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CAD, risk factors (modifiable, non-modifiable

Risk Factors: 1. Male 2. Hypertension 3. Tobacco Use 4. Advanced Age 5. Hyperlipidemia 6. Metabolic Disorders (diabetes, hyperthroidism) 7. Methamphetamine or cocaine use 8. Chronic stress or acute stress 9. Physical inactivity 10. Misc atherosclerotic changes, such as peripheral vascular disease 11. Family history: can be a rather significant risk factor for some Common risk factors that occur frequently: Hypertension, Hyperlipidmia, Smoking, Diabetes, Family history Modifiable risk factors: things you can change: hypertension, tobacco use, hyperlipidmia, diabetes mostly type II or uncontrolled diabetes, cocaine use, stress, physical inactivity Non-modifiable: risk factors you cannot change: male, age, certain metabolic disorders unable to control, other diseases unable to change. Atherosclerosis: hardening and loss of elasticity Atherosclerosis: Deposit of fatty streaks leading to irregular thickening and plaque formation Meds: lipid lowering agents, 1. statins, lowers LDL¶s a. monitor liver enzymes b. muscle weakness a side effect 2. nicotnic acids: lower triglycerides, increasing HDL a. side effect: flushing b. causes hyperglycemia and gout c. example: Niaspan 3. Fibric acids a. lower triglycerides, increase HDL b. may cause gallstones c. example: Tricor 4. Bile acid sequesters, lowers LDL, increases HDL a. not absorbed or metbolized in liver b. stays in gut, can cause GI distress c. example: Questran 5. Cholesterol absorption inhibitors, lowers LDL, increases HDL a. example: Zetia 6. Omega 3 fatty acid a. lower TG b. example: fish oil

MI, symptoms, nursing care, drug therapy.
Symptoms: 1. Angina: warning sign of a possible impending MI: chest pain, arm pain, back, jaw. a. stable angina: occurs with exercise or stress, and is relieved by nitro

b. unstable angina: occurs with exercise or stress, and increases in severity over time c. Variant: occurs during periods of rest d. Note: pain that does not go away with rest or nitro typically is a bad sign and means MI e. women and older adults do not often have the classic symptoms of angina however 2. Subjective Data: a. anxiety b. chest pain substernal or precordial c. nausea d. dizziness 3. Objective data: a. pallor and cool, clammy skin b. tachycardia/ heart palps c. diaphoresis d. vomiting e. decreased level of consciousness 4. Lab test: (levels according to ATI), normal levels are: a. Myoglobin: less than 90 mcg/L b. Creatine kinase-MB: 30 to 170 units, rise early and level off within 48 hours c. Troponin I: less than 0.03 ng/L, can remain elevated for several days d. Troponin T: less than 0.2 ng/L, can remain elevated for several days e. LDH: can be a longer term marker, not considered immediate Ischemia vs Infarction a. ischemia: abrupt interruption of O2 to the heart (during a stress test for example), temporary, can cause angina b. infarction: ischemia can lead to infarction if O2 is deprived for long enough time, leads to permanent damage. (Basically, infarcted tissue is dead tissue that will not come back. MI stands for Myocardial Infarction) Nursing care: (during MI, or suspected MI) 1. Vital signs every 15 minutes until stable, then every hour 2. Monitor ECG 3. Location, severity, quality, duration of pain 4. Hourly urine output: greater than 30 ml/hour indicated renal perfusion 5. Laboratory data (cardiac enzymes, electrolytes, ABGs) 6. Administer O2 7. Obtain IV access 8. Promote energy conservation (cluster nursing care) 9. Medications More on Medications: (for MI care or angina) 1. Vasodilators: prevents coronary artery vasospasm, reduces preload and afterload, decreases myocardial oxygen demand a. treats angina, controls BP b. use with caution with other BP meds, (can drop BP too low), can also cause orthostatic hypotension c. Head ache is common side effect (due to increased blood flow/profusion) d. example: nitroglycerin 2. Analgesics: opioid analgesic used to treat pain a. use caution with asthma patients due to respiratory despression b. assess client every 5 to 15 min c. example: Morphine 3. Beta blockers: has antidysrhythmic and antihypertensive properties, decreases imbalance between myocardial oxygen supply and demand which reduces afterload. a. in an acute MI, betablockers decreases infarct size and improves survival rates b. can cause bradycardia, hypotension

c. caution in CHF patients d. example: metoprolol (Lopressor), toprol, labatolol. (notice almost all Betablockers end in µlol¶ 4. Thrombolytic agents: used to break up blood vessels a. thrombolytic agents have similar side effects and contraindications as anticoagulants b. give within 6 hours of infarction c. monitor PT, PTT, INR, fibrinogen levels, CBC d. exxmple: streptokinase, and alteplase 5. Antiplatelet agents: prevents plateltes from forming together, reducing chance of clotting a. watch for GI upset, Tinnitus (ringing of ears) is a sign of ASA toxicity b. example: Aspirin, Plavix 6. Anticoagulants: prevents clots from forming or becoming larger a. watch for bleeding, TP, PTT, INR, ect. b. watch for the typical side effects: anemia, hemorrhage, thrombocytopenia c. examples: Heparin, and enoxaparin 7. Glycoprotein IIB/IIIA inhibitors: prevents binding of fibrogen, blocking platelet aggregation a. used in combination with ASA as a standard therapy b. can cause active bleeding c. examples: Eptifibatide (Integrilin) 8. Calcium channel blockers; reduction in contractility of muscle, reduces SA and AV node. Complications of MI 1. Acute MI: complication of angina not relieved by rest or nitro, must administer O2 and notify doc. 2. Heart failure/ cardiogenic shock: injury to left ventricle that leads to decreased cardiac output a. progressive heart failure also leads to cardiogenic shock b. symptoms: tachycardia, hypotension, inadequate urine ouput, respiratory distress c. actions: O2, possible intubation and ventilation, meds 3. Ischemic mitral regurgitation: new cardiac murmur, administer O2, notify doc 4. Ventricular aneurysms/ rupture: necrosis due to MI a. presents as sudden chest pain, dysrhythmias, hypotension c. must administer O2, call the doc. 5. Dysrhythmias: MI can injury AV node resulting in arrhythmias.

Hypertension, nursing care, drug therapy, lifestyle changes, dietary guidelines
Hypertension: (according to ATI): above 140 systolic, 90 diastolic. 120 to 139 systolic or 80 to 89 diastolic is considered pre hypertension stage 2 hypertension, greater than 160/100. Regulated by four mechanisms: 1. Barreceptors: control by altering heart rate and causing vasoconstriction or vasodilation 2. Body fluid volume: kidneys either retain (causes increase in pressure) or excrete fluid (causes decrease in pressure) For example; if someone is hypotensive, you GIVE fluid to correct the low volume and increase the pressure. 3. Renin-angiotensin system: mechanisms controling aldosterone release, reabsorption of sodium and inhibition of fluid loss. Example: ARB¶s block this system, which helps excrete sodium and excrete fluid causing a reduction in blood pressure 4. Vascular autoregulation: maintains consistent tissue perfusion Risk factors: family history, excessive sodium intake, obesity, high alcohol consumption, African American, smoking, hyperlipidemia, stress Medications: 1. Diuretics: often first line of defense, inhibits water and sodium reabsorption

a. loop diuretics secrete potassium b. potassium sparing diuretics: save potassium c. watch for electrolytes, K+ levels, dehydration, irregular pulse d. example: Lasix(loop diuretic), Aldactone (potassium sparing) 2. Calcium Channel blockers: alter movement of calcium ions causing vasoconstriction lowering BP a. caution in Heart failure patients (it can lower the ³contractility´ of the muscle, something that you don¶t want to do if you are in heart failure b. example: Verpamil, amlodipine(Norvasc), diltiazem(Cardizem) 3. ACE inhibitors: prevents conversion of angiotensin I to angiotensin II, prevents vasoconstriction (remember the renin-angiotensin system above) a. must monitor BP and pulse, signs of heart failure or edema b. extremely common side effect is cough, patient needs to notify doc if cough is present 4. Angiotensin II receptor antagonists (more commonly known as ARB¶s or angiotensin receptor blockers: block the renin-angiotensin system. a. monitor for signs of heart failure, or edema b. examples: Atacand, losartan (Cozaar) 5. Aldosterone- receptor antagonists: blocks aldosterone action, promotes excretion of potassium a. monitor renal function, increase in risk of adverse reactions as renal function decreases b. example: Inspra 6. Beta blocks: see above, decrease cardiac ouput and block release of renin. a. examples: metoprolol, atenolol 7. Central -alpha agonists: reduce peripheral vascular resistence a. not indicated for first line management of HTN a. example: Catapres Lifestyle changes: 1. sodium restriction: less than 2.3g/day 2. weight reduction, low fat diet, low alcohol diet 3. exercise, at least three times per week 4. smoking cessation 5. stress reduction

CHF - symptoms, risk factors, nursing care, drug therapy
basic definition: heart muscle is unable to pump effectively, results in inadequate cardiac output, myocardial hypertophy, pulmonary and systemic congestion. Ejection Fraction: this is a measurement of the amount of blood your heart pumps out with each beat. The higher the percentage, the more healthy your heart is! She told you something different in class, which was incorrect. Preload vs Afterload Preload: the amount of blood in the ventricle (end-diastolic volume) before the contraction. Over hydration results in an increase in preload, dehydration results in a decrease in preload Afterload: this is the ³load´ that the heart must eject blood against. a. afterload is increased when aortic pressure and vascular resistance are increased, which reduces stroke volume b. when afterload increases, there is an increase in end-systolic volume. (more blood left in the heart) c. for example: a goal of some heart failure drugs are to decrease afterload by vasodilatation, thus reducing the volume left in the heart, increasing the heart efficiency. In other words, when the arterial pressure/afterload is reduced, the ventricle can eject blood more rapidly, which increases stroke volume

How the two can affect the other: If someone has chronic hypertension, this will cause an increase in afterload, which leaves more blood in the ventricle after contraction (because less blood is ejected). Because end-systolic volume is now increased, the extra blood is added to venous return, which increases end-diastolic volume (preload). The overall effect is a reduction in stroke volume. (which isn¶t good ) Heart failure classifications: Class I: client exhibits no symptoms with activity Class II: Client has symptoms with ordinary exertion Class III: Client displays symptoms with minimal exertion Class IV: Client has symptoms at rest Left sided HF: results in inadequate tissue perfusion (heart is unable to pump to systemic circulation with any efficiency.) Ejection fraction is typically below 40% Symptoms: dyspnea, fatigue, S3 heart sound, pulmonary congestion, frothy sputum, altered mental status, symptoms of organ failure Ride sided HF: results in inadequate right ventricle output and systemic venous congestion Symptoms: jugular vein distention, ascending dependent edema, abdominal distention, fatigue, nausea, polyuria, liver enlargement, weight gain Cardiomyopathy: weakened heart muscle that leads to HF symptoms: fatigue, weakness, dysrhythmias, S3 gallop, enlarged heart. Risk factors: a. hypertension b. CAD, angina, MI c. valvular disease d. pulmonary problems e. increased metabolic needs f. anemia g. hyperthyroidism h. infection of heart muscle i. prolonged alcohol abuse j. heredity Medications for CHF: 1. Diuretics (see above for details) 2. After-load reducing agents: these reduce resistance to contraction (see above for details) a. ACE inhibitors b. ARB¶s 3. Inotropic agents: increase contractility and therefore improve cardiac output a. must monitor BP, pulse, ECG closely b. examples: digoxin, dopamine, dobutamine 4. Vasodilators: reduce preload and afterload, decrease, myocardial oxygen demand a. examples: nitroglycerine, isosorbide b. Note: nitro is typically given to treat acute bouts of angina, isosorbide typically given as a scheduled medication daily. 5. Human Btype natriutertic peptides (hBNP): treats acute heart failure by causing natriuresis (loss of sodium) a. can cause hypotension, BNP levels will increase while on this med b. examples: Natrecor 6. Anticoagulants: (see above for details)

Pulmonary Edema:

Definition: complication of heart or lung diseases that usually occurs from increased pulmonary vascular pressure secondary to cardiac dysfunction, often CHF Risk factors: 1. acute MI 2. fluid volume overload 3. hypertension 4. vavular heart disease 5. postpneumonectomy 6. acute respiratory failure 7. left-sided heart failure 8. high altitude exposure 9. trauma 10. sepsis 11. drug over dose Assessment: persistent cough, tachypnea, dyspnea, orthopnea, hypoxemia, cyanosis, crackles, tachycardia, reduced urine output, confusion, stupor, S3 heart sound, increased pulmonary artery occlusion pressure Care: position client in high folwlers position, administer O2 using high flow rebreather mask, intubation if needed, restrict fluid intake, monitor hourly urine output(urine must be greater than 30 ml/hr) Medications: a. diuretics: promotes fluid excretion b. morphine: decreases sympathetic nervous system response, promotes vasodilation c. vasodilators d. inotropic agents, improves cardiac output e. antihypertensives Complications: cardiomyopathy, acute pulmonary edema, cardiogenic shock, pericardial tamponade (fluid accumulation in pericardial sac.)

Glossary of basic terms so far.
Diastolic phase: the ³filling phase´ of the heart beat. Systolic phase: the ³ejection phase´ of the heart beat End diastolic volume: the amount of blood in the ventricle after the filling phase End systolic volume: the amount of blood left in the ventricle after the ejection Preload: the end diastolic volume Afterload: a relationship between the arterial pressure and the contractility of the heart. The higher the arterial pressure = the higher the afterload = the higher the end systolic volume =more blood left in the heart after the contraction Ischemia: a reduction in oxygenated blood to an area, considered temporary Infarction: death of tissue related to prolonged O2 deprivation Angina: a warning sign of a possible MI produced by ischemia, symptoms include chest pain, back, arm and jaw pain Cardiomyopathy: weakness in heart muscle that leads to CHF