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CCRN Cardiovascular Questions with answers, Exams of Nursing

CCRN Cardiovascular Questions with answers

Typology: Exams

2022/2023

Available from 09/15/2023

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CCRN Cardiovascular Questions with

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Cardiac Output ✔HR x SV Younger children tend to have a higher CO because their HR is faster. Cardiac Index ✔More specific indicator of hemodynamic status than cardiac output (includes body surface area in equation). CO is normally 4-8 L/min, however CI is 2.5-4.0 L/min/m2. CI=CO/BSA MAP (mean arterial pressure) ✔The mean pressure that takes into account the fact that the diastolic phase represents 2/3 of the cardiac cycle. MAP=2(DBP) + (SBP)/ Patients should maintain a MAP of at least 60 mmHg to ensure adequate perfusion to the brain and kidneys. Ejection Fraction ✔The ejection fraction should be over 50%. The is the amount of blood ejected from the left ventricle compared to the total amount available in the ventricle. An ejection fraction of 35% or less indicates a problem with contractility, outflow, or filling. The ejection fraction most closely represents left ventricular end-diastolic pressure. The LVEDP is the volume of blood under pressure left at the end of contraction. Tetralogy of Fallot ✔-Includes: VSD, overriding aorta, pulmonary stenosis, and right ventricular hypertrophy. -Condition results in low oxygenation of blood due to the mixing of oxygenatated, and deoxygnenated blood in the left ventricle via the VD, and mixing of blood from both ventricles through the aorta because of the obstruction to flow through the pulmonary valve. -End result is a right to left shunt.

-Primary symptom of TET is a low blood oxygen saturation, with or without cyanosis, from birht or developing in the first year of life. -Other symptoms include a harsh systolic murmur with a thrill, difficulty in feeding, failure to gain weight, retarded growth, and physical development. Polycythemia may be present with dyspnea on exertion, along with clubbing. -Children may have tet spells--results from a transient increase in resistance to blood flow to the lungs along with increased flow of desaturated blood to the body. May be precipitated by activity and are characterized by paroxysms of hyperpnea, irritability, prolonged crying, increasing cyanosis, and decreasing intensity of heart murmur. Maye result in hypoxic brain injury and death. Older children may squat which cuts off circulation to the legs. The squatting position raises intrathoracic pressure and systemic vascular resistance, thereby improving blood flow to the brain and vital organs. Diastolic phase ✔At birth, diastole represents half of the cardiac cycle, shortly after birth, the diastolic phase lengthens so that it represents 2/3 of the cardiac cycle. An increase in cardiac output decreases diastole. Reflex tachycardia ✔Caused by the stretch of right atrial receptors. Known as the Bainbridge reflex. The Bainbridge reflex is believed to occur to speed up the HR if the right side because overloaded and help equalize pressures in both sides. Pulmonary Artery occlusive pressure (PAOP) ✔Pressures in the left side of the heart and pulmonary filling pressures are represented by the PAOP. Balloon of the pulmonary artery catheter is inflacted, it eventually wedges in the pulmonary artery. The turbulence behind the balloon is blocked and it senses what is in front of it--the pulmonary vascular bed and left side of the heart. The normal value should be 5-12 mmHg. Left atrial pressure ✔A normal LAP is 8 mmHg. A high LAP would indicate mitral valve dysfunction. High right atrial pressures would be increased by either pulmonary stenosis or tricuspid regurgitation. S ✔The fourth heart sound disappears after the first 24 hours of life and if it stays indicates a decreased ventricular compliance.

The heart sound is produced when an atrial contraction fills up the ventricle. If heard in a newborn, sounds like a clicking sound right before S1. Systemic vascular resistance (SVR) ✔The mean pressure difference in the systemic vascular bed divided by blood flow. Indicates the resistance the left ventricle must pump against. Heart murmur ✔If murmur is associated with acute valvular regurgitation, it is called S4. S4 is associated with ventricular compliance. S3 is associated with fluid status. Stroke Volume ✔Comprised of contractility, preload, and afterload. Viscosity, blood volume, and impedance represents the components of afterload. Myocardiac sensitive toe changes, especially increased afterload. With only minute changes in afterload, the SV can fall significantly. Pulmonary catheter tracing ✔A large A wave may be seen with increased pressure during atrial contraction. Could be caused by mitral stenosis, an ischemic left ventricle, or failure of a left ventricle. Hill's sign ✔A popliteal BP that is 20+ mmHg higher than the brachial BP. Reflects the rapid rise in pulsation found in patients with aortic insufficiency. Pulsus alternanas ✔Occurs in left ventricular failure when the weakened myocardium cannot maintain an even pressure with each contraction. The pulses alternate between strong and weak. Can also be seen in CHF. Adenosine ✔Used for the suppression or elimination of sustained supraventricular tachycardia. Adverse effects may include transient arrhythmias, flushing, dyspnea, and apnea.

Caffeine and thophylline diminish the effects of adenosine. Right sided heart failure ✔Cause is often left sided heart failure. Right ventricle can't adequately pump, so filling pressures rise and the blood backs up, resulting in hepatomegaly. Thus, the CVP and RV pressures are elevated. Additional symptoms include splenomegaly, ascites, abdominal pain, S3 and S4 and weight gain. Pulmonary edema , an elevated PAD, PAOP and orthopnea are symptoms of left sided heart failure. Left heart failure EKG changes ✔Results in wide, notched P waves. Tall, peaked P waves are indicative of right sided heart failure. Changes in ST segments indicate myocardial ischemia. Atrioventricular canal defect ✔Condition that is often associated with an ostium primum ASD. This defect is also associated with a cleft in the anterior mitral valve leaflet, a VSD in the inlet portion of the ventricle septum, and a cleft in the septal leaflet of the tricuspid valve. Ventricular septal defect ✔Causes pulmonary vascular resistance (PVR) to be less than the systemic vascular resistance (SVR). This imbalance causes left to right shunting. So too much blood may enter the lungs, increasing edema and possibly delaying the maturation of arterioles. A pansystolic murmur can be heard over the left sternal border. Tet spells ✔May be treated with morphine to promote venous dilation. IV fluids can be used for volume expansion and an increase in systemic BP. If these don't work, phenylephrine or ketamine can help. Propranolol may prevent or mitigate tet spells.

Pulmonary vascular resistance (PVR) ✔The resistance against which the right ventricle must eject its volume. Calculated as a mean pressure in the pulmonary vasculature that is divided by the blood flow. Alpha-adrenergic effects of norepinephrine ✔Peripheral arteriolar vasoconstriction. Beta adrenergic effects of norepinephrine ✔Increased force of myocardial contraction, increased AV conduction time. S ✔Occurs when increased blood flow travels across the AV valves secondary to rapid passive ventricular filling from the atria. "extra fluid"--common with CHF, mitral valve insufficiency, anemia, and left to right shunts such as ASD, VSD, and PDA. Infants with CHF and interventional procedures ✔At high risk because contrast dye has a high sodium content. Sodium contributes to myocardial depression and creates an osmotic effect that temporarily increases intravascular volume. Infiltration of dopamine ✔Inject Phentolamine (Regitine) 1 mg/mL. May take as much as 5 mL to treat affected area. Bidirectional Glenn procedure ✔Used for hypoplastic left heart. Superior vena cava is anastomosed to the right pulmonary artery. Usually performed prior to 6 months of age to specifically reduce volume overload to the right ventricle. First stage is the Norwood procedure--consists of ligation of the ductus and division of the pulmonary artery.. The end result of the staged procedures is systemic circulation supplied by a single right ventricle.

Cyanotic heart defects ✔Pulmonary atresia Tetrology of Fallot Transposition of the great vessels Total anomalous pulmonary venous return Truncus arteriosus Hypoplastic left heart syndrome Tricuspid valve abnormalities. Acyanotic heart defects ✔Pulmonary valve stenosis Ventricular septal defect (VSD) Atrial septal defect (ASD) Patent ductus arteriosus (PDA) Aortic valve stenosis Coarctation of the aorta Cardiac murmurs ✔Present in 80% of patients with tricuspid atresia. A holosystolic murmur suggests blood flow through a VSD. Pansystolic murmur means that the murmur is heard throughout systole. Tricuspid insufficiency is a pansystolic murmur. Cardiac tamponade ✔The heart cannot adequately fill or eject its contents, so stroke volume decreases, which leads to decreased cardiac output. Contractility decreases because the muscle cannot adequately stretch and therefore cannot contract effectively. A dialated superior vena cava would appear on a chest x-ray because the blood content cannot empty in the right atrium. The mediastinum would be widened. A CXR will not show delination of the pericardium or epicardium. A pneumothorax may exist, but would not be an expected finding Beck's triad ✔Associated with cardiac tamponade. Consists of distended neck veins, muffled heart sounds and hypotension. Tachycardia is an early sign.

A narrowed pulse pressure occurs because fluid cannot be ejected from the heart. The muffled heart sounds occur because the fluid in the pericardial sac minimizes the transmission of sound waves. CVP monitoring ✔The C wave represents the increase in RA pressure from closure of the tricuspid valve. The W wave represents mechanical atrial diastole. A low CVP reading may indicate increased contractility or hypovolemia. A high reading may indicate LV, RV, biventricular failure, tricuspid regurgiation or stenosis, hypertension, hypervolemia, or cardiac tamponade. Tricuspid atresia ✔Tricuspid valve is missing or abnormally developed. Blocks flow from the right atrium to right ventricle. May exhibit polycythemia. Because of hypoxia in patients with tricuspid atresia, polycythemia may be present. PTT (prothrombin time) and aPTT (activated prothrombin time) may be abnormal secondary to the polycythemia. Cardiomegaly is usually present, along with a prominent right heart border that reflects enlargement of the right atrium. Sinus rhythm is generally present, with tall P waves indicative of atrial enlargement.. First degree AV block may be observed. Quincke' sign ✔Seen in patients with aortic insufficiency. This sign is elicited by pressing down on a fingertip. A visible pulsation is seen in the nail bed. This results from a pulse characterized by a rapid initial hard pulsation followed by a sudden collapse as blood flows back through an incompetent valve. Increases of afterload ✔Polycythemia--due to excess circulation of RBCs. Aortic stenosis Peripheral vasoconstriction Hypertension

Decreases afterload ✔Hypovolemia Sepsis Aortic insufficency Myocarditis diagnosis ✔Only way to diagnose myocarditis is via an endomyocardial biopsy. Environmental factors implicated in the etiology of Ebstein Anomaly. ✔Maternal ingestion of lithium in the first trimester of pregnancy. Maternal rubella Maternal benzodiazepine use Maternal exposure to varnishing substances Maternal history of previous fetal loss; EKG findings with Ebstein anomoly ✔Sinus with paroxysmal SVT Usually, NSR with intermitttent SVT, paroxysmal SVT, atrial flutter, afib, ventricular tachycardia are present. The PR is usually prolonged, accompanied by abnormal P waves consistent with right atrial enlargement. Cardiac glycosides ✔Possess positive inotropic activity, which is mediated by inhibition of sodium- potassium adenosine triphosphase. Cardiac glycosides reduce conductivity in the heart, particularly through the AV node, and therefore has a negative chrontropic effect. Cardiac glycosides can be used to slow the HR in supraventricular arrhythmias, especially afib, and are also used in patients with CHF. Sites most effected by endocarditis ✔Pulmonic valve is rarely affected by infective endocarditis. Mitral valve is most commonly affected.

Aortic valve is second most commonly affected.. Tricuspid valve is often secondarily involved due to IV drug abuse. Abnormal Q waves ✔Signify a complete thickness infarct of the myocardium. When the tissue dies due to MI, it electrically becomes dead, causing the opposing energy to become the dominant feature of the EKG. Milrinone ✔Decreases PVR and SVR Improves contractility Inhibits cyclic AMP Neo-Synephrine ✔Treatment for hypercyanotic tet spells Treatment of SVT and severe hypotension Myocarditis ✔Inflammation of the myocardium. Coxsackie B1 virus, numerous infections, systemic diseases, drugs and toxins are associated with the development. WBC less than 4000 or more than 25000 is considered abnormal. Absolute band count is not sensitive enough to predict the development of sepsis, but a ratio of immature to total polymorphonuclear leukocytes of less than 0.2 has a high predictive value. Reducing right ventricular afterload. ✔Inhaling nitric oxide, nitroglycerin, nitroprusside, PGE1, or hyperventilation. Increasing afterload ✔Use of epinephrine will increase sytemic afterload due to vasoconstriction and promote increased PVR because of the increased left heart pressures. Hypoventilation and subsequent hypoxia will also increase right heart afterload. Anaphylaxis ✔Involves mast cell degranulation with resultant histamine release and vasodilation. Results in a decrease in preload.

SIRS

✔Tachycardia or tachypnea with fever or a high leukocyte count. Sepsis ✔Sepsis is defined as SIRS in the presence of suspected or proven infection. Severe sepsis is defined as sepsis with accompanying organ dysfunction. When cardiovascular failure occurs in the setting of severe sepsis, then it is classified as septic shock. Pulmonary Hypertension and wedge pressures ✔An elevated right ventricular pressure and an elevated right atrial pressure indicate pulmonary hypertension. Wedge pressures reflect the status of the left side of the heart, so if the wedge pressure is normal, it means that fluid cannot clear the lungs, so it builds up and causes high right sided pressures. This causes edema buildup with dyspnea and exercise intolerance. Pericarditis ✔Seen on CXR Elevated sed rate and WBC count. Fever probably present. Leaning forward often relieves chest pain, whereas lying supine can make it worse. The pain may worsen on inspiration when the lungs expand and come in contact with the pericardium. Monitor for signs of cardiac tamponade and ensure that certain anticoagulants are discontinued. Narcan ✔Generally dose is 0.4 mg. Can be repeated every 3 to 4 minutes for up to 3 times. Must be alert for the potential relapse once the dose wears off. May have to administer follow up doses. Sodium nitroprusside (Nipride) ✔Patients should be monitored for cyanide toxicity.

Avoid in patients with renal problems. May result in tachycardia and severe hypotension. Monitor the venous O2 concentration and acid-base balance. If nitroprusside extravastes from and IV, it will cause tissue sloughing and necrosis. The RBC cyanide level should be less than 50 mcg/mL. Neonatal congenital heart block ✔Thought to occur when maternal antibodies pass through the placenta into the fetal circulation. Some infants are treated with corticosterioids and have a limited mediation of symptoms-- Symptoms may include thrombocytopenia, skin rash, and hepatitis. These symptoms may resolve, but some infants develop autoimmune diseases later in life. If congenital heart block does not resolve, it will become permanent. 2/3 of all infants with complete heart block require a pacemaker. Procainamide ✔Antiarrhythmic--depression of the excitability of cardiac muscle and slowing of the conduction in the atria. Adverse effects include severe hypotension (especially with rapid infusion) and A-V block. Also widens QRS complex due to the slow impulse conduction through the purkinje fibers and ventricular myocardium. If the QRS complex widens more than 35%-50%, use of procainamide should be discontinued. Adverse effects usually disappear when the drug is discontinued. Pericardial effusion ✔"Water bottle" silhouette on X-ray. QRS amplitude is decreased Diastolic filling is decreased Normal pulmonary artery pressures

✔PAS= 20-30/6-10 mmHg PAD= 5-12 mmHg PAM= 10-20 mmHg PAOP (PCWP)= 4-12 mmHg Signs of CNS toxicity from lidocaine ✔Agitation Vomiting Drowsiness Muscle twitching Later signs: Loss of consciousness Seizures Respiratory depression Apnea Cardic toxicity: hypotension, bradycardia, and heart block, leading to cardiovascular collapse. Parasympathetic and sympathetic nervous system and the right vagus nerve ✔SA node affected---slows the HR. Stimulation of the beta 2 receptor in the heart ✔Causes vasodilation (lowered SVR) Bronchodilation Smooth muscle relaxation Janeway lesions ✔flat and painless erythematous areas found predominately on the palms and soles of the feet. Osler's nodes ✔Small painful nodules that are associated with endocarditis and found on the fingers and toes. Roth Spots ✔Rounded white spots seen on the retina. Seen in endocarditis. Primary goal in cardiogenic shock

✔Goal is to improve the pumping action of the heart (improve contractility), reduce oxygen demand, and improve cardiac output. If possible, SVR (systemic vascular resistance) should be decreased and the left ventricle augmented with an inotrope. Administration of nitroprusside will reduce both preload and afterload. Cardiac workload will be decreased as is the myocardial oxygen demand. Left ventricular failure ✔Early signs: tachycardia and tachypnea Later signs: dyspnea and retractions. Cyanosis ✔Observed when at least 5 g/100 mL of deoxygenated blood is present in the circulation. Lidocaine ✔Lidocaine does not impaire normal contractility May shorten the QT interval, however side effects usually involve the CNS---slurred speech, drowsiness, confusion, seizures, parasthesias, and convulsions. Calcium channel blockers ✔Act primarily on arteriolar tissue, specifically large lumen vessels in the arterial system. Causes both systolic and diastolic pressures to be reduced. May causes a reflex barorecpetor response to speed up HR in order to maintain cardiac output. Point of maximum impulse in newborn ✔Lower left sternal border. Apical impulse of a newborn is in the 4th intercostal space, just to the left of the midclavicular line. S2 heart sound ✔Sound created by the closure of the pulmonic and aortic valves Best heart in the upper left sternal border or pulmonic area. Regurgitation systolic murmurs

✔Associated with VSD, tricuspid regurgitation, and mitral valve regurgitation. Caused by blood flow from an area of higher pressure throughout systole to an area of lower pressure. Rheumatic fever ✔Most common cause of acquired valvular disease. Causative organism is beta hemolytic Streptococcus. Infections in VAD patients ✔Pneumonia secondary to immobility is primary reason. Cardiac pressures ✔In patients with normal cardiac anatomy, right atrial pressure equals right ventricular end-diastolic pressure, which equals central venous pressure.