Cardiovascular System - Nursing Board Review PDF

Nursing Board Review Cardiovascular System Alexis Luigi Lorenzo C. Cresencia, RN, MD The Cardiovascular System Normal Anatomy The heart is in the center of the thorax Consists of Three layers- epicardium, myocardium and endocardium The Cardiovascular System The epicardium covers the out...

Nursing Board Review Cardiovascular System Alexis Luigi Lorenzo C. Cresencia, RN, MD The Cardiovascular System Normal Anatomy The heart is in the center of the thorax Consists of Three layers- epicardium, myocardium and endocardium The Cardiovascular System The epicardium covers the outer surface of the heart The myocardium is the middle muscular layer of the heart The endocardium lines the chambers and the valves The Cardiovascular System The layer that covers the heart is the PERICARDIUM There are two parts - parietal and visceral pericardium The space between the two pericardial layers is the pericardial space The Cardiovascular System The heart also has four chambers- two atria and two ventricles The Left atrium and the right atrium The left ventricle and the right ventricle The Cardiovascular System The heart chambers are guarded by valves The atrio-ventricular valves- Tricuspid and bicuspid The semi-lunar valves- Pulmonic and aortic valves  The Cardiovascular System The Blood supply of the heart comes from the Coronary arteries 1. Right coronary artery supplies the RIGHT atrium and RIGHT ventricle, inferior portion of the LEFT ventricle, the POSTERIOR septal wall and the two nodes- AV (90%) and SA node (55%)  The Cardiovascular System 2. Left coronary artery- branches into the LAD and the circumflex branch The LAD supplies blood to the anterior wall of the LEFT ventricle, the anterior septum and the Apex of the left ventricle The CIRCUMFLEX branch supplies the left atrium and the posterior LEFT ventricle  The Cardiovascular System CONDUCTION SYSTEM OF THE HEART Consists of the: 1. SA node- the pacemaker 2. AV node- slowest conduction 3. Bundle of His – branches into the Right and the Left bundle branch 4. Purkinje fibers- fastest conduction The Cardiovascular System The Heart sounds 1. S1- due to closure of the AV valves 2. S2- due to the closure of the semi-lunar valves The Cardiovascular System The Heart sounds 3. S3- due to increased ventricular filling 4. S4- due to forceful atrial contraction The Cardiovascular System Heart rate Normal range is 60-100 beats per minute Tachycardia is greater than 100 bpm Bradycardia is less than 60 bpm Sympathetic system INCREASES HR Parasympathetic system (Vagus) DECREASES HR The Cardiovascular System Blood pressure Cardiac output X peripheral resistance Control is neural (central and peripheral) and hormonal Baroreceptors in the carotid and aorta Hormones - ADH, aldosterone, epinephrine can increase BP; ANF can decrease BP The Cardiovascular System The vascular system consists of the arteries, veins and capillaries The arteries are vessels that carry blood away from the heart to the periphery The veins are the vessels that carry blood to the heart The capillaries are lined with squamous cells, they connect the veins and arteries The Cardiovascular System The lymphatic system also is part of the vascular system and the function of this system is to collect the extravasated fluid from the tissues and returns it to the blood The Cardiovascular System Cardiac Assessment CARDIAC ASSESSMENT 1. Health History Obtain description of present illness and the chief complaint Chest pain, SOB, Edema, etc. Assess risk factors Ethnic Socioeconomic HEALTH HISTORY Common Symptoms Chest pain/discomfort Pain/discomfort in other areas of upper body Shortness of breath or dyspnea Peripheral edema, weight gain, abdominal distention Palpitations Unusual fatigue Dizziness, syncope, or changes in level of consciousness Past Health, Family, and Social History Risk factors Non-modifiable Modifiable Ask the following questions: How is your health? Have you noticed any changes from last year? From 5 years ago? Do you have a cardiologist or primary provider? How often do you go for checkups? What health concerns do you have? Do you have a family history of genetic disorders that place you at risk for CVD? What are your risk factors for CAD? What do you do to stay healthy and take care of your heart? CARDIAC ASSESSMENT 2. Physical examination General Appearance Vital signs - BP, PP, MAP Inspection of the skin & extremities Inspection of the thorax Palpation of the PMI, pulses Auscultation of the heart sounds Assessment of the Skin & Extremities Assessment of the Skin & Extremities Heart Inspection and Palpation Heart Inspection and Palpation Supine with head of bed slightly elevated Apical impulse – light pulsation, 1-2cm in diameter Thrill Abnormal Heart Sounds Opening snaps – high-pitch in early diastole Systolic click – high-pitch in early systole Murmurs – turbulent flow Friction rub – harsh, grating sound both in systole and diastole CARDIAC ASSESSMENT 3. Laboratory and diagnostic studies CBC Cardiac catheterization Lipid profile Arteriography Cardiac enzymes and proteins CXR CVP 2D Echocardiography Holter monitoring Exercise ECG  The Cardiovascular System Laboratory Test Rationale 1. To assist in diagnosing MI 2. To identify abnormalities 3. To assess inflammation  The Cardiovascular System Laboratory Test Rationale 4. To determine baseline value 5. To monitor serum level of medications 6. To assess the effects of medications  The Cardiovascular System LABORATORY PROCEDURES Cardiac Proteins & Enzymes ØCK-MB (creatine kinase) ØElevates in MI within 4 hours, peaks in 18 hours and then declines till 3 days ØNormal value – 5-25 IU/L The Cardiovascular System LABORATORY PROCEDURES Cardiac Proteins and enzymes ØLactic Dehydrogenase (LDH) ØElevates in MI in 24 hours, peaks in 48-72 hours ØNormally LDH1 is less than LDH2 The Cardiovascular System LABORATORY PROCEDURES Cardiac Proteins and Enzymes ØLactic Dehydrogenase (LDH) ØMI – LDH1 greater than LDH2 (flipped LDH pattern) ØNormal value is 70-200 IU/L The Cardiovascular System LABORATORY PROCEDURES Cardiac Proteins and enzymes Myoglobin ØRises within 1-3 hours ØPeaks in 4-12 hours ØReturns to normal in a day ØNot used alone ØMuscular and RENAL disease can have elevated myoglobin The Cardiovascular System LABORATORY PROCEDURES Troponin I and T Troponin I is usually utilized for MI Elevates within 3-4 hours, peaks in 4-24 hours and persists for 7 days to 3 weeks! Normal value for Troponin I is less than 0.04 ng/mL REMEMBER to AVOID IM injections before obtaining blood sample! Early and late diagnosis can be made! The Cardiovascular System LABORATORY PROCEDURES SERUM LIPIDS Lipid profile measures the serum cholesterol, triglycerides and lipoprotein levels Cholesterol = 125-200 mg/dL (for ages 20 years and older both men and women) Triglycerides – 40-150 mg/dL HDL - 30-70 mg/dL LDL - < 100 mg/dL NPO post midnight (usually 12 hours) The Cardiovascular System LABORATORY PROCEDURES ELECTROCARDIOGRAM (ECG) A non-invasive procedure that evaluates the electrical activity of the heart Electrodes and wires are attached to the patient The Cardiovascular System LABORATORY PROCEDURES Holter Monitoring A non-invasive test in which the client wears a Holter monitor and an ECG tracing recorded continuously over a period of 24 hours  The Cardiovascular System LABORATORY PROCEDURES Holter Monitoring Instruct the client to resume normal activities and maintain a diary of activities and any symptoms that may develop The Cardiovascular System LABORATORY PROCEDURES ECHOCARDIOGRAM Non-invasive test that studies the structural and functional changes of the heart with the use of ultrasound No special preparation is needed The Cardiovascular System LABORATORY PROCEDURES Stress Test A non-invasive test that studies the heart during activity and detects and evaluates CAD Exercise test, pharmacologic test and emotional test The Cardiovascular System LABORATORY PROCEDURES Stress Test Treadmill testing is the most commonly used stress test Used to determine CAD, Chest pain causes, drug effects and dysrhythmias in exercise The Cardiovascular System LABORATORY PROCEDURES Stress Test Pre-test: consent may be required, adequate rest, eat a light meal or fast for 4 hours and avoid smoking, alcohol and caffeine The Cardiovascular System LABORATORY PROCEDURES Post-test: instruct client to notify the physician if any chest pain, dizziness or shortness of breath. Instruct client to avoid taking a hot shower for 10-12 hours after the test The Cardiovascular System LABORATORY PROCEDURES Pharmacological stress test Use of Dipyridamole Maximally dilates coronary artery Side-effect: flushing of face The Cardiovascular System LABORATORY PROCEDURES Pharmacological stress test Pre-test: 4 hours fasting, avoid alcohol, caffeine Post test: report symptoms of chest pain The Cardiovascular System LABORATORY PROCEDURES Cardiac Catheterization Insertion of a catheter into the heart and surrounding vessels Determines the structure and performance of the heart valves and surrounding vessels The Cardiovascular System LABORATORY PROCEDURES Cardiac Catheterization Used to diagnose CAD, assess coronary artery patency and determine extent of atherosclerosis The Cardiovascular System LABORATORY PROCEDURES Pretest: Ensure Consent, assess for allergy to seafood and iodine, NPO, document weight and height, baseline VS, blood tests and document the peripheral pulses The Cardiovascular System LABORATORY PROCEDURES Pretest: Fast for 8-12 hours, teachings, medications to allay anxiety The Cardiovascular System LABORATORY PROCEDURES Intra-test: inform patient of a fluttery feeling as the catheter passes through the heart; inform the patient that a feeling of warmth and metallic taste may occur when dye is administered The Cardiovascular System LABORATORY PROCEDURES Post-test: Monitor VS and cardiac rhythm Monitor peripheral pulses, color and warmth and sensation of the extremity distal to insertion site Maintain sandbag to the insertion site if required to maintain pressure Monitor for bleeding and hematoma formation The Cardiovascular System LABORATORY PROCEDURES Maintain strict bed rest for 6-12 hours Client may turn from side-to-side but bed should not be elevated more than 30 degrees and legs always straight Encourage fluid intake to flush out the dye Immobilize the arm if the antecubital vein is used Monitor for dye allergy The Cardiovascular System LABORATORY PROCEDURES CVP The CVP is the pressure within the SVC Reflects the pressure under which blood is returned to the SVC and right atrium  The Cardiovascular System LABORATORY PROCEDURES CVP Normal CVP is 2 to 6 mmHg/ 4-10 cm H2O Elevated CVP indicates increase in blood volume, excessive IVF or heart/renal failure Low CVP may indicated hypovolemia, hemorrhage and severe vasodilatation The Cardiovascular System LABORATORY PROCEDURES Measuring CVP 1. Position the client supine with bed elevated at 45 degrees 2. Position the zero point of the CVP line at the level of the right atrium. Usually this is at the MA L, 4th ICS 3. Instruct the client to be relaxed and avoid coughing and straining. CARDIAC IMPLEMENTATION 1. Assess the cardio-pulmonary status VS, BP, Cardiac assessment 2. Enhance cardiac output Establish IV line to administer fluids CARDIAC IMPLEMENTATION 3. Promote gas exchange Administer O2 therapy Position client in SEMI-Fowler’s Encourage coughing and deep breathing exercises CARDIAC IMPLEMENTATION 4. Increase client activity tolerance Balance rest and activity periods Assist in daily activities 5. Promote client comfort Assess the client’s description of pain and chest discomfort Administer medication as prescribed CARDIAC IMPLEMENTATION 6. Promote adequate sleep 7. Prevent infection Monitor skin integrity of lower extremities Assess skin site for edema, redness and warmth Monitor for fever Change position frequently CARDIAC IMPLEMENTATION 8. Minimize patient anxiety Encourage verbalization of feelings, fears and concerns Answer client questions. Provide information about procedures and medications THANK YOU