Cardiac - Welcome to the Community College of Philadelphia 心脏-欢迎来到费城的社区学院

CardiacCommunityCollegeofPhiladelphiaNursing132Spring2007AnatomyandPhysiologyReviewStructuresChambersValvesArteriesPhysiologyDirectionofflowPreloadAfterloadCoronaryCirculation

StructureEpicardiumMyocardiumEndocardiumChambersRightandLeftAtriaRightandleftVentriclesValvesAtrioventricularTricuspid-SeparatesRAfromRVMitral-SeparatesLAfromtheLVSemilunarPulmonic–SeparatesRVfromthePulmonaryArteriesAortic–SeparatesLVfromtheAortaPhysiologyBloodflowthroughtheheartCardiacconduction AutomaticityElectrophysiologyNodesPathwayAutomaticityCardiacconductionBasicEKGInterpretationWhatisanEKGandwhatdoesitmeasure/record?PQRSTMeasuringboxesHorizontalmeasuretime:smallbox0.04seconds Largebox0.20secondsVerticalvoltage:smallbox1mmor0.1mV largebox5mmor0.5mVPwaveAtrialdepolarizationSmall,smooth,roundedNotallerthan2.5mmNowiderthan0.11secQwaveFirstdownwarddeflectionShouldbelessthan0.03secondsindurationandlessthan25%oftheRwaveIndicatesmyocardialinfarctionQRSComplexRepresentsventriculardepolarizationTwaveVentricularrepolarizationUsuallyroundedShouldbesamedirectionasQRSInvertedTwavescanbeasignofischemiaPeakedTwavescanbeasignofhyperkalemiaUwaveSmallroundedwavenotalwayspresent,thoughttobepartofventricularrepolarizationPQRSTChronicStableAnginaAngina(StableChronic)MostcommonsignofischemicheartdiseaseMyocardialoxygendemandisincreasedbyexercise,smoking,eatingheavyfoods,weatherextremes,emotionaldistress,etc…AtherosclerosiscausesprogressivefixednarrowingofthearteriallumenRelievedbyrestorpharmacologicalinterventionsGoalistoprolongsurvival,reducediseaseprogressionAcuteCoronarySyndrome(ACS)UnstableAngina(UA)Non-STElevatedMyocardialInfarction(NSTEMI)STElevationMyocardialInfarction(STEMI)PenumbraUnstableAngina(UA)/Non-STElevatedMyocardialInfarction(NSTEMI)ImbalancebetweenmyocardialoxygensupplyanddemandUAoccursatrestwithoutexertionReducedmyocardialperfusionReleaseofbiochemicalmarkersvs.noreleaseofbiochemicalmarkersEvaluationandmanagementStratificationHighriskIntermediateLowriskImmediateManagementHistory,PE,12–LeadEKG,initialcardiacmarkersAssignto1of4categoriesDefiniteorPossibleCont.EKGmonitoringCardiacmarkersInfacilityobservationRepeatEKGandcardiacmarkers6-12hoursEKGandcardiacmarkersnormalfollowupstresstestasoutpatientacceptableDefiniteACSadmittohospital–ChestpainunitifavailableHospitalCareNursingManagementMinimizeoreliminateischemiaAdministermedsEducateDischargeteachingSTElevationMyocardialInfarction(STEMI)MIoccursasaresultofthromboticocclusionofoneormoreofthecoronaryarteries*******CPismostcommonsymptom,severe,doesn’tgoawayDiagnosisEKGCardiacmarkersPE,HistoryVentricularRemodeling–Changesinthesize,shape,andthicknessoftheleftventricleinvolvingboththeinfarctedandnon-infarctedsegmentsoftheventricle.Penumbra1.68millionuniquedischargesforACSin2001,30%estimatetohaveSTEMIManagementPtcontactwithhealthcaresystemInitiationoffibrinolytictherapy–<30minutesBallooninflationforPCI-<90minutesChoiceoftreatmentdecidedbyEMphysicianandresourcesofinstitutionandsurroundinginstitutionsContraindicationstofibrinolytics12leadEKGcompletedandshowntoexperiencedemergencyphysicianWITHIN10minutesCardiacMarkersTroponinCK-MBMyoglobinLabresultsshouldnotdelaytreatmentCardiacEnzymes–Troponin,Myoglobin,CK-MB,TotalCK

Whatshouldbedone?EKGLabworkPortableCXROxygenNitroglycerin:3sublingual0.04mg,IVifneeded****Phosphodiesteraseinhibitor****MorphineSulfate:2–4mgIVASAchewedBetablockerifnotcontraindicatedACEorallywithin24hoursofSTEMIforanteriorinfarct,pulm.congestion,LVEF<40%PatientEducationBeforeDischargeLifestylechangesRecognizingcardiacsymptoms:calling911ifsymptomsnotimprovingFamilyeducationaboutAED,CPRLipidManagementWeightManagementSmokingcessationCont.AntiplateletTherapy:ASA,PlavixACEinhibitorifwithoutcontraindicationsBetablockers:exceptlowriskandcontraindicationsHypertensionControlDiabetesManagementNoHormonetherapyCont.WarfarinTherapyPhysicalactivity:shouldbeencouragedandprescribedappropriately/RehabFollowupcarewithmedicalproviderSeeflowchartQuestions????CardiacCatheterizationPercutaneousCoronaryInterventions(PCI)“CardiacCatheterization〞PTCA(PercutaneousTransluminalCoronaryAngioplasty/Angiography)PCI-Angioplasty,atherectomy,intracoronarystentingWebsiteWhoundergoesPCI?StableCADUnstableanginaNSTEMISTEMIWhatisastent?PreproceduralManagementWhatdoyouthink?InformedconsentConsentforCABGEducationHoldMetformin(Glucophage),insulinetc…NPOstatusLabvalues-Whichones,andwhy??PostproceduralManagmentWhatdoyouthink?12-LeadEKGLabs-WillCEbeelevated?HydrateAnticoagulationperinstitutionSheathremoval Femstop Manualpressure Vascularclosuredevices AngiosealSANDBAGStudyNursetopatientratioof1:1.5orlessmaintainedduringsheathremovalSheathsremovedwithin4-6hoursMedicateforcomfort,HOBcanbe30degreesAllowedtoambulate8hoursafterremovalSANDBAGSARENOTEFFECTIVETOMINIMIZEBLEEDINGANDCAUSEDISCOMFOT*****Evidence-BasedPractice*******ComplicationsofPCIAbruptClosureAcuteStentThrombosis<1%VascularSpasmNSTEMISTEMI<1%CoronaryVesselPerforationArrhythmiasEquipmentFailureContrast-RelatedComplicationsCerebrovascularComplicationsCABGEmergentlyGroinComplicationsHematomaRetroperitonealbleedingArterialthrombosisPseudoaneurysmArteriovenousfistulaNursingManagement/DiagnosisAnxietyRiskofalteredmyocardialtissueperfusionRiskofdecreasedcardiacoutputRiskofalteredcerebraltissueperfusionExtracellularfluidvolumedeficitRiskofextracellularfluidvolumedeficit:hemorrhageTakeHomePoints!PTCA/PCI:Whatdotheystandfor?ReasonsforPCI:EvaluateandpossiblyprovideaninterventionStent,Atherectomy,AngioplastyGroincomplications!!!ChronicHeartFailureHeartFailure(HF)ComplexclinicalsyndromeHFisnotastandalonediagnosis-ithasacauseWhatarethecausesofHF?WhatisHF?HFisacomplexclinicalsyndromethatcanresultfromanystructuralorfunctionalcardiacdisorderthatimpairstheabilityoftheventricletofillorejectbloodCADistheunderlyingcauseofHFintwothirdsofpatientswithLVsystolicdysfunction2-DimensionalEchoisthesinglemostusefuldiagnostictoolintheevaluationofpatientswithHFSystolicDysfunctionDiastolicDysfunctionImportantConceptsMyocardialDamageQuestionsNeurohormonalEffectsHemodynamicDefenseReactionSympatheticresponseInflammatoryReactionHypertrophyorgrowthReactionRemodelingQuestionsLeftventriculardysfunctionbeginswithsomeinjurytothemyocardiumandisusuallyaprogressiveprocess,evenintheabsenceofanewidentifiableinsulttothemyocardium.Theprincipalmanifestationofsuchprogressionisaprocessknownasremodeling,whichoccursinassociationwithhomeostaticattemptstodecreasewallstressthroughincreasesinwallthickness.Thisultimatelyresultsinachangeinthegeometryoftheleftventriclesuchthatthechamberdilates,hypertrophies,andbecomesmorespherical.Theprocessofcardiacremodelinggenerallyprecedesthedevelopmentofsymptoms,occasionallybymonthsorevenyears.Theprocessofremodelingcontinuesaftertheappearanceofsymptomsandmaycontributeimportantlytoworseningofsymptomsdespitetreatment.SignsandSymptomsElevatedpulmonaryvenouspressuresDecreasedcardiacoutputPulmonarycongestion-Breathsounds?BreathlessnessWeaknessFatigueDizzinessConfusionHypotensionDeath-HFsometimesdevelopsuddencardiacdeathSignsandSymptomsIncreasedsystemicvenouspressureJugularvenousdistentionHepatomegalyDependentperipheraledemaAscitesWeightgainACC/AHAGuidelinesfortheEvaluationandManagementofChronicHeartFailureintheAdultNearly5millionpatientshaveHFNearly500,000patientsdiagnosedwithHFforfirsttimeyearly12-15millionofficevisits6.5millionhospitaldayseachyear4StagesStageA: PatientsathighriskofdevelopingHFbecauseofthepresenceofconditionsthatarestronglyassociatedwiththedevelopmentofHF.Suchpatientshavenoidentifiedstructuralorfunctionalabnormalitiesofthepericardium,myocardium,orcardiacvalvesandhavenevershownsignsorsymptomsofHF.StageAExamplesSystemichypertension,CAD,DM,hxofcardiotoxicdrugtherapyoralcoholabuse,personalhistoryofrheumaticfever,familyhistoryofcardiomyopathyStageATherapyTreatHTNEncouragesmokingcessationTreatlipiddisordersEncourageregularexerciseDiscouragealcoholintake,illicitdruguseACEinhibitioninappropriatepatients(atheroscleroticvasculardisease,DM,HTN)StageB: PatientswhohavedevelopedstructuralheartdiseasethatisstronglyassociatedwiththedevelopmentofHFbutwhohavenevershownsignsorsymptomsofHF.StageBExamplesLeftventricularhypertrophyorfibrosis,leftventriculardilatationorhypocontractility,asymptomaticvalvularheartdisease,previousmyocardialinfarctionStageBTherapyAllmeasuresunderStageAACEinhibitorinappropriatepatients(recentorremoteMIhistory,regardlessofejectionfractionandpatientswithreducedejectionfractionwhetherornottheyhaveexperiencedaMI)BetablockerinpatientswithrecentMIValverepairifneededRegularevaluationStageC: PatientswhohavecurrentorpriorsymptomsofHFassociatedwithunderlyingstructuralheartdisease.StageCExamplesDyspneaorfatigueduetoleftventricularsystolicdysfunction;asymptomaticpatientswhoareundergoingtreatmentforpriorsymptomsofHF.StageCTherapyAllmeasureunderADrugsforroutineuseDiureticsACEinhibitorsBetablockersDigitalisDietarysaltrestrictionStageD: PatientswithadvancedstructuralheartdiseaseandmarkedsymptomsofHFatrestdespitemaximalmedicaltherapyandwhorequirespecializedinterventions.StageDExamplesPatientswhoarefrequentlyhospitalizedforHForcannotbesafelydischargedfromthehospital;patientsinthehospitalawaitinghearttransplantation;patientsathomereceivingcontinuousintravenoussupportforsymptomrelieforbeingsupportedwithmechanicalcirculatoryassistdevice;patientsinahospicesettingforthemanagementofHF.StageDTherapyAllmeasuresunderA,B,andCMeticulousidentificationandcontroloffluidretentionReferraltoaHFprogramMechanicalassistdevicesHearttransplantContinuousIVinotropicinfusionsforpalliationHospicecareNewYorkHeartAssociationClassificationClassI: Nolimitationofphysicalactivity.Ordinaryphysicalactivitydoesnotcauseunduefatigue,palpitation,ordyspnea(shortnessofbreath).ClassII: Slightlimitationofphysicalactivity.Comfortableatrest,butordinaryphysicalactivityresultsinfatigue,palpitation,ordyspnea.ClassIII: Markedlimitationofphysicalactivity.Comfortableatrest,butlessthanordinaryactivitycausesfatigue,palpitation,ordyspnea.ClassIV: Unabletocarryoutanyphysicalactivitywithoutdiscomfort.Symptomsofcardiacinsufficiencyatrest.Ifanyphysicalactivityisundertaken,discomfortisincreased. Susanisa63yo,CaucasianwomenwhopresentedtotheED,c/o:N/V,fatigue,shortnessofbreath,andheartburn.ShehasahistoryofDMandHTN.HerVSwerestableanda12leadEKGshowedthefollowing:WhatisSusanexperiencing?Whatdoyou,asthenurseneedtodo,remember,consider?WhatcausesHF?WhatStageisSusan?WhatmedicationsshouldSusanreceivenowandatdischarge?TenyearslaterSusanhasnoticedsheca