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Chapter 35 Cardiac Disorders Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 1 Pathway of Blood Electrical Conduction?? Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 2 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 3 INITIATION OF IMPULSE RATE Sinoatrial (SA) node-60-100 beats per minute (bpm) Atrioventricular (AV) node-40-60 bpm Ventricle -15-40 bpm Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 4 Preload is the amount of blood remaining in a ventricle at the end of diastole or the pressure generated at the end of diastole. Increased preload results in increased stroke volume and thus increased cardiac output. Factors that increase preload include increased venous return to the heart and overhydration. Factors that decrease preload include dehydration, hemorrhage, and venous vasodilation. Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 5 Afterload is the amount of pressure the ventricles must overcome to eject the blood volume. It is determined primarily by the pressure in the arterial system. Afterload is decreased by vasodilation and increased by vasoconstriction. Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 6 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 7 Nursing Assessment of Cardiac Function Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 8 Chief Complaint and History of Present Illness Symptoms related to cardiac disorders include fatigue, edema, palpitations, dyspnea, and pain Note when symptoms occur, what aggravates them, and what relieves them Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 9 Medical History Hypertension, kidney disease, pulmonary disease, stroke, rheumatic fever, streptococcal sore throat, and scarlet fever Document previous cardiac disorders and hospitalizations. List recent and current medications and note allergies in appropriate records Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 10 Family History Assess whether immediate relatives have had hypertension, coronary artery disease (CAD), other cardiac disorders, or diabetes mellitus Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 11 Review of Systems Systematically assess whether the patient has experienced the following: weight gain, fatigue, dyspnea (shortness of breath), cough, orthopnea (difficulty breathing in a supine position), paroxysmal nocturnal dyspnea (sudden dyspnea during sleep), palpitations, chest pain, syncope (fainting), concentrated urine, or leg edema Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 12 Functional Assessment Determine how this illness has affected the patient’s ability to carry out usual activities Activity and rest patterns and usual diet Ask about sources of stress and coping strategies Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 13 Physical Examination Vital signs Blood pressure, pulses, and respirations Skin Heart sounds Heart murmurs Extremities Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 14 A, Aortic valve at the second intercostal space to the right of the sternum. B, Pulmonic valve at the second intercostal space to the left of the sternum. C, Tricuspid valve at the fifth intercostal space to the left of the sternum. D, Mitral valve at the fifth intercostal space in the midclavicular line. Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 15 Diagnostic Tests and Procedures Electrocardiogram (ECG) Ambulatory ECG (Holter monitor) Implantable loop monitor/recorder (ILR) Echocardiogram (heart sonogram) Transesophageal echocardiogram (TEE) Magnetic resonance imaging (MRI) Multiple-gated acquisition scan Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 16 Diagnostic Tests and Procedures cont’d Stress test (exercise tolerance test) Perfusion imaging Thallium imaging Ultrafast computed tomography Cardiac catheterization Electrophysiology study (EPS) Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 17 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 18 Laboratory Tests Arterial blood gases Pulse oximetry Cardiac enzymes Creatine phosphokinase Cardiac protein markers Complete blood count Lipid profile B-type natriuretic peptide (BNP) C-reactive protein (CRP) Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 19 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 20 Drug Therapy Cardiac glycosides-Digoxin Antianginals- Nitroglycerin--verapamil Antidysrhythmics-Cordarone--propranolol Angiotensin-converting enzyme (ACE) inhibitors (ACEIs)--captopril -- enalapril Diuretics—hydrochlorothiazide—spironolactone(K+ sparing) –lasix (K+ wasting) Anticoagulants—Heparin--enoxaparin --warfarin Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 21 Drug Therapy cont’d Antiplatelet agents—Plavix—ASA 81 mg Fibrinolytic agents (also called thrombolytics) Streptokinase Lipid-lowering agents-statins Analgesics—demerol, morphine Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 22 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 23 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 24 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 25 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 26 Diet Therapy Low-fat, high-fiber diet Well-balanced diet Emphasis on fruits, vegetables, grains, and proteins low in fat (fish, legumes, poultry, lean meats) Cholesterol intake should be limited to 200 mg/day; foods with trans fatty acids, limited to 8 Exercise program may help achieve optimal weight Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 27 Diet Therapy cont’d Sodium A diet containing sodium 2 g/day most often prescribed Potassium Patients taking potassium-wasting diuretics need adequate potassium in the diet Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 28 Other Therapeutic Measures Oxygen therapy Pacemakers Temporary Permanent Cardioversion Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 29 Cardiac Surgery Common surgical procedures Pacemaker insertion Repair or replace valves or septa or remove tumors Coronary artery bypass surgery Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 30 Cardiac Surgery Preoperative nursing care Interventions Fear and Anxiety Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 31 Cardiac Surgery cont’d Postoperative nursing care Interventions Ineffective Breathing Pattern Pain Ineffective Thermoregulation Decreased Cardiac Output Risk for Infection Anxiety Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 32 Cardiac Disorders Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 33 Coronary Artery Disease (CAD) Arteriosclerosis Abnormal thickening, hardening, loss of elasticity of arterial walls Atherosclerosis Form of arteriosclerosis; inflammatory disease that begins with endothelial injury and progresses to the complicated lesion seen in advanced stages of the disease process Progression of lesions Fatty streak Fibrous plaque Complicated lesions Collateral circulation Branches grow from existing arteries; provide increased blood flow Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 34 Coronary Artery Disease (CAD) cont’d Risk factors Nonmodifiable Age, gender, heredity, and race Modifiable Increased serum lipids, high blood pressure, cigarette smoking (nicotine), diabetes mellitus with elevated blood glucose, obesity, sedentary lifestyle Other factors Stress, sex hormones, birth control pills, excessive alcohol intake, high homocysteine levels Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 35 Angina Pectoris The most common symptom of CAD Demand for oxygen by myocardial cells exceeds supply Stable angina Occurs with exercise or activity and usually subsides with rest Unstable angina Pain more severe, occurs at rest or with minimal exertion, is often not relieved by nitroglycerin (NTG) or requires more frequent NTG administration, and is not predictable Variant angina Caused by coronary artery spasm; may not be associated with CAD Unpredictable and often occurs at rest Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 36 Angina Pectoris cont’d Medical treatment Initial therapy for patients with angina A B C D E Aspirin and antianginal therapy Beta-blocker and blood pressure Cigarette smoking and cholesterol Diet and diabetes Education and exercise Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 37 Acute Myocardial Infarction (AMI) Risk factors for AMI Obesity, smoking, a high-fat diet, hypertension, family history, male gender, diabetes mellitus, sedentary lifestyle, and excessive stress Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 38 Acute Myocardial Infarction cont’d Pathophysiology Begins with occlusion of a coronary artery Over 4 to 6 hours, ischemia, injury, infarction develop Ischemia results from a lack of blood and oxygen to a portion of the heart muscle If ischemia is not reversed, injury occurs Deprived of blood and oxygen, the affected tissue becomes soft and loses its normal color Continued ischemia: infarction of myocardial tissue Ischemia lasting 20 minutes or more is sufficient to produce irreversible tissue damage Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 39 Acute Myocardial Infarction cont’d Complications Heart failure, cardiogenic shock, thromboembolism, and ventricular aneurysm/rupture Signs and symptoms Pain Heavy or constrictive pain located below or behind sternum May radiate to the arms, back, neck, or jaw Patient becomes diaphoretic and lightheaded and may experience nausea, vomiting, and dyspnea The skin is frequently cold and clammy Patient experiences great anxiety; feeling of impending doom Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 40 Acute Myocardial Infarction cont’d Medical diagnosis History and the physical signs and symptoms Laboratory evidence and ECG changes Cardiac markers Troponin, myoglobin, and cardiac enzymes Electrocardiogram Ischemia: ST segment depressed; T wave is inverted If there has been total occlusion of a coronary artery, the ECG will show ST elevation (STEMI) Following infarction, another change often seen on the ECG waveforms is a significant Q wave Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 41 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 42 Acute Myocardial Infarction cont’d Medical treatment Drug therapy Sublingual or intravenous nitroglycerin Morphine or Demerol Oxygen Fibrinolytic therapy Aspirin and beta-adrenergic blockers Percutaneous coronary intervention (PCI) Intracoronary stents Coronary atherectomy Laser angioplasty Radiation therapy Coronary artery bypass graft surgery Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 43 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 44 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 45 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 46 Acute Myocardial Infarction cont’d Assessment Ask patient to describe the pain, including type, location, duration, and severity Interventions Pain Decreased cardiac output Anxiety Cardiac rehabilitation Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 47 Heart Failure (HF) Cause and risk factors Two types Disorders that increase the workload of the heart Disorders that interfere with heart’s pumping ability Patients at risk for HF: those with CAD, AMI, cardiomyopathy, hypertension, chronic obstructive pulmonary disease (COPD), pulmonary hypertension, anemia, disease of the heart valves, and fluid volume overload Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 48 Heart Failure cont’d Pathophysiology The LV, RV, or both fail as pumps Usually left side of heart fails first; right side fails as a result of the left-sided failure Compensation Sympathetic compensation Renal compensation Natriuretic peptides Ventricular hypertrophy Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 49 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 50 Heart Failure: Signs and Symptoms Left-sided heart failure Anxious, pale, and tachycardic Consecutive blood pressure readings may show a downward trend Auscultation of the lung fields reveals crackles, wheezes, dyspnea, and cough S3 and S4 heart sounds heard Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 51 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 52 Heart Failure: Signs and Symptoms cont’d Right-sided heart failure Increased central venous pressure, jugular venous distention, abdominal engorgement, and dependent edema Anorexia, nausea, and vomiting from the abdominal engorgement Fatigue, weight gain, decreased urinary output Anasarca Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 53 Heart Failure Medical diagnosis History, physical examination, radiographs, and laboratory test results Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 54 Heart Failure cont’d Medical treatment Drug therapy ACE inhibitors, diuretics, beta-adrenergic blockers, inotropic agents, cardiac glycosides, and nitrates. In addition, certain patients will benefit from B-type natriuretic peptide Intraaortic balloon pump (IABP) Ventricular assist devices (VADs) Biventricular pacing Surgery Coronary artery bypass grafting, valve repair or replacement, partial left ventriculectomy, and cardiac transplantation Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 55 Heart Failure cont’d Assessment Heart sounds, rate, and rhythm Jugular vein distention Baseline respiratory assessment of rate, rhythm, and breath sounds is vital Measure weight and blood pressure accurately Inspect skin and palpate for turgor and edema Intake and output records and daily weights Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 56 Heart Failure cont’d Interventions Decreased Cardiac Output Impaired Gas Exchange Fluid Volume Excess Activity Intolerance Anxiety Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 57 Infective Endocarditis (IE) Cause and risk factors Primarily affect the valves Incidence has decreased with the use of antibiotics, but there has been a resurgence of the problem in intravenous drug abusers Patients with valvular disease also at risk Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 58 Infective Endocarditis cont’d Pathophysiology Pathogens, usually bacteria, enter the bloodstream by any of the previously mentioned means The pathogen accumulates on the heart valves and/or the endocardium and forms vegetations Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 59 Infective Endocarditis cont’d Complications Heart failure and embolization Signs and symptoms Fever, chills, malaise, fatigue, and weight loss Chest or abdominal pain; may indicate embolization Petechiae inside the mouth and on the ankles, feet, and antecubital areas Osler nodes on the patient’s fingertips or toes Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 60 Infective Endocarditis cont’d Medical diagnosis History, physical examination, results of lab studies Echocardiography Serial blood cultures; elevated WBC Medical treatment Antimicrobials, rest, limitation of activities Prophylactic anticoagulants Surgery to replace an infected prosthetic valve Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 61 Infective Endocarditis cont’d Assessment Review patient’s history for risk factors, recent invasive procedures, pathologic cardiac conditions, and onset of symptoms Assess for temperature elevation, heart murmur, evidence of HF (cough, peripheral edema), and embolization Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 62 Infective Endocarditis cont’d Interventions Administer prescribed antibiotics Assess cardiac output and monitor for complications Teach patient about the medications prescribed and any restrictions imposed Encourage adequate rest Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 63 Pericarditis Cause and risk factors Inflammation of the pericardium May be primary disease or associated with another inflammatory process The disease may be acute or chronic Acute pericarditis caused by viruses, bacteria, fungi, chemotherapy, or AMI (Dressler syndrome) Chronic pericarditis caused by tuberculosis, radiation, or metastases Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 64 Pericarditis cont’d Pathophysiology In acute pericarditis, inflammatory process increases amount of pericardial fluid and inflammation of the pericardial membranes In chronic pericarditis, scarring of the pericardium fuses the visceral and parietal pericardia together Loss of elasticity results from the scarring Constrictive process prevents adequate ventricular filling Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 65 Pericarditis cont’d Complications Pericardial effusion or accumulation of fluid in the pericardial space May lead to cardiac tamponade Signs and symptoms Chest pain Most severe on inspiration Sharp and stabbing but may be described as dull or burning Relieved by sitting up and leaning forward Dyspnea, chills, and fever Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 66 Pericarditis cont’d Medical diagnosis Serial ECGs Echocardiogram Creatine kinase-MB fraction (CK-MB) Blood cultures Medical treatment Analgesics, antipyretics, antiinflammatory agents, and antibiotics Surgical creation of a pericardial window for chronic pericarditis with effusion Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 67 Pericarditis cont’d Assessment Assessment of heart sounds especially important Interventions Rest and reduction of activity Administer and teach patient about medications Emotional support Vital signs; auscultate for pericardial friction rub Note pain characteristics and response to analgesics and antiinflammatory agents Monitor the ECG for dysrhythmias Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 68 Cardiomyopathy (CMP) Disease of the heart muscle Cause often unknown; may be secondary to another disease process Usually leads to heart failure Three types: dilated, hypertrophic, and restrictive Risk factors with dilated cardiomyopathy (CMP) are excessive use of alcohol, pregnancy, and infections Hypertrophic CMP: common in younger individuals Amyloidosis, sarcoidosis, and other immunosuppressive disorders may predispose individuals to restrictive CMP Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 69 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 70 Cardiomyopathy cont’d Pathophysiology Dilated cardiomyopathy: dilation of the ventricle and severely impaired systolic function Hypertrophic cardiomyopathy: LV hypertrophies and there is thickening of the ventricular septum Restrictive cardiomyopathy: the myocardium becomes rigid and noncompliant Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 71 Cardiomyopathy cont’d Signs and symptoms Dilated cardiomyopathy: dyspnea, fatigue, leftsided heart failure, and moderate to severe cardiomegaly Hypertrophic cardiomyopathy: dyspnea, orthopnea, angina, fatigue, syncope, palpitations, ankle edema, and S4 sounds Restrictive cardiomyopathy: dyspnea, fatigue, right-sided HF, S3 and S4 sounds, and mitral valve regurgitation Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 72 Cardiomyopathy cont’d Medical diagnosis Echocardiography Chest radiography Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 73 Cardiomyopathy cont’d Medical treatment Dilated cardiomyopathy: positive inotropic drugs, diuretics, ACE inhibitors and vasodilators; heart transplant Hypertrophic cardiomyopathy: antidysrhythmics, antibiotics, anticoagulants, calcium channel blockers, beta-blockers; surgical interventions; implantable cardioverter-defibrillator Restrictive cardiomyopathy: similar to that of HF therapy. Heart transplantation may be considered Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 74 Cardiomyopathy cont’d Assessment Primarily for heart failure Be alert for dyspnea, cough, edema, dysrhythmias, and decreased cardiac output Interventions Similar to that of patients with HF A hopeful atmosphere and careful explanation of care requirements Encourage the family to support the patient Guide the patient to make lifestyle changes Encourage patient to make decisions and choices Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 75 Sudden Cardiac Death When heart activity and respirations cease abruptly Most common reason is coronary heart disease Often preceded by ventricular tachycardia or ventricular fibrillation and occasionally by severe bradydysrhythmias Sudden cardiac death may be the first indication of CAD Other causes: left ventricular dysfunction, cardiomyopathy, hypokalemia, antidysrhythmics, liquid protein diets, and high alcohol consumption Those who survive sudden cardiac death need extensive testing to determine its nature and cause Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 76 Sudden Cardiac Death cont’d Implantable cardioverter/defibrillator (ICD) For patients with life-threatening recurrent ventricular fibrillation who are unresponsive to medications or pacemakers The device senses heart rate, diagnoses rhythm changes, and treats ventricular dysrhythmias Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 77 Nursing Care Promote psychosocial adaptation Body image change and a fear of shocks Patients and families need teaching and support Family instructed in CPR ID bracelet and a card with instructions about the ICD setting carried at all times Advise to avoid strong magnetic fields Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 78 Valvular Disease Mitral stenosis: narrowing of the opening in the mitral valve that impedes blood flow from the LA into the LV Mitral regurgitation: allows blood to flow back into the LA during diastole Mitral valve prolapse: one or both leaflets enlarges and protrudes into the LA during systole Aortic stenosis: valve cusps become fibrotic and calcify Aortic regurgitation: fibrosis and thickening of the aortic cusps progress until the valve no longer maintains unidirectional blood flow Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 79 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 80 Cardiac Transplantation The first heart transplantation was performed in 1967 in South Africa by Dr. Christiaan Barnard Today in the United States, approximately 2500 are done annually for end-stage heart disease Donor must meet the criteria for brain death, have no malignancies outside the central nervous system, be free of infection, and not have experienced severe chest trauma Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 81 Cardiac Transplantation cont’d Donor and recipient organs carefully matched Recipient must be free of infection at the time of transplantation Patient prepped as any open-heart procedure Cardiopulmonary bypass initiated; recipient’s heart is removed except for the posterior portions of the atria Donor heart trimmed and anastomosed to the remaining native heart Patient removed from bypass, heart restarted, and chest is closed Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 82 Cardiac Transplantation cont’d Aftercare similar to that of coronary artery bypass surgery Hemodynamic monitoring, ventilation, cardiac assessment, care of chest tubes, and accurate intake and output measurements are vital Modified protective isolation used Patients and families taught sign/symptoms of infection, to avoid crowds and others with infections Lifelong immunosuppression Rejection monitored by endomyocardial biopsies Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 83 Electrocardiogram Monitoring 12-lead electrocardiogram Looks at heart from 12 directions or perspectives Permits more precise evaluation of the heart’s electrical activity Continuous ECG monitoring Most units that perform continuous monitoring use the five-lead system with four limb electrodes and a chest electrode Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 84 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 85 Electrocardiogram Monitoring Interpretation of electrocardiograms Heart’s electrical activity represented by deflections, positive and negative, from the baseline P wave, QRS complex, and T wave Criteria for interpreting electrocardiograms Rate calculation Rhythm P waves PR interval QRS complex T waves QT interval Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 86 Electrocardiogram Monitoring cont’d Interpretation of electrocardiograms Normal sinus rhythm The most common cardiac rhythm is sinus in origin because the impulse originates in the SA node; is conducted normally Common dysrhythmias (rhythm disturbance from problem in the conduction system) Atrial dysrhythmias Junctional or escape rhythms Ventricular dysrhythmias Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 87 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 88 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 89 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 90 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 91 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 92 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 93 Elsevier items and derived items © 2012 by 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catheter Swan-Ganz catheter Longer than the central venous catheter Inserted like the central venous catheter and is threaded through the RA, tricuspid valve, RV, pulmonic valve, and into pulmonary artery Cardiac output Measured continuously or by thermodilution Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 103 Hemodynamic Monitoring cont’d Arterial line Provides a direct measurement of systolic and diastolic blood pressures Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 104 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 105 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 106 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 107 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 108 Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 109 Elsevier items and derived 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