Nursing 201 Advanced Cardiac

2.0 Nursing assessment and management of patients with dysfunctions of circulation, and undergoing related diagnostic tests.

Laurie Brown RN, MSN, MPA-HA, CCRN Fall 2005

This is important!
There are three systems that must work together for the heart to beat efficiently:
1.
2. 3.

Circulatory Conduction Coronary

Review of the Cardiovascular System

Route of blood from the heart:

Arteries, arterioles, capillaries, venules, veins

Distribution of the Total Blood Volume

Heart - Approx 9 % of blood volume at any given time.

Arteries and veins act simply as conduits for blood! Only capillaries directly serve cells by exchanging materials with them.

Cardiac Tissues

Connective tissues form the fibrous skeleton and valves. Cardiac muscle produces the contractile force of the heart. Epithelial tissue lines the cardiac chambers and covers the outer surfaces of the heart.

Arterial System
General Features

Elastic Arteries Muscular Arteries Arterioles

Exterior Anatomy of the Heart

Anatomy of the Heart

Valves of the Heart

Tricuspid Directs the flow of blood from the right atrium to the left ventricle. Mitral Valve Directs the flow of blood from the left atrium to the left ventricle. Pulmonic (semilunar) Lies between the right ventricle and the pulmonary artery. Aortic Valve (semilunar) Lies between the left ventricle and the aortic artery.

Circulation in the Heart

1. Oxygen-poor blood (shown in blue) flows from the body into the right atrium. 2..Blood flows through the right atrium into the right ventricle.
3. The right ventricle pumps the blood to the lungs, where the blood releases waste gases and picks up oxygen.

3. The newly oxygen-rich blood (shown in red) returns to the heart and enters the left atrium. 4. Blood flows through the left atrium into the left ventricle. 5. The left ventricle pumps the oxygen-rich blood to all parts of the body.

The Circulatory System

Coronary Circulation

Coronary Blood Flow

Coronary Blood Flow is directly linked to oxygen demand.

Autoregulation helps to maintain normal coronary blood flow whenever coronary perfusion pressure changes due to changes in aortic pressure.

Autoregulation

Autoregulation is defined as
The intrinsic ability of an organ to maintain a constant blood flow despite changes in perfusion pressure.

Control of an event such as blood flow through a tissue (e.g., cardiac muscle) by alteration of the tissue.

Coronary Blood Flow

Heart Sounds
Heart sounds are caused by the closure
of heart valves.

The first sound (lub), or S1, is caused by closure of the atrioventricular (AV) valves. The second sound (dup), or S2, is caused by the closure of the semilunar valves.

Murmurs and Stenosis

A valve that does not close efficiently, results in the backflow of blood (i.e., insufficiency or regurgitation). A valve that does not open wide enough may cause turbulent backflow secondary to obstruction or narrowing (i.e., stenosis).

Landmarks

Pericardial Friction Rub

Non-infective Infective Autoimmune

Scratching, grating, squeaking, high pitched sound

Definitions

Cardiac output Pre-load After-load Cardiac reserve Starlings law of the heart Pulse deficit Pulse pressure

Physiology of Circulation (cont.)

Peripheral Resistance

Opposition to flow

A measure of the amount of friction blood encounters as it passes through the vessels.
Most friction is encountered in the peripheral circulation (peripheral resistance (PR)). Sources of resistance

Physiology of Circulation (cont.)

Blood Pressure

Force per unit area exerted on the wall of a vessel by its contained blood expressed in mm Hg. Usually means systemic arterial blood pressure in the largest arteries near the heart.

The differences in blood pressure within the vascular system provided the driving force that keeps blood moving through the body.

Physiology of Circulation
Blood Flow

Actual volume of blood flowing through the entire circulation or any part of it (a vessel, an organ, etc.) in a given period of time (ml/min). Equals cardiac output (CO) when applied to the entire circulation. Varies widely among individual body organs as determined by their immediate needs.

The Cardiac Cycle

1. Isovolumetric ventricular contraction

2. Ventricular ejection
3. Isovolumetric relaxation

4. Ventricular filling
5. Atrial systole

Ejection fraction (EF)

The ejection fraction (EF) represents the amount of blood pumped out of the heart (left ventricle) with each beat. In the healthy heart, it is around 70%.

An EF below 55% is considered abnormal.

What is congestive heart failure?

Tabers defines heart failure as

The inability of the heart to circulate blood effectively enough to meet the body's metabolic needs.

Symptoms of Heart Failure

Shortness of breath (dyspnea) Fatigue Edema associated with fluid overload Lightheadedness Hypoxia Orthopnea Cognitive changes Other

Auto-regulatory Mechanisms of The Heart

The heart is supplied by the two branches of the autonomic nervous system.

The sympathetic (adrenergic) The parasympathetic, or (cholinergic)

Changes Associated With Aging

Decreased vessel elasticity Increased calcification of vessels Impaired valve function Decreased muscle tone (including the heart Decreased baroreceptor response to blood pressure changes Decreased conduction ability of the heart

Other stuff

Contractility:
The ability of muscle cells to contract after depolarization. This ability depends on how much the muscle fibers are stretched at the end of diastole.

The inherent ability of cardiac muscle fibers to shorten or contract.

Cardiac Risk Factors

Non-modifiable

Modifiable
Other

Cardiac Testing

Blood Tests Electrical Structure Pressure Blood Flow Ischemic Tissue

Laboratory Tests

CK or CK-MB LDH (LDH1, LDH2) AST (SGOT) Lipids PT/PTT ABGs Electrolytes CBC Troponin & Myoglobin C-reactive protein (CRP) Homocysteine B Type Natriuretic Peptid

Tests

EKG Stress Test Transesophageal Echocardiography Echocardiography Phonocardiography

Radiographic

X-ray Fluoroscopy Angiography

Cardiac Cath DSA (Digital Subtraction Angiography)

Cardiac Testing
Angiography Angioplasty Biopsy VO2 max

Tests

Nuclear Cardiography Technetium Pyrophosphate Scanning Thallium Imaging MUGA Scan

Tests

Positron Emission Tomography (PET) MRI CAT Scan

Small Pericardial Effusion

Hemodynamic Monitoring

Physical Assessment

General appearance Mental Status Vital signs Pulses Heart rate and rhythm Perfusion Edema Lung sounds Other

Case Study FRED

82 y/o male w/30 + year history of COPD presents to the ER with C/O SOB and chest pain and now is to be admitted to your unit. He has a IV at TKO and O2 per NP at 2L. He was given a Nitro and an aspirin in the ER.

Fred

Admitting Dx: CHF, R/O MI Past Medical Hx: Mild CHF, COPD x 30 years,

CAD, HTN PE: Skin pink and dry, brisk capillary refill, oriented x 4, S3 heart sounds, SOB with any exertion, audible expiatory and inspiratory wheezes, crackles at bases bilaterally, 1+ pitting edema to mid calf

FRED
1. 2. 3. 4. 5. 6. 7. Chief Complaint Cardiac (Medical) History Tests (Labs & others) Medications Physical exam Vital signs Nursing Diagnosis

Admitting Dx: CHF, R/O MI

Past Medical Hx: Mild CHF, COPD x 30 years, CAD, HTN

Vital signs: 184/94, 122, 30, T 99.1 ABGs on RA - 7.55, CO2 26, O2 54 PE: Skin pink and dry, brisk capillary refill, oriented x 4, S3 heart sounds, SOB with any exertion, audible expiatory and inspiratory wheezes, crackles at bases bilaterally, 1+ pitting edema to mid calf

Q-R-S-T-A-A-A

Quality - dull/squeezing Region radiation changing right arm/left arm Severity/Setting rest vs exertion after meals scale of pain

Time sudden/gradual onset Alleviators Position Aggravators food/position/exertion/people constant/episodic Associated Symptoms SOB, cough, temp, nausea, diarrhea

Q-R-S-T-A-A-A

Application - Chief Complaints

What are Freds chief complaints?

Cardiac History

Ask about his personal history, family history and social history.

Fred - Medications

What medications is he currently taking?

Diuretic, ACE inhibitor, blocker, K+, Bronchodilators and Glucocorticoids

Physical Exam

What we know

SOB (subjective and objective) Vital signs ABGs SkinPerfusion Mental status Heart sounds Lung sounds Edema

Nursing Diagnosis
What nursing diagnosis would be appropriate for Fred at this time?
Remember, NDs serve to guide and direct nursing care!

Which question should you ask a client experiencing palpitations?

A. Family history of high blood pressure or heart problems B. Activity when symptoms begins C. Anything that makes symptoms more or less severe D. Amount of coffee or tea consumed each day