Cardiomyopathy

Cardiomyopathy –Assessment ● begins with a detailed history of the presenting signs and symptoms ● nurse identifies possible cause factors (heavy alcohol intake, recent illness or pregnancy, or history of the disease in immediate family members) ● If the patient reports chest pain, a thorough review of the pain, including its precipitating factors, is warranted ● review of systems includes the presence of orthopnea, PND, and syncope or dyspnea with exertion ● number of pillows needed to sleep, usual weight, any weight change, and limitations on activities of daily living are assessed ● patient's usual diet is evaluated to determine the need to reduce sodium intake, optimize nutrition, or supplement with vitamins ● physical assessment focuses on signs and symptoms of heart failure ○ baseline assessment includes key components ■ Vital signs ■ Calculation of pulse pressure and identification of pulsus paradoxus ■ Current weight and any weight gain or loss ■ Detection by palpation of the point of maximal impulse, often shifted to the left ■ Cardiac auscultation for a systolic murmur and S3 and S4 heart sounds ■ Pulmonary auscultation for crackles ■ Measurement of jugular vein distention ■ Assessment of edema and its severity Cardiomyopathy – Diagnostics ● Diagnosis is usually made from findings disclosed by the patient's history and by ruling out other causes of heart failure such as myocardial infarction ● echocardiogram is one of the most helpful diagnostic tools ○ structure and function of the ventricles can be observed easily ● Cardiac MRI may be used, particularly to assist with the diagnosis of HCM ● ECG demonstrates dysrhythmias (atrial fibrillation, ventricular dysrhythmias) and changes consistent with left ventricular hypertrophy (left axis deviation, wide QRS, ST changes, inverted T waves) ○ ARVC/D, there often is a small deflection, an epsilon wave, at the end of the QRS ● chest x-ray reveals heart enlargement and possibly pulmonary congestion ● Cardiac catheterization is sometimes used to rule out coronary artery disease as a causative factor ● Endomyocardial biopsy may be performed to analyze myocardial cells Cardiomyopathy – Pharmacological mgt ● directed at controlling symptoms Valvular Disorders – Manifestations ● Mitral Valve Prolapse ○ Most never have symptoms ○ fatigue ■ may occur regardless of activity level and amount of rest or sleep ○ shortness of breath ■ not correlated with activity levels or pulmonary function ○ lightheadedness ○ dizziness 1 ○ ○ ● ● ● ● syncope palpitations ■ Atrial or ventricular dysrhythmias may produce the sensation of palpitations ■ have been reported while the heart has been beating normally ○ chest pain ■ not correlated with activity and may last for days ○ anxiety ■ may be a response to symptoms ■ some report anxiety as the only symptom Mitral Regurgitation ○ Chronic is often asymptomatic ○ acute (resulting from a myocardial infarction) usually manifests as severe congestive heart failure ■ Dyspnea ■ fatigue ■ weakness ■ Palpitations ■ shortness of breath on exertion ■ cough from pulmonary congestion Mitral Stenosis ○ first symptom is often dyspnea on exertion (DOE) as a result of pulmonary venous hypertension ○ Symptoms usually develop after the valve opening is reduced by one third to one half its usual size ○ may experience progressive fatigue and decreased exercise tolerance as a result of low cardiac output ○ enlarged left atrium may create pressure on the left bronchial tree, resulting in a dry cough or wheezing ○ may expectorate blood (hemoptysis) or experience palpitations, orthopnea, paroxysmal nocturnal dyspnea (PND), and repeated respiratory infections ■ result of increased blood volume and pressure, the atrium dilates, hypertrophies, and becomes electrically unstable (patients experience atrial dysrhythmias) Aortic Regurgitation ○ develops without symptoms in most ○ Some patients are aware of a forceful heartbeat, especially in the head or neck ○ Marked arterial pulsations visible or palpable at carotid or temporal arteries may be present due to increased force and volume of blood ejected from a hypertrophied left ventricle ○ Exertional dyspnea and fatigue follow ○ Signs and symptoms of progressive left ventricular failure include breathing difficulties (orthopnea and paroxysmal nocturnal dyspnea (PND)) Aortic Stenosis ○ Many are asymptomatic ○ When symptoms develop, patients usually first have exertional dyspnea ■ caused by increased pulmonary venous pressure due to left ventricular failure ○ Orthopnea ○ paroxysmal nocturnal dyspnea (PND) ○ pulmonary edema ○ Reduced blood flow to the brain may cause dizziness and syncope ○ Angina pectoris is a frequent symptom 2 ■ ○ ○ results from increased oxygen demand of the hypertrophied left ventricle with decreased blood supply due to decreased blood flow into the coronary arteries and decreased time in diastole for myocardial perfusion Blood pressure is usually normal but may be low Pulse pressure may be low (30 mm Hg or less) due to diminished blood flow Valvular Disorders – Medical ● Mitral Valve Prolapse ○ directed at controlling symptoms ○ If dysrhythmias are documented and cause symptoms, patient is advised to eliminate caffeine and alcohol from the diet and to stop the use of tobacco products ■ Most patients don’t require medication, but some are prescribed antiarrhythmic medications ○ Prophylactic antibiotics are not recommended prior to dental or invasive procedures ○ Chest pain that doesn't respond to nitrates may respond to calcium channel blockers or betablockers ○ Heart failure is treated the same as it would be for any other case of heart failure ○ severe mitral regurgitation and symptomatic heart failure may require mitral valve repair or replacement ● Mitral Regurgitation ○ Management is the same as for heart failure ○ Patients with mitral regurgitation and heart failure benefit from afterload reduction (arterial dilation) by treatment with ■ angiotensin-converting enzyme (ACE) inhibitors ex. captopril (Capoten), enalapril (Vasotec), lisinopril (Prinivil, Zestril) or ramipril (Altace), or hydralazine (Apresoline) ■ angiotensin receptor blockers (ARBs) ex. losartan (Cozaar) or valsartan (Diovan) ■ beta-blockers ex. carvedilol (Coreg) ○ Once symptoms of heart failure develop, patient needs to restrict their activity level to minimize symptoms ○ Symptoms are an indicator for surgical intervention by mitral valvuloplasty (surgical repair of the valve) or valve replacement ● Mitral Stenosis ○ Patients may benefit from anticoagulants to decrease the risk of developing atrial thrombus ○ may require treatment for angina ○ If atrial fibrillation develops, cardioversion is attempted to restore normal sinus rhythm ■ unsuccessful, ventricular rate is controlled with beta-blockers, digoxin, or calcium channel blockers ● patients require anticoagulation for thromboembolism prevention ○ Patients are advised to avoid strenuous activities, competitive sports, and pregnancy as they increase heart rate ○ Surgical interventions ■ valvuloplasty, usually a commissurotomy to open or rupture the fused commissures of the valve ■ Percutaneous transluminal valvuloplasty or valve replacement may be performed ● Aortic Regurgitation ○ symptomatic patient, or patients with decreased left ventricular function, is advised to avoid physical exertion, competitive sports, and isometric exercise ■ should be instructed to restrict sodium intake to avoid volume overload 3 ○ ● Patients with aortic regurgitation and hypertension should be treated with dihydropyridine calcium channel blockers (felodipine [Plendil], nifedipine [Adalat, Procardia]) or ACE inhibitors (captopril, enalapril, lisinopril, ramipril) to provide afterload reduction ■ calcium channel blockers diltiazem (Cardizem) and verapamil (Calan, Isoptin) are contraindicated as they decrease ventricular contractility and may cause bradycardia ○ treatment of choice is aortic valve replacement or valvuloplasty, preferably performed before left ventricular failure occurs ○ Surgery is recommended for any patient with left ventricular dilation, regardless of the presence or absence of symptoms and any patient who is symptomatic Aortic Stenosis ○ Medications are prescribed to treat dysrhythmia or left ventricular failure ○ Definitive treatment is surgical replacement of the aortic valve Valvular Disorders – Surgical ● Valvuloplasty ○ Repair, rather than replacement, of a cardiac valve is referred to as valvuloplasty ■ do not require continuous anticoagulation ■ type depends on the cause and type of valve dysfunction ○ Repair may be made to ■ commissures between the leaflets in a procedure known as commissurotomy ● to the annulus of the valve by annuloplasty, to leaflets ● to chordae by chordoplasty ○ Transesophageal echocardiogram (TEE) usually is performed at the conclusion of a valvuloplasty to evaluate the effectiveness of the procedure. ○ Most procedures require general anesthesia and often require cardiopulmonary bypass ● Commissurotomy ○ most common valvuloplasty procedure ■ repair to the commissures between the leaflets ○ site where the leaflets meet is called the commissure ■ Leaflets may adhere to one another and close the commissure (stenosis) ● Less commonly, leaflets fuse in a way that in addition to stenosis, the leaflets are prevented from closing completely, resulting in backward flow of blood (regurgitation) ○ is a procedure performed to separate the fused leaflets ● Closed Commissurotomy/Balloon Valvuloplasty ○ don’t require cardiopulmonary bypass ○ valve is not directly visualized ○ more commonly performed in developing nations ■ a surgical technique performed in the operating room with the patient under general anesthesia ○ Percutaneous balloon valvuloplasty is the technique most commonly performed in the United States ■ beneficial for mitral valve stenosis in younger patients and for patients with complex medical conditions that place them at high risk for complications of more extensive surgical procedures. ○ Balloon valvuloplasty is performed in the cardiac catheterization lab ■ patient may receive light or moderate sedation or a local anesthetic ■ Mitral balloon valvuloplasty involves advancing one or two catheters into the right atrium, 4 ● ● ● ● ● through the atrial septum into the left atrium, across the mitral valve, and into the left ventricle ● A guidewire is placed through each catheter, and the original catheter is removed ● Most often, a specially designed balloon catheter is placed over the guidewire and positioned with the balloon across the mitral valve ○ Aortic balloon valvuloplasty is performed most commonly by introducing a catheter through the aorta, across the aortic valve, and into the left ventricle ■ may be performed by passing the balloon or balloons through the atrial septum Open Commissurotomy ○ performed with direct visualization of the valve ○ patient is under general anesthesia Annuloplasty ○ is the repair of the valve annulus (junction of valve leaflets and muscular heart wall) ○ General anesthesia and cardiopulmonary bypass are required for most ○ narrows the diameter of the valve's orifice ○ useful treatment for valvular regurgitation ○ 2 techniques ■ annuloplasty ring ■ tightening the annulus by folding elongated tissue over onto itself (taking tucks) in leaflets or tacking leaflets to the atrium or each other with sutures Leaflet Repair ○ Damage to cardiac valve leaflets may result from stretching, shortening, or tearing ○ Leaflet repair for elongated, ballooning, or other excess tissue leaflets is removal of the extra tissue ■ Elongated tissue may be tucked and sutured (leaflet plication) ● wedge of tissue may be cut from the middle of the leaflet and the gap sutured closed (leaflet resection) ○ Short leaflets are most often repaired by chordoplasty ■ After short chordae are released, leaflets often unfurl and resume their normal function (closing the valve during systole) ○ leaflet may be extended by suturing a piece of pericardium to it ○ pericardial or synthetic patch may be used to repair holes in the leaflets Chordoplasty ○ is the repair of chordae tendineae ○ mitral valve is most often involved ○ Stretched, torn, or shortened chordae tendineae may cause regurgitation ■ Stretched chordae tendineae can be shortened, transposed to the other leaflet, or replaced with synthetic chordae ■ Torn chordae can be reattached to the leaflet ■ shortened chordae can be elongated ■ Stretched papillary muscles, may cause regurgitation, can be shortened or relocated Valve Replacement ○ Used when valvuloplasty is not a viable alternative (when the annulus or leaflets of the valve are immobilized by calcifications, severe fibrosis or fusion of leaflets, chordae tendineae, or papillary muscles), valve replacement is performed ○ multidisciplinary team (cardiologists, cardiac thoracic surgeons, structural valve interventionalists, anesthesiologists, and nurses) work together with the patient to determine candidacy for surgical versus more minimally invasive replacement 5 ○ ○ General anesthesia and cardiopulmonary bypass are used for most All prosthetic valve replacements create a degree of stenosis when they are implanted in the heart Procedure Valvuloplasty ● Balloon Valvuloplasty ● Commissurotomy Diagnoses Used For ● ● Mitral Valve Stenosis Aortic Valve Stenosis Described the Procedure ● ● ● ● ● Open Heart Valve Repair (Valvuloplasty) ● Mitral Valve Stenosis Mitral Valve Regurgitation Aortic Valve Stenosis Aortic Valve Regurgitation ● Mitral Regurgitation ● Aortic Regurgitation ● ● ● ● Annuloplasty ● ● ● ● Chordoplasty ● Mitral Valve Regurgitation ● Notes Valvuloplasty: Repair of the cardiac valve Balloon: Catheter inserted into the vein or artery and fed through to the heart valve. Balloon is expanded at the valve to open the leaflets Commissurotomy: Cut to separate the fused leaflets Conscious sedation or general anesthesia ● Commissure: Where the leaflets of the valve meets Remove part of leafletsew it back together on itself Extend the leaflet by adding pericardium to the leaflet General anesthesiaopen heart, cardiopulmonary bypass General anesthesiaopen heart, cardiopulmonary bypass Repair of the annulus: ○ Add a new “ring” ○ Tighten annulus: folding the tissue onto itself Repair of chordae tendineae ○ Stretched can be shortened or replaced with synthetic chordae ○ Shortened- can be elongated ○ Torn can be reattached 6 Valve Replacement ● Mitral Valve Stenosis ● Mitral Valve Regurgitation ● Aortic Valve Stenosis ● General anesthesiaopen heart, cardiopulmonary bypass ● Open heart procedure; cardiopulmonary bypass ○ Old valve is surgically removed and replaced with the new valve TAVI: Transcatheter Aortic Valve Replacement ○ Minimally invasive ○ The new valve is placed inside the old valve ○ Pushes old leaflets out of the way and the new valve takes over ○ Through femoral artery or through small incision in the chest to get to an artery ● ● ● ● Mechanical Valve Bioprosthetic Animal Valves Infective Endocarditis –Assessment ● definitive diagnosis is made when a microorganism is found in 2 separate blood cultures, or in vegetation or abscess ○ At least 2 sets of blood cultures (each set including 1 aerobic and 1 anaerobic culture) drawn from different venipuncture sites over a 24-hour period (each set at least 12 hours apart), or every 30 minutes if the patient's condition is unstable, should be obtained before administration of any antimicrobial agents ○ Negative blood cultures do not definitely rule out infective endocarditis ○ Patients may have elevated white blood cell (WBC) counts ○ patients may be anemic, have a positive rheumatoid factor, and an elevated erythrocyte sedimentation rate (ESR) or C-reactive protein ● Echocardiography may assist in diagnosis by demonstrating a mass on a valve, prosthetic valve, or supporting structures and by identifying vegetations, abscesses, new prosthetic valve dehiscence, or new regurgitation ● echocardiogram may reveal development of heart failure Infective Endocarditis –Manifestations ● Primary presenting symptoms are fever and a heart murmur ○ Fever may be intermittent or absent, especially in patients who are receiving antibiotics or corticosteroids, in older adults, and in those who have heart failure or kidney injury 7 ○ ● ● ● ● ● ● ● ● ● heart murmur may be absent initially but develops in almost all patients ■ Murmurs that worsen over time indicate progressive damage from vegetations or perforation of a valve or rupture of chordae tendineae. clusters of petechiae may be found on the body Small, painful nodules (Osler nodes) may be present in pads of fingers or toes Irregular, red or purple, painless flat macules (Janeway lesions) may be present on palms, fingers, hands, soles, and toes Hemorrhages with pale centers (Roth spots) caused by emboli may be observed in fundi of the eyes ○ Splinter hemorrhages (reddish-brown lines and streaks) may be seen under the proximal half of fingernails and toenails Petechiae may appear in conjunctiva and mucous membranes Cardiomegaly, heart failure, tachycardia, or splenomegaly may occur. Headache temporary or transient cerebral ischemia; and strokes, which may be caused by emboli to cerebral arteries ○ Embolization may be a presenting symptom; it may occur at any time and may involve other organ systems ■ Embolic phenomena may occur. Heart failure, may result from perforation of a valve leaflet, rupture of chordae, blood flow obstruction due to vegetations, or intracardiac shunts from dehiscence of prosthetic valves, indicates a poor prognosis with medical therapy alone and a higher surgical risk. Infective Endocarditis – Medical ● objective of treatment is to eradicate invading organisms through adequate doses of an appropriate antimicrobial agent ● Antibiotic therapy usually is given for 2 to 6 weeks every 4 hours or continuously by IV infusion ● Serum levels of the antibiotic and blood cultures are monitored to gauge effectiveness of therapy. ● patient's temperature is monitored at regular intervals because the course of fever is one indication of treatment effectiveness ○ febrile reactions may occur as a result of medication ● patients require psychosocial support because although they feel well, they may find themselves confined to the hospital or home with restrictive IV therapy. Infective Endocarditis –Pathophysiology ● deformity or injury of the endocardium leads to accumulation of fibrin and platelets (clot formation) on the endocardium. Infectious organisms, usually staphylococci or streptococci, invade the clot and endocardial lesion ● causative microorganisms include fungi (e.g., Candida, Aspergillus) and Rickettsiae ● Infection most frequently results in platelets, fibrin, blood cells, and microorganisms that cluster as vegetations on the endocardium ● Infection may erode through the endocardium into underlying structures (e.g., valve leaflets), causing tears or other deformities of valve leaflets, dehiscence of prosthetic valves, deformity of chordae tendineae, or mural abscesses Myocarditis – Pharmacological Myocarditis – Pathophysiology ● an inflammatory process involving the myocardium/inflammation of the heart muscle 8 ● ● ● ● usually results from viral (e.g., coxsackievirus A and B, human immune deficiency virus, influenza A), bacterial, rickettsial, fungal, parasitic, metazoal, protozoal (e.g., Chagas disease), or spirochetal infection may be immune related, occurring after acute systemic infections such as rheumatic fever may develop in patients receiving immunosuppressive therapy or in those with infective endocarditis, Crohn's disease, or systemic lupus erythematosus may result from an inflammatory reaction to toxins such as pharmacologic agents used in the treatment of other diseases (e.g., anthracyclines for cancer therapy), ethanol, or radiation (especially to the left chest or upper back) Pericarditis – Nursing ● acute pericarditis require pain management with analgesics, assistance with positioning, and psychological support ● Patients with chest pain often benefit from education and reassurance that the pain is not due to a heart attack. ○ Pain may be relieved with a forward-leaning or sitting position ● To minimize complications,help the patient with activity restrictions until pain and fever subside ○ As patient's condition improves,encourage gradual increases in activity ■ if pain, fever, or friction rub recurs, activity restrictions must be resumed ● educate the patient and family about a healthy lifestyle to enhance the patient's immune system. Pericarditis – Assessment ● primary symptom is pain ○ assessed by evaluating the patient in various positions ■ nurse tries to identify whether pain is influenced by ● respiratory movements, while holding an inhaled breath or holding an exhaled breath ● flexion, extension, or rotation of the spine, including the neck ● movements of shoulders and arms ● coughing ● swallowing ○ Recognizing events that precipitate or intensify pain may help establish a diagnosis and differentiate pain of pericarditis from the pain of myocardial infarction ● When pericardial surfaces lose their lubricating fluid due to inflammation, a pericardial friction rub occurs ○ The rub is audible on auscultation and is synchronous with the heartbeat ■ may be elusive and difficult to detect ○ pericardial friction rub is a diagnostic of pericarditis ■ It is a creaky or scratchy sound and is louder at the end of exhalation ○ Nurses should monitor for pericardial friction rub by placing the diaphragm of the stethoscope tightly against the patient's thorax and auscultating the left sternal edge in the fourth intercostal space ■ site where the pericardium comes into contact with the left chest wall ○ rub may be heard best when a patient is sitting and leaning forward ● If there is difficulty in distinguishing a pericardial friction rub from a pleural friction rub, the patient is asked to hold their breath ○ pericardial friction rub will continue to be heard ● patient's temperature is monitored frequently 9 ○ Pericarditis may cause an abrupt onset of fever in a patient who has been afebrile Angina Pectoris – Pathophysiology ● Angina is usually caused by atherosclerotic disease ● angina is associated with a significant obstruction of at least one major coronary artery ● is a clinical syndrome usually characterized by episodes or paroxysms of pain or pressure in the anterior chest ● Caused by insufficient coronary blood flow, resulting in a decreased oxygen supply when there is increased myocardial demand for oxygen in response to physical exertion or emotional stress ○ need for oxygen exceeds the supply ● is a cardiac emergency ● at an increased risk of heart attack, cardiac arrest, or sudden cardiac death ● Types ○ Stable ■ Predictable and consistent pain that occurs on exertion and is relieved by rest and/or nitro ○ Unstable ■ Symptoms increase in frequency and severity ■ May not be relieved with rest or nitro ■ No pattern ○ Intractable or Refractory Angina ■ Severe incapacitating chest pain ○ Variant Angina/Prinzmetal ■ Pain at rest, usually during the night with reversible ST segment elevation ■ Caused by coronary artery vasospasm ● No blockage ○ Silent Ischemia ■ Objective evidence of ischemia (on ECG with stress test) but patient reports no pain Angina Pectoris – Nursing ● gathers information about the patient's symptoms and activities, especially those that precede and precipitate attacks ● Appropriate questions ○ answers to these questions form the basis for designing an effective program of treatment and prevention ○ “Where is the pain (or prodromal symptoms)? Can you point to it?” ○ “Can you feel the pain anywhere else?” ○ “How would you describe the pain?” ○ “Is it like the pain you had before?” ○ “Can you rate the pain on a 0–10 scale, with 10 being the most pain?” ○ “When did the pain begin?” ○ “How long does it last?” ○ “What brings on the pain?” ○ “What helps the pain go away?” ○ “Do you have any other symptoms with the pain?” ● assess the patient's risk factors for CAD, patient's response to angina, patient's and family's understanding of the diagnosis, and adherence to the current treatment plan ● Treating Angina 10 ○ ● ● If patient reports pain take immediate action ■ patient is directed to stop all activities and sit or rest in bed in a semi-Fowler's position to reduce the oxygen requirements of the ischemic myocardium ○ assesses the patient's angina, asking questions to determine whether the angina is the same as the patient typically experiences ■ change may indicate a worsening of the disease or a different cause ○ continues to assess patient, measuring vital signs and observing for signs of respiratory distress ○ in the hospital, a 12-lead ECG is usually obtained and assessed for ST-segment and T-wave changes ■ If the patient has been placed on cardiac monitoring with continuous ST-segment monitoring, the ST segment is assessed for changes ○ Nitroglycerin is given sublingually ■ Assess patient's response for relief of chest pain and effect on blood pressure and heart rate ■ If the chest pain is unchanged or is lessened but still present, administration is repeated up to 3 doses ● Each time blood pressure, heart rate, and the ST segment (if the patient is on a monitor with ST-segment monitoring capability) are assessed ○ administers oxygen therapy if the patient's respiratory rate is increased or if the oxygen saturation level is decreased ■ usually given at 2 L/min by nasal cannula ○ If the pain is significant and continues after these interventions, the patient is further evaluated for acute MI and may be transferred to a higher-acuity nursing unit Reducing Anxiety ○ Exploring the implications the diagnosis has for the patient and providing information about the illness, its treatment, and methods of preventing its progression are important nursing interventions ○ stress reduction methods, should be explored with patient ○ Addressing the spiritual needs of the patient and family may assist in allaying anxieties and fears Preventing Pain ○ nurse reviews the assessment findings, identifies the level of activity that causes the patient's pain or prodromal symptoms, and plans the patient's activities accordingly ■ If patient has pain frequently or with minimal activity, alternate the patient's activities with rest periods ○ Balancing activity and rest is an important aspect of an educational plan for patients and family Angina Pectoris Pharmacological ● Nitrates ○ Nitroglycerin ○ Short and long-term reduction of myocardial oxygen consumption through selective vasodilation ● Beta-Adrenergic Blocking Agents (Beta-Blockers) ○ Metoprolol ○ Atenolol ○ Reduction of myocardial oxygen consumption by blocking beta-adrenergic stimulation of the heart ● Calcium Ion Antagonists (Calcium Channel Blockers) ○ Amlodipine 11 ● ● ○ Diltiazem ○ Negative inotropic effects ○ Indicated in patients not responsive to beta-blockers ○ Used as primary treatment for vasospasm Antiplatelet Medications ○ Aspirin ○ Clopidogrel (Plavix) ○ Prasugrel ○ Prevention of platelet aggregation Anticoagulants ○ Heparin ○ Low Molecular Weight Heparin ■ Enoxaparin (Lovenox) ■ Dalteparin (Fragmin) ○ Prevention of thrombus formation Atherosclerosis – Pathophysiology ● thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery ● abnormal accumulation of lipid, or fatty substances, and fibrous tissue in the lining of arterial blood vessel walls. These substances block and narrow the coronary vessels in a way that reduces blood flow to the myocardium ● Accumulation of lipids, calcium, blood components, carbohydrates, and fibrous tissue on the intimal layer of the artery ○ Plaque ● most common direct results in arteries include narrowing (stenosis) of the lumen, obstruction by thrombosis, aneurysm, ulceration, and rupture ● indirect results are malnutrition and subsequent fibrosis of the organs that the sclerotic arteries supply with blood ● can develop at any point in the body ○ certain sites are more vulnerable (regions where arteries bifurcate or branch into smaller vessels, with males having more below-the-knee pathology than females) ■ proximal lower extremity include the distal abdominal aorta, common iliac arteries, orifice of the superficial femoral and profunda femoris arteries, and superficial femoral artery in the adductor canal, which is particularly narrow ○ Distal to the knee, atherosclerosis can occur anywhere along the artery Atherosclerosis Prevention ● reasonable to measure serum cholesterol and to begin disease prevention efforts that include diet modification ○ American Heart Association recommends reducing the amount of fat ingested in a healthy diet, substituting unsaturated fats for saturated fats, and decreasing cholesterol intake to reduce the risk of cardiovascular disease. ● Certain medications that supplement dietary modification and exercise are used to reduce blood lipid levels ○ HMG-CoA reductase inhibitors (statins) for first-line use in patients with PAD for secondary prevention and cardiovascular risk ○ bile acid sequestrants (cholestyramine [Questran], colesevelam [WelChol], colestipol [Colestid]), nicotinic acid (niacin [Niacor, Niaspan]) 12 ● ○ fibric acid inhibitors (gemfibrozil [Lopid], fenofibrate [Tricor]) ○ cholesterol absorption inhibitors (ezetimibe [Zetia]) ○ Patients receiving long-term therapy with these medications require close monitoring. no single risk factor has been identified as the primary contributor to the development of atherosclerotic cardiovascular disease, it is clear that the greater the number of risk factors, the greater the risk of atherosclerosis ○ Elimination of all controllable risk factors, particularly the use of nicotine products, is strongly recommended ■ Risk Factors ● Nicotine use (tobacco product such as cigarettes, e-cigarettes, or chewing tobacco) ● Diet (contributing to hyperlipidemia) ● Hypertension ● Diabetes (speeds the atherosclerotic process by thickening the basement membranes of both large and small vessels) ● Hyperlipidemia ● Stress ● Sedentary lifestyle ● Elevated C-reactive protein ● Hyperhomocysteinemia ● Increased age Atherosclerosis Nursing ● Arterial blood supply to a body part can be enhanced by positioning the part below the level of the heart ○ lower extremities, this is accomplished by elevating the head of the patient's bed or by having the patient use a reclining chair or sit with the feet resting on the floor ○ PAD, blood flow to the lower extremities needs to be enhanced, nurse encourages keeping the lower extremities in a neutral or dependent position ○ venous insufficiency, blood return to the heart needs to be enhanced, so the lower extremities are elevated ● can assist the patient with walking or other moderate or graded isometric exercises that may be prescribed to promote blood flow and encourage the development of collateral circulation ○ walk to the point of pain, rest until the pain subsides, and then resume walking so that endurance can be increased as collateral circulation develops ○ Not all patients with peripheral vascular disease should exercise ■ Before recommending any exercise program, the patient's primary provider should be consulted ■ Conditions that worsen with exercise: ● leg ulcers, cellulitis, gangrene, or acute thrombotic occlusions ● Promoting Vasodilation and Preventing Vascular Compression ○ Arterial dilation promotes increased blood flow to the extremities and is a goal for patients with PAD ■ applications of warmth to promote arterial flow and instructions to the patient to avoid exposure to cold temperatures, which causes vasoconstriction ● Adequate clothing and warm temperatures protect the patient from chilling ○ If chilling occurs, a warm bath or drink is helpful ● A hot water bottle or heating pad may be applied to the patient's abdomen, causing vasodilation throughout the lower extremities 13 ■ ● ● ● vasospastic disorders (Raynaud disease), heat may be applied directly to ischemic extremities using a warmed or electric blanket ● temperature of the heat source must not exceed body temperature ○ Nicotine from any tobacco product causes vasospasm and can dramatically reduce circulation to the extremities ■ Tobacco smoke impairs transport and cellular use of oxygen and increases blood viscosity. ○ Constrictive clothing and accessories, may impede circulation to the extremities and promote venous stasis and should be avoided ○ Crossing the legs for more than 15 minutes at a time should be discouraged as it compresses vessels in the legs Relieving Pain ○ Analgesic agents ex. hydrocodone plus acetaminophen (Vicodin, Norco, Lortab), oxycodone (Roxicodone), oxycodone plus acetylsalicylic acid (Percodan), or oxycodone plus acetaminophen (Percocet, Roxicet) may help reduce pain Maintaining Tissue Integrity ○ Poorly perfused tissues are susceptible to damage and infection ■ When lesions develop, healing may be delayed or inhibited because of the poor blood supply to the area ■ Infected, non-healing ulcerations of the extremities can be debilitating and may require prolonged and often expensive treatments ■ Amputation of an ischemic limb may eventually be necessary. Measures to prevent these complications must be a high priority and vigorously implemented. ○ Trauma to the extremities must be avoided ○ Advising the patient to wear sturdy, well-fitting shoes or slippers to prevent foot injury and blisters may be helpful, and recommending neutral soaps and body lotions may prevent drying and cracking of the skin ○ nurse should instruct the patient not to apply lotion between the toes as the increased moisture can lead to maceration of tissue ○ Scratching and vigorous rubbing can abrade the skin and create sites for bacterial invasion ■ feet should be patted dry ○ Stockings should be clean and dry ○ Fingernails and toenails should be carefully trimmed straight across and sharp corners filed to follow the contour of the nail ■ If the nails cannot be trimmed safely, it is necessary to consult a podiatrist, who can also remove corns and calluses ● Special shoe inserts may be needed to prevent calluses from recurring ○ All signs of blisters, ingrown toenails, infection, or other problems should be reported to health care professionals for treatment and follow-up ○ Patients with diminished vision and those with disabilities that limit mobility of the arms or legs may require assistance ○ Good nutrition promotes healing and prevents tissue breakdown and is included in the overall therapeutic program for patients with peripheral vascular disease. ■ Eating a diet that contains adequate protein and vitamins is necessary for patients with arterial insufficiency ■ Key nutrients play specific roles in wound healing ■ diet low in lipids may be indicated for patients with atherosclerosis Monitoring and Managing Potential Complications 14 ○ ○ ● close monitoring for and early identification of their signs and symptoms are critical monitors the patient closely for changes in cardiac rate and rhythm, heart sounds, blood pressure, chest pain, respiratory status, urinary output, skin color and temperature, mental status, ECG changes, and laboratory values ■ Any changes in condition must be reported promptly to the primary provider, and emergency measures instituted when necessary. Dyslipidemia Drugs to decrease LDL, total cholesterol, and triglycerides Atherosclerosis Medical ● management involves modification of risk factors, a controlled exercise program to improve circulation and functioning capacity, medication therapy, and interventional or surgical graft procedures ○ Statins to decrease cholesterol production by the liver Acute Coronary Syndrome Pathophysiology ● is an emergent situation characterized by an acute onset of myocardial ischemia that results in myocardial death (MI) if definitive interventions do not occur promptly ● spectrum of ACS includes unstable angina, NSTEMI, and ST-segment elevation myocardial infarction (STEMI) ● Not relieved by meds (ex: Nitro)-unstable angina ● unstable angina, there is reduced blood flow in a coronary artery, often due to the rupture of an atherosclerotic plaque. ○ A clot begins to form on top of the coronary lesion, but the artery is not completely occluded ○ is an acute situation that can result in chest pain and other symptoms that may be referred to as preinfarction angina as the patient will likely have an MI if prompt interventions do not occur. ● In an MI, plaque rupture and subsequent thrombus formation result in complete occlusion of the artery, leading to ischemia and necrosis of the myocardium supplied by that artery ● a profound imbalance exists between myocardial oxygen supply and demand. Acute Coronary Syndrome Pharmacological mgt NSG223 02.03.04 Acute Coronary Syndrome Nursing mgt NSG223 02.03.03 ● Relieving pain and other signs and symptoms of ischemia ○ Balancing myocardial oxygen supply with demand (evidenced by the relief of chest pain) is the top priority ○ Collaboration among the patient, nurse, and primary provider is critical in evaluating the patient's response to therapy and in altering the interventions accordingly. ○ Oxygen should be given along with medication therapy to assist with relief of symptoms. ■ raises the circulating level of oxygen to reduce pain associated with low levels of myocardial oxygen ■ route of administration (usually by nasal cannula) and the oxygen flow rate are documented ■ flow rate of 2 to 4 L/min is usually adequate to maintain oxygen saturation levels of at least 95% unless chronic pulmonary disease is present. ○ Vital signs are assessed frequently as long as the patient is experiencing pain and other signs or symptoms of acute ischemia ○ Physical rest in bed with the head of the bed elevated or in a supportive chair helps decrease chest discomfort and dyspnea ■ Elevation of the head and torso is beneficial for the following reasons: 15 ● ● ● ● Tidal volume improves because of reduced pressure from abdominal contents on the diaphragm and better lung expansion. ● Drainage of the upper lung lobes improves. ● Venous return to the heart (preload) decreases, reducing the work of the heart ○ Promptly relieving the pain helps to reestablish oxygen supply and demand balance, decreasing the workload of the heart and minimizing damage to the myocardium ■ helps to reduce the patient's anxiety level, leading to a decrease in the workload of the already stressed heart Improving Respiratory Function ○ Regular and careful assessment of respiratory function detects early signs of pulmonary complications ○ monitors fluid volume status to prevent fluid overload ○ encourage patient to breathe deeply and change position frequently to maintain effective ventilation throughout the lungs ○ Pulse oximetry guides the use of oxygen therapy. Promoting Adequate Tissue Perfusion ○ Bed or chair rest during the initial phase of treatment helps reduce myocardial oxygen consumption ○ limitation on mobility should remain until the patient is pain-free and hemodynamically stable ○ Skin temperature and peripheral pulses must be checked frequently to monitor tissue perfusion. Reducing Anxiety ○ reduce the sympathetic stress response ■ Less sympathetic stimulation decreases the workload of the heart, which may relieve pain and other signs and symptoms of ischemia ○ ensuring a quiet environment, preventing interruptions that disturb sleep, and providing spiritual support consistent with the patient's beliefs Myocardial Infarction Medical ● goals of medical management are to minimize myocardial damage, preserve myocardial function, and prevent complications ○ accomplished by reducing myocardial oxygen demand and increasing oxygen supply with medications, oxygen administration, and bed rest ● Use rapid transit to the hospital. ● Obtain 12-lead electrocardiogram to be read within 10 minutes. ● Obtain laboratory blood specimens of cardiac biomarkers, including troponin. ● Obtain other diagnostics to clarify the diagnosis. ● Begin routine medical interventions: ○ Supplemental oxygen ○ Nitroglycerin ○ Morphine ○ Aspirin ○ Beta-blocker ■ If not needed in the initial management period, it should be introduced within 24 hours of admission, once hemodynamics have stabilized and it is confirmed that the patient has no contraindications ○ Angiotensin-converting enzyme inhibitor within 36 hours ○ Anticoagulation with heparin and platelet inhibitors ○ Statin 16 ● ● Evaluate for indications for reperfusion therapy: ○ Percutaneous coronary intervention (PCI) ■ time from the patient's arrival in the ED to the time PCI is performed should be less than 90 minutes ● door-to-balloon time ○ Thrombolytic (fibrinolytic) therapy ■ should be given within 30 minutes of presentation to the hospital ● door-to-needle time ■ should not be used if the patient is bleeding or has a bleeding disorder ■ Within 6 hours of pain Continue therapy as indicated: ○ IV heparin, low–molecular-weight heparin, bivalirudin, or fondaparinux ○ Clopidogrel (Plavix) ○ Glycoprotein IIb/IIIa inhibitor ○ Bed rest for a minimum of 12–24 hours ○ Statin prescribed at discharge Cardiac Monitoring ● Used to diagnose dysrhythmias, chamber enlargement, myocardial ischemia, injury, or infarction and to monitor the effects of electrolyte imbalances or medication administration ● electrical impulse that travels through the heart can be viewed using of electrocardiography, the end product of which is an electrocardiogram (ECG/EKG) ○ is a graphic representation of the electrical currents of the heart ● standard ECG is composed of 12 leads, or 12 different views ● Continuous Electrocardiographic Monitoring ○ is the standard of care for patients who are at high risk for dysrhythmias ○ detects abnormalities in heart rate and rhythm ○ hardwire cardiac monitoring (found in EDs, critical care units and progressive care unit) ■ is used to continuously observe the heart for dysrhythmias and conduction disorders using 1 or 2 ECG leads ■ real-time ECG is displayed on a bedside monitor and at a central monitoring station ■ additional components can be added to the bedside monitor to continuously monitor hemodynamic parameters, respiratory parameters, and ST segments for myocardial ischemia ○ telemetry (found in general nursing care units or outpatient cardiac rehabilitation programs) ■ Is the transmission of radio waves from a battery-operated transmitter to a central bank of monitors. ■ primary benefit of telemetry is that the system is wireless, allowing patients to ambulate while one or two ECG leads are monitored ■ has electrodes placed on the chest with a lead cable that connects to the transmitter ● transmitter can be placed in a disposable pouch and worn around the neck or simply secured to the patient's clothing ● Most transmitter batteries are changed every 24-48 hours ● Continuous Monitors/Holter Monitor ○ Are small portable recorders connected to chest electrodes that record the ECG using 7 leads onto a digital memory device ○ wears the recorder for 24-48 hours and, some cases, up to 2 weeks ■ Returns the device to providers office 17 ○ ● If patient experiences symptoms, they are instructed to activate the event marker ■ May be asked to keep a diary to note the date and time of symptoms or performance of unusual activities ● provider uses diary to correlate symptoms with detected dysrhythmias ○ do not provide real-time ECG recordings ○ effectiveness depends on the patient's adherence with keeping a diary and marking events Patients must be informed of its purpose and cautioned that it does not detect shortness of breath, chest pain, or other ACS symptoms ○ instructed to report new or worsening symptoms immediately Cardiac monitoring Nursing interventions ● Alarm Fatigue due to excessive amounts of false alarms ○ to minimize false alarms, ECG recordings must be free of artifact, an abnormal ECG pattern caused by muscular activity, patient movement, electrical interference, or lead cable or electrode malfunction. ■ Artifact can mimic dysrhythmias and cause unnecessary false alarms ● key to eliminating artifact is using proper skin preparation before applying electrodes and changing the electrodes every 24 hours ○ During changes, the skin should be assessed for allergic responses (itchy, reddened skin) to the adhesive or electrode gel ■ If present, electrodes are replaced with hypoallergenic electrodes ○ Rotation of electrode placement on the skin will reduce the risk for skin breakdown ○ Electrodes and lead connections need to be positioned correctly ○ Electrical equipment in use should be inspected to be sure that it is functioning properly and has been recently checked by the medical engineering department per organization policy ○ effort should be made to individualize the ECG alarm parameters to meet the patient's monitoring needs ○ nurse's role is to respond to and correct all monitor alarms immediately ■ Inoperative (inop) monitoring alarms are used to communicate that electrodes have fallen off, leads are loose, or the system's battery power is low (e.g., telemetry). ■ Timely responses to all alarms can prevent serious consequences ○ A patient should never be connected to monitoring equipment that has not been thoroughly cleaned between patients ■ If a patient is scheduled for a device implant, electrodes should not be placed over the planned incision site ■ electrodes should never be placed over an incision, implanted device, open wounds, or inflamed skin ○ Electrodes should be removed once monitoring is discontinued and skin cleansed to remove excess electrode gel and adhesive ○ Metal-containing electrodes must be removed before sending a patient for any magnetic resonance scan ○ Monitoring devices of any type should not be submerged in water ○ Patient has atrial fibrillation, turning off the irregular heart rate alarm is appropriate Cardiac Monitoring Nursing assessment ● Cardiac stress testing (exercise stress test and pharmacologic stress test) are noninvasive ways to evaluate the cardiovascular system's response to stress 18 ○ ○ Exercise stress tests the patient walks on a treadmill (most common) or pedals a stationary bicycle ■ In preparation the patient is instructed to fast for at least 3 hours before test and avoid stimulants ex. tobacco and caffeine ● Medications may be taken with sips of water ■ Before test, primary provider may instruct patient not to take certain cardiac medications ex. beta-adrenergic blocking agents ■ Clothes and sneakers or rubber-soled shoes suitable for exercising are to be worn ■ nurse prepares patient for the test by describing how the test is performed, type of monitoring equipment used, rationale for insertion of an IV catheter, and what symptoms to report ■ exercise method is reviewed, and patients are asked to put forth their best exercise effort ■ If test is performed with echocardiography or radionuclide imaging, this information is reviewed ■ After test, patient is monitored for 10 to 15 minutes ● Once stable, patients may resume their usual activities Pharmacologic stress tests are for patients who are cognitively impaired and unable to follow directions or physically disabled or deconditioned will not achieve their target heart rate by exercising on a treadmill or bicycle ■ Vasodilating agents ex. dipyridamole (Persantine), adenosine (Adenocard), or regadenoson (Lexiscan) are given as an IV infusion ● used to mimic the effects of exercise by maximally dilating normal coronary arteries ● side effects are related to the vasodilating action and include chest pain, headache, flushing, nausea, heart block, and dyspnea ■ must avoid xanthine derivatives, including theophylline, aminophylline, and caffeine, as they block the effects of the vasodilating agents ■ Dobutamine is another option ● is a synthetic sympathomimetic agent that increases heart rate, myocardial contractility, and BP ○ increasing metabolic demands of the heart ● agent of choice when echocardiography is used as it alters myocardial wall motion (due to enhanced contractility) ● used for patients who have bronchospasm or pulmonary disease and cannot tolerate having doses of theophylline withheld ■ In preparation, the patient is instructed not to eat or drink anything for at least 3 hours before ■ patient must be told to refrain from drinking any liquids or eating food that contain chocolate or caffeine for 24 hours ● restriction includes caffeine-free coffee, tea, carbonated beverages, and medications containing caffeine (e.g., Anacin) ● If caffeine is ingested before a stress test using vasodilating agents, test will have to be rescheduled ■ Patients taking aminophylline, theophylline, or dipyridamole are instructed to stop taking these medications for 24 to 48 hours before test (if tolerated) ■ patient is informed about the transient sensations that may occur during the infusion of the vasodilating agent ex. flushing or nausea, which will disappear quickly 19 ■ ● ● patient is instructed to report any other symptoms during the test to the cardiologist or nurse ■ may take about 1 hour or up to 3 hours if imaging is performed helps determine: ○ presence of CAD ○ cause of chest pain ○ functional capacity of the heart after an MI or heart surgery ○ effectiveness of antianginal or antiarrhythmic medications ○ occurrence of dysrhythmias ○ specific goals for a physical fitness program Contraindications ○ acute MI within 48 hours ○ unstable angina ○ uncontrolled dysrhythmias with hemodynamic compromise ○ severe aortic stenosis ○ acute myocarditis or pericarditis ○ decompensated HF Cardiac Monitoring Monitoring Procedure ● electrocardiogram (ECG) is obtained by placing electrodes on the body in specific areas ● Gently abrading the skin with a clean, dry gauze pad to expose the epidermis's inner conductive layer, will reduce skin impedance ○ cleansing skin with alcohol removes any oily residue from the skin and increases the skin's electrical impedance and hindering detection of the cardiac electrical signal ● If the amount of chest hair prevents the electrode from having good contact with the skin, the hair may need to be clipped ● Poor electrode adhesion will cause significant artifact (distorted, irrelevant, and extraneous ECG waveforms), distorting capturing an accurate ECG waveform ● The number and placement site of the electrodes depends on the type being obtained ○ Most continuous monitors use 2 to 5 electrodes, usually placed on the limbs and chest ● Electrodes are attached to cable wires, which are connected to either ○ ECG machine placed at the patient's side for an immediate recording (standard 12-lead ECG). ○ cardiac monitor at the patient's bedside for continuous reading ● placement of electrodes for monitoring varies with type of technology, purpose of monitoring, and standards of the health care facility ○ standard 12-lead ECG, 10 electrodes (6 on chest and 4 on limbs) are placed on the body ■ To prevent interference from the electrical activity of skeletal muscle, limb electrodes are placed on areas that are not bony and do not have significant movement ■ limb electrodes provide the first 6 leads ● leads I, II, III, aVR (augmented voltage right arm), aVL (augmented voltage left arm), and aVF (augmented voltage left leg/foot) ■ 6 chest electrodes are applied to the chest in particular areas ● provide the V, or precordial leads: V1 through V6 ○ To locate the 4th intercostal space and the placement of V1, sternal angle and then sternal notch, which is about 1 or 2 inches below the sternal angle, are located ■ When fingers are moved to the patient's immediate right, second rib can be palpated 20 ■ ● ● second intercostal space is the indentation felt just below the second rib ■ standard 12-lead ECG reflects the electrical activity primarily in the left ventricle Locating the specific intercostal space is critical for the correct placement of each chest electrode Errors in diagnosis can occur if electrodes are placed incorrectly. Rhythm Strip Analysis ● must be analyzed systematically to determine the patient's cardiac rate and rhythm and to detect dysrhythmias, conduction disorders, and evidence of myocardial ischemia, injury, and infarction ● When examining an electrocardiogram (ECG) rhythm strip to learn more about a patient's dysrhythmia, a nurse should do the following: ○ Determine the ventricular rate. ○ Determine the ventricular rhythm. ○ Determine the QRS duration. ○ Determine whether the QRS duration is consistent throughout the strip. If not, identify other duration. ○ Identify the QRS shape. If not consistent, then identify other shapes. ○ Identify P waves. Is there a P in front of every QRS? ○ Identify the P-wave shape. Identify whether it is consistent or not. ○ Determine the atrial rate. ○ Determine the atrial rhythm. ○ Determine each PR interval. ○ Determine if the PR intervals are consistent, irregular but with a pattern to the irregularity, or just irregular. ○ Determine how many P waves for each QRS (P:QRS ratio). ● In many cases, the nurse may use a checklist and document the findings next to the appropriate ECG criterion ● 1-minute rhythm strip contains 300 large boxes and 1,500 small boxes ○ easy and accurate method of determining heart rate with a regular rhythm is to count the number of small boxes within an RR interval and divide 1,500 by that number Sinus Bradycardia & Tachycardia ● Sinus Bradycardia: What does the ECG look like? ○ Sinus bradycardia occurs when the SA node creates an impulse at a slower-than-normal rate. ■ If the bradycardia is caused by a medication, such as a beta-blocker, the medication may be withheld ■ If the slow heart rate causes significant hemodynamic changes resulting in shortness of breath, acute alteration of mental status, angina, hypotension, ST-segment changes, or premature ventricular complexes (PVCs), treatment is directed toward increasing the heart rate ○ Ventricular and atrial rate: Less than 60 bpm in the adult ○ Ventricular and atrial rhythm: Regular ○ QRS shape and duration: Usually normal, but may be regularly abnormal ○ P wave: Normal and consistent shape; always in front of the QRS ○ PR interval: Consistent interval between 0.12 and 0.20 seconds ○ P: QRS ratio: 1:1 ● Sinus Tachycardia: What does the ECG look like? ● Sinus tachycardia occurs when the sinus node creates an impulse at a faster-than-normal rate 21 ● ● ● ● ● ● Ventricular and atrial rate: Greater than 100 bpm in the adult, but usually less than 120 bpm Ventricular and atrial rhythm: Regular QRS shape and duration: Usually normal, but may be regularly abnormal P wave: Normal and consistent shape; always in front of the QRS, but may be buried in the preceding T wave PR interval: Consistent interval between 0.12 and 0.20 seconds P:QRS ratio: 1:1 PAC, A-fib & A flutter ● Premature Atrial Complex (PACs) ○ a single ECG complex that occurs when an electrical impulse starts in the atrium before the next normal impulse of the sinus node ○ may be caused by caffeine, alcohol, nicotine, stretched atrial myocardium (hypervolemia), anxiety, hypokalemia (low potassium level), hypermetabolic states (e.g., with pregnancy), or atrial ischemia, injury, or infarction ○ often seen with sinus tachycardia ○ common in normal hearts ■ patient may say, “My heart skipped a beat.” A pulse deficit (a difference between the apical and radial pulse rate) may exist ○ Characteristics ■ Ventricular and atrial rate: Depends on the underlying rhythm (e.g., sinus tachycardia) ■ Ventricular and atrial rhythm: Irregular due to early P waves, creating a PP interval that is shorter than the others. This is sometimes followed by a longer-than-normal PP interval, but one that is less than twice the normal PP interval. This type of interval is called a non-compensatory pause. ■ QRS shape and duration: The QRS that follows the early P wave is usually normal, but it may be abnormal (aberrantly conducted PAC). It may even be absent (blocked PAC). ■ P wave: An early and different P wave may be seen or may be hidden in the T wave; other P waves in the strip are consistent. ■ PR interval: The early P wave has a shorter-than-normal PR interval, but still between 0.12 and 0.20 seconds. ■ P:QRS ratio: Usually 1:1 ● Atrial Fibrillation (A Fib) ○ most common sustained dysrhythmia ○ causes electrophysiologic changes in the atrial myocardium (remodeling of the atrial electrical circuit) and structural remodeling (fibrosis), which provides the basis for continuance of the dysrhythmia ○ Risk Factors ■ Increasing age ■ Hypertension ■ Diabetes ■ Obesity ■ Valvular heart disease ■ Heart failure ■ Obstructive sleep apnea ■ Alcohol consumption—moderate (1–3 drinks/day) and high (>3 drinks/day) ■ Hyperthyroidism ■ Cardiac ischemia 22 ● ■ Cardiac inflammatory disease (pericarditis, myocarditis, amyloidosis) ■ Myocardial hypertrophy, fibrosis, or dilation ■ Atrial remodeling ■ Postoperative cardiac surgery ■ Female ○ results from abnormal impulse formation that occurs when structural or electrophysiological abnormalities alter the atrial tissue causing a rapid, disorganized, and uncoordinated twitching of the atrial musculature ○ Characteristics ■ Ventricular and atrial rate: Atrial rate is 300 to 600 bpm; ventricular rate is usually 120 to 200 bpm in untreated atrial fibrillation. ■ Ventricular and atrial rhythm: Highly irregular ■ QRS shape and duration: Usually normal, but may be abnormal ■ P wave: No discernible P waves; irregular undulating waves that vary in amplitude and shape are seen and referred to as fibrillatory or f waves ■ PR interval: Cannot be measured ■ P:QRS ratio: Many:1 ○ increased risk of heart failure, myocardial ischemia, and embolic events such as stroke ○ some are asymptomatic ○ palpitations ○ manifestations of heart failure (shortness of breath, hypotension, dyspnea on exertion, fatigue) Atrial Flutter ○ occurs due to a conduction defect in the atrium and causes a rapid, regular atrial impulse at a rate between 250 and 400 bpm ○ As the atrial rate is faster than the AV node can conduct, not all atrial impulses are conducted into the ventricle, causing a therapeutic block at the AV node ○ k factors mirror those for atrial fibrillation ■ Increasing age ■ Hypertension ■ Diabetes ■ Obesity ■ Valvular heart disease ■ Heart failure ■ Obstructive sleep apnea ■ Alcohol consumption—moderate (1–3 drinks/day) and high (>3 drinks/day) ■ Hyperthyroidism ■ Cardiac ischemia ■ Cardiac inflammatory disease (pericarditis, myocarditis, amyloidosis) ■ Myocardial hypertrophy, fibrosis, or dilation ■ Atrial remodeling ■ Postoperative cardiac surgery ○ has the following characteristics ■ Ventricular and atrial rate: Atrial rate ranges between 250 and 400 bpm; ventricular rate usually ranges between 75 and 150 bpm. ■ Ventricular and atrial rhythm: The atrial rhythm is regular; the ventricular rhythm is usually regular but may be irregular because of a change in the AV conduction. ■ QRS shape and duration: Usually normal, but may be abnormal or may be absent. ■ P wave: Saw-toothed shape; these waves are referred to as F waves. 23 ■ ■ PR interval: Multiple F waves may make it difficult to determine the PR interval. P:QRS ratio: 2:1, 3:1, or 4:1 PAC, A-fib & Aflutter Medical ● Premature Atrial Complex (PACs) ○ If infrequent, no treatment is necessary ○ If frequent (more than 6 per minute), this may indicate a worsening disease state or the onset of more serious dysrhythmias, such as atrial fibrillation. ■ Medical management is directed toward treating the underlying cause (reduction of caffeine intake, correction of hypokalemia) ● Atrial Fibrillation (A Fib) ○ Treatment depends on the cause, pattern, and duration of the dysrhythmia, ventricular response rate, and the presence of structural or valvular heart disease and other cardiac conditions ○ Strategies for rhythm control (conversion to sinus rhythm) and rate control are dependent on shared clinical decision-making between patient and primary provider ○ some cases, A Fib) spontaneously converts to sinus rhythm within 24-48 hours without treatment ○ When A Fib is accompanied with significant other morbid conditions (severe heart failure), it may be classified as “permanent,” meaning the patient and primary provider have made a joint decision to stop further attempts to restore or maintain sinus rhythm ○ management may be different in different patients, and it may change over time for any patient ○ revolves around preventing embolic events, such as stroke with antithrombotic drugs, controlling the ventricular rate of response with antiarrhythmic agents, and treating the dysrhythmia as indicated to convert it to a sinus rhythm (cardioversion) ○ Electrical Cardioversion ■ Flecainide, propafenone, amiodarone, dofetilide, or sotalol may be given before to enhance the cardioversion success and maintain sinus rhythm ■ atrial function may be impaired for 7 weeks after, warfarin is indicated for at least 4 weeks after procedure ● Repeated attempts at electrical cardioversion may be made following the administration of an antiarrhythmic medication. ○ Cardiac Rhythm Therapies ■ A Fib that doesn’t respond to medications or electrical cardioversion may be treated by cardiac rhythm therapies ex. catheter ablation, maze or mini-maze procedure, or convergent procedure ● Ablation destroys specific cells that are the cause of tachydysrhythmia ○ tissue damage is more specific to the dysrhythmic tissue with less trauma to the surrounding cardiac tissue ■ A special catheter is advanced at or near the origin of the dysrhythmia, where high-frequency, low-energy sound waves are passed through the catheter, causing thermal injury, localized cell destruction, and scarring. ● Maze or Mini Maze ○ maze procedure is an open-heart surgical procedure for refractory atrial fibrillation ■ Surgeon creates a pattern (maze) of scar tissues in the atria of the heart using a scalpel or device that delivers heat or cold energy. ■ Scar tissue does not conduct electricity. This maze of scar tissue 24 interferes with stray electrical impulses that cause a-fib. Mini maze is the modified version of a maze procedure ■ eliminates the need for opening the sternum, heart-lung bypass, and the use of cardioplegia ■ is performed by making small incisions between the ribs through which video-guided instruments are inserted. ■ The pulmonary veins are encircled with surgical incisions within the left atrium ● Convergent Procedure ○ utilizes a hybrid approach to ablation, requiring the skills of both a cardiothoracic surgeon and an electrophysiologist ○ creates a few small incisions in the abdomen ■ performs ablation of the epicardial wall around the pulmonary veins Meds that control HR: Beta-blocker, CCB Meds that Convert Heart Rhythm: Fecainide, Dofetilide, Propafenone, Amiodarone ■ Most effective when given with 1st 7 days of onset of a-fib Preventing A-Fib following cardiac surgery: Beta-blockers, statins Preventing A-Fib with HTN patients: ACE inhibitors, ARBs ○ ○ ○ ● ○ ○ Aflutter ○ involves the use of vagal maneuvers or a trial administration of adenosine, which causes sympathetic block and slowing of conduction through the AV node ■ may terminate the tachycardia ■ optimally, it will facilitate the visualization of flutter waves for diagnostic purposes ■ Adenosine is given IV by rapid administration and immediately followed by a 20-mL saline flush and elevation of the arm with the IV line to promote rapid circulation of the medication ○ treated with antithrombotic therapy, rate control, and rhythm control in the same manner as atrial fibrillation ○ Electrical cardioversion is often successful in converting atrial flutter to sinus rhythm Dysrhythmias Pharmacological ● drugs used to combat dysrhythmias alter the electrical conduction system of the heart ● Atropine is the anticholinergic drug ○ Use: ■ restoration of cardiac rate and arterial pressure during anesthesia when vagal stimulation produced by intra-abdominal traction causes a decrease in pulse rate, lessening the degree of an atrioventricular block when increased vagal tone is a factor. ■ relieves bradycardia and syncope due to hyperactive carotid sinus reflex ■ serves as an antidote for cardiac collapse with an overdose of parasympathomimetic drugs, also known as cholinergic agents and cholinesterase inhibitors, such as physostigmine ○ Adverse Effects ■ bradycardia ■ tachycardia (high doses) ■ blurred vision, mydriasis, cycloplegia, photophobia, and increased intraocular pressure ■ geriatric population: ● nervousness, weakness, confusion, or excitement are common 25 ○ ○ ○ ■ paralytic ileus ■ urinary hesitancy and retention ■ decreased sweating, which leads to heat prostration patient should be well hydrated, and the environment should be cool to protect from hyperpyrexia If the patient has a history of urinary retention, the patient should void before administering the drug Teaching ■ Avoid excessive high temperatures. ■ Drink water frequently. ■ Rinse the mouth frequently. ■ Maintain good dental hygiene. ■ Use hard candy to decrease dry mouth. ■ Void before taking the medication. ■ Visit the ophthalmologist regularly. ■ Notify your prescriber if fluid intake is greater or less than urine output. ■ Notify your prescriber if you develop a fever. ■ Notify your prescriber if weakness becomes severe. ■ Avoid the use of machinery if visual acuity or alertness is impaired Which conditions can be diagnosed or detected with an echo? ● Mitral valve prolapse ● Cardiomyopathy ● Mitral valve stenosis On an ECG, each small square is how many seconds? ● 0.04 seconds Each large square is how many seconds? ● 0.2 seconds A 6-second interval is how many squares. ● 30 large squares P Wave Represents ● The P wave represents the electrical impulse starting in the SA node and spreading through the atria. ● represents atrial depolarization ● usually is 2.5 mm or less in height and 0.11 seconds or less in duration. QRS Time Frame ● The QRS complex is normally less than 0.12 seconds in duration. QRS Complex Represents 26 ● ● ventricular depolarization normally less than 0.12 seconds in duration T Wave Represents ● The T wave represents ventricular repolarization (when the cells regain a negative charge; also called the resting state). The PR Interval Time Frame ● In adults, the PR interval typically ranges from 0.12 to 0.20 seconds in duration. What is the PR Interval ● is measured from the beginning of the P wave to the beginning of the QRS complex ● represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization What is the ST-Segment ● represents early ventricular repolarization, lasts from the end of the QRS complex to the beginning of the T wave. QT Interval Time Frame ● The QT interval is usually 0.32 to 0.40 seconds in duration if the heart rate is 65 to 95 bpm. Complications of Long QT ● Many medications commonly given in the hospital can cause prolongation of the QT interval (QTc), placing the patient at risk for a lethal ventricular dysrhythmia called torsades de pointes What is the QT Interval ● represents the total time for ventricular depolarization and repolarization, is measured from the beginning of the QRS complex to the end of the T wave ● varies with heart rate, gender, and age Normal sinus rhythm ● occurs when the electrical impulse starts at a regular rate and rhythm in the SA node and travels through the normal conduction pathway ● Ventricular and atrial rate: 60 to 100 bpm in the adult ● Ventricular and atrial rhythm: Regular ● QRS shape and duration: Usually normal, but may be regularly abnormal ● P wave: Normal and consistent shape; always in front of the QRS ● PR interval: Consistent interval between 0.12 and 0.20 seconds ● P:QRS ratio: 1:1 Warfarin INR range for mitral valve replacement ● 2-3.5 ○ 3 months Warfarin INR range for aortic valve replacement ● 1.8-2.2 27 Foods to eat with caution while on Warfarin ● Don’t change the intake of foods high in vitamin K, which decreases the effects of warfarin ● include broccoli, brussels sprouts, cabbage, cauliflower, chives, collard greens, kale, lettuce, mustard greens, peppers, spinach, tomatoes, turnips, and watercress Normal Troponin I Level ● <0.04 ng/mL Normal Troponin T ● < 0.1 ng/mL What labs should be checked prior to statin administration? ● Liver and kidney function test Procainamide ● Functional Class: Antidysrhythmic ● Therapeutic USE: Life-threatening atrial and ventricular arrhythmias ● Side Effects: hypotension, headache, dizziness ● Adverse Effects: Heart block, cardiovascular collapse lupus-like symptoms. Amiodarone ● Functional Class: Antidysrhythmic ● Therapeutic Use: Hemodynamically unstable ventricular tachycardia, SVT, Vfib not controlled by 1st line agents (Epinephrine) ● Side Effects: Hypotension, dizziness, fatigue, bradycardia ● Adverse Effects: Hepatotoxic, Pneumotoxic ● Get baselines before giving Heparin ● Functional Class: Anticoagulant, Antithrombotic ● Therapeutic Use: Thrombosis prevention in MI, PE, open Heart Surgery, DVT ● Side Effects: rash, fever, hyperkalemia ● Adverse Effects: Hemorrhage, Thrombocytopenia, anaphylaxis ● Nursing Considerations ○ Uses PTT to adjust dosing ○ Monitor PTT ● PTT level ○ Normal 25-35 seconds ○ Therapeutic/Goal PTT: 45-70 seconds ● Antidote: Protamine Sulfate: 1mg/100mg of Heparin Warfarin ● Normal INR: 1.1 or less ● Goal/Therapeutic for Afib: 2.0-3.0 ● Antidote: Vitamin K ● Avoid NSAIDs, aspirin, antibiotics and alcohol Low Molecule Weight Heparin (Enoxaparin- Lovenox) 28 ● ● Do not need PTT Antidote: Protamine Sulfate Direct Factor Xa Inhibitors (rivaroxaban, apixaban, edoxaban) ● No lab monitoring Nitroglycerin IV, Uses, Class, and Adverse effects ● Functional Class: Antianginal, Coronary Vasodilator ● Therapeutic Use: Chronic Stable Angina, Heart Failure, acute MI ● Side Effects: headache flushing, dizziness, postural hypotension ● Adverse Effects: Vascular collapse ● Nursing Considerations: ○ Careful observation of vital signs; can lower BP quickly. ○ Titrate to relieve chest pain Nitroglycerin Tabs, Class, Use, and Adverse Effects ● Functional Class: Antianginal; Cardiovascular Vasodilator ● Therapeutic Use: Prevent/treat angina ● Side Effects: headache, flushing, hypotension ● Adverse Effects: vascular collapse, syncope ● Nursing Considerations ○ Keep pills in the original bottle, away from light/heat ○ Tablets should "sting" when placed under tongue ○ Take 3 tablets q5min. If no relief, call 911 ○ Taking 1 tablet prior to strenuous activity is recommended Rosuvastatin ● Functional Class: Antilipemic ● Therapeutic Use: Reduces cholesterol ● Side Effects: myalgias, fatigue, dizziness, headache, nausea, constipation, diarrhea, abdominal pain, heartburn ● Adverse Effects: kidney failure, liver dysfunction, myositis, rhabdomyolysis ● Nursing Considerations: ○ Check Liver and kidney function prior to first administration ○ Compliance is required ○ Risk factors need to also be decreased; not a free pass ○ Not to be used in pregnancy/breastfeeding ○ Notify provider immediately with muscle weakness/pain ● Medication should be taken at nighttime or morning at the same time each day ● Take with or without food Gemfibrozil ● Functional Class: Antilipidemic ● Therapeutic Use: Decreases cholesterol and triglycerides ● Side Effects: abdominal cramps, diarrhea ● Adverse Effects: liver dysfunction, myopathy, rhabdomyolysis ● Nursing Considerations ○ Kidney, LFTs, CBC, glucose prior to administration 29 ○ 30 minutes prior dinner at the same time each day Atorvastatin (Lipitor) ● Functional Class: Antilipidemic ● Therapeutic Use: Decreases cholesterol and triglycerides ● Side Effects: abdominal cramps, constipation/diarrhea, heartburn ● Adverse Effects: liver dysfunction, pancreatitis, rhabdomyolysis ● Nursing Considerations ○ Confirm liver enzymes prior to starting medication ○ Medication should be taken at nighttime or morning at the same time each day ○ Lifestyle changes are still required; not a free pass ○ Grapefruit is not a friend Ezetimibe (Zetia) ● Functional Class: Antilipemic; Cholesterol absorption inhibitor ● Therapeutic Use: Reduces cholesterol ● Side Effects: myalgias, fatigue, dizziness ● Adverse Effects: Hepatotoxic (contraindicated in liver disease); rhabdomyolysis, angioedema ● Nursing Considerations: ○ Check Liver function prior to first administration ○ Compliance is required ○ Risk factors need to also be decreased; not a free pass ○ Not to be used in pregnancy/breastfeeding ○ Notify provider immediately with muscle weakness/pain. ○ Take in the evenings at the same time each day Colestipol ● Functional Class: Antilipemic ● Therapeutic Use: Reduces cholesterol ● Side Effects: constipation, nausea, vomiting, gas ● Adverse Effects: ● Nursing Considerations: ○ Swallow whole ○ Don’t chew or crush ○ Take in the evenings prior to meals at the same time each day ○ Take all other medications 1 hour before or 4 hours after ○ Tell provider if any unusual bleeding from gum or rectum occurs Simvastatin ● Functional Class: Antilipemic ● Therapeutic Use: Reduces cholesterol ● Side Effects: ● Adverse Effects: liver dysfunction, pancreatitis, myositis, rhabdomyolysis ● Nursing Considerations: ○ Avoid grapefruit ○ May affect blood glucose levels in diabetics ○ Report muscle pain, weakness, abdominal pain, dark urine, yellowing of skin and eyes, memory loss 30 ○ Check liver and kidney function prior to administration Alteplase ● Functional Class: Thrombolytic enzyme ● Therapeutic Use: Lysis of obstructing thrombi associated with acute MI, PE, CVA ● Side Effects: nothing common ● Adverse Effects: Bleeding ● Nursing Considerations: ○ Very short ½ life: approximately 5 minutes ○ Must be given <4.5 hrs for stroke; <6 hours for MI ○ Bleeding precautions for 24 hours Nifedipine (Procardia): ● Functional Class: Calcium Channel Blocker; antianginal; antihypertensive ● Therapeutic Use: Chronic stable angina, variant angina, hypertension ● Side Effects: headache, fatigue, flushing, nocturia, constipation ● Adverse Effects: Dysrhythmias, Stevens-Johnsons syndrome ● Nursing Considerations: ○ Change positions slowly; Avoid hazardous activities until dizziness has subsided. ○ Grapefruit still not a friend; neither is caffeine or alcohol ○ Increase fluid/fiber intake to prevent constipation ○ TAPER! Furosemide (Lasix) ● Functional Class: Loop diuretic ● Therapeutic Use: Edema, hypertension ● Side Effects: hypokalemia, NVD, hyperglycemia, hypotension ● Adverse Effects: Circulatory collapse, renal failure, thrombocytopenia, Stevens-Johnsons syndrome ● Nursing Considerations ○ Weigh patients daily (no more than 2lbs wt loss in 24 hours) ○ Maintain I&O carefully ○ Careful observation of vital signs ○ IV (SLOW!) 20mg/minute Cyclosporine ● Functional Class: Immunosuppressant, antirheumatic (DMARD) ● Therapeutic Use: Prevents rejection; rheumatoid arthritis ● Side Effects: headache, tremors, oral candida, gingival hyperplasia ● Adverse Effects: seizures, hepatotoxicity, nephrotoxicity, infection ● Nursing Considerations ● Monitor liver/kidney labs frequently ● Observe for s/s of infection ● Limit UV exposure ● Careful dental care ● Treatment is lifelong ● Report diarrhea (drug loss/rejection may occur) Metoprolol (Lopressor): 31 ● ● ● ● ● Functional Class: Antihypertensive; Beta Blocker Therapeutic Use: hypertension, acute MI to reduce mortality Side Effects: NVD, hiccups, hypotension, insomnia, dizziness Adverse Effects: bradycardia, cardiac arrest, bronchospasm Nursing Considerations ○ Grapefruit IS a friend J ○ Take with food ○ Notify provider if dizzy/difficult breathing ○ Take as directed; don't double up on dosing ○ Taper - don't stop suddenly ○ Monitor blood sugar, can mask hypoglycemia Ampicillin ● Functional Class: antiinfective - broad spectrum ● Therapeutic Use: Effect on Gram+/- cocci, Gram+/- bacilli ● Side Effects: NVD, rash ● Adverse Effects: Seizures (high doses), bone marrow depression, anaphylaxis ● Nursing Considerations: ○ Instruct patient to complete course even if no symptoms remain ○ EMPTY stomach; FULL glass of water ■ approximately 1 hour before or 2 hours after a meal ○ Use alternate contraception ○ Report sore throat (may be sign of superinfection) ○ Product must be taken in evenly spaced dosing to maintain drug level ○ recommended that serum creatinine and blood urea nitrogen (BUN) be monitored Amphotericin B ● Functional Class: antifungal ● Side Effects: fever, chills, nausea, vomiting, malaise, neprh ● Adverse Effects: respiratory failure, wheezing, dyspnea, cardiac arrest, nephrotoxicity, tachycardia, GI bleeding ● Nursing Considerations: ○ Monitor for kidney and liver toxicity ○ Notify provider if bleeding, bruising, or soft tissue swelling, renal or neurologic side effects occur ○ usually given for 4 to 12 weeks ○ monitor the patient's electrolytes for hypokalemia and hyponatremia Quinidine/ Procainamide ● Class ○ Antiarrhythmic ○ Class IA: blocks sodium and potassium channels ● Action ○ Moderate depression of depolarization. ○ Prolongs repolarization. ○ Treats and prevents atrial and ventricular dysrhythmias ○ Wide QRS tachycardia ● Side Effects ○ Prolonged QRS/QT 32 ● ○ Low BP with IV admin ○ Q: Diarrhea ○ P: Constipation Nursing Interventions ○ Observe for HF ○ Monitor BP with IV ○ Monitor QRS duration ○ Monitor for prolonged QT Lidocaine ● Class ○ Antiarrhythmic ○ Class IB: blocks sodium channels ● Action ○ Minimal depression of depolarization ○ Shortened repolarization ○ Treats ventricular dysrhythmias ● Side Effects ○ Confusion/Lethargy ○ Bradycardia ○ GI Distress ○ Tremors ○ Respiratory depression ○ Hypotension ○ dizziness ● Nursing Interventions ○ Monitor seizures-sign of toxicity Flecainide & Propafenone ● Class ○ Antiarrhythmic Class IC: strong sodium channel blocker ● Action ○ Depression of depolarization ○ Little effect on repolarization ○ Treats atrial and ventricular dysrhythmias ● Side Effects ○ Heart failure ○ Dizziness ○ Visual Disturbances ○ Dyspnea ● Nursing Interventions ○ Decrease dose with renal impairment ○ Avoid with HF or CAD Atenolol, Metoprolol Propanolol, Labetalol ● Class ○ Class II: Beta-Blockers ● Action 33 ● ● ○ Decreases automaticity and conduction ○ Treats atrial and ventricular dysrhythmias ○ Narrow QRS tachycardia Side Effects ○ Bradycardia ○ AV Block ○ Bronchospasm ○ Nausea ○ Hypotension Nursing Interventions ○ Monitor HR, PR Interval ○ No abrupt withdrawal of med Amiodarone & Dofetilide ● Class ○ Class III: Potassium channel blocker ● Action ○ Prolongs repolarization ○ A: treats and prevents ventricular and atrial dysrhythmias ○ D: treats and prevents atrial dysrhythmias ● Side Effects ○ Pulmonary toxicity ○ Renal toxicity ○ Photosensitivity ○ Bradycardia ○ Hypotension ○ Nauseas/Vomiting ● Nursing Interventions ○ NEED PFTS and renal PRIOR TO AMIODARONE ○ Monitor QT duration ○ Continuous ECG monitoring when starting Dofetilide ○ Monitor renal function Verapamil & Diltiazem ● Class ○ Class IV: Calcium Channel Blocker ● Action ○ CCB ○ Treats and prevents paroxysmal atrial dysrhythmias ● Side Effects ○ Bradycardia ○ AV Blocks ○ Hypotension ○ Constipation, Nausea ○ Dizziness, Headache ● Nursing Interventions ○ Monitor HR and PR interval ○ Watch for HF 34 Important things to teach those at risk for blood clots: ● To help prevent blood clots from forming in the leg veins, avoid or minimize situations that slow blood circulation, such as wearing tight clothing, crossing the legs at the knees, prolonged sitting or standing, and bed rest. For example, on automobile trips, stop and walk around every 1 to 2 hours; on long plane trips, exercise the feet and legs in the seat and walk around when possible ● Report any sign of bleeding (e.g., excessive bruising of the skin, blood in urine or stool). If superficial bleeding occurs, apply direct pressure to the site for 3 to 5 minutes or longer if necessary. 35 Anti-Anginals ● Nitroglycerin ○ Vasodilation ○ Decrease heart oxygen demand ○ SE: orthostatic hypotension, headache, reflex tachycardia ○ Sublingual: store in cool dark place, take up to 3 tabs 5 minutes apart ■ If 3 tabs don’t help call 911 ○ Topical: wear gloves, remove prior dose, rotate site, put on a clean hairless spot Beta Blockers ● Angina, MI, Arrhythmias ○ SE: bradycardia, hypotension, fatigue, ED (males) ■ Selective ○ Se: Bronchospasm ■ Non-selective (heart and lungs): propranolol, labetalol, carvedilol ○ Don’t stop abruptly ■ abrupt=angina and MI ○ Change positions slowly ○ Monitor BP and pulse ○ Can mask hypoglycemia Ca+ Channel Blockers ● Angina ● Verapamil, nifedipine, diltiazem ○ Vasodilation ○ Decrease HR ○ SE: peripheral edema, hypotension, bradycardia, constipation, headache ○ No grapefruit ○ Monitor BP and HR Cholesterol Medications ● Gemfibrozil ○ Decrease triglyceride production and movement ○ SE: GI upset, gallstones, hepatotoxicity and muscle pain ○ Monitor LFTs ■ Assess prior to giving ○ Take 30 min before breakfast and dinner ● Ezetimibe ○ Prevents cholesterol absorption in the small intestines ○ SE: hepatotoxicity, muscle pain ○ Monitor LFTs and Creatine Kinase (CK Levels) ■ Assess prior to giving ● Statins ○ Decrease LDL cholesterol and increase HDL cholesterol ○ Prevent coronary heart disease in high risk patients ○ SE: hepatotoxicity, muscle pain, rhabdomyolysis, GI upset ○ Take with dinner ■ Cholesterol is produced at night 36 ○ ○ Monitor LFTs and Creatine Kinase (CK Levels) ■ Assess prior to giving No alcohol or grapefruit Anti-Dysrhythmia Medications ● Class 1 ○ Lidocaine and Procainamide ■ Na+ Channel Blockers ■ Ventricular Dysrhythmias ■ Supraventricular tachycardia ■ SE: hypotension, dysrhythmia, lupus, leukopenia, thrombocytopenia ■ Monitor EKG, VS, CbC ■ Monitor Procainamide levels ● Therapeutic is 4-8 ● Class 2 ○ Beta Blockers ■ Atrial Fib and Flutter ■ Ventricular Dysrhythmias ■ SE: weakness ● Class 3 ○ Amiodarone ■ K+ Channel Blockers ■ Ventricular Fib and Ventricular Tachycardia ■ SE: hypotension, bradycardia, pulmonary toxicity, liver toxicity and cardiac toxicity, thyroid dysfunction ■ No grapefruit ■ Monitor pulmonary, renal, liver and cardiac function ● Assess prior to giving ● Class 4 ○ Verapamil and Diltiazem ■ Atrial Fib and Flutter ■ Supraventricular Tachycardia ■ Monitor VS and EKG ■ Change positions slowly 37