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Nursing of Adult Patients with Medical & Surgical Conditions Cardiovascular Disorders Diagnostic Tests Diagnostic Imaging – Radiographic exam to assess heart size, shape and position and outline of shadows. Diagnostic Tests – Computed Axial Tomography (CT/CAT Scan) • Three dimensional view of the structure Diagnostic Tests – Angiogram • radiographs are taken after injection of dye into an artery – Aortogram • visualizes the abdominal aorta and the major leg arteries with injection of dye into the femoral artery Iliac Artery Diagnostic Tests –Fluoroscopy •action-picture Fluoroscopy Demo Diagnostic Tests Cardiac Catherterization and Angiography – Visualizes the heart’s chambers, valves, great vessels, and coronary arteries – Catheter is inserted into the heart chambers to measure pressure, and blood-volume. – Contrast dye may be used for better visualization – Post-procedure: • supine, with sandbag over pressure dressing at insertion site Cardiac Catheterization Cardiac Catheterization Lab Cardiac Catheterization with Contrast Diagnostic Tests Electrocardiogram – Graphic study of the electrical activities of the myocardium Review of Cardiac Electrical Activity Diagnostic Tests Electrocardiogram – P-wave • contraction (depolarization) of the atria – QRS complex • contraction (depolarization) of the ventricles • relaxation (repolarization) of the atria is covered by the QRS complex – T-wave • relaxation (repolarization) of the ventricles Relationship of EKG to cardiac muscle activity (SA Node fires) Atrial Depolarization (Impulse to AV node) (Impulse moves through Bundle of His & Perkinje fibers) Ventricular Depolarization Ventricular Repolarization Electrocardiogram Diagnostic Tests Cardiac Monitors – Continual monitoring of the cardiac electrical activity on a video monitor – Telemetry • electronic transmission of data to a distant location Diagnostic Tests Thallium Scanning – Thallium 201 is injected and the patient exercises on a treadmill – Thallium is transported into normal cells, but not ischemic or infarcted cells Thallium Scanning Diagnostic Tests Echocardiography – Ultrasound is used to record size, shape, and position of cardiac structures – Detects: • • • • • • • • pericardial effusion ventricular function cardiac chamber size and contents ventricular muscle and septal motion and thickness cardiac output cardiac tumors valvular function congenital heart disorders. Echocardiography Echocardiogram Demo Echocardiography Diagnostic Tests Positron Emission Tomography (PET) – Computerized radiographic technique that uses radioactive substances to examine the metabolic activity of various body structures – Used to study dementia, stroke, epilepsy, tumors, and cardiac tissue PET Demonstration Diagnostic Tests Laboratory Exams – Blood cultures • Culture and sensitivity – Compete Blood Count (CBC) • • • • • RBC (erythrocytes) Hemoglobin Hematocrit WBC Platelets 4-6 million/cu.mm 10-20 gm/100ml 40-50 percent 5,000-10,000/mm 150,000-400,000/mm – Coagulation Studies • Prothrombin Time (PT) 11-12.5 seconds • Partial thromboplastin time (PTT) 60-70 seconds – Erythrocyte sedimentation rate (ESR) • Up to 20mm/minute – Serum electrolyte tests • • • • sodium - maintains fluid balance (135-145mEq/L) potassium - relaxes heart muscle (3-5 mEq/L) calcium - contraction of cardiac muscle (9-11mg/dl) magnesium - maintain level of electrical excitability in the nerves and muscles (1-2 mEq/L) – Serum lipids • • • • Total Cholesterol (140-200 mg/dl) High Density Lipoprotein (HDL) (35-85 mg/dl) Low Density Lipoprotein (LDL) (below 100mg/dl) Triglycerides (35-135 mg/dl) – Arterial blood gases • • • • • pH PaCO2 PaO2 HCO SaO2 7.35-7.45 35-45 mm Hg 80-100 mm Hg 21-28 mEq/L 95-100% Diagnostic Tests Cardiac Enzyme Studies – CPK isoemzyme II (MB) • enzyme is released when the heart muscle is damaged or necrosis occurs • levels rise in 3-6 hours, peak in 12-18 hours, and may remain elevated for 3-4 days • Normal Value 40-170 U/L – LDH • Rises within the first 24-72 hours, peaks in 3-4 days, and returns to normal in approx 14 days • Normal Value 100-200 U/L Risk Factors for Cardiovascular Disorders Nonmodifiable Factors – Family History • Parent or sibling who has CV disorder before 50 yrs – Age • Normal physiological changes • Approx 50% of all MI occur after 65 yrs – Sex (Gender) • Men are at greater risk than women – Race • African Amer. males are at higher risk of hypertension Risk Factors for Cardiovascular Disorders Modifiable Factors – Smoking • 2-3 times greater risk – Hyperlipidemia • Diet high in saturated fat, cholesterol, and calories • Cholesterol levels above 200 mg/dl – Hypertension • B/P higher than 140/90 Risk Factors for Cardiovascular Disorders – Diabetes Mellitus • Damage to vessels due to high glucose levels • High cholesterol levels (abnorm. lipid metabolism) – Obesity • Increases workload of the heart – Sedentary Lifestyle • Exercise improves the heart’s efficiency, lowers glucose & cholesterol levels, lowers B/P, reduces weight, and reduces stress levels Risk Factors for Cardiovascular Disorders – Stress • Catecholamines are released which cause increased heart rate and damage to myocardial cells – Oral Contraceptives • Not clearly defined – Older high dose contraceptives made women at higher risk for cardiovascular disorders – esp. smokers – Newer low dose contraceptives don’t seem to cause that risk – Psychosocial Factors • Type A personality – aggressiveness, competitiveness, perfectionism, & compulsiveness Cardiac Dysrhythmias Normal Sinus Rhythm – Originates in the SA node – Rate: 60-100 beats/min – Rhythm: regular Sinus Tachycardia – – – – Originates in the SA node Rate: 100-150 Rhythm: regular Causes: • exercise, anxiety, fever, shock, medications, hypothermia, heart failure, excessive caffeine, and tobacco • Not usually caused by cardiac problems – Treatment: • Directed at cause Sinus Bradycardia –Originates: SA node –Rate: less than 50-60 beats per min –Rhythm: regular –Cause: •sleep, vomiting, intracranial tumors, MI, drugs, vagal stimulation, endocrine disturbances, and hypothermia –Treatment: •Directed toward cause •Atropine to increase heart rate •Temporary or permanent pacemaker Supraventricular Tachycardia (SVT) Premature Atrial Contraction (PAC) – – – – Originates: atria Rate: 150-250 beats/min Rhythm: regular Causes: • drugs, alcohol, mitral valve prolapse, emotional stress, smoking, and hormone imbalance • usually not caused by heart disease – Treatment: • Eliminate underlying cause • Decrease heart rate – carotid sinus pressure, ocular pressure, digitalis, calcium channel blockers, propranolol, quinidine, and cardioversion Atrial Fibrillation – – – – Originates: atria Rate: 350-600 Rhythm: irregular; may be unable to count Causes: • atherosclerosis, mitral valve disease, CHF, cardiomyopathy, congenital abnormalities, COPD, and thyrotoxicosis – Treatment: • digitalis, calcium channel blockers (verapamil), antidysrhythmics (procainamide), quinidine, anticoagulants (heparin, coumadin) and cardioversion Atrioventricular Block (1st, 2nd, & 3rd degree) – Originates: SA node; impulse is slowed at the AV junction due to a defect – Rate: • 1st degree - 60-100 beats/min • 2nd degree - 30-40 beats/min • 3rd degree - may be no heart beat – Cause: • atherosclerotic heart disease, MI, CHF, digitalis toxicity, congenital abnormality, drugs, and hypokalemia – Treatment: • directed at cause • atropine and isoproterenol • pacemaker for 3rd degree Premature Ventricular Contractions (PVC) – Originates: ventricles – Rate: 60-100 beats/min – Rhythm: • regular with an occasional extra beat • may occur as a single event or may occur several times in a minute, or in pairs or strings – Cause: • irritability of the ventricules, exercise, stress, electrolyte imbalance, digitalis toxicity, hypoxia, and MI – Treatment: • Treat the cause • antidysrhythmics (lidocaine, procainamide, or bretylium Ventricular Tachycardia – Originates: ventricles; 3 or more successive PVC’s – Rate: 140-240 beats/min – Rhythm: regular to slightly irregular – Cause: • hypoxemia, drug toxicity, electrolyte imbalance, and bradycardia – Treatment • IV procainamide (decrease excitability of cardiac muscle) • Lidocaine with MI • Cardioversion Ventricular Fibrillation – – – – Originates: ventricles Rate: none Rhythm: none Cause: • untreated ventricular tachycardia, electrolyte imbalances, digitalis or quinidine toxicity, and hypothermia – Treatment: • Emergency care – CPR – defibrillation (15-20 seconds of the onset) – medications » lidocaine, bretylium, or procainamide Artificial Cardiac Pacemakers Pacemaker – Battery-operated generators that initiate and control the heart rate by delivering an electrical impulse to the myocardium – Temporary • Used for cardiac support following some MI’s or open-heart surg. – Permanent • Used when other measures have failed to convert the dysrhythmia or conduction problem • 2nd & 3rd degree AV block, bradydysrhythmias, & tachydysrhythmias Internal Pacemaker Catheter-like electrode is placed in the area to be paced and generator is embedded under the skin External Pacemaker Electrode pad is placed on the chest wall and is attached to a generator place in a pocket or pouch Artificial Cardiac Pacemakers Nursing Interventions – Post-op • • • • monitor heart rate and heart monitor assess vital signs and level of consciousness assess insertion site for erythema, edema, and tenderness bed rest with arm immobilized for first few hours – Patient Teaching • continued medical care is very important • medical-alert ID • report signs & symptoms of pacemaker failure – weakness, vertigo, chest pain, pulse changes • avoid electrical equipment – hairdryers, battery-operated toothbrushes, etc. • avoid high-output electrical genterators and large magnets (MRI) • teach patient or family member to check pulse rate • notify physician if heart rate drops below 70