RIGHT ATRIUM: BLOOD RECEIVER

Receives blood FROM LUNGS

LEFT ATRIUM: BLOOD RECEIVER

Receives blood FROM BODY

RIGHT VENTRICLE: BLOOD PUMPER

Receives blood TO LUNGS

LEFT VENTRICLE: BLOOD PUMPER

Receives blood TO BODY

ATRIOVENTRICULAR VALVES

(From Ventricles to Atriums)

SEMILUNAR VALVES

(From Arteries to Ventricles)

Tricuspid Valve: Between Right Atrium and Right Ventricle

Pulmonary Valve: Between Right Ventricle and Pulmonary Artery

Mitral Valve: Between Left Atrium and Left Ventricle

Aortic Valve: Between Left Ventricle and Aorta

RIGHT – DEOXYGENATED BLOOD

LEFT – OXYGENATED BLOOD

1 – Superior/Inferior Vena Cava

7 – Pulmonary Vein

2 – Right Atrium

8 – Left Atrium

3 – Tricuspid Valve

9 – Mitral/Bicuspid Valve

4 – Right Ventricle

10 – Left Ventricle

5 – Pulmonary Valve

11 – Aortic Valve

6 – Pulmonary Artery

12 - Aorta

BLOOD TO LUNGS

BLOOD TO LUNGS

ARTERIES

(Think A for AWAY)

VEINS

(Think V for VISITS)

Carry oxygenated blood FROM HEART TO TISSUES

Carry deoxygenated blood FROM BODY TO HEART

Exception: PULMONARY ARTERY

Carries deoxygenated blood from the heart to lungs

Exception: PULMONARY VEIN

Carries oxygenated blood from lungs to heart

SA NODE

"Pacemaker" of the heart

Sends impulse to contract atrium

Atrial Depolarization Starts

BEATS 60-100 BPM

AV NODE

"gatekeeper" of the heart

Creates delay so atria can fully empty into ventricles

Atrial Depolarization Complete

BEATS 40-60 BPM

BUNDLE OF HIS

Carries impulses from AV node to bundle branches

Ventricular Depolarization Starts + Atrial repolarization

BEATS 20-40 BPM

BUNDLE BRANCHES

Carries impulses to right and left ventricles

Ventricular Depolarization Complete

BEATS 20-40 BPM

PURKINJE FIBERS

Carries impulses to right and left ventricles

Ventricular Repolarization

BEATS 20-40 BPM

S1: LUB

·       Beginning of systole

·       Ventricles contracting

·       Closure of tricuspid & mitral valves

S2: DUB

·       End of Diastole

·       Ventricles relaxing

·       Closure of aortic & pulmonic valves

S3: LUB-DUB-TA

·       Abnormal Heart Sound

·       “Ventricular gallop”

·       Rapid ventricular filling

S4: TA-LUB-DUB

·       Abnormal Heart Sound

·       “Atrial gallop”

·       Blood forcing into stiff ventricle

Systolic Blood Pressure (SBP)

Pressure in the arteries when ventricles contract

Diastolic Blood Pressure (dBP)

Pressure in the arteries when ventricles relax

Troponin (TRP)

·       Proteins released into blood when heart muscle has been damaged

·       Most commonly used to diagnose MI

Normal: < 0.04 ng/mL

Creatine Kinase Myocardial Band (CKMB)

·       Enzyme released into blood following tissue damage to the heart

·       Not as specific as troponin, predictive of MI

Normal: < 5 ng/mL

Brain Natriuretic Peptide (BNP)

·       Peptide released from cardiomyocytes when ventricles overfill and stretch

·       Used to detect heart failure

Normal: < 100 pg/mL

Severe HF: > 900

EKG

measures electrical activity of heart

Echo

measures ejection fraction and cardiac output + assesses valve function

Cardiac Cath

measures pressure & blood flow in the heart

PR Interval

0.12 - 0.20

QRS Complex

0.06 – 0.12

QT Interval

0.35 – 0.45

6 SECOND METHOD

·       Best for irregular rhythms

·       Count # of R's in 6 second strip & multiply by 10

·       There are 30 big boxes in a 6 second strip

BIG BOX METHOD

·       Best for regular rhythms

·       Divide 300 by the # of big boxes between two R’s

SMALL BOX METHOD

·       Divide 1500 by the # of small boxes between two R’s

Rate

60 – 100 bpm

Rhythm

Regular

P Wave

Upright & before every QRS

PR interval

Normal

QRS

Normal

Rate

< 60 bpm

Rhythm

Regular

P Wave

Upright & before every QRS

PR interval

Normal

QRS

Normal

CAUSES

·       Vagal stimulation

·       Athletes

·       Medications (CCB, Digoxin, Beta Blockers)

CONSIDERED NORMAL IN

Athletes - have a lower resting heart rate due to the heart muscle being stronger & pumping more efficiently

SYMPTOMS

·       May be completely asymptomatic

·       Syncope

·       Confusion

·       Fatigue

TREATMENT

·       Asymptomatic – treatment may not be required

·       If Symptomatic

o   Atropine

o   Transcutaneous pacing

Rate

> 100 bpm

Rhythm

Regular

P Wave

Upright & before every QRS

PR interval

Normal

QRS

Normal

CAUSES

·       Emotional distress

·       Exercise

·       Fever

·       Severe bleeding/shock

·       Hyperthyroidism

·       Stimulants (Anticholinergics, cocaine, caffeine)

SYMPTOMS

·       Palpitations

·       Shortness of breath

·       Dizziness

·       Headache

TREATMENT

·       Find and treat underlying cause

·       Beta blockers or CCB (if symptomatic)

·       NSAIDs (for fever)

·       Fluid resuscitation (for hypovolemic shock)

Rate

151 - 200 bpm

Rhythm

Regular

P Wave

Undetectable (hidden in t waves)

PR interval

Normal

QRS

Narrow

CAUSES

·       Emotional stress

·       Stimulants (often triggered by premature beats)

SYMPTOMS

·       Palpitations

·       Shortness of breath

·       Chest pain

·       Syncope

TREATMENT

·       If symptomatic

o   Vagal maneuver

o   IV Adenosine

·       2 DOSES MAX

o   Dosing starts by giving 6 mg and then 12 mg if unsuccessful

o   Given FAST with flush immediately after

Rate

·       Controlled: < 100

·       Uncontrolled: > 100

Rhythm

Irregularly irregular

P Wave

Unidentifable

PR interval

Unmeasurable

QRS

Narrow

Rate

·       Controlled: < 100

·       Uncontrolled: > 100

Rhythm

Regular or irregular

P Wave

Sawtooth flutter waves

PR interval

Unmeasurable

QRS

Regular

CAUSES

·       Coronary artery disease

·       Heart Failure

·       COPD

·       Hypertension

·       Hyperthyroidism

SYMPTOMS

·       Palpitations

·       Shortness of breath

·       Dizziness

·       Chest pain

·       Anxiety

·       May be completely asymptomatic

TREATMENT

·       Oxygen

·       Cardioversion - Synced shock to attempt to restore to normal rhythm

MEDICATIONS

·       Beta blockers (Metaprolol)

·       Calcium channel blockers (Cardizem)

·       Antiarrhythmics

·       Blood thinners (Amiodarone, Digoxin)

·       Increased Risk of Blood Clots

Rate

·       Brady: < 40

·       Regular: 40-60

·       Accelerated: 60-100

Rhythm

Regular

P Wave

Inverted or absent (main sign used for identifying)

PR interval

Unmeasurable

QRS

Normal

CAUSES

·       Digoxin toxicity (Most common)

·       Sinus node dysfunction

·       Carditis

·       Cardiac surgery

·       Myocardial infarction

SYMPTOMS

·       Weakness

·       Fatigue

·       Chest pain

·       Anxiety

·       Dizziness

TREATMENT

·       Find and treat underlying cause

·       Beta blockers or CCB (if symptomatic)

·       NSAIDs (for fever)

·       Fluid resuscitation (for hypovolemic shock)

CAUSES

·       Electrolyte imbalance

·       Stimulants or stress

·       Myocardial infarction

·       Heart failure

·       Cardiomyopathy

SYMPTOMS

·       May be asymptomatic

·       May feel like heart "skipped a beat”

TREATMENT

·       Find & treat underlying cause!

·       If symptomatic

o   Correct electrolyte imbalances

o   Avoid stimulants

o   Assess for pain

Rate

Rapid and disorganized

Rhythm

Irregular

P Wave

Not visible

PR interval

Unmeasurable

QRS

Unmeasurable

CAUSES

·       Myocardial infarction

·       Electrolyte imbalance

·       Drug toxicity/overdose

·       Electrical shock

·       Hypothermia

·       Untreated Vtach

SYMPTOMS

·       Loss of consciousness

·       Most likely no pulse or blood pressure

·       Agonal breathing

·       IT IS A MEDICAL EMERGENCY!

TREATMENT

·       CPR and defibrillator

·       Follow ACLS protocol (See ACLS & BLS protocol sheet)

Rate

100-250 bpm

Rhythm

Regular

P Wave

Not visible

PR interval

Unmeasurable

QRS

Wide

CAUSES

·       Myocardial infarction

·       CAD

·       Heart Failure

·       Electrolyte imbalance

·       Digoxin toxicity

·       Stimulants

SYMPTOMS

·       MEDICAL EMERGENCY

·       May be Asymptomatic - but will become symptomatic if sustained

·       Palpitations and SOB

·       Chest pain

·       Loss of consciousness

TREATMENT

·       Pulseless

o   CPR and defibrillator

o   Follow ACLS protocol

·       Stable with pulse

o   IV Amiodarone

o   Synchronized cardioversion

CAUSES

·       Myocardial infarction

·       Electrolyte imbalance

·       Drug toxicity/ overdose

·       Electrical shock

·       Hypothermia

·       Untreated Vtach

SYMPTOMS

·       MEDICAL EMERGENCY

·       Loss of consciousness

·       Agonal breathing or apnea

·       No pulse

TREATMENT

·       CPR and epinephrine (NOT A SHOCKABLE RHYTHM)

·       Follow ACLS protocol (See ACLS & BLS protocol sheet)

Cardioversion

Defibrillation

Planned & synced shock delivered on R wave

Unsynchronized shock given in emergent situation

Why is it synced?

If shock is delivered on T wave can cause R on T Phenomenon causing vfb & lead to Cardiac Arrest

Used for:

·       SVT

·       Afb

·       Stable vtach with pulse

Used for:

·       Pulseless Vtach

·       Vfb

Joules used: 50 – 200 J

(Need consent prior to procedure)

Joules used: 200-360 J

Rate

Normal but can be slower

Rhythm

Regular

P Wave

Upright & before every QRS

PR interval

Prolonged (>0.20)

QRS

Normal

If the R is far from P, then you have a first degree

CAUSES

·       May be normal for some patients!

·       Old age

·       CAD

·       Medications that slow AV conduction (Beta blockers & calcium channel blockers)

·       Electrolyte imbalance

SYMPTOMS

·       Usually, Asymptomatic

TREATMENT

·       Usually requires no treatment

·       Monitor to ensure doesn't progress to more serious HB

Rate

Normal

Rhythm

Regularly irregular

P Wave

Normal

PR interval

Gradually prolonging

QRS

Drops in repeating pattern

Longer, longer, longer, DROP! now you have a Wenckebach!

CAUSES

·       Rheumatic fever

·       ↑ vagal tone

·       Myocardial infarction

·       Medications (Beta blockers & calcium channel blockers)

SYMPTOMS

·       May be asymptomatic

·       Dizziness

·       SOB

·       Weakness

·       AMS

·       Chest pain

TREATMENT

·       If symptomatic notify md

·       Check VS

·       Oxygen

·       EKG

·       Labs

Rate

Normal

Rhythm

Irregular

P Wave

Normal ("marching" along)

PR interval

Constant (does not get gradually longer

QRS

Randomly drops

If some p's don't get through-then you have a Mobitz II!

CAUSES

·       CAD

·       Cardiomyopathy

·       Myocardial infarction

·       Medications (Beta blockers & calcium channel blockers)

SYMPTOMS

·       Dizziness

·       Weakness

·       Syncope

TREATMENT

Asymptomatic

·       Consult cardio

·       Review meds

Symptomatic: notify MD

·       Temporary pacing

·       Permanent pacemaker

Rate

Usually, < 60 bpm

Rhythm

Regular

P Wave

Independent from QRS

PR interval

Variable

QRS

Independent from P waves

If p's and q's don't agree! then you have a third degree

CAUSES

·       Myocardial infarction

·       Digoxin toxicity

·       Cardiomyopathy

·       CAD

SYMPTOMS

·       Due to reduced cardiac output

·       MEDICAL EMERGENCY (Heart can’t pump blood efficiently)

·       Hypotension

·       Chest pain

·       Weakness

·       Pale

·       Clammy

·       Weak pulse

TREATMENT

·       Atropine

·       Temporary pacing

·       Permanent pacemaker

WHAT IS IT

Narrowing of the coronary arteries due to atherosclerosis

(Atherosclerosis - Plaque buildup in arteries from cholesterol deposits)

RISK FACTORS

Modifiable (can be changed)

·       Smoking & alcohol use

·       Overweight/Obesity

·       Diabetes

·       High cholesterol

·       Stress

·       Sedentary lifestyle

Non-Modifiable (cannot be changed)

·       Family history

·       Aging

·       Race

·       Gender

DIAGNOSTICS

NON-INVASIVE

·       EKG

·       Stress Test

·       Cardiac Catheterization (check arteries)

LABS

·       HDL

o   Good cholesterol

o   Think H for Happy

o   Want happy levels high

o   > 60 mg/dL

·       LDL

o   Bad cholesterol

o   Think L for Lousy

o   Want lousy levels low

o   < 100 mg/dL

·       Triglycerides: < 150 mg/dl

·       Total Chol: < 200 mg/dL

SYMPTOMS

·       Usually asymptomatic

·       Chest pain that goes away with rest

·       Diaphoresis

·       Shortness of breath

·       Heartburn

·       Nausea/vomiting

·       Fatigue

TREATMENT

MEDICATIONS

·       Antiplatelets: prevent clots from forming Aspirin

·       Antiplatelets: prevent clots from forming Statin

·       Nitrates: for episodes of angina (dilates vessels) Nitro-glycerine

·       Antihypertensives

o   Beta blockers

o   Calcium channel blockers

o   ACE inhibitors

o   ARBs (if cannot tolerate ACE)

PROCEDURES

·       Atherectomy: removal of plaque from artery

·       Percutaneous Coronary Intervention (PCI): unblocks arteries to restore blood flow with balloon and possible stent placement

PATIENT EDUCATION

GOAL: to prevent progression

·       Smoking cessation

·       Moderate exercise 3-4 times/week

·       Stress management

·       Weight management

·       Monitor heart rate & blood pressure

DIET

·       ↓ sodium ↓ saturated fat

·       ↓ alcohol

·       ↑ fibre ↑ fruits & vegetables

WHAT IS IT

·       Chest pain caused by reduced myocardial blood flow and oxygenation

·       Classic symptom of Coronary Artery Disease

TYPES

·       Stable

o   Occurs during physical exertion

o   Predictable

o   Relieved with nitrates & rest

·       Unstable (MEDICAL EMERGENCY)

o   Occurs at rest & more frequently

o   Usually not relieved with nitrates & rest

·       Prinzmetal/Variant

o   Caused by coronary vasospasm

o   Occurs at rest

o   Relieved by nitro & calcium channel blockers

·       Microvascular

o   Spasms of microvascular arteries

o   Pain usually lasts >20 min

o   Can be stable or unstable

COMMON TRIGGERS

·       Physical exertion (Shovelling snow, strenuous exercise)

·       Extreme cold (causes vasoconstriction)

·       Extreme heat (can lead to heat exhaustion)

·       Stress (increases myocardial demand)

·       Eating a large meal (increases O₂ demand for digestion)

·       Smoking

SYMPTOMS

·       Chest Pain

·       Feeling tight/ dull/ heavy

·       May radiate to arms, neck, jaw, or back

·       Shortness of breath

·       Weakness & fatigue

·       Dizziness

·       Pallor

·       Diaphoresis

TREATMENT

MEDICATIONS

·       Antiplatelets: prevent clots from forming

·       Calcium Channel Blockers: relax blood vessels

·       Beta blockers: reduces O₂ demand of heart

·       Nitrates: for episodes of angina (dilates vessels)

·       Administering nitro-glycerine

o   Administered sublingually every 5 minutes up to 3 doses max

o   Do not take if Sildenafil (Viagra) taken within 24 hrs

o   Call 911 if pain not relieved 5 minutes after 1st dose

PROCEDURES

·       Percutaneous Coronary Intervention (PCI): catheter inserted into arteries with possible stent placement to restore blood flow

·       Coronary Artery Bypass Surgery (CABG): vein or artery used to bypass a blocked or narrowed heart artery

NURSING INTERVENTIONS

·       Vital signs & EKG

·       Administer oxygen

·       Nitroglycerin

·       Semi-fowler's position

·       Maintain calm & quiet environment

·       Encourage rest Monitor pain

·       Lifestyle Modifications

o   Smoking cessation

o   Moderate exercise 3-4 times/week

o   Stress management

o   Weight management

o   Monitor heart rate & blood pressure

·       Diet

o   ↓ sodium ↓ saturated fat

o   ↓ alcohol

o   ↑ fibre ↑ fruits & vegetables

WHAT IS IT

·       Myocardial tissue death due to blockage of blood flow in one or more coronary arteries

·       Medical Emergency - If not treated promptly can lead to cardiac arrest

CAUSES

·       O₂ SUPPLY CAN'T MEET O₂ DEMAND

·       Atherosclerosis: plaque ruptures & becomes a blood clot, blocking blood flow

·       Arteriosclerosis: arterial walls thicken and become stiff, blocking blood flow

·       Thrombus: blood clot that obstructs vessel

·       Coronary artery spasm: temporary tightening of the vessel blocks blood flow

·       Decreased oxygen supply: due to blood loss, anaemia, or hypotension

DIAGNOSTICS

·       Patient history (check for hx of heart disease)

·       Check troponin level (normal < 0.04)

·       Echocardiogram

·       Stress test

·       Cardiac cath

·       EKG

SYMPTOMS

·       Sudden, Crushing Chest Pain

o   May radiate to jaw, arm, or shoulder

·       Shortness of breath

·       Indigestion

·       Tachycardia

·       Diaphoresis

·       Pallor

·       In Women

o   Extreme fatigue

o   Nausea

o   Shoulder or neck pain

TREATMENT

IMMEDIATE

·       Morphine: ↓ pain ↓ O₂ demand of heart

·       Oxygen: ↑ O₂ to heart

·       Nitrates: dilate arteries to ↑ blood flow

·       Aspirin: prevents blood from clotting

Next (interventions/ procedures)

·       Medication → Thrombolytics (Alteplase): dissolve clot

·       Procedures

o   PCI: balloon with possible stent to restore blood flow

o   CABG: bypass blockage to restore blood flow

Stabilization & prevention

·       Heparin IV: prevent clot formation

·       Beta blockers

·       ACE/ ARB

·       Calcium channel blockers

·       Statin

·       Antiplatelets

WHAT IS IT

·       Increased pressure on the heart due to accumulation of fluid in the pericardial space

·       Medical Emergency - Makes it difficult for the heart to pump efficiently causing ↓ cardiac output

CAUSES

·       Pericarditis (infection of the pericardial sac)

·       Pericardial Effusion (slow fluid build-up)

·       Cardiac surgery/ trauma

·       Recent MI (inflammation of cardiac tissue)

·       Cancer

SYMPTOMS

·       Classic sign: beck's triad

·       Pulsus Paradoxus

·       Dypnea

·       Fatigue

·       Chest pain or discomfort

·       Tachycardia & tachypnea

·       Drop of systolic BP>10 points during inspiration

TREATMENT

·       Pericardiocentesis: Drain fluid from around heart

·       Treat underlying cause - such as antibiotics for pericarditis

·       Hemodynamic Support –

o   Fluids (give carefully & monitor for fluid overload)

o   Volume expanders

o   Vasopressors

o   Dobutamine: ↑ contractility

NURSING INTERVENTIONS

·       Administer oxygen

·       Bed rest

·       Keep HOB elevated

·       Educate patient signs of pericardial effusion

o   Slow fluid build-up in pericardial space If not treated can result in tamponade

o   Symptoms: Chest pain, Shortness of breath, Difficulty breathing while fat

o   Goal: Catch symptoms early to prevent progression to tamponade

·       Monitor

o   Continuous vital signs & EKG

o   Lung sounds

o   Labs

What Happens

·       Chambers dilate & muscle walls become thin & weak

·       Leads to systolic pump failure

Causes

·       Coronary artery disease

·       Alcoholism

·       Toxin exposure

·       Certain viral infections (can lead to myocarditis)

Symptoms

·       Dyspnea

·       Orthopnea

·       Activity intolerance

·       Lower limb edema

Diagnostics

·       X-ray will show enlarged heart

Treatment

·       Diuretics: reduce fluid overload

·       Digoxin: improve contractility

·       Beta blockers: ↓ workload of heart

·       ACE: ↓ afterload & prevent remodelling

·       Calcium channel blockers

·       Rest periods & stress reduction

HEART FAILURE

·       The body thinks blood pressure is low due to dilated ventricles

·       Activates the RAAS system to hold onto fluid

·       Will show signs of right & left sided heart failure

What Happens

·       Heart walls become thick, stiff & non-compliant

·       Can obstruct aortic valve & cause sudden death

Causes

·       Genetics (usually diagnosed in childhood)

Symptoms

·       Usually asymptomatic

·       Dyspnea

·       Syncope

·       Chest pain

Diagnostics

·       Echo will show septal wall thickening

Treatment

·       Myectomy: remove extra tissue

Medications

·       Beta blockers: ↓HR to ↑diastolic filling time

·       Calcium channel blockers

·       NEVER GIVE THE 3 D’s (Will worsen obstruction & symptoms)

o   Digoxin

o   Dilators (Nitro)

o   Diuretics

Lifestyle Modifications

·       Intense exercise

·       Sudden position changes

·       Bearing down (Valsalva maneuver)

What Happens

·       Heart muscle becomes stiff & hard like a rock

·       Stiff ventricles cause refilling issues

Causes

·       Genetics

·       Amyloidosis, sarcoidosis

·       Radiation exposure

Symptoms

·       Dyspnea

·       Orthopnea

·       Activity intolerance

·       Lower limb edema

Diagnostics

·       Normal echo and x-ray

Treatment

·       Treat underlying cause!

·       Heart transplant

·       Decrease radiation exposure

·       Diuretics: reduce fluid overload

·       The heart muscle is too hard & stiff for other medications to have a positive effect

WHAT IS IT

·       Inflammation of the endocardium layer of the heart

CAUSE

·       Most common: Staphylococcus and Streptococci

·       Bacteria attach to valves causing damage which leads to impaired pumping action of the heart causing: ↓ Cardiac Output

·       Bacteria form clumps called "vegetations" which platelets build up over time and can form into a blood clot

RISK FACTORS

·       Age > 60

·       Artificial heart valve or devices

·       Damaged heart valves

·       Poor oral hygiene

·       Congenital heart disease

·       Immunosuppressed

·       IV drug use

·       Untreated strep throat (leads to rheumatic fever)

SYMPTOMS

Classic Signs

·       Osler's nodes (painful lesions on hands)

·       Janesway lesions (nontender lesions on palms & feet)

·       Splinter hemorrhages (clots stuck under nails)

·       Roth spots (tiny hemorrhages in eye)

·       Fever & chills

·       New/ changed heart murmur

·       Crackles & dyspnea

·       Chest pain on inspiration

·       Splenomegaly

·       Edema and/ or ascites

·       Petechiae

DIAGNOSTICS

·       Blood cultures: assess for infective agent

·       Transoesophageal Echo: assess for vegetation

·       CBC: will have ↑ WBC

TREATMENT

·       Surgery

o   Remove dead & infected tissue

·       Antibiotic therapy

o   Will require IV antibiotics up to 4 weeks will go home with picc line

·       Education

o   Monitor for signs of infection

o   Always use aseptic technique

o   Do NOT stop antibiotics (must fully finish ABX course)

NURSING INTERVENTIONS

·       Supplemental oxygen

·       DVT prevention

·       Antipyretics for fever

·       Monitor

o   Vital signs (especially temperature)

o   Heart rhythm

o   Signs of heart failure

o   Embolic episodes

·       Watch for signs of:

o   Pulmonary embolism

o   Stroke

o   Flank pain (renal)

o   Abdominal pain (spleen)

·       Dental Care

o   Educate patient about importance of good oral hygiene & to notify dentist before any invasive procedures

WHAT IS IT

·       Dysfunction of the heart affecting its ability to fill or pump blood effectively

·       Leads to ↓ cardiac output

CAUSE

·       Anything that damages or weakens the heart

·       Cardiomyopathy

·       Coronary artery disease

·       Myocardial infarction

·       Hypertension

·       Endocarditis

·       Congenital heart disease

·       Arrhythmias

·       Alcohol or drug use

SIDE

LEFT-SIDED (L = LUNGS)

·       Left side of heart can't pump blood out of heart so blood backs up into the lungs

·       Dyspnea & SOB

·       Crackles

·       Fatigue

·       Pink, frothy sputum

RIGHT-SIDED (R = Rest of the body)

·       Right side of heart can't pump received blood to the lungs so blood backs up into the body

·       Peripheral edema

·       Ascites

·       JVD

·       Hepatomegaly

DIAGNOSTIC

·       BNP blood test: biomarker released by ventricles from excessive pressure & when they become stretched

·       stress test

·       chest x-ray (may show infiltrates & cardiomegaly)

·       cardiac cath

·       Echocardiogram: Measures ejection fraction

Ejection Fraction

·       Amount of blood being ejected from left ventricle in one pump

·       Normal: 55-70%

·       Bad: < 40%

NURSING INTERVENTIONS

·       Supplemental O2

·       High fowler's position

·       Keep legs elevated

·       Fall risk precautions (due to orthostatic hypotension & fluid status)

·       Monitor

o   Daily weights

o   Strict I &O

o   VS & heart rhythm

o   Lung sounds

·       Diet

o   ↓ Sodium (2 g/day)

o   ↓ Fat

o   Fluid restriction

·       Avoid

o   OTC drugs (contain sodium)

o   Fried & processed foods

o   Canned vegetables & beans

HEART FAILURE MEDS

Ace Inhibitors/ARB

·       Vasodilate to lower blood pressure (only affect BP, not HR)

·       ARB only used if can't tolerate ACE inhibitor

·       ACE Inhibitor (-pril)

o   Ex: Lisinopril

o   Side effects: Dry, nagging cough

·       ARB -sartan (Angiotensin II Receptor Blocker)

o   Ex: Losartan

o   Side effects: Increases potassium levels

Beta Blocker (-lol)

·       Decreases workload of heart

·       Ex: Metoprolol - always check bp & HR prior to giving

·       Side Effects

o   Masks hypoglycaemia

o   Bronchospasm

o   Bradycardia

Digoxin

·       Positive inotropic that increases contractility

·       Makes heart pump strong & slow

·       Check apical pulse before administering

·       Monitor for digoxin toxicity

·       Hypokalemia increases risk so want to monitor K+ levels

Diuretics (-ide)

·       Drains excess fluid from body

·       Potassium Wasting

o   Ex: Furosemide & Torsemide

o   Used in worsening or acute heart failure

·       Potassium Sparing – Spironolactone

·       Monitor k+ levels Normal: 3.5-5

·       Always check BP before giving diuretics!

Calcium Channel Blockers

·       Relaxes vessels to lower blood pressure

·       Examples

o   Cardizem

o   Nifedipine

o   Verapamil

·       Don’t give if

o   HR < 60

o   SBP < 10 or large drop in BP

Vasodilators

·       Dilates vessels to decrease preload & afterload

·       Examples

o   Nitroglycerin

o   Hydralazine

o   Isosorbide

·       Don’t give if

o   Sildenafil taken within 24 hours

o   SBP < 100

WHAT IS IT

·       Condition where the pressure in the blood vessels is consistently higher than normal

·       Hyper = High, Tension = Pressure

·       Marked by more than 2 events of BP > 130/80

DUE TO

·       Peripheral Resistance

o   Vasoconstriction = ↑ resistance

o   Vasodilation =↓ resistance

·       ↑ Cardiac Output

o   ↑ blood volume output = ↑ blood pressure

BP READINGS

FACTORS AFFECTING BP READINGS

·       Cuff size

o   Too big = false low blood pressure

o   Too small = false high blood pressure

·       Arm Position

o   Above heart = false low blood pressure

o   Dangling = false high blood pressure

·       Whitecoat Syndrome = Temporarily high BP in doctor's office due to anxiety (allow time to relax & recheck)

CAUSES/ RISK FACTORS

PRIMARY

(Unknown Causes – look at risk factors)

·       Non-Modifiable

o   Age

o   Race

o   Family History

·       Modifiable

o   Obesity

o   Alcohol & smoking

o   Sedentary

o   Stress

o   ↑ cholesterol

o   ↑ sodium intake

·       Highest Risk

o   African Americans

o   Age >65

o   +Family history

SECONDARY

(Direct cause or pre-existing condition)

·       Diabetes

·       Kidney disease

·       Pregnancy

·       Thyroid imbalance

·       Pheochromocytoma

·       Cushing's

·       Atherosclerosis

·       Sleep apnea

SYMPTOMS

·       Often asymptomatic! Known as the "Silent Killer"

·       Headache

·       Blurred vision

·       Dizziness

·       Chest pain

·       Shortness of breath

Unmanaged HTN can lead to:

·       Stroke 

·       Myocardial infarction

·       Renal failure

·       Heart failure

TREATMENT

Medications

·       ACE/ARBs

·       Beta blockers

·       Calcium channel blockers

·       Diuretics

Lifestyle modifications

·       Weight loss

·       Stress management

·       Moderate exercise 3-4 times/week

·       Smoking cessation

DIET EDUCATION

DASH diet (Dietary Approaches to Stop Hypertension)

·       ↑ fruits & vegetables

·       low fat dairy

·       ↓ sodium & saturated + trans fats

·       ↓ alcohol & caffeine intake

·       Avoid processed foods (↑ saturated fat)

·       Avoid canned foods (contain ↑ sodium)

WHAT IS IT

(A for Away)

·       Narrowed arteries cause ↓ blood flow to extremities

·       Arteries carry oxygenated blood away from heart to the rest of the body

CAUSES

·       Hypertension

·       Uncontrolled diabetes

·       Smoking

·       Hyperlipidemia

·       Sedentary lifestyle

·       Aging

SYMPTOMS

·       Pulses – Decreased or absent

·       Skin

o   Dry and thin

o   Shiny and missing hair

·       Colour and Temperature – Pale and cool

·       Edema – None (no blood flow)

·       Pain - Intermittent Claudication (Sharp pain in calf with activity or elevation that goes away with rest)

·       Lesions –

o   Eschar & necrosis

o   Ends of toes & tops of feet

o   Deep "hole-punched" look

DIAGNOSTICS

·       Ankle-Brachial Index: Ankle blood pressure compared to arm blood pressure Lower ankle pressure indicates ↓ blood flow

TREATMENT

·       HANG ARTERIES

o   Dangle legs to promote circulation & help with pain

o   Elevating legs will make pain worse!

·       Medication

o   Antiplatelets (Aspirin or Clopidogrel)

o   Statins 

·       Procedures

o   Atherectomy: remove plaque build-up in arteries

o   Peripheral Bypass Graft: blood flow rerouted around occluded artery

·       Education

o   Stop smoking

o   Avoid crossing legs

o   Avoid cold temps (keep feet warm)

WHAT IS IT

(V for Visit)

·       Narrowed veins cause ↓ blood return & pooling in extremities

·       Veins carry deoxygenated blood from the body & tissues to the heart

CAUSES

·       Hypertension

·       Uncontrolled diabetes

·       Smoking

·       Hyperlipidemia

·       Sedentary lifestyle

·       Aging

SYMPTOMS

·       Pulses – Present (may need doppler due to edema)

·       Skin – Thick and tough

·       Colour and Temperature – Brown/yellow and warm

·       Edema – Present (blood is pooling)

·       Pain – Constant, dull and achy

·       Lesions –

o   Red, granulation & drainage

o   Medial lower legs & ankles

o   Shallow & irregular shaped

DIAGNOSTICS

·       Venous Ultrasound: Assess for blood flow & any signs of reflux in veins

TREATMENT

·       ELEVATE ARTERIES

o   Elevate legs to help promote blood return to heart

o   Dangling legs will make edema worse!

·       Medication

o   Antiplatelets (Aspirin or Clopidogrel)

o   Statins 

·       Procedures

o   Angioplasty or stent placement

o   Peripheral Bypass Graft: blood flow rerouted around occluded vein

·       Education

o   Compression stockings

o   Avoid sitting or standing long periods of time

o   Elevate legs when resting