Laurie Brown RN, MSN, MPA-HA, CCRN Fall 2005

1. Nursing 201Advanced Cardiac 2.0 Nursing assessment and management of patients with dysfunctions of circulation, and undergoing related diagnostic tests. Laurie Brown RN, MSN, MPA-HA, CCRN Fall 2005

2. This is important! There are three systems that must work together for the heart to beat efficiently: • Circulatory • Conduction • Coronary

3. Review of the Cardiovascular System Route of blood from the heart: • Arteries, arterioles, capillaries, venules, veins Distribution of the Total Blood Volume • Heart - Approx 9 % of blood volume at any given time. Arteries and veins act simply as conduits for blood! Only capillaries directly serve cells by exchanging materials with them.

4. Cardiac Tissues • Connective tissues – form the fibrous skeleton and valves. • Cardiac muscle – produces the contractile force of the heart. • Epithelial tissue – lines the cardiac chambers and covers the outer surfaces of the heart.

5. Arterial System General Features • Elastic Arteries • Muscular Arteries • Arterioles

6. Exterior Anatomy of the Heart

7. Anatomy of the Heart

8. Valves of the Heart • Tricuspid – Directs the flow of blood from the right atrium to the left ventricle. • Mitral Valve – Directs the flow of blood from the left atrium to the left ventricle. • Pulmonic (semilunar) – Lies between the right ventricle and the pulmonary artery. • Aortic Valve(semilunar) – Lies between the left ventricle and the aortic artery.

9. Circulation in the Heart 1. Oxygen-poor blood (shown in blue) flows from the body into the right atrium.2..Blood flows through the right atrium into the right ventricle.3. The right ventricle pumps the blood to the lungs, where the blood releases waste gases and picks up oxygen.

10. 3. The newly oxygen-rich blood (shown in red) returns to the heart and enters the left atrium.4. Blood flows through the left atrium into the left ventricle.5. The left ventricle pumps the oxygen-rich blood to all parts of the body.

11. TheCirculatory System

12. Coronary Circulation

13. Coronary Blood Flow • Coronary Blood Flow is directly linked to oxygen demand.  • Autoregulation helps to maintain normal coronary blood flow whenever coronary perfusion pressure changes due to changes in aortic pressure.

14. Autoregulation • Autoregulation is defined as… The intrinsic ability of an organ to maintain a constant blood flow despite changes in perfusion pressure. Control of an event such as blood flow through a tissue (e.g., cardiac muscle) by alteration of the tissue.

15. Coronary Blood Flow

16. Heart Sounds Heart sounds… are caused by the closure of heart valves. The first sound (lub), or S1, is caused by closure of the atrioventricular (AV) valves. The second sound (dup), or S2, is caused by the closure of the semilunar valves.

17. Murmurs and Stenosis… • A valve that does not close efficiently, results in the backflow of blood (i.e., insufficiency or regurgitation). • A valve that does not open wide enough may cause turbulent backflow secondary to obstruction or narrowing (i.e., stenosis).

18. Landmarks

19. Pericardial Friction Rub • Non-infective • Infective • Autoimmune Scratching, grating, squeaking, high pitched sound

20. Definitions… • Cardiac output • Pre-load • After-load • Cardiac reserve • Starling’s law of the heart • Pulse deficit • Pulse pressure

21. Physiology of Circulation (cont.) Peripheral Resistance • Opposition to flow • A measure of the amount of friction blood encounters as it passes through the vessels. • Most friction is encountered in the peripheral circulation (peripheral resistance (PR)). • Sources of resistance…

22. Physiology of Circulation (cont.) Blood Pressure • Force per unit area exerted on the wall of a vessel by its contained blood expressed in mm Hg. • Usually means systemic arterial blood pressure in the largest arteries near the heart. • The differences in blood pressure within the vascular system provided the driving force that keeps blood moving through the body.

23. Physiology of Circulation Blood Flow • Actual volume of blood flowing through the entire circulation or any part of it (a vessel, an organ, etc.) in a given period of time (ml/min). • Equals cardiac output (CO) when applied to the entire circulation. • Varies widely among individual body organs as determined by their immediate needs.

24. The Cardiac Cycle • Isovolumetric ventricular contraction • Ventricular ejection • Isovolumetric relaxation • Ventricular filling • Atrial systole

25. Ejection fraction (EF) • The ejection fraction (EF) represents the amount of blood pumped out of the heart (left ventricle) with each beat. In the healthy heart, it is around70%. • An EF below 55% is considered abnormal.

26. What is congestive heart failure? Taber’s defines heart failure as… “The inability of the heart to circulate blood effectively enough to meet the body's metabolic needs”.

27. Symptoms of Heart Failure • Shortness of breath (dyspnea) • Fatigue • Edema – associated with fluid overload • Lightheadedness • Hypoxia • Orthopnea • Cognitive changes • Other…

28. Auto-regulatory Mechanisms of The Heart • The heart is supplied by the two branches of the autonomic nervous system. • The sympathetic (adrenergic) • The parasympathetic, or (cholinergic)

29. Changes Associated With Aging… • Decreased vessel elasticity • Increased calcification of vessels • Impaired valve function • Decreased muscle tone (including the heart • Decreased baroreceptor response to blood pressure changes • Decreased conduction ability of the heart

30. Other stuff… • Contractility: The ability of muscle cells to contract after depolarization. This ability depends on how much the muscle fibers are stretched at the end of diastole. The inherent ability of cardiac muscle fibers to shorten or contract.

31. Cardiac Risk Factors • Non-modifiable • Modifiable • Other

32. Cardiac Testing • Blood Tests • Electrical • Structure • Pressure • Blood Flow • Ischemic Tissue

33. Laboratory Tests • CK or CK-MB • LDH (LDH1, LDH2) • AST (SGOT) • Lipids • PT/PTT • ABGs • Electrolytes • CBC • Troponin & Myoglobin • C-reactive protein (CRP) • Homocysteine • B Type Natriuretic Peptid

34. Tests • EKG • Stress Test • Transesophageal Echocardiography • Echocardiography • Phonocardiography

35. Radiographic • X-ray • Fluoroscopy • Angiography • Cardiac Cath • DSA (Digital Subtraction Angiography)

36. Cardiac Testing • Angiography • Angioplasty • Biopsy • VO2 max

37. Tests • Nuclear Cardiography • Technetium Pyrophosphate Scanning • Thallium Imaging • MUGA Scan

38. Tests • Positron Emission Tomography (PET) • MRI • CAT Scan Small Pericardial Effusion

39. Hemodynamic Monitoring

40. Physical Assessment • General appearance • Mental Status • Vital signs • Pulses • Heart rate and rhythm • Perfusion • Edema • Lung sounds • Other…

41. Case Study… FRED • 82 y/o male w/30 + year history of COPD presents to the ER with C/O SOB and chest pain and now is to be admitted to your unit. He has a IV at TKO and O2 per NP at 2L. He was given a Nitro and an aspirin in the ER.

42. Fred • Admitting Dx: CHF, R/O MI • Past Medical Hx: Mild CHF, COPD x 30 years, CAD, HTN • PE: Skin pink and dry, brisk capillary refill, oriented x 4, S3 heart sounds, SOB with any exertion, audible expiatory and inspiratory wheezes, crackles at bases bilaterally, 1+ pitting edema to mid calf

43. FRED 1. Chief Complaint 2. Cardiac (Medical) History 3. Tests (Labs & others) 4. Medications 5. Physical exam 6. Vital signs 7. Nursing Diagnosis

44. Admitting Dx: CHF, R/O MI • Past Medical Hx: Mild CHF, COPD x 30 years, CAD, HTN • Vital signs: 184/94, 122, 30, T 99.1 ABGs on RA - 7.55, CO2 26, O2 54 • PE: Skin pink and dry, brisk capillary refill, oriented x 4, S3 heart sounds, SOB with any exertion, audible expiatory and inspiratory wheezes, crackles at bases bilaterally, 1+ pitting edema to mid calf

45. Q-R-S-T-A-A-A • Quality - dull/squeezing • Region – radiation • changing • right arm/left arm • Severity/Setting • rest vs exertion • after meals • scale of pain

46. Q-R-S-T-A-A-A • Time • sudden/gradual onset • Alleviators • Position • Aggravators • food/position/exertion/people • constant/episodic • Associated Symptoms • SOB, cough, temp, nausea, diarrhea

47. Application - Chief Complaints… What are Fred’s chief complaints?

48. Cardiac History • Ask about his personal history, family history and social history.

49. Fred - Medications • What medications is he currently taking? • Diuretic, ACE inhibitor, ß-blocker, K+, Bronchodilators and Glucocorticoids

50. Physical Exam • What we know… • SOB (subjective and objective) • Vital signs • ABG’s • Skin…Perfusion • Mental status • Heart sounds • Lung sounds • Edema