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Pt Management & Problems of the CV System - Part 1 Cheat Sheet by

Adult Health 2

Physio­logical Changes with Age

Cardiac Valves: stiffen, calcify, degenerate = expect murmurs ("sw­ish­")
Conduction System: coronary arteries get poor blood = necrosis, arrhyt­hmias; lose pacemaker cells, lose conduc­tion, fat in SA node, coming from ectopic muscle
Left Ventricle: atrophies, stiffens, enlarges, becomes less disten­sible, dec. SV & CO, dec. EF, most noticeable w/ physical activity
Aorta & Large Arteries: thicken, stiffen, less disten­sible = pumps harder ( inc. HR) & inc. systemic vascular resistance
Barore­ceptors: located in carotid arteries; help regulate BP; less sensitive w/ age; most noticeable w/ position changes
Framingham Heart Study (1948): Landmark study done in Framin­gham, MA looking at cardiac risk and what we can do--mo­dif­iable & non-modif. risk factors
- 5,209 subjects (mean age 47) & offsprings
- Establ­ished the CV risk profile!

Assess­ment: Psycho­social

Ask about...
Occupa­tion?
Insurance?
Support system?
Pets at home?
Hobbies that may help?
* Patients won't get better if they're stressed!
 

Assess­ment: Modifiable & Non-Modif. Risk Factors

MODIFIABLE RISK FACTORS
Age: symptoms start by 40yo, unlikely to survive MI if <30yo b/c collateral circul­ation
Ethnicity: more prevalent in non-Hi­spa­nics, death rate higher in African Amer. (HTN)
Heredity: HTN, inc. lipids, DM, obesity
Gender: men > women until menopause, childb­earing women have 25% chance, women >40yo & after menopause > men (r/t heart size & collateral circul­ation)
NON-MO­DIF­IABLE RISK FACTORS
BP: biggest problem = insidious - take meds if needed
HLD: goals - total choles­terol < 200; HDL > 50, LDL < 70 - take meds if needed
Smoking: temp of vape = hyperp­lasia, asthma­-like symptoms; causes 21% of CVD deaths; carcin­ogenic; inc. epic & norepi = heart works harder, vasoco­nst­riction & dec. circul­ation, C monoxide = inc. vessel perm.
DM: r/t early athero­scl­erosis, inc. thickening of blood
Physical Inactivity: "new smokin­g", exercise inc. collateral circul­ation
Obesity: extra burden on heart
Personal Factors: stress, psych. response
Collateral circul­ation: inc. angiog­enesis; adding vessels to supply cardiac circul­ation

Obese: BMI >30 / Morbid Obese: BMI >45
Super Morbid Obese: BMI >65
 

Assess­ment: Subjective & Objective Data

SUBJECTIVE DATA (History of Symptoms)
Chest Pain: (activity w/) onset? location? severity? type? precip­itating factors? other Sx? may c/o nausea, indige­stion
- Causes: cardiac (myoca­rdial), pulm., m/s
Dyspnea or SOB: often assoc. w/ left side heart pain, dec. perfusion, orthopnic
Palpit­ations: usually PAC, c/o rapid HR = dec. EF & CO (caffeine)
Fatigue: mild to severe, may attribute to getting older (compare to daily activity)
Extremity Pain: arm (may be R), jaw
Syncope: if issue w/ CO
Weight Gain: fluid, daily wt, anasarca
OBJECTIVE DATA
General Appearance: AAOx3?, posture
- Restle­ssness assoc. w/ change in O2
Vital Signs: BP? HTN < 130/80, check BP bilat., may see a parado­xical change in BP
Heart Sounds: S1, S2; may hear S3 & S4, murmurs, clicks
Cyanosis & JVD: pallor; JVD = R-sided HF (cor pulmon­ale), seen w/ OSA; = give Lasix
Subjective Data: Ask for chief complaint (usually CP), PMH, current health
- Dehydrated = lose H20 & electr­olytes

Objective Data:
Pulse Pressure: SBP - DBP; normally 30-40
- Closer (~20): r/t vasc. resistance = dec. CO & SV
- Widened (~40): r/t slow HR, athero­scl­erosis, inc. w/ age

Diagnostic Studies

SERUM CARDIAC ENZYMES (SERUM MARKERS) OR CARDIAC BIOMARKERS
Troponin: GOLD STANDARD OF CP; appears 2-4 hr after damage to myocardial muscle, inc. further depending on damage
CK-MB: r/t cardiac muscle; detected 2-4 hr after damage, elevated 72 hr max
CK-MM: r/t skeletal muscle
CK-BB: r/t brain tissue
Myoglobin: byproduct of muscle breakdown, appears in 2-4 hr, then dec.; affects kidneys; rhabdo­myo­lysis
BNP: r/t stretch of heart; correlates + w/ HF; secreted by ventricles r/t stress
CRP: non-sp­ecific inflam­matory marker; correlates + w/ athero­scl­erosis; good for determ­ining severity of disease process
Myelop­ero­xidase: leukocyte enzyme r/t plaque instab­ility and enzyme production
Ischemia Modified Albumin: circul­ating albumin touches ischemic tissues
Homocy­steine: get from eating meat (in amino acids), linked to disease develo­pment
Serum Lipids: correlates + w/ intrav­ascular plaques
COAGUL­ATION STUDIES
Unfrac­tio­nated Heparin: if elevated, give protamine sulfate
APTT
PT/INR: if elevated, give vitamin K
Why do coagul­ation studies? To know if pt is anti-c­oag­ulated in case of procedure

Antidotes
* Coumadin = vitamin K
* Many newer generation anti-c­oag­ulants don't have antidotes! = Give cryopr­eci­pitate

More Diagnostic Studies

OTHER
EKG
shows issues r/t heart rhythm; 12-lead EKG w/ age 40yo+
Telemetry
contin­uously monitoring EKG, ambulatory
Holter Monitor
ambulatory type, pt takes it home & writes down what they do to compare it to the rhythm
X-Ray
shows enlarg­ement, fluid; pulmonary edema r/t CHF?
STRESS, NUCLEAR, & ULTRASOUND TESTS
Exercise Stress Test
look at BP and HR w/ inc. exercise and inc. myocardial O2 demand
Nuclear Perfusion Imaging
stress test & blood flow through the heart
Echoca­rdi­ogram
shows wall movement, overall ventil­atory perfor­mance; can tell how badly heart was damaged
TTE
2-D
TEE
3-D (better)

Serum Electr­olytes & the Heart

K
biggest electr­olyte r/t heart
 
Hypoka­lemia: inc. electrical instab­ility, a fib, digoxin toxicity
 
Hyperk­alemia: P-wave issues, bradyc­ardia, asystole, ventricle issues; give Kayexa­late, insulin (IVP 10 units) + D50; give Lasix
Na
r/t CHF
 
Hypona­tremia
 
Hypern­atremia
Ca
Hypoca­lcemia
 
Hyperc­alcemia
Mg
Hypoma­gne­semia
 
Hyperm­agn­esemia
P
Hypoph­osp­hatemia
 
Hyperp­hos­pha­temia
Insulin: K follows glucose into cells
               
 

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