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MS2 Exam 2
Cardiac
58
Nursing
Undergraduate 3
10/07/2013

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Cards

Term
Why are dysrhythmias a problem?
Definition
Because they affect cardiac output
Term
Automaticity
Definition
Initiate their own impulse (intrinsic pacemakers, not dependent on neuro)
Term
Excitability
Definition
Ions rapidly shift, depolarization.
Term
Conductivity
Definition
Transfer the electrical impulse from the muscle cell to muscle cell
Term
Contractility
Definition
Cardiac muscle continually convert an electrical signmal into mechanical action without rest
Term
If EKG measures electrical activity of the heart, how do we measure mechanical activity?
Definition
BP
Term
Ectopy or ectopic rhythm
Definition
Usually refers to extra or abnormal beats
Term
What is the order of pacemakers failure in the heart?
Definition
-SA Node (sinus)
-Atrial
-Junctional (AV node)
-Ventricular
Term
Average Stroke Volum (SV)
Definition
55-100 ml
Term
Average Cardiac Output
Definition
4-8 L/min
Term
Average blood volume
Definition
5L
Term
What are supportive care for symptomatic dysrhythmias?
Definition
-Assess cerebral & CV perfusion
-Give supplemental oxygen
-Check IV access, consider second line
-IVF-NS
-Stat EKG
-Stat labs: BMP, CBC, Coags, CK/Troponin
-RRT
Term
Symptoms of bradycardia
Definition
-Low BP
-Altered or loss of LOC
-Chest pain
-Heart failure
-Cool and clammy (shock state)
Term
Care for symptomatic bradydysrhythmias
Definition
-Airway, O2, IVF, and get EKG
-Call RRT/code and prepare to give Atropine rapid IV push and/or Pacing
Term
Symptoms of symptomatic tachydysrhythmias
Definition
-Low BP
-Altered or loss of LOC
-Chest pain
-Heart failure
-Cool and clammy
-Anxious
Term
Nursing care for symptomatic tachydysrhythmias
Definition
-Airway, O2, IVF, EKG
-Meds differ if SVT (Adenosine, Diltiazem) vs. VT (Amiodarone)
-Cardioversion if pulse and BP present
-Defib and CPR if no pulse or BP
Term
What area do EKG leads reflect?
Definition
Left ventricle
Term
Advantages pf "wireless" telemetry
Definition
-Real-time continuous monitoring of rhythm
-Allows immediate identification, assessment and treatment of dysrhythmia
-Does not restrict patient to bed
-Unusual events on telemetry are followed up with 12 lead EKG
Term
Advantages of 12 lead EKG
Definition
-Can measure amplitude (height) as well as time -- dx Myocardial ischemia &/or infarction and what part of the heart is affected.
-Consistent method across all providers which allows good baseline across time
-12 leads reflect more areas of the heart
Term
What is a pathophysiology r/t ST depression and ST elevation?
Definition
Depression: Ischemia
Elevation: Infarction
Term
SA node
Definition
-Primary pacemaker-starts cardiac cycle
-Initiates atrial depolarization and synchronized atrial contraction
-EKG: P wave
-HR: 60-100
-Location in right atrium makes it vulnerable to atrial enlargement or distension
Term
Sinus tachycardia
Definition
-HR > 100
-Start with the assumption that ST is compensatory if HR is 150 or less
-Look for the cause, DO NOT treat rate without knowing cause
-ST>150-pt may become hemodynamically unstable if prolonged or compromised heart
Term
Atrial dsyrhythmias: A. Fib
Definition
-Most common dysrhythmias
-R/t aging, HTN, CAD, HR, damage to right atrium
-Multiple sites send out weak uncoordinated impulses-atria quiver, no coordinated contraction to push blood into ventricles (loos of atrial kick-10%-30%
-Can be chronic underlying lung problem
Term
When someone is on Coumadin what lab do you monitor?
Definition
INR
Term
2 problems with A. Fib
Definition
-Decreased cardiac output
-Risk for impaired cerebral perfusion: loss of contraction leaves blood sitting in atria->production of multiple small clots-> increased risk of stroke
Term
Diltiazem
Definition
Calcium channel blocker-see for rate control, slows AV node
Term
A. Fib: Tachy protocol, brady protocol
Definition
Tachy: IV diltiazem, followed by infusion
Brady: Check meds, hold inotropes, BB & CBC; may need permanent pacemaker
Term
Atrial flutter
Definition
-Caused by localized irritable spot that rapidly and persistently fires impulses, seen as flutter waves
-AV node does not pass on every one
-See how atria have different rae from ventricles, but al vent impluses originate from atria
Term
Synchronized cardioversion
Definition
-Treatment for a fib and a flutter
-All myocardial cells depolarize at once, allowing a refractory period for SA node to start first
-Done at bedside on telemetry unit or outpatient
-If non-urgent (pt asymptomatic), usually try "chemical" cardioversion first with meds
Term
Why must a patient be anticoagulated before a cardioversion?
Definition
If not anticoagulated, first strong beats of newly coordinated atria will send shower of clots to the brain . . . pt will have transesophageal echo
Term
Defibrilization
Definition
Depolarizing every cell in your heart at once
-Use if no pulse on patient
Term
AV node
Definition
-Secondary pacemaker
-Normal rate 40-60 bpm
-Only electrical connection between atria and ventricles
-PRI: measures time charge is held in the AV node so ventricles have time to fill
-Normal PRI: 0.12-0.20 sec
Term
Problems with AV blocks and Junctional Rhythms
Definition
-Rate too low:
AV blocks: Impulses blocked to ventricles and vent initiated rate is low
JR: inherent rate is 40-60
-Is patient symptomatic?
Yes: Follow Brady protocol
No: Check cardiac meds
Term
Bundle of His
Definition
Extension of AV node that splits into right and left bundle branches
-QRS: AV node firing & ventricular depolarization, initiating what?
-Normal QRS: < 0.12 sec
Term
Bundle branch blocks
Definition
-Not a dysrhythmia, but abnormal conduction pattern in the ventricles.
-One BB is damaged (usually due to MI) and does not conduct impulses
-Normal fast conduction in one ventricle but delayed cell-to-cell transmission in other
Term
Ventricular dysrhythmias
Definition
-Ventricular origin of rhythm
-Ectopic vent site takes over pacing
-R/t electrolyte imbalance (esp K+ and Mg++), hypoxia, ischemia, infarction, idiopathic
-"Downward displacement of pacemaker"-bad sign
Term
Slow ventricular rhythm
Definition
-If slow, the vent rhythm is usually called an "escape" rhythm: no rhythm initiated by SA or AV node, so ventricular site starts its own rhythm (to escape death)
-<40 we do not treat with antiarrhythmics
Term
Ventricular tachycardia
Definition
-Vent rate >100
-Treatment based on symptoms: with pulse or pulseless
-Pulse: tachy protocol if symptomatic
-No pulse: CODE
-AMIODARONE IV bolus, and then infusion x 18 hours
Term
Ventricular fibrillation
Definition
-No synchronized electrical activity in ventricles
-NO CARDIAC OUTPUT
-Loss of consciousness within seconds
-Code! Requires immediate CPR and defib
Term
Asystole
Definition
-No cardiac electrical activity, no cardiac output
-Code!
-ACLS does not recommend defibrillation for asystole
-Defib Resets the electrical system-no electrical activity to reset in asystole
Term
Pulseless rhythms
Definition
Call a code and start CPR
-V tach
-V fib
-Asystole
Term
Premature beats
Definition
-Not necessarily a problem
-Check for new onset, increased frequency, oxygenation, labs (especially lytes).
-Watch for new onset or increased frequency-might indicate precipitating condition that could cause heart dysrhythmias
-PAC-A. Fib
-PVCs-V. Tach
Term
Pacemakers
Definition
-Indications: chronically or intermittenly low rate that does not meet metabolic demands (low cardiac output)
-3rd degree heart block, slow a. fib, post-ablation
-No sinus pacemaker for ventricles
-Danger re intermittent a. fib
Override pacing: for SVT
Term
Implantable cardioverter-defibrillator (ICD)
Definition
Indications:
-Documented history of v. tach or v. fib, long QT syndrome
-Significant risk factor like familial history, severe heart failure
Usually combined with pacemaker, especially in HF patients who need biventricular pacing.
Able to convert with much less electricity (comfort, anxiety)
Term
Nursing care specific to CABG
Definition
-Cardiac perfusion
-Fluid overload
-Dysrhythmias: A. fib, V. arrhythmias, Pacemakers (temp)
-Pericarditis, pericardial effusion, cardiac tamponade
-Perfusion of graft extremity
-Telemetry
-"Off pump" v. "On pump"
Term
Minimally invasive CABG
Definition
-If only one bypass needed (LIMA to LAD)
-Endoscopic
-Robotic assisted
Term
How long does a CABG last based on donor grafts?
Definition
LIMA (left internal mammary artery): 90% patent after 10 years
SVG (Saphenous vein graft): 75% occluded after 10 years
Term
"Off pump" vs "on pump"
Definition
-'On pump': heart-lung bypass machine (extracorporeal)
Heart stopped and blood circulates via machine
ECMO: extracorporeal membrane oxygenation, non-surgical support for oxygenation and perfusion
-"Off pump"-no CP bypass adn heart stabilized mechanically with tools for surgery
Term
Heart valve surgery
Definition
-Single incision
-Valve sounds
-Biomechanical (porcine, autograft, or cadaver allograft) vs mechanical valve
Term
Pre-procedure for cardiac cath
Definition
-Look out for Heparin allergies (more common) HIT
-Left main CAD="widow maker", first artery off aorta
Term
Post-procedure cardiac cath: femoral access
Definition
-Check groin access every 15 minutes for first hour-palpate
-When there is a bleed, HR will rise first, then BP is the second sign
-Hemodynamically stable: Outcome for Care Plan, AEB
-Interventions are mostly about limiting mobility adn using pressure devices
Term
Cardiac cath: radial access
Definition
More the norm in Europe but becoming more popular in America
-It awesome because you have no activity restriction
-Just wear "button pressure device" for a few hours
Term
CABG
Definition
-Purpose is to improve cardiac perfusion
-These patients have fluid overload
-A. Fib is most common complication
-Will give beta blockers and temp pacemakers to fix rhythm
Term
Pulse pressure
Definition
Difference between systolic and diastolic
Term
Thoracic surgery
Definition
-Should chest tube fall out, cover with Vaseline gauze
-Atelectasis: diminished at bases
-Pleural effusion: crackles
-Toradol is very common for surgical pain (non-opioid, NSAID)
Term
Empiric treatment
Definition
Initiation of treatment prior to firm diagnosis
Term
Bypass considerations comparing donor sites
Definition
-Arteries are better than veins
-Patients with IMA bypass, pay attention to lungs
-Arteries do better than veins because they are made for the high flow
-SVG only last about 10 years, but LIMA last about 25 years
-Hypertension lowers life of grafts
Term
Heart valves (comparisons)
Definition
Valves: before surgery there will be "murmur," after surgery (with a mech valve) it will be a "tick" sound
-Autograft: will take your own pulmonic valve and replace aortic valve and then give you a new pulmonic valve
-Porcine/autograft valve: don't require anti-coag, have les s blood damage, but don't last as long (only 10 yrs)
-Mech valve: can last rest of life
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