NPTE Cardiovascular and lymphatic PT

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NPTE Cardiovascular and lymphatic PT
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2013-05-20 13:38:28
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Note cards to help study for the national physical therapy exam
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  1. pericardium
    fibrous protective sac enclosing the heart
  2. epicardium
    inner layer of pericardium
  3. endocardium
    smooth lining of the inner surface and cavities of the heart
  4. tricuspid valve
    right A-V valve, anchored by chordae tendineae
  5. bicuspid/mitral valve
    leff A-V valve
  6. semilunar valve
    pulmonary and aortic valves: prevent back flow
  7. Right Coronary Artery
    supplies atrium, R ventricle, infer wall of left ventricle, AV node, bundle of HIS, SA node
  8. Left Coronary Artery
    supplies the LAD (L anter descending)
    LAD: supplies the L ventricle and interventricular septum, apex
  9. Left Coronary Artery
    Circumflex artery
    supplies the later and infer walls of L ventricle and portions of L atrium, SA node
  10. Coronary Sinus (vein)
    goes straight to R atrium
  11. conduction of heart beat
    SA node --> impulse spreads to both atria and they contract together-->stim the AV node --> transmits down the bundle of HIS to purkinje fibers --> impulse spreads thruout ventricles and contract together
  12. Purkinje fibers
    conducting tissue of both ventricles; R and L branches of AV node; conducts the ventricles,
  13. SA node
    pacemaker of heart, initiates impulse; sympathetic and parasympathetic innervations affecting heart rate and strength of contraction
  14. AV node
    @ R atrium/ventricle junction; merges with bundle of HIS
  15. Stroke Volume (SV)
    amount of blood ejected with each HB. normal=55-100 mL/beat
  16. Left Ventricular end diastolic volume or Preload
    amount of blood left in the ventricle at the end of diastole. Greater the filling, greater the blood pumped (Frank-Starling Law)
  17. Afterload
    force the Left Ventricle must generate during systole to overcome aortic pressure to open the aortic valve
  18. Cardiac Output
    (CO=SV*HR)
    amount of blood discharged from the left or R ventricle per min (4-5L per min)
  19. Ejection Fraction
    percentage of blood emptied from the ventricle during systole: clinically useful for measure of LV function

    =SV / preload

    normal = 60-70%, a lower EF = impaired
  20. Diastolic filling time decreases with:
    increased heart rate and heart dz
  21. Myocardial oxygen demand (MVO2)
    energy cost of myocardium

    = HR*SBP

    increases with activity and HR or BP
  22. ateries and blood travels from
    high pressure to low pressure
  23. arteries and blood flow is influenced by
    elasticiy of vessel walls, peripheral resistance, amount of blood in body
  24. capillaries
    connect arteriols and venules
  25. lymphatic system includes
    lymphatics, lymph fluid, lymph tissues, nodes, organs, (tonsils, nodes, spleen, thymus, thoarcic duct)
  26. lymph travels...
    from capillaries to vessels to ducts to L subclavian vein
  27. parasympathetic control of heart (cholinergic)
    in medulla oblongata: cardioinhib center

    • vagus nerve (CN X)
    • slows heart rate and force of contraction
    • causes coronary vasoconstriction
  28. sympathetic control of heart (adrenergic)
    located in medulla oblongata: cardioacceleratory center

    T1-T4 ganglia, releases epinenphern and nor-epinephrine

    causes increase in rate and force of contraction

    coronary vasodilation --> requires sympathetic inhibition
  29. Baroreceptors
    main mechanisms controlling heart rate

    respond to changes in BP (circulatory reflex)
  30. chemoreceptors
    • sensitive to changes in blood chemicals (O2, CO2, lactic acid
    • maintains pH
  31. hyperkalemia and HR
    increased potassium ions, decreases the rate and force of contraction, produces EKG changes
  32. hypokalemia and HR
    decreased potassium ions

    causes arrythmias, ventricular fib (V-fib)
  33. hypercalcemia and HR
    increased calcium

    increases heart actions
  34. hyocalcemia and HR
    decreased calcium

    depresses heart actions
  35. peripheral resistance - influenced by
    viscosity of blood, diameter of arterioles/capillaries
  36. increased peropheral resistance causes
    increased blood volume and pressure
  37. decreased preipheral resistance causes
    decreased arterial blood volume and pressure
  38. Positive risk factors for coronary artery dz
    • age (male >45, Female >55)
    • family hx
    • smoking hx
    • sedentary
    • obese
    • HTN
    • dyslipidemia
    • pre-DM
  39. Pallor skin
    washed out, absence of pink, rosy color
  40. grading scale for peripheral pulses
    • 0 = absent pulses
    • 1+ = pulse diminished
    • 2+ = normal
    • 3+ = full pulse, increased strength
    • 4+ = bounding
  41. Apical (apex) pulse/pulse at maximal impulse position
    supine, palpate 5th interspace, midclavical vert. line (APEX) of heart
  42. Normal HR
    60-100, <60 in athletic/trained
  43. HR for pediatric
    115-140 bpm
  44. Tachycardia
    >100bpm
  45. Bradycardia
    <60 bpm
  46. irregular pulse
    variations in force and frequency

    d/t arrythmias, myocarditis
  47. weak, thready pulse
    d/t low SV or cardiogenic shock
  48. bounding pulse
    d/t shortened ventricular systole and decreased peripheral presure; aortic insufficiency
  49. HEART SOUNDS
    aoric valve - 2nd right intercostal space at sternal border

    pulmonic valve - 2nd left intercostal space @ sternal border

    Tricuspid valve - 4th left intercostal space @ sternal border

    mitral valve - 5th left intercostal space at midclavical
  50. HEART SOUNDS
    • S1 - (lub) normal closure of mitral and tricuspid valves -- marks beginning of systole
    •    - decreased in 1st degree heart block

    • S2 - (dub) normal closing of aortic and pulmonic valves, marks end of systole
    •    - decreased in aortic stenosis
  51. Murmur - extra sounds
    • 1. systolic - falls between S1 and S2
    •    - indicates valvular dz or can be normal
    • 2. Diastolic - falls between S2 and S1
    •    - indicated valvular dz
  52. grades of Murmurs
    • grade 1 - softest audible murmur
    • grade 6 - audible with stethoscope off chest

    Thrill - abnormal tremor with a murmur felt
  53. Bruit: HEART SOUNDS
    • adventitious sound/murmur of arterial o venous origin
    • common in carotid/femoral arteries
  54. Gallop; HEART SOUNDS
    • abnormal heart rhythm with 3 sounds each cycle
    •   1. S3 - ventric. filling, occurs soon after S2
    •       
    •     - indicative of congestive (LV) heart failure
    •   2. S4 - assoc with ventric filling and atrial contraction; occurs before S1;
    •     - indicative of pathology ie. coronary heart dz (CAD), MI, aortic stenosis, chronic HTN
  55. EKG has how many leads
    12 leads
  56. EKG gives information about
    heart rate, rhythm, conduction, areas of ischemia and infarct, hypertrophy, electrolye imbalance
  57. EKG:P wave
    atrial depol
  58. EKG:P-R interval
    time required for impulse to travel from atria thru conduction cycle to purkinje fibers
  59. EKG: QRS wave
    ventricular depol
  60. EKG: ST segment
    beginning of ventricular repol
  61. EKG: QT interval
    time for electrical systole
  62. EKG: calculate HR
    count number of QRS complexes in a 6-second strip and multiple by 10
  63. Ventricular Fib
    • pulse-less, emergency, adversely affects CO,
    • requires CPR, medication, defib

    chaotic activity of ventricle originating from multiple foci; unable to determine rate

    EKG: bizzare/erratic activity without QRS complese

    no effective CO, clinical death within 4-6 min
  64. Premature ventric contraction (PVC)
    premature heartbeat arising from ventricle -- no p wave, a wide QRS that is premature, followed by long compensatory pause

    Serious PVC = >6 PVC in min, paired, or in sequential runs
  65. ventricular tachycardia
    a run of 3 or more PVCs occuring sequentially; very rapid rate (150-200 bpm), may occur paroxsymally (abruptly); usually d/t ischemic ventricle - seriously compromised CO

    wide/bizzare QRS, no P waves
  66. Supraventricular arrythmias
    atrial arrythmias, rapid, repetitive firing of one or more ectopic foci in the atria (outside sinus node)

    P waves are abnormal or absent, rhythm is irregular, chronic or paroxsymal, rapid rate

    CO is usually maintained
  67. Atrial flutter
    250-300 bpm
  68. atrial fib
    >300 bpm
  69. atrial tachycardia
    140-250 bpm
  70. Atrioventricular blocks
    if ventricular rate is slowed, CO is decreased
  71. Third degree heart block
    complete heart block, life threatening, requires meds and pace-maker
  72. ST segment depression caused by
    ischemia or injury - impaired coronary perfusion

    can be up-slopping, down-slopping or horizontal
  73. EKG changes with MI are:
    abnormal Q waves, ST elevation, T-wave inversion
  74. Nitrates
    increase HR
  75. Normal Adult BP
    <120/<80
  76. Pre-HTN
    120-130/80-89
  77. Stage 1 HTN
    130-140/90-100
  78. stage 2 HTN
    140-160/100-110
  79. stage 3 HTN
    >160/>110
  80. Primary HTN
    no known cause
  81. Secondary HTN
    D/t atherosclerosis, vascular d/o, renal dz, endocrine d/o, pregnancy, drug related
  82. hypotension
    decrease in BP below normal, blood pressure not adequate for normal perfusion/oxygenation of tissues; may be related to bed rest, drugs, arrhythmias, blood loss/shock, MI
  83. orthostatic hypotension
    sudden drop in BP with change in position

    • lightheadedness, dizziness, LOB
    • drop in systolic more than 20mmHg or standing BP less than 100 should be reported and is significant
  84. Pediatric BP
    • Infant (<2 y/o) 106-110/59-63
    • child (3-5 y/o) 113-116/67-74
  85. Mean arterial pressure (MAP)
    • arterial pressure within the larger arteries over time, dependent upon mean blood flow and arterial compliance
    • =[SBP+(DBP*2)]/3
  86. Dyspnea Scale
    • +1 = mild, noticeable to pt only
    • +2 = mild, some difficulty, noticeable to observer
    • +3 = moderate difficulty, but pt can continue
    • +4 = severe difficulty, patient cannot continue
  87. Respiratory Rate
    • New born = 30-40 bpm
    • Adult = 12-20 bpm
  88. Tachypnea
    increase in RR >22 bpm
  89. bradypnea
    decreased in RR to <10 bpm
  90. hyperpnea
    increase in depth and rate of breathing
  91. dyspnea (SOB)
    • DOE - brought on by exertion
    • Orthopnea - unable to breathe when in reclined position (supine)
    • paroxysmal nocturnal dyspnea (PND) - sudden inability to breathe occuring during sleep
  92. Breath sounds: crackles
    (rales) rattling, bubbling sounds, d/t secretions in the lungs
  93. Breath sounds: wheeze
    whistling sounds
  94. SaO2
    Normal = 95%-100%
  95. Hypoxemia
    abnormally low amount of O2 in the blood
  96. hypoxia
    low O2 level in the tissues
  97. anoxia
    complete lack of O2
  98. Anginal Scale
    • 1+ = light, barely noticeable
    • 2+ = moderate, bohtersome
    • 3+ = severe, very uncomfortable
    • 4+ = most severe pain ever experienced
  99. EKG wave
  100. Ischemic Cardiac Pain
    diffuse, retrosternal pain, sensation of tightness, achiness, associated with sweating, dyspnea, indigestion, dizziness, syncope, and anxiety
  101. Angina
    sudden or gradual onset, occurs at rest or c activity, precipitated by physical or emotional factors, hot/cold temperatures,  relieved by rest or nitroglyerine
  102. MI pain
    sudden onset, pain last for more than 30 min, may have no precipitating factors, not relieved by medications
  103. Referred Pain
    cardiac pain can be referred to shoulders, arms, neck, or jaw

    pain referred to back can occur from dissecting aortic aneurysm
  104. Edema Grading Scale
    • 1+ = mild, barely perceptible indentation <1/4 inch pitting
    • 2+ = moderate, easily identified depression, returns to normal within 15 seconds, 1/4-1/2 inch pitting
    • 3+ = severe, depression takes 15-30 seconds to rebound, 1/2-1inch pitting
    • 4+ = very severe, depression lasts for >30 seconds or more, >1 inch pitting
  105. Rubor skin color
    dependent redness with PVD
  106. Digital clubbing
    curvature of the fingernails with soft tissue enlargement at base of nail

    associated with chronic O2 deficiency, heart failure
  107. PVD (periph vascular dz) trophic changes
    pale, shiny skin, dry skin, loss of hair

    abnormal pigmentation, ulceration, dermatitis, gangrene
  108. Fibrosis
    tissues are thick, firm, and unyielding
  109. Stemmer's Sign
    dorsal skin of the toes and hands are resistant to lifting (lymphedema)
  110. Decrease in skin temperature is associated with:
    poor arterial perfusion
  111. PVD Pain to look for (periph vascular dz)
    intermittent claudication with pain, cramping, and fatigue during exercise and relieved by rest
  112. SaO2 provides an estimate of which value?
    PaO2 - partial pressure of O2. based on the oxyhemoglobin desaturation curve
  113. hypoxemia
    O2 below 90% in blood
  114. hypoxia
    low O2 levels in the tissues
  115. anoxia
    complete lack of O2
  116. cardiac pain referral
    shoulders, arms, neck, jaw
  117. dissectiong aortic aneurysm referal pain:
    back
  118. PVD Pulses are:
    absent/diminished
  119. check LE pulses in supine - femoral, popliteal, dorsalis pedis, poster tib
  120. UE pulses: check brachial, radial, and carotid
  121. clubbing of fingers/toes
    curvature of the fingernails with soft tissue enlargement at base of nail -- associated with chronic O2 deficiency and heart failure
  122. Fibrosis
    skin is thick, firm, unyielding, positive stemmers sign (lymphedema)
  123. PVD is associated with
    abnormal pigmentation, ulceration, dermatitis, gangrene
  124. poor arterial perfusion and skin temp=
    decrease in superficial skin temp
  125. Edema examiniation
    measure girth, pitting edema, caused by venous insufficiency or lymphedema, B edema = CHF
  126. always examine venous system before arterial
    venous insufficiency can invalidate arterial tests
  127. Greater Saphenous Vein : Percussion test
    in standing - palpate one segment of the vein while tapping the vein 20 cm higher - if pulse wave felt in lower hand, valves are insufficient
  128. venous filling time test -- examine time to refill veins after emptying
    in supine, elevate one leg for 1 min to 45 degrees, then place in dependent position, delayed filling (>15 s) is indicative of venous insufficiency
  129. doppler Ultrasound
    measuring systolic BP in non-palpable pulses for both venous and arterial insufficiency
  130. ABI - ankle brachial index -- ratio of LE pressure divided by UE pressure
    • Scale:
    • >1 = normal
    • .8-1 = mild PAD
    • .5-.8 = moderate PAD, intermittent claudication
    • <.5 = severe PAD; ischemia of limb, rest pain
  131. rubor of dependency - examine color of foot during elevation followed by dependency
    • insufficiency = pallor with elevation, rubor of dependency with dependent postion -- reactive hyperemia
    • changes that take longer than 30s is indicative of PAD
  132. intermittent claudication
    exercise-induced pain or cramoing in the legs that is absent at rest - typically calf pain but can also occur in the butt hip thigh or foot
  133. intermittent claudication test
    have pt ambulate until pain is felt, have pt sit and rest - note the time of walking. examine for numbness, coldness, pallor or loss of hair over tib anter
  134. lymphatic system
    • palpate nodes = cervical, axilla, epitrochlear, superficial inguinal
    • examine for edema - visual swelling, ROM, loss of funct mobility
    • measure girth
    • examine skin changes - texture, fibrotic changes
    • presence of papules, leakage, wounds
    • changes in function (ADL, funct mob, sleep)
    • paresthesias?
    • lymohangiography - x-ray of lymph nodes
  135. chest x-ray
    reveal abnormalities of lung fluids, overall cardiac shape and size (cardiomegaly), aneurysm
  136. myocardial perfusion imaging
    • Dx and eval ischemic heart dz, MI
    • identify myocardial blood flow, areas of stress induced ischemia (exercise test), old infarct
    • thallium - injected into blood and will show up in normal tissue but not ischemic/infarct tissue -- can be used with exercise test
  137. echocardiogram
    non-invasive; ultrasound to visualize internal structures - size of chambers, movement of valves, septum, abnormal wall movement
  138. cardiac catheterization
    passage of tiny tube thru heart into blood vessels with contrast medium into coronary arteries and x-ray
  139. cardiac catherization
    provides info about anamtomy of the heart and great vessels, ventricular function, abnormal wall movements - allows determination of EF (eject fraction)
  140. central line (swan-ganz cath)
    • into the R side of heart
    • measures central venous pressure, pulm artery pressure, pulm capillary wedge pressure
  141. enzyme changes associated with MI - CK or CPK
    elevation of CK or CPK (serum creatine kinase or creatine phosphokinase) - peaks at 24 hours; released after tissue injury
  142. enzyme changes associated with MI - CK-MB
    CK-MB (serum creatine kinase MB) - peaks at 12-24 hours; better isolates the source to the myocardium, high sensitivity
  143. enzyme changes associated with MI - proteins
    elevations in tropinin I, troponin T: high sensitivity 10 hours after injury
  144. enzyme changes associated with MI - myoglobin
    elevation of myoglobin
  145. serum lipids
    lipid panel - mg/dL -- used to determine coronary risk
  146. SpO2 values
    Normal: SpO2 95%-100%; Clinical sig: SaO2 below 88% - supplemental O2 required
  147. PaOs values
    Normal: PaO2 80-100 mm HgClinical sig: increased in hypervent, decreas in cardiac decompensation, COPD, some NM d/o
  148. pH values
    • Normal: pH 7.35 - 7.45Clinical sig: <7.35 = acidotic, >7.45 is alkalotic increase in: -respitory alkalosis: hypervent, sepsis, liver dz, fever-metabolic alkalosis: vomiting, potassium depletion, diuretics, volume depletiondecrease in:-respiratory acidosis: COPD, respit depressants, myasthenia-metabolic
    • acidosis (bicarbonate deficit): increased acids (DM, ETOH, starvation),
    • renal failure, increased acid intake and loss of alkaline body fluids
  149. PaCO2 values
    Normal: PaCO2 35-45 mm HgClinical sig: increas in COPD; decreas in pregnancy, PE, and anxiety
  150. normal values - ABG
    clinical significance
    • Normal: SpO2 95%-100%;
    • Clinical sig: SaO2 below 88% - supplemental O2 required

    • Normal: PaO2 80-100 mm Hg
    • Clinical sig: increased in hypervent, decreas in cardiac decompensation, COPD, some NM d/o

    • Normal: PaCO2 35-45 mm Hg
    • Clinical sig: increas in COPD; decreas in pregnancy, PE, and anxiety

    • Normal: pH 7.35 - 7.45
    • Clinical sig: <7.35 = acidotic, >7.45 is alkalotic

    • increase in:
    • -respitory alkalosis: hypervent, sepsis, liver dz, fever
    • -metabolic alkalosis: vomiting, potassium depletion, diuretics, volume depletion

    • decrease in:
    • -respiratory acidosis: COPD, respit depressants, myasthenia
    • -metabolic acidosis (bicarbonate deficit): increased acids (DM, ETOH, starvation), renal failure, increased acid intake and loss of alkaline body fluids
  151. PTT partial thromboplastin time values
    • Normal: partial thromboplastin time (PTT) 25-40sec
    • Clinical sig: increased in factor VII, IX, and X deficiency
  152. PT - prothrombin time values
    • Normal: prothrombin time (PT) 11-15secClinical sig: increased in
    • factor x deficiency, hemorrhagic dz, cirrhosis, hepatitis drugs
    • (warfarin), if clotting time is 2.5 + more than normal, PT is contraind
  153. INR values
    • Normal: INR (international normalized ratio) - ratio of individual's PT to reference range 0.9-1.1
    • Clinical sig:
    • INR below 2=desirable
    • INR above 2: consult with MD for increas risk of bleeding
    • INR above 3 = risk of hemarthrosis
  154. bleeding time values
    • Normal: bleeding time: 2-10 min; c-reactive protein CRP <10 mg/L
    • Clinical sig: increased in platelet d/o, thrombocytopenia
    • increased in levels associated with increased risk of athrosclerosis>100 mg/L associated with inflammation and infection
  155. normal values of hemostasis (clotting/bleeding times)
    clinical significance
    • Normal: prothrombin time (PT) 11-15sec
    • Clinical sig: increased in factor x deficiency, hemorrhagic dz, cirrhosis, hepatitis drugs (warfarin), if clotting time is 2.5 + more than normal, PT is contraind

    • Normal: partial thromboplastin time (PTT) 25-40sec
    • Clinical sig: increased in factor VII, IX, and X deficiency

    • Normal: INR (international normalized ratio) - ratio of individual's PT to reference range 0.9-1.1
    • Clinical sig: INR below 2=desirable
    • INR above 2: consult with MD for increas risk of bleeding
    • INR above 3 = risk of hemarthrosis

    • Normal: bleeding time: 2-10 min; c-reactive protein CRP <10 mg/L
    • Clinical sig: increased in platelet d/o, thrombocytopenia
    • increaed in levels associated with increased risk of athrosclerosis
    • >100 mg/L associated with inflammation and infection
  156. WBC values
    • Normal: WBC (white) 4,300 - 10,800
    • Clinical sig: indicative of immune
    • status; increased value in infection: bacterial and viral;
    • inflammation, hematologic malignancy, leukemia, lymphoma, drugs
    • (corticosteroids)
    • decreased in aplastic anemia, B12 or folate deficiency with immunosuppression: increas risk of infect
    • EXERCISE CONSIDERATIONS:
    • - above 5000: light ex only
    • - below 5000 with fever: exercise contraind
    • - below 1000: use mask, standard precautions
  157. RBC values
    • Normal: RBC (red):
    • female 4.2-5.9 10^6/uL;
    • male = 4.6-6.2 10^6/uL
    • Clinical sig: increased = polycythemiadecreased = anemia
  158. ESR (erythrocyte sedimentation rate) values
    • Normal: ESR (erythrocyte sedimentation rate) -
    • female=below 20 mm/hr;
    • male = below 15 mm/hr
    • Clinical sig: increased sedimentation rate in infection and inflammation:
    • rheumatic or pelvic inflamm dz, osteomylitis used to monitor effects of
    • tx; RA, SLE, Hodgkins dz
  159. Hct values
    • Normal: Hct (hematocrit) % of RBC of the whole blood
    • male = 45%-52%
    • female= 37%-48%
    • Clinical Sig: increased in erythrocytosis, dehydration, shockdecreased in severe anemias, acute hemorrhage
    • EXERCISE CONSIDERATIONS:
    • -more than 25% but less than normal = light ex only
    • -less than 25% = exercise is contraind
  160. Hgb values
    • Normal: Hgb (hemoglobin)
    • males: 13-18 g/dL
    • females: 12-16 g/dL
    • Clinical Sig: increased in polycythemia, dehydration, shock
    • decreased in anemia, prolonged hemmhorage, RBC destruction (cancer or sickle cell dz)
    • EXERCISE CONSIDERATIONS:
    • - 8-10 g/dL: results in decreased ex tolderance, increased fatigue, and tachycardia; light ex only
    • - below 8g/dL: ex contraind
  161. Normal values for CBC
    Clinical significance
    • Normal: WBC (white) 4,300 - 10,800
    • Clinical sig: indicative of immune status; increased value in infection: bacterial and viral; inflammation, hematologic malignancy, leukemia, lymphoma, drugs (corticosteroids)
    • decreased in aplastic anemia, B12 or folate deficiency
    • with immunosuppression: increas risk of infect
    • EXERCISE CONSIDERATIONS:
    • - above 5000: light ex only
    • - below 5000: with fever, exercise contraind
    • - below 1000: use mask, standard precautions

    • Normal: RBC (red): female 4.2-5.9 10^6/uL; male = 4.6-6.2 10^6/uL
    • Clinical sig: increased = polycythemia
    • decreased = anemia

    • Normal: ESR (erythrocyte sedimentation rate) - female=below 20 mm/hr; male = below 15 mm/hr
    • Clinical sig:increased sedimentation rate in infection and inflammation: rheumatic or pelvic inflamm dz, osteomylitis used to monitor effects of tx; RA, SLE, Hodgkins dz

    • Normal: Hct (hematocrit) % of RBC of the whole blood
    • male = 45%-52%
    • female= 37%-48%
    • Clinical Sig: increased in erythrocytosis, dehydration, shock
    • decreased in severe anemias, acute hemorrhage
    • EXERCISE CONSIDERATIONS:
    • -more than 25% but less than normal = light ex only
    • -less than 25% = exercise is contraind

    • Normal: Hgb (hemoglobin)
    • males: 13-18 g/dL
    • females: 12-16 g/dL
    • Clinical Sig: increased in polycythemia, dehydration, shock
    • decreased in anemia, prolonged hemmorage, RBC destruction (cancer or sickle cell dz)
    • EXERCISE CONSIDERATIONS:
    • - 8-10 g/dL: results in decreased ex tolderance, increased fatigue, and tachycardia; light ex only
    • - below 8g/dL: ex contraind
  162. platelet count values
    • normal: 150,000-450,000 cells/mm^3
    • clinical sig: increaesed in leukemia, hemoconcentration
    • decreased in thrombocytopenia, acute leukemia, aplastic anemia, cancer chemo
    • EXERCISE CONSIDERATIONS:
    • - below 20,00: AROM, ADLs only
    • - 20,000-30,000: light ex only
    • - 30,000-50,000: moderate ex
  163. fibrinogen plasma values
    • normal: 175-433 mg/dL
    • clinical sig: increased in inflamm states, pregnancy, oral contracept
    • decreased in cirrhosis, hereditary dz
  164. atherosclerosis
    • lipid plaques affecting moderate to large sized arteries
    • thickening and narrowing of intimal layer of blood vessel wall from focal accumulation of lipids, platelets, monocytes, plaque, and other debris
    • risk fx:
    • -age, sex, race, familial hx of CAD
    • - smoking, HTN, yperlipidemia, elevated cholestrol and LDL levels, elevated blood homocystine, emotional stress
    • - obesity, sedentary lifestyle, DM, elevated fibrogen levels
    • - 2 or more risk fx multiples the risk of CAD
  165. ACS acute coronary syndrome characteristics
    • ranges from angina to infarction to sudden cardiac death
    • imbalance of myocardial O2 supply and demand resulting in ischemic chest pain
    • subacute occlusions may produce no symptoms
    • symptoms present when lumen is at least 70% occluded
  166. ACS acute coronary syndrome - angina pectoralis
    • chest pain or pressure due to ischemia, may be accompanied by levines sign (pt clenches fist over sternum)
    • represents imbalance in myocardial O2 supply and demand;
    • brought on by:
    • 1. increased demands on heart: exertion, emo stress, smoking, extremes of temperature (cold), over eating, tachyarrhythmias
    • 2. vasospasm: symptoms may be present at rest
    • There are 3 types of angina:
    • 1. stable: classica exertional angina occuring during ex or ativity; occurs at a predictable rate-pressure product, RPP (HRxBP), relieved with rest and/or nitroglycerin
    • 2. unstable: (preinfarction, crescendo angina); coronary insufficiency at rest without any precipitating factors or exertion. chest pain increases in severity, frequency, and duration; refractory to treatment. increases risk for MI or lethal arrhythmia; pain is difficult to control
    • 3. variant: (prinzmetal's angina): caused by vasospasm of coronary arteries in the absence of occulsive dz. responds well to nitroglycerin or calcium channel blocker long-term
  167. ACS acute coronary syndrome - MI
    • prolonged ischemia, injury, and death of an area of the myocardium caused by occlusion of one or more of the coronary arteries
    • precipitating factors: atherosclerosis with thrombus formation, coronary vasospasm or embolism, cocaine toxicity
    • zones of infarct:
    • 1. central zone: consists of necrotic non-contractile tissue; electrically inert; on EKG - see pathological q-waves
    • 2. zone of injury: area immed adjacent to central zone; non-contractile tissue, cells undergo metabolic changes, electrically unstable, EKG shows elevated ST segment in leads over damaged area
    • 3. zone of ischmia: outer area, cells also under-going metabolic changes, electrically unstable, EKG shows T-wave inversion
  168. ACS acute coronary syndrome - MI
    Infarct sites
    • 1. transmural: q-wave infarct -- full thickness myocardium
    • 2. nontransmural: (non-Q-wave infarct) -- subendocardial, subepicardial, intramural infarcts
    • 3. sites of coronary artery occlusion: A. infer MI, R ventr infarct, distrubances of upper conduction system; R coronary artery; B. lateral MI, ventricular ectopy: circumflex artery; C. Anterior MI, distrubances of lower conduction system: left anterior descending artery
    • impaired ventricular function results in:
    • 1. decreased SV, CO, and EF
    • 2. increased end diastolic ventricular pressure
    • Electrical instability: arrythmias, present in injured and ischemic areas
  169. ACS acute coronary syndrome - Heart Failure
    • clinical syndrome in which the heart is unable to maintain adequate circulation of the blood to meet the metabolic demands of the body
    • Types of heart failure:
    • 1. left-sided heart failure: (CHF) characterized by pulmonary congestion, edema, low cardiac output due to backup of blood from L Ventricle to L atrium and lungs; occurs with insult to L ventricle from myocardial dz, excessive workload of the heart (HTN, valve dz, congenital defect), cardiac arrhythmias, heart damage.
    • 2. right-sided heart failure: characterized by increased pressure load on right ventricle with higher pulm. vascular pressures; occurs with insult to R ventricle from LV failure, mitral valve dz, or chronic lung dz (cor pulmonale). produces hallmark signs of jugular vein distention and peripheral edema.
    • 3. biventricular failure: severe LV pathology producing back-up in the lungs, increase PA pressure, and RV signs of HF
    • Associated symptoms: Mm wasting, myopathies, osteoporosis
    • clinical manifestations of heart failure
    • compensated HF: heart returns to functional status with reduced CO and ex tolerance. Control achieved thru 1. physiological compensatory mechanisms; SNS stimulation, LV hypertrophy, anaerobic metabolism, cardiac dilation, aterial vasoconstriction and 2. medical therapy
  170. Clinical manifestations of LV cardiac failure
    • LV failure:
    • S/S of pulm congestion: dyspnea, dry cough, orthopnea, paroxysmal nocturnal dyspnea, pulmonary rales/wheezing
    • S/S of low CO: hypotension, tachycardia, lightheadedness, dizziness, cerebral hypoxia: irritability, restlessness, confusion, impaired memory, sleep disturbances; fatigue/weakness, poor ex tolerance, enlarged heart on chest x-ray, murmur(extra heart sounds), murmur of mitral or tricuspid regurgiation
  171. Clinical manifestations of RV cardiac failure
    • RV Failure:
    • S/S of pulm congestion: dependent edema, wt gain, ascities, liver engorgement (heptomegaly)
    • S/S of low CO: anorexia, nausea, bloating, cyanosis, R upper quadrant pain, jugular vein distension, cyanosis at nail beds, R sided S3 sounds, murmurs of pulm or tricuspid infficiency
  172. MET Activity Chart
  173. MET: metabolic equivalent
    • amount of O2 consumed at rest (sitting) = 3.5mL/kg per min
    • MET levels: multiples of resting VO2; can be directly determined during ex tolerance tests (ETT) but not commonly done
    • MET levels are estimated during ETT
    • can be used to predict energy expenditure during certain activities
  174. Sternal precautions
    • Sternal precautions include:
    • Do not lift more than 5-8 pounds.
    • No pushing or pulling with your arms.
    • Do not reach behind your back or reach both arms out to the side.
    • Do not reach both arms above shoulder height.
    • All for 6-8 wks post-surgery

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