Adult Cardiac Care: An Overview

Objectives of Adult Cardiac Care

• Explain key terms and medical terminology related to selected cardiovascular and respiratory disorders
• Apply knowledge of selected cardiovascular disorders, including angina, CAD, myocardial infarction, and congenital heart disease, in adults and children
• Apply the nursing process to maintain health and promote self-care in adult or pediatric patients with cardiovascular disorders
• Relate diagnostic tests to patients with cardiovascular disorders
• Apply pharmacotherapeutics to treat cardiovascular disorders in adult or pediatric patients
• Determine the normal developmental changes and aging as they pertain to patients with cardiovascular disorders
• Articulate nursing responsibilities regarding nutritional requirements for patients with cardiovascular disorders
• Develop health promotion and maintenance practices for patients with acute and chronic cardiovascular disease
• Determine unique teaching/learning needs of patients with selected cardiovascular disorders
• Demonstrate the ability to deliver dignified nursing care that considers diverse cultural needs for patients with cardiovascular disorders
• Use verbal and non-verbal communication techniques effectively when caring for patients experiencing common health care deviations
• Discuss principles of safety and efficient use of systems resources when caring for patients experiencing common health care deviations related to air

Health Assessment

• Assess all patients with cardiovascular symptoms for coronary artery disease, regardless of age
• Assess for signs and symptoms of hyperlipidemias like xanthomas, corneal arcus, or abdominal pain of unexplained origin
• Obtain an electrocardiogram and an echocardiogram
• Assess for muscular weakness
• Assess for episodes of shortness of breath, dizziness, or palpitations
• Review laboratory data for abnormal values
• Gather dietary history
• Troponin levels should be assessed
• Assess for secondary risk factors like diet, smoking, overweight, high stress, and alcohol use
• Inquire about a family history of sudden or unexplained death
• Ask about other family members with biochemical or neuromuscular conditions, such as hemochromatosis or muscular dystrophy
• Assess sexual and reproductive functioning
• Assess elimination
• Assess sleep and rest patterns

Clinical Manifestations of Cardiovascular Issues

• Clinical signs include clubbing of the fingers or toes
• Other signs include pallor, ulcers on feet and ankles and edema
• Cool or cold skin and diaphoresis can also occur

Diagnostic Labs

• Blood urea nitrogen (BUN) ranges from 8–20 mg/dL
• Calcium (Ca++) ranges from 8.8–10.4 mg/dL
• Creatinine ranges from 0.6–1.2 mg/dL or 0.4–1.0 mg/dL
• Magnesium (Mg++) ranges from 1.8–2.6 mg/dL
• Potassium (K+) ranges from 3.5–5 mEq/L
• Sodium (Na+) ranges from 135–145 mEq/L
• Activated partial thromboplastin time (aPTT) is 21–35 seconds
• Prothrombin time (PT) is 11–13 seconds
• International normalized ratio (INR) is 0.8–1.2
• Hematocrit ranges from 42–52% or 36–48%
• Hemoglobin ranges from 14–17.4 g/dL or 12–16 g/dL
• Platelets range from 140,000–400,000/mm³
• White blood cell (WBC) count ranges from 4500–11,000/mm³

Diagnostic Imaging

• Diagnostic imaging includes Chest X-Ray and Fluoroscopy
• Other imaging methods include Electrocardiography and Continuous Electrocardiographic Monitoring
• Ambulatory Electrocardiography, Cardiac Stress testing, Exercise stress testing, and Radionuclide Imaging are other methods of diagnostics
• Myocardial Perfusion Imaging and Single Photon Emission Computed Tomography may be used
• Other advanced diagnostic imaging techniques include Positron Emission Tomography, Computed Tomography, and Magnetic Resonance Angiography
• Transthoracic and Transesophageal Echocardiography are also useful

Performing an EKG

• Electrodes are placed on 10 areas of the body to record heart activity from 12 angles and planes
• Electrodes and electrolyte gel are needed to transmit impulses
• The vertical axis on an EKG represents gain or amplitude
• The horizontal axis displays time
• Each small vertical square represents 0.1 millivolts (mV)
• Each small horizontal square represents 0.04 seconds
• Large squares are identified by darker lines and include five small boxes horizontally and vertically
• The paper should be run at a normal speed of 25 mm/second
• Precordial leads can be all brown or individually colored
• V1 is red, V2 is yellow, V3 is green, V4 is blue, V5 is orange, and V6 is purple

Coronary Artery Disease (CAD)

• CAD is characterized by obstruction of coronary artery blood flow, typically from atherosclerosis
• Reduced blood flow due to CAD can cause angina
• CAD can lead to myocardial infarction (MI) and sudden death
• Approximately 84 million people in the US have heart disease
• 1 in 3 people have hypertension, but only half are controlled
• Coronary Artery Disease (CAD) is the number 1 killer of adults in the US

Risk Factors

• Non-modifiable risk factors include family history of CAD, increasing age, gender, and race
• Other risk factors involve a history of premature menopause before age 40 and pregnancy-associated disorders like preeclampsia
• Genetic conditions like primary hypercholesterolemia, which result in elevated LDL, also increase risk
• Modifiable risk factors include hyperlipidemia, tobacco use, hypertension, diabetes, and metabolic syndrome
• Other risk factors include obesity, physical inactivity and chronic inflammatory conditions like rheumatoid arthritis, lupus, and HIV/AIDS
• Chronic kidney disease also elevates risk

Clinical Manifestations

• Chest pain may be displayed
• Epigastric distress also occurs
• Shortness of breath might be experienced

Angina in Women

• Angina-related symptoms such as chest, neck, jaw, shoulder, upper back or abdominal discomfort can manifest

Medications for Cardiac Conditions

• Nitroglycerin is used for the short and long-term reduction of myocardial oxygen consumption through selective vasodilation
• Metoprolol and Atenolol reduce myocardial oxygen consumption by blocking beta-adrenergic stimulation of the heart
• Amlodipine and Diltiazem have negative inotropic effects, indicated in patients not responsive to beta-blockers, and are used as primary treatment for vasospasm
• Aspirin, Clopidogrel, Prasugrel, and Ticagrelor prevent platelet aggregation
• Heparin (unfractionated), Enoxaparin, and Dalteparin prevent thrombus formation

Post-Cardiac Surgery Assessment

• Observe the catheter access site for bleeding or hematoma formation
• Assess peripheral pulses in the affected extremity every 15 minutes for 1 hour, every 30 minutes for 1 hour, and hourly for 4 hours or until discharge
• Assess BP and heart rate during these same time intervals
• Evaluate temperature, color, and capillary refill of the affected extremity during these same time intervals
• Screen carefully for arrhythmias by observing cardiac monitor or by assessing apical and peripheral pulses for rate and rhythm changes
• Analgesic medication is given as prescribed for discomfort and instruct the patient to report chest pain and bleeding or sudden discomfort from catheter insertion sites promptly
• Monitor and record intake and output and ensure patient safety

Complications and Nursing Actions

• After cardiac surgery, decreased urine output and elevated BUN/creatinine levels can indicate acute kidney injury from contrast agents
• Monitor urine output, BUN, creatinine, and electrolytes
• Provide adequate hydration and administer real protective agents

Post-CABG Patient Monitoring

• Monitor cardiovascular status and assess arterial blood pressure every 15 minutes until stable
• Assess peripheral pulses (pedal, tibial, radial)
• Monitor hemodynamic parameters to assess cardiac output, volume status, and vascular tone
• Watch for trends in hemodynamics and monitor ECG pattern for cardiac arrhythmias and ischemic changes
• Measure urine output every ½ to 1 hour at first, then with vital signs
• Observe buccal mucosa, nail beds, lips, earlobes, and extremities, and assess skin; note temperature and color
• Observe for persistent bleeding, cardiac tamponade, and signs of cardiac failure

Rheumatic Fever and Streptococcal Pharyngitis

• Acute rheumatic fever may develop after group A beta-hemolytic streptococcal pharyngitis
• Rheumatic fever patients may develop rheumatic heart disease, indicated by a new heart murmur, cardiomegaly, pericarditis, and heart failure
• Prompt and effective treatment of "strep" throat with antibiotics can prevent rheumatic fever development
• Signs and symptoms of streptococcal pharyngitis include sudden sore throat, pain when swallowing and fever
• Red and swollen tonsils with white patches or streaks of pus, petechiae and swollen lymph nodes in front of the neck are also signs

Endocarditis

• Risk factors include prosthetic cardiac valves or material used for cardiac valve repair and implanted cardiac devices and a history of bacterial endocarditis
• Congenital heart disease and unrepaired cyanotic disease, and cardiac transplant recipients with valvulopathy are risk factors
• Other risk factors are IV drug abuse, body piercing and hemodialysis

Heart Failure (HF) Management

• Strategies involve improving cardiac function with optimal pharmacologic management
• Reduction of symptoms and enhancement of functional status, Stabilization of patient condition and lowering of hospitalization risk
• Delaying the progression of HF and extending life expectancy and promotion of a lifestyle conducive to cardiac health
• Manage HF by providing comprehensive patient and family education and counseling

Core Therapy for HF Patients

• The cornerstone involves diuretic therapy and an angiotensin system blocker
• Use Beta-blockers .