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145 Cards in this Set
- Front
- Back
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Sites to asucutate for bruits
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Temporal
Carotid Subclavian Abdominal aorta Renal/iliac/femoral arteries |
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3 P's of occlussion
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Pain
Pallor Pulselessness |
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Heart sounds change with increased blood volume
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Audible splitting after 20 weeks
Systolic Ejection murmur |
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Heart sound associated with mitral valve prolapse
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MVP suggested by midsystolic click
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Name systolic murmurs
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Midsystolic
semilunar valves Ejection (turb. blood flow) early, harsh, cres-dec, aortic & pulm. sten., innocent Holosystolic (extends throughout) regurgitant flow AV valves Late systolic mitral valve prolapse |
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Diastolic murmurs
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Early diastolic
aortic or pulmonic insufficientcy (regurg), decrescendo Mid-diastolic (low rumble) turbulent flow AV valves mitral or tricuspid stenosis Late diastolic (presystolic) turbulent flow AV valves mitral/tricuspid sten. *Continuous-Patent.Ductus |
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HTN is diagnosed when b/p is
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≥ 140 systolic and ≥ 90 diastolic
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5 A's are
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Ask
Assess Advise Assist Arrange |
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Cuff bladder should cover __% of arm for correct B/P
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80%
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B/P is lowest at night "nocturnal dip" loss of this dip increases risk for
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stroke
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Pre-HTN is defined as
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120-139/80-89
50% Pre-htn turns into HTN in 4 years |
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ACE inhibitor prevents
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Conversion of Angiotension I to angiotension II
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cigarettes increase B/P by increasing
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nor-epi
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NSAIDs can increase B/P by ___mmHg
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5
best avoided in borderline and HTN pts |
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Low K intake is associated with higher BP. Recomended dose is
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90mm/dl
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Metabolic syndrome (AKA syndrome X or the deadly quartet) consists of
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upper body obesity
hyperinsulinemia and insulin resistance hypertrygliceridemia HTN (usually have low HDL's also) |
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causes of secondary htn
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renal disease (parenchymal), renal artery stenosis, endocrine abnormalities such as primary aldosteronism and thyroid disease, Cushing’s syndrome and LT corticosteroid therapy, pheochromocytoma, use of estrogen and coarctation of the aorta
Only 5% have a specific cause |
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most common cause of secondary htn
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renal dz
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ECG findings of LVH is found in ___% of chronic HTN
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15%
LVH is a strong predictor of prognosis Occurance of HF is reduced 50% if proper HTN therapy is initiated Therapy is monitored best by SBP- Therapy can regress hypertrophy |
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A high serum uric acid level is a relative contraindication to what htn therapy
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Diuretic therapy (gout)
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weight reduction can decrease B/P by
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5-20mm/Hg for each 10kg (22lb) lost
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DASH diet can decrease B/P by
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8-14mm/Hg
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why are beta-blockers and angiotensin-converting-enzyme (ACE) inhibitors are less effective at lowering high blood pressure in Black patients
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mainly to the low renin state in these patients.
non compliance due in impotence in males Incereased cough and angioedemia related to hypersensitivity to bradykinins |
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B/P and goal of renal and DM
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130/80
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Potential favorable effects of thiazide diuretic
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Thiazide-type diuretics are useful in slowing demineralization in osteoporosis
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Potential favorable effects of alpha-blockers
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alpha-blockers may be useful in prostatism. (BPH)
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Potential favorable effects of beta-blockers
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BBs can be useful in the treatment of atrial tachyarrhythmias/fibrillation,
migraine, thyrotoxicosis (short term), essential tremor, or perioperative hypertension |
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ACEIs and ARBs should not be given to
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women likely to become pregnant and are contraindicated in those who are
history of angioedema |
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BBs should generally be
avoided in individuals who have |
asthma, reactive airways disease, or second
or third degree heart block (can mask the s/s of hypoglycemia in type I DM) |
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tachyphylaxis is
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rapid apperance of a progressive decrease in response to a drug
Alpha aldostroceptor antagonist (doxazosin) |
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each antihypertensive medication bring B/P down around
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10 mm/Hg
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The more pills you prescribe the patent the less _____ they will be
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compliant
look at test question that might deal with compliance and look at frequency of dosing and think about combination dosing |
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ACEIs and ARBs have demonstrated favorable effects on the progression of diabetic and nondiabetic _____ _______
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renal disease
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Postural hypotension is
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A decrease in standing SBP >10 mmHg, when associated with dizziness or fainting,
is more frequent in older patients with systolic hypertension, diabetes, and those taking diuretics, venodilators (e.g., nitrates, alpha-blockers, and sildenafillike drugs), and some psychotropic drugs. Caution should be used to avoid volume depletion and excessively rapid dose titration of antihypertensive drugs. |
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DOC's to treat HTN in pregnancy.
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Methyldopa, BBs, and vasodilators are preferred medications for the safety of the fetus
with chronic HTN only treat if B/P > 150/100 with goal at 130-150/80-100 |
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For the most part diabetics will require ___-___ number of HTN medications
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3-5 medications.
Focus has moved farther away from what is the best to start them on to what combination do they need to be on. |
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What HTN med (class) has been shown to delay kidney disease in diabetics
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ARB's > ACEI
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Resistant hypertension is
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the failure to reach goal BP in patients who are
adhering to full doses of an appropriate three-drug regimen that includes a diuretic After excluding potential identifiable hypertension, clinicians should carefully explore reasons why the patient is not at goal BP. Particular attention should be paid to diuretic type and dose in relation to renal function |
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Hypertensive emergency is a B/P
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SBP >220 or DBP >125
DBP correlates with end organ failure >130 reduce no more than 25% in 1-2 hours and get to 160/100 in 2-6 hrs. |
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Preeclampsia is
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B/P > 140 or > 90 after 20 weeks gestation and proteinuria during pregnancy
Eclampsia: addition of seizures ***Chronic hypertension has NOT been diagnosed PRIOR to pregnancy*** Cure is to deliver baby |
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Severe preeclampsia is
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BP high over 160/110 mm Hg
Thrombocytopenia (platelets < 100,000) threat of disseminated intravascular coagulation (DIC) Severe epigastric pain (hepatic hemorrhage) Protienuria > 5g/24 hrs |
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HELLP syndrome is
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hemolysis
elevated liver enzymes low platelets (rare below 20,000) |
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Education of pt and family PIH/Preeclampsia
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Encourage fetal activity logs (3-4 movements/day)
Daily blood pressure logs (3-4 times/day) Bed Rest (try to rest on your left side) Monitor urine output/edema Daily weights/ Report 5# or > in one week Report abdominal pain, severe HA, spots before eyes Seizures may occur shortly before birth Teach seizure precautions to others Symptoms may recur in 1/3 of future pregnancies |
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Mild/moderate preeclampsia
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Moderate
Diastolic 90-110 mmHg pronounced edema platelet count > 100,000 CNS irritability minimal epigastric pain absent liver enzymes normal 0.3-5g protienuria in 24 hrs |
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In children and adolescents, hypertension is defined as BP
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that is, on repeated
measurement, at the 90th percentile or greater adjusted for age, height, and gender The fifth Korotkoff sound is used to define DBP |
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Normal B/P for newborn
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In the newborn period, this ranges from 85-90 mm Hg systolic and 55-65 mm Hg diastolic for both genders
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Normal 1year old B/P
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Acceptable levels in the first year are 90-100/60-67 mm Hg
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If HTN in pediatric pt think of _____ reasons 1st
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Renal
HTN in children is commonly renal in orgin 1 congenital 2 obstruction 3 thrombosis 4 vol overload |
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Diagnosis of HTN in a child
1.) > than 10 2.) < than 10 |
1.) > than 10 -140/85
2.) < than 10 - 130/75 |
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first heart sound caused by
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S1- closure of the AV valves (mitral and tricuspid)
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second heart sound caused by
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S2- closure of the semi lunar valves (aortic and pulmonic)
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heart sound S3 is
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usually volume overload
- low-pitched; frequent in normal children and in patients with increased CO; + in pts > 40 ind. impaired ventricular function. |
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heart sound S4 is
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stiff ventricles -
- low-pitched, presystolic; present in patients with systemic HTN, aortic stenosis |
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Major CV risk factors
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Hypertension
Cigarette smoking *Obesity (BMI ≥30 kg/m2) Physical inactivity *Dyslipidemia *Diabetes mellitus Microalbuminuria or estimated GFR <60 mL/min Age (>55 years for men, >65 years for women) Family history of premature cardiovascular disease (men <55 years or women 65 years) |
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All protease inhibitors except ____ cause increased chol, increased tg, increased fat, increased risk of DM
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atazanavir
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what garlic dose to decreased ldl?
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600-900 mg po qd. decreases ldl by 4-12%
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target of statins?
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decrease LDL
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target of niacin?
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decreases tg 25-40%
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target of bile acid resins
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decreases ldl 20-35% and raise hdl by 5%
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who should you be cautious with with bile acid resins
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caution with clients with high TG, because it may increase tg.
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s/e of bile acid resins
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gas, constipation, nausea, bloating
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s/e of statins
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rhabdo, muscle aches, gas, headache, constipation, abd pain
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s/e of niacin
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flushing!
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prevent flushing of niacin by?
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taking 81 mg ASA 30 min prior with small carb snack. take it at hs
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when does pregnant client increase chol
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36-39th week
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avg rise in chol for preg client
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30-40
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trt of preg client with high chol
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dietary therapy: high fiber, low carbs, low saturated fats
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IF you do start pediatric patient on chol med, what class would you give
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bile acid sequestrants r/t minimize risks of systemic toxicity
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#1 killer of people worldwide
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CAD
1 out of 5 Americans dies from CAD Women in the US die from IHD 2X more often than from Breast CA |
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what is Target-Organ Damage?
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Heart :
Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure Brain Stroke or transient ischemic attack Chronic kidney disease Peripheral arterial disease Retinopathy |
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Metabolic Syndrome diagnosed if 3 or > of following are +: (5 to chose from)
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-Abdominal obesity
-Trigylcerides >150mg/dL -HDL cholesterol < 40mg/dL(males) and <50mg/dL(females) -Fasting glucose > 110mg/dL -HTN |
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Increased levels of High sensitivity C reactive protien (CRP) is strong risk factor for
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CAD
Levels <1 and >3 can be indicators of future CV events CRP levels may also be elevated with other conditions such as DM, Obesity and metabolic syndromes |
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______ means that the amount of blood supplied to the tissue is inadequate to supply the needs of the tissue.
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Ischemia
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Signs/symptoms of MI
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Chest pain- usually substernal discomfort that may radiate to jaw or left arm.
Dyspnea Nausea Diaphoresis Some patients, e.g. older, females, diabetics, may have no chest pain at all. (confusion) Painless infarction- 1/3 may have no pain at all Premonitory Pain- occurs with minimal exertion or at rest!!! Pain of infarction- early morning CP, may come in waves and is more severe than angina; lasts few minutes or longer (B/P usually the highest) Other symptoms- diaphoresis, weak, apprehensive, inability to lie down, syncope, dyspnea, orthopnea, abdominal bloating, cough. |
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Lab findings of an MI might include
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may be normal, but may have elevated biocardiac markers, such as CK, CK-MB, Troponin I and T.
Creatine is important for determining risk |
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ECG changes that indicate an MI
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ECG
ST segment elevation, ST segment depression or T wave flattening or inversion |
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Treatment of MI
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Hospitalization
Bedrest 24 hour monitoring Aspirin should be given on presentation Anticoagulation therapy (possible anti thrombolytic) Nitroglycerin Beta blockers Calcium channel blockers Statins |
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Imediate treatment of STEMI
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Warrants immediate reperfusion therapy
Results from occlusive coronary thrombus at site of atherosclerotic plaque. Consider cocaine as cause in young adults without risk factors. |
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Classic sequence of ECG changes
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peaked T waves > ST- segment elevation > Q wave > T wave inversion
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DD of MI
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Costochondritis
Spinal disease- cervical, thoracic GERD Thoracic outlet syndrome Shoulder degeneration Respiratory conditions- pneumonia, PE or sp. pneumothorax. |
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Questions you wouid ask the pt with chest pain
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Is the pain between the shoulder blades?
Under the breast bone? Does the pain change location? Is it on one side only? How would you describe the pain? (Severe, tearing or ripping, sharp, stabbing, burning, squeezing, constricting, tight, pressure-like, crushing, aching, dull, heavy) Does it come on suddenly? Does the pain occur at the same time each day? Is the pain getting worse? How long does the pain last? Does the pain go from your chest into your shoulder, arm, neck, jaw, or back? Is the pain worse when you are breathing deeply, coughing, eating, or bending? Is the pain worse when you are exercising? Is it better after you rest? Is it completely relieved or just less pain? Is the pain better after you take nitroglycerin medication? After you drink milk or take antacids? After belching? What other symptoms are also present? |
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The echocardiogram allows the diagnoses and evaluation of:
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Heart murmurs
Abnormal heart valves The pumping function of the heart for people with heart failure Damage to the heart muscle in patients who have had heart attacks Infection in the sac around the heart (pericarditis) Infection on or around the heart valves (infectious endocarditis) The source of a blood clot or emboli after a stroke or TIA Congenital heart disease Atrial fibrillation Pulmonary hypertension |
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ACE Inhibitors:
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Captopril (Capoten) Enalapril (Vasotec) Lisinopril (Zestril) Quinapril (Accupril) Ramipril (Altace) Fosinopril (Monopril) Trandolapril (Mavik)
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Angiotensin Receptor Blockers:
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Candersartan Losartan Valsartan
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Aldosterone Antagonists
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Spironolactone (Aldactone) Eplerenone (Inspra)
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Target Window for Digoxin:
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Loading dose administered over 24h followed by maintenance dose based on age, weight, renal function and serum digoxin levels.
- Target plasma levels: 0.5-1 ng/mL. - Quinidine, verapamil, amiodarone– increases plasma levels of digoxin (by displacing tissue binding sites and depressing renal digoxin clearance) - Cholestyramine– decreases the absorption of digoxin |
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NYHA class I
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No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath).
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NYHA class II
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Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.
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NYHA class III
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Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.
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NYHA class IV
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Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.
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ACC/AHA stages of HF
A: |
A—high risk for developing heart failure Hypertension, diabetes mellitus, CAD, family history of cardiomyopathy
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ACC/AHA stages of HF
B: |
B—asymptomatic heart failure Previous MI, LV dysfunction, valvular heart disease
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ACC/AHA stages of HF
C: |
C—symptomatic heart failure Structural heart disease, dyspnea and fatigue, impaired exercise tolerance
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ACC/AHA stages of HF
D: |
D—refractory end-stage heart failure Marked symptoms at rest despite maximal medical therapy
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50% of hospital admissions r/t HF is because
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d/t non-adherence with diets, medication, or both
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Essentials of DX of LVHF
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LV: exertional dyspnea, cough, orthopnea, fatigue, PND
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Essentials of DX of RVHF
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RV: hepatomegaly, dependent edema; usually due to LV failure
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Definition of HF
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Syndrome, not a disease, resulting from cardiac disorders (structural or functional) that impair the ability of the ventricle either to fill w/blood (diastolic dysfunction) or eject blood (systolic dysfunction). Cardiac output not enough to meet the body’s metabolic needs.
Evidenced by signs & symptoms of inadequate tissue perfusion & volume overload. Main manifestations are dyspnea and fatigue (exercise intol.), and volume overload (peripheral edema & pulm. congestion). Develops after an insult to the myocardium initiates the process of remodeling |
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Which 2 HF are treated diffrently?
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Systolic vs. diastolic (ID’s difference in dysfunctions requiring different tx.) & therefore of prime importance to differentiate in diagnosis
Ischemic vs. non-ischemic (not really treated differently) High-output vs. low-output (similar to systolic vs. diastolic) Right-sided vs. left-sided (ID’s symptom etiology, but not really treated differently) |
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Eitology of Systolic HF
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Results from decreased contractility
Ventricles lose ability to eject blood into a high-pressure aorta Contributing factors: CAD (primary cause), MI HTN Valvular insufficiency Diabetes Dilated cardiomyopathy (viral or alcoholic) |
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Eitology of Diastolic HF
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Results from restriction in ventricular filling
Stiffness of ventricle Ventricular hypertrophy Contributing factors: HTN (primary cause) CAD Renal disease Diabetes valvular stenosis |
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Signs/Symptoms of Systolic HF
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Systolic
EF <40% Progressive SOB Displaced PMI S3 gallop (Kentucky) Pulmonary congestion Cardiomegaly Q waves on EKG Younger than 65 |
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Signs/Symptoms of Diastolic HF
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EF >40-45%
Acute pulm. edema Sustained PMI S4 gallop (Tennessee) Pulmonary congestion Normal sized heart LVH on EKG 65 years or older |
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S/S of Left sided HF
(usually precipitates RSHF) |
Symptoms
Dyspnea on exertion Paroxysmal nocturnal dyspnea (PND) Orthopnea Tachypnea Cough Hemoptysis Signs Bibasilar rales Pulmonary edema S3 gallop Pleural effusion Cheyne-Stokes respirations |
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S/S of Right sided HF
(usually after LSHF) |
Symptoms
Abdominal pain Anorexia Nausea Bloating Constipation Ascites Signs Peripheral edema Jugular venous distension (JVD) Hepatojugular reflux Hepatomegaly |
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DD of HF
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Pneumonia
COPD Pulmonary embolus Cor pulmonale Myocardial Infarction Venous insufficiency Liver or renal disease |
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Whay study give a definitive dx of HF
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Echocardiogram w/doppler flow (definitive dx. HF – & differentiates systolic/diastolic dysf.)
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Drugs that exacerbate HF
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TZD’s (Avandia) esp. if taken w/insulin
CCB’s BB’s (newly started or titrated too fast) NSAIDs/Cox-2 inhibitors r/y fluid retention Glucocorticoids Na-containing meds (i.e., antacids, Zosyn, Timentin, Colace) Infliximab (Remicade) – HIV patients Itraconazole (Sporonox) – toenail antifungal Doxorubicin Illicit drugs (i.e., cocaine) Antineoplastic drugs |
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HF signs/symptoms to watch for/notify practitioner
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Weight gain 0.5-1.5 kg, edema, PND, orthopnea, need for more pillows to sleep, decreased exercise tol.)
Hospital admissions may be avoided by early intervention by the practitioner Select patients can be taught a sliding scale for adjusting their diuretic use based on weight gain & S/S |
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L to R shunting will cause:
Cyanotic or Acyanotic HD |
Acyanotic
Since the pressure is more in the left side of the heart than in the right side, an abnormal opening between the two sides will result in blood flow from the left to the right |
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4 catagories of Acyanotic HD
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1. INCREASED PULMONARY BLOOD FLOW
Atrial septal defect (ASD) Ventricular septal defect (VSD) Patent ductus arteriosus (PDA) Atrioventricular septal defect 2. OBSTRUCTION TO BLOOD FLOW ON THE RIGHT SIDE OF THE HEART Pulmonary stenosis 3. OBSTRUCTION TO THE BLOOD FLOW ON THE LEFT SIDE OF THE HEART Coarctation of the aorta Aortic stenosis Mitral valve stenosis Other congenital lesions 4. MYOCARDIAL DISEASES |
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RF for PIH
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mostly primipara,
increased risk in htn, multipara, dm, renal ds, collagen-vascular ds, autoimmune ds |
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pih bp
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sustained sys>140
dia>90 AFTER 20 weeks gestation |
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patho of pih
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endothelial disorder causing poor placental profusion
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UA of PIH
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proteinuria shows at least 0.3 g/24h
(300mg/dl=3+) |
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mild vs. moderate preeclampsia
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mild=diastolic <90-100a
moderate= diastolic 90-110, pronounced edema, platelet >100,000, epigastric pain +, liver enzymes wnl, CNS irritability normal |
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severe preeclampsia:
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BP > 160/100
platelets <100,000 severe epigastric pain (hepatic hemorrhage) HELLP syndrome |
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eclampsia
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seizures!!!!!!!
all the preeclampsis s/s severe CNS irritabilty |
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cns mild to moderate pih
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headache
hyperreflexia |
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cns severe pih
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seizures
blurring vision scotomas clonus irritability |
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UA results mild to moderate
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0.3-0.5g/24h
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UA results for severe PIH
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>5g/24 h or cath UA with 4+ protein
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urine output mild to mod PIH
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>20-30 ml/hr
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urine output severe PIH
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<20-30ml/hr
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AST, ALT, LDH for mild to moderate pih
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WNL
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ast, alt, ldh for severe pih
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elevated lft;s, epigastric pain, ruptured liver
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platelets and hgb for mild/mod pih
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>100, 000
WNL |
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platelet and hgb for severe pih
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<100,000
elevated |
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bp for mild/mod pih
retina? |
<160/110
arteriolar spasm |
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bp for severe pih
retina? |
>160/110
retinal hemorrhage |
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growth retardation, oligohydraminos, fetal distress for mild/moderate PIH?
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absent growth retardation
oligo-may be present fetal distression-absent |
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growth retardation, oligohydraminos, fetal distress for severe PIH
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all present
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classic elements for diagnosis?
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htn
proteinuria edema clinically, you dont need all 3. |
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must have two seperate bp readings at least 6 hours apart
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true
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preeclampsia 36weeks or greater=
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delivery
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strong indication for delivery otherwise?
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epigastric pain, thrombocytopenia, visual changes
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preeclampsia home management:
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BED REST, must be reliable patient, mild sx, frequent bp ability, home health RN
Hospitalize if unreliable home, moderate sx, Fetal Indications if fetal indications, but bring plt >50,000 |
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have diuretics, dietary restriction, sodium restriction, asa, vitamin supplements shown to be useful in preeclampsia
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no
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mumur grading?
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Grade I
very faint/ not heard all positions Grade II quiet heard stethoscope on chest Grade III moderately loud but no thrill Grade IV loud and may have thrill Grade V very loud associated with a thrill Grade VI heard without steth. & has a thrill |
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innocent murmurs are grades __ through___
remember thrill/4th! |
1-3
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still's murmur
grade? loudest where? |
I-III/VI systolic murmur
loudest in supine, dinishes with inspiration, sitting or standing, or during valsalva manuever |
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innominnate or carotid bruit?
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heard in R supraclavicular area
grade 2-4 |
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venous hum?
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continous musical hum, best heard with child sitting, usually louder on right.
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conditions that increase systolic innocent murmurs
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supine position
fever anemia |
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pulmonary ejection murmur
heard louder when? |
louder when supine or when cardiac output increased, softer with standing or valsalva manuever?
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