CARDIOVASCULAR SYSTEM NCM104 LEC

KARLEEN L. JARO BSN 4-Q

Action Potential

Cardiac Conduction
• Sinoatrial (SA) node – Fires at 60–100
beats/minute
• Intranodal pathway
• Atrioventricular (AV) node – Fires at 40-60
beats/minute
• Atrioventricular bundle of His
– Ventricular tissue fires at 20-40
beats/minute and can occur at this
point and down Stroke Volume
• Right and left bundle branches • The amount of blood ejected by the left
• Purkinje fibers ventricle
• Preload
– The amount of stretch placed on the
cardiac muscle just prior to systole
– Starling’s Law
• Afterload
– The force or pressure at which the
blood is ejected from the ventricle
– Equated with systemic vascular
resistance (SVR)
• Contractility

Patient Assessment: Cardiovascular System

Physical Exam
• Inspection
– General appearance
– Jugular venous distension (JVD)
Cardiac Output/Index – Skin
• Cardiac output – Extremities
– CO = HR (beats/minute) X SV • Palpation
(liters/beat) – Pulses
– Normal adult: 4-8 liters/minute – Point of maximal impulse (PMI)
• Cardiac index • Percussion
– CI = CO(liter/minute)/Body surface area • Auscultation
(m2) – Good stethoscope
– Normal adult: 2.8-4.2 liter/minute/m2 – Positioning
– Normalizes liter flow to body size – Normal tones – S1/S2
– Extra tones – S3/S4
– Murmurs
– Rubs

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 CARDIOVASCULAR SYSTEM NCM104 LEC
KARLEEN L. JARO BSN 4-Q
Murmurs
• Timing Rate
• Location • Look at complexes in a 6-second strip and
• Transmission count the complexes; that will give you a rough
• Pitch estimate of rate
• Quality • Count the number of large boxes between two
• Intensity complexes and divide into 300
• Count the number of small boxes between two
Grading complexes and divide into 1500
• Grade 1 – Barely audible Estimate rate by sequence of numbers
• Grade 2 – Clearly audible
• Grade 3 – Moderately loud Normal Timing
• Grade 4 – Loud with a thrill • PR interval – 0.12 to 0.20 seconds
• Grade 5 – Very loud with an easily palpable • QRS interval – less then 0.12
thrill • QT interval – varies with rate. It is usually less
• Grade 6 – Very loud, no stethoscope needed, then ½ the R-to-R distance on the preceding
palpable and visible thrill waves

Important Cardiac Labs Normal Sinus Rhythm

• Coagulation studies – PTT and PT/INR • Rate is between 60 and 100 beats/minute
• Electrolytes – Potassium, magnesium, and • The rhythm is regular
calcium • All intervals are within normal limits
• Lipid studies – Cholesterol, triglycerides • There is a P for every QRS and a QRS for every
• Enzymes – CK, CK-MB, LDH P
• Troponin • The P waves all look the same

Invasive Tests Sinus Tachycardia

• Coronary angiography • Rate above 100 beats/minute
• Electrophysiology studies • The rhythm is regular
Steps to reading ECGs • All intervals are within normal limits
• What is the rate? Both atrial and ventricular if • There is a P for every QRS and a QRS for every
they are not the same. P
• Is the rhythm regular or irregular? • The P waves all look the same
• Do the P waves all look the same? Is there a P • Caused by fever, stress, caffeine, nicotine,
wave for every QRS and conversely a QRS for exercise, or by increased sympathetic tone
every P wave? • Treatment is to take care of the underlying
• Are all the complexes within normal time cause
limits?
• Name the rhythm and any abnormalities. Sinus Bradycardia
• Rate is lower than 60 beats/minute
• The rhythm is regular
• All intervals are within normal limits
• There is a P for every QRS and a QRS for every
P
• The P waves all look the same
• Caused by beta-blocker, digitalis, or calcium
channel blockers. Normal for athletes
• Don’t treat unless there are symptoms. Can
use pacing or atropine

Sinus Arrhythmia
• Rate is between 60 and 100 beats/minute
• The rhythm is irregular. The SA node rate can
increase or decrease with respirations
• All intervals are within normal limits
• There is a P for every QRS and a QRS for every
P

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 CARDIOVASCULAR SYSTEM NCM104 LEC
KARLEEN L. JARO BSN 4-Q
• The P waves all look the same • The rhythm is regular
• More common in children and athletes • There is a P for every QRS and a QRS for every
• Ask the patient to stop breathing and the rate P
will become regular • The P wave can be in three possible places
Premature Atrial Contraction (PAC) – Retrograde conduction to atria before
• Can occur at any rate ventricle; P wave would be upside
• The rhythm is irregular because of the early down before the QRS
beat but is regular at other times – If both atria and ventricle receive
• All intervals can be within normal limits stimulus at the same time, the P would
• There is a P for every QRS and a QRS for every be buried in the QRS
P – If the ventricle was stimulated first, the
• The P waves all look the same except the P in P would be located just after the QRS
front of the PAC will be different Junctional Rhythms
Paroxysmal Supraventricular Tachycardia • Junctional bradycardia
(PSVT) – Rate less than 40 beats/minute
• Rate is between 150 and 250 beats/minute • Accelerated junctional
• The rhythm is regular – Rate 60-100 beats/minute
• QRS intervals can be within normal limits • Junctional tachycardia
• There can be a P wave, but more likely it will be – Rate is greater then 100 beats/minute
hidden in the T wave or the preceding QRS • Premature junctional contractions (PJC)
wave – Early beats in the cycle that have
• Starts and stops abruptly junctional P wave morphology
• Treat with Valsalva maneuver or adenosine IV Premature Ventricular Contractions (PVC)
• Early beat that is wide (>0.12)
Atrial Flutter • Originates the ventricles
• Atrial rate is between 250 and 350 • No P wave
beats/minute. Ventricular rate can vary • Compensatory pause
• The rhythm is regular or regularly irregular • Can be defined by couplet or triplet; anything
• There is no PR interval. QRS may be normal more would be considered ventricular
• 2:1 to 4:1 f waves to every QRS tachycardia
• There are no P waves; they are now called • Monomorphic or polymorphic
flutter waves
• Problem: Loss of atrial kick and ventricular Ventricular Tachycardia
conduction is too fast or too slow to allow good • Rate is between 100 and 200 beats/minute
filling of the ventricles • The rhythm is regular, but can change to
Atrial Fibrillation different rhythms
• Atrial rate is between 350 and 600 • No PR interval; QRS is wide and aberrant
beats/minute; ventricular rate can vary • There may be a P wave, but it is not related to
• The rhythm is irregular the QRS
• There is no PR interval; QRS may be normal Torsades De Pointes
• There are many more f waves then QRSs • Polymorphous ventricular tachycardia
• Unlike flutter where the f wave will appear the • Caused by long QT syndrome. This is an
same, in fib the f waves are from different foci inherited condition or caused by antiarrhythmic
so they are different drugs
Multifocal Atrial Tachycardia (MAT) • Cannot be converted by defibrillation
• Rate is greater then 100 beats/minute • Magnesium is the drug of choice
• The rhythm is irregular • Overdrive pacing may work also
• PR interval may vary depending on how close
the foci is to the AV node; QRS may be normal Ventricular Fibrillation
• There usually is a P for every QRS and a QRS • Rapid, irregular rhythm made by stimuli from
for every P wave many different foci in the ventricula
• The P waves appear different because they are • Produces no pulse, blood pressure, or cardiac
coming from different foci output
• There needs to be at least 3 different P waves • Can be described as fine or coarse
to be classified as MAT • Most common cause of sudden cardiac death
Junctional Arrhythmia
• Rate is between 40 and 60 beats/minute First–Degree AV Block

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 CARDIOVASCULAR SYSTEM NCM104 LEC
KARLEEN L. JARO BSN 4-Q
• The rate is usually between 60 and 100 • Able to measure cardiac pressure
beats/minute • Infuses drugs
• The rhythm is regular • Some types of catheters can pace
• PR interval is prolonged past 0.20 seconds
• QRS may be of normal length Patient Management: Cardiovascular System
• There is a P for every QRS and a QRS for every
P Pharmacological Therapy
• The P waves all look the same • Fibrinolytics
• Can occur in healthy people – Alteplase – tPA
• Caused by drugs – Tenecteplase – tNK
– Reteplase – RPA
Second–Degree AV Block Type I • Anticoagulants
• Rate is between 60 and 100 beats/minute – Low-molecular-weight heparins
• The rhythm is irregular or regularly irregular – Heparin
• PR interval is progressively longer until a QRS • Platelet Inhibitors
is dropped – Aspirin
• QRS may be of normal length – Glycoprotein IIb/IIIa inhibitors
• There are more P waves than QRS waves Antidysrhythmics
• The P waves all look the same • Class I – Inhibits fast sodium channels, likely to
• Caused by drugs, myocarditis, or inferior wall cause dysrhythmias, prolongs/depresses action
MI potential
• Class II – Beta blockers
Second–Degree AV Block Type II • Class III – Amiodarone, sotalol, ibutilide, and
• Rate may be slow, caused by blocked P waves dofetilide
• The rhythm can be regular, depends on block • Class IV – Calcium channel blockers
• PR intervals may be normal or prolonged, but Inotropes
they are consistent • Drugs that are used to increase the force of
• QRS usually greater then 0.12 myocardial contraction and improve cardiac
• Can be more than one P wave for each QRS output
• The P waves all look the same – Dopamine
• Caused by anterior wall MI, conduction – Dobutamine
problems – Epinephrine
• Permanent and deteriorates rapidly – Norepinephrine
– Amrinone
Third–Degree AV Block – Milrinone
• Ventricular rate is usually between 20 and 40 Vasodilators
beats/minute • Drugs used to decrease preload
• Atrial rate is between 60 and 100 beats/minute – Nitrates
• The rhythm is regular or irregular • Promote coronary artery
• P waves and QRS waves not related; interval is perfusion
inconsistent • Can be given in many different
• QRS waves are usually greater than 0.12 ways
• There more more P waves than QRS waves • Ask about use of Viagra
• The P waves all look the same – Nitroprusside sodium
• Protect from light
12-Lead ECG • Effects of drug are gone in a
• Limb leads matter of minutes
– Standard leads: I, II, and III • Cyanide toxicity
– Augmented leads: aVR, aVL, and aVF Antihyperlipidemics
• Precordial leads • Four classes of drug
– V1,V2,V3,V4,V5, and V6 – All four have side effects that are the
• Axis same
– The direction of the flow of electricity • Liver toxicity
• GI upset
Pulmonary Artery Catheter • Diarrhea or constipation
• Measures pressure in different areas of the IABP
heart
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 CARDIOVASCULAR SYSTEM NCM104 LEC
KARLEEN L. JARO BSN 4-Q
• Decreases workload of the left ventricle by • Acute versus chronic
decreasing afterload – Acute: sudden onset of symptoms over
• Increases perfusion of the coronary arteries hours or days
• Decreases oxygen consumption – Chronic: limitations on a daily basis
• Increases cardiac output • Left- versus right-sided heart failure
Ventricular Assist Device – Left-sided: failure of the left ventricle to
• Used in patients who are refractory to other fill or empty
treatment • Can be systolic or diastolic in
• Used as a bridge to transplantation nature
• Goal of treatment – Right-sided failure: due to pulmonary
– Adequate blood flow disease or pulmonary hypertension
– Preservation of end-organ function
Management of Dysrhythmias Classification of Heart Failure
• Cardioversion • Class I – No limitation
• Radiofrequency catheter ablation • Class II – Slight limitation of physical activity
• Cardiac pacemakers • Class III – Marked limitation of physical activity
– Internal with some symptoms at rest
• Generator placed in a “pocket” • Class IV – Unable to participate in physical
in the patient’s chest activity, symptoms occur at rest (“cardiac
– External cripple”)
• Pacing wire or PA catheter Pharmacological Treatment
placed • ACEI
• Generator is external • Hydralazine
– Trancutaneous • Nitrates
• Pads placed on the skin • Digoxin
connected to a defibrillator • Diuretics
• Beta blockers
Common Cardiovascular Disorders Nursing Diagnoses
Inflammation and Infection • Decreased Cardiac Output related to altered
• Pericarditis – inflammation of the pericardium preload
– Pericardial friction rub • Decreased Cardiac Output related to altered
– Diffuse ST segment elevation contractility
– Constrictive pericarditis • Decreased Cardiac Output related to altered
– Use of NSAIDs for pain control heart rate
• Myocarditis – inflammation of the myocardium • Decreased Activity Tolerance related to
and the conduction system of the heart decreased cardiac output and deconditioning
– Unexplained heart failure, rise in serum
enzymes Acute Myocardial Infarction
– Nonspecific ST-T wave changes
– Pleuritic chest pain Atherosclerosis
• Endocarditis – infection of the endocardial • Injury to endothelium
surfaces including the valves – Increased levels of
– Symptoms occur within 2 weeks of an cholesterol/triglycerides
infection – Hypertension
– Requires a prolonged course of – Cigarette smoking
antibiotics • Deposits in the lining of the artery
Cardiomyopathies – Cholesterol cellular waste, calcium, and
• Dilated fibrin
– Increased ventricular chamber size • Atheroma
– Decreased or normal muscle size – Keeps building to partial or complete
• Hypertrophic blockage
– Left ventricular hypertrophy Risk Factors
• Restrictive • Uncontrollable
– Restrictive filling – Age
– Reduced compliance in one or both – Heredity
ventricles – Race
Heart Failure – Sex

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 CARDIOVASCULAR SYSTEM NCM104 LEC
KARLEEN L. JARO BSN 4-Q
• Modifiable – Infarcted only partial amount of muscle
– Cigarette smoking wall
– High cholesterol Cardiac Surgery
– Hypertension CABG
– Physical inactivity Coronary Artery Bypass Graft Surgery
– Obesity • Native vessels
– Diabetes mellitus – Saphenous vein
Angina Pectoris – Internal mammary artery
• Stable – chronic stable angina, classic angina • Off–pump CABG
– Paroxysmal, occurs with physical • Transmyocardial laser revascularization
exertion
– Relieved by rest or nitroglycerin Valvular Disease
• Unstable – preinfarction angina or crescendo • Stenosis
angina – Mitral stenosis
– More prolonged and severe • Rheumatic heart disease
– Need to be treated immediately – Aortic stenosis
• Variant – Prinzmetal’s angina, vasospastic • Rheumatic fever, calcification
angina with age
– Result of coronary artery spasm • Insufficiency
– Occurs at rest – Mitral insufficiency
Management of Angina • Rheumatic heart disease, age,
• Risk reduction LV dilation
– Stop smoking, diet, weight loss, – Aortic insufficiency
exercise • Rheumatic disease, aneurysm
– Medications to control cholesterol, HTN, of ascending aorta
and diabetes Cardiopulmonary Bypass
• Pharmacological • Moves oxygenated blood around the body
– Nitroglycerin, beta blockers, calcium during open heart surgery
channel blockers, and aspirin • Core body temp is lowered to 28° C to 32° C
• Invasive • Complications
– Angioplasty, PTCA, stent placement, – Increased capillary permeability
IABP, CABG – Hemodilution
– Altered coagulation
Myocardial Infarction – Damage to blood cells
– Microembolization
• Inflammation Complications
• Plaque rupture • Arrhythmias
• Thrombus formation • Fluid resuscitation
• Irreversible damage starts in 20 to 40 minutes. • Decreased cardiac contractility
This process will continue for several hours • Control of blood pressure
• Respiratory problems
Location of the Infarction • Postoperative bleeding
• Anterior Nursing Diagnoses
• Inferior • Decreased Cardiac Output related to
• Posterior – Changes in LV preload, afterload, and
• Lateral contractility
• Septal – Cardiac dysrhythmias
• Decreased Tissue Perfusion related to
Type of Infarction – Cardiopulmonary bypass, decreased
• Q-wave CO, hypotension
– Infarcted the full muscle wall • Impaired Gas Exchange related to
– Formation of pathological Q waves in cardiopulmonary bypass, anesthesia, poor
area of infarct chest expansion, atelectasis, retained
• Greater then one small box in secretions
duration • Risk for Fluid Volume Deficit related to
• Deeper then 1/3 of the R wave abnormal bleeding
• Non–Q-wave

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 CARDIOVASCULAR SYSTEM NCM104 LEC
KARLEEN L. JARO BSN 4-Q
• Risk for Infection related to surgical procedure,
invasive lines, drainage tubes, hypoventilation,
retained secretions
• Impaired Comfort related to endotracheal tube,
surgical incision, chest tubes, rib spreading
• Anxiety related to fear of death, ICU
environment
Carotid Endarterectomy
• Atherosclerotic changes in the carotid arteries
• 70% to 90% stenosis
• Clamping of the carotid arteries
• Heparinization to prevent clot formation

Postoperative Care of an Endarterectomy

• Control of blood pressure
• Assessment of cranial nerves
– VII, X, XI, XII
• Bleeding
– Note neck size
– Check for swelling – possible
hematoma formation
– Difficulty in swallowing or breathing