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1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 35 Cardiac Disorders.

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1 1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 35 Cardiac Disorders

2 2Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Learning Objectives Label the major parts of the heart. Describe the flow of blood through the heart and coronary vessels. Name the elements of the hearts conduction system. State the order in which normal impulses are conducted through the heart. Explain the nursing considerations for patients having procedures to detect or evaluate cardiac disorders.

3 3Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Learning Objectives Identify nursing implications for common therapeutic measures, including drug, diet, or oxygen therapy; pacemakers and cardioverters; cardiac surgery; and cardiopulmonary resuscitation. Explain the pathophysiology, risk factors, signs and symptoms, complications, and treatment for selected cardiac disorders. List the data to be obtained in assessing the patient with a cardiac disorder. Assist in developing nursing care plans for patients with cardiac disorders.

4 4Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Anatomy and Physiology of the Heart

5 5Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Anatomy Chambers Two upper atria (right and left) Two lower ventricles (right and left) Muscle layers Endocardium, myocardium, and epicardium Valves Atrioventricular valves Mitral and tricuspid Semilunar valves Aortic and pulmonic

6 6Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Heart Sounds The first heart sound (S 1 ), referred to as lub, occurs when the ventricles contract during systole and when the mitral and tricuspid valves close The second heart sound (S 2 ), called dub, occurs during ventricular relaxation or diastole and is caused by the closing of the aortic and pulmonic valves

7 7Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-1

8 8Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Coronary Blood Flow Left coronary artery and the right coronary artery Left coronary artery branches into the left anterior descending and circumflex arteries Right coronary artery branches to supply the sinoatrial (SA) and the atrioventricular (AV) nodes, the RA and RV, and the inferior part of the LV

9 9Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Coronary Blood Flow Venous system parallels the arterial system: the great cardiac vein follows the left anterior descending artery and the small cardiac vein follows right coronary artery Veins meet to form the coronary sinus (largest coronary vein), which returns deoxygenated blood from the myocardium to the right atrium

10 10Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-2

11 11Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-3

12 12Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Conduction SA node, called the pacemaker, initiates the impulse The impulse is carried throughout the atria to the AV node, located on the floor of the RA Impulse is delayed in the AV node, then transmitted to the ventricles through the bundle of His The bundle is made up of Purkinje cells and is located where the atrial and ventricular septa meet Bundle of His divides into left and right bundle branches Left branch divides into anterior and posterior branches: fascicles Terminal ends of right and left branches: the Purkinje bers When impulse reaches Purkinje bers, ventricles contract

13 13Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-4

14 14Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Conduction Cardiac innervation Heart innervated by sympathetic and parasympathetic bers of the autonomic nervous system Sympathetic bers distributed throughout the heart Sympathetic stimulation results in increased heart rate, increased speed of conduction through the AV node, and more forceful contractions Parasympathetic bers (part of the vagus nerve) found primarily in the SA and AV nodes and the atrial tissue Parasympathetic stimulation results in slowing of heart rate, slowing of conduction through the AV node, and decreased strength of contraction

15 15Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cardiac Function Cardiac cycle Contraction and relaxation of the heart make up one heartbeat Cardiac output Amount of blood (in liters) ejected per minute Factors that affect stroke volume: preload, contractility, and afterload Myocardial oxygen consumption Myocardial tissue routinely needs 70% to 75% of the oxygen delivered to it by the coronary arteries

16 16Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Age-Related Changes Heart Increased density of connective tissue and decreased elasticity Number of pacemaker cells in the SA node decreases, as does the number of nerve bers in the ventricles Blood vessels The number of pacemaker cells in the SA node decreases, as does the number of nerve bers in the ventricles

17 17Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Assessment of Cardiac Function

18 18Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chief Complaint and History of Present Illness Symptoms related to cardiac disorders include fatigue, edema, palpitations, dyspnea, and pain Note when symptoms occur, what aggravates them, and what relieves them

19 19Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical History Hypertension, kidney disease, pulmonary disease, stroke, rheumatic fever, streptococcal sore throat, and scarlet fever Document previous cardiac disorders and hospitalizations. List recent and current medications and note allergies in appropriate records

20 20Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Family History Assess whether immediate relatives have had hypertension, coronary artery disease (CAD), other cardiac disorders, or diabetes mellitus

21 21Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Review of Systems Systematically assess whether the patient has experienced the following: weight gain, fatigue, dyspnea (shortness of breath), cough, orthopnea (difficulty breathing in a supine position), paroxysmal nocturnal dyspnea (sudden dyspnea during sleep), palpitations, chest pain, syncope (fainting), concentrated urine, or leg edema

22 22Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Functional Assessment Determine how this illness has affected the patients ability to carry out usual activities Activity and rest patterns and usual diet Ask about sources of stress and coping strategies

23 23Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Physical Examination Vital signs Blood pressure, pulses, and respirations Skin Heart sounds Heart murmurs Extremities

24 24Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-5

25 25Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diagnostic Tests and Procedures Electrocardiogram (ECG) Ambulatory ECG (Holter monitor) Implantable loop monitor/recorder (ILR) Echocardiogram (heart sonogram) Transesophageal echocardiogram (TEE) Magnetic resonance imaging (MRI) Multiple-gated acquisition scan

26 26Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diagnostic Tests and Procedures Stress test (exercise tolerance test) Perfusion imaging Thallium imaging Ultrafast computed tomography Cardiac catheterization Electrophysiology study (EPS)

27 27Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-6

28 28Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Laboratory Tests Arterial blood gases Pulse oximetry Cardiac enzymes Creatine phosphokinase Cardiac protein markers Complete blood count Lipid profile B-type natriuretic peptide (BNP) C-reactive protein (CRP)

29 29Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-7

30 30Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Drug Therapy Cardiac glycosides Antianginals Antidysrhythmics Angiotensin-converting enzyme (ACE) inhibitors (ACEIs) Diuretics Anticoagulants

31 31Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Drug Therapy Heparin Low-molecular-weight heparin (LMWH) Warfarin Antiplatelet agents Fibrinolytic agents (also called thrombolytics) Lipid-lowering agents Analgesics

32 32Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diet Therapy Low-fat, high-fiber diet Well-balanced diet Emphasis on fruits, vegetables, grains, and proteins low in fat (fish, legumes, poultry, lean meats) Cholesterol intake should be limited to 200 mg/day; foods with trans fatty acids, limited to 8 Exercise program may help achieve optimal weight

33 33Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diet Therapy Sodium A diet containing sodium 2 g/day most often prescribed Potassium Patients taking potassium-wasting diuretics need adequate potassium in the diet

34 34Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Other Therapeutic Measures Oxygen therapy Pacemakers Temporary Permanent Cardioversion

35 35Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cardiac Surgery Common surgical procedures Pacemaker insertion Repair or replace valves or septa or remove tumors Coronary artery bypass surgery

36 36Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cardiac Surgery Preoperative nursing care Interventions Fear and Anxiety

37 37Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cardiac Surgery Postoperative nursing care Interventions Ineffective Breathing Pattern Pain Ineffective Thermoregulation Decreased Cardiac Output Risk for Infection Anxiety

38 38Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cardiac Disorders

39 39Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Coronary Artery Disease (CAD) Arteriosclerosis Abnormal thickening, hardening, loss of elasticity of arterial walls Atherosclerosis Form of arteriosclerosis; inflammatory disease that begins with endothelial injury and progresses to the complicated lesion seen in advanced stages of the disease process Progression of lesions Fatty streak Fibrous plaque Complicated lesions Collateral circulation Branches grow from existing arteries; provide increased blood flow

40 40Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Coronary Artery Disease (CAD) Risk factors Nonmodifiable Age, gender, heredity, and race Modifiable Increased serum lipids, high blood pressure, cigarette smoking (nicotine), diabetes mellitus with elevated blood glucose, obesity, sedentary lifestyle Other factors Stress, sex hormones, birth control pills, excessive alcohol intake, high homocysteine levels

41 41Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Angina Pectoris The most common symptom of CAD Demand for oxygen by myocardial cells exceeds supply Stable angina Occurs with exercise or activity and usually subsides with rest Unstable angina Pain more severe, occurs at rest or with minimal exertion, is often not relieved by NTG or requires more frequent NTG administration, and is not predictable Variant angina Caused by coronary artery spasm; may not be associated with CAD Unpredictable and often occurs at rest

42 42Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Angina Pectoris Medical treatment Initial therapy for patients with angina A Aspirin and antianginal therapy B Beta-blocker and blood pressure C Cigarette smoking and cholesterol D Diet and diabetes E Education and exercise

43 43Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Acute Myocardial Infarction Risk factors for AMI Obesity, smoking, a high-fat diet, hypertension, family history, male gender, diabetes mellitus, sedentary lifestyle, and excessive stress

44 44Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Acute Myocardial Infarction Pathophysiology Begins with occlusion of a coronary artery Over 4-6 hours, ischemia, injury, infarction develop Ischemia results from a lack of blood and oxygen to a portion of the heart muscle If ischemia is not reversed, injury occurs Deprived of blood and oxygen, the affected tissue becomes soft and loses its normal color Continued ischemia: infarction of myocardial tissue Ischemia lasting 20 minutes or more is sufficient to produce irreversible tissue damage

45 45Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Acute Myocardial Infarction Complications Heart failure, cardiogenic shock, thromboembolism, and ventricular aneurysm/rupture Signs and symptoms Pain Heavy or constrictive pain located below or behind sternum May radiate to the arms, back, neck, or jaw Patient becomes diaphoretic and lightheaded and may experience nausea, vomiting, and dyspnea The skin is frequently cold and clammy Patient experiences great anxiety; feeling of impending doom

46 46Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Acute Myocardial Infarction Medical diagnosis History and the physical signs and symptoms Laboratory evidence and ECG changes Cardiac markers Troponin, myoglobin, and cardiac enzymes Electrocardiogram Ischemia: ST segment depressed; T wave is inverted If there has been total occlusion of a coronary artery, the ECG will show ST elevation (STEMI) Following infarction, another change often seen on the ECG waveforms is a significant Q wave

47 47Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-8

48 48Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Acute Myocardial Infarction Medical treatment Drug therapy Sublingual or intravenous nitroglycerin Morphine or Demerol Oxygen Fibrinolytic therapy Aspirin and beta-adrenergic blockers Percutaneous coronary intervention (PCI) Intracoronary stents Coronary atherectomy Laser angioplasty Radiation therapy Coronary artery bypass graft surgery

49 49Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-9

50 50Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-10

51 51Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-11

52 52Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Acute Myocardial Infarction Assessment Ask patient to describe the pain, including type, location, duration, and severity Interventions Pain Decreased cardiac output Anxiety Cardiac rehabilitation

53 53Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Heart Failure Etiology and risk factors Two types Disorders that increase the workload of the heart Disorders that interfere with hearts pumping ability Patients at risk for HF: those with CAD, AMI, cardiomyopathy, hypertension, COPD, pulmonary hypertension, anemia, disease of the heart valves, and fluid volume overload

54 54Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Heart Failure Pathophysiology The LV, RV, or both fail as pumps Usually left side of heart fails first; right side fails as a result of the left-sided failure Compensation Sympathetic compensation Renal compensation Natriuretic peptides Ventricular hypertrophy

55 55Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Heart Failure: Signs and Symptoms Left-sided heart failure Anxious, pale, and tachycardic Consecutive blood pressure readings may show a downward trend Auscultation of the lung fields reveals crackles, wheezes, dyspnea, and cough S 3 and S 4 heart sounds heard

56 56Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Heart Failure: Signs and Symptoms Right-sided heart failure Increased central venous pressure, jugular venous distention, abdominal engorgement, and dependent edema Anorexia, nausea, and vomiting from the abdominal engorgement Fatigue, weight gain, decreased urinary output

57 57Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Heart Failure Medical diagnosis History, physical examination, radiographs, and laboratory test results

58 58Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Heart Failure Medical treatment Drug therapy ACE inhibitors, diuretics, beta-adrenergic blockers, inotropic agents, cardiac glycosides, and nitrates. In addition, certain patients will benefit from B-type natriuretic peptide Intra-aortic balloon pump (IABP) Ventricular assist devices (VADs) Biventricular pacing Surgery Coronary artery bypass grafting, valve repair or replacement, partial left ventriculectomy, and cardiac transplantation

59 59Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Heart Failure Assessment Heart sounds, rate, and rhythm Jugular vein distention Baseline respiratory assessment of rate, rhythm, and breath sounds is vital Measure weight and blood pressure accurately Inspect skin and palpate for turgor and edema Intake and output records and daily weights

60 60Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Heart Failure Interventions Decreased Cardiac Output Impaired Gas Exchange Fluid Volume Excess Activity Intolerance Anxiety

61 61Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Infective Endocarditis Etiology and risk factors Primarily affect the valves Incidence has decreased with the use of antibiotics, but there has been a resurgence of the problem in intravenous drug abusers Patients with valvular disease also at risk

62 62Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Infective Endocarditis Pathophysiology Pathogens, usually bacteria, enter the bloodstream by any of the previously mentioned means The pathogen accumulates on the heart valves and/or the endocardium and forms vegetations

63 63Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Infective Endocarditis Complications Heart failure and embolization Signs and symptoms Fever, chills, malaise, fatigue, and weight loss Chest or abdominal pain; may indicate embolization Petechiae inside the mouth and on the ankles, feet, and antecubital areas Oslers nodes on the patients fingertips or toes

64 64Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Infective Endocarditis Medical diagnosis History, physical examination, results of lab studies Echocardiography Serial blood cultures; elevated WBC Medical treatment Antimicrobials, rest, limitation of activities Prophylactic anticoagulants Surgery to replace an infected prosthetic valve

65 65Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Infective Endocarditis Assessment Review patients history for risk factors, recent invasive procedures, pathologic cardiac conditions, and onset of symptoms Assess for temperature elevation, heart murmur, evidence of HF (cough, peripheral edema), and embolization

66 66Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Infective Endocarditis Interventions Administer prescribed antibiotics Assess cardiac output and monitor for complications Teach patient about the medications prescribed and any restrictions imposed Encourage adequate rest

67 67Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pericarditis Etiology and risk factors Inflammation of the pericardium May be primary disease or associated with another inflammatory process The disease may be acute or chronic Acute pericarditis caused by viruses, bacteria, fungi, chemotherapy, or AMI (Dresslers syndrome) Chronic pericarditis caused by tuberculosis, radiation, or metastases

68 68Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pericarditis Pathophysiology In acute pericarditis, inflammatory process increases amount of pericardial fluid and inflammation of the pericardial membranes In chronic pericarditis, scarring of the pericardium fuses the visceral and parietal pericardia together Loss of elasticity results from the scarring Constrictive process prevents adequate ventricular filling

69 69Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pericarditis Complications Pericardial effusion or accumulation of fluid in the pericardial space May lead to cardiac tamponade Signs and symptoms Chest pain Most severe on inspiration Sharp and stabbing but may be described as dull or burning Relieved by sitting up and leaning forward Dyspnea, chills, and fever

70 70Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pericarditis Medical diagnosis Serial ECGs Echocardiogram CPK-MB Blood cultures Medical treatment Analgesics, antipyretics, anti-inflammatory agents, and antibiotics Surgical creation of a pericardial window for chronic pericarditis with effusion

71 71Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pericarditis Assessment Assessment of heart sounds especially important Interventions Rest and reduction of activity Administer and teach patient about medications Emotional support Vital signs; auscultate for pericardial friction rub Note pain characteristics and response to analgesics and anti-inflammatory agents Monitor the ECG for dysrhythmias

72 72Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cardiomyopathy Disease of the heart muscle Cause often unknown; may be secondary to another disease process Usually leads to heart failure Three types: dilated, hypertrophic, and restrictive Risk factors with dilated CMP are excessive use of alcohol, pregnancy, and infections Hypertrophic CMP: common in younger individuals Amyloidosis, sarcoidosis, and other immunosuppressive disorders may predispose individuals to restrictive cardiomyopathy

73 73Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-12

74 74Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cardiomyopathy Pathophysiology Dilated cardiomyopathy: dilation of the ventricle and severely impaired systolic function Hypertrophic cardiomyopathy: LV hypertrophies and there is thickening of the ventricular septum Restrictive cardiomyopathy: the myocardium becomes rigid and noncompliant

75 75Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cardiomyopathy Signs and symptoms Dilated cardiomyopathy: dyspnea, fatigue, left-sided heart failure, and moderate-to-severe cardiomegaly Hypertrophic cardiomyopathy: dyspnea, orthopnea, angina, fatigue, syncope, palpitations, ankle edema, and S 4 sounds Restrictive cardiomyopathy: dyspnea, fatigue, right- sided HF, S 3 and S 4 sounds, and mitral valve regurgitation

76 76Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cardiomyopathy Medical diagnosis Echocardiography Chest radiography

77 77Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cardiomyopathy Medical treatment Dilated cardiomyopathy: positive inotropic drugs, diuretics, ACE inhibitors and vasodilators; heart transplant Hypertrophic cardiomyopathy: antidysrhythmics, antibiotics, anticoagulants, calcium channel blockers, beta-blockers; surgical interventions; implantable cardioverter-defibrillator Restrictive cardiomyopathy: similar to that of HF therapy. Heart transplantation may be considered

78 78Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cardiomyopathy Assessment Primarily for heart failure Be alert for dyspnea, cough, edema, dysrhythmias, and decreased cardiac output Interventions Similar to that of patients with HF A hopeful atmosphere and careful explanation of care requirements Encourage the family to support the patient Guide the patient to make lifestyle changes Encourage patient to make decisions and choices

79 79Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-13

80 80Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Sudden Cardiac Death When heart activity and respirations cease abruptly Most common reason is coronary heart disease Often preceded by ventricular tachycardia or ventricular fibrillation and occasionally by severe bradydysrhythmias Sudden cardiac death may be the first indication of CAD Other causes: left ventricular dysfunction, cardiomyopathy, hypokalemia, antidysrhythmics, liquid protein diets, and high alcohol consumption Those who survive sudden cardiac death need extensive testing to determine its nature and cause

81 81Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Sudden Cardiac Death Implantable cardioverter/defibrillator For patients with life-threatening recurrent ventricular fibrillation who are unresponsive to medications or pacemakers The device senses heart rate, diagnoses rhythm changes, and treats ventricular dysrhythmias

82 82Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Care Promote psychosocial adaptation Body image change and a fear of shocks Patients and families need teaching and support Family instructed in CPR ID bracelet and a card with instructions about the ICD setting carried at all times Advise to avoid strong magnetic fields

83 83Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Valvular Disease Mitral stenosis: narrowing of the opening in the mitral valve that impedes blood flow from the LA into the LV Mitral regurgitation: allows blood to flow back into the LA during diastole Mitral valve prolapse: one or both leaflets enlarges and protrudes into the LA during systole Aortic stenosis: valve cusps become fibrotic and calcify Aortic regurgitation: fibrosis and thickening of the aortic cusps progress until the valve no longer maintains unidirectional blood flow

84 84Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cardiac Transplantation The first heart transplantation was performed in 1967 in South Africa by Dr. Christiaan Barnard Today in the United States, approximately 2500 are done annually for end-stage heart disease Donor must meet the criteria for brain death, have no malignancies outside the central nervous system, be free of infection, and not have experienced severe chest trauma

85 85Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cardiac Transplantation Donor and recipient organs carefully matched Recipient must be free of infection at the time of transplantation Patient prepped as any open-heart procedure Cardiopulmonary bypass initiated; recipients heart is removed except for the posterior portions of the atria Donor heart trimmed and anastomosed to the remaining native heart Patient removed from bypass, heart restarted, and chest is closed

86 86Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cardiac Transplantation Aftercare similar to that of coronary artery bypass surgery Hemodynamic monitoring, ventilation, cardiac assessment, care of chest tubes, and accurate intake and output measurements are vital Modified protective isolation used Patients and families taught sign/symptoms of infection, to avoid crowds and others with infections Lifelong immunosuppression Rejection monitored by endomyocardial biopsies

87 87Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Electrocardiogram Monitoring 12-lead electrocardiogram Looks at heart from 12 directions or perspectives Permits more precise evaluation of the hearts electrical activity Continuous ECG monitoring Most units that perform continuous monitoring use the five-lead system with four limb electrodes and a chest electrode

88 88Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-15

89 89Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Electrocardiogram Monitoring Interpretation of electrocardiograms Hearts electrical activity represented by deflections, positive and negative, from the baseline P wave, QRS complex, and T wave Criteria for interpreting electrocardiograms Rate calculation Rhythm P waves PR interval QRS complex T waves QT interval

90 90Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Electrocardiogram Monitoring Interpretation of electrocardiograms Normal sinus rhythm The most common cardiac rhythm is sinus in origin because the impulse originates in the SA node; is conducted normally Common dysrhythmias (rhythm disturbance from problem in the conduction system) Atrial dysrhythmias Junctional or escape rhythms Ventricular dysrhythmias

91 91Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-17

92 92Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-18

93 93Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-19

94 94Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-20

95 95Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-21

96 96Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-22

97 97Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-23

98 98Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-24

99 99Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-25

100 100Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-26

101 101Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-27

102 102Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-28

103 103Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-29

104 104Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 35-30

105 105Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Hemodynamic Monitoring Central venous catheter Placed through the skin, into a venous access (brachial, femoral, subclavian, or jugular sites), and threaded into the RA Catheter may have 1 to 3 lumens Mixed venous oxygen saturation

106 106Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Hemodynamic Monitoring Pulmonary artery catheter Swan-Ganz catheter Longer than the central venous catheter Inserted like the central venous catheter and is threaded through the RA, tricuspid valve, RV, pulmonic valve, and into pulmonary artery Cardiac output Measured continuously or by thermodilution

107 107Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Hemodynamic Monitoring Arterial line Provides a direct measurement of systolic and diastolic blood pressures


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