Anatomy and Physiology: Heart Layers Quiz
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Questions and Answers

What heart rate can the AV node sustain if the SA node fails?

  • 60 to 80 beats per minute
  • 50 to 70 beats per minute
  • 30 to 50 beats per minute
  • 40 to 60 beats per minute (correct)

    • What is the effect of sympathetic stimulation on the heart rate?

  • Decreases heart rate and contractility
  • Increases heart rate and conduction speed (correct)
  • Has no effect on heart rhythms
  • Decreases conduction speed through the AV node

    • Which coronary artery supplies the left atrium and the lateral surfaces of the left ventricle?

  • Left anterior descending artery
  • Right bundle branch
  • Circumflex artery (correct)
  • Right main coronary artery

    • What is the normal range for sinus heart rate?

    <p>60 to 100 beats per minute</p> Signup and view all the answers

    What are Purkinje fibers capable of if both the SA and AV nodes fail?

    <p>Acting as a pacemaker with a rate of 20 to 40 beats per minute</p> Signup and view all the answers

    How does the body respond to an increase in arterial pressure according to baroreceptor activity?

    <p>Decreases heart rate and arterial pressure</p> Signup and view all the answers

    What causes the fourth heart sound (S4) to be heard during atrial systole?

    <p>Ventricular hypertrophy or wall injury</p> Signup and view all the answers

    Which hormone is mainly involved in the regulation of vascular volume and indirectly influences blood pressure?

    <p>Antidiuretic hormone (vasopressin)</p> Signup and view all the answers

    What characterizes a third heart sound (S3) in a patient?

    <p>Is normal in individuals younger than 30 years</p> Signup and view all the answers

    What is the function of the endocardium in the heart?

    <p>It lines the inner chambers and heart valves.</p> Signup and view all the answers

    Which layer of the heart is primarily responsible for contracting to pump blood?

    <p>Myocardium</p> Signup and view all the answers

    Which valve prevents blood from flowing back into the right atrium?

    <p>Tricuspid valve</p> Signup and view all the answers

    What is the primary role of the visceral pericardium?

    <p>It provides a protective layer around the heart.</p> Signup and view all the answers

    What occurs during the relaxation phase of the heart in relation to the semilunar valves?

    <p>The semilunar valves prevent blood from flowing back into the ventricles.</p> Signup and view all the answers

    Which chamber of the heart is primarily responsible for pumping oxygenated blood into the systemic circulation?

    <p>Left ventricle</p> Signup and view all the answers

    What is the role of the sinoatrial (SA) node in the heart?

    <p>To initiate and regulate heartbeats.</p> Signup and view all the answers

    What type of blood does the right atrium receive?

    <p>Deoxygenated blood from the body.</p> Signup and view all the answers

    Where is the parietal pericardium located?

    <p>Outside the visceral pericardium.</p> Signup and view all the answers

    How much pericardial fluid is typically found in the pericardial space?

    <p>5 to 20 mL</p> Signup and view all the answers

    What is the recommended fasting duration prior to sampling a lipid profile?

    <p>12 to 14 hours</p> Signup and view all the answers

    Which cardiac enzyme is primarily used to diagnose myocardial infarction and is released into the bloodstream when the heart muscle is injured?

    <p>Troponin I</p> Signup and view all the answers

    What does a lipid profile primarily provide information about?

    <p>Cholesterol levels</p> Signup and view all the answers

    What is the purpose of a transthoracic echocardiogram?

    <p>To diagnose valve disorders and assess heart structure</p> Signup and view all the answers

    What is considered the normal range for total cholesterol according to cardiovascular diagnostic procedures?

    <p>Less than 200 mg/dL</p> Signup and view all the answers

    What is a key consideration prior to performing transesophageal echocardiography?

    <p>Instruct the client to be NPO for 4 to 6 hours.</p> Signup and view all the answers

    Which of the following is NOT an indication for hemodynamic monitoring?

    <p>Mild atrial fibrillation</p> Signup and view all the answers

    What is the correct positioning for a patient during the insertion of a pulmonary artery catheter?

    <p>Supine or Trendelenburg position</p> Signup and view all the answers

    Which parameter does mixed venous oxygen saturation (SvO2) measure?

    <p>The balance between oxygen supply and demand</p> Signup and view all the answers

    What is an appropriate action to take immediately post-procedure for a patient undergoing an exercise stress test?

    <p>Monitor the patient’s vital signs and blood pressure closely.</p> Signup and view all the answers

    Which condition primarily results in inadequate left ventricle output and subsequently inadequate tissue perfusion?

    <p>Diastolic heart failure</p> Signup and view all the answers

    What classification in the American College of Cardiology and American Heart Association staging refers to having cardiac structural abnormalities but showing no manifestations of heart failure?

    <p>Stage B</p> Signup and view all the answers

    In the New York Heart Association classification scale, which class indicates a patient displaying manifestations at rest?

    <p>Class IV</p> Signup and view all the answers

    What condition is associated with a pulmonary edema resulting from severe heart failure?

    <p>Left-sided heart failure</p> Signup and view all the answers

    Low-output heart failure may initiate on either side of the heart. What is a common consequence of right-sided heart failure?

    <p>Peripheral edema</p> Signup and view all the answers

    What condition typically leads to high-output heart failure?

    <p>Septicemia</p> Signup and view all the answers

    Which of the following is NOT a common manifestation of left-sided heart failure?

    <p>Jugular vein distention</p> Signup and view all the answers

    Which laboratory test provides a direct indication of heart failure severity?

    <p>B-type natriuretic peptides (BNP)</p> Signup and view all the answers

    In hemodynamic monitoring, which change is expected in heart failure?

    <p>Increased central venous pressure (CVP)</p> Signup and view all the answers

    What dietary consideration is critical for patients at risk of heart failure?

    <p>Fluid restrictions</p> Signup and view all the answers

    Which medication is classified as a high-ceiling loop diuretic and has the ability to cause significant diuresis even in cases of renal impairment?

    <p>Furosemide</p> Signup and view all the answers

    What is a potential complication of using high-ceiling loop diuretics that involves a significant drop in blood pressure when changing positions?

    <p>Hypotension</p> Signup and view all the answers

    Which of the following conditions is NOT typically treated with high-ceiling loop diuretics?

    <p>Hypocalcemia</p> Signup and view all the answers

    Which side effect of high-ceiling loop diuretics is characterized by levels of potassium falling below 3.5 mEq/L?

    <p>Hypokalemia</p> Signup and view all the answers

    Which nursing action is crucial when monitoring a patient receiving high-ceiling loop diuretics for dehydration?

    <p>Monitor daily weight</p> Signup and view all the answers

    Which symptom is NOT commonly associated with hypokalemia?

    <p>Muscle Twitching</p> Signup and view all the answers

    What condition may result in digoxin toxicity when using loop diuretics?

    <p>Hypokalemia</p> Signup and view all the answers

    Thiazide diuretics are contraindicated in which of the following conditions?

    <p>Renal Impairment</p> Signup and view all the answers

    Which laboratory monitoring is essential for clients on loop diuretics to detect efficacy and avoid complications?

    <p>Electrolyte Levels</p> Signup and view all the answers

    What symptom indicates a potential need to report a potassium supplement requirement in clients taking diuretics?

    <p>ECG Changes</p> Signup and view all the answers

    What is the primary mechanism by which Class III antidysrhythmic medications, such as Amiodarone, exert their effects?

    <p>Prolonging the action potential and refractory period</p> Signup and view all the answers

    Which of the following statements about Class IA sodium channel blockers is accurate?

    <p>Quinidine is a representative medication of this class.</p> Signup and view all the answers

    What effect do beta-adrenergic blockers have on cardiac function?

    <p>They prevent cardiac stimulation by sympathetic signals.</p> Signup and view all the answers

    What is a primary concern when using antidysrhythmic medications?

    <p>Medication toxicity resulting in cardiac dysrhythmias</p> Signup and view all the answers

    Calcium channel blockers primarily affect cardiac function by:

    <p>Reducing conduction and depresses depolarization.</p> Signup and view all the answers

    What is a significant complication of using loop diuretics like furosemide in clients?

    <p>Risk of ototoxicity</p> Signup and view all the answers

    Which symptom should a nurse instruct a client to report while taking furosemide?

    <p>Tinnitus</p> Signup and view all the answers

    How does furosemide primarily affect electrolyte levels in the body?

    <p>Reduces sodium and magnesium reabsorption</p> Signup and view all the answers

    In what condition is furosemide especially indicated for use?

    <p>Severe renal impairment</p> Signup and view all the answers

    Which of the following laboratory findings necessitates immediate reporting when monitoring a patient on furosemide?

    <p>Potassium level of 3.2 mEq/L</p> Signup and view all the answers

    What is the primary effect of thiazide diuretics like HCTZ when treating diabetes insipidus?

    <p>Reduce urine production by 30 to 50%</p> Signup and view all the answers

    Which adverse effect is associated with spironolactone?

    <p>Gynecomastia</p> Signup and view all the answers

    When taking ACE inhibitors, which symptom is critical for a patient to report to their doctor?

    <p>Sore throat and fever</p> Signup and view all the answers

    What is a potential serious adverse reaction to ACE inhibitors that requires immediate medical attention?

    <p>Angioedema</p> Signup and view all the answers

    Which medication can be prescribed to a client with atrial fibrillation prior to cardioversion?

    <p>Diltiazem</p> Signup and view all the answers

    Beta-adrenergic blockers can mask which common manifestation of hypoglycemia?

    <p>Increased heart rate</p> Signup and view all the answers

    Which finding indicates digoxin toxicity?

    <p>Cardiac arrhythmias</p> Signup and view all the answers

    What timing strategy should patients follow when taking ACE inhibitors?

    <p>1 hour before or 2 hours after meals</p> Signup and view all the answers

    What is a contraindication for using diltiazem?

    <p>Hypotension</p> Signup and view all the answers

    Which of the following substances should be avoided prior to an exercise stress test?

    <p>Caffeine</p> Signup and view all the answers

    Study Notes

    Heart Anatomy and Layers

    • Located in the mediastinum; the heart is composed of three layers:
      • Epicardium: Outermost layer
      • Myocardium: Middle layer and main contracting muscle
      • Endocardium: Innermost layer lining the chambers and valves

    Pericardial Sac

    • Protects the heart from trauma and infection, consisting of two layers:
      • Parietal pericardium: Tough outer membrane attaching to the sternum, vertebrae, and diaphragm
      • Visceral pericardium: Thin inner layer closely adhering to the heart
    • Pericardial space contains 5 to 20 mL of fluid for lubrication and cushioning

    Heart Chambers

    • Four chambers:
      • Right atrium: Receives deoxygenated blood from the body via superior and inferior vena cava
      • Right ventricle: Pumps blood to lungs via pulmonary artery
      • Left atrium: Receives oxygenated blood from lungs through four pulmonary veins
      • Left ventricle: Largest and most muscular, pumps oxygenated blood into systemic circulation via the aorta

    Heart Valves

    • Four valves divided into two groups:
      • Atrioventricular valves: Tricuspid (right) and Mitral (bicuspid, left) prevent backflow into atria during ventricular contraction
      • Semilunar valves: Pulmonic (between right ventricle and pulmonary artery) and Aortic (between left ventricle and aorta) prevent backflow into ventricles during relaxation

    Electrical Conduction System

    • Sinoatrial (SA) Node: Primary pacemaker, located at junction of superior vena cava and right atrium, generates impulses at 60-100 beats per minute
    • Atrioventricular (AV) Node: Located in lower aspect of atrial septum; can sustain heart rate of 40-60 beats if SA node fails
    • Bundle of His: Continuation of AV node in interventricular septum, branches into right and left bundle branches that lead to Purkinje fibers
    • Purkinje Fibers: Conduct impulses through ventricles; can act as pacemaker at 20-40 beats per minute if both SA and AV nodes fail

    Coronary Arteries

    • Right coronary artery supplies right atrium, right ventricle, inferior left ventricle, and nodes
    • Left coronary artery branches into:
      • Left anterior descending (LAD): Supplies anterior wall of left ventricle and septum
      • Circumflex artery: Supplies left atrium and lateral/posterior walls of left ventricle
    • Blockages can lead to myocardial infarction (MI)

    Heart Sounds

    • S1: First heart sound, loudest at apex, marks closure of atrioventricular valves
    • S2: Second heart sound, loudest at base, marks closure of semilunar valves
    • S3: Possible sign of decreased ventricular wall compliance; may be normal in individuals under 30
    • S4: Indicates resistance to ventricular filling due to conditions like cardiac hypertrophy

    Heart Rate

    • Normal sinus heart rate: 60-100 beats per minute
    • Sinus tachycardia: Rate over 100 beats per minute
    • Sinus bradycardia: Rate below 60 beats per minute
    • Rapid heart rate reduces filling time; very fast rates decrease cardiac output

    Autonomic Nervous System

    • Sympathetic stimulation increases heart rate and contractility via norepinephrine release
    • Parasympathetic stimulation decreases heart rate and contractility via acetylcholine release

    Blood Pressure Control

    • Baroreceptors in aortic arch and carotid sinuses detect arterial pressure changes
    • Increased arterial pressure suppresses heart rate; decreased pressure triggers heart rate increase and vessel constriction
    • Stretch receptors in vena cava and right atrium respond to changes in blood volume, influencing heart rate and pressure
    • Antidiuretic hormone (ADH) regulates blood volume and pressure; renin-angiotensin system also affects blood pressure

    Vascular System

    • Arteries transport oxygenated blood from the heart; arterioles control blood flow to capillaries
    • Capillaries facilitate nutrient and fluid exchange; venules collect blood from capillaries to veins
    • Veins return deoxygenated blood to the right heart; valves aid in blood return against gravity
    • Lymphatics drain tissue and return fluid to bloodstream

    Cardiac Markers

    • Troponin: Three proteins; Troponin I indicates myocardial injury, rising within 3 hours and lasting 7-10 days; normal: Troponin I < 0.35 ng/mL
    • High-sensitivity Troponin (hsTnT): Detects troponins early (60-90 minutes) after injury; speeds triage for potential MI

    Cardiovascular Diagnostic Procedures

    • Evaluate heart function through blood enzyme monitoring, ultrasound visualization, exercise response assessment, and catheterization.
    • Essential procedures include cardiac enzymes, lipid profile, echocardiogram, stress testing, hemodynamic monitoring, and angiography.

    Cardiac Enzymes and Lipid Profile

    • Cardiac enzymes indicate heart muscle injury; they are crucial for diagnosing myocardial infarction (MI).
    • Lipid profiles measure cholesterol levels for early heart disease detection.
    • Common indications for testing: angina, MI, heart disease, hyperlipidemia.
    • Recommended fasting for 12 to 14 hours before lipid profile sampling.

    Expected Reference Ranges for Cardiac Enzymes

    • Creatine Kinase MB Isoenzyme: 0% of total CK (20 to 200 units/L); detectable within 3 to 6 hours, lasting 2 to 3 days.
    • Troponin T: Less than 0.1 ng/mL; detectable within 2 to 3 hours, lasting 10 to 14 days.
    • Troponin I: Less than 0.03 ng/mL; detectable within 2 to 3 hours, lasting 7 to 10 days.
    • Myoglobin: Less than 90 mcg/L; detectable within 2 to 3 hours, lasting 24 hours.

    Lipid Profile Values

    • Total Cholesterol: Less than 200 mg/dL; indicates risk for heart disease.
    • LDL (Low-Density Lipoprotein): Less than 130 mg/dL; considered "bad" cholesterol.
    • Triglycerides: Males: 40 to 160 mg/dL; Females: 35 to 135 mg/dL; helps assess heart disease risk.
    • HDL (High-Density Lipoprotein): Females: >55 mg/dL; Males: >45 mg/dL; benefits cardiovascular health.

    Echocardiography

    Transthoracic Echocardiography

    • Used to assess valve disorders, cardiomyopathy, and ejection fraction.
    • Noninvasive, requires client to lie on the left side and stay still.

    Transesophageal Echocardiography

    • Provides clearer images; requires transducer insertion through the esophagus.
    • Monitors heart failure and valvular diseases; requires informed consent and NPO status for 4-6 hours.

    Stress Testing

    • Evaluates heart workload using a treadmill; can also be pharmacological.
    • Pre-test preparation includes NPO for 2-4 hours, avoiding stimulants, and comfortable attire.
    • Continuously monitor ECG and vital signs during testing.

    Hemodynamic Monitoring

    • Involves use of catheters to assess blood volume and heart pumping efficiency.
    • Key parameters: central venous pressure (CVP), pulmonary artery pressure (PAP), cardiac output (CO), and mixed venous oxygen saturation (SvO2).

    Pulmonary Artery Catheters

    • Inserted via large veins; used for numerous hemodynamic measurements and IV fluid infusions.
    • Requires specific positioning for accurate readings and follows strict sterile technique.

    Angiography

    • Invasive diagnostic procedure for evaluating coronary artery blockages.
    • Typically involves catheter insertion through a femoral, brachial, or radial vessel.
    • Considerations include maintaining NPO status pre-procedure and monitoring vital signs continuously.

    Complications of Procedures

    • Infection/Sepsis: Monitor and change dressings according to protocol.
    • Embolism: Use sterile saline to prevent air embolism; observe for dysrhythmias.
    • Cardiac Tamponade: Monitor for hypotension, jugular distention, and offer interventions like IV fluids or pericardiocentesis.
    • Retroperitoneal Bleeding: Assess for flank pain and hold pressure at the puncture site.
    • Acute Kidney Injury: Ensure hydration and monitor urinary output and electrolyte levels after the use of nephrotoxic contrast agents.

    Nursing Actions and Considerations

    • Ensure understanding before procedures through patient education and informed consent.

    • Continuously assess vital signs and circulation in areas affected by catheterization.

    • Post-procedure care includes bed rest, monitoring for adverse reactions, and guidance on activity restrictions for recovery.### Central IV Catheter Types

    • Nontunneled percutaneous central venous catheter (CVC):

      • Length: 18 to 25 cm (7 to 10 in), one to five lumens
      • Use: Short-term (less than 6 weeks)
      • Insertion: Subclavian or jugular vein, tip in distal SVC
      • Indications: Emergencies, blood administration, chemotherapy, antibiotics, total parenteral nutrition

    • Tunneled percutaneous central venous catheter:

      • Designed for long-term use
      • Features a subcutaneous tunnel with a cuff for anchoring and infection barrier
      • Indications: Frequent and long-term vascular access

    • Peripherally inserted central catheter (PICC):

      • Length: 45 to 74 cm (18 to 29 in), single or multiple lumens
      • Use: Up to 12 months
      • Insertion: Basilic or cephalic vein, tip in lower one-third of SVC
      • Indications: Blood, chemotherapy, antibiotics, total parenteral nutrition

    • Implanted port:

      • Composed of small reservoir covered by a septum, surgically implanted into chest
      • Indications: Long-term vascular access, commonly for chemotherapy

    Insertion and Considerations

    • Insertion occurs in OR, client’s room, or outpatient facility.
    • Surgical removal required for tunneled and implanted catheters.
    • Essential to obtain informed consent and maintain sterility during the procedure.
    • Use chlorhexidine to cleanse the insertion site and place a STOP sign to limit access during the procedure.

    Post-procedure Care

    • Confirm PICC placement via x-ray; assess for redness, swelling, and tenderness.
    • Clean insertion port with alcohol before accessing; use transparent dressings for visibility.
    • Follow facility protocols for dressing changes, typically every 7 days.
    • Educate the client on avoiding water immersion and venipunctures on the arm with PICC.

    Flushing Protocols

    • Use a 10 mL syringe for flushing.
    • Flush with 10 mL 0.9% sodium chloride before, during, after medication; 20 mL after blood draws.
    • Flush with 5 mL heparin (10 units/mL) when not in use as per facility policy.

    Complications and Nursing Actions

    • Phlebitis: Monitor for erythema, pain, warmth, and edema at IV site; assess for slowing infusion rate or fever.
    • Occlusion: Do not force fluid against resistance; flush in accordance with recommendations.
    • Mechanical complications: Assess for dislodged ports or catheter tips; report findings immediately.

    Cardiac Exercise Stress Test

    • Used to assess cardiac workload by exercising muscle via treadmill.
    • Indications include angina, heart failure, myocardial infarction, and dysrhythmia.
    • Ensure informed consent and fasting prior to the test; monitor vital signs and heart rhythm during.

    Electrocardiography and Dysrhythmias

    • Electrocardiography records heart electrical activity via electrodes on the chest and limbs.
    • Continuous monitoring and telemetry allows ambulatory assessment.
    • Dysrhythmias manifest as abnormal heartbeats; can be caused by various cardiac conditions.
    • Identifiable by altered heart rate, rhythm, and signs of distress such as chest pain and hypoxia.

    Pacemakers and ICDs

    • Artificial pacemakers stimulate heart when it fails to maintain rhythm; can be temporary or permanent.
    • Types include external, epicardial, and endocardial (transvenous) for temporary pacing, and leadless pacemakers for permanent solutions.
    • ICDs monitor and deliver shocks to correct life-threatening rhythms.

    Cardioversion and Defibrillation

    • Cardioversion delivers a synchronized shock for conditions like atrial fibrillation; defibrillation is unsynchronized for ventricular fibrillation or pulseless tachycardia.
    • Preprocedure care involves anticoagulation for atrial fibrillation, monitoring vital signs, and ensuring emergency equipment is on standby.
    • Postprocedure care includes monitoring for complications like embolism and decreased cardiac output.

    General Considerations

    • All procedures require careful pre, intra, and post-procedure planning to ensure patient safety and efficacy.
    • Nurses should maintain hand hygiene, follow protocols, and provide patient education to mitigate risks and complications.### Tachydysrhythmia and Pacemaker Function
    • Pacemakers can over-pace a tachydysrhythmia or deliver an electrical shock.
    • VVI mode indicates ventricular pacing and sensing with inhibition on detection of QRS complexes.

    Implantable Cardioverter/Defibrillators (ICD)

    • Contain an internal generator, indicated for:
      • Survivors of sudden cardiac death syndrome.
      • Individuals at risk for sudden cardiac death.
      • Spontaneous or symptomatic ventricular dysrhythmias.

    Indications for Pacemaker and ICD Placement

    • Pacemaker: Used for symptomatic bradycardia, complete heart block, sick sinus syndrome, sinus arrest, asystole, and atrial tachydysrhythmias.
    • ICD: Indicated for ventricular tachydysrhythmias, myocardial infarction (MI) with left ventricular dysfunction.

    Client Presentation

    • Subjective Data: Fainting, dizziness, palpitations, chest pain, anxiety, fatigue, nausea, and breathing difficulties.
    • Objective Data: Bradycardia or tachycardia, abnormal ECG, dyspnea, restlessness, jugular venous distention, vomiting, hypotension, diaphoresis, and decreased cardiac output.

    Pre-procedure Considerations

    • Assess client’s understanding of the procedure and necessity for pacemaker/ICD.
    • Obtain signed informed consent.
    • Prepare the skin without shaving; clean and dry the area.

    Client Education for Pacemaker/ICD

    • Understand the type of device to be inserted.
    • For temporary pacemakers, do not touch the dials or wet the equipment.
    • Permanent devices allow external reprogramming and have an expected battery life of 5-10 years.

    Post-procedure Monitoring

    • Document insertion details and continuously monitor heart rate and rhythm.
    • Conduct ECG comparisons and obtain chest x-ray for lead placement assessment.
    • Watch for complications like hiccups (indicating diaphragm pacing).

    Discharge Teaching for Permanent Pacemaker/ICD

    • Carry a device identification card and avoid dislodging wires.
    • Monitor pulse daily; inform provider of heart rate below pacemaker setting.
    • Report any discomfort such as dizziness, fatigue, or chest pain.
    • Avoid magnet exposure near the device and heavy-lifting restrictions for two months.

    Complications and Nursing Actions

    • Infection or hematoma at the insertion site requires monitoring and potential antibiotic administration.
    • Monitor for pneumothorax or hemothorax by assessing breath sounds and oxygen saturation.
    • ECG should be monitored for proper sensing and pacing from the pacemaker.

    Invasive Cardiovascular Procedures

    • Percutaneous Coronary Intervention (PCI): A nonsurgical method including atherectomy, stenting, and angioplasty. It's indicated for occlusion of one or two coronary arteries and emergency intervention after MI.
    • Client presentation may involve chest pain, dyspnea, nausea, and altered ECG findings.

    Complications of PCI

    • Potential complications include artery dissection, cardiac tamponade, hematoma, allergic reactions, and retroperitoneal bleeding.
    • Assess vital signs and perform quick interventions like notifying the provider or administering IV fluids as necessary.

    Coronary Artery Bypass Graft (CABG)

    • CABG restores blood flow by bypassing obstructions in coronary arteries.
    • Indications include significant blockages and conditions unresponsive to medical management.

    Nursing Actions for CABG

    • Pre-procedure actions include obtaining informed consent and thorough assessment.
    • Post-procedure care involves monitoring airway, ventilation, and respiratory function while promising early ambulation to prevent complications.

    Education Post-CABG

    • Clients should understand the importance of pulmonary exercise and pain reporting.
    • Be aware of medications that may need to be discontinued or continued around the surgery time.

    Heart Failure Overview

    • Heart failure results from the heart's inability to pump efficiently, leading to inadequate cardiac output and congestion in pulmonary/systemic circulation.
    • Causes include systemic hypertension, myocardial infarction (MI), pulmonary hypertension, dysrhythmias, valvular heart disease, pericarditis, and cardiomyopathy.
    • Pulmonary edema is a critical condition caused by severe heart failure, resulting in fluid accumulation in the lungs.

    Functional Classification

    • New York Heart Association (NYHA) Classification:

      • Class I: No symptoms with activity.
      • Class II: Symptoms with ordinary exertion.
      • Class III: Symptoms with minimal exertion.
      • Class IV: Symptoms at rest.

    • American College of Cardiology / American Heart Association Staging:

      • A: High risk for heart failure.
      • B: Cardiac structural changes without symptoms.
      • C: Historical or current symptoms of heart failure.
      • D: Refractory end-stage heart failure.

    Types of Heart Failure

    • Low-output heart failure can occur on the left or right side:

      • Left-sided failure: Inadequate output and tissue perfusion, leading to pulmonary congestion.
        • Systolic failure: Ejection fraction <40%.
        • Diastolic failure: Impaired ventricular filling.
      • Right-sided failure: Inadequate output leading to systemic venous congestion and peripheral edema.

    • High-output heart failure: Cardiac output is normal or elevated due to increased metabolic demand (e.g., septicemia, hyperthyroidism).

    Health Management

    • Maintain an active lifestyle; consult healthcare providers before starting new exercises.
    • Follow a low-sodium diet, manage fluid intake, and avoid smoking.
    • Adhere to prescribed medication regimens and schedule regular follow-ups.

    Risk Factors

    • Older adults are at higher risk due to factors such as increased systolic blood pressure and polypharmacy.
    • Social determinants: Limited healthcare access, socioeconomic status issues, and food insecurity can exacerbate heart failure.

    Symptoms of Heart Failure

    • Left-sided failure:

      • Dyspnea, orthopnea, nocturnal dyspnea.
      • Fatigue, S3 heart sound, pulmonary congestion (cough, crackles).
      • Potential altered mental status and reduced urine output.

    • Right-sided failure:

      • Jugular vein distention, peripheral edema.
      • Abdominal distention, fatigue, nausea, and weight gain.

    Cardiomyopathy Types

    • Dilated (most common), Hypertrophic, Arrhythmogenic right ventricular, and Restrictive.
    • Symptoms may include fatigue, dysrhythmias, and cardiomegaly.

    Diagnostic Measures

    • BNP Levels: Used to confirm heart failure; <100 pg/mL indicates no heart failure, while >400 pg/mL indicates heart failure presence.
    • Hemodynamic Monitoring: Elevated CVP and pulmonary pressures are indicative of heart failure.
    • Echocardiogram: Assesses heart function; normal left ventricular ejection fraction is 55%-70%.

    Patient-Centered Care

    • Monitor vital signs, daily weights, and I&O.
    • Position for optimal ventilation (high-Fowler’s).
    • Educate on medication management, dietary restrictions, and signs of toxicity (e.g., digoxin).

    Medications

    • Diuretics: Decrease preload; monitor for hypokalemia.
    • Afterload-reducing agents: Include ACE inhibitors and calcium channel blockers; observe for hypotension and potassium levels.
    • Inotropic agents: Enhance cardiac output; monitor heart rate and signs of toxicity.
    • Beta blockers: Check blood pressure and pulse regularly.
    • Anticoagulants: Monitor bleeding times and educate about risks.

    Complications

    • Acute Pulmonary Edema: Emergency situation with symptoms like anxiety, dyspnea, and frothy sputum; requires high-Fowler’s positioning, oxygen therapy, and rapid diuretics.
    • Cardiogenic Shock: Presents with tachycardia and hypotension; requires intensive monitoring and medication support.
    • Cardiac Tamponade: Characterized by jugular distention, hypotension, and muffled heart sounds; may need pericardiocentesis.

    Health Promotion

    • Encourage physical activity while considering individual capacity and consult health providers for diet and exercise guidance.
    • Educate on the importance of monitoring health closely to manage heart failure effectively.### Hemodynamic Monitoring and Assessment
    • Monitor pulmonary wedge pressures and cardiac output to evaluate hemodynamic status.
    • Perform blood gas analysis (ABGs), electrolyte checks (particularly potassium), and assess SaO2 levels and chest X-ray results.
    • Maintain a clear airway, suctioning as necessary, and monitor fluid intake, especially IV fluids.

    Urine Output Monitoring

    • Track hourly urine output; report if output is less than 30 mL/hr or if intake exceeds output.

    Emotional Support

    • Provide emotional support to both clients and their families.

    Medication Management

    • Rapid-acting diuretics like furosemide and bumetanide facilitate fluid excretion.
    • Morphine alleviates anxiety and contributes to mild vasodilation by controlling sympathetic nervous system response.
    • Vasodilators (nitroglycerin, sodium nitroprusside) should only be administered if systolic BP is above 100 mm Hg to reduce preload and afterload.
    • Inotropic agents (digoxin, dobutamine) enhance cardiac output; antihypertensives (ACE inhibitors, beta-blockers) lower afterload.

    Client Education

    • Teach effective breathing techniques and medication administration.
    • Encourage adherence to a low-sodium diet and fluid restrictions; daily weight checks are essential.
    • Report weight gain exceeding 0.5 to 0.9 kg daily (1 to 2 lb) or 1.4 kg (3 lb) weekly, and report any swelling or shortness of breath.

    Heart Failure Overview

    • Left-sided heart failure indicates inadequate left ventricle output, leading to poor tissue perfusion.
    • Systolic failure presents with an ejection fraction below 40%, showing congestion.
    • Right-sided heart failure results in systemic venous congestion and peripheral edema.

    Diagnostic Testing for Heart Failure

    • Use B-type natriuretic peptides (BNP) to confirm heart failure diagnosis and guide treatment.
    • Employ hemodynamic monitoring, ultrasound, chest X-ray, and ECG for further assessment.

    Hypertension Overview

    • Defined as systolic BP ≥ 130 mm Hg or diastolic BP ≥ 80 mm Hg over two occasions.
    • Over 40% of U.S. adults over 20 are treated for hypertension, which causes over 40,000 deaths annually.
    • Essential hypertension lacks a known cause, while secondary hypertension may result from other medical conditions or medications.

    Mechanisms Regulating Blood Pressure

    • Arterial baroreceptors in carotid sinus and aorta modulate BP by adjusting heart rate and vascular resistance.
    • Kidneys play a critical role in fluid balance, influenced by the renin-angiotensin-aldosterone system, which controls sodium reabsorption and fluid loss.

    Lifestyle Modifications for Hypertension

    • Maintain a BMI under 25, control blood glucose for diabetics, limit caffeine and alcohol, and engage in regular exercise.
    • Follow dietary guidelines emphasizing low sodium and fat intake.

    Risk Factors for Hypertension

    • Essential hypertension risk factors include genetics, high sodium intake, physical inactivity, obesity, excessive alcohol, age, and diabetes.
    • Secondary hypertension can arise from kidney disease, hormonal disorders, or certain medications.

    Symptoms and Physical Assessment of Hypertension

    • Clients often show few symptoms; however, headaches, dizziness, and visual disturbances may occur.
    • Blood pressure should be measured standing and sitting, using the correct cuff size.

    Medication Overview for Hypertension

    • Diuretics (e.g., hydrochlorothiazide, furosemide) are typical first-line treatments.
    • Combination medications may be necessary if lifestyle changes are insufficient.
    • Monitor for adverse effects like hypotension and electrolyte imbalances, especially with diuretics.

    Lifestyle and Nutritional Recommendations

    • Adhere to DASH diet rich in fruits, vegetables, and low-fat dairy; minimize sodium and unhealthy fats.
    • Aim to exercise three times a week for cardiovascular benefits and consider smoking cessation strategies.

    Complications of Hypertension

    • Recognize signs of hypertensive crisis: severe headache, blood pressure >180/120 mm Hg, visual disturbances, and epistaxis.
    • Implement IV antihypertensive treatments to carefully lower BP without exceeding safe limits.

    Patient-Centered Care and Education

    • Educate clients on medication adherence and potential side effects.
    • Encourage monitoring of blood pressure and reporting of adverse symptoms to prevent complications.
    • Ensure access to healthcare resources for ongoing management of hypertension and associated health issues.

    Indications for Diuretics

    • Manage blood pressure and promote fluid excretion in heart failure, kidney, and liver disease.
    • Prevent kidney failure by maintaining urine flow.

    Types of Diuretics

    High-Ceiling Loop Diuretics

    • Prototype Medication: Furosemide
    • Mechanism: Acts in the loop of Henle, blocking sodium and chloride reabsorption, leading to significant diuresis.
    • Therapeutic Uses:
      • Emergent fluid mobilization (e.g., pulmonary edema from heart failure).
      • Edema unresponsive to other diuretics (from liver, cardiac, or kidney issues).
      • Hypertension management (e.g., torsemide).
      • Unlabeled use for hypercalcemia.

    Thiazide Diuretics

    • Prototype Medication: Hydrochlorothiazide
    • Mechanism: Works in the early distal convoluted tubule, blocking sodium and chloride reabsorption.
    • Therapeutic Uses:
      • First choice for essential hypertension.
      • Mild to moderate edema related to heart failure or kidney/liver disease.
      • Reduces urine production in diabetes insipidus.
      • Promotes calcium reabsorption to lower osteoporosis risk.

    Potassium-Sparing Diuretics

    • Prototype Medication: Spironolactone
    • Mechanism: Blocks aldosterone, leading to sodium and water excretion while retaining potassium.
    • Therapeutic Uses:
      • Used with loop or thiazide diuretics to prevent hypokalemia.
      • Treats heart failure and hyperaldosteronism.

    Osmotic Diuretics

    • Prototype Medication: Mannitol
    • Mechanism: Raises serum osmolality, reducing intracranial and intraocular pressure by drawing fluid into the vascular space.
    • Therapeutic Uses:
      • Prevents kidney failure in hypovolemia or severe hypotension.
      • Reduces intracranial pressure from cerebral edema.
      • Assists in the oliguria phase of acute kidney injury.

    Complications and Nursing Actions

    • Dehydration: Monitor for signs like dry mouth and oliguria; report if urine output is <30 mL/hr.
    • Hypotension: Monitor blood pressure; advise gradual position changes to prevent dizziness.
    • Ototoxicity: Assess for tinnitus with furosemide; avoid concurrent ototoxic medications.
    • Hypokalemia: Monitor potassium levels; educate on high-potassium diets and report symptoms (nausea, fatigue).
    • Endocrine Effects (Spironolactone): Monitor for menstrual irregularities and gynecomastia.

    Contraindications and Precautions

    • Use caution in pregnancy and lactation; furosemide and thiazides are contraindicated in severe renal impairment and anuria.
    • Careful monitoring needed for clients with existing electrolyte imbalances, liver or kidney disease, and those on digoxin or antihypertensives.

    Administration Guidelines

    • Obtain baseline assessments (blood pressure, weight, electrolytes).
    • Administer diuretics in the morning to avoid nocturia.
    • Monitor daily weight changes; large fluctuations should be reported.
    • Administer furosemide IV slowly to prevent complications.

    Client Education

    • Educate patients on recognizing signs of complications (dehydration, hypotension, electrolyte imbalances).
    • Importance of potassium intake with potassium-sparing diuretics.
    • Keep track of blood pressure and weight regularly.
    • Report significant health changes to the provider.

    Effectiveness Indicators

    • Decrease in edema and blood pressure.
    • Increased urine output.
    • Normalized kidney function metrics (e.g., urine output ≥30 mL/hr).### Angiotensin-Converting Enzyme Inhibitors (ACE Inhibitors)
    • Prototype medication: Captopril with other options including Enalapril, Fosinopril, and Ramipril.
    • Mechanism: Blocks conversion of angiotensin I to angiotensin II, increasing bradykinin levels, leading to vasodilation.
    • Effects: Promotes excretion of sodium and water; retains potassium; reduces vascular and cardiac damage due to angiotensin II and aldosterone.

    Therapeutic Uses

    • Treats hypertension, heart failure, myocardial infarction, and diabetic nephropathy.
    • Ramipril specifically used for cardiovascular event prevention in high-risk patients.

    Complications and Nursing Actions

    • First-dose orthostatic hypotension: Temporarily stop diuretics before starting ACE inhibitors; monitor blood pressure.
    • Cough: Potential side effect due to increased bradykinin; inform clients to report and discontinue if experienced.
    • Hyperkalemia: Monitor potassium levels; avoid potassium-containing substitutes.
    • Rash and dysgeusia: Inform providers of any occurrences.
    • Angioedema: Severe swelling treated with epinephrine; discontinue the medication.
    • Neutropenia: Rare complication; monitor WBC counts and observe for signs of infection.

    Contraindications and Precautions

    • Pregnancy and lactation: ACE inhibitors are contraindicated.
    • Use cautiously in patients with renal issues or a history of angioedema.

    Drug Interactions

    • Diuretics may enhance hypotensive effects; potassium supplements increase hyperkalemia risk.
    • Concurrent use with NSAIDs can reduce antihypertensive effects.

    Angiotensin II Receptor Blockers (ARBs)

    • Prototype medication: Losartan, with others including Irbesartan and Telmisartan.
    • Mechanism: Block action of angiotensin II, leading to vasodilation and reduced aldosterone release.

    Therapeutic Uses

    • Manages hypertension, heart failure, offers stroke prevention, and slows diabetic nephropathy progression.

    Complications and Nursing Actions

    • Angioedema: Similar to ACE inhibitors; requires immediate notification and possible epinephrine treatment.
    • Fetal injury: Contraception advised for childbearing-age clients.
    • Hypotension: Monitor blood pressure and educate clients on safety when rising.

    Contraindications and Precautions

    • Contraindicated in pregnancy, lactation, and specific renal issues.

    Aldosterone Antagonists

    • Prototype: Eplerenone, alongside Spironolactone.
    • Mechanism: Block aldosterone receptors, promoting sodium and water excretion while retaining potassium.

    Therapeutic Uses

    • Treats hypertension, heart failure, premenstrual syndrome, and certain skin conditions.

    Complications and Nursing Actions

    • Monitor for hyperkalemia and educate clients on dietary restrictions regarding potassium.
    • Report severe flu-like symptoms and endocrine changes to providers.

    Direct Renin Inhibitors

    • Prototype medication: Aliskiren.
    • Mechanism: Inhibits renin, decreasing angiotensin I, II, and aldosterone production.

    Therapeutic Uses

    • Primarily indicated for hypertension management.

    Complications and Nursing Actions

    • Monitor for angioedema, hyperkalemia, and hypotension; educate clients on dietary restrictions.

    Calcium Channel Blockers

    • Prototype medications include Nifedipine, Verapamil, and Diltiazem.
    • Mechanism: Blocking calcium channels leads to vasodilation; affects blood vessels and heart function.

    Complications and Nursing Actions

    • Nifedipine: Watch for reflex tachycardia; consider beta-blocker use if needed.
    • Verapamil/Diltiazem: Monitor for bradycardia, hypotension, and gastrointestinal side effects like constipation.

    Contraindications and Precautions

    • Use cautiously in pregnancy and various cardiovascular conditions; monitor cardiac function closely.

    Alpha Adrenergic Blockers/Sympatholytics

    • Prototype medication: Prazosin, with Doxazosin, and Terazosin as alternatives.
    • Mechanism: Produces venous and arterial dilation, relaxing smooth muscles in prostate and bladder.

    Therapeutic Uses

    • Treats essential hypertension and reduces symptoms of benign prostatic hyperplasia.

    Complications and Nursing Actions

    • Orthostatic hypotension: Start with low dosage and monitor blood pressure closely; counsel on gradual position changes.

    Client Education

    • Advise caution in activities requiring alertness and to lie down if feelings of dizziness or lightheadedness occur.### Contraindications and Precautions
    • Contraindicated in clients with hypotension, bleeding disorders, or on anticoagulants.
    • Use cautiously in clients with angina, renal insufficiency, previous stroke, asthma, COPD, recent myocardial infarction, diabetes mellitus, depression, and chronic kidney disease.
    • For older adults, monitor closely due to increased sensitivity to medications.

    Interactions and Nursing Actions

    • Antihypertensive medications can enhance hypotensive effects; monitor blood pressure.
    • Avoid concurrent use with prazosin, MAOIs, and tricyclic antidepressants.
    • Beware of additive CNS depression with alcohol and other CNS depressants.

    Client Education on Sympatholytics

    • Watch for signs of hypotension—dizziness, lightheadedness; lie down if these occur.
    • Medications, such as clonidine, can be taken with food and should start at bedtime to reduce first-dose effects.
    • Do not stop medications abruptly; gradually discontinue to avoid rebound hypertension.

    Centrally Acting Alpha2 Agonists

    • Prototype: Clonidine; other examples include guanfacine and methyldopa.
    • Function: Decrease sympathetic outflow, resulting in reduced heart stimulation and decreased blood pressure.
    • Therapeutic uses include primary hypertension, severe cancer pain management, ADHD, migraines, and anxiety.

    Beta Adrenergic Blockers

    • Selective: Metoprolol, atenolol; Nonselective: Propranolol, nadolol; Alpha/beta blockers include carvedilol and labetalol.
    • Effects: Lower heart rate, myocardial contractility, and AV conduction; vasodilation via alpha blockade.

    Therapeutic Uses of Beta Blockers

    • Management of hypertension, angina, heart failure, tachydysrhythmias, and myocardial infarction.
    • Additional uses include treatment for hyperthyroidism, migraine headaches, and glaucoma.

    Complications of Beta Blockers

    • Bradycardia is common; monitor pulse and hold medication if below 50 bpm.
    • Worsening heart failure symptoms: shortness of breath, edema, fatigue; notify provider of any changes.
    • Gradually discontinue to prevent rebound excitation.

    Nitroprusside and Antihypertensive Medications

    • Nitroprusside causes direct vasodilation, lowering blood pressure effectively.
    • Monitor for excessive hypotension and cyanide toxicity; avoid long-term use.
    • Administration must be careful; keep clients supine and monitor continuously.

    Aliskiren for Hypertension

    • Works by inhibiting renin production to lower angiotensin and aldosterone levels.
    • Risks include diarrhea, angioedema, rash, hyperkalemia, and hypotension.
    • Advise against use with fatty foods and potassium supplements; monitor potassium levels closely.

    Cardiac Glycosides

    • Prototype: Digoxin; increases myocardial contraction and efficiency, decreases heart rate.
    • Therapeutic in heart failure and atrial fibrillation; can lower dysrhythmia manifestations.

    Complications and Toxicity Management of Digoxin

    • Monitor for dysrhythmias, cardiotoxicity, and GI/CNS effects indicating toxicity.
    • Manage toxicity by halting digoxin and potassium-depleting diuretics, and monitor potassium levels.
    • Treatments for severe toxicity include the use of activated charcoal or digoxin immune Fab.

    Nursing Administration and Client Education

    • Check pulse before administration and document; notify provider if low.
    • Educate clients on the importance of regular monitoring of heart rate and reporting changes.
    • Highlight the significance of adhering to the prescribed regimen and warning against abrupt cessation.

    Overview of Antidysrhythmic Medications

    • Antidysrhythmic medications modify cardiac electrophysiology to manage dysrhythmias.
    • Actions include altering conduction speeds, affecting heart's pacemakers, and stimulating autonomic responses.
    • Classifications include sodium channel blockers, beta-adrenergic blockers, potassium channel blockers, and calcium channel blockers.

    Class I: Sodium Channel Blockers

    • Slow conduction velocity in cardiac tissues.
    • Subdivided into:
      • Class IA: Quinidine, Disopyramide
        • Therapeutic uses: SVT, ventricular tachycardia, atrial flutter, atrial fibrillation.
      • Class IB: Lidocaine (IV), Mexiletine, Phenytoin
        • Short-term use for ventricular dysrhythmias.
      • Class IC: Propafenone, Flecainide
        • Used for SVT and decreases conduction velocity.

    Class II: Beta-Adrenergic Blockers

    • Prevents sympathetic stimulation in the heart.
    • Prototype: Propranolol; other options include Esmolol and Acebutolol.
    • Therapeutic uses: Atrial fibrillation, hypertension, angina, exercise-induced tachydysrhythmias.

    Class III: Potassium Channel Blockers

    • Prolongs action potential and refractory period.
    • Prototype: Amiodarone; others include Sotalol, Ibutilide, Dofetilide, Dronedarone.
    • Therapeutic uses: Conversion of atrial fibrillation, recurrent ventricular dysrhythmias.

    Class IV: Calcium Channel Blockers

    • Slow conduction and reduce myocardial oxygen demand.
    • Prototype: Verapamil; others include Diltiazem.
    • Therapeutic uses: Control ventricular rate in atrial fibrillation, SVT, and treat hypertension.

    Other Antidysrhythmic Medications

    • Adenosine: Decreases conduction through the AV node; used for paroxysmal SVT.
    • Digoxin: Increases myocardial contraction; used for heart failure and atrial fibrillation.

    Complications and Nursing Actions

    • Quinidine: Can cause diarrhea, cinchonism, cardiotoxicity (widening QRS), and hypotension; monitor ECG and vital signs.
    • Lidocaine: CNS effects can include seizures and responsiveness; ensure resuscitation equipment is available.
    • Propranolol: Monitor for bradycardia and does not initiate in AV block; check apical pulse before dosage.
    • Amiodarone: Monitor for pulmonary toxicity, visual disturbances, and potential liver dysfunction.

    Contraindications and Precautions

    • Quinidine: Not for patients with complete heart block or severe lupus. Caution with liver or kidney issues.
    • Lidocaine: Avoid in Stokes-Adams syndrome; use with caution in liver dysfunction.
    • Propranolol: Risk of complications during pregnancy; contraindicated in certain heart conditions.
    • Amiodarone: Known to potentially harm fetal development; contraindicated in newborns with AV block.

    Drug Interactions

    • Quinidine: Risk of toxicity increases with concurrent antidysrhythmics and certain antihypertensives.
    • Lidocaine: Metabolism affected by other CNS depressants, require dosage adjustment.
    • Propranolol: Can mask hypoglycemic effects; monitor blood sugars.
    • Verapamil: Risk of heart block when combined with other drug classes; monitor closely.
    • Digoxin: Levels can be increased by various antidysrhythmics; potassium levels must be monitored.

    Patient Education and Nursing Administration

    • Educate on taking medications as prescribed.
    • Monitor vital signs, especially during IV administration of lidocaine and adenosine due to rapid onset and short half-life.
    • Encourage dietary measures for potassium and educate about signs of potential toxicity for digoxin and other medications.

    Ototoxicity and Furosemide

    • Loop diuretics, such as furosemide, can lead to ototoxicity, characterized by symptoms like tinnitus, fullness in the ears, and hearing loss.
    • Patients taking furosemide should be educated to report any hearing-related symptoms immediately.
    • The risk of ototoxicity is heightened when furosemide is used in conjunction with aminoglycosides like streptomycin.

    Potassium Monitoring

    • A potassium level of 3.2 mEq/L indicates hypokalemia, falling below the normal range of 4.1 to 5.3 mEq/L in infants; this finding should be communicated to a physician.
    • Furosemide can lead to the loss of potassium, sodium, and magnesium, necessitating careful monitoring of electrolyte levels.

    Patient Assessment and Education

    • Older adult patients may experience increased risk of ototoxicity due to reduced renal metabolism of medications.
    • Nurses should monitor for signs of dehydration, using indicators like concentrated urine and specific gravity above 1.030.
    • Signs of hypokalemia can present as shallow respirations, muscle weakness, lethargy, and ectopic heartbeats, requiring prompt attention.

    Administration Guidelines

    • Furosemide should be administered at a low dose of 20 mg/minute or 40 mg over 2 minutes. It should not be diluted.
    • The medication is effective for patients with severe renal impairment, as it inhibits the reabsorption of sodium and chloride, promoting the excretion of water.

    Angina Treatment

    • For clients presenting with acute angina, such as crushing chest pain accompanied by ST changes on an EKG, nitroglycerin should be anticipated for administration due to its ability to promote vasodilation in vascular smooth muscles.

    Thiazide Diuretics

    • HCTZ (Hydrochlorothiazide) is used to treat diabetes insipidus by reducing urine production by 30-50%.

    Spironolactone

    • Derived from steroids; may cause endocrine side effects such as:
      • Gynecomastia and impotence in men
      • Irregular menses and hirsutism in women
    • Patients should be informed about potential hormonal changes.

    ACE Inhibitors

    • Can cause hypotension and dizziness; monitor blood pressure and advise patients on slow position changes.
    • Risk of severe neutropenia; patients should report symptoms of infection like sore throat and fever.
    • Instruct patients to take ACE inhibitors one hour before meals or two hours after meals.
    • NSAIDs, such as ibuprofen, may interfere with the effectiveness of ACE inhibitors; avoid combining these medications.
    • Angioedema is a serious side effect characterized by swelling of the tongue, lips, or pharynx.

    Diltiazem

    • Used to treat essential hypertension by lowering blood pressure.
    • Contraindicated in hypotensive patients.
    • Effective in treating tachydysrhythmias like atrial flutter, atrial fibrillation, and supraventricular tachycardia.
    • Often prescribed for patients with atrial fibrillation who are scheduled for cardioversion.

    Lifestyle Considerations

    • Advise patients to avoid coffee, alcohol, and caffeine on the day of an exercise stress test.

    Beta-Adrenergic Blockers

    • Treat hypertension by decreasing heart rate.
    • Can mask hypoglycemia symptoms; patients should recognize signs like hunger, nausea, and sweating.

    Digoxin Toxicity

    • Symptoms of digoxin toxicity may include:
      • Nausea
      • Anorexia
      • Fatigue
      • Visual disturbances
      • Cardiac dysrhythmias

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