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Chapter 13: Cardiovascular Alterations
Terms in this set (42)
Normal Structure of the Heart:
a. The heart's muscle is the size of a person's closed fist and lies within the mediastinal space of the thoracic cavity between the lungs, directly under the lower half of the sternum, and above the diaphragm.
Composed of Three layers
The heart consist of three layers:
a. The epicardium is known as the outermost layer of the heart.
b. The myocardium is the middle layer and is the actual contracting muscle of the heart.
c. The endocardium is the innermost layer and it lines the inner chambers and heart valves.
4 heart chambers
1. The right atrium receives deoxygenated blood from the body via the superior and inferior vena cava.
2. The right ventricle receives blood from the right atrium and pumps it to the lungs via the pulmonary artery.
3. The left atrium receives oxygenated blood from the lungs via 4 pulmonary veins.
4. The left ventricle is the largest and most muscular chamber; it receives oxygenated blood from the lungs via the left atrium and pumps blood into the systemic circulation via the aorta.
There are 4 valves in the heart:
There are 2 atrioventricular valves; the tricuspid and the mitral, which lie between the atria and ventricles.
a. The tricuspid valve is located on the right side of the heart.
b. The bicuspid (mitral) valve is located on the left side of the heart.
c. The atrioventricular valves close at the beginning of ventricular contraction and prevent blood from flowing back into the atria from the ventricles; these valves open when the ventricles relax.
There are 2 semilunar valves, the pulmonic and the aortic:
a. The pulmonic semilunar valves lie between the right ventricle and the pulmonary artery.
b. The aortic semilunar valve lies between the left ventricle and the aorta.
c. The semilunar valves often prevent blood from flowing back into the ventricles during relaxation; they open during ventricular contraction and close when the ventricles begin to relax.
a. The autonomic nervous system (sympathetic and parasympathetic) exerts control over the cardiovascular system.
a. It releases norepinephrine, which has alpha- and beta-adrenergic effects.
b. Alpha-adrenergic effects result in arterial vasoconstriction.
c. Beta-adrenergic effects increase sinus node discharge (positive chronotropic effect), increase the force of contraction, and accelerates the AV conduction time.
a. The parasympathetic nervous system releases acetylcholine through stimulation of the vagus nerve.
b. It causes a decrease in sinus node discharge and slows conduction through the AV node.
c. Chemoreceptors are sensitive to changes in partial pressure of arterial oxygen (PaO2), partial pressure of CO2 (PaCO2), and pH blood levels.
d. Chemoreceptors stimulate the vasomotor in the medulla to control vasodilation and constriction.
e. Baroreceptors are sensitive to stretch and pressure.
f. If BP increases, the baroreceptors cause the heart rate to decrease and if BP decreases, the baroreceptors stimulate an increase in HR.
Cardiac Function: Coronary Circulation
Coronary Circulation: Arteries
a. The right main coronary artery supplies the right atrium and ventricle, the inferior portion of the left ventricle, the posterior septal wall, and the SA and AV node.
b. The left main coronary artery consists of 2 major branches, the left anterior descending (LAD) and circumflex arteries.
c.The LAD artery supplies blood to the anterior wall of the ventricle, the anterior ventricular septum, and the apex of the left ventricle.
d. The circumflex artery supplies blood to the left atrium and the lateral and posterior surfaces of the left ventricle.
e. The coronary arteries supply the capillaries of the myocardium with blood.
f. If the blockage occurs in these arteries, the client is at risk for myocardial infarction (MI).
a. The 1st heart sound (s1) is heard as the atrioventricular valves close and is heard loudest at the apex of the heart.
b. The 2nd heart sound (s2) is heard when the semilunar valves close and are heard loudest at the base of the heart.
c. The 3rd heart sound (s3) may be heard if the ventricular wall compliance is decreased and structures in the ventricular wall vibrate; this can occur in conditions such as HF or valvular regurgitation. (i.e., It is more common in those younger than 30).
d. The fourth heart sound (s4) may be heard on atrial systole if resistance to ventricular filling is present; this is an abnormal finding, and the causes include cardiac hypertrophy, disease, or injury to the ventricular wall.
a. It is a sound that is caused by turbulence of blood flow through the valves of the heart.
b. A murmur is usually a rumbling, blowing, harsh, or musical sound.
c. Murmurs are audible when a septal defect is present, when a valve (usually aortic or mitral) is stenosed, or when the valve leaflets fail to approximate (valve insufficiency).
d. The presence of a new murmur warrants special attention, particularly in a patient with AMI.
Coronary Artery Disease:
a. It is the narrowing or obstruction of 1 or more coronary arteries as a result of atherosclerosis, which is an accumulation of lipid-containing plaque in the arteries.
a. The disease can cause decreased perfusion of myocardial tissue and inadequate myocardial oxygen supply, leading to hypertension, angina, dysrhythmias, MI, heart failure, and death.
b. Collateral circulation, which is more than 1 artery supplying a muscle with blood, is normally present in the coronary arteries, especially in older persons.
c. The development of collateral circulation takes time and develops when chronic ischemia occurs to meet metabolic demands; therefore, occlusion of a coronary artery in a younger individual is more likely to be lethal than one in an older individual.
d. The symptoms occur when the coronary artery is occluded, it causes ischemia.
a. Non-modifiable factors
-Age: Men older than 45 and women older than 55.
b. Modifiable factors:
-Cholesterol (High LDL, Low levels of HDL)
a. It is necessary to know the history of the patient's use of phosphodiesterase type 5 inhibitors that can be taken for erectile dysfunction, such as sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra). (e.g., These medications can potentiate hypotensive effects of nitrates such as NTG, therefore it should be contraindicated.
a. Possibly normal findings during asymptomatic periods.
b. Chest pain.
f. Cough or hemoptysis
g. Excessive fatigue
a. 12-lead ECG:
-This noninvasive test, also known as the ECG.
-It is used to identify the rhythm disturbances; pericarditis, pulmonary diseases, left ventricular hypertrophy; and myocardial ischemia, injury, and infarction.
b. Chest radiography:
-It is performed in the anteroposterior view.
-It detects cardiomegaly, cardiac positioning, degree of fluid infiltrating the pulmonary space or pericardial space.
c. Holter Monitor:
-They are used to detect the suspected dysrhythmias.
-The Holter monitor is a small portable recorder connected to the patient by three to five electrodes.
-The recorder is worn 24 to 48 hours.
d. Exercise Tolerance Test:
-It is a noninvasive test, also known as a stress test, the patient is connected to an ECG machine while exercising.
-The stress test is used to document exercise-induced ischemia and can identify those individuals who are prone to cardiac ischemia during activity, even though their resting ECGs are normal.
e. Pharmacological stress test:
-This test is done in conjunction with radionuclide scintigraphy or echocardiography.
-Medications such as regadenoson, dipyridamole, or adenosine are used to cause vasodilation of normal coronary arteries.
f. Nuclear stress testing:
-This test can be done with exercise to increase the sensitivity of the test.
-It is used for patients who have an ECG that precludes an accurate interpretation of ST-segment changes, and it is also used in conjunction with medications for patients who cannot walk on a treadmill.
-This is a non-invasive imaging procedure that uses ultrasound to visualize the cardiac structures and the motion and function of cardiac valves and chambers.
h. Transesophageal echocardiography (TEE):
-This test provides ultrasonic imaging of the heart as viewed from behind the heart.
-In TEE, an ultrasound probe is fitted on the end of a flexible gastroscope, which is inserted into the posterior pharynx and advanced into the esophagus.
-This technique provides a clear picture of the heart because the esophagus lies against the back of the heart and is parallel to the aorta.
i. Multi-gated blood acquisition study (MUGA):
-It is used to assess the left ventricular function.
-An isotope is injected, and images of the heart are taken during systole and diastole to assess the LVEF of the heart.
j. Cardiac magnetic resonance imaging (MRI):
-Is known as a noninvasive test used to evaluate tissues, structures, and blood flow.
-The technique uses magnetic resonance to create images of hydrogen ions as they are emitted, picked up, and fed into a computer.
-The computer reconstructs the image, which can be used to differentiate between healthy and ischemic tissue.
-MRI is used to diagnose or evaluate CAD, aortic aneurysm, congenital heart disease, left ventricular function, cardiac tumors, thrombus, valvular disease, and pericardial disorders.
k. Cardiac computed tomography:
-It is a non-invasive way to image the heart three-dimensionally.
-It is used to evaluate for CAD, valvular disease, pericardial disease, and aneurysms and to map the pulmonary veins before ablation.
l. Positron emission tomography (PET):
-It is a scan that is a noninvasive way to study cardiac tissue perfusion.
-Radioactive isotopes are injected IV to enable the imaging.
m. Cardiac Catheterization:
-It is an invasive procedure that can be divided into two stages (right-sided and left-sided catheterization).
-It is used to measure pressures in the chambers of the heart, cardiac output, and blood gas content; to confirm and evaluate the severity of lesions within the coronary arteries; and to assess left ventricular function.
-Best rest a minimum of 4 hours; head of bed no higher than 30 degrees.
-Monitor bleeding; newer collagen agents for hemostasis may be used.
-Anti-platelet drugs after the procedure (usually after interventions such as PCI).
-May be discharged in 6 to 8 hours after completion of test; it depends on the diagnosis and procedures done.
-It is a invasive procedure that usually involves the introduction of an electrode catheter percutaneously from a peripheral vein or artery into the cardiac chamber or sinuses and the performance of programmed electrical stimulations of the heart.
-Electrophysiology aid in recording intra-cardiac ECG's, diagnostic cardiac conduction defects, evaluating effectiveness of anti-arrhythmia's medications, and determining the proper choice of a pacemaker.
Laboratory Test for CAD:
b. Potassium (increase: narrow elevated T waves, AV conduction changes, widened QRS complex and decrease: Prolonged U wave and QT interval).
c. Calcium (increase: Prolonged PR interval, Shortened QT interval and decrease: Prolonged QT interval).
a. Troponin I and T:
-Levels are usually elevated as early as 1 hour after MI injury.
-Normal values Troponin I: less than 0.03 ng/L.
-Troponin T: less than 0.1 ng/L.
Cholesterol in CAD:
a. - HDL is good
b. -LDL is bad
No CHD and fewer than two risk factors:
a. 160 mg/dL
No CHD and two or more risk factors
a. 130 mg/dL
a. less than 100 mg/dL
Treatment of CAD
Diet: low cholesterol, low salt.
Management of hypertension and diabetes, if present.
Lipid-lowering agents include statins, bile acid resins, ezetimibe, nicotinic acid, and a newer class of medications called pro-protein convertase subtillisin/kexin type 9 (PCSK9) inhibitors.
a. Statins lower LDL by the slowing the production of cholesterol and increasing the liver's ability to remove LDL from the body and are well tolerated by most individuals.
b. Some commonly prescribed medications include lovastatin, atorvastatin, pravastatin, simvastatin, and rosuvastatin. (i.e., It is recommended that most statins be given as a single dose in the evening because more cholesterol is at night).
a. It works in the digestive tract by blocking the absorption of cholesterol from food.
b. It is often used in conjunction with other cholesterol-reducing medications.
c. It can cause liver disease, therefore liver function tests must be monitored.
d. The medication is contraindicated in patients with severe hepatic disease, when added to statins it decreases cardio problems.
Nicotinic acid, or niacin:
a. It reduces total cholesterol, LDL, and triglycerides levels, and it increases HDL.
b. The medication is available over the counter; its use in lowering cholesterol must be done under a provider.
c. It is a long acting, once-daily dose by prescription.
d. Side effects: metallic taste in mouth, flushing, and increased feelings of warmth.
e. Major side effects: Hepatic dysfunction, gout, and hyperglycemia.
f. It must be given separately from other medications due to it affecting the absorption of other meds.
g. Administer niacin at night/w food or taking 325 mg of non-enteric aspirin 30 minutes before the niacin dose can reduce some of the side effects.
Fibric acid derivatives:
a. If triglyceride levels are elevated, patients may be prescribed agents that lower triglyceride levels such as Gemfibrozil increases HDL.
b. Patients should be monitored carefully.
Medications Affecting Platelets (CAD)
a. A single dose of 81 to 325 mg of an enteric-coated aspirin per day is commonly prescribed.
b. It is to prevent platelet aggregation, other agents may be prescribed with aspirin, such as clopidogrel (Plavix), prasugrel (Effient), or ticagrelor (Brilinta).
Angina: is known as chest pain or discomfort caused by myocardial ischemia that is attributed to an imbalance between myocardial oxygen supply and demand.
-CAD and coronary artery spasms are common causes of angina.
Angina ("squeezing") is the chest pain associated with myocardial ischemia.
-It is transient and does not cause cell death, but it may be a precursor to cell death from MI.
-Angina occurs when oxygen demand is higher than oxygen supply.
Types of Angina:
a. It occurs with exertion and is relieved with rest or nitroglycerin.
b. It is also called chronic exertional angina.
c. T-wave inversion on ECG,
d. Treatment: rest and nitroglycerin.
a. It is also called pre-infarction angina.
b.It is associated with worsening cardiac ischemia.
c. The pain is more severe, may occur at rest, and requires more frequent nitrate therapy.
d. It is sometimes described as crescendo (increasing) in nature.
e. May see ST elevation on ECG,
f. Treatment: rest and nitroglycerin; drugs affecting platelets; and revascularization.
Variant (Prinzmetal's) angina: is known to be caused by coronary artery spasms.
a. It often occurs at rest and without other precipitating factors.
b. ST elevation is seen during an AMI.
c. ST segment returns to normal after the spasm subsides.
d. AMI can occur with prolonged coronary artery spasm, even in the absence of CAD.
e. Treatment: Calcium channel blockers.
Assessment of Angina/Chest Pain:
a. It can develop slow or quickly.
b. It is mild or moderate.
c. Substernal, crushing, squeezing pain may occur.
d. Pain may radiate to the shoulders, arms, jaw, neck, or back.
e. It is unaffected by inspiration and expiration.
f. Pain usually lasts less than 5 minutes; however it can last up to 15 to 20 mins.
g. It can be relieved by rest or nitroglycerin.
d. Palpitations and tachycardia
e. Dizziness and syncope
g. Digestive disturbances
a. Acute chest pain r/t to Myocardial Ischemia
b. Knowledge deficit
c. Activity intolerance
Diagnostic test and Nursing Management of Angina:
a. Readings are normal during rest, with ST depression or T-wave inversion during an episode of pain.
b. Stress testing: Chest pain or changes in the ECG or vital signs during testing may indicate ischemia.
c. Troponin and cardiac enzymes: Findings are normal in angina.
d. Cardiac catheterization: It provides info. about the patency of the coronary arteries.
Nursing interventions of Angina:
a. Assess for pain
b. Administer O2 by nasal cannula.
c. Assess vital signs and provide continuous cardiac monitoring and nitroglycerin as prescribed to dilate coronary arteries and relieve the chest pain.
d. Ensure that bed rest is maintained, place the client in semi-fowler's position.
e. Obtain a 12-lead ECG.
f. Establish an IV access route.
a. Nitrates are the most common medications for angina.
b. They usually are direct-acting smooth muscle relaxants that cause vasodilation of the peripheral or systemic vascular bed.
c. Nitrate therapy is beneficial due to decreases in myocardial O2 demand.
d. It lowers BP and relieves pain.
e. Nitroglycerin is available SubL tablets or spray/IV.
f. Oral isosorbide is a vasodilator.
g. Side effects: headache, flushing, tachycardia, dizziness, and orthostatic hypotension.
h. Avoid nitrates if right vent. Infarct is present.
Calcium channel blockers:
a. They dilate coronary arteries and reduce vasospasm.
b. They are (amlodipine).
a. They help reduce the BP in individuals who are hypertensive. (lol)
Patient care outcomes:
a. Verbalize relief of chest pain.
b. appear relaxed
c. Verbalize an understanding of angina pectoris
d. Describe cardiac risk factors and strategies to reduce them.
e. Perform activities within limits of the disease.
Acute Coronary Syndrome:
Acute Coronary Syndrome:
a. It includes diagnoses of stable angina, unstable angina, and AMI.
b. AMI is defined as myocardial necrosis caused by ischemia.
a. ACS is caused by an imbalance between myocardial oxygen supply and demand.
b. This imbalance is the result of decreased coronary artery perfusion.
c. Other causes include coronary artery spasm, coronary embolism, blunt trauma, etc.
d. Reduced blood flow to the area of the myocardium causes significant and sustained 02 deprivation.
e. Cardiac cells can withstand ischemic conditions for 20 minutes; after that period, irreversible myocardial cell damage and cellular death begin.
Acute Myocardial Infarction (AMI):
Type I MI: is a spontaneous MI and it occurs because of plaque rupture, leading to occlusion of the artery.
Type II: is an MI secondary to ischemic imbalance, in which injury is due to an imbalance between myocardial oxygen supply and/or demand.
-It may be due to coronary endothelial dysfunction, coronary vasospasm, embolism, arrhythmias, anemia, respiratory failure, hypotension, and shock.
a. Non-ST segment elevation (NSTEMI)
b. ST segment elevation (STEMI)
-Collateral circulation consists of the alternative routes, or channels, that develop in the myocardium in response to chronic ischemia or regional hypo-perfusion.
Assessment of AMI:
a. For men, chest pain is the most common sign.
b. It might be severe, crushing, tight, squeezing or simply a feeling of pressure.
c. It can be precordial, substernal, or in the back, and it can radiate to arms, neck or jaw.
d. The skin may be cool, clammy, pale, and diaphoretic.
e. The patient may be dusky or ashen; slight hyperthermia may be present.
f. They may have dyspnea and tachypnea.
g. N/V is common.
h. Hypotension may be present and is associated with dysrhythmias such as ventricular ectopy, bradycardia, or heart block.
Diagnosis of AMI:
Signs and symptoms"
a. Often atypical symptoms in women.
a. ST elevation followed by Q-wave (Q-wave myocardial infarction)
b. ST depression (non-Q-wave myocardial infarction)
Elevated serum troponin such as Troponin I, T, and total cytokinesis are used to confirm the diagnosis of AMI. (i.e., these test are periodically usually between 6 to 8 hours during the 1st 24 hours to assess for increasing levels.)
a. Acute Chest Pain
b. Poor Tissue Perfusion
a. Cardiac dysrhythmias
b. HF thromboembolism
c. Rupture of a portion of the heart
d. Heart failure
e. sudden death
f. pulmonary edema
g. Cardiogenic shock
j. Mitral valve insufficiency
k. Post-infarction angina
l. Ventricular rupture.
Medical Management: AMI
a. The initial pain of AMI is treated with morphine sulfate administered by the IV route.
b. The dose is 2 to 4 mg IV push over 5 minutes.
c. Observe the patient for hypotension and respiratory depression.
d. Nitrates: NTG may be given to reduce ischemic pain of AMI. NTG is a vasodilator and it increases coronary perfusion.
-Doses of 5 to 10 mcg/min IV and is titrated to a total dose of 50 to 200 mcg/min until chest pain is absent, pulmonary artery occlusion pressure decreases, and systolic BP decreases.
e. Oxygen is administered via nasal cannula at 4 to 6 L/min to treat and prevent hypoxemia in AMI and maintain O2 saturation at greater than 90%.
MONA: Morphine, Oxygen, Nitroglycerin, and Aspirin.
Interventional Cardiology: Percutaneous Transluminal Coronary Angioplasty
Percutaneous Transluminal Coronary Angioplasty:
a. It is to compress intracoronary plaque in order to increase blood flow to the myocardium.
b. It is usually the treatment of choice for patients with uncompromised collateral flow, non-calcified lesions, and lesions that are not present of bifurcation of vessels.
c. PTCA is performed in the cardiac catheterization laboratory.
-A balloon catheter is inserted into the femoral, brachial, or radial artery, threaded into the occluded coronary artery, and advanced with the use of a guide-wire across the lesion.
-The balloon catheter is inflated under pressure of one or several times to compress the lesion.
a. It is usually due to an angiography and it included a hematoma at the catheter insertion site, MI, stroke, or TIA, pseudo-aneurysm, dysrhythmias, infection, AKI, and Coronary artery dissection.
-Mortality rate is less than 1%.
a. It is a tube that is implanted at the site of stenosis to widen the arterial lumen by squeezing atherosclerotic plaque against the artery walls.
b. The stent also keeps the lumen open by providing structural support.
c. Stents are tightly wrapped around a balloon catheter, which is inflated to implant the stent.
d. The procedure for placing stent is similar to a PTCA.
-The patient undergoes cardiac angiography for identification of occlusions in coronary arteries.
-The balloon catheter bearing the stent is inserted into the coronary artery, and the stent is positioned at the desired site.
-The balloon is inflated, expanding the stent, which squeezes the atherosclerotic plaque and intimal flaps against the vessel wall.
-Aggressive anticoagulation is necessary to prevent coagulation.
-Monitor peripheral pulses, skin color, temperature, and inspect the insertion site for any oozing or bleeding.
a. It includes coronary artery bypass grafting (CABG).
b. Minimally invasive CABG
c. Trans-myocardial revascularization (TMR).
Coronary Artery Bypass Grafting:
a. It is known as a surgical procedure in which the ischemic areas of the myocardium are revascularized by implantation of a graft from the internal mammary artery (IMA) or the coronary occlusion is bypassed with a graft from the saphenous vein or the radial artery.
CABG is used for:
a. Chronic stable angina
b. Left main coronary artery occlusion (more than 50%).
c. Triple-vessel CAD
d. Unstable angina pectoris
e. Left ventricular failure
f. Lesions not amenable to PCI and PCI failure.
CABG is performed in the operating room while the patient receives general anesthesia and is intubated.
a. IMA is often used to create an artery-to-artery graft.
b. IMA revascularization has long-term patency than saphenous vein grafts, it is used as a graft for LAD coronary artery.
Risk associated with CABG:
a. Increased mortality associated with:
-Left ventricle dysfunction
-No. of diseased vessels.
-Decreased ejection fraction with congestive heart failure.
Minimally Invasive Coronary Artery Surgery:
Minimally invasive cardiac surgery-coronary artery bypass grafting (MICS CABG) has been evaluated as an alternative to the standard methods for CABG.
a. It is an alternative method, which allows the thoracotomy approach instead of a sternotomy, resulting in a shorter hospital stay.
b. It has been done without a cardiopulmonary bypass.
c. Off-pump coronary artery bypass (OPCAB) is not as widely used as it has been in the past due to several studies that showed no mortality benefit.
Management After Cardiac Surgery and Complications:
a. Assess the patient often and provide rapid intervention to help the patient recover from anesthesia and to prevent complications.
b. The nurse-to-patient ratio is often 1:1 during the first few hours after surgery or until the patient is extubated.
c. Monitor for hypotension, administer fluids and vasopressors as ordered.
d. Assess for hypovolemia; monitor and trend output from the pleural chest and mediastinal tubes and urine output.
d. Monitor hemodynamic pressures.
e. Rewarm the patient gradually
f. Monitor and treat fluid volume status.
g. Provide pain relief.
h. Monitor for complications.
i. Wean from mechanical ventilation per protocol; extubated; promote pulmonary hygiene every 1 to 2 hours while the patient is awake.
j. Provide emotional support to the patient and family.
Complications of CABG:
b. Impaired contractility; low cardiac output
c. Intraoperative myocardial infarction
d. Pericardial tamponade
e. Respiratory insufficiency
g. Emboli; stroke
Transmyocardial Laser Revascularization
a. It is a high-energy laser that channels from the epicardial surface into the ischemic myocardium of the left ventricular.
b. The purpose of TMLR is to increase the perfusion directly to the heart muscle.
c. It is used for with widespread atherosclerosis involving the vessels that are too small and numerous for replacement or balloon catheterization; it is performed with a small chest incision on the left side of the chest and inserts the laser device into the chest cavity.
d. It uses a laser that creates 1-mm channels ( or 20 to 24) through the ventricular muscle of the LV, blood enters these small channels, providing the affected region of the heart with oxygenated blood.
e. The opening on the surface of the heart heals; main channels remain and perfuse the myocardium.
Enhanced External Counter-pulsation (EECP)
a. It is a treatment for angina when the patient is not a candidate for bypass surgery or PCI.
b. It uses cuffs wrapped around the patient's legs to increase arterial blood pressure and retrograde aortic blood flow during diastole.
-Sequential pressure, using compressed air, is applied from the lower legs to the upper thighs.
-It improves angina and promotes a quality of life.
Radio-frequency Catheter Ablation:
Radio-frequency Catheter Ablation:
a. It is a method that is used to treat dysrhythmias when medications, cardioversion, or both are not effective or not indicated.
b. It is to permanently interrupt electrical conduction or activity in a region of arrythmogenic cardiac tissue.
c. Indications for radio-frequency include the presence of VT, atrial fibrillation, atrial flutter, and AV nodal re-entry tachycardia.
a. It is performed percutaneously.
b. It begins with a diagnostic electrophysiology study to map the areas to ablated.
c. A catheter with an electrode is positioned at the accessory (abnormal) pathway and mild painless radio-frequency energy is transmitted to the pathway causing coagulation and necrosis in the conduction fibers without destroying the surrounding tissue.
a. It is used to treat patients urgently who are waiting for a permanent pacemaker placement or to treat dysrhythmias.
-They include transvenous and transcutaneous types.
-External pacing requires large electrodes to the chest.
-This type of pacing is quite uncomfortable for the patient because of the current of electricity that is required to pace the heart. (only used in an emergency)
b. Invasive transvenous pacing:
-a pacing lead wire is placed through the ante-cubital, femoral, jugular, or subclavian vein into the right atrium or right ventricle, so that it is in direct contact with endocardium.
-Monitor the pacemaker insertion site.
-Restrict client movement to prevent the wire from being displaced.
-It is associated with many complication such as ventricular dysrhythmias, cardiac tamponade, infection, and venous thrombosis.
a. They are used to treat conduction disturbances of the heart.
b. These indications include sinus node dysfunction, AV block, neuro-cardiogenic syncope, and some tachycardias (i.e., tachycardia-bradycardia syndrome).
c. They are inserted in operating rooms, laboratory, etc.
d. The patient may require atrial and/or ventricular pacing.
e. Leads are inserted through the venous system and into the right atrium and/or right ventricle.
f. The pulse generator is attached to leads and implanted under the skin, usually on the left-side of the chest.
g. Pacemakers are powered through lithium batteries that last 7 to 10 years.
Implantable cardioverter-defibrillators (ICD):
a. It is placed in patients for primary or secondary prevention of potentially lethal dysrhythmias.
b. In primary prevention, they are for patients who are at risk for sudden cardiac death, such as HF, congenital and structural heart diseases.
a. It is a complex clinical syndrome that results from the heart's inability to pump blood sufficiently to meet the metabolic demands of the body.
b. It can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill or eject blood.
c. CAD is primary underlying cause.
Manifestations of HF:
c. Exercise intolerance
d. fluid retention, which may lead to pulmonary and peripheral edema.
They can progress to:
a. Progressive exertional dyspnea
b. Paroxysmal nocturnal dyspnea
e. Loss of appetite
f. Abdominal bloating
h. renal dysfunction
Staging of HF:
a. At high risk of developing HF, but without structural heart disease or symptoms of HF. (none)
b. Structural heart disease or symptoms of HF. (1, asymptomatic)
c. Structural heart disease with prior or current symptoms of HF. (II moderate exertion, III minimal exertion, and IV with rest)
d. Refractory HF requiring specialized interventions. (IV with rest).
Pathophysiology of HF:
a. HF is known as impaired cardiac function of one or both ventricles.
b. Patients can either have preserved ejection fraction (HFpEF) or have a reduced ejection fraction.
c. Patients with HFpEF have an LVEF of 50% or greater, and those with HFrEF have an LVEF of less than 40%.
d. Those with LVEF values are between 40% to 50% are borderline.
a. The left ventricle cannot pump efficiently.
b. The ineffective pumping action causes a decrease in cardiac output, leading to poor perfusion.
c. The volume of blood remaining in the left ventricle increases after each beat.
d. As the volume increases, it backs up into the left atrium and pulmonary veins and into the lungs causing congestion.
a. It is usually a consequence of left-sided HF, it can be a primary cause of HF after a right ventricular MI, or it may occur secondary to pulmonary pathology.
Brain natriuretic peptide:
a. Cardiac hormone:
-It is secreted by ventricular myocytes in response to wall stretch.
-Normal 100 pg/ml.
b. Plasma concentrations reflect severity of HF.
-It is decompensated HF, BNP rises.
-As HF is treated, BNP is lower.
c. It is a good marker for differentiating between pulmonary and cardiac causes of dyspnea.
Assessment of HF:
S: Swelling of legs, hands, and liver.
W: Weight gain
E: Edema (pitting)
L: Large neck veins (Jugular vein distention)
I: Irregular HF (a-fib)
N: Nocturia (lying down allows fluid to go to kidneys)
G: Girth (abdomen, increase in size... breathing issues, anorexia, and nausea).
R: Rales (crackles)
O: Orthopnea (sit up to breathe especially at night)
I: Increased HR (trying to get blood to organs)
N: Nagging cough (frothy/blood tinged sputum)
G: Gaining weight (2-3 Ib in a day or 5 Ibs. in a week)
Diagnostic Testing of HF:
1. Complete history (physical exam)
a. Intravascular volume, with examination of neck veins and presence of hepatojugular reflux.
b. Presence or absence of edema
c. Perfusion status, which includes BP, quality of peripheral pulses, capillary refill, and temperature of extremities.
d. Lung sounds, which may not be helpful.
2. Chest radiographic exam: It views heart size and configuration and to check the lung fields to determine whether they are clear or opaque. (i.e., fluid filled).
3. Hemodynamic monitoring: Invasive monitoring may be done to assess mixed venous oxygen saturation, stoke index, cardiac index, and pulmonary artery pressures, especially in those who do not response to conventional therapy.
4. Non-invasive imaging of cardiac structures: The single most useful test in evaluating patients with HF is the echocardiogram, which can evaluate ventricular enlargement, wall motion abnormalities, and valvular structures.
5. Serum electrolytes: low sodium is a sign of advanced or end-stage disease; low K+ is associated with duiresis, high potassium is seen in renal impairment; BUN and creatinine levels are elevated in low perfusion states, renal impairment, or with overduiresis.
Brain natriuretic peptide:
a. Cardiac hormone:
-It is secreted by ventricular myocytes in response to wall stretch.
-Normal less than 100 pg/ml.
b. Plasma concentrations reflect severity of HF.
-It is decompensated HF, BNP rises.
-As HF is treated, BNP is lower.
c. It is a good marker for differentiating between pulmonary and cardiac causes of dyspnea.
7. Liver function test
Nursing Interventions for HF:
Assess for worsening symptoms:
a.Right-sided (peripheral swelling) vs. Left sided (Pulm. issues)
Pt's responsiveness to medications: HR (digoxin), BP (ACE/ARB), volume status (diuretics/foley and daily weights).
-Labs: K+, BUN, creatinine, digoxin levels, BNP, and troponin.
-Cardiac and fluid restriction diet.
-Edema decreases, keep legs elevated.
-High fowler's to help with breathing.
-Safety: Orthostatic hypotension and swelling of feet (falls).
a. Low sodium diet: 2-3 grams/per day.
b. Fluid restriction: 2L per day.
c. Vaccination: flu and pneumonia.
d. Aerobic exercise as tolerated.
e. Daily weights : 2 to 3 Ibs. per day or 5 Ibs. per week. (Early sign of CHF) notify the provider.
f. Compliance with meds.
g. Smoking cessation and limit ethanol.
h. Early S+S HF: SOB, orthopnea, and weight gain.
"Always Administer Drugs Before A Ventricle Dies"
a. Ace Inhibitors: ACE:
-1st line treatment prescribed with beta blockers
-End in "pril" Lisinopril
-Side effects: Increase in K+ and dry nagging cough.
-Block the conversion of Angiotensin I and II (vasodilation, decrease BP, and kidney excrete Na+, which can lead to a decrease in aldosterone (It keeps K+ and excrete Na+)
a. It used in the place of ACE inhibitors
b. It ends in Sartan (Losartan)
c. Side effects: Hyperkalemia, no nagging cough.
d. It blocks angiotensin II receptors: vasodilation
e. Some effects as ACE inhibitors: Angiotensin II decreases aldosterone.
a. It used in combination with ACE/ARBs to decrease water and Na+ retention (decrease in edema) and helps the heart easier (patient urinates ALOT!)
b. Loop Lasix decreases potassium
c. Potassium-sparing aldosterone (increase potassium)
a. It blocks Norepinephrine effects on the heart muscle.
-Its negative inotropic effect= It decreases myocardial contraction (slow HR) and decreases cardiac workload.
-It ends in "lol": metoprolol, carvediol, bisoprol.
-Side effects: Bradycardia, mask hypoglycemia in diabetics, Not for COPD or asthmatic patients.
-Avoid Grapefruit juice due to the lack of absorption.
a. It is not used in every pt. with HF.
b. HF pt's a-fib, or a history of blood or an Ejection fraction of less 35% ("systolic dysfunction).
Arterial dilator (Hydralazine) is sometimes prescribed with a nitrate like Isordil (venous dilator).
-It is used sometimes if a patient can't take ACE or ARB.
-Vasodilation of arteries or veins to decrease the blood and fluid.
-Side effects: Hypotension leads to orthostatic.
a. Positive inotropic: It increases the hearts ability to contract stronger.
b. Negative chronotropic: It causes the heat to beat slower.
c. It allows the heart to rest and pump more blood.
d. It is not the 1st line treatment.
e. It is used in Left ventricular systolic dysfunction.
f. Toxicity an issue: It increases chances, if a patient hypokalemic (less than 3.5)
g. Digoxin range is 0.5 to 2 ng/ml.
-Check for apical pulse less than 60 bpm
h. Toxic signs: N/V, vision changes: yellowish-green halos
*IMPORTANT: Nesiritide citrate (Natrecor) intravenous for acute decompensation of HF.
Complications of HF:
a. It develops in patient with HF when the become hypertensive.
b. The pulmonary vascular system becomes full and engorged.
c. S/S: Dyspnea, cyanosis, severe anxiety, diaphoresis, pallor, and blood-tinged, frothy sputum, hypoxemia.
d. Patients with persistent volume overload may be candidates for continuous IV diuretics, ultrafiltration, or hemodialysis.
e. Furosemide is most commonly used loop diuretic.
f. The diuretic effect occurs in 30 minutes and peaks at 1 to 2 hours.
g. IV torsemide or bumetanide are alternative loop diuretics.
a. It is the most acute and ominous form of pump failure.
b. It can be seem after a severe MI and with dysrhythmias, decompensated HF, pulmonary embolus, cardiac tamponade, and ruptured abdominal aortic aneurysm.
c. Cardiogenic shock often results in death.
Inflammatory Heart Disease:
a. It is an acute or chronic inflammation of the pericardium.
b. Chronic pericarditis, a chronic inflammatory thickening of the pericardium, constricts the heart causing compression.
c. The pericardial sac becomes inflamed.
d. Pericarditis can result in loss of pericardial elasticity or an accumulation of fluid within the sac.
e. Heart failure or cardiac tamponade may result.
a. Pain is often in the anterior chest that radiates to the left side of the neck, shoulder, or back.
b. Pain is grating and is aggravated by breathing (particularly inspiration), coughing, and swallowing.
c. Pain can often worsen when in a supine position and may be relieved by leaning forward.
d. Pericardial friction rub (scratchy, high-pitched sound) is heard on auscultation and is produced by the rubbing of the inflamed pericardial layers.
e. Fever and chills.
f. Fatigue and malaise
g. Elevated WBC
h. ECG changes with acute pericarditis, ST segment elevation/ w onset of inflammation; a-fib is common.
a. Assess the pain.
b. Place the patient is a High-fowler's position.
c. Adm. O2
d. Adm. analgesics, NSAIDS such as Colchicine or ibuprofen.
-* Approximately 15 to 50 ml of fluid is present in the pericardial space.
e. Treatment of cardiac tamponade, pericardiocentesis or to remove a part of pericardium (pericardial window).
a. It is an inflammation of the inner lining of the heart and valves.
b. It occurs primarily in clients who are IV drug users, have had valve replacements or repair of valves with prosthetic materials.
c. Ports of entry for the infecting organism include the oral cavity (especially if the client has had a dental procedure in the previous 3 to 6 months).
d. Infectious lesions, (vegetation) form on the heart valves.
-These lesions have irregular edges, creating cauliflower-like appearance.
-The mitral valve is the most commonly affected valve.
-The vegetative process can grow to involve chordae tendineae, papillary muscles, and conduction system.
b. Anorexia, weight loss
d. Cardiac murmurs
e. Heart failure
f. Embolic complications from vegetation fragments travel thru the arterial circulation.
h. Splinter hemorrhages in the nail-beds.
i. Osler's nodes (reddish, tender lesions) on the pads of fingers, hands, and toes.
j. Janeway lesions (non-tender hemorrhagic lesions) on fingers, toes, nose, or earlobes.
I. Clubbing of the fingers.
a. It is an abnormal dilation of the arterial wall caused by localized weakness and stretching in the medial layer or wall of the aorta.
b. The aneurysm, it can be located anywhere along the abdominal aorta.
c. The goal of treatment is to limit the progression of the disease by modifying risk factors, controlling the BP to prevent strain on aneurysm, recognizing symptoms early, and preventing rupture.
Types of aortic aneurysm:
a. Fusiform: It is a diffuse dilation that involves the entire circumference of the arterial segment.
b. Saccular: It is distinct localized out-pouching of the artery wall.
c. Dissecting: It is created when blood separates the layers of the artery wall, forming a cavity between them.
a. Pseudo-aneurysm: It is known to occur when the clot and connective tissue that are outside the arterial wall as a result of vessel injury or trauma to all 3 layers of the arterial wall.
a. Pain extending to neck, shoulders, lower back, or abdomen.
d. Increased pulse
f. Hoarseness, difficulty swallowing due to pressure from the aneurysm.
a. It is a prominent, pulsating mass in the abdomen, at or above the umbilicus.
b. Systolic bruit over the aorta.
c. Tenderness on deep palpation.
d. Abdominal or lower back pain.
a. Severe abdominal or back pain.
b. Lumbar pain radiating to the flank and groin.
d. Increased pulse rate
e. Signs of shock
f. Hematoma on flank area.
a. Monitor V/S
b. Obtain information regarding back or abdominal pain.
c. Questioning the client regarding sensation of pulsation in the abdomen.
d. Check peripheral circulation, including pulses, temperature, and color.
e. Observe for signs of rupture.
f. Note any tenderness over the abdomen.
g. Monitor for abdominal distention.
a. It is a life-threatening emergency.
b. It requires immediate medical attention.
c. Dissection is a tear in the intimal layer of the vessel that creates a "false lumen", causing blood flow diversion into the false lumen.
d. Sudden, severe chest pain is the most common presenting symptom.
a. It involves the ascending aorta; it the most common type due to dissection being able to extend into the coronary and arch vessels.
-It usually brings about pain of the anterior chest.
a. It is confined to the descending thoracic and abdominal aorta and is often associated with pain between the scapulae.
a. It begins in the ascending aorta and may extend all the way to the iliac arteries.
a. It involves only the ascending aorta.
a. It can start in the descending aorta and continue downward to just above (type IIIA) or just below (type IIIB) the diaphragm.
Ascending dissections are more common in young patients/w marfan syndrome.
a. Immediate treatment is directed to controlling 100 to 120 mmHg and decreasing the force of contraction of the heart.
b. Beta-blockers are the initial pharmacological treatment of choice.
c. Emergency surgery is warranted to prevent death.
a. Open surgical or endo-vascular repair is treatment for large aortic aneurysms, especially acute type A aortic dissection.
b. The open or conventional repair of an aortic aneurysm is the endo-aneurysmal repair.
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