Weber Ch 20 Cardiac

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cswett
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Weber Ch 20 Cardiac
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2011-10-03 11:03:53
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Weber Ch 20 Cardiac
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  1. CV Anatomy & Physiology
    • •CV system: transports O2 & nutrients to tissues; carries waste to kidneys & lungs
    • •Heart: size of fist, 60 to 100 beats/min (adult)
    • –Responds to internal and external stimuli: exercise, temp changes, stress
    • –Endocrine and nervous systems communicate stimuli
    • –CV system adjusts: alters diameter of vessels, cardiac output, blood distribution
  2. Anatomy and Physiology: Heart and Great Vessels
    • •Heart: right or left side (two chambers each): atrium, ventricle
    • Right side: blood from venae cavae, through pulmonary arteries into lungs
    • •Left side: blood from pulmonary veins, through aorta
    • into systemic circulation
    • •Upper part, base (2nd ICS)InterCostal Space
    • •Lower part, apex (5th ICS)
    • Test: what are you hearing here (by location)?

    • Location: Behind sternum, above diaphragm, in
    • mediastinum
    • –Lies at angle: R ventricle (anterior surface),
    • –L ventricle (posterior surface)
    • –R atrium: R border of heart, L atrium posterior

    • Aorta: curves upward out of L ventricle, bends posterior/down above sternal angle
    • Pulmonary arteries: out of superior aspect R
    • ventricle near third ICS
  3. Layers of Heart & Pericardial Space
    • •3 Layers of Heart –
    • –Epicardium = outside
    • –Myocardium = middle, muscular - most heart attacks occur here (MI)
    • –Endocardium = inner & valves
    • •Pericardial sac/space –
    • –Visceral layer next to epicardium
    • –Parietal layer next to chest wall (fibrous)
    • –Pericardial space between - shouldn't have too much fluid in it
  4. Anatomy and Physiology: Blood Flow Through Heart
    • Blood flow through chambers controlled by four valves
    • –AV valves: tricuspid(right), mitral (left); separate atria from ventricles
    • Semilunar valves: pulmonic (right ventricle from pulmonary artery), aortic (left ventricle from aorta)
    • half moon - three leaflets
    • dont always close completely - due to vegitation (relaspe or regurgitation)
    • Cordae Tendinae - attach valves
  5. Anatomy and Physiology: Cardiac Cycle
    • •(ventricles relaxed; fill with blood)
    • –80% flow into relaxed ventricle
    • –20%: atrial contraction (kick)
    • •(ventricles contracting)
    • –AV valve closure (prevent backflow of blood)
    • –Semilunar valves open, allowing blood to flow into great vessels
  6. Blood flow through the heart (image)
  7. Cardiac Cycle
    • •Systole (ventricles contract): tricuspid/mitral valves close
    • –First heart sound: S1 (lubb)

    • •Diastole (ventricles almost empty): pulmonic/aortic
    • valves close
    • –Second heart sound: S2 (dubb)

    • •Ventricular contraction: increased pressure – aortic pressure increases as blood flows into aorta
    • •S1-S2 heard during normal cardiac cycle;
    • •S3-S4 abnormal adult heart sounds
    • not always abnormal in children
    • S3 is usually fluid overload
    • S4 usually stiff left ventricle from hypertrophy
  8. Electrical Conduction
    • •Electrical stimulation from SA node (R atrium); 60 to 100 per minute - normal sinus rhythem
    • SinalAtrial node - pacemaker of the heart
    • •Internodal tracts (atrial contraction) to AV node
    • is SA node doent work then control drops to AV note - 40 to 60 beats per minute
    • •Travels through bundle of His,
    • Purkinje fibers of myocardium, causing contraction

    •AV node prevents excessive atrial impulses

    SA node fails; impulses generated in AV node (slower 40-60)

    SA/AV node failure: bundle branches take over (20-40/min) - not effective - needs pacemaker- not compadable with life
  9. EKG with Systole & Diastole
    • QRS - junctional rhythems - ventrical related
    • P - atria
    • T - recovery process
  10. LYMPHATIC SYSTEM
    •Works together with the peripheral vascular system.

    •Removes fluid from interstitial spaces.

    •Excess fluid left in interstitial spaces absorbed by lymph system & carried to lymph nodes.

    •Lymph nodes located in groups along blood vessels.

    Ducts from the lymph nodes empty into subclavian veins.
  11. Neck Vessels
    • •Carotid Arteries
    • •Normally have smooth, rapid upstroke early in systole and gradual downstroke
    • - should hear NOTHING if you put your stethoscope on the carotid arteries
    • - if you hear something its a brewie - swishing sound
    • -DO NOT occlude (obliterate) both carotid arteries at the same time

    • •Jugular Veins (2 sets; internal and external)
    • •Pulses important for determining hemodynamics
    • of R heart functioning
    • •A wave = Atrial contraction
    • •X descent = RA relaxation
    • •V wave = RA filling
    • •Y descent = RA emptying into RV
  12. Peripheral Vascular System
    • •Arteries – higher pressure
    • –arterioles

    • •Capillaries – exchange O2 & nutrients for waste
    • products

    • •Veins – lower pressure but expandable
    • –venules
    • veins have valves - arteries do not - when starting IV you can run into valves

    Women with MI get pain between shoulder blades - middle of the back - Cardiac is now #1 killer of women becuase they dont seek care when they have pain
  13. Arteries' Attributes
    • •Carry oxygenated, nutrient-rich blood to capillaries
    • –High pressure system with thick walls
    • –Pulse = force of blood against arterial walls felt with heart beat

    • •Major arteries of the arm:
    • –Brachial, radial, ulnar

    • •Major arteries of the leg:
    • –Femoral, popliteal, dorsalis pedis, posterior tibial
  14. Vein Attributes
    • •Carry deoxygenated, nutrient-depleted waste blood from tissues back to the heart
    • –No force that propels blood flow
    • –Low pressure system

    • •3 mechanisms that propel blood back to heart: valves, muscular contraction, & pressure gradient
    • •Failure to propel blood back to heart result in: impeded venous return/venous stasis
  15. Deep & Superficial Veins
    • Types of veins
    • •Deep:
    • –Femoral
    • –Popliteal

    • •Superficial:
    • –Great & small saphenous veins

    coolateral ciriculation - if vein is removed (heart surgury) smaller veins will take over
  16. Present Health History
    • •Chronic illnesses such as DM, renal failure, chronic hypoxia, HTN.
    • •Medications
    • •Exercise
    • •Life style-personality type, stress, relax, sports.
    • •Alcohol consumption
    • •Eating habits.
    • •Smoking habits.- makes vessels harder & stiffer & increases viscocity of blood

    DM - diabetics have microvascular changes - neuropathic - do not process cholesterol properly - tend to have more arteriosclorosis
  17. CV General Health History: Past Health Status
    • –Chronic illnesses? (describe)
    • –Taking medications (what/when), side effects; OTC drugs (aspirin, herbs, cocaine, street drugs; how often)? cocaine blows out back side of heart - causes heart to wear out very early - MI or stroke
    • –Past tests on heart (EKG, stress test, angiogram)?
    • –Past surgery on heart or great vessels?
    • –Circulatory problems in arms or legs (ulcers, cold, reduced hair, numbness, poor healing)

    • Prednizone increases blood sugar - causes fluid retention (edema of arms & lower extremity)
    • Theofolin - another steroid - causes heart problems
    • Cardiac meds open
    • Respiratory meds close - if person has both cardiac & respiratory probles must be very careful
  18. CV General Health History: Family History
    • –Family history (HT, DM, CAD, hyperlipidemia, sudden death syndrome)
    • •Age of family members at death
    • •Gender of family members
    • –Race - back males (hypertension & heart disease)
    • –Childhood: Congenital heart disease/defect, “growing pains,” joint pains, recurrent tonsillitis, rheumatic
    • fever, murmur?
  19. CV Problem- Based History
    • Chest pain/ angina
    • Cough
    • Swelling/ edema of leg & feet
    • Nocturia - getting up to go to bathroom more than once during the night
    • Fainting/ Syncope - in need of pacemaker - older people on cardiac medication
    • CV risk factors
    • Shortness of breath
    • Fatigue
    • Leg cramps - electrolite imbalance - potassium
  20. Modifiable Lifestyle Risk Factors For Cardiovascular Disease
    • •Smoking
    • •Diet, low fat & Na
    • •Inactivity/Exercise
    • •Obesity, weight loss
    • •Hypertension
    • •Diabetes Mellitus
    • •Hyperlipidemia
    • •Alcohol
    • •Stress
  21. Health Promotion-CV Disease
    • •Leading cause of death & disability in US. Include CAD, MI, CVA, HTN, PVD, & hyperlipidemia.
    • •Goals of Healthy People 2010
    • •1. Improve CV health
    • •2. Improve quality of life.
  22. AHA Recommendations Primary Prevention
    • •Smoking Cessation.
    • •Diet limit high-cholesterol, saturated fats, increase fruits, vegetables, grains.
    • •Limit alcohol, limit salt intake.
    • •Maintain optimal wt., BMI 18.-24.9.
    • •Exercise – 30 minutes most days.
    • •Low-dose ASA if at risk.
  23. AHA Recommendations Secondary Prevention
    • •BP screening
    • •Lipid-level screening-routine for men > 35, women > 45.
    • •Lipid level for younger adults if risk
    • factors.
  24. CV Physical Examination
    • •General appearance
    • –Evaluate general condition; lying supine at 45 degrees for skin color, breathing, posture
    • –Approach from right side (gives you better position to listen to left side- heart)
    • •Peripheral vascular: measure blood pressure
    • –Orthostatic/postural hypotension
    • change position laying to sitting/ sitting to standing - more than 20 mm Hg difference is orthostatic hypotension
  25. Head & Neck Exam
    • •Palpate temporal pulses bilaterally
    • •Palpate carotid pulses one at a time
    • •Check if pulse regular, irregular, or pattern
    • •Grade pulse amplitude
    • –0 = absent
    • –1+ = diminished, barely palpable
    • –2+ = normal
    • –3+ = full volume
    • –4+ = bounding, hyperkinetic
  26. Listen for Carotid Bruits
    • •Auscultate carotid artery for bruits
    • •Use bell of stethoscope as bruits are low pitched & blowing during systole
    • •Client holds breath while you listen
    • •Normal is no sound
  27. Examination: Peripheral Vascular
    • •Upper Extremities
    • –Inspect and palpate for skin turgor/integrity:
    • •Tenting
    • •Pitting edema:
    • –1+ = 2mm deep, barely perceptible
    • –2+ = 4 mm deep but rebounds after a few seconds
    • –3+ = 6 mm deep & rebounds within 10 – 20 seconds
    • –4+ = 8 mm deep & rebounds > 30 seconds
    • –Inspect and palpate for appearance, color temperature, & capillary refill
    • –Palpate brachial & radial pulses for rate, amplitude & if regular, irregular or pattern
  28. Clubbing
    • –Inspect and palpate for appearance, color, temperature, capillary refill, and clubbing
    • –Allen Test (occlude radial & ulnar til pale then release ulnar with return of color < 5 –10 sec.)
  29. Examination: Peripheral Vascular
    • –Inspect and palpate for skin turgor/integrity
    • –Inspect and palpate for appearance, color, temperature, hair distribution, capillary refill, and
    • superficial veins
    • –Perform Trendelenburg test to evaluate competence of venous valves (varicose veins)
    • –Check Homan’s sign or measure calf circumference
    • –Calculate Ankle-Brachial Index < 0.9 art. occlusion
    • –Palpate femoral, popliteal, posterior tibial, dorsalis
    • pedis pulses for rate,amplitude & rhythm
  30. Palpating Periperal Pulses
    • •Palpate all pulses for rhythm, strength and amplitude.
    • •Temporal
    • •Carotid
    • •Brachial
    • •Ulnar
    • •Femoral
    • •Popliteal
    • •Dorsalis pedis
    • •Posterior tibial
  31. Grading Edema
    • •1+ barely perceptible pit 2 mm
    • •2+ deeper bit rebounds in sec. 4 mm
    • •3+ deep pit, rebounds 10-20 sec. 6 mm
    • •4+ deeper pit, rebound > 30 sec. 8 mm
  32. Examination: Cardiac
    • •Inspect anterior chest wall for contour, pulsations, lifts heaves, retractions
    • Palpate apical pulse for location - apical pulse is sometimes called point of maximal impulse
    • Palpate precordium for pulsations, thrills, lifts, heaves
    • Percuss heart borders for heart size
    • •Auscultate S1-S2 heart sounds for rate, rhythm, pitch, splitting
    • •Interpret ECG/EKG conduction of heart

    • Palpate apical pulse for location
    • (PMI = point of maximal impulse < 2 cm)
    • 4-5 intercostal spaces on Left Intercostal border
    • Use 2 to 3 fingers
  33. Phenmatic for
    • All
    • Physicians
    • Take
    • Money

    or APT M

    • A - Aortic - 2nd intercost palce right sternal border
    • P - Pulmonic -2nd intercostal space left sternal border
    • T - 4 ICS LB
    • M - 5 ICS MCL

    Erbs point - 3ICS LB
  34. Abnormal Heart Sounds
    • •S3 (heart failure, mitral/tricuspid regurg)
    • –S1, S2, S3 (me too)
    • –Slosh-ing-in or Ken-tuck-y or me too

    • •S4 (stiff, non-compliant ventricle, CAD)
    • –S4, S1, S2 (middle)
    • –a-Stiff-wall or Ten-ness-ee or middle

    • •Murmurs
    • –Systolic
    • –Diastolic
    • •Pericardial Friction Rub
  35. Murmer Grades - Intensity
    • •I = barely audible in quiet room
    • •II = quiet but clearly audible
    • •III = moderately loud
    • •IV = loud with associated thrill
    • •V = very loud with easily palpable thrill
    • •VI = very loud with palpable & visual thrill
    • •Patterns (crescendo, decrescendo, plateau)
  36. Systolic & Diastolic Murmers
    • Systolic Murmurs
    • •Aortic/pulmonic stenosis
    • •Tricuspid/mitral regurgitation
    • •Anemia
    • •Thyrotoxicosis
    • •Ventricular-septal defect (holosystolic)

    • Diastolic Murmurs
    • -ALWAYS pathologic - never normal in any age group
    • •Aortic/pulmonic regurgitation
    • •Tricuspid/mitral stenosis
  37. CV Age-Related Variations: Older Adults
    • •Aging heart unable to compensate if stress, blood loss, tachycardia, exertion, fever
    • –Increased age; heart size decreased, output less than 30% to 40% (decreased heart rate/vagal, contractility)
    • –Arterial walls or superficial vessels: decreased compliance (dilated, prominent, tortuous, calcified)
    • •Increased BP (systolic/diastolic) from increased peripheral resistance (widened pulse pressure & + orthostatics)
    • –Fibrosis or sclerosis of SA node or mitral and aortic valves causes altered cardiac function (heart blocks & systolic murmurs)
    • –S4 common: decreased L ventricular compliance
  38. Heart Failure to Pump Blood
    • Left Heart Failure
    • •Due to aortic stenosis, HT, or MI
    • •Frothy pink sputum (color of my computer)
    • •Bilat. Crackles
    • •Apical pulse lateral
    • •Systolic murmur
    • •Palpable apical thrill

    • Right Heart Failure
    • •Due to pulmonary HT, MI, or cor pulmonale
    • •+ JVD
    • •Peripheral edema
    • •Systolic murmur
    • •S3 (lubb-dubb-me too)
  39. Hypertension
    • •Due to increased cardiac output (heart rate & stroke volume) & increased vasoconstriction or excess fluid
    • •No specific symptoms so do screenings
    • •2003Criteria –
    • –< 120/80 = normal
    • –120-139/80-89 Prehypertensive
    • –140-159/90-99 Stage 1 hypertension
    • –>160-179/100-109 Stage 2 hypertension
    • –> 180/110 Stage 3 hypertension
    • •Need to do health screenings

    Cardiologist would like normal to be 110/ 70
  40. CV Nursing Diagnoses
    • •Decreased cardiac output
    • •Risk for imbalanced fluid volume
    • •Risk for impaired skin integrity or infection RT poor circulation
    • •Ineffective tissue perfusion: peripheral or cardiopulmonary
    • •Activity intolerance RT leg pain
    • •Knowledge deficit re CAD, HT, diet, meds
    • •Fatigue RT decreased cardiac output
    • •Acute pain RT angina, venous or arterial insufficiency
    • •Ineffective therapeutic regime management RT diet, exercise or medications

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