and creaky when it should be open -Regurg/Prolapse: open valve when it is supposed to be closed. -S1 closure of TV & MV, heard best at the apex with the bell, NORMAL. -S2 closure of PV & AV, heard best at the base with the diaphragm, NORMAL. -S3 CHF, heard best at the apex with the bell, ABNORMAL, temporary. (occurs in failure d/t rapid ventricular filling into a heart full of too much blood, early diastole) -S4 HTN or MI, heard best at the apex with the bell, ABNORMAL, permanent. (non-compliant ventricle (doesnt want to stretch), myopathy, if atria contract to push blood and ventricle is noncompliant we hear S4, late diastole) Cardiac Cycle: Rapid A-to-V filling (75%), Atria contract atrial kick (25%), MV and TV close (S1 heart sound), DURING DIASTOLE is when the heart gets its blood supply!! (AHANormal resting BP is 120/80) **Know your patients baselines!!!!!!!!!!!!!!!!!!!!! -Ventricles eject blood into pulmonary and systemic vasculature this is when we get O2! (body) -SYSTOLE occurs between S1 and S2 -Diastole occurs between S2 and S3 -An S3 would occur AFTER S2..An S4 sound would occur before S1 MURMURS: -Document them! Where do you hear it best? When in the cardiac cycle, systole or diastole? -What is the valve SUPPOSED to be doing at that time? -STENOSIS valves dont want to open. If the valve is supposed to be open and you hear a murmur? stenosis -REGURGANT valves dont want to stay closed. If its supposed to stay closed and you hear a murmur? it is a regurgant/incompetent/insufficient valve. Also referred to as prolapse - SEE pg. 22 in NOTES FOR MITRAL STENOSIS AND GRADING HEART MURMURS!!!!!!!!!!!!!!!!!!! -With grading heart murmurs, we probably will not hear anything graded 1-3. RUBS: -Inflammation of the pericardium -Have the patient hold their breath, if the rub disappears, then it is pleural friction. -If the sound remains, it is a pericardial rubYou MUST determine whether it is pleural or pericardial! ******-Rub increases when pt sits upright and leans forward with inspiration (these pts wont be comfy lying down) BLOOD PRESSURE: -Take in both arms in cardiac patients, then use arm with higher BP, may have PICCs or shunts.figure it out. -Always confirm a low BP before treating, and compare with a manual. -BP is the fastest, non-invasive, objective way to measure and assess cardiac output. -Check for pulse paradoxus (cardiac tamponade). - No real of very low diastole = ARV (aortic valve regurg) or AI. -With decreased CO, blood is shunted from GI and Renal so UOP is decreased. -If theyre hard to get, go slow with irregular HRs, elevate arm, inflate, lower arm, deflate. BRUITS: -Occur d/t turbulent blood flow through a vessel, associated with atherosclerosis -Carotids: risk for CVA, stroke -Abdomen: possible AAA (abdominal aortic aneurism) lack of integrity in wall of aorta related to high pressures -Renal: renal artery stenosis associated with ARF

LUNG SOUNDS: -Crackles which originate in both lung BASES are associated with LVHF. Higher the crackles, worse the CHF. -How far up they go POSTERIORLY reflects the degree of failure. -Should be closely monitored in patients getting blood transfusions, IVF, albumin (listen to prevent CHF) CORONARY BLOOD FLOW: -Coronary arteries lie just above the aortic valve, gets blood supply in diastole. -ANYTHING THAT SHORTENS DIASTOLE = DECREASED BLOOD FLOW TO THE HEART. -Such as conditions which increase HR: shock, hypovolemia, anemia, fever, fear/anxiety LAYERS OF THE HEART: KNOW THESE!!!! -Endocardium contains the electrical conduction system of the heart -Myocardium muscle which does the mechanical pumping -Epicardium Outer layer -Pericardium sac that surrounds the heart -Cardiac Muscle: contracts as a single unit (atria vs. ventricles).supposed to be at least.. -Simultaneous contraction due to depolarizing at the same time (if not? This is when we see arrhythmias) -Automaticity: ability of pacemaker cells to spontaneously cause a contraction without stimulation from nerves.

BEGINNING OF EKGs. STARTING WITH THE CONDUCTION SYSTEM ON PG. 25 THROUGH PG. 76 MAIN BULLETS TO ABSOLUTELY REMEMBER!!!!!!!!!!!!!!!!!! 1. SA node(60-100) fails, then AV node(40-60), then Ventricular(20-40) 2. If were going to have PVCs, we want monomorphic rather than polybeats originate from same foci. 3. Q waves >.04 (one small square) are pathologic Q waves indicative of MI, stay on EKG forever. 4. Isoelectric line stop and go signs between the waves 5. ST segment changes determine infarction (elevations-tombstones, acute MI. and depressions-ischemia) 6. T wave is the most vulnerable period in the cardiac cycle heart is getting ready to start over, repolarization 7. A PVC that hits on a T wave can turn into V-tach and V-Fib!! Tall, peaked T waves = hyperkalemia = DANGER! 8. Rare U-waves are associated with electrolytes, usually K+ 9. STEPS TO READING STRIPS!! Learn these for easy interpretation a. What are the atrial and ventricular rates? (should be the sameP=QRS) b. Is the rhythm regular or irregular c. Are the P waves rounded and upright in lead II and all look the same? d. Is there one and only one P wave for every QRS? e. Are all the complexes and intervals within normal limits? (P = .12-.20) (QRS < .10) (QT = .36-.44) f. Are the PR intervals and ST segments isoelectric? 10. If you see something funny, GO LOOK AT YOUR PATIENT!!!!!!!! Symptomatic or no? Symptomatic = BP (IVF & vasopressors), ALOC (not perfusing their heads), CP/SOB (O2 & pulse ox), UOP per hour (foley, q1-2hr I&O), Cold/clammy skin (shock mechanism, theyre shunting to core) 11. For sinus bradycardia look at the pts meds. Are they getting too much of a good thing and causing brady? 12. Sinus Tachycardia treat the cause! Fear, anxiety, anemia, shock, hypovolemia, CHF, MI, hypoxia, exercise 13. A RESTING TACHYCARDIA IS ALWAYS ABNORMAL 14. Cardiac electrolytes we want to watch are K+, Ca+, and Mag 15. With Atrial Flutter No P married to a QRS.these pts. will either convert back or go into A-Fib 16. REMEMBER THE A-Cs!!!!!! a. Atrial Arrhythmias Cardizem! b. A-Fib Coumadin/anti-coagulate! (Heparin, drips while we wait for Coumadin levels) 17. With A-Fib patients you HAVE to do apicals not radial pulses, too irregular 18. With tachys, we cannot see the problem!! SLOW DOWN THEIR HR so we can see what is happening 19. Inverted or absent P waves = JUNCTIONAL 20. Sinus/Junctional = Beta Blockers, Atrial arrhythmias = cardizem SKIM cardioversion, defibrillation pg. 65-76

INDEPENDENT STUDY IVF, CVC, TPN IVF & CVC complications: (Note: always hold pressure when d/c CVCs) 1. Infiltration tissue sloughing, necrosis, edema, nerve compression, disfigurement, loss of function, compartment syndrome. LOOK FOR: swelling, temp chg, pain, blisters, etc. --Most often caused by VESICANTS: KCl, Sodium Bicarb, Phenergan, Calcium, Mag Sulfate, Dilantin, Chemo drugs, ABX, vasopressors (Epi, dopamine, norepi), D10, Ativan, IV contrast dye --If your pt is getting a vesicant: check IV site q 1 hr, is it drip or IVP?, GET A CENTRAL LINE, consider PICCs 2. Phlebitis inflammation of vein wall & precursor to sepsis. LOOK FOR: tenderness followed by change in color --Caused by poor vein condition, too small, high osmolarity or acidic solution, fast rates, etc. --Prevention: close observation, change site q 96hrs, choose vein wisely (location, size, resilient, no start pain), change catheters started by EMT, use sterile technique, encourage pt to report any discomfort! TREATMENT OF LINE SEPSIS get new line, d/c old one, blood cultures from different sites X 2 3. Air Emboli occurs when catheter/CVC is d/cd, 10-15ml in adults is harmful. LOOK FOR: c/o CP, sudden BP drop, confusion/lightheaded, anxiety, unresponsive r/t in CO, cardiac arrest, washing machine murmur** -- Tx is LEFT SIDE, HEAD DOWN, place in Trendelenburg, O2 4. Thrombosis clots forming in the catheter tip. LOOK FOR: unable to obtain blood return, administer fluids, loss of waveform. REPORT to MD, mark as occluded. (Some hospitals will allow small doses of thrombolytic agents) TPN Complications: 1. Hyperglycemia frequent accuchecks, wean off TPN, monitor for rebound hypoglycemia when weaning, d/c *****IF TPN GOES BAD: Hang Dextrose 10% (to give them sugar) and call pharmacy. Insulin in TPN feedings can cause hypoglycemia 2. Line Sepsis Monitor site, change tubing per hospital protocol, strict asepsis 3. TPN and Fever Inspect site and notify MD, KNOW INSERTION DATE, if you d/c the old line, be sure to ask if MD wants the tip cultured, do blood cultures, abx TPN: --LIMITED fluids can hang with TPN, only lipids, insulin, some electrolytes. NO OTHER MEDS CAN INFUSE W/ TPN!! Cannot stop TPN suddenly, DO NOT stop temporarily to run other solution. Get other line or port to infuse other meds. FOR TESTING PURPOSES: From the independent study section, just remember: 1. If you think youre pt will code, ESTABLISH AN IV! 2. WATCH VESICANTS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 3. If you can give a PO med, do it! (example: K+ is a vesicant IV and is MUCH better absorbed in the GI tract) 4. Watch air emboli Left side, Head down! 5. Separate line for TPN.BAD BAD BAD nursing practice to stop TPN, run other meds, flush, restart TPN NO!!!! HEART BLOCKS: Run through notes pg. 1-35. Key Points to remember: 1. First Degree HB PR interval is prolonged longer than .20 but not longer than .40 2. Second Degree HB Not all P waves are married to a QRS.. With a drop (no QRS) we have no CO a. Type 1 (Wenckebach or Mobitz Type I) PROLONG, PROLONG, DROP b. Type 2 (Mobitz Type II) 1. Conducted, conducted, drop (less common) 2. Conducted, non-conducted, conducted, non-conducted (2:1) every other beat no CO 3. Third Degree HB SA impulses blocked b4 reaching ventricles, NOT married, atria & ventricles pace on own 4. Always be prepared for heart blocks to worsen. Monitor AMI pts closely. 5. Excessive prolongation of PR interval in First Degree can result in a loss of atrial kick 6. DANGER with 3rd degree HB is the lower in the heart the pacemaker, the slower the HR 7. 3rd degree HB Ps and QRSs are completely independent of each other, Ps go thru WHENEVER they need to 8. Treatment of CHB sick or not sick? Youre going to pace them. Sick? atropine & transcutaneous PM 9. PVCs are Wide, bizarre, and ugly! Polymorphic PVCs when they are fired from different cells 10. Always check for pulse of pts with V-Tach! CO is not good, pt will be symptomatic 11. Lidocaine suppresses the heart, in a code you want to be able to bring them back use ATROPINE instead

12. V-Fib is NO PUMPING OR CO.CODE! (V-Fib, Defib!) 13. Treatment of prolonged QT syndrome Mag is a vasodilator and can BP (slow the rate) 14. More fine the V-fib (vs. coarse) the less chance you have of reviving the pt. 15. ALWAYS treat your K+ with asystole..IF ASYSTOLE? Confirm pulselessness and verify in 2 leads 16. Consider 6 Hs and 6 Ts pg. 34 & 35. CODE BLUE SECTION: JUST KNOW FOR THE TEST 1. Little monitor on the ET tube that tells us we have color change when its in the right place 2. Mark and document where tube is at lip line (usually 20-25cm) 3. When ET tube is secure we listen for breath sounds in 5 places and watch for BILATERAL CHEST EXPANSION 4. CT to confirm placement 5. Use NG tubes when necessary (also orogastric tubes) 6. Document: 1. Size of the tube 2. Where it is at the lip line 3. Breath sounds (5) last in abdomen 4. Date inserted 7. CHEST TUBES: use occlusive dressings, OK to remove when MINIMAL DRAINAGE in CDU (<50-75ml/shift) 8. Atropine, Lidocaine, and Epi can be shot down ET Tube!(readily absorbed) As long as placement is confirmed BLOOD PRODUCT ADMINISTRATION: Colloids blood products Crystalloids fluids, maintenance IV, etc. Determine proper IV solution to infuse? Treat the cause. Most body fluids are inside the cells 0.9% NaCl Isotonic, fluid stays IN THE VASCULATURE. ONLY solution that runs with blood products Watch for overload and CHF especially in the elderly by monitoring for crackles in lungs. Hypertonic solutions are used rarely but to treat cerebral edema, IICP (3-7% NaCl) will draw fluids out of the cell Dextrose D5W is only isotonic in the bag! Provides free water, used for dehydration, No electrolytes Fluid Resuscitation colloids We run these in as fast as possible, REALLY pulls fluid into the periphery from the vasculature..WATCH FOR CHF. Examples: serum albumin (5% solution), 25% Salt Poor Albumin (SPA), Voluven, & Hespan (these are all volume-expanders) BLOOD: Blood facts: not always needed, costly not always reimbursed by medicare, rate of nosocomial infections The very old and the very young are most at risk for post-op bleeding. Autologous units are your own blood transfusing into you. Allogenic units come from another person. Save Blood!! Minimally invasive surgeries, use pts own blood in OR, use Procrit/Epogen to stimulation erythropoietin Informed consent: RN CANNOT OBTAIN THIS!!!! We can verify, double check, explain, but MD HAS TO OBTAIN IT Prepare patient: hx, BIG IV, transfusion in the past, reactions, if so premedicate with TYLENOL & BENADRYL. If previous reaction was severe enough, the pt will also get steroids. Watch those with CHF, HD, renal insufficiency ****Unless a patient is ACTIVELY hemorrhaging, they should not get more than 2 units of PRBCs in 24 hrs. Orders for blood: always specify a REASON for admin, 2 units PRBCs for hgb <8.0, 2 units FFP for PT of 17.5 KNOW THE DIFFERENCE BETWEEN TYPE & SCREEN AND A TYPE & CROSS Type & Screen Just taking one small sample to determine what pts blood type is. Type & Cross Blood type plus setting up several units in the lab in prep for surgery, etc. ADMINISTRATION: 2 RNs, be sure you have an order, must have BLOOD tubing, use only 0.9%, keep ahead of it when pts are actively bleeding blood bank will replace the units you take. TYPE AND CROSS IS GOOD FOR 72 HOURS! Vitals are immediately before, at 15 mins, and immediately after blood goes thru. Must use blood tubing and can use Pall filters/Orange filters (2nd filter for finer matter) Good for 3 units rather than 2 1. Whole Blood(450-500) RBC replacement, Plasma for volume replacement. Contains RBCs, plasma, plasma proteins, may contain WBCs that rxn risks, use leukocyte reduction filter (leukemia, aplastic anemia, transplant pts.) 2. Packed RBCs (350ml) restores RBCs, Hgb. Each unit should bring Hgb up 1 and Hct up 3-4%. **CPD is chemical in blood products that binds to calcium to keep blood from clotting. Once blood is given, the body breaks down CPD but it still binds to calcium. Pts who get 5-6+ units of blood, we have to replace calcium!

We also use blood/fluid warmers in pts with hypothermia, cold agglutins. Lasix Chasers when we need the blood but not so much volume. Blood cannot hang longer than 4 hrs, cant be returned to bank after 30 mins. We dont recheck H/H levels right away. Wait 1 hour if possible. 3. Platelets (240ml) prevents/resolves hemorrhage in pts with thrombocytes/platelets. Platelets suspended in plasma, pooled into units of 4. Each pool of 4 units should increase PLT by 50,000 4. Fresh Frozen Plasma (FFP) used in blood loss, clotting disorders (DIC, clotting factors, excessive anti-coag/too much Coumadin, liver failure). Has H2O, plasma proteins, essential clotting factors. Any factor __ deficiencies use it. Check PT, INR. Generally infused ASAP, must be before it expires in 6 hrs, volume 200-250ml 5. Cryoprecipitate (170cc=6 units) clotting factors suspended in 10-20ccs of plasma. Given if fibrinogen is low, fibrinogen = fibrin clots, helps with clotting disorders. Von Willebrand, Factor 8, Anti-Hemophilia. Admin in 4hrs Types of Blood Reactions: 1. Febrile non-hemolytic reaction most commonly seen, 90% of all rxns, results from donor leukocytes. Look for increased temps, ID this quickly! Treat using leukocyte reduction filters, watch anti-pyretics may mask more serious symptoms. 2. Bacterial contamination Look for fever, chills, hypotension, (seen once blood is done up to a few hrs later) Treat with IVF, broad-spectrum abx, BP support. **Carries high mortality rate*** 3. Acute Hemolytic ABO Incompatibility Look for fever, chills, nausea, dyspnea, hypotension, bronchospasm, vascular collapse. Treatment PREVENTION 4. Allergic reaction urticaria, itching, flushing all related to sensitivity to plasma proteins in the blood product. Treat with anti-histamines, epi, corticosteroids, BP support ***Prevention of blood reactions: vitals, stay with pt when running blood, advise pt of frequent complaints of back pain, chills, rash, itching, shock, h/a, nausea, dyspnea, bleeding, CP, cough, hematuria, BP changes, oozing @ IV site ***IF A BLOOD REACTION OCCURS: STOP the transfusion, get NEW tubing with 0.9NS, take blood and tubing back to lab, get vitals, CALL MD. Call blood bank ASAP, print transfusion complication report. Recheck all pt. ID bands. Get sterile NEW urine sample (looking for muscle breakdown, sluggish renal, rhabdo), obtain pink blood tube to see if pt developed antibodies to blood products given Labs Outcome PRBCs H/H Hgb up 1/ Hct up 3-4% PLT Platelets Up 50,000 FFP Coags (INR) INR level decreases Cryo Fibrinogen ??? Surgical interventions for cardiac disease: Medical vs surgical intervention depends on sxs , severity/number of narrowed vessels, EF, age, status of other organs 1. Intra-Aortic Balloon Pump (IABP): inflates during diastole and forces blood back into coronary vessels to oxygenate. Deflates during systole creating small vacuum making it easier for LV and Aortic valve to pump, workload 2. Mediastinotomy: Traditional OHS, for higher risk pts that are NOT candidates for less invasive procedures. Open the chest/pleural cavity pleural chest tube 3. Minimally invasive OHS approaches: a. Mid CABG small thoracotomy incision vs. sternotomy b. LIMA LAD (Left Internal Mammary Artery takes place of Left Anterior Descending c. Off pump/bypass machine only have a mediastinal tube d. Heart held in place for OR but continues to pump (Beating heart procedure) e. Partial upper sternotomy used with valvular surgeries 4. SVG (Saphenous Vein Graft) Endoscopically dissected from legs and used for CABG. Does not alter venous fx in leg 5. Internal Mammary Artery (IMA) Can be RIMA or LIMA, size is close to coronary artery, can react as normal artery bc it has nervous innervation, lasts longer than SVG. 6. Radial Artery Graft Do Allens Test, No better than SVG, virtually no sensorimotor loss, few restrictions 7. Valvuloplasty calcified valve leaftlets are cleaned off allowing better closure of valves Annuloplasty Valve opening is too wide. Reshape or tighten by sewing a ring around the opening 8. Maze Procedure indications: a-fib/flutter assoc with ASD despite drug therapy, must have a documented cerebral thromboembolism, can be done at the same time as MVR. Utilizes radiofrequency, microwave, laser, cryo-ablation

9. Mechanical Valves: St.Jude, carbomedics, bileaflet with polyester, carbon, or titanium. New valve in, old valve out. Lifelong anti-coags (body will see valve as foreign), acute hemodynamics (lifelong blood draws), NO PREGOS!!!!! Can be Bovine or Pig valves, also Hancock (may not require lifelong anti-coag, last longer than 10 yrs) Post-Operative Cardiovascular Problems: AMI, embolic event, HB/CHB, junctional rhythms, arrhythmias (a-fib/flutter, PVCs), BLEEDING (big problem in early post-op) ***Cardiac Tamponade: heart is compressed by blood in pericardial sac, prevents effective pumping. Treatment: vigilance in CT patency, EMERGENCY situation, code blue, return to surgery, pericardial window. *** Abdominal Aortic Aneurism (AAA): Risk-HTN, Cholesterol, smoking, obesity, white men, family hx. Larger the size of the aneurism, the greater the chance of rupture. Directly to OR if >5.5cm or for rapid in size. Rupture is EMERGENCY! Pts. will have pulsating/mass in abdomen, sudden SEVERE pain, hypotension,tachy,clammy, tachypnea, UOP Open Surgical repair: aorta and iliacs, ICU 5+ days, NPO, NGT (Endovascular procedure w/stent is less invasive, high risk pts, no ICU time, reinforces aortic wall via metal spring blood thru spring, aneurism shrinks) Post-Op Priorities: Strict BP control (110-130), BB, vasodilators, HOB <45deg. X2 days, peripheral pulses! Complications: arterial emboli/stroke, Acute Renal Failure, Hypovolemia, bloody stool should NEVER happen Hormonal Changes in Kidney with surgery: Vasopressin/ADH release (fluid retention, oliguria) Aldosterone Na+ retention (oliguria, water retention) Renin level (HTN) Catecholarmine release (HTN, glycogenolysis renal threshold for glucose 180, hyperglycemia osmotic dieresis Coagulation changes with surgery: Dilution of coagulation factors PLT dont adhere well when pt is cold Heparin bleeding (HITS watch PLT count post op) Hypothermia (vasocontrictive) changes Anesthetic agents affect hypothalamus in brain Cardioplegia open hearts/abdomens, cold OR, HTN history KEEP THESE PEOPLE WARM! Post op-Care: Neuro: Baseline pre-op, no reflexes, thrombotic emboli, liver/renal dysfunction, judicial use of pain meds! Respiratory: rate, depth, breath sounds, ease of breathing, chest symmetry, pulse ox, O2 Chest Tubes: work from PT to CDU, check dressing/crepitus, tape connectns, bubbling/suction, drainage Cardio: temp, hypothermia, blankets, shivering, HR rhythm/regularity, peripheral pulses, cap refill, graft sites GI: abdomen symmetry, bowel sounds, NGT, raglan/H2 blockers/Nexium GU: Renal (pre-op BUN/Creat), dieresis, hyperglycemia, UOP, dry, bleeding How can you tell if a pt. is bleeding? LABS: H/H Males: HGB: 13.5-17.5 HCT: 41-53 Females: HGB: 12.0-16.0 HCT: 36-46 Platelets: 142-424K ProTime: 9.0-11.5 PTT: 24.7-34.9 INR: 2.0

DISEASES OF THE CARDIOVASCULAR SYSTEM:: 1. Acute Coronary Syndrome (ACS) Causes: HTN, AV valvular diseases, ATHEROSCLEROSIS, anemia, thyroid issues, shock, CHF, vessel spasm/inflammation Risk factors: family hx, males, hyperlipidemia, HTN, Type A personality, obesity, sedentary, smoking, diabetes, gout IF PT COMPLAINS OF CHEST PAIN: Dont leave them! Get them into bed and place 2-4L O2 Ischemic CP: usually begins with exertion, emotion, sudden onset. Relieved by rest and Nitro.

Nitro SL (0.4mg, repeat q5mins, up to 3 times) Nitro IV (start at 5 mcg.usually 50mg/250ml of solution) Nitro paste (start with to 1 inch topically on chest or back so it is readily absorbedwear gloves!) Chest Pain: HR & BP, pulse alternans, cold/clammy skin, anxiety, Levines sign (Ensure its not pulmonary!) If cardiac or you are unsure: get a stat EKG, O2, assess pain, VS, start nitro, monitor BP after each nitro Leads III and V3 are best for monitoring ischemia 2. Myocardial Infarction: death of myocardial tissue due to a lack of O2 supply r/t plaque/inflammation. Permanent, irreparable, irreversible damage. Dead tissue will scar over, areas of damage will almost always clot off. Collateral circulation: vessels form around blockage to join vessels on the other side so circulation can continue MI process may continue for hours time = muscle balloon angioplasty will open up artery wall, stents to reinforce Classification of MI: extent of muscle involved, location of infarct, EKG changes Extent of muscle involvement: ---Transmural: involves entire myocardium, normal LV function is 60-70% and after BAMI it is 10-15%. Affects pumping, arrhythmias d/t ischemia, EKG changes ---Subendocardial: inner lining, affects conduction pathways, arrhythmias permanent, deteriorate rapidly, bradyhypertensive, need transcutaneous pacemaker but only a few hrs. Transvenous pacing temporary to get pt to the pacer lab FOR THE TEST: Just know that a Q wave is indicative of transmural MI and it is PERMANENT, pathological Sometimes they will get Right sided EKGs to see if R ventricle is involved in massive MI Precordial V1-V6 chest leads area anterior Changes seen in MI: T wave inversion (ischemia), ST elevation (injury), Pathologic Q waves (infarction, permanent) CM of chest pain: 10-15% are SILENT (non-classic sxs, flu-like, diabetic neuropathies, other comorbidities, etc.) Pain lasts > 30 minutes, is not relieved by rest or Nitro, severe, sudden, crushing, bursting Others: N/V, vagal stimulation (IWMI), SOB, rales, orthopnea (LVHF), anxiety, restlessness, confusion, diaphoresis, dysrhythmias (O2 to the heart, disrupted conduction pathways, lactic acidosis), weakness/fatigue (circ), -- RESTING TACHYCARDIAS (>24 hrs associated with high mortality rates in AMI, we dont want this!) --HYPOXIA = acidosis! Acidosis can cause dysrhythmias. --Two most common causes of dysrhythmias = hypoxia (ischemia) and electrolyte imbalance (check K, Ca, Mag) --S3 (CHF), S4 (Non-compliant LV), systolic murmur @ apex = acute MVR, laterally displaced/diffuse PMI = LVHF 3. Right Ventricular Heart Failure: JVD, edema, CVP, clear lungs, PMI sterna displaced & diffuse. Diagnosis: hx, CM, EKG changes (Q, ST, T), Troponin (rises 3 mins, elevated up to 7 days), CPK-MB (rises 6 mins, elevated 4 days), Other tests: BNP (indicative of HF, >100 is diagnostic), r/o CHF, CRP, WBC, ESR, Cortisol (r/o inflammatory process, will have pericarditis following MI). Cardiac cath, Echo (see valves & ventricles), CXR **Cardiac Catherization is THE definitive test to confirm dx and see exact % of blockage in coronary artery disease Critical to determine diagnosis STAT! Within 10 mins of ER arrival, we need EKG & labs. Suspect anyone with CP is MI* GOALS of treatment: Restore the Balance!! Increase O2 supply and Decrease O2 demand. ASA, IV, EKG mon, Nitro IV or drip, morphine, MONA, we ONLY give ASA for anti-platelet -Thrombolytic Therapy: (tPA) will lyse thrombi by converting plasminogen to plasmin within 30 mins of administration. Must be given within 3 hrs of onset of CP, can help prevent re-infarction, we know artery has opened up again when we see reperfusion dysrhythmias (we want these!! = heart muscle has blood and O2 again) tPA- follow up with Heparin drip USE PTT LEVELS! Blood thinner, so use 3 IV/draw sites, no IM/lab sticks/auto BPs, use anti-ulcer meds. Follow therapeutic levels for Heparin drips PTT (60-80), Coumadin INR (2-3) Interventions: bedrest, (HOB elevated to preload), Cardiac diet/NPO, stool softener, sedation, BB (work of heart), CCB (if unable to take BB), ACEI (AWMI or LVHF to afterload) -Nitroglycerin: vasodilates preload, afterload. Coronary arteriole dilation of non-stenotic vessels will collateral circ, give up to 3 tabs at 5 min intervals, start gtts @ 10mcg/min, monitor BPs!!!!! Get Tylenol order(vascular h/as) **Educate pt: Nitro expires @ 6 months, keep in dark, cool place, MUST burn/fizz under tongue, must LIE DOWN when you take it and NOT with Viagra/Cialis!

-Beta Blockers: -lols HR, BP, contractility thus O2 demand. O2 supply b/c HR is down. Contraindicated in CHF, monitor HR and BP closely, DO NOT STOP SUDDENLY, must wean or else rebound tachy and HTN which can cause MI, report dizziness/fatigue/SOB to MD -Calcium Channel Blockers: Cardizem DOC -- HR and contractility thus O2 demand and work of the heart. O2 supply because HR is down. Monitor HR and BP closely. DOC is ALWAYS Cardizem -ACE Inhibitors: -prils DECREASED AFTERLOAD by interfering with rennin-angiotensin causing vasodilation. Vasodilation workload of heart O2 demands. Monitor BP! -Anti-thrombics: ASA (used for anti-platelet only), Persantine, Plavix.Consider anti-ulcer meds with these! Take as directed and tarry stools will not be normal for a few days even after bleed is fixed. Report bleeding to MD -Medical Interventions: anti-arrhythmic meds, Revascularization (CABG), Dilation of stenotic vessel (PTCA) Nursing Interventions: Promote comfort, ONLY acceptable level of pain for myocardial ischemia is ZERO! Pace activities, avoid temp extremes, decrease anxiety (explain procedures, etc.), NO bearing down, no isometric exercises, stay hydrated for soft stools, prevent N/V, STAFF pulls pt. up in bed to prevent strain Preventative measures: treat lyte imbalances/resting tachys, thrombophlebitis (anti-coagulate, SCDs, ROM exercises while on bedrest), CHF (daily wt, I&O, lung sounds, monitor UOP), watch PTT with heparin. IV Therapy will almost ALWAYS be 0.9NS it treats hypovolemia. Maintain bowel elimination patterns!! Many pts arrest while pooping! Watch monitors for PVCs, V-tach, or bradycardia. Prevent (breathe with mouth or talk) Monitor Vitals temp, HR (apicals for irreg), BP (systolic 90-100 with good UOP? = We have good CO) Teach patient and family to take BPs and pulse. DIET! No questions asked, Na+ (normal intake is 2-4g per day!) Lose weight, control diabetes, no alcohol, and NO SEX! Resume only after able to climb 2 flights of stairs with no SOB/CP Complications of AMI: recurrent ischemia/infarction, arrhythmias, shock, CHF, aneurism, papillary wall rupture, pericarditis, tamponade, pulmonary embolus & CVA Aortic Aneurism: localized dilation of the aorta (normally diameter is <1.5) usually atherosclerosis but can also be caused by syphilis, infection/inflammation, dissection/trauma, Marfans RISKS: male, atherosclerosis, smoking Types: Thoracic (more rare, aortic regurg involves AV, tamponade if involves aortic root) Abdominal (more common, usually asymptomatic until rupture, may have bruits or masses, pulsations) Treatment: CONTROL BP! Stop smoking, serial ultrasound/Xrays, SURGICAL REPAIR if >5cm & good candidate IF IT RUPTURES: We will see severe, sudden, persistent abdominal or lower back pains which radiate groin, legs, butt. Abdominal rigidity and pulsation, anxiety, N/V, s/sxs of shock, loss/diminished peripheral pulses. ****CALL MD AND PREP FOR EMERGENCY SURGERY!*** Diagnosis: abdominal ultrasound, CT of abdomen, angiography of aorta ???Intro to hemodynamic monitoring: See pg. 29-31 (Only 5 concepts) 1. FOCUS on knowing normal values, understanding concepts of each, understand what it means when or 2. CVP (central venous pressure) = preload = ( Hypovolemia <4 Normal 4-8 Hypervolemia >8) 3. PAP (pulmonary artery pressure) tells pressure in lungs and indirectly about the LV (Normal 20-30/10-15) 4. PCWP (pulm capillary wedge pressure) reflects pressure in L side of heart (Normal 8-12 mmHg) 5. CO normally 4-8L/min 6. SVR (systemic vascular resistance) =diameter of blood vessels/afterload/what heart must overcome to pump Vasodilation <800 -- Normal 800-1200 -- Vasoconstriction >1200