What does a high BNP signify?
- the ventricles are working too hard (<100 is normal)
- higher the BNP the worse the HF
Why is Cardiac Catheterization done?
- Look at heart
- Look for blockages
- Look at the valves
The RIGHT side of the heart supplies what?
Venous = Pulmonary (lungs)
The LEFT side of the heart supplies what?
Arterial = throughout the body
If we want to look at the right side of the heart (venous side) we will go through WHAT for cardiac cath?
If we want to look at the left side of the heart (arterial side) we will go through WHAT for cardiac cath?
Prior to cardiac cath - why do we make sure the patient is well hydrated?
to protect the kidneys (contrast media) is toxic to kidney tissue
What is done prior to cardiac cath?
- Labs upfront (pt, ptt, platelets, kidney function, BUN, Creatinine (for contrast medium)
- Informed consent and educate patient
- IV – large gauge for fluids
- Meds reconciliation for anti-coagulants
- Transition from coumadin to heparin
- ECG – monitored the entire time during procedure
- Allergies – iodine?
- Circulation – important for two reasons (blockage/clot, or hematoma)
What do we check for circulation?
- Peripheral pulses (pre and post)
- Motor movement
When right sided cath is done what type of clot do we worry about?
- Pulmonary embolism (PE)
- vagal response
When left sided cath is done what type of clot do we worry about?
- Brain (stroke)
- Heart (MI)
- Arterial bleeding or thromboembolism
What are potential complications of cardiac cath for either side of the heart?
- Cardiac tamonade
- Pulmonary edema
- Hematoma or blood loss at insertion site
- Reaction to contrast medium
What do we worry about with contrast media?
- Hypovolemia - contrast media acts as a diuretic
- concerned about K+ loss
What does telemetry tell us?
What does an ECG tell us?
What is done prior to and during a stress test?
- 12-lead EKG
- continuous BP monitoring
- No beta-blockers (hold)
- No caffeine, alcohol, smoking (stimulants)
In a stress test, the patient exercises until one of these findings occurs:
- A predetermined HR is reached and maintained
- S/S of chest pain, fatigue, extreme dyspnea, vertigo, hypotension, ventricular dysrhythmia
- Significant ST-segment depression
- Significant T-wave inversion
- 20-minute protocol is completed
Why is a transthoracic echocardiogram done?
look at valves and wall function of the heart
Why is a transesophageal echocardiogram done?
- look at left atrium, aortic arch, mitral valve
- May do prior to cardioversion
What is meant by the term heart failure?
Heart Not pumping well
Really talking about ventricles (especially left ventricle)
What are the key features in LEFT-SIDED heart failure?
- confusion, restlessness
- tachy, palpitations
- weak peripheral pulses
- cool extremities
- cough, dyspnea, crackes or wheezes
- tachypnea (rapid breathing)
- S3/S4 summation gallop
What are the key features of RIGHT-SIDED heart failure?
- (Systemic Congestion)
- enloarged liver and spleen
- anorexia and nausea
- dependent edema (legs and sacrum)
- distended abdomen
- swollen hands and fingers
- polyuria at night
- weight gain
- increased BP (too much fluid)
- decreased BP (because of HF)
What do we teach our patients with HF in regard to weight?
- daily weights best indicator of fluid status
- same time
- same clothing
- same scale
Why does RIGHT-SIDED HF occur?
Difficulty moving blood forward so it falls back to the heart (preload is an issue)
What are the causes of RIGHT-SIDED HF?
- Right sided MI
- Left sided HF
- Resistance - pushing blood into the pulmonary tree
- >Pulmonary HTN
What sound is heard (when auscultating the heart) for LEFT-SIDED HF?
What is the formula for determining cardiac output (CO)?
- CO = HR x SV
- cardiac output = heart rate x stroke volume
What are the causes of LEFT-SIDED HF?
- MI damaged left side heart
- Valve issues (mitral / aortic) – aortic valve is a set up for HF
What is the treatment for RIGHT-SIDED HF?
What is the treatment for LEFT-SIDED HF?
- Diuretics – to decrease fluid in the lungs
- ACE inhibitor or ARB – decreases afterload
- Digoxin – increases the strength of contraction
- Beta blockers to decrease HR (later and over time)
- Nitro at high doses
When a patient with A-fib also has a valve probem, what anti-coagulant is given?
Coumadin ONLY - no other anti-coags
What part of the heart is the workhorse and therefore has the most issues?
What is a sign that mitral stenosis or mitral regurgitation has gotten worse?
dyspnea on exertion
What are two issues with the mitral valve?
- Mitral valve stenosis – narrowing of the mitral valve
- Mitral regurgitation
- Both cause Problems in the left atrium
Mitral issues usually cause
Why is aortic valve dysfunction worse than mitral valve dysfunction?
may cause left ventricle failure
What are two issues with the Aortic valve?
- Aortic Stenosis
- Aortic regurgitation
- Both back up to left ventricle
What is a symptom of Aortic Regurgitation?
Angina because the heart isn’t getting enough blood from aorta back to coronary arteries
What are the treatments for Aortic Valve dysfunctions?
- Beta blockers – increase filling time (FYI)
- Xenograft – bovine valve – doesn’t risk for clot formation
- Mechanical valve (aortic) – (non-tissue) – anticoagulation for lifetime (much higher risk
Which graft of aortic valve must the patient take anticoagulants for life?
mechanical valve (non-tissue / foreign body)
What are the causes of Valve dysfunctions?
- Infection (endocarditis) (strep)
- Advanced age
- Connective tissue disease (marfans)
What patient and family education is needed for valvular heart disease?
- notify all healthcare providers
- remind healthcare provider before dental work or respiratory procedure
- request ABX before and after procedures
- clean all wounds and apply ABX ointment
- notify provider of fever, petechiae, or SOB
A thickening or hardening of the walls of arteries
The buildup of plaque on the walls of arteries
What are the 6 P's for assessments?
- Poikilothermia (cold)
What assessments will be done for Peripheral Vascular Disease?
- 6 P's
- capillary refill (<3 sec / <5 sec elderly)
- bruit - listen (auscultate)
- -carotids, aortic, femoral, popliteal
- BP – both arms to determine issue with flow in that arm
What are the causes of Peripheral Vascular Disease?
What are the S/S of Peripheral Vascular Disease?
- Brown pigmentation
- Elevation of legs decreases pain
- Have pulses
- Ankle wounds
- Varicose veins
- Compression stockings
- Exercise - walking
Peripheral arterial disease puts a patient at risk for?
Coronary artery disease
What are the causes of Peripheral Arterial Disease?
- Claudication (Pain with movement)
What is the treatment for Peripheral Arterial Disease?
- Stop smoking
- Change diet
- Exercise as much as possible
- Nothing heat related to their skin (extreme heat or cold = NO)
- Aortic Femoral Bypass (AFB) – same circ checks for cardiac catheterization – if changes call the doctor
What are the S/S of Peripheral Arterial Disease?
- Rubor (redness) when legs are down
- Pallor when legs elevated
- Extreme pain with
- Decreased or no pulses
- No edema
- Hair loss
- Brittle/thickened nails
- Cool skin
- Toe wounds
What are the causes of Aortic Aneurysms?
- Gender (women)
- Marfan’s (Connective tissue disorder)
What is the biggest concern when assessing a patient with Aortic Aneurysms?
- Never palpate abdomen of someone with aortic aneurysm (could burst)
What are the S/S of Aortic Dissection and Tear?
- Ripping feeling to back or groin
- Pulsating mass (on echo)
- BP high initially à hypotension (bleeding out)
- Check vitals Q5M, pulses Q5M
What patient and family education needs to be done for the patient with Peripheral Vascular Disease?
- Keep feet clean - wash with mild soap
- Keep feet dry - especially ankles and between toes
- Avoid injury to feet and ankles - never go w/o shoes
- Keep toenails clean and filed - cut nails straight across
- Apply lubricating lotion to feet
- Prevent exposure to extreme temps - never use heating pad or ice
- Avoid constricting garments
- If a problem develops see podiatrist or PCP
- Avoid extended pressure on feet or ankles
Diabetic ketoacidosis (DKA) / Hyperosmolar hyperglycemic state (HHS) are metabolic derangements that occurs in patients with
Both Diabetic ketoacidosis (DKA) / Hyperosmolar hyperglycemic state (HHS) cause profound ?
Hypovolemia (dehydration) - may be severe
What are the clinical manifestations of hypovolemia (dehydration)?
- ↑ HR
- Weak peripheral pulses
- ↓ BP
- Orthostatic or postural hypotension
- dizziness, light-headedness
- ↑ Respiration - because low O2
- Skin: turgor, pallor, moisture
- ↑ temp
- ↓ urine output
What is Kussmaul Respirations?
- deep and labored breathing pattern
- associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure.
What is the treatment for Diabetic ketoacidosis (DKA) / Hyperosmolar hyperglycemic state (HHS)
Which one Diabetic ketoacidosis (DKA) / Hyperosmolar hyperglycemic state (HHS) is associated with Kussmaul Respirations?
Diabetic ketoacidosis (DKA)