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210 Ch. 26

Cardio Fx

3 Layers of the heart endocardium - inner tissue lines heart and valves, protecting myocardium - muscle fibers,pumping action. heart muscle gets blood at diastole epicardium - ext layer
What makes up the pericardium? Visceral - adheres to epicardium, potential pericarditis parietal - supports heart in mediastinum Pericardium space - 20ml fluid to lubricate
Describe diastolic phase of heart? Describe systole? D: relaxation phase of heart filling of ventricles. atrioventricular valves open, semilunar v closed, coronary aa fill S: Contraction of (atria) and ventricles. Atrioventricular valves close, semilunal valves open
Blood path from right side of heart? Rt atrium-rt vent-deoxy blood to pulmonary aa. Receives blood from sup/inf vena cava, coronoary sinus.
Blood path of left side of heart? lft atrium-lft vent-oxy blood from pulmonary vv- aorta aa
Describe atrioventricular valve separate atria from ventricls, tricuspid - rt/ mitral, bicuspid-lft
Describe semilunal valves what is important prob with valve prob? Pulmonic valve- rt vent and pulmonary aa Aortic Valve - lft vent and aorta Valve prob=risk for clotting
Describe coronary aa 3 branches: Lft main - lft ant desc down ant wall of heart. Circumflex aa circle around lateral left. Rt main - inf wall- post desc aa
What is automaticity? Excitability? Conductivity? Refractoriness? Auto: initiate electrical impulse, pacemaker cells excit: respond to electrical impulse, depolarize, q cell can fire if need cond: transmit pulse cell to cell Ref: prevent tetany
Which node is primary? SA node in jx of sup vena cava & rt atrium. Firing rate of 60-100/min. Contract atria. AV node(40-60b) fires vent thrugh Bundle of His and on to Purkinje fibers on left side to cause contraction. (30-40b)
Desribe depolarization? repolarization? Dep:contraction Rep: resting Cardiac potential: both together
What is the "atrial kick"? Atrial blood augments vent volume by 15-25% and starts systole.
Define cardiac output? Stroke volume? SV decr=? EF decr=? amt of blood pumped by ea vent during given period. Normal - 5L SV x HR = CO, norm 150lb=4-8L(rest) SV- amt of blood ejected per heartbeat. Avg = 70ml HR - 60-80 norm Decr CO!
Parasympathetic vs sympathetic impulses do what to HR? Baroreceptors? Para: slow HR sym: speed up HR by catecholamines Bar: on aortic arch and coronary aa and sensitive to BP. HTN incr baro. trigger parasym. Hypotension decr baro, trigger symp.
Define preload? pre: stretch of vent at end of diastole and affect SV. Known as LVEDP(lft vent end dias pres).
what reduces preload? incr? diuresis, nitrate(venodilating), loss of blood, dehydration. incr return of circulating blood to vent...IV fluids
what is afterload? Resistance to ejection of blood from vent. Inverse relationship bn afterload and SV. Incr by arterial vasoconstriction and decr SV. Decr by vasodilation bc less resistance to ejection, SV incr
what is contractility? force by contracting myocardium and enhanced by catecholamines and some meds: dig, dopamine, dobutamine incr leads to incr SV
What decr contractility Hypoxemia, acidosis, beta adrenergic blocking agents like atenolol
Incr preload, contractility, decr afterload leads to incr SV
Define ejection fraction % of end diastolic blood volume ejected with ea heartbeat. Left Vent SV. Measures contractility. norm - 55-65%; 40%=heart failure
Age changes to heart decr contractility, incr left vent ejection(prolonged systole), delayed conduction. incr temp, stress=incr HR
what are common s/s of CVD? Ask all about pain chest pain, SOB, peripheral edema, wt gain, abd distention, palpitations, vital fatigue, dizziness, syncope, change in LOC
angina pectoris s/s: ask chief complaint pain, 5-15m, squeezing, full pain in chest/arm/hand/jaw/epigastrium/back Aggravated by excercise/big meal/emotion Tx: rest/nitro/O2
ACS(acute coronoary syndrome) Pain like angina w/ sob, diaphoresis, palpitations, fatigue, N/V Can occur at rest/sleep Tx: morphine
Pericarditis s/s? tx? sharp pain to arms/neck/back with fever/cough/N/dizzy/tachy. Pain incr w/ inspiration/swallowing/coughing tx: sit up/analgesic/anti inflammatory
pulmonary disorders: pneumonia/pulmonary embolism s/s? cause? tx? s/s: sharp pain(pleuritic pain) from lower lung, pain on side tx: treat cause
Esophageal disorders (hiatal hernia/reflux/esophagitis substernal pain, mimics angina tx: food/antacid/nitro
Anxiety/panic stabbing/dull ache w/ diaphoresis/tachy/sob/hands tingle/fear of losing control tx: relaxation meds
Musculoskeletal disorders sharp/stabbing pain in ant chest, unilateral. Follows resp inf w/ coughing. tx: rest/ice/heat/analgesic/antiinflammatory
A month b4 with fatigue/sob/sleep disturbance/anxiety/fleeting chest discomfort(wax/wane)...nonST segment elevation(NSTEMI), ST segment(STEMI)
Skin changes with CVD pallor, peripheral cyanosis(blue nails/nose/lip/earlobes), central cyanosis(blue tongue, buccal mucosa), xanthelasma(yellow plaques on eyelids), cool/cold, moist skin
High BP pulse pressure? Postural orthostatic hypotension? 140-90 PP = SP-DP norm 30-40 orth: BP decr in upright pos. causes: decr vol, vasoconstriction, insuff. autonomic effect on constriction
Steps to take orthostatic hypotenstion 1. supine for 10m b4 1st BP 2. sitting then standing BP w/ 1-3m bn ea 3. Norm: HR incr 5-20bpm above resting, unchanged SP or decr, incr of 5mm in DP
Normal ortho ex. autonomic insufficiency ex. norm: sup:120/70, HR70/sit:100/55, HR90/stand:98/52, HR94 insuff: sup: 150/90, HR60/ sit:100/60, HR60
what is known as sinus arrythmia? pulse rate incr w/ inhalation, decr exhalation
what is the 0-4 scale of pulse quality? 0-absent +1-weak, thready +2-diminished +3-full +4-strong, bounding
When palpating temporal pulse, what should not never palpate wtih it? carotid aa bc decr blood to brain
Where is the apical,pmi area? arotic area? Pulmonic? tricuspid? Mitral valve? apical: 5th intc, left of sternum, midcl line aor:rt of sternum, 2nd intercostal space pul: 2nd intc to left of sternum tri: lower half of sternum, left parasternal area Mi: lft 5th intc, midclav line
Abnormal apical impulses? pulse below 5th intc/lateral to midcl line = lft vent enlargement palpate two diff apical pulses = vent aneurysm forceful pulse - vent heave/lift vibration = thrill/murmur
S1 & S2 are what? normal heart sounds made by closure of tricuspid/mitral(S1) & AV valves(S2), semilunar val(S2) time bn is systole/lub, dub
regarding S1 and S2, when is diastole and systole? S1(lub)-systole-S2(dub)-diastole-S1(lub)-systole-S2(Dub)
Where are S3 and S4 in cycle? S3: after S2, normal in children S4: b4 S1, never normal
Abnormal sounds like summation gap? opening snaps? systolic click? murmurs? friction rub? summ: all 4 sounds into one loud snd open: snd at opening of AV valve(mitral stenosis from high pressure in lft atrium), dias click: semilunar valve stenosis, early sys mur: turbulent blood flow rub: grating snd
s/s in extremities of vascular changes decr capillary refill, hematoma, peripheral edema, clubbing, lower extremity ulcers. Assess pedal first and work up.
Lung s/s of vascular changes pink frothy sputum(edema), cough, crackles at bases, wheezes
abd s/s of vascular changes abd distention(ascites w/ rt vent failure) can see hepatosplenomegaly(liver/spleen engorged) hepatojugular reflux: pos test for HF bladder distention: output imp
Aging can show isolated systolic hypertension which is incr systole with plateaued diastole
Norm cholesterol total: <200 LDL norm: <160- transport choles and trigly into cell, incr LDL = CVD, so LDL <70 HDL: norm m35-70, f35-85, transport choles away from tiss, need to incr HDL >40 Trigly: norm 100-200
hypo/hyperkalemia causes what cardiac probs norm? hypo: Invert Twave, dysrhythmias, vent tachy/vent fibrillation, dig toxicity hyper: heart block, asystole, vent dysrhythmias from decr renal/ spironolactone, ACE inhibitors norm: 3.5-5.0
hypo/hypercalcemia on cardiac fx norm? hypo: slow nodal fx, impair contractility, prolong Q-T, dysrh hyper: from thiazide diurectics red renal excretion, incr contractility, vfib, heart block, short Q-T, AV block, tetany norm: 8.6-10.2
hypo/hypermagnesium on cardiac fx norm? hypo: incr renal excretion, atrial/vent tachy hyper: incr use of antacids, depress contractility, heart block, asystole norm: 1.3-2.3
Blood Urea nitrogen norm? BUN and creatinine end products of protein metabolism excreted by kidneys norm: 10-20
Creatinine norm? normal creat and incr BUN = FVD norm: 0.7-1.4
Glucose fasting norm? norm: 60-110
glycohemoglobin (A1c)norm? blood glucose levels over 2-3mos. diabetic Norm: <7% Nondiabetic: 4.4-6.4%
partial thromboplastin time PTT norm? assess effects of heparin. therapuetic range: 1.5-2.5 times baseline values. aPTT<50 = incr hep dose aPTT>100 = decr hep dose
Prothrombin time PT norm? monitor level of anticoagulation with warfarin(Coumadin) norm: 9.5-12sec
International normalized ration INR norm? monitor effectiveness of warfarin therapuetic range: 2-3.5
WBC norm? 4500-11.000/mm
Hematocrit norm? Hemoglobin norm? % of RBC in 100ml of whole blood. RBC contain hemoglobin. Hct norm: m42-52%, f35-47% Hgb norm: m13-18, f12-16
Platelets norm? platelets form thrombus. Meds that decr: Plavix/ReoPro/integrilin/Aggrastat norm: 150,000-450,000
What does natriurectic peptide do to BP Regulates BP and fluid vol. Secreted by vent in response to incr preload w/ incr vent pressure. Level >100 = HF
What is hs-CRP, C-reactive protein? norm? CRP is a protein produced by liver in response to inflammation. Can be from atherosclerosis. High-sensitivity assay is venous blood test to predict CVD risk. High: >3.0 mod: 1.0-3.0 low: <1.0 High incr risk for MI
What is fx of homocysteine in cardiac abnormalities? homo: AA linked to atherosclerosis, damage of endothelial lining of aa and incr thrombus. Incr levels of homo with decr folic acid/B6 & 12 - 12hr fast needed b4 test high risk: >15 borderline: 12-15 optimal: <12
ECG monitors? 12 lead detects? 15? 18? electrical currents of heart. 12: dysrhythmias, chamber enlargement, myocardial ischemia, injury, infarction 15: rt/lft vent post infarction 18: myocardial ischemia/injury
What does ECG not detect that pt needs to know? sob/chest pain/other ACS s/s, so pt needs to report worsening s/s
What two ECG leads most often used for continuous monitoring? Leads II: best visualization of atrial depolarization(P wave) Lead V1: vent depolarization
How to apply leads 1. clip hair if need, clean/dry area 2. If sweaty put benzoin, not in area of center of electrode 3. connect to wires b4 put on skin 4. place and change q 24-48h
What are three cardiac stress tests excercise/pharmacologic/mental, emotional stress tests They help determine CAD, cause of chest pain, fx cap of heart after MI or heart surgery, med effects, dysrhythmias, excercise goals...achieve target hr
What are contraindications to stress testing severe aortic stenosis, acute myocarditis/pericarditis, severe HTN, lft main CAD/HF/unstable angina
What is monitored during stress test physically? 2 or more ECG leads, bp, skin temp, physical appearance, perceived exertion, chest pain, dyspnea, dizziness, leg cramping, fatigue
Nsg intv for stress tests 4h fast b4, no smoke/caffeine
If pt is disabled, what meds can be used to mimic pt reaching target hr? dipyridamole(Persantine)/15-30m & adenosine(Adenocard)/<10s- maximally dilate coronary aa. Dobutamine can also be used SE: chest discomfort, dizzy, ha, flushing, nausea
What does echocardiography test for? measure of ejection fraction and size/shape/motion of cardiac structures Pericardial effusions/murmurs Positive if abnormals in vent wall motion seen in stress, not rest
Transesophageal Echocardiography TEE alternative gives clearer images so first line tool for CVD
nsg intv for TEE NPO 6h b4, bed rest and elevate head to 45 deg
How do radioisotopes help detect MI? Thallium used and does not cross into scarred myocardium so they reveal myocardial ischemia, which can recover, then compare 3h later to infarctions
Diff bn ischemia and infarction Ischemia=decreased oxygen/nutrients Infarction=no blood flow to the area Ischemia can lead to infarction. ischemia means, reduced of blood supply to specific organ. while, infarction refers to death tissue.
nsg intv with nuclear imaging Tell pt getting either planar or SPECT test, no nuclear prep needed. SPECT needs arms over head for 20-30m, if not able, then planar
To test vent fx and wall motion ERNA, Equilibrium radionuclide angiocardiography, known as MUGA, Multiple-gated acquisition.
How are CT/CAT/EBCT, electrobeam, scans used for heart? evaluate masses in heart, diseases of aorta and pericardium. EBCT: amt of Ca deposits in coronary aa and atherosclerosis
PET scans are best for scanning neurologic dysfx, but also cardiac dysfx.
what is cardiac catheterization invasive diagnostic, arterial(lft sided cath) and venous(rt sided) catheters inserted in vessels. Contrast agents help visualize coronary aa.
What allergies need to be known b4 catheterization iodine used so seafood allergies, but Solu-Medrol can b given b4.
What is complication to watch for w/ pt who has DM, HF, renal dis, hypotension, dehydration contrast agent-induced nephropathy: treatable, but temp dialysis needed. Prevent wtih pre/post procedure IV hydration
nsg intv for catheterization b4: npo 8-12h,asses for hemorrhage After: peripheral pulses q15m-1h, 2-6h bed rest after outpt procedure. Vasovagal response tx: elevate lower ext above heart, IV bolus, IV atropine for brady
Angiography is used with card cath which is what contrast agent in vasc system to outline heart adn vessels.
EPS, electrophysiologic Testing invasive to distinguish atrial from vent tachycardias, syncope, palpitations, v fibb
What is involved with hemodynamic monitoring Direct pressure to assess heart CVP, central venous press, pulmonary aa press, intra-arterial bp...critical care
Hemodynamic monitoring cont. 1. flush system 2. stopcock of transducer at atrium level(phlebostatic axis) 3. est zero ref point
complications wtih hemodynamic monitoring pneumothorax, infection, air embolism
What is central venous pressure, CVP pressure in the vena cava or rt atrium. They are = to end of diastole(rest). Also reflects filling(preload) of rt vent. Norm: 2-6mm Hg, should be low
Elevated CVP means >6 = elevated rt vent preload usually from hypervolemia or rt sided HF
Low CVP means <2 = reduced rt vent preload from hypovolemia(dehydration/blood loss/V/D/overdiuresis
nsg intv for CVP confirmed by chest xray, inspected daily for inf. Sterile dsg change.
To assess lft vent fx, dx shock, pt response to meds what kind of monitoring Pulmonary artery pressure monitoring, balloon inflation to rt atrium and flows to pulm aa
What does the pulmonary aa monitor rt atrial, pulmonary aa systolic/diast, mean pulm aa, pulm aa wedge press These evaluate lft vent filling pressures(preload)
What nsg intv is important with pulm aa wedge pressure balloon inflated and floats into pulm aa occluding, so pressure read quickly and deflated
How does the Allen test help with Intra-arterial BP monitoring Det placement of radial aa cath: evaluate perfusion of hand and fingers by radial/ulnar aa...elevate hand/fist for 30s/compress both aa/release fist/release ulnar aa...pink in 6s
Nsg intv for intra-arterial bp monitoring same as CVP...flush system, transducer, monitor for complications: obstruction, hemorrhage, ecchymosis, dissection, embolism, blood loss, pain, inf
What is risk with arrythmias? blood flowing in diff directions, so wants to clot
what is nsg intv for brain hemorrhage? Put on O2 cause too much O2 slows blood flow
baroreceptors? chemoreceptors? bar: in aortic arch/carotid sinus, if decr blood then incr HR. If incr in blood, decr HR Chem: If low O2, incr HR. If incr O2, decr HR
Pressure resistance in lungs leads to? rt side enlarge, angiotensin II constricts vessels
What is usual first line med tx for heart disorders? morphine than nitro than O2
Crackles? Cheyne-Stokes resp. Hemoptysis Wheeze Cough Crack: air move thru fluid Chey: deep breath w/ apnea Hemo: bloody sputum wheez: high pitch, stenosis Cough: Ace inhibitors casue dry cough
Examination of abd looking for? ascites, distention, if bounding pulse in abd, could be aneurysm
Cardiac enzymes: CK-MB, myoglobin, troponin I CK-MB: rise in 4-8h of MI, disappear quickly Myo: rise in 1-3h, disappear Tropon: rise in 3-4h, stay for days
Created by: palmerag