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Conduction System
Cardiac Cycle
Contraction
Systole
Relaxation
Diastole
Heart Sounds
“lubdub”
Murmur
Rub is a high-pitched scratchy sound
Assessment
History
Descriptionof symptoms
Past medical hx/family hx
Medication hx
Physical Examination
General appearance
Pain
Vital signs
T,P,R,BP
Cardiac rhythm
Heart sounds
Peripheral pulses
Physical Examination
Skin
Peripheral edema
Weight
Jugular veins
Lung sounds
Sputum
Mental status
Blood pressure
Pressure of the circulating blood against the walls of the arteries, the veins,
and the chambers of the heart.
Postural Blood Pressure (Orthostatic)
Position patient in supine and flat for 10 min. before taking the initial BP
and HR
Do not remove cuff but ensure placement if correct
Assess postural BP with patient sitting on the edge of the bed with feet
dangling
Then with patient standing at the side of the bed
Wait 1-3 minutes after each postural change before measuring
An increase of HR and decrease in systolic BP by 15mm Hg or 10mm Hg
in diastolic BP
Diagnostic Tests
Laboratory test
Blood chemistry
Serum enzymes and isoenzymes
Troponin, an enzyme in myocardial contractile tissue
Creatine kinase (CK)
Diagnostic Test
Echocardiography
Transesophageal echocardiography (TEE)
Electrocardiography
12-lead ECG
Holter monitor
Stress test
Diagnostic Test
Cardiac catherization
Observe for hematoma
Evaluate color, pulse and temp
Leg straight 2-6 hours post-procedure
Arteriography
Client and family teaching after cardiac
catherization
Activity
Dressing
Pulse sites
Force fluids
Vital signs
Doppler Studies
Cardiac Dysrhythmias
Dysrythmia/ Arryhthmia
Irregularity in the heart rhythm (heart beat)
Electrical conduction disorder results in:
Abnormally Slow heart rate
Abnormally Rapid heart rate
No heart rate at all.
Heartbeat
P Wave
Impulse travels from SA through AV junction
Small,rounded, upright
Precedes the QRS complex
Atrial depolarization
PR Interval
Time it takes electrical impulse to be conducted through the atria and the AV node
Measured from the P wave to beginning of the QRS complex
Represent depolarization of heart from the atria through the AV node
(0.12-0.20 sec)
QRS Complex
Q wave – first negative or downward deflection; often not seen
R wave – first upward deflection
S- wave rest of the complex, the next downward deflection
QRS Complex – depolarization of the ventricles (both); conduction of
impulse through Bundle of His to purkinge fibers causing contraction of
ventricles
(0.04-0.12 sec)
T wave
- Represents heart reploarizing (relaxing), called refractory
period
Rounded; shape of turtle shell
(0.16 sec)
U Wave
If present indicates hypokalemia or reploarization abnormalities
Follows the T wave
ST Segment
Begins at the end of S waves and ends at the beginning of T wave
(0.12 sec)
QRS complex
Ventricular depolarization (contraction)
T wave
Ventricular repolarization (relax)
Interpretation of Cardiac Rhythm
5 – Step Plan
1. Regularity of rhythm….calipers, paper
2. Heart rate?
3. P wave
P-R interval
QRS complex
Determining Rate
3 seconds
Determining
HEART RATE (Ventricular )
Easy and accurate method
Count the number of small boxes within an RR interval and divide 1500 by that
number
Less accurate, for irregular rhythm
Count the number or RR intervals in 6 seconds
RATE
Tachycardia
HR greater than 100.
Bradycardia
HR less than 60.
Normal HR → 60-100
Normal Sinus Rhythm
Sinus
Rhythms
Look for a P wave
P wave → atrial contraction
Sinus Bradycardia
Sinus Tachycardia
Heart Disease
Coronary artery disease (CAD) is the most common type
Prevention
Cigarette smoking should be discouraged.
Regular aerobic exercise that lasts 30–60 minutes on most days of the
week should be encouraged.
Diet high in veggies
High blood pressure should be identified and treated.
Obesity should be avoided or reduced.
Diabetes mellitus should be diagnosed and treated.
Foods to avoid
Red meat
Fried chicken
Whole milk
Egg yolks
Butter
Ice cream
Pastry
Atherosclerosis Summary
Narrow the arteries so that less blood can flow to the heart
muscle
Completely block the arteries and the flow of blood
Cause blood clots to form and block the arteries.
Myocardial Ischemia
Angina Pectoris
Pain in the chest
When the myocardial oxygen demand exceeds the supply, ischemia of the
heart muscle occurs, resulting in chest pain or angina
Symptoms
Pain
Dull or tightness under the sternum
May radiate down right arm
SOB
Palloror flushing
Profuse sweating
Apprehension
Treatment
The signs and symptoms of angina are often very similar to those
of MI.
Temporary
Often relieved by rest and medication
Nitroglycerin dilates the coronary arteries and increases the blood flow;
but does not affect MI pain.
Nursing Process
Assess chest pain and vital signs
Administer oxygen, drugs and encourage rest
Notify physician
Prevention
Eliminating modifiable risk factors
Avoid precipitating events
Physical exertion
Emotional excitement
Eating a heavy meal
Exposure to cold
Medications
Nitroglycerin
Statins
Antiplatelets
Surgical management
PTCA (balloon angioplasty)
Coronary stent
CABG
Coronary Stent
Coronary Artery Bypass Graft
(CABG)
Coronary artery revascularization utilizes another vein to bypass diseased
coronary artery
Medical Management
Increasetissue perfusion
Decrease workload of the heart
Promoting tissue oxygenation
Oxygen
Nitroglycerin
Relieving pain
Morphine
Preventing complications
Limit the size of the infarct
Thrombolytic therapy
PTCA
CABG
Thrombolytic Therapy
Dissolve clots in occluded artery, reopening the vessel and allowing
perfusion of the heart muscle.
3-6 hours of the onset of symptoms
st
Most effective in 1 1hour
Excluded
Internalbleeding
Aneurysm
Recent head trauma
Hx of hemorrhagic stroke
Surgery within the past 10 days
Nursing Intervention
Administer oxygen
Administer medications
IV Morphine
Heparin
Antiplatelets
Stool softeners
Bed rest
Teaching
Treatment regimen
Cardiac rehab
Medications
Lifestyle changes
Dietary restrictions
Sexual activity
Warning symptoms
Symptoms of PVD
Intermittent claudication- pain with exercises, particularly
walking, causes excruciating pain in limb that disappears at rest.
Tingling and numbness – extremity becomes numb, or the feeling
of a persistent tingling sensation, caused by poor circulation
Symptoms of PVD
Coldness and difference in size- extremities feel cold to touch,
one leg may be colder and larger than the other.
Lack of tissue growth- skin becomes paper thin, shiny, and easily
subject to breakdown
Venous stasis ulcers- breakdown from inflamed skin causing
fluid to ooze causing skin to be impaired
Arteriosclerosis
Goals for peripheral arterial disease
Increased arterial blood supply to the extremities
Promotion of vasodilation
Prevention of vascular compression
Relief of pain
Maintaining tissue integrity
Interventions
Positioning the part below the level of heart
Reclining position
Walking
Not with pain
Promoting vasodilation
Warmth, avoid cold temperatures
Warm clothes, warm drink
Pt should test temp first
Postoperative Treatment
Pulses
Color and temperature
Capillaryrefill
Sensory and motor function
Venous Disorders
Venous insufficiency
Varicose veins
Venous Insufficiency
Blood pools in the lower extremity
Fluid leaves the blood vessel
Causing edema and the skin to become shiny and hard
Unoxygenated cells die causing release of inflammatory
chemicals
Skin becomes red and hot, tissue appears dark brown, deep
purple, or black
Chronic Venous Insufficiency
Results from obstruction of venous valves in legs or reflux of
blood back through valves
Venous ulceration is serious complication
Pharmacological therapy is antibiotics for infections
Varicose Veins
Blood Pressure
Force of blood against the walls of the arteries
Blood Pressure Readings Categories
What is hypertension?
High Blood Pressure
Remains elevated overtime
Systolic blood pressure greater than 140mm Hg
Diastolic blood pressure greater than 90 mm Hg
Based on an average of two or more consecutive measurements
Hypertension
Primary
No known cause
White coat
Anxiety
Secondary
Identified cause
Narrowing of renal arteries
Pregnancy
medications
Prognosis
With prolonged untreated essential hypertension, the elastic
tissue in the arterioles is replaced by fibrous tissue.
This process leads to decreased tissue perfusion, especially in the
target organs-heart, kidney, and brain-resulting in deterioration of
major organs.
Secondary Hypertension
Identifiable medical diagnosis
Renal vascular disease
Pregnancy-induced
Prognosis
Subsides when primary disease process is treated or corrected
Risk Factors
Nonmodifiable Risk Factors
Age
Gender
Race
Family history
Anxiety or nervousness
Palpitations
Ringing or buzzing in ears
Impotence
Headache
Dizziness
HTN
Heart disease
Stroke
Heart failure
Kidney disease
Blindness
Medical Management
Drugtherapy
Nonpharmacological therapy
Lose excess weight
Reduce saturated fat
Limit alcohol intake
Exercise regularly
Reduce sodium intake
Stop smoking
Thrombophlebitis
Deep vein thrombosis, DVT
Contributing factors
Immobility (venous stasis of blood)
Trauma
Sepsis
Clotting problems
Cancer
Obesity
Oral hormone replacement
Dehydration
Assessment findings
Treatment is aimed at Prevention
Early
movement
Mechanical prophylaxes
Compression elastic stockings
Sequentialcompression devices (SCD)
Pneumatic compression devices
Pharmacologic prophylaxis
Aspirin
Coumadin
Heparin
LMWH- Lovenox
Treatment
Complete bed rest
Anticoagulant therapy
Warm wet packs
Thrombectomy
Vena cava filter (Greenfield filter)
Anticoagulants
Heparin & Coumadin
Preventsthe formation of a blood clot
Does not effect existing thrombus
Body will dissolve over time
Anticoagulants
Heparin
Low-molecular weight heparin
Lovenox
Fragmin
Coumadin
Aspirin (antiplatelet)
Lab values
Heparin
Activated partial thromboplastin time (APTT or PTT)
LMWH
No effect on lab values
Coumadin
Prothrombin time and international normalized ration
(PT & INR)
Thrombolytic Therapy
May be used to dissolve the thrombus
Streptokinase
Urokinase
TPA tissue plasminogen activator
High risk for bleeding
Used only in emergency situation
Used only in good candidates
Monitoring
Adverse drug reaction
Bleeding
Inspect urine & stool for any GI bleeding
Skin for bruising
Avoid skin cuts
Reverse Effects
Heparin
Protamine sulfate
Coumadin
Vitamin K
Avoid foods high for therapeutic
dark leafy vegetables
Frozen fresh plasma
Buerger’s Disease (Thromboangiitis Obliterans)
Inflammatory lesions along small arteries and veins
Arteries prone to spasm
More common in men
Smoking aggravates the condition
Causes gangrene
Results in Gangrene