Cardiology for the NCLEX

Aaron Brown
Cardiovascular
system, what is that?

• The circulatory system consists of the heart, blood

vessels, blood and lymphatics.
• Arteries > arterioles > capillaries > venules > veins
> Heart
• Many Jobs:
• Send nutrients/oxygen to tissues
• to remove waste
• to transport hormones to target organs
• Transport immune cells and messengers
• clotting to prevent blood loss
• maintain body temp
• to transfer body reserves, specifically mineral salts, to
areas of need
Circulation, how does that work?
• Systemic Circulation
• Arterial
• Blood is delivered by the pulmonary veins (two from each lung) to the left atrium, passes
through the bicuspid (mitral) valve into the left ventricle and then is pumped into the
ascending aorta; backflow here is prevented by the aortic semilunar valves.
• The aortic arch toward the right side gives rise to the brachiocephalic (innominate) artery
which divides into the right subclavian and right common carotid arteries. Next, arising from
the arch is the common carotid artery, then the left subclavian artery.
• The subclavians supply the upper limbs. As the subclavian arteries leave the axilla (armpit)
and enter the arm (brachium), they are called brachial arteries. Below the elbow these main
trunk lines divide into ulnar and radial arteries, which supply the forearm.
• The descending (dorsal) aorta continues along the posterior aspect of the thorax giving rise to
the segmental intercostals arteries. After passage “through” (behind) the diaphragm it is
called the abdominal aorta.
• The abdominal aorta gives off three branches to the GI tract, and one branch to each kidney.
• At the pelvic rim the abdominal aorta divides into the right and left common iliac arteries.
These divide into the internal iliacs, which supply the pelvic organs, and the external iliacs,
which supply the lower limbs.
Circulation, how does that work?
• Systemic Circulation
• Venous
• Veins are frequently multiple and variations are common. They return blood originating
in the capillaries of peripheral and distal body parts to the heart.
• Important concepts:
• IVC returns blood from systemic circulation of the lower extremities to the RA.
• SVC returns blood from upper extremities and head to the RA.
Circulation, how does that work?
• Portal Circulation
• Blood draining the alimentary tract (intestines), pancreas, spleen and gall
bladder does not return directly to the systemic circulation
• Portal circulation exists to return all the blood from GI tract to liver before
returning to heart.
• In the liver absorbed nutrients and wastes are processed.
• After processing, the liver returns the blood via hepatic veins to the inferior
vena cava and from there to RA.
Circulation
The Heart
• Muscular organ that pumps blood to the lungs for oxygenation and to
the body
• Layers of the Heart:
• Endocardium (lining coat; epithelium)
• Myocardium (middle coat; cardiac muscle)
• Epicardium (external coat or visceral layer of pericardium; epithelium and
mostly connective tissue)
• Impulse conducting system
The Heart
Cardiac Nerves
• Modification of the intrinsic rhythmicity of the heart muscle is
produced by cardiac nerves of the sympathetic and parasympathetic
nervous system.
• Stimulation of the sympathetic system increases the rate and force of the
heartbeat and dilates the coronary arteries.
• Stimulation of the parasympathetic (vagus nerve) reduces the rate and force
of the heartbeat and constricts the coronary circulation.
Blood'Flow'Reminder'
Heart Sounds

• Sound of valves CLOSING

• S1: tricuspid and mitral
valve close
• S2: pulmonary and aortic
valve close
Heart Sounds
• A sound occurring after S2 is an “S3”
• Indicative of overloaded states such as CHF and left heart failure
• A sound occurring before S1 is an “S4”
• Atrial kick -> fluid colliding with stiff ventricle
• Indicative of chronic HTN
A P

T M
Cardiac Pathology
• Valvular Pathology
• Aortic Insufficiency
• Aortic Stenosis
• Shock
• Myocarditis
• Pericarditis
• Arrhythmias
• Arteriosclerosis
• Cardiomyopathy
Valvular Pathology: Aortic Insufficiency
• Heart valve disease that prevents the • Symptoms
aortic valve from closing completely. • Fainting
• Backflow of blood into the left • Weakness/SOB
ventricle. • Bounding pulse
• Wide Pulse Pressure
• Causes: • Chest pain on occasion
• Rheumatic fever
• Congenital abnormalities • Tests:
• Endocarditis • Palpation
• Marfan’s syndrome • Pulmonary edema present
• Ankylosing spondylitis • Echocardiogram
• Reiter’s syndrome • Left heart catheterization
• Syphilis • Aortica angiography
• Treatment:
• Dieuretics
• Surgical aorta valve repair
Valvular Pathology: Aortic Insufficiency
• Narrowing of the aortic valve • heard best at heart base
• may have ejection click
• Common in elderly, age >65 • radiates to carotid arteries
• crescendo-decrescendo murmur
• Causes:
• S4 heart sound
• hypertension
• coronary artery disease • Tests:
• rheumatic heart disease • Echo
• Symptoms • EKG
• Heart failure
• Treatment:
• SAD
• Diuretics – Best initial therapy
• Syncope
• Angina or chest pain (most common) • Surgical aorta valve repair - Definitive
• Dyspnea treatment

• Physical Exam:
• systolic ejection murmur
Shock
• Any condition wherein the heart is • Tests:
unable to meet the demands of the • Nuclear Scans
body. • Electrocardiogram
• Symptoms: • Echocardiogram
• Rapid breathing • ABG
• Rapid pulse • Chem-7
• Anxiety • Chem-20
• Nervousness • Electrolytes
• Thready pulse • Cardiac Enzymes
• Mottled skin color • Treatment:
• Profuse sweating • Norepinephrine
• Poor capillary refill • Dobutamine
• IV fluids
The client arrives in the emergency department after a
motor vehicle accident. Nursing assessment findings
include BP 80/34, pulse rate 120, and respirations 20.
Which is the client’s most appropriate priority nursing
diagnosis?

A. Alteration in cerebral tissue perfusion

B. Fluid volume deficit
C. Ineffective airway clearance
D. Alteration in sensory perception
Hypovolemic Shock
• Poor blood volume prevents the
heart from pumping enough
blood to the body.
• Causes:
• Trauma
• Diarrhea
• Burns
• GI Bleeding
• Treatment:
• Rapid infusion of IVF
• NS vs Transfusion?
Cardiogenic Shock
• Patient is euvolemic, however heart is not • hypotension
pumping enough blood to tissues • tachycardia
• Causes: • pulmonary edema
• Diffuse lung crackles
• myocardial infarction (MI) (most common cause)
• distended jugular veins
• cardiomyopathy
• cool extremities
• myocarditis
• ↓ urine output
• drug-induced
• Arrhythmias • Treatment:
• Septal defect or ruptured valve • always assess the ABCs – airway, breathing, and
circulation
• Symptoms (depends on etiology): • identify and treat the underlying cause
• myocardial infarction • supportive
• chest pain • fluid bolus
• dyspnea • oxygen
• arrhythmias • Medical
• palpitations • dopamine (first line)
• Syncope • dobutamine
• mental status change • norepinephrine
Heart Failure, whose side are you on?
Right Sided Heart Failure Left Sided Heart Failure

A. Right Upper Quadrant Pain

A. Left Ventricular Heave
B. Right Ventricular heave
B. Confusion
C. Tricuspid Murmur
C. Paroxysmal noturnal dyspnea
D. Weight gain
D. DOE
E. Nausea
E. Fatigue
F. Elevated Right Atrial pressure
F. S3 gallop
G. Elevated Central Venous pressure
G. Crackles
H. Peripheral edema
H. Tachycardia
I. Ascites
I. Cough
J. Anorexia
J. Mitral Murmur
K. Hepatomegaly
K. Diaphoresis
L. Orthopnea
Endocarditis
• Heart valve infection, probable • ESR
valvular heart disease. • ECG
• Can be caused by fungi or bacteria. • Blood cultures
• Symptoms: • P/E:
• Weakness • Presence of splinter hemorrhages
• Fever • Murmur
• Murmur • Treatment:
• SOB • IV antibiotics
• Night sweats • Monitor the patient for:
• Janeway lesions • Arrhythmias
• Joint pain • CHF
• Tests: • Glomerulonephritis
• CBC • Septic Emboli
Myocarditis
• Inflammation of the heart • Arrythmias
muscle.
• Tests:
• Causes: • Chest X-ray
• Bacterial or Viral • Echocardiogram
Infections
• ECG
• Polio
• WBC and RBC count
• Adenovirus
• Blood cultures
• Coxsackie virus
• Treatment:
• Symptoms:
• Diuretics
• Leg edema
• Pacemaker
• SOB
• Antibiotics
• Viral symptoms
• Steroids
• Joint Pain
• Syncope • Monitor the patient for:
• Pericarditis
• Fever
• Unable to lie flat • Cardiomyopathy
Pericarditis
• Inflammation of the pericardium. • Tests:
• Causes: • Auscultation
• MRI scan
• Viral
• coxsackie, adenovirus, influenza, rubella viruses • CT scan
• Bacterial (various microorganisms) • Echocardiogram (key test)
• Fungi • ESR
• Often associated with TB, • Chest x-ray
• Kidney failure • Blood cultures
• AIDS • CBC
• autoimmune disorders • Treatment:
• Surgery • NSAIDS
• Symptoms: • Pericardiocentesis
• Dry cough • Analgesics
• Pleuritis • Pericardiectomy
• Fever • Monitor the patient for:
• Anxiety • Constrictive pericarditis
• Crackles • A fib.
• Pleural effusion • Supraventricular tachycardia (SVT)
• LE swelling
• Unable to lie down flat
Question
 EKGs/ECGs

• Non-invasive way to detect

the fine electrical activity of
the heart
• Electrical activity typically
goes from base to apex,
electrodes tell us if that
activity is not moving the
way it normally should.
EKGs, what do they look like?
1. P WAVE - small upward wave; indicates atrial depolarization
2. QRS COMPLEX - initial downward deflection followed by large upright wave followed by
small downward wave; represents ventricular depolarization; masks atrial repolarization;
enlarged R portion - enlarged ventricles;
enlarged Q portion – history of MI
3. T WAVE - dome shaped wave; indicates ventricular repolarization; flat when insufficient
oxygen; elevated with increased K levels
4. P - R INTERVAL - interval from beginning of P wave to beginning of QRS complex;
represents conduction time from initial atrial excitation to initial ventricular excitation;
good diagnostic tool; normally < 0.2sec.
5. S-T SEGMENT - time from end of S to beginning to T wave; represents time between end
of spreading impulse through ventricles and ventricular repolarization; elevated with heart
attack; depressed when insufficient oxygen.
6. Q-T INTERVAL - time for singular depolarization and repolarization of the ventricles.
Conduction problems, myocardial damage or congenital heart defects can prolong this.
 ST segment: ventricles depolarized
P wave: atrial depolarization
Normal EKG PR segment: AV node conduction
QRS complex: ventricular depolarization
U wave: hypokalemia creates a U wave
T wave: ventricular repolarization
Arrhythmias
• Irregular heart beats and rhythms disorder • Dizziness
• Chest pain
• Types:
• Bradycardia • P/E:
• Tachycardia • Irregular pulse
• Ventricular fibrillation • Tests:
• Ectopic heart beat • Coronary angiography
• Ventricular tachycardia • ECG
• Wolff-Parkinson-white syndrome • Holter monitor
• Atrial fib.
• Sick sinus syndrome • Treatment:
• Sinus Tachycardia • Defibrillation
• Sinus Bradycardia • Pacemaker
• Medications
• Symptoms:
• SOB • Monitor the patient for:
• Syncope • Heart failure
• Palpitations • Stroke
• Heart attack
Arrhythmias
• Supraventricular Tachyarrhythmias
• Atrial fibrillation – Abnormal QRS rhythm and poor P wave appearance. (>300bpm.)
• Sinus Tachycardia- Elevated ventricular rhythum/rate.
• Paroxysmal atrial tachycardia- Abnormal P wave, Normal QRS complex
• Atrial flutter- Irregular P Wave development. (250-350 bpm.)
• Paroxysmal supraventricular tachycardia- Elevated bpm (160-250)
• Multifocal atrial tachycardia- bpm (>105). Various P wave appearances.
• Ventricular Tachyarrhythmias
• Ventricular Tachycardia- Presence of 3 or greater PVC’s (150- 200bpm), possible
abrupt onset. Possibly due to an ischemic ventricle. No P waves present.
• (PVC)- Premature Ventricular Contraction- In many cases no P wave followed by a
large QRS complex that is premature, followed by a compensatory pause.
• Ventricular fibrillation- Completely abnormal ventricular rate and rhythum requiring
emergency innervention. No effective cardiac output.
Arrhythmias
• Bradyarrhythmias
• AV block (primary, secondary (I,II) Tertiary
• Primary- >.02 PR interval
• Secondary (Mobitz I) – PR interval Increase
• Secondary (Mobitz II) – PR interval (no change)
• Tertiary- most severe, No signal between ventricles and atria noted on ECG. Probable use
of Atrophine indicated. Pacemaker required.
• Right Bundle Branch Block (RBBB)/Left Bundle Branch Block (LBBB) \
• Sinus Bradycardia- <60 bpm, with presence of a standard P wave.
• Saw tooth pattern p waves
Ventricular Tachycardia
Supraventricular Tachycardia