Cardiovascular System 2011

Sonny M. Moreno, RN, USRN, MAN

Anatomy and Physiology

How many layers? What is the outer membrane?

Anatomy and Physiology

Number of chambers? What is the most important chamber? What separates the chambers?

Anatomy and Physiology

Valve between RA and RV? Valve between LA and LV? Valve between RA and PA? Valve between LV and Aorta? Most important valve?

Anatomy and Physiology

Location of valves? ECG electrodes (6)?

Anatomy and Physiology

sound created after closure of AV valves? sound created after closure of SL valves? Indication of gallop? Indication of murmur?

Anatomy and Physiology

Heart sound is best heard in? Apex and base of the heart? Location of the heart?

Anatomy and Physiology

Great blood vessels? 1st branch of Aorta? Blood supply of myocardium? Stroke volume Cardiac output Ejection fraction
BC A CC A LS A

Anatomy and Physiology

Trace the pulmonary circuit?

Anatomy and Physiology

Conduction system? Main generator? Reserve generator?

ANS
SA-bachmanns bundle and
internodal tract (anterior, middle, posterior)

AV-bundle of his R & L

bundle purkinje fiber purkinje network

Anatomy and Physiology

Anatomy and Physiology

Layers Chambers Valves PMI Pulmonary Circuit Conduction System

Cardiovascular Disorders

Hyperlipidemia
Primary: Genetic Secondary: DM, Hypothyroidism, Nephrotic Syndrome, Liver Disease, Obesity, diet, use of Beta Blockers and Diuretics Dx: >200 mg/dl, >LDL, <HDL, s/sx: asymptomatic Atheroma - ATHEROSCLEROSIS Mx: Diet Exercise Weight reduction Rule out the cause Medication: STATIN

Atheroma

EFFECTS?

Coronary Artery Disease CAD

MCC: Atherosclerosis Risk Factors: MRF and NMDRF

Difference b/n Angina and MI

1. 2. 3. 4. 5.
6. Angina Incomplete block Less 15 minutes (pain) Relieved by NTG ST and T wave changes Attack is precipitated by activity Not life threatening

1. 2. 3. 4.
5. 6.

MI Complete block Over 15 minutes (pain) Not relieved by NTG ST segment depression and T wave inversion Attack is not precipitated by activity Life threatening*

Impending doom, levines sign

Angina and MI
Dx:
1. 2. 3.

Pain and NTG test Coronary angiography MUGA: MULTI GATED ACQUISITION SCAN (Nuclear Medicine)
Thallium 201 Imaging (normal) Technetium-99 Imaging (necrotic)

4.

Cardiac enzymes: increased

Troponin-T or I CK MB LDH1 higher than LDH2 (flipped LDH) AST

5. 6.

ECG WBC, ESR and Myoglobin*

 Possible ECG results: Elevation of ST segment = MI Peaked or inverted T wave = MI Pathological Q wave = MI

Nursing Diagnosis
1.

2.
3.

4.
5. 6. 7.

Pain related to an imbalance in oxygen supply and demand Anxiety related to chest pain, fear of death and threatening environment Decreased cardiac output related to impaired contraction of the heart Altered tissue perfusion (myocardial) related to coronary stenosis Activity intolerance related to insufficient oxygenation Risk for injury (bleeding) related to dissolution of clots (shock) Ineffective individual coping related to threats to self esteem*

MI management: ER!!!
1. 2. 3. 4. CBR without BP & supine position Oxygen therapy IV access line Pain control, Morphine or Meperidine, IV bolus 5. Vasodilator (NTG), IV drip or patch 6. Anxiolytic (Benzodiazepine) 7. Cardiac monitor 8. Central venous access line 9. Cardiac enzymes evaluation 10. ACLS*

Other drugs for MI:

Pharmacologic Therapy 1. Thrombolytic Agents
1. 2. 3.
1. 2. 3. 4. 1.

2.

Anticoagulant

TPA tissue plasminogen activator Streptokinase (streptase) Urokinase

Heparin Warfarin ASA (antiplatelets) Plavix Propranolol

3. 4. 5.

Beta adrenergic blocking agents Antidysrhythmic

Diltiazem*

1.
1.

Calcium Channel Blockers

Lidocaine (Xylocaine)

MI surgical interventions:
PTCA Percutaneous Transluminal Coronary Angioplasty IABP Intraaortic Balloon Pump CABG coronary artery bypass graft
Triple Saphenous Vein, LIMA and RITA*

PTCA Percutaneous Transluminal Coronary Angioplasty

IABP Intra aortic Balloon Pump

CABG Coronary Artery Bypass Graft

Postop: Cardiac rehab

Conduction of Heart

ECG Tracings and Interpretations

1. 2. 3. 4. Observe P wave Evaluate Atrial rhythm Determine Atrial rate (6-10 per strip/6 sec) Calculate PR interval (0.12-0.20 sec or 3-5 ss) Evaluate Ventricular rhythm (QRS) Determine Ventricular rate (6-10 per strip/6 sec) Calculate the duration of QRS (0.06-0.08 sec or 1.5-2 ss) Calculate QT interval (0.36-0.44 sec or 911 ss)

5. 6.
7.

8.

6 second strip: 30 big squares

Cause Dx: S/sx: Cx: Mx:

AMI complication!

Cardiac Dysrhythmias Disturbances in regular rate/rhythm due to changes in electrical automaticity or conduction

Cardiac Dysrhythmias
Atrial Arrhythmias: 1. Premature Atrial Contraction (PAC)
No mx unless symptomatic

2. Atrial Flutter
Antiarrhythmic (Amiodarone and Flecainide) Digitalis Betablockers Antiplatelet and anticoagulant

3. Atrial Fibrillation
Digitalis Defibrillation

Cardiac Dysrhythmias
Ventricular Arrhythmias: 1. Premature Ventricular Contraction (PVCs)
Xylocaine

2. Ventricular Tachycardia (vtach)

Defibrillation (unsynchronized)

3. Ventricular Fibrillation (vfib)

Defibrillation (unsynchronized) CPR Epi 1mg (1st 2 min) Repeat Defib-CPR Amiodarone 300 mg (2nd 2 min) 2nd dose 150 mg Repeat Defib-CPR Vasopressor (Dopa) 2-10mcg/kg/min (3rd 2 min)

A and V Arrhythmias

Asystole
CPR Epi 1mg (x Atropine Sulfate)

Heart Block
1st Degree 2nd Degree
Type I (Mobitz) Type II (Mobitz)

3rd Degree

Heart Block

1st Degree
> 0.20 sec PR interval Prolonging PR interval Cause: BB and CCB Mx: none not unless symptomatic

Heart Block
2nd Degree
Type I (Mobitz)
60-100 beats/min More P waves than QRS Prolonging PR interval Cause: BB and CCB Mx:
Pacemaker (TCP to Permanent)

Heart Block
2nd Degree
Type II (Mobitz)
60-100 beats/min More P waves than QRS Missing QRS Prolonging PR interval Cause: BB and CCB Mx:
Pacemaker (TCP to Permanent)

Heart Block

3rd Degree
Divorced P and QRS Less QRS (40-50 beats/min) Cause: BB and CCB Mx: ER!!!
Pacemaker (TCP to Permanent)

Heart Block

Widened QRS complex = delayed conduction to purkinje fiber

Bundle Branch Block

Elevation of ST segment = MI
STEMI-fatal NSTEMI

Peaked or inverted T wave = MI

Pathological Q wave = MI

Flattening of T wave = Hypokalemia U wave = Hypokalemia Depression of ST segment = Hypokalemia

Elevated T wave = Hyperkalemia

Long QT interval = Hypocalcemia (Torsades de Pointes)

Administer Mg Sulfate

Pericarditis
Post MI complication (Dresslers Syndrome)

CHF
Cause: FVE, heart problems Dx: <Ef, <SV, <CO (2Decho) S/sx: (R) and (L) side Mx: The goal of treatment is to improve pump function, rest the heart and reverse the compensatory mechanism of the heart. 3D: Diet, Diuretics and Digitalis

(+) Chrono tropic

(-) inotro pic

Its all about the LEFT ventricle

PRELOAD is the initial stretching of the heart prior to contraction AFTERLOAD "load" that the heart must eject blood against EJECTION FRACTION EDV = 120 ml (amt of blood in the LV before contraction) SV = 70 ml (amt of blood ejected in the LV per contraction) ESV = 50 ml (amt of blood in the LV after contraction) Ef = 58% Formula: =SV/EDV =70/120 =58%

Cardiovascular
Left Ventricular Assist Device placement (LVAD) It is used while waiting for heart transplant or if heart transplant is contraindicated. By MIMS

iNurse

 Cardiac Arrest: stopped! Dx: loss of consciousness no breathing and no pulses Mx: CPR, defibrillation and ACLS

ER!!!

Cardiac Arrest

Treatment: 1. Increase CO 2. Cardiovascular drugs and mechanical equipment utilization 3. Cardiovascular Drugs: IV Dopamine (vasopressor) IV Dobutamine (diuretic effects) IV Epinephrine (vasoconstrictor) IV Nitroprusside (vasodilator) 4.Mechanical: IABP intra aortic balloon pump (improve coronary perfusion) Defibrilator (arrhythmias can be stopped) Cardiac monitor (to detect arrhythmias)*

Cardiogenic Shock!

Shock
tissue perfusion (H20, 02, glucose)
CHD (Cardiogenic, Hypovolemic, Distributive)
ANS (Anaphylactic, Neurogenic, Septic)

ER situation (CPR)
Modified T. 02 treatment (ETT-Mech Vent.) IV line or cutdown (Intra Osseous) Drugs:
Epinephrine Inotropes and Vasopressors

Treat the underlying cause

Dont be too late!

ORGANS
BRAIN HEART KIDNEYS LUNGS SKIN

EARLY S/SX Reversible

LOC (disorientation) tachy Oliguria (>30mL/H) tachy Pallor

LATE S/SX Irreversible

Coma Brady Anuria (>10mL/H) Brady Cyanosis

GIT
LIVER

Ulceration
detoxification

Ulceration-bleeding
Sepsis

ATHEROMA effects:

 HPN Primary or Essential Hypertension: x idiopathic Secondary Hypertension: diseases s/sx: >BP on 3 separate occasions, headache, (-)s/sx (asymptomatic) Peripheral vascular resistance Tachy > cardiomegaly -> HF Dx: Mx:
N.P.
Diet Exercise Weight reduction

PHARMACOLOGIC

Ace inhibitor -pril BB ANS (hypoTN) CCb Diuretics

The Joint National Committee (JNC 7), 2003 Gold Standard: 115/75 CATEGORY SBPmm Hg DBPmm Hg Normal < 120 < 80 Prehypertension 120-139 or 80-90 Hypertension, Stage 1 140-159 or 90-99 Hypertension, Stage 2 160 or 100

 Outpouching of arterial wall bruit Abdominal Aortic Aneurysm Aneurysm: BV dilates, arterial wall Cause: AVM (arteriovenous Malformation), diseases Dx: MRI S/sx: as/sx, depending on the area involved Mx:
Drugs? Anti-HPN drugs (ABCD) BB, anticoagulant Avoid valsalva maneuver Surgical clipping Endovascular coiling (coils initiate a clotting or thrombotic reaction within the aneurysm) Stent

Peripheral Vascular Disorders

Artery
TAO

Vein
DVT Thrombophlebitis CVI Varicosities

Artery and Vein

RP

TAO
Thromboangitis Obliterans or Buergers Disease Cause: c. Smoking Dx: Doppler UTZ test (speed) (slow) = perfusion problem S/sx: 5 Ps, gangrene Intermittent chlorication Pain pallor paresthesia (priority) Pulselessness poikilothermia Mx:
Exercise: Buerger-Allen exercises (neovascularization) = inc. collateral circulation Swimming, walking Drugs: Anticoagulant, Fibrinolytics Surgery: Endarterectomy Femoro-popliteal bypass graft amputation For example: a patient who has smoked 15 cigarettes a day for 40 years has a (15x40)/20 = 30 pack year smoking history.

 Buerger-Allen exercises - A series of exercises administered to patients with peripheral vascular disease. These exercises are repeated 6-7 times at each sitting and done several times a day. 1. Support legs in an elevated position at 60-90 degrees for 30-180 seconds, or until you produce blanching of the extremity. The patient is instructed to actively dorsiflex and plantarflex the ankle throughout the procedure. 2. Allow feet to dangle over the edge of the bed for 2-5 minutes or as long as it takes to produce hyperemia, then add one minute. The total time should not exceed 5 minutes. 3. Place legs in a horizontal position for 3-5 minutes.

Disorders

DVT
1. Pratts sign (squeezing of the calf) 2. Virchows triad Decreased blood flow Increased coagulation Damaged wall

DVT pulmo embolism Thrombophlebitis CVI chronic venous insufficiency Varicosities

Disorders
DVT Thrombophlebitis CVI Varicosities Irritated lining

Disorders
DVT Thrombophlebitis CVI Varicosities

Disorders
DVT Thrombophlebitis CVI Varicosities Stasis of blood (prof, saleslady, Preggy, obese, post op patient, coma) = quadriceps teaching

Tandaan!!!
DVT Venous stasis Vein S/sx:Homans sign POOLING Duplex UTZ test (sounds to image) Venogram Thrombectomy Embolism Fibrinolytics and anticoagulant Dipyridamole (Persantin) ANTIPLATELET: to prevent occlusion Clot formation no massage may dislodge Antiembollic stockings, bago tumayo TAO Smoking Artery S/sx:Intermittent claudication LOSS OF SENSATION Doppler UTZ test (speed) Arteriogram Endarterectomy Gangrene (clostridium perfringens) Fibrinolytics and anticoagulant Dipyridamole (Persantin) ANTIPLATELET: to prevent occlusion * No raising, level of heart = no perfusion

RP Raynauds Phenomenon or
Vasospastic Disorder
Cause: X, AutoImmune, cold stress Dx: Cold Stimulation Test and Nailfold Capillaroscopy S/sx: White (spasm)Blue (dilate) -Red (constriction) Cx: gangrene Mx: x smoking, avoid trigger, 1. CCBA, BB, sympathectomy Raynauds Disease: bilateral involvement

Thank you

Cardiovascular Drugs
Statin: Lipitor NTG: Nitrostat Morphine: Diuretics: K sparer Digitalis: Lanoxin Dobu-dopa: diuresis/cardiotonic Cardio accelerator: Epi, A. SO4 Anti arrhythmic: Lidocaine Beta blockers: Propranolol, Inderal Calcium blockers: Nifedipine, Adalat ACE Inhibitor: Captopril, Lisinopril Anticoagulants: Hepa, Warfarin Antiplatelets: ASA Fibrinolytics: t-PA, Urokinase, Streptokinase Hemostasis: Amicar, Hemostan, Vit K