Exam 1 Cardiac Flashcards
AV valves
- Tricuspid valve (Flows blood from right atrium to right ventricle)
- Mitral valve (Flows blood from left atrium to left ventricle)
Semilunar valves
- Pulmonic valve (Flows blood from right ventricle through pulmonary arteries to lungs)
- Aortic valve (Flows blood from left ventricle through the aorta to the body)
What causes the S1 sound (lub)
When the AV valves (tricuspid and mitral valves) close
What causes the S2 sound (dub)
When the semilunar valves (pulmonic and aortic valves) close
What is Diastole?
- Atria and ventricles are relaxed & the atrioventricular valves are open
- Caused by SA node
- The tricuspid valve prevents the blood from flowing back into the right atrium.
- The mitral valve prevents the oxygenated blood from flowing back into the left atrium
What is Systole?
- Right and Left ventricles contract (squeeze)
- The AV valves close and the semilunar valves open
- The pulmonary artery carries the blood to the lungs. There the blood picks up oxygen and is returned to the left atrium of the heart by the pulmonary veins.
- The aorta branches out to provide oxygenated blood to all parts of the body. The oxygen depleted blood is returned to the heart via the vena cava
Cardiac Output (CO) normal value
Normal CO: 4-7 L/min
- Amount of blood pumped out by the ventricle per minute
Central Venous Pressure (CVP or RAP) normal value
Normal RAP 2-5 mmHg
- Reflects filling pressures of the right side of the heart
Mean arterial pressure (MAP) normal value
Normal 70-100 mmHg
- Average perfusion pressure
Cardiac Index (CI) normal value
Normal CI : 2.2-4.0 L/min/m2
- Adjusts CO for body size
- More precise
Stroke Volume (SV) normal value
Normal 60-70ml
- Amount of blood ejected by ventricle with each heart beat
Systemic Vascular Resistance (SVR) normal value
Normal 800-1400 dynes/sec/cm
- The resistance against which the left ventricle must pump to eject its volume
Pulmonary Artery Wedge Pressure (PAWP) normal value
Normal: 4-12 mmHg
- reflects the filling pressures in the pulmonary vasculature LEFT sided pressures
Pulmonary Artery Systolic Pressure (PAS) normal value
PAS normal: 15-26 mmHg
Pulmonary Artery Diastolic Pressure (PAD) normal value
PAD normal: 5-10 mmHg
Stroke volume variation (SVV) normal range
Normal SVV < 10-15%
SVO2 (return of blood back to the right side of the heart) normal value
Normal value 60%-80%
What is Preload?
amount of blood going to the heart (PAWP & CVP)
What is Afterload?
the pressure against which the heart must work to eject blood during systole (SVR mainly & PVR)
Elevated Preload (CVP & PAWP) causes what?
- Crackles in lungs
- Jugular vein distention
- Hepatomegaly
- Peripheral Edema
- Taut skin turgor
Decreased Preload (CVP & PAWP) causes what?
- Poor skin turgor
- Dry mucous membranes
Elevated Afterload (SVR mainly & PVR) causes what?
- Cool extremities
- Weak peripheral pulses
Decreased Afterload (SVR mainly & PVR) causes what?
- Warm extremities
- Bounding peripheral pulses
Drugs to increase SVR? (Afterload)
Dopamine, Norepinephrine (causes vasoconstriction)
Drugs to decrease SVR? (Afterload)
Nitroprusside, NTG, Hydralazine (causes vasodilation)
Treatment for Abnormal values for Right side preload (CVP)
- Diuretics
- Fluid restriction
- Fluid bolus
- Blood or blood products
Treatment for Abnormal values for Left side preload (PAWP)
- Fluid restriction
- Venodilation
- Diuretics
- Fluid
- Blood and blood products
High values (80%-90%)of SVO2 could mean?
- Hyperoxygenation
- Anesthesia
- Sepsis
- False reading
Low values (<60%) of SVO2 could mean?
- Anemia, bleeding
- Cardiogenic shock
- Hyperthermia, seizures, activity
- Hypoxemia
The nurse caring for a patient with an arterial line notes the reading of 182/130. The priority action at this time will be:
- Notify the MD
- Increase the nitroprusside IV gtt
- Verify the transducer level
- Verify the flush solution
- Verify the transducer level (make sure the equipment is working
The patient with a FloTrac monitor is noted to have a SVV of 19%. The nurse can anticipate which treatment ordered?
- Fluid bolus
- Dopamine IV gtt
- Nitroglycerine IV gtt
- Lasix per IV
- Fluid bolus (If SVV is >15%, patient’s cardiac output will increase with fluid infusion)
The nurse notes a SVR of 550 dynes/sec/cm-5. This is an indicator of:
- Vasoconstriction
- Increased right heart preload
- Increased left heart preload
- Vasodilation
- Vasodilation (lower SVR is vasodilation and higher SVR is vasoconstriction)
Nursing care for Angiography
- maintain NPO status for at least 8 hours
- obtain vital signs, heart and lung sounds, and peripheral pulses
- Consent form is signed
After operation: - Assess vital signs every 15 min x 4, every 30 min x 2, every hour x 4, and then every 4 (follow protocol)
- Assess incision site
- Maintain bed rest in supine position with extremity straight for prescribed time.
Complications with angiography
- Cardiac tamponade (fluid accumulation in pericardial sac)
- Hematoma formation (blood clots can form near the insertion site
- Restenosis of treated vessel (Clot reformation in the coronary artery can occur immediately or several weeks after procedure)
- Retroperitoneal bleeding (bleeding into retroperitoneal space can occur due to femoral artery puncture)
Sinus tachycardia (Rate: 101-150 bpm) management
- Treat cause (fever, exercise)
Sinus bradycardia (Rate: <60 bpm) management
- If client is symptomatic: Atropine, isoproterenol, Pacemaker
Atrial flutter and fibrillation management
Rhythm control
- Pharmacological:
Amiodarone, adenosine, ibutilide, disopyramide, flecainide, dofetilide, sotalol
Electrical cardioversion ** only if < 48 hours **
Surgical:
MAZE procedure, requires open heart surgery
Ablation procedure
Rate control:
Ca channel blockers, beta blockers, digoxin
Complication prevetion (stroke) anticoagulate
Premature Atrial Contractions (PAC) management
No treatment, usually benign
Junctional rhythm (40-60 bpm and p wave inverted) management
- if symptomatic:
Atropine
Accelerated junctional rhythm (61-100 bpm and p wave inverted) management
No treatment necessary
Junctional tachycardia (101-180 bpm and p wave inverted) management
-Control rapid rate with Ca channel blocker, Beta blocker, or Amiodarone
Premature junctional contractions management
- Observe
Supraventricular Tachycardia (Rate: 100-280 with a mean of 170 bpm in adults) management
Amiodarone, adenosine, and verapamil
Premature Ventricular Contraction (PVCs) management
- Treat the cause
- Antidysrhythmic medication
Ventricular tachycardia (140-180 bpm (or more)) management
- VTach (Pulseless) Defibrillate, CPR, Epinephrine, Vasopressin
- VTach (With Pulse), Amiodarone, Sotalol, Lidocaine, Cardioversion
ventricular fibrillation
amiodarone, lidocaine, epinephrine, and defibriillate
Ventricular asystole (No electrical activity)
- Check in different lead
- CPR
- Epinephrine every 3-5 minutes
PEA: Pulseless electrical activity 5 H’s and 5 T’s
5 H’s
- Hypovolemia
- Hypoxia
- Hydrogen ions (acidosis)
- Hyper or hypokalemia
- Hypothermia
5 T’s
- Tables (drug overdose)
- Tamponade
- Tension pneumothorax
- Thrombosis (coronary)
- Thrombosis (pulmonary)
First degree heart block management
- None, other than treating any possible cause
second degree heart block management
- Possible transcutaneous pacing or transvenous pacing
Third degree heart block management
- Requires pacemaker
Transcutaneous or transvenous
Hyperkalemia changes to ECG
- Tall, peaked T-waves
- Widened QRS complex, Ventricular fibrillation, Cardiac standstill
- Prolongation of the P wave & PRI
- Flattens P wave
Hyperkalemia treatment
- D50 W and IV Insulin
temporary measure for life-threatening levels - Calcium Chloride
temporary measure, increases threshold potential - Cation exchange resin products into GI tract such as Kayexalate
permanent measure - Hemodialysis or peritoneal dialysis
permanent measure
Hypokalemia changes to ECG
- PVCs
- Deterioration into V-tach or V-fib
- Depressed T-waves, inverted T-waves
- U waves
- 2nd and 3rd heart blocks
Hypokalemia treatment
K+ replacement (10 meq per hour)
- High Alert Medication
- NEVER IV push
- Monitor for phlebitis
If hypomagnesemia exists, Mg+ replacement has to take place before K+ replacement can be successful
Hypermagnesemia changes to ECG
Similar to Hyperkalemia
- Tall, peaked T-waves
- Widened QRS complex, Ventricular fibrillation, Cardiac standstill
- Prolongation of the P wave & PRI
- Flattens P wave
Hypermagnesemia treatment
calcium gluconate
Hypomagnesemia changes to ECG
Similar to K+
- Prolonged PR & QT intervals
- Presence of U waves
- T-wave flattening
- Widened QRS complex
Hypomagnesemia treatment
Magnesium IV replacement
- No Pulse
1-2 gm in 10 ml D5W over 5-20 minutes
- With a pulse
1-2 gm over 5 to 60 minutesHypercalcemia changes to ECG
- Shortened QTc interval
- Bradycardia
- Heart block (1º, 2º, and 3º) & BBB
Hypercalcemia treatment
-Loop diuretics (acute management)
Furosemide 1mg/kg along with NS to maintain stable
body water, along with a K+ replacement
- Calcitonin (slower to work)
SQ or IM - Biphosphonates
- Hemodialysis
Hypocalcemia changes to ECG
- Variable
- Bradycardia
- V-tach
- Asystole
- Prolonged QT interval (leads to torsades de pointes)
Hypocalcemia treatment
- Seizure precautions
- Oral and IV replacement
- Calcium chloride
- Calcium gluconate
What is Lead I
- Positive electrode - left arm (or under left clavicle)
- Negative electrode - right arm (or below right clavicle)
- Ground electrode - left leg (or left side of chest in midclavicular line just beneath last rib)
- Waveforms are positive
What is Lead II
- Positive electrode - left leg (or on left side of chest in midclavicular line just beneath last rib)
- Negative electrode - right arm (or below right clavicle)
- Ground electrode - left arm (or below left clavicle)
- Waveforms are positive
What is Lead III
- Positive electrode - left leg (or left side of the chest in midclavicular line just beneath last rib)
- Negative electrode - left arm (or below left clavicle)
- Ground electrode - right arm (or below right clavicle)
- Waveforms are positive or biphasic
What is lead aVR
- Positive electrode placed on right arm
- Waveforms have negative deflection
What is lead aVL
- Positive electrode placed on left arm
- Waveforms have positive deflection
What is lead aVF
- Positive electrode located on left leg
- Waveforms have a positive deflection
How does the ventricular axis work
- Normal
- Lead I is +
- Lead aVF is + - Right Axis Deviation
- Lead I is –
- Lead aVF is + - Left Axis Deviation
- Lead I is +
- Lead aVF is – - NW (indeterminate) (Left ventricle to Right ventricle
- Lead I is –
- Lead aVF is -
What causes Left Axis Deviation
- Q waves of inferior myocardial infarction
- artificial cardiac pacing
- emphysema
- hyperkalaemia
- injection of contrast into left coronary artery
- left ventricular hypertrophy
What causes Right Axis Deviation
- normal finding in children and tall thin adults
- right ventricular hypertrophy
- chronic lung disease even without pulmonary hypertension
- anterolateral myocardial infarction
- pulmonary embolus
What causes No Man’s Land (Northwest Axis)
- emphysema
- hyperkalemia
- lead transposition
- artificial cardiac pacing
- ventricular tachycardia
What is defibrillation and when do you use it
- Electrical countershock to stop chaotic electrical activity so that normal conduction can resume
- Pulseless ventricular tachycardia and ventricular fibrillation
How many joules does the biphasic waveform defibrillator (safer) use
120-200 joules
Safety for defibrillation
- Check for the pulse…never defibrillate a palpable pulse.
- Do not shock systole.
- Always use gel pads to protect pt’s skin
- Keep paddles/pads away from each other
- I’m clear, you’re clear, we all are clear
What is cardioversion
It is synchronized: Low energy shock to convert stable supraventricular or ventricular tachycardias to normal sinus rhythms
How to do cardioversion and safety
- Shock synchronized with pt’s R wave to avoid falling on T wave.
- 50j, 100 j, 200j, 300j, 360j
- Sedate patient if possible
- Have emergency cart at bedside
What is the three letter pacemaker code
- Position I =Chambers Paced
0 = none
A= atrial
V= ventricle
D= dual (atrial & ventricle)
- Position II = Chambers Sensed
0= none
A= atrial
V= ventricle
D= dual
- Position III = Response to sensing
0= none
T= triggered
I= inhibited
D= dual (T and I)When to use a pacemaker
- symptomatic bradycardia
- severe asymptomatic bradycardia
- AV block
- complete block (3rd degree)
- atrial flutter/atrial fib with slow ventricular response
- sick sinus syndrome
- tachybrady syndrome
Risk for pacemakers
- catheter dislodgment
- lead fracture
- pacemaker system failure
- erosion of pulse generator
- pacer induced tachycardia
- infection/local sepsis
- cardiac perforation with tamponade
- thrombosis of superior vena cava or right atrium
- dysrhythmias
Temporary pacemakers
- Transcutaneous (pads)
- Epicardial (wires to the heart)
- Transvenous (vein through the leg)
Permanent pacemakers
Transvenous
When are transcutaneous (pads) pacemakers used
- less than 24 hours
- waiting for someone to put one in
Asynchronous pacemaker mode
- Pacemaker does not sense pt’s intrinsic rate. Rate is fixed
Synchronous pacemaker mode
- pacemaker senses pt’s intrinsic rate and fires on demand
What is hypertension (HTN)
- Systolic blood pressure ≥140 and/or diastolic blood pressure ≥90 in people who do not have diabetes mellitus
- Patients with DM should have BP < 130/90
How to help prevent hypertension
- Diet
- Low sodium, low fat diet.
- Lower cholesterol levels to < 200 mg/dl total - Weight reduction
- Reduced alcohol intake
- Exercise
- At least 5 days a week - Decrease stress levels
- Relaxation techniques
- Avoid alcohol, smoking
Hypertension management
- Monitoring BP at home
- Goal of 140/90 or lower
- Keep a record and bring to visits with provider - Warning signs
- MI, CVA, PAD, Kidney disease - Medications
- What they are for and the side effects
- Adherence to medication regimen
Hypertension drug therapy
- Diuretics
- Thiazide diuretics first choice - Calcium channel blockers
- Verapamil, amlodipine - ACE inhibitors
- captopril, lisinopril, enalapril - Beta-adrenergic blockers
- atenolol, metoprolol, - Renin inhibitors
- aliskiren - Angiotensin II receptor antagonists
- valsartan, losartan - Central alpha agonists
- clonidine - Alpha-adrenergic agonists
- prazosin, terazosin - Aldosterone receptor antagonists
- Eplerenone
The 6 P’s of arterial insufficiency
- Pain
- Pallor
- Pulselessness
- Paresthesia
- Paralysis
- Poikilothermia (coolness)
What are aneurysms of central arteries
Permanent localized dilation of artery, enlarging artery to twice its normal diameter
Types:
- Fusiform
- Saccular
- Dissecting (aortic dissection)
- Abdominal aortic
- Thoracic aortic
Symptoms of abdominal aortic aneurysm (AAA)
- usually steady pain with a gnawing quality, unaffected by movement, may last for hours or days
- Pain in abdomen, flank, back
- Abdominal mass is pulsatile
- Bruit
- Rupture is most frequent complication and is life threatening
Rupture of abdominal aortic aneurysm (AAA)
Sudden ripping, tearing, stabbing abdominal or back pain and legs
symptoms:
- Diaphoresis, faintness, N&V, apprehension
- Hypotension, tachycardia
Symptoms of Thoracic Aortic Aneurysm
Symptoms often do not occur until the aneurysm is larger and causing pressure from the aorta on adjacent structures:
- coughing and wheezing
- Horner’s syndrome (drooping eyelid, constricted pupil and dry skin on one side of the face)
- Hoarse voice
- Difficulty swallowing
- Back pain
- Mass may be visible above suprasternal notch
Rupture of Thoracic Aortic Aneurysm
Sudden excruciating back or chest pain symptomatic of thoracic rupture. Pain can travel into arms, abdomen and lower back
Symptoms:
- Diaphoresis, faintness, N&V, apprehension
- Hypotension, tachycardia
Nonsurgical management of aneurysm
- Monitor aneurysm growth
- Maintain BP at normal level to decrease risk of rupture
Indications for aneurysm repair
- Aneurysm > 6 cm
- Progressively increasing in size
- Impending rupture
- Sx of cerebral or coronary ischemia
- Pericardial tamponade
- Uncontrollable pain
- Aortic insufficiency
Complicationsfor surgical repair of aneurysm
- Bleeding
- Graft occlusion
- Myocardial infarction
- Acute renal failure
- Distal embolization
- Colon ischemia
- Spinal cord ischemia
What is an aortic dissection
- May be caused by sudden tear in aortic intima, opening way for blood to enter aortic wall
- Creates false lumen
- Pain described as tearing, ripping, stabbing
- Life threatening
Aortic dissection management
- Assess 6 “P”s
Pain, pallor, paresthesia, paralysis, pulselessness,
poikilothermia - Control pain
- Morphine - Control HTN
-Labetolol, Esmolol
- Nipride - Diagnostic tests
-CT scan for emergent, MRI for stable, chronic
Transesophageal echocardiography (TEE) - Surgical intervention
- Resection and replacement with graft
- Cardiopulmonary bypass machine
Nonsurgical Management of Venous thromboembolism (VTE)
- Rest, preventive measures
- Drug therapy:
- Unfractionated heparin
- Low–molecular weight heparin
- Warfarin
- Thrombolytics
Surgical management of Venous thrombembolism (VTE)
- Thrombectomy
- Inferior vena caval interruption
- Ligation or external clips
Ankle Brachial Index scores
- normal (0.91 to 1.30)
- mild (0.71 to 0.90) (blood thinners)
- moderate (0.41 to 0.70) (blood thinners)
- severe (≤ 0.40)
