PCC III Notes 091817 PDF

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PCC III Notes 091817 Care of the Patient with Cardiovascular Problems Learning outcomes Identify specific lab values that indicate myocardial injury or infarction.  Prioritize nursing care of a patient post cardiac catheterization.  Describe the preparation needed for a patient needing a stress test and a transesophageal echocardiogram.  Discuss the nursing management of the client with infective endocarditis and pericarditis. o (IE) Need to have abx treatment prior to any procedure o (IE) Check for flank pain from renal insufficiency from gunk in the heart valves o (P) Acute- inflammation o (P) Chronic- causes thickening of lining  Giving corticosteroids  Drain pericardial area  Chemo and radiation can help rid of excess scar tissue  Pericardectomy  Pericardialcentisis  PG. 700 o (P) Pericardial friction rub on auscultation o (P) Substernal pain on inspiration with relief when leaning forward o Pulseless paradoxes  Prioritize the nursing care of a patient with a dysrhythmia.  Know the drug actions, nursing interventions, and patient teaching that is needed when administering patients, the following medications: sotalol hydrochloride, amiodarone, diltiazem, and digoxin.  Describe signs and symptoms the patient may experience when having sinus tachycardia or sinus bradycardia.  Prioritize the nursing interventions for a patient experiencing ventricular fibrillation.  Delegate appropriately to the licensed practical nurse and/or unlicensed personnel. o (LPN) No IV meds o (LPN) No blood o (LPN) No plan of care o (UP) No med

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o (UP) No teaching o (UP) No assessing Describe discharge teaching for a patient who has a valve replacement. o S/S of infection o Avoid caffeine o Teach anticoag therapy for mechanical valve patients o Use electrical razors o Tell all doctors o Know their own tolerance

Introduction o CVD is the #1 killer and most expensive cause of death in the U.S. (CDC) o It is estimated that by 2030, 40.5% of Americans will have CVD (AHA, 2011) o Million Hearts Serum Markers of Myocardial Damage o Troponin: Troponin T and troponin I  Normal levels Troponin T- 100 bpm o Assess fatigue, SOB, weakness, decreased BP, restlessness o ECG o 100-150 bpm is often a compensatory response to an underlying cause PG 663  Care of patient with sinus bradycardia o Assess syncope, dizziness, weakness, confusion, SOB, chest pain o Is there a cause? Meds? o ECG o IV fluids o Atropine if necessary o If sustained you might have to look at possible need for pacemaker  Which dysrhythmia am I? – Atrial fibrillation o Associated with atrial fibrosis and loss of muscle mass

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o o Common in heart disease such as hypertension, heart failure, coronary artery disease o Cardiac output can decrease by as much as 20% to 30% o Apical pulse for ONE FULL MINUTE Pharmacologic Management o Before giving any check:  Apical pulse (must be 60 or above) (and for one minute)  BP (systolic should be 90 or above) o Diltiazem (Cardizem)  Calcium channel blocker  BP around q15min o Digoxin (lanoxin)  Can be given IV push  Hold if HR is < 60  Monitor for Dig toxicity  Anorexia  N/V  Diarrhea  Confusion  Headache  Visual disturbances o Sotalol hydrochloride Which dysrhythmia am I? - Ventricular Tachycardia o Check your patient before anything to ensure the reading in accurate

o Pharmacologic Management Which dysrhythmia am I? – Ventricular Fibrillation

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o o What are you going to do?  Call a code  Start CPR  BUT ultimately they need to be shocked to reset the rhythm o Nursing Priorities o Think about these prior to class so we can discuss Care of patient with valvular heart disease o Types of valvular heart disease depend on  Valve(s) affected  Type of functional alteration(s)  Stenosis  Regurgitation Stenosis vs Regurgitation o Stenosis Opened o Regurgitation Closed Case Study o A.L. is a 72-year-old man who comes to the ED complaining of dyspnea and dizziness. o He has a history of hypertension, myocardial infarction, pacemaker (foreign body), infective endocarditis (IE), and MRSA infection. o What factors in A.L.’s history put him at risk for valvular disease?  IE  Pacemaker Mitral Valve Stenosis o Majority of adult cases result from rheumatic heart disease.  Scarring of valve leaflets and chordae tendineae  Contractures develop with adhesions between commissures of the leaflets Mitral Valve Stenosis

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o Mitral Valve Stenosis

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o Clinical manifestations  Exertional dyspnea  As little as walking from car into house  Loud S1  Murmur  Fatigue  Palpitations  Hoarseness, hemoptysis  Chest pain, seizures/stroke Case Study o Physical examination of A.L. reveals a loud systolic murmur at the fifth ICS, left midclavicular line. o A chest x-ray shows fluid in his lungs Case Study o The health care provider suspects A.L. may have mitral regurgitation o Describe the pathophysiology of mitral regurgitation  Mitral Valve Regurgitation o Incomplete valve closure o Backward flow of blood o Acute MR  Pulmonary edema o Chronic MR  Left atrial enlargement, ventricular hypertrophy → decrease in CO Mitral Valve Regurgitation

o Mitral Valve Regurgitation o Chronic clinical manifestations  Asymptomatic for years until development of some degree of left ventricular failure  Weakness, fatigue, palpitations, progressive dyspnea  Peripheral edema, S3, murmur Mitral Valve Prolapse o Confirmed with echocardiography o Clinical manifestations  Most patients asymptomatic for life  Only 10% with symptoms  Murmur d/t regurgitation  Severe MR uncommon

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Mitral Valve Prolapse o Clinical manifestations  Dysrhythmias can cause palpitations, light-headedness, and dizziness.  Infective endocarditis  Chest pain unresponsive to nitrates o Treat symptoms with β-blockers o Valvular surgery for MR Mitral Valve Prolapse o Patient teaching important  Antibiotic prophylaxis if MR present  Take drugs as prescribed  Teach importance of ABX  If having palpitations- Rx would be Beta Blockers  Healthy diet; avoid caffeine  Avoid OTC stimulants  Exercise  When to call health care provider  When symptoms increase and get worse Valvular Heart Disease- Collaborative Care o Valve replacement  Mechanical (artificial)  Last longer  Risk of thromboembolism  Require long-term anticoagulation  Can hear a click with each opening on the valve o Biologic (tissue)  Bovine, porcine, and human  No anticoagulation required (because the pig and cow already mimic human tissue)  Less durable Case Study o A.L. successfully undergoes mitral valve replacement using a mechanical valve. o What teaching will you provide A.L. prior to discharge?  Case Study-Pericarditis or Infective Endocarditis o E.F. is a 72-year-old man who comes to the clinic with “flulike” symptoms. o He has a history of hypertension, past MRSA infection, and a recently implanted pacemaker. Case Study o E.F. has petechiae in the conjunctivae and splinter hemorrhages in his nail beds. o His blood pressure is 138/64, heart rate 80, respiratory rate 18, and temperature 99.5° F (37.5° C).

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o A heart murmur is noted. Case Study o E.F. is sent to the hospital for further workup and treatment. o What diagnostic studies would you expect the admitting health care provider to order for E.F.? Case Study o E.F.’s blood culture results are positive for Staphylococcus aureus o Echocardiogram demonstrates vegetations on his mitral valve. o What treatment would you expect the health care provider to order for E.F.?...