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Acute Cardiac Disorders

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by

Bonnie Cooley

on 19 July 2016

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Transcript of Acute Cardiac Disorders

62
ECG
bpm
Thank You!
Cardiac System
4-chambered heart
right side pumps blood to the lungs
left side pumps blood to the body
Stimulated by conduction system: SA/AV/Bundle of His/Perkinje fibers
Valves separate chambers: tricuspid (between RA-RV), pulmonic (RV-PA), mitral (between LA-LV), and aortic (LV--aorta)

Damage to heart muscle
What is a heart attack?
Heart sounds:
"Lubb" is the first heart sound--when tricuspid and mitral valves close, Heard best??
"Dubb" is the second heart sound--when aortic and pulmonic valves close, Heard best??
LABS/DIAGNOSTICS
CK (CREATINE KINASE)--released by damaged cells. Elevated in 6 hours of MI, baseline in 48-72 hours
CK-MB Same as CK
Cardiac Troponin--Elevated levels sensitive indictor of MI, elevated levels up to 7 days
Myoglobin--rises in 1 hour and peaks in 4 to 12 hours
BNP (B-type natriuretic peptide) a hormone released when the ventricles are distended due to increased volume and pressure (elevated in CHF)
Homocysteine--higher risk of CAD and PVD
Acute Cardiac/Pulmondary Disorders
Hormones affecting the heart function
Epinephrine (sympathomimetic)
Aldosterone (helps control sodium)
Atrial natriuretic peptide (inhibits aldosterone)
Renin/aldosterone/angiotensin
ADH (controls water)
EKG/ECG
Holter monitor
echocardiogram
exercise stress
thallium imaging
MUGA
Cardiac Cath
Atrial fibrillation (A fib)
Atria quivering
multiple firing from irritable foci
atrial rate of 350-600 bpm

Caused by: alcohol, stimulants (caffeine, cocaine, cold meds), heart disease, hyperthyroid, COPD

Tx: O2, anticoag, cardioversion, meds, possible ablation
goal is to control rate, prevent thromboembolism and restore normal rhythm
Atrial flutter (A flutter)
similar to afib but more organized rhythm
atrial rate is 250-350 bpm
Treatment: if unstable with rapid ventricular rate--synchronized cardioversion or radiofrequency catheter ablation
Supraventricular tachycardia
150-250 bpm
Caused by drugs, alcohol, stress, smoking, hormone imbalances
Symptoms include SOB, CP, dizziness, palpitations
Tx: Vasovagal maneuvers, dig, Ca channel blockers, B blockers, amiodarone, cardioversion, ablation
Ventricular tachycardia
rate: 140-250 bpm
repetitive firing of ventricular foci
if sustained VT treated with O2 and antidysrhthymics
*if unstable, add synchronized cardioversion
**if pulseless--defib and CPR
Ventricular fibrillation
Chaotic, rapid rhythm in which the ventricles quiver
No pulse, bp, cardiac output
FATAL if not changed within 3-5 minutes
Treatment: CPR and immediate defibrillation
Premature Ventricular Contractions (PVCs)
Early ventricular contraction from irritability of the ventricles
Notify RN if multifocal, occur on the T wave or increase in frequency
Treatment depends on the cause
Angina
Stable
(exertional): occurs with activities/exertion/stress, relieved with rest/nitroglycerin
Unstable
(pre-infarction): not relieved by rest/nitroglycerin, Increase in occurrence, duration, and severity. Risk of cardiac damage
Variant/Printzmetal
: caused by coronary artery spasm
Why use nitro?
Dilates coronary arteries
Makes more O2 available to myocardium
Dilates peripheral vessels to decrease workload of the heart
Signs/symptoms:
pain
dyspnea
pallor
sweating
palpitations/tachycardia
dizziness/syncope
hypertension
digestive disturbances
Risk factors:
AGE: men >45, women >55
TOBACCO EXPOSURE
HYPERTENSION
HYPERCHOLESTEROLEMIA
STRESS
DIABETES (especially uncontrolled)
OBESITY
ILLEGAL DRUG USE
HISTORY OF PREECLAMPSIA
HISTORY OF AUTOIMMUNE DISEASE



TIME is important!
The sooner treatment is started, the better the prognosis
Chew one uncoated adult aspirin
oxygen at 2L/nasal cannula (keep O2 sats >94%)
NTG sublingual (hold if systolic bp <90mmHg)
Activity: limited
Goal: "door to needle" 90 minutes for PCI or percutaneous coronary intervention
Cardiac Rehab
Improve strength
Prevent worsening of condition
Maximize functioning
Decrease risk of recurrence


Pacemakers
Temporary
Permanent

Nursing Care:
Monitor apical pulse, rhythm, incision
Report irregular rhythms or slower rate than pacemaker is set for, CP, dizziness, change in vital signs
Teach patients:
Report signs of infection, how to care for incision,
Report CP, dizziness, fainting, irregular heart beats, palpitations, muscle twitching, hiccups.
Limit activity (limit raising arm on pacemaker side, etc). Carry pacemaker ID at all times.
Avoid having security "hand wand" over pacemaker. Avoid strong electromagnetic fields such as MRI, radiotowers or touching running car engines
Microwaves are ok
Keep cell phones of 3 watts or less 6" away from the generator and on the opposite side
If becomes lightheaded/dizzy near an electromagnetic device--move away
Calcium Channel Blockers:
Relax vascular smooth muscle (decreased peripheral vascular resistance), decrease myocardial oxygen demand, dilate coronary arteries, slow heart rate, decrease bp
Beta Blockers:
Decrease bp, heart rate, decrease workload on the heart (DO NOT use with heart failure patients)
The nurse is reinforcing teaching for a patient prescribed sublingual nitroglycerin tablets. The nurse should instruct the patient to use this medication in which of the following ways:
a. Take one tablet and lie down for 1 hour and repeat if pain unrelieved
b. Place two tablets under the tongue daily to prevent angina
c. Swallow one tablet, wait 10 minutes, swallow two tablets if papin persists, swallow 3 tablets if pain remains after 15 minutes
d. With symptoms of MI, place one tablet under the tongue and if after 5 minutes the pain is not relieved, repeat and wait 5 minutes. If persists, take a 3rd and call 911

The nurse would evaluate the patient as understanding teaching on the purpose of coronary artery bypass graft surgery if the patient made which of the following statements:
a. "It cures coronary artery disease"
b. "It is done to increase blood flow to the myocardium"
c. "It prevents spasms of the coronary arteries"
d. "It will decrease blood flow to the coronary arteries"
Mrs. Sims, age 43, is admitted to the ICU with a diagnosis of atypical chest pain that radiates to her left shoulder and down her left arm. She has a history of midsternal chest cramping. Her pain increases with rest. She smokes 1 1/2 PPD and is 50 lbs overweight. The cardiac monitor shows NSR without dysrhythmias. She has NTG sublingual ordered prn for pain.
One hour after admission, Mrs. Sims reports acute midsternal chest pain radiating to her left neck and jaw. The cardiac monitor shows sinus tachycardia with occasional PVCs. Her BP is 100/70, respirations are 20 and unlabored and skin is warm and dry.
What actions should be taken?
Mrs. Mae, age 70, is 5 days post MI without complications. You assist her back to bed at 1400 hours after she ambulates. Her oxygen is on at 2L/min via NC. Her vital signs are BP 126/78, apical pulse 82, R 18. She denies pain. The cardiac monitor shows NSR. Five minutes later, you see that the monitor shows SR with PVCs of less than six/minute, VS are BP 132/84, pulse 92 and irregular, R 22. She reports no pain but says, "I can feel my heart skipping. It takes my breath away." You call the RN while staying with the patient to provide reassurance.
What should you do first?
Place the following in the correct sequence for normal electrical impulse movement through the cardiac conduction system:
1. Purkinje Fibers
2. AV node
3. Bundle of His
4. SA node
The nurse responds to a call for assistance for a patient in pulseless V Tach. The nurse should prepare for which of the following as the first choice of treatment for this rhythm?
a. synchronized cardioversion
b. pacemaker
c. defibrillation
d. antiarrhythmic medication
The nurse is to provide teaching to a patient after insertion of a pacemaker. Which of the following instructions should the nurse give the patient regarding pacemaker care:
a. Avoid all microwaves
b. All pacemaker types are compatible with MRI
c. Avoid strong electromagnetic devices
d. You will need to be on bedrest for 48 hours
The nurse is ambulating a patient who is recovering from an MI when the patient develops CP with an irregular pulse. Which of these is the safest way for the nurse to return the patient to bed:
a. Ambulation to room with one assistant
b. With assistance by gurney
c. With assistance by wheelchair
d. After completion of ambulation
Hypoxia: condition in which there is insufficient oxygen to meet the demands of the tissues and cells
Assess: *restlessness, dizziness, apprehension/anxiety, tachypnea, tachycardia, dyspnea, cyanosis, air hunger
Interventions: ABCs, oxygen as ordered monitor O2 saturations, lung sounds, VS, positioning
ARDS
Group of disorders because of acute lung injury, most commonly widespread sepsis. May also be caused by pneumonia, trauma, shock, narcotic overdose, inhalation of irritants, burns, pancreatitis, aspiration.
Edema, atelectasis and tired respiratory muscles reduce gas exchange and lead to hypoxia
Signs/symptoms: Dyspnea, tachypnea, cyanosis. Initially patients develop respiratory alkalosis (from tachypnea) but acidosis develops as patient tires
Fine inspiratory crackles
Confusion, lethargy
Eventual decreased cardiac output, shock and death
Chest X-ray: White (excessive fluid in the lungs)

Diagnostics:
CXray, physical exam, CT scan and ABG
rule out cardiac cause by EKG

Treatment: ICU, mechanical ventilation with PEEP, diuretics to reduce pulmonary edema, IV fluids, antibiotics (if sepsis caused ARDS), position patient with good lung down, TPN
Injuries:
Rib fracture: Usually 4th through 9th ribs. Commonly caused by falls. May be caused by uncontrolled coughing. Treatment is aimed at pain control to encourage deep breathing. Healing takes about 6 weeks

Flail chest: Multiple rib fractures affect the structural support of the chest so that the affected part of the chest collapses with inhalation and bulges with exhalation. Surgical stabilization of ribs may be needed.


Pneumothorax
Air entering into the visceral or parietal pleura displacing the lung
Chest Tubes:
If pneumothorax, tube in upper anterior chest (2nd to 4th intercostal space)
If hemothorax, lower lateral chest (8th or 9th intercostal space)
Keep vaseline gauze and padded hemostats at bedside
If dressing is soiled--do not remove but reinforce
DO NOT MILK, STRIP OR CLAMP TUBE
Nursing Care of patients with chest tubes:

Observe respiratory rate, effort, and symmetry
Assess shortness of breath, pain, anxiety
Ausculatate lung sounds
Confirm that dressing is intact, observe for drainage. If necessary, reinforce the dressing and notify provider (do not change dressing unless ordered to do so and trained)
Palpate around insertion site for crepitus
Check all tubing for kinks, breaks or broken connections. Verify all connections are securely taped
Verify the drainage system is below the level of patient's chest at all times
Check drainage system for cracks or leaks
Check water seal chamber for correct water level and for tidaling (unless lung is reinflated). If continuous bubbling, check system for leaks and notify provider
Check suction control chamber for gentle bubbling (or open to air). Confirm correct amount of water as ordered
Check and mark amount of drainage in collection chamber every 8 hours or prn
Report any marked increase in bloody drainage and document
Notify RN/provider if any of the following occurs:
Patient suddenly reports increasing dyspnea
Change in the patient's assessment findings
The drainage chamber is full and needs to be changed

Miss Israel has a chest tube in place for a spontaneous pneumothorax. You note that the water seal chamber is bubbling vigorously. What would cause this? What should you do?
You are totaling intake and output for your 8 hour shift. There is 240 ml of serous fluid in the drainage chamber of the drainage system at 2200. At 1400, there was 190 ml. How much output should you record?
Pleurisy
Between visceral and parietal pleura is a small amount of fluid that reduces friction as we breathe
Membranes become inflamed and don't "slide" over each other--there is pain on inspiration, coughing or sneezing
May be related to pneumonia, TB, tumor or trauma. May be caused by autoimmune disorders or pancreatitis
Empyema

Pleural Effusion
Excess fluid collecting in the pleural space (either excess production or inadequate reabsorption)
(normal amount of fluid is 1 to 15 ml) If >25 ml, abnormal
Fluid normally enters the pleural space from capillaries and is reabsorbed by lymphatics
May be caused by liver or kidney disorders, heart failure lung cancer, inflammation, infection
Diagnostic tests: CXray, possibly thoracentesis with samples sent to cytology
Treatment:
Bedrest
possible thoracentesis
possible chest tube if fluid is recurring
possible sclerosing (which will cause the pleural space to fuse)
Collection of pus in the pleural space (pleural effusion that is infected)
Complication of pneumonia, TB or lung abscess
Treatment: same as with pleural effusion with the addition of resolving the infection (chest tube or surgery to drain the area)
SARS (severe acute respiratory syndrome)
First appeared in Asia in 2003
Influenza-like symptoms such as high fever, body aches, respiratory symptoms progressing to pneumonia
Spread by close contact with contaminated person or object or through respiratory droplets
Treated with antivirals, steroids and oxygen
Pulmonary Embolus
May be clot, air, fat
Resulting obstruction of blood flow (the lung may be ventilated, but the part of the lung has no blood flow)
Because no blood supply is available to pick up the oxygen in the affected portion of the lung, it becomes dead space and seriously impairs gas exchange
Most commonly from DVT (general anesthesia, heart failure, fractures of the lower exptremities, immobility, obesity, oral contraception, smoking and previous history of DVT or PE--fat emboli from compound fracture, amniotic fluid emboli during L&D, and air embolism from air into bloodstream

Prevention: regular ambulation, low dose subcutaneous heparin or oral warfarin if at risk, intermittent compression stockings
signs/symptoms:
sudden onset of dyspnea for no apparent reason (may be gasping for breath and anxious)
tachycardia
tachypnea
cough
pleuritic chest pain
crackles or friction rub on auscultation
hemoptysis (not common)
DEATH results if treatment is not fast and effective
Diagnostic tests:
*spiral CT with contrast
lung scan if spiral CT not available
D-dimer may rule out (blood test--it is a fibrin fragment found in the blood after any thrombus formation, not specific)

Treatment:
Thrombolytic agents may be used in life-threatening emergencies to dissolve the clot
If unable to use thrombolytics, clot may be removed via cardiac cath or surgical embolectomy (rare)
Oxygen (even if oxygen saturation is normal)
mechanical ventilation may be required
Anticoagulant for at least 3-6 months after PE to prevent recurrence
May use vena cava filter
http://www.rnceus.com/ekg/ekghowto.html

1. Is it regular?
2. What is the heart rate?
3. Are there P waves?
4. P-R interval
5. QRS interval
6. QT interval
P Waves?
P-R interval
should be 0.12-0.20 (3-5 small boxes)
measured at the beginning of the P to beginning of R
QRS measured from the beginning of the Q to the end of the S
should be 0.06-0.10
(< 3 small boxes)
QT should be less than 0.40 seconds
Full transcript