Week 6 Cardiac Flashcards
Three layers of the heart
Endocardium
Myocardium
Epicardium
4 chambers of the heart
Right atrium
Left atrium
Right ventricle
Left ventricle
Atrioventricular valves include
tricuspid- right
Mitral- left
Aortic and Pulmonic are
Semilunar Valves
Heart has own circulation
Coronary arteries
Heart and electricity
Hemodynamics and CArdiac conduction
Order of the valves with the blood flow
TPMA
Tricuspid
Palpating
Mitral
Artery
Self stimulating cells located along
Autorhythmic cells
SA node- 60-100
Internodal pathways
Causes electrical stimulation of atrium
Connection between SA node and AV node
AV Node
Secondary pacemaker
40-60
Acts as relay delay to coordinate
contractions between atrium and ventricles filing
Bundle of HIS
Atrioventricular Bundle
Purkinje Fibers
Causes electrical stimulation
30-40 bpm
use if both av and sa are malfunctioned
Pressures within the right side of the heart and pulmonary vascular system are
Significantly lower than left side of heart and systemic vascular system
Where does venous circulation accumulates?
Coronary Sinus
Then dumps back into the right atrium
Ventricular contraction creates what type of blood flow?
Upward
through venous coronary circulation
Blood that has been pushed into coronary circulation and is allowed to circulate during diastole
Atrial Systole and Ventricular Systole
Management of CAD
MONA
Morphine
Oxygen
Nitroglycerin
Aspirin
STEMI
ST elevation
Troponin is specific to cardiac muscle damage
Dialysis pt can have slightly elevated
Troponin due to inability to filter proteins
View EKG
EKG first
O2
Aspirin
Morphine
Average SV is
60-130ml
Preload
Volume of blood within the ventricles at the end of diastole, immediately prior to systole
Afterload
Resistance of systemic or pulmonary blood pressure; Systemic VAscular resistance- left side of the heart
Pulmonary Vascular Resistance
Right side of the heart
Preload and SV have a ______________ relationship
Direct
Afterload and SV have a __________________ relationship
Inverse
Contractility and SV have a direct relationship
Increased by ionotropic drugs and decreased by beta adrenergic blockers
SV
Stroke Volume
Amount of blood ejected with each heartbeat
Preload
Degree of stretch of cardiac muscle fibers at end of diastole- how much blood fills the ventricles
Afterload
Resistance to ejection of blood out of ventricles into arteries -diameter or arteries
Contractility
Ability of myocardium to contract in response to electrical conduction impulse
Ejection Fraction
Percent of blood that is ejected with each heartbeat
CO
Cardiac Output
Amount of blood pumped by ventricles in liters per minute
CO=SVxHR
Normal EFis
55% to 65%
CO at rest is
4-6 l/min
HR direct relationship with CO
Control of heart rate
Autonomic Nervous System
Sympathetic innervation of
Beta 1 receptors- increases hr
Parasympathetic Innervation of
Stimulation of Vagus nerve which SLOWS HR
Baroreceptors
Located in the Aortic Arch and bilateral Internal Carotid artery sinuses
Elevated BP
Increases parasympathetic activity
Lowered BP enhances activity
Sympathetic Activity
HTN sends impulse to the
Cerebral Medulla to activate parasympathetic activity and lower HR
Hypotension causes
Decreased amount of signals so that sympathetic responses are enhanced to increase HR and vasoconstriction
The volume of blood in the heart just before the ventricles begin to contract
Preload
Low BP baroreceptors trigger
Sympathetic nerve fibers to increase HR and vasoconstrict by release of catecholamines
Increases Beta adrenergic receptors
High BP baroreceptors trigger
Parasympathetic nerve fibers to decrease HR- vagus nerve and vasodilate
Decrease alpha agonist
Preload is compared with what law
Frank Starling Law
Afterload affected
By diameter of pulmonary artery and systemic arteries
Greater stretch of cardiac muscle will cause a greater degree of shortening - stronger contraction and increased stroke volume
Frank Starling
Preload
Degree of stretch on ventricular cardiac muscle = Left Ventricular End Diastolic Pressure
Resistance to eject blood out of ventricles
Afterload
Afterload increases….
Stroke volume decreases and lowers CO
Increased by catecholamines
Epi and Norepi
Contractility
Contractility influencing factors
Increased by sympathetic Nervous System
Increased by meds
Decreased by hypoxemia and acidosis
Decreased by some meds
If LVEF is or less the patient has what?
40%
Has left ventricular dysfunction and requires tx of HF
Measured by use of echocardiogram
Nursing considerations for Cardiac
Cardiac Assessment
Investigative Health History
Clinical Manifestations
Lab tests
Diagnostics Tests
Cardiac Assessment
Inspection
Palpitation
Auscultation
Inspection of cardiac
General appearance
Skin, nails, and mucous membranes
Anterior chest wall
JVD
Heart Rhythm on monitor
Palpation
Pulses
Cap Refill
Skin Turgor
Warmth
Moisture
Edema
Non pitting edema due to
Lymphatic disorders and obstruction
Pitting Edema
Increased hydrostatic pressure
Excess Fluid
Decreased Oncotic Pressure
Edema grading
0= no edema
1+= Slight, 2mm
2+= Mild edema, 4mm indentation, disappears in 10-25 seconds
3+= Moderate edema, 4-6mm, disappears over a minute
4+= Severe edema, disappears after several minutes
Relaxation of all 4 chambers
Diastole
Systole
Contraction of atrium just prior to ventricles
Heart sounds are the valves closing
True
S1
S2
S1- lub- closure of AV valves - marks start of ventricular systole
S2- Dub- Closure of semi- lunar valves marks the beginning of diastole
Suggestive of HF
Lub Dub Dub
S3
S4
Occurs in late diastole
Lub Lub dub
Known as gallop
Caused by CAD, cardiomyopathies
Opening Snaps
Caused by Mitral stenosis
Systolic Clicks
Opening of a rigid/ calcified semilunar valve
Murmurs are
Turbulence through heart valves
Structural defects of valves
Inflamed pericardial sac
Heard during systole and diastole
Heard best with Pt sitting forward - use diaphragm
Investigative Health Hx
Medical Dx
Surgeries
Medications
Diet and Nutrition
Elimination
Social Hx
Vital Sign s
Activity and exercise
Sleep, rest
Demographic information
Family/ genetic Hx
Cultural/ Social factors
Risk factors
Modifiable- lifestyle, diet
Nonmodifiable- genetics
Most common clinical manifestations of cardiac
Chest pain
Dyspnea
Peripheral Edema, weight gain
fatigue
Dizziness, syncope, changes in LOC
Headache, agitation `
Cardiac Assessment
Psychosocial Assessment
Self perception, self concept- Pt understanding of dx treatment and management
Roles, relationships
Sexuality, reproduction
Coping, stress tolerance
Prevention strategies
Family Hx
Be objective with your assessment
Lab Tests
Cardiac Biomarkers
- CK, CK-MB
Myoglobin
Troponin T and I
Lipid profile
Electrolytes
CBC
COag Factors
BNP
C reactive
Homocysteine
Used as a follow up test to an elevated CK in order to determine whether the increase is due to heart damage or skeletal muscle damage
CKMB, CK
Found in heart and skeletal muscle and not specific to heart damage
Myoglobin
Specific for myocardial cell damage
Troponin T and I
Lipid Profile
Triglycerides
LDL- Low density - BAD- saturated
HDL- High density- GOOD- monosaturated, polyunsaturated
Lab that indicates heart failure
BNP
Neurohormone secreted from cardiomyocytes in the ventricles in response to increased Preload
Regulates BP and fluid volume by decreasing afterload -SVR and increasing natriuresis- sodium excretion in urine
C Reactive Protein
Indicator of systemic inflammation
- Cause may be atherosclerosis
Elevated levels may indicate risk for CVD
Elevated levels may indicate endothelial cell damage and CAD - development of atherosclerosis
Homocysteine
Amino acid peptide released by ventricular cells due to over stretching
BNP
First discovered in the brain
ANP
Amino acid peptide released by atrial cells due to over stretching
Diagnostic Tests
Electrocardiography
12 lead EKG
Continuous Monitoring
Continuous Ambulatory monitoring
Transteelphonic Monitoring
Wireless mobile monitoring
Cardiac Stress Testing
Exercise Stress Testing
Pharmacological Stress Testing
are all….
Diagnostic Tests
Diagnostic Tests for Cardiac
Chest X ray
Fluoroscopy
CT
MRI
Radionuclide
Myocardial perfusion imaging
Test of ventricular function
PET
Type of medical imaging that shows Xray image on a monitor, much like Xray movie
Fluoroscopy
Invasive procedure study used to measure cardiac chamber pressures, assess patency of coronary arteries
Cardiac Catheterization
Requires ECG, hemodynamic monitoring, emergency equipment, must be available
Assess allergies and get blood work
Pre Procedure Cardiac Catheterization
Fasting for 8 -12 hours
educate procedure and encourage feelingsP
Post procedure of cardiac catheterization
Bed rest for 2-6 hours
Assess site, hematoma, compression dressing, weight, pulses, cap refill, skin color, temperature, sensation
Monitor for dysrhythmias, assess chest pain, monitor kidney function
Use of contrast dye to due what?
Narrowing of angiogram
Righ Heart cath- Vein
Left heart cath- Artery
Radiotracer, injected to the vein, emits gamma radiation as it decays, A gamma camera scans the radiation area and creates an image
Radionuclide Scan
CVP is measured on a
Central Line - Distal port
Normal CVP- 2-6 mmHg
Partially Mechanically ventilated CVP
812 mmHg due to positive pressure decreasing preload
ED doctor can utilize ultrasound to visualize
Inferior Vena Cava and with applying pressure
Can assess amount of collapse of the vein to determine an emergent need for fluid replacement
PAWP is used in the
ICU
Swan ganz catheter
Pulmonary Artery Wedge
Arterial Line
Used for critically ill patients
ABGs
Inserted into radial artery
Allen test
Monitoring proximal end of perfusion
Phelbostatic Level
Use of transducer located at 4th intercostal space- midaxillary line - located near right atrium
Gerontological Considerations Cardiac
Decreased connective tissues
- Easily palpable pulses
Gradual increase of BP
Orthostatic Hypotension
-Impaired baroreceptors
Prolonged bed rest
Dehydration
Polypharmacy
Murmur development
-60% due to hardening of valves
Primary HTN is _________________- cause
Unidentified cause
Secondary HTN is ________________________
Identifies the cause of the HTN
ex: CKD, hyperaldosteronism
Blood pressure is the measurement of force applied to the
Artery walls
BP is the product of CO and x peripheral resistance
TRUE
Damage to the endothelium walls of the artery initiates
Inflammatory response resulting in plaque build on the arterial wall
Slow, gradual process that narrows lumen artery
HTN Symptoms
Brain- Stroke
Vision- Impaired
Renal- CKD
Cardiac- MI, Heart Failure
Prolonged untreated BP causes damage to the arterial walls and late signs can be seen in damage to critical organs
Why do we want slow drop of blood pressure for HTN emergencies?
Brain and core organs are used to a certain elevated pressure and lowering BP too quickly can cause decreased perfusion to the core organs.
HTN Emergency
Blood Pressure > 180/120
Intervention
- Reduced BP 25% in first hour
- Reduce to 160/ 100 over 6 hours
IV Vasodilators
IV labetolol
Frequent monitoring of BP
HTN Urgency
Blood pressure is very high, no evidence of organ damage
Intervention
- Monitor blood pressure CV status
Assess for potential organ damage
- Fast acting oral agents
Beta Adrenergic blocker, Ace Inhibitors, or alpha2 agonists- Clonidine
Principles of Therapy HTN
Achieving and maintaining BP < 140/90 mmHg
- If goal not achievable, lowering BP to any extent is beneficial
Lifestyle Modifications
- Weight and sodium intake reduction, DASH diet
Regular physical activity
Moderate ETOH intake
Smoking Cessation
HTN Risk Factors
Smoking
Obesity
Sedentary Lifestyle
Dyslipidemia
DM
GFR <60 mL/min
Age
Family History
What are some complications HTN?
Left Ventricular Hypertrophy
MI
HF
TIA
CVA
Renal Insufficiency
Retinal Hemorrhage
HTN Assessment
History and Physical Examination
Lab Tests
-Urinalysis
- Blood Chemistry
- Cholesterol levels
ECG
Chest Xray
Thiazides, Loops, and Potassium sparing are all what?
Diuretics
Hydrochlorothiazide and chlorthalidone are
Thiazides
Furosemide and torsemide
Loop Diuretics
Spironolactone
Triamterene
Potassium Sparing
HCTZ and spironolactone watch for
Watch for HyperK
Beta Blockers end in -olol
Atenolol
Metoprolol
Labetolol
Timolol
Propanolol
Nebivolol
Acebutolol - Beta 1 and 2
Penbutolol- Beta 1 and 2
Pindolol- Beta 1 and 2
Beta 1 blocks
Sympathetic Nervous causing lower heart rate and decreased BP
Decreases myocardial demand
Beta 1 Blockers are
Heart
Beta 2 blockers related to the
Lungs
Beta 2 relaxes
Bronchial smooth muscle causing bronchial causing bronchial dilation
Glucagon
Medication to help reverse overdose of Beta 1 affects
Avoid the sudden discontinuation of beta blockers. Why?
Common cause orthostatic hypotension in geri population- decreased liver and renal failure
Can cause erectile dysfunction
These drugs inhibits Ca influx causing slower cardiac conduction
Calcium Channel Blockers
Lowers HR and BP
Reduces afterload
Medication for calcium channel blocker overdose
Calcium
Calcium CHannel blockers commonly used for Afib and Afib with rvr
TRUE
NonDihydropyridines include
Diltiazem
Verapamil
Dihydropyridines inhibit influx and cause a
Vasodilator effect
Increases oxygen delivery to myocardium
Amlodipine
Felodipine
Nicardipine
Clevidipine
Alpha Agonists 1 include
Doxazosin
Prazosin
Terazosin
Alpha 2 Agonists
Methyldopa
Clonidine
Guanfacine
Alpha 1 is used when what drug is contraindicated
Hydralazine
Receptor sites in peripheral vasculature causes
Peripheral Vasodilation
- Decreases SVR
Alpha 2 receptor sites in brain and decreases in
SVR
Vasodilators act on
Smooth muscle
Decreases SVR
Contraindicated in heart failure and sepsis
Side effect is hypotension
Hydralazine
Fenoldopam mesylate
Nitroprusside
Nitroglycerin
Vasodilators
System that controls blood pressure is the
RAAS system
What are renin inhibitors ?
Blocks conversion of angiotensinogen to angiotensin I
Monitor for hyperkalemia
Ex: Aliskiren
Inhibits conversion of angiotensin I to angiotensin II- SVR
ACE inhibitors -SVR
Common side effect with ACEs is
Angioedema
Hypotension can be reversed by_____________
Fluid Resuscitation
Benazepril
Enalapril
Lisinopril
Captopril
ACE inhibitors
Commonly used with Pt with renal impairment
ARBS do what?
Block effects of angiotensin II at receptor sites
Reduces SVR
Monitor for hyperkalemia
Alternative to ACEs
Losartan
Valsartan
Candesartan
ARBs
Potassium sparing diuretic that prevents Na+ reabsorption therefore does what?
Increases elimination of water through kidneys
Monitor for hyperkalemia
Eplerenone
Spironolactone
Aldosterone Antagonist
Spironolactone and hydrochlorothiazide
2 diuretics
Aldactazide
Atenolol and Chlorthalidone
-Beta blocker and diuretic
Tenoretic
Lisinopril and hydrochlorothiazide
- ACE inhibitors and diuretics
Prinzide
Hyzaar is
Losartan and Hydrochlorothiazide
Angio II and diuretics
Lotrel made of
Amlodipine and Benazepril
- Calcium channel blockers and ACE inhibitors
Alpha 2 Agonist and diuretic
Combipres
Clonidine and chlorthalidone
Name a few medications that can lower BP
Narcotics
Benzo
Sedatives
IV antibiotics
Nursing Dx of HTN
Deficient knowledge related to Tx or control of disease process
Ineffective health maintenance
Noncompliance of regimen
Decreased tissue perfusion
Decreased cardiac output
Problems and Complications - AEB HTN
Left Ventricular hypertrophy
Arterial Stenosis
Myocardial Infarction
HF
TIA
CVA
Renal failure or insufficiency
Retinal Hemorrhage
Planning and Goals of HTN
Understanding Tx and disease process
Participation in self care program
Absence of complications
Maintaining BP below 140/90
Interventions of HTN include
Pt education
Support Tx adherence
Consultation and collaboration
Follow up care
Emphasize control rather than cure
Reinforce and support lifestyle changes
A lifelong process
Evaluation of HTN
Reports knowledge of disease management to maintain tissue perfusion
Adheres to self care program
HTN gerontological considerations
Structural and functional changes of heart and blood vessels
Kidney function diminished
Chronic plaque deposits and calcification in vessels
Impaired vasodilation
HTN Gerontological Considerations
monotherapy
Understands regimen
Can see information
Access to medications
Expense
Opening the pill bottle
Family/ caregiver
What is heart failure?
Inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients
Characterized by fluid overload or inadequate tissue perfusion
Term HF indicates myocardial disease
There is a problem with contraction of the heart = Systolic Failure or filing of the heart= Diastolic Failure
Most HF is progressive and a _________________ disorder
Lifelong
managed with meds and lifestyle change
