Cardio

• – Smokers
• • Second hand smoke
• – Use of Drugs
• • Legal / Street
• – Diet
• – Wearing tight clothes
• • Experiencing leg cramps, numbness tingling
• – HTN, Diabetes

• • Stroke Volume:
• – Pre load
• – After load
• • (Automaticity/excitability)
• • Heart Rate
• – Fast heart rate
• – Slow heart rate
• • (Blockage Problems) AMI, CAD, Angina, PE
• • (Flow Problems) valvular disease, arrthymia's,HTN, cardiomyopathy

SV X HR

AMI, CAD, Angina, PE

valvular disease, arrthymia's,HTN, cardiomyopathy

70 mL

amount of blood ejected into blood out of left ventricle

ejection fraction

amount of blood in heart before pumped out

peripheral resistance - heart works harder to push blood against pressure

SOB, hypotension, chest pains

come in and something is clearly wrong with pt. at this time, needs treatment immediately

c/o pain on and off that started day before

will show no signs of a problem

3rd ICS LSB

• OLDCARTS
• • Precipitating factors
• • Quality
• • Region/radiation
• • S/S associated with the CP
• • Timing/response

treat immediately

complete head to toe assessment

• - Stethoscope
• – Doppler (gel)
• – Penlight
• – 2 cm ruler

CANNOT - complete assessment

CAN - instruct to report immediately anyincidence of CP, unusual fatigue, changes in heartrate, and blood pressure, dizziness

45 degree angle

point of maximum impulse

reported and recorded

inspected and palpated

• – Aortic area 2nd ICS RSB
• – Pulmonic area 2nd ICS LSB
• – Tricuspid area 4 ICS LSB
• – Mitral area 5th ICS MidclavicularLine
• – Epigastric tip of the sternum

synchronous

• “dub”
• follows short systolic phase
• Precedes the long diastolic phase
• High pitched
• best heard at the aortic area; may have two audible components,best heard on inspiration
• if there is delay in activation of contraction or valve stenosis wide splitting

• Both sounds heard as “lub‐dub” combinationand is one heart beat
• • Assess heart rate
• • Assess heart rhythm (regular)
• • Note the time between S1 and S2 (systolic pause) then time between S2 and S1 (diastolic pause)

• S3 and S4
• clicks and rubs
• murmurs

• Best heard at the apex, client on the left side
• Sounds are quiet, difficult to hear
• Resemble a gallop

• short, high pitched extra sounds
• squeaky or rubbing sounds
• with cardiac valves opening noiselessly

• Erb’s point 3rd ICS LSB
• low pitched sounds
• Use the bell of the stethoscope

• Heard as a swishing or blowing sound at the beginning,middle or end of the cycle
• between S1 and S2 is systolic
• between S2 and S1 is diastolic

• barely audible
• Audible immediately but faint
• Loud without thrust or thrill
• Loud with thrust or thrill
• Very loud, with lift/heave or thrill, audible with stethoscope only partially applied
• Louder, may be heard without stethoscope

• May be caused by anemia, fever, hyperthyroidism,vigorous exercise
• Reassess patient, review labs (elevated TSH, lowH,H) Ask about prior activity

• Obese, fluid over heart(emphysema, pericardial effusion) Can indicate diminishedvalve flexibility such asthose with rheumatic heartdisease
• New finding in person withappropriate weight height,report to HCP

• Heard with systemic hypertension, aortic valve syphilis, exercise,pulmonary HTN, mitral stenosis, CHF
• Record and report findings Correlate with history and other assessment findings

• Obese, fluid over heart aortic or pulmonic stenosis
• Review chart for priorfinding of Aortic orPulmonic stenosisReport finding to MD Document finding

• Closure of aortic valve slightly ahead of pulmonic valve, Best heard on inspiration, disappears during inhalation or breath holding
• Ask to hold breath to validate sound heard is split S2 Report and record finding Does not require intervention

• Combination of S1, S2, S3 sounds like “Ken‐tuc‐ky”
• New finding should be reported Reassess CV system

S4 is atrial gallop, occurring just before S2 orventricular systole. It sounds like “Ten‐nes‐see”When S3 or S4 become easy to hear, may be from increased resistance to filling because of loss of ventricular wall compliance (HTN, CAD) increased stroke volume (anemia, pregnancy, hyperthyroid)

Reassess patien tReview Fluid volume status/vital signs Report and record finding

Can be asymptomatic, or indicative of heart disease Usually indicates disruption of blood flow into,through or out of the heart

Record and report finding, note intensity,location, radiation Assess for radiation listen for murmur at the neck or back

May be cause by old artificial heart valve Extra heart sounds may also occur with murmurs and usually indicate pathology such as mitral valve prolapsed or aortic stenosis

Record and report

Result from rubbing of inflamed pericardial tissue

Report finding to MD Record assessment finding

May indicate increased cardiac output or left ventricular hypertrophy, along left sternal boarder indicates right ventricular hypertrophy

Record report findings

• located just lateral to MCLand 4th intercostals space in children <7 years
• common in children
• frequent in newborns until about 48 hours of age, most benign
• Brachial, radial and femoral pulses
• sign of coarctatation of aorta

• slows,
• decreases,
• decreases by 30‐40
• more difficult to palpate as the AP diameter as age deepens
• Heart failure
• Fatigue, restlessness, syncope,confusion
• loud
• common

• non‐Hispanic blacks followed by Mexican Americanand whites
• Higher among Jews from Israel
• Asians

• - highest occurrence of HTN
• - Age onset is earlier
• - HTN more severe
• - less prone to varicose veins than whites

• brachialartery
• Should be 130/80 mm Hg or less
• 10 mm Hg/
• right arm
• atherosclerosis or aortic disease
• pressure measured lying and standing
• by drop in systolic BP of 15mmHG or more and a fall in diastolic pressure

• neck on both sides of obvious pulsations Examine only one at a time;
• do not vigorously palpate the carotid artery to prevent carotid stimulation which causes drop in BP and HR
• rate, rhythm, strength of pulse
• localized, strong, thrusting, unchanged by inspiration
• rate, rhythm, strength
• apical pulse

• artery at lateral end of the clavicle and psoterior margin of sternocleidomastoid muscle
• hold breath - normall no sound is heard
• palpate for thirll, should not be one, if felt have severe artery narrowing

• - Sitting at 90 degree angle – see no veins flat, no pulsation; If distended while sitting indicates heart disease
• –vertical distance between angle of Louis andhighest level of visible point of the internal jugular vein pulsation
• – Need two rulers, line the bottom with top of the pulsation of jugularvein
• – Take a cm ruler and align perpendicular to the first ruler at the level ofthe sternal angle
• – Measure in cm the distance between the second ruler and the sternalangle
• – Measure both sides; less than 2 cm is normal

• radial
• ulnar
• brachial
• femoral
• popliteal
• dorsalis pedis
• posterior tibial

• - absent
• - diminished, barely palpable, easy to obliterate
• - easily palpable, normal pulse
• - full pulse, increased
• - strong, bounding pulse can not be obliterated

Unstable angina, acutecoronary syndrome,treated as AMI

• - Uncomfortable pressure, squeezing, fullness, substernal, can radiate to hands,numbness, tingling,aching
• - Physical exertion,emotional upset,eating large meal, exposure toextreme temps.
• - Rest, NTG, Oxygen

• - Similar symptom presentation as angina, but with associated SOB,diaphoreses,palpitations, fatigue,nausea, and vomiting pain lasts for greater than 15 minutes
• - Emotional upset orunusual physical exertion occurring within 23 hours of symptom onset, can occur at rest or while asleep
• - Morphine sulfate,reperfusion of coronary arteries

• - Sharp severe substernal or epigastric pain, can radiate to neck, arm, o rback other associated symptoms fever, malaise,dyspnea, cough, nausea,dizziness, palpitations,duration is intermittent
• - Sudden onset, pain increased with inspiration,swallowing,coughing and rotation of the trunk
• - Sitting upright,analgesia, antiinflammatory medications

• - Sharp severe substernal pain arising from inferior portion of pleura, may be able to localize the pain,duration greater 30 minutes
• - Follows an infection or noninfectious process(AMI, Cardiac Surgery,Cancer, Immunedisorder, uremia) Pleuric pain increases with inspiration,coughing, movement and supinepositioning. Occurs inconjunction withacquired lunginfections, pneumonia,Pulmonary Emboli
• -Treat the cause

• - Substernal pain sharp,burning or heavy often mimics angina, can radiateto arm, neck or shoulder,duration 5-60 minutes
• - Lying down, coldfluids, exercise
• - Food, antacid, nitroglycerinerelieves spasm

• Describe pain as stabbing to dull ache, associated with diaphoresis,palpitations, shortness of breath, tingling of hands or mouth feeling of unreality or fear of losing control duration peak in 10minutes
• Know associated trigger, unexpected or situational where symptoms are associated
• Removal of stimuli, relaxations,medication to treat anxiety, or antidepressants

• - Costochrondritis; sharp stabbing pain localized in anterior chest most often unilateral. Can radiateacross the chest to epigastric or back patientable to localize the pain duration hours to days
• - Most often follows respiratory tract infection with significant cough,vigorous exercise,post trauma, somecause idiopathic.exacerbated by deepbreath, coughing,sneezing and movement of upper torso or arms
• - Rest ice or heat, analgesic or antiinflammatorymedication

• - vascular, cardiac, renal, sympathetic nervous system
• - blood pressure, cardiac output, peripheral vascular resistance, heart rate
• –moderate tosevere HTN
• - hypotension, sexual dysfunction, sedation

• - Metroprolol (Lopressor) Atenolol (Tenormin) Propranolol (Inderal)Nadolol (Corgard)
• – decreased heart rate– decreased force of contraction– decreased rate of AV conduction
• - BRADYCARDIA, BRONCHOSPASM, Lethargy,CHF, Decreased BP, Depression
• - Assess pulse rate – Assess respiratory status especially first dose– Hold if systolic <90 or symptomatic bradycardia
• - contraindicated with brady dysrhythmia’s, AVblocks, Beta 2 chronic respiratory problems

• - HTN, Heart Failure
• - Lisiniopril, Captopril, Enalapril, Benazepril
• - cardiacoutput; without increasing heart rate; without increasing cardiac contractility
• - Orthostatic hypotension, Cough,Headache, Dizziness, Angioedema, Altered sense of taste
• - Nursing Priority: 1. regularly monitor b/p especially with 1st dose hypotension, 2. teach to rise slowly, 3.Avoid potassium supplements or potassium containing substitute salt. 4. administer on a empty stomach
• - Safety: History angioedema; 2nd / 3rd trimesterpregnancy, renal artery stenosis

• - (Verapamil, Nifedipine, Diltiazem)
• - in contractility; decreased conductivity ofthe heart; decreased demand for oxygen
• - Bradycardia, May precipitate AV block,Head ache, Constipation, Nausea, Peripheral edema
• - DO not crush or allow to chew sustainedrelease, Monitor for hypotension, Weigh client report edema,Teach to avoid grapefruit; increase dietary fiber, fluid• Safety: Monitor edema and for dysrhythmias

• - anginal pain, conjunction with beta blocker or ca channel blocker to suppress tachy rhythm
• - NTG IV (glass bottle special tubing), SL, Translingual Spray
• - Nitro‐bid, NTG Patch, Nitro Ointment, Sustained Release tablets
• - Relax vascular (arterial and venous) with more prominent effects on veins, which decrease preload. Arteriole relaxation reduces systemic vascular resistance, which reducesafterload
• - Orthostatic hypotension, Headache, Tachycardia, Dry mouth, Blurred vision
• - 1. Teach to carry with at all times if angina 2. Teach proper storage for freshness; tingling, fizzling sensation under tongue) discard every 24 months; teach call 911 not relieved within 5 minutes taking medication X33. Rotate transdermal patches and remove after 12‐14 hours to have a “patch free” interval of 10‐12 hours daily
• - Monitor both quick or slow for severe hypotension, tachycardia, dizziness, headache and syncope; use of Viagra other erectile dysfunction medications; compounds the effect of the drop in blood pressure

• - heart and lungs
• - patient is first put on the drug
• - bradycardia
• - CHF, depression
• - COPD
• - pulse rate

peripheral vascular resistance

• - HR
• - SV
• - sit up slowly when coming up from lying position (causes orthostatic hypotension)

• - peripheral edema
• - weigh daily

• - in a glass bottle with special tubing
• - vasodilation, veins and artery
• - call 911 do not let someone drive them
• - rotate sites

• - tachy dysrhythmias, SVT, PAT, Atrial Fibrillation
• - Diltiazem (cardizem), Propranolol (Inderal)Quinidine sulfate (Novoquinine), Amiodarone (Cordarone)
• - Each medication acts differently to reduce or slow impulses throughout the heart
• - Quinidine; Cinchonism effects; tinnitus, headache, nausea,dizziness: Generally all cause: hypotension, Fatigue, bradycardia.Amiodarone causes pulmonary toxicity, visual issues
• - Monitor cardiac rhythm, especially initially, report anypulse <60 bpm, Report hypotension, dysrhythmias, Instruct to take all doses, not catch up on missed doses, Report any SOB, irregular fast or slowheart beats
• - Monitor risk for falls

• - HF, Improves CO, Atrial Fibrillation or Atrial Flutter
• - Digoxin, Lanoxin
• - Affects mechanical and electrical action of the heart which increases contractility.
• - Fatigue, Visual disturbance, Anorexia, Hypokalemia,Bradycardia, dysrhythmias
• - Monitor serum dig level check toxicity 2 ng/ml is too high, Teach to monitor pulse; report if < 60 for adult;
• – Report if < 100 child; hold dose and report to MD, Teach recognize s/stoxicity; nausea vomiting diarrhea, blurred or yellow visual disturbance
• – Administer IV slowly >5 minutes
• – Loading Dose; usually 0.5‐1 mg, give 50% dose at first or 0.25‐0.5 mg IV slowly then in 6 hours 0.125 mg and repeat in 6 hours 0.125 mg
• - Know s/s of toxicity and antidote for digoxin

• - if digoxin level was ordered for pt.; know what the level is before giving
• - 2
• - slow push
• - 50% of 1st dose then 25% in 6hrs then 25% in another 6hrs
• - digitalizing
• - digibind, digiband

• – suppress ventricular arrthymia
• ‐ Blocks sodium channels and slowsconduction, reduces automaticity in ventricles and perkinje system
• –Toxicity, Drowsiness, Confusion, Parenthesis’, Seizure, Heart block and arrest, Respiratory arrest
• ‐ Assess LOC, Protect Monitor seizures, Monitor ECG, vital signs
• – Seizure precautions

isoprterenol, dopamine, epinephrine, atropine

• - increases heart rate and CO causes bronchodilation
• - tachycardia angina, hyperglycemia in diabetics

• - low dose - causes renal vasodilation. Moderate dose increases cardiac contractility, stroke volume and CO.
• - High dose increase PVR, blood pressure, renal vasoconstriction
• - tachycardia, dysrhythmias, vasoconstriction leading to tissue necrosis and extravasations

• - Causes vasoconstriction and increases heart rate,bronchodilator and is the treatment of choice for anaphylactic reactions
• - Hypertension, dysrhythmia, anginal pain, restlessness

• - Acts on smooth muscle of the heart to increase cardiac rhythm
• - tachycardia, dry mouth, drowsiness, urinary hesitancy

• - Monitor blood pressure, pulse, respirations, Monitor IV side for extravasations, Monitor ECG
• - titrated to blood pressure, patient condition, use large veins, monitor access site for extravasations cause necrosis

• - Hypercholesterolemia, Primary and secondary prevention of cardiac events, Clients with Type 2 diabetes and coronaryartery disease
• - Atorvastatin (lipitor), Simvastatin (zocor), Pravastatin(pravachol), Lovastatin (mevacor),rosuvastatin (crestor)
• - Lower cholesterol levels by inhibiting the formation of HMG_COa reductase which is an enzyme that is required for the liver to synthesize cholesterol
• - Myopathy (rhabdomyolysis severe), hepatoxicity
• - Monitor liver studies, Teach to report muscle pain, tenderness, women potential harm to unborn fetus, teach low cholesterol diet, Administer in evening without regard to meals
• - Liver toxic

• - Used as induction agent for anesthesia orconscious sedation
• ‐produces unconsciousness andamnesia
• - Administer slowly IV wait for full effect;Unconsciousness develops quickly 60‐80 seconds, persists for1 hour; Constant cardiac/respiratory monitoring with resuscitative equipment; Must be accompanied home not remember post DC instructions
• - Monitor ABC, Must be accompanied home

• - adenocard, adenoscan, adenosin
• - to treat or reduce Tachy arrthymia’s; Used as a chemical defibrillation
• - slows conduction through AV node; can interrupt reentry pathways through the AV node; can restore NRS in patient with SVT
• - chest pain, light headedness, nausea,flushing
• - Assess respiratory status, monitortransient dysrhythmia, tell patient to rise slowly fromlying sitting to standing after
• - do not give in blocks, sick sinus syndrome, atrialflutter and atrial fibrillation, Note herb drug interactionaloe, angelica, buckthorn, senna increase effects

LDH‐1 specific to cardiac damage (normal14‐26% of the total LDH; increases 24‐48hours; peaks 48‐72 hours returns normal in5‐10 days

CK‐MB is specific, increases in 3‐6 hours after MI; peaks 12=24 hours, return normal12‐48 hours

Cardiac Troponin I and Troponin I; onlyenzyme only specific to cardiac muscle; goldstandard for diagnosis of early and lateAMI; level elevates in 4‐6 hours and peaksin 10‐24 hours

Myoglobin is an early marker for AMI, but isnon specific; increases 1‐3 hours peaks in 4‐12 hours normal in 24 hours, Not used todiagnosis alone because will be elevatedwith renal and skeletal disease also

• - <22 mg/dl100-200 mg/dl
• - Lipids are measured to determinethe risk of development ofatherosclerotic disease
• - fast for 8 hrs

• - 100-200mg/dL
• -LDL is primary transporter ofcholesterol and triglyceride into the cells

• - < 160 mg/dl
• - HDL protective action transport cholesterol away from the cell
• - fast for 8 hrs

• - women 35-85/ men 35-70
• - Cholesterol main source are diet(animal produces) and liverElevated cholesterol is know toincrease risk of CADTriglycerides have a directcorrelation with and inverse onewith LSL and inverse one with HDL

• - High 3.0 greatest riskHD; Moderate 1‐3 mg.dl; Low < 1 mg/dl
• - Protein product produced by the liver to measure systemic inflammation,inflammation is thought to play a role in atherosclerosis

• - 51.2 pg/ml or > correlates with mild HF; Levels > 1000 pg/ml correlates with severe HF
• - Neurohormone that helps regulates blood pressure and fluid volume. Secreted from the ventricles in response to increased preload Levels increase asventricular walls expand from increased filling pressures making it an excellent tool for HF treatment and HF diagnosis
• - May draw in series

• - 5‐15 umo/l
• - Assess patients risk of CVD if Elevated think indicates CAD, stroke,peripheral vascular disease risk is present
• - Fast 12 hours prior to test

• - 25-28 seconds
• - When a vessel wall or tissue is injured thrombus tries to form to stop the bleeding; this activates the clotting cascade of which there are two pathways;Intrinsic which is the PTTand aPTT (partial thrombo plastin time)Extrinsic pathway is the PT or Prothrombin time
• - PTT and aPTT used to assess effects of heparin therapy Therapeutic heparin therapy want the level at 1.5‐2.5 times the patients baseline value; PT is used to assess effects of Coumadin (warfin) INR is a standardized method of reporting PTs; INR 2.0‐3.0 times normal forDVT, PE, Atrial FibINR 2.5‐3.5 times with mechanical prosthetic heart valves

• - 12 lead is the most common; used to dx dysrhythmias,conduction abnormalities, enlarged heart chambers,Myocardial ischemia, ,high or low Ca or Potassium levels
• - explain the procedure, non invasive, make sure electrodes adhere

• -continuous monitoring; placed on atthe bedside monitored at the central nurses station or remote location
• - clean surface with soap and water to remove oils from skin, dry area well. may need to shave hair. may need to apply small amount of benzoin to the skin if diaphoretic. change out every 48-72 hrs; watch for irritation of skin, dried out or loose

• - placed on the patient usually done out patient;wear monitor for 24hours, keep diary of activity and symptoms
• - explain how to keep diary, when and where to turn in the monitor

• - Client exercises, usually on treadmill, increasing speed and incline to increase heart rate, response of the client and heart is evaluated
• - Provide explanation of test.Establish base line vital signs/ECG rhythm Instruct client to Avoid smoking, 4 hours prior to test Avoid stimulants,Medication taken with sip of water; MD may tell not to take certain medication such as beta blockers Advise to wear comfortable clothes, bra,rubber sole shoes Explain what to expect what to report, will need an IV placed Reason of termination of the exercise test CHEST PAIN, GREATLY INCREASED HEART < ECG Depression or ELEVATION = positve test
• - avoid eating immediately after and avoid extreme temperature changes

• - Pharmacological stress test is done for the deconditioned, physically disabled who cannot achieve their target heart rate Use 3 vasodilating agents: persantine and adenosine,now primarily use adenosine because of the short half life of the medication (10 seconds)(effects last about 15-30 minutes side effect of chest discomfort, dizziness,headache, flushing, nausea)
• - If pharmacological test:Not eat drink 4 hours prior No Stimulants (coffee, tea, chocolate…_If taking aminophylin or theophyline should stop taking medication 24-48 hours prior instruct what to expect and side effects will disappear early Instruct what to report to cardiologist or nurse Can take up to 3 hours

• - Non invasive Used to determine;size, shape, motion of cardiac structures esp.valvular function Positive is abnormalities inventricular wall motion found during stress but not during rest. If found follow with cardiac cauterization.
• - Explain the exam, lay on table on their side,test is non invasive

• - TEE thread small transducer through mouth into esophagus produce higher quality
• - NPO 6 hours prior totest, Will have an IVstarted for conscious sedation, numb the back of the throat
• - Monitor conscious sedationKeep until alert and gag reflex has returned not fluids.Must have someone take them home

• - Used to detect Myocardial ischemia and infarction, assess left ventricular failure Cardiolite tracer is excellent for assessing perfusion to the myocardium
• - Prep depends on type of stressor and type of imaging Reassure about use of radioactive material No post procedure radiation precautions needed

• - Invasive procedure catheter threaded via rt femoral artery done to diagnose and manage serious dysrhythmias; may do it for syncope, palpitations, or both for survivors of cardiac arrest from VF (sudden death)Study can distinguish atrial from ventricular tachycardia Can evaluate how lifethreatening the arrthymia’s is Evaluate AV node function Evaluate how effective antiarrthymic medications are Determine need for other interventions pacemaker,implantable defibrillators orablation of the area of foci
• - 8 hour prior Antiarrthymic medications held 24 hours prior to the study,other meds with sip water Monitor cardiac rate, rhythm Explain procedure Require a permit for IVconscious sedation and procedure consent Medicate for anxiety, discomfort
• - Monitor vital signs,ECG monitoring,assess apical pulse,breath sounds(looking for pericardial friction rub indicatesbleeding)Inspect cath site, for hematoma, bleeding,feeling pulses in legs fee tBed rest extremity straight and HOB elevated 30 degrees4-6 hours

• - Invasive procedure Catheter introduced into the heart via groin rarely brachial; dye is infused – see cardiac circulation,measure ejection fraction, muscle function, valvular function, Diagnosis CAD, assess patency vessels,determine extent of blockage
• - Review the BUN CreatinelevelExplain procedure 8 hours May take some meds per orders Sign permit for conscious sedation and procedure Check for dye allergy/food allergy Record pre quality of pulses Record height and weight to determine amount ofdye to useTell patient will be awake for the procedure, will use mild sedatives, IV started,experience warm sensation with the dye,may be asked to cough or deep breath,May have to view video
• - Check site for hematoma,bleeding, every 15 minutes for hour then every 1-2 hours till stable If angiocele used for hemostats advise not to have any other femoral sticks for minimum of 3months Monitor for dysrhythmias,assess apical pulse, not any change in rhythm Brady cardiac-vagal response, raise only Feet and knees do not drop their head Administer fluids,administer atropine Inform patient of any restrictions Avoid flexion, head at 30degrees or less Encourage to drink lot of fluid to flush dye Monitor creatine and BUN Ensure safety not to get OOB with our assistance Discharge instruction if applicable