Title: Nursing 201 Advanced Cardiac 2.0 Nursing assessment and management of patients with dysfunctions of circulation, and undergoing related diagnostic tests.
1Nursing 201Advanced Cardiac 2.0 Nursing
assessment and management of patients with
dysfunctions of circulation, and undergoing
related diagnostic tests.
Laurie Brown RN, MSN, MPA-HA, CCRN Fall 2005
2This is important!
- There are three systems that must work together
for the heart to beat efficiently - Circulatory
- Conduction
- Coronary
3Review of the Cardiovascular System
- Route of blood from the heart
- Arteries, arterioles, capillaries, venules, veins
- Distribution of the Total Blood Volume
-
- Heart - Approx 9 of blood volume at any given
time. - Arteries and veins act simply as conduits for
blood! -
- Only capillaries directly serve cells by
exchanging materials with them.
4Cardiac Tissues
- Connective tissues form the fibrous skeleton
and valves. - Cardiac muscle produces the contractile force
of the heart. - Epithelial tissue lines the cardiac chambers
and covers the outer surfaces of the heart.
5Arterial System
- General Features
- Elastic Arteries
- Muscular Arteries
- Arterioles
6Exterior Anatomy of the Heart
7Anatomy of the Heart
8Valves of the Heart
- Tricuspid Directs the flow of blood from the
right atrium to the left ventricle. - Mitral Valve Directs the flow of blood from the
left atrium to the left ventricle. - Pulmonic (semilunar) Lies between the right
ventricle and the pulmonary artery. - Aortic Valve (semilunar) Lies between the left
ventricle and the aortic artery.
9Circulation in the Heart
- 1. Oxygen-poor blood (shown in blue) flows from
the body into the right atrium.2..Blood flows
through the right atrium into the right
ventricle.3. The right ventricle pumps the
blood to the lungs, where the blood releases
waste gases and picks up oxygen.
10- 3. The newly oxygen-rich blood (shown in red)
returns to the heart and enters the left
atrium.4. Blood flows through the left atrium
into the left ventricle.5. The left ventricle
pumps the oxygen-rich blood to all parts of the
body.
11TheCirculatory System
12Coronary Circulation
13Coronary Blood Flow
- Coronary Blood Flow is directly linked to oxygen
demand. - Autoregulation helps to maintain normal coronary
blood flow whenever coronary perfusion pressure
changes due to changes in aortic pressure.
14Autoregulation
- Autoregulation is defined as
-
- The intrinsic ability of an organ to maintain a
constant blood flow despite changes in perfusion
pressure. - Control of an event such as blood flow through a
tissue (e.g., cardiac muscle) by alteration of
the tissue.
15Coronary Blood Flow
16Heart Sounds
- Heart sounds are caused by the closure of
heart valves. -
- The first sound (lub), or S1, is caused by
closure of the atrioventricular (AV) valves. - The second sound (dup), or S2, is caused by the
closure of the semilunar valves.
17Murmurs and Stenosis
- A valve that does not close efficiently, results
in the backflow of blood (i.e., insufficiency or
regurgitation). - A valve that does not open wide enough may cause
turbulent backflow secondary to obstruction or
narrowing (i.e., stenosis).
18Landmarks
19Pericardial Friction Rub
- Non-infective
- Infective
- Autoimmune
- Scratching, grating, squeaking, high pitched
sound
20Definitions
- Cardiac output
- Pre-load
- After-load
- Cardiac reserve
- Starlings law of the heart
- Pulse deficit
- Pulse pressure
21Physiology of Circulation (cont.)
- Peripheral Resistance
- Opposition to flow
- A measure of the amount of friction blood
encounters as it passes through the vessels. -
- Most friction is encountered in the peripheral
circulation (peripheral resistance (PR)). -
- Sources of resistance
22Physiology of Circulation (cont.)
- Blood Pressure
-
- Force per unit area exerted on the wall of a
vessel by its contained blood expressed in mm Hg. -
- Usually means systemic arterial blood pressure in
the largest arteries near the heart. -
- The differences in blood pressure within the
vascular system provided the driving force that
keeps blood moving through the body.
23Physiology of Circulation
- Blood Flow
- Actual volume of blood flowing through the entire
circulation or any part of it (a vessel, an
organ, etc.) in a given period of time (ml/min). -
- Equals cardiac output (CO) when applied to the
entire circulation. - Varies widely among individual body organs as
determined by their immediate needs.
24The Cardiac Cycle
- Isovolumetric ventricular contraction
- Ventricular ejection
- Isovolumetric relaxation
- Ventricular filling
- Atrial systole
25Ejection fraction (EF)
- The ejection fraction (EF) represents the amount
of blood pumped out of the heart (left ventricle)
with each beat. In the healthy heart, it is
around 70. - An EF below 55 is considered abnormal.
26What is congestive heart failure?
Tabers defines heart failure as The inability
of the heart to circulate blood effectively
enough to meet the body's metabolic needs.
27Symptoms of Heart Failure
- Shortness of breath (dyspnea)
- Fatigue
- Edema associated with fluid overload
- Lightheadedness
- Hypoxia
- Orthopnea
- Cognitive changes
- Other
28Auto-regulatory Mechanisms of The Heart
- The heart is supplied by the two branches of the
autonomic nervous system. - The sympathetic (adrenergic)
- The parasympathetic, or (cholinergic)
29Changes Associated With Aging
- Decreased vessel elasticity
- Increased calcification of vessels
- Impaired valve function
- Decreased muscle tone (including the heart
- Decreased baroreceptor response to blood pressure
changes - Decreased conduction ability of the heart
30Other stuff
- Contractility
- The ability of muscle cells to contract after
depolarization. This ability depends on how much
the muscle fibers are stretched at the end of
diastole. - The inherent ability of cardiac muscle fibers to
shorten or contract.
31Cardiac Risk Factors
- Non-modifiable
- Modifiable
- Other
32Cardiac Testing
- Blood Tests
- Electrical
- Structure
- Pressure
- Blood Flow
- Ischemic Tissue
33Laboratory Tests
- CK or CK-MB
- LDH (LDH1, LDH2)
- AST (SGOT)
- Lipids
- PT/PTT
- ABGs
- Electrolytes
- CBC
- Troponin Myoglobin
- C-reactive protein (CRP)
- Homocysteine
- B Type Natriuretic Peptid
34Tests
- EKG
- Stress Test
- Transesophageal Echocardiography
- Echocardiography
- Phonocardiography
35Radiographic
- X-ray
- Fluoroscopy
- Angiography
- Cardiac Cath
- DSA (Digital Subtraction Angiography)
36Cardiac Testing
- Angiography
- Angioplasty
- Biopsy
- VO2 max
37Tests
- Nuclear Cardiography
- Technetium Pyrophosphate Scanning
- Thallium Imaging
- MUGA Scan
38Tests
- Positron Emission Tomography (PET)
- MRI
- CAT Scan
Small Pericardial Effusion
39Hemodynamic Monitoring
40Physical Assessment
- General appearance
- Mental Status
- Vital signs
- Pulses
- Heart rate and rhythm
- Perfusion
- Edema
- Lung sounds
- Other
41Case Study FRED
- 82 y/o male w/30 year history of COPD presents
to the ER with C/O SOB and chest pain and now is
to be admitted to your unit. He has a IV at TKO
and O2 per NP at 2L. He was given a Nitro and
an aspirin in the ER.
42Fred
- Admitting Dx CHF, R/O MI
- Past Medical Hx Mild CHF, COPD x 30 years, CAD,
HTN - PE Skin pink and dry, brisk capillary refill,
oriented x 4, S3 heart sounds, SOB with any
exertion, audible expiatory and inspiratory
wheezes, crackles at bases bilaterally, 1
pitting edema to mid calf
43FRED
- 1. Chief Complaint
- 2. Cardiac (Medical) History
- 3. Tests (Labs others)
- 4. Medications
- 5. Physical exam
- 6. Vital signs
- 7. Nursing Diagnosis
44- Admitting Dx CHF, R/O MI
- Past Medical Hx Mild CHF, COPD x 30 years, CAD,
HTN - Vital signs 184/94, 122, 30, T 99.1
- ABGs on RA - 7.55, CO2 26, O2 54
- PE Skin pink and dry, brisk capillary refill,
oriented x 4, S3 heart sounds, SOB with any
exertion, audible expiatory and inspiratory
wheezes, crackles at bases bilaterally, 1
pitting edema to mid calf
45Q-R-S-T-A-A-A
- Quality - dull/squeezing
- Region radiation
- changing
- right arm/left arm
- Severity/Setting
- rest vs exertion
- after meals
- scale of pain
46Q-R-S-T-A-A-A
- Time
- sudden/gradual onset
- Alleviators
- Position
- Aggravators
- food/position/exertion/people
- constant/episodic
- Associated Symptoms
- SOB, cough, temp, nausea, diarrhea
47Application - Chief Complaints
- What are Freds chief complaints?
48Cardiac History
- Ask about his personal history, family history
and social history.
49Fred - Medications
- What medications is he currently taking?
- Diuretic, ACE inhibitor, ß-blocker, K,
Bronchodilators and Glucocorticoids
50Physical Exam
- What we know
- SOB (subjective and objective)
- Vital signs
- ABGs
- SkinPerfusion
- Mental status
- Heart sounds
- Lung sounds
- Edema
51Nursing Diagnosis
- What nursing diagnosis would be appropriate for
Fred at this time? - Remember, NDs serve to guide and direct nursing
care!
52Which question should you ask a client
experiencing palpitations?
- A. Family history of high blood pressure or heart
problems - B. Activity when symptoms begins
- C. Anything that makes symptoms more or less
severe - D. Amount of coffee or tea consumed each day