1. Cardiovascular System C. Washington RN, MSNEd

8. Physical Assessment Vital signs wnl No abnormal heart sounds Strong & equal peripheral pulses Even & unlabored breathing Regular heart beat No pallor, cyanosis, or clubbing No syncope, fatigue, or chest pain No edema Can perform ADLs without dyspnea

9. Key Points Discomfort Indigestion Squeezing Heaviness Viselike Transient loss of consciousness Common in older adults Cardiac Pain Syncope

10. Key Points Assess the filling volume & pressure on the right side of heart Swishing sounds that develop in narrowed arteries Jugular Vein Pressure Bruits

11. Diagnostic Assessment No serum markers of myocardial damage Serum lipids within normal ranges Normal C-reactive protein Normal ECG

12. Key Points: Safety Assess for allergy to iodine After invasive test monitor insertion site for bleeding and hematoma formation Assess vital signs carefully Report new dysrhythmias after testing

13. Key Points: Health Promotion Identify pts at risk for cardiovascular disease Psychological Stress Family history Diabetes Hyperlipidemia HTN Overweight Physical inactivity Smoking

14. Key Points: Teaching How to reduce risks of Disease Exercise Diet modification Smoking cessation Medications Inform pt about nonmodifiable risk factors Family history Gender genetics

15. Coronary Heart Disease Atherosclerotic plaque in coronary arteries May be asmptomatic May lead to Angina, heart attack, dysrhythmias, heart failure, or death Cause of atherosclerotic plaque is unknown May be linked to certain risk factors

21. CAD Most common cause of ↓ coronary blood flow is plaque formation Lipoproteins & fibrous tissue in arterial wall Theory: begins with an injury to or inflammation of endothelial cells lining the artery Endothelial damage promotes platelet adhesion & aggregation & attracts leukocytes to area

22. CHD: Diagnostic Tests Diagnosis based on history & risk factors ↑ triglyceride/LDL & ↓ HDL levels Total serum cholesterol Lipid profile (triglyceride, HDL, LDL levels, & ratio of HDL to total cholesterol (ratio 1:5; ideal 1:3) NPO 10-12 hrs Etoh & many meds affect results

23. Risk Factor Management Stop smoking improves HDL levels ↓ saturated fat & cholesterol intake ↑ soluble and insoluable fibers Exercise Control HTN (maintaining 140/90 mmHg) Blood sugar control

24. Risk Factor Management Mevacor, Zocar, Lipitor- Monitor liver function & muscle pain/tenderness (may cause myopathy) If taking Digoxin, monitor for digoxin toxicity If at risk for MI, low dose ASA

25. CAD Nursing Diagnosis Imbalanced Nutrition: More than body requirements Ineffective Health Maintanance

26. CAD: Assessment Focus on identifying risk factors Health history: CP, SOB, weakness, current diet exercise patterns, Meds smoking hx etoh intake h/o heart disease, HTN, or diabetes family h/o CHD

27. CAD: Physical Assessment Weight Height BMI Blood Pressure Strenght and equality of peripheral pulses

28. Atherosclerosis Injury-> lipoproteins collect in lining of artery Macrophages go to site as part of inflammatory process Platelets, cholesterol, & blood stimulates smooth muscle cells & connective tissue proliferate abnormally Yellow fatty streak on inner lining of artery ->fibrous plaque develops ->collagen fibers proliferate -> blood lipids accumulate ->occludes vessel lumen

30. Myocardial IschemiaPathophysiology Oxygen supply inadequate to meet metabolic demands of cardiac cells Coronary perfusion & myocardial workload critical to meeting metabolic demands Oxygen content in blood is a factor

31. Cardiac ischemia Occurs when blood flow to the heart muscle (myocardium) is obstructed by a partial or complete blockage of a coronary artery.

33. Angina

34. Angina: Common Causes Atherosclerotic heart disease Hypertension Coronary artery spasm Hypertrophic cardiomyopathy

35. Angina: Pain Assessment Heavy, squeezing, pressing, burning, choking, aching & apprehension Substernal, radiating to left arm and/or shoulder, jaw, right shoulder Percipitated by exercise, exposure to cold, a heavy meal, mental tension, sexual intercourse Relieved by rest and/or nitroglycerine

36. Angina: Diagnostic Information ECG: ST depression & T wave inversion Exercise stress test: ST depression and hypotension Stress echocardiogram: changes in wall motion Coronary angiogram: coronary spasms Cardiac catheterization: detects arterial blockage

37. Angina: Nursing Assessment Dyspnea Nausea, vomiting Fatigue Diaphoresis, pallor, weakness Syncope Dysthythmias

38. CHD: Nonmodifiable Risk Factors Age (50% 65 or older) Gender (Men affected at early age) Race (AA ↑ incidence of HTN) Genetic factors

39. CHD: Modifiable Risk Factors Hypertension Diabetes

40. CHD: Modifiable Risk Factors Hyperlipidemia LDLs = less desirable lipoproteins HDLs = highly desirable lipoproteins

41. CAD: Modifiable Risk Factors Undesirable Desirable

42. CHD: Modifiable Risk Factors

43. Modifiable Risk Factors

44. CHD: Modifiable Risk Factors Physical Activity

45. CHD: Modifiable Risk Factors

46. Modifiable Risk Factors

47. Angina: Nursing Diagnosis Pain related to …… Anxiety related to ….

48. Angina: Nursing Plans & Interventions Monitor meds & instruct on proper administration Assess factors causing pain (decrease these factors) Teach risk factors/identify risk factors

49. Angina: During an attack Provide immediate rest Take vital signs Record an ECG 3 NTG tablets, 5 minutes apart Emergency if no relief after NTG x 3

50. Angina: Physical Activity Avoid isometric activity Exercise program Resume sexual activity after exercise tolerated Climb 2 flights of stairs without exertion Take NTG before intercourse

51. Angina: Diet Modify saturated fats and sodium Antilipemic meds to lower cholesterol levels

52. Angina: Medical InterventionsPercutaneoustransluminal coronary angioplasty (PTCA)

53. Angina: Medical InterventionsCoronary Artery Stent

54. Angina: Medical InterventionsArthrectomy Arthrectomy: a cath with a collection chamber is used to remove plaque that is trapped in the chamber Coronary laser therapy

57. Inadequate Oxygenation & Tissue Perfusion: Assessment Report pain: Chest Shoulder Arm Jaw Back abdomen Indigestion Diaphoresis Nausea Vomiting Anxious behavior Palpitations Fatigue Disorientation/confusion

62. Peripheral Vascular Disease Can be due to arterial or venous pathology

63. PVD: Predisposing factors Arterioclerosis Advanced age H/O DVT Valvular incompetence Arterial Venous

64. PVD: Associated Diseases Raynaud disease Buerger disease Diabetes Acute occlusion Varicose veins Thrombophlebitis Venous stasis ulcers Arterial Venous

65. PVD: Skin Assessment Smooth Shiny Loss of hair Thickened nails Brown pigment around ankles Arterial Venous

66. PVD: Color Pallor on elevation Rubor when dependent Cyanotic when dependent Arterial Venous

67. PVD: Temperature/Pulses Cool Pulse decreased or absent Warm Pulse normal Arterial Venous

68. PVD: Pain Assessment Arterial Sharp Increases with walking and elevation Intermittent claudication Rest pain when hortizonal; relieved by dependent position Persistant aching, full feeling, dull sensation Relieved when horizonal (elevate and use TEDs) Venous

69. PVD: Ulcers Very painful Occur on lateral lower legs, toes, heels Demarcated edges Necrotic Not edematous Slightly painful Occur on medial legs, ankles Uneven edges Superficial Marked edema Arterial Venous

70. PVD: Nursing Diagnosis Ineffective tissue perfusion Activity intolerance Impaired skin integrity Risk for infection Pain

71. PVD: Noninvasive Treatment Stop smoking Topical antibiotic Saline dressing Bedrest, immobilization Fibrinolytic agents if clots a problem Systemic antibiotics Compression dressing Limb elevation Fibrinolytic agents and anticoagulants Arterial Venous

72. PVD: Surgery Embolectomy Endarterectomy Arterial bypass Percutaneoustransluminal angioplasty Amputation Vein ligation Thrombectomy Debribement Arterial Venous

73. PVD: Nursing Plans & Interventions Monitor extremities color, temp sensation, pulse quality Schedule activities Rest Keep extremities elevated (if venous) Avoid crossing legs Wear nonrestrictive clothing Keep extremities warm Do not use electric heating pads

74. PVD: Teach Change position frequently Wear nonrestricitve clothing Avoid crossing legs Keep legs in dependent position Wear shoes when ambulating Obtain proper foot and nail care Discourage smoking (vasoconstriction & spasms of arteries)

75. PVD: PreOp & PostOp Care Maintain affected extremity in a level position (if venous) Slightly dependent position (if arterial) Assess surgical site for hemorrhage Anticoagulants continued to prevent thrombosis Preoperative Postoperative

76. Key Points: Vascular Problems Take vital signs Assess peripheral pulses Assess capillary refill Check sensation and temperature Pain assessment Assess ulcer Elevate legs if swollen unless arterial flow is poor

77. Electrocardiogram (ECG) Reflection of the heart's electrical circuit and its activity.

78. Coronary Circulation The heart derives its arterial supply from the coronary sinuses which lie either side of the root of the aorta. The left and right sinus give rise to the left and right coronary artery and their branches,

80. Supplies the inferior border (via Right Marginal branch)

81. Supplies the posterior surface (via Right Posterior Descending branch).

82. It also supplies the Sinoatrial node and Atrioventricular node in 90% and 65% of people respectively.

84. The other branch of the left Main Stem, the Left Circumflex, winds around the posterior surface of the left ventricle, anastamoses with the Right Posterior Descending artery.

85. Impairment of the left coronary circulation causes anterior and lateral infarction

87. In Summary The polarized or resting cell will carry a negative charge on the inside. When depolarized, the opposite will occur. This is due to the movement of sodium and potassium across the cell membrane. Depolarization moves a wave through the myocardium. As the wave of depolarization stimulates the heart’s cells, they become positive and begin to contract. This cell-to-cell conduction of depolarization through the myocardium is carried by the fast moving sodium ions.

89. Repolarization The return of electrical charges to their original state. This process must happen before the cells can be ready conduct again. Look at the next slide diagram and note the depolarization and repolarization phases as they are represented on the ECG.

91. Electric Circuit of the Heart: SA Node The intrinsic electrical circuit of the heart ‘natural pacemaker' Receives both a parasympathetic and sympathetic nerve supply. Lies at the junction of the Superior Vena Cava with the Right Atrium Connected by a rapid conduction system to the atrio-ventricular node AV nodewhich lies at the base of the interatrial septum.

92. Electric Circuit of the Heart: AV Node Regarded as the ‘gatekeeper' or resistor in the circuit Tries to maintain normal communications between the atria and ventricles. Connects to the Bundle of His Bundle of His divides into a right bundle, supplying the right ventricle and a Left bundle, which through its anterior-superior and posterior-inferior divisions supplies the two surfaces of the left ventricle.

93. Electric Circuit of the Heart

94. Electrical conduction The electrical conduction through circuits causes a rapid wave of depolarization to spread across the atria and then down through the ventricles. This depolarization and subsequent repolarization is represented by the different waves of the ECG.

95. Electrical conduction The electrical baseline of the ECG from is known as the iso-electric line. Deflections above this line are POSITIVE Deflections below are NEGATIVE. R wave is positive, S wave is negative A QRS is iso-electric when the addition of the positive and negative deflections give a net deflection of zero.

97. EKG Paper Grid where time is measured along the horizontal axis. Each small square is 1 mm in length and represents 0.04 seconds. Each larger square is 5 mm in length and represents 0.2 seconds.

98. Calculating Heart Rate When the rhythm is regular, the heart rate is 300 divided by the number of large squares between the QRS complexes. For example, if there are 4 large squares between regular QRS complexes, the heart rate is 75 (300/4=75).

99. Calculating Heart Rate The second method can be used with an irregular rhythm to estimate the rate. Count the number of R waves in a 6 second strip and multiply by 10. For example, if there are 7 R waves in a 6 second strip, the heart rate is 70 (7x10=70).

100. P Wave First small positive deflection before the QRS complex Atrial depolarization width <0.12 sec

101. PR Interval Distance from start of P wave to start of QRS complex Conduction time from SAN through the AV node < 0.20 sec

102. Q Wave First negative deflection after the P wave and before the R wave Represents conduction from the opposite side of the heart

103. R Wave First positive deflection after the P wave Ventricular depolarization

104. S Wave First negative deflection after the R wave Ventricular depolarization

105. QRS Complex Complex including the Q, R and S waves Complete ventricular depolarization <0.12 seconds

106. ST Segment Segment between the end of the S wave and the start of the T wave First part of ventricular repolarization

107. T Wave Positive wave after the QRS complex Ventricular repolarization

108. QT Interval Start of the QRS complex to the end of the T wave Ventricular depolarization and repolarization 0.42 seconds

109. Normal Sinus Rhythm Regular rhythm Heart rate 60 – 100 P wave for every ORS, identical PR interval 0.12 – 0.20 second ORS complex 0.06 – 0.10 seconds

110. Sinus Bradycardia Heart rate < 60 Regular rhythm P wave before each ORS, identical PR interval .12 - .20 seconds ORS < .12

111. Sinus Bradycardia Possible Causes Hyperkalemia Increased vagal tone-constipation, vomiting Inferior wall MI Beta blockers, digoxin, morphine Signs & Symptoms Possibly asymptomatic Fatigue, lightheadedness, syncope, palpitations, chest pain Treatment Treat underlying cause Atropine Pacemaker

112. Sinus Tachycardia Regular rhythm Heart rate 100 – 160 P wave before each ORS PR interval 0.12 – 0.20 second ORS complex 0.06 – 0.10 seconds

113. Sinus Tachycardia Possible Causes Caffeine, tobacco, ETOH Digoxin toxicity Exercise, fever, stress, pain, dehydration Inflammatory response Hypovolemia Signs & Symptoms Usually asymptomatic Palpitations or angina Treatment Treat underlying cause Beta blockers