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Cardiac Disorders
System = heart, blood vessels (arteries & veins), Blood Blood rich w/ O2 & nutrients moves through vessels called arteries to narrower arteriols to capillaries where the rich blood is absorbed by bodies cells & waste products are absorbed (CO2, urea, Cr, ammonia) deoxygenated blood returned to circulation via venules to veins for elimination through lungs & kidneys
Cardiac disorders
Heart = * 4 chambers - R & L atria, R & L ventricles * Blood from circulation to R atrium to R ventricle to pulmonary artery to lungs for gas exchange (CO2 & O2) to L atrium to L ventricle to aorta to systemic circulation Heart muscle = myocardium & surrounds the atria & ventricles
Cardiac Disorders
Pericardium = fibrous covering around the heart that protects it from injury & infection Endocardium = 3-layered membrane that lines the inner part of the heart chambers Valves = 4 - two atrioventricular (tricuspid & mitral) & 2 semilunar (pulmonic & aortic) control blood. flow between atria & ventricles & pulmonary artery & the aorta
Right Ventricle
Cardiac disorders
Conduction = Generated & conducted by the myocardium - usually * Originates in sinoatrial (SA) node - pacemaker atrioventricular (AV) node bundle of HIS purkinje fibers ventricular muscle tissue contraction from apex upward forcing blood to lungs & circulatory system
Cardiac disorders
Blood flow & Heart Rate (HR) * Ave. HR = 60 - 80 beats/min. (adult) * Ave. BP = 120/80 mm/Hg - resistance to blood flow through systemic arterial circulation Arterial BP determined by Cardiac Output (CO) = the volume of bld. expelled form the heart in 1 min. - calculated by mult. HR by stroke volume Ave. CO = 4 - 8 l/min.
Cardiac Disorders
Stroke Volume (SV) = amt. of bld ejected from the L vent. w/ each heart beat - Ave. = 70ml/beat - SV determined by 3 factors: -Preload - blood flow force that stretches the ventricle - Contractility - force of ventricular contraction - Afterload - Resistance to vent. ejection of blood caused by opposing pressures in aorta & systemic circulation Specific drugs can or preload & afterload, affecting both SV & CO - most vasodilators dec. preload & afterload a dec. in arterial pressure & CO
Desired action = restoration of normal cardiac rhythm 4 Classes: 1. Fast (sodium) Channel Blockers - dec. the fast Na influx to the cardiac cells, so - dec. conduction time of cardiac tissue, dec. likelihood of ectopic foci, inc. repolarization - 3 subgroups of fast channel blockers
Diuretics
Used for 2 main purposed: decrease hypertension (lower BP), & decrease edema (peripheral & pulmonary) in CHF and renal or liver disorders
* Other uses = Dec. cerebral edema (Mannitol), dec. intraocular eye pressure (glaucoma), dec. ascities (liver disease)
Used either singly or in combo to dec. BP & dec. edema Diuretics produce inc. urine flow (diuresis) by inhibiting Na & H2O reabsorption from the kidney tubules. Act on the kidneys in diff. locations to enhance excretion of Na (pg. 678)
Diuretics
Every 11/2 hr. the total vol. of the bodys extracellular fluid (ECF) goes through the kidneys (glomeruli) for cleansing = 1st process for urine formation - sm. particles (electrolytes, drugs, glucose & waste) filtered in the glomeruli Normally 99% of filtered Na passing through glomeruli reabsorbed. 50 - 55% Na reabsorbtion in proximal tubules, 35 - 40% in loop of Henle, 5 - 10% in distal tubules, <3% in collecting tubules Diuretics that act on tubules closest to glomerule have greatest effect in causing natriuresis (Na loss in urine) Mannitol
Diuretics
Diuretics have an antihypertensive effect by promoting Na & H2O loss by blocking Na/Cl reabsorption = a dec. in fluid vol. & a dec. of BP With fluid loss - edema should decrease. When Na is retained, H2O also retained & BP increases Many diuretics cause loss of other electrolytes (K, Mg, Cl, bicarb) 5 categories of diuretics:
Diuretics
Thiazides/Thiazide-like Diuretics
Hydrochlorothiazide (Hydrodiuril, HCTZ), Metolazone (Zaroxolyn) * Action - Distal tubules of the kidney to promote Na, Cl, & H2O excretion; acts directly on arterioles, causing vasodilation & BP; preload & CO = dec. vascular fluid & dec. in BP * Use - Rx of hypertension & peripheral edema * SE - Electrolyte imbalance (hypokalemia), hyperglycemia (inc. bld sugar), hyperlipidemia (inc. bld lipid level), dizziness, headaches, N&V
Diuretics Thiazides
* CI - renal failure * DI - Digoxin - if hypokalemia occurs, the action of digoxin is enhanced & dig. toxicity can occur * Considered potassium - wasting - K supplements are frequently prescribed & serum K levels are monitored Loop Diuretics - Act on the ascending loop of Henle by inhibiting Cl transport of Na into the circulation (inhibits passive reabsorbtion of Na) - Potent & cause marked depletion of H2O & electrolytes - Effect = dose related - dose & response
Diuretics
Loop diuretics
More potent than thiazides as diuretics, but less effective as antihypertensive agents Can renal bld flow up to 40% Have a great saluretic (Na-loosing) effect & can cause rapid diuresis vascular fluid vol. dec. in CO & BP Bumetanide (Bumex), Furosemide (Lasix) - derivatives of sulfonamides Furosemide (Lasix) * Use - Rx fluid retention/overload due to CHF, renal dysfunction, cirrhosis; hypertension; pulmonary edema
Diruetics
Loop Diuretics
Lasix (cont) - used when other conservative measures fail (Na restriction & less potent diuretics) * May be given IV or PO * SE - Electrolyte imbalance ( esp. hypokalemia K < 3.5) & dehydration, orthostatic hypotension * DI - digitalis preparations - dig. toxicity can result * Nursing - Strict I & O, daily weights, vital signs, hydration status of client * Clients should be on K supplements, monitor serum K levels closely
Diuretics
Potassium-Sparing Diuretics
Weaker than thiazides & loop diuretics Action - act primarily in the collecting distal duct renal tubules to promote Na & H2O excretion & K retention Use - mild diuretics or in combo w/ antihypertensive drugs K supplements not used - serum potassium excess (hyperkalemia) results if K supplement taken w/ potassium - sparing diuretics
Diuretics
Potassium - Sparing
Spironolactone (Aldactone), Triamterene (Dyrenium) Aldactone (an aldosterone antagonist) - Aldosterone = a mineralocorticoid hormone that promotes Na retention & K excretion; Aldosterone antagonsits inhibit the Na-K pump (K retained & Na excreted) Amiloride (Midamor) - antihypertensive agent Triamterene - Rx of edema caused by CHF or cirrhosis K - sparing diuretics used alone = less effective than when combined with reducing body fluid & Na - Usually combine w/ a potassium wasting diuretic
Diuretics
Combination
Combine a potassium sparing & potassium wasting diuretic = intensifies the diuretic effect & prevents K loss
spironolactone & hydrochlorothiazide (Aldactazide) amiloride & hydrochlorothiazide (Moduretic) triamterene & hydrochlorothiazide (Dyazide, Maxide)
When diuretic combinations are used, either combined in one tablet or as separate tablets, the dose of each is usually less than the dose of any single drug SE = hyperkalemia - caution w/ clients having poor renal function; do NOT use K supplements (unless K low)