Cardio Fx
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| 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
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| What makes up the pericardium? | Visceral - adheres to epicardium, potential pericarditis
parietal - supports heart in mediastinum
Pericardium space - 20ml fluid to lubricate
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| 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
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| 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.
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| Blood path of left side of heart? | lft atrium-lft vent-oxy blood from pulmonary vv- aorta aa
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| Describe atrioventricular valve | separate atria from ventricls, tricuspid - rt/ mitral, bicuspid-lft
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| 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
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| 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
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| 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
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| 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)
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| Desribe depolarization? repolarization? | Dep:contraction
Rep: resting
Cardiac potential: both together
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| What is the "atrial kick"? | Atrial blood augments vent volume by 15-25% and starts systole.
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| 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!
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| 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.
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| Define preload? | pre: stretch of vent at end of diastole and affect SV. Known as LVEDP(lft vent end dias pres).
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| what reduces preload? incr? | diuresis, nitrate(venodilating), loss of blood, dehydration.
incr return of circulating blood to vent...IV fluids
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| 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
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| what is contractility? | force by contracting myocardium and enhanced by catecholamines and some meds: dig, dopamine, dobutamine
incr leads to incr SV
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| What decr contractility | Hypoxemia, acidosis, beta adrenergic blocking agents like atenolol
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| Incr preload, contractility, decr afterload leads to | incr SV
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| Define ejection fraction | % of end diastolic blood volume ejected with ea heartbeat. Left Vent SV. Measures contractility. norm - 55-65%; 40%=heart failure
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| Age changes to heart | decr contractility, incr left vent ejection(prolonged systole), delayed conduction. incr temp, stress=incr HR
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| 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
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| 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
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| ACS(acute coronoary syndrome) | Pain like angina w/ sob, diaphoresis, palpitations, fatigue, N/V
Can occur at rest/sleep
Tx: morphine
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| 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
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| pulmonary disorders: pneumonia/pulmonary embolism s/s? cause? tx? | s/s: sharp pain(pleuritic pain) from lower lung, pain on side
tx: treat cause
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| Esophageal disorders (hiatal hernia/reflux/esophagitis | substernal pain, mimics angina
tx: food/antacid/nitro
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| Anxiety/panic | stabbing/dull ache w/ diaphoresis/tachy/sob/hands tingle/fear of losing control
tx: relaxation meds
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| Musculoskeletal disorders | sharp/stabbing pain in ant chest, unilateral. Follows resp inf w/ coughing.
tx: rest/ice/heat/analgesic/antiinflammatory
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| A month b4 with fatigue/sob/sleep disturbance/anxiety/fleeting chest discomfort(wax/wane)...nonST segment elevation(NSTEMI), ST segment(STEMI)
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| 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
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| 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
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| 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
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| 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
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| what is known as sinus arrythmia? | pulse rate incr w/ inhalation, decr exhalation
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| what is the 0-4 scale of pulse quality? | 0-absent
+1-weak, thready
+2-diminished
+3-full
+4-strong, bounding
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| When palpating temporal pulse, what should not never palpate wtih it? | carotid aa bc decr blood to brain
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| 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
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| 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
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| 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
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| regarding S1 and S2, when is diastole and systole? | S1(lub)-systole-S2(dub)-diastole-S1(lub)-systole-S2(Dub)
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| Where are S3 and S4 in cycle? | S3: after S2, normal in children
S4: b4 S1, never normal
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| 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
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| s/s in extremities of vascular changes | decr capillary refill, hematoma, peripheral edema, clubbing, lower extremity ulcers. Assess pedal first and work up.
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| Lung s/s of vascular changes | pink frothy sputum(edema), cough, crackles at bases, wheezes
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| 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
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| Aging can show isolated systolic hypertension which is | incr systole with plateaued diastole
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| 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
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| 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
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| 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
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| 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
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| Blood Urea nitrogen norm? | BUN and creatinine end products of protein metabolism excreted by kidneys
norm: 10-20
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| Creatinine norm? | normal creat and incr BUN = FVD
norm: 0.7-1.4
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| Glucose fasting norm? | norm: 60-110
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| glycohemoglobin (A1c)norm? | blood glucose levels over 2-3mos.
diabetic Norm: <7%
Nondiabetic: 4.4-6.4%
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| 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
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| Prothrombin time PT norm? | monitor level of anticoagulation with warfarin(Coumadin)
norm: 9.5-12sec
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| International normalized ration INR norm? | monitor effectiveness of warfarin
therapuetic range: 2-3.5
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| WBC norm? | 4500-11.000/mm
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| 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
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| Platelets norm? | platelets form thrombus. Meds that decr: Plavix/ReoPro/integrilin/Aggrastat
norm: 150,000-450,000
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| 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
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| 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
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| 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
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| 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
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| 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
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| What two ECG leads most often used for continuous monitoring? | Leads II: best visualization of atrial depolarization(P wave)
Lead V1: vent depolarization
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| 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
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| 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
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| What are contraindications to stress testing | severe aortic stenosis, acute myocarditis/pericarditis, severe HTN, lft main CAD/HF/unstable angina
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| 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
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| Nsg intv for stress tests | 4h fast b4, no smoke/caffeine
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| 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
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| 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
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| Transesophageal Echocardiography TEE | alternative gives clearer images so first line tool for CVD
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| nsg intv for TEE | NPO 6h b4, bed rest and elevate head to 45 deg
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| 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
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| 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.
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| 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
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| To test vent fx and wall motion | ERNA, Equilibrium radionuclide angiocardiography, known as MUGA, Multiple-gated acquisition.
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| 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
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| PET scans are best for scanning | neurologic dysfx, but also cardiac dysfx.
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| what is cardiac catheterization | invasive diagnostic, arterial(lft sided cath) and venous(rt sided) catheters inserted in vessels. Contrast agents help visualize coronary aa.
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| What allergies need to be known b4 catheterization | iodine used so seafood allergies, but Solu-Medrol can b given b4.
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| 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
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| 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
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| Angiography is used with card cath which is what | contrast agent in vasc system to outline heart adn vessels.
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| EPS, electrophysiologic Testing | invasive to distinguish atrial from vent tachycardias, syncope, palpitations, v fibb
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| What is involved with hemodynamic monitoring | Direct pressure to assess heart
CVP, central venous press, pulmonary aa press, intra-arterial bp...critical care
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| Hemodynamic monitoring cont. | 1. flush system
2. stopcock of transducer at atrium level(phlebostatic axis)
3. est zero ref point
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| complications wtih hemodynamic monitoring | pneumothorax, infection, air embolism
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| 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
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| Elevated CVP means | >6 = elevated rt vent preload usually from hypervolemia or rt sided HF
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| Low CVP means | <2 = reduced rt vent preload from hypovolemia(dehydration/blood loss/V/D/overdiuresis
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| nsg intv for CVP | confirmed by chest xray, inspected daily for inf. Sterile dsg change.
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| 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
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| 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)
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| What nsg intv is important with pulm aa wedge pressure | balloon inflated and floats into pulm aa occluding, so pressure read quickly and deflated
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| 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
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| 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
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| What is risk with arrythmias? | blood flowing in diff directions, so wants to clot
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| what is nsg intv for brain hemorrhage? | Put on O2 cause too much O2 slows blood flow
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| 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
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| Pressure resistance in lungs leads to? | rt side enlarge, angiotensin II constricts vessels
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| What is usual first line med tx for heart disorders? | morphine than nitro than O2
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| 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
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| Examination of abd looking for? | ascites, distention, if bounding pulse in abd, could be aneurysm
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| 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
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