Medical-Surgical Nursing of Adult III

Study Guide: Unit Exam Cardiac II-B

Videos on Reserve in Library:

CHF Video
MI Video

Congestive Heart Failure:

Terminology:

SV- the amount of blood ejected by the left ventricle during each contraction, affected by HR,
preload, afterload, contractility

CO: HR x SV, is the amnt of blood pumped from the left ventricle each min, Adult CO ranges
form 4-7L/min

Cardiac reserve: the ability of the heart to increase CO and BP to meet demands

Systole: contraction and emptying of the left and right atrium and ventricles.

Diastole: relaxation and filling of the atrium and ventricles. 2/3 of cardiac cycle

Preload: muscle stretch when ventricles are being filled/resting/diastole, before

contraction/systole. EX: sodium and water retention in blood stream increase preload

Afterload: /resistance the ventricles must overcome to eject blood.

Causes Ventricular hypertrophy (ventricles need to contract more with more force)
-hypertension, aortic valve stenosis, hypertrophic cardiomyopathy, intense athletic training

Normal compensatory efforts by the body (increased myocardial O2)

-sympathetic nervous system stimulation- increases catecholamines, causes increase in HR and BP from
vasoconstriction. SV improved by increasing venous return to heart
- rennin-angiotensin system (RAS) activation- result from decreased blood flood to the kidneys,
vasoconstriction, sodium and water retention, preload/ afterload increase. Leads to ventricular
remodeling.
- other chemical responses- immune response (pro-inflammatory cytokines released, ventricular
remodeling), Natriuretic Peptides (promote vasodilatation, dieresis thru sodium loss),
vasopressin/ADH (secreted by posterior pituitary gland when CO is decreased/cerebral perfusion,
causes vasoconstriction & fluid retention), Endothelin (secreted by stretches endothelial cells,
vasoconstrictor, increase peripheral resistance/ hypertension)
- myocardial hypertrophy- enlargement, with or out chamber enlargement, wall thicken to provide more
muscle mass/forceful contraction/CO

Causes for L CHF(congestive heart failure)

-hypertension, CAD, valvular disease (mitral/bicuspid or aortic valves), cardiomyopathy, substance abuse,
congenital defected, Dyrhythmias, Diabetes, smoking, obesity, severe lung disease, sleep apnea,
hyperkinetic hyperthyroidism.

S/S of L CHF
-indicated by decreased tissue perfusion from poor CO and pulmonary congestion from increased
pressure in the pulmonary vessels.
-acute or chronic, mild or severe
-weakness, dyspnea, orthopnea, fatigue with activity, heaviness in arms or legs
-chest discomfort, palpitations, skipped beats, fast HR, tachycardia, pallor, cool extremities
-irritating, nonproductive, nocturnal cough, paroxysmal nocturnal dyspnea
-frothy pink sputum- life threatening pulmonary edema
-acute confusion, oliguria, nocturia
-S3 first sign, early diastolic filling, LV pressure and S4 late sign failure, reflection of ventricular
compliance (gallop)


Causes for R CHF
-cause by LHF
-fluid is retained and backs up pressure into vein system,
-pulmonary problems (COPD, pulmonary hypertension, acute respiratory distress syndrome (ARDS)

S/S of R CHF
-weight gain, lower leg/hands/finger edema, nausea, anorexia, ascities, dieresis at rest.
-JVD, enlarged liver, distended ABD, polyuria, volume excess or failure BP

Paroxysmal nocturne dyspnea S/S

-awakes with breathlessness 2 to 5 hrs after falling asleep, relieved by sitting upright/walking

S/S of Cardiogenic shock (heart cannot pump enough blood to meet bodys needs, rare)
-tachypnea, SOB, Tachycardia, confusion, LOC/fainting, weak pulse, sweating, pale, cold extremities,
oliguria

Routine Labs/Dx for evaluation of CHF

-serum electrolytes Na/K/Mg/Ca/Cl, H&H, BNP, Urinalysis, Microalbuminuria, ABGs
-Chest X-ray, radioactive studies, ECG, Invasive hemodynamic monitoring

BNP- (Brain Natriuretic Peptide) produced and released by ventricles fluid overload.
Increases with age, greater concentration in Women, lower in Obese.

Invasive cardiac monitoring: Patient positioning for monitoring levels

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CVP normal pressure-central venous pressure- 2-6mm HG,
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PCWP normal pressure- pulmonary capillary wedge pressure- 5-15mmHG diastolic mean,
balloon tip is inflated and advanced and wedged in a branch of the pulmonary artery and capillary.
Senses pressures transmitted from the left atrium, which reflect the left ventricular end-diastolic
pressure,
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CO normal- 4-7l/min
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Complications of Central venous catheters- bleeding, hematoma, pneumothorax, hemothorax,
arterial pressure, dysrhythmias, venospasm, infection, air emboli, thromboembolism, brachial nerve
injury.

Treatments to reduce afterload and preload in CHF- AFTERLOAD(vasodilators, ACE inhibitors,

Natrecor, CPAP) and PRELOAD( diuretics, diet and fluid restriction)

Medications for TX of CHF

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Dobutamine, Dopamine, Milrinone (beta blockers)
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Digoxin
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Diuretics
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ACE inhibitors (pine drugs)
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Natrecor (newer Natriuretic peptide)

Key CHF nursing diagnosis and interventions to treat

-impaired gas exchange r/t ventilation/perfusion imbalance (improve gas exchange: ventilation)
-decreased CO r/t altered contractility, preload, afterload (improve CO Meds: ACEI, ARB, hBNP)
-fatigue and weakness r/t hypoxemia
-potential for pulmonary edema r/t L-sided HF
-fluid volume excess, activity intolerance, knowledge deficit: low NA+ Diet
Pulmonary edema:
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S/S: dyspnea, air hunger, SOB, crackles, cyanosis, cool and clammy, productive cough, pink,
frothy sputum, anxious, confusion, lethargic.

Lab/Dx: ABGs, RR with low CO2 early, later CO2 retention with Resp. Acidosis. Continous
monitor SPO2, serial chest X-ray, increase PCWP
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nursing interventions: impaired gas exchange: position, O2, non-rebreather @10-15L/min,
CPAP, intubation
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Medications: MS iv, diuretics, vasodilators, dopamine, Dobutamine.
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Valvular Heart Disease: Mitral Stenosis, Mitral Regurgitation, Mitral Valve Prolapse, Aortic Stenosis
and Aortic Regurgitation

Causes, Patho of heart failure, heart sounds,

Causes:
Mitral Stenosis usually results from rheumatic carditis (valve thickening by calcification/fibrosis)
d/t rheumatic fever. Valve leaflets fuse together and become stiff. Valve opening narrows
preventing normal blood flow from occurring. Increased pressure results in heart. Heart sound:
Rumbling, apical diastolic murmur.
Mitral Regurgitation (insufficiency): usually degenerative due to aging and infective endocarditis
resulting from calcification of valves. Mitral valve does not close completely during systole
(contraction)=backflow of blood into left atrium during contraction, during relaxation (diastole),
regurgitated output again flows from left atrium to left ventricle. Heart sound: High pitched
holosystolic murmur.
Mitral Valve Prolapse: (+) Family hx for conditions such as Marfan syndrome. Valve leaflets
enlarge and prolapsed into left atrium during contraction (systole). Usually asymptomatic. Heart
sound: systolic clicking.
Aortic Stenosis: Disease of wear and tear caused by congenital bicuspid or unicuspid aortic
valves. Most common in US. Aortic valve orifice narrows and obstructs left ventricular outflow
during systole (contraction.) Results in ventricular hypertrophy. Fixed cardiac output even
during times of exertion. Heart sounds: Harsh, systolic crescendo-decrescendo murmur.
Aortic Regurgitation: results from non-rheumatic conditions such as infective endocarditis,
congenital anatomic aortic valve abnormalities, Marfan syndrome, et hypertension. Aortic valve
leaflets do not close properly during diastole (relaxation) and the annulus (valve ring) is not
properly functioning. Result is back flow of blood from Aorta into left ventricle during diastole
(relaxation). Left ventricle hypertrophies to accommodate the extra backflow of blood volume
from aorta. Heart sounds: Blowing, decrescendo diastolic murmur.

Stenosis effects:
-Backflow of blood causes pulmonary congestion and right sided heart failure early in Mitral Stenosis,
and late in Aortic Stenosis. Both cause extensive ventricular hypertrophy d/t increased demands to pump
excessive amounts of back flowing blood from atria (mitral) or narrowed valves (aortic).

Regurgitation effects:
- Left atria and ventricles dilate and hypertrophy (in Mitral) to eject extra backflow of blood from
incomplete closing of mitral valve with next systole (contraction). Left ventricle dilates and
hypertrophies to accommodate the expanded blood volume backflow from aorta into left ventricle.

Lab/Dx evaluations: NOT FINDING A LOT ON LABS!

DX evaluations: Echocardiography: noninvasive procedure to visualize the structure and movement of
heart.
Transesophageal echocardiography (TEE) or Transthoracic echocardiography (TTE) performed to assess
valve problems.

Stress Echocardiography: evaluate symptomatic response and assess functional capacity.

Cardiac Catheterization: assess severity of Stenosis and effects on heart.
Chest x-ray- show enlarged heart areas or pulmonary congestion.
ECG- assess abnormalities

Treatment:
Medications: same tx as CHF, digoxin, diuretics, vasodilators, Antidysrhythmic, and
anticoagulants, antibiotics,
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surgical intervention: percutaneous balloon valvuloplasty, commissurotomy valvular repair,
annuloplasty valvular repair
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types of valve replacements: biologic or mechanical
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Endocarditis, Pericarditis, Rheumatic heart disease (Rheumatic carditis), Cardiomyopathy

Causes: PC(pericardial effusion collection of fluid, cardiac tamponade pulse paradoxus),

RHD/RC(ages 5-15 antibodies from Strep attack the endocardium), CM()

DX: PC(ECG, Echo, hemodynamic monitor, chest X-ray, CT scan, MRI), RHD/RC(WBC, ESR,
C-reaction protein, antistreptolysm), CM()

S/S: PC(pulse paradoxus), RHD/RC(fever, skin rash, chest discomfort, friction rub, HF, ECG
changes), CM()

Treatment: PC(ASA, APAP, MSAIDS, corticosteroids), RHD/RC(PCN, EES, ASA), CM()

Pericardiocentesis: needle removes fluid from pericardial sack.

CAD: includes chronic stable angina and acute coronary syndromes. Affects arteries that provide blood,
O2 and nutrients to myocardium.

Metabolic syndrome aka syndrome X. Is a risk factor for CV disease. D/T physical inactivity
and obesity. To reduce risks, manage HTN and prevent complications. See table 40-1 on page 834 for
indicators for risk factors for metabolic syndrome.

Medications for preventive and treatment of angina:

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Nitro, ASA, Morphine, Thrombolytics

Give morphine as priority in managing pain in pts having and MI!

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Angina
STEMI- ST elevation MI
NSTEMI- non-ST elevation MI
Unstable angina- chest pain for discomfort that occurs at rest or with exertion and causes severe
activity limitation. Pressure may last longer than 15 minutes or poorly relieved by rest or nitro.
Unstable angina describes new onset angina, variant (Prinzmetals) angina and pre-infarction angina.
Pts with unstable angina present with ST changes on a 12 lead ECG without changes in troponin or CK
levels.
New onset angina- pt. who has 1st angina sxs, usually after exertion or other increased demands
on the heart
Variant (Prinzmetals) angina- chest pain or discomfort resulting from coronary artery spasm
and typically occurs after rest
Pre-infarction angina- chest pain that occurs in the days or weeks before an MI
DX/Labs

ECG signs of MI- angina episodes reveal ST depression, T wave inversion or both.
Thallium Study- use radioisotope imaging to assess for ischemia or necrotic muscle tissue r/t
angina or MI. Areas of decreased or absent perfusion called cold spots identify ischemia or
infarction. Maybe used with exercise tolerance test. Dipyridamole (persantine) thallium scanning
(DTS) may also be used.
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Exercise Stress Test- after acute stages of MI this test on a treadmill maybe ordered to assess for
ECG changes consistent with ischemia, to evaluate medical therapy and to identify who might
benefit from invasive therapy. Can be used with pharmacologic agents such as dobutamine
(Dobutrex) instead of a treadmill. Treadmill exercise testing is only moderately accurate for women
compared to men. In women with suspected CAD, stress echo or single photon emission computed
tomography (SPECT) should be perfomed.
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ECHO- used to visualize structures of the heart.
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Coronary Angiography- computed tomography coronary angiography (CTCA) been helpful in
dx CAD in symptomatic pts. Noninvasive way to evaluate CAD.

PTCA- percutaneous transluminal coronary angioplasty with stent placement may be used to
reopen the clotted coronary artery. Provides excellent return of blood flow through coronary artery
when it can be performed by an interventional cardiologist within 2-3 hours of onset of sxs. When not
available pt should receive immediate thrombolytic agents if appropriate candidates and then be
transferred to facility that can perform PTCA. To maintain patency of coronary artery following PTCA
aspirin and IV heparin 3-5 days with aPTT is usually rx. Pg. 844 explains procedure in entirety.

Atherectomy-devices can either excise and retrieve plaque or emulsify it. Advantage is it
creates a less bulky vessel with better elastic recoil.

Stents- expandable mesh devices that are used to maintain the patent lumen created by
angioplasty or Atherectomy Bare metal or drug-eluting stents (DES) (drug coated) are rx for 12 months
after a stent has been placed. Figure 40-4 on pg. 845 shows a stent positioned in coronary artery

CABG- coronary artery bypass graft surgeries are most common type of cardiac surgery and
most common procedure for older adults. Occluded coronary arteries are bypassed with pts own
venous or arterial blood vessels or synthetic grafts. Internal mammary (IMA) is currently graft of choice
bc has 90% patency rate at 12 years after procedure. CABG is used when pts do not respond to medical
mgmt of CAD or when dx progression is evident.

Pre and Post nursing care- pg. 846-7 under preoperative and postoperative care

Cough, deep breathing, early amb, use sterile technique when changing sterna or donor-site
dressings, connect mediastinal tubes to water seal drainage systems, ground epicardial pacer wires by
connective to pacemaker generator, monitor pulmonary artery and arterial pressures, monitor HR and
rhythm on monitor, assess fluid and electrolyte balance, edema is common
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MI:

DX/Labs- troponin T and troponin I, CK-MB and myoglobin. All three rise quickly. CK-MB
most specific marker for MI but does not peak until 24 hours p onset of pain.
Differentiate pain and S/S of MI vs. Angina
Common dysrhythmias with MI
Cardiogenic shock and use of Intra-aortic balloon pump
Management and nursing care post MI
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Interventions to relieve chest pain
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Interventions to maintain cardiovascular stability

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Interventions to decrease cardiac workload

Interventions to prevent complications
Interventions to control risk factors