Cardiac Exam Review

A. Structural/ Inflammatory:
1. Endocarditis: infection of the heart’s endocardial surface or valves.
People at risk: Rheumatic heart disease/Rheumatic fever, IVDA- IV drug abuse, open
heart surgery & prosthetic valves, congenital heart defects, dental procedures, etc.
S/S: low grade fever, Splinter hemorrhages of nails, Roth’s spots (white spots on retina),
Janeway lesions (painless lesions on palms & soles), Osler’s nodes (painful nodules on
fingers, toes, nose, & earlobes), fatigue
Treatment: antibiotics for 6 wks, give prophylactic antibiotics before procedures, patient
teaching (rest, oral care, antibiotics)
2. Pericarditis: inflammation of the pericardium (pericardial sac)
S/S: Chest pain that radiates to left side of the neck, shoulder, back; positional changes
help ( leaning forward); pericardial friction rub (scratchy high pitched sound); diffuse ST
elevation; fever; chills; fatigue; elevated WBC
Treatment: position in high fowler’s or upright, give pain meds or NSAID’s, give
antibiotics, monitor for signs of cardiac tamponade (pulsus paradoxus, JVD with clear
lung sounds, muffled heart sounds, narrowed pulse pressure, tachycardia, ↓ CO)
B. Cardiac Tamponade: accumulation of blood/fluid in the pericardial cavity as a pericardial
effusion ↑ in volume, which restricts ventricular filling and cardiac output drops. It can happen
after a CABG.
S/S: chest pain, confused, anxious, restless, hypotension, pulsus paradoxus, JVD with
clear lung sounds, muffled heart sounds, narrowed pulse pressure, tachycardia, ↓ CO
C. Shock States:
1. Stages of Shock:
a. Initial: Occurs at a cellular level. Metabolism changes at the cellular level from
aerobic to anaerobic cause lactic acid build up. Removal of lactic acid by the liver requires
oxygen, which is unavailable b/c of ↓ tissue perfusion. (Not Clinically Apparent)
b. Compensatory: the body activates neural, hormonal, & biochemical mechanisms to
overcome the ↑ consequences of anaerobic metabolism and maintain homeostasis.
S/S: Patient is oriented x3, restless, confused, changes in LOC, ↓ CO, ↓ BP, SNS
stimulates vasoconstriction; ↓blood flow to kidneys, GI tract, & lungs, kidneys
hold onto water/ ADH secreted; ↓ rate & depth of respirations (tachypnea); ↑HR;
skin- pale & cool or warm & flushed.
 c. Progressive: compensatory mechanisms failed. ↓ cellular perfusion altered capillary
permeability.
S/S: ↓responsiveness to stimuli, delirium, tachypnea, diffuse & profound edema
(anasarca), ↓CO→ ↓ BP, ↑HR, ↓ peripheral perfusion & coronary perfusion,
↓urine output, jaundice, DIC, skin- cold & clammy
d. Irreversible: ↓ perfusion from peripheral vasoconstriction, ↓CO, bradycardia,
unresponsive, profound hypotension, hypoxia, hypothermia, skin- mottled, cyanotic
2. Classifications of Shock: fluids/ vasopressors
a. Cardiogenic Shock: occurs when either systolic or diastolic dysfunction of the
pumping action of the heart results in reduced CO. Pump failure
S/S: Tachycardia, hypotension, narrowed pulse pressure, ↑ vascular resistance,
tachypnea, cyanosis, & crackles, weak peripheral pulses, cool & clammy skin,
delayed capillary refill, ↓ urine output, anxiety, confusion, agitation, ↓BS, N/V,
Treatment: Treat cause, 1st choice of med to use dobutamine (Dobutrex)- ↑
contractility, IABP, hemodynamic monitoring, meds- nitrates, inotropes,
diuretics, vasodilators, beta blockers; oxygen
b. Hypovolemic Shock: occurs when there is a loss of intravascular fluid volume:
external loss of whole blood, loss of bodily fluids, pooling of blood, fluid shifts (burns, ascites),
vasodilation (sepsis).
S/S: tachycardia, hypotension, widen pulse pressure, tachypnea, ↓urine output,
anxiety/ confusion/ agitation, absent BS, ↓capillary refill, pallor, cool/ clammy
skin
Treatment: stop loss of blood, volume replacement: crystalloid- warmed isotonic
fluid (NS); PRBCs-if indicated; albumin
c. Septic Shock: Systemic inflammatory response to infection. Normal inflammatory
cascade is exaggerated.
S/S: vasodilation, ↑HR, ↑ resp progressing to ARDS/ respiratory failure, ↑glucose,
↓EF, ↓/↑ temp, crackles, ↓Urine output, confusion, agitation
Treatment: Fluid replacement & treat underlying infection. Antibiotics, volume
expansion- NS 2L, vasopressors (after fluid resuscitation)
D. MODS/ SIRS:
1. SIRS: Systemic Inflammatory Response Syndrome- systemic inflammatory response to a
variety of insults including infection (sepsis), ischemia, infarction, & injury.
S/S: Generalized inflammation in organs, vasodilation, ↓SVR, hypotension, ARDS (acute
respiratory distress syndrome), confusion, agitation, disorientation, lethargy, coma,
 hypoxemia, ARF (acute renal failure), ↓GI motility- GI bleeding & ulceration,
hypoglycemia, ↓urine output
LABS: Lactate 4mmol or less is normal, higher than 4mmol not normal
2. MODS: Multiple Organ Dysfunction Syndrome- is failure of 2 or more organ systems in an
acutely ill patient such that hemostasis cannot be maintained without intervention. MODS results
from SIRS.
S/S: hypoxemia, DIC, hypotension, ARDS (acute respiratory distress syndrome),
confusion, agitation, disorientation, lethargy, coma, ARF (acute renal failure), ↓GI
motility- GI bleeding & ulceration, hypoglycemia, ↓urine output
E. CABG: Coronary Artery Bypass Graft- circumvents an occluded coronary artery with an
autogenous graft (saphenous vein or internal mammary artery) for patients with severe CAD,
therefore restoring blood flow to the myocardium.
Post Op Complications: shock, severe hypotension, ↓CO, infection, bleeding, electrolyte
imbalances, ↓peripheral pulses, dysrhythmias- A-fib ↑ the risk for stroke, cardiac
tamponade, atelectasis & pleural effusion
F. Cardiac Meds:
a. Positive Inotropic- ↑ the force of myocardial contraction
b. Negative Inotropic- ↓ the force of contraction
c. Positive Chronotropic- ↑ the HR
d. Negative Chronotropic- ↓ the HR
e. Positive Dromotropic- ↑/ accelerate the conduction of the heart
f. Negative Dromotropic- ↓/ slow the conduction of the heart
1. amiodarone – antidysrhythmic: used for A-Fib, V-Tach/ V-Fib- regulates HR and ectopic
beats. Negative chronotropic
2. Levophed (norepinephrine) – Vasopressor: used for shock (cardiogenic & septic) - ↑ BP
& SVR (contractility). Positive – inotropic, chronotropic, & dromotropic
3. Coumadin – Anticoagulant: used clot treatment in confirm diagnosis of PE/DVT, clot
prevention pacemaker & mechanical valve, ↑clotting time for A-Fib, clot treatment non-
hemorrhagic Stroke, vitamin K- antidote
4. Digoxin: ↓HR & BP; used for A-Fib, heart failure; + inotropic, - chronotropic & dromotropic
Therapeutic level = 0.5-2ng/ml, half-life 24hrs
Toxicity S/S: Ventricular arrhythmias, progressive bradycardia, hypokalemia-
check K level
5. Adenosine: slows electrical conduction time through AV node. Used of for conversion of
PSVT to SR. Cause asystole for a few seconds then puts patient into normal rhythm.
6. Crystalloids: clear, can see through them, contain electrolytes. Used in fluid resuscitation.
Normal Saline, Lactated Ringers, D5/10.
7. Colloids: Protein substances have a color to them, used as plasma expanders (volume), ↑
oncotic pressure. Albumin, dextran.
G. Cardiomyopathy: a dysfunction of the cardiac muscle that can be associated with HTN,
CAD, cardiotoxic agents, valvular disorders, & vascular or pulmonary diseases.
1. Dilated Cardiomyopathy (DC): left ventricular dilation & impaired systolic
contractile dysfunction. Most common type.
S/S: dyspnea, orthopnea, fatigue, irregular HR & rhythm, may develop
rapidly or slowly, crackles, JVD
2. Hypertrophic Cardiomyopathy (HC): myocardial hypertrophy without ventricular
dilation. The septum becomes enlarged and might obstruct blood flow from left ventricle.
Rigid & stiff ventricles therefore restricted filling.
S/S: often asymptomatic, Dyspnea (most common), fatigue, syncope, angina,
SVT or A-Fib, orthopnea
3. Restrictive Cardiomyopathy: stiff ventricles that aren’t necessarily thickened. The
heart becomes very stiff, restricting diastolic filling, & cardiac muscle stretch. Causes
right- sided heart failure.
S/S: dyspnea, fatigue, ascites, conduction disturbances/ dysrhythmias (need ICD)
H. IABP: is used after MI or cardiogenic shock to ↓afterload (by reducing SBP), help the heart
profuse better, provides temporary circulatory assistance. Keep HOB no higher than 30
degrees! Always check peripheral pulses!
Possible complications: displacement, ↓ peripheral perfusion→ limb ischemia, occlude
renal arteries→↓urine output→renal failure, infection, bleeding, thromboembolism
I. DIC (Disseminated Intravascular Coagulation): an abnormal response of the clotting cascade
stimulated by a disease or disorder. Can be triggered by tumors, burns, sepsis, tissue injury,
immunologic disorders.
Causes: shock (hemorrhagic, cardiogenic, anaphylactic), septicemia, tissue damage,
snake bite, heat stroke, cirrhosis, hemolytic processes, glomerulonephritis, thrombotic
thrombocytopenic purpura
S/S: severe muscle/ back/ abdominal pain; bleeding in a patient with no hx of bleeding-
pallor, petechiae, purpura, oozing blood, bleeding from everywhere, hematomas,
occult bleeding. Tachypnea, hemoptysis, orthopnea, tachycardia, hypotension, GI
 bleeding, abd. distention, bloody stools, hematuria, halos (vision changes), headache,
mental status changes, irritability, HTN, fever, dizziness
Diagnostic Test: prolonged prothrombin time (PT) & partial thromboplastin time (PTT),
↓fibrinogen & platelets
Hallmark Signs: ↑PT, PTT, & FSP (Fibrin Split Products), ↓fibrinogen & platelets. FSP
works to coat platelets, interfere with thrombin, & attach to fibrinogen which interferes
with polymerization process necessary to form a clot.
(fresh frozen plasma- replaces all clotting factors), Platelets (if less than 20,000),
Cryoprecipitate (replaces Factor VIII & fibrinogen)
J. Dysrhythmias:
1. Atrial Fibrillation: atria fire rapidly from multiple foci (total disorganization),
irregular rhythm, no P wave, HR over 100, no PR interval or QRS interval, ventricular
rate 160-200.
S/S: palpitations, ↓BP, weakness, dizziness, SOB, chest pain
Treatment: CCB (Cardizem), digoxin, beta blocker, amiodarone, Coumadin,
cardioversion
2. 3 degree Heart Block:(CHB) atria & ventricles work independently, SA node fires at
a rate 60-100, ventricles don’t receive impulse, regular rhythm, P waves- dissociation
with QRS complex, no defined PR & QRS intervals, AV node rate 40-60
Treatment: O2, 1st choice external pacemaker- until permanent pacemaker can be
inserted, symptomatic- atropine, epinephrine, dopamine
3. Ventricular Tachycardia: a run of 3 or more PVCs that occur when an ectopic foci
fire repetitively & ventricle takes over as pacemaker, life threatening, rate 150-250,
usually regular rhythm maybe irregular, QRS > 0.12s, no P wave, no PR interval, Can
have a pulse or be pulseless ( start CPR).
Treatment: check pulse, if pulse- prepare for sedation & cardioversion;
No pulse- open airway, CPR, code blue, epinephrine 1mg q3-5min, defibrillate
(drug→ shock→ drug→ shock); amiodarone
4. Ventricular Fibrillation: chaotic firing within ventricles; no QRS, P wave, rate, or
CO. Patient is unresponsive, pulseless, & in an apneic state. Irregular rhythm.
Treatment: CPR- no pulse, defibrillate, epinephrine 1mg q3-5min; vasopressin,
amiodarone, procainamide, lidocaine, atropine, intubation, temporary pacemaker
5. Premature Ventricular Contractions (PVCs): single irritable focus within the
ventricles that fires prematurely to initiate an ectopic beat. Irregular rhythm, P wave
present with regular beat, Widened QRS interval.
 Multifocal PVCs: PVCs initiated from different foci appear different in shape
from each other
Bigeminy: every other beat
Trigeminy: every third beat
Couplet: 2 consecutive PVCs in a row
Salvos: 3 PVCs in a row
Ventricular Tachycardia: 3 or more consecutive PVCs
Treatment: O2, beta blocker, usually don’t give any meds until the cause is
found
K. Abdominal Aortic Aneurysm (AAA): outpouching or dilation of the vessel wall
Who at Risk: African American males with atherosclerosis, HTN
S/S: may be asymptomatic, ecchymosis of flank or umbilicus area – Grey Turner’s sign;
abdominal tenderness; lumbar pain that radiates to the back- back pain becomes severe if
rupture has occurred, epigastric discomfort
Diagnostics: CT scan
Treatment: surgery, Dacron graft
Nursing Care: monitor VS, pallor, diaphoresis, LOC, pain, hemodynamics, graft patency
including BP, UO, CVP; peripheral pulses frequently, labs, give IV fluids and monitor
kidney function