1. Cardiovascular Disorders Understanding Medical Surgical Nursing 4 th ed., Ch 21, 23, 24, (p.459-483), 26 Pharmacology Clear & Simple, Ch 16. Objectives 1. Describe diagnostic test for the cardiovascular system. 2. Compare nonmodifiable risk factors in coronary artery disease (CAD) with factors that are modifiable in lifestyle & heath management. 3. Compare etiology/pathophysiology, S&S, medical management, & nursing interventions for clients with cardiovascular disorders. 4. Specify teaching for clients with cardiovascular disorders.

2. Normal Aging Patterns Δ’s in cardiac musculature lead to reduced efficiency & strength, resulting in ↓’ ed cardiac output. Older Adult Considerations Age 65 years

3. Older Adult Considerations Heart Failure Edema Medications Teaching

4. Aging & the Cardiovascular System Atherosclerosis Arteriosclerosis BP ↑’ s Vein Valves More Incompetent Heart Muscle Less Efficient Dysrhythmias Common

5. Cardiovascular Disease Number 1 Killer Healthy Lifestyle Smoking Cessation Dietary Fat Reduction 2 Servings of Fish Weekly Exercise

6. Cardiovascular Disease (cont’d) Go Red for Women American Heart Association’s Nationwide Movement to Celebrate the Power Women Have to Band Together to Wipe Out Heart Disease Color Red & Red Dress Linked with This Ability

7. Cardiovascular Assessment Health History Symptoms – WHAT’S UP? Allergies Past Medical Hx Medications Family Hx Health Promotion Methods Diagnostic Studies

8. Cardiovascular Assessment cont’d Physical Assessment VS’s (T, P, R, BP, & Pain) Inspection Oxygenation, Skin Color Extremities: Hair, Skin, Nails, Edema, Color JVD Capillary Refill Clubbing

9. Physical Assessment (cont’d) Palpation Point of Maximum Impulse Extremity Temperature Edema Homans’ Sign* Auscultation Heart Sounds

10. Joint Commission National Client Safety Goal Improve Accuracy of Client Identification Use at Least 2 Client Identifiers (Neither Client's Location) Whenever Collecting Laboratory Samples or Administering Medications or Blood Products Use 2 Identifiers to Label Sample Collection Containers in Presence of Client

11. Joint Commission National Client Safety Goal (cont’d) Immediately Prior to Any Invasive Procedure, Conduct Final Verification Process to Confirm Correct Client, Procedure, Site, & Availability of Appropriate Documents Improve Effectiveness of Communication Among Caregivers For Orders/Telephonic Reporting of Critical Test Results, Verify Complete Order/Test Result by Reading Back Complete Order/ Test Result to Person Giving it

12. Blood Studies Blood Lipids Triglycerides, Cholesterol, Phospholipids hs-CRP Homocysteine Cardiac Biomarkers Creatine Kinase, Troponin, Myoglobin

13. Blood Studies B-type natriuretic peptide (BNP) Protein secreted from ventricles in response to overload, such as in heart failure BNP levels below 100 pg/mL indicate no HF. BNP levels of 100-300 pg/mL suggest HF present. BNP levels above 300 pg/mL indicate mild HF BNP levels above 600 pg/mL indicate moderate HF. BNP levels above 900 pg/mL indicate severe HF.

14. Blood cultures Complete blood count (CBC) –Erythrocyte sedimentation rate (ESR) Coagulation studies Electrolytes –Magnesium, K+, Calcium, Phosphorus, Glucose Arterial blood gases Blood Studies

15. Diagnostic Studies Chest X-Ray CT Scan Magnetic Resonance Imaging Cardiac Calcium Scan

16. Diagnostic Studies Plethysmography Diagnoses Deep Vein Thrombosis/Pulmonary Emboli/Peripheral Vascular Disease Pressure Measurement BP Readings Along Extremity

17. Diagnostic Studies (cont’d) Arterial Stiffness Index http://www.healthfair.com/schedule-a-screening/arterial- stiffness-index/ http://www.healthfair.com/schedule-a-screening/arterial- stiffness-index/ Atherosclerosis/Cardiovascular Disease Tilt Table Test http://www.youtube.com/watch?v=5H5FZTAic7c http://www.youtube.com/watch?v=5H5FZTAic7c Lying to Standing BP & HR Doppler Ultrasound Impaired Blood Flow Reduces Sound Waves

18. Diagnostic Studies Electrocardiogram (ECG or EKG) Shows Cardiac Electrical Activity 12-lead ECG = 12 Different Views Waveforms Change Appearance in Different Leads Continuous Monitoring Often in Lead II –Waveforms Upright in Lead II

19. Interpretation of Cardiac Rhythms Six-step Process 1. Regularity of Rhythm 2. Heart Rate 3. P Wave 4. P–R Interval 5. QRS Complex 6. QT Interval Normal Cardiac Waves Are Equal Distances Apart

20. Holter Monitor Cardiac Monitors: Continuous assessment of cardiac electrical activity. Telemetry: ambulatory pts. Diagnostic Studies

21. Exercise StressTest Cardiac Stress Test Cardiac Response to Exercise & ↑’ ed Oxygen Needs Peripheral Vascular Stress Test Vascular Response to Walking

22. U/S Records Motion Heart Structures Valves Heart Size, Shape, Position Transesophageal Echocardiogram Probe in Esophagus Clearer Picture NPO Until Gag Reflex Returns Echocardiography http://www.youtube.com/watch?v=482CdbvapBU

23. Radioisotope Imaging Radioisotopes IV, Gamma Camera Scan Detects Cardiac Ischemia/ Damage/ Perfusion Thallium Imaging Technetium Pyrophosphate Scan Technetium 99m Sestamibi MUGA Scan Positron Emission Tomography (PET) scan

24. Diagnostic Studies Fluoroscopy: action-picture radiograph, observation of movement. Angiogram: use of fluoroscopy to view cardiovascular system. radiographs w/radiopaque dye  artery. Aortogram: x-ray w/dye  aorta

25. Digital subtraction angiography: visualizes heart’s chambers, valves, great vessels & coronary arteries. 1.Pressures w/in heart 2. bld.-volm. Relationship to cardiac competence 3.Valvular defects, arterial occlusion, congenital anomalies Consent needed Assess allergy to contrast medium, iodine, & seafood http://www.youtube.com/watch?v=O9-gNv_-k48 http://www.youtube.com/watch?v=O9-gNv_-k48 Cardiac Catherization (Angiography)

26. Post procedure: –Monitor Pedal pulses –Enc. Fluids after procedure –Avoid movement of leg keep extended –Maintain pressure over the femoral access site –Check drsing & access site for bleeding –HOB no more than 30 °

27. Percutaneous Transluminal Coronary Angioplasty (PTCA) http://www.youtube.com/watch?v=j9498DF8TU4 Catheter containing a balloon used to dilate occluded arteries Preprocedure, maintain NPO status after midnight Postprocedure, assess distal pulses in both extremities; maintain bedrest with limb straight for 6 to 8 hrs; assess for bleeding, changes in VSs Laser angioplasty Preprocedure & postprocedure care similar to PTCA

28. Dysrhythmias Rhythm Disturbances Impulse Formation Disturbed Disturbance in Conduction

29. Normal Sinus Rhythm Rules Originates from SA node with atrial & ventricular rates of 60 to 100 beats/min Rhythm: Regular Heart Rate: 60 to 100 bpm P Wave: Rounded, Before each QRS PR Interval: 0.12 to 0.20 Seconds QRS Interval: < 0.10 Seconds

30. Sinus bradycardia Atrial & ventricular rates less than 60 beats/min Attempt to determine cause; if medication is suspected cause, hold, notify health care provider Administer atropine sulfate as prescribed Sinus tachycardia Atrial & ventricular rates greater than 100 beats/min Identify, remove cause of tachycardia Dysrhythmias

31. Premature Atrial Contractions Atrial Flutter Atrial fibrillation No definitive P wave can be observed Administer oxygen & anticoagulants, prepare for cardioversion as prescribed atrial rate 350 – 600 bpm, ventricular rate 100 –180

32. Premature ventricular contraction Notify health care provider if PVCs, c/o CP, runs of ventricular tachycardia occur

33. Ventricular tachycardia: rate 140 - 240 Repetitive firing of irritable ventricular ectopic focus at rate of 140 to 250 beats/min Client may be stable or unstable Administer lidocaine (Xylocaine) as prescribed

34. Ventricular fibrillation Chaotic rapid rhythm; ventricles quiver Defibrillate immediately as prescribed; initiate cardiopulmonary resuscitation (CPR)

35. Defibrillation: Asynchronized countershock; terminates pulseless VT or VF. Delivers a direct electric shock to the myocardium to restore NSR Automatic External Defibrillator http://www.youtube.com/watch?v=ZOBEidFXezA http://www.youtube.com/watch?v=ZOBEidFXezA Implantable Cardioverter fibrillator Instruct client on: basic functions of ICD, complications to report immediately how to take pulse to avoid strenuous activity or contact sports to report any signs of infection or feelings of faintness or N/V

36. Asystole Rhythm: None Heart Rate: None P Waves: None P–R Interval: None QRS Interval: None

37. Cardioversion (synchronized shock) delivery of a synchronized electrical shock to the myocardium to restore normal sinus rhythm. monitor Skin burns Respiratory problems Changes in ST segment Rhythm disturbances BP

38. Increase the force of myocardial contraction & slow the HR Side effects, toxic effects GI disturbances (anorexia, N/V, diarrhea) Visual disturbances Bradycardia Interventions Monitor for toxicity; digoxin level above 2 ng/mL Monitor K+ level for hypokalemia Monitor AP; if less than 60/min, hold medication, notify health care provider Cardiac Glycosides

39. Classification: Cardioglycoside Agent: Digoxin (Lanoxin) Action: ↑ cardiac force & efficiency, slows HR, ↑ cardiac output, ↓ cardiac workload. Nursing Interventions: monitor AP to ensure rate ≥ 60 (call MD if held). Monitor for digitalis toxicity (N/V, HA, anorexia, dysrhythmias, bradycardia, tachycardia, fatigue, visual disturbance: blurred vision, double vision & yellow-green vision, seeing halos around objects & seeing flickering lights). confusion, seizures, diarrhea

40. Monitor for hypokalemia, hypomagnesemia & hypercalcemia may predispose pt to Digoxin toxicity. Therapeutic level: 0.5 - 2 mg/dL Advise pts to consume foods high in potassium & magnesium & foods low in calcium. Monitor potassium levels. High Potassium Foods: bananas, potatoes, beets, parsnips, turnips, broccoli, melons, peaches, cantaloupes, kiwi, prunes, dried apricots, dates, figs, oranges, tomatoes & squash Digoxin Nursing Interventions cont’d

41. Beta-adrenergic Blockers Beta Blockers (“lols”) –↓ the workload of the heart & ↓ myocardial oxygen demands ↓ HR & BP May mask symptoms of hypoglycemia in DM client –Side effects Bradycardia Hypotension Bronchospasm –Interventions Monitor apical pulse rate & BP Monitor for respiratory distress Instruct the DM client to monitor for signs of hypoglycemia

42. Classification: B-adrenergic blockers Agent: Propanolol (Inderal) Metoprolol (Lopressor) Action: ↓ myocaridal O2 demand, ↓ work load of heart, & HR Nursing Interventions: Monitor HR & BP, bradycardia, hypotension, new dysrhythmias, dizziness, HA, nausea, diarrhea, sleep disturbances. Use caution w/clients w/bronchospastic disease.

43. Beta-Adrenergic Blocker carvedilol (Coreg) Mechanism of action - blocks beta1, beta2, & alpha1 receptors, which ↓’ s HR& BP, ↓ ’s afterload, & reduces the workload on the heart

44. Ace Inhibitors “prils” Angiotensin-converting enzyme Prevent peripheral vasoconstriction Used to treat HTN & HF Side effects Persistent dry cough Hypotension Tachycardia Hyperkalemia Hypoglycemia in diabetic client Interventions Avoid use with K+ supplements & potassium-sparing diuretics Monitor VSs & for signs of hyperkalemia Instruct DM client about the risk for hypoglycemia Instruct client to report persistent dry cough

45. ACE Inhibitor lisinopril (Prinivil) Mechanism of action - blocks ACE enzyme, which ↓’ s BP, ↑’ s cardiac output, ↓’ s preload & reduces peripheral edema; ↑’ ed excretion of Na ⁺ & water leads to ↓’e d blood volume primary use - HF & HTN Important adverse effects - ↑ K⁺ levels, cough, taste disturbances, hypotension

46. –↓ the workload of the heart & ↓ myocardial oxygen demands Promote vasodilation of coronary & peripheral vessels Used to treat angina, dysrhythmias, & HTN Used with caution in HF, bradycardia, or atrioventricular block –Side effects Bradycardia Hypotension Reflex tachycardia Calcium channel blockers http://www.youtube.com/watch?v=dE-4D1dwMZQ

47. –Interventions Monitor apical HR & BP Monitor for signs of HF Instruct the client to report dizziness or fainting M “Meals” U “under” 100 for systolic BP hold C “calcium” blocker H “HTN” treatment Common Calcium Channel Blockers amiodipine (Norvasc) nifedipine (Procardia) verapamil (Isoptin, Verelan) diltriazem (Cardizem) Calcium channel blockers cont’d

48. Classification: Calcium channel blockers Agent: Verpamil (Calan, Isoptin) Diltiazem HCL (Cardizem) Action: produces relaxation of coronary vascular smooth muscle, dilates coronary arteries. Nursing Interventions: Use caution in clients w/CHF; Monitor AP & BP, watch for fatigue, HA, Dizziness, peripheral edema, nausea, tachycardia

49. Suppress dysrhythmias by inhibiting abnormal pathways of electrical conduction through the heart Classifications Class I: sodium channel blockers Class II: β-blockers Class III: potassium channel blockers Class IV: calcium channel blockers Interventions for antidysrhythmics Monitor HR, respiratory rate, & BP Provide continuous cardiac monitoring Administer IV antidysrhythmics Monitor for signs of fluid retention Monitor for effective response Antidysrhythmic Medications

50. Amiodarone (Cordarone, Pacerone) Flecainide (Tambocor) Lidocaine (Xylocaine) Procainamide (Procan, Procanbid) Propranolol (Inderal) Quinidine (many trade names) Interventions Monitor for Worsening arrhythmias Allergic reaction Chest pain, dizziness, syncope, SOB, cough Edema of the feet or legs Blurred vision Common Cardiac Dysrhythmias Medications

51. Prevent extension & formation of clots by inhibiting factors in clotting cascade & decreasing blood coagulability –Side effects Bleeding –Heparin sodium Normal activated partial thromboplastin time (aPTT) 20 to 30 seconds Antidote is protamine sulfate –Enoxaparin (Lovenox) –Warfarin sodium (Coumadin) Anticoagulants

52. Normal lab values Bleeding time: 1 – 9 minutes PTT: 20 – 26 seconds PT: 9.05 – 11.8 seconds INR: 2 -3 (standard warfarin therapy)

53. Classification: Anticoagulant Action: Used in tx of A-Fib w/embolization to prevent complication of stroke. Nursing Interventions: Assess for signs of bleeding & hemorrhage: monitor prothormbin time (PT) freq during therapy; review foods high in vitamin K. Clients should have consistently limited intake of these foods d/t foods causing levels to fluctuate. Warfarin (Coumadin)

54. Teach Pt. Wear a Medic-Alert identification when on anticoagulation therapy. A steady (rather than fluctuating) amt of green leafy vegetables should be eaten so that INR values do not fluctuate d/t the vitamin K found in these foods. Monthly blood tests are done. Avoid a straight razor to avoid cuts & bleeding.

55. GENERIC NAME: enoxaparin BRAND NAME: Lovenox MECHANISM: Enoxaparin is a low molecular weight heparin (LMWH) that is used to prevent blood clots. It is produced by chemically breaking heparin into smaller-sized molecules. Unlike heparin, the effect of enoxaparin does not need to be monitored with blood tests. Enoxaparin is used to treat or prevent blood clots & their complications (DVT or PE).prevent blood clots SIDE EFFECTS: The most common is bleeding. Clients should avoid: anti-platelet medications (ASA, clopidogrel, warfarin, or nonsteroidal anti-inflammatory drugs (NSAIDs) ibuprofen or naproxen. clopidogrelwarfarinibuprofennaproxen Antidote: protamine sulfate

56. Antiplatelet Agents Inhibit aggregation of platelets & prolong bleeding time Side effects Bleeding Interventions Monitor for bleeding Implement bleeding precautions

57. Classification: non-narcotic analgesic, anti-inflammatory Action: Used in tx of MI, A-Fib w/embolization to prevent complication of stroke. Nursing Interventions: Assess for signs of GI bleeding & hemorrhage: monitor for GI distress. For S&S of MI give 325 mg PO. acetylsalicylate (ASA)

58. Cardiac Pacemakers http://www.youtube.com/watch?v=Y5rvTeAYuIY External & Temporary Internal & Permanent Override Dysrhythmias Generate an Impulse Can Be Placed in Atria, Ventricle, or Both Dual-chamber Pacemaker

59. Nursing Care for Pacemakers Monitor ECG Rest Several Hours Monitor AP, Symptoms Incision Care How to Take Radial Pulse Symptoms to Report Pacemaker ID Card Things to Avoid Trigger Metal Detectors Grounded Appliances Safe Periodic Pacemaker Checks

60. Cardiac Arrest Sudden cessation of cardiac output & circulatory process. S&S: abrupt loss of consciousness, gasping respirations followed by apnea, absence of pulse, absence of BP, pupil dilation, pallor & cyanosis.

61. Coronary Atherosclerotic Heart Disease Coronary artery disease (CAD): Narrowing or obstruction of one or more coronary arteries as result of atherosclerosis Atherosclerosis: common arterial disorder characterized by yellowish plaques of cholesterol, lipid & cellular debris in inner layers of walls of lg. & medium-size arteries, primary cause of atherosclerotic heart disease (ASHD).

62. Arteriosclerosis Artery/arteriole walls Thicken Harden Loose elasticity Atherosclerosis Type of Arteriosclerosis Plaque Formation in Arterial Wall Childhood Onset

63. Total Cholesterol: Desirable less than 200 mg/dL Borderline 200 – 239 mg/dL High 240 mg/dL or greater HDL Cholesterol (high-density lipoproteins) Desirable 60 mg/dL or greater LDL Cholesterol (low-density lipoproteins) Desirable less than 130 mg/dL (+risk factors Triglycerides: less than 150 mg/dL

64. Antilipemic Medications HMG-CoA reductase enzyme inhibitors “statins” Reduce cholesterol, triglyceride, or low-density lipoprotein levels Bile sequestrants Side effects Constipation Interventions Increase fluid intake & fiber in diet 3-Hydroxy-3-methyl-glutaryl–coenzyme A (HMG- CoA) reductase inhibitors Side effects GI disturbances, visual disturbances, elevated serum liver enzyme levels

65. Antilipemic Medications cont’d Nursing interventions Monitor serum cholesterol & triglyceride levels Instruct client about foods low in fat & cholesterol Instruct client to follow an exercise program Instruct client to report visual problems or GI disturbances

66. Medications for Hyperlipidemias Classification: Antihyperlipidemics Agent: atorvastatin (Lipitor), simvastatin (Zocor), lovastatin (Mevacor) Action: Inhibits HMG-CoA reductase, the enzyme that catalyzes the early step in cholesterol syntheisis. Nursing Interventions: Assess baseline labs, cholesterol & triglyceride, & liver function. Adm. in pm. Instruct pt. to follow prescribed diet & periodic lab tests are needed.

67. ASHD/CAD Non-modifiable Risk Factors Age Gender Ethnicity Genetic Predisposition for Hyperlipidemia

68. ASHD/CAD (cont’d) Modifiable Risk Factors DM HTN Smoking Obesity Sedentary Lifestyle ↑’ ed Serum Homocysteine ↑ C-reactive protein (CRP)

69. ASHD/CAD (cont’d) Modifiable Risk Factors (cont’d) ↑’ ed Serum Iron Levels Infection Depression Hyperlipidemia http://www.youtube.com/watch?v=N2diPZOtty0 http://www.youtube.com/watch?v=N2diPZOtty0 Elevated Apolipoprotein B Excessive Alcohol Intake

70. ASHD/CAD (cont’d) Diagnostic Tests for Increased CVD Cholesterol Elevated Increases Risk Low-density Lipoproteins (LDL) Increased risk High-density Lipoproteins (HDL) Protective

71. ASHD/CAD (cont’d) Diagnostic Tests (cont’d) Lp(a) Cholesterol Elevated Increases Risk Apolipoprotein B > Apolipoprotein A Increased Risk Triglycerides Increased Risk

72. ASHD/CAD (cont’d) Diagnostic Tests (cont’d) C-reactive Protein Inflammation in Coronary Artery Shows Increased Risk Elevated Leukocyte Count in Women Increased Risk

73. Atherosclerosis/CAD Contributes to Complications: Angina, MI, HTN, TIA, Stroke Sudden Death Prevention Modify Risk Factors Low-cholesterol Diet Lipid-lowering Agents Low Dose ASA

74. ASHD/CAD (cont’d) Nursing Interventions Reduce activity, Exercise Assess VSs, Monitor ECG Support & reassure client Administer oxygen, nitrates, Lipid-lowering Agents, Prepare for possible tx’s

75. Instruct on Medications Nitrates: dilate coronary arteries; decrease preload & afterload: (nitroglycerin) Calcium channel blockers: dilate coronary arteries & reduce vasospasm: nifedipine (Procardia) Cholesterol-lowering medications: reduce development of atherosclerotic plaques: lovastatin (Mevacor) β-blockers: reduce BP in individuals with HTN: sotalol (Betapace) Nursing Interventions

76. ASHD/CAD (cont’d) Nursing Interventions Educate client about: diagnostic tests modifiable risk factors Instruct client to: eat low-calorie, low-sodium, low- cholesterol, low-fat diet, with increase in dietary fiber importance of regular exercise

77. ASHD/CAD Surgical procedures Percutaneous Transluminal Coronary Angioplasty (PTCA) Laser angioplasty Atherectomy Vascular stent Transmyocardial Laser Revascularization –http://www.youtube.com/watch?v=Fq4m0ajqcd0http://www.youtube.com/watch?v=Fq4m0ajqcd0 –http://www.youtube.com/watch?v=5rQjJ5hsgKwhttp://www.youtube.com/watch?v=5rQjJ5hsgKw Coronary artery bypass graft (CABG) –Dx after cardiac catheterization

78. Angina Pectoris Angina chest pain or discomfort that occurs if an area of heart muscle doesn't get enough oxygen-rich blood. may feel like indigestion. symptom of underlying heart problem, (CAD) Chest pain resulting from myocardial ischemia

79. Types of Angina Stable Angina Most common exertional; occurs with activities that involve exertion, exercise, emotional stress Arteries Cannot ↑ Blood to Heart During ↑’ ed Activity Usually Stops with Rest/Vasodilator

80. Unstable Angina occurs with unpredictable degree of exertion or emotion; increases in occurrence, duration, severity over time No pattern. May occur more often & be more severe than stable angina. Can occur with or without physical exertion, & rest or medicine may not relieve the pain. Requires emergency treatment, is a sign that an MI may happen soon.

81. Types of Angina (cont’d) Variant Angina (Prinzmetal’s Angina) Rare. A spasm in a coronary artery causes this type of angina. Medicine can relieve this type of angina Longer Duration Usually Occur at Rest Often Same Time Each Day (btw midnight & early morning Coronary Artery Spasm pain can be severe Serious

82. Angina S&S Mild or moderate pain; may radiate to shoulders, arms, jaw, neck, back; usually lasts less than 5 minutes; relieved by rest &/or NTG; dyspnea; pallor; diaphoresis Female Angina S&S Chest Pain, Jaw Pain, Heartburn Atypical Symptoms Describe Less Severe Pain Fatigue Nausea Breathlessness

83. Diagnostic Tests ECG Stress Test Echocardiography Chemical Stress Testing Radioisotope Imaging Coronary Angiography/catherization Blood Test (cardiac enzymes normal)

84. Angina Interventions Surgical procedures Same as for CAD Medications Same as for CAD Antiplatelet medications inhibit platelet aggregation, reduce risk of developing acute MI

85. Angina Interventions Nursing Interventions Assess pain Bedrest Administer oxygen, nitroglycerin as prescribed Assess ECG strip Instruct client about diet, wt management, exercise, lifestyle changes following acute episode

86. 2 Types of Organic Nitrate Short-acting is taken sublingually – nitroglycerin Drug Profile - Organic Nitrate, Vasodilator Nitroglycerin (Nitrostat, Nitrobid, Nitro- Dur), short-acting nitrate Long-acting is taken orally or transdermally - isosorbide dinitrate Tolerance often develops Reduce symptoms of HF

87. Medications for Angina Classification: Antianginals Agent: Nitroglycerin Action: to dilate coronary arteries & increase blood flow to damaged areas. Rapid onset of action within 2 – 5 mins. Nursing Interventions: Nitroglycerin SL (doesn’t relieve MI) Nitroglycerin SL, may repeat dose in 5min. intervals if pain doesn’t subside, up to 3x. Oxygen & ASA unless contraindicated.

88. Myocardial Infarction (MI) Pathophysiology Occurs when myocardial tissue is abruptly, severely deprived of oxygen, leading to necrosis and infarction; develops over several hours Location of MI Left anterior descending artery: anterior or septal MI Circumflex artery: posterior or lateral wall MI Right coronary artery: inferior wall MI

89. Silent Ischemia Myocardial Ischemia Without CP Sudden Cardiac Death Cardiac Arrest Triggered by Lethal Ventricular Dysrhythmias or Asystole from an Abrupt Occlusion of a Coronary Artery

90. MI S&S Crushing, Viselike Pain Radiates to Arm/Shoulder/Neck/Jaw SOB Restlessness Dizziness, Fainting Nausea Sweating

91. Women & MI Leading Cause of Death African American Women at Higher Risk Higher Mortality Rate, More Complications than Men Prodromal Symptoms the Month Before MI –Unusual Fatigue, Sleep Disturbances, Dyspnea Delay Treatment Less Aggressive Treatment Given

92. S&SS&S Atypical—Women/Older Adult –Absence of Classic Pain –Epigastric or Abdominal Pain –Chest Cramping –Fatigue –Anxiety –Dyspnea –Restlessness –Falling

93. Older Adults & MI Report Shortness of Breath, Fatigue, Fast/Slow Heartbeats, Chest Discomfort Silent MI Collateral Circulation

94. Timely Medical Care “Act in Time to Heart Attack Signs” Call 9-1-1 (or Local Emergency #) www.nhlbi.nih.gov/actintime/ www.nhlbi.nih.gov/actintime/ National Heart Attack Alert Program “60 Minutes to Treatment” www.nhlbi.nih.gov/about/nhaap

95. Diagnostic Tests Consider Patient History Serial ECG Cardiac Troponin I or T Myoglobin CK-MB C-reactive Protein Magnesium

96. ECG Changes With MI

97. Pre-Hospital Care “Time is Muscle” Chew One Uncoated Adult ASA Call 911 in 5 Minutes for Unrelieved Chest Pain Do Not Drive Self Emergency Percutaneous Coronary Intervention Mission: Lifeline www.americanheart.org/www.americanheart.org/ Door-to-Balloon Time: 90 Minutes www.d2balliance.org/

98. Nursing Interventions Acute Stage Monitor Oxygen ASA Morphine Sulfate Thrombolytics Remain w/pt “MOAN” Vasodilators Nitrates Beta Blockers Antidysrhythmias Place in semi- Fowler’s position

99. Nursing Interventions following acute episode Bedrest Bedside Commode ROM exercises as prescribed; activity progression as tolerated & as prescribed; monitor for complications Emotional Supportfor Complications of MI Dysrhythmias, HF, pulmonary edema, cardiogenic shock, thrombophlebitis, pericarditis

100. Nursing Interventions (cont’d) Intra-aortic Balloon Pump Glucose Control Daily Wt. No Caffeine, Clear Liquids Fluid Restriction Low-fat, Low-cholesterol, Low-Na ⁺ Diet

101. Cardiac Rehabilitation Arrange for client to begin before the time of discharge Optimizes Functioning Protocols Specify Activities Wt. Loss Smoking Cessation Outpatient Program After Discharge

102. Medication Interventions Vasodilators Nitroglycerin (NTG) Calcium Channel Blockers Diltiazem, Amlodipine, Nifedipine, Verapamil Beta blockers Propranolol, Metoprolol, Atenolol

103. Medication Interventions (cont’d) ACEI Captopril, Lisinopril, Ramipril, Enalapril Statins Atorvastatin, Fluvastatin, Lovastatin, Pravastatin, Simvastatin, Rosuvastin Antiplatelets Aspirin, Clopridogrel (Plavix)

104. Thrombolytics Dissolve clots Contraindications Active bleeding, stroke or other intracranial problems, surgical client, hepatic or renal disease, uncontrolled HTN, recent cardiopulmonary resuscitation, or hypersensitivity Side effects Bleeding Interventions Monitor for bleeding Implement bleeding precautions Antidote Aminocaproic acid (Amicar) is antidote for streptokinase

105. alteplase (Activase) Mechanism of action - convert plasminogen to plasmin which causes fibrin to degrade, then preexisting clot dissolves Primary uses - acute MI, pulmonary embolism, acute ischemic CVA, DVT, arterial thrombosis, coronary thrombosis, clear thrombi in arteriovenous cannulas and blocked IV catheters Adverse effects - abnormal bleeding; contraindicated in clients w/active bleeding or recent trauma

106. Medication Interventions (cont’d) Fab Four Cardiac Drugs Antiplatelets Statins ACEIs Beta Blockers

107. Invasive Procedures PCI Balloon Angioplasty Coronary Artery Stents Myocardial Revascularization Coronary Artery Bypass Graft Coronary Artery Occlusions Bypassed with Vein/Artery Grafts ↑’ s Blood Flow/Oxygen to Myocardium

108. Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) Thoracoscope No Cardiopulmonary Bypass Small Incisions Two Coronary Arteries Maximum Port-Access Coronary Artery Bypass Combines Peripheral Cardiopulmonary Bypass (CPB) with Minimally Invasive Heart Access

109. Nursing Interventions Monitor VSs Report Symptoms Incisional Care Patient Education Disease Information Medications Diet Activity Rehabilitation

110. Valvular Heart Disease Stenosis Narrowed, Valve Does Not Open Completely Forward Blood Flow Hindered Decreases Cardiac Output Regurgitation (Insufficiency) Valve Does Not Close Completely Blood Flow Backs Up

111. Mitral Valve Prolapse (MVP) Etiology Unknown Hereditary Women 20 - 55 Years of Age S&S Often None Anxiety, Fatigue CP, Palpitations Dysrhythmias Dyspnea

112. Mitral Valve Prolapse (MVP) Therapeutic Interventions None, Unless Symptoms Healthy Lifestyle Avoid Stimulants/Caffeine Stress Management Beta Blockers for Tachycardia Valve Surgery for Severe MVP monitor for fatigue, atypical chest pain, palpitations, syncope, systolic click

113. Mitral Stenosis Etiology Common – Prior Rheumatic Fever Congenital Defects, Tumors Rheumatoid Arthritis Systemic Lupus Erythematosus Calcium Deposits Signs & Symptoms None Early Murmur, A Fib, CP, Palpitations Exertional Dyspnea, Cough, Hemoptysis Fatigue

114. Mitral Stenosis (cont’d) Diagnostic Tests ECG: P-wave Δ’s CXR: Enlarged Chambers 2-D & Doppler Echocardiography Coronary Angiogram Therapeutic Interventions monitor for dyspnea, orthopnea, rumbling apical diastolic murmur, pitting peripheral edema Prophylactic Antibiotics per Criteria Anticoagulants: Atrial Fibrillation Percutaneous Balloon Valvuloplasty

115. Mitral Regurgitation (insufficiency) Etiology Rheumatic Heart Disease (Most) Endocarditis Congenital Defects Chordae Tendineae Dysfunction Mitral Valve Prolapse S&S None Early Murmur, Palpitations, Fatigue, A-Fib, CP Dyspnea, Cough, Hemoptysis

116. Mitral Regurgitation (cont’d) Diagnostic Tests ECG: P-Wave Δ’s CXR: Enlarged Chambers 2-D & Doppler Echocardiography Coronary Angiogram

117. Mitral insufficiency (Regurgitation)cont’d Therapeutic Interventions monitor for dyspnea, orthopnea, dizziness, signs of right ventricular failure, pitting peripheral edema, high- pitched systolic murmur None, Unless Symptoms Prophylactic Antibiotics per Criteria ACE Inhibitors Anticoagulants: A-Fib Mitral Valve Repair/Replacement http://www.youtube.com/watch?v=QVk7zmJbX1s http://www.youtube.com/watch?v=QVk7zmJbX1s

118. Valvular Heart Disease(cont’d) Tricuspid stenosis: monitor for effort intolerance, fluttering sensations in neck, cyanosis, ↓ cardiac output, peripheral edema, rumbling diastolic murmur Tricuspid insufficiency: monitor for signs of right ventricular failure, ascites, pleural effusion, peripheral edema, systolic murmur Pulmonary stenosis: monitor for dyspnea, syncope, signs of right ventricular failure, ascites, systolic thrill Pulmonary insufficiency: monitor for signs of right ventricular failure, ascites, systolic thrill

119. Aortic Stenosis Pathophysiology Aortic Valve Narrowed Left Ventricle Contracts More Forcefully Left Ventricle Hypertrophies Decreased Cardiac Output Eventual Heart Failure

120. Aortic Stenosis (cont’d) Signs & Symptoms None Early Angina Murmur Syncope Orthopnea Dyspnea on Exertion Fatigue Pulmonary Edema Diagnostic Tests ECG Chest X-Ray: Enlarged Left Ventricle 2-D & Doppler Echocardiography Serial Echocardiography Cardiac Catheterization

121. Aortic Stenosis (cont’d) Therapeutic Interventions monitor for dyspnea on exertion, angina, syncope, orthopnea, harsh systolic murmur Surgery Aortic Valve Replacement Valvotomy Treat HF Symptoms Prophylactic Antibiotics per Criteria

122. Aortic insufficiency (Regurgitation) Pathophysiology Aortic Valve Does Not Close Left Ventricle’s Volume Increases Left Ventricle Dilates Left Ventricle Fails Decreased Cardiac Output Pulmonary Edema

123. Aortic insufficiency (Regurgitation) Etiology Rheumatic Heart Disease (Most) Congenital Defects Syphilis Endocarditis Severe HTN Rheumatoid Arthritis Aortic Dissection

124. Aortic insufficiency (Regurgitation) cont’d Signs & Symptoms None Early Exertional Dyspnea, Fatigue Corrigan’s Pulse: Palpated Pulse Forceful, Quickly Collapses Widened Pulse Pressure Angina at Night

125. Aortic insufficiency cont’d Diagnostic Tests ECG, Chest X-Ray 2-D & Doppler Echocardiography Coronary Angiogram Therapeutic Interventions Monitor for dyspnea, orthopnea, angina, tachycardia, diastolic murmur Vasodilator Surgical Valve Replacement Prophylactic Antibiotic Therapy per Criteria

126. Valvular Heart Disease (cont’d) General Nursing interventions Administer prescribed treatment for heart failure as prescribed Administer oxygen as prescribed Administer IV fluids as prescribed Administer diuretics, digoxin (Lanoxin) as prescribed Provide low-sodium diet as prescribed Administer antibiotics as prescribed

127. Nursing Interventions (cont’d) Maintain Fluid Volume Daily Wt.s, Assess for Edema, I&O Diuretics as Ordered; Monitor K ⁺ Levels Education Medications Anticoagulants Monthly INR/PT Tests Medic Alert Identification Include Caregivers for Elderly Revised Endocarditis Prevention – Prophylactic Antibiotics

128. Evaluation Reports Satisfactory Pain Relief VS’s Normal/No HF Signs Reports Reduced Fatigue, Task Completion Remains Free of Edema, Maintains Wt, Clear Lung Sounds Verbalizes Understanding of Teaching/with No Symptom Recurrence

129. Cardiac Valvular Surgery Minimally Invasive Surgery Endoscopy Robotic Traditional Open Cardiac Surgery with Cardiopulmonary Bypass Stenosed Valve Repair Balloon Valvotomy Commissurotomy http://www.youtube.com/watch?v=VrIxRfWDOm8 Insufficient Valve Repair Annuloplasty http://www.youtube.com/watch?v=m0qotSyH5CE http://www.youtube.com/watch?v=7LfWleowgUk http://www.youtube.com/watch?v=m0qotSyH5CEhttp://www.youtube.com/watch?v=7LfWleowgUk

130. Heart Valve Replacement Mechanical Durable Creates Turbulent Blood Flow Lifelong Anticoagulation Used for Younger Adults

131. Heart Valve Replacement (cont’d) Biological Types Porcine (Pig) Bovine (Cow) Allografts (Human) Autograft Cultural Considerations Not as Durable as Mechanical Valves No Lifelong Anticoagulation Used for Older Adults

132. Valve Replacement Complications Biological Valves Degenerative Changes Calcification Mechanical Valves INR/PT Monitoring for Bleeding Risk Thrombus/Embolism Formation Anemia Endocarditis

133. Nursing Process: Cardiac Surgery Preparation Assessment Circulatory Status Pain Control Needs Diagnostic Tests Typing & Cross-matching of Blood Needed Preoperative Vascular Nursing Diagnoses Acute or Chronic Pain Anxiety Deficient Knowledge

134. Cardiac Surgery Preparation Teaching Pain Management Endotracheal Tube/Ventilator Communicating Chest Tubes Coughing/Deep Breathing IV Lines Urinary Catheter Preoperative Medications prophylactic antibiotics Antiseptic Scrub Showers NPO

135. Postoperative Cardiac Surgery Nursing Care Pain/Provide Relief VSs, ECG, ABGs, I&O Lung Sounds Incision Promote Lung Expansion Cough & Deep Breathe Turn Ambulate

136. Postoperative Cardiac Surgery Nursing Care (cont’d) Prevent Infection Hand Hygiene, Sterile Technique Cleanse Stethoscope Each Client, Each Handwashing Monitor Temperature Teaching Pain Management, Medications Activity Follow-up Monitoring/Care

137. Layers of the Heart

138. Infective Endocarditis Entry of Organism into Bloodstream Risk Factors Immunocompromised Artificial Heart Valve Congenital/Valvular Heart Disease IV Drug Use Gingival Disease Prevention Oral/Dental care Prophylactic Antibiotics per Criteria

139. Infective Endocarditis (cont’d) S&S Fever Murmur Splinter Hemorrhages Petechiae Janeway Lesions Osler’s Nodes Petechiae Janeway Lesions Osler’s Nodes

140. Infective Endocarditis (cont’d) Diagnostic Tests Blood Cultures Echocardiography Therapeutic Interventions IV Antimicrobial Drug Rest/Supportive Care Home IV Antimicrobial Therapy Surgical Valve Replacement/Repair

141. Infective Endocarditis Therapeutic Nursing Interventions cont’d Monitor VSs & Cardiac status Report HF/Emboli Signs Maintain antiembolic stockings as prescribed Teach Good Hygiene, Oral/Dental Care Report Symptoms: Fever, Chills, Sweats

142. Pericarditis Inflammation of Pericardium Acute Chronic Etiology Infections, Lyme Disease Drug Reactions, Trauma Connective Tissue Disorders Neoplastic Disease Postmyocardial Infarction Dressler’s Syndrome Renal Disease or Uremia

143. Pericarditis (cont’d) S&S CP; Substernal, Radiates, Grating Increases with Deep Inspiration Pericardial Friction Rub Dyspnea Low-grade Fever Cough Diagnostic Tests ECG, Echocardiogram, CT Scan, MRI WBC Pericardial Fluid

144. Pericarditis Nursing Interventions Position in high Fowler’s position, upright, leaning forward Bedrest Pericardiocentsis Monitor for signs of cardiac tamponade & Cardiac Function Monitor VSs Provide Pain Relief NSAIDs, Corticosteroids

145. Pericarditis Nursing Management Treat Cause Antibiotics Hemodialysis Pericardial Window Pericardiectomy Education

146. Pericardiocentsis http://www.youtube.com/watch?v=nRFa6OdX9xU http://www.youtube.com/watch?v=nRFa6OdX9xU

147. Cardiac Tamponade Pericardial effusion; occurs when space between parietal & visceral layers of pericardium fill with fluid Data collection Pulsus paradoxus; ↑ central venous pressure; jugular vein distention with clear lungs; distant, muffled heart sounds; ↓ cardiac output Interventions critical care unit as prescribed Administer IV fluids as prescribed Prepare client for pericardiocentesis as prescribed Monitor for recurrence of tamponade following pericardiocentesis

148. Myocarditis Pathophysiology & Etiology Acute or chronic inflammatory disorder of myocardium as result of pericarditis Rare Often Follows Virus S&S None fever; pericardial friction rub; murmur Possible Viral Infection Signs Chest Pain, Tachycardia

149. Myocarditis (cont’d) Therapeutic Nursing Interventions Reduce Heart’s Workload Oxygen Treat Cause Antimicrobial Treat Heart Failure administer analgesics, salicylates, NSAIDs drugs, antibiotics, digoxin (Lanoxin) as prescribed VSs/Cardiac Status Diversional Activities Energy Conservation Education

150. Rheumatic Heart Disease A result of rheumatic fever, an inflammatory disease that predominantly results from delayed childhood reaction to inadequately treated childhood pharyngeal or URT infection (group A-B-hemolytic streptococci).

151. Cardiomyopathy Enlargement of Heart Muscle Subacute or chronic disorder of heart muscle Dilated cardiomyopathy: heart ejects less than 40% of blood in left ventricle (normal is 70%); reduced cardiac output leads to HF Hypertrophic cardiomyopathy: characterized by massive ventricular hypertrophy; may cause obstruction of left ventricular outflow Restrictive cardiomyopathy Characterized by restricted filling of ventricles http://www.youtube.com/watch?v=rXyVzOmyWfo

152. Cardiomyopathy Secondary type Infective: viral, bacterial, fungal, protozoal (myocarditis) Metabolic, Nutritional Alcohol Drugs (prescribed & Cocaine “crack”) Radiation therapy Systemic lupus erythematosus, Rheumatoid arthritis

153. Cardiomyopathy (cont’d) S&S Symptoms of left ventricular heart failure Diagnostic Tests Chest X-Ray (Cardiomegaly) Echocardiography ECG Cardiac Catheterization

154. Cardiomyopathy (cont’d) Therapeutic Interventions Treatment symptomatic, similar to care of heart failure (dilated & restrictive cardiomyopathy), similar to care of MI (hypertrophic cardiomyopathy) No Cure Palliative Care Anticoagulants Dilated ACE Inhibitors, Beta Blockers, Diuretics, Digoxin Biventricular Pacing Implantable Defibrillators Heart Transplant

155. Inability of heart to maintain adequate circulation to meet metabolic needs of body Older Term: Congestive Heart Failure (cardiac insufficiency) http://www.youtube.com/watch?v=RHJBVTdBJvI –Classification Acute, chronic Heart Failure (HF)

156. Causes: MI, chronic HTN S&S Dyspnea, Orthopnea, Cough Paroxysmal nocturnal dyspnea (PND) Pulmonary crackles Evidence of pulm vascular congestion w/pleural effusion (CXY) Left Ventricular Failure (HF)

157. Acute HF, Life-threatening pallor dyspnea, orthopnea, Severe Fluid Congestion in Alveoli, ↑ Resp with Accessory Muscles large amts of blood-tinged mucus diaphoresis Crackles, Wheezes Anxiety, Restlessness a medical emergency Pulmonary Edema

158. X-Ray, CT, MRI ABGs Pulmonary Pressures BNP – B type Natriuretic Peptide NT – proBNP – N-terminal pro BNP Pulmonary Edema Diagnosis

159. PE Therapeutic Interventions Immediate Treatment Reduce Workload of Left Ventricle Treat Underlying Cause Fowler’s Position Oxygen/Mechanical Ventilation Morphine IV Diuretics IV Inotropic Agents IV Vasodilators IV

160. Right Ventricular Failure (HF) Causes: Lt. HF, Chronic lung disease S&S Distention jugular veins (severe) Anorexia, nausea, & abd distention Liver enlargement w/RUQ pain Edema (pitting) feet, ankles, sacrum

161. Pitting Edema

162. Pitting Edema Scale SCALEDEGREERESPONSE 1 + TraceSlightRapid 2 + Mild4 mm (0 - 1/4 in) 10 – 15 seconds 3 + Moderate6 mm (¼ - ½ in) 1 – 2 minutes 4 + Severe8 mm (1/2 - 1 in) 2 – 5 minutes

163. Immediate Nursing management Place in high Fowler’s position Administer oxygen as prescribed Suction PRN as prescribed Monitor VS frequently Maintain strict I&O Administer diuretics, morphine sulfate & digitalis as prescribed Assess lung sounds Monitor Labs – K+ Monitor Wt. Heart Failure (cont’d)

164. Following acute episode Instruct client about: modifiable risk factors proper administration of medication regimen to avoid over-the-counter medications to eat a low-sodium, low-fat, low- cholesterol diet to balance activity levels Heart Failure (cont’d)

165. Heart Failure (HF) TX: Medications to ↑ cardiac efficiency Angiotensin-converting enzyme inhibitors (ACE inhibitors - ACEIs) Angiotensin-receptor blockers (ARBs) Beta-adrenergic blockers Digitalis Vasodilators Diuretics, Potassium Supplements

166. First-Choice Drugs ACE Inhibitors & Diuretics Given first Reduce most symptoms of mild to moderate HF Fewer side effects

167. Diuretic furosemide (Lasix) Mechanism of action - prevents reabsorption of Na ⁺ by the nephron of the kidney, which ↑’ s excretion of Na ⁺ & water; ↓’ s blood volume, edema, & congestion; ↓’ s BP, & ↓’ s workload on heart. Cardiac output then ↑’ s Primary use - acute HF Important adverse effects - electrolyte imbalances

168. Second-Choice Drugs Phosphodiesterase inhibitors, vasodilators, & beta-adrenergic blockers Used in severe HF First-choice drugs not effective

169. Phosphodiesterase Inhibitors milrinone (Primacor) Mechanism of action - blocks phosphodiesterase enzyme, which ↑’ s the amt. of calcium available for myocardial contraction, which then ↑’ s force of contraction & vasodilation Primary use - short-term support of advanced HF Important adverse effects - ventricular dysrhythmia

170. Vasodilators Isosorbide (Isordil) Mechanism of action - relaxes vascular smooth muscle, which leads to vasodilation, which ↓ ’s cardiac workload & ↑’ s cardiac output Primary use - cannot tolerate ACE inhibitors, angina pectoris, HTN Important adverse effects - HA, hypotension, reflex tachycardia

171. Natriuretic Peptide nesiritide (Natrecor) Mechanism of action - acts on kidney, which increases excretion of Na ⁺ & water, thereby ↓ BP; also causes vasodilation, which ↓’ s preload Primary use - severe HF Important adverse effects - severe hypotension

172. Nonpharmacological Methods for HF Stop using tobacco Limit salt (Na ⁺ ) intake & eat foods rich in K ⁺ & magnesium Limit alcohol consumption Implement a medically supervised exercise plan Learn & use effective ways to deal w/stress Reduce wt. to an optimum level Limit caffeine consumption

173. Chronic Heart Failure Progressive Signs & Symptoms May Worsen Over Time

174. Signs & Symptoms Fatigue & Weakness, Cyanosis Exertional Dyspnea Orthopnea, Paroxysmal Nocturnal Dyspnea Cough, Crackle & Wheezes Tachycardia, CP Cheyne-Stokes Respiration Edema, Anemia, Malnutrition Nocturia Altered Mental Status

175. Complications of Heart Failure Liver & Spleen Enlargement Pleural Effusion Thrombosis & Emboli Cardiogenic Shock

176. Diagnostic Tests Screening Tests BNP Serum BUN, Creatinine Liver Function Tests Thyroid Function Test Ferritin Chest X-Ray, Echocardiography, ECG Exercise Stress Testing Cardiac Magnetic Imaging Cardiac Catheterization/Angiography Sleep Studies

177. Therapeutic Intervention Goals Improve Heart’s Pumping Ability & ↓ Heart’s Oxygen Demands Identify & Correct Underlying Cause ↑ Strength of Heart’s Contraction Maintain Optimum Water & Na ⁺ Balance ↓ Heart’s Workload

178. Drug Therapy Oxygen Therapy ACE Inhibitors or ARBs Beta Blockers Diuretics Inotropic Agents Vasodilators

179. Therapeutic Interventions Activity Na ⁺ & Wt. Control Pacemakers, ICD Cardiac Resynchronization Therapy Mechanical Assistive Devices Intra-aortic Balloon Pump Ventricular Assist Device Total Artificial Heart Implantable Replacement Heart

180. Ventricular Assist Devices & Artifical Heart Support Failing Heart Bridge to Transplantation Destination Therapy Heart Replacement

181. Surgical Interventions CABG Valve Replacement Ventricular Reconstruction

182. Nursing Interventions Oxygen Rest & Activity Positioning Fluid Management Reduce Oxygen Consumption Medications/Teaching Low-Na ⁺ Diet Wt. Control Education Coping

183. Cardiac Transplantation End Stage Heart Failure Strict Selection Criteria

184. Suitable physiologic/chronologic age End-stage heart disease refractory to medical therapy Dilated cardiomyopathy Inoperable CAD Compliance with medical regimens Demonstrated emotional stability & social support system Financial resources available Indications

185. Systemic disease w/poor prognosis Active infection, Active or recent malignancy DM, type 1, w/end-organ damage Recent or unresolved pulmonary infarction Severe pulmonary HTN unrelieved w/meds Irreversible renal or hepatic dysfunction Active peptic ulcer disease Severe osteoporosis Severe obesity Hx of drug or alcohol abuse or mental illness Contraindications

186. Criteria for a Potential Heart Donor Younger than 40 years Weigh within 20 lbs of prospective recipient. Presence of no active infections Presence of no significant cardiac or malignant disease No HTN or DM

187. Cardiac Transplantation (cont’d) Immunosuppressive Therapy Preoperatively Lifelong Antirejection Therapy Complications Rejection Infection Malignancies Anti-rejection Medicine Side Effects Grapefruit juice may ↓ potency of meds as it ↑’ s body metabolism.

188. Nursing Interventions Pre & Postop surgical care Monitor temporary pacemaker, labs Monitor NGT & CT Monitor O2, I/O’s, IVs, urine cath Assess Pain Assess Pt. emotional state Assess for complications of rejections Cardiac Transplantation (cont’d)