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Transcript
Cardiovascular Lisa Pearson, RN MSN The Heart • The heart is divided into 2 sides (right and left) • There are 2 major vessels leading blood in and out of the heart (vena cava and aorta) • The right side of the heart has deoxygenated blood as does the vena cava • The left side of the heart has oxygenated blood as does the aorta Blood Flow of Heart • Deoxygenated blood is carried to the heart through the vena cava • Vena Cava • Right Atrium • Tricuspid Valve • Right Ventricle • Pulmonary Valve • Pulmonary Arteries • Lungs (gas exchange occurs) Blood Flow of the Heart • Oxygenated blood is sent from the lungs to the left side of the heart through the pulmonary veins • Pulmonary Veins • Left Atrium • Bicuspid (mitral) Valve • Left Ventricle • Aortic Valve • Aorta Blood Flow • Once oxygenated blood is pumped into the aorta, the oxygenated blood reaches the body through: • Arteries • Arterioles • Capillaries (gas exchange occurs) Blood Flow • Once gas exchange occurs in the capillaries, the deoxygenated blood must return to the right side of the heart: • Capillaries (gas exchange) • Venules • Veins • Vena Cava Blood Flow The Valves of the Heart • The tricuspid valve is located in the right side of the heart separating the right atrium and right ventricle. • The tricuspid valve is known as tricuspid, right, and AV valve. • The tricuspid valve prevents backflow of blood from the right ventricle back into the right atrium. • Essentially, it is a trapdoor. The Valves of the Heart • The pulmonary valve, also called pulmonic valve, is also located on the right side of the heart. • This valve is found in the right ventricle and leads to the pulmonary arteries. • The pulmonary valve is a trapdoor that prevents backflow of blood from entering back into the right ventricle once it enters the pulmonary arteries. The Valves of the Heart • The bicuspid or mitral valve is located on the left side of the heart. • This valve separates the left atrium and left ventricle. • This valve prevents any blood from flowing back into the left atrium from the left ventricle. The Valves of the Heart • The aortic valve is located in the left ventricle and allows blood to enter into the aorta. • This valve prevents blood from backing back up into the left ventricle. Sounds of the Heart • Normal heart sounds heard with a stethoscope are produced by the closing of the heart valves. • The first sound is S1 and is heard at the beginning of systole as “lubb” when the tricuspid and mitral valves close. • The second heart sound is S2 and is heard at the start of diastole as “dupp” when the aortic and pulmonic semi-lunar valves close. Sounds of the Heart • Extra heart sounds usually indicate a pathological condition. • Normally, no other sounds are heard between S1 and S2. • Placing the stethoscope at the apex of the heart may help in hearing S3 or S4 (extra heart sounds). • Having the patient lean forward or lie on left side can make the heart sounds easier to hear by bringing the area of the heart closer to the chest wall. Sounds of the Heart • S3 is normal for children and younger adults (pregnancy last trimester); however, may be a cardinal sign of heart failure in other adults. • S3 may sound like a gallop and is a low-pitched sound heard early in diastole. Heard after S2 sounds like the “y” in Ken-tuck-y. • S3 sound may be caused by rapid ventricular filling causing vibrations. • S3 may be heard with left-sided heart failure, fluid-volume overload, and mitral valve regurgitation. • S4 is a low-pitched sound similar to a gallop but heard late in diastole right before S1 after the atria contract. Sounds like “ten” in Ten-nes-see. • S4 sound may be caused by slow ventricular filling. Atria contract and eject blood into resistant ventricles, causing vibrations heard as S4. • S4 occurs with HTN, CAD, and pulmonary or aortic stenosis, and hx of MI. Sounds of the Heart • Murmurs are caused by turbulent blood flow through the heart and major blood vessels. • A murmur is a prolonged sound caused by a narrowed valve opening or a valve that does not close tightly. • A swishing sound that ranges in intensity from faint to very loud is produced. Sounds of the Heart • The heart has 3 pericardial membranes that make up the pericardial sac. • The outermost membrane is the fibrous pericardium which is a loose-fitting sac around the heart. • The middle layer is parietal pericardium which is a serous membrane that lines the fibrous layer. • The inner most layer is the visceral pericardium or epicardium which is a serous membrane on the surface of the heart muscle. • Between the parietal and visceral layers is serous fluid, which prevents friction as the heart beats. Sounds of the Heart • A pericardial friction rub occurs from inflammation of the pericardium. • Can be soft and faint to loud enough to be audible without a stethoscope. • A rub has a grating sound like sandpaper being rubbed together that occurs when the pericardial surfaces rub together during the cardiac cycle. • A pericardial friction rub may occur after a myocardial infraction or chest trauma. Heart Sounds Heart Wall Layers • There are 3 layers of the heart wall. • The first layer is the epicardium which is the outer layer. • The second layer is the middle layer which is the myocardium. This layer forms most of the heart wall and is responsible for the contraction of the heart. • The third layer is the inner most layer called the endocardium. It consists of small blood vessels and bundles of smooth muscle. Heart Wall Layers • The thickness of the heart walls or a chamber’s wall depends on the amount of high-pressure work the chamber does. • Because the atria only have to pump blood into the ventricles, their walls are relatively thin. • The walls of the right ventricle are thicker because it pumps blood against the resistance of the pulmonary circulation. • The walls of the left ventricle are thickest of all because it pumps blood against the resistance of the systemic circulation. • The more a muscle works, the larger it becomes. Heart Wall Layers • Pressure changes within the heart affect the opening and closing of the valves. • The amount of blood stretching the chamber and the degree of contraction of the chamber wall determine the pressure. • Example: as blood fills a chamber, the pressure rises; then, as the chamber wall contracts, the pressure rises further. This increase in pressure causes the valve to open and blood to flow out into an area of lower pressure, leading to an equal pressure state. Heart Wall Layers • The heart of course is a muscle and must have its own blood supply. • The coronary vessels include arteries, capillaries, and veins which bring oxygen rich blood to the heart muscle and also carry away de-oxygenated blood from the heart muscle. • The two main coronary arteries are the first branches of the ascending aorta which are the right coronary artery and the left coronary artery. Heart Wall Layers • The right coronary artery supplies blood the right atrium, part of the left atrium, and most of the right ventricle, and the inferior part of the left ventricle. • The left coronary artery, which splits into the anterior descending and circumflex arteries, supplies blood the left atrium, most of the left ventricle, and most of the interventricular septum. Heart Wall Layers • The cardiac veins lie superficial to the arteries. • The largest vein, the coronary sinus, opens into the right atrium. • Most of the major cardiac veins empty into the coronary sinus; the anterior cardiac veins, however, empty into the right atrium. Heart Blood Supply Cardiac Conduction • How does the heart beat? • The heart has its own specialized electrical system that sends impulses throughout the heart to cause the “lub-dub” sound of the heartbeat. • This specialized electrical system is called the cardiac conduction or conduction system which makes the atria and ventricles contract which is a heartbeat or one cardiac cycle. • The conduction system of the heart begins with the heart’s pacemaker: the sinoatrial (SA) node. • The impulse initiated from the SA node travels down an electrical pathway that makes both atria contract at the same time and then the ventricles contract at the same time which makes one heartbeat or a cardiac cycle. Cardiac Conduction • A fraction of a second after the two atria contract simultaneously, the ventricles contract simultaneously. • The contraction of the atria and ventricles is known as systole. • The relaxation of the atria and ventricles is known as diastole. • So…when the atria contract simultaneously, they are in systole and the ventricles are in diastole. • So…when the ventricles contract simultaneously, they are now in systole while the atria are resting in diastole. • During systole, the atria and ventricles pump, force, or squeeze blood out of the chambers into the next area (atria blood goes to ventricles and ventricle blood goes to pulmonary arteries and aorta). • During diastole, the atria and ventricles fill with blood again (atria will receive blood from vena cava and pulmonary veins and ventricles receive blood from atria). Cardiac Conduction • So…back to the electrical conduction of the heart. • The SA node is known as the pacemaker of the heart and is located in the wall of the right atrium. • The SA node initiates or generates the first impulse to get the heartbeat going by sending an electrical impulse throughout an electrical connecting system of the heart. • When the SA node fires, an electrical signal or impulse shoots down an electrical pathway to the atrioventricular (AV) node which is located in the lower interatrial septum. • Once the impulse is received by the AV node, the signal travels to the Bundle of His which is located in the upper interventricular septum. • Now the impulse is in the ventricles! Cardiac Conduction • So…the impulse leaves the AV node and travels down the Bundle of His which branches off into the right and left bundle branches. • The right bundle branch is the electrical pathway that runs down the right side of the ventricle septum. • The left bundle branch is the electrical pathway that runs down the left side of the ventricle septum. • Once the impulse races down the right and left bundle branches, the impulse continues to travel around each ventricle through the Purkinje fibers. • The Purkinje fibers wrap around each ventricular myocardium. • The impulse ends in the Purkinje fibers. Cardiac Conduction Cardiac Conduction • Let’s review this once again…a complete cardiac cycle or one heartbeat. • The SA node in the upper right atrium wall fires an impulse which travels to the AV node (this initial impulse is also sent across the left atrium). • When the impulse is traveling throughout the atria, the atria is stimulated to contract. • Once the impulse is received by the AV node, the AV node acts as a relay station and sends the impulse down the Bundle of His which divides into two branches down the ventricular septum called the right and left bundle branches and the impulse continues down through the Purkinje fibers which wrap around each ventricle. • Once the impulse is sent from the AV node the impulse speeds through the Bundle of His, right and left bundle branches, and Purkinje fibers which now stimulate the ventricles to contract. Cardiac Conduction • Let’s look at the “pacemakers” of the heart. • The SA node is the heart’s primary pacemaker which initiates the start of a heartbeat. • Sometimes, for some reason, the SA node may not work right. It may fire occasionally, too often, or not at all. • If the SA node decides it does not want to function correctly, the heart has a backup plan! • Pacemaker cells are located in lower areas of the heart and can initiate an impulse only when they don’t receive an impulse from another area. • The backup pacemakers are the AV node and Bundle of His/Purkinje fibers. Cardiac Conduction • The SA node has a firing rate of 60 to 100 beats/minute. This means each time there is an impulse initiated in the SA node, the heart is going to beat 60-100 beats/minute which is a normal heart rate. • If for some reason the SA node is not working right, then the AV node will fire 40-60 beats/minute. This means if no signal is received from the SA node, then the AV node will initiate the heartbeat but will be at a slower rate. • If the SA node and the AV node decide not to work right, then the last resort for a the heart to continue to have heartbeats is found in the Bundle of His/Purkinje fibers. • The Bundle of His/Purkinje fibers will initiate the heartbeat of a cardiac cycle at a firing rate of 20 to 40 beats/minute. • The person with a defective SA node will need medical assistance for a permanent pacemaker because the heart will not continue to beat with just the AV or Bundle of His/Purkinje fibers firing. Cardiac Conduction • Regulation of heart rate is generated by the SA node; however, the nervous system can change the heart rate in response to environmental circumstances. • The sympathetic and parasympathetic nervous systems are responsible for the changes of heart rate in response to environmental circumstances. • The sympathetic nervous system increases heart rate, BP, Cardiac Output and force of contraction thanks to the hormone epinephrine. Example: Fight or Flight Syndrome, fear, low oxygen, low BP, etc. • The parasympathetic nervous system decreases heart rate. Example: vagal nerve stimulation such as bearing down with BM. Cardiac Conduction • The heart has what is called a depolarization- repolarization cycle. • When the atria and ventricles contract, this is known as depolarization. • When the atria and ventricles complete a cardiac cycle (one heartbeat), repolarization occurs. • Repolarization is the resting part of the heart’s cardiac conduction prior to the next firing of the SA node which begins another heartbeat. • We will talk more about this when we learn to read an ECG strip. Cardiac Output • • • • • • • Cardiac Output refers to the amount of blood the heart pumps in 1 minute from the left ventricle. To determine the cardiac output, multiply the heart rate by the stroke volume (the amount of blood ejected with each heartbeat). The average resting heart rate of 75 beats/minute with an average resting cardiac output of 5 to 6 L per minute. Starling’s Law states that with exercise, the heart rate and stroke volume increases as does the cardiac output as much as 4 times the resting level. Ejection Fraction is a measure of ventricular efficiency and is usually about 60%. Ejection Fraction is refers to the percentage of blood that’s pumped out of a filled ventricle with each heart beat. The usual normal amount of blood left over is approximately 120 to 130 ml. Percentages less than 60% means more blood is being left in the ventricle due to the ventricle not pumping as forcefully. Hormones and the Heart • We learned that the hormone epinephrine is released from the adrenal medulla under stressful situations and will increase the heart rate, BP, cardiac output, and contractions of the heart. • Aldosterone is released from the adrenal cortex which is important for cardiac function to help regulate blood levels of sodium and potassium which are needed for the electrical activity of the myocardium. (even a small deficiency or excess of K+ can impair the heart beat and rhythm). Hormones and the Heart • The heart actually produces and stores two neurohormones A-type natriuretic peptide (ANP) and B-type natriuretic peptide (BNP). Both help ensure cardiac equilibrium. • Disruptions in fluid balance within the circulatory system trigger release of these hormones, which act as natural diuretics and antihypertensives. • ANP is found in atrial tissue and is released by the atria in response to acute increased fluid volume and blood pressure. • BNP is found in ventricular tissue and helps accurately diagnose and grade heart failure severity. It is released by the ventricles in response to prolonged fluid volume overload or elevated pressure. • The atria and ventricles become enlarged in response to increased fluid volume. Hormones and the Heart • As nurses, you would most likely see physicians writing orders for a BNP level. • The higher the BNP level, the greater the degree of heart failure. • Also, the higher the BNP, the patient’s level of difficulty in completing ADLs increases. • As the nurse, you would need to be aware of the BNP level and plan your nursing care of the patient accordingly. Blood Vessels • Blood flows through the body in five types of vessels: arteries, arterioles, capillaries, venules, and veins. • When blood leaves the left side of the heart, it leaves via the aorta which is the largest artery of the body. The aorta then branches off throughout the body into arteries which in turn become smaller vessels which are the arterioles. The arterioles become very small vessels called capillaries. The capillaries send blood back to the heart by venules, veins, and then the vena cava (largest vein of body). Blood Vessels • The capillaries are microscopic and only allow blood cells to pass in single-file. • The capillaries are where nutrients and gas exchange occur. They also have filtration of fluid in the capillaries. • The filtration of some of the plasma of the blood in the capillaries forms tissue fluid. • Some of this tissue fluid is returned to the capillaries and some is collected in lymph capillaries. Blood Vessels • Once in the lymph capillaries, it is know called lymph. It will be returned to the blood through the lymph vessels. • If the pressure in blood capillaries increase, more tissue fluid than usual is formed, which is too much for the lymph vessels to collect which in turn becomes EDEMA. • This process of forming edema is important to remember when learning and understanding heart failure. Blood Vessels • Arteries have thick, muscular walls to accommodate high speed and pressure of blood flow. • Arterioles have thinner walls than arteries and control blood flow to capillaries. • Capillaries have microscopic walls and have a capillary sphincter that makes blood cells enter in single-file. • Venules gather blood from the capillaries and have thinner walls than arterioles. • Veins have thinner walls but larger diameters than arteries. • Valves in the veins (especially lower extremities) prevent blood backflow. Pressure from the moving volume of blood from below pushes pooled blood in each valved segment toward the heart. Blood Pressure • When you take a patient’s BP, you’re measuring the lateral force that blood exerts on the arterial walls as the heart contracts (systolic pressure) and relaxes (diastolic pressure). • Use a cuff that’s 20-25% wider than the patient’s arm circumference and make sure you place it centered on the upper arm. (if cuff is too high or too low or too small or too big, then the BP reading will not be accurate). • Support the patient’s arm at heart level. Check BP in both arms unless contraindicated. • Use the bell of the stethoscope and deflate the cuff at 2 to 3 mm Hg per second. • Normal BP range is systolic 90-140 and diastolic 60-90. (90/60140/90). Blood Pressure • If heart rate and force increase, then BP will increase to a limit. • If the heart is beating very fast, the ventricles are not filled completely before they contract, cardiac output decreases, and BP drops. • Vasoconstriction causes BP to increase. • We will discuss HTN later. Nursing Assessment of CV System • Nursing assessment of the CV system includes a patient health history and physical examination. • If the patient is experiencing an acute problem (chest pain, SOB, etc.), focus on the most serious signs and symptoms and physical assessment data until the patient is stabilized. An in-depth nursing assessment can be completed when the patient is stable. • Subjective Data you would include in your assessment is past and current symptoms, any medications currently taking, recreational drugs, surgeries and dates, current treatments, diet, activity, tobacco use, and recent stressors. • Subjective Data: health history, medical history, medications, family history, and health promotion. Nursing Assessment of CV System • Objective Data: physical assessment, BP, pulses, respirations, inspection, clubbing, palpation, percussion, auscultation. • When checking BP on admission or first assessment, check BP in each arm lying, sitting, and standing unless contraindicated. * The older adult is at an increased risk for developing orthostatic hypotension, which could precipitate a fall due to a combination of age related changes, immobility, chronic illnesses, and medications. • Clubbing of the nail beds occurs from oxygen deficiency over time. Often caused by congenital heart defects or the long-term use of tobacco. • Clubbing is characterized by the distal ends of the fingers and toes appear swollen and appear club-like. Nursing Assessment of CV System Diagnostic Studies for CV System • There are two types of diagnostic studies: non-invasive and invasive. • Non-invasive studies include CXR (chest x-ray), CT (cardiac calcium scan),cardiac calcium scan, magnetic resonance imaging (MRI), electrocardiogram (ECG/EKG), holter monitor, exercise tolerance testing, tilt table test, cardiac stress test, peripheral vascular stress test, echocardiogram (echo), transesophageal echocardiogram (TEE), radioisotope imaging, thallium imaging, positron emission tomography (PET), doppler ultrasound, and blood work. • Invasive studies include angiography, cardiac catheterization, hemodynamic monitoring, and electrophysiologic study. Diagnostic Studies for CV System • CXR: no discomfort, can reveal enlarged heart, calcifications, and fluid around heart. Will confirm correct placement of pacemaker leads and other IV lines. Assess for possible pregnancy. No signed consent required. • Cardiac Calcium Scan: shows plaque or calcifications in the coronary arteries. Patient told to avoid caffeine and smoking 4 hours before test. May need written consent signed. • MRI: may or may not be used for cardiac diagnostic testing. Patients with pacemakers, metal implants, metal shavings, or shrapnel are not candidates for this test. May or may not have signed consent. • ECG/EKG: assesses the electrical activity of the heart from different views. Assesses for abnormalities such as MI, ischemia, electrolyte imbalances, etc. No consent form. May need to shave hair to place electrodes. Diagnostic Studies for CV System • Holter Monitor: may be used for 48 hours to capture any abnormalities. Teach to push event button and document what activity was during event. May or may not have consent form. • Tilt Table Test: helps with diagnosis of syncope (fainting spells) by assessing heart rate and BP during a change in position from lying down to standing up. May or may not have consent signed. • Exercise Tolerance/Stress Test: measures cardiac function or peripheral vascular disease during a defined exercise protocol (treadmill/bike). Patient teaching: no smoking, eating, or drinking 2-4 hours prior to test. Wear comfortable shoes, bra, clothing. Rest after test before eating. Avoid eating or drinking stimulants for a few hours after test. May or may not have signed consent. Diagnostic Studies for CV System • Cardiac Stress Test: simulates sympathetic nervous system (fight or flight) stimulation. Shows heart response to increased oxygen needs. Used to evaluate coronary artery disease, ischemic heart disease, cause of chest pain, and dysrhythmias. Baseline VS prior to test. Patient will use treadmill, bike, or stair climber. VS and ECG continue to be monitored after test until return to baseline. May or may not have consent signed. • Peripheral Vascular Stress Test: patient walks for 5 minutes at 1.5 miles per hour on treadmill. Pulse measurements are checked at certain intervals including baseline, during test, and after test. Test is stopped if claudication occurs. May or may not have signed consent. Diagnostic Studies for CV System • Echocardiogram (echo): ultrasound of heart which can detect abnormalities of septum, valves, and other structures of the heart. No prep required. No consent form to be signed. • Transesophageal Echocardiogram (TEE): able to visualize the heart with a clearer picture by placing transducer in the esophagus. The picture is clearer because the lungs and ribs are not obstructing the view as with echo. Patients are prepped as NPO for about 6 hours prior to test, will receive sedative, and have throat anesthetized. Suction continuously during procedure. Nurse should check for gag reflex return as routine post-op care. Consent form should be signed. Diagnostic Studies for CV System • Radioisotopes: shows cardiac contractility, injury, and perfusion. Patient should lie supine with arms over head for about 30 minutes to help medication circulate to heart. Radioactivity is small and gone within a few hours. May or may not have consent form signed. • Thallium Imaging: Thallium 201 given IV to evaluate cardiac blood flow and perfusion. With exercise, thallium given 1 minute before end of test to circulate thallium. Scan done within 10 minutes and repeated in 2 to 4 hours for comparison. Cold spots on initial images indicate ischemia. If cold spots are gone in later images, it indicates exercise-induced ischemia. If the cold spots are still present in later images, they show scarred areas. If unable to do exercise with test, then Persantine or adenosine (coronary vasodilators) can be given. May have consent form signed. Diagnostic Studies for CV System • Positron Emission Tomography (PET): Special medication is given IV and scans are performed to evaluate cardiac perfusion and cardiac metabolic function. Exercise may also be used. Patient’s blood sugar must be 60 to 140 for accuracy. Consent may be signed. • Doppler Ultrasound: evaluates PVD. Painless, takes about 20 minutes to complete. No consent form signed. Lab Work Common for CV • Cardiac Enzymes: when heart cells are damaged or die, they rupture and release enzymes into the bloodstream. Levels of these enzymes rise in the serum as a result. You will see orders from physicians that state: VP Cardiac Enzymes now and q8h x3. • Cardiac Enzymes lab work includes: creatine kinase (CK) which is also called creatine phosphokinase (CPK). Troponin I, CK-MB, and myoglobin. • Troponin I: are highly sensitive indicators of myocardial damage, which is helpful in diagnosing MI. Elevated levels within 4-6 hours of damage may be seen. These levels peak in 10-24 hours and remain elevated for up to 7 days after injury. Lab Work Common for CV • CK: is found in three types of tissue (brain, skeletal muscle, and heart muscle). CK-BB is brain; CK-MM is skeletal muscle; and CKMB is cardiac muscle. • CK-MB levels rise within 4-6 hours after cardiac cells are damaged, peak in 12-24 hours, and return to normal in 49-72 hours. These levels are drawn in serial intervals (q8h). It is important to avoid IV and IM injections before drawing the first CK to prevent elevation in the CK levels from cell trauma caused by the procedure. Afterwards, IV meds are preferred to IM medications to prevent contributing to this elevation. Lab Work Common for CV • Myoglobin: is a protein found in skeletal and cardiac muscles and is released into the bloodstream when cell damage occurs. It can only provide an estimate of damage and is used with other more specific tests such as Troponin to diagnosis MI. Levels elevate within 1 hour of an acute MI. Peak levels are reached 4-12 hours after an MI, and levels return to normal within 18 hours after the onset of chest pain, so it is a test that must be done early when MI is suspected. • Blood Lipids include triglycerides, cholesterol, and phospholipids. A lipid profile may be ordered which can screen for increased risk for coronary artery disease (CAD). Diagnostic Studies for CV System • Angiography: two types; arteriography and venography. Arteriography examines arteries. Venography studies veins. Dye is injected into the vascular system to visualize the vessels on radiographs. This test is used to assess blood clot formation, peripheral vascular disease (PVD), and to test vessels for potential grafting use. Assess for allergies, NPO for about 4 hours before test, teach that the dye produces a hot, burning feeling when injected. Consent should be signed. Post-op care includes VS, allergic reaction signs, hemorrhage at the injection site, and pulses are monitored. Diagnostic Studies for CV System • Cardiac Catheterization: assesses heart’s anatomy and physiology. Measures pressures in heart chambers, great blood vessels, and coronary arteries and provides information on cardiac output and oxygen saturation. Fluoroscopy is used, and dye can be injected once the catheter is in place to visualize the heart chambers and vessels. This is often done before cardiac surgery. Consent must be signed. Assess patient for allergies to iodine and procedure dyes. Patient is NPO after midnight prior to test. May be awake or slightly sedated during procedure. May feel a warm, flushing sensation when the dye is injected. Procedure may take 2-3 hours. May use right or left groin. Groin to be used is prepped prior with soap and water, shaved, and cleansed with special antimicrobial solution. During a catheterization, the physician may insert stents or perform angioplasty (ballooning to open vessels). Other tests may be done during this test. Diagnostic Studies for CV System • Cardiac Catheterization continued: complications can be allergic reaction, breaking of the catheter, hemorrhage, thrombus formation, emboli of air or blood, dysrhythmias, MI, CVA, and puncture of the heart chambers or lungs. Patient remains supine with affected leg straight for several hours after procedure. May have sandbag, pressure dressing, or seal dressing to groin site. May be done as outpatient. • Hemodynamic Monitoring: is bedside monitoring to monitor the pressures of the blood vessels or heart. A catheter is attached to a transducer and monitor, called an arterial line (A-line), which is in the radial or femoral artery to measure arterial BP. Cardiac pressures, cardiac output, central venous pressure, wedge pressure, etc. is used. May be through Swan-Ganz line. RN or MD will perform hemodynamic monitoring. Diagnostic Studies for CV System • Electrophysiologic Study: to study the heart’s electrical system. Catheter with electrodes are inserted via the femoral vein into the right side of heart. The heart’s electrical impulses are then recorded and pacing can also be done. Dysrhythmias can be triggered and ablation can be done. Patient is NPO 6-8 hours prior to test. Consent form must be signed. Therapeutic Interventions for CV System • Exercise may be ordered 2-3 times a week such as with cardiac rehab. • Smoking Cessation • Diet: low fat, low cholesterol, low sodium diet may be ordered. To reduce fat, red meats, fried foods, whole milk, and cheese should be limited or avoided. Cholesterol can be reduced by avoiding egg yolks, organ meats, animal fats, and shellfish. Five to six servings of fresh fruit and vegetables should be eaten daily. Increasing fish intake and eating poultry without skin are parts of healthy diet. • Oxygen may be used at home. Teach no open flames or smoking with oxygen use. If concentrator is used, backup tanks should be kept in home. • Medications may be prescribed. Therapeutic Interventions for CV System • Antiembolism devices such as elastic stockings (TED) and intermittent pneumatic compression devices (SCD) may be used even in the home to prevent blood clots and help with circulation. TED hose must be applied correctly to avoid tourniquet effect. May be removed for a short time daily to inspect skin or irritation. • Lifestyle changes may need to be changed such as stress reduction, meditation, and relaxation. Therapeutic Interventions for CV System • Cardiac Surgery may be needed for valve replacement and/or bypass of coronary vessels. • Patients should be taught to hold any blood thinners 5-7 days prior to surgery to prevent excessive bleeding. • Patients and family members should be taught prior to surgery what to expect prior to surgery, during surgery, and after surgery.