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NCM 118

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NCM 118  PR interval- Starts of the P to the start of the

QRS complex
Cardiovascular Disorders
- Not prolonged; .12-20 secs= 3-5 small boxes
Functions: - Abnormal patterns: Heart block

 Transport of O2, hormones, and nutrients


 Rate- count number of QRS; 60-100 bpm
 Transport of waste products for excretion - Abnormal; Tachy and bradycardia
 Generate BP
 Routing blood  ST-segment- end or QRS to start of T wave;
 Ensuring one-way blood flow usually flat
 Regulating blood supply - Abnormal: MI or Ischemia (elevated)
Anatomy:
The conduction System: Cardiac Tamponade- compression of heart due to fluid
SA- AV- Bundle of His- R and L bundle brunches- accumulation in the pericardial sac
Purkinje Fibers Chest trauma- Accumulation in the pericardial-
 Depolarization- Contraction Compression of the ventricles- decreased
 Repolarization- Relaxation Ventricular filling- Signs and Symptoms

 SA node- impulse start; “Physiologic


pacemaker”. P- wave, 60- 100 bpm, Atrial Beck’s Triad:
depolarization
 Decreased BP
- Located in junction of the SVC and right
 Distended Jugular vein
atrium
 Distant Heart Sound
 AV node- Secondary pacemaker; 40- 60 bpm, Signs & Symptoms:
delays electrical impulse to allow ventricular
filling  Dyspnea
- Located in interatrial septum  Increased in CVP
 Pulsus paradoxus
 R and L bundle branches- Ventricular  Signs of shock
depolarization; QRS complex  Chest pain- sharp and stabbing (caused
- Interventricular septum(bundle of His) by the heart rubbing against pericardium)
- Inferior to the bundle of His - May increase with coughing, swallowing,
deep breathing, or lying flat
 Purkinje- muscle fibers create a synchronized - Can be relieved by sitting up, and leaning
contraction; T wave; Ventricular repolarization. forward
- Located in the walls of the ventricle  Pain in the back, neck or left shoulder
 Difficulty breathing when lying down
5 ECG parameters:  A dry cough
ECG Morphology  Anxiety or fatigue

 P wave- small round and uptight Lab procedure:


- Abnormal patterns will lead to Atrial Rhythm  Echocardiogram- the extent of trauma; structural
and functional changes
 QRS complex- narrow, positive deflection at  Chest x-ray- Heart displacement, hypertrophy
lead II. .06 -.10 secs. and fluid in pericardial sac
1 small box= .04 secs Management:
- Abnormal patterns: Ventricular rhythm  Monitor ECG changes
 Elevate bed 40-60 degrees  S1- mitral and tricuspid valve close
 Monitor for complications  S2- Aortic and pulmonary valve close
 Assist Pericardiocentesis
S3 and S4- low pitch sound
 Administer IVF
 Monitor ECG, urine output and BP  S3- may indicate heart failure
 Monitor for recurrence of tamponade  S4- heard before S1
Non-pharma:

 Limit activity until symptoms resolve MITRAL STENOSIS- obstruction of blood flowing
 Hospitalize for close observation from the left atrium into the left ventricle
 Avoid Anticoagulants (increased risk of
- Can lead to right-sided heart failure
hemopericardium)
S/Sx:
Pharmacologic:
 Dyspnea
NSAID therapy; aspirin preferred in pt. with recent MI
 Fatigue
Colchicine 0.6 mg bid- recurrent pericarditis  Dry cough
 Wheeze
Corticosteroids- refractory or recurrent cases
 Atrial Fibrillation
- Prednisone up to 1.5 mg/kg/day x 3-4 wk  Heart murmur
may be added in pt. with severe symptoms of
acute pericarditis and suspected connective- Treatment:
tissue disease  Anticoagulant
Heart wall:  Antianemic
 Valvuloplasty
 Endocardium- inner layer
 Myocardium- muscular middle layer Nx Care:
 Epicardium- protective outer layer  Advise to avoid strenuous activities and
competitive sports

Chambers:

 Right Atrium- receives blood from the vena cava Blood supply:
and coronary sinus  Left coronary artery- supply much of the anterior
 Left Atrium- Receives blood from the pulmonary wall and most of the left ventricle
veins from the lungs  Right coronary artery- supply most of the wall of
 Right Ventricle- pumps blood to the pulmonary the right ventricle
trunk to the lings
 Left Ventricle- pumps blood to the aorta to the Heart rate:
parts of the body - 60-100 bpm
- Influenced by the sympathetic and
parasympathetic nervous system
The valves:
Pulse Scale:
 Atrioventricular- between atria and the ventricles
(Tricuspid and Bicuspid) 0- Not palpable
 Semilunar- located in the aorta and in the trunk +1- weak thready, obliterated with pressure
(Aortic and Pulmonary valve)
+2- diminished pulse, cannot be obliterated
The valves and the Heart sound:
+3- easy to palpate, full pulse cannot be obliterated
S1 and S2- high pitch
+4- strong, bounding pulse; may be abnormal
- Avoid when hyperkalemia, ace inhibitor,
arbs medication
Blood pressure:
 Potassium-wasting- Furosemide (Lasix);
- 120/80 mmhg Bumetanide (Bumex); Mannitol; Diuril
(Chlorothiazied)
Regulated by: - Eat potassium rich food (potato, apricot,
 Nervous system banana, orange, watermelon, strawberry)
 ADH/ vasopressin Beta- Blockers:
 RAA mechanism
- Blocks beta receptors in the heart causing:
Prehypertension- 120- 139/ 80-89 decrease heart rate, force of contraction, rate
Stage 1 hypertension- 140-159/90-99 of A-V conduction

Stage2 hypertension- >160/>100 B1- affect heart


B2- affect lungs

HYPERTENSION- blood pressure of 140/90 or above


after 2 consecutive readings ACE inhibitors:
 Accuracy of the BP reading depends on the - Decrease peripheral vascular resistance
selection of the correct cuff size without increasing CO, cardiac rate, cardiac
 Bladder width should be approximately 40% of contractility.
the circumference or 20% wider than the
diameter of the midpoint of extremity. Calcium channel blockers:
 Increased sympathetic activity
- Verapamil, Nioedipine, Diltiazem
 Increased absorption of water and sodium
- Blocks calcium access to cells
 Increased activity of the RAA system
- Cause decrease contractility, conductivity
 Increased vasoconstriction of the peripheral and demand for oxygen.
vessels
 Insulin resistance Angiotensin Receptor blockers:
 Medications
- Administer without regard to meals
Non- pharmacologic Management: - Review renal function test
- Blocks vasoconstriction effect of renin-
 Weight reduction angiotensin system
 Sodium restriction - Salt substitution or potassium supplement-
 Caffein Restriction do not use
 Relaxation
 Low fat diet Complications:
 Exercise  Coronary disease
 Smoking cessation  Renal disease
 DASH diet  Stroke
 Alcohol limitation

Factors affecting CO:


Pharmacologic management:
 Heart rate
Diuretics:  Stroke volume:
 Potassium- sparing- Spironolactone/Aldactone; - Preload- degree to which cardiac muscle cells are
Eplerenone (Inspra); Amiloride (Midamor); stretched just before they contract
Triamterene (Dyrenium). - Afterload- pressure that must be overcome for
the ventricles to eject blood
Pulse Pressure:  Exchange substance
- 30-40mmhg Layers:
Narrow pulse pressure- <40; heart is not pumping enough  Tunica- adventitia
blood  Tunica media- elastic tissue and smooth muscle
 Tunica intima- endothelium and basement
- Primary: fluid replacement
membrane
Wide pulse pressure- >60mmhg

CORONARY ARTERY DISEASE:


Areas to Auscultate:
- Result from the focal narrowing of the large
 Aortic- right 2 intercostal
nd
and medium sized coronary arteries due to
 Pulmonic- left 2nd intercostal deposition of atheromatous plaque in the
 Erb’s point- left 3rd intercostal blood vessel wall (atherosclerosis)
 Tricuspid area- left 4th intercostal - Fatty streak- Atheroma- Ischemia
 Mitral area- left 5th intercostal midclavicular Causes:
Head to toe cardiac cues:  Increased LDL, thrombus. Clots, platelet plugs
1. Hair- Brittle, dry- due to cardiac or vascular
Risk factors:
insufficiency
2. Eyes- blue tinged conjunctiva- possible cyanosis;  Age, fam. History, hypertension, DM, smoking,
Raise yellow- orange plaque under eyelids- Obesity, Sedentary lifestyle, hyperlipidemia
chronic serum cholesterol elevation
3. Lips/tongue- blue- cyanosis; dry- dehydration Blood Chemistry:
4. Jugular vein- distended- hypervolemia, right-  Lipid profile
sided HF, pericardial tamponade or constrictive
pericarditis Components:
5. Chest- Crackle- left-sided HF
1. Cholesterol- <200 mg/dl
6. BP- >140/90 hypertension
7. Abdomen- fluid accumulation or enlarged tender Affected by:
liver- right sided HF; pulsating mass- abdominal
aortic aneurysm  Age
8. Skin- dry/cool- poor nutrition; blue tinged-  Diet
cyanosis. Pallor- anemia or decreased circulation  Exercise patterns
9. Sacrum- edema in bed ridden pt.  Genetics
10. Nails- clubbing- chronic low O2 sat as in  Menopause
congenital cardiac or pulmonary disease; Thick  Tobacco use
nails- poor nutrition and impaired O2 delivery
11. Lower extremities- absence of hair- poor
circulation 2. Triglycerides- 40-190 mg/dl
12. Legs/ankles/feet- check for edema, low pulse, - Levels have direct correlation with LDL and
sensation, pressure areas an inverse one with HDL
3. Lipoprotein- HDL >40 mg/dl

Blood vessels and circulation: VLDL, LDL, HDL

Functions: - NPO post- midnight

 Carry blood  Stress Test- Determines amount of stress that the


 Direct blood flow heart can manage before developing abnormal
 Regulate blood pressure rhythm or ischemia
 Transport - NPO 4-6 hrs, avoid caffeine 12 hrs prior
- During: ECG changes= stop test - Normal activity is resumed and diary is kept.
- Wear light and comfortable cloth, rubber  Cardiac Catheterization- Insertion of catheter
shoes, soft-soled shoes into the heart and surrounding vessels
- Used to diagnose CAD, assess coronary
 Cardiac Catheterization- an invasive procedure artery patency and determine extent of
which radiopaque arterial and venous catheters atherosclerosis
are introduced into selected blood vessels of the
Pre: ensure consent, assess for allergy to shellfish
right and left sides of the heart.
or seafood (due to iodine injection), enforce NPO
- Site of insertion: femoral artery
(to reduce risk of aspiration)
- Assess for shellfish allergy
- Local Anesthesia Intra-test: Inform pt of a fluttery feeling as the
- During: Iodine injection catheter passes through the heart
o S/Sx: warmth, flushing, salty
- Feeling of warmth and metallic taste may
metallic taste
occur
- Post: Place sandbag(5lbs) over site; Straight
leg for 4-6 hrs; Complete bed rest without Post- test- Monitor vital signs and cardiac rhythm
BRP 4-12 hrs
- Watch out for: Anaphylactic shock; - Maintain sandbag at the insertion site if
diminished distal pulses- indicates that artery required (for pressure in the insertion site)
of insertion is damaged - Monitor for bleeding and hematoma
- Maintain strict bed rest for 6-12 hrs.
 PTCA (Percutaneous transluminal coronary - Client may turn from side to side
angioplasty)- Balloon tip cath + Stem - Legs should always be straight
- Post: keep straight leg 4-6 hrs; CBR for 12 - Monitor dye allergy
hrs - Encourage fluid intake (to excrete dye)
- Watch out for: neurovascular compromise/  Stress Test
absent distant pulses
Pre: Consent may be required, adequate rest; Eat light
meal or fast for 4 hrs; Avoid smoking, alcohol and
 CABG (Coronary artery bypass graft) – 2 sites caffeine
(donor and receiving site)
- Grafting at the saphenous vein Post: Instruct to notify of the development of any
- Post: Mediastinal tube; 400 ml/hr , <100 ml symptom
(CBR for 24 hrs)
- WOF: DVT, bright red bruising
Goal of care: equal demand and supply of O2 in the body
Medication:
ANGINA:
Nitrates (Nitroglycerin)- SL, Spray, Nitropatch or
Levine’s sign- sudden onset of pain in the chest infusion
Types: Nx Consideration: Instruct on dosage, Store
Stable- caused by stress or strenuous activity Properly (at room tempt, avoid direct sunlight), Monitor
side effects
Unstable- thrombus or Vaso occlusion
Beta- blockers
Printzmetal’s- vasoconstriction of coronary artery
Calcium Channel Blockers
Aspirin
Laboratory Procedures:

 Holter Monitor- non-invasive test in which the


client wears a holter monitor and an ECG tracing Nursing management:
recorded continuously over a 24 hr perios  Advise to stop all activities
 Teach client to use nitroglycerin Quality
 Obtain 12 lead ECG
Region and radiation
 Instruct to maintain bed rest
 Administer O2 at 3L/min Severity
 Assist in possible treatment modalities
Timing
PTCA- to vascularize myocardium, prevent occurrence
Angina MI
of angina, increase survival rate, compress plaque against
Quality of pain Pressing, Pressing,
the blood vessel wall squeezing, tight, squeezing, tight,
- NPO after midnight, informed consent and vise-like vise-like
Timing Usually 1-3 More than 15
Allergy assessment
mins. Up to 10 mins.
Coronary artery Stent- conjunction with PTCA mins.
Region, Substernal, Substernal,
Coronary artery bypass graft Radiation radiating to radiating to
shoulder, arms, shoulder, arms,
neck, lower jaw neck, lower jaw
MYOCARDIAL INFARCTION- refers to process by Dyspnea, Dyspnea,
which areas of myocardial cells in the heart are nausea, nausea,
permanently destroyed vomiting, vomiting,
sweating and sweating and
- Inverted T wave; ST elevation; pathologic Q weakness weakness
wave
3 Areas of damage: Lab findings:

Area of Infarction- O2 deprived, damage irreversible, Myocardial Enzymes


causes Q wave on EKG
Lactic Dehydrogenase- normal: 70-200 IU/L
Area of Injury- next to the infarct. Tissue is viable as LDH1 < LDH 2
long as circulation remains adequate. Increasing O2 may
- Analyzed if pt. is delayed in seeking
save this area from necrosis.
treatment
- Causes S-T segment elevation on EKG - Elevated: 24 hrs; Peak: 48-72 hrs

Area of Ischemia- viability may not be damaged as long Myoglobin- Normal:0-80 ng/ml
as MI doesn’t extend and collateral circulation is able to
- Early marker but not cardiac specific; rules
compensate.
out early diagnosis of MI
- Causes depressed S-T segment. - Elevate: 1-3 hrs; Peak: 4-12 hrs; Normalize:
24 hrs
S/Sx:
Creatinine Kinase- has 3 isoenzymes; cardiac
 Chest pain with radiation- sudden, substernal, specific
crushing, tightness, severe, unrelieved by Nitro
 Dyspnea - Elevate: 4-8 hrs; Peak 18 hrs; Normalize 48-
 Pallor 72 hrs
 Restlessness (Primary presenting S/sx) Troponin- Normal: I: <0.6 ng/ml; T: <0.2 ng/ml
 Anxiety
 Diaphoresis - Used for early and late diagnosis
 Nausea and vomiting - 3 proteins
 S4 and dysrhythmias - Cardiac specific
- Elevate: 4-8 hrs; Peak: 12- 24 hrs;
Pain Assessment: Normalize: 1 wk
Precipitating factor Nx Management:
 Intensive care for first 48hrs Sinus Bradycardia- <60 bpm; pattern similar to NSR
 Bed rest for first 12 hrs
- Treated only if symptomatic
 O2 by nasal cannula at 2-5 L/min
 Liquid diet for the first 4-12 hrs Management: Administer atropine, prepare for
 Small, frequent feedings are often recommended transcutaneous pacemaker

Treatment: Sinus Tachycardia- >100bpm; treat underlying cause

 Morphine Hyperkalemia- peak T wave; flat P wave


 O2 Hypokalemia- U wave
 Nitroglycerin
 Aspirin Hypercalcemia- shortened QT interval
 Thrombolytics Hypocalcemia- prolonged QT interval
 Anticoagulant
Asystole- flat line; absent QRS complex
Patient education:
- No pulse, no respi
 Lifestyle changes- weight and diet control, stress
management, exercise Ventricular Fibrillation- rapid disorganized ventricular
 Tips on sexual activity rhythm that causes ineffective quivering of the ventricles
o Know when to resume - PEA
o Assume less fatiguing position
o Sex as an appetizer rather than a dessert Ventricular tachycardia- 3 or more consecutive PVC
o Subtle and sufficient foreplay
Cardioversion Defibrillation
o Know when to safely resume sexual Synchronized Unsynchronized
activities Elective Emergency
o Avoid sildenafil citrate Low energy (50- 200 Higher energy (200- 360
joules) joules)
Complications:

 Arrhythmias
 Heart Failure Pacemaker Client education:
 Cardiogenic shock
 Dressler’s syndrome- cause pericarditis (fever,  Wear medic alert
pleuritic pain and pericardial effusion)  Avoid applying pressure over device
 Report fever, redness, swelling or soreness at
implantation site
CARDIAC DYSRHYTHMIA-  Report persistent hiccupping
 Avoid contact sports
Properties of the heart:  Wear loose fitting
 Automaticm- ability to initiate electric impulse  Report signs of infection
 Conductibility- ability to transmit an electrical  Lie down if he feels a shock
impulse from one cell to another  Avoid electromagnetic field
 Excitability- ability to respond to an electrical  Restriction on activities
impulse
 Refractoriness- cardiac muscle cannot be
excited during whole period of systole and early HEART FAILURE- inability of the heart to maintain
part of diastole. This period prevents waves adequate CO to meet the metabolic needs of the body
summation and tetanus because of impaired pumping action
 Contractility- ability of the cardiac muscle to
Left sided- symptoms are pulmonary
contract
S/Sx: Paroxysmal nocturnal dyspnea, elevated pulmonary  Place in High fowler’s position
capillary wedge pressure, blood-tinged sputum, cough,  Oxygenate in high concentrations
orthopnea, exertional dyspnea, cyanosis  Suction as needed
Treatment:  Monitor VS
 Administer Medication
 Morphine  Rotating Tourniquet
 Aminophylline  Monitor I and O
 Digoxin
 Diuretics
 Oxygen
 Gasses

Digoxin 0.5-2.0 mg/ml


Lithium 0.8-1.5 mEq/L
Dilantin 10-20 mcg/dL
Theophylline 10-20 mcg/dl

Right sided HF
S/Sx: Dependent edema, Jugular vein distention,
Abdominal distention, Hepatomegaly, Splenomegaly,
Nocturnal Diuresis, Hepatojugular reflex

Class1 Class 2 Class 3 Class 4


Ordinary Symptom Comfortabl Symptom
physical s with e at rest but s present
activity, does increased symptoms at rest
not cause pain activity present in
less than
Asymptomati No ordinary
c symptom activity
at rest
No limitations Marked
of ADL Slight limitation of
limitation ADL
of ADL

Hemodynamic monitoring:
Central Venous pressure- Normal: 0-8 mmhg

- Pressure within the SVC


- Reflects the pressure under which blood is
returned to the SVC and the right atrium
- Tube placement are confirmed through x-ray
- Monitor for complications: Infection and Air
embolism
Pulmonary artery pressure monitoring- PAP: 15
mmhg; PAWP: 4.5-13 mmhg

- A tool used in critical care for assessing left


ventricular function
Immediate management:

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