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59 Cards in this Set
- Front
- Back
Coronary Artery Disease (CAD) |
Nurse will assess for EKG changes, angina pectoris
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Arteriosclerosis |
Nurse will assess for s/s of MI including pain, EKG changes, diaphoresis, and pallor
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Atherosclerosis |
Nurse will assess for pain, EKG changes, diaphoresis, pallor Patient is at risk for MI; should consider lifestyle changes such as reducing high fat foods, smoking cessation |
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Ischemia |
Nurse will assess for pain, EKG changes, diaphoresis, and pallor Treat pt w/ suspected MI w/ MONA-Morphine, oxygen, nitroglycerin, aspirin |
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Thrombus |
The nurse will promptly administer anticoagulant prophylactics in pts at risk for thrombus formation |
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Hyperlipidemia |
Nurse should educate patient about risk reduction (regular lipid screen, diet, exercise, use of lipid-lowering drugs)
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Metabolic Syndrome |
Nurse should encourage risk factor reduction through weight reduction, increased physical activity, interventions to lower BP (meds/low Na), lower serum glucose (good control), and lower serum lipids (meds/dietary)
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Angina Pectoris |
Nurse will administer nitroglycerin as ordered to pt experiencing angina pectoris to increase perfusion and O2 supply |
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Stable Angina |
Nurse will teach patient to avoid triggering factors and to self-administer nitroglycerin when experiencing angina at home |
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Variant/Prinzmetal, or vasospastic angina |
Nurse will teach patient to avoid triggering factors and to self-administer nitroglycerin when experiencing angina at home |
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Cardiac catheterization |
Assess pt for contraindications to catheterization: severe CHF, severe electrolyte imbalances, bleeding diathesis, serum creatinine >1.5 |
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Percutaneous Coronary Intervention (PCI) |
Keep NPO status prior to procedure |
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Stents |
Nurse should assess CV, vital signs, and ECG to avoid complications Nurse should assess distal pulses frequently as part of post-op focused assessment |
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AV Fistula |
Protect site by ensuring all staff understands NO BP or lab drawn on that arm Nurse should ensure that their is a sign informing other health care team members that no BP or lab drawn on that arm |
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Acute coronary syndrome (ACS) |
Nurse should administer appropriate meds (as ordered) - MONA |
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Unstable Angina |
Nurse should maintain pt on continuous tely monitor and carefully assess for s/s of ACS |
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Myocardial infarction (MI) |
Administer appropriate drugs (MONA) |
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NSTEMI |
Monitor ECG & encourage pt to inform nurse of any new s/s Administer appropriate drugs (MONA) |
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STEMI |
If on thrombolytic therapy, monitor for signs of reperfusion such as chest pain & ST segment elevation Encourage pt to inform nurse of any new s/s |
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Troponin |
High levels can indicate MI; nurse should notify MD of suspected MI |
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Creatine Kinase (CK) |
Nurse should recognize and monitor CK-MB for cardiac ischemia & infarction |
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Myoglobin |
Nurse should monitor for heart muscle damage |
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MONA |
Nurse should administer and titrate drugs per order for patients with suspected MI |
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Remodeling |
Nurse should monitor signs for adequate myocardial oxygen supply. Administer and titrate meds to balance O2 supply and demand |
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Coronary artery bypassing grafting (CABG) |
Nurse should provide post-op care to promote recovery & prevent complications (early mobilization, asses neuro status, OOB to chair, etc) |
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Annuloplasty |
Nurse should elevate HOB, encourage turning, C&DB post-op, and change dressing using aseptic technique |
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Aortic Valve Regurgitation |
Nurse should assess palpitation and diastolic murmur that is heard best at 2nd right intercostal space and radiating to the left sternal border |
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Aortic Valve Stenosis |
Nurse will assess for dyspnea, angina, exertional syncope, increased pulmonary artery pressure, and harsh crescendo-decrescent systolic murmur developing due to the valve orifice becoming one-third of its normal size |
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arrhythmogenic right ventricular cardiomyopathy (ARVC) |
Nurse should assess for palpitations, lightheadedness, and fatigue
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Beck's triad |
Classic assessment findings for patients with cardiac tamponade, consisting of decreased blood pressure, muffled heart sounds, and jugular venous distension
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Cardiac Tamponade |
Nurse should monitor for anxiety, CP (sharp, stabbing, radiating to shoulder, back or abdomen), cyanosis, palpations, tachypnea, weak or absent pulses
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Cardiomyopathies (CMPS) |
Caused by alcohol intake, hypertension, CAD, or may be idiopathic
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Dilated Cardiomyopathy (DCM) |
Nurse should continuously monitor for changes in mental status, fluid status, peripheral persuion, and heart rate and rhythm.
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Echocardiography |
The noninvasive assessment of the structures and function of the heart and great vessels utilizing high-frequency (ultrasound) sound waves
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Effusion |
abnormal accumulation of fluid
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hypertrophic cardiomyopathy (HCM) |
NI:Administer beta-adrenergic blocking agents and calcium antagonists as prescribed |
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infective endocarditis (IE) |
NI:Assess for new or changing murmurs, embolic events, and skin manifestations |
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mitral valve prolapse (MVP) |
Assess for sharp stabbing chest pain during rest or periods of stress, panic attacks,chronically cold hands and feet. |
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mitral valve regurgitation |
NI: If acute, assess for sudden onset of dyspnea, blowing high-pitched, systolic murmur and thready peripheral pulses. NI: If chronic, assess for gradual onset of dyspnea, peripheral edema, S3 and pansystolic murmur at the apex radiating to the left axilla. |
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mitral valve stenosis |
Assess for dyspnea, orthopnea, afib, and loud first heart sound (S1) |
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myocarditis |
Educate pt to avoid excessive fatigue and stop all activities immediately when light-headedness, dyspnea, or faintness occurs |
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pericardial effusion |
An excess buildup of pericardial fluid that is a threat to normal cardiac function. The fluid buildup is the result of an accumulation of infectious exudates or toxins and/or blood. |
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pericardial friction rub |
Auscultate for grating, scraping, or crunching sound over pericardial sac. |
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pericarditis |
NI:Assess for pericardial friction rub or pericardial effusion |
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pulmonic valve regurgitation |
Assess for high-pitched diastolic blowing murmur along left sternal border, dyspnea,and afib. |
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pulmonic valve stenosis |
Assess for systolic crescendo-decrescendo murmur heard in 2nd left intercostal space and tall peaked T waves from atrial hypertrophy. |
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restrictive cardiomyopathy (RCM) |
Assess for S3 systolic murmur, syncope, exercise intolerance, signs of pulmonary and systemic congestions |
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rheumatic fever |
NI:Assess for fever, headache, swollen tender joints with small bony protuberances, SOB, elevated WBC. |
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rheumatic heart disease |
Educate patient to decrease myocardial oxygen demand/cardiac workload |
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tricuspid valve regurgitation |
Assess for high-pitched blowing systolic murmur heard over xiphoid process, prominent waves in the neck veins, and tall P waves in normal sinus rhythm. |
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tricuspid valve stenosis |
Low-pitched rumbling diastolic murmur heard over 4th intercostal space of left sternal border, prominent waves in the neck veins, and tall P waves in normal sinus rhythm. |
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valvuloplasty |
Educate patient that this procedure is surgically repairing a valve leaflet under general anesthesia and cardiopulmonary bypass. |
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Ascites: |
Nursing:nurse will know ascites is a clinical manifestation of heart failure and will assess for other signs such as, hypotension, rales, tachypnea, confusion,pitting edema etc |
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Cardiomegaly |
Nursing:this is found in stage B of heart failure- these patients are usually asymptomatic; treatment if a cardiomegaly along with other signs of stage B heart failure are found is admin ACE inhibitors, ARBs and beta blockers to prevent further damage to the myocardium |
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Diastolic dysfunction |
Nursing:nurse will know that this type of heart failure most often effects older women and patients with HTN, diabetes, obesity and A Fib; treatment focuses on controlling HTN, ischemia and ventricular rate when A Fib is present and minimizing congestion |
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Left-sided heart failure |
S/S:fatigue, activity intolerance, SOB, cough, pulmonary congestion, crackles,orthopnea, poor concentration |
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Left Ventricular Ejection Fraction (LVEF): |
Nursing:nurse will know that a dysfunctional LVEF correlates with systolic dysfunction and will be aware that the heart will be unable to pump blood to sustain metabolic demands and if damage is extensive Left, Right or biventricular HF can occur- watch for symptoms of HF and determine |
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Right-sided heart failure |
S/S: ascites, edema, elevated neck veins, lower extremity swelling Nursing:determine if the signs/symptoms are associated with heart failure. Rule out other disorders such as neurological |
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Systolic Dysfunction |
left ventricular systolic dysfunction (LVSD) results in volume overload and decreased contractility. The heart is unable to pump enough blood to sustain the body’s metabolic demands and can result in heart failure. Most commonly caused by CAD & HTN. |