Action Potential

Cardiac Conduction
� Sinoatrial (SA) node � Fires at 60�100 beats/minute
� Intranodal pathway
� Atrioventricular (AV) node � Fires at 40-60 beats/minute
� Atrioventricular bundle of His
� Ventricular tissue fires at 20-40 beats/minute and can occur at this point and
down
� Right and left bundle branches
� Purkinje fibers

Cardiac Output/Index
� Cardiac output � CO = HR (beats/minute) X SV (liters/beat)
� Normal adult: 4-8 liters/minute
� Cardiac index
� CI = CO(liter/minute)/Body surface area (m2)
� Normal adult: 2.8-4.2 liter/minute/m2
� Normalizes liter flow to body size

Stroke Volume
� The amount of blood ejected by the left ventricle
� Preload
� The amount of stretch placed on the cardiac muscle just prior to systole
� Starling�s Law
� Afterload
� The force or pressure at which the blood is ejected from the ventricle
� Equated with systemic vascular resistance (SVR)
� Contractility

Patient Assessment: Cardiovascular System

Physical Exam
� Inspection
� General appearance
� Jugular venous distension (JVD)
� Skin
� Extremities
� Palpation
� Pulses
� Point of maximal impulse (PMI)
� Percussion
� Auscultation
� Good stethoscope
� Positioning
� Normal tones � S1/S2
� Extra tones � S3/S4
� Murmurs
� Rubs
Murmurs
� Timing
� Location
� Transmission
� Pitch
� Quality
� Intensity

Grading
� Grade 1 � Barely audible
� Grade 2 � Clearly audible
� Grade 3 � Moderately loud
� Grade 4 � Loud with a thrill
� Grade 5 � Very loud with an easily palpable thrill
� Grade 6 � Very loud, no stethoscope needed, palpable and visible thrill

Important Cardiac Labs

� Coagulation studies � PTT and PT/INR
� Electrolytes � Potassium, magnesium, and calcium
� Lipid studies � Cholesterol, triglycerides
� Enzymes � CK, CK-MB, LDH
� Troponin

Invasive Tests
� Coronary angiography
� Electrophysiology studies
Steps to reading ECGs
� What is the rate? Both atrial and ventricular if they are not the same.
� Is the rhythm regular or irregular?
� Do the P waves all look the same? Is there a P wave for every QRS and conversely
a QRS for every P wave?
� Are all the complexes within normal time limits?
� Name the rhythm and any abnormalities.

Rate
� Look at complexes in a 6-second strip and count the complexes; that will give you
a rough estimate of rate
� Count the number of large boxes between two complexes and divide into 300
� Count the number of small boxes between two complexes and divide into 1500
Estimate rate by sequence of numbers

Normal Timing
� PR interval � 0.12 to 0.20 seconds
� QRS interval � less then 0.12
� QT interval � varies with rate. It is usually less then � the R-to-R distance on
the preceding waves

Normal Sinus Rhythm

� Rate is between 60 and 100 beats/minute
� The rhythm is regular
� All intervals are within normal limits
� There is a P for every QRS and a QRS for every P
� The P waves all look the same

Sinus Tachycardia
� Rate above 100 beats/minute
� The rhythm is regular
� All intervals are within normal limits
� There is a P for every QRS and a QRS for every P
� The P waves all look the same
� Caused by fever, stress, caffeine, nicotine, exercise, or by increased
sympathetic tone
� Treatment is to take care of the underlying cause
Sinus Bradycardia
� Rate is lower than 60 beats/minute
� The rhythm is regular
� All intervals are within normal limits
� There is a P for every QRS and a QRS for every P
� The P waves all look the same
� Caused by beta-blocker, digitalis, or calcium channel blockers. Normal for
athletes
� Don�t treat unless there are symptoms. Can use pacing or atropine

Sinus Arrhythmia
� Rate is between 60 and 100 beats/minute
� The rhythm is irregular. The SA node rate can increase or decrease with
respirations
� All intervals are within normal limits
� There is a P for every QRS and a QRS for every P
� The P waves all look the same
� More common in children and athletes
� Ask the patient to stop breathing and the rate will become regular
Premature Atrial Contraction (PAC)
� Can occur at any rate
� The rhythm is irregular because of the early beat but is regular at other times
� All intervals can be within normal limits
� There is a P for every QRS and a QRS for every P
� The P waves all look the same except the P in front of the PAC will be different
Paroxysmal Supraventricular Tachycardia
(PSVT)
� Rate is between 150 and 250 beats/minute
� The rhythm is regular
� QRS intervals can be within normal limits
� There can be a P wave, but more likely it will be hidden in the T wave or the
preceding QRS wave
� Starts and stops abruptly
� Treat with Valsalva maneuver or adenosine IV

Atrial Flutter
� Atrial rate is between 250 and 350 beats/minute. Ventricular rate can vary
� The rhythm is regular or regularly irregular
� There is no PR interval. QRS may be normal
� 2:1 to 4:1 f waves to every QRS
� There are no P waves; they are now called flutter waves
� Problem: Loss of atrial kick and ventricular conduction is too fast or too slow
to allow good filling of the ventricles

Atrial Fibrillation
� Atrial rate is between 350 and 600 beats/minute; ventricular rate can vary
� The rhythm is irregular
� There is no PR interval; QRS may be normal
� There are many more f waves then QRSs
� Unlike flutter where the f wave will appear the same, in fib the f waves are from
different foci so they are different
Multifocal Atrial Tachycardia (MAT)
� Rate is greater then 100 beats/minute
� The rhythm is irregular
� PR interval may vary depending on how close the foci is to the AV node; QRS may
be normal
� There usually is a P for every QRS and a QRS for every P wave
� The P waves appear different because they are coming from different foci
� There needs to be at least 3 different P waves to be classified as MAT
Junctional Arrhythmia
� Rate is between 40 and 60 beats/minute
� The rhythm is regular
� There is a P for every QRS and a QRS for every P
� The P wave can be in three possible places
� Retrograde conduction to atria before ventricle; P wave would be upside down
before the QRS
� If both atria and ventricle receive stimulus at the same time, the P would be
buried in the QRS
� If the ventricle was stimulated first, the P would be located just after the QRS
Junctional Rhythms
� Junctional bradycardia
� Rate less than 40 beats/minute
� Accelerated junctional
� Rate 60-100 beats/minute
� Junctional tachycardia
� Rate is greater then 100 beats/minute
� Premature junctional contractions (PJC)
� Early beats in the cycle that have junctional P wave morphology
Premature Ventricular Contractions (PVC)
� Early beat that is wide (>0.12)
� Originates the ventricles
� No P wave
� Compensatory pause
� Can be defined by couplet or triplet; anything more would be considered
ventricular tachycardia
� Monomorphic or polymorphic

Ventricular Tachycardia
� Rate is between 100 and 200 beats/minute
� The rhythm is regular, but can change to different rhythms
� No PR interval; QRS is wide and aberrant
� There may be a P wave, but it is not related to the QRS

Torsades De Pointes
� Polymorphous ventricular tachycardia
� Caused by long QT syndrome. This is an inherited condition or caused by
antiarrhythmic drugs
� Cannot be converted by defibrillation
� Magnesium is the drug of choice
� Overdrive pacing may work also

Ventricular Fibrillation
� Rapid, irregular rhythm made by stimuli from many different foci in the
ventricula
� Produces no pulse, blood pressure, or cardiac output
� Can be described as fine or coarse
� Most common cause of sudden cardiac death

First�Degree AV Block
� The rate is usually between 60 and 100 beats/minute
� The rhythm is regular
� PR interval is prolonged past 0.20 seconds
� QRS may be of normal length
� There is a P for every QRS and a QRS for every P
� The P waves all look the same
� Can occur in healthy people
� Caused by drugs
Second�Degree AV Block Type I
� Rate is between 60 and 100 beats/minute
� The rhythm is irregular or regularly irregular
� PR interval is progressively longer until a QRS is dropped
� QRS may be of normal length
� There are more P waves than QRS waves
� The P waves all look the same
� Caused by drugs, myocarditis, or inferior wall MI

Second�Degree AV Block Type II

� Rate may be slow, caused by blocked P waves
� The rhythm can be regular, depends on block
� PR intervals may be normal or prolonged, but they are consistent
� QRS usually greater then 0.12
� Can be more than one P wave for each QRS
� The P waves all look the same
� Caused by anterior wall MI, conduction problems
� Permanent and deteriorates rapidly

Third�Degree AV Block
� Ventricular rate is usually between 20 and 40 beats/minute
� Atrial rate is between 60 and 100 beats/mictive
� Restrictive filling
� Reduced compliance in one or both ventricles
Heart Failure
� Acute versus chronic
� Acute: sudden onset of symptoms over hours or days
� Chronic: limitations on a daily basis
� Left- versus right-sided heart failure
� Left-sided: failure of the left ventricle to fill or empty
� Can be systolic or diastolic in nature
� Right-sided failure: due to pulmonary disease or pulmonary hypertension

Classification of Heart Failure

� Class I � No limitation
� Class II � Slight limitation of physical activity
� Class III � Marked limitation of physical activity with some symptoms at rest
� Class IV � Unable to participate in physical activity, symptoms occur at rest
(�cardiac cripple�)
Pharmacological Treatment
� ACEI
� Hydralazine
� Nitrates
� Digoxin
� Diuretics
� Beta blockers
Nursing Diagnoses
� Decreased Cardiac Output related to altered preload
� Decreased Cardiac Output related to altered contractility
� Decreased Cardiac Output related to altered heart rate
� Decreased Activity Tolerance related to decreased cardiac output and
deconditioning

Acute Myocardial Infarction

Atherosclerosis
� Injury to endothelium
� Increased levels of cholesterol/triglycerides
� Hypertension
� Cigarette smoking
� Deposits in the lining of the artery
� Cholesterol cellular waste, calcium, and fibrin
� Atheroma
� Keeps building to partial or complete blockage
Risk Factors
� Uncontrollable
� Age
� Heredity
� Race
� Sex
� Modifiable
� Cigarette smoking
� High cholesterol
� Hypertension
� Physical inactivity
� Obesity
� Diabetes mellitus
Angina Pectoris
� Stable � chronic stable angina, classic angina
� Paroxysmal, occurs with physical exertion
� Relieved by rest or nitroglycerin
� Unstable � preinfarction angina or crescendo angina
� More prolonged and severe
� Need to be treated immediately
� Variant � Prinzmetal�s angina, vasospastic angina
� Result of coronary artery spasm
� Occurs at rest
Management of Angina
� Risk reduction
� Stop smoking, diet, weight loss, exercise
� Medications to control cholesterol, HTN, and diabetes
� Pharmacological
� Nitroglycerin, beta blockers, calcium channel blockers, and aspirin
� Invasive
� Angioplasty, PTCA, stent placement, IABP, CABG

Myocardial Infarction

� Inflammation
� Plaque rupture
� Thrombus formation
� Irreversible damage starts in 20 to 40 minutes. This process will continue for
several hours

Location of the Infarction

� Anterior
� Inferior
� Posterior
� Lateral
� Septal

Type of Infarction
� Q-wave
� Infarcted the full muscle wall
� Formation of pathological Q waves in area of infarct
� Greater then one small box in duration
� Deeper then 1/3 of the R wave
� Non�Q-wave
� Infarcted only partial amount of muscle wall
Cardiac Surgery
CABG
Coronary Artery Bypass Graft Surgery
� Native vessels
� Saphenous vein
� Internal mammary artery
� Off�pump CABG
� Transmyocardial laser revascularization

Valvular Disease
� Stenosis
� Mitral stenosis
� Rheumatic heart disease
� Aortic stenosis
� Rheumatic fever, calcification with age
� Insufficiency
� Mitral insufficiency
� Rheumatic heart disease, age, LV dilation
� Aortic insufficiency
� Rheumatic disease, aneurysm of ascending aorta
Cardiopulmonary Bypass
� Moves oxygenated blood around the body during open heart surgery
� Core body temp is lowered to 28� C to 32� C
� Complications
� Increased capillary permeability
� Hemodilution
� Altered coagulation
� Damage to blood cells
� Microembolization
Complications
� Arrhythmias
� Fluid resuscitation
� Decreased cardiac contractility
� Control of blood pressure
� Respiratory problems
� Postoperative bleeding
Nursing Diagnoses
� Decreased Cardiac Output related to
� Changes in LV preload, afterload, and contractility
� Cardiac dysrhythmias
� Decreased Tissue Perfusion related to
� Cardiopulmonary bypass, decreased CO, hypotension
� Impaired Gas Exchange related to cardiopulmonary bypass, anesthesia, poor chest
expansion, atelectasis, retained secretions
� Risk for Fluid Volume Deficit related to abnormal bleeding
� Risk for Infection related to surgical procedure, invasive lines, drainage tubes,
hypoventilation, retained secretions
� Impaired Comfort related to endotracheal tube, surgical incision, chest tubes,
rib spreading
� Anxiety related to fear of death, ICU environment
Carotid Endarterectomy
� Atherosclerotic changes in the carotid arteries
� 70% to 90% stenosis
� Clamping of the carotid arteries
� Heparinization to prevent clot formation

Postoperative Care of an Endarterectomy

� Control of blood pressure
� Assessment of cranial nerves
� VII, X, XI, XII
� Bleeding
� Note neck size
� Check for swelling � possible hematoma formation
� Difficulty in swallowing or breathing

CARDIOVASCULAR SYSTEM NCM104 LEC

KARLEEN L. JARO BSN 4-Q