cardiovascular: valvular, cardiomyopathy, aneurysm and cardiac surgery click here- click here- heart...
TRANSCRIPT
Cardiovascular: Valvular, Cardiomyopathy, Aneurysm and
Cardiac Surgery
Click here- Heart valves at work!
Review of Heart Valve sounds (etc)
A&P Heart Valves- Click here
Valvular Heart Disease(Access to Helpful Interactive Sites)
HeartPoint: HeartPoint Gallery (many resources here!)
Valvular Disease (great introductory video!)
Valvular Heart Disease:
Heart Valves at Work *UTube
Flashcards (Test your knowledge!)
PathophysiologyStenosis-
narrowed valve, sloews forward blood flowincreases afterload, dec. CO
Regurgitation (insufficiency)increases preloadheart pumps same blood againblood volume and pressures reduced in front of affected valve; increased behind affected valveresults in heart failure
Caused byRheumatic Heart DiseaseAcute conditions (infective endocarditis)Acute MICongenital Heart Defects
Aging, etc
*All valvular diseases have characteristic murmurs (click to hear!) •Damaged valve disrupts blood flow=turbulence & sound!
Mitral Valve Stenosis
Mitral Valve Stenosis
Etiology/Pathophysiology:Most cases due to rheumatic feverContractures and adhesions of valve leaflets- “fish mouth”Dec. flow into LV>LA hypertrophy>inc. pulmonary pressures> pulmonary hypertensionDec. CO-lead to Rt. Heart failure
Mitral Valve StenosisClinical Manifestations:
Early symptom-dyspnea on exertion (DOE)Cough, hemopysis, etc.
Late- Signs Rt. Heart failure (dec. CO)Atrial fib. (enlarged atrium)Murmur- loud S1, low pitched diastolic murmurHoarseness, seizures, stroke (emboli risk)
Management Mitral Valve Stenosis
Treatment for Mitral Stenosis (non-surgical) Balloon Valvuloplasty
Heart Surgery Innovations - (27 min)
11:22 valves20 beating heart20 aortic valve
Valvular SurgeryAccess site to see and hear the
newest information!
Mitral Regurgitation
Etiology/Pathophysiology/ManfesationsValve does not close fullyRegurgitation of blood into LA during systoleDev. LA dilation and hypertrophy > pulmonary congestion > RV failureLV dilation and hypertropy-accommodate increased preload (from regurgitation)Dec. COAcute and chronic MR
Acute-poorly tolerated-fulminating pulmonary edemaChronic- Lt. ventricular failure, S3 sound, pansystolic murmur
Mitral Regurgitation
Treatment of Mitral Valve Regurgitation
Innovations (Percutaneous) MitraClip Repair
MitraClip 3D Animation View video -procedure to correct mitral valve regurgitation! Non-invasive
Mitral Valve ProlapseEtiology/Pathophysiology/Manifestations
Mitral valve cusps “billow’ into atrium during ventricular systoleMost common form valvular disease, associated with Marfan’s syndrome (Michael Phelps…does he have it?)
Usually benign-complications- MR, infective endocarditis (IE) , SCDUsually asymptomatic- mid systolic click, and last holosystolic murmurChest pain (atypical)-does not respond to antianginalsDysrhythmia risk?Need for prophylactic antibiotics (IE risk)
Midsytolic click & late systolic murmur (Click here to hear characteristic sounds of MVP)
UTube- Mitral Valve Prolapse (brief lecture-informative)
UTube- Mitral Valve Prolapse (current research-re prophylactic antibiotics)
Endocarditis and MVP
Mitral Valve Prolapse
Aortic Stenosis
Etiology/Pathophysiology/ManifestationsCongenital or due to rheumatic fever or aging May be asymptomatic for yearsObstruction LV to aorta > inc afterload > L. ventricular hypertrophy > dec. COEventual pulmonary hypertension, myocardial ischemia and later right heart failure*DOE, angina, syncopy (SAD)- Classic Symptoms *Poor prognosis-if symptoms and obstruction not relieved*Nitroglycerin contraindicatedNormal to soft S1; absent S2; harsh systolic crescendo-decrescendo murmur, loud S4 (click for sound)
Classic Symptoms
Syncope
Angina
Dyspnea
Aortic Stenosis
Aortic Valve animation
Aortic valve*Normal aortic valve has 3 leaflets-not 2 (bicuspid) (Arnold Schwarzenegger- lead to aortic stenosis and require valve replacement)
Aortic Stenosis
Access these sites to learn about procedures to treat/replace damaged aortic valves
Aortic Stenosis
Minimally Invasive Aortic Heart Valve Replacement
Percutaneous Aortic Valve Replacement
Percutaneous aortic valve replacement (AVR)- new treatment being investigated for select patients with severe symptomatic aortic stenosis… Research at Cleveland Clinic is evaluating a percutaneous technique for implanting a prosthetic valve inside diseased calcific aortic valve. The procedure is performed in catheterization lab…a catheter is placed through femoral artery (in the groin) and guided into chambers of the heart. A compressed tissue heart valve is placed on the balloon-mounted catheter and is positioned directly over the diseased aortic valve. Once in position, the balloon is inflated to secure the valve in place. *For patients with severe peripheral vascular disease, surgeons and cardiologists are testing an alternative approach through the left ventricular apex of the heart.
Percutaneous AVR a) Balloon valvuloplasty; b) Balloon catheter with valve in the diseased valve;c) Balloon inflation to secure the valve; d) Valve in place
Heart Valve replacement
(Aortic valve, patient resource, mechanical, biological)
Aortic RegurgitationEtiology/Pathophysiology/Manifestations
Congenital valvular defect
Acute causes- trauma, aortic dissection (life threatening)
Chronic- rheumatic heart disease, bicuspid valvular disease
Retrograde blood flow (inc. preload) from ascending aorta > L ventricle dilation, hypertrophy
Eventual dec. myocardial contractility > dec. CO
Develop pulmonary hypertension, Rt. Ventricular failure (*inc. L. ventricular end diastolic pressure=LVED)
If severe- characteristic “*water hammer pulse” (Corrigan’s pulse), wide pulse pressure, and Musset’s sign
Soft or absent S1, presence of S3, S4; soft, high pitched diastolic murmur, systolic ejection click; Austin Flint murmur
Water Hammer pulsePulse- “water hammer” -jerky pulse that is full, then collapses due to aortic insufficiency/regurgitation (blood ejected into aorta regurgitates back through aortic valve into L. ventricle ). AKA-called a Corrigan pulse or a cannonball, collapsing, pistol-shot, or trip-hammer pulse. (Click to view video)
Aortic Regurgitation
Echocardiography
Tricuspid and Pulmonic Valve Disorders
•Etiology/Pathophysiology/Manifestations– Tricuspid stenosis (more common than
regurgitation)• Result in R. atrial enlargement > inc. systemic venous
pressure > atrial fibrillation, peripheral edema, ascites, etc.
• Found mostly in rheumatic heart disease, IV drug users– Pulmonic stenosis
• Result in R. ventricular hypertension and hypertrophy• Fatigue , loud midsystolic murmur
– Uncommon valve disorders
Collaborative Care
KeysPrevent recurrent rheumatic fever, infective endocarditisIdentify by characteristic murmurAware of effect of stenosis, regurgitation on cardiac hemodynamics (preload, afterload)Appropriate prophylactic therapy (antibiotics before invasive procedures-at risk patients)Manage heart failure if presentManage complications-ie dysrhythmias, risk for emboli (a-fib) etc.*Treatment depends upon valve involvedAdequate follow-up care.
Medications/Diet Manage complications (ie heart failure, dysrhythmias)
ACE, DigDiureticsVasodilatorsBeta blockersAnticoagulants *a-fib common*Prophylactic antibioticsTreatment specific for disease (ie no *nitroglycerin if aortic stenosis)
DietLow sodium-if risk for heart failure
Diagnostic Tests
Echo- assess valve motion and chamber sizeTEE
CXREKGCardiac cath- measure pressure gradients (hemodynamic function)
Transesophageal echocardiogram
Surgical Intervention
*Not all types valve disease require surgical interventionValvuloplasty-general term valve repair, invasive/non-invasive methodsPercutaneous balloon valvuloplasty (non-invasive)Surgery
Open commissurotomy- open stenotic valvesAnnuloplasty- repair of valve’s outer ring-used for stenosis, regurgitant valveValve Replacement
Mechanical-need anticoagulantBiologic-only last about 15 yearsRoss Procedure-transfer pulmonic valve for aortic
Valve Replacement Surgery
Patient Teaching-Heart Valve Replacement Surgery (click here)
Ross Procedure
Mechanical valve prosthesis- modern tilting disk variety (for mitral valve); last indefinitely from structural standpoint; patient requires continuing anticoagulation due exposed non-biologic surfaces.
Excised porcine bioprosthesis; main advantage of bioprosthesis is lack of need for continued anticoagulation-drawback include limited lifespan, on average from 5 to 10 years (sometimes shorter) due to wear and calcification. (No immune suppressive agents required.)
Important-teaching needs for valve replacement
Nursing DiagnosesDecreased Cardiac OutputActivity IntoleranceExcess Fluid VolumeIneffective therapeutic regimenRisk for InfectionIneffective Protection
What Is New?
•Heart valve replacement without need for open heart surgery.
•Typically, diseased or defective valves replaced with an artificial valve or a tissue valve (from pig or cow).
•A new, less invasive procedure, known as percutaneous transcatheter heart valve implantation, involves use of balloon catheters and large stents…
•New heart valve transported via stent; stent then expanded to implant the valve.
• For patients not able to undergo open-heart surgery… percutaneous heart valve implantation may impact significantly on survival and quality of life. Click for more!
New Cont.•New technologies…a tiny metallic clip is being studied for treatment of mitral regurgitation- MitraClip 3D Animation View video -procedure to correct
•Valves may last a lifetime for older patients, younger patients may need several replacement procedures over time.
•One focus of research-create longer-lasting replacement valves, particularly for patients with congenital heart disease. Research potential toward this goal: stem cell research and the use of endothelial cells.
CardiomyopathyCondition is which a ventricle has become enlarged, thickened or stiffened. As a result heart’s ability as pump is reduced3 Types
DilatedHypertropicRestrictive
Cardiomyopathy
Primary-idiopathicSecondary
Ischemia- from CADInfectious/viral diseaseExposure to toxinsMetabolic disordersNutritional deficienciesGenetic
Dilated Cardiomyopathy
*Most common typeDiffuse inflammation rapid degeneration myocardial tissueHeart chambers dilate; impaired systolic
function, *atrial enlargement40% dev. R & L heart failure; dec. EF *Dysrhythmias are common- SVT, A-fib, VTPrognosis poor-*need transplant
Dilated CardiomyopathyFactors Causing:
Genetic predispositionMay follows infectious endocarditis & viral infections Alcohol related
S&S- (heart failure)Fatigue, orthopnea, noctural dyspneaIrregular heart rate, pulmonary crackles, S3, S4Heart murmurs, sudden cardiac death!
Dilated CardiomyopathyCollaborative Care
*Focus-control heart failureEnhance contractility; dec. afterload
Dx Tests (signs heart failure)
Doppler ECHO, EKG, heart cath Lab (BNP)Chest X-Ray
Diet/DrugsLow NaHF meds
Cardiomyopathy- very large heart, circular shape, all chambers are dilated, flabby, myocardium poorly
contractile
Normal weight 350 gms –dilated cardiomegaly-700 gms
Dilated CardiomyopathyCollaborative Care
Surgical/resynchronizationization therapy
VAD or LVAD
CRT (cardiac resynchronization therapy)
Dilated CardiomyopathyCollaborative Care
Heart transplant
Hypertrophic Cardiomyopathy (HCM)Genetic; IHSS (idiopathic hypertrophic subaortie stenosis), HOCM (hypertrophic obstuctive cardiomyopathy) Hypertrophy of ventricular mass; impaired ventricular filling (diastole); dec. CO > inc pulmonary & venous pressuresForceful ventricular contraction*Obstruction aortic outflow (not all cases)S&S: syncopy, angina, dyspnea (SAD); S4 develop during or after physical activity*Sudden cardiac death (dysrhythmia)
Hypertrophic Cardiomyopathy (HCM)Collaborative Care
GoalsImprove ventricular filling
*Reduce ventricular contractilityRelieve L. ventricular outflow obstruction
Diagnostic Tests“Forced” apical sound (laterally)EKG, ECHO (L. ventricular hypertrophy, abnormal wall motion)Heart cath
MedsNegative inotropes (Ca channel blockers, beta blockers)*NO vasodilators, digitalis (usually), nitrates
Note obstruction-aortic outflow (HCM)
Hypertrophic Cardiomyopathy (HCM)
Collaborative Care
Surgical/Other InterventionsCardioverter/defibrillator (At risk patients)AV pacing if outflow obstructionVentriculomyotomy and septal myomectomyAlcohol septal ablationLive Search Videos: cardiomyopathy
Restrictive Cardiomyopathy
Least commonRigid ventricular walls that impair filling (impaired diastolic) Contraction (systolic) and EF normalPrognosis-poorS & S
Fatigue, dyspnea, exercise intoleranceR. sided heart failure
Restrictive cardiomyopathy
Restrictive Cardiomyopathy
Collaborative CareDx Test
Chest X-ray (cardiomegaly?, show R. and L atrial enlargement)EKG (tachycardia), supraventricular dysrhythmias, AV blockECHO wall motion, EMB, CT nuclear imaging
Medications*No specific treatmentMeds to improve diastolic filling, manage heart failure, dysrhythmia
Surgical/Other TreatmentPoor prognosisTransplant maybe (depends underlying cause)
Biopsy of heart (EMB)
Review-Management Cardiomyopathy
Vad-bridge to transplantHeart TransplantMyloplastyICD- antiarrhythmics are negative inotropesDual chamber pacemaker*Hypertrophic- excision of ventricular septum-myotomy, inject denatured alcohol in coronary artery that feeds top portion of septum.*Transplant
Heart transplant (slide show)
Virtual transplant (try it!)
Heart Transplant
Click here-YouTube- Heart-Lung machine
A new heart!
CardiomyopathyNursing Diagnoses
Decreased Cardiac OutputFatigueIneffective Breathing PatternFearIneffective Role PerformanceAnticipatory grieving
Case studyMs. C. 81 y/o admitted to CCU with SOB; has a hx of mitral valve regurgitation with left ventricular enlargement. She received 100mg Lasix IV in ER and her dyspnea improved. She has O2 at 3L/min. She has crackles bibasilar and monitor is SR rate 94-96 with occ. PVC’s. The only med ordered is morphine 2-4mg IV as needed for chest pain or dyspnea.
As you go to assess her, you find her in bed at 60 degree angle. She is
pale, has circumoral cyanosis and respirations are rapid and labored.
1. What action should you take first?
A. Listen to breath soundsB. Ask when the dyspnea startedC. Increase her O2 to 6L minuteD. Raise the HOB to 75-85 degrees
Case studyMs. C. 81 y/o admitted to CCU with SOB; has a hx of mitral valve regurgitation with left ventricular enlargement. She received 100mg Lasix IV in ER and her dyspnea improved. She has O2 at 3L/min. She has crackles bibasilar and monitor is SR rate 94-96 with occ. PVC’s. The only med ordered is morphine 2-4mg IV as needed for chest pain or dyspnea.
As you go to assess her, you find her in bed at 60 degree angle. She is
pale, has circumoral cyanosis and respirations are rapid and labored.
1. What action should you take first?
A. Listen to breath soundsB. Ask when the dyspnea startedC. Increase her O2 to 6L minute (symptoms indicate acute hypoxemia, need
to inc O2 flow, HOB already elevated)
D. Raise the HOB to 75-85 degrees
Case Study-Question 2, 3
2. Which of these complications are you most concerned about, based on your assessment?
A. Pulmonary edemaB. Cor pulmonaleC. Myocardial infarctionD. Pulmonary embolus
3. Which action will you take next?A. Call the physician about client’s condition.B. Place client on a non-rebreather mask with FiO2 at 95%.C. Assist client to cough and deep breathe.D. Administer ordered morphine sulfate 2mg IV.
Case Study-Question 2, 3
2. Which of these complications are you most concerned about, based on your assessment?
A. Pulmonary edema- hx of inc SOB, mitral valve regurgitation, and sx hypoxemia, pink frothy sputum indicate L. ventricular failure….prioroity
B. Cor pulmonaleC. Myocardial infarctionD. Pulmonary embolus
3. Which action will you take next?A. Call the physician about client’s condition.B. Place client on a non-rebreather mask with FiO2 at 95%. (in this case, priority is still oxygenation, give morphine and call physician still appropriate…)
C. Assist client to cough and deep breathe.D. Administer ordered morphine sulfate 2mg IV.
Case Study questions #4, 5
4. What additional assessment data are most important to obtain at this time?
A. Skin color and capillary refillB. Orientation and pupil reaction to lightC. Heart sounds and PMID. Blood pressure and apical pulse
5. B/P is 98/52, apical is 116, irregular at 110-120 with frequent multifocal PVC’s. Physician is called and these orders received. Which one should be done first?
A. Obtain serum dig levelB. Give furosemide 100mg. IVC. Check blood potassium levelD. Insert #16 french foley catheter
Case Study questions #4, 5
4. What additional assessment data are most important to obtain at this time?
A. Skin color and capillary refillB. Orientation and pupil reaction to lightC. Heart sounds and PMID. Blood pressure and apical pulse (Need VS to know changes in CO)
5. B/P is 98/52, apical is 116, irregular at 110-120 with frequent multifocal PVC’s. Physician is called and these orders received. Which one should be done first?
A. Obtain serum dig levelB. Give furosemide 100mg. IVC. Check blood potassium level (Must know serum K level, low level might be cause of PVC, know prior to Lasix)
D. Insert #16 french foley catheter
Question #6, 7, 8 6. Which order could be assigned to an LVN?
A. Obtain serum digoxin levelG. Give furosemide 100mg. IVC Check blood potassium levelD. Insert #16 french foley catheter
7. While waiting for potassium level, you give morphine sulfate IV to the patient. A new graduate asks why you are giving the morphine. What is the best response? It will:
A. prevent chest pain.B. decrease respiratory rate.C. make her comfortable if intubation required.D. decrease venous return to heart
8. Her K is 3.1; physician orders KCL 20meq. IV. How this be given?A. Utilize a syringe pump to infuse KCL over 10 minutes.B. Dilute KCL in 100 ml of D5W and infuse over 1 hour.C. Use a 5ml syringe and push KCL over at least 5 minutes.D. Add KCL to 1 liter of D5W and give over 8 hours.
Question #6, 7, 8 6. Which order could be assigned to an LVN?
A. Obtain serum digoxin levelG. Give furosemide 100mg. IVC Check blood potassium levelD. Insert #16 french foley catheter (All LVNs trained to insert Foleys)
7. While waiting for potassium level, you give morphine sulfate IV to the patient. A new graduate asks why you are giving the morphine. What is the best response? It will:
A. prevent chest pain.B. decrease respiratory rate.C. make her comfortable if intubation required.D. decrease venous return to heart (Morphine dec. venous return, dec. ventricular preload)
8. Her K is 3.1; physician orders KCL 20meq. IV. How this be given?A. Utilize a syringe pump to infuse KCL over 10 minutes.B. Dilute KCL in 100 ml of D5W and infuse over 1 hour.(only safe way, too fast, > cardiac arrest; too slow may not correct problem rapidly enough)
C. Use a 5ml syringe and push KCL over at least 5 minutes.D. Add KCL to 1 liter of D5W and give over 8 hours.
Questions #9, 10, 119. After infusing KCL, you give Lasix. Which of nursing action will be most useful in evaluating if lasix is having desired effect?
A. Obtain the client’s daily weightB. Measure the hourly urine outputC. Monitor blood pressureD. Assess the lung sounds
10. The physician orders a natrecor 100mcg IV bolus and an infusion of 0.5 mcg/ min. Which assessment data is most important to monitor during the infusion?
A. Lung soundsB. Heart rateC. Blood pressure
D. Peripheral edema 11. Which nurse should be assigned care for this client?
A. Float RN who worked on CCU stepdown for 9 years and floated before to CCUB. RN from staffing agency, 5 years CCU experience and orienting to CCU todayC. CCU RN, already assigned to a newly admitted client with chest traumaD. New graduate RN who needs experience in caring for client with left ventricular failure.
Questions #9, 10, 119. After infusing KCL, you give Lasix. Which of nursing action will be most useful in evaluating if lasix is having desired effect?
A. Obtain the client’s daily weightB. Measure the hourly urine outputC. Monitor blood pressureD. Assess the lung sounds (Major problem-pulmonary edema, lung sounds most important)
10. The physician orders a natrecor 100mcg IV bolus and an infusion of 0.5 mcg/ min. Which assessment data is most important to monitor during the infusion?
A. Lung soundsB. Heart rateC. Blood pressure (natrecor causes vasodilation, diuresis, ck for hypotension)
D. Peripheral edema 11. Which nurse should be assigned care for this client?
A. Float RN who worked on CCU stepdown for 9 years and floated before to CCU (had
experience with this type patient & on unit) B. RN from staffing agency, 5 years CCU experience and orienting to CCU todayC. CCU RN, already assigned to a newly admitted client with chest traumaD. New graduate RN who needs experience in caring for client with left ventricular failure.
Question #12, 13
12.Which information would be important to report to the physician?
A. Crackles and oxygen saturationB. Atrial fibrillation and fuzzy visionC. Apical murmur and pulse rateD. Peripheral edema and weight
13. All meds are scheduled for 9 AM. Which would you hold until you discuss it with the physician?
A. Furosemide 40mg po bidB. Ecotrin 81mg po dailyC. KCL 10meq three times a dayD. Captopril 6.25mg po three times a dayE. Lanoxin .125mg po every other day
Question #12, 13
12.Which information would be important to report to the physician?A. Crackles and oxygen saturationB. Atrial fibrillation and fuzzy vision (dysrhythmias, visual disturbances, common side effects of digoxin toxicity)
C. Apical murmur and pulse rateD. Peripheral edema and weight
13. All meds are scheduled for 9 AM. Which ones would you hold until you discuss it with the physician?
A. Furosemide 40mg po bidB. Ecotrin 81mg po dailyC. KCL 10meq three times a dayD. Captopril 6.25mg po three times a dayE. Lanoxin .125mg po every other day
**Hold Furosemide and Lanoxin- low potassium potentiates dig toxicity
Abdominal Aortic Aneurysm
Click Here for an excellent lecture on AAA- Abdominal Aortic Aneurysms!! (You Tube)
Quickly tells you all the essentials!
Aortic AneurysmsAortic Aneurysm – go to page 5
Aneurysms (video)
Aneurysms = Time Bombs
•Outpouchings or dilations of arterial wall
•May involve aortid arch, thoracic aorta and/or abdominal aorta
•*1/2 all aneurysms larger than 6 cm rupture within one year.
•*Thrombi form on dilated arterial wall lead to emboli
•Male and smoking great risk factor,
Classifications Aneurysms
True- Fusiform, Saccular
False- (a pseudoaneurysm)- have disruption all layers arterial wall, from trauma, etc.
C.Aortic dissection; D. “False” aneurysm
Saccular- true aneursym, pouchlike, narrow neck connecting buldge to one side of arterial wall
Fusiform- most are fusiform; 98% are below renal artery, circumferential, relatively unifrom in shape
Thoracic Aortic Aneurysm
Frequently asymptomaticMay have substernal, neck or back painCoughing, due to pressure placed on the windpipe (trachea) Hoarseness Dysphagia Swelling (edema) in neck or arms Myocardial infarction, or stroke due to dissection or rupture involving branches of the aorta
Abdominal Aortic AneursysmPain intensity correlates to size and severityPulsating mass in mid and upper abdomen; bruit over the massMay have thrombiCan rupture causing shock and death in 50% of rupture casesMimic pain associated with abdominal or back disorders“Blue toe syndrome” due to emboliComplications-Rupture!
AnteriorPosterior (better chance for survival)
Dissecting aneurysms-unique and life threatening. A break or tear in tunica intima and media allows blood to invade or dissect layers of vessel wall. Blood is usually contained by adventitia, forming a saccular or longitudinal aneurysm.
Aortic Dissection - blood invades or dissects the layers of the vessel wall (not really an aneurysm)
Aortic dissection occurs when blood enters the wall of aorta, separating its layers, and creating a blood filled cavity
Aortic dissection
Life threatening emergencyIntima tears, causes hemorrhage into mediaHypertension- main causeWith contraction of heart, inc. pressure, further damageCause uncertain- hypertension- *primary, Marfan’s syndrome, blunt trauma, inc age symptom- excruciating pain-tearing, ripping sensation90% mortality if untreated
Manifestations of Aortic D issection Aneurysm
Abrupt, severe, ripping or tearing pain in area of aneurysm
Mild or marked hypertens ion early
Weak or absent pulses and blood pressure in upper extremities
S yncopeC omplications: hemorrhage,
ischemic kidneys (renal failure), MI, heart failure, cardiac tamponade, seps is , weakness or paralys is of lower extremities .
*Symptoms depend upon location
Collaborative Care
Goal-*identify and prevent ruptureDiagnostic Tests
Most dx on routine work-upIf identified, tests specific to determine size, locationCXR, CT or MRI, Abd ultrasound, TEE, ECHO, angiography, Abd. UltrasoundEKGRecognize “Terrible Triad” impending rupture
Pulsating hematoma, back pain, hypotension
Collaborative Care-Medications
Anti-hypertensivesBeta blockers, VasodilatorsCalcium channel blockersNipride*Avoid direct arterial vasodilators (as hydralazine)
SedativesNiacin, mevocor, statinsPost-op anti-coagulants
Collaborative Care/Surgery, Other Options
Usually repaired if >5cmOpen procedure- abd incision, cross clamp aorta,aneuysm opened and plaque removed, then graft sutured in place
Pre-op assess all peripheral pulsesPost-op-check urine output and peripheral pulses hourly for 24 hours- (when to call Dr.)
Endovascular stents- placed through femoral artery
Surgical repair of an abdominal aortic aneurysm. A, Incising the aneurysmal sac. B, Insertion of synthetic graft. C, Suturing native aortic wall over synthetic graft.
Bifurcated (two branched) endovascular stent grafting of an aneurysm. A, Insertion of a woven polyester tube (graft) covered by a tubular metal web (stent). B, Stent graft is inserted through large blood vessel (e.g., femoral artery) using a delivery catheter. Catheter is positioned below renal arteries in area of aneurysm. C, Stent graft is slowly released (deployed) into blood vessel. When stent comes in contact with blood vessel, it expands to preset size. D, A second stent graft can be inserted in contralateral (opposite) vessel if necessary. E, Fully deployed bifurcated stent graft
Aneurysm repair
Live Search Videos: aneurysm
Live Search Videos: aortic aneurysm-percutaneous approach to abdominal aneurysm repair
Nursing Diagnoses
Risk for Ineffective Tissue PerfusionRisk for InjuryAnxietyPainKnowledge Deficit
PreventionUltrasound-extremely effective at detecting AAAs. U.S. Preventive Services Task Force (USPSTF) recommends-anyone aged 65 to 75 who has ever smoked undergo a one-time ultrasound screening for AAA
2.Prevent atherosclerosis
3.Treat and control hypertension
4.Diet- low cholesterol, low sodium and no stimulants
5.Careful follow-up if less than 5cm-can grow 0.5cm/yr
Key Complications
Rupture- signs of ecchymosisBack painHypotensionPulsating massLive Search Videos: aortic aneurysm (See rupture)
ThrombiRenal Failure
Priority Question # 1, #21. During initial post-operative assessment of a patient who has just transferred to post-anesthesia care unit after repair of an abdominal aortic aneurysm all of these data are obtained. Which has most immediate implications for client’s care?
A. Arterial line indicates a blood pressure of 190/112.B. Monitor shows sinus rhythm with frequent PAC’s.C. Client does not respond to verbal stimulation.D. Client’s urine output is 100ml of amber urine.
2. It is the manager of a cardiac surgery unit’s job to develop a standardized care plan for post-operative care of client having cardiac surgery. Which of these nursing activities included in care plan must be done by an RN?
A. Remove chest and leg dressings on the second post-operative day and clean the incisions with antibacterial swabs.B. Reinforce patient and family teaching about the need to deep breathe and cough at least every 2 hours while awake.C. Develop individual plan for discharge teaching based on discharge medications and needed lifestyle changes.D. Administer oral analgesic medications as needed prior to assisting patient out of bed on first post-operative day.
Priority Question # 1, #21. During initial post-operative assessment of a patient who has just transferred to post-anesthesia care unit after repair of an abdominal aortic aneurysm all of these data are obtained. Which has most immediate implications for client’s care?
A. Arterial line indicates a blood pressure of 190/112. (HIGH RISK OF RUPTURE)
B. Monitor shows sinus rhythm with frequent PAC’s.C. Client does not respond to verbal stimulation.D. Client’s urine output is 100ml of amber urine.
2. It is the manager of a cardiac surgery unit’s job to develop a standardized care plan for post-operative care of client having cardiac surgery. Which of these nursing activities included in care plan must be done by an RN?
A. Remove chest and leg dressings on the second post-operative day and clean the incisions with antibacterial swabs.B. Reinforce patient and family teaching about the need to deep breathe and cough at least every 2 hours while awake.C. Develop individual plan for discharge teaching based on discharge medications and needed lifestyle changes. (RN develops individual teaching plan)
D. Administer oral analgesic medications as needed prior to assisting patient out of bed on first post-operative day.
Case study from Hospital
Patient History27 year old male F ull C ode African AmericanL ives alone in apartmentF amily hx DMMorbid obesity (314.6 lbs )Height: 5’11Ambulates with walker
Medical His tory:E T OH abuseS mokerHypertens ionDO E
S leep apneaT rach (8/30)E jection F raction 50%Hemodialys is (M-W-F )Mitral insufficiency, Mild regurgitation(mitrial, tricuspid)P ressure ulcer on coccyxR espiratory failure with trach , pneumonia, delirium
(8/13) P t appeared in E R w c/o flank and abd pain
B /P 270/159 (C ardene drip which decreased pressure to 185/73)
Na 138 K 4.4 C h108 B UN 24 C reat 3.0 G lucose 147 C a 8.5 Hgb 12.5
Admiss ion diagnos is : Malignant hypertens ionT ype B Aortic D issectionR enal insufficiencyMorbid obes ity
P t teaching:S moking cessationC ontrol HTNL ifestyle changesDiet controlUse of s tool softeners (increase fluid and fiber in diet)
• E X T R A DX DE VE L O P E D DUR ING HO S P IT AL S T AY :
• Myopathy• Acute respiratory failure• C hronic kidney disease• P neumonia due to S taph
and Hemophilus Influenze
• HT N encephalopathy acute renal dis eas e with les ion of tubular necros is
• Delirium• Uns pec d/o of kidney and
ureter
Diagnostic Test
LabsWB C 12.9 ?R B C 3.13 ?Hgb 8.9 ?Hct 26 ?P lt 200Na 129 K 3.6C hl 90 ?B un 120 ?AG AP 16 ?Mg 2.3C reat 10 ?G lucose 115 ?P hos 8 ?
C hest X -ray to visualize thoracic aortic aneurysms: C ardiac s ilhouette remains enlarged. P os ition of endotrachial tube opacity. P ulmonary vascular congestion pers ist. Aortic arch enlarged; mild perihilar interstitial pulmonary edema. Atelectas is or edema adjacent to left ventricular border improved. L ungs underinflated with evidence of pulmonary edema.
C T to allow precise measurement of aneurysm: S tanford B thoracic aortic dissection distal to origin of L eft subclavian to above iliac arteries . C ompromised flow of left renal artery. L eft ventricular hypertrophy and left renal s tone.
Vital S igns : B /P - 109/53 P -88 R - 18 T -100.8
S urgery
• S urgery is done when an aneurysm is 6 cm in diameter, expanding fast or symptomatic. T ype B diss ections are surgically repaired depending on extent of involvement and risk for rupture.
• Aneurysm excised and replaced with s ynthetic fabric graft.
Nsg Dx:• R isk for Ineffective tissue
perfus ion.• Anxiety
Med i ca ti on s Al lergy:PCN
T reated with long term beta blocker therapy and antihypertens ive drugs as needed to control heart rate and blood pressure. Initially treated with I.V beta blockers such as propranolol (Inderal),metoprolol (L opressor), Normodyne or B revibloc to reduce heart rate to 60 bpm. Niprideinfus ion to reduce systolic to 120mmHg. C alcium channel blockers may also be used. Direct vasodilators are avoided because they may worsen the dissection. After surgery anticoagulants may be initiated; used indefinitely and maybe even lifelong.
P t meds: Albuterol 2.5mg IH q8hHeparin 5000u S Q q8hF lonase nas al spray 2 sprays each nose q12hAmphojel 1020mg q8hC atapress 0.2mg q4hMinoxidil 10mg P O q12hE ns ure supp 240ml P O T IDP rotonix 40mg po dMultivitamin 1 tab P O dL exapro 20mg P O d R enal D ietP rocrit 10000u S Q MWF R P ermacath, R AC , S L
Discharge Instructions P t discharged to C ornerstone at S t
David’s for R ehab with trach P sychiatry consult for behavioral
problems C ardiology seeing pt for B /P control
(ranging from 110-130 systolic upon discharge)
R egular diet American Heart Association
P hys ical therapy being used but still needs lots of rehab
P lan is to medically manage aortic dissection for now and once s table he’ll follow up w vascular surgery for definitive treatment.
F /U w vascular surgery andC ardiothoracic M.D when d/c from C ornerstone, nephrology, internal medicine, infectious diseasepsychiatry
Discharged 09-26
Discharge Medications :
F lonase dailyHeparin 5000 u q 8hAlbuterol MDI p.r.nAmphojel 30cc q8hAtenolol 50mg q 12hC lonidine 0.2 p.r.nMinoxidil 10mg B .I.DE nsure T .I.D w mealsP rotonix 40mg dMultivitamin dL exapro 20mg dP rocrit q M-W-F subcu10,000uAtivan p.r.n
OPEN HEART SURGERY
Diagnostic Tests
EKGEKG
exercise stress testexercise stress test
CXRCXR
cardiac cath- cardiac cath-
echocardiogramechocardiogram
thallium scanthallium scan
PRE-OP TEACHING
Open Heart Surgery
Open Heart Surgery-What to Expect!
Intra-op Events
hypotensionhypotension
cardioplegiacardioplegia
cross clamping aortacross clamping aorta
cardiopulmonary bypasscardiopulmonary bypass
heparinizedheparinized
CP Bypass
Heart Lung Machine (video)
Post-op Appearance
mechanical ventilator-SIMV modemechanical ventilator-SIMV mode
hemodynamic monitoring- dec. COhemodynamic monitoring- dec. CO
cardiac monitoring-SVT and Afib cardiac monitoring-SVT and Afib commoncommon
mediastinal tube-100cc first hour to mediastinal tube-100cc first hour to 500/24500/24
multiple IV sites and linesmultiple IV sites and lines
pacer wirespacer wires
foley-hourly outputfoley-hourly output
Assessmentvital signsvital signs
PAPPAP
PCWPPCWP
COCO
urine outputurine output
bleedingbleeding
fluid balance and neurofluid balance and neuro
Complicationsdecreased cardiac outputdecreased cardiac outputcardiac tamponadecardiac tamponadehypokalemiahypokalemiaHemorrhage-replace cc for cc . 100 first Hemorrhage-replace cc for cc . 100 first hr. then 55/24 hourshr. then 55/24 hoursneuro changesneuro changesresp insufficiencyresp insufficiencyinfection and pain-demoral, splint infection and pain-demoral, splint incision. Offer pain med: percoset or incision. Offer pain med: percoset or vicodin q 4hr. vicodin q 4hr.
Cardiac tamponade
Paradoxical pulse is a pulse that markedly decreases in amplitude during inspiration. On inspiration, more blood is pooled in the lungs and so decreases the
return to the left side of the heart; this affects the consequent stroke volume.
•Cardiac tamponade (influenced by volume and rate of accumulation)
•Beck triad (jugular venous distention, hypotension, and muffled heart sounds)
•Pulsus paradoxus is measured by careful auscultation with a blood pressure cuff. The first sphygmomanometer reading is recorded at the point when beats are audible during expiration and disappear with inspiration. The second reading is taken when each beat is audible during the respiratory cycle. A difference of more than 10 mm Hg defines pulsus paradoxus.
•Cyanosis
• No drainage from mediastinal tube
Decreased Cardiac Output
decreased preload-need fluiddecreased preload-need fluid
inc. afterload- need to dec. B/P inc. afterload- need to dec. B/P (Nipride)(Nipride)
dec. contractility- need dobutaminedec. contractility- need dobutamine
Arrhythmias- SVT and Afib commonArrhythmias- SVT and Afib common
Post-op Care Goals
Promote CV function, tissue Promote CV function, tissue perfusion and stablization of VSperfusion and stablization of VS
cont.Promote respiratory function and sufficient Promote respiratory function and sufficient oxygenation by promoting chest drainage and oxygenation by promoting chest drainage and use of ISuse of IS
Goals
Promote fluid and electrolyte balancePromote fluid and electrolyte balance
Promote renal functionPromote renal function
Promote rest, comfort, and relief of Promote rest, comfort, and relief of painpain
Promote neurological functionPromote neurological function
Promote psych adjustmentPromote psych adjustment
Promote early movement and Promote early movement and ambulationambulation