Nursing of Adult Patients with Medical & Surgical Conditions

1. Nursing of Adult Patients withMedical & Surgical Conditions Cardiovascular Disorders

2. Diagnostic Tests • Diagnostic Imaging • Radiographic exam to assess heart size, shape and position and outline of shadows.

3. Diagnostic Tests • Computed Axial Tomography (CT/CAT Scan) • Three dimensional view of the structure

4. Diagnostic Tests • Angiogram • radiographs are taken after injection of dye into an artery • Aortogram • visualizes the abdominal aorta and the major leg arteries with injection of dye into the femoral artery Iliac Artery

5. Diagnostic Tests • Fluoroscopy • action-picture Fluoroscopy Demo

6. Diagnostic Tests • Cardiac Catherterization and Angiography • Visualizes the heart’s chambers, valves, great vessels, and coronary arteries • Catheter is inserted into the heart chambers to measure pressure, and blood-volume. • Contrast dye may be used for better visualization • Post-procedure: • supine, with sandbag over pressure dressing at insertion site

7. Cardiac Catheterization

8. Cardiac Catheterization Lab

9. Cardiac Catheterization with Contrast

10. Diagnostic Tests • Electrocardiogram • Graphic study of the electrical activities of the myocardium

11. Review of Cardiac Electrical Activity

12. Diagnostic Tests • Electrocardiogram • P-wave • contraction (depolarization) of the atria • QRS complex • contraction (depolarization) of the ventricles • relaxation (repolarization) of the atria is covered by the QRS complex • T-wave • relaxation (repolarization) of the ventricles

13. Relationship of EKG to cardiac muscle activity (SA Node fires) Atrial Depolarization (Impulse to AV node) (Impulse moves through Bundle of His & Perkinje fibers) Ventricular Depolarization Ventricular Repolarization

14. Electrocardiogram

15. Diagnostic Tests • Cardiac Monitors • Continual monitoring of the cardiac electrical activity on a video monitor • Telemetry • electronic transmission of data to a distant location

16. Diagnostic Tests • Thallium Scanning • Thallium 201 is injected and the patient exercises on a treadmill • Thallium is transported into normal cells, but not ischemic or infarcted cells

17. Thallium Scanning

18. Diagnostic Tests • Echocardiography • Ultrasound is used to record size, shape, and position of cardiac structures • Detects: • pericardial effusion • ventricular function • cardiac chamber size and contents • ventricular muscle and septal motion and thickness • cardiac output • cardiac tumors • valvular function • congenital heart disorders.

19. Echocardiography Echocardiogram Demo

20. Echocardiography

21. Diagnostic Tests • Positron Emission Tomography (PET) • Computerized radiographic technique that uses radioactive substances to examine the metabolic activity of various body structures • Used to study dementia, stroke, epilepsy, tumors, and cardiac tissue PET Demonstration

22. Diagnostic Tests • Laboratory Exams • Blood cultures • Culture and sensitivity • Compete Blood Count (CBC) • RBC (erythrocytes) 4-6 million/cu.mm • Hemoglobin 10-20 gm/100ml • Hematocrit 40-50 percent • WBC 5,000-10,000/mm • Platelets 150,000-400,000/mm • Coagulation Studies • Prothrombin Time (PT) 11-12.5 seconds • Partial thromboplastin time (PTT) 60-70 seconds • Erythrocyte sedimentation rate (ESR) • Up to 20mm/minute

23. Serum electrolyte tests • sodium - maintains fluid balance (135-145mEq/L) • potassium - relaxes heart muscle (3-5 mEq/L) • calcium - contraction of cardiac muscle (9-11mg/dl) • magnesium - maintain level of electrical excitability in the nerves and muscles (1-2 mEq/L) • Serum lipids • Total Cholesterol (140-200 mg/dl) • High Density Lipoprotein (HDL) (35-85 mg/dl) • Low Density Lipoprotein (LDL) (below 100mg/dl) • Triglycerides (35-135 mg/dl) • Arterial blood gases • pH 7.35-7.45 • PaCO2 35-45 mm Hg • PaO2 80-100 mm Hg • HCO 21-28 mEq/L • SaO2 95-100%

24. Diagnostic Tests • Cardiac Enzyme Studies • CPK isoemzyme II (MB) • enzyme is released when the heart muscle is damaged or necrosis occurs • levels rise in 3-6 hours, peak in 12-18 hours, and may remain elevated for 3-4 days • Normal Value 40-170 U/L • LDH • Rises within the first 24-72 hours, peaks in 3-4 days, and returns to normal in approx 14 days • Normal Value 100-200 U/L

25. Risk Factors forCardiovascular Disorders • Nonmodifiable Factors • Family History • Parent or sibling who has CV disorder before 50 yrs • Age • Normal physiological changes • Approx 50% of all MI occur after 65 yrs • Sex (Gender) • Men are at greater risk than women • Race • African Amer. males are at higher risk of hypertension

26. Risk Factors forCardiovascular Disorders • Modifiable Factors • Smoking • 2-3 times greater risk • Hyperlipidemia • Diet high in saturated fat, cholesterol, and calories • Cholesterol levels above 200 mg/dl • Hypertension • B/P higher than 140/90

27. Risk Factors forCardiovascular Disorders • Diabetes Mellitus • Damage to vessels due to high glucose levels • High cholesterol levels (abnorm. lipid metabolism) • Obesity • Increases workload of the heart • Sedentary Lifestyle • Exercise improves the heart’s efficiency, lowers glucose & cholesterol levels, lowers B/P, reduces weight, and reduces stress levels

28. Risk Factors forCardiovascular Disorders • Stress • Catecholamines are released which cause increased heart rate and damage to myocardial cells • Oral Contraceptives • Not clearly defined • Older high dose contraceptives made women at higher risk for cardiovascular disorders – esp. smokers • Newer low dose contraceptives don’t seem to cause that risk • Psychosocial Factors • Type A personality • aggressiveness, competitiveness, perfectionism, & compulsiveness

29. Cardiac Dysrhythmias • Normal Sinus Rhythm • Originates in the SA node • Rate: 60-100 beats/min • Rhythm: regular

30. Sinus Tachycardia • Originates in the SA node • Rate: 100-150 • Rhythm: regular • Causes: • exercise, anxiety, fever, shock, medications, hypothermia, heart failure, excessive caffeine, and tobacco • Not usually caused by cardiac problems • Treatment: • Directed at cause

31. Sinus Bradycardia • Originates: SA node • Rate: less than 50-60 beats per min • Rhythm: regular • Cause: • sleep, vomiting, intracranial tumors, MI, drugs, vagal stimulation, endocrine disturbances, and hypothermia • Treatment: • Directed toward cause • Atropine to increase heart rate • Temporary or permanent pacemaker

32. Supraventricular Tachycardia (SVT) • Premature Atrial Contraction (PAC) • Originates: atria • Rate: 150-250 beats/min • Rhythm: regular • Causes: • drugs, alcohol, mitral valve prolapse, emotional stress, smoking, and hormone imbalance • usually not caused by heart disease • Treatment: • Eliminate underlying cause • Decrease heart rate • carotid sinus pressure, ocular pressure, digitalis, calcium channel blockers, propranolol, quinidine, and cardioversion

33. Atrial Fibrillation • Originates: atria • Rate: 350-600 • Rhythm: irregular; may be unable to count • Causes: • atherosclerosis, mitral valve disease, CHF, cardiomyopathy, congenital abnormalities, COPD, and thyrotoxicosis • Treatment: • digitalis, calcium channel blockers (verapamil), antidysrhythmics (procainamide), quinidine, anticoagulants (heparin, coumadin) and cardioversion

34. Atrioventricular Block (1st, 2nd, & 3rd degree) • Originates: SA node; impulse is slowed at the AV junction due to a defect • Rate: • 1st degree - 60-100 beats/min • 2nd degree - 30-40 beats/min • 3rd degree - may be no heart beat • Cause: • atherosclerotic heart disease, MI, CHF, digitalis toxicity, congenital abnormality, drugs, and hypokalemia • Treatment: • directed at cause • atropine and isoproterenol • pacemaker for 3rd degree

35. Premature Ventricular Contractions (PVC) • Originates: ventricles • Rate: 60-100 beats/min • Rhythm: • regular with an occasional extra beat • may occur as a single event or may occur several times in a minute, or in pairs or strings • Cause: • irritability of the ventricules, exercise, stress, electrolyte imbalance, digitalis toxicity, hypoxia, and MI • Treatment: • Treat the cause • antidysrhythmics (lidocaine, procainamide, or bretylium

36. Ventricular Tachycardia • Originates: ventricles; 3 or more successive PVC’s • Rate: 140-240 beats/min • Rhythm: regular to slightly irregular • Cause: • hypoxemia, drug toxicity, electrolyte imbalance, and bradycardia • Treatment • IV procainamide (decrease excitability of cardiac muscle) • Lidocaine with MI • Cardioversion

37. Ventricular Fibrillation • Originates: ventricles • Rate: none • Rhythm: none • Cause: • untreated ventricular tachycardia, electrolyte imbalances, digitalis or quinidine toxicity, and hypothermia • Treatment: • Emergency care • CPR • defibrillation (15-20 seconds of the onset) • medications • lidocaine, bretylium, or procainamide

38. Artificial Cardiac Pacemakers • Pacemaker • Battery-operated generators that initiate and control the heart rate by delivering an electrical impulse to the myocardium • Temporary • Used for cardiac support following some MI’s or open-heart surg. • Permanent • Used when other measures have failed to convert the dysrhythmia or conduction problem • 2nd & 3rd degree AV block, bradydysrhythmias, & tachydysrhythmias

39. Internal Pacemaker • Catheter-like electrode is placed in the area to be paced and generator is embedded under the skin

40. External Pacemaker • Electrode pad is placed on the chest wall and is attached to a generator place in a pocket or pouch

41. Artificial Cardiac Pacemakers • Nursing Interventions • Post-op • monitor heart rate and heart monitor • assess vital signs and level of consciousness • assess insertion site for erythema, edema, and tenderness • bed rest with arm immobilized for first few hours • Patient Teaching • continued medical care is very important • medical-alert ID • report signs & symptoms of pacemaker failure • weakness, vertigo, chest pain, pulse changes • avoid electrical equipment • hairdryers, battery-operated toothbrushes, etc. • avoid high-output electrical genterators and large magnets (MRI) • teach patient or family member to check pulse rate • notify physician if heart rate drops below 70