CARDIOVASCULAR SYSTEM KARLEEN L.

JARO
Action Potential

NCM104 LEC BSN 4-Q

Cardiac Conduction • Sinoatrial (SA) node – Fires at 60–100 beats/minute • Intranodal pathway • Atrioventricular (AV) node – Fires at 40-60 beats/minute • Atrioventricular bundle of His – Ventricular tissue fires at 20-40 beats/minute and can occur at this point and down • Right and left bundle branches • Purkinje fibers

Stroke Volume • The amount of blood ejected by the left ventricle • Preload – The amount of stretch placed on the cardiac muscle just prior to systole – Starling’s Law • Afterload – The force or pressure at which the blood is ejected from the ventricle – Equated with systemic vascular resistance (SVR) • Contractility Patient Assessment: Cardiovascular System Physical Exam • Inspection – General appearance – Jugular venous distension (JVD) – Skin – Extremities • Palpation – Pulses – Point of maximal impulse (PMI) • Percussion • Auscultation – Good stethoscope – Positioning

Cardiac Output/Index • Cardiac output – CO = HR (beats/minute) X SV (liters/beat) – Normal adult: 4-8 liters/minute • Cardiac index

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CI = CO(liter/minute)/Body surface area (m2) Normal adult: 2.8-4.2 liter/minute/m2 Normalizes liter flow to body size

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Normal tones – S1/S2 Extra tones – S3/S4 Murmurs Rubs

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CARDIOVASCULAR SYSTEM KARLEEN L. JARO
Murmurs • Timing • Location • Transmission • Pitch • Quality • Intensity Grading Grade 1 – Barely audible Grade 2 – Clearly audible Grade 3 – Moderately loud Grade 4 – Loud with a thrill Grade 5 – Very loud with an easily palpable thrill Grade 6 – Very loud, no stethoscope needed, palpable and visible thrill

NCM104 LEC BSN 4-Q
Rate •

• • • • • •

Look at complexes in a 6-second strip and count the complexes; that will give you a rough estimate of rate • Count the number of large boxes between two complexes and divide into 300 • Count the number of small boxes between two complexes and divide into 1500 Estimate rate by sequence of numbers Normal Timing • PR interval – 0.12 to 0.20 seconds • QRS interval – less then 0.12 • QT interval – varies with rate. It is usually less then ½ the R-to-R distance on the preceding waves Normal Sinus Rhythm • Rate is between 60 and 100 beats/minute • The rhythm is regular • All intervals are within normal limits • There is a P for every QRS and a QRS for every P • The P waves all look the same Sinus • • • • • • • Tachycardia Rate above 100 beats/minute The rhythm is regular All intervals are within normal limits There is a P for every QRS and a QRS for every P The P waves all look the same Caused by fever, stress, caffeine, nicotine, exercise, or by increased sympathetic tone Treatment is to take care of the underlying cause Bradycardia Rate is lower than 60 beats/minute The rhythm is regular All intervals are within normal limits There is a P for every QRS and a QRS for every P The P waves all look the same Caused by beta-blocker, digitalis, or calcium channel blockers. Normal for athletes Don’t treat unless there are symptoms. Can use pacing or atropine

Important Cardiac Labs • Coagulation studies – PTT and PT/INR • Electrolytes – Potassium, magnesium, and calcium • Lipid studies – Cholesterol, triglycerides • Enzymes – CK, CK-MB, LDH • Troponin Invasive Tests • Coronary angiography • Electrophysiology studies Steps to reading ECGs • What is the rate? Both atrial and ventricular if they are not the same. • Is the rhythm regular or irregular? • Do the P waves all look the same? Is there a P wave for every QRS and conversely a QRS for every P wave? • Are all the complexes within normal time limits? • Name the rhythm and any abnormalities.

Sinus • • • • • • •

Sinus Arrhythmia • Rate is between 60 and 100 beats/minute • The rhythm is irregular. The SA node rate can increase or decrease with respirations • All intervals are within normal limits • There is a P for every QRS and a QRS for every P

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CARDIOVASCULAR SYSTEM KARLEEN L. JARO
The P waves all look the same More common in children and athletes Ask the patient to stop breathing and the rate will become regular Premature Atrial Contraction (PAC) • Can occur at any rate • The rhythm is irregular because of the early beat but is regular at other times • All intervals can be within normal limits • There is a P for every QRS and a QRS for every P • The P waves all look the same except the P in front of the PAC will be different Paroxysmal Supraventricular Tachycardia (PSVT) • Rate is between 150 and 250 beats/minute • The rhythm is regular • QRS intervals can be within normal limits • There can be a P wave, but more likely it will be hidden in the T wave or the preceding QRS wave • Starts and stops abruptly • Treat with Valsalva maneuver or adenosine IV • • • Atrial Flutter • Atrial rate is between 250 and 350 beats/minute. Ventricular rate can vary • The rhythm is regular or regularly irregular • There is no PR interval. QRS may be normal • 2:1 to 4:1 f waves to every QRS • There are no P waves; they are now called flutter waves • Problem: Loss of atrial kick and ventricular conduction is too fast or too slow to allow good filling of the ventricles Atrial Fibrillation • Atrial rate is between 350 and 600 beats/minute; ventricular rate can vary • The rhythm is irregular • There is no PR interval; QRS may be normal • There are many more f waves then QRSs • Unlike flutter where the f wave will appear the same, in fib the f waves are from different foci so they are different Multifocal Atrial Tachycardia (MAT) • Rate is greater then 100 beats/minute • The rhythm is irregular • PR interval may vary depending on how close the foci is to the AV node; QRS may be normal • There usually is a P for every QRS and a QRS for every P wave • The P waves appear different because they are coming from different foci • There needs to be at least 3 different P waves to be classified as MAT Junctional Arrhythmia • Rate is between 40 and 60 beats/minute

NCM104 LEC BSN 4-Q
The rhythm is regular There is a P for every QRS and a QRS for every P • The P wave can be in three possible places – Retrograde conduction to atria before ventricle; P wave would be upside down before the QRS – If both atria and ventricle receive stimulus at the same time, the P would be buried in the QRS – If the ventricle was stimulated first, the P would be located just after the QRS Junctional Rhythms • Junctional bradycardia – Rate less than 40 beats/minute • Accelerated junctional – Rate 60-100 beats/minute • Junctional tachycardia – Rate is greater then 100 beats/minute • Premature junctional contractions (PJC) – Early beats in the cycle that have junctional P wave morphology Premature Ventricular Contractions (PVC) • Early beat that is wide (>0.12) • Originates the ventricles • No P wave • Compensatory pause • Can be defined by couplet or triplet; anything more would be considered ventricular tachycardia • Monomorphic or polymorphic • • Ventricular Tachycardia • Rate is between 100 and 200 beats/minute • The rhythm is regular, but can change to different rhythms • No PR interval; QRS is wide and aberrant • There may be a P wave, but it is not related to the QRS Torsades De Pointes • Polymorphous ventricular tachycardia • Caused by long QT syndrome. This is an inherited condition or caused by antiarrhythmic drugs • Cannot be converted by defibrillation • Magnesium is the drug of choice • Overdrive pacing may work also Ventricular Fibrillation • Rapid, irregular rhythm made by stimuli from many different foci in the ventricula • Produces no pulse, blood pressure, or cardiac output • Can be described as fine or coarse • Most common cause of sudden cardiac death First–Degree AV Block

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CARDIOVASCULAR SYSTEM KARLEEN L. JARO
• • • • • • • • The rate is usually between 60 and 100 beats/minute The rhythm is regular PR interval is prolonged past 0.20 seconds QRS may be of normal length There is a P for every QRS and a QRS for every P The P waves all look the same Can occur in healthy people Caused by drugs

NCM104 LEC BSN 4-Q
• • • Able to measure cardiac pressure Infuses drugs Some types of catheters can pace

Patient Management: Cardiovascular System Pharmacological Therapy • Fibrinolytics – Alteplase – tPA – Tenecteplase – tNK – Reteplase – RPA • Anticoagulants – Low-molecular-weight heparins – Heparin • Platelet Inhibitors – Aspirin – Glycoprotein IIb/IIIa inhibitors Antidysrhythmics • Class I – Inhibits fast sodium channels, likely to cause dysrhythmias, prolongs/depresses action potential • Class II – Beta blockers • Class III – Amiodarone, sotalol, ibutilide, and dofetilide • Class IV – Calcium channel blockers Inotropes • Drugs that are used to increase the force of myocardial contraction and improve cardiac output – Dopamine – Dobutamine – Epinephrine – Norepinephrine – Amrinone – Milrinone Vasodilators • Drugs used to decrease preload – Nitrates • Promote coronary artery perfusion • Can be given in many different ways • Ask about use of Viagra – Nitroprusside sodium • Protect from light • Effects of drug are gone in a matter of minutes • Cyanide toxicity Antihyperlipidemics • Four classes of drug – All four have side effects that are the same • Liver toxicity • GI upset • Diarrhea or constipation IABP

Second–Degree AV Block Type I • Rate is between 60 and 100 beats/minute • The rhythm is irregular or regularly irregular • PR interval is progressively longer until a QRS is dropped • QRS may be of normal length • There are more P waves than QRS waves • The P waves all look the same • Caused by drugs, myocarditis, or inferior wall MI Second–Degree AV Block Type II • Rate may be slow, caused by blocked P waves • The rhythm can be regular, depends on block • PR intervals may be normal or prolonged, but they are consistent • QRS usually greater then 0.12 • Can be more than one P wave for each QRS • The P waves all look the same • Caused by anterior wall MI, conduction problems • Permanent and deteriorates rapidly Third–Degree AV Block • Ventricular rate is usually between 20 and 40 beats/minute • Atrial rate is between 60 and 100 beats/minute • The rhythm is regular or irregular • P waves and QRS waves not related; interval is inconsistent • QRS waves are usually greater than 0.12 • There more more P waves than QRS waves • The P waves all look the same 12-Lead ECG • Limb leads – Standard leads: I, II, and III – Augmented leads: aVR, aVL, and aVF • Precordial leads


• Axis –

V1,V2,V3,V4,V5, and V6 The direction of the flow of electricity

Pulmonary Artery Catheter • Measures pressure in different areas of the heart

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CARDIOVASCULAR SYSTEM KARLEEN L. JARO
Decreases workload of the left ventricle by decreasing afterload • Increases perfusion of the coronary arteries • Decreases oxygen consumption • Increases cardiac output Ventricular Assist Device • Used in patients who are refractory to other treatment • Used as a bridge to transplantation • Goal of treatment – Adequate blood flow – Preservation of end-organ function Management of Dysrhythmias • Cardioversion • Radiofrequency catheter ablation • Cardiac pacemakers – Internal • Generator placed in a “pocket” in the patient’s chest – External • Pacing wire or PA catheter placed • Generator is external – Trancutaneous • Pads placed on the skin connected to a defibrillator • Common Cardiovascular Disorders Inflammation and Infection • Pericarditis – inflammation of the pericardium – Pericardial friction rub – Diffuse ST segment elevation – Constrictive pericarditis – Use of NSAIDs for pain control • Myocarditis – inflammation of the myocardium and the conduction system of the heart – Unexplained heart failure, rise in serum enzymes – Nonspecific ST-T wave changes – Pleuritic chest pain • Endocarditis – infection of the endocardial surfaces including the valves – Symptoms occur within 2 weeks of an infection – Requires a prolonged course of antibiotics Cardiomyopathies • Dilated – Increased ventricular chamber size – Decreased or normal muscle size • Hypertrophic – Left ventricular hypertrophy • Restrictive – Restrictive filling – Reduced compliance in one or both ventricles Heart Failure

NCM104 LEC BSN 4-Q
• Acute versus chronic – Acute: sudden onset of symptoms over hours or days – Chronic: limitations on a daily basis Left- versus right-sided heart failure – Left-sided: failure of the left ventricle to fill or empty • Can be systolic or diastolic in nature – Right-sided failure: due to pulmonary disease or pulmonary hypertension

Classification of Heart Failure • Class I – No limitation • Class II – Slight limitation of physical activity • Class III – Marked limitation of physical activity with some symptoms at rest • Class IV – Unable to participate in physical activity, symptoms occur at rest (“cardiac cripple”) Pharmacological Treatment • ACEI • Hydralazine • Nitrates • Digoxin • Diuretics • Beta blockers Nursing Diagnoses • Decreased Cardiac Output related to altered preload • Decreased Cardiac Output related to altered contractility • Decreased Cardiac Output related to altered heart rate • Decreased Activity Tolerance related to decreased cardiac output and deconditioning Acute Myocardial Infarction Atherosclerosis • Injury to endothelium – Increased levels of cholesterol/triglycerides – Hypertension – Cigarette smoking • Deposits in the lining of the artery – Cholesterol cellular waste, calcium, and fibrin • Atheroma – Keeps building to partial or complete blockage Risk Factors • Uncontrollable – Age – Heredity – Race – Sex

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CARDIOVASCULAR SYSTEM KARLEEN L. JARO
Modifiable – Cigarette smoking – High cholesterol – Hypertension – Physical inactivity – Obesity – Diabetes mellitus Angina Pectoris • Stable – chronic stable angina, classic angina – Paroxysmal, occurs with physical exertion – Relieved by rest or nitroglycerin • Unstable – preinfarction angina or crescendo angina – More prolonged and severe – Need to be treated immediately • Variant – Prinzmetal’s angina, vasospastic angina – Result of coronary artery spasm – Occurs at rest Management of Angina • Risk reduction – Stop smoking, diet, weight loss, exercise – Medications to control cholesterol, HTN, and diabetes • Pharmacological – Nitroglycerin, beta blockers, calcium channel blockers, and aspirin • Invasive – Angioplasty, PTCA, stent placement, IABP, CABG • Myocardial Infarction • • • • Inflammation Plaque rupture Thrombus formation Irreversible damage starts in 20 to 40 minutes. This process will continue for several hours

NCM104 LEC BSN 4-Q
Infarcted only partial amount of muscle wall Cardiac Surgery CABG Coronary Artery Bypass Graft Surgery • Native vessels – Saphenous vein – Internal mammary artery • Off–pump CABG • Transmyocardial laser revascularization – Valvular Disease • Stenosis – Mitral stenosis • Rheumatic heart disease – Aortic stenosis • Rheumatic fever, calcification with age • Insufficiency – Mitral insufficiency • Rheumatic heart disease, age, LV dilation – Aortic insufficiency • Rheumatic disease, aneurysm of ascending aorta Cardiopulmonary Bypass • Moves oxygenated blood around the body during open heart surgery • Core body temp is lowered to 28° C to 32° C • Complications – Increased capillary permeability – Hemodilution – Altered coagulation – Damage to blood cells – Microembolization Complications • Arrhythmias • Fluid resuscitation • Decreased cardiac contractility • Control of blood pressure • Respiratory problems • Postoperative bleeding Nursing Diagnoses • Decreased Cardiac Output related to – Changes in LV preload, afterload, and contractility – Cardiac dysrhythmias • Decreased Tissue Perfusion related to – Cardiopulmonary bypass, decreased CO, hypotension • Impaired Gas Exchange related to cardiopulmonary bypass, anesthesia, poor chest expansion, atelectasis, retained secretions • Risk for Fluid Volume Deficit related to abnormal bleeding

Location of the Infarction • Anterior • Inferior • Posterior • Lateral • Septal Type of Infarction • Q-wave – Infarcted the full muscle wall – Formation of pathological Q waves in area of infarct • Greater then one small box in duration • Deeper then 1/3 of the R wave • Non–Q-wave

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CARDIOVASCULAR SYSTEM KARLEEN L. JARO
Risk for Infection related to surgical procedure, invasive lines, drainage tubes, hypoventilation, retained secretions • Impaired Comfort related to endotracheal tube, surgical incision, chest tubes, rib spreading • Anxiety related to fear of death, ICU environment Carotid Endarterectomy • Atherosclerotic changes in the carotid arteries • 70% to 90% stenosis • Clamping of the carotid arteries • Heparinization to prevent clot formation • Postoperative Care of an Endarterectomy • Control of blood pressure • Assessment of cranial nerves – VII, X, XI, XII • Bleeding – Note neck size – Check for swelling – possible hematoma formation – Difficulty in swallowing or breathing

NCM104 LEC BSN 4-Q

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