Download Cardiac Lecture

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………..
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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”
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Atrial Arrhythmias…………. A-Fib & AFlutter
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Ventricular Arrhythmias
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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
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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
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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
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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.
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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
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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
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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.