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cardiac vascular certification
nursing application for pericardum: - The pericardial space lies between the two layer of the inner pericardial layer. This space usually contains 10 to 30 mL of pericardial fluid, which reduces friction between the parietal and visceral layers of the inner pericardium. The serous inner layer is similar to the membranes that line the pleura and peritoneum. development of cardiac tamponade from pericardial effusion is more dependent on the length of time the effusion took to develop, rather than a fixed amount of fluid accumulation in the pericardial space. rapid accumulation is more likely to trigger tamponade symptoms. Pericardium - A multi-layered sac that encloses the heart, the four pulmonary veins, and portions of the main pulmonary artery, inferior vena cava, superior vena cava, and ascending aorta. it outer layer is fibrous. Inner layer is serous, flat squamous cells that secrete serous fluid, and is divided into two parts: parietal, outer, and visceral, inner. Right atrium - collects deoxgenated , venous, blood from the superior vena cava and inferior vena cava. delivers blood through the tricuspid valve to the right ventricle. epicardium - layer of squamonous epithelial cells forming the outer heart wall. Is largely equivalent to the visceral layer of the serous pericardium. includes the surface coronary arteries, a fat layer, and the part of the lymphatic system associated with the heart. epicardium nursing application: - depolarization begins in the edocardium and spreads outward to the epicardium, although the epicardium is capable of transmitting depolarizing impulses as well. pacing wires may be placed in either the endocardium or the epicardium, but some studies show that epicardial pacing leads have a higher incidence of complications and/or failure. Myocardium - layer of muscle tissue between the epicardium and the endocardium that contracts to provide systemic blood circulation. Largest portion of the heart wall. myocardium nursing applications - myocardial muscle cells are unique in that they are capable of depolarizing independent of nerve stimulation. Depolarization should be distinguished from automaticity, which is a characteristic not of general myocardial cells, but of the specialized conductive muscle fiber bundles in the nodes, bundle of his and purkinje fibes. The myocardium relies on correct acid base balance, oxygen, and balanced electrolytes for proper function. potassium, magnesium, calcium and sodium are the most notable electrolytes that affect the myocardium. Endocardium -
layer of endothelial cells, smooth muscle tissue and small blood vessels that forms the inside of the heart wall. Endothelial cells also cover the heart valves and the inside of blood vessels. provides a barrier between the blood in the heart chamber and the myocardium. Endocardium nursing applications: - between the endocardium and the myocardium lies the subendocardial layer, which contains cardiac nerves and purkinje fibers. Depolarization moves from the endocardium outward toward the epicardium and repolarization happens in reverse. A myocardial infarction that extends into the endocardium is called a transmural infarction. Endocarditis affects the heart valves. purkinje fibers - modified cardiac muscle fibers near the apex of the heart that function as conduits for electrical impulses and store glycogen as an energy source. located in the subendocardial layer between the endocardium and myocardium in the ventricles purkinje fibers nursing application - The AV node transmits the impulse to the bundle of his, which then splits into left and right bundle branches, which in turn transmit impulses to the purkinje fibers, which then conduct the impulses to the ventricles. if no impulses reaches the fibers, they will automatically depolarize at 20 to 40 beats/min. right ventricle - delievers deoxygenated blood through the pulmonary valve to the pulmonary artery, which branches into the left and right pulmonary arteries left atrium - collects oxygenated blood from the four pulmonary veins. delivers blood through the mitral valve to the left ventricle left ventricle - delivers oxygenated blood through the aortic valve to the aorta and systemic circulation. jugular venous distension - a phenomenon demostrated by the right jugular vein that reflects right atrial pathology. abnormal filling and or pressures in the RA cause backward pulsations. jugular venous distension nursing applications - to check JV pulsation, elevate the HOB to 30 - 45 degrees. have pt turn head slightly to the left and observe the right side of the neck using a strong penlight placed at the angle to the neck. evaluate pulsations during expiration. pulsation may be difficult to distinguish from normal carotid artery pulsation. Pulsation is normal when seen within 1-3 cm above the angle of louis/sternal angle. if pulsation is seen above that, near the jaw or ear, note the location, document and report if necessary. cardiac output - the amount of blood pumped into the systemic circulation from the left ventricle. Cardiac output = stroke volume times heart rate. cardiac output nursing application - stroke volume is influenced by preload, afterload, and contractility of both the left atrium and ventricle, which are ultimately influenced by the preload, afterload, and contractility of the right side of
the inotropic function of the myocardium; ability to contract. includes both the velocity of contraction in reaction to electrical stimulus and the amount the myocardial fibers shorten during contraction. measured by the RV or LV stroke work index contractility nursing application - An ECHO measures contractility noninvasively. Contractility is only as effective at increasing stroke volume as preload and compliance are effective at filling the heart chambers. Increasing contractility when afterload is elevated increases myocardial 02 demands. increases: inotropes (dobutamin, milrinone) decreases: beta blockers, CA channel blockers ventricular complaiance - the ability of the myocardum to stretch to accommodate preload volume. described in terms such as Stiff, noncompliant, and dilated ventricular compliance nursing application - Do not confuse compliance with contractility. Compliance describes myocardial stretch and contractility describes myocardial contractions. Alterations in compliance may give false pictures of preload volumes. because these are pressure readings, a stiff ventricle that dose not stretch to accommodate preload fluid volume will produce elevated pressure readings even though volume is not elevated. the same is true with a dilated ventriclue; lower pressure readings may not correlate to lower preload volumes. increase: mild/mod aortic regurgitation, dilated cardiomyopathy decrease: restrictive pericarditis, hypertrophic cardiomyopathy, ischemia, increased intrathoracic pressures. (high ventilator PEEP) Coronary artery perfusion - Both the right and left coronary arteries arise at the base of the aorta, sinus of valsalva; immediately above the aortic valve. coronary arteries are perfused during diastole. valvular auscultation points; - aortic valve: right sternal obrder, 2nd ICSs. pulmonic valve: left sternal border, 2 ICS. tricuspid valve: left sternal border, 4-5 ICS. mitral valve: left midclavicular line, 5th ICS. Normal heart sounds: S1 - closure of the mitral and tricuspid valves. loudest over mitral area, 5 ICS. systole, 1/3 of the cardiac cycle. normal heart sounds: S2 - closure of pulmonic and aortic valve. loudest over aortic area, 2nd ICS. diastole, 2/3 of the cardiac cycle. extra heart sounds: S3 - ventricular gallop: auscultated in fluid overload; when preload is elevated. normal in kids, high cardiac output, 3rd trimester of pregnancy. Listen over apex area. sound is caused by a rapid rush of blood into a dilated, overfilled ventricle. other causes: cardiomyopathy, ventricular septal defect (VSD) mitral or tricuspid reguritation.
extra heart sounds: s4 - Atrial gallop (pre-systolic) sound caused by vibration of atria ejecting into non compliant ventricles. Auscultated during ischemia, increased resistance to ventricular filling. Other causes: Ischemia, HTN, pulmonary stenosis, CAD, aortic stenosis, left ventricular hypertrophy. Listen over tricuspid or mitral area. extra heart sounds: split heart sounds - When one valve closes later than the other, best heard during inspiration. Split s1: mitral closes before tricuspid valve, RBBB, PVCs, Ventriclar pacing. Split s2: aortic closes before pulmonic valve, overfilled right ventricle, atrial septal defect (ASD) Acute coronary syndrome - pathophysiology: progressive atherosclerosis with plaque rupture causing blood clot formation leading to an imbalance of o2 supply and demand. In ACS, there is and imbalance of oxyen supply and demand. - O2 supply: Coronary arteries, diastolic filling time, cardiac output, hemoglobin. O2 Demand: heart rate, contractility, preload, afterload. cardiac risk factors: non modifiable: - age, gender, family history, race cardiac risk factors: modifiable: - smoing, diet, hyperlipidemia, physical inactivity, obesity, hypertension, diabetes mellitus. cardiac biomarkers: - Troponin 1: is the most sensitive and specific. elevates in 3 to 6 hours, peaks in 14 to 20 hours and returns to normal in 1 to 2 weeks. most labs >0.4 mcg/L is considered elevated. CPK, CK-MD and myoglobin may also be elevated, no longer recommended to routinely check. chest pain assessment. - onset? location? Duration? Characteristics? Associates s/s? relieving factors? treatment? stable angina - exertional: symptoms cease when exertion stops. May have a fixed vessel stenosis with demand ischemia, may require sublingual nitroglycerin unstable angina - increasing frequency, time and duration, sign and precusor to a MI. 10 to 20 % have a MI, may consider antiplatelet therapy. variant, prinzmetal's angina - sudden pain caused from coronary artery vasospasm, occurs at rest or when sleeping, get 12 lead ECG with and without symptoms. Will see ECG changes with pain and symptoms. Treat with nitroglycerin and calcium channel blockers to relieve spasm. non ST elevation ACS (NSTE-ACS) -
afterload reduction. Decreases workload of heart. Use Cautiously in UA and NStemi, increased mortality in large patient registry. causes hypotension. Avoid if suspected right ventricular infarction. post PCI therapy: access site - radial artery access site is becoming more popular: fewer complications. Monitor for arterial vasospasm. Femoral: monitor for bleeding, hematoma, retroperitoneal bleeding. Rare cases, can develop pseudoaneurysms, AV fistual. post PCI Therapy: retroperitoneal bleeding - will see soft bp that is fluid responsive, Back pain, tachycardia; may not see if patient received beta blockers. Late sign is flank ecchymosis (grey turner's sign) assess coags, control bleeding. monitor renal function closely (dye load) post PCI medication management - Aspirin, (indefinitely) P2Y12 inhibitor (usually for 1 year), beta blocker (indefinitely), statin (high dose indefinitely), ACE Inhibitor or ARB (if EF <40%, indefinitely) P2Y12 inhibitors - Clopidogrel (Plavix) 300 to 600 mg load; continue 75 mg daily for 12 months Prasugrel (Effient) 60 mg load; continue 10 mg for 12 months Ticagrelor (Brilinta) 180 mg load; 90 mg BID for 12 months Other recommendations: Unfractionated Heparin or Bivalirudin, angiomax: - used during PCI; finish in cath lab; half life 25 min with normal renal function. Dose; 0.75 mg/kg IV bolus. Then 1.75mg/kg/hr IV infusion for duration of the procedure. May continue for 4 hours post procedure. Other recommendations: GP IIb/IIIA inhibitors at time of PCI - Abciximab, reopro. Eptifibatide, Integrilin. Tirofiban, Aggrastat. monitor platelet count and for bleeding. Beta blockers: oLOL - Start within 24 hours if hemodynamically stable. Hold if hypotension or signs of hypoperfusion/shock. Metoprolol tartrate and carvedilol mostly used. (metoprolol tartrate is the only form of metoprolol that is cardio protective.) blocks catecholamin and sympathetic nervous system. Cardio protective, decreases arrhythmias, decreases HR and Contractility. Decreases myocardial O consumption. Long term, decreases morbidity and mortality. continued indefinitely. Educate patients on symptoms, may feel exhausted, depressed. myocardial oxygen demand - The amount of oxygen required to avoid myocardial ischemia/hypoxia. Myocardial cells normally use 75% of available oxygen, in contrast to other tissues, which generally use 25% of available O2 in the bloodstream. myocardial oxygen demand: decrease demand - lower preload, after load, HR, and contractility myocardial oxygen demand: increase supply -
oxygen; increase flow, such as NTG, ASA, anticoagulants; remove occlsions, such as PTCA, CABG, Fibrinolytics impedance cardiography - noninvasive estimate of CO, SVR, SV and other parameters using variations in electrical impedance from chest sensors combined with basic hemodyanamics such as BP and HR. impedance Cardiography nursing application - insertion of a pa catheter is invasive and time consuming, PA catheters are not advised for use when a pt has arrhythmias, coagulopathy, complete left BBB, ebsteins anomaly, WPW syndrome, tricuspid or pulmonic stenosis, ToF or RA/RV/ PA masses. In these cases, impedance cardiography may provid some insight about a pts hemodynamic without increasing risks associated with PA catheters. myocardial oxygen demand nursing application - the four components of cardiac output, HR, preload, afterload, contractility, affect MOD. when a pt is experiencing chest pain, the goal is to lower oxygen demand and increase oxygen supply. In a normal hear, the coronary arteries dilate during activity to increase blood/o2 supply. in a normal heart, the coronary arteries dilate during activity to increase blood/ oxygen supply to the myocardium. when coronary arteries are affected by atherosclerosis, they do not have the capability to dilate, thus lowering the supply of oxygen and causing ischemia. Borg perceived exertion scale - The borg rating of perceived exertion RPE, allows a person to self rate the perceived intensity of an exercise on a scale from 6 to 20. A rating of 12 to 14 is generally considered "moderate" intensity. borg perceived exertion scale nursing application - this scale is useful for nurses since the scale can be used to roughly estimate the pt's HR by multiplying the perceived exertion rate times 10. if the pt's perceived exertion is too high, the exercises may need to be modified to avoid unnecessary stress on the pt's heart. This scale is also useful for assessing exertion intensity for patients who take medications that modulate heart rate, blood pressure or other hemodynamics. Apical Impulse (PMI) - a visible and/or palpable pulsation at the apex of the heart that occurs when the heart bumps against the chest wall; corresponds with S1 and carotid pulsation. Normally found at the midclavicular line 5th intercostal space (ICS). An absent PMI is considered a normal finding. apical impulse nursing application - to better assess the PMI, instruct the pt to sit up and lean forward, exhale completely and/or assume the left lateral decubitus position. it may be impossible to assess PMI on a pt with copious breast tissue. if located, document the amplitude, size intensity, location and duration. Size should be no larger than about a penny or nickel size. for suspected findings associated with abnormal apical impulses, see the PMI abnormalities card. murmur - swishing sound related to blood flow through cardiac valves rub - rough or squeaky sound related to inflammation of tissues surrounding either the heart or the lungs
patients, requires energy expenditure and reduces oxygen and energy reserves more quickly than if retractions were not present. 5 lead EKG nursing applications - V1 is the preferred lead with which to monitor wide QRS morphology, BBB and ventricular dysrhythmias, VT vs SVT. The disadvantage to V! is that it gives no information about axis shifts and little to no information about P and T waves. Leads 1, 2, 3 and AVF give information about axis shift and Pwaves. MCL 1 lead - stands for modified chest/central lead and is the bipolar version of the unipolar V1 in both the 5 and 12 lead systems. requires special configuration of the 3 leads in order to obtain MCL tracing. MCL 1 lead nursing application - to monitor MCL 1 that are several methods: if monitor is reading lead 1 place LA on V1 position, RA on left shoulder, if monitor is reading lead 2, place LL on V1 position, RA on left shoulder, if monitor is reading lead 3 place LL on V1 positon , LA on left shoulder. the V1 location is 4th ICS, right sternal border. in all above scenarios, the left over third lead may be place in the V6 location (5th ICS, midaxillary line). In the lead 1 scenario, with the LL lead in the V6 location, obtain an MCL6 tracing by changing the lead to lead 2 without changing the location of the leads. QT interval - the interval between the beginning of a QRS complex to the end of the T wave. should be no longer than half the R to R length. QTc denotes QT intervals that have been corrected via chart in relation to HR. Normal QTc in men is 0.42 seconds, normal QTc in women is 0.43 seconds QT interval nursing applications - primary concern is for lengthened QT intervals, which represent delayed ventricular repolarization lengthened QT may be caused by electrolyte abnormalities, usually hypomagnesium or hypokalemia, medications, such as antibotics, antiarrhythmics, antipsychotics, or genetic mutations. Normalize electrolytes and monitor for ventricular arrhythmias and Torsades de pointes. Baroreceptor reflex - vasomotor response to changes in blood pressure within systemic vessels. baroreceptor, nerve tissues, in the aortic arch ad carotid sinus sense pressure changes and communicate those to the medulla. stretch receptor in the right atrium senses fluid excess. baroreceptor reflexes nursing application - these reflexes respond sluggishly when the patient displays orthostatic hypotension. three reflexes directly affect CV Function baroreceptor reflexes carotid massage - this maneuver manually triggers the baroreceptors to signal the edulla to slow the SA node rate and conduction across the AV node; do not us if pt has hx of TIA, stroke or MI within last 3 months or any hx of VF/VT or known carotid artery disease. baroreceptor reflexes aortic reflex - high arterial BP stimulates the medulla to decrease HR and Cardiac output, and thus decrease BP, accounts for reflex bradycardia associated with acute hypertensive crisis.
baroreceptor reflexes bainbridge reflex - high venous BP stimulate RA stretch receptors, which cause the medulla to increase HR in order to deal with the excess venous return. Chemoreceptor reflexes - vasomotor responses to changes in arterial oxygen, carbon dioxide and acid base (pH) levels. peripheral chemoreceptors are located in the aortic arch and carotid arteries, central chemoreceptors are located in the medulla itself. chemoreceptor reflexes nursing application: - Elevated arterial carbon dioxide leels cause the chemoreceptors to alert the vasomotor center, medulla, which stimulates the adrenergic sympathetic system to increase HR and BP in an attempt to reduce CO2 and increase O2 delivery to tissues. Respiratory activity is also stimulated by chemoreceptor reflexes. for this reason pts with COPD who are accustomed to higher CO2 levels and lower O2 levels should not have these levels drastically altered as that may be counterproductive to maintaining the pt's respiratory drive, which may be dependent on hypoxia instead of hypercapnia. to maintain spontaneous respirations in a chronically hypercapnic COPD pt avoid increasing SaO2 >92% CK-MB - a muscle enzyme creatine kinase specific to the heart muscle. May be elevated if cardiac tissue is damaged by trauma, exertion or myopathy. Two serial elevations are required to confirm acute MI or one elevation at least double the highest normal value. CK-MB nursing application - CK-MB is most diagnostic of acute MI when accompanied by elevations in both troponin and myoglobin. isolated CK-MB elevation has minimal diagnostic value for acute MI. A ratio between the CK and the CK-MB may also help with diagnosis. A ration of CK-MB may also help with diagnosis. a ration of CK-MB: total CK >5 indicates cardiac muscle damage. a ration <3 indicates skeletal muscle damage. both levels must be elevated for ratio to be valid. Troponins - cardiac marker of choice for pt with ACS. only one efevated troponin level is required to diagnose MI. usually performed serially to determine peak, and estimate extent of MI. troponin nursing applications - pt with hx of unstable angina who had negative CK-MB and elevated troponin levels, with or without ECG changes, are now classified as having NSTEMI. Some studies have shown that 80 plus % of pt with acute MI will manfiest elevated troponin within 2 to 3 hours of ED arrival. Troponin also remains elevated for 10 plus days, increasing it value in diagnosing MI even when the pt presents long after initial onset. Troponin T and I are both used to diagnose MI, but troponin T may also be elevated in pt with end stage renal disease, especially those receiving dialysis. Dialysis decreased troponin 1. myoglobin - heme protein found in both cardiac and skeletal muscle. considered an early marker for MI, rises 2 to 4 hours after onset. a 25 plus % increase over serial tests within 1 to 2 hours of each other is strongly indicative of acute MI myoglobin nursing application -
CV Resuscitation Meds: atenolol - used for MI, CP, PSVT, A-Fib/flutter, HTN. 5 mg IVP Over 5 minutes. May repeat once. CV resuscitation meds: atropine - used for Bradycardia 0.5 to 1 mg IV q3 to 5 mins. Max 0.04 mg/kg CV resuscitation meds: Digoxin - used for a fib/flutter, PSVT. load with 10 to 15mcg/kg IV. continue with IV or PO dosing CV resuscitation Meds: diltiazem - used for Afib/flutter, PSVT refractive to adenosine. 0.25 mg/kg/IVP over 2 minutes, may repeat 0.35 mg/kg slow IVP in 15 minutes. drip 5-15 mg/hr titrate to hr>60. CV resuscitation Meds: dopamine - used for shock, bradycardia, renal perusion, 2 to 20 mcg/kg/min IV. renal dose 2 to 5 mcg/kg/min. CV resuscitation Meds: epinerphrine - used for cardiac arrest, 1 mg of 1:10000 IVP every 3 to 5 minutes. CV resuscitation Meds: furosemide; lasix - used for fluid overload, pulmonary edema, renal insufficiency. 0.5 to 1 mg/kg IVP. Monitor potassium levels CV resuscitation Meds: glucagon - used for CA channel blocker toxicity 2mg IV. Beta-blocker toxicity 50 to 150 mcg/kg IV, after bolus, infuse, 1 to 5 mg/hr. CV resuscitation Meds: isoproterenol; isuprel - used for bradycardia in non innervated hearts, beta blocker toxicity, and Torsades de pointes; 2 to 10 mcg/min IV. titrate to desired HR. CV resuscitation Meds: lidocaine; xylocaine - used for VF/VT DO NOT GIVE for ventricular escape rhythms. 1 to 1.5 mg/kg IV repeat 0.5 to 0.75 mg/kg every5 to 10 minutes. Max 3 mg/kg infusion 1 to 4 mg/min CV resuscitation Meds: magnesium sulfate - used for Cardiac arrest R/T torsade de pointes 1 to 2 g IVP. Used for non arrest torsades. Load with 1 to 2 g in 50 to 100mL D5W over 5 to 60 minutes, infusion; 0.5 to 1 gm/hr, titrate to control arrhythmia. CV resuscitation Meds: metoprolol; lopressor - used for MI, CP, PSVT, afib/flutter, HTN; 5mg slow IVP every 5 min, max: 15mg may also be used po for HTN control. CV resuscitation Meds: midazolam, versed - used for seizures, sedation; 2.5 mg IVP or 0.1mg/kg max: 5mg/dose CV resuscitation Meds: morphine - used for CP, analgesia, pulmonary edema; 1 to 4 mg IVP monitor BP
CV resuscitation Meds: nitroglycerine, NTG - used for MI, CP. 0.4mg SL every 3 to 5 minutes max 3 doses. Used for MI, CP, or HTN. infusion; 5mcg/min initially increase by 5 mcg/min every 3 to 5 minutes up to 20mcg/min then gradually by 10 and then 20 mcg/min max 200 to 400 mcg/min CV resuscitation Meds: nitorprusside; nipride - used for severe HTN; infusion 0.5 to 8 mcg/min. CAUTION: risk of cyanid poisoning at rates >2mcg/kg/min. Max dose 8mcg/min should not be continued longer than 10 minutes Ondansetron (Zofran) - Antiemetic. N/V 4mg IVP Procainamide (Pronestyl) - Antiarrhythmic used for recurrent VF/VT; 20mg/min infusion. max: 17mg/kg Sodium Bicarbonate - used for hyperkalemia, metabolic acidosis. 1 meq/kg IV may repeat 0.5 meq/kg every 10 minutes. overdoses; TCA, ASA, Benadryl, pb and cocaine. Vasopressin (Pitressin) - The antidiuretic action of vasopressin is ascribed to increasing reabsorption of water by the renal tubules 40u IV x1. cardiac ischemia/angina replaces one dose of epinephrine Verapamil (Isoptin) - calcium channel blocker used for PST, A fib/flutter. 2.5 to 5 mg/ IV over 2 minutes; may repeat 5 to 10mg 15min later max 20mg Adult pulmonary HTN, group 1 - causes: genetics, HIV, portal HTN, congenital heart disease drug abuse, connective tissue disease, schistosomiasis. treatment: no primary treatment. Advanced Tx: prostanoids endothelin receptor antagonists. other: only type considered pulmonary arterial HTN, consider 02, diuretics, anticoagulants digoxin, and exercise therapies. Adult pulmonary HTN, group 2 - causes: LA/LV heart dx, chronic pulmonary venous HTN, valve dx. Treatment: treat underlying heart dx. Advanced Tx: may be harmful. other: consider 02, diuretics, anticoagulants digoxin, and exercise therapies. Adult pulmonary HTN, group 3 - causes: chronic lung dx, hypoxemia. Treatment: treat lung dx, O2. advanced treatment: not FDA approved. other: consider 02, diuretics, anticoagulants digoxin, and exercise therapies. Adult pulmonary HTN, group 4 - causes: Thromboembolic disease. Treatment: anticoagulants. Advanced tx: pulm thromboendarterectomy. other: consider 02, diuretics, anticoagulants digoxin, and exercise therapies. Adult pulmonary HTN, group 5 -
Preeclampsia is a specialty disorder and should not be treated like regular HTN; meds that act on the RAAS such as ace inhabits, ARBS and direct renin inhibitors should not be used Adult causes of secondary HTN - obstructive sleep apnea: excessive daytime sleepiness. Aortic coarctation: diminished femoral pulses compared to radial pulses. Primary aldosteronism (Conn's syndrome): unexplained hypokalemia. Bilateral renal artery stenosis: flash pulmonary edema with normal LVEF. Pheochromocytoma: HTN with palpitations, headache, and sweating. other potential causes include Cushing's disease, cranial tumors, hyperparathyroidism and various types of chronic kidney diseases HTN and target organ damage - Early treatment for HTN aims to proactively prevent damage to body organs. Treatment after the pt has already experienced organ damage aims to prevent further injury to organs already damaged and reduce risk of other organ damage. organs most affected by HTN - eyes: hypertensive retinopathy. Brain: TIAs, ischemic/hemorrhagic strokes, cerebral encephalopathy, severe malignant HTN. peripheral arteries: endothelial damage that promotes atherosclerosis. Heart: CAD, MI, LV hypertrophy, HF. Kidneys, nephropathy, ESRD/Failure. Right Ventricle MI - usually considered as a whole; lies to the right of the anterior portion of the LV and wraps around toward the right breast and around to the back of the heart to meet with the inferior and posterior portions of the LV Anterior MI - Part of the LV that is closest to the sternum and to the left breast Lateral MI - strip of the LV that divides the anterior wall from the posterior/inferior wall; divided into the high lateral portion nearest the left atrium, and the low lateral portion closer to the apex of the heart. Inferior MI - part of the LV that lies closes to the daphragm;AHA recommends that this term include both the inferior wall and what was formerly referred to as the posterior wall. posterior MI - term is controversial and is used most often when discussing ECG interpretation; has been used to describe the basal lateral or basal inferior wall. septal MI - the portion of muscle between the RV and LV that contains all the descending portions of the bundle branches. Angioplasty (PTCA) - percutaneous transluminal coronary angioplasty. one PCI procedure that uses a balloon to compress arterial plaque and dilate the designated portion of the artery. Angioplasty (PTCA) nursing application -
PTCA causes plaque formations to rupture, triggering coagulation and formation of a thrombus. Thus, anticoagulation is essential during the procedure to avoid this complication. In addition, the pt should continue with antiplatelet medications following the procedure. reocclusion of an artery following PTCA alone is frequent, so this procedure is often paired with the insertion of stents or other PCI procedures. If coronary arteries cannot undergo angioplasty or stenting, consider recommending rotablation or CABG. Post PCI radial access care - radial arterial access is associated with fewer complications than femoral access; pt can ambulate after recovered from sedation. pressure on site should not occlude the radial artery; use a pulse oximeter on the thumb or index finger to monitor pulse, test radial flow by occluding the ulnar artery briefly. use wrist splint or arm board during removal and observation. Maintain pressure for 30 minutes to 2 hours then reduce balloon pressure gradually per facility protocols. post PCI femoral access care - Activated clotting time should be ,180 seconds prior to sheath removal. sheath usually removed in the cath lab after procedure and pressure applied times 20 to 30 minutes with manual or device supplied pressure. Bedrest with affected leg straight; 1 to 2 hours for 4 to 5fr sheaths and 2 to 4 hours for a 6 to 8 fr sheaths. bedrest times may be shorter if VCD was used after sheath removal. may elevate HOB up to 30 degrees and/or allow pt to shift to side lying postion if affected leg can be kept straight. mark edges of any hematoma to monitor for enlargement. remind pt that bedrest time starts over if bleeding reoccurs and to avoid coughing or straining. report mass or bruit at insertion site. vascular closure devices VCD: absorbable collagen, suture mediated staple/clip. Post MI patient education - smoking cessation is the single best action to reduce risk of death after MI (reduces risk>50%) Do not take NSAIDs following and MI (ventricular remodeling, risk of HTN, HR, and renal failure) EXCEPT for low dose aspirin as directed Avoid Cox2 inhibitors (celcoxib/celebrex) Treat general pain with acetaminophen, Narcotics, or nonacetylated salicylates (salsalate); naproxen may be considered if necessary Early recovery activity usually consists of 5 to 10 minute of walking at a time. Pt should avoid exercise in presence of unstable angina, uncontrolled tachycardic rhythms or HTN, decompensated HF, and/or 3rd degree AVB Follow up for post MI testing (usually scheduled for 3 wks after MI) obtain appropriate vaccinations as directed (flu) do not change or stop any medications suddenly without consulting cardiologist or current practitioner. Follow lifting and activity limits if PCI procedure was performed (activities can be evaluated using a metabolic equivalent MET chart) Sexual activity for stable pts can usually be resumed in 7 to 10 days post MI Cardiac rehabilitation programs benefit all pt in the ACS spectrum Address pt potential for anxiety, stress, depression and social isolation. CABG things to remember ; contraindications: - Aortic atherosclerosis, high risk of neuro complication, if pt requires aortic clamping either on or off bypass (CPB) Coronary arteries <1.5mm distal to stenosis Severe LV failure with comorbid pulmonary, renal or PVD dx
