Understanding Echocardiograms

Echocardiogram

• A noninvasive ultrasound assesses heart structure and function
• Diagnoses valve disorders and cardiomyopathy like wall motion abnormalities, valve problems, and ejection fraction
• Detects fluid around the heart

Transthoracic Echocardiogram (TTE)

• A non-invasive external ultrasound of the heart
• Good image quality that can be limited by body habitus
• Sedation and routine prep are unneeded
• It is used to diagnose valve disorders and cardiomyopathy
• Evaluates heart structure size, shape, and motion
• Measures ejection fraction to determine heart health; a low ejection fraction is bad

Ejection Fraction

• It is non-reversible but its progression can be slowed

How Echocardiograms are Used

• Uses sound waves (no radiation)
• Gel is applied to help waves pass through the skin
• A probe is moved over the chest area
• The gel is wiped off after the procedure

Patient Education for Echocardiograms

• Explain the test's purpose
• Explain that the test takes 30-60 minutes
• Reassure that the procedure is painless and requires no sedation or recovery time

Transesophageal Echocardiogram (TEE)

• An invasive procedure where a scope is passed into the esophagus
• Offers superior image quality due to its proximity to the heart
• Produces clear ultrasonic images because waves pass through less tissue
• Detects clots, valve issues, endocarditis, and congenital defects
• More convenient for obese patients or women with large breasts; it bypasses extra tissue for a better heart view

How TEEs are Used

• Involves passing a small transducer through the mouth into the esophagus
• Sedation is used to prevent the gag reflex
• Provides images of the heart

Patient Education for TEEs

• Explain the test purpose
• The patient must be NPO for at least 6 hours prior to the test
• Explain to the patient how the procedure will be performed

Cath Lab

• Used for coronary angiography and stent placement
• Done in the cath lab or OR
• Invasive procedure to evaluate the presence and degree of coronary artery blockage
• Goal is to find and fix blockages, opening up the artery

Catheter Insertion

• A catheter is inserted into one of three types of vessels and threaded into either side of the heart
• The vessels are femoral, brachial, and radial

Percutaneous Coronary Intervention (PCI)

• Performed when cardiologists can access the blockage via a catheter
• Involves procedures like percutaneous transluminal coronary angioplasty (PTCA), arthrectomy, and stenting

Percutaneous Transluminal Coronary Angioplasty (PTCA)

• Stent goes around a balloon, which is inflated on the blockage to expand
• The stent is placed and left there

Arthrectomy

• Procedure to clean out blockages

Stenting

• Involves inserting expandable tubes into a narrowed or blocked artery

Rheolytic Thrombectomy

• Involves aspirating clots out of the vessel

Post Cath Care

• Frequently check vital signs and hemodynamic status
• Enforce bed rest per protocol, due to blood thinners and fall risk

Catheter Placement in the Groin

• Keep the patient on bedrest and lay them back for 1-2 hours
• Avoid bending and bleeding at the puncture/incision site
• The head of the bed must not be more than 15 degrees and bending the hip can cause bleeding

Assessing for Complications

• Look for bleeding at the perforation, heart, and insertion site
• Position is important because they will hold pressure on the cath site for 15 minutes
• For wrist bleeding; draw air out of the balloon slowly
• For groin bleeding; assess the site and look for bleeding beneath

Other Complications

• Hematoma formation involves bleeding inside the tissues
• Assess the site for color, swelling, and hardness
• Thrombosis has a risk of clot from bedrest, assess circulation via capillary refill, pedal pulse, and skin tone
• Cardiac dysrhythmias

Kidney Damage

• Radioactive dye is hard on the kidneys, an IV helps remove the dye

Discharge Instructions

• Avoid heavy activity for 24-48 hours and lifting over 5-10 pounds until cleared by a cardiologist
• Keep the site clean with soap and water, and pat it dry
• Watch for infection and report abnormalities or hematomas
• Medication teaching

Complications

• Bleeding/hematoma requires holding pressure and calling the provider
• Infection, dysrhythmias, contrast-induced nephropathy, thrombosis, allergic reaction to contrast dye, and arterial dissection are all complications

Cardiomyopathy

• Disease that affects the heart muscle, stretching of the heart

CHF (Heart Failure)

• Can be thought of as pump failure

Types of Heart Failure

• Left (Ventricular) failure causes a backup into pulmonary circulation
• Right-sided heart (ventricular) failure causes systemic circulation failure
• High output failure is due to increased metabolic need
• Systolic heart failure means the heart cannot contract or push forcefully enough to reduce injection fraction
• Diastolic heart failure means the heart doesn't relax or refill as it should

Left-Sided Heart Failure

• Involves the inability of the left ventricle to fill or eject enough blood out
• Think lungs since blood gets backed up in the lungs

Effects of Left Sided Heart Failure

• Decreased cardiac output leads to impaired tissue perfusion (especially toes and fingers)
• There’s increased venous pressure
• Backing up of blood (pulmonary congestion) leads to breathing issues
• Weakness, fatigue, dyspnea, orthopnea, pulmonary congestion, cough, and pink-frothy sputum are signs/symptoms
• Chest discomfort and irregular heart rhythm

Right-Sided Heart Failure

• Involves the inability of the right ventricle to fill or eject enough blood into the pulmonary circulation
• The right side of the heart normally pumps deoxygenated blood to the lungs

Other Symptoms

• Peripheral edema, ascites, and enlarged liver
• Diuresis at rest occurs because lying down puts less workload and the body does its job
• Jugular distention and dependent edema are also seen
• Fluid retention and high blood pressure are symptoms

Diagnostics and Lab Testing

• B-type natriuretic peptide (BNP) is a hormone that promotes vasodilation & diuresis, produced when the ventricles have fluid overload; used to determine heart failure
• CMP indicates electrolytes
• CBCs look at blood supply or anemia
• Chest XRAY sees the heart and fluid presence
• Echocardiography visualizes the heart structure with sound waves

Nursing Interventions

• Take medications as prescribed
• Stay active, but don’t overdo it and take breaks
• Limit salt intake to avoid fluid overload
• Report symptoms to the provider
• Elevate the head of the bed and use extra pillows
• Avoid NSAIDs

Medications

• ACE inhibitors & ARBs which block aldosterone and prevents water and sodium retention which means a cough is normal and harmless
• Diuretics get rid of excess fluid and reduce workload
• Digoxin increases contractility while slowing the heart rate and SNS
• Beta-blockers reduce the workload and vasodilate

More Interventions

• Continuous Positive Airway Pressure (CPAP) is used for sleep apnea
• Cardiac Resynchronization Therapy (CRT) uses a pacemaker

Other Lifestyle Changes and Interventions

• Encourage dietary modifications, such as a low sodium diet

Pulm Edema

• A large amount of fluid backing up in the lungs (LHF)
• A complication of LHF related to fluid backup

Nursing Assessment & Interventions

• Assess for shortness of breath at rest, anxiety, restlessness, and confusion
• Monitor increased BP, reduced urinary output, pink-frothy sputum, and dysrhythmias
• If not hypotensive, sit the patient up and drop legs to reduce venous return
• Provide high flow oxygen therapy, nitroglycerin, diuretics, and IV morphine

Dietary & Lifestyle Changes

• Focus on sodium reduction

CAD (Coronary Artery Disease)

• Also known as heart disease
• CAD is a broad term including stable angina and acute coronary syndromes
• One of the most prevalent cardiovascular diseases in adults

Atherosclerosis

• Blocked/hardened/narrowed coronary arteries
• Results in myocardial infarction through plaque buildup in arterial walls
• High cholesterol attaches to arterial walls where it becomes hardened resulting in a deficient blood supply.

Risk Factors

• Non-modifiable risk factors are age, gender, ethnicity, and family history
• Modifiable risk factors include smoking, diet, activity, and obesity

Diagnostics and Lab Testing

• Look at lipid panels, LDL (bad cholesterol) <100, HDL (good cholesterol) >60, triglycerides >= 175 mg/dL
• Elevated BP
• ECG or EKG

Other Testing and Interventions

• Stress test and cardiac cath
• Check troponin T levels

Nursing Interventions

• Medication adherence and monitor for chest pain

Patient Teaching

• Stop smoking

Diet Modifications

• Follow a low fat, low cholesterol, high fiber/Mediterranean diet
• Patients should limit their intake of sweets and sugar-sweetened beverages
• Refer to a dietitian

Physical Activity

• Regular, moderate physical activity increases HDL levels and reduces triglyceride levels
• Reduces the incidence of coronary events and overall mortality risk
• Aim for 150 minutes of moderate or 75 minutes of vigorous aerobic activity per week

Medication Education

• If diet alone cannot normalize cholesterol levels, use meds alongside diet

Further Info

• Bile acid sequestrants, HMG-CoA (statins), and cholesterol absorption inhibitors can be used

Angina Pectoris

• An imbalance between oxygen supply and the cardiac muscle's demand
• It causes chest pain and can lead to ischemia

Chronic Stable Angina

• Patient has had angina before
• Easily relieved with medication (nitroglycerin)

Signs and Symptoms

• Chest pain, may be poorly localized and may radiate
• Feeling of weakness or numbness in the arms, wrists, and hands
• Shortness of breath, pallor, diaphoresis, dizziness or lightheadedness, nausea & vomiting are symptoms

Maintained with Meds

• Nitroglycerin is the main treatment
• Dissolve under the tongue, one at a time, 5 minutes apart (max of 3 doses)
• If no improvement after 3 doses, seek immediate medical attention

Myocardial Infarction

• Heart attack caused by plaque holding on to platelets and causing blood clots, preventing oxygen from reaching the heart
• Described as feeling like an elephant is sitting on the chest

Stemi

• EKG shows how the hearts beating, STEMI EKG can look like a tombstone with ST elevation

Nonstemi

• Shows a normal sinus rhythm

Nursing Assessment

• Assess airway, vital signs, breathing, and circulation
• Prep the patient for cath lab to open the blockage
• Obtain 12-lead ECG for STEMI
• Ask about pain location, radiation, how the patient would describe the pain, and if it is similar to previous pain

Other Questions for Patients

• "Can you rate the pain on a 0-10 scale, with 10 being the most pain?"
• "When did the pain begin?"
• "How long does it last?"
• "What brings on the pain?"
• “What helps the pain go away?"
• “Do you have any other symptoms with the pain?”

Medical and Nursing Interventions

• Morphine sulfate for pain
• Oxygen administration
• Nitroglycerin and Aspirin/Plavix

Other Interventions

• Beta blocker for vasodilation and to reduce HR & BP
• Have patient stop activities and sit and rest in bed in a semi-Fowler's position
• Monitor troponin T, CKMB, and lipid profiles
• Possible stress test or thallium, microalbuminuria, blood coagulation studies, check electrolytes, and possible chest XRAY

Types of Angina and Patient Teaching

• Unstable angina: new onset, increasing frequency and severity, not relieved with rest or nitroglycerin
• Intractable or refractory angina: severe incapacitating chest pain
• Variant angina/Prinzmetal’s angina: pain at rest with reversible ST-segment elevation; caused by coronary artery vasospasm
• Silent ischemia: objective evidence of ischemia (such as electrocardiographic changes with a stress test), patient reports no pain

Complications After MI

• Death, arrhythmia, rupture, tamponade, heart failure, valve disease, aneurysm of ventricle, Dressler’s syndrome, embolism, recurrence/ mitral regurgitation

Vascular Information

• “Peripheral” means away from the heart (fingers, toes, brain, ears, nose, etc!)

HTN (Hypertension)

• The pressure in a cardiovascular system determined by cardiac output (how much the heart can pump out, HR x Stroke Volume = CO)

High BP Impacts

• High BP can affect the heart, kidneys, brain, peripherals, etc

Peripheral Vascular Resistance

• Small arterioles; smallest diameter; responsive to fight or flight

Diagnosis of HTN

• Must be based on 2+ accurate readings taken 1-4 weeks apart or 2-3 week period

Arterial Baroreceptors

• Take action when a change is sensed
• Can lead to vasoconstriction and vasodilation
• Sense changes in body position, such as orthostatic hypotension

Regulation of Body Fluid Volume

• Kidneys regulate BP by retaining or excreting fluid

RAAS (Renin-Angiotensin-Aldosterone System)

• Converts angiotensin 1 to angiotensin II and controls aldosterone release
• Causes sodium to be reabsorbed and retain fluid

Vascular Autoregulation

• Maintains tissue perfusion

HTN Classifications (for Patients <60)

• Normal: both systolic and diastolic must be 120-139 mmHg & 80-89 mm Hg
• Stage 1 HTN: systolic or diastolic 140-159 mm Hg & 90-99 mm Hg
• Stage 2 HTN: systolic or diastolic >/= 160 mm Hg & >/=100 mm Hg

HTN Classifications (Age Considerations)

• Ages 60-65 ~ 150/90
• Ages 150 mm Hg; diastolic >130-150 mm Hg
• Common symptoms include morning HA, blurred vision, and dyspnea
• May lead to kidney failure, left ventricular heart failure or stroke if untreated

Modifiable Risk Factors

• Maintain healthy weight; exercise regularly (30-60 minutes/day, 5 days/week); DASH meal plan; reduce daily sodium intake (2300 mg or less a day, 1500 mg a day for people 50+); limit daily alcohol intake; avoid tobacco/ nicotine; decrease caffeine intake; maintain potassium and calcium intake; reduce stress; and monitor BP daily.

Nonmodifiable Risk Factors

• Age, family hx, gender, race

Signs and Symptoms

• Headaches, facial flushing, diaphoresis, nosebleeds, dizziness, fainting, vision changes, nocturia are common

CMS

• Often asymptomatic “silent killer” and targets organs with retinal damage, cardiac changes, renal changes, and neurological changes

Other Interventions

• Lifestyle modification, limit alcohol, quit smoking, monitor BP regularly, and exercise

Medical Management

• Diuretics (first prescribed) and antihypertensives as a means of medical management

Medication Side Effects

• Too low BP (hypotension); dizziness; bradycardia; orthostatic hypotension; erectile dysfunction; electrolyte imbalance; cough

Patient Teaching

• Stand up slowly, and encourage medication adherence
• Encourage regular BP checks

Complications of Prolonged Force

• Prolonged arterial muscle thickening increases work
• Increased force damages arterial inner lining, high cholesterol forming a plaque, and hardened plaque in the artery

Other Complications

• Aneurysm; accelerated atherosclerosis; narrowed vessel lumen; ventricular hypertrophy; myocardial infarction; heart failure; cerebrovascular disease; renal failure; and retinopathy

Hypertensive Crises

• Hypertensive Crisis: occurs rapidly; may be urgent or emergent; REQUIRES IMMEDIATE INTERVENTION

More On Hypertensive Crisis

• CM: extremely elevated diastolic/systolic pressure; severe headache; dizziness, blurred vision; shortness of breath; anxiety
• Administer oxygen; position in semi-Fowler’s position, or reverse Trelleborg, or higher, to take pressure off the heart; start IV access; administer IV antihypertensive therapy
• IV HYPERTENSIVE THERAPY: sodium nitroprusside- Nipride: for emergency hypertension crisis; fast, potent vasodilator; causes venous and arterial vasodilation; infusion pump; protect from light;
• Monitor BP every 5-15 minutes until diastolic

Prostate-Specific Antigen (PSA) Levels

• 0-4 ng/mL=normal
• 4-10 ng/mL=prostatitis

• 10ng/mL = cancer

Primary Prostate Symptoms

• Urgency, frequency, and nocturia
• After it progresses: urinary retention, hematuria, enlarged prostate, back pain, secondary to metastasis (bone pain, because cancer can spread to lymph nose and bones); painful ejaculation; sexual dysfunction

Symptoms d/t Metastasis

• Backache, hip pain, perineal and rectal discomfort, enemia, weight loss, weakness, nausea, oliguria (decreased urine output)

Radical Prostatectomy Nursing Interventions

• For Radical Prostatectomy: maintain hydration with IV therapy; care for wound drains; analgesics ; prevent emboli; prevent pulmonary

TURP (Transurethral Resection of the Prostate)

• Surgical removal of prostate tissue through the urethra
• Closed procedure where patients given anesthesia; removes part of the enlarged prostates
• A 3-way catheter is inserted to irrigate the bladder to prevent blood clots

Post Op Care For TURP

• CHECK FOR BLADDER OCCLUSION FIRST! - Irrigation to remove clots; insure drainage bag is not full
• 30-45 mL retention balloon through the urethra of the bladder
• Taped to patient’s abdomen or thigh
• Monitor decrease in hematuria, first day red urine is normal but after 24 hours should be pinkish, clots are normal, bright-red urine after 24 hours report

Other Aspects of TURP

• Check B NO suppository, and vital signs
• Closed continuous bladder irrigation and possible serial urines after cathether removal
• Ambulate early and no prolonged sitting
• Stool softeners

Post-op Teaching

• Avoid alcohol, kegal exercises and increase fluids
• Resume sexual function after 6-8 weeks

Other Factors

• Erectile Dysfunction is also called impotence and it has risk factors like beta-blockers and antidepressants
• Offer reassurance

Prostatitis

• Inflammation or infection of the prostate and organisms reaching the prostate through the urethra or the blood stream
• Extremely painful, especially in acute cases

Acute Bacterial Prostatitis

• Low back pain, deep pain between the anus & scrotum; chills & fever; dysuria, frequency, urgency, nocturia; discomfort when sitting; anal penetration=bad hygiene

Medications For Acute

• Antipyretics, antispasmodics that may have UTI, and stool softeners
• Encourage fluid intake

Chronic Prostatitis

• Involves chronic UTI with weak stream, difficulty starting urination, pain and urethral discharge

Reduce Fluid Intake

• Avoid retention of prostatic fluid by providing reduced fluid intake

Nursing Care

• Increase fluids and avoid foods/fluids that promote a diuretic effect
• Sitz bath and donut pillows are indicated