MedSurg2 Unit 1

Approximate adult blood volume

5 L

Cardiac Output

Stroke Volume (amount of blood heart can pump with each beat) X Heart Rate

-If one is impacted, the other tries to compensate

Preload

(Rubber band / Stretch)

-Volume of blood in ventricles at end of diastole

(blood in chamber before heart contracts)

Afterload

(Pressure)

-Resistance L ventricle must overcome to circulate blood

(resistance heart faces as it contracts)

Contractility

Force of contraction

-Heart squeezing to empty

Cardiac Physical Assessment

-Inspection

Skin color & temp

Cap refill

Edema

JVD

Cardiac Physical Assessment

-Palpation

-PMI (ONLY at 5th ICS, Left MCL)

-Check for thrill (abnormal)

Feeling apical pulse in 2 or more locations could indicate

L ventricular enlargement

Feeling a thrill from a murmur could indicate

Valvular disorder

Cardiac arrest

Thrill over blood vessel could indicate

Partial obstruction (turbulent blood flow)

When is a thrill or bruit expected?

ONLY with dialysis

Cardiac Physical Assessment

-Auscultation

-BP

-HR, rhythm, S1, S2

-Murmurs (never expected)

S3 beat

Heart Failure

Normal in children/young adults

S4 beat

MI

HTN

CAD

Stenosis

Labs used for cardiac diagnostic assessment

CBC

BMP/CMP

PT, INR, aPTT, anti-Xa

CK-MB

Troponin I

BNP

Cholesterol

Cardiac Diagnostic Labs:

-CK-MB

Measures direct muscle damage to heart

-Increased reading = more damage

CK-MB lab values

0-3

Cardiac Diagnostic Labs:

-Troponin I

Measures heart damage

Troponin I lab values

< 0.5 ng/mL

Cardiac Diagnostic Labs:

-BNP

Measures cardiac fluid volume

(increased = worse HF)

< 100 pg/mL

BNP lab values

<100

WBC lab values

4,500-11,000

RBC lab values

M: 4.6-6.2

F: 4.2-5.4

Hgb lab values

M: 13-18

F: 12-16

Hct lab values

M: 42-52%

F: 35-47%

Platelets lab values

150,000-450,000

Sodium (Na+) lab values

135-145

Potassium (K+) lab values

3.5-5.0

Calcium (Ca+) lab values

8.2-10.2

Chloride (Cl-) lab values

98-107

Glucose lab values

70-99

Magnesium (Mg+) lab values

1.3-2.1

Phosphate (PO4) lab values

2.5-4.5

Serum Osmolality lab values

275-300

BUN lab values

10-20

Creatinine lab values

0.7-1.4

Total Cholesterol lab values

150-200

HDL lab values

M: 35-70

F: 35-85

(>70 desirable)

LDL lab values

<160

Triglycerides lab values

100-200

Cardiac Diagnostic Tests:

-ECG/EKG

Measures *electrical* impulses of the heart

Cardiac Diagnostic Tests:

-Stress Test

-Treadmill or chemical & hooked to ECG

-Pain or cardiac changes = positive test

Cardiac Diagnostic Tests:

-Traditional Echocardiography

US to check heart function

-No prep needed

Cardiac Diagnostic Tests:

-Transesophageal Echocardiography (TEE) *

-Probe down esophagus to get direct view of heart (invasive)

-Used to check for clots & rule out arrhythmias

TEE Pre Op

NPO

Throat numb

Consent

Meds

TEE Post Op *

Monitor gag reflex & check before giving food/water/meds

Cardiac Diagnostic Tests:

-Myocardial Perfusion Imaging (SPECT)

Radioactive US

-Checks for degree of muscle damage

-Radioactive isotopes given, they won't enter damaged area

Cardiac Diagnostic Tests:

-Cardiac Catheterization

Can be with or without angiography (dye)

-Cath through artery into heart

-Used to view arteries and/or place stent

Cardiac Catheterization

-Pre Op

-NPO 6 hrs

-Educate pt

-Check kidney function (BUN, Creatinine)

Cardiac Catheterization

-Pre Op Education

-Will be lying on hard table for 1 hr during procedure

-Meds given for comfort

-May have palpitations when cath is advanced

-Dye may cause heat, flushing, inc HR, feeling of needing to void (will last

Cardiac Catheterization

-Why check kidney function?

If it is poor, cannot use dye

Cardiac Catheterization

-Post Op * (7)

-Assess site frequently for bleeding ** (PRIORITY)

-Bed rest per protocol

-ECG & VS

-IV & PO fluids (flush out dye)

-Monitor UO (kidneys)

-Monitor pulse distal to puncture site

-Instruct pt to report chest pain, bleeding (wetness), or discomfort

Cardiac Catheterization

-Patient Education *

-Don't bend at waist, strain, or lift heavy objects for 24 hrs

-Avoid baths

-Call HCP if: bleeding, swelling, new bruising, pain at site, or temp ≥ 101.5

Hemodynamic Monitoring

Invasive system used in critical care to provide information about:

-Cardiac Effectiveness

-Blood Volume

-Tissue Perfusion

Hemodynamic Monitoring:

-Central Venous Pressure (CVP) Monitor

Measures blood pressure above the R atrium

CVP Normal Values **

*2-8*

-

Hemodynamic Monitoring:

-Intra-arterial BP Monitoring

IV cath into artery for direct BP reading

-Most accurate reading, fluctuates with every pulse

Hemodynamic Monitoring:

-Pulmonary Pressure Monitor

Invasive line into pulmonary artery with balloon on end

-Inc readings = LHF, high pressure in lungs and blood not moving forward

Electrical Impulses

-Pathway

SA node

AV node

Bundle of His

(If one doesn't work, will start in the next)

SA Node

Sinus Rhythm (normal)

-P wave for every QRS

-BPM: 60-100

AV Node

Backup if SA node stops working, can send impulses but triggers atrium at slower rate

-P wave messed up somehow (abnormal)

-BPM: 40-60

Bundle of His

If impulses start here, the SA and AV node have failed, heart starts dying

-Wide QRS complex

-BPM: 30-40 bpm

Electrocardiogram (ECG)

-Normal Reading

-P wave: SA node

-QRS: ventricular response

-T wave: vulnerable period (CANNOT shock here)

-ST Segment: check for MI here (elevated with MI)

Determining rate based on ECG

(All strips 6 seconds on test)

-Count R waves & times by 10

Determine regular vs irregular rhythm on ECG

Regular:

-All complexes match (P, QRS, T same on each one)

-P:R intervals all the same distance

When looking at an ECG, it's always important to do what?

Make sure what you SEE matches what you FEEL **

Normal Sinus Rhythm

-P wave for every QRS (SA node- Sinus)

-Regular (R waves all same distance)

-Rate 60-100

Types of Arrhythmias (Dysrhythmias)

-Sinus (P wave for every QRS)

-Atrial (irregular P wave but narrow QRS)

-Ventricular (wide QRS)

Stable Arrhythmias *

*NO S/S*

Have time to treat

Unstable Arrhythmias

*HAVE S/S* - need immediate intervention

-Altered mental status

-SOB

-Dizziness

-Chest pain

-Hypotension

-Shock

-Diaphoresis

-Cyanotic

Sinus Bradycardia *

-P for every QRS, could be INVERTED

-Narrow QRS

-Regular

-Rate

Asymptomatic (stable) Sinus Bradycardia

-Treatment

No treatment

-Determine cause

Symptomatic (unstable) Sinus Bradycardia

-Treatment

1. Atropine (PRIORITY- pulls HR back up)

2. Transcutaneous pacing

3. Determine cause

Sinus Tachycardia *

-*P for every QRS*

-QRS narrow

-Regular

-*Rate >100 bpm*

Sinus Tachycardia

-Treatment

1. Identify cause

2. Treat cause

-Ex: Acute blood loss- IVF & blood transfusion

Types of Pacemakers

-Transcutaneous (external)

-Implanted (internal)

Considerations for implanted pacemakers

Keep cell phone 6-12 inch away from device

-No cell phones in front shirt pockets

Pacemakers

-Potential Complications

-Failure to pace (shocks but nothing happens)

-Failure to capture (HR not where it needs to be)

Interventions if pacemaker fails to capture

Inc output

Change batteries

Reposition

Atrial Arrhythmias

Premature Atrial Complex (PAC)

Atrial Flutter

Atrial Fibrillation

Supraventricular Tachycardia

Premature Atrial Complex (PAC) *

-Extra beat before P wave

-Pause before next complex after occurs

-Irregular

Premature Atrial Complex (PAC)

-Common causes

Caffeine

Stress

Anxiety

Hypokalemia

Premature Atrial Complex (PAC)

-Treatment

-Treat cause

-No meds unless frequent (>6 per min) ** (see general treatment)

Atrial Flutter *

-More than 1 P wave for every QRS

-Saw tooth P wave

-ALWAYS regular

Atrial Flutter S/S

-Could be asymptomatic (stable)

-Fatigue/lightheadedness

-Palpitations/chest pain

-SOB

-Hypotension

Atrial Flutter has *small* risk of?

Pulmonary or systemic emboli

Atrial Flutter

-Treatment

Determine stable vs unstable (see general treatment)

-Unstable = cardioversion immediately

Atrial Fibrillation *

-No P wave

-ALWAYS irregular

Types of atrial fibrillation **

-Controlled (stable): HR <100

-Uncontrolled (unstable): HR >100

When a pt has atrial fibrillation, they are at HIGH risk for?

Pulmonary or systemic emboli

Atrial Fibrillation S/S

-Could be asymptomatic (stable)

-Fatigue/lightheadedness

-Palpitations/chest pain

-SOB

-Hypotension

Atrial Fibrillation

-Treatment

Determine stable vs unstable (see general treatment)

Supraventricular Tachycardia (SVT) *

Atrial Arrhythmia

-High rate (>140)

-Regular

-Narrow QRS

-Can have sudden onset (be in sinus rhythm & then convert), be intermittent, & terminate suddenly **

Difference between sinus tachycardia and superventricular tachycardia

SVT has higher rate (>140)

SVT S/S

-Could be asymptomatic (stable)

-Fatigue/lightheadedness

-Palpitations/chest pain

-SOB

-Hypotension

Medication used to treat SVT

Adenosine

-Chemical cardio converter

-Stops heart & resets the electrical impulses (will have long pauses before flips back)

-Educate pt that they will feel heart stop

Adenosine

-Indication *

Treats SVT (converts back to NSR)

Adenosine

-Route *

IVP (rapid)

-6mg and may repeat with 12mg x2

Adenosine

-Side Effects

Arrhythmias

Hypotension

Dizziness

Dyspnea

Adenosine

-Know *

-May have asystole (heart stops before flipping back into NSR)

-Have emergency equipment nearby (incase doesn't start back)