Cardiac Exam Review Slide *Hard*

Cardiac Exam Review - May 2024

• Cardiovascular Problems - Possible Indicators:
  • Chest pain
  • Heart murmurs (turbulent blood flow through a valve)
  • Dyspnea on exertion
  • Dizziness
  • Poikilothermia (peripheral arterial disease)
  • Orthostatic hypotension
  • Dependent rubor
  • Edema

Diagnostic Tests

• Stress Test: NPO 2-4 hours, no smoking/caffeine, wear comfortable clothing, and walk.
• EKG (ECG): Lie still, normal breathing, ensure accurate lead placement; skin clean and dry.
• Holter Monitor: 24-72 hour continuous monitoring (for low risk, intermittent symptoms)
• Echocardiography: Shows heart motion.
• Duplex Ultrasound: Shows blood flow through arteries and veins; identifies blockages.

Cardiac Catheterization/Angioplasty

• Prep: Check for prior reactions to contrast dye. Signed consent needed.
• Pre-procedure: NPO 6-8 hours
• Procedure: Local anesthesia; warm, flushed feeling.
• Post-procedure: Increased fluids. Maintain bed rest, pressure dressing.
• Follow-up: Monitor neurovascular status, vital signs, heart rate, rhythm. No flexion of extremity.

Neurovascular Checks

• Assess circulation: color, temperature, capillary refill, pulse quality.
• Assess motion: ability to move digits.
• Assess sensation: paresthesia, ability to feel pain/pressure.

Cardiac Exam Review - Question and Answers

• Question 1: A client presents with 8-10 hours sleep, smoking, weekend alcohol use, rare exercise, low back pain, dyspnea on exertion, chest discomfort, and a sour taste in their mouth. What findings may indicate cardiovascular issues? Select all that apply.

  • Rarely exercising
  • Chest discomfort
  • Back pain
  • Sour taste in mouth
  • Dyspnea on exertion
  • Smoking history
  • Sleep pattern
  • Alcohol use

• Question 2: A patient is following cardiac catheterization. What action is needed to assess neurovascular status of the extremity?

  • Check pedal pulses bilaterally.

Lab Values

• Cardiac Biomarkers (Troponin, CK-MB): Elevated levels indicate cardiac muscle damage and potential myocardial infarction. Troponin elevated for 7-10 days after injury.
• Total Cholesterol and LDL-C: Levels above 200 mg/dL increase heart disease risk. High levels of LDL-C further increase risk. Major sources: red meat, eggs, cheese, and full-fat dairy.
• PT/INR: Used to monitor warfarin levels. Normal values vary depending on equipment. Therapeutic range is 2-3 regardless of lab used.

Question 3

• Cholesterol Level of 240: Which foods should a client with a high cholesterol level (240 mg/dL) avoid in large amounts? Select all that apply.
  • Eggs
  • Whole milk
  • Red meat
  • Pasta
  • Chicken
  • Whole wheat

Decreased Cardiac Output

• Signs: Dizziness, syncope, weak/rapid pulse, hypotension, weakness, fatigue, activity intolerance, dyspnea.

Hypertension

• Normal BP: Less than 120/80.
• Accuracy: Correct cuff size; patient still; no talking; back/feet supported. Arm supported at heart level.
• Rest: 5 minutes before checking.
• BPI check considerations: avoid testing both arms with mastectomy, dialysis catheter. Orthostatic hypotension: check BP in lying, sitting, and standing position (done sequentially) and look for decrease in BP and increase in pulse with dizziness.
• Risk factors (modifiable): Obesity, sedentary lifestyle, high fat/sodium/calorie diet, stress, smoking, excessive alcohol intake (more than 1-2 drinks/day), less than 5 hours of sleep
• Risk factors (non-modifiable): Family history, age, gender, ethnicity (non-Hispanic blacks at highest risk)
• Complications: Stroke, vision loss, heart failure, cardiomegaly, myocardial infarction, peripheral arterial disease, renal damage (second most common cause of chronic renal failure)

Patient Teaching for Hypertension

• Medications: Take as instructed. Do not stop abruptly. Take medication even if blood pressure is normal.
• Sodium: Decrease sodium intake.
• Pulse/BP Checks: Monitor Pulse and blood pressure before beta-blockers and calcium channel blockers.
• Position changes: Change positions slowly to avoid orthostatic hypotension.

Cardiac Surgery

• Pre-op: Hold anticoagulants and diuretics for up to 1 week and 24 hours before surgery. Diabetics should avoid insulin or antidiabetic medications before surgery.
• Post-Op: Monitor vital signs, heart rhythm, urine output, and lung sounds.
• Pain management: Medicate for pain before moving patients.
• Respiratory Function: Encourage incentive spirometry.
• Additional: Sternotomy dressing changes under sterile technique.

Medications (General)

• Beta-blockers/Calcium Channel Blockers: Check Pulse and blood pressure before administering. Not recommended if pulses or BP are below certain levels.
• ACE Inhibitors/Other Antihypertensives: Check BP before administering. Hold if below certain levels.
• Diuretics: Monitor potassium levels. Diuretics like furosemide , bumetanide can decrease potassium. Spironolactone may increase it. Hold if hypokalemic.
• Warfarin: Monitor PT/INR. Consistent vitamin K intake recommended. No OTC medications without consulting healthcare provider (like aspirin & NSAIDs). Bleeding precautions (soft toothbrush, electric razors, avoid barefooting, medical alert identification)

Question 4

• Question: Nurse is administering 9 a.m. medications; BP 118/64; pulse 68; morning potassium 3.2 mEq/L (range 3.5-5mEq/L) . Which action is needed?
  • Administer all medications as prescribed.

Other Topics

• Valve Disorders: Etiology: congenital, aging, endocarditis, rheumatic fever. Symptoms: heart murmur, dysrhythmias, palpitations, chest pain; Complications: heart failure, stroke, endocarditis, Interventions: medications to manage dysrhythmias and heart failure, preventative stroke; valve repair or replacement, Biologic valves last 7-10 years (no anticoagulation required); Mechanical valves require lifelong anticoagulation
• Endocarditis: Risk factors: Valve disorders, IV drug use, gum disease, prior endocarditis, rheumatic fever. Signs and symptoms: Heart murmur, fever, malaise, petechiae, Janeway lesions, Osler's nodes, splinter hemorrhages. Treatment: Antibiotics. Complications: Heart failure, valve dysfunction, stroke.
• Pericarditis: Inflammation of pericardial lining. Symptoms: Pleuritic chest pain (sharp, heavy), worse with coughing and deep breathing, better when sitting up and leaning forward; Friction rub; Dyspnea. Complications: Heart failure, cardiac tamponade (jugular venous distention, tachycardia, hypotension, muffled heart sounds).
• Cardiomyopathy: Enlargement of heart. Dilated (most common): Heart stretched, less contractile. Common etiologies: hypertension, pregnancy, alcoholism; Restrictive: Heart walls rigid, don't expand or contract normally; Hypertrophic: heart muscle enlarged; decreasing volume of heart chambers
• Deep Vein Thrombosis (DVT): Clot in a vein. Risk factors: venous stasis, immobility, oral contraceptives, smoking, vessel injury, (surgery), crush injuries, IV catheters, hypercoagulability (dehydration). Symptoms: redness, warmth, edema, pain, hard (indurated) distended vein. Treatment: anticoagulants, compression/antiembolism stockings, elevation, warm compresses. Complications: Pulmonary embolism, recurrent DVTs, venous insufficiency.
• Math (Cardiac Output): Stroke volume x heart rate; convert to liters/minute and round to the nearest 10th; Drop factors (drops per minute): Volume X drop factor/time; Hourly rate (infusions < 1 hour): volume X 60/time; Hourly rate (infusions > 1 hour): volume / hours