Cardiovascular System NCLEX Review

Cardiovascular Disorders

Fluid and electrolyte imbalances affecting the heart:

Hypokalemia

Causes: Vomiting, diarrhea, gastric suctioning, poor nutrition
Increased cardiac electrical instability, ventricular dysrhythmias
Increased sensitivity to digoxin
Muscle weakness and parathesias
ECG - flattening and inversion of the T wave, the appearance of a U wave, and ST depression

Hyperkalemia

Causes: renal failure, burns, crushing injuries, potassium supplements
asystole and ventricular dysrhythmias
Muscle weakness and paralysis
Nausea and diarrhea
ECG – tall peak T waves, widened QRS complexes, prolonged PR, flat P waves

Hypocalcemia

Causes: Hypoparathyroidism, loop diuretics, renal failure
Nervous system excitability
Tetany followed by carpal spasms
Trousseaus sign
Chovosteks sign
Seizures
can cause ventricular dysrhythmias, prolonged ST and QT intervals, and cardiac arrest

Hypercalcemia

Causes: hyperparathyroidism, excess calcium intake, immobility
Sedative effect on nervous system
Confusion
Lack of coordination and muscle weakness
Abdominal pain and distention
Can cause shortened ST segment and widened T wave,

Hypomagnesemia

Increased neuromuscular irritability
Tremors, tetany, seizures
Depression and confusion
Dysphagia
can cause ventricular tachycardia and fibrillation.
Tall T waves and depressed ST segments.

Hypermagnesemia

Depressed CNS
Depressed cardiac impulses
Muscle weakness
Hypotension
Shallow respirations
Prolonged PR interval and widened QRS complex.

Hyponatremia

Causes: vomiting, excess water intake, diuretics
Increased ICP
Confusion and convulsions
Muscle cramps
Nausea and vomiting

Hypernatremia

Causes: Tube feedings with no water flushes, inadequate water intake, diabetes insipidus
Excess thirst
Altered LOC
Hypertension with normal or increased ECF
Tachycardia
Postural Hypotension with decreased ECF

Diagnostics

Holter Monitoring

ECG tracing recording for 24 hours
Identifies dysrhythmias
Evaluates antidysrhythmic or pacemaker therapy.

Echocardiography

Use to detect valvular abnormalities, congenital heart defects, wall motion, ejection fraction, and cardiac function.
Transesophageal echocardiograph- prep patient same as endoscopy
Interventions: determine and advise client to lie still, breathe normally, and refrain from talking

Exercise electrocardiography testing (stress test)

Preprocedure:

NPO 3 to 6 hours.
Obtain consent
Adequate rest
Light meal 1-2 hours before the test
Avoid smoking, ETOH, caffeine
Withhold theophylline products 12 hrs before
Withhold calcium channel blockers on the day before
Wear not constrictive clothing, rubber-soled shoes
Instruct to notify HCP: chest pain, dizziness, SOB during procedure

Preprocedure:

Obtain consent
Inform about radioisotope, exposure risk is minimal

Postprocedure:

Assess VS
Assess site for bleeding or discomfort
Fatigue is expected

Cardiac Catheterization

Preprocedure:

Obtained informed consent
Assess allergies for seafood, iodine, or radiopaque dyes
NPO 2-6 hours prior to procedure
Document VS and peripheral pulses
Inform client they may feel heat, palpitations, desire to cough when dye is injected.
Prep the site
Administer sedatives
Insert IV line
Withheld Metformin 24 hours before the test and do not resume until prescribed (48 hours post procedure or after renal function studies)

Postprocedure:

Monitor vital signs
Check pulses
Assess for bleeding
Bedrest 4-6 hours with insertion site extremity straight

II. Cardiac Disorders

Coronary artery disease

Narrowing or obstruction of 1 or more coronary arteries due to atherosclerosis, which is an accumulation of lipid-containing plaque in the arteries.

Chronic Causes:

Nonmodifiable

- Age, genetics, race, men

Modifiable

- Elevated cholesterol, smoking, hypertension, DM, obesity, substance use

Assessment findings:

ECG: ST depression or ST elevation (risk for ischemia)
Pain may radiate down left arm, jaw pain may be present and symptom relief with nitroglycerin
Angina: Chest pain resulting from myocardial ischemia caused by inadequate myocardial blood and oxygen supply

Nursing interventions

Health promotion and education (diet, exercise, smoking cessation)
Medication management
Surgical management

Surgical Interventions:

Percutaneous transluminal coronary angioplasty (PTCA)
Laser angioplasty
Atherectomy
Vascular
Coronary artery bypass grafting

Medications:

Vasodilators
Aspirin
Angiotensin receptor blockers
Calcium channel blockers
Cholesterol-lowering medications
Beta-blockers

Myocardial Infarction

Causes:

Blockage: coronary artery disease (most common)
Coronary spasms: cocaine or hypertension
Coronary artery dissection.
Embolism
Cardiac Hypertrophy

Workups:

Troponin I: peaks within 4-12 hours, up to 3 weeks
CK Level: within 6 hrs, peaks at 18 hrs
CKMB: first enzyme elevated after MI, peaks at 18-24 hours
Myoglobin: rises within 1 hour, peaks within 4-6 houts hrs, returns to normal less than 24 hours
WBC: elevated within 2 days, lasts 1 week.
ECG- ST elevation, T wave inversion

Signs and symptoms:

Radiating Chest pain- severe, stabbing, crushing
Nausea/vomiting
Acute pulmonary edema
Cardiac arrest and dysrhythmias
Cardiogenic shock
Low grade fever
Decreased urine output

Interventions

Thrombolytic therapy (tPA
Family and client support
Bedrest to decrease stress on the heart
Position patient in semi-fowlers
Monitor Vitals and ABCs
Monitor intake and output
Establish IV access
Administer meds
Pain management
Administer o2 as needed
Prevent complications: dysrhythmias, shock, CHF, PE, recurrent MI
Teach patient life style modifications

Heart Failure

The inability of the heart to maintain adequate cardiac output to meet the metabolic needs of the body because of impaired pumping ability.
Diminished cardiac output results in inadequate peripheral tissue perfusion.
Congestion of the lungs and periphery may occur; the client can develop acute pulmonary edema.

Right vs. Left Heart Failure

Left-sided HF

Most common
Can be SYSTOLIC or DIASTOLIC
Pulmonary signs and symptoms

DROWNING

Difficulty breathing

Rales (crackles)

Orthopnea

Weakness

Nocturnal Paroxysmal dyspnea

Increased heart

Nagging cough

Gaining weight

Right-sided HF

Congested hepatic circ: hepatomegaly, swelling.
Caused by left sided heart failure, “cor pulmonale”
Peripheral signs and symptoms

SWELLING

Swelling of legs, hands, liver, abdomen

Weight gain

Edema (pitting)

Large neck veins

Lethargic Irregular heart rate (atrial fibrillation)

Nocturia

Girth of abdomen increased

SYSTOLIC- “Left ventricular systolic dysfunction” : issue in ejection fraction (EF); N:50% or greater

DIASTOLIC “left ventricular diastolic dysfunction”: Normal EF

Nursing Interventions:

Assessing

Assess for worsening symptoms
Patient responsiveness to medication treatment:
watch heart rate (Digoxin)
respiratory status
blood pressure (vasodilators cause hypotension)
diuretics (strict intake and output, daily weights, monitor electrolyte levels, especially K+)

Monitoring

Fluid status
Cardiac diet
Fluid restriction
Lab values: watching BNP, kidney function BUN & creatinine, troponins levels, electrolytes
Edema in legs
Safety

Educating

Early signs and symptoms heart failure exacerbation:
Low salt and fluid restriction
Vaccination to prevent illness, such as annual flu and to be up-to-date with pneumonia vaccine
Exercise aerobic (as tolerated)
Daily weights
Compliance with medications
Smoking cessation
Limiting alcohol

Cardiogenic Shock

What happens during Cardiogenic shock?

decreased stroke volume -> decreased cardiac output -> decreases perfusion to the body’s cells that make up our organs and tissues = cell injury

Signs and symptoms:

Heart

Back flow of blood from the left side to the lungs (pulmonary congestion, crackles, dyspnea, increased respiratory rate, low oxygen, increased heart rate)
As it progresses, blood will back flow from the lungs to the right side of the heart (neck veins become distended due to an increase in venous pressure and there will be a high CVP…central venous pressure)
Chest pain
Hypotension
Weak peripheral pulses

Brain: leads to confusion, agitation, restlessness

Kidneys: Water retention and oliguria, renal failure

Skin: decreased capillary refill, cool, pale, and clammy skin

Nursing Interventions: