Exam 1

1st-Degree AV Block

PR interval is longer than $0.20\,\text{sec}$, but every P wave has a QRS; rhythm is usually regular.

2nd-Degree AV Block Type I (Wenckebach)

PR interval gets progressively longer until a QRS complex is dropped.

Wenckebach Memory Trick

“Longer, longer, drop.”

2nd-Degree AV Block Type II

PR interval stays constant, but QRS complexes are suddenly dropped.

2nd-Degree AV Block Type II Key Point

More serious than Type I; may require pacing.

3rd-Degree/Complete Heart Block

P waves and QRS complexes have no relationship to each other.

3rd-Degree Heart Block: Atria and Ventricles

Atria and ventricles beat independently of each other.

Asymptomatic Bradycardia

Assess and monitor the patient.

Symptomatic/Hemodynamically Unstable Bradycardia

May require atropine, pacing, or other interventions.

Bradycardia Nursing Principle

Always assess the patient, not just the monitor.

QT Interval

Represents ventricular depolarization and repolarization.

Prolonged QT Interval

Increases the risk for dangerous, life-threatening dysrhythmias.

Atrial Flutter

Characteristic “sawtooth” pattern with a typically very fast atrial rate.

Atrial Flutter: Ventricular Rhythm

May be regular or irregular.

Atrial Fibrillation

Irregularly irregular rhythm with no clearly identifiable normal P waves.

Atrial Fibrillation: Major Risk

Increased risk of thrombus formation and stroke.

Atrial Fibrillation: Treatment Goals

Rate control and anticoagulation when indicated to reduce thromboembolic risk.

Catheter Ablation

A procedure used to treat certain abnormal heart rhythms.

Catheter Ablation: Catheter Route

Catheter advances through a blood vessel, commonly from the femoral area, toward the heart.

Catheter Ablation: Tissue Destruction

Provider identifies abnormal cardiac electrical activity and destroys or isolates the tissue.

Radiofrequency Ablation

Uses heat to destroy or isolate abnormal tissue.

Cryoablation

Uses freezing temperatures to destroy or isolate abnormal tissue.

Ablation Memory Trick

Ablation = eliminate abnormal electrical pathways.

Heart Failure Manifestations

Dyspnea, fatigue, fluid retention, peripheral edema, pulmonary edema, crackles, cough, and decreased appetite.

Left-Sided Heart Failure Memory Trick

Think LEFT = LUNGS; heart is not pumping properly to the body.

Left-Sided Heart Failure Findings

Dyspnea, pulmonary edema, crackles, cough, and orthopnea.

Right-Sided Heart Failure Memory Trick

Think RIGHT = REST OF BODY; backflow affects the right side and systemic circulation.

Right-Sided Heart Failure Findings

Peripheral edema, increased abdominal girth, ascites, weight gain, and jugular venous distention.

Ejection Fraction (EF)

Percentage of blood pumped out of the ventricle with each contraction.

Low Ejection Fraction (EF)

Indicates reduced pumping function of the ventricles.

Echocardiogram

Evaluates cardiac structure and function and helps determine ejection fraction.

BNP (B-type Natriuretic Peptide)

Lab test used to evaluate for the presence and severity of heart failure.

Chest X-ray in Cardiac Assessment

Can show pulmonary congestion and pulmonary edema.

ECG (Electrocardiogram)

Evaluates cardiac rhythm and electrical activity.

Coronary Artery Disease (CAD)

Impaired blood flow through the arterial supply to the myocardium.

Modifiable CAD Risk Factors

Hypertension, diabetes, smoking, obesity, physical inactivity, unhealthy diet, and high cholesterol.

Nonmodifiable CAD Risk Factors

Age and family history/heredity.

Platelet Adhesion

Platelets attach and bind to the injured vessel wall.

Platelet Activation

Platelets change shape and become functionally activated.

Platelet Aggregation

Platelets clump together.

A-A-A Platelet Memory Trick

Adhesion $\rightarrow$ Activation $\rightarrow$ Aggregation.

Angiography/Angioplasty Components

May include cardiac catheterization, contrast dye, visualization of coronary vessels, angioplasty, and stent placement.

Stent

A small mesh tube used to help keep a coronary artery open.

Angioplasty/Stent vs. CABG

Percutaneous catheter interventions (angioplasty/stent) are distinct from surgical bypass (CABG).

CABG

Coronary Artery Bypass Grafting.

CABG Procedure

Open-heart surgery using a blood vessel graft to create a new route around a blocked coronary artery.

Post-Angiography Monitoring

Bleeding, hematoma, cardiac rhythm changes, vital-sign changes, and neurovascular status of the affected extremity.

Post-Angiography Activity

Bed rest and restrictions on movement of the affected extremity.

Post-Angiography Medication Education

Reinforce medication adherence, statin therapy, and beta-blocker therapy when prescribed.

Post-Angiography Lifestyle Education

Heart-healthy diet, appropriate exercise/aerobic activity, and smoking cessation.

Chest Pain with Risk Factors

Chest pain, leg pain, dizziness, smoking history, obesity, older age, and lack of exercise require careful cardiovascular assessment.

PQRST: P

Provocation.

PQRST: Q

Quality.

PQRST: R

Region/Radiation.

PQRST: S

Severity.

PQRST: T

Timing (when it began) and Treatment.

Chest Pain Assessment Parameters

Assess pain description, exacerbating factors, relieving measures, and whether pain is chronic/stable or new.

First Sign of Chest Pain Nursing Action

Instruct the patient to relax and rest, and notify the nurse immediately when any chest pain begins.

Nitrates for Chest Pain

Administer nitrates as indicated by provider orders/protocol.

Oxygen for Chest Pain

Provide oxygen via nasal cannula when oxygen saturation is $\le 90\%$.

ECG for Chest Pain

Obtain when indicated to evaluate for ST-segment and T-wave changes.

Chest Pain: Emotional Support

Offer assurance and emotional support, explain treatments/procedures, and encourage questions.

Assess Patient Knowledge: Angina

Assess knowledge of causes of angina, diagnostic procedures, treatment plan, and CAD risk factors.

Smoking Cessation Assessment

Assess readiness to quit smoking and encourage participation in a smoking cessation program.

Smoking Cessation Support Organizations

American Heart Association, American Lung Association, or American Cancer Society for support groups and interventions.

Chest Pain Parameter: Description

Monitor description, exacerbating factors, relieving factors, and whether pain is chronic/stable or new.

Chest Pain Parameter: Vital Signs

Monitor vital signs during chest pain and after nitrate administration.

Chest Pain Parameter: ECG

Monitor ST-segment changes and T-wave changes.

Chest Pain Parameter: Oxygen Saturation

Monitor $SpO_2$; supplemental oxygen may be used when $SpO_2 \le 90\%$.

Chest Pain Parameter: Response to Interventions

Monitor the effectiveness of all provided nursing interventions.

Chest Pain Parameter: Response to Nitrates

Monitor the patient closely after nitrate administration.

Chest Pain Parameter: Knowledge Level

Assess understanding of angina causes, diagnostic procedures, treatment plan, and CAD risk factors.

Chest Pain Parameter: Smoking Status/Readiness

Assess readiness to quit and participation in smoking cessation support.

CVC

Central venous catheter.

CVC Infection Prevention: Daily Review

Review the continued need for the central line every day.

CVC Key Principle

Remove unnecessary central lines as soon as they are no longer needed.

CVC Infection Prevention Practices

Use hand hygiene, aseptic technique, site care, dressing changes, and line maintenance.

Critical Care Pain: Communicating Patient

Use self-report whenever possible.

Critical Care Pain: Intubated Patient

Use an appropriate behavioral pain assessment tool such as CPOT.

CPOT

Critical-Care Pain Observation Tool; used for pain assessment in nonverbal critically ill patients.

0–10 Pain Scale

Patient self-report method for measuring pain intensity.

RASS

Richmond Agitation-Sedation Scale; measures level of sedation and agitation.

CAM-ICU

Confusion Assessment Method for the ICU; used for delirium assessment.

CPOT, RASS, CAM-ICU Memory Trick

CPOT = Pain; RASS = Sedation/Agitation; CAM-ICU = Delirium.

Critical Care: Anxiety/Decreased Ability to Cope

A contributing factor to pain and anxiety in critically ill patients.

Critical Care: Decreased Mobility

A physical factor contributing to pain and anxiety in critical care.

Critical Care: Potential Family Dysfunction

A psychosocial factor contributing to patient pain and anxiety.

Critical Care: Lack of Control

An environmental/psychological factor contributing to pain and anxiety.

Critical Care: Fear

An emotional factor contributing to pain and anxiety in critically ill patients.

Critical Care: Inability to Get Comfortable

A physical comfort issue contributing to pain and anxiety.

Critical Care: Loneliness

A social/emotional factor contributing to pain and anxiety.

Critical Care: Difficulty Breathing

A physiological stressor contributing to pain and anxiety.

Critical Care: Pain

A major physical stressor in critically ill patients.

Critical Care: Age & Developmental Stage

Factors that influence how a patient experiences pain and anxiety.

Critical Care: Experiences With Illness and Hospitalization

Past health experiences influencing pain and anxiety responses.

Critical Care: Social Support

Presence or absence of support networks affecting pain and anxiety.

Critical Care: Personal Philosophies

Personal beliefs about life, death, and spirituality affecting coping, pain, and anxiety.

Critical Care: Sleep Disruption

Disruption in normal sleep-wake cycles contributing to pain and anxiety.

Critical Care: Thirst

A physical discomfort contributing to anxiety and distress.

Critical Care Stressors: Procedures, Restraints, Swallowing

Medical procedures, physical restraints, and difficulty swallowing that contribute to pain and anxiety.