Elizabeth Spokoiny 101x Cardiac Case Study Jan 2 Cardiovascular A&P Assessment Nursing 101 Complete the sentence

e or answer the question. 1. The three layers of the heart are the endocardium, myocardium, and epicardium.

2. The electrical impulse of the heart is generated by the sinoatrial node. 3. The electrical activity of the heart is recorded on an ECG. 4. During the phase of systole the myocardium contracts. 5. During the phase of diastole the myocardium relaxes. 6. The amount of blood pumped by each ventricle in 1 minute is the cardiac output.
7. The volume of blood in the ventricles at the end of diastole, before the next contraction, is called preload. 7. The peripheral resistance against which the left ventricle pumps is called afterload.

8. The exchange of cellular nutrients and metabolic end products takes place in vessels called
capillaries.

9. The two main factors influencing blood pressure are cardiac output and systemic vascular
resistance.

10. The brachial artery is the recommended site for taking blood pressure.
12. When blood pressure is measured, the pressure in the cuff is lowered, and Korotkoff sounds are auscultated.

13. The term for the difference between the systolic blood pressure and diastolic blood pressure is
pulse pressure.

11. With increased age, the amount of collagen in the heart increases and the amount of elastin
decreases.

12. Orthostatic blood pressures are measured while the patient is lying down, sitting, and
standing.

16. The sound generated by turbulent blood flow through major arteries is termed a murmur. 17. The 1st heart sound, S1, is associated with the closure of the mitral and tricuspid valves. 18. The second heart sound, S2, is associated with closure of the aortic and pulmonic valves. 19. What part of stethoscope is used to auscultate the 1st and 2nd heart sounds? diaphragm 20. Regarding lipoproteins, an elevation in which one increases the risk of CAD? Which one is
associated with a decreased risk of CAD? Increases risk is high LDL, decreases risk is high HDL (if low increased risk), high LP a and LP PlA2 increases risk.

Case Study Acute Decompensate Heart Failure Mr. J 62 female with history of CHF, HTN. Smoking 2 packs for 40 years refused to quit. Complain of flu like symptoms for past 3 days. Had not taken HTN or heart failure meds or any meds for 4 days. She is admitted to the ED with acute SOB, pulmonary edema and dx w/ decompensated HF. Subjective Anxious, fatigue, SOB, unable to eat or drink. Objective data 5 ft 10 in wgt 210 lbs Vitals 99.6 /37.6, HR 118 irregular, RR 34, BP 90/58 CV distant S1 S3 present, PMI at 6th ICS, all peripheral pulses are 1+, JVD +, at fib HR132, Resp crackles, decrease BS RLL, coughing frothy blood tinged sputum, spo2 82% on room air. GI BS present, hepatomegaly 1. What are signs of right and left sided heart failure? Left sided HF: inadequate CO, pulmonary edema AEB frothy pink sputum (other pulm. congestion, cough, bibasilar crackles), inadequate tissue perfusion. Symptoms include: dyspnea, orthopnea, nocturnal dyspnea, fatigue, displaced apical pulse (hypertrophy), s3, altered mental status, symptoms of organ failure. Right sided HF: Results in systemic venous congestion, inadequate R output. Symptoms include: Jugular venous distention, ascending dependent edema (legs, ankles, sacrum), abd. Distention, ascites, fatigue, weakness, nausea, anorexia, nocturia, hepatomegaly and tenderness, weight gain. 2. What diagnostic procedures and findings would help to establish a diagnosis of decompensated HF with pulmonary edema? An elevated BNP over 100 pg/ml indicates heart failure, ABGs, serum electrolytes (Na+/K+, ) thyroid function tests, CBC, chest X Ray (enlaged heart/fluid in lungs), arterial catheter for BP, PAWP, echocardiogram, EF, ECG, cardiac enzymes. 3. What monitoring will be used to evaluate Mr. J condition? ECG ,SaO2, CI, pulmonary artery catheter for intrarterial BP, PAPs, , PAWP, CO. I/O measurements 4. What nursing interventions are appropriate for Mr. J at the time of admission? High Fowlers, O2 supplement, adminster prescribed diuretics, monitor BP, ECG, I/O and BS. 5. Drugs are started - what is rationale for administering of each of following a. IV furosemide mobilizes edematous fluid, reduce pulmonary venous pressure b. Milrinone (Primacor) increase myocardial contractility, promotes vasodilation leading to increased tissue perfusion, and diuresis c. Enalapril blocks RAAS (neurohormonal blocks aldosterone) less Na+ uptake, reduces fluid, also inhibits ventricular hypertrophy d. Metoprolol Blocks negative effects of SNS stimulation, reduces HR e. IV morphine reduces preload, afterload and relieves pain, dilates pulmonary and systemic blood vessels. Decreases O2 demands 6. Evidence based care for patient with HF are set forth in 4 core measures. Which two of these measures should be implemented by nurse? 1. give written discharge instructions or educational materials to patient or caregiver and include: activity level, discharge medications, follow-up appt. weight monitoring, and what to do if symptoms worsen. 4. Patients who are current smokers (at any time during year before admission) are given smoking cessation advice or counseling during hospital stay. 7. Based on assessment write 1 or more appropriate nursing dx for Mr. J. Are there any collaborative problems? ND #1: Decreased cardiac output related to myocardial injury secondary to cardiac failure AEB s3, JVD, HR 118/irregular, diminished pulses, low BP 90/58. ND #2: Impaired gas exchange related to increased preload and alveolar capillary membrane changes AEB SaO2 82%, decreases BS RLL, coughing frothy blood tinged sputum, tachypnea, tachycardia, SOB, pt. did not take any meds for past 4 days. Collaborative problems: Pt. is smoker, resistant to cessation, noncompliant with treatment 8. Other questions you would want to know. When did pt. last smoke? Would another attempt at a cessation program be beneficial at this time? Does pt. understand treatment regimen? Does pt. have resources to obtain medications? Does pt. have support system? Is this pt. a candidate for hospice referral?

CASE STUDY Cardiac Coronary Artery Disease Mrs. C a 47 yr old Navaho woman comes to clinic with burning sensation in her epigastric area extending into her sternum Subjective Data Has had chest pain with activity that is relieved with rest for past 3 months Has had type 2 DM since age 35 Smoked 1 pc day for 27 yr More than 30% over ideal body weight Has no regular exercise program Expresses frustration with physical problems Has no health insurance Objective Data Physical exam, anxious, clutching fits Appears overweight and withdrawn Diagnostic study Cholesterol 248 mg/dl LDL 160 mg/dl Glucose 210 mg/dl Collaborative Care ASA 80 mg PO Nitroglycerin 0.4 mg sublingual PRN or chest pain Exercise treadmill testing Questions 1. What are Mrs. C risk factors for CAD? Smoking, diabetes, obesity, sedentary lifestyle, high LDL 2. What nursing measure should be instituted for help decrease her risk factors? smoking cessation program, diabetes education, low income health care program referral (social wk), 3. what symptoms would lead you to suspect the pain may be angina? pain with activity, relieved by rest 4. What kind of ECG changes would indicate myocardial ischemia low ST segment, T wave inversion 5. What is the rationale for the use of ASA and NTG? ASA prevents platelet aggregation/thrombus, NTG reduced preload, afterload and is a vasodilator. 6. What information should the RN provide to Mrs. C before the treadmill testing? Wear comfortable clothes and shoes for walking, report any symptoms before or during test 7. Write one or more appropriate nursing diagnoses. Are there any collaborative problems? ND #1: Ineffective self health management related to lack of knowledge about disease process and risk reduction strategies for CAD AEB lack of regular exercise, obese, frustration with physical problems, lack of health care insurance leading to lack of regular care for health education, and continued smoker. ND #2: Anxiety related to lifestyle changes AEB clutching fits, withdrawn behavior, verbal frustration over condition and lack of physical health Collaborative problems: DM, high lipids, obesity, smoker./