test 4

afterload

Resistance heart must overcome to eject blood.
RT: pulmonic resistance
LT: systemic resistance

preload

degree of stretch of the cardiac muscle fibers at the end of diastole

cardiac output

Volume of blood pumped by heart per minute.
4-6 L a minute

ejection fraction

percentage of blood ejected out with each beat

inotropy

force of myocardial contraction

chronotropy

heart rate

stroke volume

The amount of blood ejected from the left ventricle in one contractio, measured in mL

coronary artery disease

narrowing or obstruction of one or more coronary arteries, results from atherosclerosis

what labs are used to determine overall cardiovascular risk?

high-sensitivity C-reactive protein (hs-CRP) test results together with other screening tools such as measurements of lipid levels

fasting lipid profile should demonstrate what values?
LDL
TOTAL cholesterol
HDL
Triglycerides

LDL: <100 mg/dL

total: <200 mg/dL

HDL: males- >40mg/dL, females- >50 mg/dL

Triglycerides: <150 mg/dL

what kind of diet for CAD prevention

AHA/Mediterranean Diet: both provide similar key elements: an emphasis on plant foods (fruits, vegetables, whole-grain breads, beans, nuts, and seeds), minimally processed foods, seasonally fresh foods, inclusion of fish, and minimal intake of red meat

HMG-CoA reductase inhibitors also known as ________, examples, and what they do

Statins.
- Atorvastatin (Lipitor), Rosuvastatin (Crestor), Simvastatin (Zocor)
*works in the liver and prevents lipids from being produced

teachings, nursing interventions of statin meds

monitor serum liver enzymes, report unexplained muscular pain (myopathy) immediately (rhabdomyolysis-weakness, tea colored urine)

-administer in the evening, take as prescribed

-AVOID grapefruit juice

Fibric Acids (Fibrates)

-lipid lowering drug therapy
Gemfibrozil (Lopid)
-lowers triglycerides, increase HDLs (takes lipids AWAY from arteries)
-contraindicated in severe kidney and liver disease (monitor liver/kidney function)
-use cautiously when also taking statin med

Bile Acid Sequestrants

-lipid lowering
colestipol (colestid), cholestyramine (questran)
*They work inside your digestive system by binding to bile acids—which are made of cholesterol. This forces your body to flush the bile acids out in your stool, prompting your liver to pull more cholesterol from your blood to make new ones (decreasing hepatic cholesterol)
-effect GI and interfere with absorption of many drugs

PCSK-9 inhibitors

Alirocumab (Praluent), Evolocumab (Repatha)
-subcut every 2-4 weeks
lipid lowering drug
-destroys LDL receptors (responsible for pulling LDL out of the blood) PCSK9 inhibitors essentially block this protein, allowing more LDL receptors to remain active and remove excess cholesterol from your bloodstream

Cholesterol Absorption Inhibitor

Ezetimibe (Zetia)
Inhibits absorption of cholesterol in small intestine

depolarization
repolarization

Depolarization: contraction
Repolarization: relaxation

P WAVE

represents the electrical impulse starting in the SA node and spreading through the atria. represents atrial depolarization. It is normally 2.5 mm or less in height and 0.11 seconds or less in duration.

PR interval

measured from the beginning of the P wave to the beginning of the QRS complex and represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization. In adults, the PR interval normally ranges from 0.12 to 0.20 seconds in duration

QRS complex

represents ventricular depolarization
0.06 to 0.12 seconds duration

QRS duration

time required for depolarization of both ventricles (0.04 TO 0.10)

ST segment

represents early ventricular repolarization, lasts from the end of the QRS complex to the beginning of the T wave

T wave

represents ventricular repolarization (when the cells regain a negative charge; also called the resting state)

U wave

thought to represent repolarization of the Purkinje fibers; although this wave is rare, it sometimes appears in patients with hypokalemia (low potassium levels), hypertension, or heart disease

QT interval

represents the total time for ventricular depolarization and repolarization, is measured from the beginning of the QRS complex to the end of the T wave

what is caused by disturbance in electrical conduction of the heart and causes can be drugs, acid base balance, electrolyte imbalance, thermal changes, disease, trauma, nicotine

arrhythmias

what assessment should you do with an arrhythmia

heart rate, apical 1 min, rhythm

with arrhythmias, patients are normally asymptomatic until what is altered and how does this present

cardiac output

-palpitations, syncope, pain, dyspnea, diaphoresis, hypotension, electrolyte imbalances

what is sinus bradycardia and how is it treated

rate of sinus node less than 60 beats per min (sinus bradycardia)

can be symptomatic or asymptomatic, can be normal in some individuals

TX: atropine (anticholinergic drug used to treat slow heart rhythms by blocking the vagus nerve's inhibitory effects on the heart. It accelerates the sinus node's pacemaking and speeds up conduction through the AV node), pacemaker, holding meds, 02, notify RN. Apply transcutaneous pacemaker pads (TCP) if atropine does NOT work

what two rhythms are the only rhythms to defibrillate

VTACH
VFIB

sinus tachycardia

rates >100 bpm

TX: depends on cause, vagal maneuver (breathing through a straw to simulate vagus nerve), valsalva maneuver (exhaling forcefully against a closed airway (pinching the nose and closing the mouth) or glottis, similar to popping your ears. This temporarily increases pressure in the chest, altering blood pressure and heart rate), adenosine, synchronized cardioversion (synched with QRS, deliver on R. if you deliver on T wave, it can cause ventricular dysrhythmia)

AFIB

irregularly fast or erratic heartbeat (arrhythmia) that affects the heart's upper chambers

supraventricular tachycardia (SVT) (above ventricles)
also called paroxysmal supraventricular tachycardia
-adenosine to identify underlying heart rate

most common type of supraventricular tachycardia

Atrioventricular nodal reentrant tachycardia (AVNRT)

pulse deficit

difference between apical and radial rate
apical-radial

what is pacemaker close to SA node firing earlier than expected

premature atrial complex
caused by: caffeine, alcohol, nicotine, stretched atrial myocardium, hypervolemia, atria ischemia, infartion
No TX for infrequent
more than 6 per min is frequent and treat underlying cause

multiple rapid impulses from many atrial foci at a rate of 300 to 600 times per minute

atrial fibrillation

(a common heart rhythm disorder. Instead of a single electrical signal controlling the heartbeat, many "spark plugs" in the heart's upper chambers (atria) fire randomly. This causes the atria to quiver (fibrillate) chaotically rather than beating in a steady rhythm)
*highly irregular

what is causing decreased cardiac output in atrial fibrillation?

loss of atrial kick

how is atrial fibrillation classified?
paroxymal
persistent
long standing persistent
permanent
nonvalvular

paroxymal: suddent onset, lasts less or equal to 7 days. can recoccur

persistent: continuous, more than 7 days

long standing persistent: continous, more than 12 mos

permanent: decision has been made not to restore sinus rhythm

nonvalvular: absence of moderate to severe mitral stenosis (narrowing/stiffening of mitral valve)

AFIB RVR

AFIB meds

-antithrombic meds (bc risk of blood clot): warfarin, apixiban (eliquis)
-meds to control HR: beta blockers (block sympathetic system), calcium channel blockers (diltazem, cardizem)
-meds to convert heart rhythm or prevent afib: amiodarone, dofetilide

if a person is in AFIB for >48 hrs, what meds would you guve and why

adequate anticoagulants to prevent stroke from blood clots

if there is not a time to determine length of AFIB, what procedure is done to look at heart from inside

TEE- transesophageal electrocardiogram.

what is an elective procedure that must be synchronized with the QRS and patient is delivered 50-200 joules?

cardioversion
*patient is awake & frequently sedated
*consent form must be signed and EKG monitoring
*delivered on R wave

what is an emergency procedure for VTACH and AFIB and begins with 200-360 joules?

defibrillation
there is no cardiac output, patient is unconscious and requires EKG monitoring
**if its VIB, you DeFib! call a code!

difference in synch on/off with cardioversion and defibrillation

Setting Sync "On" (Synchronized Cardioversion) delivers a timed shock exactly on the heart’s R-wave to prevent triggering fatal rhythms like ventricular fibrillation. Setting Sync "Off" (Defibrillation) delivers an immediate, unsynchronized shock, which is necessary when the heart has completely stopped or shows chaotic, unorganized electrical activity

other procedures of AFIB

catheter ablation therapy: thin tubes into blood vessels and guides them to the heart, scars or destroys heart tissue thats triggering the arrhythmia

maze procedure: open heart surgery, pattern of scar tissue is made in the upper chambers forcing a normal path and sinus rhythm

left atrial appendage occlusion: a minimally invasive procedure that permanently seals off the left atrial appendage—the heart pouch where most stroke-causing clots form in patients with atrial fibrillation, watchman device is placed that slowly grows into the endothelium preventing clots from getting out preventing strokes

what is an impulse that starts in a ventricle and is conducted through the ventricles before the next normal sinus impulse? caused by caffeine, nictonine, alcohol, cardiac ischemia/infarction, increased workload on heart, electrolyte imbalances.

*feels like heart is skipping a beat

premature ventricular complexes
*tx usually based on cause and usual benign finding

Unifocal PVCs
bifocal PVCs
Cuplet PVCs

unifocal: extra beats look identical on ECG tracing, originate from a single, specific location

bifocal: extra beats in two distinctly different shapes or forms on the ECG, two different locations inside the ventricles

cuplet: pattern or grouping rather than shape of beat, two PVCs happen back-to-back, with no normal heartbeats between them

triplet
bigeminy PVC
trigeminy PVC

triplet: three consecutive premature ventricular contractions (extra heartbeats originating in the lower chambers) on an ECG, classfied as VTACH

bigeminy: a normal heartbeat is consistently followed by a Premature Ventricular Contraction (PVC), a pattern of two beats close together, followed by a slight pause. It often feels like a skipped beat, flip-flop, or pounding in the chest

trigeminy: a heart rhythm pattern where a premature ventricular contraction (PVC) occurs every third heartbeat, creating a repeating sequence of two normal beats followed by one early, extra beat

what is three or more PVCs in a row, repetitive firing or an irritable ventricular focus usually at greater than 100 beats/min, can be stable/unstable/pulselessness and what is treatment

ventricular tachycardia
tx: QUICKLY, id cause (H&Ts), synchonized cardioversion (WITH PULSE), antiarryhmic drugs.

Torsades De Point

is type of VTACH
tx: magnesium sulfate
can be caused by haloperidol, CNS disease

what are the Hs of VTACH/VFIB

hypovolemia
hypoxia
acidosis
hypokalemia
hyperkalemia (tx but not cure by insulin, calcium gluconate, D50 (hypertonic solution)
hypoglycemia (d50)

Ts of vtach/vfib

hypothermia
toxins
cardiac tamponade (fluid in sac surrounding heart)
heart attack (go to cath lab)
thrombosis (PE) (heparin drip)

what is rapid, disorganized ventricular rhythms that causes ineffective quivering of the ventricles and what is the treatment

ventricular fibrillation
tx: cardiac emergency- No CO- start CPR, defibrillate (is NOT synchronized), antiarrythmic drugs within 2 mins. epinephrine every 3 mins, then amiodarone if failed

what med is used to prevent patient from remembering defibrillation

versed (midazolam)

ventricular asystole is

nonshockable

*confirmed in 2 different leads

*check monitor is still on.

*assess for h & ts

*meds: epi, atropine(stimulates sympathetic response)

first degree atrioventricular block

when all the atrial impulses are conducted through the AV node into the ventricles at a rate slower than normal

-prolonged PR interval: greater than 0.20 seconds

-can be a precursor of higher degreees of AV block

-asymptomatic, assess cause. can cause further block

-regularly irregular

electronic device that provides electrical stimuli to heart muscles

pacemaker (cardiac resynchronization therapy)
- can be for slower than normal impulse formation, symptomatic AV or ventricular conduction disturbance
-temporary or permanent
creates an artifical block and can produce Left Bundle Branch Block (LBBB) pattern on ECG
- can be single or dual chamber

different modes of pacing in pacemakers
-synchronous
-asynchronous
-overdrive

synchronous: only if HR falls below set rate

asynchronous: fires regardless of intrinsic rate (hearts natural beating rate)

overdrive: suppress underlying rhythm so sinus node will regain control

implantable loop recorder

a tiny device placed just under the skin of your chest that continuously monitors your heart's electrical activity. It is designed for long-term use (up to 3 years) to diagnose infrequent or hidden heart rhythm issues like atrial fibrillation (AFib), palpitations, or unexplained fainting.

ACE inhibitors work on the

RAAS system
-pril

primary site for blood formation and maturation

bone marrow
-used for anemic and pancytopenia (shortage of all 3 major cells)
-aspirated in posterior superior iliac crest for biopsy. must sign consent form, physician gives.
-sharp brief pain in procedure. lidocaine is used, direct pressure after. patient can lay on that side.

what is the oxygen carrying component of an RBC and what is the lab value range

hemoglobin 12-18

lifespan of RBCs

120 days

complications of bone marrow biopsy

infection (osteomylitis), bleeding

what is reduction in oxygen-carrying capacity through either fewer RBCs or a reduction in hemoglobin

anemia
*is not a disease in itself, something else is causing it. it is a sign of an underlying disorder (decreased RBC production-nutrient deficient, decreased erythropoietin (which is how RBC are made), decreased iron), blood loss(inner, outer), increased RBC destruction (hemolysis-sickle cell, meds: methlydopa), incompatible blood, trauma

what vitamins/minerals are essential to RBC

iron, ferritin (stores iron,releases when needed), vitamin b12, folate
-transferrin which transports iron
- TIBC is the iron bonding capacity

what are some manifestiations of anemia

fatigue, weakness, pallor, jaundice, cardiac/respiratory symptoms, tongue changes, nail changes, angular cheilosis (mouth cracking), pica

measurement of RBC percentage in total blood volume, can detect blood disorders and can monitor internal bleeding post surgery

HCT

vcauses of polycthemia (too much rbc which causes blood to thicken and move more slowly)

hemoconcentration, dehydration from fluid loss, low oxygen, congenital heart diseases, pulmonary disorders which increase bone marrow stimulation, tumors, cushing syndrome (prolonged exposure to cortisol in body, usually caused by steroids)

cause of anemia

blood loss, low RBC production, high RBC destruction, malnourishment, ulcer/colon cancer, trauma, internal bleeding, menstruation, sickle cell anemia, splenomegaly, radiation/chemo

MCV

MCH

mcv: size of RCBs, think SUV (normal is 80-100 fL. <80-micocytic, >100-macrolytic

mch: color (amount of hgb) of RBCs, think C (chrome for color) 26-34 pg/cell

iorn deficiency anemia

most common in the world and most commonly caused by blood loss

I intake low or blood loss

R restless legs, strange cravings

O oxygen low (tachycardia, fatigue, pale)

N nails and structures (brittle nails, glossitis)

LOW for lab values

L low ferritin, low serum iron, low hgb/hct

O oxygen capacity high (Total Iron-Binding Capacity, or TIBC, is high)

W WBCs are fine, but RBCs are microcytic (small and pale)

*late sign of anemia

* common in premie babies

how to treat iron deficiency anemia

increase dietary iron (dark green vegetables, beets, dried beans, legumes, breads/cereals, red meat, eggs, tuna)
iron supplements: absorbed better with vitamin c. 1 hr before meals or 2 hrs after
can be given IM ztrack or IV
-educate: liquid iron stains teeth, black stool and constipation

folic acid deficiency

caused by inadequate dietary intake, malnutrition, malabsorption

onset and progression is slow

FOLATE Mnemonic:

Fatigue & Weakness: Lack of healthy red blood cells causes pale skin and low energy.

Oversized cells: increased MCV

Leafy greens: Leafy greens, fortified cereals, and citrus are top sources.

Alcoholism: Heavy alcohol use is a major cause of depletion.

Tongue swelling: Can cause a sore, red, or smooth tongue (Glossitis).

Embryo defects: Crucial for fetal spine development; deficiency causes neural tube defects like spina bifida and acromegaly (childbearing age should have 400-800 mcg daily)

*IM or PO

Vitamin b12 anemia

-inadequate source of b12 or malabsorption, can be caused by meds that decrease gatric acid, vegetarianism, veganism

PERNICIOUS Mnemonic:

P - Parietal cells in the stomach are destroyed (autoimmune).

E - Extrinsic factor (Vitamin B12 itself) can't be absorbed without the Intrinsic Factor.

R - Red blood cells become abnormally large (increased MCV)

N - Neurological symptoms (tingling, numbness, nerve damage) are the hallmark, which differentiate it from folate deficiency and can become permanent.

I - Intrinsic Factor is missing.

C - Cobalamin is the medical name for Vitamin B12.

I - Injections (intramuscular) are required for life-long treatment.

O - Originates primarily from animal products (meat, eggs, dairy, Seafood).

U - Unexplained fatigue, weakness, and pale skin occur due to low oxygen-carrying capacity.

S - Schilling test historically used to diagnose it (rarely used now)

will also have Lhermitte's Sign (flex neck, electrical shock down spine)

sickle cell disease

Genetic disorder in which red blood cells have abnormal hemoglobin molecules and take on an abnormal shape.

SICKLE Mnemonic:

S - Splenic sequestration & Strokes: Sickled cells can get trapped in the spleen (causing enlargement) and block blood vessels in the brain.

I - Infections: Because the damaged spleen cannot filter bacteria properly, patients are highly susceptible to infections. (osteomylitis)

C - Crises (Pain): Blocked blood vessels cause severe, unpredictable pain crises (vaso-occlusive crises-caused by infection, fever, dehydration, physical exertion, excessive cold exposure, hypoxia).

K - Kidney & Lung issues: Reduced blood flow damages organs, potentially leading to renal issues (jaundice bc as RBCs hemolyse, bilirubin is released) or Acute Chest Syndrome.

L - Lifespan of cells: Normal red blood cells live 90-120 days, but sickle cells only survive 10-20 days, causing severe anemia.

E - Enlarged facial bones (bone enlarging bc bone marrow is enlarging the body is compensating), Eye & Organ damage: Small vessel blockages can lead to vision issues and long-term damage to the heart, liver, and bones

-also primarily african descent

meds/treatment of sickle cell disease

hematopoetic stem cell transplant (bone marrow transplant)
hydroxyurea (PO med, reduces frequency of pain crisis, elevates hgb levels making them more flexible to prevent blockages)
folic acid (support rapid red blood cell production)
hydration
transfusion therapy
pain management
preventing infection

blood transfusion therapy

type and screen, consent, culture consent, IV patency- has to be started within 30 mins, VS before and every 15 mins, hang with normal saline

Factor VIII (A) (memory trick: 8 rhymes with A)

Factor 1x is (B)

HEMO Mnemonic:

H - Hemarthrosis (Bleeding into the joint spaces, causing swelling and pain) (tx RICE).

E - Easy bruising.

M - Muscle and soft tissue bleeding (hematomas).

O - Oozing (Prolonged bleeding after minor trauma or dental procedures)

*effects males, females are carriers.

*toddlers is usually dx age

*DESMOPRESSIN (Ddvap) increase plasma factor VII

*recombinant factor to replace what they're lacking

*PTT elevated

*incurable

*avoid NSAIDS, acetylsalicylic acid (aspirin

thrombocytopenia

- Idiopathic thrombocytopenic purpura- an autoimmune disorder where the immune system mistakenly attacks and destroys the body's platelets (follows viral infection or immunization in children)
- Heparin induced thrombocytopenia (immune response to heparin)

*decreased platelets -> easy bruising, petechiae, bleeding

pulmonary embolism

obstruction of one or more branches of pulmonary artery. can be caused by thrombus (blood clot), piece of tumor, amniotic fluid, air, or fat

DVT greatest risk factor.

lab studies: ABGs, BNP, Troponin, D Dimer

imaging: xray, ecg, MDCTA (multidetector row computed tomography angiography- tells size and location), chest ct, V/Q scan (ventilation and perfusion scan= an imbalance shows likeliness of MI), pulmonary angiography (uses X-rays and contrast dye to visualize the blood vessels in your lungs)

PE management

anticoagulants and surgical management
-enoxoparin (lovenox)- low molecular weight heparin used to treat and prevent blood clots (give bubble, abdomen)
-unfractionated heparin- monitor PTT to make sure platelets aren't dropping
-thrombolytic therapy (activase)- only med that dissolves clot
surgical
-embolectomy- removes embolism
-coil in surgery to capture and remove clot
-inferior venacava filter (IVC) clot gets caught in filter to keep it from going to lungs

difference in ischemic stroke and hemorrhage stroke

ischemic is blockage of a blood vessel, hemorrhagic is bleeding into the brain.

*cerebrovascular accidents.
-CT within 20 mins

transient ischemic stroke TIA

can be warning of impending stroke
symptoms resolve within 24 hrs

FAST mnemonic

Face- look for uneven smile

Arm- check if one arm is weak

Speech- slurred

Time- call 911 at first sign

which stroke is sudden onset caused by sudden blockage of cerebral blood vessel causing lack of blood flow

ischemic stroke
-thrombotic caused by atherosclerosis
-embolic- blood clot travels from elsewhere and blocks artery in brain

manifestations of ischemic stroke

Symptoms depend on the location and size of the affected area
Numbness or weakness of face, arm, or leg, especially on one side
Confusion or change in mental status
Trouble speaking or understanding speech
Difficulty in walking, dizziness, or loss of balance or coordination
Sudden, severe headache
Perceptual disturbances

management of ischemic stroke

rt-PA: must present with 3-4.5 hours of stroke symptom onset
-no hemmorhage on head on CT
-symptoms present for 30 min, not rapidly improving or attributable to another disease
- imaging is consistent with acute ischemic stroke

mechanical intervention: endovascular thrombectomy, intra arterial mechanical thrombectomy: both using catheter to remove clot

left cerebral hemisphere stroke

weakness/paralysis RT side of body, right visual field deficit, aphasia (affects speech, writing, and ability to understand)
altered intellectual ability, slow cautious behavior

**LEFT BRAIN=LANGUAGE & LOGIC

right cerebral hemisphere stroke

left side of body
spatial perception defecit(impairs the brain's ability to process and interpret visual information regarding the location, distance, and orientation of objects)
increased distractibility
impulsive behavior and poor judgement
lack of awareness of deficits

**RIGHT BRAIN=RECKLESS &RUSHED

visual agnosia

eyes process but brain doesn’t comprehend what an object is

what meds are a risk factor of hemorrhagic stroke

sympathetic nervous system stimulants such as amphetamines, cocaine

symptoms of hemorrhagic stroke

severe headache described as worst headache they've ever had, early and sudden changes in LOC, n/v, bleeding, possibly seizures

complications of hemorrhagic stroke

cerebral hypoxia, decreased blood flow, vasospasm (sudden constriction of artery), increased ICP, HTN

-prevent and mitigate complications
-surgery can clip aneurysm or coil to keep from rupturing

nursing interventions strokes

-positioning to prevent contractures
-Botulinum toxin type A injected intramuscularly into wrist and finger muscles to prevent spasticity
-passive exercise
-standing/ambulation when ready
-self care
-approaching on visual side
-swallowing precautions
-catheters/bedpans
-speech therapy
-skin assessment
-family counseling
-vital signs due to ICP/pneumonia

inability of heart to pump enough cardiac output to meet the demands of the body

heart failure
defect in ventricular filling (diastolic)- ventricles not relaxing
ventricular ejection (systolic)