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Heart is polarized when ready for automatic heart beat. Electrical conduction begins at SA node (right upper atrium) heart beats 70-100 bpm AV node = 50-60 bpm Purkinje fibers: 10-30 bpm heart sounds (systole: contraction) heart sounds (dub): contraction of ventricles and closure of mitral and tricuspid valves.
Heart is polarized when ready for automatic heart beat. Electrical conduction begins at SA node (right upper atrium) heart beats 70-100 bpm AV node = 50-60 bpm Purkinje fibers: 10-30 bpm heart sounds (systole: contraction) heart sounds (dub): contraction of ventricles and closure of mitral and tricuspid valves.
Heart is polarized when ready for automatic heart beat. Electrical conduction begins at SA node (right upper atrium) heart beats 70-100 bpm AV node = 50-60 bpm Purkinje fibers: 10-30 bpm heart sounds (systole: contraction) heart sounds (dub): contraction of ventricles and closure of mitral and tricuspid valves.
St. Jude College of Nursing Heart A&P Organ that produces heart beat and propels blood. Location: behind ribs; padded by lungs Structure: Upper chambers: atria Lower cambers: ventricles Valves: tricuspid, mitral, pulmonary, aortic Heart A&P Blood Supply: Coronary arteries arise from aorta by aortic valve. Right coronary artery: SA node (55% of people); AV node (90%); Posterior chambers and septum Left coronary artery: bifurcates into left descending artery (anterior heart) & left circumflex artery (SA node in 45%) Heart A&P Charge spreads to Bundle of His in septum, down bundle branch fibers to Purkinje network. Slight hesitation, then repolarization (setting up to be ready for next SA node stimulation) SA node = 70-100 bpm AV node = 50-60 bpm Purkinje fibers: 10-30 bpm
Heart A&P Function: Circulate blood; maintain blood pressure Vena cava right atria tricuspid valve right ventricle pulmonary artery lungs where it is oxygenated Pulmonary veins left atria mitral valve left ventricle aortic valve aorta body
Heart A&P Heart Sounds: S 1 (lub): Closure of mitral & tricuspid valves & contraction of ventricles (Systole: Contraction) S 2 (dub): Closure of pulmonary & aortic valves and contraction of atria (Diastole: Relaxation) S 3 : Filling of ventricles (follows S 3 ) S 4 : Abnormal: prior to S 1
Sinus arrhythmia: pressure of lungs on inspiration pressure in pulm. artery late closure of pulmonary valve splitting (l-lub- dub) Heart A&P ELECTRICAL CONDUCTION: Sinus atrial (SA) node (right upper atrium) begins automatic heart beat. Heart is polarized when ready to beat. Depolarization means charge occurs (K moves out; Na moves into cell). Current flows across the atrium. Pauses at the AV node. Atrioventricular (AV) node (located in left lower atrium) sends charge forward. Neuro & Muscle Action NERVE INNERVATION: K (inside nerve cells) Na and Calcium (in interstitial tissue) When nerve is stimulated, channels in axian open & Na & calcium enter (+ and - charges produce a spark or nerve contraction. K = Na cant enter; no contraction. K = Na is not pulled inside; weak contraction; fatigue; weakness. Calcium = no contraction or rigid. Neuro & Muscle Action MUSCLE ACTION: Myosin and actin (muscle proteins) in muscle are normally kept apart by additional protein. When stimulated by nerve, calcium enters cells and binds with protein separating myosin & actin allowing myosin and actin to contact. Muscle contracts. calcium: Fibrillation (constant contraction). calcium: Tetany; muscles cant contract. Heart A&P Preload: Ability to stretch ( difficulty with hypertrophy, ischemia; blood volume)
Afterload:Resistance of valves & blood vessels ( viscosity; arteriosclerosis, hypertension)
Contractility: Force of contractions (pericardial fluid; exhaustion; ischemia) Heart AP Stroke volume: Amt.. of blood ejected from ventricle with a heart beat. Cardiac output: Amt.. of blood pumped out of heart/minute (cardiac output = stroke volume X heart rate) Cardiac reserve: ability to stroke volume & HR. Bradycardia: Slow heart rate Tachycardia: Rapid heart rate
Sympathetic Parasympathetic Heart: Increases Decreases Blood vessels: Constrict Dilate BP & P: Increases Brings to normal Bronchi: Dilates Constricts Skin: Sweats Dry Intestine: Decreases Increases Liver: Glycogenesis None Pancreas: None Secretes Salivary: Saliva None Bladder: Relaxes Contracts Heart A&P Baroreceptors in carotid & aortic arch respond to BP: blood pressure SNS response. Sympathetic nervous system HR; vessel constriction (including coronary vessels) Epinephrine (from adrenal) dilatation BP to PNS response. Parasympathetic nervous system: HR & vessel dilatation. Heart A&P Central Chemoreceptors: medulla PaO2 or PaCO2 ( pH)= Tachycardia & vessel constriction. Peripheral chemoreceptors: Carotid & aortic arch PaCO2 or pH = Bradycardia & vasodilatation. Cardiac Drugs Block sodium influx: (class I antiarrhythmics) Block potassium (class III antiarrhythmics) Interfere with calcium (calcium blockers or class IV antiarrhythmics) Stimulate SNS: adrenergic effect: rate (class II antiarrhythmics) Stimulate PNS: cholinergic effect: rate. Block SNS: antiadrenergic effect: rate. Block PNS: anticholinergic effect: rate.
Congestive Heart Failure Inability to pump enough blood to meet bodys metabolic demands Acute or insidious; left or right sided LEFT SIDED: Output of left ventricle is less than input. Causes: hypertension; valve stenosis ( afterload); myocardial infarction Hypertension hypertrophy & HR. Heart grows exhausted and fails.
Congestive Heart Failure Failure = BP stim. of SNS HR & force of contractions & vasoconstriction Volume of blood in lungs . Fluid moves into interstitial lung tissue, then into alveoli (hydrostatic pressure) Pulmonary edema air exchange If capillaries break, blood alveoli RAA system constriction, NA & H20 retention. Congestive Heart Failure ASSESSMENT: Dyspneic, SaO2 ; rales, anxiety, cyanosis, urinary output; bloody sputum with cough. Chemoreceptors respiratory rate. Easy fatigue; dizziness (cerebral hypoxia) K from NA retention Develop Orthopnea: inability to breath when supine; feeling of smothering. Congestive Heart Failure Orthopnea occurs because: Heart ability improves with rest; fluid returns from alveoli to capillaries & back to heart. Overloads left ventricle LCHF Pressure in lung capillaries and fluid shift into alveoli worsens aeration. Chest X-ray or MRI: left side heart size.
Congestive Heart Failure RIGHT SIDED CONGESTIVE FAILURE Output of right ventricle is less than input from VC Causes backward pressure of VC & systemic venous circulation. Cause: Results from LHF; COPD, CHD with septal defect Congestive Heart Failure ASSESSMENT: Back pressure in VC liver & spleen size (hepatomegaly; splenomegaly) pressure in abd vessels ascites Overall systemic edema (dependent) Jugular vein distention pulmonary artery circulation dyspnea (not enough blood reaches alveoli to be oxygenated) X-ray or MRI right side heart size Congestive Heart Failure When BP , kidney produces renin. Renin acts on angiotensinogen (plasma proteins produced by liver) angiotensin I. Angiotensin I converted to angiotensin II by enzyme produced by lungs. II is potent vasoconstrictor; stim. thirst center in hypothalamus; constricts renal arterioles; stim. secretion of aldosterone BP; blood volume by fluid & NA retention ( preload). Congestive Heart Failure NURSING DIAGNOSIS: Activity intolerance related to congestive heart failure. THERAPY/INTERVENTIONS: Rest Diuretics to evacuate extra fluid Drug to and strengthen heart rate. EXPECTED OUTCOME: Client returns to normal activities.
Digoxin CLASSIFICATION: Cardiac glycoside; compound derived from foxglove plant. BRAND NAME: Lanoxin ACTION: Slows impulse conduction through the AV node (PNS stimulation) to slow and strengthen the heart contraction (increase calcium availability to heart muscle). PREGNANCY RISK CATEGORY: A
Digoxin ADMINISTRATION: P.O. OR IV (never IM) a. A loading dose: 10-15 mcg/kg of pts weight is given first (1/2 initially; 1/4 3-6 hrs later; 1/4 3-6 hrs later) b. Maintenance dose: 0.25 mg P.O daily (25% of loading dose). ADVERSE ACTIONS: Narrow window between effectiveness & toxicity.Toxicity with hypoxemia, hypokalemia, myocardial ischemia. Long half life (36 hrs) can lead to sustained response.
Digoxin GI: Nausea, vomiting. Neuro: Headache, vision changes (halos/blue- green color discrimination) Cardiac: Ventricular arrhythmias; SA arrest NURSING INPLICATIONS: Take apical pulse b/4 administration: Question order if 60 in adults. Teach patients how to take their pulse b/4 administration. Patients should report: low pulse rate; persistent cough; SOB; weight gain; edema of ankles, nausea/vomiting.
Nifedipine (Procardia) CLASSIFICATION: Calcium channel blocker Antianginal Antihypertensive ACTION: Prevent calcium from entering cardiac and vessels cells vasodilatation & slows nerve conduction in heart. O2 heart perfusion.
Nifedipine (Procardia) PREGNANCY RISK CATEGORY: C ADMINISTRATION: PO (slow release) ADVERSE EFFECTS: Dizziness NURSING IMPLICATIONS: Dont break sustained release capsules Monitor BP until regulated ECG Measure of the electrical conduction of the heart (measuring current flow between negative to positive lead) ELECTRODES (for monitoring): - under right clavicle + over left lower rib If reading a 12 lead ECG, read lead II.
ECG PAPER: Small blocks: 0.04 sec* Large blocks: 0.2 seconds (5 small blocks) 5 large blocks = 1 second 6 second strip = 30 large blocks* USUAL GRAPH: If current is flowing + lead upward deflection. If current is flowing + lead downward deflection. ECG P-WAVE: Current flowing over atria. Appearance: Smooth upward curve Duration: 0.06-0.12 seconds(2-3 small blocks) Height: 2-3 blocks high Problems: If no wave: SA node not originating heart beat. If long wave: atrial hypertrophy If irregular wave: atrial fibrillation ECG P-R INTERVAL: From beginning of P-wave to beginning of QRS wave. Appearance: P-wave plus hesitation space b/4 AV node. Duration: 0.12-0.20 secs (3-5 small blocks). Problems: Short: suggests impulse originated outside SA node. Long: suggests poor conduction (digitalis toxicity or heart block) ECG QRS SPIKE: Ventricular contraction; High, upward spike after P-R interval. Appearance: Begins with downward spike (Q); next the high R, then downward S. Duration: 0.06-0.10 (1 1/2 -10 small blocks) 1/2 of P-R interval) Height: 3-30 blocks. Problems: If low: poor contraction from pericardial fluid? If wide: poor conduction (myocardial infarction?) ECG S-T SEGMENT: End of ventricular contraction and beginning of repolarization (referred to as J-point) Appearance: Space from S wave to beginning of T-wave. Isoelectric (neither + nor -) Problems: depressed or elevated: ischemia or digitalis toxicity. ECG T-WAVE Repolarization to prepare for next heart beat. Duration: varies Height: 0.5 mm (5 small blocks) Problems: Absent: Repolarization not occurring; Inverted: heart damage (ischemia); hyperkalemia
ECG Q-T INTERVAL: Ventricular depolarization & repolarization (point from beginning of QRS to end of T- wave. Duration: Should not be greater than 1/2 the distance between consecutive R waves. U-WAVE An additional small wave at end of pattern. May indicate electrolyte interference. ECG 1. Count the rate: (QRS spikes X 10 on a 6 second (30 block) strip 2. Assess the rhythm: (are the QRS spikes steady?) 3. Assess the P-wave: Is there one b/4 all QRS? Is is normal appearance and length? 4. Assess the P-R interval: Is is steady? 5. Assess the QRS spike: Are they consistent? 6. Assess the T-wave: Is there one after every QRS?
ECG HEART BLOCK: Current originates in SA node but doesnt reach the AV node. P-R length unusually long. 1st degree: Normal rhythm; long R-R interval. 2nd degree: Regular rhythm; P-R interval lengthens; P-waves without QRS 3rd degree: Regular rhythm but difference in atrial & ventricle heart rates Coronary Artery Disease A group of disorders including atherosclerosis, arteriosclerosis, hypertension, and unhealthy lifestyles. Lipids (Fats) Made from carbon, hydrogen and O 2 the same as carbohydrates (not water soluble). Necessary for cell wall formation & energy (9 Kcal/gm) Triglycerides (fats & oils) Phospholipids (lecithin) Sterols (cholesterol) Digested by salivary, stomach & pancreas lipase; cholesterol absorbed directly Fat links to plasma proteins for transport through blood. Triglycerides 95% of fat in food Main way that fat is stored in body Most cells store little; adipose cells can store an unlimited supply. All have 3 carbon atoms at center; fatty acids attached: 3=triglyceride; 2=diglyceride; 1=monoglyceride. Short chain, intermediate & long chain (2-24 carbon atoms); short chain are easiest to absorb. Lipids (fats) SATURATED FAT (ALL CARBON SITES ATTACHED TO HYDROGEN NO DOULBE BONDS)
H H H | | | H--CCCH | | | H H H
MONOUNSATURATED FAT (1 DOUBLE BOND)
H H H | | | C=CCH | | | H H H
POLYUNSATURATED FAT (2 OR MORE DOUBLE BONDS)
H H H H | | | | C=C=C=C | | | | H H H H
Triglycerides Low density lipids (LDL): Transport fat to body cells Bad fat Derived from animal sources High density lipids (HDL): Transport fat back to liver Good fat Omega-3 Fats Unsaturated The first double bond is at the 3rd position. Found in fatty fish: mackerel, salmon, tuna, sardines & trout. Plants: canola oil, soybean, hazelnuts, green leafy vegetables. triglycerides, BP, anti-inflammatory; maybe cancer. Lipids (fats) How to tell saturated from unsaturated fats: Unsaturated: From plants; liquid at room temperature, spoil easily: Mono= olive & canola Saturated: From animals; hard at room temperature, high melting point: coconut, palm oil, butter, meat. Hydrogenated & TransFats Hydrogenated: Hydrogen is added to unsaturated fats. Changes them to saturated. Makes the best French fries, flaky pie crusts) Loses cardiovascular protection effect. Transfat: Hydrogen bonds are rearranged; becomes partially hydrogenated oil (stick margarine, microwave popcorn) Acts like saturated fat Phospholipids A phosphate compound (SO4) attaches to last carbon. Water soluble Necessary in body for prostaglandins, lung surfactant Sterols (Cholesterol) Necessary for bile, sex hormones (testosterone & estrogen); adrenocortical hormones myelin sheaths, & vitamin D. Found in all animal products. Not essential to eat any as liver produces it by enzyme HMG-CoA. Bile digests fat, then is reabsorbed and returned to liver. Fiber removes bile so helps cholesterol.
Cholesterol Blood Levels: Cholesterol: 200 mg/dL LDL = 130 mg/dL HDL= 29-77 mg/dL (should be 50) If LDL to HDL is 3:1; if risk for CVD
Hypertension Largest untreated disease in U.S. Silent killer Essential or Primary: Genetic (paternal); excessive sodium intake; sensitivity to sodium; renin- angiotensinI - angiotensinII release; abnormal sympathetic NS response; stress; obesity; insulin resistance. Secondary: Kidney, adrenal gland, coarctation/aorta)
Hypertension Thickening of arterial walls occurs afterload. Sodium retention promotes volume to preload and cardiac output Cardiac Output = Cardiac volume X heart rate. (80 ml is usual stroke volume) Na leads to potassium. Renin angiotensin I to angiotensin II BP.
Blood Pressure Category: Systolic: Diastolic: Optimal: 120 80 Normal: 130 85 High normal: 130-139 85-89 Stage I HTN 140-150 90-99 Sage II HTN 160-179 100-109 Stage III HTN 180 110
Hypertension Systolic BP reflects cardiac output (pressure in arteries) Diastolic BP reflects peripheral resistance (pressure while heart is filling) Hypertension Lifestyle Changes: Weight: q 2 lbs = 1 mm decrease Salt intake: reduce to 6 gm/table salt (Usual is 15 gm/day). Saturated fats & cholesterol Nicotine (nicotine BP by vasoconstriction) Alcohol (not over 1-2 oz daily) Stress (stress to SNS response)
Hypertension Potassium Na (citrus fruit & bananas) Exercise (30-45 min/3-4 X week) Arteriosclerosis Stiffening and thickening of arterial walls. Affects small arterioles. BP because compliance falls. Atherosclerosis Large vessels and points of turbulence (bifurcation & rapid flow) Begins with fatty streak in artery. Fat is irritating to artery wall; produces inflammation when in contact by O2. (oxidized) Macrophages invade. Platelets enter and produce clotting. Calcium walls off macrophages to produce stiff plaques. Angina Pain from myocardial ischemic pain An imbalance between O2 demand and coronary blood supply. O2 demand increases with exercise, sex. O2 supply limited by stress, smoking ASSESSMENT: Pain over left chest that radiates to left arm (nagging to sharp) Angina Two Types: Stable: I: Prolonged exercise II: Walking over 2 blocks. III: Walking under 2 blocks IV: Minimal exertion or rest
Easily relieved with rest and nitroglycerin Angina Unstable: Pain occurs at rest, after meals Depression of ST segment Atherosclerosis RISKS: Dyslipidemia; sedentary life style; high fat diet. COMPLICATIONS: Renal Disease: Sclerotic changes glomerulo destruction. Microalbuminurea; Creatine clearance will be .
Atherosclerosis Cerebral Disorders: Temporary ischemic Attacks (TIAs): 2-15 minutes of weakness, paralysis, confusion, difficulty speaking, writing, calculating (a senior moment). 50% of people having a TIA will have a CVA (stroke) in 5 yrs. Atherosclerosis Cerebral Vascular Accident (stroke) Males/females; elderly Embolus breaks loose from vessel plaques Blocks artery so cuts off circulation to tissue beyond that; ruptures and cuts off circulation as well as bleeds into tissue. Leads to paralysis; loss of speech, motor function, etc. NURSING DIAGNOSIS: Ineffective tissue perfusion related to involved blood vessels
Atherosclerosis THERAPY/INTERVENTIONS: Change lifestyle: LDL weight exercise fiber in diet saturated fat (all fat = 30% of total calories; saturated fat = 10% - step 1; 7% = step 2 diet) Atherosclerosis Pharmacology: Reduce dyslipidemia: Inhibit enzyme that promotes liver production of cholesterol (HMG- CoA) (statins) Bile acid sequestrants excretion of cholesterol Reduce hypertension: SNS response. blood volume RAA system response
Atherosclerosis Diuretics (thiazides & loop) and beta blockers (#1) ACE inhibitors (#2) Calcium channel blockers (#3) EXPECTED OUTCOME: Client follows modified lifestyle; triglycerides & cholesterol at normal levels.
Hypertension of Pregnancy 10% of pregnancies. 3 classic symptoms: hypertension (140/90); albuminuria; weight gain & edema Probably results from foreign protein; causes vasospasm. Severe Preeclampsia (160/110) & eclampsia (if seizures occur) Malignant Hypertension
Rapid HTN development leads to kidney failure, retinal damage and congestive heart failure. Need to caution this is not a malignancy. Coronary Artery Disease RISK: White male Women develop it ten years later than men; 35-55=m/w 55= even Over 55= w/m Heart does not receive enough oxygen (perfused during relaxation or diastole) Associated with hypertension & atherosclerosis. Peripheral Vascular Disease RISK: Diabetes mellitus; elderly ASSESSMENT: Cold, numbness of extremities. Hairless and dry skin Cramps in legs with exercise (intermittent claudication) TIAs Dizziness on movement Erectile dysfunction Diuretics Afferent artery Efferent artery | | ------- | |--------- | | - Na+ is reabsorbed | | - Potassium sparing diuretics proximal | | - K+ is reabsorbed descending -- | | - Na+ is reabsorbed tubule | | - Thiazide diuretics | | - Distal ascending tubule ----------- Loop of Henle ( H2O is reabsorbed) Osmotic (loop) diuretics Chlorothiazide HCl (Diuril) CLASSIFICATION: Thiazide diuretic ACTION: Inhibits reabsorption of sodium in distal renal tubule; excretion of sodium & H2O. PREGNANCY RISK CATEGORY: C ADMINISTRATION: PO, IV Chlorothiazide HCl (Diuril) ADVERSE EFFECTS: Dizziness; dry mouth, orthostatic hypotension, erectile dysfunction, muscle cramps NURSING IMPLICATIONS: Take drug early in the day so sleep is not disrupted by voiding. Increased urination will occur. Stand up slowly to prevent dizziness. Supplement diet with potassium (citrus fruit & bananas)
Furosemide (Lasix) CLASSIFICATION: Loop diuretic ACTION: Inhibit reabsorption of sodium & H2O from proximal tubules excretion of sodium & H2O. PREGNANCY RISK CATEGORY: C ADMINISTRATION: PO, IV
Furosemide (Lasix) ADVERSE ACTIONS: Same NURSING IMPLICATIONS: Same
Ethacrynic Acid (Edecrin) a second common loop diuretic Spironolactone (Aldactone) CLASSIFICATION: Potassium sparing diuretic ACTION: blocks the effect of aldosterone in distal tubule sodium & H2O (spares K+) PREGNANCY RISK CATEGORY: D ADMINISTRATION: PO ADVERSE EFFECTS: Same NURSING IMPLICATIONS: No need for K+ supplement Propranol (Inderol) CLASSIFICATION: B-adrengenic blocker Antihypertensive Antianginal Antiarrhythmic ACTION: SNS response vasodilatation; HR; afterload; BP to renin release PREGNANCY RISK CATEGORY: C
Propranol (Inderol) ADMINISTRATION: PO, IV ADVERSE EFFECTS: Dizziness, bradycardia, heart block; bronchospasm, pulmonary edema NURSING IMPLICATIONS : Should be tapered gradually Captopril (ACE Inhibitor) CLASSIFICATION: Antihypertensive angiotensin converting enzyme inhibitor (ACE inhibitor) ACTION: Blocks conversion of angiotensin I to angiotensin II so blocks vasoconstriction & aldosterone secretion BP & sodium excretion & H2O excretion
Captopril (ACE Inhibitor) PREGNANCY RISK CATEGORY: C ADMINISTRATION: PO ADVERSE EFFECTS: Tachycardia, MI, GI irritation NURSING IMPLICATIONS: Take in-between meals for best absorption Must be tapered before being stopped Change position slowly to prevent dizziness
Losartan (Cozaar) CLASSIFICATION: Angiotensin II Receptor Blocker Antihypertenive ACTION: Blocks binding of angiotensin II to tissues PREGNANCY RISK CATEGORY: D (fetal death) ADMINISTRATION: PO ADVERSE EFFECTS: Dizziness
Losartan (Cozaar) NURSING IMPLICATIONS: Assess for pregnancy or breast feeding Can take without regard for meals Should be tapering before stopping
Atorvastatin (Lipitor) CLASSIFICATION: Antilipidemic HMG-CoA Inhibitor ACTION: Inhibits action of the enzyme that begins cholesterol synthesis so serum cholesterol & LDL; HDL. ADMINISTRATION: Oral (adjunct to diet and lifestyle changes)
Atorvastatin (Lipitor) PREGNANCY RISK CATEGORY: X ADVERSE EFFECTS: Liver dysfunction. Myopathy. NURSING IMPLICATIONS: Must accompany lifestyle changes. Liver function tests are necessary (q 6mo to 1 yr). Caution it is pregnancy risk X. Nitroglycerin CLASSIFICATION: Antianginal agent ACTION: Vasodilation BP & afterload. ADMINISTRATION: Oral form is rapidly transformed by liver so is ineffective. Given sublingual (action in 1-3 minutes; peak 30-60 minutes) or by transdermal patch (30-60 minutes; peak 8-12 hours). Nitroglycerin ADVERSE EFFECTS: Hypotension NURSING IMPLICATIONS: Teach how to use sublingual (dont chew) or apply patch. Dont apply patches over hair. Change patch to bath, swim, etc. Rise from lying or sitting position slowly. Restricted Fat Diets General Rules: Cholesterol 300 mg/day. Limit egg yolks to 3-4/week. Use fatty fish, omega-3 plant sources Trim fat from meat Avoid frying food; use herbs for taste Use unsaturated fats (canola or olive) Use new omega-3 spreads (Benecol) Use fat free milk; no-fat cheese