Chapter 31 Cardiovascular System Assessment - Complex

Which amount of time in seconds is considered normal for capillary refill? 1 4 6 8

1 The capillary refill test assesses arterial flow to the extremities. The fingernail is pressed, and the time required for the refilling of blood is noted. This refill is appreciated by the change in the color of the nail bed. This should occur in less than two seconds with normal tissue perfusion and cardiac output. Capillary refill times of four seconds, six seconds, and eight seconds indicate an underlying defect in circulation.

How will the nurse document a weakly palpable pulse? 0 1+ 2+ 3+

1+ A weak pulse in a patient with cardiovascular disease is indicated by 1+. The absence of a pulse is indicated by 0. A normal pulse rate is indicated by 2+, and 3+ indicates an increased, full, bounding pulse.

A patient's systolic BP is 120 mm Hg, and the diastolic pressure is 60 mm Hg. Which value is the mean arterial pressure (MAP)? 40 mm Hg 60 mm Hg 80 mm Hg 100 mm Hg

80 mm Hg The MAP is the average pressure within the arterial system that is felt by organs in the body. It does not refer to the mean of systolic BP (SBP) and diastolic BP (DBP). The MAP can be calculated by (SBP + 2DBP) ÷ 3. Therefore if the SBP is 120 and the DBP is 60, the MAP should be (120 + 2 × 60)/3, which is equal to (120 + 120)/3 = 80 mm Hg.

Which aspect of the heart's action does the QRS complex on the ECG represent? Depolarization of the atria Repolarization of the ventricles Depolarization from atrioventricular (AV) node throughout ventricles The length of time it takes for the impulse to travel from the atria to the ventricles

Depolarization from atrioventricular (AV) node throughout ventricles Rationale: The QRS recorded on the ECG represents depolarization from the AV node throughout the ventricles. The P wave represents depolarization of the atria. The T wave represents repolarization of the ventricles. The interval between the PR and QRS represents the length of time it takes for the impulse to travel from the atria to the ventricles.

The nurse provides postprocedural care to a patient admitted to an inpatient unit after cardiac catheterization. Which assessment is the highest priority? Determining the level of pain Checking for sensation in the feet Verifying the patency of the IV site Inspecting the procedure puncture site

Inspecting the procedure puncture site The highest priority for a patient who has undergone cardiac catheterization, upon arrival to the nursing unit, is to first assess the catheterization site for signs of hemorrhage. Assessments of pain, sensation, and the IV site are all important assessments, but they are of lower priority than checking the cardiac catheterization site.

The registered nurse observes another health care provider performing a cardiac assessment on a patient. Which activity by the health care provider would the nurse question? Documents a normal peripheral pulse as 2+ Identifies that a capillary refill of three seconds is abnormal Uses the diaphragm of the stethoscope to auscultate for S1 and S2 heart sounds Inspects the neck veins while swiftly moving the patient from supine to upright

Inspects the neck veins while swiftly moving the patient from supine to upright To assess for jugular vein distention, the health care provider should inspect the large veins in the neck while the patient is gradually moved from a supine position to an upright (30- to 45-degree position). The patient should not be repositioned too quickly. When a normal peripheral pulse is a normal force, it should be documented as 2+. A capillary refill should occur in less than two seconds with normal tissue perfusion and cardiac output (CO). S1 and S2 are heard best with the diaphragm of the stethoscope because they are high-pitched sounds.

Asymmetry in limb circumference

Measurable swelling of involved limb Possible etiologies: venous thromboembolism varicose veins lymphedema

Measuring BP

Measure BP bilaterally. Readings can vary from 5 to 15 mm Hg between arms. Use the arm with the highest BP for later measurements. Obtain an orthostatic (postural) BP and HR: -supine -sitting with legs dangling -standing SBP should not decrease more than 20 mm Hg from the supine to the standing position. HR should not increase more than 20 beats/min from the supine to the standing position.

Which technique would the nurse use to assess for the presence of a pulse deficit? Ask the patient to take a deep breath and hold it. Position the patient supine and palpate the pedal pulses. Palpate the radial pulse while auscultating the apical pulse. Use the bell of the stethoscope when auscultating S1 and S2.

Palpate the radial pulse while auscultating the apical pulse. To detect a pulse deficit, simultaneously palpate the radial pulse when auscultating the apical area. Palpating the pedal pulses will not indicate a pulse deficit. It is not necessary to ask the patient to hold his or her breath during cardiac auscultation. The diaphragm is more appropriate than the bell when auscultating S1 and S2.

The nurse observes a bluish tinge around the ears of a patient with cardiovascular disease. Which condition is likely to be present? Diabetes Endocarditis Vasoconstriction Venous thromboembolism

Vasoconstriction A bluish tinge around the ears or in the ears indicates peripheral cyanosis, which is characterized by vasoconstriction. Vasoconstriction is the narrowing of blood vessels as a result of the contraction of the muscular walls of the vessels, resulting in reduced blood flow. This reduced blood flow will result in insufficient oxygen supply by the heart to other parts of the body, causing a bluish tinge in the extremities of ears. Diabetes causes ulcers in patients with cardiovascular disease. Endocarditis causes clubbing of the nail beds. Venous thromboembolism results in asymmetry in limb circumference.

Diastole

relaxation of the myocardium allows for filling of the ventricles relaxation phase of the heart

Korotkoff sounds

sounds of turbulent blood flow through a compressed artery

Heaves

sustained lifts of the chest wall in the precordial area that you can see or palpate. They may be caused by left ventricular hypertrophy. Normally no pulsations are seen or felt here.

Systolic blood pressure (SBP)

systolic blood pressure (SBP) is the peak pressure exerted against the arteries when the heart contracts Normal BP is SBP <120 mm Hg and DBP <80 mm Hg4 The main factors influencing BP are CO and systemic vascular resistance (SVR)

Which anatomic feature of the heart directly stimulates ventricular contractions? SA node AV node Bundle of His Purkinje fibers

Purkinje fibers Rationale: The Purkinje fibers move the electrical impulse or action potential through the walls of both ventricles triggering synchronized right and left ventricular contraction. The sinoatrial (SA) node initiates the electrical impulse that results in atrial contraction. The atrioventricular (AV) node receives the electrical impulse through internodal pathways. The bundle of His receives the impulse from the AV node.

Mean Arterial Pressure (MAP)

the average pressure within the arterial system that is felt by organs in the body. It is not the average of the DBP and SBP, because the length of diastole exceeds that of systole at normal HRs. MAP is calculated as follows: MAP = (SDB + 2DB) / 3

Which action does the T wave in a patient's electrocardiogram (ECG) represent? Depolarization of the atria Repolarization of the ventricles Repolarization of the Purkinje fibers Delayed repolarization in hypokalemia

Repolarization of the ventricles On an ECG, the T wave represents repolarization of the ventricles. Depolarization of the atria is represented by the P wave. The U wave, if present, can represent either repolarization of the Purkinje fibers or hypokalemia.

QRS complex

Represents depolarization from the AV node throughout the ventricles. There is a delay of impulse transmission through the AV node that accounts for the time between the beginning of the P wave and the beginning of the QRS wave.

Which artery supplies the atrioventricular (AV) node and the bundle of His in most people? Circumflex artery Right coronary artery Left main coronary artery Left anterior descending artery

Right coronary artery The right coronary artery supplies blood to the bundle of His and the AV node in the heart for 90% of the population, and a blockage of this artery can affect the blood supply to the bundle of His. The circumflex artery, left main coronary artery, and left anterior descending artery do not supply blood to the bundle of His.

Ejection fraction (EF)

the percentage of end-diastolic blood volume that is ejected during systole, can be measured. The EF provides information about the function of the left ventricle during systole.

murmur

turbulent blood flow across the affected valve results

What position should the nurse place the patient in to auscultate for signs of acute pericarditis? Supine without a pillow Sitting and leaning forward Left lateral side-lying position Head of bed at a 45-degree angle

Sitting and leaning forward Rationale: A pericardial friction rub indicates pericarditis. To auscultate a pericardial friction rub, the patient should be sitting and leaning forward. The nurse will hear the pericardial friction rub at the end of expiration.

Splinter hemorrhages

Small red to black streaks under fingernails Possible etiologies: Infective endocarditis (infection of endocardium, usually in area of cardiac valves)

Rigidity pulse

Stiffness or inflexibility of vessel wall Possible etiology: Atherosclerosis

A patient is admitted to the hospital with chest pain. Which diagnostic studies would the nurse expect to be prescribed? Select all that apply. Stress test Chest x-ray Funduscopy Electrocardiogram Electroencephalogram

Stress test Chest x-ray Electrocardiogram A patient with chest pain undergoes tests to assess cardiovascular status. A stress test shows the function of the heart under stress or exercise. A chest x-ray helps one to understand the status of structures in the chest and can assist in understanding any abnormality. An electrocardiogram helps one to understand the electrical activity of the heart and is extremely important while assessing a patient with cardiac troubles. A funduscopy is done to examine the eyes and is not related to the cardiovascular system. An electroencephalogram is done to examine the brain and neurologic system.

A patient's BP is 90/50. What is the patient's mean arterial pressure (MAP)? Record the answer by rounding to the nearest whole number. ____

The MAP is 63: (90 + 2(50))/3 = 63.

The BP of a patient is 90/60 mm Hg. What should the nurse document as the patient's pulse pressure? Record the answer using a whole number. ________ mm Hg

The difference between the systolic BP (SBP) and diastolic BP (DBP) is the pulse pressure. The patient's SBP is 90, and the DBP is 60; therefore the pulse pressure is 90 - 60 = 30 mm Hg.

The nurse is performing an assessment for a patient with fatigue and shortness of breath. Auscultation reveals a heart murmur. What does this assessment finding indicate? Increased viscosity of the patient's blood Turbulent blood flow across a heart valve Friction between the heart and the myocardium A deficit in conductivity impairs normal contractility

Turbulent blood flow across a heart valve Rationale: Turbulent blood flow across the affected valve results in a murmur. A murmur is not a direct result of variances in blood viscosity, conductivity, or friction between the heart and myocardium.

Which abnormality is likely to result in a heart murmur? Increased viscosity of the patient's blood Turbulent blood flow across a heart valve Friction between the heart and the pericardium A deficit in heart conductivity that impairs contractility

Turbulent blood flow across a heart valve Turbulent blood flow across the affected valve results in a murmur. A murmur is not a direct result of variances in blood viscosity or conductivity. Friction between the heart and pericardium may cause an audible friction rub.

Arterial bruit

Turbulent flow sound in peripheral artery Possible etiologies: Arterial obstruction or aneurysm

Heart murmurs

Turbulent sounds occurring between normal heart sounds. Characterized by loudness, pitch, shape, quality, duration, timing Possible etiologies: heart valve disorder abnormal blood flow patterns

Which action does the QRS complex represent in an electrocardiogram? Depolarization of the atria Repolarization of the ventricles Depolarization of both ventricles Repolarization of the Purkinje fibers

Depolarization of both ventricles An electrocardiogram is commonly used to detect abnormal heart rhythms and to investigate the cause of chest pain. The time taken for depolarization of both the ventricles is represented by the QRS interval. Depolarization of the atria is represented by the P wave. The T wave in the electrocardiogram should be upright, and it represents the time for ventricular repolarization. If present, the U wave indicates the repolarization of the Purkinje fibers.

Mechanical heart system

Depolarization triggers mechanical activity. Systole, contraction of the heart muscle, results in ejection of blood from the ventricles. Relaxation of the heart muscle, diastole, allows for filling of the ventricles. Cardiac output (CO) is the amount of blood pumped by each ventricle in 1 minute. It is calculated by multiplying the amount of blood ejected from the ventricle with each heartbeat: CO = SV X HR per min. For the normal adult at rest, CO is maintained in the range of 4 to 8 L/min. Cardiac index (CI) is the CO divided by the body surface area (BSA). The CI reflects the relative CO for the body size. The normal CI is 2.8 to 4.2 L per minute per meter squared (L/min/m2)

A patient's pulmonary artery is blocked and damaged. Which consequence will the patient experience first? Impaired flow of deoxygenated blood to the lungs Impaired flow of oxygenated blood away from the lungs Impaired flow of oxygenated blood from the aorta to all body parts Impaired flow of deoxygenated blood from the right atrium to the right ventricle

Impaired flow of deoxygenated blood to the lungs The pulmonary artery carries deoxygenated blood from the right ventricle of the heart to the lungs. Therefore damage to the pulmonary artery leads to impaired flow of deoxygenated blood from the right side of the heart initially (on its way to the lungs). Subsequently, it impairs the flow of oxygenated blood away from the lungs and from the systemic aorta to all other body parts. Blood flow between the right atrium and the ventricle would not be affected unless blood begins to back up through the system later.

Which action should the nurse implement with auscultation during a patient's cardiovascular assessment? Position the patient supine. Ask the patient to hold their breath. Palpate the radial pulse while auscultating the apical pulse. Use the bell of the stethoscope when auscultating S1 and S2.

Palpate the radial pulse while auscultating the apical pulse. Rationale: To detect a pulse deficit, simultaneously palpate the radial pulse when auscultating the apical area. The diaphragm is more appropriate than the bell when auscultating S1 and S2. A sitting or side-lying position is most appropriate for cardiac auscultation. It is not necessary to ask the patient to hold their breath during cardiac auscultation.

Which question would the nurse ask to assess a patient for orthopnea? "How many times do you get up at night to urinate?" "How many pillows do you use for sleeping at night?" "Do you get awakened by shortness of breath at night?" "Are you comfortable walking and talking at the same time?"

"How many pillows do you use for sleeping at night?"

How will the nurse document a weakly palpable pulse? 0 1+ 3 2+ 3+

A weak pulse in a patient with cardiovascular disease is indicated by 1+. The absence of a pulse is indicated by 0. A normal pulse rate is indicated by 2+, and 3+ indicates an increased, full, bounding pulse.

Which are the major factors that influence BP? Select all that apply. Capillary refill Cardiac output Oxygen saturation Pulmonary pressure Systemic vascular resistance

Cardiac output Systemic vascular resistance The two main factors influencing BP are cardiac output and systemic vascular resistance. Capillary refill, oxygen saturation, and pulmonary pressure do not influence BP.

Which assessment finding would the nurse expect for a patient with ventricular hypertrophy? Hypotension Increased cardiac output Cardiac output of 4 L/min/m2 Increased size of the heart chambers

Cardiac output of 4 L/min/m2 The patient with ventricular hypertrophy has an enlargement of the heart muscle without an increase in cardiac output (CO) or the size of the chambers. The normal CO is 2.8 to 4.2 L/min/m2. The patient experiences elevated BP, not hypotension. If the arterial BP is elevated, the ventricles meet increased resistance to the ejection of blood, thus increasing the work demand of the heart, causing the muscles of the heart to enlarge. The enlargement occurs in the walls without an increase in the size of the chambers.

Which condition would the nurse suspect if a U wave is present on a patient's electrocardiogram? Hypothermia Hypokalemia Hypocalcemia Hypothyroidism

Hypokalemia The U wave appears and exceeds the T-wave amplitude in the electrocardiogram if the serum potassium level in the blood is less than 3 mEq/L. Because the normal potassium levels in the blood are in the range of 3.5 to 5.0, the presence of a U wave indicates hypokalemia. The presence of a U wave does not indicate altered body temperature or hypothermia. A U wave may be seen during hypercalcemia but not during hypocalcemia. A U wave does not indicate decreased thyroxine levels or hypothyroidism.

The nurse identifies a U wave on a patient's electrocardiogram. Which dietary instruction will be beneficial to the patient? Use raw coconut oil for cooking. Increase consumption of bananas. Increase consumption of milk products. Increase consumption of foods with omega-3 oils.

Increase consumption of bananas. The presence of a U wave in the patient's electrocardiogram may indicate hypokalemia or repolarization of the Purkinje fibers. Hypokalemia can be caused by excessive sweating, diarrhea, or excessive laxative use. Bananas are a rich source of potassium. Therefore increasing the consumption of bananas will be beneficial for the patient. Coconut oil increases digestion and bowel function. Raw and virgin coconut oil have a laxative effect and should not be recommended. Milk and milk products like cheese are rich in sodium but not in potassium. Omega-3 oils help flush toxins out of the body. Therefore increasing the consumption of omega-3 oils would produce a laxative effect in the patient and potentiate hypokalemia.

A patient at risk for cardiovascular disease has splinter hemorrhages. Which condition is consistent with this finding? Varicose veins Arteriosclerosis Vasoconstriction Infective endocarditis

Infective endocarditis Splinter hemorrhages are small, red-to-black streaks under the fingernails that indicate the presence of infective endocarditis. Ulcers in a patient with a risk for cardiovascular disease indicate varicose veins or arteriosclerosis. Peripheral cyanosis indicates vasoconstriction.

Which area is the site of impaired blood flow for a patient who has a mitral valve disorder? Vena cava and right atrium Left atrium and left ventricle Right atrium and right ventricle Right ventricle and pulmonary artery

Left atrium and left ventricle The mitral valve is located between the left atrium and the left ventricle. Blood flow would not be impaired between the vena cava and right atrium, right ventricle and pulmonary artery, or right atrium and right ventricle in a patient with mitral valve disorder.

Which finding in a patient's laboratory reports supports a conclusion that the patient is at high risk for myocardial injury? Creatine kinase (CK)-MB value of 2% Troponin I value of 3.5 ng/mL Cholesterol value of 250 mg/dL B-type natriuretic peptide (BNP) value of 140 pg/mL

Troponin I value of 3.5 ng/mL Troponin is a contractile protein released after a myocardial infarction. If the value of troponin I is greater than 2.3 ng/mL, it indicates that the patient is at high risk for myocardial injury. A CK-MB value greater than 4% to 6% indicates myocardial infarction. A cholesterol value of 250 mg/dL indicates cardiovascular heart disease. A b-type natriuretic peptide (BNP) value of 140 pg/mL indicates heart failure.

Which abnormality is likely to result in a heart murmur? Increased viscosity of the patient's blood Turbulent blood flow across a heart valve Friction between the heart and the pericardium A deficit in heart conductivity that impairs contractility

Turbulent blood flow across a heart valve Turbulent blood flow across the affected valve results in a murmur. A murmur is not a direct result of variances in blood viscosity or conductivity. Friction between the heart and pericardium may cause an audible friction rub.

Which manifestation would the nurse expect in an elderly patient with arterial stiffening? Widened pulse pressure Decreased venous tortuosity Decreased systolic BP Thinning of the intima of the arteries

Widened pulse pressure Arterial stiffening in the elderly patient results in loss of arterial compliance and increases pulse wave velocity, resulting in widened pulse pressure. The presence of inflamed, painful, or cordlike varicosities indicates increased venous tortuosity. Arterial stiffening can result in increased systolic BP. Arterial stiffening is caused by a loss of elastin in arterial walls and subsequent thickening of the intima of the arteries.

A patient's baseline heart rate is 85 beats/min. Which heart rate would indicate sympathetic nervous system stimulation in this patient? Heart rate of 50 beats/min Heart rate of 70 beats/min Heart rate of 80 beats/min Heart rate of 110 beats/min

Heart rate of 110 beats/min Stimulation of the sympathetic nervous system increases heart rate. The normal heart rate is in the range of 60 to 100 beats/min. Therefore the patient with a heart rate of 110 beats/min has a stimulated sympathetic nervous system. Stimulation of the sympathetic nervous system does not decrease the patient's heart rate. Therefore the heart rate of 50 beats/min does not indicate stimulation of the patient's sympathetic nervous system. The heart rates of 70 and 80 beats/min are normal findings and do not indicate stimulation of the patients' sympathetic nervous systems.

The nurse is providing information about potential complications to a patient who is scheduled for a transesophageal echocardiography (TEE). Which information would the nurse include? Select all that apply. Hemorrhage Dysrhythmias Renal impairment Transient hypoxemia High levels of lactate dehydrogenase

Hemorrhage Dysrhythmias Transient hypoxemia TEE evaluates mitral valve disease and endocarditis vegetation in the patient. Complications of this procedure include tearing of the esophagus, hemorrhage, dysrhythmias, and transient hypoxemia. Some contrast media cause nephrotoxicity in patients; however, transesophageal echocardiography does not involve the injection of contrast medium into the patient's heart. Increased levels of lactate dehydrogenase are not a complication of the procedure.

A nurse is reviewing a patient's laboratory results: blood cholesterol level of 350 mg/dL, homocysteine level of 14 µmol/L, b-type natriuretic peptide (BNP) of 90 pg/mL, cardiac troponin I (cTnI) level of 0.3 ng/mL, myoglobin level of 16 mcg/L, and C-reactive protein of 4 mg/L. Which interpretation would the nurse reach from these laboratory results? Heart failure Pulmonary complications Myocardial infarction (MI) High risk of cardiac disease

High risk of cardiac disease The patient has a high risk of developing cardiovascular disease, as evidenced by the high cholesterol levels, the homocysteine levels, and the C-reactive protein level. High cholesterol levels directly impact the heart and the blood vessels. A high homocysteine level indicates amino acid production during protein catabolism. It can harm the endothelium. C-reactive protein is a marker of inflammation, and a level of 4 mg/L indicates a high risk of cardiac disease. A normal level of BNP also rules out pulmonary complications. The BNP level is normal, thus ruling out heart failure. The patient has normal levels of troponin and myoglobin, which are indicators of myocardial injury; therefore the patient has not had an MI.

Pericardial friction rub

High-pitched, scratchy sound heard during S1 and/or S2 at the apex. Heard best with patient sitting and leaning forward, and while holding breath at the end of expiration Possible etiology: Pericarditis

A patient with a history of myocardial infarction is scheduled for a transesophageal echocardiogram to visualize a suspected clot in the left atrium. What information should the nurse include when teaching the patient about this diagnostic study? IV sedation may be administered to help the patient relax. Food and fluids are restricted for 2 hours before the procedure. Ambulation is restricted for up to 6 hours before the procedure. Contrast medium is injected into the esophagus to enhance images.

IV sedation may be administered to help the patient relax. Rationale: IV sedation is administered to help the patient relax and ease the insertion of the tube into the esophagus. Food and fluids are restricted for at least 6 hours before the procedure. Smoking and exercise are restricted for 3 hours before exercise or stress testing but not before TEE. Contrast medium is administered IV to evaluate the direction of blood flow if a septal defect is suspected.

The nurse is providing care for a patient who has decreased cardiac output due to heart failure. As a basis for planning care, what should the nurse understand about cardiac output (CO)? CO is calculated by multiplying the patient's stroke volume by the heart rate. CO is the average amount of blood ejected during one complete cardiac cycle. CO is determined by measuring the electrical activity of the heart and the heart rate. CO is the patient's average resting heart rate multiplied by the mean arterial blood pressure.

CO is calculated by multiplying the patient's stroke volume by the heart rate. Rationale: Cardiac output is determined by multiplying the patient's stroke volume by heart rate, thus identifying how much blood is pumped by the heart over a 1-minute period. Electrical activity of the heart and blood pressure are not direct components of cardiac output.

Effects of aging on cardiovascular system

CVD is the leading cause of death in adults older than age. -most common CV problem is coronary artery disease (CAD) due to atherosclerosis. Physiologic changes in the cardiovascular system are a result of combined effects: aging process disease environmental factors lifetime health behaviors 1. amount of collagen in the heart increases and elastin decreases. These changes affect the heart muscle's ability to stretch and contract One major change: 2. Response to physical or emotional stress. -increased stress: CO and SV decrease due to reduced contractility and HR response. Aging does not really affect the resting supine HR. When the patient changes positions (e.g., sits upright), the sympathetic nerve pathway results in a blunted (reduced) HR response. 3. Heart valves become thicker and stiffer from: lipid accumulation degeneration of collagen fibrosis -aortic and mitral valves are most often affected. -changes result in either regurgitation of blood when the valve should be closed or narrowing of the orifice of the valve (stenosis) when the valve should be open. The turbulent blood flow across the affected valve results in a murmur. 4. Numbers of pacemaker cells in the SA node and conduction cells in the internodal tracts, bundle of His, and bundle branches decrease with age. -changes contribute to the development of sinus and atrial dysrhythmias and heart blocks. Many older adults have an abnormal resting ECG that shows increases in the PR, QRS, and/or QT intervals. 5. The ANS control of the cardiovascular system changes with aging. 6. The number and function of β-adrenergic receptors in the heart decrease with age. -not only has a decreased response to physical and emotional stress but also is less sensitive to β-adrenergic agonist drugs. 7. Exercise results in a much smaller increase in CO for older adults than for younger adults. 8. arteries and veins thicken and become less elastic. Arteries increase their sensitivity to vasopressin (antidiuretic hormone). Both changes increase SBP with a decreased or unchanged DBP, increasing the pulse pressure. Valves in the large leg veins do not return the blood to the heart as effectively, often resulting in dependent edema. Orthostatic hypotension -may be related to drugs and/or decreased baroreceptor function. Postprandial hypotension -decrease in BP of at least 20 mm Hg that occurs within 75 minutes after eating -may occur in otherwise healthy older adults. Both orthostatic and postprandial hypotension may be related to falls in older adults.

Capillaries

Capillaries connect the arterioles and venules. The thin capillary wall, made up of endothelial cells, has no elastic or muscle tissue The exchange of cellular nutrients and metabolic end products takes place through these thin-walled vessels.

Which portion of the vascular system exchanges cellular nutrients and metabolic end products? Capillary vessels Smooth muscle of the arteriole Endothelial layer of the arteries Elastic middle layer of the veins

Capillary vessels The exchange of cellular nutrients and metabolic end products takes place through the thin-walled capillaries, which connect the arterioles and the venules. Exchange of cellular nutrients and metabolic end products does not occur in the arteriole, arteries, or veins.

Chemoreceptors

Chemoreceptors are found in the aortic and carotid bodies and the medulla. They can cause changes in respiratory rate and BP in response to increased arterial CO2 pressure (hypercapnia) and, to a lesser degree, decreased plasma pH (acidosis) and arterial O2 pressure (hypoxia). Chemoreceptors in the medulla stimulate the vasomotor center to increase BP.

Blood pressure

arterial blood pressure - measure of the pressure exerted by blood against the walls of the arterial system. systolic blood pressure (SBP) - the peak pressure exerted against the arteries when the heart contracts. diastolic blood pressure (DBP) - the residual pressure in the arterial system during ventricular relaxation (or filling). main factors influencing BP: -CO -systemic vascular resistance (SVR): SVR is the force opposing the movement of blood. This force is created primarily in small arteries and arterioles. Normal BP is SBP <120 mm Hg and DBP <80 mm Hg4

Which heart valve sound is heard best at the left midclavicular line at the level of the fifth ICS? a. Aortic b. Mitral c. Tricuspid d. Pulmonic

b Rationale: Assess the mitral valve by auscultating at the left midclavicular line at the fifth intercostal space (ICS).

A P wave on an ECG represents an impulse arising at the a. SA node and repolarizing the atria. b. SA node and depolarizing the atria. c. AV node and depolarizing the atria. d. AV node and spreading to the bundle of His.

b Rationale: The first wave, P, begins with the firing of the sinoatrial (SA) node. It represents depolarization of the fibers of the atria.

The part of the vascular system responsible for hemostasis is the a. thin capillary vessels. b. endothelial layer of the arteries. c. elastic middle layer of the veins. d. smooth muscle of the arterial wall.

b Rationale: The innermost lining of the arteries is the endothelium. The endothelium maintains hemostasis, promotes blood flow, and under normal conditions, inhibits blood coagulation.

Which subjective data related to the cardiovascular system should be obtained from the patient (select all that apply)? a. Annual income b. Smoking history c. Religious preference d. Number of pillows used to sleep e. Blood for basic laboratory studies

b, c, d Rationale: The health history should include assessment of tobacco use. Ask the patient about any cultural or religious beliefs that may influence the management of the cardiovascular problem. Patients with heart failure may need to sleep with the head elevated on pillows or sleep in a chair.

Cardiac Biomarkers (labs)

b-Type natriuretic peptide (BNP) <100 pg/mL (100 pmol/L) Peptide that causes natriuresis. High in HF. Levels increased after nesiritide (Natrecor) infusion and for 1 month after cardiac surgery. CK-MB Concentrations <4%-6% of total creatine kinase (CK) Tests for myocardial cell injury. High levels highly indicative of MI. Serum levels increase within 3-6 hr after MI, peak after 12-24 hours, normalize within 48 hours. Explain purpose of serial sampling. Copeptin <10 pmol/L Reflects arginine vasopressin (AVP) concentration. High levels highly indicative of MI. Higher in men, after exercise, and with stress. Influenced by fasting and water load. C-reactive protein (CRP) High-sensitivity (hs) CRP assay. Lowest risk: <1 mg/dL Moderate risk: 1-3 mg/dL High risk: >3 mg/dL Marker of inflammation. May help predict risk for cardiac disease and cardiac events such as an acute MI. High in bacterial infections and inflammatory disorders. Homocysteine 4-14 μmol/L Levels may increase with age Amino acid made during protein catabolism. Risk factor for cardiovascular disease. Associated with vitamin B12 and folate deficiencies. NT-Pro-BNP ≤74 yr: 124 pg/mL >75 yr: 449 pg/mL Helps to assess severity of HF. Levels are higher in women and patients with renal insufficiency. Troponin (cardiac) Troponin T (cTnT) <0.1 ng/mL (<0.1 mcg/L) Troponin I (cTnI) Negative: <0.03 ng/mL (<0.03 mcg/L) Contractile proteins released after an MI. Both troponin T and troponin I test for cardiac injury/ischemia. Serial sampling needed: draw 3 sets of troponins 3-6 hours apart.

An expected finding in the assessment of an 81-year-old patient is a. a narrowed pulse pressure. b. diminished carotid artery pulses. c. difficulty isolating the apical pulse. d. an increased heart rate in response to stress.

c Rationale: Myocardial hypertrophy and the downward displacement of the heart in an older adult may cause difficulty in isolating the apical pulse.

A patient with a tricuspid valve disorder has impaired blood flow between the a. vena cava and right atrium. b. left atrium and left ventricle. c. right atrium and right ventricle. d. right ventricle and pulmonary artery.

c. Rationale: The tricuspid valve is found between the right atrium and right ventricle.

Irregular pulse

irregular or irregularly irregular. Skipped beats Possible etiology: Dysrhythmias

Arteries and Arterioles

large arteries -have thick walls composed mainly of elastic tissue This elastic property cushions the impact of the pressure created by ventricular contraction and provides recoil that propels blood forward into the circulation. Large arteries contain some smooth muscle. Examples of large arteries aorta pulmonary artery Arterioles -have more smooth muscle -little elastic tissue Arterioles serve as the major control of arterial BP and distribution of blood flow. They respond readily to local conditions such as low oxygen (O2) and increasing levels of carbon dioxide (CO2) by dilating or constricting. The innermost lining of the arteries is the endothelium. The endothelium -maintains hemostasis -promotes blood flow -under normal conditions, inhibits blood coagulation. When the endothelial surface is disrupted (e.g., rupture of an atherosclerotic plaque), the coagulation cascade is initiated and results in the formation of a fibrin clot.

The nurse is assessing a patient who has suspected cardiac failure. Which questions would the nurse ask related to the patient's sleep-rest pattern? Select all that apply. "Do you need to sleep upright in a chair?" "How long does it take you to fall asleep?" "Do you fall asleep with the television on?" "How many pillows do you need to sleep at night?" "Do you exercise within two hours of going to bed?

"Do you need to sleep upright in a chair?" "How many pillows do you need to sleep at night?" Many patients with heart failure need to sleep upright in a chair or with several pillows. The nurse would note the number of pillows needed to sleep or the need to sleep upright (orthopnea) and whether this has changed recently. Indications of insomnia and sleeping habits (e.g., how long it takes to fall asleep, falling asleep with the television on, exercising before going to bed) are not part of the assessment for cardiovascular problems.

The nurse is performing a health history on a patient with cardiovascular disease. Which questions reflect the Health Perception-Health Management functional health pattern? Select all that apply. "Do you use recreational drugs?" "How long have you been married?" "Have you lost or gained any weight recently?" "Do you drink alcoholic beverages? How often?" "Do you use extra pillows when you sleep? How many?" "How many years have you smoked, and how many packs a day?"

"Do you use recreational drugs?" "Do you drink alcoholic beverages? How often?" "How many years have you smoked, and how many packs a day?" Questions about smoking history, alcohol use, and any use of habit-forming drugs, including recreational drugs, reflect the Health Perception-Health Management functional health pattern. Questions about marriage reflect the Role-Relationships functional health pattern. Questions about weight gain or loss reflect the Nutritional-Metabolic health pattern. The use of extra pillows for sleep may be indicative of heart failure and reflects the Sleep-Rest health pattern.

Which statement made by the patient scheduled for a transesophageal echocardiogram (TEE) indicates the need for more instruction? "I will remove my dentures before the test." "My spouse will drive me home after the test is completed." "I can't eat or drink anything for six hours before this test." "I will be able to have lunch as soon as the test is finished."

"I will be able to have lunch as soon as the test is finished." The patient may not eat or drink until the gag reflex has returned. Patient instructions for a TEE include remaining nothing NPO for at least six hours before the test, removing dentures, and having a designated driver if the patient has the test as an outpatient.

A patient with a myocardial infarction is preparing for discharge following successful treatment. Which information is important for the nurse to include in the discharge teaching related to elimination? "A goal is to have a bowel movement only once a day." "It is important to avoid straining during bowel movements." "A goal is to not have bowel movements immediately after eating." "It will be necessary to take a medication daily to regulate the bowels."

"It is important to avoid straining during bowel movements." It is extremely important that the patient doesn't strain during bowel movements. Straining during bowel movements puts pressure on the heart for circulation of blood. This can aggravate heart troubles. Passing stools more than once a day and passing stools after eating are safe. Advising the patient to take unsupervised over-the-counter (OTC) drugs is not advisable because they can be detrimental to the patient's health.

Which instruction would the nurse give to a patient who is scheduled for Holter monitoring? "Keep a diary of all activities and symptoms." "Remove the monitor only to shower or bathe." "Refrain from exercising while wearing this monitor." "Connect the monitor whenever you feel symptoms."

"Keep a diary of all activities and symptoms." A Holter monitor is worn continuously for at least 24 hours while a patient continues with usual activity and keeps a diary of activities and symptoms. The patient should not take a bath or shower while wearing this monitor. Normal patient activity is encouraged to stimulate conditions that produce symptoms. Event monitoring involves the starting of a recording as soon as symptoms begin or as soon thereafter as possible.

Which instructions would the nurse provide to a patient who is scheduled for a transesophageal echocardiogram (TEE)? Select all that apply. "Remove dentures prior to the test." "Refrain from tobacco use 24 hours before the test." "It is permissible to eat light meals between the scans." "Withhold caffeine products for 12 hours before the test." "Consume nothing by mouth for six hours before the test."

"Remove dentures prior to the test." "Consume nothing by mouth for six hours before the test." TEE is a diagnostic test for cardiovascular assessment in which a probe with a transducer at the tip is swallowed, and the health care provider controls the angle and depth. The patient should remove dentures prior to the test to prevent partial airway obstruction by dislodgement of dentures. The patient should be on NPO status for six hours before the test to minimize the risk of vomiting and aspiration. Patients should refrain from tobacco use for 24 hours before undergoing positron emission tomography (PET), not before TEE. Light meals can be taken between scans during exercise nuclear imaging, not during TEE. Caffeine products should be withheld for 12 hours before pharmacologic nuclear imaging, not before TEE.

The patient tells the nurse that he does not understand how there can be a blockage in the left anterior descending artery (LAD), but there is damage to the right ventricle. What is the best response by the nurse? "One coronary vessel curves around and supplies the entire heart muscle." "The LAD supplies blood to the left side of the heart and part of the right ventricle." "The right ventricle is supplied during systole primarily by the right coronary artery." "It is actually on the right side of the heart, but we call it the left anterior descending vessel."

"The LAD supplies blood to the left side of the heart and part of the right ventricle." Rationale: The best response is explaining that the lower portion of the right ventricle receives blood flow from the left anterior descending artery as well as the right coronary artery during diastole.

The patient reports being confused about how there can be a blockage in the left anterior descending artery (LAD) although there is damage to the right ventricle. Which explanation would the nurse give? "The LAD blood vessel supplies all of the blood to both ventricles." "The left ventricle is supplied primarily by the right coronary artery." "The LAD supplies blood to the left side of the heart and part of the right ventricle." "It is actually on your right side of the heart, but we call it the left anterior descending vessel."

"The LAD supplies blood to the left side of the heart and part of the right ventricle." The lower portion of the right ventricle receives blood flow from the left anterior descending artery as well as the right coronary artery during diastole. Both ventricles are not completely supplied by the same vessel because there are three major vessels supplying the two ventricles. The left ventricle is supplied primarily by the LAD and circumflex arteries. The LAD is on the left side of the heart.

A patient with angina is scheduled for a stress test. Which instructions should the nurse give to the patient regarding the test? Select all that apply. "Wear comfortable clothes and shoes for the test." "Refrain from smoking for three hours before the test." "Do not engage in strenuous exercise for three hours before the test." "Do not consume caffeinated food or drinks for an hour before the test." "Report any uncomfortable symptoms that you experience during the test."

"Wear comfortable clothes and shoes for the test." "Refrain from smoking for three hours before the test." "Do not engage in strenuous exercise for three hours before the test." "Report any uncomfortable symptoms that you experience during the test." The patient scheduled for a stress test should not smoke for three hours before the test. Smoking may alter the oxygen-carrying capacity of the blood and result in an increased workload of the heart. This can interfere with accurate test results. Engaging in strenuous exercise also increases the activity of the heart and interferes with the stress test. The patient should wear comfortable clothes and shoes for walking and running during the test. The patient should immediately report any discomfort experienced during the test, which can indicate undue stress on the heart. In such a case, the test would need to be discontinued. Caffeine-containing foods and fluids should be avoided for 24 hours before the test because they can interfere with the test results.

A patient with cardiovascular disease is scheduled for a triglyceride test. Which preprocedural instructions would the nurse give? Select all that apply. "Avoid tobacco use for 24 hours before the test." "You are permitted to drink water before the test." "Avoid consuming alcohol for 24 hours before the test." "You are permitted to eat a light breakfast before the test." "Retain as much urine in your bladder as possible before the test

"You are permitted to drink water before the test." "Avoid consuming alcohol for 24 hours before the test." A triglyceride test should be performed in a fasting state, but the patient can drink water. Alcohol consumption will raise triglyceride blood levels by producing more fatty acids from the liver. Therefore the nurse would instruct the patient to drink water and to withhold alcohol for 24 hours before the test. Voiding will not affect the triglyceride levels in the blood. Tobacco should be withheld for 24 hours before positron emission tomography (PET). The test should be performed on the patient in a fasting state for 12 hours, and the patient should avoid milk or food except for water.

A patient with a history of angina is being treated with nitrates and β-adrenergic receptor blockers (β-blockers). Which important information would the nurse give to the patient regarding sexuality? "Stop taking β-blockers because they can cause impotence." "Stop taking nitrates when planning to have sexual intercourse." "You cannot take erectile dysfunction (ED) drugs like sildenafil." "You cannot have sexual intercourse while taking these medicines."

"You cannot take erectile dysfunction (ED) drugs like sildenafil." The nurse should advise the patient to avoid taking ED drugs such as sildenafil. This is because the combination of ED drugs and nitrates can cause significant hypotension. β-Blockers may cause ED; however, the drug should not be stopped without consulting the health care provider. Discontinuing nitrates can worsen the angina. The patient should not be asked to avoid intercourse.

Which instruction by the nurse to a patient who is about to undergo Holter monitoring is accurate? "You may remove the monitor only to shower or bathe." "You should connect the monitor whenever you feel symptoms." "You should refrain from exercising while wearing this monitor." "You will need to keep a diary of your activities and symptoms."

"You will need to keep a diary of your activities and symptoms." Rationale: A Holter monitor is worn continuously for at least 24 hours while a patient continues with usual activity and keeps a diary of activities and symptoms. The patient should not take a bath or shower while wearing this monitor.

Which is the order in which the blood flows through the heart? 1. To the left atrium through the pulmonary veins 2. Through the mitral valve and into the left ventricle 3. Through the tricuspid valve into the right ventricle 4. Through the pulmonic valve into the pulmonary artery and to the lungs 5. Through the aortic valve into the aorta and then into the systemic circulation 6. From the inferior and superior venae cavae and the coronary sinus into the right atrium

1. From the inferior and superior venae cavae and the coronary sinus into the right atrium. 2. Through the tricuspid valve into the right ventricle. 3. Through the pulmonic valve into the pulmonary artery and to the lungs. 4. To the left atrium through the pulmonary veins 5. Through the mitral valve and into the left ventricle 6. Through the aortic valve into the aorta and then into the systemic circulation First, the deoxygenated blood from the inferior and superior venae cavae and the coronary sinus enters the right atrium. Then the blood flows through the tricuspid valve and enters the right ventricle. From the right ventricle, blood flows through the pulmonic valve into the pulmonary artery and to the lungs. Then the oxygenated blood enters into the left atrium through the pulmonary veins. After flowing through the mitral valve of the left atrium, the blood enters the left ventricle. From the left ventricle, the blood is ejected through the aortic valve into the aorta and then into the systemic circulation.

In which order would the nurse perform the actions to measure a patient's BP? 1. Place the appropriate-size cuff on the upper arm. 2. Lower the cuff pressure and auscultate the artery. 3. Note the diastolic pressure when the sound disappears. 4. Note the tapping sound as the systolic BP (SBP). 5. Inflate the cuff to 20 to 30 mm Hg above the estimated SBP.

1. Place the appropriate-size cuff on the upper arm. 2. Inflate the cuff to 20 to 30 mm Hg above the estimated SBP. 3. Lower the cuff pressure and auscultate the artery. 4. Note the tapping sound as the systolic BP (SBP). 5.Note the diastolic pressure when the sound disappear The nurse would first place the appropriate size of cuff on the upper arm. This is because the brachial artery is the recommended site for measuring the BP, and the wrong cuff size can give an inaccurate reading. The cuff is then inflated to a pressure 20 to 30 mm Hg above the most recently recorded SBP. This causes the blood flow in the artery to cease. The nurse would then lower the pressure in the cuff while auscultating the artery and also note the first phase of the Korotkoff sound. It is a tapping sound caused by the spurt of blood into the constricted artery. This is the SBP. Finally, when the sound disappears, the nurse notes the diastolic pressure.

In what order does blood flow through the heart? 1. Lungs 2. Left atrium 3. Right atrium 4. Mitral valve 5. Left ventricle 6. Right ventricle

1. R atrium R ventricle lungs L atrium mitral valve L ventricle Blood flows (from the body via the superior and inferior vena cava) into the right atrium. Blood passes from the right atrium (through the tricuspid valve) into the right ventricle, then (via the pulmonic valve into the pulmonic artery) the lungs. Blood flows back from the lungs (via the pulmonary veins) into the left atrium. Blood flows from the left atrium through the mitral valve into the left ventricle and then (via the aortic valve) to the aorta and the body.

Which anatomic feature of the heart directly stimulates ventricular contractions?

4 The Purkinje fibers (4) move the electrical impulse or action potential through the walls of both ventricles, triggering synchronized right and left ventricular contraction. The sinoatrial (SA) node (1) initiates the electrical impulse that results in atrial contraction. The atrioventricular (AV) node (2) receives the electrical impulse through internodal pathways. The bundle of His (3) receives the impulse from the AV node.

Vascular system

3 major types of blood vessels arteries veins capillaries Arteries, except for the pulmonary artery, carry oxygenated blood away from the heart. Veins, except for the pulmonary veins, carry deoxygenated blood toward the heart. Arterioles and venules Small branches of arteries and veins Blood circulates from the left side of the heart into arteries, arterioles, capillaries, venules, and veins, and then back to the right side of the heart.

Heart structure

4 chambers: 2 atria (right and left) 2 ventricles (right and left) Size of a fist. 3 layers: endocardium: thin inner lining myocardium: layer of muscle epicardium: outer layer Pericardium: covers the heart. It is a fibroserous sac. This sac consists of 2 layers: 1. inner (visceral) layer of the pericardium (part of the epicardium) 2. outer (parietal) layer A small amount of pericardial fluid (around 10 to 15 mL) lubricates the space between the pericardial layers (pericardial space) and prevents friction between the surfaces as the heart contracts. septum vertically divides the heart. interatrial septum creates a right and left atrium interventricular septum creates a right and left ventricle. The thickness of the wall of each chamber is different. The atrial myocardium is thinner than that of the ventricles. The left ventricular wall is 2 to 3 times thicker than the right ventricular wall. The thickness of the left ventricle is needed to make the force needed to pump the blood into the systemic circulation.

Heart valves

4 valves keep blood flowing in a forward direction. The cusps of the mitral and tricuspid valves are attached to thin strands of fibrous tissue called chordae tendineae Chordae are anchored in the papillary muscles of the ventricles. This support system prevents the eversion of the leaflets into the atria during ventricular contraction. The pulmonic and aortic valves (also known as semilunar valves) prevent blood from regurgitating into the ventricles at the end of each ventricular contraction.

Which condition would increase the friction between the heart layers and manifest as a friction rub? An atrial myocardium thinner than the ventricle Different thicknesses in the walls of each chamber 5 mL of fluid in the space between the pericardial layers 12 mL of fluid in the space between the pericardial layers

5 mL of fluid in the space between the pericardial layers Pericardial fluid between the pericardial layers prevents friction between the layers as the heart contracts. Approximately 10 to 15 mL of pericardial fluid is sufficient to reduce the friction. Therefore 5 mL of pericardial fluid indicates that the patient experiences greater friction between the pericardial layers. If the atrial myocardium is thinner than the ventricle, it indicates normal heart anatomy. The wall of each chamber of a normal heart is a different thickness; it does not cause greater friction. Pericardial fluid of 12 mL is a normal finding and does not indicate friction between the pericardial layers.

Cholesterol

<200 mg/dL (<5.2 mmol/L) (varies with age and gender) A blood lipid associated with arteriosclerosis. High level is a risk factor for cardiovascular heart disease. Can obtain in a non-fasting or fasting state.

Lipoprotein (a) (Lp[a])

<30 mg/dL (<0.3 g/L) High levels indicate an increased risk for atherosclerosis, MI, and stroke. Can obtain in a nonfasting or fasting state.

Bradycardia

<60 beats/min Possible etiologies: Rest or sleeping SA or AV node damage athletic conditioning side effect of drugs (e.g., β-blockers) hypothyroidism

Tachycardia

>100 beats/min Possible etiologies: exercise anxiety shock need for increased cardiac output hyperthyroidism

Which patient condition is likely the cause of a heart murmur? Stiffened arteries A damaged valve Dependent edema in the legs Varicosities in the large veins

A damaged valve The turbulent flow of blood across a damaged valve results in a heart murmur. Stiffened arteries, edema, and varicosities do not cause murmurs.

What does the P wave in this figure represent? Atrial depolarization Ventricular depolarization Excitation of the Purkinje fibers Conduction through the atrioventricular (AV) valves

Atrial depolarization The P wave indicates atrial depolarization. The QRS complex represents depolarization from the AV node throughout the ventricles. The PR interval represents the time it takes the impulse to spread through the atria, AV node, bundle of His, bundle branches, and Purkinje fibers to the point immediately preceding ventricular contraction. The U wave, if seen, represents repolarization of Purkinje fibers, or the U wave may be associated with hypokalemia.

Which objective data would the nurse expect to see in the health record when taking care of a patient with a diagnosis of acute coronary syndrome (ACS)? Acute heart palpitations A rise in troponin levels Shortness of breath, especially at rest Decreased levels of C-reactive protein (CRP

A rise in troponin levels Biomarkers are useful in the diagnosis of ACS, and troponin is the biomarker of choice. Acute heart palpitations and shortness of breath are subjective data used in the assessment of probable diagnosis of ACS. CRP has been linked with the presence of atherosclerosis and the prediction of future heart event risks in patients with myocardial infarction (MI).

Which findings during the cardiovascular assessment of a patient require further evaluation? Select all that apply. A thready pulse is present. Hands and feet are cold to the touch. Edema is absent in the extremities. Capillary refill takes four seconds. Veins in the neck are not distended.

A thready pulse is present. Hands and feet are cold to the touch. Capillary refill takes four seconds. Blood loss, decreased cardiac output, aortic valve disease, or peripheral arterial disease can result in a thready pulse. Hands and feet that are cold to the touch may indicate intermittent claudication, peripheral arterial disease, low cardiac output, or severe anemia. Capillary refill taking longer than two seconds indicates the possibility of reduced arterial capillary perfusion or anemia. The absence of edema in the extremities and a lack of distention of the veins in the neck are normal findings and not causes for concern.

Autonomic Nervous System (ANS) effect on the heart

ANS -sympathetic nervous system (SNS) -parasympathetic nervous system (PNS) Stimulation of the SNS: -increases the HR, speed of impulse conduction through the AV node, and force of atrial and ventricular contractions This effect is mediated by specific sites in the heart called beta (β)-adrenergic receptors, which are receptors for norepinephrine and epinephrine. In contrast, stimulation of the PNS- -mediated by the vagus nerve -slows the HR by decreasing the impulses from the SA node and thus conduction through the AV node.

A patient who is wheelchair-bound is scheduled for a multigated acquisition (MUGA) scan to aid in the diagnosis of coronary artery disease (CAD). Which revisions in the test procedure will the nurse anticipate? Vital signs will be monitored more frequently. Adenosine will be administered IV. The degree of incline on the treadmill will be lower. A 12-lead electrocardiogram (ECG) will be performed.

Adenosine will be administered IV. A MUGA scan is a common nuclear imaging test for heart wall motion during systole and diastole. Because the patient is unable to exercise, IV adenosine (Adenocard) will be given to dilate the coronary arteries and simulate the effect of exercise. The nurse will monitor vital signs, but this is not the priority action at this time. The patient will not be prepared for the treadmill because he or she is unable to exercise. A 12-lead ECG is not performed as part of the MUGA scan.

Afterload

Afterload is the peripheral resistance against which the left ventricle must pump. Depends on the size of the ventricle, wall tension, and arterial BP. If the arterial BP is elevated, the ventricles meet increased resistance to ejection of blood, increasing the work demand. Eventually this results in ventricular hypertrophy, an enlargement of the heart muscle without an increase in CO or the size of chambers. Although we often think of afterload as affecting left heart function, both right and left ventricles work against resistance. The right ventricle pumps against the afterload of pulmonary arterial resistance.

Point of maximal impulse (PMI)

Also called the apical pulse. Reflects the pulsation of the apex of the heart. When the patient is supine, palpate the mitral valve area for the point of maximal impulse (PMI) PMI lies medial to the midclavicular line in the 4th or 5th ICS. If you can palpate the PMI, record its position in relation to the midclavicular line and ICSs. If the PMI is below the fifth ICS and left of the midclavicular line, the heart may be enlarged.

Which location would the nurse assess for edema caused by a cardiac condition? Face Wrist Ankle Chest

Ankle Edema is a common and early symptom of cardiovascular conditions. The nurse would look for edema by depressing the skin over the tibia or medial malleolus for five seconds. This edema is commonly seen in dependent areas, such as on the feet and the ankle, as a result of gravity. Edema on the face, wrist, or chest may be caused by other, noncardiac conditions.

Potential Cardiovascular Effects of Select Noncardiac Drugs

Anticancer agents: daunorubicin doxorubicin CV Effects: dysrhythmias cardiomyopathy Antipsychotics: chlorpromazine haloperidol CV Effects: dysrhythmias orthostatic hypotension Corticosteroids: cortisone prednisone CV Effects: hypotension edema potassium depletion Hormone therapy, oral contraceptives: estrogen + progestin (Prempro) CV Effects: MI thromboembolism stroke hypertension Nonsteroidal antiinflammatory drugs (NSAIDs): celecoxib (Celebrex) diclofenac ibuprofen CV Effects: MI stroke hypertension HF Psychostimulants amphetamines cocaine CV Effects: tachycardia angina MI hypertension dysrhythmias Tricyclic antidepressants amitriptyline doxepin (Silenor) CV Effects: dysrhythmias orthostatic hypotension

A patient has blood regurgitating into the ventricles of the heart at the end of each ventricular contraction. Which structures would the nurse expect will show damage on the patient's two-dimensional echocardiogram report? Select all that apply. Aortic arch Aortic valve Pulmonic valve Papillary muscle Chordae tendineae

Aortic valve Pulmonic valve The semilunar valves (aortic valve and pulmonic valve) are one-way valves that separate the ventricles from major arteries. The aortic valve separates the left ventricle from the aorta, whereas the pulmonary valve separates the right ventricle from the pulmonary artery. As the ventricles contract, ventricular pressure exceeds arterial pressure, the semilunar valves open, and blood is pumped into the major arteries. Therefore damage to the semilunar valves can result in regurgitation of blood into the ventricles. The aortic arch receives blood from the left ventricle but does not prevent the regurgitation of blood into the ventricles. Chordae tendinea are anchored in the papillary muscles of the ventricles. This support system prevents the eversion of the leaflets into the atria during ventricular contraction.

Which conditions are accompanied by a thready pulse? Select all that apply. Hyperthyroidism Hyperkinetic states Aortic valve disease Cardiac dysrhythmias Peripheral arterial disease

Aortic valve disease Peripheral arterial disease A thready pulse is a weak, slowly rising pulse observed in patients with aortic valve disease and peripheral arterial disease. Hyperthyroidism and hyperkinetic states are associated with a bounding pulse. An irregular pulse is observed in patients with cardiac dysrhythmias.

Pulse deficit

Apical heart rate exceeding peripheral pulse rate Possible etiologies: Dysrhythmias, most often atrial fibrillation/flutter or premature ventricular contractions

Arterial blood pressure

Arterial blood pressure is a measure of the pressure exerted by blood against the walls of the arterial system.

Which effects of aging would the nurse consider in planning care for an 80-year-old person? Select all that apply. Heart valves become thicker. Arterial blood vessels become thin and fragile. The resting supine heart rate is markedly reduced. The number of pacemaker cells in the SA node decreases. There is a decreased response to physical and emotional stress.

Arterial blood vessels become thin and fragile. The number of pacemaker cells in the SA node decreases. There is a decreased response to physical and emotional stress. Heart valves become thicker and stiffer as a result of lipid accumulation, degeneration of collagen, and fibrosis. The number of pacemaker cells in the sinoatrial node decreases with age. By age 75, a person may have only 10% of the normal pacemaker cells. The autonomic nervous system control of the cardiovascular system changes with aging. The number and function of β-adrenergic receptors in the heart decrease with age; thus the older adult has a decreased response to physical and emotional stress. Arterial and venous blood vessels thicken and become less elastic with age. The resting supine heart rate is not markedly affected by aging.

A patient with pericarditis is admitted to the hospital. In which patient position would the nurse assess for a pericardial friction rub? Ask the patient to sit and lean forward. Place the patient in a standing position. Maintain the patient in a supine position. Place the patient in three positions: supine, sitting, and standing.

Ask the patient to sit and lean forward. In a patient with pericarditis, a high-pitched sound can be auscultated. This sound can be heard during heart sound S1 or S2 at the apex. The best position for hearing this sound is when the patient is in a sitting position and leaning forward. The sound is not well heard in other positions, such as supine or standing.

A nurse is caring for a patient immediately following a transesophageal echocardiogram (TEE). Which assessments are appropriate for this patient? (Select all that apply.) Assess for return of gag reflex. Assess groin for hematoma or bleeding. Monitor vital signs and oxygen saturation. Position patient supine with head of bed flat. Assess lower extremities for circulatory compromise.

Assess for return of gag reflex. Monitor vital signs and oxygen saturation. Rationale: The patient undergoing a TEE has been given conscious sedation and has had the throat numbed with a local anesthetic spray, thus eliminating the gag reflex until the effects wear off. Therefore it is imperative that the nurse assess for gag reflex return before allowing the patient to eat or drink. Vital signs and oxygen saturation are important assessment parameters resulting from the use of sedation. A TEE does not involve invasive procedures of the circulatory blood vessels. Therefore it is not necessary to monitor the patient's groin and lower extremities in relation to this procedure or to maintain a flat position.

A nurse is caring for a patient immediately following a transesophageal echocardiogram (TEE). Which interventions would the nurse perform? Select all that apply. Assess for the return of the gag reflex. Assess the groin for hematoma or bleeding. Monitor vital signs and oxygen saturation. Position the patient supine, with the head of the bed flat. Assess the lower extremities for circulatory compromise.

Assess for the return of the gag reflex. Monitor vital signs and oxygen saturation. The patient undergoing a TEE has been given conscious sedation and has had the throat numbed with a local anesthetic spray, thus eliminating the gag reflex until the effects wear off. Therefore it is imperative that the nurse assess for the return of the gag reflex before allowing the patient to eat or drink. Vital signs and oxygen saturation also are important assessment parameters following the use of sedation. A TEE does not involve invasive procedures of the circulatory blood vessels; therefore it is not necessary to monitor the patient's groin and lower extremities in relation to this procedure or to maintain a flat position.

A patient is scheduled for cardiac catheterization with coronary angiography. Which primary purpose for the procedure would the nurse explain to the patient? Bypassing obstructed vessels Assessing the presence of arterial blockages Opening and dilating blocked coronary arteries Assessing the need for antianginal medications

Assessing the presence of arterial blockages Cardiac catheterization with angiography is performed to assess the extent and severity of coronary artery blockage. The results of a cardiac catheterization will facilitate decisions regarding the need for coronary artery bypass surgery, angioplasty, or medical management.

A patient is diagnosed with venous thromboembolism. Which assessment finding would the nurse expect? Abnormal capillary refill Unusually warm extremities Asymmetry in limb circumference Pitting edema of lower extremities

Asymmetry in limb circumference Venous thrombosis is the formation of clots and most commonly occurs in the pelvis or lower extremity—that is, in the deep veins of the legs. This condition results in asymmetry in limb circumference. Possible reduced arterial capillary perfusion and anemia cause abnormal capillary refill. Thyrotoxicosis results in unusually warm extremities. Interruption of venous return to the heart and right-sided heart failure are associated with pitting edema of the lower extremities.

Which factor could contribute to a patient's pedal pulse being absent? Atherosclerosis Hyperthyroidism Arteriovenous fistula Cardiac dysrhythmias

Atherosclerosis Atherosclerosis can cause an absent peripheral pulse. The feet would be cool also and may be discolored. Hyperthyroidism causes a bounding pulse. An arteriovenous fistula gives a thrill or vibration to the vessel, although this would usually not be found in the foot. Cardiac dysrhythmias cause an irregular pulse rhythm.

The nurse determines that a patient's pedal pulses are absent. What factor could contribute to this finding? Atherosclerosis Hyperthyroidism Atrial dysrhythmias Arteriovenous fistula

Atherosclerosis Rationale: Atherosclerosis can cause an absent peripheral pulse. The feet would also be cool and may be discolored. Hyperthyroidism causes a bounding pulse. Arteriovenous fistula gives a thrill or vibration to the vessel, although this would not be in the foot. Cardiac dysrhythmias cause an irregular pulse rhythm.

A patient who has a history of heart failure and chronic obstructive lung disease is admitted with severe dyspnea. Which value would the nurse expect to be elevated if the cause of dyspnea was cardiac related? Serum potassium Serum homocysteine High-density lipoprotein B-type natriuretic peptide (BNP)

B-type natriuretic peptide (BNP) Rationale: Elevation of BNP indicates the presence of heart failure. Elevations help to distinguish cardiac versus respiratory causes of dyspnea. Elevated potassium, homocysteine, or HDL levels may indicate increased risk for cardiovascular disorders but do not indicate that cardiac disease is present.

Which assessment would the nurse make to monitor a patient for an adverse effect of amitriptyline? Serum potassium levels Symptoms of thromboembolism Peripheral extremities for edema BP after standing up

BP after standing up Amitriptyline is used to treat depression. It causes orthostatic hypotension. Therefor, monitoring the patient's BP when the patient is in a standing position will help provide effective care. Amitriptyline does not increase the patient's risk of edema. Therefore the nurse will not check the patient for the symptoms of edema. Unlike corticosteroids, amitriptyline does not increase the elimination of potassium and does not cause hypokalemia. Amitriptyline does not impair clotting and does not obstruct blood flow in the vessels. Therefore the nurse will not check for the symptoms of thromboembolism.

Baroreceptors

Baroreceptors in the aortic arch and carotid sinus (at the origin of the internal carotid artery) are sensitive to stretch or pressure within the arterial system. Stimulation of these receptors (e.g., volume overload) sends information to the vasomotor center in the brainstem. This results in temporary inhibition of the sympathetic nervous system and enhancement of the parasympathetic influence, causing a decreased HR and peripheral vasodilation. Decreased arterial pressure causes the opposite effect.

Abnormal capillary refill

Blanching of nail bed for ≥2 sec after release of pressure Possible etiologies: Possible reduced arterial capillary perfusion anemia

The nurse provides education to a patient who is scheduled for a serum test for triglycerides and lipoproteins. Which information would the nurse include? Avoid alcohol for 12 hours before the test. Blood can be drawn in a nonfasting or a fasting state. The initial lipoproteins test result will be used for diagnosis and treatment. A triglyceride level of greater than 100 mg/dL would be considered to be high risk.

Blood can be drawn in a nonfasting or a fasting state. The nurse instructs the patient that both tests may be obtained in a nonfasting state or a fasting state. Consumption of alcohol should be restricted for at least 24 hours before the test. Because there are marked day-to-day fluctuations in the serum lipoprotein levels, more than one test is required for accurate diagnosis and treatment. The reference interval for triglycerides is less than 160 mg/dL for males and less than 135 mg/dL for females.

Peripheral cyanosis

Bluish or purplish tinge in extremities or in nose and ears Reduced blood flow from Possible etiologies: HF vasoconstriction cold environment

Which findings would indicate to the nurse that a patient is experiencing prolonged oxygen deficiency? Select all that apply. Erythematous rashes on the extremities Bluish or purplish tinge in the central areas of the tongue Pulse rate of 70 beats/minute and BP of 120/80 mm Hg Obliteration of the normal angle between the base of the nail and the skin Hands and feet warmer than normal and respiratory rate of 20 breaths/minute

Bluish or purplish tinge in the central areas of the tongue Obliteration of the normal angle between the base of the nail and the skin Prolonged oxygen deficiency is characterized by cyanosis and clubbing of the nails. Therefore the presence of a bluish or purplish tinge in the central areas of the tongue and obliteration of the normal angle between the base of the nail and the skin indicates that the patient has an oxygen deficiency. The presence of erythematous rashes on the extremities indicates that the patient has a skin infection but not an oxygen deficiency. A pulse rate of 70 beats/minute and a BP of 120/80 mm Hg are normal findings and do not indicate that the patient has an oxygen deficiency. A deficiency of oxygen results in hypothermia and may make the patient's hands and feet cooler than normal. A respiratory rate of 20 breaths/minute is a normal finding.

Which artery is recommended for checking a patient's BP? Radial Carotid Brachial Femoral

Brachial BP is recorded using a device known as a sphygmomanometer and a stethoscope. The ideal and correct site for checking the BP is the brachial artery. This artery is on the arm near the elbow. The radial artery is on the wrist. The carotid artery is in the neck region, and the femoral artery is around the groin. Any other site other than the brachial artery is not suitable for checking the BP with a sphygmomanometer.

Which blood component is a marker of inflammation reflecting an increased risk of cardiovascular disease? Myoglobin N-terminal pro-brain natriuretic peptide (NT-Pro-BNP) C-reactive protein (CRP) B-type natriuretic peptide (BNP)

C-reactive protein (CRP) CRP is a marker of inflammation that can predict the risk of cardiac events and cardiac diseases. Myoglobin is a low-molecular-weight protein that is sensitive to myocardial injury. NT-Pro-BNP helps in assessing the severity of heart failure. BNP is a peptide that causes natriuresis, and its elevation distinguishes a cardiac versus respiratory cause of dyspnea.

Cardiac index (CI)

Cardiac index (CI) is the CO divided by the body surface area (BSA). The CI reflects the relative CO for the body size. The normal CI is 2.8 to 4.2 L per minute per meter squared (L/min/m2)

Cardiac output (CO)

Cardiac output (CO) is the amount of blood pumped by each ventricle in 1 minute. It is calculated by multiplying the amount of blood ejected from the ventricle with each heartbeat: stroke volume (SV) times heart rate (HR) per minute: CO = SV X HR For the normal adult at rest, CO is maintained in the range of 4 to 8 L/min.

While auscultating a patient's heart, the nurse hears turbulent sounds between normal heart sounds. Which complication would the nurse suspect? Aneurysm Cardiac dysrhythmias Left ventricular failure Cardiac valve disorder

Cardiac valve disorder Turbulent sounds heard between normal heart sounds are known as murmurs. Murmurs are found in patients with a cardiac valve disorder. An aneurysm is associated with a turbulent flow sound in the peripheral artery. Cardiac dysrhythmias are characterized by an apical heart rate exceeding the peripheral pulse rate. Left ventricular failure is associated with an extra, low-pitched heart sound in early diastole.

Which condition may be present if the nurse hears a patient's S4 heart sound? Hypertension Angina pectoris Cardiomyopathy Postural hypotension

Cardiomyopathy S4 is an extra heart sound caused by atrial contraction. It can be normal in older adults. The common pathologies that cause this sound are cardiomyopathy, left ventricular hypertrophy, atrial stenosis, and coronary artery disease (CAD). Hypertension is increased BP, and postural hypotension is a fall in BP after standing, and these conditions do not cause S4. Angina pectoris is pain in the chest region and is not accompanied by S4.

coronary angiography, cardiac catheterization

Coronary angiography is done with a left-sided heart catheterization. The catheter is positioned at the origin of the coronary arteries, and contrast medium is injected into the arteries. Patients often feel a temporary flushed sensation with dye injection. The images show the location and severity of any coronary blockages Complications of cardiac catheterization: bleeding or hematoma at the puncture site; allergic reactions to the contrast media; looping or kinking of the catheter; infection; thrombus formation aortic dissection dysrhythmias MI stroke puncture of the ventricles, septum, or lung tissue.

Which physiologic change of aging increases the risk of a 75-year-old patient experiencing a sinus dysrhythmia? Decreased pulse pressure Decreased systolic BP (SBP) Decreased resting supine heart rate (HR) Decreased number of pacemaker cells in the SA node

Decreased number of pacemaker cells in the SA node The number of pacemaker cells in the SA node decreases with age. By age 75, a person may have only 10% of the normal number of pacemaker cells. Arterial and venous blood vessels thicken and become less elastic with age. Arteries increase their sensitivity to vasopressin (antidiuretic hormone). With aging, both of these changes contribute to a progressive increase in SBP and a decrease or no change in diastolic BP (DBP). Thus an increase in the pulse pressure is found. The resting supine HR is not markedly affected by age.

Color changes in extremities with postural change Pallor, cyanosis, mottling of skin after limb elevation.

Dependent rubor (reddish blue discoloration). Glossy skin Possible etiologies: Chronic decreased arterial perfusion

Jugular venous distention

Distended neck (jugular) veins with patient sitting at 30- to 45-degree angle Possible etiologies: high right atrial pressure right-sided HF

A patient being treated for peripheral vascular disease reports erectile dysfunction (ED). Which medication classifications listed in the patient's health record may be contributing to the condition? Select all that apply. Diuretics Phosphodiesterase (PDE) inhibitors β-Adrenergic receptor blockers (β-blockers) Corticosteroids Antidepressants

Diuretics β-Adrenergic receptor blockers (β-blockers) β-Blockers, which are used to treat cardiovascular disorders, have ED as a major side effect. Taking diuretics along with medications for peripheral vascular disease increases problems in sexual function, such as decreased libido and difficulty ejaculating. PDEs such as sildenafil (Viagra) are often the first-line therapy for ED, not the cause of it. Oral antidepressants do not directly cause ED in patients with peripheral vascular disease, although they may contribute to decreased libido. Corticosteroids help reduce breathing difficulty but do not impair sexual activity.

Which instruction would the nurse provide to a patient who is scheduled for exercise testing? Stop smoking one hour before the test. Do not take β-adrenergic receptor blockers (β-blockers) 24 hours before the test. Avoid strenuous exercise six hours before the test. Avoid caffeine-containing foods three hours before the test.

Do not take β-adrenergic receptor blockers (β-blockers) 24 hours before the test. β-Blockers may be held 24 hours before the test because they blunt the heart rate (HR) and limit the patient's ability to achieve maximal HR. The nurse informs the patient not to consume caffeine-containing foods (and caffeine-containing fluids) for 12 hours before the test. The nurse also instructs the patient to avoid strenuous exercise and smoking for three hours before the test.

Which medication listed in a patient's health record is a potential cause of the patient's cardiomyopathy? Ibuprofen Prednisone Doxorubicin Chlorpromazine

Doxorubicin Doxorubicin is an anticancer medication that results in cardiomyopathy. Ibuprofen is a nonsteroidal antiinflammatory drug (NSAID) that results in hypertension, myocardial infarction, and stroke. Prednisone is a corticosteroid that causes hypotension, edema, and potassium depletion. Chlorpromazine is an antipsychotic medication that results in dysrhythmias and orthostatic hypotension.

action potential

Electrical impulse starts depolarization of the heart cells and leads to heart muscle contraction.

A patient with cardiovascular disease who is sitting at a 45-degree angle has distended neck veins. Which condition is a likely cause of this finding? Vasoconstriction Poor venous return Elevated right atrial pressure Incompetent valves in the veins

Elevated right atrial pressure Bulging of the external jugular vein is known as jugular vein distention. When the arterial pressure in the right atrium increases, the pressure in the jugular vein increases; this results in distention of the veins. Vasoconstriction causes peripheral cyanosis. Poor venous return causes ulcers. Incompetent valves in veins lead to varicose veins.

The registered nurse observes another health care provider caring for a patient who is undergoing transesophageal echocardiograph studies. Which action by the provider needs correction? Places a bite block in the patient's mouth Ensures that the patient's dentures fit snugly Administers anesthetic in the patient's throat Instructs the patient not to eat for six hours before the study

Ensures that the patient's dentures fit snugly Dentures should be removed because they may be dislodged during the study and cause airway obstruction. The procedure involves placing a bite block after inserting the probe to displace the tongue. The gag reflex prevents the passage of food from the throat. Therefore the care provider should instruct the patient to avoid eating for six hours before the test in order to prevent vomiting and aspiration. The care provider should administer anesthetic in the patient's throat to produce a localized effect and reduce pain.

A patient with a history of cardiovascular disease reports symptoms of erectile dysfunction (ED). The patient tells the nurse, "I am really frustrated and embarrassed." Which response would the nurse provide? Select all that apply. Educate the patient on medications to treat ED. Ask the patient about his normal sexual habits and routine. Explain that ED may be a symptom of peripheral vascular disease. Validate the patient's feelings, and ask a colleague to complete the assessment. Review the patient's medications and explain that ED can be a side effect of a cardiac drug.

Explain that ED may be a symptom of peripheral vascular disease. Review the patient's medications and explain that ED can be a side effect of a cardiac drug. ED may be a symptom of peripheral vascular disease, or it can be a side effect of cardiac medication, such as a β-blocker or a diuretic. A full cardiovascular assessment should be performed prior to making assumptions about medication therapy, particularly when medications for ED are contraindicated if the patient is also taking a nitrate. A history of the patient's sexual routine is important in the cardiac assessment because there are many symptoms of cardiac conditions that could impede sexual activity, such as shortness of breath or chest pain. However, taking this history should wait until the nurse has explained the connection between ED and vascular disease. Validating the patient's frustrations may help diffuse the situation after the link has been explained. It is not necessary to have a colleague complete the assessment.

Lipoproteins (HDL, LDL)

HDL Recommended Male: >45 mg/dL Female: >55 mg/dL Low risk for CAD: ≥60 mg/dL High risk for CAD: <40 mg/dL LDL <130 mg/dL Moderate risk for CAD: 130-159 mg/dL High risk for CAD: >160 mg/dL There are marked day-to-day fluctuations, so more than 1 level is needed for accurate diagnosis. Can be obtained in a nonfasting or fasting state. Assess risk for heart disease by dividing the total cholesterol level by the HDL level and obtaining a ratio. Low risk: Ratio <3 Average risk: Ratio 3-5 Increased risk: Ratio >5

An elderly patient presents to a clinic for a routine physical examination. The nurse reviews the patient's medical record and notes a slow, progressive increase in systolic BP (SBP). Which action would the nurse take? Alert the health care provider immediately. Ask the patient about any symptoms of dizziness. Explain to the patient that this is a normal age-related change. Inform the patient that an antihypertensive medication will be prescribed

Explain to the patient that this is a normal age-related change. As adults age, arterial stiffening from the loss of elastin in the arterial walls can cause thickening of the arteries and progressive fibrosis, which may have the downstream effect of causing increased SBP and a decrease or no change in diastolic BP. Thus an increase in pulse pressure is found. The nurse may explain to the patient that this is a normal age-related change. There is no need to alert the health care provider immediately because this is not a life-threatening emergency. It may be prudent to assess for dizziness during cardiac evaluation because orthostatic hypotension is common in the older adult. Insufficient data are provided to determine if an antihypertensive medication is needed.

3rd heart sound (S3)

Extra heart sound, low pitched, heard in early diastole. Similar to sound of a gallop Possible etiologies: Left ventricular failure. Volume overload. Mitral, aortic, or tricuspid regurgitation. Hypertension (possible)

4th heart sound (S4)

Extra heart sound, low pitched, heard in late diastole. Similar to sound of a gallop Possible etiologies: Forceful atrial contraction from resistance to ventricular filling: left ventricular hypertrophy aortic stenosis hypertension coronary artery disease

While reviewing laboratory reports, the nurse notes that a patient's homocysteine level is 17 μmol/L. Which treatment would the nurse anticipate will be prescribed? Nesiritide infusion Estrogen + progestin infusion Vitamin C and vitamin K supplements Folic acid and vitamin B12 supplements

Folic acid and vitamin B12 supplements When a patient's homocysteine levels are greater than 10.4 μmol/L, it indicates that the patient has hyperhomocysteinemia. Hyperhomocysteinemia is caused by a deficiency in folic acid, vitamin B12, and vitamin B6; therefore administering folic acid and vitamin B12 supplements will be beneficial for the patient. Nesiritide helps to increase b-type natriuretic peptide (BNP), but it does not treat deficiencies of folic acid, vitamin B12, and vitamin B6. Estrogen + progestin helps to increase estrogen levels in the blood but does not reduce homocysteine levels. Homocysteine levels increase because of folic acid and vitamin B deficiencies but are unrelated to vitamins C and K.

Unusually warm extremities

Hands and feet warmer than normal Thyrotoxicosis

Cold extremities

Hands and/or feet cold to touch. External covering needed for comfort Possible etiologies: Intermittent claudication peripheral arterial disease low cardiac output severe anemia

Which response occurs after a rupture on the endothelial surface of an artery? Initiates coagulation cascade Decreases viscosity of the blood Promotes blood flow in the artery Decreases platelet aggregation at the site

Initiates coagulation cascade The endothelium is the innermost layer of the arteries in the body. After damage to any part of the artery, it initiates cascade formation and aids in the formation of a fibrin clot to reduce the risk of bleeding. The endothelium does not decrease the viscosity of the blood in the artery in either normal or damaged conditions. The endothelium promotes blood flow in the artery during normal conditions but not after a rupture. The endothelium increases platelet aggregation at the ruptured site to repair the ruptured part of the epithelial surface.

PVD Inspection

Inspect: -skin for color -hair distribution -venous pattern Check the extremities -edema -dependent rubor -clubbing of the nail beds -varicosities -lesions such as stasis ulcers Edema in the legs can be caused by -gravity -varicosities -right-sided HF Inspect the large neck veins (internal and external jugular) while gradually moving the patient from a supine position to an upright (30 to 45 degrees) position. Distention and prominent pulsations of the neck veins, referred to as jugular venous distention, can be caused by right-sided HF.

The registered nurse observes another health care provider performing a cardiac assessment on a patient. Which activity by the health care provider would the nurse question? Documents a normal peripheral pulse as 2+ Identifies that a capillary refill of three seconds is abnormal Uses the diaphragm of the stethoscope to auscultate for S1 and S2 heart sounds Inspects the neck veins while swiftly moving the patient from supine to upright

Inspects the neck veins while swiftly moving the patient from supine to upright To assess for jugular vein distention, the health care provider should inspect the large veins in the neck while the patient is gradually moved from a supine position to an upright (30- to 45-degree position). The patient should not be repositioned too quickly. When a normal peripheral pulse is a normal force, it should be documented as 2+. A capillary refill should occur in less than two seconds with normal tissue perfusion and cardiac output (CO). S1 and S2 are heard best with the diaphragm of the stethoscope because they are high-pitched sounds.

PR, QRS, and QT intervals

Intervals between these waves reflect the time it takes for the signal to travel from 1 area of the heart to another. We can measure these time intervals. Changes from these time references often indicate pathologic conditions.

The nurse is admitting a patient who is scheduled to undergo a cardiac catheterization. What allergy information is most important for the nurse to assess and document before this procedure? Iron Iodine Aspirin Penicillin

Iodine Rationale: The provider will usually use an iodine-based contrast to perform this procedure. Therefore, it is imperative to know whether the patient is allergic to iodine or shellfish. Knowledge of allergies to iron, aspirin, or penicillin will be secondary.

Absent pulse

Lack of pulse Possible etiologies: atherosclerosis trauma embolus

A patient has a severe blockage in the left coronary artery. Which cardiac structures will likely be affected by the blockage? Select all that apply. Left atrium Left ventricle Bundle of His Interventricular septum Atrioventricular (AV) node

Left atrium Left ventricle Interventricular septum The left coronary artery arises from the aorta and divides into two main branches: the left anterior descending artery and the left circumflex artery. These arteries supply the left atrium, the left ventricle, the interventricular septum, and a portion of the right ventricle. The AV node and bundle of His are usually supplied by the right coronary artery.

Which finding on an older adult's electrocardiogram indicates cellular aging and fibrosis of the conduction system? Regular cardiac rhythm Lengthened QT intervals Increased amplitude of QRS complex Shortened PR interval and shortened QRS complex

Lengthened QT intervals Lengthened QT intervals in an elderly patient's electrocardiogram indicate cellular aging and fibrosis of the conduction system. The patient with cellular aging and fibrosis of the conduction system is characterized by irregular cardiac rhythms, lengthened PR and QRS complex, and a decreased amplitude of the QRS complex.

Which techniques will the nurse use while assessing a patient's heart sounds? Select all that apply. Listen for friction rubs with the patient upright and leaning forward. Use the diaphragm of the stethoscope to listen to S1 and S2 sounds. Listen for S3 and S4 sounds with the bell of the stethoscope. Ask the patient to lean forward to enhance the sounds at the mitral area. Place the patient in a left side-lying position to detect sounds from the second intercostal space.

Listen for friction rubs with the patient upright and leaning forward. Use the diaphragm of the stethoscope to listen to S1 and S2 sounds. Listen for S3 and S4 sounds with the bell of the stethoscope. The nurse listens to the S1 and S2 sounds with the diaphragm of the stethoscope because they are high pitched. S3 and S4 are extra heart sounds. If these sounds are present, then they can be detected with the bell of the stethoscope. The nurse instructs the patient to lean forward while sitting. This helps to enhance sounds from the second intercostal space. The nurse listens to friction rubs when the patient sits in an upright position and leans forward following expiration. The patient is positioned in a left side-lying position to enhance the sounds at the mitral area.

The BP of a 71-year-old patient admitted with pneumonia is 160/70 mm Hg. Which age-related change contributes to this finding? Stenosis of the heart valves Decreased adrenergic sensitivity Increased parasympathetic activity Loss of elasticity in arterial vessels

Loss of elasticity in arterial vessels An age-related change that increases the risk of systolic hypertension is a loss of elasticity in the arterial walls. Because of the increasing resistance to flow, pressure is increased within the blood vessel, and hypertension results. The valvular rigidity of aging causes murmurs, and decreased adrenergic sensitivity slows the heart rate. BP is not raised. Increased parasympathetic activity would slow the heart rate.

The blood pressure of an older adult patient admitted with pneumonia is 160/70 mm Hg. What is an age-related change that contributes to this finding? Stenosis of the heart valves Decreased adrenergic sensitivity Increased parasympathetic activity Loss of elasticity in arterial vessels

Loss of elasticity in arterial vessels Rationale: An age-related change that increases the risk of systolic hypertension is a loss of elasticity in the arterial walls. Because of the increasing resistance to flow, pressure is increased within the blood vessel, and hypertension results. Valvular rigidity of aging causes murmurs, and decreased adrenergic sensitivity slows the heart rate. Blood pressure is not raised. Increased parasympathetic activity would slow the heart rate.

Lipoprotein-associated phospholipase A2 (Lp-PLA2)

Low risk: ≤151 ng/mL Moderate risk: 152-194 ng/mL High risk: ≥195 ng/mL Indicates inflammation and increased risk for CAD. Serum levels are measured by the PLAC test. Can obtain in a nonfasting or fasting state.

An older adult presents to the emergency department with recent weight gain, pitting edema to the bilateral lower extremities, and distended neck veins. Which other assessment findings would the nurse expect? Select all that apply. Irregular heart rate Lower extremity cyanosis Third heart sound (S3) upon auscultation Displaced point of maximal impulse (PMI) High-pitched scratching sound during S1 or between normal heart sounds

Lower extremity cyanosis Third heart sound (S3) upon auscultation Displaced point of maximal impulse (PMI) Pitting bilateral lower extremity edema, weight gain, and jugular venous distention (JVD) are all hallmarks of heart failure. Lower extremity cyanosis, a third heart sound, and displaced PMI are all symptoms that are often found in the patient with heart failure. Irregular heart rate is a hallmark of atrial fibrillation. A high-pitched scratching sound during or between normal heart sounds is indicative of a pericardial friction rub and more commonly indicates pericarditis, not heart failure.

The nurse assesses a patient with cardiac problems and finds that one calf is larger than the other. Which conditions are possible explanations for this finding? Select all that apply. Lymphedema Hypertension Varicose veins Angina pectoris Venous thromboembolis

Lymphedema Varicose veins Venous thromboembolis There may be asymmetries in the circumference of two limbs in disorders like lymphedema, varicose veins, and thromboembolism. In these disorders, the affected limb is generally increased in circumference. Hypertension doesn't cause swelling of the limbs. Angina pectoris refers to pain in the chest and doesn't cause changes in the circumference of the lower extremities.

Triglycerides

Male: 40-160 mg/dL Female: 35-135 mg/dL Mixtures of fatty acids. Elevations are associated with cardiovascular disease and diabetes. Avoid alcohol for 24 hr before testing. Can obtain in a nonfasting or fasting state.

Measurement of Arterial Blood Pressure

Measured by invasive and noninvasive techniques. Invasive technique: catheter insertion into an artery. The catheter is attached to a transducer, and the pressure is measured directly. Noninvasive technique: indirect measurement of BP can be done with a sphygmomanometer and stethoscope. The sphygmomanometer consists of an inflatable cuff and a pressure gauge. The BP is measured by auscultating for sounds of turbulent blood flow through a compressed artery (termed Korotkoff sounds). The brachial artery is the recommended site for taking a BP. 1. After placing the right size cuff on the upper arm 2. inflate the cuff to a pressure 20 to 30 mm Hg above the SBP. This causes blood flow in the artery to cease. 3. If the SBP is not known, estimate the pressure by palpating the brachial pulse and inflating the cuff until the pulse ceases. The pressure noted at this time is the estimated SBP. 4. Inflate the BP cuff 20 to 30 mm Hg above this number. 5. As you lower the pressure in the cuff, listen to the artery for Korotkoff sounds. 5 phases of Korotkoff sounds. 1st - a tapping sound caused by the spurt of blood into the constricted artery as the pressure in the cuff is gradually deflated. This sound is the SBP. 5th - occurs when the sound disappears, which is the DBP. BP is recorded as the ratio of SBP to DBP (e.g., 120/80 mm Hg). Sometimes, an auscultatory gap occurs - a loss of sound between the SBP and DBP. Proper BP technique is essential for correct readings: using the correct cuff size positioning arm at heart level Another noninvasives -automated device that uses oscillometric measurements to assess BP. -does not involve auscultation, the same attention to proper technique is essential for accuracy. Doppler ultrasonic flowmeter -assess SBP and pulse The hand-held transducer is positioned over the artery (identified by audible, pulsatile sounds). The cuff is applied above the artery, inflated until the sounds disappear, and then inflated another 20 to 30 mm Hg beyond that point. The cuff is then slowly deflated. The point where sounds return is the SBP.

Which heart valve sounds are best heard at the left midclavicular line at the fifth intercostal space (ICS)? Aortic Mitral Tricuspid Pulmonic

Mitral The mitral valve can be assessed by auscultation at the left midclavicular line at the fifth ICS. The aortic area is best heard at the right second intercostal space. The tricuspid area is assessed best at the midleft sternal border. The pulmonic valve is heard best at the left second intercostal space.

The nurse teaches a caregiver about the plan of care for an older adult patient who has orthostatic hypotension. Which action by the caregiver will the nurse emphasize? Monitoring for the risk of falls Encouraging laughter therapy Encouraging treadmill exercises Taking the patient out for recreation

Monitoring for the risk of falls Orthostatic hypotension, or postural hypotension, is low BP that occurs in patients when they stand up from sitting or lying down. Patients with orthostatic hypotension are at an increased risk of falls. Therefore the caregiver should monitor for falls in the patient. The caregiver can encourage laughter therapy and treadmill exercises, but these measures are not as beneficial as monitoring the patient for falls. The caregiver can take the patient out for recreation, but it is not as beneficial as monitoring the patient's risk of falls.

A patient's laboratory report reveals increased creatine kinase (CK-MB) enzymes. Which condition is consistent with this result? Stroke Myocardial infarction (MI) Coronary artery disease (CAD) Peripheral vascular disease (PVD)

Myocardial infarction (MI) CK-MB enzymes are present in the cardiac muscle and are released into the blood as a result of cell injury. An increase in CK-BB enzymes indicates brain injury. Homocysteine is an amino acid produced during protein catabolism; elevated levels of this amino acid are an indication of stroke, CAD, and PVD

Factors affecting cardiac output (CO)

Numerous factors can affect either the HR or SV and thus the CO. Heart Rate (HR): controlled by the autonomic nervous system can reach as high as 180 beats/min for short periods without harmful effects With rapid HRs, there is less time for diastolic filling and perfusion of the coronary arteries Stroke Volume (SV): Affected by preload, contractility, and afterload. Increasing preload, contractility, and afterload increases the workload of the heart muscle, resulting in increased O2 demand. The Frank-Starling law states that, to a point, the more the myocardial fibers are stretched, the greater their force of contraction. The volume of blood stretching the ventricles at the end of diastole, before the next contraction, is called preload. Preload - can be increased by conditions such as hypertension, aortic valve disease, and hypervolemia. Preload is decreased when a rapid HR or hypovolemia reduces ventricular filling during diastole. Contractility - can be increased by epinephrine and norepinephrine released by the sympathetic nervous system. Increasing contractility raises the SV by increasing ventricular emptying. Afterload is the peripheral resistance against which the left ventricle must pump. Afterload depends on the size of the ventricle, wall tension, and arterial BP. If the arterial BP is elevated, the ventricles meet increased resistance to ejection of blood, increasing the work demand. Eventually this results in ventricular hypertrophy, an enlargement of the heart muscle without an increase in CO or the size of chambers. Although we often think of afterload as affecting left heart function, both right and left ventricles work against resistance. The right ventricle pumps against the afterload of pulmonary arterial resistance.

Clubbing of the nail beds

Obliteration of normal angle between base of nail and skin Possible etiologies: endocarditis congenital defects prolonged O2 deficiency

A 78-year-old patient experiences sinus dysrhythmias. A reduction in which type of cells leads to this condition? Conduction cells in the bundle of His Conduction cells in the internodal tracts Conduction cells in the bundle branches Pacemaker cells in the sinoatrial (SA) node

Pacemaker cells in the sinoatrial (SA) node A reduction in the number of pacemaker cells in the SA node may account for sinus dysrhythmias in the older adult patient. Reductions in the number of conduction cells in the bundle of His, internodal tracts, and bundle branches contribute to the development of atrial dysrhythmias and heart blocks.

Displaced point of maximal impulse (apical pulse)

Palpate (or auscultate) the point of maximal impulse below the fifth ICS and to the left of the MCL Possible etiologies: cardiac enlargement because of coronary artery disease HF cardiomyopathy

The nurse is preparing to take a new patient's BP using a sphygmomanometer and a stethoscope. Which action should the nurse take? Use the same-size cuff as used for all other patients. Wait until an automated BP machine is available. Palpate the brachial pulse and inflate the cuff until the pulse ceases. Apply extra pressure on the cuff manually to measure BP

Palpate the brachial pulse and inflate the cuff until the pulse ceases. While measuring BP with the sphygmomanometer and a stethoscope, if the systolic BP is not known, then the nurse should palpate the brachial pulse and inflate the cuff until the pulse ceases. When a BP measurement is scheduled, the nurse should be timely and take the patient's BP, using the appropriate technique rather than waiting to use a machine. Choosing the correct-size cuff for each patient's arm size gives accurate results for BP. Applying extra pressure can increase the pressure on the brachial artery, which can give inaccurate test results.

Palpate

Palpate the upper and lower extremities bilaterally (assess for symmetry) for: -temperature -moisture -pulses - edema -to assess for symmetry Edema: -depressing the skin over the tibia or medial malleolus for 5 seconds. Normally, there is no depression after you release pressure. pitting edema -grade it from 1+ (mild pitting, slight brief indentation) to 4+ (very deep pitting, indentation that lasts a long time). Palpate the pulses in the neck and extremities for rhythm and force of arterial blood flow. Palpate each carotid pulse separately to avoid vagal stimulation and dysrhythmias. Compare the characteristics of the arteries in the right and left extremities simultaneously to determine symmetry. Palpating the arteries identified rate the force of the pulse using scale: 0 = Absent 1+ = Weak 2+ = Normal 3+ = Increased, full, bounding Note the rigidity (hardness) of the artery. The normal pulse feels like a tap, but a narrowed or bulging vessel wall vibrates. The term for a palpable vibration is thrill. Capillary refill is used to assess arterial flow to the extremities. Position the patient's hands near the level of the heart and squeeze a nail bed briefly to produce blanching. Color should return to the nail bed in less than 2 seconds with normal tissue perfusion and CO.

Which term would the nurse use to document a patient's report of awakening during the night with sudden shortness of breath? Orthopnea Atrial fibrillation Intermittent claudication Paroxysmal nocturnal dyspnea

Paroxysmal nocturnal dyspnea Paroxysmal nocturnal dyspnea is defined as attacks of shortness of breath, especially at night, which awaken the patient. Orthopnea is the need to sleep in an upright position. Intermittent claudication affects the muscles of the leg during exercise related to decreased oxygen delivery to the muscle. Atrial fibrillation is a conduction abnormality of the heart.

A nurse reviews the medical records of four patients with cardiovascular disease. Which patient is likely to have jugular venous distention? Patient 1 Patient 2 Patient 3 Patient 4

Patient 2 Patient 2 has right-sided heart failure, which is associated with jugular vein distention. Patient 1 has reduced blood flow and is at increased risk of pressure injuries. Patient 3 has venous thromboembolism, which results in asymmetry in limb circumference. Patient 4 has an arterial obstruction, which is associated with arterial bruit.

The nurse is reviewing the BP values of four patients. Which patient would the nurse suspect to be at the highest risk for ischemia? Patient A Patient B Patient C Patient D

Patient A Mean arterial pressure (MAP) is determined using BP. MAP = (SBP + 2DBP) divided by 3. The MAP of patient A is less than 60, which indicates that the patient's organs are not adequately perfused. Therefore the nurse suspects that patient A has a risk of ischemia. The MAP of patient B is 60, the MAP of patient C is 70, and the MAP of patient D is over 110. A MAP between 60 and 100 indicates that the organs are adequately perfused. Therefore patients B, C, and D are not at risk for ischemia.

Which patient's mean arterial pressure (MAP) does the nurse calculate as potentially inadequate to perfuse organs? Patient A Patient B Patient C Patient D

Patient D The MAP refers to the average pressure within the arterial system that is felt by organs in the body. It is not the average of the diastolic blood pressure (DBP) and systolic blood pressure (SBP) because the length of diastole exceeds that of systole at normal heart rates. MAP is calculated as follows: MAP = (SBP + 2 DBP) ÷ 3. A MAP greater than 60 mm Hg is needed to perfuse the vital organs of an average person under most conditions. When the MAP is low for a period of time, vital organs are underperfused and will become ischemic. Patient D's MAP is 57.3 mm Hg; systolic BP of 88 + 2 x diastolic BP (42 + 42) = 172 ÷ 3 = 57.3. Patient A's MAP is 96 mm HG. Patient B's MAP is 67 mm Hg. Patient C's MAP is 117 mm Hg.

The nurse is reviewing the laboratory reports of four patients. Which patient's cardiac index is abnormal? Patient A Patient B Patient C Patient D

Patient D The cardiac index is calculated by dividing the cardiac output by the body surface area. The normal values of the cardiac index are in the range of 2.8 to 4.2 L/min/m2. The cardiac output and body surface area of patient D are 4 L/min and 1.9 m2, respectively. Therefore the cardiac index = 4/1.9 = 2.1 L/min/m2, which is abnormal. The cardiac output and body surface area of patient A are 6 L/min and 1.6 m2, respectively. Therefore the cardiac index = 6/1.6 = 3.75 L/min/m2, which is normal. The cardiac output and body surface area of patient B are 5 L/min and 1.5 m2, respectively. Therefore the cardiac index = 5/1.5 = 3.33 L/min/m2, which is normal. The cardiac output and body surface area of patient C are 7 L/min and 1.8 m2, respectively. Therefore the cardiac index = 7/1.8 = 3.88 L/min/m2, which is normal.

The nurse reviews the cardiac laboratory test results of four patients and suspects which patient had a recent myocardial infarction (MI)? Patient A Patient B Patient C Patient D

Patient D An elevated copeptin (normal <10 pmol/L), an elevated CK-MB (normal 4-6%) and an elevated Troponin I (normal <0.03 ng/dL) indicate a possible MI. C-reactive protein can also indicate an acute MI (high risk greater than 3 mg/dL) or risk for cardiac disease. BNP is not used as a biomarker for MI but is high in heart failure (normal <100 pg/mL). Homocysteine is considered a risk factor for cardiac disease (normal 4-14 µmol/L). Patient A, B and C's Copeptin, CK-MB, C-reactive protein and Troponin I are all within normal range.

The nurse reviews the cardiac laboratory test results of four patients and suspects which patient had a recent myocardial infarction (MI)? Patient A Patient B Patient C Patient D

Patient D An elevated copeptin (normal <10 pmol/L), an elevated CK-MB (normal 4-6%) and an elevated Troponin I (normal <0.03 ng/dL) indicate a possible MI. C-reactive protein can also indicate an acute MI (high risk greater than 3 mg/dL) or risk for cardiac disease. BNP is not used as a biomarker for MI but is high in heart failure (normal <100 pg/mL). Homocysteine is considered a risk factor for cardiac disease (normal 4-14 µmol/L). Patient A, B and C's Copeptin, CK-MB, C-reactive protein and Troponin I are all within normal range. p. 668

Which assessment findings would the nurse expect when assessing a patient with right-sided heart failure? Select all that apply. Peripheral cyanosis Splinter hemorrhages Pericardial friction rub Jugular vein distention Pitting edema of the lower extremities

Peripheral cyanosis Jugular vein distention Pitting edema of the lower extremities Reduced blood flow from heart failure may cause peripheral cyanosis. Jugular vein distention is the result of blood backup on the right side of the heart. Patients with right-sided heart failure may present with pitting edema of the lower extremities as a result of interruption of venous return to the heart. Splinter hemorrhages are often caused by infective endocarditis. A pericardial friction rub is indicative of pericarditis.

Which factors affect a patient's stroke volume? Select all that apply. Preload Afterload Contractility Cardiac index Cardiac output

Preload Afterload Contractility Increased or decreased preload, afterload, and contractility alter the stroke volume of the blood. The cardiac index and cardiac output are affected by stroke volume but do not affect the stroke volume of the blood.

The nurse performing a cardiovascular assessment on an 85-year-old patient expects which age-related finding? Presence of S4 Decreased resting supine heart rate Increased response to physical stress Slight shortening of QRS complex interval

Presence of S4 Due to changes in the heart with aging, a fourth heart sound (S4) might be heard. The supine heart rate is not affected by aging. The response to physical stress is decreased. The QRS complex interval may lengthen.

Which vessel carries oxygenated blood from the lungs to the heart? Pulmonary vein Pulmonary artery Inferior vena cava Superior vena cava

Pulmonary vein The pulmonary vein, in contrast to all other veins, carries oxygenated blood toward the heart from the lungs. The pulmonary artery carries deoxygenated blood from the right ventricle to the lungs. The inferior vena cava carries deoxygenated blood from the legs and abdomen to the right atrium of the heart. The superior vena cava carries deoxygenated blood from the arms and head to the right atrium of the heart.

A normal splitting of S2 is best heard in which auscultatory area on the diagram? Mitral Aortic Tricuspid Pulmonic

Pulmonic Normally no sound is heard between S1 and S2. An exception to this is a normal splitting of S2, which is best heard at the pulmonic area during inspiration. A splitting of S2 is not normally heard at Erb's point or the mitral, aortic, or tricuspid locations.

If a patient's BP is 120/80 mm Hg, what is the patient's pulse pressure? Fill in the blank using a whole number. __ mm Hg

Pulse pressure is calculated as the difference between the systolic BP (SBP) and the diastolic BP (DBP). It is normally about one third of the SBP. If the patient's BP is 120/80, the pulse pressure would be 120 - 80, which is equal to 40 mm Hg.

Pulse Pressure and Mean Arterial Pressure

Pulse pressure is the difference between the SBP and DBP. It is normally about one third of the SBP. If the BP is 120/80 mm Hg, the pulse pressure is 40 mm Hg. An increased pulse pressure due to an increased SBP may occur during exercise or in people with atherosclerosis of the larger arteries. A decreased pulse pressure may occur with heart failure (HF) or hypovolemia. Another measurement related to BP is mean arterial pressure (MAP). The MAP refers to the average pressure within the arterial system that is felt by organs in the body. It is not the average of the DBP and SBP, because the length of diastole exceeds that of systole at normal HRs. MAP is calculated as follows: MAP = (SBP + 2DBP)/3 A person with a BP of 120/60 mm Hg has an estimated MAP of 80 mm Hg. A MAP greater than 60 mm Hg is needed to perfuse the vital organs of an average person under most conditions. When the MAP is low for a period of time, vital organs are underperfused and will become ischemic.

Pulse pressure (PP)

Pulse pressure is the difference between the SBP and DBP. It is normally about one third of the SBP. If the BP is 120/80 mm Hg, the pulse pressure is 40 mm Hg. An increased pulse pressure due to an increased SBP may occur during exercise or in people with atherosclerosis of the larger arteries. A decreased pulse pressure may occur with heart failure (HF) or hypovolemia.

Which cardiovascular assessment findings are considered normal for an adult patient? Select all that apply. Pulses 2+ Point of maximal impulse (PMI) not visible Heart rate 64, regular Capillary refill 3 seconds Blood pressure right arm: 124/80 mm Hg; left arm: 110/62 mm Hg

Pulses 2+ Point of maximal impulse (PMI) not visible Heart rate 64, regular Blood pressure right arm: 124/80 mm Hg; left arm: 110/62 mm Hg Pulses of 2+, a nonvisible point of maximal impulse, a heart rate between 60 and 100, and a blood pressure difference between arms of 5 to 15 mm Hg are all considered normal. Color should return to the nail bed in less than 2 seconds with normal tissue perfusion and cardiac output.

Which action would the nurse take to assess a patient for jugular venous distention? Place the patient in a supine position. Raise the patient to about 45 degrees. Place the patient in a sitting position, leaning forward. Observe the vein in three positions: supine, sitting, and standing

Raise the patient to about 45 degrees. Jugular venous distention can be seen in right-sided heart failure. In this condition, the large veins in the neck are distended as a result of the back pressure exerted by the blood. It is best appreciated when the patient is raised to approximately 45 degrees or slightly less. This exerts pressure and helps in the visualization of the jugular veins. Placing the patient in other positions, such as supine, sitting, leaning, or standing, does not help in clear visualization of jugular venous distention.

Which action would the nurse take to assess a patient for jugular venous distention? Place the patient in a supine position. Raise the patient to about 45 degrees. Place the patient in a sitting position, leaning forward. Observe the vein in three positions: supine, sitting, and standing.

Raise the patient to about 45 degrees. Jugular venous distention can be seen in right-sided heart failure. In this condition, the large veins in the neck are distended as a result of the back pressure exerted by the blood. It is best appreciated when the patient is raised to approximately 45 degrees or slightly less. This exerts pressure and helps in the visualization of the jugular veins. Placing the patient in other positions, such as supine, sitting, leaning, or standing, does not help in clear visualization of jugular venous distention.

Which type of pulse would the nurse expect when assessing a patient who is anxious? Rapid Thready Irregular Pulsus alternans

Rapid A rapid pulse, tachycardia, is associated with anxiety caused by increased adrenaline. A thready pulse is associated with peripheral arterial disease, aortic valve disease, and decreased cardiac output. The pulse is irregular in patients with cardiac dysrhythmias. Pulsus alternans is observed in patients with heart failure and cardiac tamponade.

The nurse observes that blanching of a patient's nail beds continues for three seconds after the release of pressure. Which condition is the potential cause of this finding? Thyrotoxicosis Intermittent claudication Reduced arterial capillary perfusion Interruption of venous return to the heart

Reduced arterial capillary perfusion Reduced arterial capillary perfusion results in a decreased amount of oxygen supply to body parts, which results in blanching of the nail beds for more than two seconds after the release of pressure. Hands and feet that are warmer than normal indicate thyrotoxicosis. When the hands and feet are cold to the touch, it indicates intermittent claudication. Visible finger pitting edema on the application of firm pressure indicates an interruption of venous return to the heart.

Pulsus alternans

Regular rhythm, but strength of pulse varies with each beat Possible etiologies: HF cardiac tamponade

A nurse is preparing a patient for a transesophageal echocardiogram (TEE). Which intervention would the nurse perform? Inform the patient that skin irritation is likely. Remove dentures and place a bite block in the mouth. Provide lead shielding to areas that are exposed to radiation. Provide information about risks associated with general anesthesia.

Remove dentures and place a bite block in the mouth. While preparing a patient for a TEE, the nurse asks the patient to remove the dentures and places a bite block in the mouth. This is done because an ultrasound transducer will need to be swallowed and passed through the esophagus. When preparing the patient for a chest x-ray, the nurse provides lead shielding to areas that are exposed to radiation. If the patient is undergoing ambulatory ECG, then the nurse asks the patient to carefully observe possible symptoms of skin irritation. The patient will receive IV sedation; general anesthesia is not used for the procedure.

Blood flow through the heart

SVC --> Rt atria --> Tricuspid --> Rt ventricle --> Pulmonic valve --> Lungs --> Lt atria --> Mitral valve --> Lt ventricle --> aortic valve --> aorta --> Body 1. The right atrium receives venous blood from the inferior and superior venae cava and the coronary sinus. The blood then passes through the tricuspid valve into the right ventricle. 2. With each contraction, the right ventricle pumps blood through the pulmonic valve into the pulmonary artery and to the lungs. 3. Oxygenated blood flows from the lungs to the left atrium by way of the pulmonary veins. 4. It then passes through the mitral valve and into the left ventricle. 5. As the heart contracts, blood is ejected through the aortic valve into the aorta and thus enters the systemic circulation.

Systemic vascular resistance

SVR is the force opposing the movement of blood. This force is created primarily in small arteries and arterioles. The main factors influencing BP are CO and systemic vascular resistance (SVR) bp = co x svr

During a physical examination, where would a nurse auscultate for the patient's aortic area? Fifth intercostal space to the left of the sternum Second intercostal space to the left of the sternum Fifth intercostal space to the right of the sternum Second intercostal space to the right of the sternum

Second intercostal space to the right of the sternum The surface anatomy for the aortic area is in the second intercostal space to the right of the sternum. The pulmonic area is in the second aortic area to the left of the sternum. The tricuspid area is in the fifth left intercostal space. No auscultation is performed in the fifth right intercostal space.

Bounding pulse

Sharp, brisk, pounding pulse Possible etiologies: Hyperkinetic states (e.g., anxiety, fever) anemia hyperthyroidism

Which structure initiates the action potential in the heart? Bundle of His Purkinje fibers Sinoatrial node Left bundle branch

Sinoatrial node The sinoatrial node is called the pacemaker of the heart, and it initiates the electrical impulse, or action potential, in the heart. By way of the Purkinje fibers, the action potential moves through the walls of ventricles, but it is not initiated at this point. The action potential moves from the atrioventricular node through the bundle of His and the right and left bundle branches, but it is not initiated at these points.

Autonomic Nervous System (ANS) effect on blood vessels

Sympathetic nervous system (SNS) -is the source of neural control of blood vessels Alpha1 (α1)-adrenergic receptors are found in vascular smooth muscles. Stimulation of α1-adrenergic receptors results in vasoconstriction. Decreased stimulation to α1-adrenergic receptors causes vasodilation. The parasympathetic nerves have selective distribution in the blood vessels. For example, blood vessels in skeletal muscle do not receive parasympathetic input.

Systole

Systole, contraction of the heart muscle, results in ejection of blood from the ventricles.

Which effects of aging on the cardiovascular system would the nurse anticipate when providing care for older adults? Select all that apply. Systolic murmur Diminished pedal pulses Decreased cardiac reserve Increased maximal heart rate Increased recovery time from activity

Systolic murmur Diminished pedal pulses Decreased cardiac reserve Increased recovery time from activity Well-documented cardiovascular effects of the aging process include valvular rigidity leading to systolic murmur, arterial stiffening leading to diminished pedal pulses or possible increased BP, and an increased amount of time that is required for recovery from activity. Maximal heart rate tends to decrease with age as a result of cellular aging and fibrosis of the conduction system. The aging patient experiences decreased cardiac reserve as a result of myocardial hypertrophy, increased collagen and scarring, and decreased elastin.

What age-related cardiovascular changes should the nurse assess for when providing care to an older adult patient? (Select all that apply.) Systolic murmur Diminished pedal pulses Increased maximal heart rate Decreased maximal heart rate Increased recovery time from activity

Systolic murmur Diminished pedal pulses Decreased maximal heart rate Increased recovery time from activity Rationale: Well-documented cardiovascular effects of the aging process include valvular rigidity leading to systolic murmur, arterial stiffening leading to diminished pedal pulses or possible increased blood pressure, and an increased amount of time that is required for recovery from activity. Maximal heart rate tends to decrease rather than increase with age related to cellular aging and fibrosis of the conduction system.

Which symptoms would the nurse expect to find when assessing the cardiovascular system of an 83-year-old patient? Select all that apply. Systolic murmur Diminished pedal pulses A narrowed pulse pressure Increased systolic BP Difficulty in isolating the apical pulse

Systolic murmur Diminished pedal pulses Increased systolic BP Difficulty in isolating the apical pulse Gerontologic differences in the assessment of the cardiovascular system include the presence of a systolic murmur, diminished pedal pulses, increased systolic BP, and difficulty in isolating the apical pulse. The pulse pressure may be widened, not narrowed.

A patient is being admitted for valve replacement surgery. Which assessment finding is indicative of aortic valve stenosis? Pulse deficit Systolic murmur Distended neck veins Splinter hemorrhages

Systolic murmur Rationale: The turbulent blood flow across a diseased valve results in a murmur. Aortic stenosis produces a systolic murmur. A pulse deficit indicates a cardiac dysrhythmia, most commonly atrial fibrillation. Right-sided heart failure may cause distended neck veins. Splinter hemorrhages occur in patients with infective endocarditis.

T wave

The T wave represents repolarization of the ventricles.

U wave

The U wave, if seen, may represent repolarization of the Purkinje fibers. A large U wave may occur with hypokalemia.

Which statement describes cardiac reserve? The amount of blood pumped by each cardiac ventricle in one minute The peripheral resistance against which the left ventricle must pump The ability to respond to health and illness demands by altering cardiac output The amount of blood in the ventricles at the end of diastole, before the next contraction

The ability to respond to health and illness demands by altering cardiac output The ability of the cardiovascular system to alter cardiac output in response to numerous situations in health and illness, such as stress, hypervolemia, and exercise, is known as cardiac reserve. The amount of blood pumped by each ventricle in one minute is called cardiac output. Afterload is the peripheral resistance against which the left ventricle must pump. Preload is the amount of blood in the ventricles at the end of diastole, before the next contraction.

A patient's heart rate is 72 beats/min. If 0.070 L of blood is ejected from the patient's ventricle with every heartbeat, what cardiac output value would the nurse document in the patient's medical record? Record the answer using a whole number. ___________ L/min

The amount of blood ejected from the ventricle with each heartbeat is known as the stroke volume. Therefore this patient's stroke volume is 0.070 L. Cardiac output (CO) is calculated by multiplying the stroke volume (SV) by the heart rate (HR), or CO = SV × HR. Therefore CO = 0.070 × 72 = 5.0 L/min.

Which interpretation would the nurse make after assessing a patient and identifying murmurs? The cardiac valves are affected. The patient has high BP. The patient has a pericardial friction rub. There is decreased ventricular compliance

The cardiac valves are affected. Murmurs are heard when the blood flow is turbulent as a result of dysfunctional valves. The valves may be affected as a result of the accumulation of lipids, the degeneration of collagen, and fibrosis. High BP does not cause murmurs. A pericardial friction rub is usually heard as a high-pitched, scratchy sound. A decreased compliance of ventricles during filling would result in the S4 heart sound.

What is an appropriate explanation for the nurse to give to a patient about the purpose of intermittent pneumatic compression devices after a surgical procedure? The devices keep the legs warm while the patient is not moving much. The devices maintain the blood flow to the legs while the patient is on bed rest. The devices keep the blood pressure down while the patient is stressed after surgery. The devices provide compression of the veins to keep the blood moving back to the heart.

The devices provide compression of the veins to keep the blood moving back to the heart. Rationale: Intermittent pneumatic compression devices provide compression of the veins while the patient is not using skeletal muscles to compress the veins, which keeps the blood moving back to the heart and prevents blood pooling in the legs that could cause deep vein thrombosis. The warmth is not important. Blood flow to the legs is not maintained. Blood pressure is not decreased with the use of intermittent sequential compression stockings.

Electrocardiogram (ECG)

The electrical activity of the heart can be detected on the body surface using electrodes. It is recorded on an electrocardiogram (ECG). Letters P, QRS, T, and U to name the separate waveforms

P wave

The first waveform. Begins with the firing of the SA node. It represents depolarization of the atria.

The nurse is teaching a group of nursing students about the anatomic characteristics of the heart. Which information would the nurse include? The right and the left atria are similar in size. The atrial myocardium is thicker than that of the ventricles. The right ventricular wall is three times thicker than the left ventricle. The left ventricle is thicker to pump the blood into the systemic circulation

The left ventricle is thicker to pump the blood into the systemic circulation. The left ventricle is thicker because it needs to pump the blood into circulation. The right and left atria are different sizes and have different wall thicknesses. The atrial myocardium is thinner than that of the ventricles. The left ventricular wall is two or three times thicker than the right ventricular wall.

The nurse is teaching a group of nursing students about the anatomic characteristics of the heart. Which information would the nurse include? The right and the left atria are similar in size. The atrial myocardium is thicker than that of the ventricles. The right ventricular wall is three times thicker than the left ventricle. The left ventricle is thicker to pump the blood into the systemic circulation.

The left ventricle is thicker to pump the blood into the systemic circulation. The left ventricle is thicker because it needs to pump the blood into circulation. The right and left atria are different sizes and have different wall thicknesses. The atrial myocardium is thinner than that of the ventricles. The left ventricular wall is two or three times thicker than the right ventricular wall.

A patient's stroke volume is 0.074 L, and the heart rate is 74 beats/minute. The systemic vascular resistance is 19 mm Hg/min/L. What mean arterial BP should the nurse enter in the patient's medical record? Record the answer using a whole number. ___________ mm Hg

The mean arterial pressure (MAP) BP is manually calculated by multiplying the cardiac output by systemic vascular resistance. Cardiac output is obtained by multiplying the stroke volume by the heart rate. Therefore the patient's cardiac output is 0.074 × 74 = 5.476, and MAP is 5.476 × 19 = 104 mm Hg.

A patient's systolic BP (SBP) is 100 mm Hg and diastolic BP (DBP) is 70 mm Hg. What number will the nurse document as the patient's mean arterial pressure? Record the answer using a whole number. ________ mm Hg

The mean arterial pressure (MAP) is calculated by using the formula MAP = (SBP + 2DBP)/3. Therefore MAP = (100 + 2(70))/3 = (100 + 140)/3 = 240/3 = 80 mm Hg.

Blood supply to myocardium

The myocardium has its own blood supply, the coronary circulation. Blood flow into the 2 major coronary arteries occurs primarily during diastole (relaxation of the myocardium). Left coronary artery (LCA): arises from the aorta divides into 2 main branches: left anterior descending artery (LAD) left circumflex artery (LCX). These arteries supply: left atrium left ventricle interventricular septum part of the right ventricle Right coronary artery (RCA) also arises from the aorta its branches supply: right atrium right ventricle part of the posterior wall of the left ventricle In 90% of people, the atrioventricular (AV) node and the bundle of His receive blood supply from the right coronary artery. For this reason, blockage of this artery often causes serious defects in cardiac conduction. The divisions of coronary veins parallel the coronary arteries. Most of the blood from the coronary system drains into the coronary sinus (a large channel), which empties into the right atrium near the entrance of the inferior vena cava.

EKG or ECG

The normal electrocardiogram (ECG) pattern. The P wave represents depolarization of the atria. The QRS complex indicates depolarization of the ventricles. The T wave represents repolarization of the ventricles. The U wave, if present, may represent repolarization of the Purkinje fibers, or it may be associated with hypokalemia. The PR, QRS, and QT intervals reflect the time it takes for the impulse to travel from one area of the heart to another.

Immediately after completing an exercise class, a patient's BP is 140/85 mm Hg. What number would the nurse document as the pulse pressure? Fill in the blank using a whole number. ____

The pulse pressure is the difference between the systolic BP and the diastolic BP; 140 - 85 = 55.

How many seconds does it take for the ventricular conduction system to deliver an electrical impulse? Use a leading zero, if applicable. Record the answer to the second decimal place. __ second(s)

The ventricular conduction system delivers the impulse within 0.12 second. The action potential is generated from the sinoatrial node. It travels through the conduction system, including the atrioventricular (AV) node, bundle of His, and the left and right bundle branches. The action potential moves through the walls of both ventricles by means of Purkinje fibers.

Preload

The volume of blood stretching the ventricles at the end of diastole, before the next contraction. Preload can be increased by conditions such as hypertension aortic valve disease hypervolemia. Preload is decreased when a rapid HR or hypovolemia reduces ventricular filling during diastole. Contractility can be increased by epinephrine and norepinephrine released by the sympathetic nervous system. Increasing contractility raises the SV by increasing ventricular emptying. 3

While auscultating the patient's heart sounds with the bell of the stethoscope, the nurse hears a ventricular gallop. How should the nurse document what is heard? Diastolic murmur Third heart sound (S3) Fourth heart sound (S4) Normal heart sounds (S1, S2)

Third heart sound (S3) Rationale: The third heart sound is heard closely after the S2 and is known as a ventricular gallop because it is a vibration of the ventricular walls associated with decreased compliance of the ventricles during filling. It occurs with left ventricular failure. Murmurs sound like turbulence between normal heart sounds and are caused by abnormal blood flow through diseased valves. The S4 heart sound is a vibration caused by atrial contraction, precedes the S1, and is known as an atrial gallop. The normal S1 and S2 are heard when the valves close normally.

Which blood studies would the nurse expect to see prescribed in a focused evaluation of a patient with cardiac disease? Select all that apply. Troponin Homocysteine C-reactive protein Blood urea nitrogen Thyroid-stimulating hormone

Troponin Homocysteine C-reactive protein Troponin, homocysteine, and C-reactive protein are laboratory tests that may help provide clues to cardiovascular health and possible indicators for cardiac disease. Thyroid-stimulating hormone evaluates the thyroid, and blood urea nitrogen evaluates kidney function; these may not be pertinent initially to a focused cardiovascular assessment.

A patient presents to the emergency department reporting chest pain for 3 hours. What component of the blood work is most clearly indicative of a myocardial infarction (MI)? CK-MB Troponin Myoglobin C-reactive protein

Troponin Rationale: Troponin is the biomarker of choice in the diagnosis of MI, with sensitivity and specificity that exceed those of CK-MB and myoglobin. CRP levels are not used to diagnose acute MI.

A patient presents to the emergency department reporting chest pain. Which component of the patient's blood work would most specifically indicate an acute myocardial infarction (MI)? Troponin Myoglobin Creatine kinase (CK) C-reactive protein (CRP)

Troponin Troponin is the biomarker of choice in the diagnosis of MI, with sensitivity and specificity that exceed those of other markers. CK enzymes are found in a variety of organs and tissues. Myoglobin elevation is a sensitive indicator of very early myocardial injury but lacks specificity for MI. CRP levels are not used to diagnose acute MI; rather, an increased level has been linked with the presence of atherosclerosis.

Veins and venules

Veins -large-diameter, thin-walled vessels that return blood to the right atrium -The venous system is a low-pressure, high-volume system. The larger veins have semilunar valves at intervals to maintain the blood flow toward the heart and to prevent backward flow. The amount of blood in the venous system is affected by several factors: -arterial flow -compression of veins by skeletal muscles -changes in thoracic and abdominal pressures -right atrial pressure. Largest veins: -superior vena cava, which returns blood to the heart from the head, neck, and arms -inferior vena cava, which returns blood to the heart from the lower part of the body. Pressure in the right side of the heart affects these large vessels. Elevated right atrial pressure can cause distended neck veins or liver engorgement because of resistance to blood flow. Venules -smaller vessels made up of a small amount of muscle and connective tissue. -collect blood from the capillary beds and channel it to the larger veins.

A nurse is caring for a patient who smokes tobacco and has a two-year history of using oral contraceptives. Based on the history, the patient would be assessed for which condition? Hypotension Cardiomyopathy Dependent edema Venous thromboembolism

Venous thromboembolism The long-term use of oral contraceptives can lead to serious side effects. In addition, smoking enhances the risk of developing complications such as venous thromboembolism. Hypotension is not an effect of oral contraceptives. Similarly, contraceptives do not affect the muscles of the heart and do not cause cardiomyopathy. Dependent edema is not a common side effect of oral contraceptives.

Ulcers

Venous: Necrotic crater-like lesion usually found on lower leg at medial malleolus. Characterized by slow wound healing Possible etiologies: Poor venous return varicose veins incompetent venous valves Arterial: Pale ischemic base, well-defined edges usually found on toes, heels, lateral malleoli Possible etiologies: Arteriosclerosis diabetes

Thrill

Vibration of vessel or chest wall Possible etiologies: aneurysm aortic regurgitation arteriovenous fistula

Varicose veins

Visible dilated, discolored, tortuous vessels in lower extremities Possible etiology: incompetent valves in vein

Pitting edema of lower extremities or sacral area

Visible finger indentation after application of firm pressure, weight gain, tightening of clothing (including shoes), marks or indentations from constricting garments Possible etiologies: interruption of venous return to heart right-sided HF

Thready pulse

Weak, slowly rising pulse easily obliterated by pressure Possible etiologies: Blood loss decreased cardiac output aortic valve disease peripheral arterial disease

A nurse is preparing to teach a group of women in a community volunteer group about heart disease. What should the nurse include in the teaching plan? Women are less likely to delay seeking treatment than men. Women are more likely to have noncardiac symptoms of heart disease. Women are often less ill when presenting for treatment of heart disease. Women have more symptoms of heart disease at a younger age than men.

Women are more likely to have noncardiac symptoms of heart disease. Rationale: Women often have atypical angina symptoms and nonpain symptoms. Women experience the onset of heart disease about 10 years later than men. Women are often more ill on presentation and delay longer in seeking care than men.

When assessing a patient, you note a pulse deficit of 23 beats. This finding may be caused by a. dysrhythmias. b. heart murmurs. c. gallop rhythms. d. pericardial friction rubs.

a Rationale: A pulse deficit occurs if there is a difference between the apical and radial beats per minute. It indicates cardiac dysrhythmias.

When a person's blood pressure rises, the homeostatic mechanism to compensate for an elevation involves stimulation of a. baroreceptors that inhibit the sympathetic nervous system, causing vasodilation. b. chemoreceptors that inhibit the sympathetic nervous system, causing vasodilation. c. baroreceptors that inhibit the parasympathetic nervous system, causing vasodilation. d. chemoreceptors that stimulate the sympathetic nervous system, causing an increased heart rate.

a Rationale: Baroreceptors in the aortic arch and carotid sinus are sensitive to stretch or pressure within the arterial system. Stimulation of these receptors sends information to the vasomotor center in the brainstem. This results in temporary inhibition of the sympathetic nervous system and enhancement of the parasympathetic influence, which cause a decrease in heart rate and peripheral vasodilation.

Which nursing responsibilities are priorities when caring for a patient returning from a cardiac catheterization (select all that apply)? a. Monitoring vital signs and ECG b. Checking the catheter insertion site and distal pulses c. Helping the patient to ambulate to the bathroom to void d. Telling the patient that he will be sleepy from the general anesthesia e. Teaching the patient about the risks of the radioactive isotope injection

a, b Rationale: The nursing responsibilities after cardiac catheterization include assessing the puncture site for hematoma and bleeding; assessing circulation to the extremity used for catheter

A patient has a severe blockage in his right coronary artery. Which heart structures are most likely to be affected by this blockage (select all that apply)? a. AV node b. Left ventricle c. Coronary sinus d. Right ventricle e. Pulmonic valve

a, b, d Rationale: The right coronary artery (RCA) supplies blood to the right atrium, the right ventricle, and part of the posterior wall of the left ventricle. In 90% of people, the RCA supplies blood to the atrioventricular (AV) node, bundle of His, and part of the cardiac conduction system.

Conduction system

consists of specialized tissue responsible for creating and transporting the electrical impulse, or action potential. This impulse starts depolarization of the heart cells and leads to heart muscle contraction. The electrical impulse 1. normally begins in the sinoatrial (SA) node (pacemaker of the heart). Impulses from the SA node travel through interatrial pathways to depolarize the atria, resulting in a contraction. 2. Travels from the atria to the AV node through internodal pathways. 3. Then moves through the bundle of His and the left and right bundle branches. The left bundle branch has 2 divisions: anterior posterior. 4. Then moves through the walls of both ventricles via Purkinje fibers. The ventricular conduction system delivers the impulse within 0.12 second. This triggers a synchronized right and left ventricular contraction and ejection of blood into the pulmonary and systemic circulations. Last, repolarization occurs when the contractile and conduction pathway cells regain their resting polarized condition. Heart muscle cells have a compensatory mechanism that makes them unresponsive or refractory to restimulation during the action potential. During ventricular contraction, there is an absolute refractory period during which heart muscle does not respond to any stimuli. After this period, heart muscle gradually recovers its excitability, and a relative refractory period occurs by early diastole.

Diastolic blood pressure (DBP)

diastolic blood pressure (DBP) is the residual pressure in the arterial system during ventricular relaxation (or filling). Normal BP is SBP <120 mm Hg and DBP <80 mm Hg4 The main factors influencing BP are CO and systemic vascular resistance (SVR) BO = CO X SVR

Cardiac reserve

difference between resting and maximal cardiac output The cardiovascular system must respond to many situations in health and illness (e.g., exercise, stress, hypovolemia). The ability to respond to these demands by altering CO is termed cardiac reserve.

Coronary sinus

enlarged vessel on the posterior aspect of the heart that empties blood into the right atrium