Cardiac Med Surg

P Wave
• Represents atrial contraction (depolarization)
• Represents the time it takes the electrical impulse to travel from the SA node to the ventricle
• Suggests problems usually with the AV node, bundle of HIS, or bundle branches but can also be from the atria
QRS complex
• QRS complex represents ventricular contraction (depolarization)
• Problems are usually from bundle branches or in the ventricles
ST segment
• ST segment indicates the period of time between the end of ventricular contraction (depolarization) and the start of ventricular relaxation (repolarization)
• ST is usually on baseline ( should be no electrical activity)
T wave
• T wave is ventricular relaxation (repolarization)
• Problems are usually from electrolyte imbalances, ischemia, or infarction
QT interval
• Represents the total time for ventricular contraction
• Problems are usually from something affecting repolarization (i.e. Drugs, electrolyte imbalances changes in HR)
The heart composed of three layers
endocardium- a thin inner lining
myocardium-a layer of muscle
epicardium- the outer layer
Conduction System
specialized nerve tissue responsible for creating and transporting the electrical impulse or, action potential.
Sinoatrial (SA) Node
The pacemaker of the heart.
Absolute refractory period
period in which cardiac muscle does not respond to any stimuli.
triggers machanical activity.
contraction of the myocardium, results in the ejection of blood from the ventricles.
allows for filling from the ventricles.
Cardiac Output (CO)
amount of blood pumped by each ventricle one minute.
The volume of blood in the ventricles at the end of diastole, before the next contraction.
the peripheral resistance against which the left ventricle must pump.
Arterial Blood Pressure (BP)
a measure of the pressure exerted by blood against the walls of the arterial system.
Systolic Blood Pressure (SBP)
the peak pressure exerted against the arteries when the heart contracts.
Diastolic Blood Pressure (DBP)
the residual pressure in the arterial system during ventricular relaxation (or filling).
Pulse Pressure
the difference betwenn SBP and DBP.
Mean Arterial Pressure (MAP)
refers to the average pressure within the arterial system that is felt by the organs in the body.
A pt with a trisuspid disorder will have impaired blood flow between the..
right atrium and right ventricle.
A pt has a severe blockage in his rightcoronary artery. Which cardiac structure is most likely to be affected by this?
AV node
If the Purkinjie system is damaged, conduction of the electrical impulse is impaired through..
The portion of the vascular system responsible for hemostasis is the..
endothelial layer of the arteries
The auscultatory area in the left midclavicular line at the level of the fifth ICS is the..
mitral area.
Blood flows from
an area of higher pressure to an area of lower pressure (pressure gradient).
Atrioventricular (AV) valves:
separate the atria from the ventricles, The tricuspid valve separates the RA from the RV. The mitral (bicuspid) valve separates the LA from the LV. During ventricular diastole, these valves act as funnels and help move blood from the atria to the ventricles. During systole, the valves close to prevent backflow (regurgitation) of blood into the atria.
Semilunar valves
are the pulmonic valve and the aortic valve that prevent blood from flowing back into the ventricles during diastole.
The pulmonic valve separates the right ventricle from the pulmonary artery.The aortic valve separates the left ventricle from the aorta.
The left main artery divides into two branches
the left anterior descending (LAD) branch and the left circumflex (LCX) branch.
right coronary artery (RCA) originates from
the right sinus of Valsalva, encircles the heart, and descends toward the apex of the right ventricle.
To maintain adequate blood flow through the coronary arteries
mean arterial pressure (MAP) must be at least 60 mmHg.
electrophysiologic properties of heart muscle are responsible for
regulating heart rate (HR) and rhythm.
consists of relaxation and filling of the atria and ventricles.
consists of the contraction and emptying of the atria and ventricles.
Myocardial contraction results from
the release of large numbers of calcium ions from the sarcoplasmic reticulum and from the blood.
Cardiac muscle relaxes when
calcium ions are pumped back into the sarcoplasmic reticulum.
cardiac output (CO)
the amount of blood pumped from the left ventricle each minute. Cardiac Output = Heart rate x Stroke volume
Stoke volume (SV)
is the amount of blood ejected by the left ventricle during each contraction.
parasympathetic (vagus nerve) system
slows the HR
sympathetic stimulation
increases heart rate.
Preload refers
to the degree of myocardial fiber stretch at the end of diastole and just before contraction.
Afterload is
the pressure or resistance that the ventricles must overcome to eject blood through the semilunar valves and into the peripheral blood vessels.
vascular system serves several purposes:
Provides a route for blood to travel from the heart to nourish the various tissues of the body. Carries cellular wastes to the excretory organs. Allows lymphatic flow to drain tissue fluid back into the circulation. Returns blood to the heart for recirculation.
Arterial system:
blood moves from the larger arteries to a network of smaller blood vessels, called arterioles, which meet the capillary bed.
Venous system:
blood travels from the capillaries to the venules and to the larger system of veins, eventually returning in the vena cava to the heart for recirculation.
Nutrients are exchanged across capillary membranes by
osmosis, filtration, and diffusion.
Blood pressure (BP)
is the force of blood exerted against the vessel walls.
Three mechanisms mediate and regulate BP:
1. The autonomic nervous system (ANS)
2. The kidneys
3. The endocrine system
Veins have
the ability to accommodate large shifts in volume with minimal changes in venous pressure.Veins have valves to help prevent backflow while muscles in the extremities help push the venous blood forward.
Major symptoms usually identified by patients with cardiovascular disease (CVD)
include chest pain or discomfort, dyspnea, fatigue, palpitations, weight gain, syncope, and extremity pain. When assessing for symptoms, ask the patient if he/she has "discomfort," "pressure," and "indigestion."
dyspnea on exertion (DOE)
This is usually an early symptom of heart failure and may be the only symptom experienced by women.
dyspnea that appears when he/she lies flat.
Paroxysmal nocturnal dyspnea (PND)
develops after the patient has been lying down for several hours. In this position, blood from the lower extremities is redistributed to the venous system, which increases venous return to the heart. A diseased heart cannot compensate for the increased volume and is ineffective in pumping the additional fluid.
(fluttering in the chest) that occur during or after strenuous physical activity may indicate overexertion or possible heart disease.
refers to a brief loss of consciousness. Conditions such as cardiac rhythm disturbances, especially ventricular dysrhythmias, and valvular disorders, such as aortic stenosis, may trigger this symptom.
Extremity pain may be caused by two conditions:
ischemia from atherosclerosis and venous insufficiency of the peripheral blood vessels.Patients who report a moderate-severe cramping sensation in their legs or buttocks associated with an activity such as walking have intermittent claudication related to decreased arterial tissue perfusion.
Late signs of severe right-sided heart failure
are ascites, jaundice, and anasarca (generalized edema) as a result of prolonged congestion of the liver. Heart failure may also cause fluid retention.
(dusky redness) that replaces pallor in a dependent foot suggests arterial insufficiency.
muscle fatigue and discomfort, numbness, pain, coolness, and loss of hair distribution from a reduced blood supply.
nail straightens out to an angle of 180° and base of nail becomes spongy. Caused by chronic oxygen deprivation in body tissues, common in patients with advanced chronic pulmonary disease, congenital heart defects, and cor pulmonale (right-sided heart failure).
Peripheral edema is a common finding in patients with cardiovascular problems.
Bilateral edema of the legs - heart failure or chronic venous insufficiency. Abdominal and leg edema - heart disease and cirrhosis of the liver. Localized edema in one extremity - venous obstruction (thrombosis) or lymphatic blockage.
Document the location of edema as precisely as possible.
140/90 mmHg
BP < 90/60 mmHg may not be adequate for providing enough oxygen and sufficient nutrients to body cells.
Postural (orthostatic) hypotension
occurs when the BP is not adequately maintained while moving from lying to a sitting or standing position.
Paradoxical blood pressure
is an exaggerated decrease in systolic pressure by more than 10 mmHg during the inspiratory phase of the respiratory cycle.
pulse pressure
The difference between the systolic and diastolic values is referred to as pulse pressure.
Hypokinetic pulse
is a weak pulse indicative of a narrow pulse pressure. Seen in patients with hypovolemia, aortic stenosis, and decreased cardiac output.
Hyperkinetic pulse
is a large "bounding" pulse caused by an increased ejection of blood. Occurs in patient with high cardiac output (exercise, sepsis, or thyrotoxicosis) and those with increased sympathetic system activity (pain, fever, or anxiety).
swishing sounds
Normal Heart Sounds.
The first heart sound (S1) is created by closure of the mitral and tricuspid valves. It is softer and longer. The second heart sound (S2) is caused mainly by the closing of the aortic and pulmonary valves.
Abnormal Heart Sounds
Abnormal splitting of S2 is referred to as paradoxical splitting and has a wider split heard on expiration.
S3 is called a ventricular gallop, and S4 is referred to as atrial gallop. Murmurs reflect turbulent blood flow through normal or abnormal valves. Pericardial friction rub originates from the pericardial sac and occurs with the movements of the heart during the cardiac cycle.
Serum Markers of Myocardial Damage
Acute myocardial infarction (MI), also known as acute coronary syndrome, can be confirmed by abnormally high levels of certain proteins or isoenzymes. These serum studies are commonly referred to as cardiac markers and include troponin, creatine kinase-MB, and myoglobin.
Serum Lipids
Elevated lipid levels are considered a risk factor for coronary artery disease (CAD). Cholesterol, triglycerides, and the protein components of high-density lipoproteins (HDLs) and low-density lipoproteins (LDLs) are evaluated to assess the risk for CAD.
Blood Counts
The erythrocyte count is usually increased in heart disease.
Decreased hematocrit and hemoglobin levels indicates anemia and can lead to angina or aggravate heart failure.
The leukocyte count is typically elevated after and MI and in various infectious and inflammatory diseases of the heart.
What is the primary cause of CAD?
*Endothelial lining altered as result of inflammation and injury, platelets begin to stick and form a clot that block off blood flow through the artery
What causes damage to the endothelium in CAD?
Hypertension (uncontrolled)
Elevated homocysteine
What is C-reactive protein and how does it relate to CAD?
It is a protein released by the liver that rises when systemic inflammation occurs. Chronic elevation is associated w/ unstable plaques and the oxidation of low-density LDL cholesterol (caused by CAD)
(Normal value = <1)
What would keep collateral circulation from forming and what occurs when there is no time for collateral circulation to develop?
A rapid onset of ACS or coronary vasospasm; and ischemia or infarction of the cardiac muscle occurs.
What would you teach a patient with CAD?
When atherosclerotic plaque occlusion of the coronary arteries occurs over a LONG period of time, there is a greater chance of developing collateral circulation, which enables the myocardium to receive adequate amounts of oxygenated blood. EXERCISE helps to develop healthy collateral circulation. Also, increase HDL cholesterol and decrease LDL.
What are risk factors/modifiable factors associated with CAD?
Non Modifiable
Gender (M>F)
African American women & white middle-aged men
Family hx

Elevated serum lipids
Hypertension (>140/90)
Diabetes type II
Metabolic syndrome
Homocysteine level
Psychologic states (Depression/Anxiety)
Substance abuse (cocaine, alcohol, etc.)
Why is HTN a risk factor of CAD?
B/C the shearing stress of HTN causes endothelial damage & more force is needed to pump blood through a damaged artery
What are some "Healthy People" recommendations for CAD?
Maintain a healthy weight
Reduce sodium intake
Increase physical activity
Avoid tobacco (especially smoking)
Limit daily alcohol
Diet of low cholesterol & sat. fat and HIGH in fruits and veggies
What medications are used to tx CAD?
Antiplatelets (Aspirin, Plavix)
What is Stable Angina?
Intermittent chest pain that occurs over a long period with the same pattern of onset, duration, and intensity of symptoms caused by reversible myocardial ischemia (caused by narrowing of coronary arteries).
What are the clinical manifestations of Stable Angina?
Pain lasting usually 3 to 5 minutes (subsides when precipitating factor is relieved)
Pain at rest is UNUSUAL
ST segment depression

Patient Describes
constrictive, squeezing, heavy, suffocating
Pain is substernal and may radiate to neck, jaw, shoulders, L arm, or between shoulder blades.
What product of anaerobic metabolism causes the "pain" sensation of Stable Angina?
Myocardium becomes hypoxic and LACTIC ACID accumulates from anaerobic metabolism. The lactic acid irritates nerve fibers and pain travels to cardiac nerve roots and thoracic posterior nerve roots.
What are the 5 types of stable angina and what happens w/ each?
1) Silent Ischemia--asymptomatic, associated with DM

2) Nocturnal angina--occurs only at night but not necessarily during sleep or recumbant position

3) Angina Decubitus--occurs only when recumbant and is relieved by standing/ sitting

4) Prinzmetal's (variant) Angina--occurs at rest in response to spasm of coronary artery (hx of migraine, cocaine, Raynauds); may be relieved by moderate exercise

5) Microvascular Angina (MVD)--affects distal branches of CA, pain triggered by ADLs vs. physical exercise; may feel fatigued or anxious
What would you teach a patient about taking Nitroglycerin?
*4mg sublingual (do NOT chew or swallow/ do not inhale spray form); Relieves pain in 3 min
*Repeat q 5 min x3; if still not affective, call 911
*Don't take if systolic <90
*Don't combine w/ drugs for erectile dysfunction
*Teach about Orthostatic Hypotension (sit down before taking)
*Always take med w/ you, keep in closed/dark bottle, good for 6 mos after opening.
*May cause tingling/burning under tongue
*HR may increase and may develop pounding headache
*For prophylaxis: take 5-10 min before activity
What diagnostic studies determine the presence of Stable Angina?
*Health hx/physical exam
*Lab studies
*12-lead EKG
*Chest x-ray
*Exercise stress test or Pharmacological stress test
*PCI (percutaneous coronary intervention)
*Cardiac catheterization
*Angiogram (to view)
What occurs with Acute Coronary Syndrome (ACS)?
A once stable atherosclerotic plaque deteriorates and ruptures, exposing intima to blood. (stimulates platelet aggregation and local vasoconstriction)
*May cause partial or total occlusion of CA (can result in myocardial damage)
What are the three types of ACS?
1) Unstable angina (UA)
2) Non-ST segment elevation MI (Non-STEMI)
3) ST-segment elevation (STEMI)
What are the clinical manifestations of Unstable Angina ACS?
*Chest pain has new qualities
*Occurs at rest or sleep, increasing frequency, easily provoked by minimal or no exertion
*pain gets worse and changes in pain pattern
*doesn't have to have hx of chest pain
*Women present with SOB, FATIGUE, indigestion, & anxiety
What is a Non-STEMI?
Partial occlusion of artery w/ damage to the endocardium (ST wave depression or normal ST in EKG)
What is a STEMI?
Complete occlusion of artery w/ damage to myocardium (ST wave elevation in EKG)
What are the clinical manifestations of ACS Myocardial Infarction?
PAIN is hallmark:
*Severe, immobilizing chest pain NOT relieved by rest, position change, or nitrate administration
*Described as heaviness, constriction, tightness, burning, pressure, or crushing
*May occur while pt is at rest, asleep, or awake
*Substernal, retrosternal, epigastric & may radiate to neck, jaw, arms, back

*Women: SOB & Fatigue
*Older adults: confusion, PE, dizziness, dysrhythmias

Sympathetic NS Stimulation d/t epinephrine and norepinephrine (catecholamine) release:
*diaphoresis: sweating/wet skin
*Skin: ashen, pale, and/or cool to touch

Cardiovascular Symptoms:
*Increased HR & BP
*Crackles in lungs
*Abnormal heart sounds (S1 and S2 are NORMAL)

*Fever within first 24 hours
Describe the healing process of an MI?
1) Within 24 hours, leukocytes infiltrate the are of necrosis
2) Enzymes are released from dead cardiac cells
3) Neutrophils and Macrophages remove necrotic tissue
4) Development of collateral circulation improves areas of poor perfusion
5) Serum glucose may be elevated from glycogenolysis and lypolysis
6) Necrotic zone identifiable by EKG changes
7) 10-14 days after MI, scar tissue is still weak and vulnerable to stress
8) By 6 weeks after MI, scar tissue has replaced necrotic tissue but is less compliant than normal tissue which may lead to CHF
9) Ventricular remodeling (myocardium may hypertrophy and dilate to compensate--may cause heart failure)
What are the complications of an MI?
*Dysrhythmias (most common cause of cell death pre-hospital)
*Heart Failure presenting w/ dyspnea, restlessness, agitation, tachycardia, pulmonary congestion (crackles), S3 or S4 heart sounds, and respiratory distress
*Cardiogenic Shock (occurs when inadequate oxygen and nutrients are supplied to heart's tissues because of severe LV failure.)
*Papillary muscle dysfunction (causing mitral valve regurgitation and murmur)
*Ventricular aneurysm
*Acute Pericarditis "Dressler's Syndrome" (inflammation of pericardium; may have fever & friction rub may be heard)
What are the Serum cardiac markers, what are the levels, and what do they mean?
*Draw these within 10 minutes of ER arrival*
1) Myoglobin-earliest indicator, 99-100% sensitive to heart if measured w/in 12 hours of MI event

2)Troponin I and T- most specific for MI
*Normal Troponin T =<0.1 ng/mL
*Normal Troponin I =<0.4 ng/mL so >2.3=MI

3) CK-MB- specific for MI; level correlates w/ size of infarction. (>5% = MI); Rise 3-12 hours after MI and peak in 24 hours; return to normal in 2-3 days
What is the MONA protocol?
Depending on agency protocol:
1) Administer morphine 5-10mg as ordered
2) Administer oxygen at 4L per N/C as ordered
3) Continue nitrate therapy as ordered
4) Administer 81-325mg Aspirin (ASA) as ordered
What is the acute nursing management of an anginal attack?
1) Administration of supplemental oxygen
2) 12-lead EKG as ordered
3) Prompt pain relief first w/ nitrate followed by an opioid analgesic if needed (vasodilation)
4) Auscultation of heart sounds
5) comfortable positioning of patient
6) For anxiety give Benzodiazepine
What is the etiology of Sudden Cardiac Death?
Most are caused by ventricular dysrhythmias (V-tach, V-fib); caused less commonly as result of LV outflow obstruction (aortic stenosis)
What are the primary risk factors of SCD?
*Left ventricular dysfunction: look @ ejection fraction (REMEMBER: normal EF is 50-70%
*Male gender (esp. African American)
*Family hx of premature atherosclerosis
What are the characteristics of a Normal Sinus Rhythm?
*Rate is normal (43 and 93 beats/min in men and 52 and 94 beats/min for women; 110 to 150 beats/min in infants)
*P waves are present on an ECG
*Rhythm is regular
What is considered normal P-wave morphology?
*Upright in leads I, II and usually aVF
*Inverted in aVR
*Upright, biphasic or inverted in III and aVL
*The right to left activation results in P waves that are upright or biphasic in V1 and V2, and upright in V3 through V6
What ECG changes can be noted with LEFT atrial enlargement?
*The P wave is WIDE in lead II (≥0.12 sec) and is usually NOTCHED in I and II.
*The P duration/PR segment is greater than 1.6.
*The terminal P wave in lead V1 is deep and delayed with the negative deflection being greater than 40 m sec in duration and/or ≥0.1 mV in height.
What ECG changes can be noted with RIGHT atrial enlargement?
*Prominent P waves (0.2 mV in height) in the limb leads, particularly II and aVF, and in an anterior lead such as V1.
*The initial P force in lead V1 is often ≥60 mV-msec.
*The P wave duration is 0.11 sec or less with an axis of 65º or more.
What is the purpose of the SA node?
The heart's natural "pace-maker"; sets the pace for the heart.
What is characteristic of a normal PR interval?
*0.12 seconds-0.2 seconds
*PR intervals shorten as heart rate increases
NOTE: PR interval may be prolonged by intraatrial, AV nodal, and infranodal conduction abnormalities.
What are the two types of sinus arrhythmias?
1) Respiratory type (phasic)
2) Non-respiratory type (non-phasic)
What is characteristic of a Respiratory or phasic arrhythmia?
*Common, normal, decreases in age
*Results from changes in autonomic tone during the respiratory cycle .
*Inspiration reflexively inhibits vagal tone, thereby increasing the heart rate. With expiration, vagal tone rises to its previous state, and the rate declines again.
*This type of sinus arrhythmia disappears with breath holding.
What is characteristic of a Non-respiratory or non-phasic arrhythmia?
*The acceleration and deceleration of the SA node is not related to the respiratory cycle.
*This form of arrhythmia can occur in the normal heart, diseased heart, or after digitalis intoxication.
What are the signs and symptoms of dysrhythmias?
*Palpitations, dizziness, lightheadedness, syncope, chest discomfort, neck discomfort, dyspnea, weakness, and anxiety
*Secondary consequences of arrhythmias, often due to underlying heart disease, are an additional source of symptoms (e.g., congestive heart failure, ischemia, and thromboemboli.)
*Arrhythmias such as ventricular fibrillation and asystole can cause cardiac arrest.
What are the goals of therapy in arrhythmia patients?
*Improve symptoms
*Decrease anxiety
*Identify the causal mechanism of the arrhythmia
*Tailor a plan of care for the patient
*Educate the patient on s/s of an acute cardiac event
*Prevent a potentially serious cardiac event
What are the risk factors associated with A-fib?
*Age (greater than 65)
*Left atrial enlargement shown to precede and predispose AF
*Hypertensive heart disease
*Coronary artery disease
*Valvular disease/history of rheumatic fever
*Chronic Kidney disease
*Sleep Apnea
What meds are used for A-fib?
1) Amiodarone: when no other meds have worked; used to slow heart rate down
2) Anticoagulants (warfarin): r/t risk of thrombus formation
What are potential complications of cardioversion?
*Transient Ischemic Attack (TIA)
*Stroke can occur if a blood clot forms in the left atrium because of sluggish blood flow and a piece of the clot breaks off. Embolus may also travel to kidney, eye, extremities
What is Infective Endocarditis?
An infection of the endocardial layer (contiguous w/ valves) of the heart
What are the classifications/types of Infective Endocarditis?
1) Acute: individuals w/ healthy valves and manifests as a rapidly progressive illness (healthy but drug abuser)
2) Subacute: individuals with preexisting valve disease and the clinical course of the infection may extend over months (often chronic)

*NOTE: also classified by cause (IVDA or fungal) and Site involvement (prosthetic valve endocarditis-PVE)
What are predisposing conditoins that increase the risk of Infective Endocarditis?
Those predisposed by:
1) Cardiac conditions (prosthetic valves, RHD, Pacemakers, Marfan's syndrome, etc.)
2) Non-cardiac conditions (hospital-acquired bacteria, IV drug abuse)
3) Procedure-associated risks (IV devices, oral procedures, respiratory procedures, GU/GI procedures)
What are some causative agents of Infective Endocarditis?
bacteria, viruses, fungus

*NOTE: contributing factors include: Aging, IVDA, prosthetic valves, & intravascular devices
How does Infective Endocarditis occur?
Blood flow turbulence within the heart allows causative organisms to infect previously damaged valves or other endothelial structures
How is Infective Endocarditis treated?
*Penicillin has greatly improved the prognosis of the disease
What situations warrant prophylaxis for IE?
*GU/GI or respiratory procedures ONLY if pt is in high risk category (valve replacement, IVDA, etc.)
*Oral procedures involving perforation of oral mucosa, dental extractions/implantations, teeth cleaning w/ anticipated bleeding
*Presence of wound infection
*Presence of UTI
What are vegetations associated with IE?
Consist of fibrin, leukocytes, platelets, and microbes that adhere to the valve surface or endocardium (may result in embolization)
What happens w/ left-sided vegetations?
Emboli can progress to various organs (brain, kidneys, and spleen) & Limb infarction (tissue death) may occur
What happens w/ right-sided vegetations?
The lesions progress to the lungs and result in pulmonary embolism (PE)
What are the clinical manifestations of IE?
Chills, weakness, malaise, fatigue, anorexia, arthralgias, back pain, abdominal discomfort, weight loss, headache, clubbing of fingers, osler's nodes (bumps on fingers/toes), Roth's spots (spots on retina), low grade fever
How is Infective Endocarditis diagnosed?
Two blood cultures are drawn from two different sites. (Negative cultures should be kept for 3 weeks if clinical diagnosis remains endocarditis b/c of possibility of slow growing organisms)
What are the treatment goals of IE?
1) Normal or baseline cardiac function
2) Performance of ADLs w/o fatigue
3) Knowledge of therapeutic program to prevent recurrence of endocarditis
What are some nursing diagnoses for IE?
1) Decreased CO r/t altered rhythm, valvular insufficiency, and fluid overload
2) Activity intolerance r/t generalized weakness and alteration in oxygen transport secondary to valvular dysfunction
3) Hyperthermia related to infection of cardiac tissue (inflammatory response/fever)
What should be expected upon evaluation of treatment of IE?
*Vital signs WNL
*Absence of fever, chills, diaphoresis, HA
*Completion of ADLs w/o fatigue, SOB, or physiologic distress
*Increased understanding of disease process and self-care
*Ability to recognize s/s of infection
*Knowledge of pre-procedure ABX, report valve problems to all health care providers
What assessment/physical symptoms would be noted in someone with Pericarditis?
*Progressive, severe chest pain that is sharp
*Pt may exhibit shallow breathing
*Pain worse with deep inspiration and lying supine
*Relieved by sitting up and leaning forward
*Pain may radiate (often to trapezius)

*HALLMARK: Pericardial friction rub (scratching, high-pitched)
What are the types of valvular disorders?
Regurgitant and Stenosis (Mitral, Aortic, Tricuspid)
What happens in Valvular regurgitation?
*Valves do not close completely
*Allows back flow through the valve in the area just to the left of that valve
*Can result from deformity or erosion of valve cusps
*Caused by: bacteria (acquired) or congenital
What happens in Valvular stenosis?
*valve leaflets fuse together and cannot fully open or close
*the opening narrows and becomes rigid
*Impeded forward flow
*Caused by: bacteria (acquired) or congenital
What is Mitral Stenosis?
Stenosis that has narrowed the mitral valve obstructing backflow from the L atrium into the L ventricle during diastole (relaxation)
What is Mitral Stenosis caused by?
*Usually as a result of acute or chronic RHD of bacterial endocarditis
*Rarely from congenital heart defects
What are clinical manifestations of Mitral Stenosis?
*Most common is dyspnea on exertion
*hemoptysis r/t back flow (coughing up blood)
*Frequent pulmonary infectoins (bronchitis/pneumonia)
*Paroxysmal nocturnal dyspnea

*Right-sided HF manifestations (JVD, hepatomegaly, ascites, peripheral edema, basilar crackles, & severe/late cyanosis of the face and/or extremities
What would the nurse find upon assessment of Mitral Stenosis?
*Loud S1
*Split S2
*Mitral snap (r/t atrial pressure)
What happens to cardiac output as it relates to mitral valvular disease?
1. Normal balance of oxygen supply/demand is upset
2. Heart begins to fail
3. Increased muscle mass/size = increased myocardial oxygen consumption
4. Size and workload of heart exceeds blood supply
**Which causes ischemia followed by dyspnea and pain, losing functional muscle
**Contractile force, SV, and CO decrease d/t loss of functional muscle, leading to increased pressure on the left side of the heart reflected backward into the pulmonary system causing pulmonary edema and HTN and right-sided ventricular failure.
What is Mitral Regurgitation?
Mitral valvular insufficiency that allows the blood to flow back into the Left Atrium during systole b/c the valve does not fully close.
What is a common cause of Mitral Regurgitation?
*RHD (rheumatic heart disease)
*Congenital defects may also cause Mitral regurg.
What are the manifestations of Mitral Regurgitation?
*Dyspnea on exertion

*manifestations of left-sided heart failure: pulmonary congestion, pulmonary edema, and increase in high pulmonary pressure which may lead to Rt side complications
What is Aortic Stenosis?
An obstruction of blood flow from the L ventricle into the aorta during systole (contraction)
What happens in Aortic Stenosis?
*Valvular annulus decreases in size, increasing the work of the L ventricle to eject volume through the narrowed opening into the aorta
*The ventricle hypertrophies (to compensate and maintain adequate SV and CO)
*Workload increases myocardial oxygen consumption (may precipitate myocardial ischemia)
*Coronary blood flow may decrease
*L ventricular end-diastolic pressure increases r/t reduced SV
*L atrial pressure increases (pulmonary vascular congestion and pulmonary edema may result)
What is cardiomyopathy and how is it classified?
Constitutes a group of diseases that directly affect the functional ability of the myocardium

1) Primary: etiology is unknown
2) Secondary: result of another disease
Does cardiomyopathy affect function and conduction?
What are the 3 types of cardiomyopathy?
1) Dilated
2) Hypertrophic
3) Restrictive
What is Dilated cardiomyopathy?
*Left Ventricle is dilated and has thinned; therefore increasing chamber size and volume.

*Characterized by diffuse inflammation and rapid degeneration of myocardial fibers

*Impairment of systolic function (contractility)
*Atrial enlargement
*Blood stasis in L ventricle
What are the goals of therapy in Dilated cardiomyopathy?
* Interventions focus on controlling HF by enhancing myocardial contractility and decreasing afterload.

*Nitrates/loop diuretics to decrease preload
*ACE inhibitors (decrease afterload)
*Beta blockers (control neurohormonal stimulation)

*Drug and nutritional therapy
*Alcohol abstinence
*Ventricular assistive device (VAD) to allow heart to rest and recover from acute HF
What are some causes of Dilated cardiomyopathy?
*Cardiotoxic agents
*CAD (ischemia)
*Metabolic disorders
*Muscular dystrophy
*Valvular disease
What is hypertrophic cardiomyopathy?
*Massive ventricular hypertrophy where chamber size and volume are decreased

1) Rapid, forceful contraction of L ventricle
2) Impaired diastole (relaxation/filling)
3) Obstruction to aortic outflow
(usually dx in healthy, active young men and puts them at risk for Sudden cardiac death)
What are the goals of therapy for hypertrophic cardiomyopathy?
Improve ventricular filling by reducing ventricular contractility and relieving L ventricle outflow obstruction
(Beta blockers, CCB, internal card. defib, AV pacing, or septal repair)
What is restrictive cardiomyopathy?
*Ventricles stiffen, lose compliance, and become resistant to filling (Impairs diastolic filling and stretch)
*Demand high diastolic filling pressures to maintain CO
*Systolic functioning remains unaffected.
What is the goal of therapy for restrictive cardiomyopathy?
No specific tx. Interventions are aimed at improving diastolic filling and the underlying disease process (heart transplant may be indicated)
Auscultation points:
aortic: 2nd intercostal R of sternum
pulmonic: 2nd intercostal L of sternum
Erb's point: 3rd intercostal L of sternum
Tricuspi: 4th intercostal Lof sternum
Mitral (apex): 5th intercostal mid-clavicular
the AV node is located in the
intra-atrial septum
The amount of blood ejected from the left ventricle in one minute
cardiac output
The amount of blood ejected from the L ventricle in one contraction:
stroke volume
This is a measure of ventricular efficiency:
ejection fraction
The sympathetic NS increases the heart rate by releasing:
The PARA sympathetic NS DECREASES heart rate by releasing:
These are located in the carotid and aortic arteries and sense changes in BP
These are located in the carotid and aortic arteries and sense changes in oxygen levels
venous pain gives a person a feeling of
fullness, heaviness
arterial pain gives a person a feeling of
sharp, throbbing
Symptoms of lack of arterial blood flow:
decreased hair distribution
thick brittle nails
shiny, taut, dry skin
Longer capillary refill times indicate a decrease of blood flow to the extremity, or ________
If the skin is cool to the touch, this indicates
if the skin is the temperature of the environment, this is called poikilothermy and is indicative of:
insufficient arterial blood flow
a warm or hot extremity is indicitive of a _______ problem.
When might you hear the s3 sound in the heart?
it's normal in kids and young adults
L sided heart failure
fluid volume overload
mitral valve regurgitation
When might you hear the s4 sound in the heart?
pulmonary stenosis
The 3 outer layers of the heart
Fibrous pericardium
parietal pericardium
visceral pericardiam (epicardium)
Lowered BP stimulates the kidneys to secrete:
When renin is released from the kidneys, renin splits the plasma protein angiotensinogen to form_________.
angiotensin 1
angiotensin 1 is changed to angiotensin 2 by an enzyme found in the _______ tissue.
angiotensin 2 causes arteriole vasoconstriction and stimulates the secretion of ______. Both of these cause the BP to go up.
aldosterone is secreted by the ______ ______ and increases the reabsorption of sodium ions.
adrenal cortex
noepinephrine and epinephrine from the _____ _______ cause the BP to go up, along with aldosterone and angiotensin.
adrenal medulla
Antidiuretic (ADH) hormone is released from the pituitary and causes the BP to go
Atrialnatrietic hormone (ANP) causes the BP to go
The BP in pulmonary circulation is always low. It's usually around
Why is it important to keep pulmonary BP low?
to prevent filtration in the pulmonary capillaries that could lead to pulmonary edema
hepatic portal circulation is a special part of systemis circulation. Blood from digestive organs flows thru the ______ vein into the liver before returning to the heart.
hepatic portal
What two electolytes does aldosterone regulate?
The only symptom of an MI in the older pt may be __________. Often, chest pain is not present in the older adult.
L sided heart failure symptoms
pink, frothy sputum
pulmonary edema
crackles, wheezes
R sided heart failure symptoms
peripheral edema
jugular vein distension
weight gain
paresthesia occurs as in extremeties as a result of reduced nerve conduction due to a lack of
In a cardiac assessment, BP readings are done on both arms. The arm with the ____ reading is used for ongoing measurements.
The BP reading when taken on the leg is normally ____mm/Hg higher than on the arm.
Orthostatic hypotension is a drop in systolic BP greater than ____, or a rise in diastolic greater than ____, and an increase in heart rate of greater than ___ BPM
4 factors that may cause hypotension
fluid volume defecit (hemorrhage)
Guidelines for orthostatic hypotension assessment:
lie flat 5 minutes before 1st reading
don't eat or smoke for 30 minutes before
don't talk or cross legs during readings
take first pressure lying, sit up, wait 3 minutes, take sitting, assist to stand and take immediately, then again 3 minutes later
this is the difference between apical and radial pulse readings
pulse defecit
Numbers for pulse assessment:
1+ weak, thready
2+ normal
3+ bounding
In the abnormal blood vessel that has a bulging or narrowed wall, a vibration is felt called
when auscultating an abnormal blood vessel with the steth, turbulent blood flow thru a narrowed artery is called
a dry cough can occur from the irritation caused by the lung congestion due to
heart failure
a heart murmur is caused by a ______ valve opening.
a pericardial friction rub is caused by inflammation of the pericardium. Best heart ____ of sternum. May occur after an MI or chest trauma.
when doing a CT with contrast, what levels are measured in the patient before injecting dye?
GFR (glomerular filtration rate)
When doing a CT with contrast on a pt with mild to moderate renal insufficiency, pts should receive premeds and 2 post procedure doses of ________.
What test is given to detect impaired perfusion?
thallium test
areas of the thallium scan where nothing is seen indicate cold spots that signify _______ or _______
If a pt is unable to exercise for a stress test, _____ is injected to simulate the heart exercising
When a pt is given persantine to simulate exercise, instruct the pt not to ingest _____ for 12 hours before the test.
What test is done to see ventricular funtion, and ejection fraction, as well as the effects of drugs, MI, CHF?
What protein can predict MI risk?
c reactive protein
c reactive protein indicates ________ of the coronary vessels.
elevated levels of this amino acid in the blood indicate a risk for CAD and PVD
homocystine (7-8 is normal)
after an MI, damaged cells release
creatine kinase
creatine kinase levels elevate in ___ hours after MI, and return to normal ___ hours after.
Which creatine kinase is measured that is specific to the heat muscle
This is a cardiac cell protein that detects minor myocardial damage not detected by CK-MB.
cardiac troponin
cardiac troponin peaks in 10-24 hours after MI and stays elevated for ____ days
protein found in skeletal and cardiac muscle that rises before CK-MB or troponin so it can detect an MI earlier
myoglobin (elevates within 1h of MI)
What are the 3 cardiac biomarkers?
creatine kinase
What is the electrolyte necessary to regulate the heart beat and BP?
magnesium (1.6-2.6 normal)
what are the affects of hypomagnesia?
What are some causes of hypomagnesia?
What should a person's total cholesterol be less than?
What should a person's LDL (bad cholesterol) be?
less than 100
What should a persons HDL (good cholesterol) be?
greater than 60
What should a person's triglycerides be?
less than 150
How long must a person be NPO before angiography?
a cardiac catheterization checks the blood flow of?
coronary arteries
What nursing assessments are done post cardiac cath?
firm pressure at site to prevent hemorrhage/hematoma, vital signs, assess puncture site, confirm peripheral pulses, lie flat and dont flex the extremity used for several hours, encourage fluid to flush dye
Complications of a cardiac cath
puncture of heart of lungs
allergic reaction
breaking cath
emboli of air or blood
MI or stroke
central venous pressure is measured with a central cath inserted into the _____ _____.
vena cava
central venous pressure is measured to see if the pt is over or under _______.
This study is done to diagnose dysrhythmias, must be NPO 6-8 hours. A cath with electrodes is inserted via femoral artery into the R side of heart.
electrophysiolgical study
smoking causes vasoconstriction that lasts up to _____ hours after smoking.
a nursing intervention for chest pain is to give the pt _____ ______
supplemental o2
indications for antiembolism devices such as TED or SCD
TED hose should stop ____ inches below kneecap.
SCD's inflate to _____mm/Hg of pressure, starting at the ankle and working up.
If pts have angina, ________ can be taken prophylactically before sex.
after an MI, a pt can resume sexual activity when they can climb ____ flights of stairs without symptoms.
What routine tests are done for cardiac admissions?
12 lead ECG
chest xray
coagulation studies
chemistry profile
crossmatch for blood
drugs stopped before cardiac surgery
aspirin 3-7 days
warfarin 4-5 days
heparin 4 hours pre op
diuretics 2 days
This diversion allows for a bloodless, motionless surgical field while the function of the heart is maintained by a pump
cardiopulmonary bypass machine
before going on a CP bypass machine, person is hypercoagulated to ____ times the normal PTT.
what is used to reverse heparin when a CP bypass machine is in use?
protamine sulfate
a CP bypass machine can cause fluid shifts and edema that continue for up to ___ hours after surgery.
the 2 main coronary arteries of the heart are the first branches of the:
ascending aorta
backflow during ventricular contraction is prevented by
tricuspid and mitral valves
the L atrium of the heart receives blood from the the
4 pulmonary veins
the tricuspid and mitral valves are anchored to the floor of the ventricles by the
chordae tendinae and papillary muscles
The force of the L ventricle is __ times that of the right ventricle.
The SA node is located in the wall of the
r atrium
If the AV node becomes the pacemaker, how many BPM does it produce?
40-60 bpm
The bundle of His can generate an impulse for the ventricles, but is much slower at a rate of ____
20-35 bpm
The sequence of events in one heart beat is called the
cardiac cycle
what causes the semilunar valves to close?
a backflow of blood
In the brain, the _____ contains the cardiovascular centers.
ANP hormone increases sodium _____ in the kidneys by inhibiting the secretion of aldosterone.
ANP is secreted with the BP goes up or the blood volume stretches the walls of the ______, causeing water and sodium to be lost.
arteries have 3 layers. Which layer changes the diameter and influences BP by way of the sympathetic nervous system?
veins don't have as important a role as arteries in maintaining _____
capillaries are responsible for shunting and redirecting blood where it's needed by way of the
precapillary sphincters
an elevated bp causes the capillaries to push out more lfuid into the interstial spaces, which can lead to
arterioles and veins stay in a state of slight _______ in order to maintain BP.
venous return depends on several factors:
constriction of veins, skeletal muscle pumping, diaphragm conpresses abd veins, valves
normal elasticity of large arteries contributes to normal ___
What is the heart lined with that is smooth and prevents clotting?
What kind of pts are more sensitive to tachycardia?
elderly and MI pts
What segment of the ECG would be examined for elevation or depression in pts with chest pain or cardiac injury?
ST segment
The QT interval measures the time from the start of ventricular depolarization to repolarization. The normal time range of this is:
0.34-0.43 seconds
An inverted T wave can indicate:
coronary ischemia
What kind of problems can occur with pacemakers?
failure to sense pts own beat
failure to pace due to malfunction
lack of depolarization
When should a pacemaker be used?
for brady or tachycardia that doesn't respond to meds OR after an MI to allow the heart time to heal
possible causes of ventricular fibrillation
v-tach rules:
regular rhythm, with occasional irregularity
150-250 bpm
no p wave
no pr interval
QRS interval greater than 0.10 seconds
causes of v-tach
myocardial irritability
respiratory acidosis
digoxin toxicity
cardiac cath procedures
pacing wires
when are PVC's dangerous?
more than 6 per minute
occur regularly
multifocal pvc's
falling on the T wave
caused by an MI
Common causes of PVC's
PVC's can occur in different shapes. This type of PVC looks all the same because they all come from the same place.
PVC's can occur in different shapes. This type of PVC's do not look alike because they originate from different areas of the ventricle.
Where do most atrial fibrillation impulses come from?
pulmonary veins (there are 4 of them)
A Fib Rules:
irregularly irregular
atrial rate not measureable
ventricular rate <100=controlled response
ventricular rate >100=rapid vent. response
no p waves
no pr interval
QRS interval is <_ 0.10 seconds
Causes of A fib:
rheumatic or ischemic heart disease
heart failure
PE post op after a CABG
Causes of PAC
cigarette smoking
myocardial ischemia
enlarged atria
valve disorder
digoxin or other meds
electrolyte imbalance
heart failure
dysrhythmias that occur in old people
sick sinus syndrome
heart block
In atrial flutter what rate do the atria contract at?
250-350 bpm
The classic characteristics of atrial flutter are more than one _____wave. They occur in a sawtooth pattern.
Atrail flutter rules:
atrial rhythm regular, vent rhythm can be regular OR irregular
heart rate varies
p waves show flutter with sawtooth pattern
QRS interval_<.010 seconds
The presence of symptoms in atrial flutter depend on the _______ rate.
What is the goal of tx for atrial flutter?
convert to a normal sinus rhythm
What is used to convert atrial flutter if meds don't work?
In A-fib, how many bpm can occur?
350-600 (however, the AV node blocks most of those impulses so the ventricular rate is much lower)
In A-fib there is no measureable or definable ____ waves.
A-fib increases the risk of death due to?
What problems occur due to A-fib?
faint radial pulse
if the a fib is rapid and sustained, heart failure
If A-fib is unstable, what therpeutic measure is used?
If A-fib is stable, what therapuetic measures are used?
beta blockers, calcium channel blockers, digoxin and COUMADIN (warfarin)
How long must a person with a-fib be anticoagulated before performing cardioversion?
3 weeks
To isolate and eradicate impulses from the pulmonary veins in a-fib, what procedure may be done
catheter ablation
a device that can be implanted for atrial fibrillation that has dual pacing chambers that correct a-fib:
implantable atrial defibrillator (IAD)
This is a surgery that is done to correct a-fib in which incisions create a route for electrical impulses to travel to the AV node
maze procedure
The part of the heart that is pace making during v-tach is:
the ventricles
The seriousness of v-tach is determined by the _____ of the dysrhythmia.
If someone goes into v-tach and is pulseless and not breathing, what is your first action?
start CPR until a defibrillator is available
Meds for vtach are epinephrine, vasopressin and amiodarone. What electrolyte is given in vtach if it is low?
v-fib occurs when many ectopic ventricular foci fire at ______ time.
the same
In v-fib there is a complete loss of:
cardiac output (if not terminately immediately, death will occur)
pts experiencing v-fib lose ______ immediately.
what are the symptoms of vtach?
circulatory collapse
respiratory arrest
pupil dilation
Therapeutic measures for v-fib
immediate defibrillation
endotracheal intubation
meds: epinephrine, vasopressin, amiodarone, magnesium if low
Asystole is referred to as:
cardiac arrest
what are 2 causes of asystole?
loss of muscle due to MI
These kind of pacemakers are used in emergency situations because they are quick and easy to apply.
Inserting a pacemaker uses ________ to guide insertion. The leads are inserted via a vein into the heart.
a single lead pacemaker paces the
right atria
a double lead pacemaker paces the right:
atria and ventricle
non-activity response pacemakers are usually set at a prescribed rate of _____ bpm.
When a patient has a pacemaker, a small ____ is seen on the ECG where the paced beat occurs.
Nursing care post pacemaker placement:
cardiac monitor and rest several hours
monitor apical pulse frequently
monitor site q2-4h for bleeding
report change in rhythem, pain or vitals
may have a sling for 24-48h to prevent dislodgement
pt teaching for pacemakers:
check incision daily for infection
a hard ridge will form over the incision
report if pulse is slower than set rate
tell airport security (may set of metal detector)
no lifting of more than 10 lbs for 6 weeks
wear medical bracelet or have ID to identify as pacemaker pt
What is used to verify that cardiac contraction has occured?
What is the 6 step process for dysrythmia interpretation?
heart rate
p waves
pr interval
qrs interval
qt interval
Rules for normal sinus rhythm:
regular rhythm
60-100 bpm
p waves round, precede qrs
pr interval is 0.12-0.20 seconds
qrs is
disorders that change the _____ cause alteration in p wave shape and size
The u wave is small and often sunseen. It is found most commonly in pts with
method to determine heart rate using a 6 second ecg strip
count the number of R waves and multiply by 10
If someone is hypoxic, what would you expect their heart rate to be like?
SA node pacing is _____ bpm
AV node pacing is _____bpm
Ventricular pacing is ____ bpm
path of conduction in the heart
sa node to bachman's bundle
down the internodal tracts
av node (where it is briefly delayed)
Bundle of his
right and left bundle branches
purkinje fibers
Period from the beginning of 1 heartbeat to the beginning of the next
cardiac cycle
ECG graph paper is calibrated into a grid with small squares. There are 25 blocks in each square grid. Each small square within the grid is ____ seconds
The height of a waveform on an ECG measures
This occurs when there is no wave deflections on the ECG
isoelectric line
The P wave represents atrial
The PR interval represents the amount of time it takes the impulse to travel from ____ to ______
sa node
av node
The qrs complex represents ventricular
The qrs is always larger than the P wave because the ventricles have more
muscle mass
the QRS interval represents the time ti takes for the impulse to travel from the AV node to
the ventricles
the T wave represents ventricular
prolonged or shortened ____ intervals can lead to ventricular dysrythmia
The ST segment represents the time from the end of ________ depolarization to the end of repolarization.
a ____ second ECG strip is used when interpreting rhythms
The same spacing between each ___ to ____ is seen in regular rhythms. If the distance varies, the rhythm is irregular
R to R
What must a P wave look like to be considered normal?
all look alike
one P wave in front of every QRS
dysrhythmias arising in the ____ node are rarely dangerous
Coumadin (warfarin)
there is an increased risk of hemorrhage/brusing
monitor PT and INR
antidote is vitamin K
In PAC's there is a shortened ___ to ___ interval which is seen where the premature beat occurs
R to R
PVC's, PAC's, tachycardia, bradycardia and fibrillation are caused by a disturbance in impule _______.
PVC rules
rhythm depends on underlying rhythm
heart rate depends on underlying rhythm
p waves absent before qrs complex
no pr interval
QRS complex: If PVC > 0.10 secs, T wave in opposite direction of QRS
in endocarditis, assess the nail bed for?
splinter hemorrhages

clubbing (subacute form)
what will you see on the skin of a endocarditis pt?
where are osler's nodes found?
pads of fingers and toes

they are painful
what are roth's spots?
oval, white-centered hemorrhages present on retina during fundoscopic exam
what are janeway lesions?
non-tender, erythematous, and nodular lesions found on palms and soles
what is the prime diagnostic test for endocarditis?
blood culture

(monitored by lab for 3-4 weeks)
in endocarditis, _____ levels will be low
Hematocrit and hemoglobin
what diagnostic tool is used to determine valvular abnormalities?
what drug SHOULD NOT be used for endocarditis?
what is the most common infective orgniasm in infective endocarditis?
s. viridans
s. aureus
with whom does infective endocarditis occur with?
IV drug users
have had valve replacements
have systemic infection
structural cardiac defects
when do clinical manifestations usually occur in infective endocarditis?
2 weeks
almost all patients with infective endocarditis develop what heart sound?
S3, S4
what is the most common complication of infective endocarditis?
heart failure
what is a major complication of infective endocarditis in up to half of patients?
arterial embolization
what are the peripheral signs of endocarditis?
osler's nodes
roth's spots
janeway lesions
splinter hemorrhages
what kind of oral care is necessary for patients with endocarditis?
soft brushes
no flossing
rinse with water
bursh teeth at least twice a day
what kind of antibodies do you check for with someone with endocarditis?
rheumatoid factor
they would be left over from someone who had rheumatoid heart disease
what is rheumatic carditis?
a SENSITIVITY response that develops after strep, or group A strep infection.
rheumatic carditis is characterized by?
formation of aschoff bodies (small nodules in the myocardium that are replaced by scar tissue)
in RC, where does the most serious damage occur?
endocardium, with inflammation of valve leaflets developing

hemorrhagic and fibrous lesions form along the inglamed surgaces of the valves, resulting in stenosis or regurgitation
with valvular stenosis, what occurs to the structure of the heart?
mitral stenosis can result from what disease process?
rheumatoid carditis

rheumatoid carditis causes valve thickening by fibrosis and calcification
in mitral stenosis what will you see structuraly?
atria dilates
ventricle hypertroph
what wil you see in those with mitral stenosis?
pulmonary problems (dyspnea, orthnopnea, paroxysmal noctural dyspnea, palpitations, dry cough)
people with mild stenosis are usually:
what is the major cause of mitral regurgitation?
rheumatic heart disease
what are common symptoms of mitral regurgitation?
often unsymptomatic for MANY years
what are non-rheumatic heart disease causes of mitral regurgitation?
papillary muscle dysfunction,
ischemic heart disease
infectious endocarditis
mitral valve prolpase occurs because:
valvular leaflets enlarge and prolpase into the atria during systole
mitral valve prolapse can occur with what congenital problem?
is the valvular disease considered the disease of "wear and tear"
aortic stenosis
what are the classic symptoms of aortic stenosis?
dyspnea, angina, and syncope occuring on exertion
what is the most common valvular disease?
aortic stenosis
what occurs late in aortic stenosis?
what is the gold standard for diagnosing valvular disease?
echocardiography (TEE)
atrial fibrillation is a common finding in what valve disorders?
mitral stenosis and mitral regurgitation
Thiazide Diuretics
Use: Hypertension/edema (Diuri)l S/E: Low K+, hyperglycemia, hyperuricema N/I: Monitor electrolytes especially K+
Loop Diuretics
Use: Hypertension/edema (Lasix) S/E: Low K+, dizziness, sunscreen N/I: monitor eectrolytes esp. K+
Potassium Sparing Diuretics
Use: Hypertension/edema (Aldactone) S/E: Hyperkalemia: N/I: watch potassium and sodium substitutes. Monitor K+
Ace Inhibitors
Use: Hypertension/CHF (Accupril) S/E:Dry cough, hyperkalemia, angioedema N/I: watch potassium and sodium substitutes. Monitor K+
Angiotensin 11 receptor blockers
Use: Hypertension/CHF (Benicar) S/E: Hyperkalemia angioedema, dizziness N/I: watch potassium and sodium substitutes. Monitor K+
Beta Blockers
Use: Hypertension/MI (Inderal) S/E: Exercise intolerance, fatigue, bradycardia N/I: *Do not stop abruptly
Calcium Channel blocker
Use: Hypertension/Atrial tachycardia (Verapamil) S/E: Constipation, SOB, dizziness, GI upset, flushing, peripheral edema N/I: *Do not stop abruptly
Alpha blockers
Use: Hypertension/benign prostrate hypertrophy (Hytrin) S/E: Orthostatic hypotension, broncospasm N/I: Do not stand abruptly
Combined Alpha/Beta Blockers
Use:Hypertension/Heart failure (Trandate) S/E: Orthostatic hypertension, masks low blood glucose N/I: Do not stand abruptly
Direct Vasodilators
Use: Hypertension/CHF (Apresoline) S/E: Headache, sodium retention, tachycardia, fluid retention N/E: Monitor electrolytes,
Central Alpha Agonists
Use: Hypertension/Heart failure (Catapress) S/E: Sedation, dry mouth, bradycardia N/E: Do not stop abruptly
Cardiac glycosides
Use: CHF/ Tachyarrhythmias (Digoxin) S/E: Fatigue, bradycardia nausea, vomiting N/I: Watch for s/s of toxicity, hold if pulse<60, check Digoxin level & electrolytes
Use: Anticoagulant (Coumadin) S/E: Bleeding. N/I: Avoid Vitamin K. Do not combine with NSAIDS, aspirin, heparin. Check PT/INR
HMG-CoA reductase Use: Reduce LDL
(Lipitor) S/E: GI distress, may affect liver/kidney function and cause Muscle pain, N/I: Liver enzymes, Call MD if muscle pain
Use: Reduce triglyerides (Tricor) S/E: GI distress, may affect liver/kidney function. Muscle pain N/I: Liver enzymes, Call MD if muscle pain
Nicotinic Acid
Use: Reduce LDL, triglyerides, Increase HDL (Niacin) S/E: Flushing, pruritus, GI distress N/I: Check Liver enzymes
Bile Acid Sequestrants
Use: Reduce LDL, triglyerides (Questran) S/E: Constipation, bloating, decrease fat soluble vitamins N/I: Watch dosing schedule.
coronary atherosclerosis
A 58 yom with a hx of smoking, hypertension, and diabetes presents to you with chest pain with weakness, dyspnea and nausea. past labs reveal elevated serum cholesterol. After assessment, you inform the patient that he is not having an MI or heart failure, but that he is fortunate because you will diagnose this patient with.....
Angina Pectoris
a 34 yom presents to you with pallor, faintness, and dizzeness. The patient tells you he experienced severe chest and jaw pain 20 minutes prior, but that it is mostly relieved on its own. When asked about events leading up to this, he tells you that it was very sudden while playing basketball. The pain is described as an 8/10 and located to the left of the sternum. Troponin level is normal which rules out an acute MI. You suspect this patient has....
Acute myocardial infarction
A 64 yof presents to you with severe chest pain with an onset of 30 minutes. Pain radiates to the left arm and is accompanied by SOB, dizziness and anxiety. Her troponin level is elevated along with your sense of urgency because you know this patient is most likely suffering from...
Mitral valve prolapse
A 74 yof presents to you with orthopnea, peripheral edema, JVD, and fatigue, all classic symptoms of heart failure. Upon further inspection, you notice a systolic murmur during auscultation. It is very likely that this patient has...
Mitral valve stinosis
A 42 yom presents to you with fatige, JVD, and pulmonary edema. He states that he felt short of breath earlier, but now these new symptoms came in the following hours. You auscultate and hear a diastolic murmer at the apex of the heart. This patient is probably suffering from....
Aortic regurgitation
A 38 yof presents to you with signs of CHF. She states she was working in the garden and began to feel fatigued. She has dyspnea and orthopnea. You hear an s3 heart sound with a diastolic blowing murmur. This patient most likely has....
Aortic stenosis
42 yof presents with dyspnea and syncope. Patient is confirmed for angina pectoris and you hear a harsh rasping crescendo-decrescendo systolic murmur. This patient most likely has....
Rheumatic endocarditis
72 yom presents with chest pain. You hear a significant murmur and friction rub. Xray confirms cardiomegaly and pericarditis. The patient tells you he has a prosthetic heart valve. You know that this patient is most likely suffering from...
Patient presents with flu-like symptoms. Fatigue, dyspnea, and palpatations are also present. Patient begins clutching chest and you notice a dysrhythmia. This patient probably has ....
86 yof presents with chest pain described as sharp and constant. She states if she sits up and leans forward it is relieved a bit but when she lays down and inhales its worse. You hear a friction rub and notice fever, tachycardia and tachypnea. Patient has a hx of MI. This patient probably has
acute arterial occlusion/ peripheral arterial disease
a 58 yom presents with aching, cramping, fatigue, weakness in legs that is relieved with rest. Patient states that his legs feel numb. Classic signs of....
buergers disease
28 yom presents with pain in his feet. You notice digital ulceration with color changes. You know that if not treated, gangrene may set in because this patient most likely has...
Patient presents with pain that is constant. Patient has dyspnea. imaging reveals a ballooning in a vessel in the brain. This is known as an....
Raynauds syndrome
a 45 yom was shoveling snow for 2 hours and now presents with pallor and color changes in the hand. This patient probably has
arterial vascular disease
42 yof presents with paleness of the lower extremeties, edema, thick and brittle nails. She tells you to take the pillow out from under her feet because it is causing pain. Pulses are decreased and her legs feel cool. This patient probably has...
venous vascular disease
Patient presents with cyanosis of the legs. Edema is present and she asks you to elevate her legs to reduce pain. She is positive homans sign. She has strong distal pulses and her legs are warm. this patient has....
A 48 yom with a hx of chf and a fib presents with palpabale, firm, cord like veins in her legs. The area is warm and tender to the touch. Edema is present. This is known as...
systolic pressure greater than 140 with diastolic pressure greater than 90
A 72 yof presents with dizziness, palpatation and syncope. When taking her vitals you notice an irregular heart rate of x-x-x--x---x------xx-x-x-x. This is known as a.....
What would the nurse assess for as a causative agent in patient who presents to the clinic with Rheumatic Heart Disease?
pharyngeal infection by Lancefield Group A beta-hemolytic Strep
In a patient with Rheumatic Heart Disease, how long does it for the symptoms to develop?
Several weeks after the initial respiratory infection occurs. (1-6 weeks)
What is a unique symptom of Rheumatic Heart Disease?
Erythema marginatum (red raised rash); usually on chest, back, or abdomen
What will the nurse assess for on the EKG of a patient with Rheumatic Heart Disease?
Prolonged P-R interval
A patient presents to the ER with pain in the left chest that radiates to the L shoulder, neck and back.What disorder would the nurse suspect the patient to have?
How is pericarditis pain different from Myocardial pain?
It increases with inspiration, cough, movement of the trunk, and deep breathing. It is worse when lying flat and better when sitting up leaning forward.
What will the nurse assess for on the EKG of a patient with Pericarditis?
PR interval depression; tachycardia; bradycardia; Atrial Fibrillation
With a patient diagnosed with pericarditis who is having chest pain, what would the nurse assess for on the EKG?
ST segment elevation; T wave inversion without Q wave changes - these changes can remain for weeks to months
The nurse is listening to the heart sounds of a patient diagnosed as having a Pericardial Friction Rub. What is the KEY diagnostic tool in assessing for this disorder?
Heart sounds described as grating, scraping, squeaking, or crunching; the sounds are a result of friction between the roughened inflamed areas of the pericardium
What assessment tool would the nurse use to distinguish between a pericardial and pleural friction rub?
Have the patient hold his/her breath for a few seconds. If it continues, it's a pericardial rub not pleural.
The nurse knows that if the onset of Pericardial Effusion is rapid, an 80mL increase of fluid may cause enough compression of the heart to cause?
Shock and death
The nurse knows what three things are included in the "Beck's Triad" of Cardiac Tamponade?
decreased b/p, jugular vein distention, muffled heart sounds
When assessing a patient with Cardiac Tamponade, the nurse notices that the patient has developed Pulsus paradoxus. The nurse knows that this means?
It is a 10mmHg decrease of systolic b/p on inspiration as a result of pericardial swelling.
What are bacterial antibiotics and TB drugs used for in Cardiac Tamponade?
Used to treat the causative organism
The nurse knows that in a patient with myocarditis, the inflammation can affect what key function of the heart?
Affects the heart's ability to pump; can present as an emergency
What will the nurse assess for on the EKG of a patient diagnosed with Myocarditis?
Diffuse ST segment abnormalities, T wave changes, dysrhythmias and heart block
What are classification of drugs are used as part of immunosuppressive therapy of Myocarditis?
steroids; to reduce cardiac damage if autoimmune factors are present
What would antimicrobials be used for in a patient with Myocarditis?
If the myocarditis developed from a bacterial infection
What are classification of drugs are used in Myocarditis to prevent thrombi on heart walls?
What classification of drugs are used as needed in Myocarditis?
What classifications of drugs are used in patients with Myocarditis with CHF?
ACE inhibitors, Beta blockers, Dig, Diuretics
A nurse is taking care of a patient who recently had a prosthetic heart valve procedure from having Infective Endocarditis. The nurse knows that the patient can still develop an infection up to how many days and more post op?
Up to more than 60 days post op
The nurse knows that the most common skin bacteria causing Infective Endocarditis is?
Staph aureus
What classifications of drugs are used as IV antibiotic therapy for patients with Infective Endocarditis?
penicillins, cephalosporins, antitubercular drugs or if fungal organism - may require a combination of drugs
The nurse knows that after how many days, a patient with Infective Endocarditis who has no response to antibiotic therapy will need a valve replacement?
7-10 days
What is the blood culture procedure for a patient with Infective Endocarditis?
Blood cultures obtained from different sites 2x or 3x over a 24 hour period and may be incubated over 3 weeks.
What is important for the nurse to remember regarding cultures and antibiotics?
The nurse should always do cultures before administering antibiotics.
The nurse knows that a patient with Infective Endocarditis who is having a tracheo-esophageal echocardiogram (TEE) should be NPO before the procedure for how long?
6 hrs because conscious sedation is used; also observe pt for return of gag reflexes
What is the medical management for a patient with a nursing diagnosis of: Ineffective Tissue Perfusion r/t emboli formation, dislodging of a vegetative growth?
Administer anti-coagulants and monitor for therapuetic levels to keep emboli from forming throughout the body
What is the medical management for a patient with a nursing diagnosis of: Decreased Cardiac Output r/t action of diseased valve, increased body demands 2nd to infection, and 2nd to CHF?
Administer diuretics, inotropic agents, and Na diet to decrease fluid retention
What is the medical management for a patient with a nursing diagnosis of: Hyperthermia r/t the response to the cardiovascular disease process?
Administer antibiotics and anti-pyretic as necessary to treat the causative organism.
The nurse knows that a unique clinical manifestation of Aortic Valve Regurgitation is?
Musset's sign: head bobbing with each heartbeat
What does the nurse know when listening for heart sounds of a patient with Tricuspid Valve Disease?
Murmurs heard become louder with inspiration
The nurse knows that a patient who recieves a biological valve replacement does not usually require what classification of drugs?
The nurse knows that a patient on anticoagulant therapy should avoid?
ASA or anti-inflammatory drugs, foods high in vitamin K (green leafy vegetables, brocolli, asparagus, brussel sprouts, cabbage)
What should the nurse teach the patient on anticoagulant therapy about dental procedures?
The need to take antibiotics prior to invasive dental work to prevent endocarditis
Why are anticoagulants used in patients with Dilated Cardiomyopathy?
to prevent emboli
Why are diuretics used in patients with Dilated Cardiomyopathy?
to decrease fluid overload
Why are beta blockers and ACE inhibitors used in patients with Dilated Cardiomyopathy?
They may be able to slow or stop heart muscle damage
Why are antiarrythmics used in patients with Dilated Cardiomyopathy?
Control muscle irritability
Why is Dig used in patients with Dilated Cardiomyopathy?
For symptoms of HF
What classifications of drugs are used in patients with Hypertrophic Obstructive Cardiomyopathy to decrease obstruction and hypercontractility?
Negative inotropic meds (beta-blocking agents, calcium antagonist)
What classifications of drugs are used in patients with Hypertrophic Obstructive Cardiomyopathy and also have atrial fib?
Anticoagulants and Antiarrhythmic agents to prevent sudden cardiac death
What classifications of drugs are used in patients with Restrictive Cardiomyopathy?
antiarrhythmics, diuretics, beta or calcium channel blockers, anticoagulants
What classifications of drugs are used in patients with Arrhythmogenic Right Ventricular Cardiomyopathy?
beta blockers, antiarrythmics
Pulse deficit
The difference between the rate of an apical pulse and the rate fo a radial pulse
coronary artery disease
Risk factors for CAD
High cholesterol, cigarette smoking, diabetes, sedentary lifestyle, being male, high blood pressure, obesity, type A personality, family history, being female after menopause.
ACE inhibitors
Angiotensin Converting Enzyme Inhibitors
generic names of these drugs end in "PRIL"
work against the renin-angiotensin-aldosterone (RAA) system to dilate arteries and decrease resistance toblood flow in the arteries (reduce afterload) less fluid is retained because aldosterone release is blocked. Rx for HF, and some Hypertension and MI
Preoperative care; fear and anxiety (Ch 35)
determine what pt already knows and what the would like to know. Encourage pt. to identify feelings & explore the basis of the feelings. GOOD pt. teaching and individualized. NEVER ASSUME u know how they r feeling
3 types of angina
stable angina
occurs most often with exercise or activity and usually subsides w/ rest. Pain is usually substernal and described as vicelike, burning, squeezing or smothering. other symptoms: diaphoresis, dyspnea, nausea and vomiting. Often predictable andrelief is fast.
unstable angina
pain is more severe than stable, occurs at rest or minimal exersion, often not relieved by nitro,or requires more frequent (3)doses. Not predictable. Higher risk for AMI
variant angina
may not be associated with CAD. ST elevation may be seen then subsides and goes back to normal when pain is gone. usually treated w/ calcium channel blockers
Cardiac Rehabilitation
4 phases
1:inpatient management
2:immediately after discharge, telemetry monitoring during exercise
3: later rehab, unmonitored
4: maintenance
as soon as pt is stable begin to teach pt and family about exercise, meds, & diet. Purpose: minimalize risk of repetition and adverse cardiac events. Goal: highest level of wellness and work ability. It is individualized!
Heart murmur
sound produced by turbulent blood flow across the valves; when the do not close properly. timing is related to when it is heard in cardiac cycle: systole or diastole
Pulse oximetry
non-invasive measure of arterial O2 saturation
Stress test
non-invasive method of assessing presence and severity of CAD by recording cardiovascular response to exercise. Continuous ECG monitoring while pt uses treadmill or stationary bike. Every 2-3 min. the speed is increased until 1) pt cannot continue, 2) maximum HR is attained (220-pt's age=maxHR) 3) symptom's intervene,4)significant changes are detected on ECG
Stop sign's CAD=angina, dizzy, dyspnea, dysrhythmia, falling B/P
Cardiac catheterization
cath. is passedthrough artery and dye is injected. Radiographs are taken to visualize heart structures and vessels. B/P, P, ECG monitored during. PRE=Teach pt what to expect flushing sensation w/ dye inserted, allergies to seafood or iodine need to notify radiologist, NPO for specified time before cath., Give sedative if ordered, Obtain signed consent. POST= monitor puncture sight and pulses of extremity, maintain pressure per protocol. enforce bedrest
Cardiac enzymes=
are released when heart cells die as result of damage.
CREATINE KINASE=male=55-170,female=30-135
CK isoenzymes=MM=100%, MB=0%rises 4-6 hrs after AMI peak is 18-24hrs, return to normal 2-3days, BB=0%
TROPONIN T (cTnT)=less than 0.1,
TROPONIN I (cTnI)=less than 0.03,rise 3-6hrs from onset of symptoms and peak 12hrs, remain 10-14days,
MYOGLOBIN=less than 90, increased 1-4hrs. also found in skeletal muscles and can be elevated by exercise, renal failure, neuromuscular diseases-which makes it a difficult to use
Patient teaching for discharge after MI
take meds as prescribed(provide written instructions), low-fat & sodium diet to reduce weight and heart workload, cardiac rehab when available, stop smoking-it constricts vessels, refer to local chapter of AHA
Sign of hypokalelmia
(low potassium)
when pts are taking diuretics (except potassium sparring) monitor for signs and symptoms of a low potassium level=dysrhythmias, muscle weakness, and diminished bowel sounds.
delays impulse conduction through AVnode to slow HR, increases strength or force of myocardial contraction, increases stroke volume and CO. Used for HF, Afib and flutter, paroxymal atrial tachycardia. Hold dose and notify Dr. if apical P listened to for 1 full min. is less than 60.
Orthostatic postural hypotension
decreased Systolic BP with postural changes ussually 20mm, monitor for light headedness, dizzy, syncope. Instruct slow position changes, prolonged standing in one position, no taking long hot bath
Pulse quality (levels)
can be described as: regular, irregular, regularly irregular
graded with 4-point scale
0=abscent (not palpable)
1=weak or thready(easily obliterated with slight pressure that returns upon release)
2=normal(easily palpated)
associated with decreased blood flow tissue perfussion distal to occlussion, intermittent sharp, cramping, squeezing pain in legs after activity that subsides after rest. BURNING, ACHING PAIN W/ EXERCISE
Capillary refill
should be less than 3 sec, tissue perfussion
Homan's sign
positive if pain is felt during dorsiflection of calf muscle, INTENDED to dectect DVT, not reliable
Allen's test
occludes radial ulnar arteries then let go the circulation should return, should be done before ABG collection.
Assessing for Edema
press thumb into edema for 5 seconds
1=less than 1/4 in
2=1/4-1/2 in
3=1/2-1 in
4=more than 1 in
Arterial (insufficiency) stases ulcers
begins in TOES, painful,pale,crusty, located over bony prominences
Venous ulcers
begins in the ANKLES, develop very slowly, usually painless, difficult to heal.
Post angiogram care
bed rest several hrs, monitor pts vitals and pulses hourly for 6hrs. assess injection sight for bleeding, hematoma, pulsating mass, Neurovascular checks(pulses, sensation, movement, color, warmth)
How does walking help circulation
increases blood flow, good for Venous Vascular Disease
Buerger-Allen exercises
good for artery insufficiency(PVD)feet up till blanched for 2-3min.; then sit up w/ feet dangle until turn red for 5-10min.; then flex, extend, pronate, and supinate each foot 3x's; finally lie flat in supine position for 10 min.
Stress and PVD
stress causes vasoconstriction, which is detrimental to pt with comprimised circulation; resistance to blood flow is increased which reduces blood flow to tissue.
Vascular disease and elastic stockings
provide sustained even pressure over calves and thighs. this compresses superficial veins resulting in improved blood flow to deeper veins. put on in am an take off for skin assess 10-20min while legs are in nondependant position at least 2x's a day.
What would you teach pt. about dangling his legs
dangling enhances arterial blood flow, elevating legs above heart promotes venous return
Signs of bleeding when pt. is on warfarin
Notify Dr. if blood is evident in urine, stool, emesis, or integument. exsessive bruising, gums bleeding, antidote vit K
Postoperative care after vein ligation and stripping
elevating extremety helps prevent edema, encourage mov't to prevent stasis w/i leg, monitor pts vitals and pulses complaints of pain, capillary refill, Neurovascular checks(pulses, sensation, movement, color, warmth) Do not leave legs in dependant position or cross legs. anti- coagulants given to prevent thrombus.
ringing in the ears overdose of aspirin
Important postoperative sign/event that needs to be reported
changes in vitals and bleeding
Postoperative abdominal aortic aneurysm
monitor vital's, hemodynamic status, RENAL FAILURE, and fluid balance; inspect and palpate extremities for color, warmth, and peripheral pulses. BOWEL SOUNDS, lung sounds, STRICT I&O 30ML/HR
Varicose veins
heaviness, edema, muscle fatigue, cramps
varicosities ar dialated, tortuous, superficial veins; rusults from incompetent valves in the veins that cannot prevent backflow of blood. Result from: hereditart weakness, aging, pregnancy, obesity, prolonged standing. Restrictive clothing aggrivates. can occur in esophageal and hemorrhoidal veins also
Normal blood pressure
Hypertension and older adults
REDUCED ELASTICITY causing decrease in CO and increase in PVR
Modifiable risks for hypertension
weight reduction, stop smoking, sodium and alcohol restriction, exercise and relaxation techniques.
prolonged hypertension constricts and damages cerebral arteries which puts patient at risk for cerebrovascular accident or CVA(stroke);TIA transient ischemis attack(mini-stroke) a thrombus(clot) occludes vessel or a rupture of blood vessel. hypertension gives 7fold increased risk.
Patient teaching for person on antihypertensive medications; drug therapy table
teach about possible orthoBP change position slowly, monitor BP
Why are older adults more at risk foe side effects like orthostatic hypotension
fall risk; sedation
DASH diet
HIGH IN: fruits, veggies, low fat dairy, whole grains, poultry and fish, nuts, possium, calcium, magnessium; protein and fiber. LOW IN:saturated fat, total fat, cholesterol, red meat, sugared bev., salt and sodium.
Circulatory assessment, pg. 689
chief complaint and history of present illness, medical history, family history, review of systems, functional assess. physical exam:vitals, skin, heart sounds, lung sounds, extremities, diagnostic tests and procedures
Conduction pathway for cardiac contraction
SAnode (pacemaker) initiates impulse whichmakes atria contract,impulse is carried throughout atria to AVnode located on the floor of the RA. Impulse is delayed in AVnode then transmitted to the ventricles through the bundle of His; which is made of Purkinje cells divided into left and right bundle branches. The terminal ends of both sides are the Perkinje Fibers; where when the inpulse reaches causes the ventricles to contract.
cool limb suggests
arterial problem
warm limb suggests
venous problem
upon assesment you find a pulsating mass to the left of umbilicus while palpating ABD
could be aneurism
decreased temp. at ischemic site
paleness, over an area of decreased blood supply
reddish brownish discoloration of the extremities; indicative of severe arterial occlisive damage in vessels that remain dilated and unable to constrict
fight or flight
rest and digest
ACE inhibitor
Vasotec decreases B/P
symptoms of Hypertension Crisis
severe headache, blurred vision, nausea, restlessness, confusion
Complication of prolonged Hypertension
Renal failure
ventricles contract
amount of blood remaining at the end of dyastole
To increase O2 in the Myocardium
give supplement O2
A factor that aggrivates PVD
smoking and stress
A concern with hypertension
w/o symptoms
silent killer
What is a possible concern with the elderly taking lasix
fall risk
Deep venous thrombosis is the formation of a blood clot in a vein that is deep inside a part of the body, usually the legs. Symptoms: Changes in skin color (redness) in one leg; Increased warmth in one leg; Leg pain in one leg
to improve O2 of embolism or SOA
supplement O2; HOBup
signs and symptoms of lymphangitis
enlarged lymph nodes
what receives blood from the superior and inferior vena cava's
Right atrium
what are the terminal ends of the right and left branches of the heart
perkinje fibers
cardiac cells loose thier internal negativity
epinephrine and norepinephrine
hormones released
what is the cause of primary hypertension
numb, tingle, cool, pale skin, palor
what are the layers of the heart from inside out
SAnode also called
Pacemaker for the heart
Atrioventricular valves
tricuspid on right and bicuspid(mitral)on left
sounds of cardiac cycle
lub, dub
if the b/p cuff is to small what will be the result
increased b/p
do you need a signed consent for a stress test
which area in the heart is strongest
Left ventricle
name the valves in the heart
How many impulses does the SA node generate per minute
collateral circulation
results over time when the is an occlusion
AV node
death of tissue
cool temp in an area
why are women past childbearing age at greater risk for heart attacks than they were before menopause?
estrogen protection
What does PQRST mean when assessing patient for chest pain?
P-precipating factors (activity), Q- quality(pressure, squeezing,burning) R-radiation S-S&S (diaphoresis, pallor, weak) T- timing (sudden, constant)
What are some respiratory signs associated with chest pain?
DOE, PND, Orthopnea
What does a person's skin look like when they might be having chest pain or an MI?
pallor, cyanosis
What are some things you would inspect for when assessing the heart patient?
clubbing, cap refill, peripheral edema, JVD
Where would you listen anatomically for the mitral area?
5th ICS
pulmonic area?
2nd ICS along the left sternal border
aortic area?
2nd ICS along the right sternal border
tricuspid area?
5th ICS at left lower sternal border
erbs point?
3rd ICS left sternal border
What is the point of maximum impulse?
5th ICS left midclavicular line
if the point of maximum impulse moves laterally, what does this indicate?
left ventricular hypertrophy
if you hear an S3 (ventricular gallop) what might this mean?
early sign of HF
if you hear an S4 (atrial gallop) what might this mean?
if older than 50, a systolic BP greater than 140 is important to what dieases risk factors?
CVA, and CV
What is the procedure called when you measure the BP of brachial artery 2x with doppler, then measure BP above malleolus at dorsalis pedis & posterior tibial 2x. Divide the ankle by brachial.
Ankle/Brachial index
An ankle brachial index of <1.0 indicates ???
arterial obstruction
an ankle brachial index of <0.8 indicates???
moderate PVD
an ankle brachial index of <0.5 indicates???
severe PVD
a lab test (diagnostic test) for troponin is specific to what?
cardiac muscle only. any rise in Troponin is diagnostic and is used in early dx.
CK-MB is a diagnostic test specific to what?
cardiac or myocardial damage.
in CK-MB test, you can see the peak level within how long of injury?
24 hours after onset of pain
what is Myoglobin used for?
used to rule out MI in early stages
Lipid profile measures?? (4 things)
cholesterol. triglycerides. HDL, LDL.
Total cholesterol desirable levels?
200 mg
Triglycerides desirable level?
HDL desired level?
LDL desired level?
<100 and <70 with CV disease
smoking, alcohol, coffee, sugar, obesity all raise ___ levels.
Measures the amount of time it takes for the blood to clot. Used to monitor therpeutic effects of heparin.
.PTT (partial thromboplastin time)-
What is the normal range for PTT?
60 to 70 seconds.
What is the therapeutic range for PTT?
90 to 140 seconds (1 to 2 x the normal)
What is APTT?
aptt is the modified ptt. it adds the clotting factors to activate the blood sample before timing the clot. Removes the time variable. How long does it take for this persons blood to form a clot?
What is the normal APTT?
30 to 40 seconds
A measure of an activity of prothrombin, fibrinogen, clotting factors, and the time it takes for a firm fibrin clot to form.
PT (prothrombin time)
What is PT used for?
Used to elevate the therapeutic effects of anticoagulants like Coumadin (warfarin)
What is the normal PT?
11-12 sec
PT is similar to what other diagnostic test?
INR ratio
INR normal range is ??
0.7 to 1.8
BUN elevation is seen with??
After a stress test, the patient should take a hot shower T or F?
False. causes vasodilation.
What is purpose of stress test?
the cardiacs response to increased workload
Which test measures ventricular wall motion & ejection fraction as the patients ECG is synchronized with pictures taken of the blood passing through the heart.
What is the most invasive test?
Cardiac cath!
What might you explain to a pt who is about to receive a cardiac cath?
may experience palpitations, warm sensation when dye in injected, desire to cough when dye injected
Post op cardiac cath?
bed rest, remain still, dont flex extremities
which disease is a narrowing of the coronary arteries from either plaque, stricture, or clot that prevents adequate blood flow to myocardium causing ischemia and/or infarction?
Coronary Artery Disease (CAD)
lack of oxygen
dying heart muscle
disorders or complications of CAD?
angina, HF, MI, HTN
what is the leading cause of death in the US with one death occuring every 40 seconds?
Cardiovascular disease (CVD)
To have metabolic syndrome, you must have 3 of 5 possible conditions...what are they?
HTN, DM, decreased HDL, increased triglycerides, large waist circumfrence
chest pain that has a predictable pattern, feels the same each time it occurs, lasts the same amt of time, always relieved by NTG or rest.
Stable angina
which type of angina is assoc.w/ fixed artherosclerotic plaque?
stable angina
chest pain that is unpredictable. occurs while at rest or at night. last longer than 15 mintues. not relieved with NTG or rest.
unstable angina
chest pain that occurs at rest with ST elevation on the EKG due to artery spasm
Variant chest pain
patient has never had chest pain symptoms before. this is their first time.
New-onset angina
chest pain that occurs days or weeks before MI
Women are more likely to have S&S of atypical angina, what are some atypical S&S?
pain between shoulders, aching jaw, choking sensation, feeling of indigestion
what does Morphine do for person having MI?
relieves pain, decreases O2 demand
what does NTG do for person having MI?
dilates arteries, decreases venous return
what does aspirin do for a person having MI?
prevents clot formation
what do ACE inhibitors do?
prevents ventricular remodeling
patients that are on drugs for ED also do what to the BP which could be a risk for someone taking new heart medications?
Ed drugs lower BP bc they are vasodilators. Patients should not take these drugs together.
the physiologic state in which heart is unable to pump enough blood to meet the metabolic needs of body at rest or exercise.
Heart failure
pt can move back and forth between classifications
New York Heart classifications
progressive in nature. based on symptoms that are additive.
AHA/American college of cardiology
what is the best indicator for fluid overload?
most important in assessment of HF?
assessing LV ejection fraction with Echocardiogram. should be 50 to 70%
ACE inhibitors most common side effect?
what type of medication teaching would you give for a person taking digoxin?
teach them how to take their pulse before they take it to make sure its not already low bc dig can lower BP
what is the normal range for digoxin levelS?
DO NOT take digoxin with what two things?
antacids and/or laxatives
what are some signs of dig toxicity?
loss of appetite, N/V, diarrhea, palpitations, visual changes (halo)
Infection of the endocardium
Usually affects the valves
Usually bacterial in origin (staph or strep)
Clumps of fibrin, leukocytes, platelets, microbes adhere to valves - microembolization into lungs and systemic circulation
Risk factors for Endocarditis
IV drug abuse
History of congenital heart disease
Invasive procedures
Symptoms of Endocarditis
Fever, chills, malaise, fatigue
Arthralgia, myalgia
Splinter hemorrhages in nail beds
New or worsened murmur
HF symptoms
Symptoms related to emboli
Diagnosis of Endocarditis
Blood cultures
Cardiac cath
Treatment of Endocarditis
Antibiotics - atleast 6 weeks
Valve surgery
Prophylactic antibiotics before invasive procedures
Nursing Dxs related to Endocarditis
Decreased CO
Activity Intolerance
Fluid accumulation in pericardial space which compresses the heart and decreases CO
Caused by:
Cardiac surgery, invasive procedures (PMR insertion, cardiac cath)
Autoimmune diseases (RA, lupus, scleroderma)
Symptoms of Pericarditis
Pericardial friction rub
Muffled heart sounds
Acute sharp chest pain
Worse when lying down, DB, moving the trunk
Better when sitting up and leaning forward
Dyspnea—rapid shallow breaths in response to pain

Patient will be SOB and may be confused, agitated, and tachycardic
Diagnosis of Pericarditis
Pericardial tap to determine cause
Treatments of Pericarditis
Treat underlying cause
Nursing Considerations r/t Pericarditis
Careful assessment - r/o MI
Manage pain - positioning, NSAIDs (monitor for GIB)
Manage anxiety
Prepare for possible pericardial tap
Mitral Valve Stenosis
Most commonly due to Rheumatic HD
Left atrium is pumping hard to get to the left ventricle - back flow into the lungs
Mitral Valve Stenosis Symptoms
Pressure overload in LA, pulmonary vasculature, and RV - pulmonary congestion and R-sided HF
May have emboli from stagnant blood in RA
Mitral Valve Regurgitation
Acute due to damage from MI, rupture of chordae tendineae - emergency

Chronic due to rheumatic HD, endocarditis
Mitral Valve Regurgitation Symptoms
Acute: pulmonary edema and shock, new murmur
Chronic: Weakness, fatigue, exertional dyspnea
Mitral Valve Prolapse
Most common form of valvular HD in US
Valve leaflets buckle back into the LA
Usually benign

Complications: Endocarditis, Mitral regurg
Diagnosis of Valve Disorders
Echo - primary diagnostic tool for valves
Cardiac cath
Medications for Valve Disorders
Prophylactic antibiotics
Antiplatelet/ anticoagulants
Beta blockers
Other treatments for valve disorders
Percutaneous baloon valvuplasty
Valve repair or replacement

Kinds of valve replacement:
Mechanical requires lifelong anticoaguation
Biologic (porcine, cadaver)—don't last as long
Peripheral Artery Disease
Atherosclerotic process

Common sites:
Arotic bifurcation
Distal popliteal

Non diabetics: usually invovles the femoral-popliteal area
Diabetics: arteries below the knee
PAD Symptoms
Intermittent claudication—leg pain with activity, relieved by rest
Impotence with arotoiliac occlusion
Constant pain w severe disease
Decreased or absent pulses
Cool to touch
Cap refill > 3 sec
Smooth round ulcers, "punched out"
Skin: shiny, thin, taut, hair loss
Elevation pallor, dependent rubor
PAD Complications
Non healing ulcers over bony prominences of the feet and lower leg
PAD Diagnosis
Doppler to assess pulse
Ankle-brachial index (ABI)
Calculate by dividing the ankle SBP by brachial SBP. Should be about equal (0.9-1.3) The lower the number, the worse the PAD.
<0.40 indicates severe disease
Duplex imaging—noninvasive, maps blood flow
PAD Treatments
Similar to CAD - Treat hyperlipidemia & BP, decrease platelet aggregation, smoking cessation
Control high BS in diabetics
Exercise therapy
Wound care, prevent further skin breakdown
Nursing Dxs r/t PAD
Ineffective tissue perfusion
Impaired skin integrity
Acute pain
Activity intolerance
Venous Thromboembolus (VTE)
Most common venous disorder
Superficial or deep (DVT—deep vein thrombosis)
Superficial due to IV therapy
DVT - Post op, immobility
Causes of VTE
Virchow's Triad - venous stasis, damage to the endothelium (trauma or surgery, pressure, IV therapy), hypercoagulability
VTE: Thrombophlebitis
Symptoms of superficial thrombophlebitis:
Palpable firm cord-like vein
Surrounding area tender to palp, warm, red
May be edematous

Application of warm moist heat
DC IV if related
TEDs to decrease venous stasis
May be asymptomatic
Unilateral leg edmea extermity painful, skin warm to touch, red
Positive Homans sign

PE (emergency)
VTE: Pulmonary Embolus (PE)
Common pulmonary complication in hospitalized pts
Most common from DVT but can also be fat or air embolus
Sometimes first sign of DVT
Symptoms of PE
Severity of S/S depend on size of emboli & size and number of involved vessels
Sudden onset of dyspnea, tachypnea, tachycardia
Cough, hemoptysis
Pleuritic chest pain
Anxiety, MS changes due to hypoxia
Sudden death
DVT/PE Diagnosis
D dimer (if neg, low probability, but high rate of false positives)
Venous dopplers
Duplex scanning
Lung Scan (VQ-ventilation/perfusion)
Pulmonary angiography
Spiral CT
VTE Prophylaxis
Early ambulation
TEDs to decrease venous stasis
Sequential/intermittent compression devices (SCDs)
Anticoagulation for high risk patients
VTE Treatment
Anticoagulation: LMWH, heparin, Coumadin
Oxygen for PE
Vena cava filter
four chambered hollow muscular oragan size of a fist
serous membrane on the outside of the heart
constructed of cardiac muscle
lines the inner surface of the chambers of the heart
Right atrium
receives deoxygenated blood
Left atrium
receives oxygenated blood
Right ventricle
pumps deoxygenated blood
Left ventricle
pumps oxygenated blood powerhouse
Atrioventricular valves
Tricuspid and bicuspid valves
Semilunar valves
Pulmonary and aortic semilunar valves
An inherent ability of the heart muscle tissue to contract in a rhythmic pattern
The ability to respond to a stimulus
Impulse pattern
Sinoatrial node to AV node to bundle of His to right and left bundle branches to Purkinje fibers
Cardiac cycle
A complete heartbeat
Atria contract while ventricles relax
Ventricles contract while atria relax
Phase of contraction
Phase of relaxation
Period between contraction of the atria or ventricles during which the blood enters the relaxed chambers
Coronary blood supply
Right and left coronary arteries
Branch off of the aorta
Encircle the heart like a crown
Supply the myocardium with blood
Coronary veins
Return the unoxygenated blood to the coronary sinus, then to the right atrium
Systemic circulation
Circulates blood from the left ventricle to all parts of the body and back to the right atrium
Carries oxygen and nutritive materials to all body tissues and removes products of metabolism
Pulmonary circulation
Circulates blood from the right ventricle to the lungs and back to the left atrium of the heart
Carries deoxygenated blood to the lungs to be reoxygenated and removes the metabolic waste product, carbon dioxide
Nonmodifiable factors
Family history
Sex (gender)
More common in women
African american
Modifiable factors
Diabetes mellitus
Sedentary lifestyle
Oral contraceptives
Psychosocial factors
Cardiac dysrhythmias
Any cardiac rhythm that deviates from normal sinus rhythm
Sinus tachycardia
Sinus bradycardia
Supraventricular tachycardia
Atrial fibrillation
Atrioventricular block
Premature ventricular contractions
Ventricular tachycardia
Ventricular fibrillation
Cardiac Arrest
The sudden cessation of cardiac output and circulatory process
Cause: ventricular tachycardia, ventricular fibrillation, and ventricular asystole
Signs and symptoms: abrupt loss of consciousness with no response to stimuli; gasping respirations followed by apnea; absence of pulse and blood pressure; pupil dilation; pallor and cyanosis
Treatment: cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS)
Coronary artery disease (CAD)
A variety of conditions that obstruct blood flow in the coronary arteries
A common arterial disorder characterized by yellowish plaques of cholesterol, lipids, and cellular debris in the inner layers of the walls of the arteries; the primary cause of atherosclerotic heart disease (ASHD)
Angina pectoris
Cardiac muscle is deprived of oxygen
Increased workload on the heart
symptoms: Pain (usually relieved by rest)
Anxiety; apprehension
how Nitro is administered at home
Nitroglycerin dilate blood vessels
Sublingual at home at the onset of chest pain, stop activity, place one wait 5 min place another one wait 5 min wait place a 3rd one then if pain still present then call 911.
Percutaneous transluminal coronary angioplasty (PTCA)
open vessels in the heart
Coronary artery bypass graft (CABG)
very risky
Myocardial infarction
heart attack
Occlusion of a major coronary artery or one of its branches with subsequent necrosis of myocardium
Most common cause is atherosclerosis plaque
Ability of the cardiac muscle to contract and pump blood is impaired
clinical manifestations of a MI
Asymptomatic (silent MI)
Pain (not relieved by rest, position, or nitroglycerin) watch vitals hypotensive and tachycardiac
SOB; dizziness; weakness
Pallor—ashen color
Sense of impending doom
Labs elevated levels of SGOT, elevated AST elevated PCKMB, elevated LDH, elevated TRIPONIN\
MONA, morophine, oxygen,nitrates, aspirin ER response
Medical management/nursing interventions of Angina
Surgical interventions
Coronary artery bypass graft (CABG) very risky
Percutaneous transluminal coronary angioplasty (PTCA) open vessels in the heart
Stent placement
Medical management/nursing interventions
of MI
Fibrinolytic agents clot destroyer
Percutaneous transluminal coronary angioplasty (PTCA)
Coronary artery bypass graft surgery
Pharmacological management
Vasopressors, analgesics, nitrates, beta-adrenergic blockers, calcium channel blockers, antidysrhythmics, diuretics, inotropic agents, diuretics, stool softeners
Fibrinolytic agents
clot destroyer
Heart failure
fails to act act normally Abnormal condition characterized by circulatory congestion resulting from the heart's inability to act as an effective pump
symtoms of HF
Decreased cardiac output
Anxiety; restlessness
Oliguria cant pee
Decreased GI motility
Pale, cool skin
Weight gain
Left ventricular failure
Pulmonary congestion
Paroxysmal nocturnal dyspnea
Cough; frothy, blood-tinged sputum secondary to pulmonary edema
Pulmonary crackles
Pleural effusion (x-ray)
most common
Right ventricular failure
Distended jugular veins
Anorexia, nausea, and abdominal distention
Liver enlargement
Ascites - fluid in stomach
Edema in feet, ankles, sacrum; may progress up the legs into thighs, external genitalia, and lower trunk
usually cause by Left Ventricular Failure
Medical management/nursing interventions
Pharmacological management
Increase cardiac efficiency
ACE inhibitors (decrease blood pressure)
Bed rest, HOB elevated
Treat edema and pulmonary congestion with diuretics no sodium or fluids
Monitor fluid retention (weigh same time post void daily; strict I&O)
A sustained elevated systolic blood pressure greater than 140 mm Hg and/or a sustained elevated diastolic blood pressure greater than 90 mm Hg.
Vasoconstriction (increases blood pressure )
Essential (primary) hypertension
Primary don't know why have it
Secondary hypertension
caused by salt,
Attributed to an identifiable medical diagnosis
90% to 95% of all diagnosed cases
symptoms of Hypertension
Headache; blurred vision
Medical management/nursing interventions
of Hypertension
Pharmacological management
Antihypertensive medications; diuretics
Dietary recommendations
Weight control, reduction of saturated fats, and low sodium
No smoking
Arterial embolism
Blood clots in the arterial bloodstream
May originate in the heart
Foreign substances
symptoms of Aterial Embolism
Absent distal pulses
Pale, cool, and numb extremity
Tiny blood vessels joining arterioles and venules
Large vessels carrying blood away from the heart
Vessels that convey blood from the capillaries to the heart
Pulse deficit
the difference between the apical and radial pulse rates
Risk factors for CAD
Age (male older than 45, female older than 55 or postmenopausal) HTN, smoking, hyperlipidemia, diabetes, family history,obesity,stress
ACE inhibitors
Enalapril (Vasotec)
Captopril (Capoten)
Lisinopril (Zestril)
Preoperative care; fear and anxiety
accurate information about what to expect-physical comfort, back rub-If pt anxiety remains to high notify doctor
Difference between angina and unstable angina
angina (also called chronic angina or exertional angina) occurs most often with exercise./ unstable angina. occurs when at rest and is not relieved by NTG
cardiac rehabilitation
exercise program that is individualized for each patient.
1) inpatient management
2) immediately after discharge, using telemetry monitoring during exercise
3) later rehab, which is unmonitored
4) maintenance
Heart mumur
a heart sound that reflects damaged or abnormal heart valves
pulse oximetry
a noninvasive method of measuring oxygen in the blood by using a device that attaches to the fingertip
stress test
ECG taken under controlled exercise stress conditions, an electrocardiogram plus blood pressure and heart rate measurements shows the heart's response to physical exertion (treadmill test)
Cardiac catheterization
a catheter is passed through a vein or artery into the heart to withdraw samples of blood; to measure pressures within heart chambers or vessels; and to inject contrast media for fluoroscopic radiography and cine film imaging of the chambers of the heart and coronary arteries
Cardiac enzymes
Creatine Phosphokinase (CPK)-male:55-170U/L,
CPK Isoenzymes MM: 100%
MB: 0%
BB: 0%
Troponin T (cTnT) <0.1ng/ml
Troponin I (cTnI) <0.3ng/ml
Myoglobin Male: <92ng/ml
Female: <76ng/ml
Patient teaching for discharge after MI
take meds, low-fat low-sodium dietcardiac rehab, stop smoking, maintain weight, AMA use resources, exercise
sign of hypokalemia
anorexia, abdominal distention, vomiting, diarrhea, muscle cramps,weakness,dysrhythmias, postural hypotension, dyspnea, shallow respirations confusion depression, polyuria,and nocturia
cardiac glycosides; induce inotropic effects, cardiac output, tissue perfusion; treat cardiac failure and congestive heart failure
Orthostatic postural hypotension
occurs when a person's BP drops suddenly on moving from a lying position to a setting or standing porition.
pulse quality (levels)
pain associated with decreased perfusion that is aggravted by exercise-can affect any major muscle group
capillary refill
the amount of time it takes for capillaries that have been compressed to refill with blood
Homan's sign
The patient is positioned in supine. The therapist maintains the leg in extension and passively dorsiflexes the patient's foot. A positive test is indicated by pain in the calf and may be indicative of deep vein thrombophlebitis.
Allen's test
Check for patency of the radial or ulner arteries.
Palm up - Have person make a fist, occlude both radial and ulnar arteries, have client release fist, look for pale color @ palm of hand, release pressure on ulnar artery, watch for color to return to hand. (should pink up within 3-5 seconds if ulnar artery is patent). (Pallor to hand persists if arterial insufficiency or occlusion to artery). Repeat for radial artery.
assessing for edema
press hmb into the edematous area for about 5 seconds- the severty is graded 1-4 less than 1/4 in=1; 1/4to 1/2in=2; 1/2 to 1in.=3; and more than 1inch= 4 depression remains= pitting edema
Arterial stases ulcers
arterial stasis begin as ulcerations on the toes- painful, pale, crusty and located over bony prominences
venus ulcers
begins as ulcers on the ankles-develope slowly and are usually painless and difficult to heel
post angiogram care
stimulate circulation, monitor tissue perfusion-circulation assessment 5-Ps Pain, Pulse, Pallor, Paresthesia (sensation), Paralysis (movement)
treadmill stress test
Non-invasive test used to test the heart condition in a controlled exercise condition using an ECG is called?
how does walking help circulation?
Walking contracts the muscles of the lower extremities, pushing venous blood upward toward the heart and promoting the developement of collateral circulation
Buerger-Allen exercises
Done for Peripheral Vascular Disease,1. Elevate and support legs @ 45-90 degree angle for 2 to 3 minutes or until skin blanches. 2. Sit with feet in a dependant position so the skin turns red. Support the legs in this position for 5 to 10 minutes. Then Flex, Extend, Pronate, and Supinate each foot for 3X. 3. Lay flat in a supine position for 10 minutes. -Page. 694
Stress and PVD
stress causes peripheral vasoconstriction, restriction to blood supply that is already compromised
vasular disease and elastic stockings
prevents venous pooling and stimulates circulation-ted hose
What would you teach pt. about dangling his legs?
Buerger- Allen exercises-improve blood flow
signs of bleeding when pt. is on warfarin
the heart muscle
tricuspid valve
separates the RA from the RV
mitral (bicuspid) valve
separates the LA from the LV
backflow (during systole, the valves close to prevent the backflow of blood into the atria)
pulmonic valve
separates the RV from the pulmonary artery
aortic valve
separates the LV from the aorta
2/3 of the caqrdiac cycle, consists of relaxation and filling of the atria and ventricles
consists of the contraction and emptying of the atria and ventricles
myofibril sarcomere
the basic contra tile unit of the myocardial cell
cardiac output
the amount of blood pumped from the LV each minute (depends on the relationship between HR and SV; it is the product of these two variables)
HR x SV = ?
cardiac index
can be determined by dividing the CO by the BSA (normal range is 2.7 to 3.2 L/min/m2 of BSA)
refers to the number of times the ventricles contract each minute.
stroke volume
the amount of blood ejected by the LV during each contraction.
refers to the degree of myocardial fiber stretch at the end of diastole and just before contraction
the pressure or resistance that the ventricles must overcome to eject blood through the semilunar valves and into the peripheral blood vessels.
the peripheral component of afterload; is the pressure that the heart must overcome to open the aortic valve
systemic vascular resistance
a combination of blood viscosity (thickness) and arteriolar constriction
myocardial contractility
affects SV and CO and is the force of cardiac contraction independent of preload
systolic BP
the amount of pressure/force generated by teh left ventricle to distribute blood to the aorta with each contraction of the heart; It is a measure of how effectively the heart pumps and is an indicator of vascular tone.
diastolic BP
is the amount of pressure/force against the arterial walls during the relaxation phase of the heart
are in the arch of the aorta and at the origin of the internal carotid arteries; they are stimulated when the arterial walls are stretched by an increased BP; impulses from these _________inhibit the vasomotor center, which is located in the pons and the medulla; inhibition of this center results in a drop in BP
peripheral chemoreceptors
these receptors are sensitive primarily to hypoxemia (a decrease in the partial pressure of arterial oxygen (PaO2); When stimulated, these chemoreceptors send impulses along the vagus nerves to activate a vasoconstrictor reesponse and raise BP
an increase in partial pressure of arterial CO2; along with acidosis, also stimulate the central chemoreceptors in the respiratory center of the brain
hydrostatic pressure
the force of the weight of water molecules pressing against the confining walls of a space
the number of packs per day multiplied by the number of years the patient has smoked
a BMI of 25 - 30
BMI > 30
dyspnea that appears when he or she lies flat
paroxysmal nocturnal dyspnea (PND)
develops after the patient has been lying down for several hours. In this position, blood from the lower extremities is redistributed to the venous system, which increases venous return to the heart. A diseased heart cannot compensate for the increased volume and is ineffective in pumping the additional fluid into the circulatory system. Pulmonary congestion results. The patient awakens abruptly, often with a feeling of suffocation and panic. He or she sits upright and dangles the legs over the side of the bed to relieve the dyspnea. This sensation may last for 20 minutes.
A feeling of fluttering or unpleasant feeling in the chest caused by an irregular heartbeat
A sudden weight increase of 2.2 pounds (1 kg) can result from excess fluid (1 L) in the interstitial spaces. Weight gain is the best indicator of fluid retention. This condition is commonly known as _______. It is possible for weight gains of up to 10 to 15 pounds (4.5 to 6.8 kg, or 4 to 7 L of fluid) to occur before edema is apparent. Ask whether the patient has noticed a tightness of shoes, indentations from socks, or tightness of rings.
brief loss of conscioiusness; The most common cause is decreased perfusion to the brain. Any condition that suddenly reduces cardiac output, resulting in decreased cerebral blood flow, can lead to a syncopal episode. Conditions such as cardiac rhythm disturbances, especially ventricular dysrhythmias, and valvular disorders, such as aortic stenosis, may trigger this symptom.
refers to dizziness with an inability to remain in an upright position. Explore the circumstances that lead to dizziness or syncope.
intermittent claudication
Patients who report a moderate to severe cramping sensation in their legs or buttocks associated with an activity such as walking have ___________ ___________related to decreased arterial tissue perfusion. Claudication pain is usually relieved by resting or lowering the affected extremity to decrease tissue demands or to enhance arterial blood flow.
generalized edema
A bluish or darkened discoloration of the skin and mucous membranes in light-skinned people is referred to as _______. This condition results from an increased amount of deoxygenated hemoglobin. It is not an early sign of decreased perfusion but occurs later with other symptoms. Dark-skinned patients may experience cyanosis as a graying of the same tissues.
dusky redness that replaces pallor in a dependent foot (suggests arterial insufficiency).
The angle of the normal nail bed is 160 degrees. With ______, the nail straightens out to an angle of 180 degrees, and the base of the nail becomes spongy.
a systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher, or taking drugs to control blood pressure. A blood pressure that exceeds 135/85 mm Hg increases the workload of the left ventricle and oxygen consumption of the myocardium.
includes blood pressure (BP) readings of 120 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic without antihypertensive drug therapy. Prehypertensive patients are at a high risk for developing hypertension. (Normal BP is a systolic blood pressure less than 120 mm Hg and diastolic blood pressure less than 80 mm Hg.)
paradoxical blood pressure
an exaggerated decrease in systolic pressure by more than 10 mm Hg during the inspiratory phase of the respiratory cycle (normal is 3 to 10 mm Hg). Certain clinical conditions that potentially alter the filling pressures in the right and left ventricles may produce a paradoxical BP. Such conditions include pericardial tamponade, constrictive pericarditis, and pulmonary hypertension.
pulse pressure
The difference between the systolic and diastolic values
ankle-brachial index (ABI)
can be used to assess the vascular status of the lower extremities. A BP cuff is applied to the lower extremity just above the malleolus. The systolic pressure is measured by Doppler ultrasound at both the dorsalis pedis and posterior tibial pulses. The higher of these two pressures is then divided by the higher of the two brachial pulses to obtain the ABI.
toe brachial pressure index (TBPI)
may be performed instead of or in addition to the ABI to determine arterial perfusion in the feet and toes. [TBPI is the toe systolic pressure divided by the brachial (arm) systolic pressure.]
jugular venous distention (JVD)
an increase in jugular venous distention (JVD) causes _____ ______ ______.
pulsus alternans
a weak pulse alternates with a strong pulse despite a regular heart rhythm. It is seen in patients with severely depressed cardiac function. They may be asked to hold their breath to exclude any false readings. You can palpate the brachial or radial arteries to assess this condition, but it is more accurately assessed by auscultation of blood pressure.
swishing sounds that may occur from turbulent blood flow in narrowed or atherosclerotic arteries. Assess for the absence or presence of bruits by placing the bell of the stethoscope over the skin of the carotid artery while the patient holds his or her breath. Normally there are no sounds if the artery has uninterrupted blood flow. A bruit may develop when the internal diameter of the vessel is narrowed by 50% or more, but this does not indicate the severity of disease in the arteries. Once the vessel is blocked 90% or greater, the bruit often cannot be heard.
apical impulse OR point of maximal impulse (PMI)
Pulses in the mitral area (the apex of the heart) are considered normal and are referred to as the _____ _____ or the _____ __ ____ _____
The PMI should be located where?
at the left fifth intercostal space (ICS) in the midclavicular line. If it appears in more than one ICS and has shifted lateral to the midclavicular line, the patient may have left ventricular hypertrophy.
paradoxical splitting
Abnormal splitting of S2; has a wider split heard on expiration. _____ _____ of S2 is heard in patients with severe myocardial depression that causes early closure of the pulmonic valve or a delay in aortic valve closure. Such conditions include myocardial infarction (MI), left bundle-branch block, aortic stenosis, aortic regurgitation, and right ventricular pacing.
ventricular gallop
S3 is called a _____ ______
atrial gallop
S4 is referred to as _____ _____
S3 and S4 sounds can be caused by?
decreased compliance of either or both ventricles.
reflect turbulent blood flow through normal or abnormal valves. They are classified according to their timing in the cardiac cycle: systolic ________(e.g., aortic stenosis and mitral regurgitation) occur between S1 and S2, whereas diastolic _______(e.g., mitral stenosis and aortic regurgitation) occur between S2 and S1. _______can occur during presystole, midsystole, or late systole or diastole or can last throughout both phases of the cardiac cycle. They are also graded according to their intensity, depending on their level of loudness.
pericardial friction rub
originates from the pericardial sac and occurs with the movements of the heart during the cardiac cycle. Rubs are usually transient and are a sign of inflammation, infection, or infiltration. They may be heard in patients with pericarditis resulting from MI, cardiac tamponade, or post-thoracotomy.
a myocardial muscle protein released into the bloodstream with injury to myocardial muscle. _______ T and I are not found in healthy patients, so any rise in values indicates cardiac necrosis or acute MI. Specific markers of myocardial injury, troponins T and I, have a wide diagnostic time frame, making them useful for patients who present several hours after the onset of chest pain.
creatine kinase (CK)
an enzyme specific to cells of the brain, myocardium, and skeletal muscle. The appearance of ____ in the blood indicates tissue necrosis or injury, with levels following a predictable rise and fall during a specified period.
Another early marker of an MI is _______. _______, a low-molecular-weight heme protein found in cardiac and skeletal muscle, is the earliest marker detected—as early as 2 hours after an MI with rapid decline after 7 hours. Because myoglobin is not cardiac specific and is found in skeletal and cardiac muscle, its clinical usefulness is more limited than troponin.
an amino acid that is produced when proteins break down. A certain amount of ________is present in the blood, but elevated values may be an independent risk factor for the development of CVD (cardio vascular disease).
Highly sensitive C-reactive protein (hsCRP)
a marker of inflammation. Any inflammatory process can produce _____ in the blood. Elevations are seen also with hypertension, infection, and smoking. A level less than 1 mg/dL is considered low risk; a level over 3 mg/dL places the patient at high risk for heart disease. The most useful time to measure ______ appears to be for risk assessment in middle-aged or older persons.
small amounts of protein in the urine, has been shown to be a clear marker of widespread endothelial dysfunction in cardiovascular disease (along with elevated CRP). It should be screened annually in all patients with hypertension, metabolic syndrome, or diabetes mellitus. ___________ has also been used as a marker for renal disease, particularly in patients with hypertension and diabetes.
an invasive diagnostic procedure that involves fluoroscopy and the use of contrast media. This procedure is performed when an arterial obstruction, narrowing, or aneurysm is suspected.
cardiac catheterization
The most definitive but most invasive test in the diagnosis of heart disease is _____ ______. It may include studies of the right or left side of the heart and the coronary arteries.
intravascular ultrasonography (IVUS)
An alternative to injecting a medium into the coronary arteries is _______ _______, which introduces a flexible catheter with a miniature transducer at the distal tip to view the coronary arteries. The transducer emits sound waves, which reflect off the plaque and the arterial wall to create an image of the blood vessel. _______ ______ is more reliable than angiography in indicating plaque distribution and composition, arterial dissection, and degree of stenosis of the occluded artery.
electrophysiologic study (EPS)
an invasive procedure during which programmed electrical stimulation of the heart is used to cause and evaluate lethal dysrhythmias and conduction abnormalities. Patients who have survived cardiac arrest, have recurrent tachydysrhythmias, or experience unexplained syncopal episodes may be referred for EPS.
stress test (aka - exercise electrocardiography or exercise tolerance)
assesses cardiovascular response to an increased workload. The stress test helps determine the functional capacity of the heart and screens for asymptomatic coronary artery disease. Dysrhythmias that develop during exercise may be identified, and the effectiveness of antidysrhythmic drugs can be evaluated.
As a noninvasive, risk-free test, ________ is easily performed at the bedside or on an ambulatory care basis. _________uses ultrasound waves to assess cardiac structure and mobility, particularly of the valves. It helps assess and diagnose cardiomyopathy, valvular disorders, pericardial effusion, left ventricular function, ventricular aneurysms, and cardiac tumors.
pharmacologic stress echocardiogram
A slightly more aggressive form of echocardiogram is a _____ _____ _____ using either dobutamine or dipyridamole. This test is usually used when patients cannot tolerate exercise. Dobutamine (Dobutrex) increases the heart's contractility; dipyridamole (Persantine, Apo-Dipyridamole ) is a coronary artery dilator. Patients are required to be NPO status for 3 to 6 hours before the test except for sips of water with medications.
Transesophageal echocardiography (TEE)
Echocardiograms may also be performed transesophageally (through the esophagus). ________ ________ examines cardiac structure and function with an ultrasound transducer placed immediately behind the heart in the esophagus or stomach. The transducer provides especially detailed views of posterior cardiac structures such as the left atrium, mitral valve, and aortic arch.
myocardial nuclear perfusion imaging (MNPI)
The use of radionuclide techniques in cardiovascular assessment is called _____ ______ ______ _____). Cardiovascular abnormalities can be viewed, recorded, and evaluated using radioactive tracer substances. These studies are useful for detecting myocardial infarction (MI) and decreased myocardial blood flow and for evaluating left ventricular ejection. Conducting myocardial nuclear imaging tests, in conjunction with exercise or the administration of vasodilating agents such as dipyridamole (Persantine, Apo-Dipyridamole ), allows clearer identification of how the heart responds to stress.
multigated blood pool scanning
During ____ _____ _____ _____, the computer breaks the time between R waves on the ECG into fractions of a second, called "gates." The camera records blood flow through the heart during each of these gates. By analyzing the information from multiple gates, the computer can evaluate the ventricular wall motion and calculate ejection fraction (percentage of the left ventricular volume that is ejected with each contraction) and ejection velocity. Areas of decreased, absent, or paradoxical movement of the left ventricle may also be identified.
coronary artery calcium (CAC) score
using electronic-beam computed tomography (EBCT), helps determine whether calcifications are present in the arteries; calcifications are a common component of arterial plaque. The 64-slice CT is used to determine the ____ _____ _____ _____, which is a measure of the amount of coronary artery calcification. The test cannot predict the site of future events or determine the severity of the risk.
Hemodynamic monitoring
an invasive system used in critical care areas to provide quantitative information about vascular capacity, blood volume, pump effectiveness, and tissue perfusion. It directly measures pressures in the heart and great vessels. These procedures are usually performed for more seriously ill patients and can provide more accurate measurements of blood pressure, heart function, and volume status.
pulmonary artery occlusive pressure (PAOP)
A pulmonary artery catheter is a multi-lumen catheter with the capacity to measure right atrial and indirect left atrial pressures or pulmonary artery wedge pressure (PAWP), also known as the ______ _____ _____ _______.
pulmonary artery wedge pressure (PAWP) [additional info]
_____ _____ _____ _____ closely reflects left atrial pressure and LVEDP in patients with normal left ventricular function, normal heart rates, and no mitral valve disease. The PAWP is a mean pressure and normally ranges between 4 and 12 mm Hg.
pulmonary artery wedge pressure (PAWP) [definition]
Normal pulmonary artery pressure (PAP) ranges from 15 to 26 mm Hg systolic/5 to 15 mm Hg diastolic (mean, 15) and is constantly visible on the monitor. When the balloon at the catheter tip is inflated, the catheter advances and wedges in a branch of the pulmonary artery. The tip of the catheter can sense pressures transmitted from the left atrium, which reflect left ventricular end-diastolic pressure (LVEDP). The pressure measured during balloon inflation is called the _____ _______ _______ _______.
impedance cardiography (ICG)
a flexible and fast-acting noninvasive monitoring system that consists of four ICG electrodes, four electrocardiogram (ECG) electrodes, and a portable ICG monitor. Simply stated, it measures the total impedance (resistance) to the flow of electricity in the heart. ICG can be used in any setting: in the intensive care unit (ICU), in the emergency department (ED), and in the home. It is used to assess, plan, and individualize the treatment plan for patients with heart failure, severe trauma, or fluid management.
a widening; bulging of the wall of the heart, the aorta, or an artery caused by congenital defect or acquired weakness
the abnormal narrowing of a passage or opening, such as a blood vessel or heart valve
the failure of a heart valve to close completely; also called incompetence
increase in the size of cells and consequently an increase in the size of the organs
local and temporary lack of blood flow due to the mechanical obstruction of the circulation to a part of the body; may result in infarct if the circulation is withheld too long
localized necrosis resulting from obstruction of the blood supply
Cardiac Output (CO)
measurement of the amount of blood ejected from either ventricle of the heart per minute
Stroke Volume (SV)
measurement of the amount of blood ejected from a ventricle in one contraction
Heart Rate (HR)
is the number of heartbeats per minute; found by taking the pulse
a graphical recording of the cardiac cycle produced by an electrocardiograph
Stress Test
performed to assess cardiovascular health and function during and after stress
record of the heart obtained by directing ultrasonic waves through the chest wall
Cardiac Cath
the purpose of this procedure is to confirm and evaluate severity of lesions within the coronary arteries. assess left vent function; measure pressure in teh heart chambers, cardiac output, and blood gas content.
a radiographic study of the blood vessels after the injection of a contrast medium
Nuclear Imaging
the generation of images of components of the body (organs, tissues) by using techniques based on the measurement of radiation
chest x-ray
taking a radiographic picture of the lungs and heart
Laboratory Tests
CK, isoenzymes, serum protein Troponin T, cholesterol are all examples of _____________ used for determining cardiac issues.
sound heard when valves open and close, the ______ is the result of the valves not completely closing.
the _____ side of the heart is responsible for oxygenation of blood
Atrial kick
the movement of the last 20% of blood from the atrium to the ventricle is known as _______.
a condition in which an artery wall hardens and thickens due to plaque buildup
what is the most popular test for looking for valve problems? ,
Ultrasound imaging of the heart using transducer within the esophagus
multi-gated acquisition scan. Nuclear medicine exam of heart function and wall motion. This test is often used to determine damage from a MI.
CK (creatine kinase)
creatine kinase; released into the bloodstream after injury to heart or skeletal muscles
if this test is elevated it indicates damage heart muscle
if this test is elevated it indicates damage skeletal muscle
O2 needed for activity/metabolic equivalent. starts low & goes up
injection used to look for hot spots post MI.
if there is a back up on the right side of the heart it will show up in the form _____.
if there is a back up on the left side of the heart it will show up in the _____.
inflammation of the endocardium and heart valves and can often result scarring
coronary artery disease (CAD)
a stage of arteriosclerosis involving fatty deposits (atheromas) inside the arterial walls
Inflammatory Disease
a disease characterized by inflammation
a common disorder in which blood pressure remains abnormally high (a reading of 140/90 mm Hg or greater)
Angina Pectoris
a heart condition marked by paroxysms of chest pain due to reduced oxygen to the heart
Myocardial Infarction
destruction of heart tissue resulting from obstruction of the blood supply to the heart muscle
failure of the heart to pump blood away from the heart causing accumulation of fluid in the tissues and lungs
Medical tx of _______ includes Qestran, Lopid, Zocor
Inflammatory Disease
TX for _____ includes rest, antiinfectives (Gentamycin, Cephalosporin) Surgical: Valve replacement, Cardiomyopathy--Transplant
Inflammation of pericardial sac
TX of _____ includes antiinflammatories, antiinfectives, Torodol.
Angina Pectoris
chest pain caused by a temporary loss of oxygenated blood to heart muscle often caused by narrowing of the coronary arteries.
Gentamycin, Cephalosporin
while taking ________ you need to have peak and troughs to ensure that we are within therapeutic ranges
Angina Pectoris
TX of _______ includes Rest, Oxygen, Nitrate--Nitroglycerin
Beta Blockers--Tenormin, Calcium Channel Blockers
Cardizem, Procardia, Nitroglycerin.
failure of the heart to pump blood away from the heart causing accumulation of fluid in the tissues and lungs
what is the best tx for a MI if caught quickly?
TX of ____ is Cardiac glycosides, Diuretics, Potassium supplements, or Cardiac glycosides/ Digoxin
the proper level for digoxin is ___.
S/S of ____ include cough, feeling bloated, low CO, neck vein distention, irritability, cool
Abnormal origin, rate or direction of conduction of electrical impulses in the heart's electrical conduction system
Supraventricular Tachycardia
A heart rate of over 100 bpm caused above the ventricle
Atrial Fibrillation
Electrical impulses move randomly throughout the atria, causing the atria to quiver instead of contracting with a normal rhythm.
Complete Heart Block
a condition in which the AV node is non functional and no impulses from SA node reach the ventricles
Supraventricular Tachycardia (SVT)
tx of ____ includes a cal channel blocker like Verapamil (Calan)
Atrial Fibrillation
s/s of ___________ includes irregularly irregular HR.
Atrial Fibrillation
tx for ___ includes Cardiac Glycoside, Anticoagulant-Coumadin
Complete Heart Block
tx for ____ includes a pacemaker.
AV Sequential
pacemaker that stimulates first the atrium, then the ventricle, adding the 20% atrial kick
Demand Pacemaker
Fires only when heart rate drops below programmed minimum.
Fixed Pacemaker
this type of pacemaker will fire continuously at a predetermined rate