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Cardiovascular System. Nursing 1120 By: Diana Blum RN MSN Metropolitan Community College. Basics. In the mediastinum Right side is under sternum About the Size of a fist Weighs 10-14 oz. Cardiac Function. Primary function : to pump blood through the pulmonary and systemic circulations.

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Cardiovascular system

Cardiovascular System

Nursing 1120

By: Diana Blum RN MSN

Metropolitan Community College


Basics
Basics

  • In the mediastinum

  • Right side is under sternum

  • About the Size of a fist

    • Weighs 10-14 oz.


Cardiac function
Cardiac Function

  • Primary function : to pump blood through the pulmonary and systemic circulations


3 layers of cardiac tissue
3 Layers of Cardiac tissue

  • Endocardium:

  • Myocardium:

  • Epicardium:


Blood flow
Blood Flow

  • Right Atrium: receives blood from vena cava and from coronary arteries

  • Tricuspid Valve: passes blood from right atrium to right ventricle

  • Right Ventricle: bottom chamber of the heart that contracts (systole) and pushes blood through pulmonic valve and into pulmonary artery


Blood flow continued
Blood Flow Continued

  • Pulmonary artery: carries blood to the lungs

  • Pulmonary veins: carry the newly oxygenated blood back to the heart

  • Left Atrium: accepts blood from pulmonary veins

  • Mitral Valve: moves blood from left atrium to left ventricle

  • Left Ventricle: thickest and strongest muscle

    • Cone shaped and contains apex of heart

    • When the LV contracts (Systole) blood is ejected into aorta and out to Body


Coronary arteries
Coronary Arteries

  • Two major coronary arteries

    • arise from the aorta beyond the aortic valve.

    • Blood flows to the coronary arteries during diastole

  • Left main, LAD, Circumflex feeds most of Left side of the heart

  • Right feeds SA node, AV node, RA, RL


Collateral circulation is a network of tiny blood vessels, and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.


Conduction system
Conduction System and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • SA node: (pacemaker)

    • initiates the impulse

    • travels thru atria to the AV node, located on the floor of the RA

    • Impulse is delayed at AV node, then transmitted to bundle of His


Conduction continued
Conduction Continued and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.


Cardiac cycle
Cardiac Cycle and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • Contraction and relaxation of the heart:

  • Diastole:

  • Systole:


  • Video Mysterious Heart Volume 2 chapter 3 and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.


Cardiac output
Cardiac Output and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • the volume of blood ejected by the heart each minute and is determined by stroke volume and the heart rate.

  • Normal stroke volume is 60-100 ml

  • Normal cardiac output is 4 to 8 L / min

  • (CO = HR X SV)


Factors affecting stroke volume
Factors affecting Stroke Volume and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • Preload: the amount of blood remaining in the ventricles at the end of diastole or the pressure generated at the end of diastole

  • Contractility: is the ability of the cardiac muscle fibers to shorten and produce a muscle contraction. (Inotropic, + or -)

  • Afterload: amount of pressure the Ventricle must overcome to eject blood volume out


Heart rate
Heart Rate and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • SA node : pacemaker of heart 60-100 bpm

  • AV node : 40 -60 bpm

  • Heart is innervated by sympathetic and parasympathetic nervous system

    • Sympathetic: speeds HR, and increases force of contraction

    • Parasympathetic: slows HR and force


Heart tones
Heart Tones and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • Murmur: Produced by turbulent sounds across valves

    • Rub: inflamed pericardium-best heard along left sternal border

    • S3 murmur: sounds like “Kentucky”

    • S4 murmur: sounds like “Mississippi”

      http://www.blaufuss.org/

      http://www.med.ucla.edu/wilkes/Rubintro.htm


Health history
Health History and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.


Present illness
Present Illness and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • Fatigue

  • Edema

  • Palpitations

  • Pain

  • Aggravating and relieving factors


Past medical history
Past Medical History and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • HTN

  • renal disease

  • pulmonary disease

  • DM

  • CVA

  • rheumatic fever

  • streptococcal sore throat

  • scarlet fever

  • previous cardiac disease or conditions

  • currents meds and allergy


Family history
Family History: and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • CAD

  • HTN

  • DM


Review of systems
Review of systems and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • weight gain

  • fatigue

  • dyspnea

  • cough

  • orthopnea

  • palpitations

  • chest pain

  • fainting

  • concentrated urine

  • edema


Functional assessment
Functional assessment and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • effects of illness on ADLs and rest patterns

  • smoker

  • diet

  • stress

  • coping


Physical assessment
Physical Assessment and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • General:

  • VS: orthostatic bp in both arms, apical rate and rhythm, respiratory rate and effort

  • peripheral pulses:

  • Skin: color hair distribution, cap refill, temp

  • Thorax: heart sounds, lung sounds, sputum

  • Extremities: pulses, color, temp, edema


Age related changes
Age Related Changes and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • Heart less able to adapt to changing needs related to activity

  • Valves thicken and stiffen

  • # of pacemaker cells decrease

  • Nerve fibers decrease

  • Frequent dysrhythmias


Diagnostic tests
Diagnostic Tests and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • EKG: rate, rhythm, ischemia (T-inverted), injury (ST segment elevation), arrhythmias, strain, infarction (q wave)

  • Echocardiogram: (TEE) sound wave test detects size of chambers, valve integrity, flow, wall motion, Cardiac Output


Diagnostic tests continued
Diagnostic Tests Continued and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

Biomarkers:

Troponin will show elevation 3-6 hr after symptoms begin/injury peak in 12 hours stay in system 10-14 days

<0.10 is negative

0.10-0.60 is intermediate and may indicate injury

>0.60 is positive evidence of MI

Myoglobin increases 1-4 hours after MI

CPK-MB will show increase 4-6 hrs after MI peaks in 18-24 hours in system 2-3 days

BNP can be elevated 48 hrs after MI which indicates heart failure


Diagnostic tests continued1
Diagnostic Tests Continued and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • CBC: anemia

  • CMP: screening K+, etc

  • PT, INR

  • PTT

  • Lipid profile: see next 2 slides


Diagnostic tests continued2
Diagnostic Tests Continued and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • ABG: assess acid/base levels

  • Pulse Oximetry: generally >92%

  • Holter monitoring: 24+ hr of EKG + events

  • Stress test: treadmill or pharmacological

  • Cardiac Catheterization: invasive, NPO 6-8h, consent. Visualizes chambers, valves, arteries, pressures, CO

  • Heart-CT scan: assesses CAD, MRI

  • Nuclear scans: assess heart muscle viability

  • EPS: NPO, consent, IV, assess electrical activity


CAD and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

Video-mysterious heart volume 3 chapter 2


Etiology of cad
Etiology of CAD and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • CAD occurs when the intimal lining of the coronaries begin to plaque resulting in jagged edges and narrowed passageway for blood flow

  • Atherosclerosis results in impaired blood flow to the heart muscle


Risk factors for cad
Risk Factors for CAD and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • Non-controllable-

  • Controllable-


S s of cad
s/s of CAD and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • Angina which results from a lack of 0xygen to the heart muscle

    • 4Es=

  • Weakness, diaphoresis, SOB

  • N/V


Mi myocardial infarction
MI: Myocardial Infarction and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

  • Occlusion of a coronary artery resulting in necrosis of the heart muscle.

  • Risk factors: same as for CAD

  • Pathophysiology: AMI-over 4-6 hrs ischemia injury and infarction develop. Ischemia=lack of 02 to heart muscle, if not relieved=injury. After 20 min of ischemia=infarction

  • Main S/S: chest pain and accompanying S/S



Data collection
Data Collection circulation begins.

  • Same as for CAD but will assess symptom of chest pain with accompanying s/s

  • May have EKG changes with or with-out ST-T wave changes or Q wave changes

  • Cardiac Bio-markers (Troponin, Myoglobin, CPK, CKMB)

  • May proceed with Echocardiogram to assess if wall motion sluggish

  • May go to cath lab


Angina or mi
Angina or MI circulation begins.

  • Angina without MI} often relieved with rest and NTG

  • Angina with MI } may be relieved with rest, NTG, 02, MS, rescue angioplasty, etc.

    • Think MONA

      • Morphine

      • Oxygen

      • Nitroglycerin

      • Aspirin

        http://www.youtube.com/watch?v=4GlQmTlP2jE&feature=related


Treatment continued video mysterious heart volume 3 chapter 3 7
Treatment continued…video mysterious heart volume 3 chapter 3-7

  • ASA:

  • MS:

  • Beta-blocker

  • ACE inhibitor:


Treatment continued
Treatment continued chapter 3-7

  • May need antiarrhythmic meds

    • like what???

  • Stool softeners to reduce valsalva maneuver and prevent constipation r/t narcotic use and bed rest

  • Treat: HTN, DM other co-morbid illnesses

  • Cardiac Rehab to follow


Treatments
Treatments chapter 3-7

  • Low fat low cholesterol diet

  • Prescribed exercise program 5-7 days a week

  • Knows correct use of NTG for angina

  • Management of DM, HTN

  • Stop smoking

  • Medications to reduce work load or dilate


Low salt diet 2000mg does not include
Low salt diet (<2000mg) does not include: chapter 3-7

  • Soups:

  • Snacks:


Low fat 30 low cholesterol 200mg
Low fat <30% Low cholesterol <200mg chapter 3-7

  • Lean meat: skinless

  • Dairy limited: egg beaters, skim milk

  • Olive oil, canola oil

  • Avoid: fried, fatty or heavily marbled meats, sausage, lunch meat, spareribs, frankfurters, salt pork, canned fish in oil, yolks, duck. Cream sauces, gravy, buttered vegetables, sweet rolls, other processed foods


Exercise
Exercise chapter 3-7

  • 5-7 X week is goal to include stretches with warm-up, progressive walking program, light weights, stretches with cool down.

  • Strengthens heart muscle, reduces BP, BS, weight, stress, tension, appetite, LDLs.

  • Increases HDLs, energy and self esteem and improves immune system


Principles of exercise
Principles of Exercise chapter 3-7

  • Practice on regular basis

  • Know how to do own pulse

  • Strive for target heart rate

  • Stop if chest pain occurs

  • Complications: CHF & Dysrhythmias


Nursing interventions for mi
Nursing interventions for MI chapter 3-7

  • Comfort measures

  • Freq VS, cardiac monitoring, I&O, CMS checks, spacing activities

  • Heart & lung sounds, assess fluid volume status, IV responsibilities, note BP & Pulse prior to heart meds!!

  • Client education r/t diet, meds, pulse taking activity, elimination, reporting chest pain and correct use of nitro products for angina


Medications for heart disease
Medications for Heart Disease chapter 3-7

  • Anti-Anginal:

  • Anti-Hypertensive:

  • Anti-Arrhythmic: l

  • Cardiac glycoside:


Medication continued
Medication continued chapter 3-7

  • Thrombolytic:

  • Anti-coagulant:

  • Anti-platelet aggregate:

  • Lipid-Lowering agents:

  • Diuretics:

  • Electrolyte replacement:


Medication continued1
Medication continued chapter 3-7

  • 02 to maintain 02 sat > 92% to reduce chance of angina/ischemia

  • If Angina the nurse needs to have the client lie down, take VS then report to charge nurse ,met team, call md.

  • Instruct client: If develops chest pain, sit down take 1 nitro every 3- 5 min x 3. If chest pain not relieved call 911



  • 90% will develop complication chapter 3-7

  • 80% will demonstrate arrhythmia

    • the most common cause of death in clients in the pre-hospital period. (VT>>>VF)

  • CHF and severe Left ventricular failure

  • Papillary muscle dysfunction

  • Pericarditis

  • Thromboembolism

  • Ventricle rupture


Nursing diagnosis
Nursing Diagnosis chapter 3-7

  • Decreased cardiac output r/t Dysrhythmias

  • Acute Pain r/t lack of 02 to myocardium

  • Anxiety r/t to feeling of doom, lack of understanding of medical diagnosis




Pacemaker chapter 3-7

  • New in 1958

    • purpose to restore the regular rhythm

      • improve tissue perfusion and cardiac output.

  • Temporary / permanent

  • Single chamber or double chamber

  • Teach client how to take 1 min pulse, s/s to report to MD-dizzy, angina, dyspnea

  • Carry card and know precautions



AICD chapter 3-7

  • Implantable defibrillator to correct a life threatening rhythm disturbance.

    • Has pacemaker back-up.

  • check battery q2months

  • Instruct on how to take pulse for 1 min

  • s/s to report to MD: firing, s/s of dizziness, dyspnea, weakness, carry card and wear bracelet, CPR for family. Know precautions


  • Nursing care for client with newly implanted pacemaker or AICD.

    • Assess cardiac monitor for capture/pacing (pacer)

    • VS post-op then q 4 hours, IV, bed rest till am

    • Dressing dry and intact until AM then often may remove. Increase activity progressively

    • Instruct client not to raise arm above shoulder for 5days. May shower in 5 days


Angioplasty with stent
Angioplasty with Stent AICD.

  • Procedure done at the time of cardiac cath.

  • Balloon angioplasty is accomplished to widen or open specific coronary vessel-stent is inserted to maintain patency of the vessel.

  • pre-procedure Plavix given with follow up Plavix

http://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav=


Ep with ablation
EP with Ablation AICD.

  • Mapping of myocardial tissue to determine irritable focus.

  • Low voltage current delivered to ablate tissue causing SVT or VT

  • 90% effective

  • http://video.google.com/videoplay?docid=5590000557631435292


Nursing care
Nursing Care AICD.

  • NPO prior

  • Coumadin stopped 4 days prior, Heparin 4 hours prior

  • Post – procedure same as heart cath

    • Cardiac monitoring

    • Muscloskeletal and groin checks

    • VS

    • Ambulate prior to discharge


Cardiac surgery
Cardiac Surgery AICD.

  • Coronary artery bypass

  • Valve replacement or repair

  • Septal repair and other congenital repairs

    • CCU post op, chest tubes

    • Pre-op teaching with post op expectations

    • See client teaching for CABG, Valve repair/replacement, care of PTCA, MI



Congestive heart failure
Congestive Heart Failurehttp://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav

  • Video..the mysterious heart volume1 chapter 3


  • DEFINITION:http://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNavEF < ____% or when the myocardium is no longer able to pump efficiently


  • Systolic failure= http://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNavmost common


Causes of chf
Causes of CHFhttp://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav

  • CAD, advancing age

  • HTN is a major factor > CHF x 3

  • DM, Smoking, Obesity

  • Valvular incompetency, alcohol or other chemicals, idiopathic,(unknown)


S s of left sided chf
S/S of Left Sided CHF http://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav

  • Fatigue

  • Angina

  • Tachycardia

  • Cool extremities

  • Hacking cough

  • Crackles

  • Frothy sputum

  • Gallop


S s of right sided chf
S/S of Right Sided CHFhttp://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav

  • Jugular distention

  • Anorexia/nausea

  • Dependent edema

  • Distended abdomen

  • Weight gain

  • BP problems


Assessment findings
Assessment Findingshttp://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav

  • C/O SOB, weakness, dry cough, fatigue, can not lie down must sit up to breath, has gained weight

  • Auscultation of the heart} rapid HR, extra heart sounds

  • Auscultation of the lungs} rales, wheezing

  • Examination of the extremities for peripheral edema


System compensation
System Compensationhttp://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav

  • Mediated thru Sympathetic Nervous System: as CO drops, baroreceptors alert brain

    • stimulation Beta 1=>>Stimulation Beta 2=

      • Activate Alpha receptors peripherally=constriction=>>


Compensation
Compensation http://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav

  • Causing S/S of CHF because:

  • Contractility decreases

  • Stroke volume and CO continue to decrease

  • Afterload (pressure on the other side of the aorta) increases

  • Preload ( pressure caused by increase volume to heart creating an exaggerated stretch in the muscle) increases


Renal compensation
Renal Compensationhttp://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav

  • CO drops initiating renin-angiotensin mechanism

    • Results in powerful vasoconstrictor


Ventricular hypertrophy
Ventricular Hypertrophyhttp://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav

  • The heart enlarges which results in strain

  • The increase in volume causes the ventricles to dilate

  • Eventually remodeling will occur


Diagnostic tests1
Diagnostic Testshttp://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav

  • H&P

  • Chest x-ray

  • EKG:

  • Echocardiogram:

  • CBC:

  • CMP:

  • Thyroid function

  • ABGs

  • BNP=B type natriuretic peptide= hormone released in response to Ventricular stretch ( CHF peptide)

  • Nuclear studies to determine heart function, EF, tissue viability

  • Cardiac Cath to determine exact nature of heart function


Chf management
CHF Managementhttp://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav

  • Directed at: Improving LV function (Contractility) by decreasing intravascular volume and decreasing vascular resistance

  • Decreasing venous return (Preload)

  • Decreasing BP (Afterload)

  • Improving gas exchange and 02

  • Increasing the CO and reducing anxiety


Continued
continuedhttp://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav

  • ACE inhibitors to < afterload by dilating vessels and < BP (ARBs)

  • Beta blockers to < 02 demand by reducing the contractility of the heart and HR (not given in acute period)

  • Diuretics <preload by reducing volume returning to the heart-Lasix & (Aldosterone Antagonists) K+ supplement


Continued1
continuedhttp://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav

  • ASA in low doses or Plavix to help prevent blood clot formation

  • Anticoagulants for those with poor EFs to prevent CVA

  • Antiarrhythmics to control ectopy

  • Biventricular pacing (CRT=cardiac resynchronization therapy) to improve CO

  • Digoxin to increase contractility of myocardial fibers and improving cardiac output. +inotropic agent


Treatment of chf
Treatment of CHFhttp://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav

  • Treat underlying cause

  • Rest and hi Fowlers to reduce work load and improve ventilation

  • 02 at 2-6 L/min with 02 sats >92% to increase available 02 and prevent hypoxemia

  • Freq VS and cardiac monitoring


Treatment continued1
Treatment continuedhttp://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav

  • I & O q shift

  • Daily am weights before breakfast and after voiding. 2-3# weight gain in 1-4 days call MD

  • Sodium restricted diet

  • Medications: to decrease intravascular volume thus reducing venous return, dilate and reduce BP and improve contractility

  • http://chfsolutions.com/zip_how_aquapheresis_works.html#


Educating the chf client
Educating the CHF Clienthttp://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav

  • Education re: heart failure

    • Explanation of heart failure

    • Expected S/S and when to call MD

    • Self monitoring of daily weights

    • Know medications and need to take them

    • 2000mg sodium restricted diet

    • Importance of low level daily exercise program (energy conservation)

    • Prognosis / advanced directives



Lead placement
Lead Placementhttp://preop.medselfed.com/asp/center.asp?centerId=heart&partnerId=preop&id=&cachedate=&emailId=&affId=&campId=&hideNav



To map to determine if regular or irregular
To map= to determine if regular or irregular caused by a problem in the conduction system.

Each small box measures 0.04

1 big box (5 small boxes) is equal to a HR of 300

2 big boxes is hr of 150

3 big boxes is hr of 100

4 big boxes is hr of 75

5 big boxes is hr of 60

6 big boxes is hr of 50

7 big boxes is hr of 43

8 big boxes is hr of 38



P wave
P wave caused by a problem in the conduction system.

Measures: 0.12-0.20


QRS WAVE caused by a problem in the conduction system.

Measures: 0.06-0.10


Qt wave
QT Wave caused by a problem in the conduction system.


Heart rates
Heart rates caused by a problem in the conduction system.

  • NSR: heart rate is ___bpm

  • ST: heart rate ____ bpm

  • SB: heart rate ____bpm


NSR caused by a problem in the conduction system.


Sinus rhythm
Sinus rhythm caused by a problem in the conduction system.

  • PR interval- 0.12-0.20sec

  • QRS-0.06-0.10sec

  • QT segment 0.36-0.44 sec

  • Heart rate 60-100


Sinus arrythmia
Sinus caused by a problem in the conduction system.arrythmia

Hr= 60-100 bpm

On strip it looks regular but does not map out

PR interval= 0.12-0.20


Junctional escape rhythm
Junctional caused by a problem in the conduction system. escape rhythm

HR 40-60 bpm

<60 bpm is accelerated

Rhythm is regular

Pwaves not always present


SB caused by a problem in the conduction system.


Sinus bradycardia
Sinus Bradycardia caused by a problem in the conduction system.

  • All criteria same except rate < 60bpm

  • S/S: dizziness, syncope, angina, hypotension, sweating, nausea, dyspnea

  • Sometimes no S/S

  • Treat underlying cause

  • IV atropine, pacemaker


ST caused by a problem in the conduction system.


Sinus tachycardia
Sinus Tachycardia caused by a problem in the conduction system.

  • All criteria same as with NSR except rate >100

  • Causes: fever, dehydration, hypovolemia, increased sympathetic nervous system stimulation, stress, exercise, AMI

  • S/S: Palpations #1, angina and < CO from < V filling time

  • Treatment: correct cause, eliminate caffeine, nicotine, alcohol. Beta blockers may be ordered


First degree heart block
First degree heart block caused by a problem in the conduction system.

Rate is usually WNL

Rhythm is regular

Pwaves are normal in size and shape

The PR interval is prolonged (>0.20 sec) but constant


Second degree heart block type 1
Second degree heart block type 1 caused by a problem in the conduction system.

Pwaves are normal in size and shape;

Some pwaves are not followed by QRS

PR interval: lengthens with each cycle until it appears without QRS Complex

then the cycle starts over

QRS is usually narrow


Second degree heart block type 2
Second degree heart block type 2 caused by a problem in the conduction system.

Ventricular rate is usually slow

Rhythm is irregular

Pwaves are normal in size and shape (more pwaves than QRS)

PR interval is within normal limits

QRS is usually wide


3 rd degree heart block of complete heart block
3 caused by a problem in the conduction system.rd degree heart block of complete heart block

Ventricular rate is regular but there is no correlation between pwaves and QRS

Pwaves are normal in size and shape

No true PR interval


Mykentuckyheart com
mykentuckyheart.com caused by a problem in the conduction system.


Atrial fibrillation
Atrial Fibrillation caused by a problem in the conduction system.

heartyhealth.com

Erratic wavy base

Pr is not measurable

QRS 0.10 sec or less usually

http://www.youtube.com/watch?v=VKxQgjj2yVU&feature=related


A fib continued
A fib continued caused by a problem in the conduction system.

  • Atrial rate > 400 bpm with a varying Ventricular rate

  • Overall rhythm irregular

  • No P waves, unable to measure PR interval

  • QRS=normal: Twave undeterminable

  • Causes: Rheumatic fever, mitral valve stenosis, cad. HTN, MI, hyperthyroidism, COPD, CHF see pp. 604


A fib continued1
A fib continued caused by a problem in the conduction system.

  • Concern is the development ________________________________________________________________________

  • Treatment: Ca channel blockers and anti- arrhythmics to convert, beta blockers to HR, anticoagulants to prevent embolization.

  • Synchronized cardioversion


Atrial flutter
Atrial caused by a problem in the conduction system. flutter

Atrial rate of 250-450 bpm ventricular rate varies

Atrial rhythm is regular ventricular rate is irregular

No identifiable p waves

P wave is not measurable

Qrs: 0.10 or less usually


Paced beat
Paced beat caused by a problem in the conduction system.

Pacer spike should fall before the P wave unless a dual

Chamber pacemaker; if it does not there could be a problem


Premature ventricular conduction pvc
Premature ventricular conduction (PVC) caused by a problem in the conduction system.

Extra beat

Types

uniform=go the same direction

multifocal= go in different direction

R on T=when the pvc fall on the preceding twave

couplet= 2 pvcs together

bigeminy= pvc every other beat

trigeminy=pvc every third beat


Ventricular tachycardia
Ventricular tachycardia caused by a problem in the conduction system.

Monomorphic:

Polymorphic:


Torsades de pointe
Torsades caused by a problem in the conduction system. de pointe

This is a polymorphic VT

Usually electrical imbalance in nature r/t NA+ or K+


Ventricular fibrillation
Ventricular Fibrillation caused by a problem in the conduction system.

Rate can not be determined because of no identifiable waves

Rapid chaotic rhythm with no pattern

No p waves

No PR interval

No QRS


Vtach vfib
Vtach/Vfib caused by a problem in the conduction system.

  • Both can be life threatening

  • VT= V HR 100-250 bpm

  • Causes: AMI, CAD, hypokalemia, dig toxic

  • S/S: palpitations, dizzy, angina, <LOC

  • Treatment: assess for pulse, if none, defib

  • VF=Rate undeterminable Cause: same

  • Treatment: CPR


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Hypertension
Hypertensionhttp://www.campaignfornursing.com/events/WINNERS/pennsylvania/


  • HTN is described as persistent elevation of arterial blood pressure greater than 140/90 on at least 2 or more readings on different dates.

  • The Joint National Committee, Detection, Evaluation, and Treatment of High Blood Pressure defines normal:

    • BP as S < 120 mm Hg and D < 80 mm Hg

    • PreHTN: SBP 120-139 DBP 80-89

    • Stage 1: SBP 140-159 DBP 90-99

    • Stage 2: SBP >160 DBP >100


Types of hypertension
Types of Hypertension pressure greater than 140/90 on at least 2 or more readings on different dates.

  • Essential HTN: (Primary) which is the most common 90-95% of population

  • Secondary HTN: is a result of another disease, kidney, pregnancy.


Factors that determine arterial pressure
Factors that determine arterial pressure pressure greater than 140/90 on at least 2 or more readings on different dates.

  • Cardiac output

  • Peripheral vascular resistance


Possible causes of pvr
Possible Causes of PVR pressure greater than 140/90 on at least 2 or more readings on different dates.

  • Narrowing of blood vessels, PVD, CAD, kidney disease: renin/angiotensin =vasoconstriction

    • Release of catecholamine (epinephrine and adrenalin) = vasoconstriction

  • blood volume= more work to pump

  • Blood viscosity=harder to pump

  • Ability of blood vessel to stretch


Causative factors of htn
Causative Factors of HTN pressure greater than 140/90 on at least 2 or more readings on different dates.

  • Hyperlipidemia Obesity

  • Atherosclerosis Sedentary

  • DM Family Hx

  • Cigarette smoking

  • Age > 60

  • Men

  • Post menapausal women


S/S pressure greater than 140/90 on at least 2 or more readings on different dates.

  • Often none

  • Occipital headache more severe on rising

  • Lightheadedness

  • Epistaxis

  • Known as the ‘Silent Killer’


Complications
Complications pressure greater than 140/90 on at least 2 or more readings on different dates.

  • Damage to blood vessels of the eyes, heart, kidney, brain resulting in:

  • Stroke

  • CHF

  • AMI

  • Renal failure

  • Blindness


Lifestyle change education
Lifestyle Change Education pressure greater than 140/90 on at least 2 or more readings on different dates.

  • Exercise, dash diet, stop smoking, weight management and control, stress reduction, medications and recording BP frequently

  • Avoid OTC meds

  • Instruct on how to do postural BPs


Valvular disorders
Valvular Disorders pressure greater than 140/90 on at least 2 or more readings on different dates.


  • STENOSIS: pressure greater than 140/90 on at least 2 or more readings on different dates.

  • INSUFFICIENCY:


Stenosis
Stenosis pressure greater than 140/90 on at least 2 or more readings on different dates.

  • Narrowing of the opening of the valves. Limits the amount of blood which is ejected from one chamber to the next.


Mitral stenosis
Mitral Stenosis pressure greater than 140/90 on at least 2 or more readings on different dates.

  • Mitral valve leaflets become thickened and fibrotic. Affect women age 20-40

  • CHF may develop

    • TX if failure develops: Digoxin, Lasix, beta blockers, and anti arrhythmics, lo Na diet, etc

    • Will monitor with yearly echocardiogram

    • Surgery if worsens

  • Prophylactic antibiotics prior to invasive procedure or dental work


Insufficiency
Insufficiency pressure greater than 140/90 on at least 2 or more readings on different dates.

  • The inability of the valves to close completely.

  • Allows the blood to backflow.

  • Mitral valve is the most commonly affected


Cardiac insufficiency can be caused by many factors – by a swelling of the heart muscle (1), an enlargement of the hollow chambers in the heart (2), a heart attack (3) or a blood clot (4).


Mitral insufficiency
Mitral Insufficiency swelling of the heart muscle (1), an enlargement of the hollow chambers in the heart (2), a heart attack (3) or a blood clot (4).

  • Often accompanies mitral stenosis as a result of _______________.

  • Valve leaflet become rigid and shorten, prevents closure of valve.

  • Hypertrophy of Left Atrium and Ventricle = L sided heart failure occurs

  • Murmur heard.

  • F/U with echocardiogram

  • TX: vasodilators, same as for stenosis


Mitral valve prolapse
Mitral Valve Prolapse swelling of the heart muscle (1), an enlargement of the hollow chambers in the heart (2), a heart attack (3) or a blood clot (4).

  • When the Left ventricle leaflets become enlarged, and protrude into the left atrium during systole.

  • Benign but may progress to Mitral insufficiency

  • More common in women age 20-55


S s of mitral prolapse
S/S of mitral prolapse swelling of the heart muscle (1), an enlargement of the hollow chambers in the heart (2), a heart attack (3) or a blood clot (4).

  • Often none

  • Others experience chest pain, palpitations, dizziness, syncope, dysrhythmias

  • Monitor with echocardiogram

  • May do heart catherization

  • Manage stress, beta blockers if tachycardia


Aortic stenosis
Aortic Stenosis swelling of the heart muscle (1), an enlargement of the hollow chambers in the heart (2), a heart attack (3) or a blood clot (4).

  • Occurs when valve cusps become fibrotic and calcify.

  • Most commonly caused by aging and atherosclerosis.

  • Occurs most predominantly in men

  • Untreated will lead to Left sided CHF


Aortic insufficiency
Aortic Insufficiency swelling of the heart muscle (1), an enlargement of the hollow chambers in the heart (2), a heart attack (3) or a blood clot (4).

  • Caused primarily by rheumatic fever

  • May also be caused by chronic HTN

  • Predominantly in men

  • Hypertrophy of the Left ventricle and eventually_______________________

  • Blood may eventually back up into the pulmonary system and lead to _______________________________


S s and treatment
S/S and Treatment swelling of the heart muscle (1), an enlargement of the hollow chambers in the heart (2), a heart attack (3) or a blood clot (4).

  • Aortic murmur, tachycardia, palpitations, CHF with fatigue, SOB, ascites

  • Monitored with echocardiogram assessing L ventricular dilatation

  • Chest X-ray-enlargement of heart

  • May do cardiac cath

  • May need valve repair or replacement




Endocarditis
Endocarditis infections and may include any layer of the heart:

  • Inner layer: tends to affect the valves (Mitral=L).

  • Organisms (Bacterial or fungal) present in blood stream and collect (colonize) on the valves:

    • Rheumatic heart disease, congenital defects or mitral valve prolapse

    • IV drug users or invasive procedures



Pathophysiology
Pathophysiology prophylactic antibiotics prior to any invasive procedure including dental.

  • Bacteria may enter blood stream:

  • Bacteria collect on valves and vegetate

  • Complications: Ventricular septal defect, CHF(#1 cause of death) and embolization


S/S prophylactic antibiotics prior to any invasive procedure including dental.

  • Fever- (99-105)

  • Chills and night sweats may accompany

  • Malaise, fatigue and weight loss

  • Appearance of petechiae in the mouth, conjunctiva and legs

  • Chest and abdominal pain indicating embolization


Treatment and diagnostics
Treatment and Diagnostics prophylactic antibiotics prior to any invasive procedure including dental.

  • H&P and Lab tests

    CBC with diff with leukocytosis, sed rate, (+)blood cultures

  • May have heart murmur Echocardiogram to visualize valves and vegetation

  • Chest x-ray: CHF

  • Long term antibiotics, rest, limited activity, prophylactic anticoagulants, valve replacement after inflammation treated


Nursing assessment
Nursing Assessment prophylactic antibiotics prior to any invasive procedure including dental.

  • Frequent VS and assess for fever

  • Assess for heart murmur

  • Note cough

  • Assess peripheral edema

  • Rest with limited activity, administer meds in a timely manner


Nursing diagnosis1
Nursing Diagnosis prophylactic antibiotics prior to any invasive procedure including dental.


  • myocarditis prophylactic antibiotics prior to any invasive procedure including dental.


  • Muscle layer: prophylactic antibiotics prior to any invasive procedure including dental.Local or diffuse inflammation of the myocardium. May be viral or bacterial, an autoimmune process or drug toxicity.

  • May result in cardiomyopathy=


Pathophysiology1
Pathophysiology prophylactic antibiotics prior to any invasive procedure including dental.

  • Characterized by degeneration and necrosis of myocardial tissue that is different of that caused by MI

  • Tissue next to necrosed area hypertrophies, loses elasticity, results in CHF and arrhythmias


S/S prophylactic antibiotics prior to any invasive procedure including dental.

  • Asymptomatic

  • May have fever, fatigue, sore throat, dyspnea, muscle aches

  • Lymph nodes may be enlarged

  • Chest pain 7-10 days after virus

  • CHF S/S


Diagnosis
Diagnosis prophylactic antibiotics prior to any invasive procedure including dental.

  • Based on Hx, S/S, and testing-enzymes>

  • May hear friction rub, rales

  • Jugular vein distention

  • Chest x-ray, echocardiogram=hypertrophy

  • EKG=arrhythmias

  • Biopsy (RV) shows lymphatic infiltration and cell necrosis


Treatment
Treatment prophylactic antibiotics prior to any invasive procedure including dental.

  • Bed rest

  • 02

  • Meds: cardiac glycoside-Lanoxin, anticoagulants, antiarrhythmic, antibiotics, steroids

  • Cardiac monitoring

  • NI same as for endocarditis

  • ND same as for endocarditis


  • Pericarditis prophylactic antibiotics prior to any invasive procedure including dental.


  • Outer-surrounds heart prophylactic antibiotics prior to any invasive procedure including dental.

  • Inflammation of the pericardium.

  • Primary or secondary

  • Acute or chronic

  • Acute: virus, bacteria, fungi, chemotherapy, MI

  • Chronic: TB, radiation or metastases


Pathophysiology2
Pathophysiology prophylactic antibiotics prior to any invasive procedure including dental.

  • Inflammation causes an increase in the amount of pericardial fluid and inflammation of surrounding tissues.

  • Adhesions may occur

  • May lead to tamponade


Tamponade
Tamponade prophylactic antibiotics prior to any invasive procedure including dental.


S/S prophylactic antibiotics prior to any invasive procedure including dental.

  • Chest pain is hallmark

  • Most severe on inspiration, sharp, stabbing, or dull and burning.

  • Pain is relieved by sitting up or leaning forward

  • Dyspnea, chills and fever


Diagnosis1
Diagnosis prophylactic antibiotics prior to any invasive procedure including dental.

  • WBC elevated

  • Serial EKG show that ST segment increases and resolves in several weeks. A fib may occur

  • Echocardiogram to see pericardial thickening and effusion

  • Enzymes can be increased

  • Blood cultures to ID organism


Treatment1
Treatment prophylactic antibiotics prior to any invasive procedure including dental.

  • Analgesics

  • Antipyretics

  • Anti-inflammatory agents

  • Antibiotics

  • May need OR to create a pericardial window to allow for drainage of fluid

  • NI and ND same as for endocarditis



Assessment
Assessment prophylactic antibiotics prior to any invasive procedure including dental.

  • Heart rate and rhythm, color, temperature, cognition

  • Circulation: peripheral CMS checks

  • Vital signs to include 02 saturations and telemetry interpretation

  • Subjective: c/o chest pain, SOB, fatigue, lightheadedness, dizziness


Nursing diagnosis2
Nursing Diagnosis prophylactic antibiotics prior to any invasive procedure including dental.


Ekg practice
Ekg practice prophylactic antibiotics prior to any invasive procedure including dental.


References
References prophylactic antibiotics prior to any invasive procedure including dental.

  • www.mirule.com retrieved on 4/8/07.

  • Images found at www.aol.com. Retrieved on 4/8/07.

  • Aehlert, B. RN BSPA (2006). EKGs Made Easy. Mosby (3rd ed). St Louis.


  • The End prophylactic antibiotics prior to any invasive procedure including dental.


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