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Hypertension preload versus after load
Three factors affect stroke volume: preload, contractility, and afterload. Preload. Preload is the amount of blood remaining in a ventricle at the end of diastole or the pressure generated at the end of diastole. Increased preload results in increased stroke volume and, therefore, increased cardiac output. Factors that increase preload include increased venous return to the heart and overhydration. Factors that decrease preload include dehydration, hemorrhage, and venous vasodilation. Contractility. Contractility is the ability of cardiac muscle fibers to shorten and produce a muscle contraction. Inotropy is a term used to refer to the contractile state of the cell. Factors that increase contractility are said to have a positive inotropic effect, and factors that decrease contractility create a negative inotropic effect. Afterload. Afterload is the amount of pressure the ventricles must overcome to eject the blood volume. It is determined primarily by the pressure in the arterial system. Afterload is decreased by vasodilation and increased by vasoconstriction.
2. KNOW WHAT IS MODIFIABLE AGE P631
Risk Factors. Factors that increase the risk of atherosclerosis include increased serum lipids, high blood pressure, cigarette smoking (nicotine), diabetes mellitus with elevated blood glucose, obesity, sedentary lifestyle, age, gender, race, and heredity. These risk factors are divided into two categories: risk factors that can be modified and those that cannot be modified. Risk factors that cannot be modified are age, gender, heredity, and race. The focus of patient education is on reducing the risk factors that can be modified. Other factors that may also contribute to the development of coronary heart disease are stress, sex hormones, birth control pills, excessive alcohol intake, and high homocysteine levels. Healthy People 2010 has set several goals related to serum lipid levels. One of these is to reduce the mean total blood cholesterol in adults from 206 mg/dL to 199 mg/dL. In addition, efforts will be made to reduce the proportion of adults with high blood cholesterol, increase the proportion of adults who have had their blood cholesterol checked within the past 5 years, and increase the proportion of individuals with CAD who have LDL levels treated to the goal of equal to or less than 100 mg/dL
3. TEE DIAGNOSTIC TEST
TRANSESOPHAGEAL ECHOCARDIOGRAM At times, the echocardiogram is not diagnostic and a transesophageal echocardiogram (TEE) is used. A flexible endoscopic probe with an ultrasound transducer is passed down the back of the throat into the esophagus. A local anesthetic to the throat decreases the gag reflex. Occasionally, an intravenous sedative is needed to reduce patient anxiety. Images are obtained from behind the heart as the probe moves down into the stomach. The probe is down for approximately 15 to 20
Atherosclerosis begins with injury to the endothelial cells that line the wall of the arteries. and in some cases after myocardial infarction Examples of these medications are captopril (Capoten). Signed consent required. In addition. and. is an inflammatory disease that begins with endothelial injury and progresses to the complicated lesion seen in advanced stages of the disease process. WHAT MEDS ARE ACE INHIBITORS AND HOW IT AFFECTS THE ARTERIAL SYSTEM ON PATIENTS ACE inhibitors may be prescribed for some patients to minimize the abnormal shaping or remodeling that can occur in the damaged ventricular muscle. which is characterized by the following: • 1. and complicated (advanced) lesions. ACE inhibitors decrease preload and afterload by blocking the RAA system. which leads to inflammation and dysfunction of the endothelial cells.A rate of 60 to 100 bpm • 2.10 second or less 6. 7.A PR interval that is within 0. FIVE CHARACTERISTICS OF A NORMAL SINUS RHYTHM The normal finding is called a normal sinus rhythm. NURSING INTERVENTION WILL BE IMPORTANT WITH THE TEE TEST FOR PT SAFETY Used when conventional echocardiogram not diagnostic. decreased blood volume. a form of arteriosclerosis. and lower blood pressure.A QRS complex that is 0. resulting in vasodilation.A P wave preceding each QRS complex o 4. gag reflex. and quinapril (Accupril). The TEE provides information useful in the evaluation of ventricular wall motion and function and possible heart valve disorders. results in the deposit of LDLs along the intima of arteries. less fluid is retained because aldosterone release is blocked. if sedated. ACE inhibitors are thought to limit the progression of ventricular remodeling. In addition. When enough foam cells accumulate. may have IV. Endothelial injury. level of consciousness 5. they progress to the lesions associated with atherosclerosis: fatty streaks.12 to 0. ACE inhibitors are prescribed for patients with heart failure.minutes. 4.A regular rhythm • 3.20 second • 5. These deposits are called foam cells. Monitor vital signs. enalapril (Vasotec). Same purpose as echocardiogram Tell patient what to expect: throat will be anesthetized. 2 . fibrous plaque. Angiotensin-converting enzyme (ACE) inhibitors (ACEI) work against the renin-angiotensinaldosterone system to dilate arteries and decrease the resistance to blood flow in the arteries (reduced afterload). some cases of hypertension. Probe inserted through esophagus into stomach (behind heart). ATHEROSCLEROSIS :KNOW THE CONDITION Atherosclerosis.
and heredity. unstable. Fibrous Plaque. and may have smooth or rough edges. platelets. high blood pressure. efforts will be made to reduce the proportion of adults with high blood cholesterol. It is commonly found in the aorta by age 10 and in coronary arteries by age 15 regardless of race. Collateral blood vessels are new branches that grow from existing arteries to provide increased blood flow. and increase the proportion of individuals with CAD who have LDL levels treated to the goal of equal to or less than 100 mg/dL (Centers for Disease Control and Prevention/National Institutes of Health.Progression of Lesions. Complicated lesions develop as ulceration or rupture of the plaque occurs and platelets adhere to the lesion. or environmental factors. diabetes mellitus with elevated blood glucose. One of these is to reduce the mean total blood cholesterol in adults from 206 mg/dL to 199 mg/dL. may develop in one portion of the artery or circle the entire lumen. gender. There are no symptoms associated with these lesions. and race. heredity. and migrate over the fatty streak. or chest pain. In addition. results when the demand for oxygen by the myocardial cells exceeds the supply of oxygen delivered. Fibrous plaque contributes to the loss of arterial elasticity and impairs the vessel's ability to vasodilate to meet increased oxygen needs. Collateral Circulation. proliferate. The fibrous plaque is whitish or grayish appearing. gender. collateral circulation may develop. sedentary lifestyle. obesity. Platelet adherence can trigger the coagulation cascade with the development of a thrombus that obstructs (occludes) the artery. and high homocysteine levels. and variant. Risk factors that cannot be modified are age. Complicated Lesions. The focus of patient education is on reducing the risk factors that can be modified. There are different types of angina: stable. Factors that increase the risk of atherosclerosis include increased serum lipids. 8. gender. This forms a fibrous plaque that protrudes out from the wall of the artery into the lumen. If plaque formation occurs slowly. Smooth muscle cells. Other factors that may also contribute to the development of coronary heart disease are stress. Healthy People 2010 has set several goals related to serum lipid levels. birth control pills. DIFFERENCE BETWEEN STABLE AND UNSTABLE Angina pectoris (shortened to angina). Yellow-colored lipids (fat) fill smooth muscle cells. chronically stimulated by LDLs and platelet activated growth factors. Other substances (WBCs. Stable angina (also called chronic angina or exertional angina) occurs most often with exercise or activity and 3 . excessive alcohol intake. Risk Factors. age. These risk factors are divided into two categories: risk factors that can be modified and those that cannot be modified. sex hormones. 2005). calcium) adhere to and collect within the plaque. The fatty streak is the earliest lesion to develop in atherosclerosis. The fatty streak is thought to be reversible. The fibrous plaque is the characteristic lesion of progressing atherosclerosis. Fatty Streak. race. which develops over time. the most common symptom of CAD. cigarette smoking (nicotine). EXPLAIN UNSTABLE ANGINA . produce collagen. producing streaks of fat that cause no obstruction to the affected vessel. lipids. increase the proportion of adults who have had their blood cholesterol checked within the past 5 years.
If they do not close properly. and heavy meals. burning. physical exertion. Cardiac contractility may decline. is often not relieved by NTG or requires more frequent NTG administration. The patient may describe a change in the pain pattern or in the severity of the pain. The valves may thicken and stiffen. Accompanying symptoms are diaphoresis. emotional stress. It also takes longer to return to normal after exercise or stress. READ ABT THE CONDITION AGE-RELATED CHANGES It is difficult to separate the normal age-related changes in the heart and blood vessels from the changes caused by disease. The pain of unstable angina is more severe. the neck. Other precipitating factors are smoking. Cardiac dysrhythmias are more common in older people but should still be evaluated because they can be dangerous.usually subsides with rest. dyspnea. age-related changes progress slowly. Physical exercise does not have to be strenuous to be helpful. The number of pacemaker cells in the SA node decreases. causing incomplete emptying of the chambers. but recognizable III Loud. The pain may radiate to either arm. Unstable angina may occur in a patient with a history of stable angina. Unstable angina (categorized and treated as an acute coronary syndrome) is also called crescendo angina or preinfarction angina. the shoulder. or smothering. HEART MURMURS CAUSED BY VALVES THAT DO NOT CLOSE WELL. occurs at rest or with minimal exertion. unstable angina may be the first clinical manifestation of CAD that a patient experiences. as does the number of nerve fibers in the ventricles. making the heart less able to adapt to changes in circulating blood volume. The pain is usually substernal and described by the patient as viselike. Table 35-2 Grading of Heart Murmurs GRADE DESCRIPTION I Very faint II Faint. Usually. 9. stable angina lasts only a few minutes and is relieved by rest or with nitroglycerine (NTG). Or. The valves may also partially block the path of blood flow. unstable angina is considered more serious than stable angina and will be treated differently. the jaw. whereas pathogenic changes are more likely to be sudden. nausea. In general. Patients with unstable angina are at higher risk for acute myocardial infarction (AMI) and are often hospitalized for diagnostic workup and treatment. and vomiting. and is not predictable. The aging heart takes longer to respond to stress and then responds less dramatically. In either case. squeezing. the patient may have a murmur. or the epigastrium. Stable angina occurs intermittently and is often predictable. HEART Changes in the heart muscle include increased density of connective tissue and decreased elasticity. Health Promotion Considerations Long-Term Conditioning Long-term conditioning with an exercise program may help decrease arterial stiffening and improve the function of the left ventricle in older individuals. but moderate in intensity IV Loud and accompanied by a palpable thrill 4 . Activity should become a part of an individual's regular routine.
Tell patient what to expect. The procedure is done in a special room. Signed consent required. Assess allergies to seafood or iodine and inform radiologist. pulse. and pressures in the various structures are measured. the catheter is inserted into a vein and threaded into the vena cava. A heart murmur is the sound produced by turbulent blood flow across the valves. and pulmonary artery. infection. Murmurs are graded according to intensity or loudness (Table 35-2). 10. under fluoroscopy (Fig. accompanied by a palpable thrill. Give sedative if ordered. maintain pressure per protocol if a vascular sealing device is not used. Check puncture site. Nursing care before and after the procedure is very important. or both. 35-6). and they are located using the anatomic landmarks where they are heard best. or medium pitch.GRADE V VI DESCRIPTION Very loud. NPO for specified time before procedure. In a catheterization of the left side of the heart. The timing of a murmur relates to when it is heard in the cardiac cycle: systole or diastole. RV. The femoral vein and artery are the preferred insertion sites. Blood samples may be drawn. Murmurs are recorded as having high. low. and films are made of the visualized heart structures. The function of the coronary arteries and the aortic and mitral valves may be assessed. Radiographs are taken to visualize heart structures and blood vessels. 11. and embolus or thrombus formation. RV. RA. and ECG are monitored throughout test. Enforce bed rest as ordered. SEE #10 WHAT DO U CK BEFORE GOING TO HAVE THIS PROCEDURE AND WHAT ALLERGIES? 5 . the catheter is inserted into an artery and threaded against the flow of blood into the coronary arteries or the LV. Monitor vital signs and peripheral pulses on affected extremity. may be heard with the stethoscope slightly above the client's chest Heart Murmurs. The function of the pulmonic and tricuspid valves may be assessed. and pulmonary artery may be determined. Pressures in the RA. CORONARY ARTERIOGRAPHY) Cardiac catheterization is a procedure in which a catheter is inserted into a vein or artery and is threaded into the heart chambers. Vital signs and ECG are monitored during the procedure. hematoma formation. In a catheterization of the right side of the heart. coronary arteries. A contrast dye is injected through the catheter. Complications of cardiac catheterization include bleeding. Tell patient to expect flushing sensation when dye is injected. CARDIAC CATHETERIZATION (CARDIAC ANGIOGRAPHY.WHY IS IT IMPORTANT TO CK FOR BLEEDING AT THE PUNCTURE SITE WITH CARDIAC CATHERIZATION PTS? A catheter is passed through a vein or artery and dye is injected. & 11 . Blood pressure. and audible with the stethoscope partially off the client's chest Extremely loud.
and return to normal within 2 to 3 days if no new damage occurs. The CPK-MB can be expected to rise 4 to 6 hours after an AMI. elevated LDL levels are associated with a higher risk of CAD. 13. 2007). The HDLs are desirable because they promote the excretion of cholesterol. Levels may elevate slightly as a result of lesser insults. Triglycerides are a major contributor to CAD. Triglyceride levels increase when LDL levels increase. and remain in the circulation for up to 2 weeks (cTnI remains elevated for 5 to 7 days. The normal triglyceride level is less than 150 mg/dL. The cholesterol accumulates in the arterial lumen and in time results in decreased blood flow and occlusion. Currently. troponin T (cTnT) and troponin I (cTnI) are specific to cardiac muscle and are released into the circulation after an acute myocardial infarction. Troponin T (cTnT) and troponin I (cTnI) are proteins released from cardiac muscle when the muscle is damaged. The nurse can plot these trends. and remain in the circulation for up to 2 weeks. the high-density lipoproteins (HDLs) and the low-density lipoproteins (LDLs) are the two that most closely correlate with coronary artery disease. TESTS TO DETECT MYOCARDIAL INFARCTIONS ALSO LDH 3-6 DAYS Troponin Troponin is a protein involved in the contraction of muscles. Serial trends should be observed. and testicular hormones. generally not detectable in healthy individuals. will elevate significantly after an acute myocardial infarction. such as an episode of angina. A good way to remember the difference is that HDLs are healthy and LDLs are lethal. They are produced in the liver. Two subtypes. Troponin levels. It is used to form bile salts for the digestion of fat and for the production of adrenal.12. therefore higher levels of HDLs are encouraged. Troponin levels may be drawn in the emergency room Creatine Phosphokinase The creatine phosphokinase enzyme is found in high concentration in three tissues: the brain. 6 . peak in 12 to 24 hours at more than 6 times the normal value. LDL(LETHAL) VS HDL( HEALTHY) LEVELS Several forms of cholesterol are identified. On the other hand. Lipid Profile A lipid profile is a battery of tests that measure the most common serum lipids: cholesterol. Cholesterol is a blood lipid produced by the liver. hypertension. The type of creatine phosphokinase (CPK) specific to heart tissue is CPK-MB. The normal adult serum cholesterol level is less than 200 mg/dL. peak in 24 hours. Elevation of the CPK-MB level indicates damage to the myocardial cells. Elevated cholesterol levels (hypercholesterolemia) are associated with increased risk of CAD. the heart. however. and the skeletal muscle. and lipoproteins. Troponin levels rise in 3 to 6 hours from onset of symptoms. This test is done in the emergency department because the results are available more quickly than the cardiac enzymes. therefore lower LDL levels are encouraged. peak in 24 hours. Troponin levels elevate in 3 hours after myocardial injury. triglycerides. ovarian. cTnT for 10 to 14 days). and AMI. the recommendations are for HDL levels greater than 40 mg/dL and for LDL levels less than 100 mg/dL (American Heart Association. Musculo-skeletal injuries (especially fractures and surgery) and recent excessive athletic activity can also elevate the total CPK level.
and weight loss fail to bring cholesterol levels under control. teach patient: • Continue diet and exercise. 645. teach patient: • Continue diet and exercise. along with diet and exercise. teach patient: • Continue diet and exercise. exercise. Monitor liver function tests. Serial laboratory tests (lipid profile and liver function) will be closely monitored. • Take with meals to decrease GI side effects. Decreases triglyceride levels. Lowers LDL cholesterol. For best effect. Nicotinic acid (niacin) Decreases synthesis/secretion of VLDL and LDL by liver. To get the best effect. The goal of therapy is for the patient to have decreased serum triglyceride and LDL levels and an improved HDL level. KNOW THAT ATROPINE INCREASES THE HEART RATE AND MONITOR PT FOR TACHYCARDIA AND URINE RETENTION ATROPINE SULFATE Usage: Vagal blocker. and quit smoking. teach patients: • Continue diet and exercise. Increases HDL. Decreases synthesis of LDL. for many patients with heart disease. • Report muscle tenderness. Increases HDL cholesterol. Interferes with absorption of some other drugs. 15. 14. • Take with meals.Atorvastatin (Lipitor) Increases rate of removal of LDL from plasma. LIPID-LOWERING AGENTS Cholestyramine (Questran) Prescribed when diet. Nursing interventions: Assess HR and rhythm and BP. For best effect. exercise.Low HDL levels can be raised by being physically active at least 30 minutes every day. Pravastatin (Pravachol).Lovastatin (Mevacor). For best effect. Patients on this group of medications need to be encouraged to adhere to diet restrictions.Simvastatin (Zocor). Selected lipid-lowering medications are included in the Drug Therapy table on p. and by losing weight (or maintaining a healthy weight). so check drug-drug interactions before giving. by not smoking. Used in symptomatic bradycardia and bradydysrhythmias. • Take as single dose in the evening • Have routine eye examinations 7 . Increases HR and CO in heart blocks and severe bradycardia. KNOW THE THERAPEUTIC LIPID LEVELS Lipid-Lowering Agents Lipid-lowering medications are frequently part of the overall treatment plan. • Increase fluid intake to counter constipating effects Gemfibrozil (Lopid) Decreases synthesis and secretion of VLDL by liver.
All staff should know the exact amount of fluid allowed and must record all intake. Even with fluid volume excess. KNOW THE S/S OF FUILD VOLUME EXCESS AND CHF Monitor for jugular venous distention Fluid Volume Excess The patient will have normal and peripheral edema. This allows time for a dietary consultation to be arranged. by weight of 145 lbs. advise the patient to avoid foods high in sodium (a list should be provided). Acknowledge the difficulty. and ability to as ordered. muscle weakness or twitching. For a 2-g sodium diet. and monitor the patient for adverse effects. In severe cases. increased aldosterone. and abdominal distention. a limitation of 500 to 1000 mg/day may be prescribed. Reduced sodium intake decreases fluid retention. WHAT DO U DO BEFORE DIGOXIN? 8 . The person who prepares the patient's meals at home must be included in the teaching sessions. Protect release daily living without dyspnea. absence Maintain intravenous lines and correct sodium and water of crackles and wheezes in fluid infusion rate. Fluid restriction can be very uncomfortable for the patient. Therefore measures are taken to reduce the fluid volume to normal while improving the function of the heart. The patient and family must understand why fluids are restricted so that the patient does not exceed the prescribed intake. an attempt to maintain normal cardiac output. which should be followed by reinforcement by the nurse. Administer diuretics retention. and to use no more than 2 cups of milk products daily. Frequent serum electrolyte measurements are usually ordered. Patients often have difficulty changing their use of seasonings. If intravenous fluids are administered. It is best to identify the type of diet to be prescribed on discharge as early as possible. If fluid retention is not relieved by other means. cramps. fluid restriction may be instituted. edematous extremities from pressure or injury. and explain how sodium limitation contributes to improvement of cardiac function. not to add salt before or after cooking. daily and intake and output accurately. it compounds the problem by increasing the workload on the heart. Administer diuretics as ordered. 17. The patient may be limited to 2 g of sodium/day. report an output of less than 30 mL/hr to the physician as well. Signs and symptoms that may indicate fluid or electrolyte disturbances include cardiac dysrhythmias. Auscultate heart related to decreased fluid balance as evidenced and lung sounds q 4 hr. Note the results and notify the physician of abnormal findings. changes in mental status. thereby reducing the cardiac workload.16. Present oral fluids in small containers. If hourly urine output is being measured. monitor the rate of administration very carefully. The patient should be weighed daily. An intravenous catheter is usually placed to provide a line for drug administration. Unfortunately. CHF The most common therapeutic dietary measure for CHF is sodium restriction. The most common adverse effects of diuretic therapy are fluid and electrolyte disturbances. absence of edema. Measure weight glomerular filtration rate. and increased lungs. and offer them at reasonable intervals. Frequently provide mouth care. the patient may feel thirsty because of electrolyte imbalances. Fluid Volume Excess Fluid retention is a response to HF. Teach about sodium antidiuretic hormone participate in activities of restriction and rationale.
Assess apical pulse for 1 min. Examples are digoxin (Lanoxin) and digitoxin. a maintenance dose is prescribed to maintain the therapeutic effects. myocardial irritability. Increases effects may be indicated by dysrhythmias. Toxic (Lanoxin) (positive inotropic effect). causing increased stroke volume and cardiac output. anorexia. These drugs have high potential for toxicity and require close monitoring. Use with caution in all patients with obstructive lung disease. Cannot be Delays impulse conduction through administered intramuscularly. withhold the dose and contact the physician. Monitor weight daily. and chronic stable angina. Monitor blood glucose with diabetes. Monitor K+ AV node to slow heart rate (negative levels. and disturbances. Teach the patient: 9 . Decreases HR. Decreased renal function may Digoxin or force of myocardial contraction delay excretion and lead to toxicity. nausea. When rapid effects are needed.0 ng/mL. May cause bronchial constriction. nausea. check for peripheral edema. visual disturbances). administer K+ supplements as chronotropic effect). hypertension. visual atrial fibrillation and flutter. and abdominal pain. 18. Cardiac Glycosides The cardiac glycosides are also called cardiotonics or digitalis glycosides. pulse <60. WHY DO U STOP A BETA BLOCKER AND WHY OR WHY NOT? Propranolol (Inderal) Nonselective beta-adrenergic blocker. Used for HF. Because patients are often on cardiac glycosides for long-term therapy. Toxic level: >2. and contractibility. Therapeutic level: 0. May be administered with diuretic to decrease Na+ and water retention. syncope. migraines. Increases strength ordered. They are also used to treat some cardiac dysrhythmias. Teach the patient: • Take radial pulse for 1 min at the same time each day. Cardiac glycosides are widely used in the treatment of heart failure (HF). stroke volume and CO.8–2. myocardial infarction. and electrolytes before administering first dose. They slow the heart rate (negative chronotropic effect) and increase the force of myocardial contraction (positive inotropic effect). hold and notify physician if <60. ECG. Auscultate lungs for crackles and heart for S3 and S4. Once therapeutic blood levels are obtained. paroxysmal atrial tachycardia. a patient can be given a loading dose (called a digitalizing dose) of cardiac glycosides. Decreases BP in hypertension.CARDIAC GLYCOSIDES Obtain baseline vital signs. they must be taught to monitor their own pulse and to report symptoms of toxicity (anorexia. If the rate is below 60 bpm in adults. Decreases CO. These drugs have several important pharmacologic actions on the heart. Common practice is to count the apical pulse before giving each dose. Used in dysrhythmia.0 ng/mL. Monitor vital signs.
check for edema. increase activity slowly. and check the blood pressure in both arms. Next. also known as postural hypotension. and standing positions. 19. As blood pressure decreases. the pulse should increase as a compensatory mechanism. KNOW HOW TO ASSESS FOR ORTHOSTATIC HYPOTENSION (SEE BP) Orthostatic hypotension. and tends to affect primarily older adults. Position the arm at the heart level. • Weigh daily. Note the pulse pressure (difference between the systolic and diastolic pressures) because it is a noninvasive measure of cardiac output. taper over 2 weeks. refers to a condition where the blood pressure falls rapidly after a change in body position. The problem is relatively common. measure blood pressures and pulse rates in the lying. Patients with orthostatic hypotension usually experience symptoms of low blood pressure when they stand up after sitting or lying for a period of time.• Do not discontinue this drug abruptly. use alcohol only in moderation. • There is not the normal increase in heart rate with exercise and stress. • While on this drug. 10 . decrease sodium intake. • Take at the same time(s) each day. sitting. Blood Pressure. no smoking. though younger patients sometimes experience the condition as well. The diagnosis of orthostatic hypotension requires a blood pressure decline of 20mmHg in the systolic pressure or 10mmHg in the diastolic pressure within five minutes of rising from a seated or lying position. A blood pressure decrease of 20 mm Hg or more with a position change indicates decreased blood volume or an autonomic response. The correct-size blood pressure cuff must be used.