2002 60113-MED-SURG - assess PDF

Preview

Summary

assess...

Description

MEDICAL-SURGICAL Layer of the Heart: Endocardium ( inner ) - facilitates blood flow, contains valve & chambers Myocardium ( middle ) - contracting muscle, cardiac muscle Pericardium ( outer ) o Layer of Pericardium  Visceral ( epicardium )  Pericardial ( 5-20cc of fluid ) serves as cushion, lubricant  Parietal

AV valves ( atrioventricular valves ) “Atria” o 1 way flow of blood  Tricuspids ( right atria )  Bicuspids/ Mitral ( left atria ) SL valves ( semilunar valves )  Pulmonary SL valve  Aortic SL valve Ventricle contract : Semi Lunar valve open ( AV valve closed ) Ventricle relax : Semi Lunar valve closed ( blood filling ) ( Av valve open ) -

Myocardium Endocardium

Visceral (epicardium)

Circulation:

left

from Vena cava

to Lungs

deoxygenated

Pulmonary circulation

Pulmonary veins

System

oxygenated

Systemic circulation

Valves & Chambers:

Bundle of HIS

Intranodal tract

AV node

Bundle branches Right Purkinje Left Purkinje

Cardiac Cycle Two main phase o Systole : contraction / ejection o Diastole : relaxation / refill  Difference between Systolic & Diastolic is the PULSE PRESSURE ( PP: 30 – 40cpm ) narrowed pulse – hypovolemia ( PP: 60cpm ) wided pulse – increased in Stroke volume

Fibrous layer

right

SA node

Coronary Artery

Pericardial cavity

Parietal (pericardium)

Conduction System SA node ( sinoatrial node ) main pacemaker of the heart : 60 – 100bpm AV node ( atrioventricular node ) 2nd pacemaker of the heart : 40 – 60bpm Bachmann’s node ( node in the left atrium )

Branch out from ascending aorta Right Coronary Artery – supplying the Right Atrium / Right Ventricle / inferior portion of Left Ventricle Left Coronary Artery o Circumflex – supplying the Left Atrium / posterior portion of Left Ventricle o Left Anterior Descending Artery (LADA) – supplying the Left Ventricle /Apex Electrophysiologic Properties A – utomacity – C – ontractility – transmit impulse C – onductivity – contraction E – xcitability – respond to stimuli R – efractiones – ability to finish a response before initiating another response.

Cardiac Output Amount of blood pump by the heart particularly by the left ventricle per minute Stroke Volume (SV) – amount of blood pump by the heart in every beat SV = amt (ml) Beat Contractility : ( Inotropic ) ability of cardiac muscle to contract Preload : amount of the blood from the ventricle after the end of diastolic phase (Frank Staring Law : the greater the stretch, the better the pump) o Venous returns o Regurgitation of the blood Afterload : resistance of LV must surpass as the heart pump blood to the circulation o Systemic resistance ( HPN ) o Blood viscosity ( DM. polycythemia vera, multiple myeloma ) Heart Rate ( HR ) – number of heart beat per minute HR = Beats Minute

Formula: Cardiac Output CO =

amt (ml) Beat

X

Beats Minute

HEART RATE & STROKE VOLUME REGULATOR Autonomic Response Symphatetic Nervous System ( SNS ) ( Fight or Flight Response ) o Norepinephrine (adrenal gland) kidney o Dilated pupils(compensate) Mydriatic o Constricted blood vessel o Increased SV/HR Parasymphathetic Nervous System ( PNS ) o Rest & Digest Response Baroceptors o Pressure detectors ( common carotid, right atrium, aortic arc ) Chemoreceptors o Chemical detectors ( O2, CO2, pH ) o Aortic arc, carotid bodies o CO2 : 35 – 35mmHg ( normal ) volatile gas o O2 : 80 – 100mmHg ( normal ) o CO2 + H2O = H2CO3 (carbonic acid ) increased pH level Proprioceptors o Stretch detectors ( tendons ) Electrocardiograph ( ECG )

-

Vertical : impulse Horizontal : duration Small box : 1mm/.04sec Big box : 5mm / .2sec Isoelectric line : straight/ middle line

-

Deflection : raise & falls of line ( wave ) Wave : line deviated from isoelectric line ( P wave ) Complex : group of continuous waves ( QRS complex ) Segment : isoelectric line between waves ( ST segment ) Interval : wave + segment ( PR interval ) P wave – atrial depolarization PR segment – conduction delay from SA node – AV node QRS complex – ventricular depolarization ST segment – early ventricular repolarization PR – atrial depolarization + conduction delay of SA node – AV node T wave – ventricular repolarization U wave – unknown Electrode Placement Right arm – white / Right leg - green Left arm – black / Left leg – red Chest Electrode Placement 1st Node – 4th ICS right of sternum 2nd Node – 4th ICS left of sternum 3rd Node – between the 2nd & 4th node 4th Node – 5th ICS left 5th Node – 6th ICS left 6th Node – axillary line Holters Monitoring ( activity diary ) Stress Testing ( threadmill test ) Detection of level of activity o Ischemic heart disease o Chest pain o Evaluate effectiveness of activity o Develop cardiac rehab.program Echocardiograph Ultrasound of the heart Supine position: HOB elevated 15 – 20 degree Slightly turned to the left side Chest Xray Magnetic Resonance Imaging ( MRI ) The MRI scan uses magnetic and radio waves, meaning that there is no exposure to X-rays or any other damaging forms of radiation. Cardiac Fluoroscopy Cardiac Catherization Introduction of radiopaque venous catheter o Right radial / antecubital o Left brachial / femoral

Before: Assess for allergy ( seafoods : iodine/contrast dye ) Assess for bleeding parameters Assess for kidney function Administer pre medication as ordered Patient usually sedated ( valium ) After: CBR / monitor V/S Prevent bleeding Immobilized affected extremities Do circulation assessment Angiography / Arteriography is a test that uses an injection of a liquid dye to make the arteries easily visible on X-rays Laboratories ( cardiovascular function ) Blood component RBC WBC ( leukocytes ) Platelets (thrombocytes )

3

Normal value ( mm ) 4-6 million 4,5000-11,000 150,0000- 450,000

Erythrocyte Sedimentation Rate ( ESR ) It is a common hematology test that is a nonspecific measure of inflammation Male : < 15 – 20mm/hr Female : < 25 – 30mm/hr Blood Urea Nitrogen ( BUN ) 10 – 20mg/dl ( normal ) Easily affected by hydration status Blood Lipids NPO ( 10 – 12hrs ) Serum cholesterol: < 200mg/dl Triglycerides : 100 – 200mg/dl Auscultation : ( Heart Sound ) S1 – apex – lubb – closure of AV valve ( contracting / ejecting ) systole phase S2 – base – dub – closure of SL valve ( relaxation / refill ) diastole phase S3 – above 30y.o – ventricular gallop ( rapid ventricular refill ) S4 – atrial gallop ( resistance to ventricular refill ) o Summation gallop ( S1, S2, S3, S4 ) Aortic – 2nd ICS right sternum Pulmonic – 2nd ICS left sternum Mitral – 5th ICS midclavicular line Tricuspid – 5th ICS left sternum

Stethospcope Diaphragm – hi pitch ( heart, lung , abdominal sound ) Bell – low pitch

-

Decubitus Angina : ( occurs when ever standing or lying ) Silence Ischemia : ( no manifestation but appear in laboratory test )

CM: ANGINA PECTORIS

Paroxysm chest pain ( myocardial ischemia ) Pathogenesis: imbalanced in demand ( cardiac output ) & supply ( myocardial tissue perfusion ) Precipitating Factor: Coronary Atherosclerosis – narrowing of artery ( fatty deposit ) Coronary Thrombosis / Embolism Hypertension ( HPN ) – increased in afterload Decreased blood flow with shcok Direct Trauma Polycythemia Vera Coronary Artery Spasm Etiology: Physical Exertion Environment / Extreme Weather Digestion Every Meal Eating a heavy meal Valsalva Maneuver Emotion Stress Sexual Excitation Hot Bath or Shower Types of Angina Pectoris Stable / Exertional Angina : predictable Unstable Angina : unpredictable ( Intermittent Coronary Syndrome ) Variant Angina : “ Prinzmetal” (even at rest) Intractable Angina : chronic ( resistant to medication / treatment ) Post Infarction Angina : ( myocardial infarction ) Intractable Angina : ( more responsive to medication ) Nocturnal Angina : ( occurs when sleeping )

-

Pain ( lactic acidosis ) o Substernal, crushing or squeezing o Radiate from neck to arms up to back o Unaffected by inspiration / expiration Pallor Palpitation / Tachycardia Dizziness / Faintness Dyspnea

DX test: ECG, Stress Test, cardiac Catheterization, Cardiac Enzymes NI: CBR ( decreased demand ) Oxygenation Lifestyle modification Medication o Nitrates ( nitroglycerine ) vasodialtion of coronary artery : decreased demand & afterload ( heart ) : 3 – 6 months o Calcium Channel Blocker ( VAND ) Verapamil, Anlodipine, Nicardipine, Diltiazem  calcium – innervating muscular movement o Antilipidemic – “statin” : prevent atherosclerosis o Beta Adrenergic Blockers “olol” o Antiplatelet : ( ASA ) Acethy Salicylic Acid o Anticouagulant : Heparine Surgical: PTCA ( Percutaneous Transluminal Coronary Angioplasty ) Vascular Stent Laser Angioplasty Atherectomy CABG ( Coronary Artery Bypass Graft ) MYOCARDIAL INFARCTION Heart attack : formation of localized necrotic areas in the myocardium

Risk factor: CAD ( Coronary Artery Disease ) atherosclerosis Elevated cholesterol level Smoking ( damage the endothelium: vasospasm ) nicotine HPN, DM, stress ( increased the workload / afterload ) Classification of MI Transmural Infarct : starts in the myocardium going to pericardium & endocardium Sub endocardial Infarct : starts in the myocardium going to endocardium Intramural Infarct : isolated / patchy & localized myocardium death 3 areas developed ( after MI ) Area of Infarction : O2 totally deprived ( damage is irreversible ) Q wave pathologic Area of Injury : damage is reversible ( cell is viable as long as collateral circulation is present ) ST segment elevation Area of Ischemia : blood circulation is only reduced ( most of the time it is not damage ) T wave inverted CM: Prolonged pain ( > 3o min ) Unrelieved by Nitroglycerin Crushing Severe Radiating Pain Levines Sign Anxiety / apprehension ( increased restlessness ) Feeling of Doom Pallor, Cyanosis, coolness of extremities Mild fever ( hard to assess ), dyspnea, leukocytosis Nausea & vomiting ( nasovagal stimuli ) Syncope ( sudden loss of consciousness )

DX studies: Cardiac Enzymes ( most accurate ) CK ( Creatinine Phophokinase ) 26 -174u/L  CKmB ( myocardial ) O – 5% total ( normal )  CKmM ( damage muscle tissue )  CKbB ( reflects brain tissue damage ) LDH ( Lactate Dehydroginase ) 90 – 176u/L  LDH1 (.2 - .36u/L)  LDH2 (.35 - .46u/L)(heart) LDH3 – LDH4 – LDH5 ( liver ) LDH1 > LDH2 (flipped) LDH1 < LDH2 (normal) Complication of MI Dysrrhythmia : Vtach ( emergency ) CHF : increased inotropic activity Cardiogenic Shock : pump failure ( #1 cause of death ) Post Infarction Angina Pericarditis : Transmural Infarct Pulmonary Edema : ( CHF ) TX: Goal: o Prevent further tissue injury o Decreased cardiac workload o Increased O2 NI: O2 ( nasal cannula ) CBR : 24 – 48hrs w/o bathroom Semi-fowlers ( immediate phase ) Monitor Cardiac function ( ECG ) o Continuous ECG monitoring o Blood pressure ( cardiogenic shock ) Lifestyle Modification ( diet, exercise ) o Low salt – fat o Compliance to treatment Pharmacotherapy: Morphine Sulfate ( Opiate Analgesic ) o Severe pain – SNS – increased CW Nitroglycerin ( Nitrates ) o Vasodilation – decreased CW / Afterload ( dilation of coronary artery ) Thrombolytics ( dissolve clot / thrombus ) fibrinolysis process o Best given in the 1st 6hrs o Streptokinase, Urokinase,

-

-

-

-

-

o Tissue Plasminogen Activator o Monitor patient for bleeding Benzodiazepine ( Anxiolytic ) o Diazepam/Lorazepam  Valium : ( relaxation )  Flumazenil : ( antidote ) Anticoagulant (prevent thrombus formation) o Heparin o Coumadin Anitplatellet o ASA : ( Acethyl Salicylic Acid ) platelet aggregation o Dipyridamole ( Persatin ) o Clopidogrel ( Flavix ) Beta Adrenergic Blockers ( SNS ) o Beta1 – heart ( Propanolol / Atenolol ) o Beta 2 – lungs Laxatives ( Lactulose ) prevent bowel straining o Valsalva Maneuver (contraindicated to HF ) o Rectal Temp. ( stimulate vagal response / bradycardia )

CONGESTIVE HEART FAILURE Inability of heart to maintain cardiac output Cause by impaired pumping activity

Classification Types of CHF R-sided CHF L-sided CHF

Forward failure Lungs System

Backward failure Vena cava Lungs

Ejection fraction : % of blood pump by the ventricle after a diastolic phase

Manifestation: RSCHF: o JVD, o Peripheral edema o Hepatomegaly o Spleenomegaly, nausea & vomiting, o Feeling of bloutedness, o Ascites (peritoneal cavity fluid) o Decreased urine output o Anasarca ( generalized edema) LSCHF: o Crackles/rales ( pulmonary edema ) o Increased ventilation o Cough o Dyspnea o Paroxysimal Nocturnal Dyspnea o Decreased urine output Direct damage to the heart o Myocarditis o Ventricular Aneurysm ( cells dilated / turn back to normal size ) o Ventricular Overload  Increased Preload: mitral / aortic regurgitation, VSD ( ventricular septal defect), ASD( atrial septal defect ) IVF overload  Increased Afterload: aortic / pulmonary valve stenosis, HPN o Constriction of Left Ventricles  Pericarditis, cardiac tamponade ( constriction of ventricle / rapid accumulation of pericardial fluid ), restrictive cardiomyopathy ( HYDRATION STATUS : weight is the best indication ) TX: Promote oxygenation Promote rest & activity Facilitate fluid balance Providing skin care Promote nutrition Promote elimination Pharmacotherapy: Digitalis therapy: “ treatment of choice” o Digoxin ( Lanoxin )

-

-

-

MOA: + inotropic effect ( inc. SV ) - chronotropic effect ( dec. HR ) Maintenance drug: ( digitalis toxicity ) o Nausea & vomiting ( early stage ) o Visual disturbances : yellow – green halo vision ( snowy vision ) o Dysrhythmia / Arrhythmia (dangerous) o Assess:  PR: ( bradycardia )  K+ level ( hypokalemnia )  3.5 – 5mEq/L  Potentiates digitalis toxicity Vasodilators: ( Hydralizine ) o Calcium channel blockers ( VAND )  Verapamil  Amlodipine  Nicardipine  Diltiazem Symphatomemitics: o Dopamine / Dobutamine ( severe HF ) Diuretics therapy: o Loop diuretics ( Furosemide ) o K+ wasting diuretics  Best given in the morning monitor UO/BP

VALVULAR HEART DISEASE Mitral Valve Disease MITRAL STENOSIS Narrowing of the mitral valve Manifestation: Initially assympthomatic Diastolic murmur ( abnormal heart sounds ) Dyspnea Atrial fibrillation / hypertrophy o Chamber quivering o Thrombus formation MITRAL REGURGITATION Incompetent mitral valves Manifestation: Dyspnea / fatigue Atrial fibrillation High pitch systolic murmur LSCHF ( manifestation )

Infection ( viral :HIV / bacteria : streptococcal. Staphylococcal, entero ) Tumor ( metastasis ) o Lungs, blood, lymph Connective Tissue Disease ( SLE ) Systemic Lupus Erythematus Common Complication: Heart failure Cardiac tamponade Manifestation: Chest pain ( aggravated by supine position & relieve by sitting and leaning forward ) Pericardial Friction Rub ( scratchy high pitch sound ) Sign & symptoms of inflammation ( increased ESR, leukocytosis, fever ) DOB & fatigue ( oxygenation problem ) -

MITRAL VALVE PROLAPSED Manifestation: Dyspnea / fatigue Systolic click Chest pain & palpitation Aortic Valve Disease AORTIC VALVE STENOSIS Narrowing of the aortic valve Manifestation: Dyspnea, syncope, chest pain Left Ventricular Hypertrophy LSCHF ( manifestation ) AORTIC REGURGITATION Manifestation: Corrigans ( water hammer pulse ) quick sharp pulse / suddenly collapse High pitch diastolic murmur Tricuspid Valve Disease TRICUSPID VALVE REGURGITATION / STENOSIS RSCHF like symptom Dyspnea, syncope PULMONIC VALVE DISEASE RSCHF like symptom Dyspnea, syncope TX: Depend on the clinical manifestation Valvular Repair o Commissurotomy ( commissure ) o Annuloplasty ( annulos ) o Chordoplasty ( chordate tindenae ) o Leaflet repair Valvular Replacement o Mechanical ( synthetic ) o Tissue ( living organism ) Valvular Graft / Tissue ( living organism ) o Xenograft / Heterograft (non human ) o Homograft ( human source ) o Isograft ( same person ) INFLAMMATORY DISEASE OF THE HEART PERICARDITIS Causes: Mechanical injury to the heart ( invasive )

MYOCARDITIS Caused by infection Manifestion: Murmur & Summation Gallop rhythm Sign of Infection / Inflammation DOB & fatigue Complication: Thrombus Heart failure Cardiomyopathy ( dysfunction of the heart/ myocardial defect-disease ) INFECTIVE MYOCARDITIS Manifestation: Signs of infection ( fever ) DOB & fatigue Splinter Hemorrhages ( strain blood in the nails ) Oslers nodes ( painful nodules in the fingers ) Janeways Lession ( flat macules : palm/soles ) pinkish – purflish TX: Promote oxygenation Facilitate proper rest activity pattern Administer medication ( CANADA ) o C-orticosteroid (anti-inflammatory) o A-ntiplatelet o N-SAID’s o A-ntibiotics o D-Igoxin o A-ntidysrhthmia

CARDIAC DYSRHYTHMIA NORMAL SIGN RHYTHM Originate from SA node Atrial/ ventricular rate ( normal ) PR interval / QRS complex ( normal ) P : QRS ratio 1 : 1 SINUS BRADYCARDIA Sinus node creates / slower than normal rate ( 60bpm ) SA node PR interval / QRS complex ( normal ) Causes: o Metabolic rate ( hypothyroidism ) o Sleep decreased metabolic rate o Vagal stimuli ( valsalva, sunctioning increased ICP ) TX: Sinus Bradycardia that lead to Bradycardia o Atropine Sulfate ( anticholinergic ) .5mg – 3mg “ treatment of choice” Bradycardia ( IDEA ) o I-soprotenolol o D-opamine o E-pinephrine o A-tropine SINUS TACHYCARDIA SA node ( adult 100bpm ) Faster than normal Causes: Stress / hypermetabolic rate Medication ( aminophylline ) o IDEA o Illicit drugs ( shabu ) PR interval / QRS complex (normal) Rates exceed 100bpm TX: Digoxin (- ) chronotropic Calcium Channel Blockers “ VAND ” Beta Adrenergic Blockers ( decreased contractility & HR ) “olols” MOST COMMON DYSRHYTHMIA ATRIAL FLUTTER SA node is not the main pacemaker Ectopic atrial focus captures heart rhythm Conduction defect on the atrium SAW TOOTHED ( atrial rate 250 – 400bpm ) PR interval is difficult to determine

P / QRS ratio 2:1, 3:1, 4:1 so on……

ATRIAL FIBRILLATION Atrial quivers ( 300 – 600bpm ) Multiple rapid impulses ( many foci ) No definitive P wave PR interval cannot measured VENTRICULAR DYSRRHYTHMIA PVC ( premature ventricular contraction) Ectopic beat originating from ventricle Conducted before the next sinus PVC of 6 or more is life threatening (>6/min) Occurs in repetitive patterns / alternating repetitive pattern / continuous repetitive pattern o Bigeminy ( N-PVC ) 2nd turn o Trigeminy ( N-N-PVC ) 3rd turn  Couplet ( 2x PVC )  Triplet ( 3x PVC ) QRS complex may be unifocal ( same foci ), multi-focal ( came from different foci ) VENTRICULAR TACHYCARDIA Irritable focus on the ventricle ( emergency ) Ventricular rate ( 100 – 200 ) Ventricular no time to refill QRS complex prolonged ( .12sec/complex ) Risk for asystole VENTRICULAR ASYSTOLE Absence of QRS complex No heart beat, palpable pulse No respiration Need immediate treatment Causes: ( SSSCAT ) o S-evere hypoxia ( cerebral ) o S-evere electrolyte imbalance o S-hock o C-ardiac tamponade o A-cidosis o T-ension Pneumothorax TX: Artificial Cardiac Pacemaker Antiarrhythmic drugs CLASS I ( fast sodium channel blocker ) o CLASS IA - moderate depression of depolarization but prolonged repolarization ( Procainamide )

CLASS IB – minimal depression of depolarization but prolonged repolarization ( Lidocaine ) o CLASS IC – marked depression of depolarization / no effect on repolarization ( Propafenone ) CLASS II ( beta adrenergic blocker ) increased automacity /conduction CLASS III prolonged repolarization/ Amiodanone CLASS IV ( calcium channel blocker ) o

-

Pacemaker Indication: Permanent normal impulse / temporary slower than formation Pacing mode By demand ( if heart needs a demand ) By set ( settings ) Cardioversion Delivery of Electrical Current Synchronized with patient electrical event Send electrical impulse: QRS compl...