Cardiovascular System Sonny M. Moreno, RN, USRN, MAN Anatomy and Physiology How many layers?

How many layers? What is the outer membrane? Number of chambers? What is the most important chamber? What separates the chambers? Valve between RA and RV? Valve between LA and LV? Valve between RA and PA? Valve between LV and Aorta? Most important valve? Location of valves? ECG electrodes (6)? sound created after closure of AV valves? sound created after closure of SL valves? Indication of gallop? Indication of murmur? Heart sound is best heard in? Apex and base of the heart? Location of the heart? Great blood vessels? 1st branch of Aorta? Blood supply of myocardium? Trace the pulmonary circuit? Conduction system? Main generator? Reserve generator? ANS SA-Bachmanns bundle and intermodal tract(anterior, middle, posterior) AV-Bundle of His-R&L bundlePurkinje fiber-Purkinje network. Layers Chambers Valves PMI Pulmonary Circuit Conduction System

Primary: Genetic Secondary: DM, Hypothyroidism, Nephrotic Syndrome, Liver Disease, Obesity, diet, use of Beta Blockers and Diuretics

Dx: >200 mg/dl, >LDL, <HDL, s/sx: asymptomatic Atheroma - ATHEROSCLEROSIS Mx: Atheroma EFFECTS? Diet Exercise Weight reduction Rule out the cause Medication: STATIN

Coronary Artery Disease CAD MCC: Atherosclerosis Risk Factors: MRF and NMDRF Difference b/n Angina and MI Angina 1. Incomplete block 2. Less 15 minutes (pain) 3. Relieved by NTG 4. ST and T wave changes 5. Attack is precipitated by activity 6. Not life threatening

Cardiovascular Disorders Hyperlipidemia

 Myocardial Infarction 1. Complete block 2. Over 15 minutes (pain) 3. Not relieved by NTG 4. ST segment depression and T wave inversion 5. Attack is not precipitated by activity 6. Life threatening* Angina and MI Dx: 1. Pain and NTG test 2. Coronary angiography 3. MUGA: MULTI GATED ACQUISITION SCAN (Nuclear Medicine) Thallium 201 Imaging (normal) Technetium-99 Imaging (necrotic)

Elevation of ST segment = MI Peaked or inverted T wave = MI Pathological Q wave = MI

Nursing Diagnosis 1. Pain related to an imbalance in oxygen supply and demand 2. Anxiety related to chest pain, fear of death and threatening environment 3. Decreased cardiac output related to impaired contraction of the heart 4. Altered tissue perfusion (myocardial) related to coronary stenosis 5. Activity intolerance related to insufficient oxygenation 6. Risk for injury (bleeding) related to dissolution of clots 7. Ineffective individual coping related to threats to self esteem* MI management: ER!!! 1. CBR without BP 2. Oxygen therapy 3. IV access line 4. Pain control, Morphine or Meperidine, IV bolus 5. Vasodilator (NTG), IV drip or patch

4. Cardiac enzymes: increased Troponin-T or I CK MB LDH1 higher than LDH2 (flipped LDH) AST

5. ECG

6. WBC, ESR and Myoglobin* Possible ECG results:

6. Anxiolytic (Benzodiazepine) 7. Cardiac monitor 8. Central venous access line 9. Cardiac enzymes evaluation 10.ACLS* Other drugs for MI: Pharmacologic Therapy 1. Thrombolytic Agents 1. TPA tissue plasminogen activator 2. Streptokinase (streptase) 3. Urokinase 2. Anticoagulant 1. Heparin 2. Warfarin 3. ASA (antiplatelets) 4. Plavix 3. Beta adrenergic blocking agents 1. Propranolol 4. Antidysrhythmic 1. Lidocaine (Xylocaine) 5. Calcium Channel Blockers 1. Diltiazem* MI surgical interventions:

PTCA Percutaneous Transluminal Coronary Angioplasty IABP Intraaortic Balloon Pump CABG coronary artery bypass graft Triple Saphenous Vein, LIMA and RITA*

PTCA Percutaneous Transluminal Coronary Angioplasty IABP Intra aortic Balloon Pump CABG Coronary Artery Bypass Graft Postop: Cardiac rehab Conduction of Heart

ECG Tracings and Interpretations 1. Observe P wave 2. Evaluate Atrial rhythm 3. Determine Atrial rate (6-10 per strip/6 sec) 4. Calculate PR interval (0.120.20 sec or 3-5 ss) 5. Evaluate Ventricular rhythm (QRS) 6. Determine Ventricular rate (6-10 per strip/6 sec) 7. Calculate the duration of QRS (0.06-0.08 sec or 1.5-2 ss)

8. Calculate QT interval (0.360.44 sec or 9-11 ss) 6 second strip: 30 big squares

3. Ventricular Fibrillation (vfib) Defibrillation (unsynchronized) CPR Epi 1mg (1st 2 min) Repeat Defib-CPR Amiodarone 300 mg (2nd 2 min) 2nd dose 150 mg Repeat Defib-CPR Vasopressor (Dopa) 2-10mcg/kg/min (3rd 2 min) A and V Arrhythmias

Cardiac Dysrhythmias Disturbances in regular rate/rhythm due to changes in electrical automaticity or conduction Atrial Arrhythmias:

1. Premature Atrial Contraction (PAC) No mx unless symptomatic

2. Atrial Flutter Antiarrhythmic (Amiodarone and Flecainide) Digitalis Betablockers Antiplatelet and anticoagulant

Asystole CPR Epi 1mg (x Atropine Sulfate) Heart Block 1st Degree 2nd Degree Type I (Mobitz) Type II (Mobitz)

3. Atrial Fibrillation Digitalis Defibrillation

Ventricular Arrhythmias:

3rd Degree

1. Premature Ventricular Contraction (PVCs) Xylocaine

1st Degree > 0.20 sec PR interval Prolonging PR interval Cause: BB and CCB Mx: none not unless symptomatic

2. Ventricular Tachycardia (vtach) Defibrillation (unsynchronized)

2nd Degree Type I (Mobitz) 60-100 beats/min More P waves than QRS Prolonging PR interval Cause: BB and CCB Mx: Pacema ker (TCP to Permane nt)

Mx: ER!!! Pacemaker (TCP to Permanent) Heart Block

Widened QRS complex = delayed conduction to purkinje fiber Elevation of ST segment = MI STEMI-fatal NSTEMI Peaked or inverted T wave = MI Pathological Q wave = MI Flattening of T wave = Hypokalemia U wave = Hypokalemia Depression of ST segment = Hypokalemia Elevated T wave = Hyperkalemia Long QT interval = Hypocalcemia (Torsades de Pointes) Pericarditis Post MI complication (Dresslers Syndrome) CHF Cause: FVE, heart problems Dx: <Ef, <SV, <CO (2Decho) S/sx: (R) and (L) side Mx: The goal of treatment is to improve pump function, rest the heart and

Type II (Mobitz) 60-100 beats/min More P waves than QRS Missing QRS Prolonging PR interval Cause: BB and CCB

Mx: Pacemaker (TCP to Permanent) Heart Block

3rd Degree Divorced P and QRS Less QRS (40-50 beats/min) Cause: BB and CCB

reverse the compensatory mechanism of the heart. 3D: Diet, Diuretics and Digitalis Its all about the LEFT ventricle PRELOAD is the initial stretching of the heart prior to contraction AFTERLOAD "load" that the heart must eject blood against EJECTION FRACTION EDV = 120 ml (amt of blood in the LV before contraction) SV = 70 ml (amt of blood ejected in the LV per contraction) ESV = 50 ml (amt of blood in the LV after contraction) Ef = 58% Formula: =SV/ED V =70/120 =58%

Cardiac Arrest: stopped! Dx: loss of consciousness no breathing and no pulses Mx: CPR, defibrillation and ACLS

Cardiac Arrest Treatment: 1. Increase CO 2. Cardiovascular drugs and mechanical equipment utilization 3. Cardiovascular Drugs: IV Dopamine (vasopressor ) IV Dobutamine (diuretic effects) IV Epinephrine (vasoconstric tor) IV Nitroprusside (vasodilator) 4.Mechanical : IABP intra aortic balloon pump (improve coronary perfusion) Defibrilator (arrhythmias

Cardiovascular

Left Ventricular Assist Device placement (LVAD) It is used while waiting for heart transplant or if heart transplant is contraindicated.

By MIMS

can be stopped) Cardiac monitor (to detect arrhythmias) * Cardiogenic Shock! Types: CHDans Stages: early, late, end stage or decompensatory BV, CO, CB, TP: brain, heart, kidneys, lungs ER situation!!!

s/sx: >BP on 3 separate occasions, headache, (-)s/sx Dx:

Mx: N.P. Diet Exercise Weight reduction

PHARMACOLOGIC

Aneurysm: bv dilates, arterial wall Cause: AVM, diseases

Mx: Position: Modified Trendelenburg, v.s. monitoring O2 therapy (high flow) IV line, BT, Cut Down (CVP) ETT, Mechanical Ventilator

Dx: S/sx: as/sx, depending on the area involved

Mx: Drugs? Surgical clipping Endovascular coiling (coils initiate a clotting or thrombotic reaction within the aneurysm) Stent

Drugs: Cardiotonics (Dopamine, digitalis) Epinephrine, Antihistamine, Steroids, Bronchodilators Ranitidine, Antibiotics*

ATHEROMA effects: HPN Primary or Essential Hypertension: x Secondary Hypertension: diseases

Disorders Artery TAO

Vein DVT

Thrombophlebitis CVI Varicosities

ankle throughout the procedure. 2. Allow feet to dangle over the edge of the bed for 2-5 minutes or as long as it takes to produce hyperemia, then add one minute. The total time should not exceed 5 minutes. 3. Place legs in a horizontal position for 3-5 minutes. Disorders DVT Thrombophlebitis CVI

Artery and Vein RP

TAO Thromboangitis Obliterans or Buergers Disease Cause: c. Smoking Dx: Doppler UTZ test (speed) S/sx: 5 Ps, gangrene Mx: Exercise: BuergerAllen exercises Drugs: Anticoagulant, Fibrinolytics Surgery: Endarterectomy Buerger-Allen exercises - A series of exercises administered to patients with peripheral vascular disease. These exercises are repeated 6-7 times at each sitting and done several times a day.

Varicosities Disorders DVT Thrombophlebitis CVI Varicosities Disorders DVT Thrombophlebitis CVI Varicosities Disorders DVT Thrombophlebitis CVI Varicosities

1. Support legs in an elevated position at 60-90 degrees for 30-180 seconds, or until you produce blanching of the extremity. The patient is instructed to actively dorsiflex and plantarflex the

 DVT

Tandaan!!!

Vasospastic Disorder Cardiovascular Drugs Statin: Lipitor NTG: Nitrostat Morphine: Diuretics: K sparer Digitalis: Lanoxin Dobu-dopa: diuresis/cardiotonic Cardio accelerator: Epi, A. SO4 Anti arrhythmic: Lidocaine Beta blockers: Propranolol, Inderal Calcium blockers: Nifedipine, Adalat ACE Inhibitor: Captopril, Lisinopril Anticoagulants: Hepa, Warfarin Antiplatelets: ASA Fibrinolytics: t-PA, Urokinase, Streptokinase Hemostasis: Amicar, Hemostan, Vit K

Venous stasis Vein S/sx:Homans sign POOLING Duplex UTZ test (sounds to image) Venogram Thrombectomy Embolism Fibrinolytics and anticoagulant Dipyridamole (Persantin) ANTIPLATELET: to prevent occlusion TAO

Smoking Artery S/sx:Intermittent claudication LOSS OF SENSATION Doppler UTZ test (speed) Arteriogram Endarterectomy Gangrene Fibrinolytics and anticoagulant Dipyridamole (Persantin) ANTIPLATELET: to prevent occlusion *

RP Raynauds Phenomenon or