cardiovascular review ii-1

8/8/2019 Cardiovascular Review II-1

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Cardiovascular Review II

Ana H. Corona, MSN, FNP-C

Nursing Instructor

October 2007MedlinePlus; Random Outlines 2007; nurseCE.com


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Coronary Artery Disease (CAD) Coronary arteries cannot deliver adequate blood

supply to the heart muscle to meet the tissue

demand.

Characterized by obstruction or narrowing of the

vessel lumen.

Risk factors some cannot be changed while

other risk factors can be modified or eliminated.

Patient education is an important aspect of thenursing care of patients with CAD because the

educated patient can take steps to improve his

condition.


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Risk Factors

Risk factors that cannot be changed (non-modified):

age, sex, race, genetic make-up, and

family history. The major risk factors fall into the category

of modifiable risk factors:

Hypertension, elevated serum cholesterollevels, and cigarette smoking.

Additional modifiable risk factors:

weight, activity level, and stress levels


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Arteriosclerosis

Primary cause of CAD. Arteriosclerosis isdefined as hardening or thickening of the

arteries.

Characterized by thickening and loss of elasticity

of the arterial walls.

Deposits of yellowish plaques (called

atheromas) are formed within the medium and

large sized arteries. These atheromas are made up of cholesterol,

lipoid material, and lipophages (cells that ingest

or absorb fat).


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Diagnostic Tests

Ankle/brachial index (ABI)

Arteriography

Cardiac stress testing CT scan

Doppler study

Intravascular ultrasound (IVUS)

Magnetic resonance arteriography (MRA)


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Medications/Treatment

Low-fat diet

Weight loss

Exercise. Blood thinners

Cholesterol lowering agents

Angioplasty Stents


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Coronary Heart Disease (CHD)

Coronary heart disease (CHD) is a collective

name for a number of ischemic diseases of

the myocardium.

The major diseases of CHD are:

angina pectoris

cardiac dysrhythmias

myocardial infarction

congestive heart failure (CHF)

sudden cardiac death.


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Diagnostic Tests

EKG

Exercise Stress Test

Echocardiogram

Nuclear scan Coronary angiography/arteriography

Electron-beam computed tomography (EBCT) tolook for calcium in the lining of the arteries -- the

more calcium, the higher your chance for CHD Coronary CT angiography

Magnetic resonance angiography


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Medications ACE inhibitors to lower blood pressure Blood thinners (antiplatelet drugs) to reduce

your risk of blood clots

Beta-blockers to lower heart rate, blood

pressure, and oxygen use by the heart Calcium channel blockers to relax arteries,

lowering blood pressure and reducing strain onthe heart

Diuretics to lower blood pressure

Nitrates (such as nitroglycerin) to stop chest painand improve blood supply to the heart

Statins to lower cholesterol


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Angina Pectoris

A clinical syndrome of ischemic heart disease Manifested by paroxysmal chest pain.

An early warning of CV deterioration.

The symptoms occur as a result of myocardial

oxygen demand that exceeds the ability of thecoronary arteries to deliver oxygen.

(The coronary arteries supply the myocardiumwith the oxygenated blood it needs to workeffectively.)

The main cause for this inability to meet oxygendemand is the presence of atherosclerosis thatcauses advanced occlusion or stenosis of one ormore of the three major branches of thecoronary artery tree.


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Angina Pectoris

The pain of angina pectoris occurs whenthe heart is stressed or worked to a pointwhere the oxygen demand is greater thanthe amount of oxygen that can be

delivered. This usually occurs with exertion

Onset of pain will occur with exertion, and

relief will normally occur with rest. Rest will decrease the workload on theheart, thereby decreasing the heart'soxygen demand and relieving the pain.


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Unstable Angina Pectoris

A term used to describe the exacerbation

of the symptoms of angina pectoris.

Characterized by increased severity ofsymptoms, increased ease in provoking

attacks of angina, and less predictability in

controlling angina attacks.

Symptoms may be severe enough to

mimic an acute myocardial infarction.


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Diagnostic Tests

Blood tests to check the levels of creatine

phosphokinase (CPK), myoglobin, and

troponin I and T

Coronary angiography

ECG

Echocardiography Stress tests


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Medication/Treatment

Blood thinners (antiplatelet drugs)

Aspirin and clopidogrel may reduce the

chance of heart attack in certain patients. Heparin and nitroglycerin.

Other treatments may include medicines

to control blood pressure, anxiety.


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Acute Myocardial Infarction (AMI)

Results from an imbalance between oxygendemand and oxygen supply to the myocardium.

In 90 percent of the cases this imbalance is

preceded by atherosclerosis and decreased

blood flow in the coronary arteries. The inadequate blood flow results in decreased

oxygen delivery to the heart muscle, which

causes ischemia, injury, and death of a portion

of the myocardium (infarction).


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Myocardial Infarctions

Myocardial infarctions are described as beinganterior, inferior, or posterior, depending uponthe location of the infarcted area of the heartmuscle.

Infarcts can be further classified as beingtransmural or non-transmural.

A transmural infarct (Non Q-Wave MI) is onethat involves damage to the full thickness of the

myocardium. A non-transmural MI involves only a partialthickness of the muscle.


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Signs & Symptoms AMI

Chest Pain is the major presenting symptom. Pain is usually substernal and may radiate to the

neck, shoulders, arms, or epigastric area.

Pain is described as heaviness, constriction,burning, or similar to indigestion.

There may be little or no pain present at all.

May be difficult to distinguish from angina.

Shortness of breath, diaphoresis, weakness,fatigue, anxiety, nausea, vomiting, abnormal

blood pressure, and abnormal heart rate. Pain, anxiety, and arrhythmias occur in the early

stages of MI.

Ventricular fibrillation is the greatest threat to life

in the first hours after MI.


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Diagnostic Tests

Coronary angiography CT scan

Echocardiography

Electrocardiogram (ECG) -- once or repeated

over several hours

MRI

Nuclear ventriculography

Troponin I and troponin T CPK and CPK-MB

Serum myoglobin


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Management of AMI ECG monitoring

Bedrest to reduce the workload of the heart

Intravenous therapy

Morphine to reduce pain and relieve anxiety

Oxygen

Nitroglycerin to relieve pain

Thrombolytic Therapy

Aspirin: Antiplatelet medications to help preventclots

Heparin or lovenox vasodilators, beta blocker, calcium channel

blockers and lidocaine as antiarrhythmictherapy.


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Nursing Care & Management

Three major considerations: observationand prevention of further myocardial

damage and complications, promotion of

an environment that allows for maximumcomfort and rest, and patient education to

fully prepare the patient for discharge.


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Nursing Care & Management: Continue

Observation and prevention include thefollowing nursing considerations:

(a) Frequent monitoring of the vital signsand ECG.

(b) Observation for signs of impendingheart failure by close monitoring of intakeand output, daily weight, breathe sounds,and serum enzymes.

(c) Careful assessment anddocumentation of each episode of chestpain to include severity, duration,

medication given, and relief obtained.


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Nursing Care & Management: continue

Promotion of a restful and comfortableenvironment:

(a) Provide emotional support to reduceanxiety and stress.

(b) Orient patient to the (CCU) routine andenvironment.

(c) Schedule patient care activities carefully to

avoid interrupting the patient's sleep.


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Patient Education

(a) Promote compliance with prescribed

meds, diet, and other tx measures by

explaining the need for each and the possible

consequences of noncompliance.

(b) Review all activity limitations and

restrictions.

(c) Counsel the patient on the action thatshould be taken when he is confronted with

chest pain or other symptoms.


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Heart Failure (CHF) Inadequate cardiac output,

resulting in poor perfusion of all organ systems.

Left heart failure: The pumping action ofthe left ventricle is compromised, but theright ventricle continues to function

normally. There is an imbalance between the out-put

of each ventricle.

The right heart continues to pump bloodinto the lungs to be oxygenated.


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CHF: left sided heart failure

The failing left heart is unable to return thatsame volume of blood to the systemiccirculation.

Results in accumulation of blood in thepulmonary blood vessels.

Increased pressure in the pulmonaryvessels causes fluid to leak into the

interstitial lung tissue, compromising gasexchange.

This condition is called pulmonary edema.


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Right Sided Heart Failure

Right sided heart failure usually follows leftsided failure.

The increased pressure in the pulmonaryvessels causes "back pressure" to the right

side of the heart. This interferes with venous return, and

consequently, the organs of the bodybecome congested.


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CHF: right sided heart failure

This condition, known as congestive heartfailure (CHF), is manifested by neck veindistention and body edema.

Right sided failure may occur without leftsided failure.

This condition, called corpulmonale, may

be caused by pulmonary hypertensionsecondary to lung disease or by thepresence of pulmonary emboli.


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CHF Diagnostic Tests

Echocardiogram Heart catheterization

Chest x-ray

Chest CT scan

Cardiac MRI

Nuclear heart scans(MUGA, RNV)

ECG, which may alsoshow arrhythmias

CBC

Blood chemistry Serum sodium

BUN

Creatinine Liver function tests

Serum uric acid

Atrial natriuretic peptide(ANP) and brainnatriuretic peptide (BNP)

Urinalysis

Urinary sodium

Creatinine clearance

Swan-Ganzmeasurements (rightheart catheterization)


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Medications/Treatment Low Sodium Diet

ACE inhibitors such as captopril and enalapril -- thesemedications open up blood vessels and decrease thework load of the heart.

Diuretics -- there are several types including thiazide, loopdiuretics, and potassium-sparing diuretics; they help rid

your body of fluid and sodium. Digitalis glycosides -- increase the ability of the heart

muscle to contract properly; prevent heart rhythmdisturbances

Angiotensin receptor blockers (ARBs) such as losartan

and candesartan which, like ACE inhibitors, reduce theworkload of the heart; this class of drug is especiallyimportant for those who cannot tolerate ACE inhibitors

Beta-blockers -- this is particularly useful for those with ahistory of coronary artery disease


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Nursing Care & Management CHF

During the acute phase, nursing considerationsinclude the following:

Monitoring fluid retention by weighing the patientdaily.

Monitoring intake and output. Frequent assessment of vital signs.

Frequent monitoring of electrolytes.

Promoting mental and physical rest to reduce theworkload of the heart.

Administration of prescribed medications toimprove the heart's effectiveness as a pump.

Administration of prescribed dietary restrictions(sodium and fluids).


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Nursing Care & Management CHF

Patient education should include the following

nursing considerations:

Instruction on effective coping mechanisms

that will reduce stress in daily living.

Compliance in taking prescribed

medications.

Compliance in following the prescribeddietary and fluid restrictions.

The importance of regular check-ups.


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Q1

Cyanosis and potential cyanide poisoning

are possible with

a. nitroglycerinb. nitroprusside (Nipride)

c. nitrofurantoin (Macrodantin)

d. nitrous oxide


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A1

b. nitroprusside (Nipride)


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Q2

Identify the beta blocker(s)

a. guanabenz (Wytensin)

b. prazocin (Minipres)c. acetbutolol (Sectral)

d. enalapril (Vasotec)


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A2

c. acetbutolol (Sectral) -- hint -- look for

the "olol" suffix!


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Q3

Identify the ACE inhibitor(s)

a. atenolol (Tenormin)

b. captopril (Capoten)c. propranolol (Inderal)

d. ranitidine (Zantac)


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A3

b.captopril (Capoten) -- hint-- look for

the "pril" suffix!


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Q4

Digoxin (Lanoxin) causes

a. negative inotropic, positive chronotropicaction

b. negative inotropic, negative chronotropicaction

c. positive inotropic, positive chronotropic

actiond. positive inotropic, negative chronotropic

action


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A4

d. positive inotropic, negative

chronotropic action


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Q5

Your patient is lethargic, nauseated, and has apulse of 52. You see that he is taking digoxin(Lanoxin) 0.25mg daily, and also has

hydrochlorothiazide (HydroDiuril) 50mg twicedaily. He is also playing with the color knobs onthe television. You would check for a

a. drop in sodium levels

b. drop in potassium levelsc. drop in digoxin (Lanoxin) levels

d. drop in calcium levels


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A5

b. drop in potassium levels


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Q6

Asthmatic patients could experience

bronchoconstriction problems with which

of the following agents?

a. isoproterinol (Isuprel)

b. digoxin (Lanoxin)

c. pindolol (Visken)

d. dextromethorphan


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A6

c. pindolol (Visken) -- a beta blocker

can cause B-2 blocking which can

result in bronchospasm


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Q7

Hypertensive therapy available as a 7-day

patch

a. atenolol (Tenormin)b. methyldopa (Aldomet)

c. minoxidil (Loniten)

d. clonidine (Catapres)


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A7

d.clonidine (Catapres)


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Q8

Regarding nitroglycerin

a. tingling on the tongue is a sign of toxicity with

the sublingual tablets

b. special tubing is always used for IV infusion

c. oral nitrates such as Isordil and Sorbitrate are

just as effective as topical patches

d. care should be taken to avoid absorption of thepaste or injection solution onto the skin of the

caregiver


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A8

d.care should be taken to avoid

absorption of the paste or injection

solution onto the skin of the caregiver


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Q9

Nonpharmacologic therapy ofhypertension includes

a. dynamic exercise at least 3 times a week

b. magnesium and calcium supplementation

c. moderation in alcohol consumption

d. weight loss

e. all of the above

f. a, c, d only


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A9

e. all of the above


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Q10

Angiotensin II

a. is increased in the presence of enalapril

(Vasotec)b. causes drops in aldosterone levels

c. can result in water retention

d. increases sodium excretion


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A10

c.can result in water retention


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Q11

The antihypertensive agent also used for

hair regrowth is

a. nitroglycerinb. nitroprusside (Nipride)

c. minoxidil (Loniten) -- the topical hair

regrowth product is also known as

Rogaine

d. verapamil (Calan)


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A11

c. minoxidil (Loniten) -- the topical hair

regrowth product is also known as

Rogaine


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Q12

High fiber diets can have what effect on

the blood levels of digoxin (Lanoxin)?

a. lower

b. raise

c. no change


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A12

a. lower


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Q13

Your patient has a heart rate of 79. After

being stabilized on propranolol (Inderal),

what is a likely heart rate?

a. 84

b. 65

c. propranolol (Inderal) has no effect on

heart rate


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A13

b. 65


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Q14

For atrial fibrillation and atrial flutter, you

turn to

a. lidocaine (Xylocaine)

b. quinidine (Qunidex)

c. amantadine (Symmetrel)

d. pilocarpine (Isopto Carpine)


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A14

b. quinidine (Qunidex)


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Q15

The equation MAP = CO x TPR

a. is used to determine the flow rate of TPNs

b. describes the relationship of cardiac output and

total peripheral resistance to the average blood(or mean arterial) pressure

c. shows that a decrease in CO can cause an

increase in TPR

d. shows that an increase in MAP always means

an increase in CO


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A15

b. describes the relationship ofcardiac

output and total peripheral resistance

to the average blood (or mean

arterial) pressure


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Q16

Antidote for warfarin overdose

a. protamine zinc insulin

b. protamine sulfatec. vitamin K

d. warfarin


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A16

c. vitamin K


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Q17

Antidote for heparin overdose

a. protamine sulfate

b. vitamin Kc. vitamin E

d. cyanocobolamine


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A17

a. protamine sulfate


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Q18

Antiplatelet agents include all of the

following except

a. acetylsalicylic acid

b. acetaminophen

c. ticlopidine (Ticlid)

d. dipyridamole (Persantine)


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A18

b. acetaminophen


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Q19

Regarding cholesterol therapy, the goal is

to

a. reduce LDL and raise triglycerides

b. reduce LDL and raise HDL

c. raise LDL and raise HDL

d. raise LDL and reduce triglycerides


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A19

b. reduce LDL and raise HDL


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Q20

Which organ requires extra monitoring

when the patient is undergoing lipid-

lowering therapy?

a. kidney

b. brain

c. liver

d. pancreas


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A20

c. liver


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Q21

A classic drug interaction, greatly involving

an increased bleeding time, involves

warfarin and

a. vitamin B-6

b. acetaminophen

c. acetylsalicylic acid

d. all of the above


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A21

c. acetylsalicylic acid


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Q22

Which vitamin is involved in the coagulant

process?

a. vitamin C

b. vitamin B-6c. vitamin D

e. vitamin K


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A22

e. vitamin K


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Antihypertensive Drugs

Beta Blockers

Atenolol (Tenormin)

Penbutolol (Levatol)

Metoprolol (Lopressor)

Carteolol (Cartrol)

Esmolol (Brevibloc)

Betaxolol (Kerlone) Acebutolol (Sectral)

Nadolol (Corgard)

Pindolol (Visken)

Timolol (Blocadren)

Propranolol (Inderal)

Labetalol(Trandate/Normodyne)

For hypertensive emergencies

Nitroprusside (Nipride)

Others Methyldopa (Aldomet)

Clonidine (Catapres)

Guanfacine (Tenex)

Guanabenz (Wytensin)

Reserpine (Serpasil)

Guanethidine (Ismelin) Prazocin (Minipres)

Hydralazine (Apresoline)

Minoxidil (Loniten)

Ace Inhibitors:

Captopril (Capoten) Enalapril (Vasotec)

Lisinopril (Zestril/Prinivil)

Benazepril


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Diuretics "Water pills"

Hydrochlorothiazide (HydroDiuril) Chlorothiazide (Diuril)

Methchlothiazide (Enduron)

Chlorthalidone (Hygroton)

Indapamide (Lozol) Furosemide (Lasix)

Bumetanide (Bumex)

Ethacrynic acid (Edecrin)

Spironolactone (Aldactone)

Triamterene with hydrochlorothiazide(Dyazide/Maxide)


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Anti-anginal drugs

Nitroglycerin (Nitrostat)

Amyl nitrate Isosorbide Dinitrate (Isordil)

PETN (Peritrate)

Dipyridamole (Persantine)

D f di h th i


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Drugs for cardiac arrhythmia

Quinidine (Quinidex) Digoxin (Lanoxin)

Procainamide

(Procan/Pronestyl)

Disopyramide (Norpace) Lidocaine (Xylocaine)

Tocainide (Tonocard)

Mexiletine (Mexetil)

Encainide (Enkaid)

Bretylium (Bretylol) Nifedipine (Procardia)

Bepridil (Vascor)

Isradipine (DynaCirc)

Nimodipine (Nimotop) Diltiazem (Cardizem)

Nicardipine (Cardene)

Verapamil

(Calan/Isoptin)

cardiovascular review ii-1

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