Cardiac Crash Course Archer Review Welcome! ● ● ● ● ● If you have a question please enter it in the chat! I will do my best to answer questions as we go, but if I miss one will always circle back to you! We will be taking a 10 minute break halfway through. Handouts & powerpoint slides are located in the ‘Handouts’ section of your GoToWebinar control panel. You can download and print them from here! Within one week of course completion you will receive an email with your OnDemand streaming link so that you may re-watch this course. You have access for 1 month! If you have any technical issues or questions about streaming, handouts, etc. please email support@archerreview.com Anatomy & Physiology Blood flow through the heart Hemodynamics ● Preload ● Afterload ● Compliance ○ ○ ○ ● Amount of blood returning to right side of the heart Pressure against which the left ventricle must pump to eject blood How easily the heart muscle expands when filled with blood Contractility ○ Strength of contraction of the heart muscle ● Stroke volume ● Cardiac output ○ ○ Volume of blood pumped out of the ventricles with each contraction The amount of blood the heart pumps through the circulatory system in a minute Cardiac Output WHY is cardiac output SO important?! ● ● ● ● Tissue perfusion! End organ function Delivery of oxygen and nutrients to each and every cell in the body! Poor cardiac output?? ○ ○ ○ ○ ○ Decreased LOC (not enough blood flow to the BRAIN) Chest pain, weak peripheral pulses (not enough blood flow to the HEART) SOB, crackles, rales (not enough blood flow to the LUNGS) Cool, clammy, mottled extremities (not enough blood flow to the SKIN) Decreased UOP (not enough blood flow to the KIDNEYS) CO = SV X HR Causes of DECREASED CO Bradycardia Arrhythmias Pulseless v-tach V-fib Asystole SVT Hypotension MI Cardiac muscle disease Electrocardiograms Causes of INCREASED CO ● ● ● Increased blood volume...sometimes Tachycardia...sometimes Medications ○ ○ ○ ● ACE Inhibitors ARBS Nitrates Inotropes P-wave: normal PR Interval: 0.12-0.20 QRS: <0.12 Rate: 60-100 Regularity: Regular Normal Sinus Rhythm P-wave: Normal PR Interval: 0.12-0.20 QRS: <0.12 Rate: <60 Regularity: Regular Sinus Bradycardia Causes: -Sleep -Inactivity -Very athletic -Drugs -MI P-wave: Normal PR Interval: 0.12-0.20 QRS: <0.12 Rate: >100 Regularity: Regular Sinus Tachycardia P-wave: “saw-tooth” PR Interval: none QRS: <0.12 Rate: 250-400 Regularity: Regular or Irregular Atrial Flutter Causes: -Caffeine -Exercise -Fever -Anxiety -Drugs -Pain -Hypotension -Volume depletion Causes: -Heart disease -MI -CHF -Pericarditis P-wave: ‘wavy’ PR Interval: none QRS: <0.12 Rate: >400 Regularity: irregular Causes: -Heart Disease -Pulmonary Disease -Stress -Alcohol -Caffeine P-wave: hidden PR Interval: immeasurable QRS: <0.12 Rate: 150-250 Regularity: Regular Causes: -Caffeine -CHF -Fatigue -Hypoxia -Altered pacemaker in heart Atrial Fibrillation Supraventricular Tachycardia (SVT) ing. eaten te, r h t e olera be lif CAN patients t T! Some me do NO so P-wave: none PR Interval: none QRS: >0.11 - ‘wide & bizarre’ Rate: 150-250 Regularity: Regular Ventricular Tachycardia (V-Tach) P-wave: none PR Interval: none QRS: none Rate: none Regularity: Irregular Ventricular Fibrillation (V-fib) Causes: -MI -Ischemia -Digoxin toxicity -Hypoxia -Acidosis -Hypokalemia -Hypotension Causes: -MI -Ischemia -Hypoxia -Acidosis -Hypokalemia -Hypotension -Most common cause of sudden death ING N E T REA IA!! H T E LIF YTHM H R AR NING E T A THRE MIA!! E F I L YTH H R R A P-wave: possible to have some random p-waves PR Interval: none QRS: none Rate: none Regularity: n/a Asystole Causes: -Follows VT/VF in cardiac arrest -Acidosis -Hypoxia -Hypokalemia -Hypothermia -Overdose Coronary Artery Disease (CAD) LIFE- NG!!! TENI A E R TH What is coronary artery disease? ● ● The most common type of cardiovascular disease. Includes two types ○ ○ Chronic stable angina Acute coronary syndrome (aka MI) Chronic Stable Angina ● ● ● ● Chronic disease caused by narrowing of coronary arteries and plaque build up. There are periods of decreased blood flow to the heart muscle Decreased blood flow leads to decreased oxygen, and ischemia. Ischemia causes chest pain Treatment ● Nitroglycerin ○ ○ ○ ○ ○ ○ Venous and arterial dilation → decreased afterload → increased CO Given sublingual Administer 1 pill q5 minutes for 3 doses Do not swallow Keep in a dark bottle in dry, cool place Expected side effect = headache Education ● DECREASE THE WORKLOAD OF THE HEART! ○ ○ ○ ○ ○ ○ ○ Rest Do not overeat No caffeine Avoid temperature extremes No smoking Promote weight loss Reduce stress Correct answer: B A is incorrect. Nitroglycerin is not contraindicated in atrial fibrillation. Therefore, it is safe to administer the drug even if there is atrial fibrillation. B is correct. Nitroglycerin is a vasodilator that causes a decrease in blood pressure. The nurse should not administer any drug that causes the blood pressure to drop when the client’s systolic blood pressure is below 90 mm Hg. C is incorrect. Headaches are a common side effect of nitroglycerin and should not be a reason to withhold the drug. D is incorrect. A warm flushed feeling is also a side effect of Nitroglycerin, which is caused by its vasodilatory effects. NCLEX Question The client is admitted for having unstable angina. The nurse caring for the client understands that nitroglycerin should not be given to the client if he manifests which sign or symptom? a. b. c. d. Atrial fibrillation A blood pressure of 78/59 mm Hg. Headache A warm flushed feeling Myocardial Infarction (MI) What is a myocardial infarction Myocardial infarction = acute coronary syndrome = unstable angina ● ● There is decreased blood flow to the heart, leading to decreased oxygen, and not only ischemia, but also necrosis. Goal is to act quickly and limit the damage. Assessment ● Chest pain ○ ○ ○ ● ● ● ● Crushing Radiating to left arm or jaw Between shoulder blades Epigastric discomfort/indigestion Fatigue SOB Vomiting Labs ● CPK-MB ○ ○ ● Troponin ○ ○ ● Cardiac specific isoenzyme Increases with damage to cardiac cells Cardiac biomarker Increases with myocardial damage Myoglobin ○ ○ ○ Protein in muscle cells Increases with damage to ANY muscle cell Negative results can help rule out an MI, but positive results are not specific. Treatment ● Cath lab within 90 minutes for PCI ○ ● ● ● ● Especially important if it’s a STEMI! Oxygen Aspirin Nitroglycerin Morphine Education ● ● ● Quit smoking Increase activity gradually Diet ○ ○ ○ ● Low fat Low salt Low cholesterol Exercise ○ ○ Avoid isometric exercises Walking is a good choice NCLEX Question A 45-year-old man is rushed to the ER with reports of substernal chest pain and diaphoresis. Cardiac troponin levels were taken and found to be elevated. The ER nurse understands that nursing interventions would focus on which priority? a. Increase oxygenation to the heart and reduce the heart’s workload b. Prevent complications and confirm a diagnosis of myocardial infarction c. Alleviate the patient’s anxiety d. Pain relief Correct answer: A A is correct. The client is showing signs and symptoms of myocardial infarction. The priority for nursing care should be focused on increasing oxygen delivery to the heart and reducing its workload to prevent further damage. B is incorrect. Confirming the diagnosis should be done; however, since the client is already exhibiting signs of reduced myocardial oxygenation (chest pain), the nurse should prioritize oxygen delivery to the client. C is incorrect. It is the nurse’s responsibility to alleviate the client’s anxiety; however, the nurse should prioritize oxygenation to the client. D is incorrect. Pain relief should be important in the care of the patient with myocardial infarction; however, it should not take priority over myocardial oxygenation. Break time! Heart Failure What is heart failure? The inability of the heart muscle to pump enough blood to meet the body's needs for blood and oxygen. ● ● ● Often results as a complication of other diseases #1 cause of HF is hypertension Other causes: ○ ○ ○ ● Cardiomyopathy Endocarditis MI Two types: Left and Right Left-sided Heart Failure Left side of the heart cannot move blood forward to the body. Blood is backing up in the LUNGS. Assessment: ● ● ● ● ● ● ● Pulmonary congestion Wet lung sounds Dyspnea Cough Blood tinged sputum S3 Orthopnea Right Heart Failure Right side of the heart cannot move blood forward to the lungs. Blood is backing up in the BODY. Assessment: ● ● ● ● ● ● ● ● Jugular venous distention Dependent edema Hepatomegaly Splenomegaly Ascites Weight gain Fatigue Anorexia Treatment ● ● DECREASE THE WORKLOAD OF THE HEART! Primary strategy is to decrease afterload: ○ ○ ACE Inhibitors ■ Arterial dilation→ decreased afterload → Increased stroke volume ARBS ■ Decrease BP → decreased afterload → Increased CO ● Increase contractility ● Diuresis ○ ○ Digoxin Pt needs help reducing excess fluid Education ● ● ● Take diuretic medications in the AM Monitor electrolyte levels while on diuretics Low sodium diet ○ ● Elevate the HOB ○ ● Will help with diuresis Daily weight ○ ○ ○ ● This helps decrease fluid Same time Same scale Same clothes Report any increase of 2-3 lbs in one day Hypertension What is hypertension? High blood pressure! Normal <120/80 Elevated 120-129/80 Hypertension >130/>80 Hypertensive Crisis >180/>120 Causes & Risk Factors ● ● ● ● ● ● ● ● ● ● Family history African american race Increased age Obesity HLD CAD Stress Smoking High salt intake Caffeine Assessment ● ● ● ● ● ● ● Often asymptomatic until very severe Vision changes Headaches Dizziness Nosebleeds SOB Angina Complications ● ● ● ● ● Stroke MI Renal Failure Heart Failure Vision loss Treatment & Education ● Medications ○ ○ ○ ○ ● Diet ○ ○ ○ ○ ○ ● ACE inhibitors Beta Blockers CCB Diuretics DASH Low salt Avoid caffeine and alcohol Weight loss Smoking cessation Lifestyle ○ Less sitting more walking NCLEX Question A hypertensive client has prescribed antihypertensive medication. The client tells a clinic nurse that she prefers to take an herbal substance to help lower her blood pressure. Which is the most appropriate response for the nurse? a. Tell the client that herbal substances unsafe and should never be used b. Encourage the client to discuss the use of herbal substances with her attending physician c. Teach the client how to take her blood pressure and ask her to monitor it every fifteen minutes d. Tell the client that if she takes the herbal substance it will require the nurses to check her blood pressure closely Answer: B The most appropriate response is B. Although the use of herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are on conventional medication therapy are discouraged from using herbal materials with similar pharmacological effects because the combination may lead to an excessive reaction of unknown interaction effects. The nurse would advise the client to discuss the use of the herbal substance with her attending physician. Options A, C, and D are inappropriate nursing actions. Shock What is shock?? ● ● A state where the vital organs are not receiving adequate oxygenation. This lack of oxygenation causes organ damage and forces the cells to use anaerobic metabolism to create energy….producing lactate. ● Cardiovascular system is composed of: ○ ○ ○ ● ● The blood The vasculature The heart A disruption in any of these three components can cause a lack of oxygen delivery to the organs, causing shock. Which component is ‘broken’ determines the type of shock. Types of Shock Hypovolemic Cardiogenic Distributive Hypovolemic Shock Pathophysiology ● ● ● ● Low blood flow There is a loss of the circulating volume Not enough blood to enter the heart (preload), which decreases cardiac output. The body will vasoconstrict to compensate. Causes ● ● ● Hemorrhage Traumatic injury Dehydration ○ ○ ● Vomiting Diarrhea Burns Assessment ● Compensation ○ ○ ○ ○ ● Weak Pale Tachycardic Anxious Failing ○ ○ ○ ○ ○ ○ ○ ○ Hypotension Weak pulses Tachycardic Decreased LOC Pale Cool Clammy Decreased UOP Treatment ● Fix the cause ○ ○ ● Replace volume ○ ○ ● Stop vomiting/diarrhea Stop bleeding ■ Repair in OR Isotonic IVF ■ NS ■ LR Blood products Support perfusion ○ Vasopressors Cardiogenic Shock Pathophysiology ● ● ● ● ● The heart fails to pump sufficient blood out to the organs “Pump failure” Something is stopping the heart itself from getting blood out to the body Without sufficient blood delivered to the body, there is inadequate oxygenation Lack of oxygen impairs normal cellular metabolism Causes ● ● MI Cardiac tamponade* ● Pulmonary embolism ○ *Obstructive shock Assessment ● Decreased perfusion ○ ○ ○ ○ ○ ● Hypotension Weak pulses Cool, pale, clammy Decreased UOP Decreased LOC Volume overload ○ ○ ○ ○ ○ JVD Crackles SOB Muffled heart sounds S3 Treatment ● TREAT THE CAUSE ○ ○ ○ ● Improve contractility ○ ○ ● MI ■ PCI ■ CABG PE ■ Thrombolytics Tamponade ■ Pericardiocentesis Dopamine Dobutamine Decrease afterload ○ ○ Diuretics Dobutamine ● ● ● IABP LVAD Transplant Distributive Shock Pathophysiology ● ● ● ● ● ● Something causes an immune or autonomic response in the body This alters vascular tone The result is massive peripheral vasodilation With so much vasodilation, the blood pressure is inadequate to provide blood flow to the vital organs. Without sufficient blood delivered to the body, there is inadequate oxygenation Lack of oxygen impairs normal cellular metabolism Causes ● Anaphylactic ○ Allergic reaction ● Neurogenic ● Septic ○ ○ ○ SCI Systemic infection Causes release of inflammatory cytokines Assessment ● ● ● ● ● ● Decreased oxygen Hypotension Tachycardia Tachypnea Warm, flushed skin Decreased LOC Specific: ● Anaphylactic ○ ○ ○ ○ ● Neurogenic ○ ○ ● Hives Rash Swelling Wheezing SCI Priapism Septic ○ ○ Hyperthermic Infection Treatment ● Anaphylactic ○ ○ ○ ● Neurogenic ○ ○ ● Epinephrine Corticosteroids Bronchodilators Cooling Supportive care Septic ○ ○ IV antibiotics IVF NCLEX Question A client in septic shock in the intensive care unit is receiving a Dopamine infusion. Upon assessment, the nurse notices that the client’s; blood pressure is 195/120 mm Hg. Which initial nursing action would the nurse implement? a. b. c. d. Discontinue dopamine. Notify the physician Administer Furosemide. Assess the clients’ GCS Answer: A A is correct. The initial action for the nurse is to discontinue Dopamine, which is a vasoconstrictor, the medication that causes the client’s high blood pressure. B is incorrect. The nurse needs to notify the physician in order to arrange an adjustment of the medication dosage. However, this should not be the initial action of the nurse. C is incorrect. The nurse can give Furosemide to decrease the patient's blood pressure. But the nurse should terminate the exact cause of hypertension which is Dopamine. D is incorrect. The nurse can assess the client's GCS, but the nurse should decrease the client's blood pressure. NCLEX Question A client has just been transferred back to his room following a below knee amputation of the right leg. The nurse is closely monitoring the client. Which sign would prompt the nurse to assess further as it could indicate a developing complication? A. B. C. D. The client is growing increasingly restless The client has a blood pressure of 187/78 mmHg The client has a pulse rate of 89 bpm Hypoactive bowel sounds were found upon auscultation of 4 quadrants Correct answer: A Rationale: A postoperative client who is growing increasingly restless should prompt the nurse to monitor closely and assess further as it can indicate hemorrhage, shock, or pulmonary embolism. A blood pressure of 187/78 mmHg is healthy as well as a pulse rate of 89 bpm. Hypoactive bowel sounds are expected postoperatively. The correct answer, therefore, is option A, while options B, C, and D are incorrect. NCLEX Question A nurse is taking care of a client with severe burns. She knows that the patient is at risk for which of the following? A. B. C. D. Hypovolemic shock Distributive shock Cardiogenic shock Obstructive shock Correct answer: A A is correct. Burn victims are at risk for hypovolemic shock. This is due to the increase in capillary membrane permeability leading to third spacing and a loss of fluid in the vascular space. Low volume = low pressure → hypovolemic shock. B is incorrect. Distributive shock occurs when there is profound vasodilation leading to loss of pressure. Examples include anaphylaxis and sepsis. C is incorrect. Cardiogenic shock is due to failure of the heart muscle to pump sufficient blood to the organs. This could be due to an MI or severe heart failure. D is incorrect. Obstructive shock is a subcategory of cardiogenic shock where the heart is obstructed from pumping sufficient blood to the organs. The classic example of this is cardiac tamponade. NCLEX Question A nurse is taking care of a client with severe burns. Because of fluid shifting, the nurse knows that the focus of attention is preventing hypovolemic shock. Which is the best intervention to address this? A. B. C. D. Administer dopamine as ordered Apply medical antishock trousers Infuse IV fluids are indicated Infuse fresh frozen plasma Correct answer: C Rationale: An expected event during the early postburn period is fluid shifting, where large amounts of plasma fluid extravasates into interstitial spaces. To address the fluid loss, the best intervention would be to administer crystalloid and colloid solutions. Fresh frozen plasma may achieve this, but this is expensive and carries a slight risk of disease transmission. Medical antishock trousers are applied when the client is already in hypovolemic shock. It is not used for prevention. Dopamine causes vasoconstriction and raises blood pressure but does not prevent hypovolemia from burning clients. The correct answer is option C. Options A, B, and D are incorrect. How do I study?!?! The Sure Pass Program 1. Rapid Prep a. b. 2. Practice Questions a. b. c. 3. Use the Archer Qbank with 2500+ NCLEX Questions Learn from each question with detailed answer rationals Identify the areas you need more study on, and go back to those Rapid Prep videos! Assess your readiness a. b. 4. Attend the live course. Review OnDemand videos to master concepts Launch as many readiness assessments as you would like Achieve a score greater than the ‘Average Peer Score’ predictor 4 times - you are ready! PASS YOUR NCLEX!! If you follow the Sure Pass Program and fail the NCLEX, Archer will give you a 100% money back refund for ALL PRODUCTS! Upcoming Archer Review Courses: Thank you for joining our Crash Course! Pharmacology March 31st - 10am - 12pm CST IVF and Electrolytes April 7th - 10am - 12pm CST Endocrine & Diabetes Management April 16th - 10am - 12pm CST FULL RAPID PREP REVIEW April 20th & 21st 8am-6pm CST
