Cardiovascular Flashcards
What is perfusion
Getting blood to tissues
What factors affect perfusion
Gender
Age
Genetics
Alterations in perfusion (Clotting/Bleeding disorders, Congenitatl heart defects, CAD)
Circulatory Blood Flow
Vena cava > Right Atrium > Tricuspid valve > Right Ventricle > Pulmonic Valve > Pulmonary Artery > Lungs > Pulmonary Vein > Left Atrium > Mitral Valve > Left Ventricle > Aortic Valve > Aorta > Body
Lifespan considerations (Pregnancy)
- Increased circulating volume = increased cardiac workload
- Venous stasis in lower extremities = Peripheral edema, varicose veins, hemorrhoids, postural hypotension
- Increased fibrin and clotting factors = DVT risk
Lifespan considerations (Pediatrics)
- Apical pulse until 2-3 years
- Systolic BP = 70+(2 x age)
- Obtain BP last
- High HR and CO to meet high metabolic rate
- Decreased O2 = Decreased HR
- Cardiac arrest usually secondary to hypoxemia
Cardiac conduction pathway
- SA Node
- AV Node
- Bundle of His
- Bundle branches
- Purkinje Fibers
Nursing considerations for perfusion
GOAL: Promote circulation and cardiopulmonary function
- Input & Output (Lines/drains/tubes)
- Pressure support
- EKG Monitoring
- Compression devices
- Psychosocial support
Cardiac perfusion/Diagnostics
- Pulse Oximetry
- BP
- Chest XR
- CBC
- Cardiac enzymes (Troponin, CKMB, Myoglobin)
- Lipids/Cholesterol
- EKG
- ECHO
- Cardiac Catheterization
Cardiac Enzymes
Troponin
- Peaks on Second Day
Myoglobin
- Peaks early on first day after onset of AMI
CKMB
- Peaks before first day is over
Automaticity
The ability of the cardiac cells to generate an electrical impulse spontaneously and repetively
Excitability
The ability of non-pacemaker cells to respond to an electrical impulse and to depolarize
Conductivity
The ability to send an electrical stimilus from cell membrane to cell membrane
Contractility
The ability of musclec cells to shorten and to contract forcefully
Depolarization
Conduction of an impulse to contract
Repolarization
Recharging to contract again
P wave
Atrial depolarization (Contraction of the atria)
PR interval
Time from atrial depolarization to ventricular depolarization (0.12-0.2 seconds)
QRS complex
Ventricular depolarization (Contraction of ventricle)
- Hides atrial repolarozation
- 0.06-0.1 seconds
ST segment
Represents period of time between the end of ventricuolar depolarization and the beginning of ventricular repolarization
- Normal appearance: Isoelectric (Flat) and in line with baseline
T wave
Represent ventricular repolarization (recovery of the ventricles to their resting state)
Nomal Appearance: Upright in most leads, smooth, and rounded
- May see abnormal T wave in electrolyte imbalance or ischemia
5 steps for EKG interpretation
1.) Rythym - regular/irregular
2.) Rate
3.) Assess P waves
4.) Assess PR interval
5.) Assess QRS
How to determine rhythm
Look at is it regular or irregular
Measure R wave to R wave (Regular = No more than 3 small boxes off)
Assess P waves
1 P wave before every QRS
Samee size and same shape
Assess PR interval
PR interval extends from the beginning of the P wave to the beginning of the QRS complex
Important to determine if there is heart block or conduction system disease
Assess QRS Complex
Tall and skinny
All look the same
Quick steps for EKG interpretation
Rate: Fast, Normal, Slow
P wave before every QRS
QRS: Tall and skinny
Assess client
What causes dysrhythmias
1.) Disturbance in impulse formation
2.) Disturbance between electrical conductivity and mechanical response
3.) Disturbance in impulse conduction
4.) Combination of issues
Types of Dysrhythmias
Sinus
Atrial
Ventricular
Types of sinus dysrhytmias
Bradycardia
Tachycardia
Supraventricular tachycardia
Sinus Bradycardia
HR < 60 bpm
Causes
- Athletes
- Hypoxia
- Beta-blockers
- Digoxin
- Increased ICP
- Valsava maneuver
Bradycardia symptoms and treatments
Symptoms
- Syncope
- Hypotension
- Confusion
- SOB
- Chest pain
Treatment
- IV fluids
- Oxygen
- Atropine
- Pacing
Sinus Tachycardia
HR > 100
Causes
- Fever
- Dehydration
- Pain
- Exercise
- Drugs
- Anemia
Sinus tachycardia symptoms and treatment
Symptoms
- Palpitations
- Cool skin
- Syncope
- Hypotension
- Chest discomfort
- Restlessness and anxiety
Treatment
- Address the problem
Superventricular tachycardia (SVT)
Rhythm: Regular
Rate: 100-280 BPM
P waves: Cannot see
PR interval: Cannot calculate
QRS: Tall and skinny but narrow
patient can be stable or unstable
Superventricular tachycardia (SVT) treatment
- Vagal maneuver
- Adenosine
- Cardioversion
Atrial Dysrhythmias
- Premature atrial contractions
- Atrial fibrillation
- Atrial Flutter
Premature Atrial contractions (PAC)
Originates with atrial tissue
- Atrial tissue fires before next sinus impulse is due
Atrial fibrillation (Afib)
P waves: non-distinguishable
QRS: Tall and skinny
A fib heart disease cause
- Hypertension
- HF
- CAD
- Some infections
Symptoms and main concerns of Afib
Symptoms
- Dependent on ventricular response
Main concern
- Thrombus formation
A fib treatment
- Anticoagulants
- Medications for rate control
(Beta blockers, amniodarone, Diltiazem) - Cardioversion
Atrial flutter
P waves: Saw-tooth pattern
QRS: Tall and skinny
Concerns/treatment/symptoms: Same as Afib
Ventricular Dysrhythmias
- Premature Ventricular Contractions (PVC)
- Ventricular tachycardia
- Ventricular Fibrillation
- Torsades de Pointes
Premature Ventricular Contractions
Originates with the ventricles - Ventricle tissue fires before receiving sinus impulse
Ventricular tachycardia (VTach)
P waves: None
QRS: Tall and Wide
LIFE-THREATENING
VTach Treatment
CPR
Defibrillator
Ventricular Fibrillation (VFib)
P waves: None
QRS: Not discernable
No pulse because no cardiac output
V fib Treatment
CPR
Defibrillate
Torsade de Pointes
Classic Twist - Polymorphic ventricular tachycardia
Deadly rhythm - needs Magnesium
Asystole
No electrical activity
Assess your patient
Pulseless Electrical Activity (PEA)
Electrical activity with NO PULSE
- Assess your client
Cardioversion
- Synchronized shock
- Used with emergencies for unstable tachydysryhtmias and stable tachydysrhythmias that do not respond to medical therapies
Defibrillation
- Asynchronous shock
- Only Vtach without a pulse and V fib
Cardiac Arrest
Main point: Risk for anoxic brain injry
Stenosis valvular infection
Narrow Valve Opening
Regurgitant valvular dysfunction
“Leaky”, does not close completely
Causes of valve dysfunction
- Congenital
Acquired
- Degenerative disease (Aging, HTN, Atherosclerosis)
- Rheumatic diseases (Gradual fibrotic changes and calcification)
- Infective endocarditis (Streptococcal infections destroy valves)
Aortic or Mitral valve dysfunction can cause
- LVH
- Decreased CO
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Fatigue and weakness
- Dysrhythmias
- JVD
Mitral Stenosis
Diastolic Murmur
- Blood cannot flow freely from LA to LV
Mitral insufficiency/Regurgitation
Systolic Murmur
- Blood backflows from LV to LA
Aortic Stenosis
Systolic Murmur
- Blood cannot flow freely from LV to aorta
Aortic insufficiency/Regurgitation
Diastolic murmur
- Blood backflows from the aorta to LV
How to diagnose valvular disoders
Main: Echocardiogram (TEE, TTE)
others:
- CXR
- EKG
- Exercise stress test
Patient care/assessments valvular condition
- Monitor weight
- Heart rhythm
- Administer O2
- Administer medications
- Monitor vital signs
- Energy conservation techniques
- Medications (Diuretics, inotropic agents, anticoagulants)
Percutaneous balloon valvuloplasty
Use of a catheter to go into the heart and open up stenotic valves
Valve replacements
Mechanical
- Requires anticoagulants for life
Bioprosthetic
- needs more frequent replacement
Layers of the heart
- Fibrous pericardium
- Parietal pericardium
- Pericardial cavity
- Epidcardium
- Myocardium
Endocardium
Pericarditis S/S
Infection of the pericardial sac
- Chest Pain
- Pain worse while lying down, breathing, coughing, swallowing (Improves while sitting forward)
- Dyspnea
- Pericardial friction rub
Pericarditis Causes
Respiratory Infection, MI, systemic connective tissue disease
Pericarditis Treatment
- Antibiotics
- Prednisone
- NSAIDs
- Pericardiocentesis as indicated
Myocarditis S/S
Infection of the heart muscle itself
- Chest Pain
- Can be asymptomatic
- Tachycardia
- Heart Murmur
- Dysrhythmias
- Cardiomegaly
Myocarditis causes
- Infection
- Inflammatory diseases (Crohn’s)
Myocarditis Treatment
- Antibiotics
- Prednisone
Endocarditis S/S
Infection of the heart valve
- Fever
- Myalgia
- Heart Murmur
- Petechiae/Rash
Endocarditis Causes
Strep infection (rheumatic); infection due to drug use, implanted cardiac devices, invasive procedures
Endocarditis Treatments
- Antibiotics
- Prednisone
- Valve debridement as indicated
Cardiac Tamponade
Fluid accumulation in the pericardial sac - EMERGENCY
Cardiac Tamponade Presentation
- Hypotension
- Muffled heart sounds
- JVD
- Pulsus paradoxus (SBP decrease > 10 mmHg during inspiration)
Diagnostics for Inflammatory conditions
Blood cultures
- Infective Disorders
Throat Swab
- Rheumatic endocarditis
Cardiac enzymes
- Pericarditis
Inflammatory markers
- ESR, CRP
Others
- Echo
- EKG
Patient care for inflammatory
Cardiac assessment
- Heart sounds
Oxygen
Monitor vitals
Medications (Antibiotics, NSAIDs (pericarditis), Prednisone)
Procedures
- Pericardiocentesis if fluid sounds in the heart
- Valve debridement (Endocarditis)
Mitral Prolapse
Systolic Murmur
Blood backflows from LV to LA
What to know about prostaglandins
Prostaglandins keep Patent Ductus Arteriosus open
- Prostaglandin inhibitors (NSAIDs) Close PDA
Coarctation of the Aorta
- Pinch of the aorta
- Obstructs blood flow to the body
Treatment
- Prostaglandins to Keep ductus open
Patent Ductus Arteriosus (PDA)
Increased pulmonary blood flow
Ductus doesn’t close
- Left to Right Shunting
Treatment
- NSAIDs
Tetralogy of Fallot
- Decreased Pulmonary Blood flow
- Right to left shunting
Combination of Pulmonary Stenosis, Thickened right ventricle wall, Ventricular septal defect, Aorta overrides septal defect
Atrial septal defect
Increased pulmonary blood flow
Left to right shunting
Surgery to treat
Ventricular septal defect
Increased pulmonary blood flow
Left to right shunting
Surgery to treat
Heart Failure
When the heart is not able to pump effectively and is unable to maintain adequate circulation to meet tissue needs
Causes of Heart Failure
- Systemic Hypertension
- MI
- Pulmonary Hypertension (R sided)
- Dysrhythmias
- Valve problems
- Pericarditis
- Cardiomyopathy
Left Sided Heart Failure
The left side cannot pump blood forward
- Forward Effects: Less blood can reach the tissue –> Decreased tissue perfusion
- Backwards Effects: Blood backs up –> Fluid builds up in the lungs (Pulmonary Congestion)
Left-sided heart failure pressentation
- Dyspnea
- Orthopnea
- Fatigue
- Displaced apical pulse (Hypertrophy)
- S3 gallop
- Pulmonary congestion
- Frothy pink tinged sputum
- Altered mental status
- Nocturia
Right-sided heart failure
The right side of the heart fails in its job as a pump
- If occurring by itself it may be a respiratory problem ( Cor Pulmonale)
- Blood cannot move forward and it accumulates in the body (Venous congestion)
Right-sided HF presentation
- JVD
- Dependent Edema
- Ascites
- Fatigue/Weakness
- Nausea
- Anorexia
- Polyuria
- Hepatomegaly and tenderness
- Weight gain
Lab values (BNP)
Moderate HF: Greater than 600 pg/mL
Severe HF: Greater than 900 pg/mL
Nursing care for HF - Actions
Place in High Fowlers
Administer O2
Practice energy conservation
Low sodium Diet
Possible Fluid Restriction
Nursing care for HF - Meds
- Diuretics
- Afterload reducing agents
- Inotropic Agents
- Beta-blockers
- Vasodilators
- Human B-type natriuretic peptides
Do not Take NSAIDs
Cause of HF in infants
CHD
Arrhythmias
Acidosis
Severe anemia
Cardiomyopathy
HF presentation in Infants
Impaired cardiac function
Pulmonary congestion
HF Treatment in infants
Identify cause (treat if possible)
- Support cardiac function
- Promote oxygenation
- Adequate nutrition and rest
Care for infants with HF
Medications
- Furosemide, ACEi, Digoxin
Maintain oxygenation and cardiac function
Nutrition
- Small frequent meals, upright for feedings, supplement with gavage feedings, increased caloric needs
Complication of HF
Acute Pulmonary Edema
- LIFE THREATENING-MED EMERGENCY
Expected findings
- Anxiety, Tachypnea, Acute respiratory distress, dyspnea at rest, Change in LOC, Evidence of fluid in the lungs
Treatment for Acute pulmonary Edema
- Positioning
- High flow O2
- IV morphine
-IV rapid-acting loop diuretics - Frequent monitoring
- Labs (ABGs, Electrolytes)
- Fluid restriction
Hypertension expected findings
“Often silent”
- Headache
- Facial Flushing
- Dizziness
- Fainting
- Retinal changes
- Nocturia
Pharmacological treatment for HTN
- Diuretics
- Calcium channel blockers
- ACEs/ARBs
- Aldosterone receptor agonists
- Beta blockers
- Central A2 agonist
- Alpha-adrenergic antagonists
Nonpharmacological Treatment for HTN
Nutrition
- Low sodium, low fat and cholesterol, limit alcohol
- Weight reduction
- Smoking cessation
- Stress reduction
Hypertensive Crisis
Extremely high BP (180/120)
Severe headache
Blurred vision, disorientation, dizziness
Epistaxis
Hypertensive Crisis Treatment
IV antihypertensives
Monitor BP every 5-15 mins
Assess Neuro status
Coronary artery disease
Leading cause of death in the US
Umbrella term
- Angina
- ACS (Acute coronary syndrome)
- AMI (Acute Myocardial Infarction)
Modifiable risk factors for CAD
- Hyperlipidemia
- Cigarette use
- HTN
- Obesity
- Diabetes
- Physical activity level
- Stress
- Diet
- Renal disease
- OCP/HRT
CAD Clinical manifestations
Chest pain
- Crushing/Squeezing/Tight
Dyspnea
Tachycardia
Pallor, Mottling, Diaphoresis
N/V
Anxiety/fear/sense of doom
Stable Angina
Pain relieved with rest and nitroglycerine
Unstable ungina
Pain is NOT relieved with rest or Nitro
EKG changes and No positive cardiac markers
Goals for CAD Therapy
Relive chest pain
Reduce extent of myocardial damage
Maintain cardiovascular stability
Decrease cardiac workload
Prevent complications
Pharmacology for CAD
Reduce oxygen demand, increase O2 supply (Beta-blockers, calcium channel blockers, Nitrates)
Lower cholesterol (Statins)
Pain control (Nitro, morphine)
Reduce clotting (Thrombolytics, anticoagulants, antiplatelets)
Antidyryhtmics and vasopressors (Amiodarone, propanolol, etc)
Non pharmacological therapy for CAD
- PCI/PCR
- CABG
- Intra-aortic balloon pump
- Ventricular assist device
Cardiac Catheterization
Diagnostic and therapeutic
Non-surgical intervention (PCI)
Access through radial or femoral artery
Balloon or stent placement
Atherectomy
Cardiac catheterization: Nursing care
Before Cath: Fasting 12 hrs
After Cath:
4-6 hrs bed rest
Monitor hemodynamic status
Apply pressure to site
maintain client arm/leg straight
- Pain control
- Monitor I & Os
CABG
Therapeutic
Surgical intervention
Graft vessels from leg or synthetic vessel, bypasses blocked in the new circulatory pathway, Less prefered that PCI unless contraindicated
CABG nursing care
Pre-op
- Consents
- IV access
Post-op
- Chest tube management
- Pain control
- Monitor Hemodynamic status
- Monitor for infection
- Monitor I&Os
- IS, Splinting for coughing
Peripheral arterial disease
Results from arteriosclerosis > Hardening of the vessels
Peripheral venous disorders
Venous thromboembolism > DVT
Venous insufficiency
Varicose Veins
PAD- Peripheral arterial disease / Symptoms
Disorder involving arteriosclerosis of the extermities artery
S/S
- Intermittent claudication
- Palpabale coolness
- Pallor
- Parasthesia
- Thick toenails
- Loss of hairs
Common problem for diabetics
Arterial ulcers
- Ischemic skin wounds develop gradually
- Extremity may be pale and pulseless
- Wounds are often “DRY”
- Pain increases when extremity is elevated
Nursing care- PAD
- Gradually increase exercise
- Promote vasodilation, avoid vasoconstriction
- Do not wear restrictive clothing
- Medications (Statins, Antiplatelet)
- Procedures: Percutaneous transluminal angioplasty, atherectomy, grafts
Compartment syndrome
Acute arterial complication
- Tissue pressure within a confined space that restricts blood flow
6 Ps
- Pain
- Pressure
- Paralysis
- Paresthesia
- Pallor
- Pulselessness
Treatment
- Fasciotomy
Deep vein thrombosis
3 components of the Virchows triad
- Endothelial injury, Stasis, Hypercoagulability
Stasis of venous blood in lower extremities can lead to thrombus formation
Thrombus can travel to lungs and cause PE
S/S of DVT and treatment
Redness over vein
Warmth over vein
Tenderness over a vein
ropiness over a vein
swelling of calf
treatment
- Anticoagulation : heparin
- Surgery
- Filter placement
Venous insufficiency
Results from periods of prolonged venous hypertension cause back of blood in the deep veins
Cause
- Sitting or standing in one position too long
- Obesity
- Pregnancy
- thrombophlebitis
Presentation
- Stasis dermatitis (brown knee sock)
Varicose Veins
Abnormally dilated superficial vein
High pressure is known to occur in prolonged standing or sitting, as well as pregnancy and obesity
Presentation
- Cramping, muscle aches, pain after sitting, pruritis
Venous ulcers
Caused by trauma or pressure on the lower limb
skin breakdown: Tissue damage and necrosis occur because of lack of venous circulation
Tend to be “WEEPY” compared to arterial ulcers
Nursing care for venous insufficiency
- Elevate legs
- Compression stockings
Procedures
- Laser procedures
- Sclerotherapy
- Vein stripping
Ulcers
- Wound care
Are diabetics going to get a PCI or a CABG
CABG
