Cardiac Crash
Course
Archer Review
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Anatomy & Physiology
Blood flow through the heart
Hemodynamics
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Preload
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Afterload
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Compliance
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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
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Strength of contraction of the heart muscle
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Stroke volume
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Cardiac output
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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?!
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Tissue perfusion!
End organ function
Delivery of oxygen and nutrients to each and every cell in the body!
Poor cardiac output??
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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
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Increased blood
volume...sometimes
Tachycardia...sometimes
Medications
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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)
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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
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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
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What is coronary artery disease?
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The most common type of cardiovascular disease.
Includes two types
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Chronic stable angina
Acute coronary syndrome (aka MI)
Chronic Stable Angina
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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
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Nitroglycerin
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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
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DECREASE THE WORKLOAD OF THE HEART!
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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
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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
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Chest pain
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Crushing
Radiating to left arm or jaw
Between shoulder blades
Epigastric discomfort/indigestion
Fatigue
SOB
Vomiting
Labs
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CPK-MB
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Troponin
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Cardiac specific isoenzyme
Increases with damage to cardiac cells
Cardiac biomarker
Increases with myocardial damage
Myoglobin
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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
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Cath lab within 90 minutes for PCI
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Especially important if it’s a STEMI!
Oxygen
Aspirin
Nitroglycerin
Morphine
Education
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Quit smoking
Increase activity gradually
Diet
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Low fat
Low salt
Low cholesterol
Exercise
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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.
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Often results as a complication of other diseases
#1 cause of HF is hypertension
Other causes:
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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:
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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:
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Jugular venous distention
Dependent edema
Hepatomegaly
Splenomegaly
Ascites
Weight gain
Fatigue
Anorexia
Treatment
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DECREASE THE WORKLOAD OF THE HEART!
Primary strategy is to decrease afterload:
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ACE Inhibitors
■ Arterial dilation→ decreased afterload → Increased stroke volume
ARBS
■ Decrease BP → decreased afterload → Increased CO
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Increase contractility
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Diuresis
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Digoxin
Pt needs help reducing excess fluid
Education
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Take diuretic medications in the AM
Monitor electrolyte levels while on diuretics
Low sodium diet
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Elevate the HOB
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Will help with diuresis
Daily weight
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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
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Family history
African american race
Increased age
Obesity
HLD
CAD
Stress
Smoking
High salt intake
Caffeine
Assessment
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Often asymptomatic until very severe
Vision changes
Headaches
Dizziness
Nosebleeds
SOB
Angina
Complications
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Stroke
MI
Renal Failure
Heart Failure
Vision loss
Treatment & Education
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Medications
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Diet
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ACE inhibitors
Beta Blockers
CCB
Diuretics
DASH
Low salt
Avoid caffeine and alcohol
Weight loss
Smoking cessation
Lifestyle
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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??
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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.
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Cardiovascular system is composed of:
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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
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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
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Hemorrhage
Traumatic injury
Dehydration
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Vomiting
Diarrhea
Burns
Assessment
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Compensation
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Weak
Pale
Tachycardic
Anxious
Failing
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Hypotension
Weak pulses
Tachycardic
Decreased LOC
Pale
Cool
Clammy
Decreased UOP
Treatment
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Fix the cause
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Replace volume
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Stop vomiting/diarrhea
Stop bleeding
■ Repair in OR
Isotonic IVF
■ NS
■ LR
Blood products
Support perfusion
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Vasopressors
Cardiogenic Shock
Pathophysiology
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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
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MI
Cardiac tamponade*
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Pulmonary embolism
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*Obstructive shock
Assessment
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Decreased perfusion
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Hypotension
Weak pulses
Cool, pale, clammy
Decreased UOP
Decreased LOC
Volume overload
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JVD
Crackles
SOB
Muffled heart sounds
S3
Treatment
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TREAT THE CAUSE
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Improve contractility
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MI
■ PCI
■ CABG
PE
■ Thrombolytics
Tamponade
■ Pericardiocentesis
Dopamine
Dobutamine
Decrease afterload
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Diuretics
Dobutamine
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IABP
LVAD
Transplant
Distributive Shock
Pathophysiology
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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
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Anaphylactic
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Allergic reaction
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Neurogenic
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Septic
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SCI
Systemic infection
Causes release of inflammatory cytokines
Assessment
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Decreased oxygen
Hypotension
Tachycardia
Tachypnea
Warm, flushed skin
Decreased LOC
Specific:
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Anaphylactic
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Neurogenic
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Hives
Rash
Swelling
Wheezing
SCI
Priapism
Septic
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Hyperthermic
Infection
Treatment
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Anaphylactic
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Neurogenic
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Epinephrine
Corticosteroids
Bronchodilators
Cooling
Supportive care
Septic
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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
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a.
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3.
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