Cardiovascular Disorders

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Cardiovascular Disorders

• Adult Health II
• Developed by
• Cheryl McConnell RN MSN

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Complex Treatments for Clients with Acute
Myocardial Infarction

• Thrombolytic therapy
• Coronary artery bypass graft

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Thrombolytic Therapy

• Used to dissolve existing clot
• Lysis of clot and restores circulation through
  coronary arteries
• Can be given IV or intracoronary during heart
  cath
• Must be used within 6 hours of onset
• Decreases infarct size and muscle damage
• Improved outcome

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Thrombolytics

• Streptokinase
• Watch for anaphylaxis
• Less expensive
• Tissue plasminogen activator (t-PA)
• More effective if chest pain gt 3 hours duration
• More expensive

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Nursing Care Before and During Thrombolytic
Therapy

• Precise history
• Look for factors that could cause bleeding
• Explanation to client
• Numerous IV accesses
• Continual vital signs
• Supine with head flat
• Infusion site assessment
• Distal assessment
• Limited mobility

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Post Thrombolytic Infusion

• EKG changes
• Should see resolving of infarct
• Dysrthymias
• Bed rest as flat as possible
• No punctures for at least 24 hours
• Look for hidden bleeding
• Will be on Heparin drip
• Watch for reocclusion of vessel

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Coronary Artery Bypass Graft

• Bypass between aorta and coronary artery
• Uses clients own vein or artery
• Used for multi-vessel disease, LAD blockage, and
  those with diabetes
• Will be on cardiopulmonary bypass during
  procedure

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Care Prior to CABG

• Standard preoperative teaching
• Tubes to expect
• Chest tubes
• Endotracheal tube
• Pacemaker wires
• Swan Ganz catheter
• Foley catheter
• Post operative environment critical care

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Postoperative Care after CABG

• Continual vital signs
• Hypotension and bradycardia are common
• Should not be tachycardic
• Assess heart tones and lung sounds
• Look for manifestations of ? cardiac output
• Urine output lt 30 cc/hr
• Monitor chest tube drainage

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More Postoperative Care

• Pain management
• Continuous for first 24 hours then PCA
• Care of a client on a ventilator
• After extubation
• Wound management/infection
• Psychosocial
• Post pump syndrome
• Rehab

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Advanced Cardiac Disorders

• Cheryl McConnell RN MSN

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Content

• Cardiac Tamponade
• Pericarditis

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Cardiac Tamponade

• Rapid collection of blood in pericardial sac
• Compresses the heart
• Decreases ventricular filling
• Life threatening condition
• Causes
• Post CABG occluded drains
• Trauma
• Hemorrhage
• Pericardial effusion

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Cardiac Tamponade Continued

• Signs and Symptoms
• Pulsus paradoxus
• Muffled heart tones
• Dyspnea
• Tachycardia
• Narrowed pulse pressure
• Distended neck veins
• ? LOC, urine output
• Cool, mottled skin

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Treatment for Cardiac Tamponade

• Emergency pericardialcentesis/surgery
• Treat the cause
• Monitor hemodynamics for early detection of
  recurrence

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Pericarditis

• Inflammation of the pericardial sac
• Inflammation
• Edema
• Leakage of plasma proteins
• WBCs respond to inflammation invade site
• May lead to pericardial effusion
• Leads to scarring and decrease in contractility

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More Pericarditis

• Causes
• ESRD
• Infections
• MI
• Trauma/surgery
• Autoimmune/connective tissue diseases
• Rheumatic fever
• Medications
• Radiation

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Signs and Symptoms of Pericarditis

• Chest pain
• Sharp pain that is worse with movement,
  breathing, and position
• Pericardial friction rub
• Febrile
• Dyspnea
• Tachycardia

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Diagnostic Exams for Pericarditis

• CBC
• Cardiac enzymes
• EKG
• Echo
• Hemodynamic monitoring
• CXR
• CT/MRI

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Treatment of Pericarditis

• NSAIDS
• Steroids
• Pericardiocentesis
• Surgery
• Pericardial window
• Pericardectomy

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Nursing Care

• Pain management
• Maintenance of oxygenation
• Monitor for decreased CO
• Progressive activity as tolerated
• Teaching
• Home care

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CARDIOGENIC SHOCK

• Developed by
• Cheryl McConnell RN MSN
• Based on content by Kathy Rainwater

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Definition

• An abnormal condition characterized by a
  decreased pumping ability of the heart that
  causes a shock like state with inadequate
  perfusion to the tissues.
• Mortality rates exceed 70

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PATHOPHYSIOLOGY

• Loss of about 40 of cardiac pumping ability.
• CO and oxygen delivery ?
• Blood remains in the ventricle after systole
• Impairs left ventricular filling during diastole.
• Blood then begins to back up into the lungs,
  right heart, and the venous system.

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SIGNS AND SYMPTOMS

• Venous congestion
• Under perfusion of brain and kidneys
• Changes in sensorium
• ? urinary output
• Crackles
• Tachypnea

• Hypocapnia and alkalosis at first
• Hypercapnia and acidosis later
• Pale, cool, and clammy skin
• Decreased bowel sounds

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CAUSES

• MI
• Heart failure
• Cardiomyopathy
• Acute arrhythmias
• Cardiac tamponade
• Severe heart valve dysfunction
• Pulmonary embolism
• Tension Pneumothorax

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RISK FACTORS

• Pre-existing myocardial damage or disease
• Diabetes
• Advanced age
• Dysrhythmias

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LAB STUDIES.

• Cardiac enzymes
• CBC
• Electrolytes
• Coagulation profile
• ABGs

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ASSESSMENT

• Hypotension
• Urine output lt 30 ml/hr
• Cold, clammy skin
• Poor peripheral pulses
• Tachycardia
• Tachypnea
• ? LOC
• Continuing chest discomfort

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TREATMENT

• CARDIOGENIC SHOCK IS A MEDICAL EMERGENCY
• THE TWO MAIN GOALS
• ENHANCE CO
• REVERSE THE SHOCK OF SYNDROME

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TREATMENT

• Dopamine, Dobutamine, Epinephrine, Digoxin may be
  required to increase BP and heart functioning
• Pain management
• Bed rest
• Oxygen
• IV fluids

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OTHER TREATMENTS

• Cardiac pacing
• Cardiac monitoring
• Intra aortic balloon counterpulsation (IABP)
• Surgical repair if feasible.
• PTCA may be an alternative to surgery

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Cardiac Dysrhythmias
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Cardiac Dysrhythmias

• Disturbance in the hearts electrical system
• Benign
• Lethal
• Electrical impulse generated
• SA node
• AV node
• Purkinje fibers

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• Depolarization
• Systole
• Contraction
• Repolarization
• Diastole
• Resting

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Components of a Cardiac Complex

• P wave
• Impulse from SA node
• Atrial depolarization and contraction
• QRS complex
• Ventricular depolarization and contraction
• Q first negative deflection
• R first positive deflection
• S first negative deflection after the R wave

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• PR interval
• Represents the time it takes the impulse to move
  from the SA node, thru the AV node, to the
  ventricles so that contraction may occur
• Long PR intervals (gt 0.20 seconds) indicate a
  slowing of the impulse
• T wave
• Ventricular repolarization or resting
• ST segment
• From end of ventricular contraction (QRS) to
  beginning of T wave
• Shows early repolarization
• Heart is very irritable during this time

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Normal Sinus Rhythm

• Physiologically normal
• Rate 60 to 100
• Impulse arising from the SA node with intact
  pathway conduction system
• Nursing Care
• How is the client tolerating the rhythm?

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Sinus Bradycardia

• Impulse originates in the sinus node but occurs
  at a slower rate (lt 60)
• Causes
• Vagal stimulation
• Ischemia to SA node
• Athlete
• Medications
• Sleep
• Pain
• Hypothermia

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Care for Sinus Bradycardia

• Assess cardiac output
• Remove the cause
• Atropine IVP

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Sinus Tachycardia

• Impulse originating in sinus node but rate is gt
  100
• Causes
• ? sympathetic nervous system activity
• Need for ? oxygen
• Fever, pain, hypovolemia, heart failure, MI,
  acidosis, medications
• Accompanying signs/symptoms
• Dyspnea, SOB, dizziness, palpitations, chest pain

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Care for Sinus Tachycardia

• Assess cardiac output
• Initially will increase
• Then will drop significantly
• Early sign of heart failure
• Treat the cause
• Beta blockers, calcium channel blockers

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Atrial Fibrillation

• No effective contraction of the atria
• Quivering
• Blood pools in atria
• Stagnant blood clots
• Client at risk for embolic events
• Seen with heart failure, CAD, hypertension,
  hyperthyroidism

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• No P waves present only a wavy line then
  ventricular contraction and QRS complex
• Heart rhythm is irregular
• Rate of ventricular contraction varies

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Treatment of Atrial Fibrillation

• When rapid heart rate
• Calcium channel blockers
• Beta blockers
• Digoxin
• Anticoagulation
• Cardioversion
• When client tolerates rate
• Anticoagulation

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Premature Ventricular Contractions

• Dysrhythmia originates in the ventricle so the
  change in rhythm is seen in the QRS
• QRS becomes wide and bizarre in shape
• Due to an altered pathway and irritated cardiac
  tissue
• Ventricles beat early before filling occurs

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PVCs Continued

• Caused by anxiety, tobacco, alcohol, caffeine,
  hypoxia, hypokalemia, heart failure, CAD, MI
• Can be precursor to lethal dysrhythmias
• R on T phenomenon

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Treatment for PVCs

• Treat the underlying cause
• Lidocaine IVP
• IV drip
• Amiodarone hydrochloride (Cordarone) IVP
• IV drip
• PO maintenance dose
• MUST have prompt aggressive treatment in clients
  with heart disease

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Ventricular Tachycardia

• Bursts of ventricular rapid contractions
• May be sustained VT if over 30 minutes long
• Severe compromise of cardiac output
• May tolerate rhythm for short time without signs
  or symptoms

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V-Tach Continued

• Causes hypoxia, hypokalemia/magnesia, drug
  toxicity, MI, mitral valve prolapse, CAD
• Signs and Symptoms
• Depend on the amount (if any) perfusion to the
  body
• Varies from ? cardiac output to cardiac arrest

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Treatment for V-tach

• Awake
• O2, lidocaine, cordarone,
• Sedation ---- then cardioversion
• Unstable
• O2, sedation, cardioversion
• Then lidocaine or cordarone
• Pulseless
• CPR, immediate defibrillation, Epinephrine,
  Lidocaine, Cordarone

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Ventricular Fibrillation

• No organized ventricular rhythm
• Ventricles are quivering
• No pulse
• No cardiac output
• Also called sudden cardiac death
• Medical emergency

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V-Fib Continued

• Causes
• Ischemia, infarction, dig toxicity, electrolyte
  imbalances, hypothermia, electrocution
• Treatment
• Immediate defibrillation if possible
• CPR
• Epinephrine
• Lidocaine
• Cordarone

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Asystole

• Cardiac standstill
• No electrical impulse
• Causes
• MI, heart failure, hyperkalemia, ischemia,
  conduction defects

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Treatment for Asystole

• Immediate CPR
• Atropine
• Epinephrine
• Pacing

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Countershock Therapy For Cardiac Dysrhythmias
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What is Countershock?

• An electrical current used to depolarize cardiac
  cells
• Used for tachydysrhythmias
• Two types
• Synchronized cardioversion
• Defibrillation

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Synchronized Cardioversion

• The electrical shock is delivered at a specific
  time during the cardiac cycle
• Used for clients with a PULSE
• Synchronization prevents R on T phenomena
• Usually elective procedure
• Performed only by ACLS certified personnel

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Nursing Care for a Client Who Will Be
Cardioverted

• Pre
• Assessment of rhythm
• Code cart, IV access
• Conscious sedation protocols
• During
• Synchronization button activated
• Safety
• Assessment
• May need more than one cardioversion

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Client Care During Cardioversion Continued

• Post
• Assessment
• Monitor for complications
• Post sedation care
• Documentation of rhythm strip and client
  tolerance

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Defibrillation

• A random shock that is not synchronized to the
  cardiac cycle
• Emergency treatment for PULSELESS dysrhythmias
• Early defibrillation increases survival
• Nursing care
• Code situation
• Automatic External Defibrillators
• Available in public places

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Automatic Implantible Cardioverter Defibrillators
(AICD)

• Internal device that detects dangerous
  dysrhythmias and delivers appropriate type of
  countershock
• Surgically implanted tiny leads in right
  ventricle
• Pulse generator placed in chest
• Post implantation care similar to post pacemaker
  care

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Pacemakers
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Pacemakers

• Used when heart cannot sustain conduction
  stimulus
• Provides electrical stimulus that initiates
  cardiac cycle
• Used for both emergent and chronic conditions

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Types of Pacemakers

• Temporary
• External pulse generator
• Lead threaded thru a vein into right ventricle
• External Temporary
• Pacing pads placed on chest no internal lead
• Permanent
• Surgical implanted pulse generator and lead

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How Does the Pacemaker Work?

• Lead senses when the HR drops below preset rate
• Generates impulse to bring HR up
• Paces either ventricle, atria, or both
• Single chamber
• Dual chamber
• Impulse stimulation shows on rhythm strip as a
  spike that starts cardiac cycle

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Care After A Pacemaker Insertion

• Constant cardiac monitoring
• CXR
• Restricted ROM on affected side for 24 hours
• Watch for complications
• Infection
• Hiccups
• Dysrhythmias

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Client Teaching FollowingA Pacemaker Insertion

• Type and setting of pacemaker
• How to take pulse
• Signs and symptoms of pacemaker failure
• Battery life
• No tight fitting clothes over generator site
• Stay away from magnetic devices