LESSON 3: MEDSURG (C.

21)

ASSESSMENT OG CARDIOVASCULAR FUNCTION

Cardio- heart
Vascular- blood vessels

FUNCTIONS:1. Delivers oxygen and nutrients.

2. Remove waste and toxins.
3. Maintain perfusion

WALLS OF THE HEART

1. Endocardium- inner layer
2. Myocardium- the middle
3. Epicardium- outer layer

LAYERS OF BLOOD VESSELS

1. Tunica intima- inner
2. Tunica media- middle
3. Tunica externa- outer

CARDIAC CONDUCTION
SYSTEM:
ELECTROPHYSIOLOGY

Primary pacemaker- SA nodes

Secondary- AV nodes

Cardiac Action Potential

DEPOLARIZATION (Phase 0)
- electrical activation of cell caused by influx of sodium into cell while potassium exits.
REPOLARIZATION (Phase 1-3)
- return of cell to resting state caused by re entry of potassium into cell while sodium exits.
REFACTORY PERIODS (Resting phase)
 Effective refractory period- phase in whick cell are incapable of depolarizing.
 Relative refractory period- phase in which cells require stronger-than-normal stimulus
to depolarize.
CARDIAC CYCLE
- refer to the events that occur in the heart from the beginning of one heartbeat to the
next.
- number of cycles depends on heart rate.
- each cycle has three major sequential events:
 Diastolic
 Atrial sytole
 Ventricular systole

STROKE VOLUME- the amount of blood ejected with each heartbeat.

CARDIAC OUTPUT- amount of blood pumped by the ventricle in liters per minute.
Formula: heart rate × stroke volume
PRELOAD- degree of stretch of the cardiac muscle fibers at the end of diastole.
AFTERLOAD- resistance to ejection of blood from ventricle.
CONTRACTILITY- ability of the cardiac muscle to shorten in response to an electrical
impulse.

Influencing factors
 CONTROL OF HEART RATE
- autonomic nervous system, baroreceptors- control BP
 CONTRIL OF STROKE VOLUME
- preload: Frank- Starling Law
- afterload: affected by systemic vascular resistance, pulmonary vascular resistance

CONTRACTILTY
-increased by catecholamines, SNS, certain medications.
- responsible in fight of flight response
*epinephren
*adrenaline
*dopamine
*serotonine
- increased contractility results in increased stroke volume
- decreased by hypoxemia, acidosis, certain medications.

ASSESSMENT OF THE CARDIOVASCULAR SYSTEM

 Health history
 Demographic profile
 Family/ genetic history
 Cultural/ social factors
 Risk factors
* modifiable- nababago
*nonmodifiable- hindi nababago
HEALTH HISTORY
 Common symptoms
- chest pain/ discomfort
- pain/ discomfort in other areas of the upper body
- SOB/ dyspnea
- peripheral edema, weight gain, abdominal distention
- unuseal fatigue, dizziness, syncope, change in LOC

PAST HEALTH, FAMILY, AND SOCIAL HISTORY

 Medication
- medicine that can changes in heart rate:
*anti hypertensive (calcium channel blockers, beta blockers)
*OTC ( cold meds, decongestant)
*thyroid meds
*antidepressant
*cocaine/ ampethamines
*anti asthma medicine
 Nutrition
 Elemination
 Activity, exercise
 Sleep, rest
 Self-perception/ self-concept
 Roles and relationships
 Sexuality and reproduction
 Coping and stress tolerance.

PHYSICAL ASSESSMENT OF THE CARDIOCASCULAR SYSTEM

 General apperance
 Skin and extremities
 Pulse pressure
 BP; orthostatic changes
 Arterial pulses
 Jugular venous pulsations
 Heart inspection, palpation, auscultation
 Assessment of other system

LABORATORY TESTS.
 Cardiac biomakers- cardiac enzyme
-creatinine phosphokinase
 Blood chemistry, hematology, coagulation
 Lipid profile- cholesterol; triglycerides
 Brain (b-type) natriuretic peptide
 C-reactive protein- presence of inflammation
 Homocysteine
ELECTROCARDIOGRAPHY
 12- lead ECG
 Continous monitoring
- hardwire
- telemetry
- lead system
- ambulatory monitoring

CARDIAC STRESS TESTING

 Exercise stress test
- patient walks on treadmill with intensity progressing according to protocols
-ECG, V/C, symptoms monitored
 Pharmacologic stress testing
-vasodilating agents given to mimic exercise
-MRI

DIAGNOSTIC TESTS
 Radionuclide imaging
-myocardial perfusion imagine
- positron emission tomography
- test of ventricular function, wall motion
- computed tomography
- magnetic resonance angiography

ECHOCARDIOGRAM
 Noninvasive ultrasound test that is used to:
- measure the ejection fraction
- examines the size, shape, and motion of cardiac structures.
 Transthoracic- non invasive
 Transesophageal- invasive; can detect blood clot; thin tube

CARDIAC CATHETERIZATION
 Invasive procedure used to diagnose structural and functional diseases of the heart and
great vessels.
 Right heart catheterization
- pulmonary artery pressure and oxygen saturations may be obtained; biopsy of myocardial
tissue may be obtained.
 Left heart catherterization
-involves use of contrast agent

NURSING INTERVENTION
5. Observe cath site for bleeding 1. Maintain bed rest 2-6hours
6. Assess peripheral pulses 2. Instruct patient to report chest pain, bleeding
7. Evaluate temp, color 3. Monitor for contrast-induced nephropathy
8. Screen for arrythmias 4. Ensure patient safety
HEMODYNAMIC MONITORING
 Central venous pressure
- a measurement of the pressure in the vena cara or right atrium
- normal CVP is 2-6mmHg
 Pulmonary artery pressure
-normal pulmonary artery pressure is 11-20mmHg at rest
 Intra-arterial bp monitoring
 Minimally invasive cardiac output monitoring devices

PULMONARY ARTERY CATHETER AND PRESSURE MONITORING SYSTEM

- also done to measure pressure in the right heart chamber and to estimate pressure in the
left chamber
- the amount of blood pumps per minutes- CARDIAC OUTPUT
-resistance to blood clot from the heart- PERIPHERAL RESISTANCE
-and the volume of blood
 LESSON 4: MEDSURG(C.22)
MANAGEMENT OF PATIENTS WITH ARRHYTHMIAS
AND CONDUCTION PROBLEM

Arrhythmia
- abnormal rhythm of the heart or irregular heartbeat.

 Disorder of formation or conduction (or both)of electrical impulses within heart

 Can cause disturbances of:
*Rate
*Rhythm
*Both rate and rhythm
 Potentially can alter blood flow and cause hemodynamic changes
 Diagnosed by analysis of electrographic waveform

2 TYPES
 Atrial
- premature atrial complex
- atrial flutter
- atrial fibrillation
 Ventricular
- premature ventricular complex
- ventricular tachycardia
- ventricular fibrillation
- ventricular asystole

NORMAL ELECTRICAL CONDUCTION

 SA nodes
 AV nodes
 Conduction
 Bundle of his
 Right and left bundle branches
 Purkinje fibers
 Depolarization- stimulation systole
 Repolarization- relaxation diastole
ECG ELECTRODE PLACEMENT

*V1
*V2
*V3- middle
*V4
*V5- anterior axillary
line
*V6- mid- axillary line

THE ELECTROCARDIOGRAM (ECG)

 Electrode placement
- electrode adhesion
 Types of ECG
 ECG interpretation
- P wave
-QRS complex
- T wave
- U wave
- PR interval
- ST segment
- QT interval
- TP interval
- PP interval
Patient with an Arrhythmia
 Causes of arrhythmia, contributing factors, the arrhythmia’s effect on the heart’s ability
to pump an adequate blood volume.
 Assess indicators of cardiac output and oxygenation.
 Health history: previous occurrence of decreased cardiac output, possible causes of the
arrhythmia
 All medications (prescribe and OTC)
 Psychosocial assessment: patient’s “perception” of arrhythmia
* skin (pale and cool)
* signs of fluid retention (JVD, lung auscultation)
* rate, rhythm of apical, peripheral pulses)
* heart sounds
* BP, PR

COLLABORATIVE PROBLEMS AND POTENTIAL COMPLICATONS

 Cardiac arrest
 Heart failure
 Thromboembolic event, especially with atrial fibrillation

PLANNING AND GOALS

 Eradicating or decreasing occurrence of arrhythmia to maintain cardiac output
 Minimizing anxiety
 Acquiring knowledge about arrhythmia and its treatment

INTERVENTIONS
 Monitor and manage the arrhythmia
-Assess VS on an ongoing basis
-Assess for lightedness, dizziness, fainting
-If hospitalized:
*obtain 12-lead ECG
*continuous monitoring
*monitor rhythm strips periodically
-Antiarrhythmic medications
*6-mins walk test
 Reduce anxiety
- stay with patient
- maintain safety and security
- discuss emotional response to arrhythmia
- help patient develop a system to identify factors that contribute to episodes of the
arrhythmia
- maximize the patient’s control

 Promote home and community based care

 Educate the patient about self-care
- treatment options
- therapeutic medication levels
- how to take pulse before medication administration
- measures to decrease recurrence
- plan of action in case of an emergency
- CPR (family)
 Continuing care
-referral for home care
- hemodynamically unstable with signs of decreased CO
- significant comorbidities
- socioeconomis issues
- limited self-management skills
- electronic device recently implanted
EVALUATION:
- maintain CO
*stable VS, no sign of arrhythmia
- experience reduced anxiety
*positive attitude, confidence in ability to act if an emergency occurs
- express understanding of arrhythmia and treatment

ADJUNCTION MODALITIES AND MANAGEMENT

 Used when medications alone are ineffective against arrhythmias
 Pacemakers
 Cardioversion
 Defibrillation
 Nurse responsible for assessment of the patient’s understanding regarding the
mechanical therapy
IMPLANTED TRANSVENOUS PACEMAKER

COMPLICATION OF PACEMAKER USE

 Infection
 Bleeding or hematoma formation
 Dislocation of lead
 Skeletal muscle or phrenic nerve stimulation
 Cardiac tamponade
 Pacemaker malfunction

CARDIOVERSION AND DEFIBRILLATION

 Treat tachyarrhythmias by delivering electrical current that depolarizes critical mass of
myocardial cells
- when cells repolarize, sinus node is usually able to recapture rolse as heart pacemaker
 In cardioversion, current deliver is synchronized with patient’s ECG
 In defibrillation, current deliver is unsynchronized
PADDLE PLACEMENT FOR DEFIBRILLATION

SAFETY MEASURE FOR DEFIBRILLATION

 Ensure good contact between skin, pads, and paddles
 Use conductive medium, 20-25 pounds of pressure
 Place paddles so they do not touch bleeding or clothing and are not near medication
patches or oxygen flow
 If cardioverting, turn synchronizer on
 If defibrillating, turn synchronizer off
 Do not change device until ready to shock
 Call “clear” three time; follow checks required for clear
 Ensure no one is contact with patients, bed, or equipment

IMPLANTED CARDIVERTER DEFIBRILLATOR (ICD)

 Device that detects and terminates life-threatening episodes of tachycardia and
fibrillation
 Anti-tachycardia pacing

NURSING INTERVENTION OF THE PATIENT

WITH PERMANENT ELECTRONIC DEVICE
 ECG assessment
 CXR
 Nursing assessment
- CO and hemodynamic stability
- incision site
- signs of ineffective coping
- level of knowledge and education needs of family and patient