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71 Cards in this Set
- Front
- Back
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What is PTCA?
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Percutaneous Transluminal Coronary Angiography.
A balloon tipped catheter is advanced to an area (via an artery, aorta & then to the coronary artery) of the coronary artery that has stenosed, a balloon is inflated to compress the plaque against the inner lining of the artery to open the artery up. The balloon is then deflated & removed. |
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What does PTCA treat?
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Anginal pain & acute MI.
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How long can PTCA correction last?
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Depends on the persons willingness to comply to meds/diet/exercise. Often redevelopment will occur within 6-10 years.
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What is a Coronary Artery Stent?
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Same concept as with PTCA; however, the balloon is surrounded by a teflon mesh so that when the balloon is inflated it expands the mesh and the mesh lining stays in place. These patients are treatment with antiplatelet meds for 3-6 months. (Plavix/Aspirin/Clopidogrel)
This is a step up from just the PTCA. |
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What is an atherectomy?
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Like roto rooter w/ suction. Invasive, cutting/shaving/grinding of plaque with suction to remove the plaque.
Can be open or closed. |
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What is an arterectomy?
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A surgical removal of part of an artery, usually in the case of atherosclerosis.
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What S&S might you see with 90% blockage of the carotid artery?
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Confusion
Syncope Bruit over Carotid Artery (listen w/ bell) |
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List some of the associated complications r/t PTCA, Stent or Atherectomy/Arterectomy.
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*Dissection of the artery
*Perforation of the artery (worse) *Abrupt closure (balloon opens but plaque re-expands and closes off artery *Vasospasm of coronary artery - Manipulation can irritate & cause narrowing. Pt. may experience chest pain later. *Acute MI - Plaque breaks off & causes blockage *Acute Dysrhythmias - any manipulation of the heart can cause dysrhythmias - usually afib or tachy. Usually can take care of on the spot. *Cardiac Arrest - severe complication of invasive procedures. |
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What are the most important post-procedures for coronary cath?
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Lie flat for 6 h
Monitor distal pulses Remain in extended position |
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What are some indications for CABG
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Previous procedures unsuccessful
90% blockages Uncontrolled angina Left Anterior Descending Coronary Artery Blockage Multivessel Disease MI Prevention |
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Define stable angina
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Chest pain related to activity that is relieved by NTG or stopping activity
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Define unstable angina
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Chest pain that can occur at any time with or without activity & not necessary relieved by NTG.
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Which artery is the "Widow Maker"
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Left Anterior Descending Coronary Artery
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What vein is the most common vein to use with CABG? What needs to be done to the vein?
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Great Saphenous Vein
Turned around so the valves are allowing blood flow in the right direction. Others: Small Saphenous, Cephalic, Basilic, L&R Mammary. |
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What is the antidote for heparin?
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Protamine Sulfate
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How does the traditional coronary artery bypass graft work?
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The blood bypasses the heart & lungs by going through a machine which oxygenates & warms the blood, back to the aortic arch. The heart is stopped and is bloodless & motionless. Heparin is used to prevent clotting.
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How does off pump CABG work?
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Patient receives high dose beta blockers to slow heart to about 40 bpm. Myocardial stabilizers still the section of the heart being worked on. This is not bloodless & harder to work but less risks/trauma.
Less risk of blood clot formation, less destruction of cells (RBC), no bypass machine & assoc. risks. |
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What complications can occur with CABG? (Endoscopic, Traditional w/ Bypass Machine, Alternative Off Pump?
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Cardiac - Dysrhythmias, Heart Failure, MI
Pulmonary - Embolisms (esp. w/ bypass machine) Fluid Volume - Alterations, Destroyed RBC's w/ machine, monitored in R atrium w/ CVP Neurologic - thromboembolism or decreased C.O. Renal - decreased C.O. decreases renal perfusion or renal emboli causes blockage in renal arteries. |
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What pre-op assessments would be performed prior to CABG?
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H&P Exam - Is patient stable
Tests - MRI shows blockages, Chest X-Ray, CBC, Complete Metabolic Profile, Echo or TEE to look at valves, EKG. Psychosocial - support system, past compliance compliance, job, financial, home/homeless Teaching - diet changes, exercise, activity, what to do & when. D/C criteria is walk 1 mile on treadmill. |
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What intraoperative nursing management occurs w/ CABG?
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Cardiopulmonary - lung sounds, crackles, etc.
Explain Procedure - answer questions as needed Assist w/ surgery as needed Provide comfort & safety |
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What post-op nursing management occurs w/ CABG?
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Cardiovascular
* S&S of internal bleeding - BP drop, tachycardia, pale, diaphoretic, decreased LOC * PE - chest pain, SOA - listen to lungs bilaterally, should be clear if no PE * Dysrhythmias Home & Community based care * Lots of teaching * Compliance * When to call doc * Follow-up appts. |
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Most likely NANDA & Interventions w/ CABG?
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1 - Decreased cardiac output / Restore C.O.
2 - Impaired Gas Exchange / Promote adequate gas exchange 3 - Risk for F&E imbalance / Restore F&E balance |
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What are the most common indications for heart transplant?
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#1 - Cardiomyopathy
#2 - Ischemic Heart Disease #3 - Valvular Disease #4 - Rejection of previously transplanted heart #5 - Congenital heart disease |
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What indicates are required for potential candidates?
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Severe symptoms uncontrolled by medical therapy
No other surgical options Prognosis of < 2 years to live |
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What screenings must potential heart transplant candidates go through?
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Age is considered
Pulmonary status Other chronic health conditions - DM, uncontrolled hypertension, lymphomas, cancers, etc. |
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What is transplant psychosis?
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A social, emotional & psychological breakdown that occurs with heart transplants that causes the recipient to attempt suicide when compared to the general population rate.
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When a heart becomes available how is the recipient list determined?
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* ABO Blood Type
* Body Size - no peds for adults, no adults for pecs. M/W can work but if a man gets a woman's heart, their may be some lifestyle modifications. Won't climb mount everest or swim the english channel... * Geography from Donor/Recipient. Four hours from harvest to transplant window max. |
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What is the most common method of heart transplant? How does this work?
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Orthotopic
The recipient keeps his own aorta, pulmonary artery & superior & inferior vena cava and the new heart is sewn onto these great vessels. However, some surgeons also leave a portion of the atria with the vena cava & pulmonary veins in place & sew the new heart together there. |
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What is the biggest post-op concern in heart transplantation? What education needs to be provided?
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Balance the risk of infection with the risk of rejection because all of the anti-rejection meds suppress the immune system. It is a fine balance. Meds are cyclosporine, Imuran, CellCept, Prograf.
Education: Hand hygiene, avoiding sick people & infectious processes. No live vaccines. Diet low in fat & lipids (they are prone to CAD post transplant) |
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What med classes are common post heart transplant?
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Beta Blockers
Anti-Rejection Meds Statins (lower cholesterol r/t development of CAD) |
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What are some of the common complications post heart transplant?
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*Rejection/Infection - WBC drawn weekly for 6 mos. Monitor for rejection. C-Reactive Protein & ESR monitored closely.
*Atherosclerosis/CAD - patients will be on statin & anti-inflammatory meds. Regular heart scans. *Hyperplasia of coronary artery lining (intima) *Osteoporosis r/t anti-rejection meds - lose bone density. Risk fx, kyphosis, etc. *Skin Cancer r/t immunosuppression - teaching wearing hats, sunscreens, monitoring lesions/moles *Weight gain r/t chronic anti-inflammatory steroids - higher blood sugars, hyperlipidemia, cushings (moon face) |
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What is the #1 infectious organism related to endocarditis?
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Streptococcus - kids who had a lot of strep infections as kids are at greater risk of developing endocarditis.
Then...Staphylococcus, Enterococcus, Pneumococcus. |
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What are some risk factors r/t endocarditis?
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*Strep/Staph/Entero/Pneumo infections earlier in life
*Prosthetic Heart Valve or degenerative or calcified heart valves...any valvular disorder *Decreased immune response *IV Drug Users *Long term use of catheters or suprapubic catheters *Long term IV infusions *Pts on hemodialysis (end stage renal disease) *Any blood born pathogen |
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What happens physiologically in endocarditis?
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A microbial infection creates an endocardial lesion. This results in platelets, fibrin, blood cells & microorganisms that cluster as vegetations. These vegetations can become dislodged creating emboli. The first valve attacked usually is the mitral valve because it has the highest work load.
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Where would a mitral valve endocarditis emboli end up if it were to break lose?
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In the brain causing a stroke.
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What are the two most likely culprits if a mitral valve suddenly develops a murmur?
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Almost always pathologic indicating retro flow.
Incompetent mitral valve. Infective endocarditis. |
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What are the common manifestations r/t endocarditis?
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They occur insidious, slowly...
Murmur - new onset Fever - low grade Oslers nodes - PAINFUL nodules on pads of fingers/toes Janeway Lesions - PAINLESS macules on palms/soles that look like freckles Roth Spots - Spots on the fundus of the eye. Splinter Hemorrhages - on the toenails & fingernails Headache Petechia Malaise, Anorexia & Weight Loss Cough Joint/Back Pain + Blood Cultures x 2 Echo or TEE ESR & CRP + Rheumatoid Factor Leukocytosis Anemia |
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What is the definitive diagnosis for infective endocarditis?
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Two positive blood cultures for microorganism then is confirmed by an echo or TEE of the heart to look for changes of the mitral valve.
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What is the medical management of Infective Endocarditis?
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4-6 weeks of IV antibiotics to get rid of blood born pathogen.
C&S to get right antibiotic to kill bug If valve damaged - valvuloplasty (cleaning), or valve replacement |
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What is the key for patients who have had Infective Endocarditis?
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Prevention - Once you've had, you will always be at risk of developing again!!!
Prophylactic w/ any invasive procedure - Dentist cleaning - Cystoscopy - TURP - Bronchoscopy - Heart catheterization (not capillary procedures such as blood glucose levels) |
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What are the complications r/t infective endocarditis?
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Heart failure - r/t loss of compliance of mitral valve
Cerebral Vascular Complications - r/t emboli Valve stenosis/Regurgitation Hemodynamic Compromise r/t decreased C.O. |
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What is pericarditis?
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An inflammation of the lining of the pericardium leading to an inability of the heart to fill with blood & decreased C.O. This can occur due to fluid filling the pericardial sac, thickening or decreased elasticity of the pericardium, or the layers of the pericardium fusing together.
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What amount of fluid build up can cause significant problems r/t pericarditis?
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> 50 ml causes drop in C.O.
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What is the significant causative problem with pericarditis?
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The edema associated with inflammation.
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What S&S would you see with pericarditis?
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#1 - Chest pain increases on inspiration.
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What is the most common symptom & the most common sign? What are some other signs?
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Symptom - chest pain
Sign - Friction Rub (louder at end of exhalation - 4th intercostal space LSB) Others: Mild fever, increased WBC Count, Rapid/Labored Resp., Elevated CRP, severe HTN?, weak/thready pulse, nonproductive cough, muffled heart tones. Dyspnea |
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How do you tell the difference between a pericardial rub and a pleural rub?
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The pericardium surrounds the heart
The pleura surrounds the lungs They sound the same If you hear the rub when the patient holds their breath, then it has to be a pericardial rub. If you don't hear the rub when holding breath, then it is a pleural rub. |
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What diagnostic tests are run for Pericarditis?
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TEE/Echo - to look at the sac showing enlargement & fluid
CT or MRI - to find out more about what's happening |
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What medical management is given for Pericarditis?
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Analgesics or NSAIDs
Corticosteroids - decreases inflammatory process If emergency (cardiac tamponade/pericardial effusions) - then pericardiocentesis |
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What is pericardiocentesis?
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A large bore needle is pushed into the pericardial sac and the fluid is drained off. The doc will be pulling on the syringe to create negative pressure. When they hit resistance, they have hit the pericardium. Immediately going through the pericardium they will get return of fluid in to syringe. The patient will notice an immediate improvement.
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What procedure might be performed if pericarditis is persistent/chronic?
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Persistent: Pericardial Window - allows for continuous drainage into the chest cavity
Chronic: Pericardectomy - a large section of the pericardium is removed where the inflammation/scarring has occurred. |
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What nursing management goes with Pericarditis?
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Pain management - keep under control
Positioning - Tripod position Psychological Support - pt fearful, pending doom Education - what treatments may be needed Monitor for S&S and infection |
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What is pericardial effusion?
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An accumulation of fluid in the pericardial sac beyond 50 ml of fluid. As fluid increases it puts pressure on the heart (cardiac tamponade).
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What is cardiac tamponade?
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An excessive fluid buildup in the pericardial sac that compresses the heart & prevents it from expanding. The pressure outside the heart is greater than the pressure inside the heart, in all of the chambers, therefore decreased ability to fill (pressure on atria), decreased C.O. (ventricles can't expand). This is life threatening.
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What are the cardinal signs of Tamponade?
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Systolic BP falls
Diastolic BP raises Pulse pressure decreases (<30 mm Hg) JVD Distant/Muffled Heart Sounds Pulsus Paradoxis - change in Sys BP > 10 mm Hg higher during exhalation than during inhalation. Chest pain/pressure SOA Labile to low BP |
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If you have trouble hearing heart tones, what position should you place the patient to try again?
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Roll the patient on their left side, this allows the apex of the heart to fall closer to the chest wall.
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What diagnostic tests are run for Pericardial Effusion/Cardiac Tamponade?
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Chest X-Ray
Echo |
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What is the medical management for pericardial effusion or pericardial tamponade?
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Pericardiocentesis - drain fluid off pericardium
Pericardiotomy (pericardial window) If no treatment - cardiogenic shock |
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So what is the chain of events for untreated pericarditis?
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Pericarditis --> Pericardial Effusion --> Cardiac Tamponade --> Cardiogenic Shock
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What are the 3 systems "attacked" by Cardiogenic Shock?
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Cardiorenal
Cardiovascular Cardiopulmonary |
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What is the #1 cause of Cardiogenic Shock?
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MI
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What happens in the Cardiopulmonary attack of Cardiogenic Shock? What results?
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Myocardial Ischemia --> Decreased Contractility --> Decreased C.O. --> Increased Pulmonary Blood Volume --> Pulmonary Interstitial Edema --> Hypoxia --> Myocardial Ischemia
Once the Hypoxia occurs, the cells convert to anaerobic metabolism which produces lactic acid, this acid builds up and causes the patient to wind up in metabolic acidosis. |
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What occurs in the Cardiovascular attack of Cardiogenic Shock?
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Myocardial Ischemia --> Decreased Contractility --> Decreased C.O. --> Decreased BP --> Decreased Coronary Artery Perfusion --> Myocardial Ischemia
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What are the clinical manifestations of Cardiogenic Shock?
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Chest Pain
Cerebral Hypoxia - decreased LOC Decreased BP - Falls through the floor Rapid/Weak Pulse Cold/Clammy Skin Tachypnea Crackles Decreased Urine Output Dysrhythmias |
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What specific assessment & diagnostics go with Cardiogenic Shock?
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*Hemodynamic Monitoring (ICU)
*Increased PAWP *Decreased C.O. *Increased Systemic Vascular Resistance *Activation of RAAS *Increased Lactic Acid Levels *Organ Failure |
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What medical management occurs with Cardiogenic Shock?
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#1 - Correct underlying problem (Stent, CABG, etc...)
Reduce further demand on heart - vent/sedate to reduce workload of heart to virtually nothing Improve Oxygenation - O2, Bipap, Vent... Restore Tissue Perfusion - restore C.O. |
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What pharmacological management occurs with Cardiogenic Shock?
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Diuretics - reduce circulating blood volume
Vasodilators - Like alpha agonists Clonidine/Catapres Positive Inotropics - Digoxin - Increase contractility Vasopressors - Dopamine - increase B.P. |
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What do we do to treat the failure of the cardiovascular downward spiral in Cardiogenic Shock?
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Administer Vasopressors (Dopamine)
IABP |
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What do we do to treat the failure of the cardiopulmonary downward spiral in Cardiogenic Shock?
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Administer diuretics
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What is an Intra-Aortic Balloon Pump?
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A balloon tipped catheter that is introduced through the Femoral Artery and advanced to the Descending Thoracic Aorta. The timing of the inflation/deflation of the balloon is timed with the EKG. When the heart is relaxed (diastole), the balloon is inflated to create blood flow resistance through the aorta & force blood to the coronary arteries. Just before the heart contracts (systole), the balloon deflates to allow for easy passage of blood to the system.
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What assessment & diagnostics will occur with Cardiogenic Shock?
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EKG
Cardiac Enzymes Chest X-Ray CBC Complete Metabolic Profile Cath |
