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Critical Care Nursing A Holistic Approach Part 5 Some revisions made by Cindy Fichera RN MSN Cardiovascular System Anatomy and Physiology of the Cardiovascular System Chapter 16 Review Blood Flow to and from the Heart Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. The Cardiac Cycle • A series of……………. – Electrical – Chemical – Mechanical Events- the heart beats • Contract-systole • Relax-diastole • Happens simultaneously Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Keep this in mind… • In addition to abnormalities in the Cardiac Cycle another issue that causes serious Cardiac Dysfunction/Abnormalities is a – CORNARY ARTERY OCCLUSION – CA Occlusion = Ischemia to the Heart •Meaning lack of Perfusion to the Cardiac Muscle this is a Myocardial Infarction! • Will put this all together as we progress.. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Electrical & Chemical Events • Polarized- Electrically neutral • Depolarization – (contract, systole) – NA in K out • Repolarization – (relax, diastole) • Exchange of electrolytes in and out of cell – NA & K pump – Calcium – Diagram in text 16-4, pp 196 – K in NA out – Figure in text 16-3, pp 195. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. One Normal Sinus Beat………….Electrical Event NORMAL ECG Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Cardiac Conduction=Electrical Event…. • Sinoatrial (SA) node • Atrioventricular (AV) node • Bundle of His Atrioventricular or the junction • Right and left bundle branches • Purkinje fibers • IMP: Know where conduction sites are for diagnostic purposes….. I.e. P wave abnormalities is an atrial arrthymia. QRS ventricular issue Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Your head, your heart & blood vessels……… • Autonomic Nervous System commands your heart to speed up, slow down and blood vessels constrict & dilate. • Parasympathetic stimulation, cholinergic=slows down – Acetylcholine released – Vagus nerve • *GI & GU opposite-increases tone, increases motility • Sympathetic, adrenergic stimulation =speeds up – Catecholamine=Epinephrine, powerful vasoconstrictor……….. • Receptor Sites – Alpha & Beta responses… – Diagram in text table 16-1 pp.200 Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Cardiac Output/Index • Cardiac output – CO = HR (beats/minute) X SV (liters/beat) – Normal adult: 4-8 liters/minute • Cardiac index – CI = CO(liter/minute)/Body surface area (m2) – Normal adult: 2.8-4.2 liter/minute/m2 – Normalizes liter flow to body size Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. ***Stroke Volume=The amount of blood leaving the left ventricle during systole/contraction • Preload – The amount of stretch placed on the cardiac muscle just prior to systole/contraction. Directly related to amount of fluid in RV. – Increasing volume to the heart increases preload. • Afterload – The force or pressure at which the blood is ejected from the ventricles – Equated with systemic vascular resistance (SVR) • Contractility – Contractile state of the heart= Inotropic Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Coronary Circulation.. Diagram 16-11,pp.202 • Right Coronary – PDA, posterior descending • RCA = Blood flow to RA, RV and inferior and posterior wall of heart….. • Left Coronary • Left main CA has 2 branches off it.. – L main, LCA – 1-LAD, Left Descending CA • Diagonal off LAD, (D1, D2) – 2-Circumflex Artery • Marginal branches off Circ. (M1, M2) – Left branches feed primarily the L heart and the anterior part of the heart. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Patient Assessment: Cardiovascular System Chapter 17 Cardiac Assessment….. Obtain Subjective & Objective Data • Subjective Data- What does the patient say????? – Cardiac Pain is unique. – Refer to box 17-1, pp. 207. • Give examples…………. • Identify PMH & Risk Factors Boxes 17-2 & 17-3 pp.209 &210 – Are factors modifiable? **Know modifiable/unmodifiable factors** – MI or CAD – PE – MVP or Rheumatic Fever = Possible Valve disease – DM – Family History Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Objective Data….. What do you see?? • 1-Inspection – General appearance – Skin- PWD – Peripheral Edema • 3-Percussion • 4-Auscultation – IV site – Good stethoscope – JVD= Right Arterial pressure – AP- regular/irregular • JVD should not exceed 3cm above angle of Louis – Chest =Trachea midline, Equal rise & fall of chest • 2-Palpation – Normal tones – S1/S2 – Extra tones – S3/S4 • All 4 together = Summation Gallop figure – Murmurs – Rubs – Pulses: Radial, pedal, post tib. 0-4 (2 is normal) Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. ***Important Cardiac Labs • Electrolytes – Potassium, sodium, magnesium, calcium etc • Enzymes – CK and CK-MB AKA CPK – CPK Isoenzymes= MB BB MM • Detectable 4-6 hr. after onset of MI. Peak 18-24 hr. • Returns to normal in 36-40 hours. – CPK-MB=How much of the CK consists of mycocardial bands. – * just know “detectable” times for enzymes… • Troponin=3 forms Trop. I, Trop.T and Trop C – Troponin I and T-Very Cardiac specific!! • It is a protein and very sensitive • Can be detectable in 3 hours after injury. Peaks 12-16 hr. • Stays elevated 5-10 days. – Some research says this is best indicator for an MI because of it specificity and sensitivity. (ie American College of Cardiology) • BNP=B type Natriuretic Peptide. A hormone that is released by ventricles in response to ventricular volume expansion/ventricular stretch caused by heart failure. – Diagnostic serum tool for CHF • Coagulation studies – PTT and PT/INR Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. More on Enzymes……………… • CPK: Is an enzyme released by skeletal & smooth in the presence of injury – MB: Myocardial Bands, in the heart. – BB: Brain Bands, in the brain. – MM: Muscle Markers, non-specific skeletal muscle throughout the body. – ** The CPK-MB and the “index”, is the ratio between CPK & MB, or how much of the CPK is related to cardiac and not to other isoenzyme areas.. – Ranges for MB: • MB may begin to increase in 3 hours for up to 12 hours. • Women: 40-150 U/L • Male: 60-400 U/L, • If Total CPK is elevated then you run the MB and the “index” – Index =% of MB in total CPK More than 5% is considered evidence of MI. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. More on Enzymes……………… Cont.. • Troponin: Troponin I and T. Troponin is a contractile protein attached to actin & myocin. In the presence of injury it is released into serum. – Troponin: > 1.5 = MI – Best indicator for an MI.. Why?? See slide 19 • Myoglobin: Not usually seen in diagnostics of MI. Is a protein found in striated/skeletal muscle. Good marker for Rhabdomyolysis. – Rhabdomyolysis is the breakdown of muscle fibers with leakage of potentially toxic cellular contents into the systemic circulation. • 3rd spacing, Hypovolemia, Hyperkalemia, Metabolic Acidosis, Acute Renal Failure. • Tons of fluids, correct lyte and acid/base imbalances. • CPK in thousands………. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Invasive Tests and Cardiac Diagnostics Studies • 12 Lead EKG • Always get a CXR on cardiac patients. • Electrophysiology studies: Used to identify conduction pathways of heart.. Stress tests, Echocardiography, Holter Monitor – Review on own……… • Coronary angiography AKA Cardiac Catheterization Will cover under Hemodynamic Monitoring Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Cardiac Catheterization • Added under “Hemodynamic Monitoring” later in lecture.. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Dysrhythmias & 12 Lead Electrocardiogram Steps to reading ECGs.. Overview…… • What is the rate? • Is the rhythm regular or irregular? • Do the P waves all look the same? Is there a P wave for every QRS and conversely a QRS for every P wave? • See next slide for 3 Step Process……….. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. 3 Step Interpretation………… • Rate-Look at complexes in a 6-second strip and count the complexes; that will give you a rough estimate of rate • Rhythm Reg or Irreg? Do R waves follow a consistent pattern? • Wave Form 2 things to identify – A-Do the P waves all look the same? Is there a P wave for every QRS and conversely a QRS for every P wave? – B- PR and QRS interval – 1) PR interval – 0.12 to 0.20 seconds= Atrial Depolarization (Time from onset of A. Depolar to V. depolar. • Beginning of P to beginning of Q – 2) QRS interval – less then 0.12=Ventricular Depolarization • Beginning Q to end of S • (see next slide for visual of PR and QRS interval, from pp. 244) Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Step 1 Different Ways to Calculate Rate………… • ***Look at complexes in a 6-second strip and count the complexes; that will give you a rough estimate of rate. Count the R wave in the QRS complex…. • Count the number of large boxes between two complexes and divide into 300 • Count the number of small boxes between two complexes and divide into 1500 • See next slide………………… Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Step 2 Rhythm • Irregular or Regular- Do your R waves march out evenly?? Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Normal Timing for Step 3- Wave Form. • PR interval – 0.12 to 0.20 seconds • QRS interval – less then 0.12 • (See next slides) Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Normal Timing for Step 3 Wave Form • Each small box .04 seconds • .20 seconds =5 small boxes.. Visualize PR and QRS interval. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Review of Normal Timing to get PR & QRS interval, Step 3………….. • 1 Normal Sinus • PR interval – 0.12 to 0.20 seconds= Beat………………… Atrial depolarization & repolarization • QRS interval – less then 0.12 seconds= Ventricular depolarization Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Outline of Rhythm's • Sinus Rhythms: – Normal Sinus – Sinus Tach & Sinus Brady • Junctional Rhythms • Ventricular Rhythms: Bottom part of heart. More lethal. QRS issues. Wide complex… – Sinus Arrest – Sinus Arrhythmia – 1st, 2nd, 3rd degree blocks • Atrial Rhythms: Top part of heart. Not as lethal. P wave issues. Narrow complex…. – PVC’s, unifocal & multifocal. More than 10 per minute usually treat and/or over 3 PVC’s in a row with a rapid rate…. – V-fib-defib!! – V-tach- pulse or no pulse? – Astyole- – A-fib – A-flutter – Supraventricluar Tach. – Next slides outline of treatment & visuals Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Sinus Rhythms………… disregard “D” Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Atrial Arrhythmias…………. A-Fib & AFlutter Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Ventricular Arrhythmias Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Ventricular Tachycardia, Ventricular Fibrillation & Torsades de pointes Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Good treatment tips for the future RN’s • Red flag vital signs: – HR under 60 or over 150. – Check patient first! – Weak radial pulse, systolic BP near 80. Get manual BP. – • Slow Down……. Always IV, O2 and monitor! • Speed up or slow down heart? How? – – For symptomatic tachycardias with a pulse – Again check complex.. – Narrow Complex=Top part – Drugs-Narrow Complex • Adenosine • CA Channel Blocker, Cardizem Electricity or drugs! • Speed up………. • Beta Blocker, Lopressor – Wide Complex=Bottom Part, more lethal – For symptomatic bradycardias and blocks. – Blocks on pp.255-256 • Amiodorone – Pacer (electricity) or Atropine. • Lidocaine • FYI- Too much potassium. You’ll see peaked or tented T waves on EKG – • Electricity-Synchronized Cardio version. Fast rates!!! NO PULSE…….. CPR & SHOCK (electricity) Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Cardiac Catheterization & Hemodynamic Monitoring • Diagnostically visualize RCA & LCA & LV – A specialized type of nursing. – Visualization of CA’s are done under fluoroscopy. – Lead worn. – Looking for valve disease, structural abnormalities and occlusions/lesions • Procedure – Access femoral or radial artery. Sheath inserted. – Guide Wire inserted into sheath, up the aorta and into the arch. – Judkins Catheter introduced over guide wire, wire pulled out. – DYE injected into CA = Visualization – ** Check creatinine Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Cardiac Catheterization. cont & Hemodynamic Pressures • The Left Heart Cath………… • Judkins Catheter & Pigtail Catheter – JL, Judkins L visualizes the LCA – JR, Judkins R visualizes the RCA – The Pigtail catheter used for obtaining LV-EDP pressure – Watch for what????? – Left heart Homodynamic Pressures (all pressure stuff)_ • Aortic Pressure AO • End-Diastolic Pressure EDP Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Cardiac Catheterization. cont & Hemodynamic Pressures….. • Right Heart Cath – Right Femoral Vein – R heart cath, AKA Swan Ganz cath., looking at volume issues. – Hence, overall is your CVP (Central Venous Pressure)!!!!! Can be a port in your CL. • Ie, Hypovolemia, – Pressures obtained with R Heart Cath., Swan.. • RA,RV, PA & PAWP • Relatively speaking are pressures lower on R that L? Why? Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Pressures up or down????? • Globally Speaking……….. • Conditions that decrease your hemo-dynamic pressures • Hypovolemia • Vasodilation • Conditions that increase your hemo-dynamic pressures • Fluid Overload • Right & Left Ventricular Failure • Pulmonary Hypertension • Stenosis of heart valves Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. • Great table for Quick Review Hemodynamic Pressures pp 278-table 17-17 • **Understand CVP:CVP measures right ventricular preload. Know causes for increased and decreased pressure. Pp. 278- Table 17-17 – Decreased CVP, directly R/T decreased circulating volume. No volume, No BP, – Range 2-8 mm Hg Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Patient Management: Cardiovascular System Chapter 18 Pharmacological Therapy • Fibrinolytics (has lytic activity) – Alteplase – tPA – Reteplase – RPA • Anticoagulants – Heparin – Lovenox – Angiomax (helps prevent further fibrin formation) • Platelet Inhibitors – Aspirin- Give to AMI patients. – Research indicates that ASA decreases the likelihood of an MI. – Plavix – Pradaxa Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Antidysrhythmics………. • Class I – Inhibits fast sodium channels, prolongs action potential – IA, IB, IC i.e. Lidocaine • Class II – Beta blockers. i.e. Lopressor/Metoprolol • Class III – Blocks potassium channels. i.e. Amiodarone, • Class IV – Calcium channel blockers Cardizem/Diltiazem & Verapamil – Lidocaine & Amiodarone for Ventricular Arrhythmias – Cardizem, Adenosine & Lopressor for Atrial Arrhythmias – Atropine-speed up heart. “unclassified” per book – Nice diagram 18-4 & 18-5, pp. 299 & 300 – *AHA 2011 Guideline change- Adenosine can now be used for VTach with a pulse. – *AHA 2011 Guideline change-Amiodarone can now be used for fast atrial arrhythmias Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Inotropes AKA Vasopressors • Drugs that are used to increase the force of myocardial contraction and improve cardiac output. • Vasopressors – Dopamine – Dobutamine – Epinephrine – Norepinephrine – *Neosynephrine Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Vasodilators • Drugs used to decrease preload, amount of fluid to heart and afterload-pressure. – Nitrates • Promote coronary artery perfusion • Can be given in many different ways • Ask about use of Viagra – Nipride/Nitroprusside Sodium Drip • Given in hypertensive crisis • Protect from light • Effects of drug are gone in a matter of minutes • Cyanide toxicity • Bring down pressure slow. Too fast may cause a CVA • What can a vasodilator/constrictor do to a BP??? – Copyright Nurses have parameters. Can titrate to effect……… © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. ACE Inhibitors • Action: Targets the KIDNEY. Antagonists to the renin angiotensin-aldosterone system • ACE inhibitors prevent: – Angiotensin I conversion to angiotensin II; produces potent vasoconstriction and stimulation of aldosterone • Remember angiotensin II vasoconstricts and produces aldosterone which increases NA hence holds on to H20. • No angiotensin II, no aldosterone, no vasoconstriction & no holding on to H20 • Name ends in “IL” Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. PCI (Percutaneous Coronary Intervention) • Pt having an ACUTE MI AKA STEMI, 1mmST elevation in 2 or more leads. • Visualize the CA as previously stated. • “Door to balloon time” • Pre-dilate balloon, this is the “angioplasty”. Inflation is documented in procedure • Stent inserted • Pictures pp 307 • Complications– CA Spasm, Dissection of CA, Re-stenosis of CA Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. CABG vs PCI • Is Dependant on the location of the lesion and the numbers of lesions.. • Lesions in L main CA get shipped for bypass. • 3 or more lesions candidate for bypass. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. IABP Intra-Aortic Balloon Pump • Know indications for IABP, pp.329 – See box 18-15! • Pt. very very sick. • 3 Main indications: – 1-Cardiogenic Shock – 2- LV Failure with Post-Op Cardiac Surgery=Low Cardiac Output – 3-Unstable Angina Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Management of Dysrhythmias.. Know.. • Electrical Cardioversion – slow down the fast heart – Low amount of electricity on the up swing of the R wave. – Sync Markers – Used for fast rhythms with pulses. IE A-Fib, A-flutter, V-tach, with a pulse and PSVT • Cardiac pacemakers – speed up a slow heart • Usually in 2nd degree type 2 heart block and in 3rd degree full heart blocks – Trancutaneous • Pads placed on the skin connected to a defibrillator – External • Pacing wire placed • Generator is external – Internal • Generator placed in a “pocket” in the patient’s chest Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. ICD’s……………. Implantable cardioverter defibrillators VS. Intra aortic balloon pump… • ICD – Metal piece in chest that picks up on sudden cardiac arrest. – Heart stops, “automatic” shock fired!!!! – Best prophylactic intervention…. • Intra aortic balloon pump – A mechanical device in the heart for patients with no LV function. Pt refractory to pharmacologic interventions. – Inserted through the femoral artery. Risk for bleeding. – Seen in specialized units. Pt very very sick. – Usually has unstable angina – Pt has no BP & in shock Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. ABC’s….. Review & scenario • Red flag vital signs: • Slow Down……. – For symptomatic tachycardias with a pulse Check patient first! – Again check complex.. – Weak radial pulse, systolic BP near 80. Get manual BP. – Narrow Complex=Top part – Always IV, O2 and monitor! – Drugs-Narrow Complex – HR under 60 or over 150. – • Adenosine • Speed up or slow down heart? How? – • CA Channel Blocker, Cardizem Electricity or drugs! • Beta Blocker, Lopressor • Speed up………. – – – For symptomatic bradycardias and blocks. • Amiodorone Pacer (electricity) or Atropine. • Lidocaine – • FYI- Too much potassium. You’ll see peaked or tented T waves on EKG Wide Complex=Bottom Part, more lethal • Electricity-Synchronized Cardio version NO PULSE…….. CPR & SHOCK (electricity) Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Beta Blocker Tip • Block Beta 1 & 2 receptor sites = Beta 1 in heart. Beta 2 in lungs. Physiologically decrease BP, heart rate, vasodilate and bronchoconstrict. Nice chart, pp.302, Table 18-6 • Think of what happens when you block them as in giving a beta blocker?????? • Beta Blockers come as “Cardioselective”, which blocks beta 1 only. (Decreases HR. No pulmonary effects) Safe for everyone • IE Atenolol/Tenomin & Lopressor/Metoprolol – “Nonselective” blocks beta 1 and 2. Hence causing decreased HR and Bronchospasm…. • IE Inderal/Propanolol Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Common Cardiovascular Disorders • Chapter 19 common disorders • Review on own short chapter Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Heart Failure Chapter 20 Heart Failure • Acute versus chronic – Acute: sudden onset of symptoms over hours or days – Chronic: limitations on a daily basis • Left- versus right-sided heart failure – Again goes back to blood flow of heart!!! – Left-sided: failure of the left ventricle to empty • Back up to lungs, pulmonary edema – Right-sided failure: Failure of right ventricle being able to pump also due to pulmonary disease or pulmonary hypertension • Back to body, peripheral edema – Know S & S of heart failure – Severe heart failure patients at risk for cardiac arrest. Best prophylactic intervention is an implanted defibrillator. • Pg. 404-405 ABC’s first! See slide 61 Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Pharmacologic Management in Heart Failure • Review of anti-hypertensives, also used in chronic heart failure. – ACE inhibitors: Usually end in “il”. Stops renin (a powerful vasoconstrictor from the kidney) from forming & enabling aldostrone(holds NA, retains fluid) from being secreted. Hence, vasodilates the kidney. – Diuretics: Stimulate kidneys to excrete fluids to diuresis. i.e. lasix/furosemide. • Given initially in stable CHF patients – Beta Blockers: Blocks beta receptor sites. – Nitrates: Relax smooth muscle. Ie Nitro – Digoxin: Cardiac glycoside – Potassium Sparing Diuretics: Spironolactone – Calcium Channel Blockers: Reduce spasm – Diagram 20-4, 408-409, Need a vasopressor as well? Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Management in Acute Heart failure • Airway & Breathing…… ?? Needs intubation • Diurese the patient.. – Goal- 1 liter of urine within 2 hours. Pp. 405 • Circulation – Increase contractility. Administer inotropes. – Vasodilate to reduce Preload, the amount of fluid going back to heart. • Patient Education.. Limit salt intake.. Why???? Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Acute Myocardial Infarction Chapter 21 Statistics • A coronary event happens every 26 sec in the USA • The death rate for coronary heart disease – African American men – 262/100,000 – White men – 228.4/100,000 – African American women – 176.7/100,000 – White women – 137.4/100,000 Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Risk Factors- Atherosclerosis • Uncontrollable • Modifiable – Age – Cigarette smoking – Heredity – High cholesterol – Race – Hypertension – Gender – Physical inactivity – Obesity – Diabetes mellitus – Stress • Again know……. – ETOH Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Acute Coronary Syndrome (ACS) • Refers to “symptoms” of an MI. Can be angina CP or can be an MI… • 2 Categories – Unstable Angina- Not a patients typical CP. CP at rest.. No ST changes. No initial bump in enzymes (aka biomarkers) – AMI • STEMI-ST elevation MI • NON STEMI- No ST changes. Pt can rule in via enzymes. Initial bump in enzymes. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Angina Pectoris • Cardiac pain unique!! Again refer to Refer to box 17-1, pp. 207 or diagram 21-2 pp 421 (same diagram) • Stable – chronic stable angina, classic angina – Paroxysmal, occurs with physical exertion – Relieved by rest or nitroglycerin • Unstable – preinfarction angina or crescendo angina – More prolonged and severe – Need to be treated immediately • Variant – Prinzmetal’s angina, vasospastic angina – Result of coronary artery spasm – Occurs at rest Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Zones of Injury.. Evolving ST segment changes in the EKG pp. 428-430 • Goal-Restore oxygen. As heart muscle is ischemic changes “evolve” on the EKG. Irreversible damage can set in 20-40 minutes…. Changes on EKG evolve as follows…… • Ischemia: Myocardial ischemia indicated by inverted T waves. Is reversible. • Injury- Close to myocardial infarction indicated by elevated or depressed ST segments. Mostly seen elevated ST segments. Almost reversible. • Necrosis- A portion of myocardial tissue dead. Not reversible. Indicated by pathological Q waves on EKG. – Q waves indicate the infarction was “transmural”. Meaning it effected all layers of the heart. AKA Qwave MI. – “Non Q wave MI” means it didn’t effect all layers. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Inversion of the T wave Depression of ST segment Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Treatment of Angina pp.421-423 • You are the nurse and your patient is complaining of CP what do you do????? – Your Assessment AKA Physical Exam • Initial Interventions • Lab Tests?? • CXR – Management • Nitro and Morphine • Beta Blockers • Calcium Channel Blockers • ASA and anticoagulants • ??? IABP or PTCA (percutaneous transluminal coronary angioplasty) Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Location of Myocardial Infarction .. The big picture………. • Anterior Wall MI look at leads V1, V2, V3 and V4. LAD affected. Look for Left sided symptoms. • Lateral Wall MI look at leads V4, V5 and V6. Still L sided symptoms. Mainly Circ. affected. • Inferior Wall MI look at leads II, III and avf. RCA effected. Look for R sided symptoms. • Right Ventricular Wall MI obtain V4R or R sided EKG to see R ventricular involvement and inferior leads. – text pp. 433 figure 21-13. AMI/Lateral wall Note leads V2, V3 and V4 (anterior) and V5 & V6 (lateral). – Text pp. 433 figure 21-14. IMI note II, III and AVF . – RV infarction. Note II III and AVF in R sided EKG= IMI and RV infarction Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Cardiac Rehabilitation…………. • A Candidate of an MI, is a candidate for cardiac rehab!!!!!!!!!!!! • Exercise, education and counseling….. • Include family………. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Cardiac Surgery Chapter 22 CABG Coronary Artery Bypass Graft Surgery • Vessels Used – Saphenous vein – Internal mammary artery (LIMA or RIMA) Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Valvular Disease • L sided Valves……….. • Stenosis – Mitral stenosis • Rheumatic heart disease – Aortic stenosis • Rheumatic fever, calcification with age • Insufficiency – Mitral insufficiency • Rheumatic heart disease, age, LV dilation – Aortic insufficiency • Rheumatic disease, aneurysm of ascending aorta Treatment may consist of reconstruction of valve or replacement of valve…….. Treatment Eventually Valvular reconstruction or Replacement Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Cardiac Surgery………..Important… • Preoperatively: Consider all physical and psychological aspects!! – Full H & P, base line labs including coag studies, CXR, EKG maybe ABG’s for chronic COPD. – Patient education/teaching: relieve anxiety, include family and patient. Refer to text pp 451 and box 22-2 (not table 22-2). • Intraoperatively: Chest opened & ribs spread. Pt on bypass machine. Hemodynamic monitoring important. • Postoperatively: Immediate care involves cardiac monitoring, re-warming the patient, maintaining/stabilizing respiratory and hemodynamic functions, monitor for Dysrhythmias, Volume resuscitation, maintain adequate UO, control BP etc.. See box 22-3, pp 453 – Control Pain, why?? Sympathetic nervous response. – Neuro status.. Change in MS due to sedatives or did pt shoot a clot?? – Monitor bleeding… see next slide Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Controlling bleeding……… Very Important. • Coagulation studies: – PTT & APTT monitors bleeding times for patients on Heparin • Antidote=Protamine Sulfate – PT and INR monitors bleeding times for patients on Coumadin. • Antidote=Vitamin K • IV infusions for blood loss: Different types of infusions work on different parts of clotting cascade (13 clotting factors) to promote coagulation/clotting/platelet formation…….. – FFP- Fresh frozen plasma – Cryoprecipitate- Factors I & VIII – DDAVP AKA desmopressin acetate-Factor VIII • Intravascular Hypovolemia can be secondary to blood loss. What hemodynamic measurement will be decreased and why??? Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Carotid Endarterectomy • Atherosclerotic changes in the carotid arteries • 70% to 90% stenosis • Clamping of the carotid arteries • Heparinization to prevent clot formation • Review on your own………………. Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition. Postoperative Care of an Endarterectomy • Control of blood pressure • Assessment of cranial nerves – VII, X, XI, XII • Bleeding – Note neck size – Check for swelling – possible hematoma formation – Difficulty in swallowing or breathing Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.