MED SURG 2 EXAM 1 - Comprehensive review of Professor Martinez Medical Surgical Nursing II Exam PDF

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Comprehensive review of Professor Martinez Medical Surgical Nursing II Exam 1. Includes lecture, powerpoint, and textbook notes including photos/charts from textbook. Awesome review!...

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MED SURG 2 EXAM 1 Ch. 25 – ASSESSMENT OF CARDIOVASCULAR FUNCTION Conduction System  Automaticity = ability to initiate an electrical impulse  Excitability = ability to respond to an electrical impulse  Conductivity = ability to transmit an electrical impulse from one cell to another SA node à AV node à bundle of his à right bundle branch à left bundle branch à purkinje fibers *SA node is the primary pacemaker of the heart Depolarization: electrical activation of cell caused by influx of sodium into cell while potassium exits cell Repolarization: return of cell to resting state caused by re-entry of potassium into cell while sodium exits Refractory periods  Effective refractory period: phase in which cells are incapable of depolarizing  Relative refractory period: phase in which cells require stronger-than-normal stimulus to depolarize Cardiac Action Potential Phases (won’t ask but understand) Phase 0 = Na comes into the actual cell (RAPID depolarization, SODIUM IN) Phase 1 = early cell repolarization – K+ coming out of the cell (POTASSIUM OUT) Phase 2 = plateau phase (rate of repolarization slows); Ca+ ENTER CELL Phase 3 = complete repolarization (return of cell to resting state) Phase 4 = resting phase before the next depolarization Aorta has the highest pressure (biggest) high force…pressure in left ventricle + aorta highest pressure is higher pressure in the cardiac system ** Majority of MI occurs in left ventricle! CO = HR x SV Cardiac output = total amt. of blood ejected by one of the ventricles in L/min (in resting adult about 4-6 L/min) Stroke volume = amount of blood ejected from one of the ventricles per heartbeat (average = 60-130 mL) Changes in HR are due to inhibition or stimulation of the SA node by the parasympathetic and sympathetic divisions. PNS travels to SA node through vagus nerve à vagal stimulation = slows the HR

SNS increases HR by innervation of the beta-1 receptors located within SA node (occurs through an increase in circulation catecholamines (secreted by the adrenal gland) and by excess thyroid hormone, which produces a catecholamine-like effect HR also affected by CNS and baroreceptor activity (sensitive to changes in BP) à when BP is high – baroreceptors stimulate PNS activity, lowering HR. When BP is low à they stimulate SNS activity, raising HR. SV is determined by preload, afterload, and contractility. Preload = how much blood is within the ventricle before you pump it out (at the end of diastole right before systole occurs) Afterload = the resistance of ejection of blood from the ventricle Contractility = the force generated by the contracting myocardium Women usually develop CAD 10 years later than men b/c they benefit from female hormone estrogen and its cardioprotective effects 1. Increase in HDL (transports cholesterol out of arteries 2. Reduction in LDL (deposits cholesterol in the artery) 3. Dilation of the blood vessels (enhances blood flow to the heart) *post-menopausal women = higher risk of CAD b/c estrogen levels slowly disappear COMMON SYMPTOMS of CVD  Chest pain  Dyspnea  Peripheral edema, weight gain, abdominal distention  Palpitations  Fatigue  Dizziness, syncope, changes in level of consciousness Chest pain – identify quantity (0-10), location, and quality. Radiation of pain? Associated S/S like sweating or nausea; duration? Assess for other cardiac conditions; assess for other significant conditions  Pneumonia, pulmonary embolism  Hiatal hernia, GERD  Costochondritis  Vascular “Costochondritis – inflammation process in the cartilage (pain can be so severe that they think they’re having a heart attack); TX would be rest… would still do an EKG” ASSESSMENT:  Medications – aspirin = common OTC med that improves outcomes in CAD pts  Nutrition – nut. risk factors = hyperlipidemia, HTN, diabetes  Height + weight  BMI ** (assessment for obesity)  Lab results – glucose, glycosylated Hb (diabetes), cholesterol, HDL, LDL, triglyceride levels

 Diet & eating habits (commercially prepared foods, high-sodium, etc)  Elimination – nocturia = common in pts with HF **  Screen for bloody urine or stools in pts taking platelet-inhibiting meds (ex. aspirin, Plavix; platelet aggregation inhibitors, or anticoagulants (ex. heparin, warfarin (Coumadin), Lovenox, etc.  Activity, exercise – activity-induced angina or SOB may indicate CAD  Sleep, rest:  orthopnea (need to sit upright or stand to avoid feeling SOB) often occurs in pts with worsening HF  paroxysmal nocturnal dyspnea – sudden awakening with SOB = another symptom of worsening HF  Self-perception/concept – quit smoking (to reduce risk of future CV probs)  Roles, relationships – assess the pts support system (esp. bc many invasive cardiac procedures like cardiac catheterization and percutaneous coronary intervention (PCI) are being performed as outpatient procedures!  Sexuality, reproduction – impotence may develop in men as a side effect of cardiac meds (ex. beta blockers) – may cause some men to stop taking it!  Coping, stress tolerance  high levels of anxiety are assoc. with increased incidence of CAD  pts with CAD and HF should be assessed for depression (pts with score of 3 or higher should be referred for further eval.)  social readjustment rating scale – widely used tool to measure life stress  pts with a score less than 150 = slight risk for future illness  score of 150-299 = moderate risk PHYSICAL ASSESSMENT (Any deviations from the normal?)  Heart as a pump à reduced pulse pressure, displaced PMI from 5th ICS midclavicular line, gallop sounds, murmurs  Atrial/ventricular filling volumes à JVD, peripheral edema, ascites, crackles, postural BP changes  Cardiac output à reduced pulse pressure, hypotension, tachycardia, reduced urine output, lethargy, disorientation  Compensatory mechanisms à peripheral vasoconstriction, tachycardia “Best diagnostic tool – echocardiogram (DX choice to pick up a regurgitation or stenosis)” CARDIAC-SPECIFIC  General appearance – changes to LOC, BMI > 30  Assessment of skin/extremities  S/S of acute obstruction of arterial blood flow in extremities = “6 P’s”= Pain, pallor, pulselessness, paresthesia, poikilothermia (coldness), paralysis  Should be assessed during the first few hours after invasive cardiac procedures like cardiac catheterization, PCI, or cardiac electrophysiology testing  Hematoma  Edema (peripheral edema = feet, ankles, or legs à common in HF or PVDs like DVT or chronic venous insufficiency) or pitting edema  Prolonged capillary refill

 Clubbing of fingers and toes  Hair loss, brittle nails, dry scaly skin  BP

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 Pulse pressure = systolic – diastolic!  normally 30-40  decreased pulse pressure reflects reduced SV and ejection velocity (shock, HF, hypovolemia, mitral regurgitation) or obstruction to bloow flow during systole (mitral or aortic stenosis)  pulse pressure < 30 = serious reduction in CO!!  Postural blood pressure changes à postural/ orthostatic hypotension in pts with CVD most often due to sig. reduction in preload, which compromises CO. TAKE BP LAYING, SITTING, STANDING! Arterial pulses  Pulse rate  Pulse rhythm  Pulse amplitude – absent, diminished, normal, bounding  If pulse is absent or hard to palpate = doppler Jugular venous distention à right-sided heart failure, fluid overload Heart inspection/palpation Heart auscultation  Normal heart sounds = S1, S2 (AV closure, semilunar closure)  Abnormal heart sounds = S3, S4 Assessment of lungs à  hemoptysis à pink/frothy = pulmonary edema  cough, crackles, wheezes Assessment of abdomen à distention = ascites, hepatojugular reflex = positive test confirms DX of HF, bladder distention = urine output is an important indication of cardiac fxn

*right sided heart failure = ASCITES, HEPATOJUGULAR REFLEX, DISTENTION “MR. ASS” (systolic) & “MS. ARD” (diastolic)  (ACRONYM) Mitral regurgitation and atrial stenosis = systolic murmurs Mitral stenosis and aortic regurgitation = diastolic murmurs (not good sign*) LAB EVALUATION DX of MI is made by evaluating the HX & physical exam, 12-lead ECG, + labs that measure cardiac biomarkers. Cardiac biomarkers  Creatinine Kinase (CK)  Creatinine Kinase Isoenzymes (CK-MB)  Proteins  Myoglobin  Troponin T and Troponin I  “troponin most specific to cardiac” Lab Tests  Lipid profile – cholesterol, triglycerides, lipoproteins (LDLs and HDLs)  Normal cholesterol = less than 200 mg/dL (elevated cholesterol = higher risk CAD)

 Normal LDL level = less than 160 mg/dL  LDL = BAD  LDL transports cholesterol + triglycerides into the cell & deposits these substances in the arterial walls  TX plan based on TARGETTING LDL!  Normal HDL  men = 35-70; women = 35-85  HDL = GOOD ** want higher  HDL transports cholesterol away from the tissue and cells of the artery wall to the liver for excretion  Brain (b-type) natriuretic peptide (BNP) = neuro-hormone that helps regulate BP and fluid volume  BNP level increases as ventricle walls expand from pressure increase – makes helpful for DX, monitoring, and prognostic tool in the setting of HF.  BNP level > 100 suggests HF  BNP more specific to CHF **  C-reactive protein (CRP) = protein produced by liver in response to systemic inflammation  Homocysteine = an amino acid linked to development of atherosclerosis  Elevated level = high risk CAD, stroke, PVD  12-hour fast needed before taking blood for this **  Blood chemistries p.676 * know normal values  BUN  Coagulation studies  PTT = used to assess the effects of heparin  PT = used to monitor the level of anticoagulation with warfarin (Coumadin)  INR therapeutic range = 2-3.5 warfarin (Coumadin)  Hematologic studies  CBC  WBC  Hgb  Hematocrit  Platelets DX EVALUATION ELECTROCARDIOOGRAPHY (EKG)  Electrical activity of the heart (12 leads, looks at 12 different views)  Used to DX: o Dysrhythmias o Conduction abnormalities o Chamber enlargement o Myocardial ischemia, infarction, injury o Electrolyte disturbances (high or low Ca+ and K+ levels) 

CONTINUOUS EKG MONITORING o Standard of care for pts @ high risk for dysrhythmias

o Monitors more than one lead at a time o Monitors for ST segment changes  myocardial ischemia = ST-segment depression  myocardial infarction = ST-SEGMENT ELEVATION ** o Provides visual and audible alarms o Interprets and stores alarms o Trends data over time o Prints copy of rhythms o Telemetry = type of continuous EKG on general nursing care units o Inform pts on continuous EKG monitoring  DOES NOT detect SOB, chest pain, or other ACS symptoms. Teach them to report new or worsening symptoms immediately! CARDIAC STRESS TESTING o Normally: cardiac arteries dilate to four times their usual diameter in response to increased metabolic demands for oxygen and nutrients  Atherosclerotic vessels dilate less  ischemia  Abnormalities are likely to be detected during times of increased demand (stress) o Cardiac stress test procedures are noninvasive ways to evaluate response to stress o Stress test determines the following 1. Presence of CAD 2. Cause of chest pain 3. Functional capacity of the heart after an MI or surgery 4. Effectiveness of antianginal or antiarrhythmic medications 5. Occurrence of dysrhythmias 6. Specific goals for physical fitness program o CONTRAINDICATIONS  Contraindications  Severe aortic stenosis  Acute myocarditis or pericarditis  Severe HTN  Suspected left main disease  Heart failure  Unstable angina o COMPLICATIONS  Complications  AMI  Cardiac arrest  Heart failure  Unstable angina o ACLS training required

o EXERCISE STRESS TESTING

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Walks on a treadmill, bike, arm crank Exercise intensity increases Patient monitoring (EKG, VS) Target HR achieved=>? Ischemia

o PHARMACOLOGIC STRESS TESTING  Physical disability/deconditioned  Persantine and Adenocard IV  Mimic effects of stress  Dobutamine if no tolerance to exercise

NURSING INTERVENTIONS      

NPO x 4 hours Avoid stimulants (caffeine, tobacco) Meds with sips of water May instruct to hold beta blocking agents, theophylline, aminophylline before test Appropriate attire Sensations with medications

CARDIAC EVALUATIONS  Transthoracic echocardiography  Transesophageal echocardiography  Noninvasive  Ejection fraction  Size, shape and motion of cardiac structures  Pericardial effusions  Determines chamber size  Etiology of heart murmurs  Function of heart valves  Ventricular wall motion  Consent must be obtained for the T echocardiograph  Check gag reflex before you feed them after any procedure  45 degrees post the T echocardio when feeding  Myocardial perfusion imaging  Computerized tomography  MRI  PET scan  PET scan evaluates a myocardial perfusion very well  MRI useful in DX in any type of aortic stenosis – visualizes heart muscles, aorta, and pericardium as well; no radiation  Pacemaker – must make sure that it is MRI compatible as well CARDIAC CATHETERIZATION **  Invasive diagnostic procedure  Radiopaque arterial and venous catheters advanced into right and left heart  Guided by fluoroscopy  Gold standard for diagnosis=  CAD

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Coronary artery patency Determines extent of atherosclerosis Determines whether revascularization may be necessary Pulmonary artery HTN Valvular hear disease

Right sided catheter precedes the left sided (usually gonnad o the right side before the left side) Left side goes to the femoral artery to check to aortic arch and the branches that come off of the aortic arch Angiography = opaque type of material is also an injection of a radio contract can also be used in conjunction with the cardiac catheterization to observe the anatomy more clearly and determine any atherosclerosis that may be present *make sure patient doesn’t have allergy to IODINE  CARDIAC CATH COMPLICATIONS  Anaphylaxis (iodine)  Contrast induced nephropathy[CIN] (increase of baseline creatinine by 25% within 2 days of procedure)  Bleeding  Manual pressure  FemoSTop  QuickSeal/AngioSeal  Sutures Always check the BUN when you do the CBC Manual pressure on the actual site where the patient has had the catheter Assess the PULSES DISTALLY (both sides but main concern is side where the catheter was put in…) *monitor patient’s hemodynamic stability – why? Complications include thrombus, perforation, rupture, infection, lots of dysrhythmias (stimulation of the atrial areas) CHECK BUN+ CREATININE PT, PTT à must check before sending this pt off ASK ALLERGIES TO IODINE - minor allergy to iodine doesn’t mean the procedure won’t happen…ask them what happens? Maybe give Benadryl before and the procedure can still be done NURSING INTERVENTIONS  Fast 8-12 hours prior  Transportation home  Explanation of procedure  Observe catheter access site for bleeding/hematoma  Neurovascular assessment of extremity  Screening for dysrhythmias  Bedrest for 2-6 hours, positioning  Monitor cardiovascular status/chest pain/VS  Monitor for CIN Nephrotoxicity as a result of your contrast – concern Compression at the arterial site where they had the catheterization

Check for bleeding Check the pulses at least q15 min for hour? Monitor for recurrence of chest pain! Hemodynamic Monitoring Central Venous Pressure (CVP)  Measures filling pressure in right atrium/ventricle at end of diastole (PRELOAD)  Hypervolemia  Hypovolemia  Normal CVP = 2-6 mm Hg ** CVP is important in the measuring of the RIGHT ATRIUM and right ventricular filing – things like hypovolemia, CHF, etc will affect your CVP

Pulmonary Artery Pressure Monitoring  Assess left ventricular function  Diagnose ethology of shock  Evaluate response to therapy  Administer medications  Place pacemaker  Measures cardiac chamber pressures Phlebostatic level = reference point for the atrium when the patient is in a supine position – helps with measuring of the BP most accurately Role as RN = learn how to set it up correctly The stop cock is always positioned (like a valve) at the left atrium – same as any type of pulmonary artery catheter – In the mid axillary line in the 4th intercostal space – the purpose is to establish the zero point initially to correlate it to atmospheric pressure at first….the main thing to always look for as with any type of invasive equipment = possibility of pneumothorax, air emboli, S/S of infection Pulmonary Artery Catheter (PAC) = sterile procedure Intra-arterial BP Monitoring  Obtains direct and continuous BP measurement in critically ill patients with severe hypertension or hypotension  Obtain arterial blood gas specimen  Radial artery Arterial line can also be used to obtain ABG Mainly ICU

HYPERTENSION

Essential HTN = BP must be greater than 140/90 on 2 separate occasions in order to DX 1st line TX of HTN = thiazide diuretics Usually ACE inhibitors? Depending on what were trying to regulate (if someone has kidney issues you would use these instead to spare kidneys) Primary HTN = “essential HTN”; high BP unidentified cause; 90% of cases Secondary HTN = identifiable cause for HTN (renal disease, hyperaldosteronism, medications (prednisone), pregnancy, 10% of cases BP = CO x peripheral resistance * CO = HR x SV HTN results in… ↑ CO and ↑ peripheral resistance (constriction of blood vessels)

PATHO:  Genetic= 40 single gene mutations identified  Increased sympathetic nervous system activity related to dysfunction of the ANS  Increased renal reabsorption of sodium, chloride and water  Increased activity of RAA system: expansion of extracellular fluid volume and ↑SVR  ↓ vasodilation of the arterioles related to dysfunction of the endothelium  Resistance to insulin action  Activation of immune system contributing to renal inflammation Clinical Manifestations: ► May reveal no abnormalities other than elevated BP ► Retinal changes/hemorrhages

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Papilledema (swelling of optic disc) Specific s/s may indicate vascular damage CAD, angina, AMI LVH Heart failure ↑Creatinine, BUN (nocturia) CVA/TIA

Optic disc is more thickened (eyes) Microaneurysms in the eyes (little red spots in eyes) –looking at the pt eyes important when it comes to BP Cotton wool spots AV knicking BP Diabetes Assessment & DX Findings: ► Health history ► HPI ► Physical examination  Retinal examination ► Laboratory  Urinalysis  Blood chemistry  Lipid profile  12-lead EKG  Echocardiography ► Risk factor assessment as per Joint National Committee of Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 7  Classifies HTN  Guides treatment Looking for proteinuria (common can also happen with pregnant women) BUN creatinine clearance Lipid profile – targeting LDL (to see if the pt needs to go on a statin or not) – want it higher than 50 or 6 … Don’t have to fast to obtain a cholesterol but do have to fast to obtain accurate LDL level 12 lead EKG Ejection fraction concern with echo Valvular disease Murmurs are what echos are really used for JNC 7 guidelines = emphasizes the control mostly of systolic BP – determines the TX a patient recieves based on the AGE and the pts comorbidity JNC 7 helps classify HTN (stage 1, 2, or 3) and based on which stage then there’s a diff medication that the pt will be started on! Understand this

JNC Medical Management: ► Achieve and maintain arterial BP at 140/90 mm Hg or lower  130/80 mm Hg for people with DM or CKD Pharmacologic Management: ► Uncomplicated HTN  Diuretics, beta blockers or both à “beta blockers are NOT the first-line” ► Promote adherence  Prescribe simplest treatment schedule  Ideally one pill/day ► Diuretics  Thiazide diuretics  Loop diuretics  Potassium-sparing diuretics  Aldosterone receptor blockers ► Central Alpha-2 Agonists  Reserpine  Methyldopa  Clonidine ► Beta blockers  Atenolol  Metoprolol  Propranolol – also used for someone with migraines (and BP) ► Vasodilators  Hydralazine  Nitroglycerin  Minoxidil

► ACE Inhibitors – concerned w/ hypokalemia and they develop cough down the line  Captopril  Enalapril  Lisinopril ► Angiotensin II Receptor Blockers (ARB)  Losartan  Vals...