Cardiovascular Flashcards
what anatomical landmark is the apex of the heart found at ?
Intercostal space of the 5th rib and Left mid clavicular line
Apex is the lowest part of the heart formed by the inferolateral part of the left ventricle. It projects anteriorly
What is the base considered to be in the heart ? what anatomical landmark is it at?
the upper border of the heart, involves the left atrium part of the righr atrium and proximal portion of the great vessels
2nd rib space
what is the endocardium, epicardium, pericardium and myocardium
endocardium - Lines the interior of the heart chambers and valves
epicardium- serous layer of the pericardium. Contains the epicardial coronary arteries and veins, autonomic nerves, and lymphatics
pericardium - Double walled connective tissue sack that surrounds the outside of the heart and great vessels
myocardium- Makes up the majority of the heart wall. Made up of thick contract tail Lair made up of muscle cells
What is the aorta and its anatomical pathway?
The aorta is the largest artery in the body.
Starts at the upper left ventricle, ascends and goes backward and left arch of aorta)
Then descends to the thorax to become the thoracic aorta, then passes to the abdominal cavity to become the abdominal aorta
What are The inferior and superior vena cava
suppioer vena cava- Returns blood from the head neck arms to the right atrium
Inferior vena cava- Returns blood from the lower body viscera to the right atrium
What are the pulmonary veins and artery?
Pulmonary viens Carry oxygenated blood from the lungsto the left atrium
Pulmonary artery -Carry deoxygenated blood from the right ventricle to the lungs
Separates the right and left ventricles? What separates the right and left atrium?
The wall between the atria = atrial septum
Wall between the ventricles is the ventricle septum
What valve separates the right atrium and the right ventricle?
Tricupsid or Right AV valve (3 leaflets)
Valve separates the left atrium and the left ventricle
Mitral valve or Left AV valve (2 leaflets)
whats the role of the right and left heart chambers
The right side collects blood from the body.
Left side pumps blood to the body
What does the aortic valve connect?
LV and aora to pump blood to body
What does the pulmonary valve connect
RV and pulmonary artery
What is the pathway for blood in the heart?
Superior/inferior vena cava> RA> tricupsid> RV>pulmonary valve> pulmonary trunk> L/R pulmonary arteries> R/L lung> pick up O2 drop off CO2> pulmonary veins> LA> bicupsid (mital) > LV> Aortic valve> aorta > coronary/systemic circulation
where do the right and left coronary arteries come from ?
ascending aorta, just below where the aorta leaves the LV
- coronary arteries supply the myocardium
what 3 arteries come off the aortic arch ?
Brachiocephalic artery
left, carotid artery
left subclavian artery
what are the main branches of the right coronary artery ?
Sinus node artery
right marginal artery
posterior descending artery
what are the main branches of the left coronary artery ?
Circumflex artery
left anterior descending A.
What artery supplies the left atrium
Circumflex artery
What artery supplies the right atrium
Sinus node artery
What artery supplies the right ventricle
right marginal artery
Artery supplies the bottom of the ventricles
posterior descending artery
which vessels are the Great vessels of the heart
Inferior vena cava
Superior vena cava
pulmonary arteries /veins
aorta
what makes up the coronary venous circulation?
cornonary sinus
cardiac veins
thesbian veins
what drains into the coronary sinus ? where does this drain into?
- Great cardiac vein
- small and middle cardiac veins
- veins drain into the RA
what is the normal pace maker of the heart? What does it do? How does conduction go from L and R atria?
SA node
- causes the atria to contract
- backman bundle conduct cardiac impulse from R to L
What does the AV node do?
- causes the ventricles to contract
- accomplished by the bundle of His, at the lower end of the AV node, which pass to the interventricular septum to form left and right branches which become purjunkie fibers.
- purjunkie fibers extend into ventricle wall
what influences the rate, rhythm, and contractility of the heart?
autonomic nervous system
- vagus and sympathetic nerves make up the cardiac plexus
what is the sympathetic influence on the heart?
release of epinephrine and no epinephrine
- sympa nerves stimulate heart to beat faster (chronotropic effect) and with greater force (inotropic)
- increased: contractility, venoconstriction, arterial vasoconstriction, which leads to increased BP, total peripheral resistance, and CO
what is the parasympathetic influence on the heart?
ACH released from the vagus nerve to slow the heart rate (chronotropic effect) mainly though SA node
- Decrease in HR small decrease in contractility and results in decreased BP
what is the baroreceptor reflex?
- detect change in pressure
- maintain BP
- high pressure (arterial barorecpetors) receptors located in the carotid sinus, aortic arch, R subclavian
- low pressure (cardiopulmonary) recpetors
- Pressure is maintained by sympa or parasympa input
what is the bainbridge reflex? will it cause increase of decrease in HR?
- increases HR
- increase in venous return will cause stretch to recpetors on RA wall
- sends afferent vagus signal to cardio vascualr center in medulla
- parasympa activity inhibited therfore increasing HR
Chemoreceptors reflex
- located in aortic body and cartid body
- respond to changes in O2 tension and pH
- < 50mmhg O2 or acidosis will cause:
- increased ventilation depth and rate by parasympa system to decrease HR and contractility
- persistent hypoxia will result in the sympa system
What will occur with persistent hypoxia
activation of sympa activity (after para is activated to try to deepen breaths and decrease contractility)
What will occur secondary to a Valsalva maneuver
increased: central venous pressure,
Decreased: venous return, CO, BP
- decrease is sensed by baroreceptors which increases HR via the sympa system.
- When the glottis open again, venous return increases and therefore increase BP and Heart contractiltiy which will stimulate the parasympa system to decrease the HR
what is pre load and after laod ?
Pre load is the tension built up in the ventricles after being filled post diastole
after load is the resistance of the peripheral vasculature. Resistance agiainst the heart pumping out
- includes aorta complaince, blood viscosity and mass
what is stroke volume and cadiac output
SV: norm is 60-80ml
blood ejected from L ventricle
CO: blood pumped out of L/R ventricle per min
- CO= SVxHR
- men= 5L/min, women is little bit lower
- can go up to 25L/min with exercise
T/F when averages over time CO will = Venous return
true
cardiovascular system is closed loop
what type of veins will have more valves?
Deep> superficial
LE > UE
what are S/S of hypovolemia
- tachycardia, elevated temp, orthostatic hypo tension
- caused by decreased blood volume; severeburns, dehydration, diuretics for HTN, sweating,
what are s/s of hypervolemia?
- leg swelling, ascites, fluid in lungs
- caused by: fluid overload such as in heart failure, kidney dx, excess fluid like blood transfusion, elevated NA+,
what is the norm blood volume in a man
5L
- slighlty less in a female
what is plasma ?
makes up 50% of blood volume
- water electrolyes and protiens
- important in regulating BP and temp
what are RBCs
- make up 40% of total blood volume
- polycythemia increases risk for stroke and heart attack
what will a high or low number of platletes cause?
high: can result in stroke or heart attck
low: thombosytopenia increases risk for thrombosis that can result in abnormal bruise & bleedings
What are the 5 types of WBCs and what do they do?
Basophils - allergic repsonse
Neutrophils - protect body from infection bu eating
lymphocytes- t- lymphocytes, natural killers that protect agianst viruses, destroy some cancer, B-cells make antibodies
monocytes-eat dead/damaged cells and defend against organisms
eosinophils- kill parasites, destroy cancer, involved in allergic response.
which ribs are considered true ribs?
ribs 1-7 = true
attach to sternum by costal cartilage
- false ribs do not attach to costal cartilage, they attach to the cartilage of the rib above
which ribs only connect to 1 thoracic vertebrae ?
what about the ones that dont?
1,10, 11, 12
- Ribs that don’t connect to one vertebrae have a superior and inferior facet to articulate to 2 adjacent thoracic vertebrae
- the rib # of superior costal facet will articulate with the inferior facet
- superior facet articulates with the inferior costal facet of lower vertebrae
what makes up the costotransverse joint
- Transverse process of each vertebrae will have costal facet.
- Costal facet articulates with facet on rib tubercle
- will form the costotransverse joints
What are the muscles of principal inspiration
Diaphragm.
External intercostals; Oriented upward and backward from lower rib to upper rib
How are internal intercostal muscles oriented? What will contraction of the internal and external intercostal muscles do
Obliquely upward and forward from the upper rib to the lower rib
- Contraction of internal and external intercostal muscles will cause the ribs to elevate for inspiration
What will movement of the upper ribs increase? Elevation of the lower ribs will increase?
Movement of upper ribs increases A-P chest diameter
Elevation of lower ribs increases transverse diameter
What muscles are used during exhalation? Active exhalation?
- Quiet breathing requires passive recoil of lungs in rib cage.
- Forceful exhale; rectus abdominis, external oblique, internal oblique, transversus abdominis.
- Will depress lower ribs and compress rib contents therefore pushing and diaphragm up and helping with active exhalation
Is considered to be a part of the upper respiratory tract?
What is its function?
Nasal cavity, larynx , and pharynx
- fxn: Warm or cool air and filter air before it reaches alveoli.
- Nostril hair filters out particles
Is considered to be a part of the lower respiratory tract?
What is its function?
larynx to the alveoli (includes the trachea, which is the beginning of the larynx )
- Includes conducting airways, terminal respiratory units
- The airways divide roughly 23 times between trachea and alveoli.
Where does the trachea begin where does it end?
- Begins at the larynx, approximately at base of neck.
- Ends at carina, at T4
- Carina divides the tracheae get into right and left main bronchi
How many lobes does the right and left lung have
- Right lung: 3 lobes; upper middle and lower
- Left lung: upper and lower, lingula
- Lingula is the same as the right middle lobe
Describe the normal conditions for the pleurae
the visceral pleurae will cover the lungs and the parietal pleurae will cover the ribs, mediastineum, vertebrae, diaphragm,
- the two will touch eahc other and are only separated by serous fluid
what carries blood from the heart to the lungs?
the pulmonary trunk, pulmonary arteries
what do the bronchial arteries do
deliver O2 blood to the lungs and connective tissue and bronchi.
- this blood drains into the bronchial veins
how does symps and parasympa innervation innervate the lungs?
para: vagus nerve
sympa: post ganglionic sympathetic fibers will innervate smooth muscle of the bronchi, and pulomonary vessels
what controls breathing? what is the response to hypoxemia ?
motor neurons that innervate respiratory muscles will be stimulated by central and peripheral chemo receptors and mechano receptors
hypoexemia response
- central chemo receptors in medulla sense pressure of CO2and H+ and react by increasing ventialtion
- peripheral chemoreceptrs wil react via cartic bodies that increase ventilation
- mechanoreceptors inhibit mus activity when force is potentially dangerous
What is anatomic dead space volume
Air that occupies non-respiratory airways
What is expiratory reserve volume
Maximal amount of air that can be exhaled after a tidal exhalation.
15% of lung volume
Forced expiratory volume
Volume of air expired maximally In the 1st 2nd 3rd second of forced vital capacity maneuver
Forced vital capacity
Volume of air expired forcefully after forced Max inspiration
Functional residual capacity
Lung volume after normal exhale
FRC=ERV+RV
40% of total lung volume
Inspiratory capacity
Max amount of air that can be inspired after tidal exhalation
IC=TV+IRV
inspiratory reserve volume
Max amount of air that can be inhaled after normal total volume inhalation.
50% of total lung volume
Minute volume ventilation
Air volume expired in one minute.
VE = TE x respiratory rate
Peak expiratory flow
Max flow of air at beginning of forced expiratory maneuver
Residual volume
Volume of gas in lungs at end of max expiration.
-25% of total long volume
tidal volume
Total volume inhaled and exhaled with each breath and quiet breathing.
10% of total lung volume
Total lung capacity
volume of air after max inspiration sum of all lung volumes
TLC = RV + VC.
or
TLC = FRC + IC
Vital capacity
Volume change that occurs between max inspiration and expiration.
VC = TV + RV + ERV.
75% of lung volume
Determines how much oxygen chemically combined with hemoglobin
Physically dissolved oxygen contributes to the PaO2, this determines how much oxygen combines with hemoglobin.
Oxygen is more available in hemoglobin that in the plasma.
why are airway clearance techniques used?
To help impaired cilliary transport or inability to protect airway (impaired cough)
cann atelectasis be due to mucus plugging?
yes, is suspected to be caused by muscus build up air way clearance can be used
what is active cycle breathing?
used to be called forced expiratory technique
-Emphasize breathing with the huff cough
-Three phases;
*Breathing control at tidal volume
*Thoracic exhalation : deep breathes, Percussion and vibration can be paired with expiration
Forced expiratory technique, A few huffs with open Gladys
What is the procedure and precautions for active cycle of breathing
breathing control– Begin with breathing, controled gentle relax breathing (diaphragmatic breathing), For 5 to 10 seconds or as long as patient needs to prep for next phase. Performed at tidal volume at resting respiratory rate
Thoracic expansion– 3 - 4 slow deep relaxed inhalations to inspiratory reserve with passive exhalation.Chest percussion, vibration or shaking may be combined with exhalation.
forced expiratory technique:1-2 Huffs at mid-low lung volume with Glottis open into expiratory reserve volume. Brisk adduction of upper arms can be added for thorax compression
precautions
Splint postoperative incisions with pillow. Contraindication if bronchospasm or hyperreactive airways
autogenic drainage
Controlled breathing is used to mobilize secretions with exhales and no postural drainage or coughing to imprive airflow in small airways by clearing mucus.
- 30-45mins
What is the procedure and precautions for autogenic drainage
-Patient sitting upright with back support.
-Controlled breathing at three lung volumes for: Unsticking phase:
Breathe in through the nose at low volume hold 2-3 secs and hold to allow contralateral ventilation, exhale to expiratory reserve volume
Collecting phase:
Breath at tidal volumes interspersed by 2 to 3 second breath holds
Evacuating phase:
Breathe deeper from low-mid inspiratory reserve volume, With breath holding followed by a huff
-precautions: Requires motivation and concentration to learn. Not suitable for easily distracted or children
Directed huffing and cough
attempts to elicit maximum force exhalation by directed cough to compensate for physical limitations.
Cough+ huff
Patient is directed to cough by closing Glottis and hold breath for 1- 2 seconds, then contracting expiratory muscles to produce increase thoracic pressure then coughing sharply 2 -3 times with a slightly open mouth
huff: inhale deeply with rapid exhalation by pretending to fog mirror or saying ha ha Ha
What are precautions and contraindications to huff cough
Don’t do if :
possible transmission of infection.
Elevated intracranial pressure or known intracranial aneurysm.
Reduce coronary artery perfusion/myocardial infarction.
Unstable head neck or spine.
Potential for aspiration/regurgitation.
Abdominal pathology: AAA. Hiatal hernia, pregnancy
Untreated pneumothorax.
Osteoporosis.
Flail chest
High frequency airway oscillation
A cappella or pickle are used to produce high frequency airway vibration to mobilize secretions
procedure:
Inhale slowly to 75% with device and mouth. Hold breath for 2- 3 secs. Exhale for 3- 4 secs. Repeat 10- 20x. Follow with 2 to 3 coughs or Huffs
What are precaution/intra- contraindications for high frequency airway oscillation
Acute asthma, COPD. Above 20 mmHG intracranial pressure. Hemodynamic instability Recent face surgery or trauma. Acute sinusitis. Nosebleed. Esophageal surgery. Active hemoptysis Nausea. Suspected tympanic membrane rupture or middle ear pathology. Untreated pneumothorax
What are precautions and contraindications for postural drainage in all positions
Intracranial pressure above 20 mmHG. Head and neck injury until stabilized. Active hemorrhage/hemodynamic instability. Recent spine surgery. Emphysema. Active hemoptysis Bronchopleural fistula. Pulmonary edema associated with congestive heart failure. Large Plural effusion. Pulmonary embolism. Confuse/ anxious patient who cannot tolerate position. Read fracture. Surgical wound
What are precautions and contraindications for postural drainage in trendelenburg
Uncontrolled hypertension. Distended abdomen. Esophageal surgery. Recent growth Hemoptysis related to lung carcinoma. Uncontrolled airway at risk for aspiration (tube feeding or recent meal)
What is the position for postural drainage for the apical segments.
Right and left upper lobes.
Seated.
Percussion and vibration performed above clavicles
What is the position for postural drainage for the posterior segments
-Respectively belong to right and left upper lobe of the lung.
Right:
Patient is turned 1/4 from prone on left side so the medial border of the right scapula can be percussed and vibrated.
Bed in horizontal patient in prone shoulder raised with pillow
What is the position for postural drainage for the lingula
-upper left lobe
-prone
1/4 from supine on right side with foot of bed elevated 12 inches.
Percussion and vibration over left chest between auxilla and left nipple
What is the position for postural drainage for the anterior segments
- L and R lobes
- supine
- Percussion and vibration performed below clavicle’s with the bed and horizontal
What is the position for postural drainage for the right middle lobe
Patient is turned 1/4 from supine on the left.
Bed and is elevated 12 inches.
Percussion and vibration over right chest between auxilla and right nipple
What is the position for postural drainage for the supperior segments
left and right lobes
- prone
- bed horizontal
- Percussion and vibration below the inferior border of left and right scapula
What is the position for postural drainage for the anterior basal segment
left and right lobe
- supine
- bed end is elevated 18 inches
- Percussion and vibration over lower R/L ribs
What is the position for postural drainage for the posterior basal segments
left and right lobe
- prone
- bed end is elevated 18 inches
- Percussion and vibration over lower R/L ribs over the posterior side
What is the position for postural drainage for the lateral basal segments
- sidelying
- bed is 18 inches elevated
- Percussion and vibration over lower R/L ribs
- If for left lower lobe have patient lye on right side to expose left side
What are accessory muscles of inspiration?
Sternocleidomastoid. Scalene's. Pectoralis major sternocostal portion, pectoralis minor, Serratus anterior
what are the 4 parameters of of respiration?
-Rate- # breaths/ min
-Rhythm-regularity of inspirations/ expirations inspire:expire= 1:2 (COPD 1:3-4)
-Depth volume of air exchanged with each breath. deeper or shallower than tidal volume
Character -effort and sound. Laboured breathing; use of accesory mus, wheezing/crackles.
how long should you asses respiratory rate?
observe or palpate 60 secs and document 4 parameters
what are the norms for respiration for a new born?
1 year?
10 years?
adult?
new born? 33-45
1 year? 25-35
10 years?15-20
adult?12-20
what is apnea ?
absence of spontaneous breathing
Biot’s
Irregular breathing. Breaths vary in-depth, rate with periods of apnea associated with increased intracranial pressure or medulla damage
Bradypnea
Under 12 breaths per minute. Associated with nuerologic or electrolyte imbalance, infection, or high cardio resp fitness
Cheyne- stokes
Decreasing rate and depth of breathing with periods of apnea can occur due to CNS damage
Eupnea
breathing norm for rate and depth
Hyper/ hypopnea
Increased/ decreased rate and depth of breathing
kussmaul’s breathing pattern
Deep and fast breathing, associated with metabolic acidosis
Paradoxical breathing
Best wall moves in with inhalation and out with exclamation due to chest trauma or paralysis or diaphragm
Tachypnea
fast RR >20 breaths/min in adults
What is rate pressure product
Index of myocardial oxygen consumption and coronary blood flow
correlates to onset of angina or ECG abnormalities for pts with heart disease
- S/S of myocardial ischemia occur at reproducible RPP value
How do you measure and interpret RPP rate pressure product
HRxSBP reported at 10^3
RPP obtained during an exercise test can dicatate exercise Rx and by keeping exercise below level will redice angina
What is ABI?
compares systolic blood pressure at ankle and arm to check for peripherla artery disease
- BP taken at brachial and tibialis posterior artery with sphygmomanometer and doppler
divide the highest of the 2 measurements of ankle and arm (ankle/arm)
->1.3 ridgid arteries- need for a US check to look for PAD
1-1.3 normal, no blockage
.80-.99 - mild PAD, the beginning
. 4-.79- moderate claudication and blockage
>.4 severe PAD
Which vitals are taken to measure the lung function to oxygenate the blood
SaO2 - Oxygen saturation of hemoglobin (Refers to how much hemoglobin is saturated on the RBC for molecules/cell)
Pao2 - arterial partial pressure actual oxygen content in arterial blood
Vital measures the lungs ability to remove carbon dioxide? changes in this molecule indicate what
PaCO2
-Changes in co2 reflect changes of pH in the body
Molecule acts as a buffer from blood becoming too acidic or basic
HCO3- Bicarb
What is the normal pH for an adult
7.35- 7.45
PaC02 norm
40mmhg @ sea level
35-45
Partial pressure of carbon dioxide in arterial blood (PaCO2) provides info on how well the lungs are able to remove CO2
Pa02 Norm
97 mmHg @ sea level
80-100 norm
HCO3- norm
24meq/L
SaO2 norm
95-98%
Acidemia
Elevated blood acidity less than 7.35 (low Ph)
Alkalemia
Decreased blood acidity pH is greater than 7.45
Eucapinea
hyper/hypocapenia
Normal CO2 levels in arterial blood 35 to 45mmHG
Hyper - Elevated levels of CO2
Hypo Low levels of CO2
Hypoxemia
Mild hypoxemia
Moderate hypoxemia
Severe hypoxemia
Hypoxemia - Low 02 in arterial blood <80mmHg
Mild hypoxemia 60-79 mmHg
Moderate hypoxemia 40-59 mmHg
Severe hypoxemia <40
What is the difference between hypoxemia and hypoxia
Hypoxemia is low arterial blood.
Hypoxia is low level of O2 in the tissue despite adequate perfusion
What are cardiac biomarkers?
Enzymes leak out of heart cells into blood after MI
Indicator of CK, creatine phosphokinase and tropnin in blood
CK-MB- MI indicator up to 2 days after an incident. Most elevated 4 hours after
Tropinin-I- MI indicator up to 5 - 7 days
What’s considered good cholesterol and what does it do
- HDL is referred to good because it helps carry away LDL and protects against arthro-genesis.
- LDL is bad. Associated with fatty plaque buildup in arteries that can reduce BF
What PaCO2 and pH will indicate respiratory acidosis
PaCO2 >45
pH <7.4
(not compensated, therefore values of greater and less than will be opposite)
PaCO2 and pH values would you indicate for compensated metabolic alkalosis
PaCO2 >45
pH >7.4
(compensated, therefore values will be in the ‘same direction’)
PaCO2 and pH values would you indicate for compensated metabolic acidosis
PaCO2 <35
pH <7.4
(compensated, therefore values will be in the ‘same direction’)
What PaCO2 and PH will indicate respiratory alkalosis
PaCO2 <35
pH >7.4
(not compensated, therefore values of greater and less than will be opposite)
What HCO3- and pH will indicate metabolic acidosis
ph <7.4
HCO3- <22
What HCO3- and pH will indicate respiratory alkalosis
ph >7.4
HCO3- <22
What HCO3- and pH will indicate metabolic alkalosis
ph >7.4
HCO3- >26
What HCO3- and pH will indicate respiratory acidosis
ph <7.4
HCO3- >26
what reading error will happen if the BP cuff is too small
reading will be too high and false
if in doubt use larger cuff
how slow if the BP cuff deflated?
2-3 mmhg / second
A you are listening to BP, what is the 1st sounds that is heard?
systolic- appearance of clear tapping sounds
When the sounds disappear completely in a BP reading, what does the is indicate
diastolic
what are phases I-V in BP reading
I - systolic, first sound II- sounds become softer and longer III- sound is crisp and louder IV- sounds are muffled and softer V- Sound disappears all together
what us the norm BP for an adult
<120/<80
what is elevated HTN
120-129 systolic
or
< 80 Diastolic
stage 1 HTN
130-139 systolic
or
80-89 Diastolic
stage 2 HTN
140-159 systolic
or at least 90 Diastolic
Hypertensive crisis
> 180
and or
120
What does systolic pressure and diastolic pressure measure
SBP: pressure on arteries when heart is contracting/ ejection phase
DBP: Force agianst arteries at rest
IS BP directly related to CO and Total peripheral resistnace?
yes
therefore effective measure at for the pumping mechanism of the heart
how fast does SBP increase with MET equivalent
8-12 mmhg
- with sustained activity, no further increases ahppen
- if SBP doesnt rise with work load, can indicate functional reserve capacity of heart has been exceeded
how much can diastolic BP increase or decrease ?
10 mmhg
At what BP should exercises be terminated in phase 1 cardiac rehab
> 130mmhg SBP or over 30 beats above Resting HR
decrease in SBP of >10 mmhg
110 DBP
What is pulse pressure? What is normal and during exercise?
difference btwn SBP and DBP
should increase with activity to 40-50 mm (Systolic increase por. to exercises when DBP stays the sameish)
If PP gets too high, may indicate stiffening of aorta secondary to arthrosclerosis
What type of exercises increase BP
concentric and valsalva
Concentric> eccentric
Concentric/ eccentric > isokinetic
How does our body compensate for age to maintain blood pressure
Same volume of blood filled ventricles, but pumping is less affective. Body compensates by increasing blood pressure to maintain homeostasis
If a patient is performing an exercise test and SBP fails to increase or decrease with increasing workload, what does that indicate?
Plateau or decrease in cardiac output
By how much should SBP decrease after 3 mins of exercise ?
general guidline:
- SBP normally decreases soon after exercise stops.
- Post SBP should be less than 90% of peak SBP
When is diaphragmatic breathing indicated?
- post sx when pt has pain in chest or abdomen
- learning/instructing active cycle of breathing or airway clearance
- dyspnea at rest it min activity
- inability to perform ADLs or 2/2 dyspnea or inefficient breathing pattern
what are precautions/ contraindication for diaphragmatic breathing (DB)
- mod-severe COPD, marked hyperinflation of chest
- paradoxical breathing patterns
- increased inspiratory effort
- increased dyspnea during DB
how do you teach diaphragmatic breathing
1 hand on chest 1 hand on belly
breathe into belly and keep chest still
in thorugh nose, out through pursed lips
what are the expected outcomes from diaphragmatic breathing
Decrease:
RR
Use of accessory muscles during exhalation
Respiratory flow rate
Increase:
tidal volume
activity tolerance
subjective improvement of dyspnea
what is inspiratory muscle training (IMT)
- strengthens diaphragm and interscostal muscles
inspiratory muscle training (IMT) contraindications and percautions
signs of inspiratory muscle fatigue: - tachypnea, reduced tidal volume increased PaCO2 bradypnea, decreased minute ventilation
inspiratory muscle training (IMT) procude
calculate the training load by measuring MIP max inspiratory pressure with manometer
2 types of IMT: Threshold and flow resistive
- T`hreshold: valve opens at critical pressure and provides consistent and specific pressure for IMT regardless of how slow/quick breathing rate is
-Flow resistive: decreasing diameter increases resistance
- place tool over mouth and INHALE forcefully to open valve
- adjust pressure spring to adequate load
- the higher the setting the higher the load
- Pt begin at 30-40% of MIP
- breathe against resistance at resting respiratory rate and tidal volume 5-15 mins 3x day
what are thr benefits of IMT
increase inspiratory mus strength and endurance, fxn exercise capacity
decrease dyspnea at rest and with exercise
paced breathing and exhale with effort technique
- PB strategy to decrease work of breathing and dyspnea during activity
- EET prevent breath holding; inhale at rest, exhale with work
when would you use paced breathing and exhale with effort technique
- dyspnea at rest or min activity
- inefficient breathing pattern in activity
- inability to perform activity due to pulmonary limitation
- outcome is patient will have less fear of becoming short of breath during activity and be able to complete w.o dyspnea
how do you teach paced breathing and exhale with effort technique
time exhales with work and inhales with rest/easy periods
walking: breathe in thro nose 2 steps, breathe out with pursed lips for 4 steps
Stairs: in thro nose while standing, exhale with pursed lips during 2 stairs
lifting: inhale thro nose before lift in sit/stand, exhale with pursed lips during bend and reach. Pause. inhale thro nose when grabing object, exhale while standing
when would you use PLB pursed lip breathing
- Reduce respiratory rate, reduce dyspnea, maintain small positive pressure in bronchioles that can help emphysema/ airway collapse
- forcing exhalation is a contraindication
what is segmetnal breathing ?
localized breathing or thoracic expansion to help regional ventilation post sx for pulmonary complications.
- asymmetrical chest wall expansion may imply pathology
- hand placement verbal cues or coordination can be done to facilitate or inhibit pattern
Segmental breathing procedure:
basal atelectasis: sitting
Sidelying with affected lung up
postural drainage postions with affected side up to help with secretion removal
- firm handplacment over area that needs to expand as the pt breathes in.
- as pt breathes out, pt decreases hand placment pressure
When would you choose to use incentive spirometry ?
Decreased: intrathoracic volume, chest wall compliance,
increased flwo resistance from decreased lung volume
ventilation: perfusion V:Q mismatch
When would you not choose to use incentive spirometry ?
- uncooporative patient
- cant breathe deep
vital capacity is less than 10%
mod-severe COPD
incentive spirometry benefits ?
absence or imprive atelectasis decreased RR improved PaO2, forced vital capacity,peak expiratory flows - resolved fever - normal pulse rate
what postions can help with dyspnea
leaning forward with arms supported will allow pect to raise ribcage
- reverse trendeleburg: head above trunk and LE
- Semi fowler, head of bed height at 45* and pillow under knees
What does RPE assess?
patient exertion
-shouldnt consider mus soreness, pain or shortness of breath
what is considerd 70% of max HR according to RPE
13-14
what does a RPE of 11-13 correspond to?
upper limit of HR while in early cardiac rehab training
when can RPE sub for HR when Rxing exercise intensity
- ability to monitor HR is compromised
- pts with exercise based rehab prgram without preliminary exercises test
- HR response to exercise is altered (cardiac transplant)
- physical activities other than endurance are assessed
What is considered very very light (or weak in revised RPE)
original: 7 (6-20)
6= nothing
revised: 0.5
0= nothing (0-10)
What is considered somewhat hard (moderate in revised RPE)
Original: 13
Revised:3
What is considered hard (strong in revised RPE)
Original: 15
Revised:5
What is considered very hard (very strong in revised RPE)
Original: 17
Revised:7
What is considered very very hard (very very strong in revised RPE)
Original: 19 (max will go up to 20)
Revised:10
what if PFT testing (pulmonary function testing)
measures volume/ floe of air during inhalation and exhalation
- will measure forced vital capacity FVC, forced expiratpry volume in first second (FEV1), mid expirtory flow and peak expirtory flow.
How is PFT testing (pulmonary function testing) performed
patient is seated and exhales as maximally and as forcefully for as long as they can into mouth piece for 6 seconds
what would the PFT testing (pulmonary function testing) results be for a obstructive ventilatory impairment
- FEV1/FVC < 70 is indicator
- results are decreased flow
- airway narrowing during exhale caises disporportioante reduction in max airflow comparred to the volume displacement that can occur
how is obstruction classified via FVC
>100- normal 70-100 mild 60-70 moderate 50-60 mod-severe <50% severe obstruction
WHAT ARE OBSTRUCTIVE PATHOLOGIES (cap lock srry)
asthma, emphysema, chronic bronchitis
what would the PFT testing (pulmonary function testing) results be for a restrictive ventilatory impairment
- FVC is reduced and or FEV1/FVC are normal or >80%
- characterized by reduced lung volume are near normal expiratory flow rates
what are restrictive lung diseases?
interstitial lung disease
pleural diseases
chest wall deformities
obesity, pregnancy, neuromsk disease or tumor
What types of pathologies/ clinical indications for in/outpatient cardiac rehab?
Medically stable post MI stable angina coronary bypass sx PTCA Percutaneous transluminal coronary angioplasty compensated HF cardiomyopathy heart transplant cardia sx PAD high risk for CAD with dx of DM, HTN or obesity end stage renal dx
Who wouldn’t be recommended for cardiac rehab ?
unstable angina
resting SBP >200 or resting diastolic greater than 110 mmhg
orthostatic BP drop by 20 with symps
critical atherosclerosis
acute systemic illness.fever
uncontrolled atrial or ventricular arrhythmias
3rd degree ventricular block w.o pace maker
active pericarditis/myocarditis
recent embolism
thrombophlebitis
resting ST segment elevation/depression >2mm
uncompensated FH
orthopedic or metabolic condition prohibiting exercise
What is phase 1 of cardiac rehab
- inpatient cardiac rehab
- begins with physician referral and medically stable patient
- patient and family education
Exercises emphasis on AROM, self care, low level exercise, ambulation, vital monitoring
-Exercises prescribed according to heart rate and RPE - lasts 3-5 days
when is a patient considered medically stable To begin cardiac rehab
- no new or recirrent chest pain in 8 hours
- no new signs of congestive HF; dyspnea at rest or bilateral basilar crackles
- no new sig abnormal hearth rhythm or ECG changes in 8 hours
- stable CK and troponon levels
when should exercise be discontinued during
phase 1 of Cardiac rehab?
HR >130 or >30 above resting HR
DBP>110
decrease in SBP 10mmhg
significant arterial and ventricular dysrhythmias
2/3rd degree heart block
s/s of angina, marked dyspnea, and ECG changes suggestive of ischemia
what are considerations for active exercise in phase 1 of cardiac rehab?
1-4 mets; progress from sitting to standing
UE exercises should not stress post surgical incisions
when can LE and UE exercise start after a bypass graft or a infarct ?
bypass graft : 24 hours
infarct 2 days
how should aerobic exercises be Rxd in cardiac rehab phase 1?
Mode, intensity, duration, frequency, progression
Mode: supervised walking on level surface (2-3 mets) to walking on steps or treadmill (3-4 mets)
Intensity: <13 RPE. Post infarct: <120bpm or <20 bpm from resting. Post Surgery: <30 bpm from resting
Duration:3-5 min bouts increasing to 10-15 of continous activity
Frequency: first 3 day: 3-4x/day. After 3days 2x/day with increased duration
Progression: based on tolerance and risk stratification
when can activity be progressed within phase 1 of cardiac rehab ?
adequate increase of HR
adequete rise in SBP
no dysarthmias or ST changes on ECG
no cardiac symptoms: palpitations, dyspnea, angina,excess fatigue.
what outcomes are expected after phase 1 of inpatient cardiac rehab?
- prevent harmful effects of bed rest
- walk 5-10 min continuously or 1000ft 4x day
- can perform stairs IND
- know safe HR and RPE
- recognize abnormal signs/ symps that suggest activity intolerance
When a patient enters phase 2 of cardiac rehab, what is performed during their medical entrance exam ?
-when entering OP cardiac rehab, exercise test with ECG is done to monitor conditions such as:
HR, rhythm, signs/ symptoms, ST segment change, exercise capacity, target HR, baseline, risk stratification
- Physical exam: med hx, lung auscultation, BMI, pulses skin integrity, orthopedic status, resting ecg, exam of chest and leg wounds after CABG ect
how many sessions would a patient with a stable coronary artery disease have to perform to determine exercise level
6-12
What is rec’d for pts who have mod-high risk and/or are unable to understand/ adhere to activity levels
continuous ECG and BP monitors, med supervision until safety is established usually over 12 session
when would you discontinue exercise in phase 2 of cardiac rehab ? (Indications to stop exercise due to red flags)
- plateau or decrease in HR with increased work
- SBP plateau or fall with work increase or >250
- DBP >115
- ST segment depression > 1mm
- 2/3rd heart block
- ventricular arrhythmias
- angina or other symptoms of cardiac insuff
- Rating of 1 on Angina scale is recommended end point of activity for inpatient and outpatient cardiac rehab
How should aerobic exercises be Rxd for phase 2 cardiac rehab?
Mode, intensity, duration, frequency, progression
Mode: activities with large mus groups for rhythmic activity; walking hiking, running, jumprope, skiing, bike,swimming,rowing ect
Intensity based off HR,RPE and MET.
- If pt has not has exercise testing done, +20 bpm from resting HR at standing is used as target for exercise HR.
- Target HR is est by upper and lower limits, karvonen or MET formula
Duration:
- initial training: 15- 20 mins of continuous training in 1st month
- improvement stage: 25- 30 mins 3-4 months
- maintenance stage: >40 mins after 6 months
Frequency 3-5x/week
Progression as pt confidence and fitness improve
an RPE rating of 12-16 is equal to what capacity
MAX capacity 65-85% in cardiac rehab
an RPE rating of 11-13 is equal to what capacity
UPPER LIMIT OF initial cardiac rehab phase in outpatient.
IS RPE specific to the mode of exercise
yes
What is the norm heart rate of an infant, child, adult
Infant: 100-130
Child: 80-100
Adult:60-100
What is bradycardia, tachycardia
bradycardia, <60 bpm
tachycardia<100
How do you characterize the volume of a pulse
0- abscence
1+ - small or reduced
2+ normal
3+ large,bounding
What is considered light activity according to MET
light 1-3 METs walking slow toileting drivign desk.comuter work making bed doing dishes bathing/cooking (2-3 mets) playing cards/craft playing intrument fishing (sitting)
What is considered moderate activity according to MET
3-7 walking 3mph walking 4mph (7 mets) washing car sweep/vacuum light gardening carry/stack wood power lawn mowing dancing ping pong sex golf,walking (4-7 mets) swim (4-8 mets) doubles tennis bike on flat
What is considered vigorous activity according to MET
walking 4.5 mph jog run (11.5 highest) shovel carry heavy load heavy farm work dig ditch backpacking basketball bke flat 14-16mph
How do you time the pulses for regular and irregular rhythms
regular 15 secs x 4
irregular count for 60
How do you palpate the radial and ulnar pulse
radial Lateral to flexor carpi radialis
ulnar Between flexor digitorum superficialis and flexor carpi ulnaris
cardiac catheterization
Thin catheter is advanced through an artery in leg/arm to coronary arteries. Contrast dye is injected. Evaluate narrowing or occlusion of coronary artery, measures blood pressure and O2 in blood
angiography
Shows location of plaque and coronary arteries and extent of occlusion via cardiac catheterization
Carotid ultrasound
Sound waves examine/visualize carotid artery. Screen for blockages that may indicate increase risk of stroke and evaluate use of stent or function of artery after carotid after endarterectomy
chest radiograph
Visualize location size and shape of heart, lungs, blood vessels, ribs and bones. Can show fluid in lungs or plural space, pneumonia, emphysema, cancer
CT scan
New CT scanners can take photos of coronary arteries without need some times for catheterization
echocardiogram
Heart function is viewed in real time via high frequency sound waves. Provides information on size and function of ventricles, thickness of septum, wall/ valves, and chambers.
Electrophysiologic testing
Evaluate rhythm or electrical conduction abnormalities using 3 to 5 catheters inserted into blood vessel and threaded to heart. Recordings help locate abnormal tissue that cause cardiac arrhythmias
Fluoroscopy
Continuous x-ray shows heart and lungs. Involves high dose of radiation, component of cardiac catheterization and electrophysiological testing. Unless for those tests, It has been replaced by echocardiograms
Invasive hemodynamic monitoring
Monitoring of cardiovascular status via intra-arterial catheter and intravenous lines to measure pressure, volume, temp.
-Balloon catheter Swan-Ganz catheter: placed in pulmonary artery to get pulmonary artery wedge pressure and left arterial pressure
- Thermodilution catheter measures cardiac output.
- Central venous pressure (CVP) line- measures vena cava or right atrium pressure
MRI
Assess damage after MI or heart disease, structural problems and aorta, presence of plaque and blockages and blood vessels. Images masses located in mediastinum but cant image the lungs
- 3-D images of the heart blood vessels to assess size and function of chambers
Myocardial perfusion imaging MPI
Known as radionucleotide stress test and nuclear stress test.
- Shows how heart is perfused at rest and under exercise stress.
- Radionucleotide agent injected into blood at rest and maximal level of exercise.
- Heart images show areas of reduced blood flow due to narrowing of one or more coronary arteries
Pharmacological stress test
Cardiovascular stressed is induced by pharmacological agents as a diagnostic procedure. Includes adenosine dipyridamole and dobtamine
Phonocardiography
Helps detect S3 and S4 heart sound for heart failure diagnosis. Diagnostic test creates graphic record for heart sounds and great vessels
Positron emission tomography PET
Small amount of radioactive material is injected inhaled or swallowed.
Increased radioactive material accumulates in areas of high chemical activity or areas of disease.
Different or brighter spots on the skin appear.
PET is helpful with cancer and heart disease diagnosis
Venography
Radio opaque dye is injected into vein while x-ray create image of vein to detect clot or blockage
Ventilation perfusion scan
Small amounts of radioactive material studies airflow and blood flow and lungs. Commonly used to diagnose PE
What does pulse oximetry measure
SP O2 indicates partial pressure of oxygen in arterial blood.
At which SPO2 should activity be stopped for acutely ill patients or chronic lung disease?
acutely ill patients >90
chronic lung disease >85
Arthrectomy
Similar to angioplasty except catheter has a rotating shaver to cut the plaque away and increase blood flow
Automatic implantable cardioverter defibrillator AICD
Surgically implanted device similar to pacemaker. Continuously monitors heart rhythm and delivers electrical shocks to restore normal heart rhythm when necessary
Balloon angioplasty
- Small balloon tipped catheter is inserted into stenotic artery.
- Balloon is expanded at blockage of narrowed artery to widden it.
- Often a small metal coil is left in the narrowed artery to help prop it open and decrease chance of re-stenosis.
- This is the stent
Balloon valvuloplasty
Cardiac catheterization treats stenotic heart valves.
- Balloon tipped catheter is threaded through the veins to faulty heart valve valve.
- Then inflated to open narrowed valve and increase blood flow
Cardiac ablation
Chemical or radio frequencies are used to destroy myocardial areas that have been identified via electrophysiologic testing that can cause cardiac arrhythmias
-Option for patients who have Tachyarrhythmias that can’t be controlled by medication or arrhythmias it’s respond well to abolition such as wolf Parkinson White syndrome
Cardiac pacemaker
Surgically implanted in the left anterior chest wall under the skin.
- Standard treatment for conditions affecting slow heart rate and arrhythmias.
- Prevent slow heart rate in order to prevent fatigue lightheadedness and fainting.
Cardioversion
Done to restore normal heart rate for tacky arrhythmias that do not respond to medication. Electric shocks delivered by defibrillator through chest electrodes
Coronary artery bypass graft surgery (CABG)
- Surgery performed to treat coronary arteries narrowed/included.
- Attempt to revascularized myocardium.
- Blood is rerouted around affected artery and joins patient’s saphenous vein, internal thoracic/mamamary artery or radial artery to connect affected artery above and below occlusion
Enhannced extracorporeal counterpulsation EECP
nonInvasive procedure cuff on lower extremities inflate to compress veins to assist with venous return to the heart
Heart Transplant
Failing, diseased heart is replaced with healthy donor heart.
Received in patients with end-stage heart failure when other treatments are not successful.
Intra-aortic Balloon counterpulsation IABP
Inflation and deflation of balloon in aorta provide circulatory assistance for patient with infarct or with cardiogenic shock
Valve replacement
Thetic valve is implanted to replace leaky or narrowed heart valve.
Types:
Mechanical (ball in cage, tilting desk, bileaflet)
tissue graft from same patient.
Cadaver.
Pig
Ventricular assist device VAD
Mini pump implanted to help provide mechanical support to ventricle.
-Right ventricular device RVAD attaches to right atrium and pulmonary artery bypass the right ventricle.
-Left ventricular device attaches to the left atrium bypasses L ventricle
biventricular device BiVAD- Ventricles are bypassed.
-VADs commonly used as temporary treatment for people waiting for heart transplant
- increasingly as permanent treatment for heart failure
Antihistamine agents
Action
Indication
SIde effect arrhythmias, postural hypotension, GI distress, dizzyness,, drowsiness, blurred vision, headache, fatigue. nausea, thickening of secretions
Implication for PT : Guard patient is case for positional hypotension
Examples benadryl, alegra
Anti-inflammatory
Action
Indication
SIde effect: like glucocorticoids, destruction of bone and airways tissue. Systemic effects minimized with airway passage.
Implication for PT : not for acute episodes. EDU on correct inhaler use
Examples Q var, pulmicort, leukotriene
Bronchodilator agents
Action
Indication relieves bronchospasm/ wheezing/ SOB in asthma, COPD,
SIde effect : paradoxical bronchospasm, dry mouth, GI distress, chest pain, palpitations, tremor, nervousness, asthma related death with salmterol a long lasting sympathomimetic
Implication for PT take long lasting before PT and bring short acting (rescure inhaler) to PT
Examples anticholinergic atrovent, spiriva, vetolin, serevent,
Expectorant agents
Action Indication SIde effect Implication for PT Examples
Mucolytic agents
Action Indication SIde effect Implication for PT Examples
airway adjuncts
Devices used to maintain or protect airway to provide mechanical ventilation or to promote airway clearance.
- Oral pharyngeal airway: plastic tube to fit curvature of soft palate and tongue holds tongue away from back the throat to maintain clearance.
- Nasal pharyngeal airway: latex/rubber tube inserted through nose to allow nasotracheal suctioning
- Endotracheal tube: plastic tube inserted in trachea from mouth or nose to provide airway to allow mechanical ventilation
- Tracheostomy tube: artificial airway inserted in trachea from incision in neck below vocal cords used in patients needing prolong mechanical ventilation
Bullectomy
- Bullae form when alveoli are destroyed by emphysema.
- Bullectomy is surgical procedure where more of the large air spaces are removed.
- Improves breathing
Lung transplant
Reserved for patients with end-stage COPD, interstitial pulmonary fibrosis, cystic fibrosis, and other serious lung diseases but do not have serious comorbidities
Mechanical ventilation
Severe pulmonary dysfunction may require assistance from positive pressure mechanical ventilator.
- Positive pressure from ventilator provides force to deliver air into lungs by increasing intrathoracic pressure.
- Connected to tracheostomy tube or mask to assist patient breathing
What is oxygen therapy indicated
Treatment of acute and chronic hypoxemia.
- PaO2 less than 55
- oxygen saturation less than 88%
normal HR for a infant
100-130
normal HR for an adult
60-100
normal HR for a child
80-100
