Unit 7 Cardiovascular/Hematology

Cardiac Structures and Vessels

4 chambers

-right/ left atrium, right/left ventricle

Cardiac layers

-epicardium,myocardium, endocardium

Coronary artieries

Valves

-tricuspid,pulmonic, mitral, aortic

Flow of blood through heart

1- Superior and inferior vena cava

2- right atrium

3- tricuspid valve

4- right ventricle

5- pulmonic valve

6- pulmonary artery

7- lungs

8- pulmonary artery

9- left atrium

10- mitral valve

11- left ventricle

12- aortic valve

13- aorta

14- body

Cardiac conduction

Sinoatrial node

Atrioventricular node

Bundle of His

Right and left bundle branches

Purkinje Fibers

What is cardiac output

-amount of blood ejected from the left ventricle in 1 min

- stroke volume x heart rate= cardiac output

Hormones and the Heart

Epinephrine increases

-HR

-force of contraction

-cardiac output

-systolic blood pressure

Aldosterone

-regulates sodium and potassium

Atrial natriuretic peptide

-excretes sodium

Components of blood vessels

Arteries

Veins

Capillaries

Pathways of circulation

Pulmonary

-Right ventricle, lungs, left atrium

Systemic

-L ventricle, aorta, blood goes to body

Aging and the Cardiovascular system

-conduction less effective

-atherosclerosis

-resting blood pressure increases

-decreased heart rate

-vein valves incompetent

what to inspect during cardiovascular exam

-oxygenation, skin color

-extemities: hair, skin, nails, edema, color

-jugular vein distention

-capillary refill

-clubbing (diamond shape is normal)

what to palpate during cardiovascular exam

-point of maximum impulse

-extremity temperature

-edema

what to auscultate during cardiovascular exam

-heart sounds (S1 and S2)

-murmurs

-pericardial friction rub

lab tests for cardiovascular system

-Cardiac biom markers

-Lipids

-Electrolytes

-BNP

-PT/INR/aPTT

-D dimer

Diagnostic testing

-chest radiograph

-CT scan

-MRI and angiography

-stress test

Information for Electrocardiogram (ECG)

-records cardiac electrical activity

-12,15,18 leads

Signal averaged ECG

-risk for ventricular arrhythmias

Ambulatory ECG monitoring

-holter monitoring

Information about Echocardiogram

-ultrasound

-records motion: heart structures, valves, heart shape size and position

types

-strain

-stress

-transsesophageal

Information regarding echocardiogram

-throat anesthetized

-probe placed esophagus

-clearer images then echo

-as needed until gag reflex returns

Therapuetic interventions

-Lifestyle and cardiac care

-antiembolism devices

-oxygen

-medications

Components of cardiac cycle

P wave: electrical pulse starting in the SA node

P-R interval (Q): traveling to AV node

QRS: 3rd-5th steps are being fired up

T wave: ventricles relaxing, filling with blood

Information about Sinus Bradycardia

s/s

-usually none (fatigue,fainting, SOB)

treatment

-none if asymptomatic

-oxygen, atropine, dopamine or epinephrine

-pacing (pace maker)

-fix electrolyte imbalance

Information about Sinus Tachycardia

s/s

-none (angina or dyspnea, may be palpations)

-older adults are more sensitive

Interventions

-treat cause

-meds: adenosine, beta blockers, calcium channel blockers)

What is Atrial fibrillation

- Overloading of SA node, causes ventricles to respond quivering/twitch

Rhythm: irregular

HR: not measurable

P waves: non identifiable

Information about Atrial Fibrillation

s/s

-palpatations

-faint radial pulse

Purpose of interventions

-correct sinus rythm

-prevent blood clots

-control rate

Therapuetic interventions for Atrial Fibrillation

-synchronized cardioversion if unstable

-medications

-anticoagulation

-ablation (after)

-surgical maze procedure

What is asystole

Rhythm: none

Heart rate: none

P waves: none

PR interval: none

QRS: none

Signs and symptoms of Asystole

-unconscious

-no heart sounds, peripheral pulses, blood pressure

-respiratory arrest

-cyanosis

-pupil dilation

Asystole Therapuetic Interventions

-CPR

-ACLs protocols (intubation with oxygen)

-Treat cause

Information about Cardiac Pacemakers

Generate an electrical pulse

Traditional types:

-external and temporary

-internal and permanent

Leads placed in atria, ventricle or both

-spike on ECG begins paced beat

Leadless pacemaker

Pacemaker ECG Tracings

A. Atrial pacemaker (spike before P wave)

B. Ventricular only pacemaker (spike before QRS)

C. Dual chamber pacemaker (spike before P and QRS)

Cardiac pacemaker problems

-failure to sense

-failure to pace

-failure to capture

Nursing care for Pacemaker

-Monitor ECG

-monitor apical pulse

-monitor for symptoms

note: monitor enzymes for any cardiac procedure

Pacemaker education

-incision care

-activity restrictions

-symptoms of infection signs to report

(note: monitor for hiccups, could be problem with leads)

-ID card

-periodic pacemaker checks

Safety Considerations for Pacemakers

-microwaves are safe and can be used

-security devices safe but can trigger (avoid wands)

-Revo MRI Surecan Pacing System safe

-Move away if become symptomatic

Electromagnetic devices to avoid

-MRI

-welder

-radio tower

-touching running auto engine

What is defibrillation

Electrical shock to reset lethal ventricular arrhythmias

-pulseless VT

- V fib

Paddles placed on chest

-2nd intercostal space, right of sternum

-anterior axillary line, 5th intercostal space

Announce clear for safety, dont be touching patient

What is Automatic External Defibrillator (AED)

-automatically analyzes rhythms

-automatically delivers or prompts users to deliver electrical shock

(if shockable rhythm V fib or VT is detected)

Information about Implantable Cardioverter Fibrillator

-automatically defibrillates when lethal rhythm detected

-cardioverts when VT detected

-increased risk for falling (usually in person with pacemaker)

What is Synchronized Cardioversion

Allows R wave to be sensed for safe delivert

Used in arrhythmias if R wave present

-VT with pulse

- Afib, flutter, supraventricular tachycardia

Painful

-sedation used

Low energy

-25-50 joules

Definition of blood pressure

-pressure exerted by blood on walls of blood vessels

Determined by

-cardiac output

-peripheral vascular resistance

-vessel stretch

-blood viscosity

-blood volume

Blood pressure ranges

Normal: less then 120/80

Elevated: 120-129/80s

Hyper tension

Stage 1: 130-139/80-89

Stage 2: more then 140/90

Types of Hypertension

Primary hypertension

-unknown cause

Secondary hypertension

-known cause (medications, CKD, heart issues)

S/S of hypertension

None "silent killer"

Rare: headache, blood nose, aniexty, dyspnea

Diagnosis of Hypertension

-risk factor presence

-signs and symptoms

-kidney/heart failure

-BP readings

High potassium foods

-bananas

-orange juice

-dark leafy greens

-sweet potatoes

-chocolate

-milk

-french fries and potato chips

Complications of Hypertension

-atherosclerosis

-coronary artery disease

-eye damage

-kidney damage

-heart failure

-myocardial infarction

-stroke

What is hypertensive urgency

-severe BP elevation w/o target organ dysfunction progression

-severe headaches, nosebleeds, SOB and severe anxiety

-ambulatory treatment with oral medications

What does Hypertensive Emergency look like

-Systolic BP higher then 180

-Diastolic BP higher then 120

-risk for progression of target organ dysfunction

Treatment: IV nitroprusside

Patient Safety for Hypertension

- medication has possible side effects of hypotension

-dizziness may increase risk of falling

-rise slowly to decrease risk of orthostatic hypotension

-hydration balance is important

Information about Cardiovascular disease

-leading cause of death in US

-affects quality of life and ADLs

-unmodifiable/modifiable risk factors lead to CVD

-education is important

What is Coronary Artery Disease (CAD)

-obstruction of coronary artery blood flow

-usually from atherosclerosis

Blood flow reduction causes

-angina

-MIs

-sudden death

Prevention of CAD

-stop smoking

- low LDL

-lipid lowering agents

-Normal BP and blood sugars

-low dose aspirin as prescribed

Information about Angina Pectoris

-chest pain (CP)

-symptom of ischemia (inadequate blood flow)

Causes

-CAD

-vasospasm

-valvular heart disease

-hypertension

-heart failure

Angina Pectoris Pathophysiology

-narrowed blood vessels unable to dilate

-carry less blood/oxygen for heart muscle

-less oxygen causes myocardial ischemia which then causes pain

3 types of angina

-Stable angina

-Unstable angina

-Variant angina

Information of Stable Angina

-occurs with moderate exertion in familiar pattern

-usually stops with rest, Sl nitroglycerin

-pain is predictable

Information about Unstable Angina

-pain in unpredictable

-occurs with less exertion (at rest, during sleep)

-unrelieved with rest/ SL nitroglycerin

-can lead to MI

Information about Variant Angina (Prinzmetal)

-due to coronary artery spasm

-longer duration, pain is more severe

-can occur at rest

-often at same time each day (usually at night)

-serious condition

S/S of Angina

Pain

-heaviness,tightness,crushing pain in chest center

-pain may radiate to arms, shoulder,neck,jaw or back

Pale

Diaphoretic

Dyspnea

Angina Diagnostic Tests

-ECG, Stress test ECG

-echocardiography

-chemical stress testing

-CT,MRI

-Radioisotope imaging

-Coronary angiography

Anti-Anginal Medications and Therapies

-Vasodilators

-Beta blockers

-Calcium channel blockers

-Antiplatelets

-Statins

Nursing Care for CAD and Angina

-ensure IV access

-rate pain

-administer oxygen

-administer NTG, Aspirin, and analgesics

-remain with pt and provide emotional support

Acute Coronary Syndrome

Unstable angina

-can lead to MI

MI

-Non Stemi

-Stemi

Information about Silent Ischemia

MI without chest pain

-occurs in older patients, women

-often seen with hypertension and diabetes

Information about Myocardial Infarction

-Death of heart muscle

-Pathophysiology: coronary artery blockage reduces blood supply

Types

-Non stemi: partial blockage

-Stemi: complete blockage

S/S of Myocardial Infarction

-crushing, viselike pain (radiates)

-diaphoresis

-dizziness, fainting

-dyspnea

-nausea

-restlessness

Women and Myocardial Infarction

-CAD/MI leading cause of death in women

-African Americans more at risk

-Higher mortality rate and complications then men

-Prodromal symptoms the month before MI

Myocardial Infarction Atypical S/S for women and older adults

-absense of classic pain

-dyspnea

-fatigue

-anxiety, restlessness

-chest cramping

-epigastic or abdominal pain

-falling

Diagnostic testing for Myocardial Infarctions

-Serial ECG

- highly sensitive cardiac troponin (cTnT)

-myoglobin

-creatine kinase (CK)-MB

-CRP

-magnesium nd potassium

Myocardial Infarction Therapeutic Intervention Information

Goal: restore cardiac perfusion within 90 min

PCI

-ballon angioplasty, coronary artery stents

Thrombolytics

-time sensitive, administer 1-6 of symptom onset

Myocardial Revascularization

Coronary artery bypass graft (CABG)

-cornary artery occlusions bypassed with vein/artery graft

-increases blood flow/oxygen to myocardium

Myocardial Infarction Medications

-oxygen

-antiplatelets

-nitrates

-morphine sulfate

-vasodialators

-beta blockers

-antiarrthymics

Myocardial Infarction Therapuetic interventions

-bedrest/commode

-daily weight

-low sodium, LDL and fat diet

-weight loss

Nursing Care for Myocardial Infarction

-monitor vitals

-monitor for arrhythmias

-report symptoms

-provide incisional care

-monitor for depression

Patient education for MIs

-disease information

-medications

-diet

-activity and exercise

-stress reduction

-rehabilitation

Venous Thromboembolism Disease (VTE) information

DVT- blood clot develops in deep veins

PE- part of DVT clot breaks off and travels to lungs

Thrombophlebitis

-most common disorder

-clots forms and inflammation follows

-can be superficial or deep

VTE etiology

-made up of blood products, such as platelets, RBCs, WBCs and fibrin

-attaches to wall of blood vessel causing vessel to shrink in diameter

-three factors involved in formation

VTE Prevention

-identify risk factors

-maintain mobility

-antiembolism devices

-medications

-follow IV therapy protocol

VTE S/S

Superficial

-redness, warmth, swelling, tender, induration

-common sites are legs due to varicose veins or arms due to IV therapy

Deep

-swelling, pain, warmth, edema, venous distention

-cyanosis

-elevated temp

some have no S/S

VTE complications

-PE

-DVT

-Chronic venous insufficiency

VTE diagnostics

-D dimer (blood test for possible clots, doesn't give location)

-Ultrasound

-Venography

-CT/MRI

VTE Nursing Interventions

Superficial

-WMP

-analgesics, NSAIDS

-compression devices

-elevation

Deep

-WMP

-anticoagulants

-compression devices

-elevation

-early ambulation

-thrombolytic therapy/surgery if needed

Peripheral Arterial Disease Pathophysiology

-disorder of arterial circulation

-chronic, progressive arterial narrowing

-reduces blood supply

-ischemia develops

-affects lower extremities

Common cause of Peripheral Arterial disease

-Atherosclerosis (leading cause)

-Organic cause by structural changes from plaque and inflammation

-Functional cause from vasospasms as noted in Raynaud disease

Compensatory mechanisms for Peripheral Arterial Disease

-peripheral vasodilation

-anaerobic metabolism

-development of collateral circulation

-eventually lack blood supply produces ischemia

-results in ulceration, gangrene, necrosis of extremity

-amputation may be necessary

S/S of Peripheral Artery Disease

-pain in extremity

-muscle cramping

-hair loss on extremity

-dry, flaky scaly skin

-thickened toenails

-intermittent claudication (pain w/ activity)

-reddish purple when dependent, pale when elevated

-diminished or absent pulses

Diagnostic Testing for Peripheral Arterial Disease

-ankle, brachial index

-doppler ultrasound

-MRI and CT

-arteriography

-plethysmography

Therapuetic Interventions for Peripheral Arterial Disease

-low fat, cholesterol and calorie diet

-medications

Invasive therapies

-PTA

-Atherectomy

-Stents

-Aortofemor bypass

What is Heart Failure

-syndrome occurs from progressive inability of heart to pump enough blood to meet bodys oxygen/nutrient needs

Causes of Heart Failure

-CAD (most common)

-cardiomyopathy

-hypertension

-heart valve disorders

-MIs

Pathophysiology of Heart Failure

-each ventricle pumps an equal amount of of blood

-if it is more than either ventricle can handle, the heart is not an effective pump

-left ventricle typically weakens first

Left Sided Heart Failure

Afterload

-force generated by left ventricle to eject blood into aorta through aortic valve

Peripheral vascular resistance

-pressure within aorta/arteries

-influences afterload

Blood backs up from left ventricle into lungs

Alveolar Edema results

Right Sided Heart Failure

Major cause of L sided HF

-must continually pump blood against increased fluid in pulmonary artery and lungs

Cor Pulmonale

-right ventricle hypertrophies and fails due to increased pulmonary pressures

Backward build up of blood in systemic blood vessels

Peripheral edema results

Compensatory Mechanisms of Heart Failure

Maintain cardiac output when low

-sympathetic nervous system raises HR (⬆️ o2 needs)

-RAAS antidiuretic hormone save water

-chambers enlarge (dilation)

-muscle mass increase (⬆️ o2 needs)

What is Acute Heart Failure (Pulmonary edema)

-severe fluid congestion in alveoli

-life threatening

-feel like you can't breathe/drowning

S/S of Acute Heart failure

-pink,frothy sputum

-rapid resp with accessory muscles

- severe dyspnea, orthopnea

-crackles, wheezes

-anxiety, restlessness

-clammy, cold skin

Diagnostics for Acute Heart Failure

-arterial blood gases

-pulmonary pressure (will be increased)

-x ray

-clinical presentation

Therapuetic interventions for Acute Heart Failure

-reduce workload of left ventricle and treat underlying cause⭐️

-semi fowlers, provide oxygen

-IV: diuretics, inotropic agents and vasodilators

S/S of Chronic Heart Failure

Same as Acute Heart failure

-edema

-nocturia

-cyanosis

-malnutriton

-altered mental status

Complications of Chronic Heart Failure

-liver and spleen enlargement

-pleural effusion

-thrombosis and emboli

-cardiogenic shock

Diagnostic testing (LABS) for Chronic Heart Failure

-BNP ⭐️ (0-100)

-BUN, creatinine

-liver and thyroid function tests

-ferritin

Diagnostic Testing for Chronic Heart Failure

- X ray, MRI

-echo

-electrocardiogram

-stress test and sleep studies

-cardiac cath/ angiography

Therapeutic Interventions for Chronic Heart Failure

Purpose: improve hearts pumping ability and decrease hearts oxygen demands

-maintain optimum water and sodium balance

-identify and treat underlying cause

-medications

-activity

-pacemakers