Mid-term Study Guide

cardiac output equation

stroke volume x HR

list and define the components of stroke volume

• Preload

  • The volume of blood returning to the heart in the left ventricle

  • Correlated with end diastolic volume

• Contractility

  • Strength of heart contraction

• Afterload

  • The pressure the heart must contract to pump blood into aorta

  • Inversely related to stroke volume

define tidal volume, inspiratory reserve volume, and expiratory reserve volume

• Tidal volume: resting breath volume (inhalation and exhalation)

• Inspiratory reserve volume: The additional air that can be forcefully inhaled beyond tidal volume inspiration

• Expiratory reserve volume: The additional air that can forcefully exhaled beyond tidal volume exhalation

define residual volume, inspiratory capacity, and functional residual capacity

• Residual volume: Air that's left in the lungs after maximal exhalation

• Inspiratory capacity: Maximum amount of air that is present after maximal inspiration (tidal volume + inspiratory reserve volume)

• Functional residual capacity: Air remaining in the lungs after a normal exhalation (expiratory reserve + residual volume)

define vital capacity and total lung capacity

• Vital capacity: Maximum amount of air that can be exhaled after a maximal inspiration (inspiratory reserve + tidal volume + expiratory reserve)

• Total lung capacity: Maximum volume to which the lungs can be expanded (sum of all lung volumes)

describe atherosclerosis and its risk factors

• Progressive hardening and narrowing of arteries

• “Response to injury” mechanism

  • Irritant damages the endothelium and waste products and cholesterol start to accumulate in that area

• Risk factors

  • Modifiable: smoking, inactivity, obesity, cholesterol, BP, stress, diabetes

  • Non-modifiable: Age, family history, males more common

what classifies chronic stable angina

• Well established level of onset

• Can predict which activities will provoke

• Usually able to bring symptoms under control

describe vasospastic (Prinzmetal) angina

• Chest discomfort associated with ST-segment elevation or depression

• Occurs at rest instead of during a predictable level of activity

• Not associated with any preceding increase in myocardial oxygen demand

define acute coronary syndrome

acute chest discomfort lasting > 20 minutes and not relieved by rest or taking nitroglycerin

• medical emergency

define unstable angina

severe blockage of a coronary vessel, but has not yet resulted in permanent myocardial death (infarction)

differentiate NSTEMI and STEMI myocardial infarctions

• NSTEMI

  • no ST segment elevation

  • severe occlusion

  • necrosis

• STEMI (worse than NSTEMI)

  • ST segment elevation

  • complete occlusion

  • transmural necrosis

how do pain patterns of pericarditis, pleuritic chest pain, and GI induced differ

• Pericarditis: pain at rest, not relieved with rest or NTG. responds to anti-inflammatory medications

• Pleuritic chest pain: discomfort/pain, changes with breathing, may hear pleural friction rub

• GI induced: prolonged epigastric discomfort usually related to food intake and relieved by antacid

list the structural vs functional HF classifications

• Structural:

  • Right

  • Left

  • Bi-ventricular

• Functional:

  • Systolic

  • Diastolic

list S&S of left vs right HF

• Left sided

  • Caused by left ventricle injury and will reduce cardiac output

  • Blood can back up into the lungs leading to pulmonary congestion

• Right sided

  • Right ventricle injury OR because of elevated pressures that wear out the right ventricle

  • Result in reduced right ventricular output and may result in peripheral congestion

differentiate systolic and diastolic HF

• Systolic dysfunction

  • Due to a decrease in myocardial contractility

  • Ejection fraction <40%

• Diastolic dysfunction

  • Impaired ventricular filling due to reduced compliance of the myocardium

  • Ejection fraction is normal (55-75%)

list and describe the types of cardiomyopathy

• Dilated

  • Myocardium stretches and weakness

  • Blood pools in the heart

• Hypertrophic

  • Irreversible thickening of the myocardium from a genetic cause

• Restrictive

  • Walls of the heart are too rigid to expand

  • Heart cannot be filled

list S&S of restrictive pulmonary disease

• Tachypnea

  • Increased respiratory rate

• Hypoxemia

  • Low levels of oxygen in the blood

• Reduced lung sounds

• Decreased lung volumes and capacities

• Greater susceptibility to carbon monoxide poisining

• Cor Pulmonale

• Dyspnea

• Irritating, dry cough

• Wasted/emaciated appearance

describe atelectasis and PT implications

• Incomplete expansion occurs when lung tissue collapses and becomes non-aerated

• PT implications

  • Can respond to deep breathing exercises, using a spirometer and coughing

describe pneumonia and PT implications

• Inflammation and secondary fluid buildup in the lungs create a restrictive effect

• PT implications

  • Drug therapy is primary focus

  • Help with postural drainage, percussion, vibration, cough techniques

describe ARDS and PT implications

• Initial inflammatory response followed by an exaggerated inflammatory response, resulting in breakdown of alveolar-capillary barrier

• PT implications

  • Mechanical ventilation

  • Prolonged prone positioning under sedation

  • Early mobilization as soon as pt. is stable

differentiate cardiogenic and non-cardiogenic pulmonary edema

• Cardiogenic pulmonary edema is caused by HF

• Non-cardiogenic is not related to HF

list and describe the 2 types of COPD

• Emphysema

  • Characterized by destruction of alveolar walls and secondary enlargement of the alveoli as air becomes trapped

  • Result in reduced airflow OUT of the airways, hyperinflation and poor gas exchange

• Bronchitis

  • Impacts the bronchial tubes, resulting in excess secretions and persistent cough

  • Result in reduced airflow OUT of the airways, hyperinflation and poor gas exchange

list COPD changes to lung volume, structure, posture, and muscle function

• changes to lung volumes

  • All lung volumes and capacities will increase

• changes to structure

  • Elevation of shoulder girdle

  • Horizontal ribs

  • Barrel shaped thorax

  • Low, flattened diaphragms

• changes to posture

  • Tripoding with hands on knees is a common reliving position

  • kyphosis

• changes to muscle function

  • Shift from type I to type II

  • Promote muscle wasting

  • Poorer exercise capacity and decreased lower extremity functioning

describe asthma, its medical management, and PT implications

• Chronic inflammatory disorder of the airways

• Medical management

  • Short term relief medications (albuterol)

  • Long term controller and long active bronchodilators (adviar)

• PT implications

  • Should not begin treatment until a good medication and symptom control is established

  • Use bronchodilator 30 mins before exercise

  • Controlled breathing techniques

describe cystic fibrosis, its medical management, and PT implications

• Life threatening, genetic disorder that affects epithelial surfaces of organs

• Proliferative production of thick secretions that lead to recurrent infections

• Medical management

  • Antibiotics, mucus thinners, CFTR modulators, nutrition

• PT implications

  • Secretion clearance, controlled breathing exercise, exercise and strengthening, postural re-education, thoracic stretching

describe bronchiectasis, its medical management, and PT implications

• Irreversible dilation of bronchi with chronic inflammation and infection, due to lung scarring and lumen obstruction

• Medical management

  • Antibiotics, bronchodilators

• PT implications

  • Secretion clearance, controlled breathing, strengthening and endurance exercises

list normal lab values for troponin I, troponin T, creatine kinase, BNP

• Troponin I: <0.04

  • indicates heart attack

• Troponin T: <0.1

  • indicates heart attack

• Creatine Kinase: 30-170 U/L

  • indicates heart attack

• BNP: <100 pg/mL

  • Indicates HF

what does ABG (arterial blood gas) measure

pH, oxygen levels, carbon dioxide levels, oxygen saturation

what does PTT, INR, and D-Dimer measure

• PTT

  • Measures how quickly blood clots and a person's response to anticoagulant therapies

• INR

  • Helps ensure that test results are standardized

• D-Dimer

  • Measures the amount of fibrin degradation

  • DVTs are associated with high levels of D-Dimer

what are the PT precautions for a patient who just had a cardiac catheterization

• Patients are usually on bed rest for 4-6 hours after the procedure if venous, 6-8 hours if arterial

• PT should be deferred or limited to bedside treatment within the parameters of these precautions

define FVC and FEV-1 and how obstructive/restrictive diseases change them

• FVC

  • Forced vital capacity

  • Amount of air you can breathe out after max inspiration

  • Obstructive diseases will demonstrate large lung volumes but reduced FVC because of the inability to get the air out forceful

  • Restrictive diseases will demonstrate small lung volumes and possible reduced FVC if there is a reduction in muscle strength

• FEV-1

  • Forced expiratory volume

  • Amount of air you can breath out in 1 second

  • Obstructive diseases will have a decreased FEV-1

  • Restrictive will have proportionally reduced FEV-1

list the heart auscultation landmarks for aortic, pulmonic, tricuspid, and mitral areas

• aortic: right 2nd intercostal space

• pulmonic: left 2nd intercostal space

• tricuspid: left inferior sternal margin

• mitral: left 5th intercostal space, mid-clavicular line

list causes of S3, S4, regurgitation murmur, and pericardial friction rub

• S3

  • Normal in healthy children/young adults

  • Sign of CHF in older adults

  • Blood rapidly striking a compliant left ventricle

• S4

  • HTN cardiac disease, CAD, history of MI or CABG

• Regurgitation murmur

  • Blood leaking backwards into the left atrium due to incompetent mitral valve

  • Can contribute to heart failure

• Pericardial friction rub

  • Inflammation of the pericardium, leading to rubbing

list causes for wheeze, stridor, and crackles

• Wheeze

  • Associated with airway obstruction from bronchoconstriction or secretions

  • Commonly head on expiration

• Stridor

  • Significant upper airway obstruction

  • Heard on both inspiration and expiration

  • Medical emergency

• Crackles

  • Wet/coarse

    • From fluid or secretion

  • Dry/fine

    • From sudden opening of closed airways (atelectasis)

list anti-hypertensive drugs and their side effects

• diuretics, ACE inhibitors, calcium channel blockers

• side effects:

  • orthostatic hypotension, dizziness, lightheadedness, post-exertional hypotension

what is hypertensive heart disease

• HTN that results in increased afterload and left ventricular hypertrophy

list BP safety cutoffs

• resting 180/110

  • need clearance BEFORE exercising

• exercise 250/115

  • STOP activity

describe abdominal aortic aneurysm and S&S

• Weakening/dilation of the abdominal aorta caused by chronic HTN, atherosclerosis, genetic predisposition, etc. Rupture is usually fatal

• S&S

  • pulsating tumor over abdomen, unexplained chest/abdominal/back pain, leg pain, numbness, poor distal pulses

what medication class is -artan

ARBS

• Losartan

what medication class is -ide

loop diuretic

• Furosemide

what medication class is -ipine

calcium channel blocker

• Nifedipine

what medication class is -olol

beta blocker

• Propranolol

what medication class is -oxin

cardiac glycoside

• Digoxin

what medication class is -phylline

methylxanthine

• Theophylline

what medication class is -pril

ACE inhibitor

• Lisinopril

what medication class is -statin

anti-hyperlipidemic

• Simvastatin

what medication class is -terol

B2 agonist bronchodilator

• Albuterol

what medication class is -zosin

A1 antagonist anti-HTN

• Terazosin

define P wave, PR interval, QRS complex, ST segment, T wave

• P wave: SA node fires → atria are depolarized

• PR interval: slight delay at AV node

• QRS complex: ventricles depolarize

• ST segment: pause before repolarization of the ventricles

• T wave: repolarization of the ventricles

what defines a normal sinus rhythm

• Rounded, symmetrical, upright p waves before every QRS complex

• Consistent length of PR interval

• Identical QRS complexes

• Consistent length between 2 consecutive R waves

• HR between 60-100

define and list causes of sinus bradycardia and sinus tachycardia

• Sinus bradycardia: resting HR < 60 bpm, caused by physical training, β-blockers, suctioning or vomiting, or increased intracranial pressure. Monitor for possible syncope. 

• Sinus tachycardia: resting HR > 100 bpm, caused by increased sympathetic activity (pain, anxiety), or if the demands of oxygen are increased (infection, anemia, MI, etc.)

define sinus arrhythmia and sinus pain/block

• Sinus arrhythmia: phasic quickening and lowering of HR, respiratory (normal in children, older adults), non-respiratory caused by fever, infection, medication side effects, etc.

• Sinus pause/block: complete skip of one cardiac cycle (P wave through T wave), caused by increased parasympathetic dominance, injury to the SA node, or medication side effects. Monitor for possible syncope.

define wondering atrial pacemaker

at least 3 different P waves, caused by irritable foci in the atria.

define pre-mature atrial complex, atrial tachycardia, and paroxysmal atrial tachycardia

• Pre-mature atrial complex: premature ectopic focus fires ahead of the SA node, absent or different-looking P-wave.

• Atrial tachycardia: 3 or more PACs in a row, with an elevated heart rate above 100 bpm

• Paroxysmal atrial tachycardia: may present in bursts lasting minutes or hours

define atrial flutter and atrial fibrillation

• Atrial flutter: characteristic sawtooth appearance with “flutter waves”; caused by a single ectopic focus firing in a cyclical pattern in the atria

• Atrial fibrillation: erratic quivering of atria. No true P-waves. Loss of atrial contraction reduces CO by up to 30%

define pre-mature junctional complexes, junctional rhythm, and junctional tachycardia

• Premature junctional complexes: premature impulses originating from the AV node. Inverted or absent P-wave.

• Junctional rhythm: AV node takes over as the primary pacemaker of the heart (complete absence of P-waves).

• Junctional tachycardia: a junctional rhythm with elevated HR (resting > 100 bpm)

define the 4 types of AV heart block

• First degree: Longer than normal PR intervals. Considered a benign rhythm

• Second degree Type I: Progressive lengthening of PR intervals, until a QRS is skipped

• Second degree Type II: No progressive lengthening of PR intervals, random drops of QRS complexes. May see multiple P-waves preceding QRS complexes

• Third degree: no relationship between atria and ventricles. This is a medical emergency!

define PVCs, ventricular tachycardia, and ventricular fibrillation

• PVCs: wide bizarre QRS complexes with no p wave. They may be caused by stress, caffeine, etc., and are found in up to 75% of adults.

• Ventricular tachycardia: 3 or more PVCs in a row. May occur in asymptomatic bursts. 100+ bpm

• Ventricular fibrillation: erratic quivering of the ventricles. medical emergency, requires defibrillation to remain alive (and prevent asystole – flatline).

list when to STOP treatment based on PVCs

• More frequent than 6/minute

• Land directly on a T wave

• Multi-focal PVS (look different from each other)

• 2+ in a row

list signs of ischemia and signs of infarction

• Ischemia (with activity):

  • T-wave inversion: highly sensitive.

  • ST-segment depression: if seen at rest, or does not resolve, this is an NSTEMI.

• Infarction:

  • ST-segment elevation (STEMI).

  • ST-segment depression (NSTEMI).

  • Pathological Q waves.

what defines orthostatic hypotension

Drop in SBP ≥ 20 mm Hg, or DBP ≥ 10 mm Hg from supine to sit, or sit to stand

what is classified as hypertensive for men and women

• >220/100 for men.

• >190/90 for women.

list and describe non-invasive techniques to re-establish blood flow

• PCI

  • inflating a balloon on the tip of a catheter in a coronary artery (stenting)

• Endarterectomy

  • surgical removal of part of the inner lining of an artery and any plaque deposits

• Thrombectomy

  • removal of a blood clot from an artery

list and describe invasive techniques to re-establish blood flow

• CABG

  • bypassing the blocked artery using graft vessels

• Medial sternotomy

  • incision made at the chest bone to access the heart

  • involves sternal precautions

list the sternal precautions

• 6-8 weeks

• no shoulder flexion or abduction above 90 degrees

• 8-10lb lifting limit

• no pushing or pulling

describe ablation, cardioversion, and thoracotomy

• Ablation: surgical destruction of ectopic foci (often used to address a-fib).

  • Following procedure: the leg used for catheter access must remain straight and immobile for 3-4 hours for a venous access site, and 4-6 hours for an arterial access site.

• Cardioversion: use of electrical shocks to the heart to reset tachyarrhythmias.

• Thoracotomy:

  • Lung cancer/tumor resection

  • Strong incidence of ipsilateral shoulder pain, which may become chronic. No driving and minimal stair activity for the first 2-3 days to minimize incisional bleeding or hematoma risk.

list clinical indicators of unstable angina

• Angina at rest; lasting more than 20 minutes

• Occurrence of the patients typical angina at a significantly lower level of activity than usual

• Deterioration of a previously stable pattern (ex. Happening several times a day vs several times a week)

• Loss of myocardial reserve (ex. Drop in BP during exercise)

list common and uncommon warning signs of a heart attack

• Common

  • Uncomfortable pressure, fullness, squeezing or pain in the center of the chest

  • Pain that spreads to the throat, neck, back, jaw, shoulders, or arms

  • Chest discomfort with lightheadedness, dizziness, sweating, pallor, nausea, or SOB

  • Prolonged symptoms unrelieved by antacids, nitroglycerin, or rest

• Uncommon

  • Unusual chest pain, stomach, or abdominal pain

  • Continuous midthoracic or interscapular pain

  • Continuous neck or shoulder pain

  • Isolated right biceps pain

  • Pain relieved by antacids but unrelieved by rest or nitroglycerine

  • Nausea or vomiting

  • Unexplained intense anxiety, weakness, or fatigue

  • Breathlessness or dizziness

list S&S of a pulmonary embolism

• Most common is dyspnea (shortness of breath)

• Unexplained chest pain (worsened by breathing)

• Tachycardia

• coughing up blood

list treatments for cardiogenic pulmonary edema

• Treatment needs to decrease cardiac preload and help maintain oxygenation

  • Venodilators

    • Decrease preload by reducing venous return 

  • Diuretics

    • Decrease fluid and sodium in the body

  • ACE inhibitors

    • Reduce afterload by lowering BP

  • Positive inotropes

    • Improve myocardial contractility

  • Supplemental oxygen

list indicators of congestive heart failure of an x-ray

• Enlarged silhouette of the heart

• Opacities in the lung fields

• Blunting of costophrenic angles (lower ribs and diaphragm)

list ankle brachial index scores (ABI)

• >1.30: indicates rigid arteries, check for peripheral artery disease

• 1.0-1.29: normal

• 0.91-0.99: borderline, beginning of peripheral artery disease

• 0.41-0.90: mild to moderate blockage, intermittent claudication during exercise

• <0.4: severe blockage, severe peripheral artery disease. May have claudication pain at rest. May indicate tissue necrosis

ankle brachial index (ABI) equation

ankle SBP / brachial SBP

list lipid drug side effects

• Resting muscle pain: lead to muscle breakdown and rhabdomyolysis in extreme cases

• GI distress

• Fatigue

• Muscle cramping

• Headaches

when is PT contraindicated in relation to atrial flutter

if atrial flutter has a resting HR above 100bpm even if asymptomatic