Exam 2 Flashcards
What is normal cardiac output
5-6 liters of blood per minute
Efficiency of the cardiovascular system depends on what four things?
- Heart’s ability to pump
- Patency of the blood vessels
- Quality of the blood
- Quantity of the blood
What is happening during the “P” wave?
Impulse travels through the atria
What happens during the QRS complex?
Impulse travels through the ventricles
What happens during the “T” wave
Re-polarization of the ventricles
When does re-polarization of the atria occur?
Somewhere during the QRS complex
What is polarization?
- Where is sodium
- Where is potassium
Ready or resting state
- Na+ is extracellular
- K+ is intracellular
What is depolarization?
- Where is sodium
- Where is potassium
Contraction
- Na moves into the intracellular
- K+ moves into the extracellular
What is repolarization?
- Where is sodium
- Where is potassium
- Na moves back extracellular
- K moves back intracellular
Role of the autonomic nervous system in control of the heart
PSNS slows heart (negative chronotropic, negative inotropic)
SNS compensates heart that is giong to slow (positive chronotropic, positive inotropic, positive dromotropic)
Two types of hormones that affect the heart
- Catechonlamines (Adrenergic responses)
- Thyroid hormone
Two types of catecholamines that affect the heart
Norepinephrine
Epinephrine
How does Thyroid hormone affect the heart rate
Increased thyroid hormone –> increases BMR –> Increases HR
WBCs originate from (3)
- Bone marrow
- Spleen
- Lymph
Role of albumin
Exerts osmotic pressure intravascularly
Role of fibrinogen
Hemostasis in the plasma
Role of globulins
Defense
General composition of blood
55% plasma
45% solid particles
Composition of plasma (9)
90% water
10% albumin, fibrinogen, globulins, nutrients, oxygen, carbon monoxide, antibodies
What solid particles are in the blood?
- Leukocytes
- Erythrocytes
- Thrombocytes
Normal leukocyte level in the blood
5,000 - 10,000
Normal hematocrit levels
- Males
- Females
- Males: 42-50%
- Females: 40-48%
Normal hemoglobin levels:
- Males
- Females
- Males: 13-18
- Females: 12-16
Normal hemoglobin and hematocrit: Females
Hemoglobin: 12-16
Hematocrit: 40-48%
Normal hemoglobin and hematocrit: Males
Hemoglobin: 13-18
Hematocrit: 42-50%
Functions of the blood (5)
- Transports O2 and Nutrients to the cell
- Transports CO2 and waste away
- Leukocytes and antibodies help fight microorganisms
- Promotes hemostasis (platelets)
- Circulates hormones
Hemostasis: Def
Bringing platelets to the site of injury
Normal platelet count (thrombocytes)
100,000 - 400,000
Location of the aortic valve
2nd intercostal space, right sternal boarder
Location of pulmonic valve
2nd intercostal space, left sternal boarder
Location of Tricuspid valve
4th intercostal space, left sternal border
Location of Mitral valve
5th intercostal space, midclavicular line
Stroke volume (def)
The amount of blood ejected from the heart with each contraction
Heart rate (def)
Beats per minute
Cardiac output (equation)
CO = SV x HR
Average SV
~70
Average HR
~80
Average CO
5.6L / minute
When you think preload, think _______.
VOLUME
When you think afterload, think ______.
PRESSURE
How do you lower preload? (4)
- Vasodilators
- Blood loss
- Diuretics
- FVD
How do you raise preload? (4)
- Vasoconstrictors
- Blood donation
- FVE
- Valve regurg
How do you lower afterload? (3)
- Vasodilatators
- Nitroglycerine
- Hypertrophied left ventricle
How do you raise afterload? (4)
- Vasoconstrictors
- HTN
- Epinephrine
- Dopamine
Arterial pressure must counteract ________
Ventricular systole.
Indirect measurements of CO: Appendages (3)
- 2+ pulses
- Skin is warm and dry
- Good capillary refill
Indirect measurements of CO: Vital signs (3)
- BP WNL
- HR WNL
- RR WNL, breath sounds clear
Indirect measurements of CO: CNS
A&Ox3
Direct measures of CO (2)
- Swan-Ganz / R heart catheter
- Cardiac catheterization
Role of a Swan Ganz / R Heart catheter (2)
1) Monitors fluid load (CVP)
2) Thermester Coupler (2nd lumen) - measures CO
Two locations of baroreceptors
- Aortic arch
- Carotid sinus
Role of baroreceptors
Respond to changes in BP
What do the baroreceptors do when BP rises? + 2 results
Stimulate PSNS
- Vasodilitation
- Decreased HR (Neg Inotrope, Neg chronotrope)
What do the baroreceptors do when BP falls? + 2 results
SNS is stimulated
- Increased HR (positive chronotrope)
- Increased contractility (positive inotrope)
Two locations of chemoreceptors
- Aortic arch
- Carotid sinus
Chemoreceptors respond to changes in… (3)
1) Acidosis (pH 45)
2) Hypercapnia
3) Hypoxia
When stimulated, chemoreceptors will increase… (3)
- RR
- HR
- CO
Left ventricle has to over come pressures in the _______
aorta
Right ventricle has to overcome pressures in the ______
pulmonary system
Cor Pulmonale (def)
Right ventricular Failure
Diagnostic cardiac tests (7)
1) Electrocardiogram
2) Echocardiogram
3) Stress Test
4) Radionucleotide imagery
5) Cat scan
6) Positron Emission
7) Chest X-Ray
Holter Monitor
- What is it
- Function
- Type of portable ECG
- Shows us the 24-hour ECG while patient goes about normal activity
What is a trans esophageal echo (TEE)?
-Indications
Patient swallowsa transducer to get an echocardiogram
- For very obese patients
What is the difference between an Echocardiogram and an Electrocardiogram?
An echocardiogram is a moving picture of structures of the heart – looks at mechanics of valves and walls.
An electrocardiogram (ECG) looks at the electrical activity of the heart only.
How much do arteries expand during stress?
4x larger!
Two types of stress test
- Exercise (pt on treadmill)
- Pharmacological (vasodilator mimics effect of exercise)
What is Bruce’s protocol?
- Increase the speed and incline of the treadmill every 3 minutes (Stress test)
Contraindications of stress test (4)
- Severe aortic stenosis
- Acute MI
- Severe hypertension
- Atherosclerosis
Why is severe aortic stenosis contraindicated with stress test?
Patient cannot get enough blood volume out to perfuse coronary arteries, brain
Why is an acute MI contraindicated with stress test?
Patient already has increased oxygen demand and inability to deliver it
Why is severe hypertension contraindicated with stress test?
Increases risk for stroke, MI
Complications of stress test (4)
- MI
- CHF (congestive heart failure)
- Cardiac arrest
- Arrhythmias
What is a negative stress test?
What does this mean?
- No symptoms at target heart rate
- Means that signs and symptoms probably not coming from the heart
What is a positive stress test?
What does this mean?
- Symptomatic: Pain, light-headedness
- Stop immediately
What is the target heart rate
80-90% of max predicted for patient’s age level
Indications for an echocardiogram (2)
Suspect aortic stenosis
Suspect mitral valve regurg
Pros of echocardiogram
- Non-invasive
- No prep needed
Radionucleotide imagery (def)
Diagnostic test that uses isotopes to detect coronary artery perfusion or infracted areas of the heart.
More blood volume indicated by more visible isotopes.
Recommendations for diabetes medications and CAT scans
High contrast dye increases risk of renal failure when contrast dye is combined with metformin or glucophage – hold these meds for 24-48 hours while pt is treated and kidney levels are monitored, plus gie plenty of fluids to flush
What is a CAT scan? What can be observed?
- Narrow beams of x-ray that enables cross-sectional views of STRUCTURE
- Can look at calcium plaques, atherosclerosis
One cat scan is equal in radiation to _______ times X-Rays
100-250x
What is the difference between a CAT scan and a PET scan?
a CAT scan looks at STRUCTURE
a PET scan looks at FUNCITON
Indications for a PET scan
- Looking for cancer or metastasis of cancer
Which is most accurate: TEE, Thalium scan, or PET scan
PET scan
Why are two isotopes used in the PET scan?
- One shows circulation
- The other shows metabolic function (by showing which cells take up the most isotopes - hence cancer diagnosis).
What does a chest x-ray look at?
What doesn’t it look at?
Looks at size, contour, position of the heart
Does not give info on coronary arteries
What type of enzymes are very specific to organ?
Iso-enzymes
What tests would you draw up in an acute situation?
- CK-MB
- Troponin
- Myoglobin
- CBC
Creatinine Kinase
An enzyme that comes from many types of tissues
CK-MB
Contractile protein specific to myocardium
Troponin
Most cardiac specific contractile protein. Gold standard; found only in cardiac muscle
Normal troponin levels (2)
Troponin I: <0.2 mcg/L
Troponin: Definitive MI diagnosis (levels)
> 2.3 mcg/L
- When does Troponin elevate?
- When does it peak?
- How long does it remain elevated?
- Elevates within 2-4 hours of an MI
- Peaks within 4-24 hours
- Remains elevated about a week
What is myoglobin?
Heme protein that helps transport O2
Where is myoglobin found
In cardiac AND skeletal muscles
- When does myoglobin elevate?
- When does it peak?
Elevates early: Within 30-60 minutes
Peaks within 6 hours
Role of myoglobin diagnostically
Doesn’t confirm that a patient has MI, but negative results can help RULE OUT MI.
When are iso-enzyme levels taken?
What is the goal?
Immediately, then three hours later.
Goal = 2 negative results.
What is CRP?
When is it produced?
- An abnormal serum glycoprotein
- Produced by the liver in response to inflammation
What does C-Reactive Protein tell you about cardiac function?
- Not cardiac specific, but a risk factor (correlational)
What is homocysteine?
An amino acid that increases as the result of B vitamin deficiencies
What releases BNP and when?
- Secreted by ventricles
- In response to high preload
When is BNP assessed?
To determine if problem is cardiac or respiratory (rises if cardiac)
What is BNP (def)
Neurohormone that helps regulate BP and fluid volume
Goal of BNP (and mechanism)
- To decrease fluid
- Stop renin-aldosterone-angiotensin
Functions of cholesterol (3
- Hormone synthesis
- Cell membrane formation
- Brain / nerve cells
Sources of cholesterol
- Dietary (animal and trans fats)
- Liver
When is a lipid profile taken?
At FASTING levels (8-12 hours after a meal)
Lipid profile normals:
- Cholesterol
- Triglycerides
- LDLs
- HDLs
- Cholesterol: <40
What are triglycerides
Fatty acids made with glycerol
High levels of triglycerides are associated with:
- Meals
- Stress
- Obesity, Poorly controlled diabetes
- Heavy alcohol use
_____ often directly correlated with high LDL levels
High triglyceride levels
Where are triglycerides stored? How are they transported?
- Stored in fatty tissue
- Transported in lipoproteins
LDLs: What do they cause
Form deposits on artery walls –> atherosclerosis –> CAD
Role of HDLs
Help remove fat from arterial wall, brings it to liver for breakdown, excretion
LDLs v HDL
“Lousy and Low” versus “Healthy and High”
Four things that will help increase HDLs
- Stop smoking
- Control DM
- Attain or maintain normal weight
- Increase physical activity
What is Cardiac Catheterization / Angiogram?
Invasive test to diagnose CV disease through direct visualization
How is Cardiac Catheterization done?
Percutaneous stick into femoral vein, dye goes through. Or done through femoral artery.
What should you do before an angiogram? (4)
- Administer some sedation
- Assess pulses distal from site
- Assess skin
- Assess ROM
What should you do after an angiogram? (4)
- Stand over patient holding pressure for 20 minutes
- Leg or limb immobilized for 2-8 hours
- HOB raised no more than 30 degrees
- Plenty of fluids to wash out dye
- Assess Q15
What should you assess before and after an angiogram?
- Vital signs
- Distal pulses
- Temp of limbs
- Color of limbs
Potential complications of an angiogram (6)
- MI (assess for chest pain)
- Bleeding from insertion site
- Clots: Pt may be losing circulation distal to insertion site
- Higher risk for pulmonary emobli
- Higher risk for stroke
- Allergic reaction to contrast dye
Three options if blockage is found during an angiogram
- Tx with meds
- Put in a stint
- Send patient to OR for bypass graft.
Intrinsic rates:
- SA node
- AV node
- Ventricles
- SA node: 60-100 bpm
- AV node: 40-60 bpm
- Ventricles: 20-40 bpm
Define irritability
A group of cells along the conduction pathway start speeding up; override the higher pacemaker site for control
Irritability: Common cause
Often due to hypoxia of myocardium
Effects of high calcium on the heart
High: Irritability
Effects of low calcium on the heart
Low: Tetany in skeletal muscles (not as much on heart)
Effects of high potassium on the heart (3)
- Peaked T wave
- irregular heart beat
- Slow / weak HR
Effects of low potassium on the heart (1)
- Low T wave
Electrical flow of lead 2
- From right arm to left leg
- P & QRS are all upright
How much time is represented by every little ECG box?
.04 seconds
How long is an average PR interval?
3-5 boxes
0.12 - 0.2 seconds
How long is an average QRS complex?
- 3 small boxes or less
- 0.12 seconds or less
SINUS BRADYCARDIA
- Rate:
- Rhythm:
- P wave:
- PRI:
- QRS:
- What does it look like?
- Rate: <60
- Rhythm: Normal
- P wave: Present
- PRI: 0.16 seconds (normal)
- QRS:0.08 (normal)
- Normal, just slow
Causes of sinus bradycardia (5)
- Digoxin
- Beta blockers
- Cholinergics
- Severe visceral pain
- Athletes
What would you assess with a SINUS BRADYCARDIA patient?
- Primary: Inadequate perfusion to brain: CNS issues: Lightheaded, change in LOC, restless
- Secondary: Cold pale skin
Intervention for a patient with sinus bradycardia – symptomatic
- Identify cause
- Atropine
- Pacemaker
Sinus Tachycardia
- Rate:
- Rhythm:
- P wave:
- PRI:
- QRS:
- What does it look like:
- Rate: 120
- Rhythm: Normal
- P wave: Present
- PRI: 0.16 (normal)
- QRS: 0.08
- Normal, just fast
(Non-medicine) Causes of sinus tachycardia (5)
- Fever
- Pain
- Shock
- Anxiety
- Meds
What would you assess with SINUS TACHYCARDIA?
- Restless ness, change in LOC
- Skin is cool, pale (unless feverish)
Interventions for a patient with sinus tachycardia (2 categories, 2 interventions each)
1) Innervate PSNS (carotid massage, valsalva)
2) Meds (beta blockers, calcium channel blockers)
Premature atrial contractions
- Rate:
- Rhythm:
- P wave:
- PRI:
- QRS:
- What does it look like:
- Rate: Normal
- Rhythm: Irregular
- P wave: Not regular – varying sizes and shapes
- PRI: Elongated (0.24 seconds)
- QRS:Normal (0.08, regular)
- High QRS, irregular
How do you know if a premature atrial contraction is atrial or ventricular
QRS is higher with ventricular
Causes of Premature Ventricular Contraction (2)
- Spontaneous
- After heart surgery
Atrial flutter
- Rate:
- Rhythm:
- P wave:
- PRI:
- QRS:
- What does it look like:
- Rate: Normal
- Rhythm: Regular
- P wave: Not regular
- PRI: Not measurable
- QRS:0.08, WNL
- What does it look like:
- Sawtooth P&T; atrial rates can be up to 250 per minute
Atrial flutter: Treatment
1) Intervention
2) Meds (3)
1) CARDIOVERSION – machine is set to synchronize with patient’s QRS: Stop heart, allow SA node to take over again
2) Meds:Beta blockers, digoxin, calcium channel blockers
Atrial fibrillation
- Rate:
- Rhythm:
- P wave:
- PRI:
- QRS:
- What does it look like:
- Rate: If 100 = rapid ventricular response - Rhythm: Irregular - P wave: Not distinct - PRI: Not distinct - QRS: WNL 0.08 - What does it look like: Atria is chaotic; atrial rate can be up to 350/min; ventricular rate may be <100
Symptoms of rapid ventricular response
- Lightheadedness, changes in LOC, restlessness
Atrial fibrillation increases _______.
Risk of clot formation in atria –> Increased risk for MI, ischemic stroke
Prophylactic treatment for atrial fibrilation
Coumadin, Warfarin
Normal PT
Therapeutic PT
Normal PT: 12-13
Therapeutic = 18 (1.5x)
Normal INR
Therapeutic INR
Normal: 0.8-1.2
Therapeutic = 2.0-3.0
Hallmarks of PVC (3)
1) QRS is wide, bizarre
2) QRS comes early
3) Compensatory pause
Premature ventricular contraction
- Rate:
- Rhythm:
- P wave:
- PRI:
- QRS:
- What does it look like:
- Rate: Depends on underlying rhythm
- Rhythm: Variable
- P wave: Absent
- PRI: No P wave
- QRS:Wide and bizarre
- What does it look like: Compensatory pause after the PVC
What is the big danger with PVC?
R on T phenomenon
What is the R on T phenomenon?
If there is another impulse from elsewhere in the heart during the refractory period, can throw patient into vtach or vfib
How can you tell if a PVC is unifocal or multifocal?
- If PVCs look alike, source is the same group of cells: UNIFOCAL
- If PVCs look different –> different sites: MULTIFOCAL
R on T phenomenon: Treatment
Amnioderone (Anti-arrhythmic) if frequent
Define Couplet
PVCs occur in pairs
Define Bigeminy
Every other beat is a PVC
Define Trigeminy
Every third beat is a PVC
Define Quadrigeminy
Every fourth beat is a PVC
When is the absolute refractory period?
Just before Q to partway through T
When is the relative refractory period?
Second half of T
Ventricular Tachycardia:
- Rate:
- Rhythm:
- P wave:
- PRI:
- QRS:
- What does it look like:
- Rate: 140
- Rhythm:
- P wave: None
- PRI: None
- QRS: Cannot distinguish from T
- What does it look like:No atria firing
What will you assess with a Vtach patient who is hemodynamically compromised?
- Loss of consciousness
- Decreased or absent HR
- Emergency
What would you do to treat a VTach patient?
- Pulse
- Pulseless
Pulse: Cardiovert and / or use meds
Pulseless: Defibrilate
Why would you cardiovert with a VTach patient?
Because of R on T phenomenon
Ventricular Fibrillation
- Rate:
- Rhythm:
- P wave:
- PRI:
- QRS:
- What does it look like:
- Rate: X
- Rhythm: X
- P wave: X
- PRI: X
- QRS:X
- What does it look like:
CHAOTIC! Ectopic beats from ventricles. Nothing to be analyzed! Can’t even determine rate because there is no R wave.
Ventricular Fibrillation : Treatment (2)
- CPR
- Defibrillate if shockable rhythm
What would you assess on a VFib patient? (2)
- Unconscious
- No pulse
Ventricular standstill (Asystole)
NO ELECTRICAL ACTIVITY
Treatment of Ventricular Standstill (2)
- CPR
- Atropine
How do chances of survival change with asystole?
For every minute of ventricular standstill, chances of survival drop.
After 10 minutes, chances of survival are 0.
Most blocks are _________.
Bradycardic
First degree A-V block
- Rate:
- Rhythm:
- P wave:
- PRI:
- QRS:
- What does it look like:
- Rate: Slow
- Rhythm: Regular
- P wave: Present
- PRI: Consistantly elongated (>.20)
- QRS:WNL (0.08)
- What does it look like:
Hallmark of First degree AV block
PRI is >.20
How would you treat a symptomatic AV block patient (2)
- Atropine
- Pacemaker
Second degree heart block: MOBITZ TYPE I = WENCKEBACH
- Hallmark
“GOING, GOING, GONE!”
- Gradually lengthening PR intervals until you have a P with no QRS to follow
Treatment for Wenckebach (2)
- Atropine
- Pacemaker
Second degree heart block: MOBITZ TYPE II = CLASSICAL
- Rate:
- Rhythm:
- P wave:
- PRI:
- QRS:
- What does it look like:
- Rate: Usually bradycardic
- Rhythm: R-R can be regular
- P wave: More Ps than QRS
- PRI: Elongated
- QRS: Sometimes absent
- What does it look like: More Ps than QRS
Second degree heart block: MOBITZ TYPE I = WENCKEBACH
- Rate:
- Rhythm:
- P wave:
- PRI:
- QRS:
- What does it look like:
- Rate: Usually bradycardic
- Rhythm: Going, going GONE.
- P wave: Present
- PRI: Elongates until QRS disappears
- QRS:Occasionally absent
- What does it look like: Going, gone, gone.
Third degree AV block (complete)
- Rate:
- Rhythm:
- P wave:
- PRI:
- QRS:
- What does it look like:
- Rate: Ventricular rate is slow
- Rhythm: Regular P-P, regular R-R
- P wave:
- PRI:
- QRS: Wider than normal
- What does it look like:
Treatment for 3rd degree (complete) block (2)
- Needs pacemaker immediately (emergency)
- Atropine alone will not change much: Would speed up atria, but not change the blockage.
What would you assess with a 3rd degree AV block patient?
Decreased LOC
Hemodynamically compromised