Recording-2025-06-23T18:04:56.693Z

Heart Rate and Cardiac Output

• Heart rate is measured in beats per minute (BPM).
  • Normal range: 60-100 BPM.
• Stroke volume is the amount of blood ejected with each heartbeat.
• Cardiac output is calculated by multiplying stroke volume by heart rate, indicating the amount of blood pumped per minute.

Preload and Afterload

• Preload: The degree of stretch of the cardiac muscle fiber at the end of diastole (relaxation phase).
  • The more the muscle stretches during diastole, the more forcefully it contracts.
  • Some medications influence preload.
• Afterload: The amount of resistance the heart has to pump against, or the resistance to the ejection of blood from the ventricle.
  • Some medications influence afterload.

Basic EKG Components

• The horizontal axis represents time.
• The vertical axis represents amplitude or voltage.
• P Wave:
  • Represents atrial depolarization, which is the electrical impulse that precedes atrial contraction.
  • Atrial depolarization is not the same as atrial contraction; depolarization is the electrical impulse, while contraction is the actual muscle movement.
  • EKG shows depolarization and repolarization, but not the actual muscle contraction.
• QRS Complex:
  • Represents ventricular depolarization.
• T Wave:
  • Represents ventricular repolarization.
• Atrial Repolarization:
  • Occurs during the QRS complex but is masked by the larger ventricular activity.
• U Wave:
  • Represents repolarization of the Purkinje fibers within the ventricles.
  • May be normal or abnormal; sometimes seen in patients with potassium imbalance or hypertension.
  • Often too small to see on a real EKG.

EKG Box Size and Time Measurement

• Smallest box:
  • Represents 0.04 seconds.
• Five small boxes:
  • Represent 0.2 seconds (5 \times 0.04 = 0.2).

Heart Rate Calculation from EKG

• Heart rate can be calculated using an EKG strip.
  • Count the number of QRS complexes on a 10-second strip and multiply by 6 to get the heart rate in BPM.

EKG Rhythm Identification

• Rate:
  • Determine the heart rate and whether it falls within the normal range.
• Rhythm:
  • Identify if the rhythm is regular.
  • Criteria for regular rhythm:
    • A P wave should be present before every QRS complex.
    • The distance between R waves (R to R interval) should be consistent throughout the strip.

Normal Sinus Rhythm

• Heart rate is between 60 and 100 BPM.
• Rhythm is regular.
  • A P wave is present before every QRS complex.
  • R to R intervals are consistent.

Sinus Bradycardia

• Heart rate is less than 60 BPM.
• Rhythm is regular.
  • A P wave is present before every QRS complex.
  • R to R intervals are consistent.

Sinus Tachycardia

• Heart rate is above 100 BPM.
• Rhythm is regular.
  • A P wave is present before every QRS complex.
  • R to R intervals are consistent.

T Wave and QRS Direction

• In a regular rhythm, the T wave and QRS complex should point in the same direction.
  • If the T wave and QRS complex point in opposite directions, it is called a T wave inversion.
  • A T wave inversion indicates a problem.

12-Lead EKG vs. Telemetry Monitoring

• 12-Lead EKG:
  • Diagnostic tool used to identify specific cardiac issues.
  • Provides a 10-second snapshot of the heart's electrical activity.
• Telemetry Monitoring:
  • Continuous monitoring of the heart rhythm, often used for cardiac patients.
  • Allows for constant tracking of rhythm and immediate notification of any arrhythmias.

Procedure for 12-Lead EKG

• Patient should lie still for 10 seconds during the reading to avoid artifacts.
• Artifacts can make the EKG difficult to interpret.

Abnormal Rhythms

• Atrial Fibrillation (A-Fib):
  • Irregular rhythm where R to R intervals do not match up.
  • P waves are not clearly identifiable.
• Atrial Flutter:
  • Irregular rhythm characterized by a saw tooth wave pattern between R to R intervals.
  • More organized and possibly slower rate compared to A-Fib.
• Both A-Fib and atrial flutter involve uncoordinated electrical activation causing the atria to twitch rather than contract.
  • This increases the risk of blood clots, requiring patients to be on anticoagulants.
  • Beta blockers may be used to control heart rate in these conditions.

ST Segment Changes

• The ST segment is located between the S wave of the QRS complex and the T wave.
• Normal ST Segment:
  • Lies on the horizontal axis.
• ST Elevation:
  • Indicates possible myocardial infarction (MI), specifically STEMI (ST-elevation MI).
• ST Depression:
  • May indicate a valve problem or digoxin toxicity.

Clinical Significance of EKG Understanding

• Understanding basic EKG concepts is crucial for nurses, even those not working on cardiac floors, as many patients are on telemetry monitoring.
• Knowledge of EKG allows for early identification of potential cardiac issues.

Other Types of Myocardial Infarction (MI)

• Non-ST Elevation MI (NSTEMI) does not show ST segment changes on the EKG.
  • Diagnosed by elevated troponin levels in blood work.

Coronary Artery Disease (CAD) and Atherosclerosis

• CAD often starts with atherosclerosis.
• The coronary arteries supply the heart muscle with oxygenated blood.
• Atherosclerosis is the formation of focal deposits of cholesterol and lipids (plaque) that obstruct circulation in the arteries.

Process of Atherosclerosis

• Initial Phase: Fatty Streaks
  • Lipids deposit in the intima of the arterial wall.
  • Lesions can begin in childhood.
• Progression to Advanced Lesions
  • Influenced by genetics and environmental factors (e.g., smoking, hypertension).
• Response to Injury
  • Monocytes and smooth muscle cells migrate to the lesion.
  • Smooth muscle cells form a fibrous cap over a core filled with lipids and inflammatory infiltrates (atheroma or plaque).
• Plaque Rupture
  • Arterial pressure can cause unstable plaques to rupture.
  • Platelets are attracted to the rupture site, causing thrombus (clot) formation.
  • Clot formation leads to ischemia and potentially myocardial infarction.

Atheroma/Plaque Composition

• Atheroma/plaque consists of smooth muscle cells forming a fibrous cap over a core filled with lipids and inflammatory infiltrates.
• Plaques are unstable and prone to rupture, leading to clot formation.

Signs and Symptoms of Atherosclerosis

• Symptoms vary based on the location and degree of vessel obstruction.
• Chest pain (ischemic pain due to lack of oxygen) may occur.
• Can be asymptomatic, especially in the early stages.

Atypical Symptoms

• Older Patients, Diabetics, and Heart Failure Patients:
  • May experience atypical symptoms such as shortness of breath and weakness, or may be silent (no symptoms).
• Women:
  • May experience shortness of breath, weakness, and nausea.
  • Nausea may be mistaken for a gastrointestinal issue.

Non-Modifiable Risk Factors for Atherosclerosis

• Genetics:
  • Family history of CAD.
• Increasing Age:
• Race:
  • African Americans have a higher risk.
• Gender:
  • Men are affected earlier than women, but after age 55, the incidence is the same.
  • More women die from heart disease each year, often due to delayed recognition of symptoms and seeking treatment later.

Modifiable Risk Factors for Atherosclerosis

• Smoking
• Diet
• Exercise
• Conditions controlled with medication (e.g., hyperlipidemia, hypertension, diabetes).

Fasting Lipid Panel (FLP)

• Recommended for all adults 20 years or older every five years, or more often if abnormal.
• Checks LDL, HDL, total cholesterol, and triglycerides.

Recommendations for Individuals with Cardiovascular Events

• Individuals who have experienced an MI, cardiac cath, or bypass surgery should have an FLP performed within a few months of the event, then every six weeks until goals are reached, and then every four to six months.

Primary vs. Secondary Prevention

• Primary Prevention:
  • Preventing atherosclerosis from happening initially.
• Secondary Prevention:
  • Preventing atherosclerosis from progressing, once it has started.

Modifiable Risk Factors: Hyperlipidemia

• Adhere to a low-cholesterol diet.
  • Mediterranean diet is often recommended (vegetables, fish, reduced red meat).
• Increase physical activity.
• Medications (lipid-lowering drugs).

Diet Recommendations for Hyperlipidemia

• Lower total fat and saturated fat intake.
• Increase fiber intake.
• Limit cholesterol intake to less than 200 mg per day.

Physical Activity Recommendations

• 150 minutes per week of moderate exercise.
  • Moderate exercise means you should be able to talk during the exercise.

Effects of Physical Activity

• Increases HDL (good cholesterol) and decreases triglycerides.

Smoking and Atherosclerosis

• Smoking causes vasoconstriction, increasing heart rate and blood pressure.
• Increases the risk of cancer and clot formation.
• Carbon monoxide, produced during tobacco burning, binds to hemoglobin, preventing oxygen binding and transport which leads to the smoker patient higher risks of clots.

Hypertension and Atherosclerosis

• Hypertension accelerates the process of atherosclerosis; therefore, it’s essential to control blood pressure.

Diabetes and Atherosclerosis

• Diabetes accelerates the process of atherosclerosis; it’s essential control blood glucose levels.
• Most diabetic patients die from cardiovascular disease rather than diabetes itself.

Lipid-Lowering Drugs

• Statins and Fabric Acid Derivatives:
  • Restrict lipoprotein production.
• Bile Acid Sequestrants:
  • Increase lipoprotein removal.
• Cholesterol Absorption Inhibitors:
  • Inhibit the absorption of cholesterol.

Contraindications for Lipid-Lowering Drugs

• Contradicted in viral or alcoholic hepatitis due to the risk of liver toxicity.

Angina and Chest Pain

• Occurs as plaque builds up in the arteries.

Stable vs. Unstable Angina

• Stable Angina:
  • Chest pain that goes away with rest or nitroglycerin.
• Unstable Angina:
  • Chest pain that does not subside with rest or nitroglycerin.

Pathophysiology of Angina

• Imbalance between oxygen supply and demand in the heart muscle.
• Factors that increase oxygen demand or decrease supply:
  • Exercise: Increases oxygen demand.
  • Cold Weather: Causes vasoconstriction and decreases oxygen supply.
  • Heavy Meal: Blood shifts to the GI tract, reducing supply to the heart.
  • Stress: Causes vasoconstriction, decreases oxygen supply.

Ischemic Pain

• Muscle pain due to lack of oxygen.

Signs and Symptoms of Angina

• Use COLDSPA to gather information about the pain.
• Pain Characteristics:
  • Pressure or sharp pain behind the sternum.
  • May radiate to the left arm, shoulder, jaw, or neck.
• Symptoms in Elderly and Diabetic Patients:
  • May have neuropathy, reducing the sensation of pain.
• Atypical Symptoms:
  • Shortness of breath, weakness, nausea, dizziness, lightheadedness.

Diagnostic Tests for Angina

• 12-lead EKG
• Troponin levels (cardiac enzyme)
• Chest X-ray (to rule out other differential diagnoses).

Chest X-Ray and Pregnancy

• Ask female patients whether they are pregnant to avoid exposing a fetus to radiation.

Acute Treatment for Angina

• Nitroglycerin (vasodilator) is the first-line drug.
• If nitroglycerin doesn't work, morphine is considered.

Nitroglycerin Teaching for Home Use

• As soon as chest pain starts, stop activity and sit down which is meant to reduce oxygen demands.
• Place one tablet under the tongue and let it dissolve.
• Wait five minutes; if pain persists, take another tablet.
• Repeat up to three tablets, five minutes apart.
• Call 911 if pain does not subside after the third tablet.
• Do not drive to the hospital because you may be having a heart attack; it’s best to be transported in the ambulance.

Acute In-Hospital Care for Angina

• Check blood pressure before administering nitroglycerin.
• If blood pressure is safe, administer nitroglycerin and wait five minutes.
• Continue to check blood pressure before each dose.
• If pain persists after three doses of nitroglycerin, administer morphine.

Contraindications for Nitroglycerin

• Concurrent use of vasodilators like Viagra can cause a dangerous drop in blood pressure.
• Ask patients if they have taken Viagra in the last 24-48 hours; if yes, nitroglycerin cannot be used.

Nitroglycerin Routes of Administration

• Sublingual (tablet under the tongue)
• Ointment or patch: Applied to non-hairy areas.
  • Put on gloves because if you touch nitroglycerin, your blood pressure will drop too.
  • Ointment or patch cannot be used to treat active chest pain; it only prevents future angina events.
  • Typically applied in the morning and removed at bedtime to prevent tolerance.
  • Before applying a new patch or ointment, make sure there is not an existing one. Wipe the area with wet towel before the new patch is applied.

Side Effects of Nitroglycerin

• Headache
• Hypotension
• Lightheadedness and dizziness signals that blood pressure has dropped too low.

Beta Blockers

• Drugs that end in -olol
  • Carvedilol (Coreg) is a combined alpha and beta blocker.
• Blocks the sympathetic nervous system, decreasing heart rate and blood pressure.
• Monitor heart rate and blood pressure before administration.
• Must be slowly tapered off to prevent dysrhythmias and rebound hypertension.
• Contraindicated in patients with uncontrolled asthma.
• Can mask the symptoms of hypoglycemia.
• The action is to block beta 1 receptors which normally bind epinephrine and norepinephrine (adrenaline), increases contractility in cells, and increases rate of depolarization in the SA node.

Calcium Channel Blockers

• Used to prevent and treat vasospasm.
• Amlodipine:
  • Increases heart rate.
• Diltiazem and Verapamil:
  • Decrease heart rate; monitor heart rate closely; notify the doctor if heart rate drops below 50 BPM.
• Verapamil can cause peripheral edema due to vasodilation; notify the doctor if edema develops.
• Patients should avoid grapefruit juice, as it inhibits the metabolism of calcium channel blockers, leading to high blood levels.

Antiplatelet Medications

• Aspirin:
  • Dose Range: 81-325 mg.
  • Do not use for pain relief; it’s used as an antiplatelet agent to prevent clot formation.
  • Major side effect: GI bleeding.
• Clopidogrel (Plavix):
  • Acts on a different pathway to block platelet activation.
  • Takes a few days to achieve effects.
  • Sometimes used in combination with aspirin.
• Antiplatelets prevent clots but do not dissolve existing clots.

Anticoagulant Mediations

• Heparin:
  • Can be administered IV or SubQ.
• Enoxaparin (Lovenox):
  • Administered only SubQ as a prefilled syringe; injected into the skin with the air bubble to seal the medication within the subcutaneous tissue (do not expel air).
• Bleeding Precautions:
  • Patients are at increased risk for bleeding, so it’s essential to monitor for signs of bleeding (increased heart rate, decreased blood pressure).
  • Apply longer pressure after invasive procedures.
  • Avoid IM injections and continuous BP monitoring.

Heparin-Induced Thrombocytopenia (HIT)

• Condition when the patients develop low platelets levels when they are on heparin.

Oxygen Therapy

• Considered a medication, so it can cause toxicity.
• Signs and Symptoms of Oxygen Toxicity:
  • Nausea, vomiting, substernal pain, cough, nasal stuffiness.
• When patients are having chest pain, administer oxygen, even if their O2 saturation is already okay.
• Start with 2 liters of oxygen unless more is in the orders.

Medication Checklist

• Before administering nitroglycerin: blood pressure must be checked.
• Before administering metoprolol: blood pressure and heart rate must be checked because this drops the heart rate.
• Before administering morphine: respiration, BP and heart rate needs to checked.

Stress Test to Diagnosis CAD

• Used to stress the heart and assess how it responds.
• Types of Stress Test:
  • Exercise Stress Test: Walking on a treadmill or using a stationary bike.
  • Pharmacological Stress Test: Giving a medication to mimic the effect of exercise.

Procedure for Exercise Stress Test

• Establish maximum heart rate: 220 - age.
• Target heart rate is 80-90% of maximum.
• Slowly increase the intensity of exercise while monitoring EKG and vital signs.
• Monitor for:
  • Patient Complaints: Chest pain, extreme fatigue, shortness of breathe.
  • Pale or diaphoretic skin.
  • Abnormal Decreased BPN and heart rate.
  • Dysrhythmia or ST segment changes on EKG.
• The technician will stop the test immediately once either a target is reached or the patient showed any of the symptoms.
• Stop the test when patient complains any of the symptoms.
• When you report any of the symptoms test. This is called positive stress test . So positive is not good.

Pharmacological Stress Test Using Vasodilators

• Medications such as dipyridamole or adenosine can be used to mimic the effects of exercise.
• Side Effects: Flushing and nausea (warn the patient about this in advance).

Prior to Conducting Stress Test

• Patient should sign consent.
• Fasting for 4 hours before the test to avoid complications.
• Avoid tobacco, alcohol, caffeine before.
• Avoid intense exercise 3 hours before the test.
• Avoid or Hold Beta Blockers prior because beta blocker is going to drop your heart rates.
• Let the patient know there will be IV is needed for the test.

After stress Test Review

• After testing there is some observation period which could take 10-15 minutes.
• Follow up Med Surg will ask basic questions. Such as checking vital signs what the patient is complaining about.
• We want to avoid taking Hot bath or shower after the test for at least one to two hours. These activities causes patients to have vasodilation which causes BPN to drop.

The Nursing process of Angina Patients.

1. Assess the patient for the follow characteristics:
   • Cold Spa assessments.
   • Assess the risk factors which can be non modifiable and modifiable factors.
   • Assess their lungs sounds by doing physical assessments. Always asking if there are any heart burn
2. Nursing Diagonosis.
   • ineffective tissue perfusion due to plaque obstructing the vessel.
   • Evedienced by the patients complaining of Angina. ( 1 - 10 pain scale)
3. Planning and Goals.
   • Putting the patients on semi semi Flowlers position and have that person fully assessed every single time as a intervention.
   • The major thing is to stay calm because these patienst are suffering from very high levels of stress.
4. Evalution
   • Teach the patients everything there is once a follow up happens.

Case study 1:

• The patient is a sixty two year old male. Significant History of Angina from last week.
• Gains have been assessed and it it roughly equals about 8 and 7 pounds.

1. Nitroglycerin.
2. Metoprolol
3. Cordizem.
4. Linosinopril.
   • Main teaching the side effects and making sure the patient is under stable blood conditions. Make sure the blood is balanced as well.
     • Blood constringency
     • Carbone Monixode.
   • Make sure if he has to take Nitroglycerin he carries it all times. And teach how to take the medicine as as necessary conditions presents.
   • 6 months to get renewed.
     • Major sides effects are headaches and hypotension .
5. Teach the patients to have low soduim because the gains have increased since last assessment.

• Having those symptoms the patients should start to report symptoms of dry breath and go under nessecacry measurements to do so.
• The patients must be always in shape and should do regular exercises 1.5 miles
• Patients should get rid of any type of modifeable factor as quick as posible. This can be the factor fo death.

Myocardial Infarction (MI): Acute Coronary Syndrome (ACS)

• Umbrella term encompassing unstable angina, STEMI, and non-STEMI conditions.

• Treatment Overview:

  • Begin with 12-lead EKG, troponin level assessment.
  • Administer chest X-Ray to assess the cardiac rhythm.
  • When chest discomfort is going to morphine treatment. The body will not fully respond.

• Goal minize death to the issue and prevent any type of other compalicition.

Symptoms.

• The patient will experiance shortness of breath but may be GI based such nausea and anxieties

Pharmalogical Therapy
Use the acronym MONA

Morphin
Oxegen
Nitrogen
Aspreine

ACI is benifical because it is giong to reduce the chances of moretality
BTA blocker is given during the session and is crucial for helping in emergency situation.
Pharmacolytics: Does the clots the only thing is that has the ability to dissolve clots. But you must give to in the time frame of within 6hours of the symptoms showing.
Always make sure there is no bleeding in patients.
Anitplatelet:
A: Aspiren.
A: Clavix.
These are used to prevent blood clots as stated earlier
Any type of medication can induce thrombocytopenia as well.
The nurse should take care during bleeding risks. Also it has been know that these cause patients from having oxygen toxicity so the nurse needs to keep an eye during procedure to insure that oxygen is constant in body during the risks.
Also that the patient should always be oxygen since can cause more problems in the body.
Most of the things can be helped but it can also be the compalications as well.

The patients should go over and over to ensure these are well known. Some may include PT's and OT services as follow.
Always insure the patient is okay with the help of OT and PT help.

1. Follow the protocol of MI
2. Baseline is good to have because any sign of damage will trigger an alarm.
3. One of the main components to check will be the output of your own outputs.
   • Fowler position
4. Always call the phsyician if there are any concerns.
5. Bed res for any type of issues in the process, these have to be known before it can be a dangerous situation.
6. Patient is required to have a IV to administer. medication.

Ablation process requires the a team of professionals from doctor to even you. Always check for alergy so we can prevent any issues.
Also ensure that the document is signed so it legally okay to procced.
Patience is vital through the the whole team of physicians.

1. When vitals are observed. The nurse should use glovses to ensure that no bacteria are tranferred from her to patients's issues. This is always crucial because if she does not where there are high risks of contamination from the patient body from bacteria and other things.
2. Check for any pulse in that areas, always a requirement.
   • Always check the legs every 6hours because of potential blood supply.
   • Most patients are back pain because of the procedure. But always report if anything doesn't seem right.
     • Always do labs for patients while knowing.
       CABG: Coronary Art Bypass Graft or open heart surgery
       The most important rule is to know for you patients by doing vitals sign. The nurse can fully know.
       A: Patients's heart rhythm is fine always. ( Check with 5 -point leads) for accurate numbers
       B: Understand the patients. What has he experianced for all this. Always do to baseline and assess to know if everything is under the set conditions( Look for skin color). Monitor urine output because this has to checked every couple of hours.
       Movement: Has to started immideality to make the potential compalications go down.

Patients also must be consiterned well known facts about themselves that can add more risk.
Be familiar with compalications these facts.

1: Patient has to have proper medication and has to ordered under doctors.
2: Avoid taking showers even though that might feel clean.
3: Always encourage the patients to use any incentitive treatment or meter to measure air.
4:Patient lies more often to the side prevent bleeding.

Case study II:

This 55 year old has been transported and this can result this things as result. The patients is experiencing signs such as ( mid sternal pain, radiating toward the the side the neck and down to the arm).
Symtoms: has been having shortnes of breath, cool ,diaphram).
112 high blood rate numbers , respirations and everything is border line Highs.
twelve lead shows its STEMI. ( Which means that its emergency).

This usually how procced with oxygen and ensure there is a monitor

Aspirin or nitrogliciren will all assist. but the main thing at the end ensure that their heart rate stays 100 and BPN is controlled.
There is chest pain being experienced.
Because it is stemi its going to require some one right or to have some type of a surgery. This is a result for the patient heart conditions may come as a result if things are not followed correctly.