WEEK 4 - CARDIOVASCUALR CONDITIONS

Identify the main areas in the body that ischemia can occur and describe the associated signs & symptoms

A condition where the blood supply to an organ or tissue is restricted, typically due to narrowed or blocked blood vessels. This results in a lack of oxygen (hypoxia) and essential nutrients, leading to tissue damage.

• Ischemia in the heart is called MYOCARDIAL ISCHEMIA with S/S of: angina, arrhythmias, dyspnoea and radiation of pain to other body parts.  

• Ischemia in the brain is called STROKE with S/S of: face drooping, arm weakness, speech difficulty 

• ischemia in the renal system called RENAL ISCHEMIA with S/S of: acute kidney injury, oliguria (decreased) or Anuria (absent) of urine.

• Ischemia in the limbs is called the peripheral arterial disease with S/S of: pain, cramping, skin changes (cyanotic, purple)

Explain the pathophysiology of atherosclerosis.

• It is the progressive thickening and narrowing of an artery wall due to the accumulation of fatty substances, such as high cholesterol, smoking, and high blood sugar.

• Atherosclerosis is the leading cause of many diseases, like cardiac arrest, stroke,and  peripheral vascular disease 

Identify the relevant nursing assessments and management of a patient with peripheral artery disease

• Pain AX

• skin Ax

• Neurovascular obs

• Ensure there’s enough O2 supply 

• encourage circulation and perfusion - walking, warmth, avoid constriction

• IV fluids

• Medication administration - antiplatelets (reduce chances of blood clot), statins (reduce hyperlipidemia)

• high or semi-Fowler’s position 

• monitoring obs 

Identify and describe the varying causes of stroke

STROKE - BLOOD SUPPLY TO THE BRAIN IS BLOCKED OR REDUCED BY:

• ISCHEMIC STROKE (blockage) - most common, when a blood vessel supplying the brain is narrowed or blocked, cutting off oxygen and nutrient supply. It can be due to a thrombotic (blood clot), or an Embolic (a mobile blood clot or a piece of plaque)

• HAEMORRHAGE STROKE (bleeding) - a blood vessel in the brain leaks or ruptures —> blood spills into the brain tissue or the surrounding areas. The pooling of blood creates pressure that damages brain cells. It can be due to intracerebral (within the brain tissue) or subarachnoid (the area between the brain and the tissue that covers it).

• TRANSIENT ISCHEMIC ATTACK OR TIA (‘mini-stroke’) - temporary blockage of blood flow (ischemia) to the brain, similar to an ischemic stroke.

Identify the non-modifiable or modifiable risk factors associated with stroke

MODIFIABLE - atherosclerosis risk factors including: hypertension, atrial fibrillation, diabetes, smoking, and hyperlipidemia, sedentary lifestyle

NON-MODIFIABLE - Age, family history/ genetics, race/ethnicity, gender, prior stroke or TIA

Discuss angina and myocardial infarction in relation to Acute Coronary Syndrome.

BOTH ANGINA AND MYOCARDIAL INFARCTION ARE CONDITIONS THAT FALL UNDER THE UMBRELLA TERM ACUTE CORONARY SYNDROME.

• UNSTABLE AGINA (UA): when there’s a significant yet incomplete blockage of a coronary artery. The blood flow is restricted but not cut off completely = the heart muscles is inured but does not die.

• MYOCARDIAL INFARCTION (“HEART ATTACK”): occurs when ischemia (thrombus) is severe enough and prolonged enough to cause irreversible necrosis of the heart muscle cell.

Angina (specifically Unstable Angina) is a warning sign of ACS where the heart is starved of oxygen but survives. Myocardial Infarction is the progression of ACS, where the heart tissue actually dies due to the severity and duration of the ischemia.

What is the difference between STEMI and NSTEMI?

• NSTEMI - partial blockage or intermittent occlusion, NO ST elevation, causes necrosis of the innermost layer of the heart.

• STEMI - Complete or sustained blockage of the coronary artery, ST elevation shows on ECG, causes full-thickness (transmural) necrosis of the heart.

Compare and contrast the nursing management of a patient experiencing unstable angina vs ST elevation myocardial infarction (STEMI)

UNSTABLE ANGINA:

• vitals signs, pain Ax, ECG, cardiac Ax (inspection, palpation, auscultation)

• Pain management - Nitrates

• ongoing monitoring - ECG, Vitals, Cardiac enzymes

• Medications - antiplatelet (aspirin), beta blocker 1 (metoprolol), statins (atorvastatin).

• interventions - telemetry, possible coronary angiograph, lifestyle changes (diet, exercise)

MI (STEMI):

• initial Ax - rapid ax, 12-lead ECG, IV access, labs, O2 administration

• Pain management - morphine, nitrates, O2 if hypoxia

• Ongoing monitoring - ECG, O2 stats, Vitals, Troponin levels, rhythm checks.

• medications - antiplatelet and thrombolysis (dissolves dangerous blood clot with clot-busting drugs) or primary PCI (percutaneous coronary intervention) urgently. 

• intervention - immediate reperfusion (PCI or thrombolysis) or ICU care.

Explain three (3) key education points that you would discuss with a person to reduce their risk of acute coronary syndrome

LIEFESTYLE MODIFICATIONS:

• quit smoking, reduce alcohol consumption, reduce saturated fatty foods, engage in regular exercise

MEDICATION ADHERENCE:

• Emphasise the importance of taking prescribed meds (anti-hypertensives, statins, antiplatelets) on time.

RECOGNISE SYMPTOMS EARLY ON:

• educate on the warning signs of ACS (e.g, chest pain, SOB, sweating excessively, nausea)  and the importance of seeking help when these symptoms initially begin. 

A patient is admitted to hospital with an acute coronary syndrome. The nurse knows that this diagnosis indicates that the patient has experienced

unstable angina or a myocardial infarction

Describe the normal conduction pathway of the heart

1. SINOATRIAL (SA) NODE: The heart’s natural pacemaker.

• located in the upper wall of the Right Atrium 

• initiates the electrical impulse at the rate of 60 to 100 beat per min.

• cause both left and right atria to contract (atrial systole)—→ means pushing blood into ventricles

2. ATRIOVENTRICULAR (AV) NODE: The gatekeeper.

• located at the lower part of interatrial septum above the tricuspid valve.

• Delays electrical impulse (~0.1 sec) to allow ventricles time to fill completely.

• It’s the heart’s backup peacemaker - which can generate (40 -60 bpm) if SA node fails.

3. BUNDLE OF HIS (ATRIVENTRICULAR BUNDLE): Main pathway for impulse to reach ventricles

• passes through the fibrous skeleton connecting the atria and ventricles

• the impulse exists the AV node and travels down the bundle of his to reach the ventricles.

4. RIGHT AND LEFT BUNDLE BRANCHES: The split of bundle of his —> either left or right bundle branches which is along the interventricular septum

• carry the impulse towards the Apex of the heart, delivering it to both ventricles.

5. PURKINJE FIBERS: 

• spread throughout the ventricular walls.

• rapidly transmit the impulse to the ventricular muscles causing coordinated contraction from the Apex upwards to the pulmonary artery and aorta.

Explain the cardiac conduction system in relation to an ECG

1. P WAVE (ATRIAL DEPOLARISATION): originates from SA node and spreads through both atria —→ causing the atria to contract.

1. PR INTERVAL (AV NODAL DELAY): The impulse reaches the AV node and is deliberately delayed before the ventricles are activated.

1. QRS COMPLEX (VENTRICULAR DEPOLARISATION): The impulse travels the bundle branches and the Purkinje fibres —→ causing electrical activation (depolarisation) of the ventricles, causing them to contract.

1. T WAVE (VENTRICULAR REPOLARISATION): Ventricular cells are returning to their resting electrical state (repolarisation) —→ preparing for the next impulse.

1. ST SEGMENT: the time between the end of ventricular depolarisation and the start of ventricular repolarisation 

WHAT IS THIS ECG READING?

Atrial fibrillation (AF) usually The atria not contracting effectively instead they fibrillate or quiver 

• Rhythm: irregularly irregular (no consistent R-R interval).

• P wave: absent 

• PR interval: not measurable 

• QRS complex: normal, unless there’s a conduction delay.

• Rate: depends if controlled AFib (< 100bpm), uncontrolled or rapid ventricular rate (RVR) is (>100bpm). 

WHAT IS THIS ECG READING?

VENTRICULAR TACHCARDIA: electrical impulses spread abnormally and slowly through the ventricular muscle —→ ineffective atrial contraction and poor ventricular filling. highly dangerous if sustained.

• rhythm: regular 

• Rate: 100 - 250 bmp

• P wave: usually absent or not related to QRS (AV dissociated)

• QRS complex: Wide (>0.12 sec) and bizarre in shape

• T wave: often opposite direction to QRS

WHAT IS THIS ECG READING?

VENTRICULAR FIBRILLATION (VF): multiple chaotic and disorganized electrical impulses arising from the ventricular muscle fiber.

• Rhythm: chaotic, disorganized - no identifiable rhythm 

• Rate: not measurable 

• P wave: Absent 

• QRS complex:  absent, replaced by irregular, rapid fibrillatory waves 

• T wave:  not identifiable 

WHAT IS THIS ECG READING?

NORMAL SINUS RHYTHM:

• Rhythm: regular

• rate: 60 100 bpm

• P wave: present 

• QRS complex: normal or present 

• T wave: identifiable

WHAT ARE THE SHOCKABLE RHYTHMS?

• Ventricular fibrillation (VF)

• pulseless ventricular tachycardia (VT)

What is the main indication for performing 12 lead ECG?

• baseline history of pt’s heart rhythm 

• patient complaining of chest pain 

• irregular heart rate - either too low or two high 

• pre-surgery 

• Pm history or Fm history of heart complications 

• Serial ECG - for consistent monitoring 

• electrolyte imbalance 

Identify the key risks associated with a 12 lead ECG?

Interferences: 

• sweat 

• hair 

• metal contact 

• movement 

• allergic to the lead sticky tape

What are the nursing Ax or interventions for performing an ECG?

• Patient privacy

• Spine position

• explanation of privacy

• reassurance

• encourage little to no movement

What is the role of telemetry monitoring?

• used to continuously observe vital signs especially in critical care or cardiac units

• enables early interventions —> hence rapid response to life - threatening changes.

What’s the difference between an ECG and a continuous telemetry monitoring?

• Both are cardiac monitoring 

• ECG provides a snapshot of the heart’s electrical activity at a specific time 

• Telemetry is an ongoing rea-time monitoring of the heart rate and rhythm 

WHAT DOES DRSABCD STANDS FOR?

DANGER - environmental hazards (water or power cords) or manual handling

RESPONSE - Command them to say their name or squeeze your hands. or produce a painful stimuli like squeezing of the trapezius

SEND FOR HELP - emergency buzzer, ambulance 000

AIRWAY - make sure their airways is clear

BREATHING - look for the rise of chest or shoulders, listen or feel their breathing with your finger or cheek.

CPR/ CIRCULATION - chest compression rate is 100 -120 per min, depth would be more than 5 cm in adults or 1/3 depth of their chest. Chest compression ratio is 30 by 2.

DEFIBRILLATE - VF is the most common cause of adult cardiac arrest.