Adult Health II Exam 1
Parts of an ECG wave form
*P Wave - Atrial contraction (DEpolarization of the sinus node; start of the heartbeat) PR Segment - Movement of electrical activity from atria to ventricles QRS Complex - Ventricle contraction (DEpolarization) ST Segment - Time between ventricular depolarization and repolarization *T Wave - Ventricle relaxing (REpolarization; reset for the next impulse) TP Interval - Ventricles are relaxing and refilling
Ejection fraction normal values
55% - 75% Percentage of blood that leaves the heart when it squeezes
How to calculate HR using a rhythm strip
6 Second Method Count the number of R's in between the 6 second strips and multiply by 10 (be sure and check that the strip is 6 seconds; count the boxes) 6 R's x 10 = 60 beats per minute Big Box Method 300 divided by the number of big boxes between 2 R's 300/5 = 60 beats per minute
Aortic Aneurysms
A weakness in the wall of the aorta that makes it susceptible to rupture (caused from untreated HTN)
High output heart failure
Increased metabolic needs Septicemia (fever) Anemia Hyperthyroidism
Coronary Artery Disease (CAD)
Ischemia Diminished blood supply to tissues or partial disruption of flow -Angina (stable/unstable) -Can lead to MI Myocardial Infarction (MI) Tissue death or COMPLETE blockage
Labs associated with MI
LIPID PROFILE Cholesterol (total) LDL (clogs arteries) Triglycerides (cause inflammation and lumen to constrict, we want triglycerides to be managed) HDL (acts like drano to unclog arteries)
Abnormal Heart Sounds
Abnormal ventricular filling (Extra heart sound) S3 Early diastole in rapid ventricle filling S4 Late diastole and high atrial pressure (forcing blood into a stiff ventricle
What is Stroke Volume?
Amount of blood pumped out from the left ventricle with each heartbeat (in one squeeze)
Heparin
Anticoagulant used for prevention and treatment of venous thrombosis and pulmonary embolism aPTT therapeutic levels 60-80 seconds PTT therapeutic levels 120-140 seconds
Valvular problems
Aortic or mitral stenosis(narrowing) clots can form, lack of oxygenate to the brain
Aortic Dissection
Arterial wall splits apart Back pain or "tearing sensation" S/S - Hypovolemic shock, diaphoresis, N/V, faintness, decreased/absent pulses, neurologic deficits, hypotension, tachycardia
Defibrilation
Asynchronous Done with an automated external defibrillator (AED) Higher amount of joules (energy) used Resume CPR after shock Unstable patients Elective treatment of Pulseless ventricular tachycardia (VT) Ventral fibrillation (VF) "If it has a V, Give them the D" Medication Amiodarone Lidocaine Epinephrine "You can always give a dead patient Epi"
Pacemaker
Bradycardia - any rhythm <60/min (treat if the client is symptomatic) Medication Atropine *Dopamine or epinephrine if unresponsive to atropine*
Myocardial Infarction S/S
Crushing pain, pressure and tightness (in the chest, arms, neck, shoulder or jaw) Shortness of breath Fatigue, lightheadedness, or sudden dizziness Women may present with atypical angina: Indigestion Heartburn Abdominal pain N/V
Cardiomyapathy
CAD Infection or inflammation of heart muscle Various cancer treatment Prolonged alcohol use
Labs associated with MI (duration)
CARDIAC ENZYMES Myoglobin - (24 hrs) Early indicator of MI Elevated following a MI, and with skeletal muscle injury Creatine kinase-MB (2-3 days) Early indicator of MI Isoenzyme specific to the myocardium; elevation indicates myocardial muscle injury Troponin I - (7-10 days) 1st to become elevated after MI Troponin T - (10-14 days) Remains elevated longer than Troponin I, so indicator of long-term damage
Actions in case of cardiac arrest
Call for help Start CPR Shock
Valvular diagnostic procedures
Chest Xray 12 lead ECG Echocardiogram Transesophageal Echocardiogram (TEE)
Acute Coronary Syndrome S/S
Chest pain Jaw/arm pain Diaphoresis Nausea Radiation of Pain
New York Heart Association's Functional Classification Scale Heart Failure
Class I - no symptoms with activity Class II - has symptoms with ordinary exertion Class III - Has symptoms with minimal exertion Class IIII - Has symptoms at rest
Assessing a patient with frequent PVCs
Closely monitor for VT and get lab values to check electrolytes
Normal Heart Sounds
Closing of the valves S1 (Lub) Tricuspid and mitral valve closure S2 (Dub) Aortic and pulmonic valve closure Diastolic Murmur Narrowing stenosis of the mitral of tricuspid
A nurse in an emergency department is assessing a client who has a bradydysrhythmia. Which of the following findings should the nurse monitor for?
Confusion bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monior the client's mental status
Acute Coronary Syndrome (ACS)
Disruption of flow from coronary arteries to heart
Valvular medications and procedures
Diuretics Afterload-reducing agents Inotropic agents Percutaneous balloon valvuloplasty Valve replacement
Diagnostic Procedures for MI
Electrocardiogram - noninvasive Echocardiogram - noninvasive Stress testing - exercise or non exercise Thallium scan - nuclear scan Cardiac catheterization (angiography) - Invasive Coronary Artery Bypass Graft - Invasive
Valvular insufficiency
Failure of a heart valve to close tightly, thus allowing regurgitation of blood
Left Sided Heart Failure Findings
Fluid backs up into the lungs (pulmonary symptoms) (Left side think Lungs) Acronym "DROWNING" Dyspnea Rales (crackles) Orthopnea Weakness/fatigue Nocturnal paroxysmal dyspnea Increased HR Nagging cough (frothy, blood tinged sputum) Gaining weight (2-3 lbs/day) Other S/S Weak peripheral pulses Decrease UOP Hypotension S3 gallop
Right Sided Heart Failure Findings
Fluid backs up into the venous system (Right = the Rest of the body) Acronym "SWELLING" Swelling of the legs and hands Weight gain Edema (pitting) Large neck veins (JVD) Lethargy/fatigue Irregular heart rate Nocturia Girth (ascites) Other S/S Hepatomegaly Splenomegaly Anorexia
Problems associated with fluid overload (hypervolemia)
Heart Failure Kidney dysfunction Vital signs: tachycardia, bounding pulse, HTN, tachypnea, increased central venous pressure GI: ascites and liver enlargement Respiratory: crackles, cough, dyspnea Peripheral edema, weakness, altered LOC Complications - pulmonary edema, place in high fowlers to maximize ventilation and administer oxygen
Permanent Pacemaker complication
Hiccups
Endocarditis S/S
High fever Heart murmur Petechiae on the body or in the eyes Blood clots (stroke and heart attack) Night sweats
What is Cardiac Output?
How much blood the heart pumps per minute HR x SV = CO
How Calcium affects the ECG
Hypocalcemia -Prolonged ST segment -Prolonged QT interval Hypercalcemia -Shortened ST segment -Widened T wave
How Potassium affects the ECG
Hypokalemia -ST depression -Flat/inverted T wave -U wave Hyperkalemia -Flat P wave -Prolonged PR interval -QRS widening -Tall, peaked T wave
How magnesium affects the ECG
Hypomagnesemia -Tall T wave -ST depression Hypermagnesemia -Prolonged PR interval -QRS widening
Acute Coronary Syndrome Risk Factors
Male pattern baldness Obesity Tobacco use Diabetes Family history HTN Sedentary lifestyle Ethnic background
Indications and S/S of A-fib
Manifestations Most commonly asymptomatic Slurred Speech *Report to HCP* Fatigue Malaise Dizziness SOB Tachycardia Anxiety Palpitations Rate Usually over 100 BPM Rhythm Irregular P Wave None. They are irregular (fibrillary waves) PR Interval Visible QRS Complex Normal
Medications for patients having a MI
Morphine decreases oxygen demand on the client's heart (decreases preload) Oxygen Nitroglycerin prevents coronary artery vasospasm and reduces preload and afterload, decreasing myocardial oxygen demand Aspirin prevents platelets from forming together, which can produce arterial clotting (ASA prevents vasoconstriction; give with NTG)
AAA
Most common related to atherosclerosis S/S - Lower back pain, gnawing feeling in abdomen, pulsating abdominal mass, bruit over aneurysm, elevated BP
NSTEMI
Non ST Elevation MI; a heart attack that is not diagnosed on the EKG but is diagnosed by an elevated troponin on blood test (Ischemia)
Patient Centered Care for Anuerysms
Nursing Care - Vital signs, assess the onset, oxygen, IV access Medications - reduces systolic between 100-120mm HG, long term maintain systolic at or less than 130-140 Therapeutic Procedures - AAA resection, percutaneous aneurysm repair, thoracic aortic aneurysm repair
Unstable angina
Occurs at rest, not exertion and more frequently (unpredictable) Isn't relieved by rest/nitroglycerin
Stable angina
Occurs with exercise or emotional stress Relieved by rest and nitroglycerin (predictable)
Interpreting EKGs
P Wave (sinus rhythm) Should be present and upright Comes before QRS complex One P wave for every QRS complex QRS Complex (P wave before every QRS complex) Should not be widened or shortened -This may indicate problems *Widen is often seen in PVCs, electrolyte imbalances, and drug toxicity* R-R Are the R-R intervals consistent? -Regular or Irregular
Heart Rhythm Measurements
PR interval 0.12 - 0.2 QRS Complex 0.06 - 0.12 >0.12 = slowing down QT Interval <0.40 seconds 1 small box = 0.04 seconds 1 large box (25 small boxes) = 0.20 seconds 5 large boxes = 1 second
A patients is 36 hours status post a myocardial infarction. The patient is starting to complain of chest pain when they lay flat or cough. You note on auscultation of the heart a grating, harsh sound. What complication is this patient most likely suffering from?
Pericarditis
Sublingual Nitroglycerin Instructions
Place under the tongue 1 tab every 5 minutes, up to 3 doses If angina is not relieved or is worse 5 minutes after first dose, call 911
Beta Blockers
Precautions (The B's of Beta Blockers) Bradycardia and heart blocks Breathing problems Bad for heart failure patients (in an acute setting) Blood sugar masking (masks s/s of hypoglycemia) Blood pressure lowered (hypotension)
What is Central Venous Pressure?
Pressure in the superior vena cava Shows how much pressure from the blood is returned to the right atrium from the superior vena cava
Valvular problems client education
Prophylactic antibiotics Daily weight Encourage cardiac DASH diet
STEMI
ST Elevation MI, real-time ongoing death of heart tissue due to ischemia/infarction
Pericarditis S/S
Stabbing chest pains Friction rub heard over the sternal border Fever Dyspnea
Interventions for a patient with A-fib
Stable PT Oxygen Drug therapy: -Beta blockers -Calcium channel blockers -Digoxin (hold 48 hrs prior to cardioversion) -Amiodarone -Anticoagulants therapy to prevent clots 4-6 wks prior to cardioversion to prevent dislodgement of thrombi into the bloodstream (the atria quiver causes pooling of blood in the heart which increases the risk for clots = increased risk for MI, PE, CVAs, & DVTs) Unstable PT Oxygen Cardioversion
Cardioversion
Synchronized Shock Synced shock delivered only during the R wave of the QRS complex Lower amount of joules (energy) used Not done with CPR Stable patients (must have a QRS complex) Elective treatment of (patients who are symptomatic) Atrial dysrhythmias Supraventricular tachycardia (SVT) Ventricular tachycardia with a pulse Medications Amiodarone Adenosine Verapamil
What is Preload?
The amount of STRETCH that the heart has before it squeezes *Thicker myocardium decreases the stretch*
What is Afterload?
The resistance that the heart must push against to get the blood out of the heart; the SQUEEEZE *HTN causes too much afterload*
Beta Blockers
Treats -Hypertension -Stable angina -Chronic/compensated heart failure (not acute HF) -Dysrhythmias
A doctor has ordered cardiac enzymes on a patient being admitted with chest pain. You know that ___________ levels elevate 2-4 hours after injury to the heart and is the most regarded marker by providers.
Troponin
A nurse is caring for a client who is 1 hour postoperative following an aortic aneurysm repaid. Which of the following findings can indicate shock and should be reported to the provider?
Urine output 20 mL/hr Urine output <30 mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood floe to the kidneys, hypovolemia, or graft thrombosis or rupture