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106 Cards in this Set

  • Front
  • Back
Give the blood flow through the heart.
1. Superior/Inverior Vena Cave
2. R Atrium
3. R Ventricle
4. Pulmonary Arteries
5. Lungs
6. Pulmonary Veins
7. L Atria
8. L Ventricle
9. Aorta
Which coronary artery does the most work?
The ones supplying the Left Ventricle. Most specifically, the Left Anterior Descending Artery (the widow-maker)
Define Preload
Preload is the amount of blood filling the R Atrium & Ventricle. When in a hypervolemic state, the preload is going to be greater & cause an increase in stretch of the ventricles
Define Afterload
Afterload is the resistance to ejection. It can be both pulmonic resistance & peripheral vascular resistance. The less pliable the arteries are, the greater the resistance.
Define ejection fraction. What are the common %'s from the R & L Ventricles?
This is the % of blood ejected from the ventricles per contraction. Normal RV EF is 42% & normal LV EF is 50%.
Define Cardiac Output. What is a normal cardiac output in a resting adult?
It is the Heart Rate x Stroke Volume (HRxSV=CO)

Normal is 5L/minute in a resting adult
What are some Age Related changes affecting the heart?
* myocardial thickening & hypertrophy = cardiomegaly
* LVH causes LV to be less compliant, decreasing fill & decreases C.O.
* Valves thicken & sclerose causing heart murmurs.
* Conduction systems misfire causing dysrhythmias. (afib #1)
* SNS less responsive to activity = activity intolerance = increased fatigue.
* Aortic tree & arch harden (arteriosclerosis)
* Isolated Systolic HTN = Increased Systolic BP while Diastolic pressure remains normal because of loss of compliance of great vessels. Tx if above 160.
* Baro Receptor response is decreased so there is less vasoconstriction when going from lying to standing = orthostatic hypotension & risk of falling.
What valves close & cause the S1 & S2 sounds. Where are they heard the loudest?
S1 is the closing of the Tricuspid & Mitral valves & is heard most easily at the Apex of the heart. You will hear LUB dub, LUB dub when listening at this location.

S2 is the closing of the aortic & pulmonic valves & is heard at the base of the heart. You will hear lub DUB, lub DUB when listening at this location.
What causes the S3 & S4 heart sounds. What do they sound like?
S3 is the splitting of S2. It will sound like Ken-Tucky, Ken-Tucky.

S4 is the splitting of S1. It will sound like Tenne-ssee, Tenne-ssee. This is when you will feel a rocking of the heart if you palpate at the PMI.
What conditions cause S3 & S4 heart sounds?
S3 = Heart Failure
S4 = Hypertensive Crisis
What differences will you find between the M/F hearts?
The female heart is:
* Smaller in overall size
* Smaller coronary arteries
* More prone to blockages r/t smaller size
* Harder to cardiac cath
What effect +/- does estrogen play on the heart?
+: Decreases atherosclerosis. Women have better lipid panels than men & less coronary artery disease.
-: Estrogen increases coagulation proteins & therefore women are at greater risk for DVT & PE.
What is the first sign you will see with decreased cardiac output?
A sudden change in LOC r/t decreased cerebral perfusion. What is their orientation to Person/Place/Time/Situation. How does this compare to THEIR normal?
What changes will you see in the skin r/t decreased Cardiac Output?
* Pallor
* Low O2 Sat (could be r/t anemia or decreased arterial perfusion)
* Cap Refill slow (check fingernails)
* Cyanosis or lips or oral mucosa
What is the difference between Peripheral Cyanosis & Central Cyanosis? Where do you look?
Peripheral is not as serious. Skin pallor, nail beds, lips, earlobes, extremities, cap refill, low or no O2 sats.

Central is SERIOUS. Tongue & buccal mucosa is blue. Needs intubation/vent
Define Xanthelasma. What is this indicative of?
Little fat deposits on the inner eye lids.

Long term high cholesterol.
Define Arcasinillis. What is this indicative of?
Blue grey ring around pupils of the eye.

Long term high cholesterol.
What is ecchymosis? What should you be checking?
Bruising. Unexplained bruising could indicate anticoagulation.
What is pulse pressure. When should you be concerned. What does it indicate? What other symptoms might you see?
The difference between the systolic & diastolic BP. 120/101 = 19 pulse pressure. < 30 mm Hg is of concern & indicates decreased cardiac output. Other symptoms would be decreased o2 sats, confusion, decreased urinary output.
What is pulse deficit.
The difference between the apical pulse & some other peripheral pulse. Apical = 98, radial = 70, then the pulse deficit is 28. This means the ventricle contracted 28 times but there was no palpable pulse.
When do the coronary arteries receive oxygenated blood?
When the heart is in diastole.
What are the two jobs of the AV node?
1 - slow down the rate of contraction so that the ventricles have time to fill.
2 - splits the electrical signal between the L & R bundle branches (then to the purkinje fibers causing contraction of the ventricles)
What is depolarization?
Depolarization is the Discharge of electricity in the heart causing the contraction of the atria or the ventricles. AKA systole.
What is repolarization?
Repolarization is the recharge of electricity in the heart while the heart is resting. AKA diastole.
What 3 factors affect Stroke Volume?
Preload, Afterload & Contraction.
What is contraction?
The force exerted by the contracted myocardium.
What do chromo, dromo, and ino mean?
Chrono - Rate
Dromo - Conduction
Ino - Contraction Force
What is Troponin? What does it detect & when can it be detected?
A protein found in cardiac muscle that gets released when the heart is ischemic (MI). It can be detected within 3-4 hours of an event & up to 1-3 weeks later.
What are the lab values for NA, K, Ca, Mg, BUN, Creatinine & Albumin?
Na (135-145)
K (3.5-5.0)
Ca (8.6-10.2)
Mg (1.3-2.3)
BUN (10-20)
Creatinine (0.7-1.4)
Albumin (3.5-5.0)
What are the lab values for RBC, WBC, Platelets?
RBC (3.5-5.5 M)
WBC (5,000 - 10,000)
Platelets (150,000 - 450,000)
What are the values for Hemoglobin & Hematocrit (M/F)?
Hemoglobin (M: 16-18 / F: 12-16)
Hematocrit (M: 42-52% / F: 35-47%)
What is the first line of protection against bleeding?
Platelets
What are the values for Fasting Glucose, HBA1C?
Fasting Glucose (60-110)
HB A1C < 7% reflects near-normal Blood Glucose Levels
HB A1C for a non-diabetic should be 4.4-6.4%
What is normal Cholesterol, HDL, LDL & Triglycerides?
Cholesterol (< 200)
HDL (M: 35-70 / F: 35-85)
LDL (<160)
Triglycerides (100-200)
What is BNP? What does it do? Is it effective? How do we treat?
Brain Natriuretic Peptide - a hormone in the heart that helps to regulate BP & fluid volume.

It gets released when pressures in the heart are too high. Tells kidneys to shut down RAAS system.

It is not effective b/c the increased pressures in the heart causes decreased C.O. which causes lower pressures in the kidneys. The kidneys read that as trauma, blood loss, hypovolemia & this signal is stronger so RAAS stays turned on.

We treat with ACE inhibitors to inactivate the RAAS system.
What is C-Reactive Protein? Where is it produced? Is it an effective marker for atherosclerosis?
A protein produced by the liver in response to any systemic inflammation. It is effective only when there is no evidence of any other inflammatory process.
What is homocysteine?
It is an amino acid linked to the development of atherosclerosis. Atherosclerosis is the underlying disorder in CAD, stroke & peripheral vascular disease; however, it only indicates a risk factor, it is not an independent predictor of these.
How do you check for Orthostatic Hypotension? What changes are considered normal? What do abnormal findings indicate?
Have person lying down for ~ 10 minutes & take BP & HR, change position to sitting & wait 1-3 minutes. Take BP & HR. Change position to standing & wait 1-3 minutes. Take BP & HR.

Normal: HR increase 5-20 above resting rate, Systolic pressure is the same or a slight decrease of 10 mm Hg, Diastolic pressure has a slight increase up to 5 mm Hg.

Abnormal: Indicates either intravascular volume depletion or inadequate vasoconstriction.
What is the quality scale for pulse?
0 - Absent
1+ - weak/thready, difficult to palpate & obliterates with pressure.
2 + - Diminished Pulse but can't be obliterated
3+ - Easy to palpate, full/normal
4+ - strong/bounding
What does distended JVD indicate?
Usually increased preload on the R side of the heart. Blood is backing up in the Jugular Vein causing distention.
How do you assess for JVD?
Place the patient in a bed with the HOB elevated to 45 degrees. Stand a ruler straight up from the sternal notch & then from the top of the JVD, extend another ruler straight across to the first creating a right angle. The number of cm on the ruler is the level of JVD. As volume decreases, the cm's will also decrease upon further assessments.
What changes in extremities might you find with cardiovascular diseases?
Skin changes, loss of hair on lower extremities indicates decreased arterial perfusion, ulcers at locations other than pressure points & bony prominences (areas such as shins & outsides of the feet), peripheral edema, check the nail beds for clubbing, temp of extremities, quality of pulses bilaterally, cap refill, vascular changes (numbness, discomfort, pain, tingling)
What is Homan's sign? Is it accurate?
Homan's is pain in the calf when the bottom of the foot is pressed upward. It indicates the possibility of a DVT. It does not singly indicate as such but if there is other evidence: redness, increased circumference, heat...
What is orthopnea? What causes it?
A difficulty breathing when lying flat.

A redistribution of blood from the lower extremities & splanchnic beds to the lungs. In pts with LV problems, this additional fluid causes reduction in vital capacity & pulmonary compliance with SOA. Additionally, pts with CHF the pulmonary circulation may be already overloaded.
What is an ECG/EKG?
A graphic representation of electrical currents in the heart. A 12-lead is used to diagnose dysrhythmias, conduction abnormalities, chamber enlargements, & myocardial ischemia, injury or infarction. Continuous ECG monitoring is standard for dysrhythmias & detects abnormalities in heart rate & rhythm.
What are some different types of EKG's?
12 Lead - Most reliable direct connect to EKG machine.

Tele - Battery operated pack (6 Leads?). Radio waves to EKG strip computer in central location.

Holter - Continuous ambulatory monitor w/ tape recorder for up to 24 h. Person keeps diary for comparison purposes. Usually done for 5-7 days.

Signal Averaged EKG - Records 150-300 QRS waves, takes an average of these wave forms.

Trans-telephonic - Uses telephone mouthpiece to transmit ECG to another location. Used for permanent pacemakers.
What is the most common stress test performed? How is it conducted?
Pharmacological Stress Test

The patient receives two Vasodilating Agents (Persantine-lasts 15 to 30 minutes & Adenosine-lasts 10 seconds) & mimics the effects of exercise. If ST segment changes then test is stopped immediately & antidote (caffeine) is given. An ST segment depression indicates myocardial ischemia.
What defines a positive stress test?
Chest pain or change in ST segment. Depression in ST segment indicates myocardial ischemia. Elevation indicates myocardial infarction.
What nursing interventions get implemented prior to a pharmacologic stress test?
NPO for 4 hours prior. No caffeine or meds with caffeine prior. Test takes 1-3 hours.
What is studied with a traditional Echo?
A 2D study of blood flow of the heart. Can also detect size, shape & motion of cardiac structures. Can diagnose pericardial effusion, causes of heart murmurs, function of prosthetic heart valves, ventricular wall motion.
How is a traditional echo performed?
This is a painless procedure but patient will have to periodically be turned on the left side or hold their breath. It is the transmission of sound waves into the heart through the chest wall via an ultrasound transducer. The test takes about 30-45 minutes.
How is a Transesophageal Echocardiograph performed?
A tube with transducer is passed thru mouth to esophagus. This system performs clearer images because the transducer does not have to compete with bone & tissue to get images. Its like watching 1950's TV in HD.
What can a TEE check for?
Heart Failure, Valvular Disease, Thrombi.
What pre procedure steps are taken prior to TEE?
* Pt NPO for 6 h
* IV line for sedative & any other meds (stress test)
* Patient is under moderate sedation (can maintain own patent airway & respond appropriately to commands)
* Throat is anesthetized before probe
What is cardiac catheterization?
An invasive procedure used primarily to study Coronary Artery Disease, latency & extent of athersclerosis. Performed with angiography. The right side of the heart is accessed via a vein & left heart accessed via an artery. A radiopaque catheter is introduced an extended to the heart & then via Angiography a contrast agent is introduced to view the vascular system of the heart.
What parts of the cardiopulmonary system need to be accessed via a VEIN?
R Atria & Ventricle, Pulmonary Artery & Pulmonary Arterioles, the Tricuspid & Pulmonary Valves.
What part of the cardiopulmonary system need to be accessed via an ARTERY?
Aorta, L Atria & Ventricle, the Coronary Arteries, the Mitral & Aortic Valves.
What pre & post interventions are important for cardiac catheterization?
Pre: * Fast 8-12 h, Duration < 2 h lying flat on hard table, IV meds for comfort, sensations - palpitations, pounding, extra beats, LABS (BUN/Creatinine), deep breathing & coughing during procedure, contrast may make them feel need to urinate.
Post: * Assess cath site for bleeding, peripheral distal pulses q15x4 then q1x2h until pulses stable, Neuro checks, Monitoring for dysrhythmias, Bed rest for 6 h w/ leg straight at cath site, oral & IV hydration to flush contrast, Monitor Creatinine levels, I&O's, Fall Risk, Instruct pt to report chest pain & & bleeding or sudden discomfort @ site.
What is Central Venous Pressure (CVP) monitoring?
Pressure in the R Atrium to determine preload/filling.
What is considered normal pressure with CVP monitoring?
4-8 mm Hg. Measurement can be continuous or intermittent.
What does a low & high CVP indicate?
Low: Preload is low or hypovolemia.
High: Preload is high or hypervolemia.
What can you do with the port of CVP?
Draw blood, infuse IV meds & fluids
What are common complications with CVP administration?
Infection
Pneumothorax
Air Embolism (make sure caps are air right)
Facts about Pulmonary Artery Pressure.
Access?
Measures?
Access: Venous
Measures: allows for PAWP which measures Left Ventricular Filling Pressure (Preload) & tell us how well the LV is pumping/functioning
What can you do with Pulmonary Artery Pressure Catheter?
You can assess a variety of hemodynamic measurements, collect blood samples, infuse IV fluids.
How is a Pulmonary Artery Pressure Catheter placed?
The doc inserts the catheter through a large vein & into the R atrium, a balloon is inflated that allows it to float into the R ventricle & up into the branch of the pulmonary arteries. The balloon is then immediately deflated & the catheter is placed in a locked position so it can't move. This balloon then allows for Pulmonary Artery Wedge Pressure Measurements.
Explain the pathophysiology as to how PAWP measures function of the LV.
The PAWP is measured when a balloon is inflated in the pulmonary artery creating an instantaneous PE. If the LV is functioning well, blood is ejected easily out the aorta. If the LV is not functioning well, blood backs up in the LA, Lungs & Pulmonary Artery creating an increase in back pressure against the PAWP balloon.
What does an ART (intra-arterial blood pressure) line measure?
It is a direct & continuous internal measurement of BP.
What can be done with an ART line? What can't be done with an ART line?
Can: Obtain ABG's & blood samples
Can't: No fluids or IVP meds through line
What are the possible complications that can occur r/t the placement of an ART line?
Pain
Arteriospasm
Infection
Distal Ischemia
What is/does the P wave represent?
It is the atrial contraction.
It represents the depolarization of the atria as the electrical activity spreads from the SA node through the atria & lasts .08 to .1 second.
What is the PR interval? What is occurring here?
The period of time from the beginning of the P wave to the beginning of the QRS complex.

The flatline segment is the delay of the AV node which allows the filling of the ventricles.

If the interval is > 0.2 seconds, then there is an AV conduction block, which is termed a 1st degree heart block if the impulse is still conducted into the ventricles.
What is the QRS complex? What does it represent?
It is the ventricular contraction. It represents the depolarization of the ventricle.

Normal QRS occurs in 0.06 to 0.1 seconds. >0.1 is prolonged and indicates conduction is impaired within the ventricles.
What is the ST segment? What is this marker significant in identifying?
A period of isoelectric flatline following the QRS complex that occurs at the beginning of ventricular repolarization.

The ST segment is depressed during myocardial ischemia.
The ST segment is elevated during myocardial infarction.
What does the T wave represent?
Ventricular repolarization.
Rate: < 60
Rhythm: Regular
P Wave: Consistent shape & in front of QRS
PR Interval: Consistent
QRS: Usually normal
P:QRS Complex: 1:1
Sinus Bradycardia
Rate: Atrial (250-400), Ventricular (75-100)
Rhythm: Atrial regular / Ventricular usually regular
P Wave: Sawtooth shape
PR Interval: Difficult to determine
QRS Shape: Normal or abnormal
P:QRS: 2:1, 3:1, 4:1
Atrial Flutter
Rate: 100+
Rhythm: Regular
P Wave: Consistent shape & in front of QRS
PR Interval: Consistent
QRS: Usually normal
P:QRS Complex: 1:1
Sinus Tachycardia
Rate: Atrial Rate (300-600), Ventricular Rate (120-200)
Rhythm: Irregular
**P Waves: No discernible P waves.
QRS Shape: Usually normal but can be abnormal
PR Interval: Cannot be measured
P:QRS: Many:1
Atrial Fibrillation
Rate: 60-100
Rhythm: Regular
P Wave: Consistent shape & in front of QRS
PR Interval: Consistent
QRS: Usually normal
P:QRS Complex: 1:1
Normal Sinus Rhythm
Rate: Ventricular (>300)
Rhythm: Irregular without pattern
QRS Shape: Irregular undulating waves w/o recognizable QRS complexes
Absent audible heart beat, pulseless & absent respirations
Ventricular Fibrillation
Rate: Ventricular (100-200)
Rhythm: Usually regular
P Wave: Difficult to detect
PR Interval: Irregular if P wave can even be seen
QRS Shape: Bizarre abnormal shape
P:QRS: Difficult to find P wave but if found 1:multiple
Ventricular Tachycardia
Is Sinus Bradycardia normal or abnormal for the GENERAL POPULATION?
Abnormal. It would only be normal for a trained athlete who has a lower resting rate.
What are some causes of Sinus Bradycardia?
Trained athlete, vagal stimulation (vomiting/straining), Meds (beta blockers), MI
In the event of sinus bradycardia, what should be done?
Atropine should be given if patient is symptomatic - stimulates the SNS to speed the heart up. (positive chronotrope)
What are some causes of Sinus Tachycardia?
Anything causing Decreased C.O.: Blood loss, Pain, Shock, Hypovolemia, Heart Failure

Also: stress, anemia, anxiety, exercise, caffein, alcohol, smoking, drugs (cocaine/ecstasy)
In the event of sinus tachycardia, what should be done?
Beta Blockers (negative chronotrope)
Catheter Ablation of the SA node
What are some causes of Afib?
#1: Age
Valvular Heart Disease
CAD
Open Heart Surgery
Holiday Drinking
What treatment is used for Afib?
Coumadin: Stroke Prevention
Calcium Channel Blocker (Cardizem)
Pacemaker
What are some symptoms you might see with atrial flutter?
SOA
Decreased BP
Chest Pain
What would you do to treat a patient with Atrial Flutter?
Adenosine (if symptomatic, prob not convert to NSR)
Cardioversion
What are some causes of Ventricular Tachycardia & Ventricular Fibrillation?
CAD, Electrolyte Imbalance
What treatment would be carried out for Ventricular Tachycardia?
Defib (if symptomatic)
Lidocaine rapid IVP (- chronotropic)
CPR
What treatment would you give for Ventricular Fibrillation?
Defib
Epinephrine (Positive Chronotropic & Vasoconstrictor)
CPR
What is cardioversion?
A timed/synchronized electrical shock aligned with the QRS complexes
What is defibrillation?
An untimed electrical shock of the heart.
What are the main components to a pacemaker?
1: Pulse Generator - sets the rate
2: Leads: Sensing leads (sense the pace of the heart) & Pacing Leads (sends the appropriate rate to the heart)
Where is the pace maker usually inserted?
Under the left Anterior Chest Wall.
What is the most common complication of pacemaker implantation?
Infection
Then . . . Bleeding, Hematoma, Pneumothorax
What meds are considered to be Positive Inotropes?
Digoxin, Dopamine, Dobutamine & Epinephrine
What meds are considered to be Negative Inotropes?
Beta Blockers, Calcium Channel Blockers
What meds are considered to be Positive Chronotropes?
Isuprel (Isoproterenol), Epinephrine, Atropine
What meds are considered to be Negative Chronotropes?
Beta Blockers
What categories does Digoxin fall under? +/- dromo, chrono, ino?
- Chronotrope (Controls HR down)
+ Inotrope (increases contractility)
What is a major side effect of Niacin?
Flushing
What do statins do? What should be monitored?
Improve cholesterol
Monitor LFT's