Transcript LWW PPT Slide Template Master

Chapter 17:
Patient Assessment:
Cardiovascular System
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Assessment of Jugular Venous Pressure
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Assessment of Point of Maximal Intensity
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Areas of Auscultation
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Question
Which statement about pulsus paradoxus >10 mm Hg is
correct?
A. The pulse disappears during expiration and reappears
during inspiration.
B. The pulse disappears during inspiration and reappears
during expiration.
C. It is found in a patient with left ventricular failure.
D. It is a normal finding caused by breathing.
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Answer
B. The pulse disappears during inspiration and reappears
during expiration.
Rationale: Pulsus paradoxus is an abnormal finding when it
is >10 mm Hg, and it is found in patients with COPD or
cardiac tamponade. Answer B is the correct definition of
pulsus paradoxus. Answers A and D are incorrect.
Answer C describes pulsus alternans.
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Heart Sounds and Timing in Cardiac Cycle
Heart Sound
Timing of Cardiac
Cycle
Mechanism
S1
Isovolumetric
contraction
Closure of mitral,
tricuspid valves
S2
Isovolumetric
relaxation
Closure of aortic,
pulmonic valves
S3
Early ventricular filling
Past 35 years of age,
seen with ventricular
dilation. Systolic heart
failure.
S4
Atrial contraction
Seen with stiff
noncompliant ventricle
- ventricular
hypertrophy
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Question
Where is the left ventricular S4 heard with the bell of a
stethoscope?
A. Apex
B. Lower left sternal border
C. Apex with the patient turned slightly to the left side
D. Xiphoid
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Answer
A. Apex
Rationale: The left ventricular S4 is heard at the apex. The
right ventricular S4 is heard at the left sternal border.
The summation gallop is heard at the apex with the
patient turned slightly to the left side. The right
ventricular S3 is heard at the xiphoid or lower portion of
the left sternal border.
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ECG Electrode Placement
See Figure 17-13.
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Dealing With Complications After Cardiac
Diagnostic Procedures
• Anticipate potential complications.
• Keep emergency supplies close by.
• Treat the patient first and the monitor/equipment
afterwards.
• Report and act on changes immediately.
• Stay with the patient; call for help as needed.
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Question
Which of the following statements made by the client
reflects adequate understanding about a thallium stress
test?
A. I can eat the morning of the test; eating won’t interfere
with the test results.
B. I can have a caffeinated drink several hours before the
test.
C. Thallium will not cause renal damage.
D. I should take the full dose of my beta-blocker the
morning of my test.
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Answer
C. Thallium will not cause renal damage.
Rationale: Thallium is not nephrotoxic. The client should
remain NPO for 4 to 6 hours because digestion would
increase the amount of blood to the GI system; this
could cause decreased blood supply to the coronary
arteries, leading to incorrect results. Caffeine increases
the heart rate; the patient would have to exercise for
less time to reach the maximum heart rate, and the
optimal test results may not be achieved. Beta-blockers
should be held the day of the test because they
interfere with the patient’s ability to reach exercise
potential.
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Waveforms of the ECG
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Configurations of the QRS Complex
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Calculating a Corrected QT Interval
• Half of preceding R-R interval in seconds
• QT interval depends on heart rate
• Normal values
– Men: not >0.42 seconds
– Women: not >0.43 seconds
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Assessing the Rhythm Strip
1. Determine atrial (P-P) and ventricular (R-R) regularity.
2. Determine the atrial (P-P) and ventricular rate (R-R).
–
If regular, count number of large boxes between 2
consecutive P waves or 2 consecutive QRS
complexes and divide by 300.
–
If irregular, count the number of complexes in 6
seconds and multiply by 10.
3. P waves: present, absent, all look alike or not, ratio of P
waves to QRS complexes
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Assessing the Rhythm Strip (cont.)
4. Determine PR interval; normal is 0.12 to 0.20 sec
• Does the interval vary? Is there a pattern?
5. Determine the QRS complex; normal is 0.06 to 0.11 sec
• Do the complexes look the same?
6. Determine if the ST segment is isoelectric, elevated, or
depressed.
7. Determine the corrected QT interval.
8. Is the patient stable or not stable?
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Sinus Rhythms
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Atrial Dysrhythmias
Rhythm
Etiology
Manifestations
Management
PAC
Stress, caffeine,
tobacco, alcohol
Early complex with
P wave present
with shorter PR
interval
No treatment
needed
PSVT
Same as for PAC
Often started after
a PAC and ends
abruptly (150 to
250 bpm)
Vagal maneuvers;
IV adenosine,
cardioversion, or
overdrive pacing, if
prolonged
Atrial
flutter
Underlying heart
disease
Sawtooth P waves;
2:1, 3:1, 4:1 (250
to 350 bpm)
Consider
ventricular
response, how
long in rhythm,
potential for
thromboembolism
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Atrial Dysrhythmias (cont.)
Rhythm
Etiology
Manifestations
Management
Atrial
fibrillation
Usually
underlying heart
disease
No definable P
waves:
fibrillatory
waves
Irregular:
irregular pattern
No PR interval
Consider
ventricular
response, how
long in rhythm,
potential for
thromboembolism
Multifocal atrial
tachycardia
Severe
pulmonary
disease
Rapid atrial
tachycardia with
3 or more
different-shaped
P waves
Treat underlying
pulmonary
disease and slow
ventricular rate
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Junctional Dysrhythmias
Rhythm
Etiology
Manifestations
Management
PJC
Stress, caffeine,
tobacco, alcohol,
or post-MI
Early complex
with inverted P
wave before,
buried within, or
after QRS. QRS
is usually
normal.
No treatment
needed
Junctional
rhythm
Ischemic
damage to SA
node, digitalis
toxicity,
secondary to
cardiac meds,
hypoxia,
hypokalemia
P wave may be
inverted and
before QRS with
PR <0.12 sec, or
after QRS, or
buried in QRS.
QRS is normal.
Treat underlying
cause.
Improve cardiac
output.
Treat if
symptomatic with
atropine, pacing.
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Ventricular Dysrhythmias
Rhythm
Etiology
Manifestations
Management
PVC
Stress,
hypokalemia,
irritation to
heart, heart
disease
Premature beat
No P wave
Wide, bizarre QRS
with T wave in
opposite direction
No treatment
needed; monitor
Ventricular
bigeminy
Same as for PVC Each sinus beat is
followed by PVC
Treat any
underlying cause
Ventricular
trigeminy
Same as for PVC Two sinus beats are
followed by PVC
Treat any
underlying cause
R-on-T
phenomenon
Cardiac meds,
pacemaker
firing too close
to vulnerable
period
Treat underlying
cause.
Treat
dysrhythmia.
PVC too close to T
wave: ventricular
repolarization
(vulnerable period)
- could cause V-fib
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Ventricular Dysrhythmias (cont.)
Rhythm
Etiology
Manifestations
Management
Ventricular
tachycardia
MI, irritation
to heart,
hypokalemia
No P wave (usually)
Wide bizarre QRS
Rate >100
ACLS guidelines
Torsades de
pointes
(QRS polarity
changes from
positive to
negative)
Underlying
heart disease
with
prolonged QT,
hypothermia,
cardiac meds
No P wave
Magnesium sulfate
Wide bizarre
IV, isoproterenol,
polymorphous QRS
overdrive pacing
Rate >100
May change to VF or
SR
Ventricular
fibrillation
(VF) - coarse
or fine
MI or other
factor that
damages the
heart
Irregular oscillations ACLS guidelines,
at baseline
emergent
No P wave
defibrillation
No recognizable
QRS
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Accelerated Idioventricular Rhythm
Rhythm
Etiology
Manifestations
Management
Accelerated
idioventricular
rhythm
Acute MI,
coronary
reperfusion after
thrombolytics,
digitalis toxicity
No P waves
Wide bizarre
QRS
Regular
ventricular rate
(50 to 100)
If because of
digitalis toxicity,
stop digoxin.
If pt is
hemodynamically
stable, no
treatment.
If pt is not
hemodynamically
stable, treat with
atropine or atrial
pacing.
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Heart Blocks
Rhythm
Etiology
Manifestations
First degree
Drugs or cardiac PR >0.20 sec
disease that
QRS normal
affects AV node
No treatment;
monitor
Mobitz I
Wenckebach
Drugs or cardiac
disease that
affects AV node,
inferior wall MI,
myocarditis
Stop med, if
cause; no
treatment;
monitor
P waves present
Pattern with PR
interval
progressively
lengthens until a
QRS is dropped
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Management
Heart Blocks (cont.)
Rhythm
Etiology
Manifestations
Management
Mobitz II
Drugs or
cardiac
disease that
affects AV
node; acute
anterior wall
MI
Fixed PR interval during AV
conduction and nonconducted
P wave when block present
(2:1, 3:1,4:1)
P-P regular
May see bundle branch block
If pt has
symptoms:
atropine,
pacing
If
asymptomatic
: monitor
(could become
third degree)
Third
degree
(complete)
Cardiac
disease that
affects AV
node
P waves present; P-P regular
Pacing
QRS present; R-R regular
No relationship between P and
QRS
QRS narrow - junctional
escape
QRS wide - ventricular escape
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Indwelling Arterial Catheter
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Pulmonary Artery Catheter
See Figure 17-53.
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Arterial Pressure Waveform
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Normal Pulmonary Artery Waveforms
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Normal Values and Wave Configurations
as a Pulmonary Artery Catheter Is
Inserted
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Nursing Considerations When Assessing
Hemodynamic Parameters
• Note marking of catheter at insertion site
– A black line is 10 cm
– A heavy black line is at 50 cm and 110 cm
• Maintain consistent leveling, zeroing, and measurement
techniques
• Perform parameters at end-expiration
• Note if it takes less than 1.25 to 1.5 mL of air to wedge
• Set alarms and troubleshoot accordingly
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Obtaining Pulmonary Wedge Pressure
With Mechanical Ventilation
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Nursing Considerations With Continuous
Mixed Venous Monitoring
• Enhance O2 delivery
– Mechanical ventilator settings at optimum
– Positioning and chest physiotherapy
– Deep-breathing exercises and coughing
– Administer PRBCs
• Decrease O2 demand
– Use monitor to guide activities
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