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What does a high BNP signify?
- the ventricles are working too hard (<100 is normal)
- higher the BNP the worse the HF
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Why is Cardiac Catheterization done?
- Look at heart
- Look for blockages
- Look at the valves
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The RIGHT side of the heart supplies what?
Venous = Pulmonary (lungs)
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The LEFT side of the heart supplies what?
Arterial = throughout the body
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If we want to look at the right side of the heart (venous side) we will go through WHAT for cardiac cath?
VEIN
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If we want to look at the left side of the heart (arterial side) we will go through WHAT for cardiac cath?
ARTERY
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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
- V/S
- NPO
- 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)
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What do we check for circulation?
- Peripheral pulses (pre and post)
- Sensory
- Motor movement
- Color
- Temp
- Pain
-
When right sided cath is done what type of clot do we worry about?
- Pulmonary embolism (PE)
- Thrombophlebitis
- vagal response
-
When left sided cath is done what type of clot do we worry about?
- Brain (stroke)
- Heart (MI)
- Arterial bleeding or thromboembolism
- Dysrhythmias
-
What are potential complications of cardiac cath for either side of the heart?
- Cardiac tamonade
- Hypovolemia
- 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?
dysrhythmias
-
What does an ECG tell us?
Ischemia
-
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
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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?
- fatigue
- weakness
- oliguria/nocturia
- angina
- confusion, restlessness
- dizziness
- tachy, palpitations
- pallor
- weak peripheral pulses
- cool extremities
- cough, dyspnea, crackes or wheezes
- tachypnea (rapid breathing)
- S3/S4 summation gallop
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What are the key features of RIGHT-SIDED heart failure?
- (Systemic Congestion)
- JVD
- 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
- >COPD
- >ARDS
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What sound is heard (when auscultating the heart) for LEFT-SIDED HF?
S3
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What is the formula for determining cardiac output (CO)?
- CO = HR x SV
- cardiac output = heart rate x stroke volume
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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
- HTN
-
What is the treatment for RIGHT-SIDED HF?
- Positioning
- Vasodilation
- Diuretic
-
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?
Left ventricle
-
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
A-fib
-
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?
- Rheumatologic
- Congenital
- Infection (endocarditis) (strep)
- HTN
- 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
Arteriosclerosis
-
The buildup of plaque on the walls of arteries
Atherosclerosis
-
What are the 6 P's for assessments?
- Pain
- Pallor
- Pulselessness
- Parasthesia
- Paralysis
- 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?
obesity
-
What are the S/S of Peripheral Vascular Disease?
- Brown pigmentation
- Elevation of legs decreases pain
- Have pulses
- Edema
- Ankle wounds
- Varicose veins
- Elevate
- Compression stockings
- Exercise - walking
-
Peripheral arterial disease puts a patient at risk for?
Coronary artery disease
-
What are the causes of Peripheral Arterial Disease?
- Obesity
- DM
- Claudication (Pain with movement)
- Smoking
-
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?
- HTN
- Atherosclerosis
- Smoking
- Age
- Gender (women)
- Syphilis
- Marfan’s (Connective tissue disorder)
- Genetic
-
What is the biggest concern when assessing a patient with Aortic Aneurysms?
- Bruit
- 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
- Syncope
- Diaphoresis
- Hoarseness
- 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
DM
-
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
- confusion
- ↑ 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)
INSULIN
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Which one Diabetic ketoacidosis (DKA) / Hyperosmolar hyperglycemic state (HHS) is associated with Kussmaul Respirations?
Diabetic ketoacidosis (DKA)
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