lOMoARcPSD|6828319

Cardio Study Guide

Med Surg 2 (West Coast University)

StuDocu is not sponsored or endorsed by any college or university

Downloaded by Frida Grillo (cigcna@gmail.com)
 lOMoARcPSD|6828319

Study Guide Topics

● Cardiac Diagnostic Tests (ATI)

o Echocardiogram
▪ Ultrasound of heart
▪ Dx: valve disorders & cardiomyopathy
▪ Indications:
o Cardiomyopathy
o Heart failure
o Angina
o MI
o Stress Testing
▪ Pt walks on treadmill to exercise cardiac muscle
▪ Gives info about workload of heart
▪ DC one HR reaches a certain rate
▪ Note: Pts can tire easily, disabled or physically challenged & not finish test
o HCP can prescribe pharmacological (chemical stress test)
▪ Meds = dipyridamole, adenosine, dobutamine given instead of walking
● Indications
o Angina
o HF
o MI
o Dysrhythmias
o Hemodynamic Monitoring
▪ Indications:
o Serious or critical illness
o HF
o Post coronary artery bypass graft (CABG) Pt
o ARDS
o Acute kidney injury
o Burn injury
o Trauma injury
▪ Special indwelling cath gives info on:
o Blood volume & perfusion
o Fluid status
o How well heart is pumping
● Parameters assessed
o CVP central venous pressure
o PAP Pulmonary Artery Pressure
o PAWP Pulmonary Artery Wedge Pressure
o CO Cardiac output
o Intra-arterial blood pressure
● Hemodynamic monitoring system:
o Pressure transducer
o Pressure tubing
o Monitor
o Pressure bag & flush device
● Placement of arterial lines
o Radial = Most common
o Brachial
o Femoral
o Angiography (Cardiac Catheterization)
▪ Evaluates degree of coronary artery blockage
▪ Performed on low extremities (femoral mainly or brachial) determines blood flow & blocked areas
▪ Occlusions seen w/ injection of contrast media
o Assess for Ax to shellfish & iodine
● Indications:
o Unstable angina
o ECG changes: T wave inversion, ST segment elevation, depression)
o Confirm location & extent of heart disease
o Vascular Access
▪ Determined by characteristics of prescribed therapy:

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

o Med type
o pH & osmolality
o Length of time for therapy
● Used to decrease number of insertions & risk for adverse reactions
● Types of access:
o Central IV therapy
o Non-tunneled percutaneous venous cath (CVC)
o Peripherally inserted central cath (PICC)
o Tunneled percutaneous central venous cath
▪ Long term use
o Implanted port

● Coronary Artery Disease (CAD) Blood vessel disorder Atherosclerosis

o Etiolgy & Patho
▪ Atherosclerosis = major cause of CAD
o Lipid deposits in intima of artery
o Endotheilial injury & inflammation play a huge role in development
o C-Reactive Protein = inflammation marker
▪ Increased levels seen with unstable plaque & LDL
● CAD
o Progressive disease
o When symptomatic disease is usually well advanced
o Total occlusion of vessel COLLATERAL CIRCULATION
▪ Vessels find way to supply blood to vessels to compensate
▪ Could lead to ischemia or infarction with rapid CAD
o R/F Modifiable vs. Non modifiable
▪ Non-modifiable (Cant change)
o Age
o gender
o ethnicity Hispanic & African American
o Family Hx heart disease & MI
o Genetics DM & HTN
● Modifiable (Can change) ENCOURAGE LIFESTYLE CHANGES
o Elevated serum lipids
▪ Serum cholesterol > 200
▪ Fasting triglyceride > 150
o Elevated BP
o Tobacco use
o physical inactivity
o obesity
o Diabetes
o Metabolic syndrome
o Psychologic states
o Elevated homocysteine level
o Cardiac tests
▪ Total Cholesterol
o Screens heart disease
● Triglycerides
o Evaluates Pt’s risk for heart disease
▪ LDL = Bad cholesterol
o ↑ levels→ atherosclerosis
o Transports cholesterol to body’s cells from liver
▪ HDL= Good cholesterol
o Remove excess cholesterol out of bloodstream
o ↓ chance of CAD
o Labs
▪ Lipid Profile Used for early detection of heart disease
o Total Cholesterol
▪ Normal: <200mg/dL
o Triglycerides
▪ Normal: (M) 40-160 mg/dL (F) 35-135 mg/dL
o LDL
▪ Normal: < 130 mg/dL
▪ ↑ Risk for CAD: 130-160 mg/dL

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

▪ Recommended = <100
o HDL
▪ Normal: (M) > 55 mg/dL (F) > 45 mg/dL
o Nutritional Therapy
▪ Goal = ↓ LDL
● ↓ saturated fat & cholesterol
● ↑ complex carbs & fiber (Whole grains, fruits, & veggies
● ↓ red meat, egg yold, whole milk
● ↑ omega 3 fatty acids
o fatty fish twice a week (salmon, tuna)
o tofu
o soybeans
o canola
o walnut
o flaxseed
▪ Foods to DECREASE & ADD MORE OF
o Saturated Fat- Use sparingly, ↓ these foods
▪ Animal fat (bacon, lard, egg yolk, dairy fat)
▪ Oils (Cocunut, palm oil)
▪ Butter
▪ Cream Cheese
▪ Sour Cream
o Monosaturated Fat- In moderation
▪ Fish oil
▪ Oils (canola, peanut)
▪ Avacado
▪ Nuts (almonds, peanuts, pecans)
▪ Olives (green, black)
o Polysaturated Fat- Use primarily & ↑ intake
▪ Vegetable oils (safflower, corn, soybbean, flaxseed, cottonseed)
▪ Some fish oil, shellfish
▪ Nuts (walnuts)
▪ Seeds (pumpkin, sunflower)
▪ Margarine
o Medications (pg 711 table 33-5)
▪ Statins atorvastatin (Lipitor), simvastatin (Zocor)
o S/E
▪ Rash
▪ GI disturbances
▪ Elevated liver enzymes
▪ Myopathy
▪ Rhabdomyolisis
o Considerations
▪ Monitor liver enzymes
▪ Monitor creatine kinase muscle weakness or pain occurs)
o Drug Alert: simvastatin (Zocor)
▪ Increase risk of rhabdomyolisis when used with:
● gemfibrozil (Lopoid)  Fibric acid deriative
● niacin (Lopoid)
● Types of Angina
o Angina (Chest pain)
▪ Clinical manifestation of myocardial ischemia
▪ Caused by ↑ demand for 02 or ↓ supply of 02
▪ Most common reason for angina:
o Narrowing coronary arteries by atherosclerosis
o Leads to insufficient blood flow
● Stenosed artery ischemia secondary to atherosclerosis
o Chronic Stable Angina
▪ Chest pain intermittently over time with similar pattern & lasts for a few minutes
▪ Provoked by: physical exertion, stress, emotional upset
▪ Pain Characteristics: squeezing, heavy, tight, suffocating
o Radiate to jaw, neck, shoulders, arms
o No change with position or breathing
o Not described as sharp or stabbing

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

o Pain at rest is unusual

▪ ECG→ ST depression, T wave inversion
▪ Tx nitroglycerin &bed rest
o Nocturnal Angina
▪ Pain only at night
o Angina Decubitus
▪ Pain when laying down
▪ Relieved by sitting or standing
o Prinzmetals Angina
▪ Spasm of major coronary artery D/T ↑ calcium
▪ Pain at rest (no physical demand)
o Occurs with REM, ↑ 02 consumption, & exposure to cold temps
▪ Triggers→ smoking, ↑ levels of histamine, cocaine, epinephrine
▪ ECG→ Mimics MI (Transient ST Elevation)
▪ Seen with Hx of Raynauds Phenomenom, migraines, heavy smoking
▪ Can occur with absence of CAD
▪ Tx calcium channel blockers & nitrates
o Microvascular Angina
▪ Occurs in absence of CAD or coronary spasm of major coronary artery
▪ Myocardial ischemia secondary to microvascular disease affecting the small, distal branches of coronary arteries (Coronary
Microvascular Disease or Syndrome X)
▪ Common in postmenopausal women
▪ Triggered by ADL’s
▪ Tx Nitroglycerin
o Unstable Angina
▪ Rupture of unstable plaque, exposing thrombogenic surface
▪ New-onset angina
▪ Chronic stable angina that ↑ in frequency, duration, severity
▪ Symptoms: fatigue, SOB, indigestion, anxiety
▪ Occurs at rest or with minimal exertion
▪ Lasts more than 10 mi
o TQ: Difference between stable & unstable angina
▪ Stable treated by nitrates & goes away after exercise, stress…ect.

● Tx, S/E, Teaching: Chronic Stable Angina

o Goal of Tx reduce symptoms & risk of MI & death
o NITROGLYCERIN
▪ Vasodilator→ relaxes vessels
o Dilate peripheral blood vessels
▪ ↓ SVR, venous pooling
▪ ↓ venous blood return to heart (preload)
o Dilate coronary arteries & collateral vessels
▪ ↑ blood flow to ischemic areas of heart
o SHORT ACTING NITRATES
▪ 1st line of Tx for angina
▪ Routes of admin.
o Oral: Extended release swallow whole
o Sublingual Nitroglycerin (SL NTG)
o Spray = Nitrolingual
● Relieves pain in 5 min. & lasts 30-40 min.
● Recommended dose= 1 TAB or 1 SPRAY
● Repeat ST NTG Q5min for max of 3 doses if symptoms worsen/unchanged after 5 min
● Symptoms don’t resolve call 911
● TQ: Pt has angina with 6/10 pain. She takes 1 dose and pain levels is 2/10. What do you tell your Pt? Take another dose of
nitrate. Max 3 doses
o LONG ACTING NITRATES
● Routes of admin.
o Oral- Isosorbide dinitrate (Isordil), Isosorbide mononitrate (lmdur)
o IV- Nitroglycerin (Tridil)
o Ointment- (Nitropaste)
▪ For nocturnal & unstable angina
▪ Placed on upper body of arm over flat muscular surface
o Transdermal- (Transderm-Nitro)
▪ Given once a day in AM, and place patch on area with no hair

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

▪ Steady plasma levels during 24 hours

▪
o Side effects
▪ Headache TQ: what is an expected side effect of nitrates
▪ TQ: Pt complaining of headache. What do you tell your Pt to do?
o Nap in a low cool environment
▪ Orthostatic Hypotension
▪ Flushing
▪ Dizziness
o Pt Teaching
▪ Educate Pt about S/E
▪ Headaches will decrease over time
▪ Take acetaminophen (Tylenol) for headaches
▪ Ortho. Hypotension is a complication of all nitrates
o Monitor BP after initial dose
o Inform Pt of 8-hour nitrate free period during night unless Pt. has nocturnal angina
▪ Don’t take with Viagra d/t severe hypotension
▪ Have med close at all times
▪ Keep away from light & heat sources
▪ Replace TABS every 6 months
▪ Place under tongue till dissolved
▪ Spray directly on tongue
▪ Tingling sensation felt when given
▪ Change positions slowly to prevent O. Hypotension
▪ Prophylatic use→Take TAB 5-10 min prior to activity
▪ Report Freq or Nocturnal Angina to HCP
● Acute Coronary Syndrome: Angina to Myocardial Infarction
o Etiology & Patho
▪ Exacerbation of CAD caused by angina
▪ Imbalance b/t myocardial 02 supply & demand
▪ Can be d/t Thrombus formation
▪ Abrupt stoppage of 02 to heart muscle Myocardial Ischemia Tissue Necrosis (if blood & 02 not restored)
▪ Cardiac enzymes released in blood when heart muscle suffers injury
▪ ECG→ STEMI (ST Elevation) Emergency situation
o Assessment
▪ Angina (Refer to types above)
▪ R/F Males, Postmenopausal women, ethnicity, sedentary lifestyle, HTN, Smoking, Hyperlipidemia, obesity, excessive
drinking, DM, hyperthyroidism, methamphetamine or cocaine use, stress
o Manifestations
▪ MI Pain Characteristics:
o Sharp when taking breath
o Heavy, pressure, tight, burning, constricted, crushing,
o Pt cant speak
o Radiates to lower jaw, shoulder, arm
o Indigestion with epigastric pain
o Occurs when active, at rest, asleep, or awake
o Common in morning hours
o Lasts for 20 min or longer
o Elderly Pt change in LOC, SOB, pulmonary edema, dizziness, or dysrhythmia
● Obj. Assessment Findings
o Pallor, cool. Clammy skin
o Tachycardia & heart palpitations
o S3 & S4 heard
o Fever
o Tachypnea & SOB
o Diaphoresis
o N/V
o ↓ LOC
o Labs
● Labs
o Cardiac Enzymes Specific markers released in blood to Dx. Myocardial Infarction
▪ Troponin T
● Normal: < 0.1 ng/mL
● Detected 2-3 hr post myocardial injury

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

● Expected duration: 10-14 days

▪ Troponin I
● Normal: 0.03 ng/mL
● Detected 2-3 hr post myocardial injury
● Expected duration: 7-10 days
▪ CKMB Creatine Kinase MB isoenzyme
● Normal: 0% of total CK (30 to 170 units/L)
● Detected 3-6 hr post myocardial injury
● Expected duration: 2-3 days
▪ Myoglobin
● Normal: < 90 mcg/L
● Detected 2-3 hr post myocardial injury
● Expected dutcome: 24 hr.
● Diagnostic Tests
o ECG
o Stress Test
o Thallium Scan
▪ Assess for ischemia or necrosis
o Cardiac Catheterization
▪ Interventions
o MONA or ONAM (Morphine, 02, Nitro, ASA)
▪ Oxygen
▪ Nitro
▪ ASA
▪ Morphine
o Monitor the following:
▪ VS Q5 min until stable, then q1hr
▪ Continuous cardiac monitoring
▪ Pain- PQRST
▪ Hourly urine output (>30 mL/hr = renal perfusion)
▪ Labs: cardiac enzymes, electrolytes, ABG’s
▪ 02 2-4 LPM
o 02 (2-4 LPM)
o Obtain & Maintain IV access
o Promote energy conservation
● Medications:
o Vasodilators
▪ Nitroglycerin
o Morphine
▪ Analgesic
● Caution with pt who have asthma or emphysema d/t respiratory depression
o Beta-Blockers
▪ Metoprolol (Cardioselective BB) decrease effects on respiratory system
● Antidysrhythmic & antiHTN effects
o Thrombolytics
▪ Alteplase & retelase
o AntiPLT agents
▪ Baby aspirin 81 mg & clopidogrel
● GI effects caution with HX of GI ulcers
● Tinnitus sign of aspirin toxicity
o Anticoagulants
▪ Heaparin & enoxaparin
o Glycoprotein IIB/IIA inhibitors
● Pt teaching
o Cardiac rehab should be consulted
o Nutrition services consult for weight management
o Monitor & report signs of infection (fever, incisional drainage, rednss)
o Avoid straining, strenuous exercise, emotional stress
o Response to chest pain
▪ Instructions for SL nitro
o Encourage to exercise regularly
▪ Complicationso
o Acute MI
o Heart Failure injury to L ventricle leads to decreased CO & HF

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

o Cardiogenic shock Progessive HF leads to this

o Ventricular aneurysms/Rupture
▪ D/t necrosis from MI
o Dysrhythmias
▪ Inferior wall MI inferior myocardial tissue from R coronary artery is injured by thrombus
● Wtgy7rrBradycardia
● Second-degree heart blocl
▪ Anterior wall MI left anterior descending coronary artery is injured d/t lack of blood supply
● PVC
● Bundle branch block
● Complete heart block

● ECG Readings by Electrocardiography

o PQRST
▪ P Wave = Atrial depolarization (CONTRACTION)- 2 ques. Both answers were P wave
▪ QRS Complex= Ventricular depolarization (CONTRACTION)
▪ T wave= Ventricular repolarization (RELAX/FILL)
o STEMI (↑ ST Elevation)
▪ Indicates Myocardial Infarction
o NSTEMI (↓ ST depression)
▪ Indicates Angina

o Arrhythmias & Dysrhythmias

▪ Normal sinus rhythm
o SA Node
o 60 – 100 BPM
● Sinus Bradycardia
o Ventricular slow rate <60 BPM
o Normal when sleeping, & in athletes
o PNS stimulation
o Manifestations:
▪ Hypotension
▪ Pale, cool skin
▪ Weakness
▪ Angina
▪ Dizziness or syncope
▪ Confusion or disorientation
▪ SOB
o Treatment
▪ Medications
● Atropine (anticholinergic) = Drug of choice
● Dopamine = 2nd drug of choice
● Epinephrine
▪ Pacemaker
▪ DC, hold, or reduce dosage of med
● Sinus Tachycardia
o Rate: >100 BPM
o SNS stimulation
o Assoc. with exercise, fever, hypotension, hypovolemia, anemia, hypoxia, hypoglycemia, MI, HF, hyperthyroidism,
anxiety, fear & drugs
o Certain Meds can ↑ HR
o Manifestations:
▪ Dizziness
▪ Dyspnea
▪ Hypotension
▪ Angina with CAD
o Treatment:
▪ Goal is to ↓ HR & myocardial 02 comsumption
▪ Vagal maneuvers
▪ Monitor for serious dysrhythmia
▪ IV beta blockers- metoprolol (Lopressor), adenosine (Adenocard)
▪ Calcium Channel blockers- diltiazem (Cardizem)
▪ Cardioversion
● Atrial Flutter

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

o Rate: 200-350
o Continuous quivering of heart
o ↓ CO = Risk of stroke
o Assoc. with CAD, HTN, mitral valve disorders, pulmonary embolism, chronic lung disease, cor pulmonale,
cardiomyopathy, heart failure, hyperthyroidism
o Tx: Thrombolytics, Anticoagulants
● Atrial Fibrillation
o Ans: Irregular rhythm
o Rate: 350-600
o SA node rapidly fires & causes Ineffective atrial contractions
o Ventricles cannot fill & clots will form
o At risk for stroke D/T ↓ CO
o Seen with HTN, kidney disease, heart failure
o Treatment:
▪ Antidysrhythmic drugs
● Amiodarone
● ibutiide
● Digoxin
▪ Anticoagulants- Coumadin (Warfarin)
● Drug of choice
o Used 3-4 weeks before & several weeks after cardioversion
o Monitor INR
● ‘Prevents risk of stroke & dislodged clots
● Used for Pts in A. Fibb longer than 48 hours
● used 3-4 weeks before & several weeks after cardioversion
● Used long term if cardioversion does not work
▪ Electrical cardioversion
● Converts A. Fibb to normal sinus rhythm
▪ Radiofrequency ablation
● Used when there is no response to cardioversion
▪ Maze procedure cryoablation
● Surgical Incision in both atrias, cryoablation (cold therapy) stops formation & conduction of signals
and returns to normal sinus rhythm

● Heart Failure
o Etiology
▪ R/F = HTN & CAD
▪ Primary Causes:
o HTN
o CAD including MI
o Rheumatic heart disease
o Congenital heart defects (Ventricular septal defect)
o Pulmonary HTN
o Cardiomyopathy (viral, postpartum, substance abuse)
o Valve disorders ( mitral stenosis)
o Myocarditis
o Pathophysiology
▪ Infeffectionm heart pumping
o Ejection Fraction (EF)
▪ L. Ventricular Ejection Fraction
o Amount of blood pumped from L. ventricle into arteries with each heartbeat
o Normal range = 55% - 70%
o ↓ in L. Ventricular Ejection Fraction D/t
▪ impaired contractile function
▪ ↑ afterload
▪ Cardiomyopathy
▪ R. Ventricular Ejection Fraction
o Amount of blood pumped from R. ventricle to lungs with each heartbeat
▪ Normal range = 45-60%
● EF with Heart failure = <45% & as low as 10%

o L. Sided Heart Failure

▪ L. Ventricular dysfunction
▪ Blood backed into L. Atrium & Pulmonary veins

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

▪ “Back up in lungs”
▪ ↑ Pulmonary pressure causes fluid in alveoli
▪ Causes
o HTN
o CAD, angina, MI
o Valvular Disease (mitral & aortic)
▪ Clinical Manifestations = Pulmonary Congestion/Edema
o Signs
▪ LV heaves
▪ Pulsus alternans: difference in apical & radial pulse was the answer
▪ ↑ HR
▪ PMI displaced inferiorly & left of MCL
▪ ↓ Pa02, slight ↑ PaC02
▪ Crackles
▪ S3 & S4 heart sounds
▪ Pleural effusion
▪ Changes in LOC
▪ Restlessness, confusion
o Symptoms
▪ Weakness, fatigue
▪ Anxiety, depression
▪ Dyspnea
▪ Shallow respirations (32-40/min)
▪ Paroxymal nocturnal dyspnea
▪ Orthopnea
▪ Dry, hacking cough
▪ Nocturia
▪ Frothy, pink tinged sputum (advanced pulmonary edema)

o R. Sided Heart Failure

▪ R. Ventricular Dysfunction
▪ Most common cause = L. Sided Heart failure
o Pul. Congestion & ↑ pressure in vessels → Pulmonary HTN- Cor Polmonale
▪ Blood backs up to R. Atrium & venous circulation→ venous congestion
▪ “Back up in body”
▪ Clinical Manifestations = Venous Congestion/Edema
o Signs
▪ RV heaves
▪ Murmurs
▪ JVD
▪ Edema (pedal, scrotum, sacrum)
▪ Weight gain
▪ ↑ HR
▪ Ascites
▪ Anasarca (massive gen. edema)
▪ Heptatomegaly
o Symptoms
▪ Fatigue
▪ Anxiety, depression
▪ Dependent, bilateral edema
▪ RUQ pain
▪ Anorexia & GI bloating
▪ Nausea
o Acute Decompensated Heart Failure (Exacerbation of Chronic heart failure)
▪ Sudden onset of S&S of HF
▪ Universal findings Systemic & pulmonary congestion
o D/t ↑ left sided & right sided fillig oressures
▪ Seen with L. Heart Failure & CAD
▪ ↑ Pul. Pressure d/t failed L. Ventricles (lungs become less compliant w/ small airways)
o ↓ lung compliance
o ↑ airway resistance
o ↑ lymphatic flow
● Clinical Manifestations (Note: Manifest as Pulmonary Edema)
o Anxious, pale, cyanotic
o Cool clammy skin

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

o Dyspnea
o Orthopnea
o Tachypnea
o Use of accessory muscles
o Cough with frothy blood tinged sputum
o Crackles, wheezes, rhonchi
o Tachycardia
o Hypo/hypertension
o Further progressed = Alveolar edema
▪ Abnormal ABG’s (Respiratory Acidosis)
▪ Life threatening→ alveoli filled with serosangious fluid
● Interventions
o ATI INTERVENTIONS
▪ Monitor daily weight & I&O
▪ Assess for SOB & dyspnea
▪ Give 02 as prescribed
▪ Monitor VS & hemodynamic pressures
▪ High fowlers position to maximize ventilation
▪ Check ABG’s, electryolytes (K if on diuretics),
▪ Assess for digoxin toxicity
▪ Bed rest till stable
▪ Conserve energy & assist w. ADL’s
▪ Diet restrictions (restrict fluids & sodium intake)
▪ Emotional support
o Continuous monitoring of VS, SP02, U.O.
o Hemodynamic monitoring for unstable Pts.
▪ Intraarterial BP
▪ PAWP
▪ CO
o 02 to ↑ Sp02
▪ Severe Pulmonary Edema may require BIPAP (↓ preload), intubation, & mechanical ventilation
o High Fowlers position
o Ultrafiltration (aquapheresis) for volume overload & resistance to diuretics
o Circulatory assisted devices (Intrathoracic Balloon Pump, Ventricular Ass. Dev.
● Pt teaching

o Chronic Heart Failure

▪ D/T worsening ventricular function & chronic neurohormone activation
o results in ventricular modeling
o Involves size, shape, mechanical performance of ventricle changes
▪ Nursing Diagnosis
o Impaired gas exchange
o Decreased cardiac output
o Excess fluid volume
o Activity intolerance
▪ Clinical Manifestations
o Fatigue
o Dyspnea
o orthopnea
o Paroxysmal Nocturnal dyspnea
o Tachycardia
o Edema (Peripheral, Pitting)
o Nocturia
o Skin changes
▪ Dusky skin
▪ Low extremities are shiny & swollen with ↓ or no hair
▪ Chronic swelling= brown ankles & lower legs
o Behavior changes
▪ ↓ LOC in later stages
o Weight changes
▪ Fluid retention leads to renal failure
▪ Anorexia/ Nausea → Ascites, Hepatomegaly
● Indication of Ascites = Weight gain 3 lbs in 2 days
o ADHD- Exacerbation of Chronic HF

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

▪ Cachexia → muscle wasting & fat loss; masked by edema conditions

● Interventions
o Check BNP levels↑with chronic stable HF
▪ Also seen in PE, Renal failure, Acute coronary syndrome
o Monitor daily weight and I&O
o Assess for SOB & dyspnea on exertion
o Give 02 if prescribed
o Monitor vitals & hemodynamic pressures
o High fowlers position
o Check ABG’s, electrolytes (K+ if on diuretics), Sa02, & CXR findings
o Assess for signs of digoxin toxicity
o Encourage bed rest until stable
o Encourage energy conservation & assist with ADL’s
o Maintain dietary restrictions as prescribed (restricted fluid intake & sodium)
o Provide emotional support to Pt. & family
● Pt teaching
o Educate Pt on manifestations (FACES)
▪ Fatigue
▪ Limitation of Activities
▪ Chest congestion/cough
▪ Edema
▪ SOB
o Take diuretics in the morning
o Weigh daily
o Call HCP if weight gain of 4 lbs. in a week
o Call HCP if orthopnea happens.

● CHF Medications
Digoxin
o Drug therapy for HEART FAILURE, A.FIBB
▪ ↑ Contractility, ↓ HR, ↑CO
▪ Therapeutic level: 0.8-1.8
▪ Narrow safety range: >1.8 (CALL DOC. HOLD DOSE)
▪ Antidote = Digibind (Other Name?)
o Side effects
▪ Dizziness
▪ headache
▪ Malaise
▪ Fatigue
▪ anorexia
▪ Muscle weakness
▪ visual disturbances
▪ hypokalemia (most common reason for digoxin-related dysrhythmias)
o Digoxin Toxicity: > 1.8
▪ Early signs
o N/V
o Anorexia
o fatigue
o Headache
o Muscle weakness
o depression
o Seeing Halo signs- Ans: seeing something yellow
● Late signs
o Dysrhythmias Hypokalemia (flat or inverted T wave) is the most common dig related dysrthymia
o Bradycardia
o Atrioventricular block
o Interventions
▪ Take apical HR for 1 min.
▪ Hold med if apical pulse is < 60/min & notify HCP
▪ Monitor for signs of hypokalemia & hyperkalemia
o Can ↑ or ↓ effects of digoxin
● Monitor for early signs & late signs of toxicity
o Pt teaching
▪ Count pulse for 1 min before taking med

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

▪ Pulse is irregular <60 or >100 BPM hold dose & notify HCP
▪ Take dose at same time of day
▪ Do not take at same time with antacids; Separate meds at least 2 hours
▪ Report signs of digoxin toxicity
▪ Have digoxin & potassium levels checked regularly
▪ Eat potassium rich foods to avoid hypokalemia
▪ Effective when Pt can perform ADL’s
Diuretics
(K+ sparring diuretic) Spiroalactone (Aldactone), Epelerenone (Inspra), Amiloride (Midamor), Triameterene (Dyrenium)
o Causes hyperkalemia & hyponatremia
o ↓ fluid volume (edema)
o ↓ preload
o ↓ pulmonary venous pressure
o Relieve symptoms of HF (edema)
o Interventions
▪ Monitor K+ levels during treatment (Normal = 3.5-5)
▪ Monitor for Ortho. Hypo & hyperkalemia
▪ Use in caution in patients taking digoxin; hyperkalemia may ↓ effects of digoxin
▪ Contraindicated with renal failure
▪ Caution with ACE inhibitors & Ang 2 Blockers
▪ Assess male Pts for gynecomastia (common S/E with prolonged use)
o Pt Teaching
▪ Avoid K+ riched foods
o Avocado, banana, cantaloupe, dried fruits, grapefruit juice, honeydew, Prunes, raisins, oranges and orange juice
o Baked beans, refried beans, black beans, butternut squash, broccoli, carrots, greens (except Kale), mushrooms,
potatoes (white and sweet), tomatoes, vegetable juices
o Bran, chocolate, granola, milk, nutritional supplements, salt, salt substitutes, yogurt, nuts and seeds

(Loop diuretic) Furomeside/ Lasix or Bumetanide (Bumex)

 Role of LASIX
▪ ↓ volume overload (preload)
▪ ↓ sodium reabsorption, ↑ sodium & water loss
▪ ↓ pulmonary venous pressure
▪ Relieve symptoms of HF (edema)
o Adverse Effects Hypernatremia & Hypokalemia
▪ Tinnitus
▪ Hyperglycemia
▪ hypokalemia
▪ Hypotension
▪ Hyperuricemia
▪ Ototoxicity
▪ Allergic reactions in Pts sensitive to sulfatype drugs
o Interventions
● Give lasix IV no faster than 20 mg/min
● Monitor Daily weight and I&O’s
● Monitor orthostatic hypotension
● Monitor for electolyte imbalances (hypokalemia)
● Monitor for hyperglycemia D/t impaired insulin secretion
● Pt may need high dose if they develop tolerance
o Pt teaching
▪ Take daily & in the AM
▪ Report signs of weight gain to HCP
● Eat food & drinks high in K+ (bananas, citrus, potatoes, fish, leafy greens) to prevent hypokalemia

(Thiazide diuretic) Hydrochlorothiazide (HCTZ) or Metolazone (Zaroxolyn)

 MOA
 S/E
 Interventions
 Teaching

Anti-Hypertensives
 ACE Inhibitors captopril (Capoten), benazepril (Lotensin), enalapril (Vasotec)
o MOA
 Dilates venules & arterioles

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

 Improves renal blood flow

  fluid volume
 Relieve S&S of HF
o S/E
o Interventions
o Teaching
 Angiotensin II Receptor Blockers (ARB’s) iosartan (Cozaar), valsartan (Diovan)
o MOA
 Promotes reverse remodeling
 Prevents any further cardiac damage
  morbidity & mortality
o S/E
o Interventions
o Teaching
 Vasodilators nitrates (Nitroglycerin), isosorbide dintrate (Isordil)
o MOA
  cardiac afterload  CO
 Dilates renal arterioles  renal perfusion & fluid loss
  BP, Preload
 Relieves S&S of HF (dyspnea)

Beta-Adrenergic Blockers
 metoprolol (Topril XL), bisoprolol (Zebeta), carvedilol (Coreg)
o MOA
 Promotes reverse modeling
  afterload
 Inhibits SNS
o S/E 4B’s
 Bradycardia
 BP  & Bronchoconstriction
 Bronchospasm do not give to Asthmatics
 Blood sugar masks effects of hypoglycemia (Caution w/ diabetics)

o Interventions
o Teaching

Morphine
  Anxiety
  Preload & Afterload

● S&S of Hypo/Hyperkalemia
o Hypokalemia <3.5 (Due to of Lasix)
▪ ECG→ T wave flat or inverted, eventual U wave, peaked T wave, QRS prolonged
▪ Muscle weakness or cramps (legs muscles are affected first)
● Shallow respirations
● ↓GI motility
● Lethargy
● Anorexia
● Dysrhythmias
● Cardiac Arrest
o Hyperkalemia >5 (Due to spironolactone)
▪ ECG→ High peak Twave
● Muscle twitching
● loss of muscle tone
● Fatigue
● Paresthesias
● Dyspnea
● Cramping
● Diarrhea

● Anticoagulants- Coumadin (Warfarin)

o Role of Coumadin with A. FIbb
▪ Coumadin prevents more blood clots from forming
▪ A. Fibb will result in thrombus formation

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

▪ Cardioversion can cause clots to dislodge.

▪ Pt is at risk for stroke
o Labs= INR, PT, APTT
▪ INR= Normal (0.7-1.8), Pt on Coumadin (2-3)
▪ PT= Coumadin (11-14 sec.) – 2 questions both answers are PT
▪ APTT= Heparin (30-70 sec) /Normal (25-35 sec)
o Interventions:
▪ Assess for contraindications
o Active bleeding
o Peptic ulcer disease
o Hx of stroke
o Recent trauma
● Monitor adverse effects
o Thrombocytopenia
o Anemia
o Hemorrhage
o Pt. teaching
▪ Remind Pt of risk for bruising & bleeding while on these meds
▪ Ques on role of comadin/warfarin: Prevents stroke

● Thrombocytopenia
o Pt teaching (SATA)
▪ Notify HCP for any manifestations of bleeding
o Black, tarry, or bloody bowel movements
o Black or bloody vomit, sputum, urine
o Ecchymosis, petechiae, bleeding gums, nosebleeds
o Headaches or changes in how well you see
o Difficulty talking, sudden weakness of arm or leg, confusion
● Ask HCP in regards to restrictions in your normal activity
o Ask if you can perform vigorous exercise (risk for falls)
● Do not blow nose forcefully, pat if necessary
o Hold head back & pinch bridge of nose
o Place ice pack on nose & neck
o If bleeding doesn't stop in 10 min. call HCP
● Apply water based lubricant around lips
● Dont bend down with your head lower than your waist
● Prevent constipation by drinking plenty of fluids
● Shave only with an electric razor
● Do not tweeze your eyebrows or other body hair
● Do not puncture your skin (tattoos, piercings)
● Avoid NSAIDs & herbs that cause bleeding
● Prevent injury when ambulating by wearing close toe shoes, & removing tripping hazards in home
● Use soft bristle tooth brush
● If menstruating keep track of number of pads/day. DO NOT USE TAMPONS
● Ask HCP if having dental cleaning, manicure/pedicure

● Oxygen therapy related to COPD & Asthma

o Role of 02 therapy
▪ Tx of COPD & other problems assoc with hypoxemia
o Interventions
▪ Assess LOC & VS before 02 therapy & after
o Pt teaching
▪ Do not smoke with 02 NC in place; can cause burns
▪ No open flames where 02 is being used
▪ “No Smoking Sign” on Pts door
▪ Ques: About Pt going home and asking if she will 02 therapy at home?
o Ans: Respiratory therapist will discuss this…something like that
▪

● Goal of SP02 with Asthma and COPD

o Maintain Sa02 > 90% during rest, sleep, & exertion
o Maintain Pa02 > 60 mmHG
o COPD Pt has signs of dyspnea→ 02 NC 6L and call doctor

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

● COPD Interventions
o COPD Chronic inflammation of airways, lung parenchyma, & Pul. Blood vessels
▪ Complication = Infection
o Can be caused by 02 administration especially in home health care
o Heated nebulizers are high risk of Psuedomanoas aeruginosa
o A1- Antitrypsin genetic risk factor for COPD
▪ Serum protein produced by liver
▪ Normally found in lungs
▪ Function: protect normal lung tissue from attack by proteases during inflammation R/T cigarette smoking & infections
o Clinical Manifestations
▪ Develops slowly
▪ PA findings
o Dyspnea
o Irregular breathing pattern
o Productive cough in AM
o Hypoxemia
o Prolonged expiratory phase
o Wheezes & crackles
o Use of accessory muscles
o Hyperresonance on percussion d/t air trapping
o Decreased breath sounds
o Barrel Chest: expected fining for COPD Pt
o Tripod Position
o Pursed lip breathing
o Bluish-red color skin (Polycythemia & cyanosis)
o Dependent edema secondary to R. Heart failure
o Clubbing of fingers & toes (later stages)
o Decreased Spo2
o Interventions
▪ High Fowlers position
▪ Encourage effective coughing, or suction to remove secretions
▪ Encourage deep breathing & use if incentive spirometer
▪ Administer breathing tx & meds as prescribed
▪ Give 02 as prescribed
▪ Monitor for skin breakdown around nose & mouth from 02 device
▪ Promote adequate nutrition (high calorie foods)
▪ Increase fluid intake to 2-3L/day to liquefy mucus
o Answer was have pt drink 8 bottle of water a day
▪ Monitor weight and note any changes
▪ Instruct Pt to practice deep breathing techniques (purse lip breathing)- what you teach ur COPD Pt with dyspnea
▪ Pts who have COPD can need 2-4L/min 02 NC or up to 40% venturi mask
▪ Put 6LPM NC for Pt with severe dyspnea
▪ Pt has worsening respiratory status…nurs AXN? Ans: Evaluate
o Pt teaching
▪ Ques: About Pt going home and asking if she will 02 therapy at hom
▪ Refer to assistance programs, such as food delivery services
▪ Set up referral services, including home care services (portable oxygen)
▪ Encourage to eat high calorie foods to promote energy
▪ Encourage rest periods as needed
▪ Promote hand hygiene to prevent infection
▪ Reinforce importance of taking meds (inhalers, oral meds) as prescribed
▪ Promote smoking cessation
▪ Encourage immunizations (influenza & pneumonia) to decrease infection
▪ Use oxygen as prescribed. Inform caregivers not to smoke around oxygen due to flammability
▪ Provide support to Pt & family
o Pt teaching for decreasing RISK OF INFECTION with home 02 use
▪ Brush teeth or use mouthwash several times a day
▪ Wash NC (prongs) with liquid soap & thoroughly rinse once or twice a week
▪ Replace NC every 2-4 weeks
▪ If you have a cold, replace cannula after symptoms pass
▪ Always remove secretions that are coughed out
▪ If you use an 02 concentrator, every day unplug the unit & wipe down the cabinet with a damp cloth & dry it
▪ Ask the company providing the equipment how often to change the filter

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

● Role of Albuterol (Bronchodilator)

o Short acting beta 2 agonist
▪ Rescue Tx for Asthma
▪ Effective for relieving & preventing bronchospasm
▪ Rapid relief of acute symptoms & prevent exercise induced asthma
▪ Prevent release of inflammatory mediators from mast cells
▪ Not for long term use
▪ Onset = minutes
▪ Duration= 4-8 hours
o Nebulizer (Breathing) Tx
▪ Question: Pt is having severe asthma attack… Ans: Give jet nebulizer breathing tx
▪ Used if Pt have difficulty with MDI’s or severe asthma
▪ Given via facemask or mouthpiece
▪ Deep diaphragmatic breathing & hold breath for 2-3 sec
▪ Instruct Pt to breathe normally b/t large forced breaths to prevent alveolar hypoventilation and dizziness
▪ After Tx cough effectively
▪ Can have potential bacterial growth
o Instruct Pt for home use to wash daily in soap & water, rinse with water, & soak for 20 to 30 min in a 1:1 white vinegar-
water solution, followed by water rinse & air drying
o Side effects when used frequently :
▪ Tremors
▪ Anxiety
▪ Tachycardia
▪ Palpitations
▪ Nausea
o Drug Alert
▪ Use caution in Pt with cardiac disorders
o ↑BP, HR
o CNS stimulation
o ↑risk of dysrhythmias

● Meter Dose Inhalers

o MDI Meds
▪ Albuterol→ Short acting beta 2 agonist
▪ Ipatropium→ Anticholinergic
▪ Theophylinne→ Methylxanthines
▪ Salmeterol→ Long acting beta 2 agonist
o Pt teaching-
▪ Know steps for teaching MDI- 5 answers where you have to drag to next box in order; don’t remember last one
▪ Take off cap & shake inhaler
▪ Have pt inhale & exhale first
▪ Hold your inhaler the was your doctor instructed:
o Inhaler 1 to 2 inches in front of mouth
o With a spacer
o Inhaler directly in mouth
▪ As your breathe in slowly through mouth, press down on inhaler one time (If using a spacer, first press down on inhaler.
Within 5 sec. begin to breathe slowly)
▪ Keep breathing in slowly, as deep as you can
▪ Hold breath for 10 sec
▪ For inhaled quick relief meds, wait 1 min between puffs
▪ Clean & rinse holder with warm water
▪ Whistling sounds indicates the Pt. is loosing medication
▪ For quick relief meds- Take as needed.
o Problems Using MDI
▪ Failing to coordinate activation with inspiration
▪ Activating MDI in mouth while breathing through nose
▪ Inspiring too rapidly
▪ Holding MDI upside down or sideways
▪ Inhaling more than 1 puff with each inspiration
▪ Not shaking MDOI before use
▪ Not waiting a enough time b/t each puff
▪ Not opening mouth wide enough
▪ Not having adequate strength to activate MDI
▪ Being unable to understand & follow directions

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

● Beta blockers in Asthma & HF- KNOW YOUR BETA BLOCKERS

o Asthma
▪ Contraindicated d/T severe bronchoconstriction
o Heart Failure
▪ Meds: Metoprolol, Bisoprolol, Ans:Carvedil- question this med for pt with heart failure and hx of asthma
o Promotes reverse modeling
o ↓ afterload
o Inhibits SNS
o Side effects
▪ Hypotension
▪ Bronchospasm
▪ Blood sugar- masks effects of hypoglycemia
▪ Bradycardia
o Interventions
▪ Monitor BP, HR, Orthostatic hypotension, orthopnea
▪ Use in caution with Pts who have cardiac disorders
o Elevated BP, & HR
o CNS stimulation
o Increased risk of dysrhythmias
o Pt teaching
▪ Check BP regularly
▪ Change positions slowly
▪ Check weight daily
▪ Follow HCP on increasing med dosage

● Theophylline
o Bronchodilator with mild antinflammatory effects
o Given to Asthmatic Pts if Tx is uneffective
o Narrow safety range: 5-20
▪ Toxic when >20
o Side effects
▪ Nausea
▪ Headache
▪ Insomnia
▪ GI disturbances
▪ Tachycardia
▪ Dysrhythmias
▪ Seizures
o Interventions
▪ Assess vitals
▪ Monitor serum blood levels
o Pt teaching
▪ ANs: Avoid caffeine to prevent intensifying adverse effects
▪ Report signs of toxicity: N/V, seizures, insomnia

● Prevention of Oral candidiasis

o S/E of corticosteroids- Med is Buthmedisone (something like that)
o Ans:Rinse mouth after taking med
o Good oral hygeine
o Clean container

● Peak Flow Meter (Green, Yellow, Red Zone)

● Pulmonary function tests (PFT)- Asthmatics

o What do PFT’s measure
▪ Lung volume & capacity
▪ Diffusion capacity
▪ gas exchange

Downloaded by Frida Grillo (cigcna@gmail.com)

 lOMoARcPSD|6828319

▪ flow rates
▪ airway resistance & ventilation
o Forced vital capacity (FVC) <15-20%
▪ Indication of Asthma = ↑ of 12% with bronchodilators
o Pt. teaching for test
▪ Do not smoke on day of test
▪ Avoid eating large meals prior
▪ ANs: DO NOT use bronchodilators on day of test for 8-12 hours
o B/C it makes PFT’s less accurate
▪ Avoid coffee, cola. chocolate drinks @ least 6 hours prior
▪ Hold inhaled steroids & theophylline for 5 days prior
▪ After test continue taking meds as usual
● Hypoxemia Manifestations
o Restlessness
o ↑ Anxiety
o Ans:Agitation
o Inappropriate behavior
o ↑ HR, BP
o Difficult to speak in complete sentences
o ↑ RR (> 30 breaths/min)
o Hyperresonace with percussion
o Inspiratory & expiratory wheezes with auscultation
o Silent chest (severe diminished breath sounds) = indication of obstruction & impending respiratory failure

● ABG interpretation
o pH= 7.35-3.45
o Co2= 35-45
o HCO3= 22-28
o Pa02= 60-100
o Ans: Respiratory Acidosis

Downloaded by Frida Grillo (cigcna@gmail.com)