Anatomy & Physiology Cardiac System
Med Surg: Cardiac
Blood flow of the heart
1. Deoxygenated blood gets “vacuumed” back to the
vena cava (superior and inferior vena cava)
2. Right Atria - Tricuspid Valve - Right Ventricle.
3. Through the pulmonary valve & pulmonary arteries
into the lungs to drop off CO2 & pick up O2 (oxygen) in
the capillaries.
4. This oxygenated blood is then pumped through the
pulmonary veins.
5. Left Atrium - Mitral Valve (bicuspid valve) - Left Ventricle
• Side note: Left ventricle is the “BIG momma pumper”
pumping oxygen rich blood OUT to the body = cardiac
OUTput
6. Left Ventricle pumps O2 rich blood through the aortic
valve & then finally
7. The Aorta & out to the body via the “Arteries =
pump аway”.
Anatomy of the heart
Cone shaped organ located in the
mediastinal space.
The pericardial sac encases the
heart and protects it, lubricates and
holds 5-20 ml of pericardial fluid.
This has two layers.
• the parietal pericardium which is
the outer membrane.
• the visceral pericardium is the
inner membrane attached to the
heart.
Consists of 3 layers
• Epicardium: outermost layer of
the heart.
• Myocardium: middle layer of the
heart, the contracting muscle.
• Endocardium: innermost layer of
the heart, lines the inner
chambers and the valves.
Function of circulation
Delivers 02, nutrients, hormones and
antibodies to organs, tissues and cells.
Removes the end product of cellular
metabolism
Function of the heart
Pumps oxygenated blood into the
arterial system to supply capillaries
and tissue.
Pumps oxygen poor blood from the
venous system through the lungs
to be reoxygenated.
Pulmonary
Valve
4 valves
Two atrioventricular valves that close
at the beginning of ventricular
contraction. They prevent blood from
flowing back into the atria.
• Tricuspid valve: on the right side
of the heart.
• Bicuspid valve: on the left side of
the heart.
Two semilunar valves that prevent
blood from flowing back into the
ventricles during relaxation.
• Pulmonic semilunar valve:
between the right ventricle and
pulmonary artery.
• Aortic semilunar valve:
between the ventricle and the
aorta.
Coronary arteries
• Right main coronary artery:
supplies the right atrium and
ventricle, the inferior left
ventricle, posterior septal
wall, 1SA and AV nodes.
• Left main coronary artery:
consists of two main branches left
anterior descending which
supplies blood to the left ventricle
and the ventricular septum and
circumflex arteries which supply
blood to the left atrium and the
lateral/posterior aspects of the
left ventricle.
RA
LA
valve
valve
Aortic
Valve
RV LV
4 chambers
• Right atrium: carries
deoxygenated blood from the
body via superior and inferior
vena cava.
• Right ventricle: carries blood
from the right atrium and pumps
it into the lungs through the
pulmonary artery.
• Left atrium: carries oxygenated
blood from the pulmonary veins.
• Left ventricle: carries oxygenated
blood from the left atrium and
pumps it into the systemic circuit
through the aorta.
Electrical conduction:
• SA node: pacemaker of the heart
and initiates contraction at 60-100
BPM.
• AV: receives impulses from the SA
node initiates and sustains impulses
at 40-60 BPM.
• Bundle of His: continuation of the
AV node and branches into the the
bundle branches which terminate in
the purkinje fibers.
• Purkinje fibers: network of
conducting strands beneath the
ventricular endocardium. They can
act as a pacemaker when the SA and
AV fail as pacemakers. They can
sustain at 20-40 BPM.
Hypertension
Med Surg: Cardiac
Pathophysiology
Numbers to know:
Hypertension is chronic high blood pressure, which if not
treated can cause damage to organs from all that
high pounding pressure
• Brain - CVA (stroke risk!) NCLEX TIP
• Heart - MI (heart attack) & HF (heart failure)
• Kidney - CKD (Renal failure)
• Blood vessels - Atherosclerosis (scared arteries)
• Eyes - Blindness (Retinopathy NCLEX TIP
MEMORY TRICK
Systolic/Diastolic
‘’San/Diego’’
Squeeze/Decompress
STAGE 2: 140/90 (or more)
“NORMAL BP”
STAGE 1: 130-139/80-89
ELEVATED: 120-129/80
OVER
(or less)
140/90
NORMAL: 120/80 (or less)
Signs & Symptoms NO SYMPTOMS = Silent KILLER
A –Achy head (Headache) NCLEX TIP
B –Blurred vision (retinopathy)
C –Chest pain (angina)
SEVERE: HTN Crisis OVER 180/120
Immediate Action:
• B - Beta blockers “Blocks Beats”
• C - CCBs “C Calms the heart”
• D - Dilators (Vasodilators) “Nitro = Pillow”
• E - Emergency to ICU!
OH LORDY!
LOW: 90/60 (or less)
Labs
BNP - B-type Natriuretic Peptides
• 100 & Less = Normal
• 300+ Mild
• 600+ Moderate
• 900+ SEVERE
Cholesterol Panel
• Total Cholesterol = 200
• Triglycerides = 150
• LDL = Under 100
• HDL = OVER 40
NOTE: All should be low, except the HDL
“Happy - keep them HIGH”
Imaging
• Echocardiogram measure
Ejection fraction (blood pumped out of heart)
55 - 70% = normal
Less than 40% = Heart Failure
• ECG & EKG - Tall R peaks from the high pumps
• Side note: 3 BP measurements - 1 week apart,
confirms diagnosis
Pharmacology
Blood Pressure Lowering Drugs ABCD
A –Ace inhibitors -pril Lisinopril
B
Education
DIET LOW SCC (Sodium, Calories, Cholesterol)
REDUCE ALCOHOL & CAFFEINE
C
EXERCISE: WALKING (30 min. x 5 days/wk)
D
STOP SMOKING & ALCOHOL
STRESS REDUCTION
D
Causes
SODA
S –Stress, Smoking, Sedentary Lifestyle
O–Obesity, Oral Contraceptives (birth control)
D–Diet (High sodium & cholesterol)
Diseases
DM, Renal disease, HF, Hyperlipidemia (Over 200)
A–African men & Age (old)
A–Angioedema
C–Cough
E–E+ imbalances (LOW sodium, HIGH potassium)
ARBS “-sartan” Losartan
–Beta blockers (slows HR) “-lol” Atenalol
Blocks Beats
Caution: 4 B’s
Bradycardia (60 or Less)
Bottomed out BP (80/60)
Breathing problems (COPD, Asthma)
Blood sugar masking (diabetics)
–Calcium channel blockers
Calms heart, Controls BP
Niphedipine, Cardizem, Verapamil
–Diuretics
D–Drains Fluid “Diurese”
K+ Wasting–Furosemide & HCT
(caution: Low K+, Eat fruits & green leafy)
K+ Sparing–Spironolactone
(avoid Salt Substitues)
–Dilators (vasodilators) (Relieves Pressure)
Nitroglycerin = Pillow (rest & relaxed heart)
Caution: No Viagra = DEATH
AC Anti-Clogging of the arteries
A –Antiplatelet (Anti Clumping)
C
A–ASA
C–Clopidogrel Caution: Bleeding
–Cholesterol Lowering
Lovastatin “stay clean”
Caution: Liver Toxic, NO grapefruit
MI, Angina, CAD
Med Surg: Cardiac
Pathophysiology
Diagnostics
1st–EKG
(Any chest pain or MI symptoms)
Myocardial Infarction (MI) the heart muscles DIE “necrosis”
from lack of oxygen. This occurs when there is a
blockage of the coronary arteries, the “O2 tubes”
feeding the heart oxygen.
Signs & Symptoms
O2
PAIN–Jaw, back, mid back/shoulder pain, heartburn (epigastric),
Substernal
Key words = priority: “Sudden” “Crushing” “radiating” NCLEX TIP
SOB “dyspnea” “labored breathing”
NAUSEA Vomiting “Abdominal pain”
SWEATING “Diaphoresis”
PALE COOL SKIN “dusky”
ANXIETY
NormalNormal
ST elevation
ST elevation
ST Depression
Causes
SODDA
S–Stress, Smoking, Stimulants (caffeine, amphetamines)
O–Obesity–(BMI over 25)
D–Diabetes & HTN (over 140/90)
D–Diet (high cholesterol) animal fats
A–African American males & Age (over 50)
*Men more than women
Progression
CAM
C–CAD “coronary artery disease”
A–ACS “acute coronary syndrome”
Angina - Stable “Safer”- relieved w/rest
Angina - Unstable “Unsafe” - Unrelieved
M–MI (heart die)
Patient Education
DRESS
D–Diet low (sodium & fluids (2g/2L per day)
Prevent HF Heart Failure=Heavy Fluid
Report "New, Rapid" Weight Gain-Water Gain!
R–Reduce Stress, Alcohol, Caffeine, Cholesterol (animal fats)
E–Exercise (30 min x 5 days/wk)
S–Smoking Cessation
S–Sex (2 flights of stairs with NO SOB) NCLEX TIP
*AVOID NSAIDS (naproxen, ibuprofens) = increases CLOT risk!
Treatment: Pharmacology
AC–Anti Clogging of Arteries
A–Antiplatelet HOLD if: Platelets 50K or LESS
“below 50 gets risky” (not INR, not aPTT)
A–ASA
C–Clopidogrel
C–Cholesterol Lowering “-Statin”
Lovastatin “stay clean”
CAUTION:
NO grapefruit
Liver Toxic–report “clay colored stools”
Muscle pain (Rhabdomyolysis risk)
Late night–take at dinner
2nd–LABS
T–Troponin (Over 0.5 ng/mL)
T–Trauma (ONLY indicator of MI)
Other labs: Crp, Ckmb,
Myoglobin, CRP (inflammation)
Treatment: Pharmacology
DURING–Any Chest Pain
O–Oxygen
A–Asa
N–Nitro–under tongue x 3 Max
M–Morphine - Any pain after = MI (injury)
AFTER–MI
Clot Stabilization:
Heparin: prevents CLOT growth (NOT dissolve only t-PA)
PTT: 46 - 70 “3 x MAX” Antidote: Protamine Sulfate
Memory Trick: “HaPTT” frog
Heart Rest:
B–Beta Blockers (-lol) Atenolol
Blocks both BP & HR (Lol = Low BP & HR)
CAUTION:
B–Bad for Heart Failure patients (CHF)
B–Bradycardia (60 or Less) & BP low (HR LESS than 60)
B–Breathing Problems “wheezing” (Asthma, COPD)
B–Blood sugar masking “hides s/s” (Diabetics)
C–Calcium Channel Blockers
Calms BP & HR-(AVOID Low Hr & BP)
(Nifedipine, Diltiazem, Verapamil)
-dipine “declined BP & HR”
-zem “zen yoga for heart”
-amil “chill heart”
D–Dilators (vasOdilators = O2 to heart)
Nitroprusside (only for HTN crisis) & Isosorbide
Nitro “Pillow for heart”
NO viagra “-afil” Sildenafil = DEATH!
Nitro drip: STOP if Systolic BP below 90 or 30 mmHg Drop
SE: HA is Common + SLOW Positions changes “syncope” t
DISCHARGE–GOING HOME
CHOLESTEROL
PANEL
C-CLOGGED ARTERIES (risk)
200 or Less-Total Cholesterol
150 or Less-Triglycerides
100 or Less-LDL
40 or More = HDL
Heart Rest:
1st choice A–Ace (-pril) Lisonopril “chill pril”
2nd choice A–ARBs (-sartan) Losartan “relax man”
Antihypertensive (BP ONLY) *HOLD: Low BP (not HR)
Precautions:
A–Avoid Pregnancy
A–Angioedema “thick tongue”
(Airway Risk) *only Ace NCLEX TIP
C–Cough *only Ace
Creatinine (Kidney) (normal: 0.9 -1.2) *only Ace
E–Elevated K+ (normal 3.5-5.0) NCLEX TIP
AVOID Salt Substitues + Green Leafy veggies
• 1st–Cardiac Monitor
• High Potassium = High Pump
• Monitor: muscle cramps, spasms,
peaked T waves, ST changes
MI, Angina, CAD II
Med Surg: Cardiac
Cath Lab
C–Contrast = Kills Kidneys “Angioplasty, Angiogram, CABG”
A–Allergy to Iodine (warm flushing normal)
B–Bleeding–direct manual pressure (above site)
NO=heparin, warfarin, ASA, clopidogrel
C–Creatinine “Kidney” (normal: 0.9 - 1.2)
REPORT: Creatinine Over 1.3 & Urine below 30 ml/hr
STOP Metformin 48 hrs (before/after)
C–Can’t feel pulses (Pulses = Perfusion O2)
Diminished pulses (4-12 hrs post-procedure) MAX
PRIOITY:
Non palpable pedal pulse AFTER = CALL HCP (Dr.)
Key words: “cool leg, pulse non palpable,
present only with doppler US.
Complications After MI
ACUTE: (weeks after)
Cardiogenic Shock (severe hypotension)
V fib/V tach (no pulse) = DEADLY
Defibrillate=Don’t have a pulse
Cardioversion=Count a pulse *synchronize*
CHRONIC: (lifetime)
Heart failure “Heavy Fluid”
Rapid weight gain (Water Gain),
Worsening crackles (fluid in lungs “pulmonary, edema”)
Sudden edema (JVD, peripheral edema “+1 pitting”)
#1 Priority–IV Diuretics–Furosemide, Bumetanide “dried”
(NOT isosorbide)
NitrOglycerin
O2 to Heart
NO viagra “-afil” Sildenafil = DEATH!
NORMAL ADVERSE EFFECT:
HA=Normal Side Effect
Hypotension=Adverse effect
(need slow position changes)
PILL (or spray)
Nitro Patch (Transdermal nitro patch)
S–Stable Angina
S–Safe Angina
S–Stops when activity STOPS (Stress Induced)
*Take Before strenuous activity
GOAL:
NO chest pain=Daily activities
“comb hair, fix hair, get dressed, make up, making bed etc.”
TAKING MED:
CALL 911: PAIN 5 min. After 1st dose.
3 doses max x 5 min apart
NO SWALLOW–SL under
STORAGE:
NO LIGHT–NO HEAT
NOT: pill box, car, plastic bag, pocket
YES: purse ok
*Replace every 6 months
U–Unstable Angina
U–Unsafe Angina
U–Unrelieved with rest /Unpredictable (anytime)
1 x daily NOT PRN
1 patch at a time NOT 2 patches
YES Shower is ok
LOCATION: Rotate locations Daily
“Clean, Dry, shaven area” teach patient to wash hands
after application
Upper Body (subclavian, arm, upper chest)
NOT: hairy, scarred, burned, callous
NOT BROKEN SKIN
*TEST TIP: Patch fall off? (Over 1 hour ago)
Take nitro (pill/spray) New patch can take 40–60 min.
*Nurses wear gloves! Will cause MAJOR HA if it comes
into contact with skin!
0.4 mg
MI, Angina, CAD III
Med Surg: Cardiac
Anticoagulants (clot prevention)
Bleed Risk (Patient Education)
Antiplatelets (LESS potent)
ASA & Clopidogrel
Platelets LESS than 50k = RISKY (Normal: 150–400k)
NOT INR or PTT
Anticoagulants (MOST potent)
Warfarin = INR “warINR”
Range: 2.5–3.5 (3 x MAX range)
Antidote: Vitamin K (green leafy veggies) *NOT K+ = potassium*
Heparin (Enoxaparin) = aPTT “HaPTT” frog Partial Thromboplastin
Range: 46–70 (3 x MAX range)
Antidote: Protamine Sulfate
NO peptic ulcers (or active bleeds)
NO Rugs/dim halls (well-lit halls)
NO razors, hard brushing, constipation
NO NSAIDS like naproxen/ ibuprofen
NO EGGO vitamins
E–E Echinacea, Vitamin A
G–Gingko, Garlic, Ginseng
O–Omega 3
MYOCARDIAL INFARCTION
Treatment
(+) Positive Troponin = Heart Attack (MI)
PRIORITY: REMOVE THE CLOT!
CLOT BUSTER “Thrombolytics, Fibrinolytics”
“CATH LAB” OR SURGERY
“PCI” -graphy, -plasty
BEFORE
NPO 6 - 12 hrs
AFTER
NO heavy lifting–lie flat
NO Baths–Shower ok (dont soak)
Infected Incision
“red, warm, drainage”
t-PA: Alteplase, Streptokinase (Allergy risk)
Dissolves Clot ONLY (heparin does NOT)
BLEED RISK
8 hour duration
NO injections (IV, SQ, IM, ABG)
NOT via central lines (CVC)
ONLY “compressible site” (IV, PICC)
NOT FOR:
Active Bleeds:
Peptic Ulcers (but menstruation is safe)
History:
Arteriovenous malformations
Intracranial “Cerebral” hemmorhage
Hypoglycemia (relative contraindication)
Hypertension (over 180/110) TEST TIP
STRESS TEST
Non MI (non priority) • Spot the Narrowing
TREADMILL STRESS TEST
STOP test:
chest pain
ST elevation
NormalNormal
CHEMICAL: NUCLEAR PHARMACOLOGICAL STRESS TEST
24–48 hours BEFORE
NO Cigarettes, Caffeine (tea, soda, coffee) *NO DECAF
NO Meds: Nitro, Beta Blocker, Theophylline (stimulant)
NPO (nothing oral) 4 hrs before/after
ST elevation
ST elevation
Heart Failure
Med Surg: Cardiac
Patho
The heart fails to maintain adequate cardiac output
(oxygenated blood pumped OUT to the body) due to
impaired pumping ability.
MEMORY TRICKS
• HF - Heart Failure (failure to pump blood forward)
• HF - Heavy Fluid (backs up in lungs / body)
Weight Gain = Water Gain
Signs & Symptoms
R - RIGHT Sided HF
R - ROCKS BODY with fluid
• Peripheral Edema
• Weight Gain = Water Gain
• JVD (big neck veins)
• Abdominal Growth
- Ascites (fluid in abdomen)
- Hepatomegaly (big liver)
- Splenomegaly (big spleen)
L - LEFT sided HF
L - LUNG fluid
• Pulmonary Edema
• Crackles in lungs
“Rales that don't clear with
a cough”
• Pink Frothy “blood tinged”
sputum
• Orthopnea - difficulty
breathing when lying flat
Causes
R - RIGHT-Sided HF
L-LEFT sided HF
• HTN (high BP)
• Pulmonary HTN
• Stiff “fibrotic” lungs
• Left-sided HF can cause
Right HF
Weak heart = weak pump
• After a heart attack (MI myocardial infarction)
• Ischemic heart disease low oxygen to heart
muscles (CAD, ACS)
3 Common EXAM Questions:
Patient with heart failure who is
constipated!
What would the nurse recommend?
Which food item should the heart
failure patient avoid?
Select all that apply.
1. Walking
1. Chips - NO SODIUM!
2. Increase fiber
2. Fruits
3. Stool Softeners
3. Veggies
4. Drink extra water - NO!
4. Grilled chicken & fries - NO!
5. Canned beans - NO!
6. Bread
A client with chronic heart failure took cold medicine for her flu. She
presents with new productive cough with pink frothy sputum and
worsening crackles.
What action should the nurse take first?
1. Assess lung sounds
2. Give bumetanide IV Push - YES
3. Notify the HCP
4. Clock out for lunch
Look for
KEY WORDS
“New, sudden, worsening, rapid symptoms”
# 1 Action is Furosemide = “Body Dried”
Risk Factors
1. Hypertension (high BP) is the #1 risk factor
2. Atrial fibrillation & other dysrhythmias
3. Mitral valve regurgitation
4. Cardiomyopathy
Diagnostic tests
• Labs: BNP (brain type natriuretic peptides)
Memory trick: B - Broken ventricles
Over 900+ = SEVERE HEART FAILURE
• Echocardiogram measures
Ejection Fraction (blood pumped out of heart)
55 - 70% = normal
40% or LESS = BAD (heart failure)
• Hemodynamic Monitoring
“Swanz Ganz” (Pulmonary Artery catheter)
Over 8 = is NOT GREAT! (normal: 2 - 8 mmHg)
Priority Interventions
For Pulmonary Edema Crisis (lung fluid)
KEY WORDS
“New, sudden, worsening, rapid symptoms”
# 1 Action is Furosemide = “Body Dried”
• H - HOB 45 degree or higher
(Semi-fowler’s, High fowler’s, orthopneic position)
• O - Oxygen
• P - Push Furosemide + Morphine, Positive inotropes
• E - End sodium & fluids
(Sodium Swells the body)
NO drinking fluids + STOP IV fluids
Heart Failure II
Pharmacology & Care
Pharmacology
Lisinopril • Losartan
A – ACTS on BP only (not HR)
A – ACE (-pril) Lisinopril “chill pril” 1st choice
A – ARBS (-sartan) Losartan “relax man” 2nd choice
Atenolol
A–Avoid Pregnancy
A–Angioedema (Airway Risk) *only Ace
C–Cough *only Ace
E–Elevated K+ (normal 3.5-5.0)
Nifedipine, Cardizem, Verapamil
B – BETA BLOCKERS (-lol) AtenoLOL “LOL = LOW”
Cardiac Glycoside
Nitroglycerin
Potassium Wasting & Sparing
Milrinone *inotropic drug-LAST LINE therapy-palliative care
Blocks both BP & HR (AVOID Low HR & BP)
Caution: HOLD IF:
B–Bradycardia (LESS than 60) & BP low (90/60)
only hold if the patient is in an acute exacerbation of CHF
B–Breathing problems “wheezing” (Asthma, COPD)
B–Bad for Heart Failure patients
B–Blood sugar masking “hides S/S” (Diabetics)
C – CALCIUM CHANNEL BLOCKERS
Nursing Care & Interventions
DRBEDSS
LOW Sodium & Fluid (2L + 2g or LESS/day)
(Change positions slowly!)
(Should NOT be increasing)
(with pillows) High Fowlers
(3lbs/day or 5 lbs/7 days =
Worsening!)
(2 flights of stairs with NO SOB)
‘’TED hose’’ (decreases blood pooling,
Remove daily)
Calms BP & HR (AVOID Low HR & BP)
(Nifedipine)
-dipine “declined BP & HR
-amlodipine “chill heart”
D – DIURETICS Drain Fluid
D–Drains Fluid “Diurese” “Dried”
K+ Wasting–Furosemide & Hydrochlorothiazide
(caution: Low K+, Eat melons, banana & green leafy veg)
K+ Sparing–Spironolactone “Spares potassium”
(AVOID Salt Substitues, melons & green leafy veg)
D – DILATORS (Vasodilators)
Nitroglycerin, Isosorbide
Nitroglycerin “Nitro = Pillow for heart”
Caution: NO Viagra “-afil” Sildenafil = DEATH!
Nitro drip: STOP = Systolic BP below 90 or 30 mmHg Drop
Adverse effect:
HA= side effect
Low BP= adverse effect (SLOW position changes)
D – DIGOXIN (Inotropic)
NO OTC meds (Cough or Flu, Antacids
or NSAIDS) NCLEX TIP
NO Canned or packaged foods (chips, sauces, meats,
cheeses, wine)
NEVER massage calves (CHF patients)
NCLEX TIP
Digs for a DEEP contraction
Increased contractility
Apical Pulse x 1 minute
Toxicity (over 2.0) Vision changes, N/V TEST TIP
Potassium 3.5 or less (higher r/t toxicity)
Peripheral Vascular
Med Surg: Cardiac
NARROW
PVD | VEIN
NARROW
PAD | ARTERY
Signs & Symptoms
Signs & Symptoms
VEINY
ARTS
V VOLUMPTUOUS PULSES - Warm legs
E EDEMA (blood pooling)
I IRREGULAR SHAPE SORES (Exotic pools)
N NO SHARP PAIN (Dull pain)
Y YELLOW & BROWN ANKLES
A ABSENT PULSES,
Absent Hair (Shiny) = Cool legs
R ROUND, RED SORES (blood pooling)
T TOES & FEET PALE or BLACK “Eschar”
S SHARP CALF PAIN
(intermittent Claudication)
E - Exercise • E-Elevation (recliner chair)
Patient Education
Positioning
PVD
VEINS = ELEVATE
(Vacuum)
Positioning
PVD & PAD
C–Constriction AVOID
C–Cross legs
C–Constrictive clothing
C–Cigarettes
C–Caffeine
C–Cold Temperatures
T–Toenails trimmed ONLY by Dr.
NCLEX TIP
PAD
ARTERIES = HANG
(Away)
DVT, RAYNAUD’S & BUERGER’S
DVT - Deep Vein Thrombosis
Treatments
Pathophysiology
CLOT in a deep vein
DURING CLOT-DV
D Don’t Walk (bed rest)
V Venous return (eleVate)
Signs & Symptoms
CHANT
COWS
C CALF PAIN & CRAMPING
O ONE-SIDED SWELLING (Unilateral)
W WARM & RED (Blood pooling)
S SOB & CHEST PAIN = PE! (Call Doctor)
AFTER CLOT
C Calf Exercise & Isometrics
H Hydration
NCLEX TIP
A Ambulation
N NO long sitting (Car, Airplane, Bedrest)
T Ted & SCDs (AFTER CLOT resolved)
Raynaud’s & Buerger’s Disease
Signs & Symptoms
R–RAYNAUD’S • R–RING FINGER
B–BUERGER’S • B–BLACK FINGERS & TOES
Valve disorder
Med Surg: Cardiac
Pathophysiology
Mitral valve
Aortic valve
Mechanical
valves
The heart is like a 4 bedroom suite.
The valves are like doors & the
chambers are like rooms. If valves
have trouble closing it can result in
black flow of blood & insufficient
blood flow to the body.
Stenosis: stiff, narrowed, hard valves
Regurgitation: Return of blood or
backflow of blood as the valve does
not completely close.
Main Types
• Aortic Stenosis
• Aortic Regurgitation
• Mitral Stenosis
• Mitral Regurgitation
Causes
Pharmacology
Anything that can damage the heart!
• Congenital heart disease (pre-term babies)
• Cardiomyopathy - a disease of the heart
muscle
• Heart Attack - damaged heart muscles
• Infection:
• Rheumatic fever - ruins the heart
• Endocarditis - infection in the heart
• Anticoagulants: Heparin & Warfarin
• Antiplatelet: Aspirin & Clopidogrel
• Nitroglycerin for chest pain
Signs & Symptoms
Think LOW oxygen from LOW heart pumps.
Regurgitation
• Aortic
Tachycardia, dyspnea, fatigue
• Mitral
Edema, pleural effusion, enlarged organs
& ascites
Stenosis
• Aortic
Angina, sys. murmur, syncope, fatigue,
orthopnea
• Mitral
Cyanosis, activity intolerance, diastolic
murmur, s/s of right ventricular failure,
clear lung sounds
Surgeries
• Valve replacement - Warfarin therapy life long
• Balloon valvuloplasty - Stenosis
Patient Education
• AVOID dental procedures for 6 months after
surgery & take antibiotics before dental exams.
• Warfarin (anticoagulant)
• Life long drug with “routine blood tests”
• 2.5 - 3.5 INR (for valve replacements)
• Even intake of Green leafy veggies (vitamin K)
NOT increased & NOT decreased intake
- nice & even
• Bleeding precautions
• NO brushing teeth too hard
• NO shaving - only electric shaver
• NO throw rugs & always well lit halls
Endocarditis / Pericarditis
Med Surg: Cardiac
ENDOCARDITIS
Causes
• Dirty Needles
• Dental visits
• Heart Surgery: Valve replacements
& CABG
• Untreated Strep Throat
Pathophysiology
Inflammation INside the heart
• Infective = bacteria (mold on heart valves)
• Noninfective = No bacteria (only inflammation)
Heart valves can’t close fully
Less cardiac output = Less oxygen OUT
Treatment
Signs & Symptoms
•
• Antibiotics
• Valve repair or Replacement
C - Clots in the heart & brain
• Risk for stroke CVA - monitor for “agitation” “change
in level of consciousness”
NCLEX TIP
• Splinter hemorrhages (clots under fingernails)
L - Lung fluid (crackles)
• O - Overheated (fever)
• T - Too little Oxygen (low cardiac output)
•
• Clubbing fingers
*Roth spots, Osler’s nodes, Janeway lesions
(body’s immune response)
PERICARDITIS
Acute MI
AUTOIMMUNE DISORDERS
INFECTION
RENAL FAILURE
Uremia (High BUN)
ORAL CARE
brush 2x day NO FLOSSING
LET ALL PROVIDERS KNOW
DENTAL VISITS OR SURGERY
ADHERENCE
• Precordial chest pain
• Elevated WBC (over 10,000)
• C-reactive protein
• Cardiac Tamponade
1. JVD
2. Muffled heart sounds
3. Pulsus paradoxus
(drop in sys. BP by 10 mmHg)
Inflammation OUTside the heart
(heart gets compressed & can’t pump)
Less cardiac OUTput = Less oxygen OUT
HEART ATTACK
MONITOR
Signs & Symptoms + Labs
Pathophysiology
Causes
Education
Treatment
• NSAIDS (indomethacin)
• Steroids (prednisone)
• Pericardiocentesis (needle in the heart)
used to drain any fluid or blood in the heart sac.
Cardiomyopathy
Med Surg: Cardiac
Pathophysiology
• Dilated Cardiomyopathy:
Think “Distended heart muscles”,
clients present with fibrosis (stiff
hard muscles) of the myocardium
and endocardium, dilated chambers,
making it hard for the heart to pump
out oxygen rich blood.
DILATED
RESTRICTIVE
HYPERTROPHIC
Distended heart muscle
“Rock hard’’ heart muscle
Huge trophy-like heart muscle
• Restrictive Cardiomyopathy:
Think “Rockhard heart muscles”, so
the heart cannot RE-fill with REstrictive cardiomyopathy, emboli (blood
clots) are common.
• Hypertrophic Cardiomyopathy:
Think “Huge Trophy like heart
muscles” in the middle septum
which can obstruct the aorta block
ing all oxygenated blood out to the
body - very deadly!
Obstructive = blocks the aortic valve
Non-obstructive = does not block
Pharmacology
Labs & Diagnostics
• Chest X-ray & MRI
• Echocardiogram measures
Ejection Fraction (blood pumped out
of heart) 55 - 70% = normal 40% or
LESS = BAD (heart failure)
• Angiography
Highlights the coronary arteries to
see blockages & rule out ischemic
heart disease (low oxygen to heart
muscles)
• BNP
“B-type or Brain Natriuretic Peptides”
Breaking & Stretching of ventricles
All problems lead to
LESS cardiac output meaning
LESS oxygen rich blood OUT to the
body.
Causes
NCLEX TIP
• Hypertrophic = genetics ONLY NCLEX
TIP
• Dilated & Restrictive
• Genetics
• Damage to the heart = radiation
Signs & Symptoms
• Low oxygen
• Restlessness, agitation, altered
level of consciousness NCLEX TIP
• syncope, dizzy + fatigue
• Heart failure signs
• Left-sided = lung fluid
• Right-sided = rocks the body with
fluid (edema, ascites, JVD)
Dilated cardiomyopathy
• S3 murmur
• Cardiomegaly (dilated heart)
Restrictive Cardiomyopathy
• (same general low oxygen & HF)
Hypertrophic Cardiomyopathy
• Typically asymptomatic (no s/s)
until heavy exercise & then the
child DIES!
NCLEX TIP
BNP ELEVATED
100 OR LESS - NORMAL
HOLD MED IF:
1. Apical Pulse 60
2. Potassium (K+) 3.5
(Risk for Dig Toxicity)
3. Digoxin Toxicity OVER 2.0
101-299+ MILD ELEVATION
300+ MILD HF
600+ MODERATE HF
900+ SEVERE HF
Vision Changes, N/V, Fatigue ‘’dizzy’’
Education
Side note:
Hypertrophic Cardiomyopathy
• B - Beta blockers
• C - Calcium channel blockers
NO DDD
• D - Dilators
• D - Digoxin
• D - Diuretics
NO strenuous activity!
This can block the aorta.
Cardiac Tamponade
Med Surg: Cardiac
Pathophysiology
COMPRESSION OF THE HEART
caused by fluid collecting in the pericardial sac.
(weaker pump = less cardiac output)
This is a medical emergency as fluid
or blood fills the pericardial sac,
compressing the heart so that it cannot
fill & pump! The result is a
dramatic drop in blood pressure
that can kill the client.
MEMORY TRICK
• C - Cardiac Tamponade
• C - Compression on the heart
• C - Critical client!
Causes
ACUTE
TRAUMA: (Stabbing or MVA)
CHRONIC: Pericarditis
Treatments
PERICARDIOCENTESIS
1. CARDIAC MONITOR
2. CATHETER ATTACHED
to drainage system
3. ASSESS DRAINAGE
(Type & speed of drainage)
Signs & Symptoms
BECKS TRIAD BEC
B • Big Jugular Veins Distension (JVD)
E • Extreme Low BP (Hypotension)
C • Can’t hear heart sounds (muffled)
PULSE PARADOXES
Systolic drop of 10 mmHg
(120/80 to 110/80)
ECG
QRS complexes
(short & uneven height)
Heart Sounds &
5 EKG Lead Placement
Heart Sounds
Memory Trick
APETM
“All Pigs Eat Too Much”
PULMONIC
(2nd Intercostal Space
L Sternal Border)
AORTIC
(2 Intercostal Space
R Sternal Border)
A - Aortic
P - Pulomonic
E - Erb’s point
T - Tricuspid
M - Mitral
nd
TRICUSPID
(3nd or 4th Intercostal Space
L Sternal Border)
ERB’S POINT
(3rd Intercostal Space
L Sternal Border)
MITRAL
(5th Intercostal Space
Midclavicular Line)
5 EKG Lead Placement
QRS Complex
R
Memory Trick
P
PR Segment
PR Interval
Q
ST Segment
White on Right
Smoke over Fire
Brown in the Middle
Grass under sky (white)
T
S
QT Interval
Proper 12-Lead Placement for Left Side of Chest
v1
4th intercostal space to the right of the sternum
v2
4th intercostal space to the left of the sternum
v3
directly between the leads V2 & V4
v4
5th intercostal space at midclavicular line
v5
level with V4 at left anterior axillary line
v6
level with V5 at left midaxilary line
(directly under the midpoint of the armpit)
v4R 5th intercostal space, right midclavicular line
v1
v4R
v2 v
3
v4
v5
v6
5 Step
EKG INTERPRETATION
Heart rate
Rhythm
P wave
PR interval
(in seconds)
QRS
(in seconds)
60 -100/min
Regular
Present before
each QRS, identical
P/QRS ratio 1:1
0.10 - 0.20
(<5 small squares)
Normal shape
< 0.12
8 x 10 = 80
Heart Rate
1. Normal Sinus Rhythm
Rate - 60 -100
count the peaks - we have 8 here
multiply by 10 = 80 beats!
1
2
3
4
5
6
7
8
Rhythm
2. Rhythm - R peaks are evenly spaced apart.
To quickly measure this simply grab some
paper & mark 2 R peaks then just march it out.
The R peaks should be even every time.
R
R
R-R int.
R
R
R
R
P Wave
R
3. P wave - which is our atria contracting is it present? & does it have its buddy QRS?
we need a P with QRS every time
P
T
Q
PR interval (in seconds)
P
R
P
PR int.
R-R int.
5 mm
0.2 sec
PR
ST
seg.
seg.
P
PR int.
T
Q
S
QRS
int.
ST int.
QT int.
0.5 mV
5 mm
0.2 sec
QRS (in seconds)
5. QRS - Ventricles contracting
Is it present, upright & TIGHT?
Should NOT be wide, should only be
3 boxes - .12 seconds here.
T
Q
S
0.5 mV
4. PR interval - basically measures the
time it takes between atrial contractions
& ventricular contractions should be 5 mini
boxes or less - or .10 - 2.0 seconds here.
R
S
R
9 ECG Strips on the NCLEX
1. Normal sinus rhythm
Treatment:
None - continue to monitor
Causes:
Being healthy
Memory tricks
Normal beat - evenly spaced
2. Bradycardia
BRADY Bunch
old TV show (slow times)
<60
Treatment:
Atropine ONLY if symptomatic
showing low perfusion (pale,
cool, clammy)
Causes:
ATROPINE
Vagal maneuver (bearing down),
Memory tricks
meds (CCB, Beta Blockers)
BRADYcardia
Below 60/min
3. Ventricular Fibrillation (V Fib)
Treatment:
1. V Fib - Defib #1 Defibrillation
immediately Stop CPR
to do it & before drugs!
*NO synchronization needed
2. Drugs: LAP - Lidocaine,
Memory tricks
Fib is flopping- squiggly line
4. Ventricular Tachycardia (V Tach)
Amiodarone, Procainamide
Causes:
Untreated V Tach, Post MI,
Causes:
Post MI, Hypoxia,
Treatment:
1. Early Defibrillation! NCLEX TIP
V Tach Tombstone pattern
A
LIDOCAINE
P
PROCAINAMIDE
AMIODARONE
E+ imbalance, proarrhythmic meds
Low potassium, Low magnesium
Memory tricks
L
Apply defibrillator pads
Call out & look for everyone to be
CLEAR!
Shock & IMMEDIATELY continue
chest compressions
2. When to Shock? NCLEX TIP
V Tach with No pulse = Defibrillation
V Tach with Pulse = Cardioversion
Memory tricks
C
C - Count a pulse
C - Cardiovert
*Synchronize First
& Sedation
D
D - Dead - NO PULSE
D - DEFIB!!
*NO Synchronize
D - Don't wait
9 ECG Strips on the NCLEX II
5. Atrial Fibrillation (A Fib)
Digoxin
Causes:
Valvular disease, Heart failure, Pulm. HTN,
A
COPD, after heart surg.
Treatment:
1. Cardioversion (after TTE to rule out clots)
*Push Synch
2. Digoxin - Deep Contraction
Check ATP Before giving:
A - Apical pulse 60
T - Toxicity (Max 2.0 range) visual disturbances,
T
Max 2.0
60
40 kg
P
N/V, Anorexia
Memory tricks
No P wave = Fibrillation FloPPing
6. Atrial Flutter (A Flutter)
P - Potassium below 3.5 - HIGHER risk for
toxicity
< 3.5
3. Anticoagulants: Warfarin (monitor INR, Vit.
K antidote, moderate green leafy veggies)
Potassium
K+
Causes:
Valvular disease, Heart failure, Pulm. HTN,
COPD, after heart surg.
Treatment:
1. Cardioversion (after TTE to rule out clots)
*Push Synch
2. Digoxin - Deep Contraction
Check ATP Before giving:
A - Apical pulse 60
T - Toxicity (Max 2.0 range) visual disturbances,
N/V, Anorexia
Memory tricks
A FluTTer = sawTooTh
P - Potassium below 3.5 - HIGHER risk for
toxicity
3. Anticoagulants: Warfarin (monitor INR, Vit.
Max 2.0
40 kg
< 3.5
K
Potasssium
K+
KAPLAN
Causes:
Stimulants, Strenuous exercise, hypoxia,
heart disease
Super Fast = Supraventricular
60
K antidote, moderate green leafy veggies)
7. SVT - Supraventricular Tachycardia
Memory tricks
DIGOXIN
Treatment:
1. Vagal Maneuver (bear down like
having a bowel movement, ice cold
stimulation)
2. Adenosine - RAPID PUSH & flush
with NS - HR may stop
Which medication should be held 48-hours
prior to an elective cardioversion for SVT?
Digoxin due to increased ventricular
irritability
Client with SVT has the following
assessment data: HR 200, BP 78/40, RR 30
Priority action: Synchronized
cardioversion
PRIORITY
3. Cardioversion - *Push Synch
8. Torsades de Pointes
Memory tricks
M
Magnesium
Causes:
Post MI, Hypoxia, Low magnesium
Treatment:
Magnesium Sulfate NCLEX TIP
Memory tricks
Tornado Pointes
Magnesium
Mg+
M
Mellows out the heart
9 ECG Strips on the NCLEX III
9. Asystole - Flatline
Epinephrine, Atropine & CPR
*NO Defibrillation
(NO shock) NCLEX TIP
Memory tricks
Assist Fully! … patient is flatlined
R
R
PP
Q
P
Q
S
NCLEX Key Terms
R
PP
Q
S
S
1. P wave = Atrial rhythm
Asystole
4. “Bizarre” - Tachycardia
“Lack of QRS complexes”
Answer: Asystole
Q
S
3.
V Tach
Ventricular Tachycardia
“Bizarre rhythm with wide QRS complex”
Answer: Ventricular Tachycardia
Question:
R
3.
Question:
2. QRS wave - Ventricular rhythm
5. “Sawtooth” - Atrial Flutter
“Wide bizarre QRS complexes”
Answer: V Tach
3. “Chaotic or unorganized” - Fibrillation
Question:
A FluTTer = sawTooTh
“Chaotic rhythm with no P waves”
Answer: Atrial Fibrillation
Atrial Flutter
“CHAOTIC rhythm without QRS complexes”
Answer: Ventricular Fibrillation
Atrial Fibrillation
If you know these, you will pass the NCLEX!
NCLEX TIP
Normal sinus rhythm
Bradycardia
Ventricular Fibrillation (V Fib)
Ventricular Tachycardia (V Tach)
Atrial Fibrillation (A Fib)
Atrial Flutter (A Flutter)
Torsades de Pointes
Asystole - flatline
3.
SVT - Supraventricular Tachycardia
EKG Quick view
9 strips to know for the Nclex
Normal sinus rhythm
Bradycardia
Ventricular Fibrillation (V Fib)
Ventricular Tachycardia (V Tach)
Atrial Fibrillation (A Fib)
Atrial Flutter (A Flutter)
SVT - Supraventricular Tachycardia
Torsades de Pointes
Asystole - flatline