cardiovascular system - normal

7/31/2019 Cardiovascular System - Normal

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Cardiovascular

SystemNormal


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ANATOMYAND

PHYSIOLOGY


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Heart and Heart Wall Layers Located in the left side of the

mediastinum Consists of 3 Layers:

EPIcardium MYOcardium

ENDOcardiumEPI-MYO-ENDO


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Pericardial Sac Encases and protects the heart from

trauma and infectionHas 2 Layers:

Parietal Pericardium Tough, fibrous outer membrane

Visceral Pericardium Thin, inner layer that closely adheresto the heart

Pericardial Space Between PP and VP; holds 5-20 ml of

pericardial fluid Lubricates pericardial surfaces and

cushions the heart


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Structures ofthe Heart

ChambersAtria- (2) upper chambers

Thin walledReceive blood from veins

Send blood to ventriclesVentricles- (2) lower

chambersThick walled

Receive blood from atriaPump blood out througharteries

SeptumWall that divides heart

into right and lefthalves

Septum

Pulmonary valve

Right atrium

Tricuspid valve

Right ventricle

Left atrium

Aortic valve

Mitral valve

Left ventricle


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Prevent backflow of bloodKeep blood moving in one

direction

Between the chambersAt junctions of artery

and chamber

Tricuspid valve

Pulmonary veins

Mitral valve

Left atrium

Pulmonary valve

Aortic valve

Right atrium

Valves seen from above

Chordea tendinea

Pulmonaryvalve

Valves
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Chordae

tendinease Heart strings Cord-like

tendons

Connect papillarymuscles totricuspid andmitral valves

Prevent inversionof valve

Papillary muscles Small muscles

that anchor the

cords

Papillarymuscle


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aortic valve

left common carotid artery

left subclavian artery

brachiocephalic artery

right pulmonary artery

septum

left pulmonary artery

aorta

pulmonary trunk

left pulmonary veins

left atrium (auricle)

mitral valve

pulmonary valve

papillary muscle

left ventricle

right pulmonary veins

superior vena cava

right atrium

tricuspid valve

right ventricle

inferior vena cava

2006 Merriam-Webster, Inc.

Structures of the Heart


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Chambers of the Heart


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Great Vessels of theHeart

Superior and InferiorVena Cava

Pulmonary Arteries Pulmonary VeinsAorta


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ATRIOVENTRICULARVALVES

Close at the beginning ofventricular contraction

Prevents blood from flowing backin the atria from the ventricles

Open when the ventricle relaxes Tricuspid Valve right side of the

heart Bicuspid (mitral) Valve left side

of the heart


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SEMILUNAR VALVES

Prevents blood from flowing backinto the ventricles duringrelaxation

Open during ventricularcontraction

Close when ventricles begin torelax

Pulmonic Semilunar Valve Lies between RV and PA

Aortic Semilunar Valve Lies between LV and Aorta


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Bl d l


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Blood Flowthrough the

HeartSVC &IVC

Right Atrium

Tricuspid Valve

Right Ventricle

Pulmonary SemilunarValve

Pulmonary Arteries

L

U

N

G

S

Pulmonary Veins

Left Atrium

Bicuspid / Mitral Valve

Left Ventricle

Aortic Semilunar Valve

Aorta

BODY


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Conduction System

Generates and transmitselectrical impulses that

stimulate contraction ofthe myocardium


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Conduction System Sinoatrial Node (SA Node)

Main pacemaker that initiates eachheartbeat

Located at the junction of SVC andRA

Generates electrical impulses at 60-

100 times per minute Controlled by the sympathetic andparasympathetic nervous system

Atrioventricular Node (AV Node) Located in the lower aspect of the

atrial septum Receives electrical impulses from SA

node If SA node fails, AV node can initiate

40-60 bpm


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Bundle of His Continuation of the AV node

Right and Left bundle branches

Purkinje Fibers Diffuse network of conducting

strands located beneath theventricular endocardium

Spread the wave of depolarization

through the ventricles Can act as a pacemaker at 20-40bpm when higher pacemaker fail


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Coronary Arteries Supply the capillaries of myocardium

with blood Right coronary artery

Supplies the RA and RV, inferiorportion of the LV, posterior septal

wall, SA and AV nodes Left coronary artery Left anterior descending artery

Supplies blood to the anteriorwall of the LV and apex of theLV

Circumflex artery Supplies blood to the left atriumand the lateral and posterior

surfaces of the LV


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Heart Sounds S1

1stheart sound Heard as the AV valves close

Heard loudest at the apex of theheart

S2 2nd heart sound Heard when SL valves close Heard loudest at the base of the heart


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Listen to heart with stethoscope: lubb-dupp

lubb: start of ventricular contraction

dupp: start of ventricular relaxation

Ab l H t


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Abnormal HeartSounds

Paradoxical SplittingAbnormal splitting of S2 Caused by early closure ofpulmonic valve or delay inaortic valve closure

Gallops S3 and S4


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S3 (Ventricular Gallop) Heard if ventricular wall compliance is

decreased and structures in the

ventricular wall vibrate CHF, valvular regurgitation Normal in individuals younger than 30

years old

S4 (Atrial Gallop)Abnormal finding Resistance to ventricular filling Cardiac hypertrophy

Disease Injury to the ventricular wall Quadruple Gallop

Severe heart failure


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Murmurs Reflect turbulent blood flow

through normal or abnormalvalves Systolic murmurs

Occur between S1 and S2 Diastolic murmurs

Occur between S2 and S1 Pericardial Friction Rub

Sign of inflammation orinfection

Pericarditis, cardiac tamponade


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Cardiac Output Volume of blood in litersejected by the heart

each minute 4 7 liters/minute Cardiac Output = Heart

rate/ Stroke volume


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Heart Rate The FASTER the HR, the less time the

heart has for filling and the cardiacoutput decreases

Increase in HR = increase in oxygenconsumption

Normal HR: 60-100 bpm

Sinus Tachycardia: more than 100bpm Sinus Bradycardia: less than 60 bpm


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Stroke VolumeAmount of bloodejected by the left

ventricle during eachsystole


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Preload Degree of myocardial fiber

stretch at the end ofdiastole and just before

contraction Determined by the amount

of blood returning to the

heart from both the rightheart and left heart


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Afterload Pressure or resistance thatthe ventricles must

overcome to eject blood

through the semilunarvalves and into theperipheral blood vessels

Amount of resistance isdirectly related to arterialblood pressure and thediameter of blood vessels

A t i N


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Autonomic NervousSystem

Sympathetic Response Release of norepinephrine

increase HR and peripheralvasoconstriction

Stimulation occurs when decreasein BP is detected

Parasympathetic Response Release of acteylcholine

decreases HR Stimulation occurs when

increasein BP is detected


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BP Control When BP decreases as a result ofhypovolemia, sympathetic response occurs =

increase HR and BP When BP increases as a result of

hypervolemia, parasympathetic responseoccurs = decrease HR and BP Antidiuretic hormone (vasopressin) influences

BP by regulating vascular volume

Increase in blood volume = decrease ADH= increase in diuresis (ihi) = decrease BP Decrease in blood volume = increase ADH

= decrease in diuresis (ihi) = increase BP


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Renin, a vasoconstrictor, causesBP to increase

Renin converts angiotensin toangiotensin I; angiotensin I isthen converted to angiotensin IIin the lungs

Angiotensin II stimulates releaseof aldosterone, which promotessodium and water retention by

the kidneys, thus, increaseblood volume and BP


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Vascular System Arteries

Blood passes AWAY from the heart Convey highly oxygenated blood

Veins

Carry deoxygenated blood TO theheart

CapillariesAllow exchange of fluid and nutrients

between blood and interstitial spaces Lymphatics

Drain the tissues and return tissuefluid to the blood

Blood vessels have different structures:


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Blood vessels have different structures:Arteries and Arterioles

Epithelial cells of arteries/veins are surrounded by smooth muscle andconnective tissue Arteriesare very elastic (a property of connective tissue), to

accommodate very high blood pressure leaving the heart Arterioles are less elastic and have more smooth muscle, allowing

constriction/dilation

Blood vessels have different structures:


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Blood vessels have different structures:Veins

Veins have thinner walls and less musclethan arteries (lower blood pressure) Valves in veins prevent the backflow of

blood Blood flow is aided by muscular

contractions


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Types of

Circulation

di l


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Pulmonary Circuit

Systemic Circuit

Lung

Pulmonary

vein

Aorta

Left

atrium

Left

ventricle

Pulmonary

artery

Right

atrium

Right

ventricle

Vena

cava

oxygen-poor blood

oxygen-rich blood

CardiovascularCircuits

P l a


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PulmonaryCirculation

Takes place on theright side of theheart.

Pumps blood low inoxygen to the lungsto pick up oxygen andreturn to heart


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Coronary Circulation

Although blood fills the

chambers of the heart,the muscle tissue ofthe heart is so thick thatit requires coronary bloodvessels to deliver blood

deep into themyocardium.

The coronary circulation consists of the blood vessels

that supply blood to, and remove blood from theheart muscle itself.


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Coronary Circulation

The vessels that supply blood high in oxygen tothe myocardium are known as coronaryarteries.


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Hepatic Portal System

H p ti P t l S st


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Hepatic Portal SystemThe liver is the only digestive organdrained by the inferior vena cava- blood leaving the capillary bedssupplied by the celiac and superior andinferior mesenteric arteries flows intothe veins of the hepatic portal system

- a blood vessel connecting 2 capillarybeds is a portal vessel and the networkis a portal system

Venous blood that absorbs nutrientsfrom the small intestine, parts of thelarge intestine, stomach, and pancreasflows directly to the liver- regulates levels of nutrients and

amino acids in the circulating blood


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Fetal Circulation


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Fetal Circulation

O t d bl d t th bili l i f th l t


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Oxygenated blood enters the umbilical vein from the placenta

Enters ductus venosus

Passes through inferior venacavaEnters the right atrium

Enters the foramen ovale

Goes to the left atrium

Passes through left ventricle

Flows to ascending aorta to supply nourishment tothe brain and upper extremeties

Enterssuperiorvena cava

Goes to right atrium

Enters the right ventricle


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Enters pulmonary artery withsome blood going to the lungs

to supply oxygen andnourishment

Flows to ductus arteriosus

Enters descending aorta ( someblood going to the lower

extremeties)

Enters hypogastric arteries

Goes back to the placenta

S i l St t i F t l


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Special Structures in FetalCirculation

Placenta Where gas exchange takes placeduring fetal life

Umbilical Arteries Carry unoxygenatedblood from the fetus to placenta

Umbilical Vein Brings oxygenated bloodcoming from the placenta to the fetus

Foramen Ovale Connects the left and rightatrium. It pushes blood from the right atrium

to the left atrium so that blood can besupplied to brain, heart and kidney


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Ductus Venosus - Carry oxygenatedblood from umbilical vein to inferiorvenacava, bypassing fetal liver

Ductus Arteriosus - Carry

oxygenated blood from pulmonaryartery to aorta, bypassing fetallungs.


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DiagnosticTests and

Procedures


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Cardiac Enzymes

CK-MB (Creatine kinase,myocardial muscle) Reflects cell trauma Elevation indicates myocardial damage

Elevation occurs within 4-6 hours andpeaks 18-24 hours following an acuteischemic attack

Normal value is 0-5% of the total Total CK is 26-174 units/L Isoenzymes

CK MB Cardiac muscle CK MM Skeletal muscle CK BB Brain tissue


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Cardiac Enzymes

Lactate dehydrogenase(LDH) Elevation occurs 24 hours

following MI and peak in 48-72hours Normally LDH 1 is lower than

LDH 2. if opposite, the pattern is

flipped indicating myocardialnecrosis Normal: 140-280 IU/L


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Cardiac Enzymes

Troponin Composed of 3 proteins: Troponin C Cardiac Troponin I Cardiac Troponin T

Trop I: lower than 0.6 ng/mL Rises within 3 hours and persists

for up to 7 days Higher than 1.5 ng/mL consistent

with MI Trop T: 0-0.2 ng/mL Any rise indicate myocardial cell

damage Commonly used in the Philippine

setting to detect MI


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Cardiac Enzymes

Myoglobin Oxygen binding protein found in

cardiac and skeletal muscle

Level rises within 1 hour after celldeath, peaks in 4-6 hours andreturns to normal within 24-36hours

Normal: lower than 90 mcg/L Elevation could indicate MI


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Other Normal Values

Creatine kinase CK Male 55-170U/L Female 30-135 U/L

CK - MB (isoenzyme) 0-7 U/L Lactic dehydrogenase (LDH)

LDH1 22%-36%

LDH2 35%-46% LDH313%-26% LDH4 3%-10%

LDH52%-9%


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Complete Blood Count

RBC decreases in RHD and endocarditis;and increases in conditions withinadequate tissue oxxygenation

WBC increases in infectious andinflammatory diseases of the heart andafter MI

Elevated hematocrit level can resultfrom vascular volume depletion(hypovolemia)

Decrease in Hemoglobin (hgb) andHematocrit (hct) can indicate anemia

Red blood cell countilli


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Men 4.7-6.1 million/mm3 Women 4.2-5.4 million/mm3 Infants and children 3.8-5.5 million/mm3 Newborns 4.8-7.1 million/mm3

White blood cell count Adults and children greater than two years of age

5,000-10,000/cm3 Children less than two years 6,200-17,000/mm3 Newborns 9000-30,000/mm3

Hematocrit Men 42-52% Women 37-47% (pregnancy>33%) Children 31-43% Infants 30-40% Newborns 44-64%

Hemoglobin Men 13.5-18.0 g/dl Women 12-16 g/dl (pregnancy >11 g/dl) Children 11-16 g/dl Infants 10-15 g/dl Newborns 14-24 g/dl


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Coagulation Studies

An increase in coagulationfactors can occur during andafter MI which places the client

at risk for thrombophlebitis andextension of clots in thecoronary arteries aPTT

PT Clotting time Platelet count

A i d P i l h b l i


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Activated Partial ThromboplastinTime (aPTT)

Measures the amount of time it takesin seconds for recalcified citratedplasma to clot after partialthrmboplastin is added to it

Used to monitor heparin therapy andscreen for coagulation studies

Normal: 20-36 seconds If value is prolonged, initiate bleeding

precautions

P th bi ti (PT)


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Prothrombin time (PT) Prothrombin is a vitamin K-dependent

protein produced by the liver necessary

for clot formation Measures the amount of time it takes in

seconds for clot formation Monitor warfarin therapy, vitamin K

deficiency, DIC Normal: PT value within 2 seconds of the

control (plus or minus) PT 9.6 11.8 seconds MALE PT 9.5 11.3 seconds FEMALE

Diet high in green leafy vegetablescan increase vitamin K, whichshortens the PT

PT longer than 30 seconds: bleedingprecaution


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Clotting time Time required for the

interaction of all factors

involved in the clottingprocess Normal: 8-15 minutes

Platelet count Normal: 150,000

400,000 cells/ mm If lower: bleeding precaution


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Lipid Assessment

Total cholesterol: less than 200mg/dL

Triglycerides: less than 200 mg/dL high density lipoprotein (HDL): 30-

70 mg/dL Good cholesterol

low density lipoprotein (LDL): lessthan 130 mg/dL

Elevated lipid assessment increasesthe risk of coronary artery disease


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Copyright 2005 Dr. Salme

Taagepera, All rights reserved.

http://images.medscape.com/pi/editorial/cmecircle/2004/3598/images/libby/slide005.gif


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Bad v. Good cholesterol!


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Electrolytes

Sodium 135-145 mEq/L

Potassium 3.5 5 mEq/L

Calcium 8.6 10 mg/dL or 4 5 mEq/L

Magnesium

1.6 2.6 mg/dL Phosphorus

2.7 4.5 mg/dL


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Potassium Hypokalemia: cardiac

instability, dysrhythmias

T wave inversion, U wave,ST depression Hyperkalemia: ventricular

dysrhythmias Tall peaked T waves,prolonged PR intervals, flatP waves


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Sodium Decreases with the use of diuretics Increases in heart failure,

indicating water excess

Calcium Hypocalcemia: ventricular

dysrhythmias, cardiac arrest Hypercalcemia: AV block,

tachy/bradycardia, cardiac arrest


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Phosphorus Should be interpreted with calcium

levels because kidneys retain or excreteone electrolyte in an inverse relationship

Magnesium Low: ventricular tachycardia and

fibrillation; tall T waves, depressed STsegments

High: muscle weakness, hypotension andbradycardia, prolonged PR, widenedQRS


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Blood Urea Nitrogen Elevated in heart disorders that

adversely affect renal circulation suchas heart failure and cardiogenic shock

Normal: 8-25 mg/dL Blood Glucose

Elevated in acute cardiac episodes Normal FBS: 70-110 mg/dL

B-type natriuretic peptide


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B type natriuretic peptide(BNP)

Released in response toventricular and atrial stretch

Marker for CHF

Normal: should be lower than100 pg/mL The higher the level, the more

severe CHF is


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Chest X-ray

Done to determine the size,silhouette and position ofthe heart

Remove jewelry


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Echocardiography (ECG)

Noninvasive test that records the electricalactivity of the heart

Useful for detecting cardiac dysrhythmias,location and extent of MI and evaluationof cardiac medications

Client should lie still, breathe normally No electrical shock can occur


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Holter Monitoring

ECG tracing over a period of 24hours or more as the client performsADLs

Client wears a Holter monitor

Avoid tub baths and showering


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Echocardiography

Noninvasive Based on the principle of ultrasound Evaluates structural and functional

changes of the heart

Client should lie still and breathenormally


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Exercise testing (Stress test)

Studies the heart during activity andevaluates coronary artery disease

Treadmill testing is the mostcommonly used

If the client is unable to tolerateexercise, IV infusion of dipyridamole(Persantine), dobutamine oradenosine is given to dilate the

coronary arteries Can be invasive if used withradionuclide testing


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Client Education

Adequate rest night before procedure Eat a light meal 1-2 hours Avoid smoking, alcohol and caffeine Meds withheld prior the procedure:

Theophylline 12 hours Beta blockers and calcium channel

blockers 24 hrs

POST: Avoid hot bath 1-2 hoursafter


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Digital Subtraction


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Digital SubtractionAngiography

Combine x ray with fluoroscopy forvisualization of the cardiovascularsystem

Contrast medium (dye) is injected

Assess allergies to seafood, iodine Pre-medicate with antihistamine

and steroids to avoid untowardreactions

POST Monitor VS and injection site for

bleeding

Magnetic Resonance Imaging


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Magnetic Resonance Imaging

(MRI)

Produces images of the heartand great vessels throughinteraction of magnetic fields

Provides info on chamber size,

thickness, valves and blood flowthrough great vessels andcoronary arteries

CONTRA:

Pacemaker and otherimplanted items

Metallic objects Claustrophobia


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Cardiac Catheterization

Invasive test involving insertion of acatheter into the heart andsurrounding vessels

Femoral vein: entry point


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PRE Consent


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Consent Assess allergies to dye

Seafood, iodine Withhold solid food 6-8 hours and liquid 4

hours to prevent vomiting and aspiration Document clients height and weight

Baseline VS and peripheral pulses Local anesthetic before catheter insertion Need to lie still on a hard table for 2 hours Client may feel a warm, flushed sensation, a

desire to cough and palpitations as the dye isinjected


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Prepare the insertion site by shavingand cleaning with antiseptic solution

Insert IV line as prescribed Withhold Metformin 48hrs prior

POST


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Monitor VS and cardiac rhythm at leastevery 30 minutes for 2 hours initially

If chest pain occurs, notify the physician Monitor extremity of insertion site at least

every 30 minutes for 2 hours Peripheral pulses

Color Warmth Sensation

Notify physician Extremity is cool, pale, cyanotic, loss ofperipheral pulse, hematoma


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Keep the leg (insertion site)extended and straight 4-6 hours

to prevent arterial occlusion Strict bed rest 6-12 hours; may

turn side to side Encourage fluid intake to promote

renal excretion of dye


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C t l V P


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Central Venous Pressure

CVP: pressure under which blood isreturned to the SVC and RA

Normal CVP: 3-8 mmHg Elevated: increase in blood volume

due to sodium and water retention,renal failure, excess IV fluids

Decreased: hypovolemia, hemorrhage,severe vasodilation with blood pooling

in the extremities


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Client should be in supine, HOB 45degreesActivity increases intrathoracic

pressure (false high result)

Zero point of the transducershould be at the level of the rightatrium Midaxillary line at the 4th

intercostal space


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Therapeutic

Management

Percutaneous TransluminalCoronary Angioplasty (PTCA)


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Coronary Angioplasty (PTCA)

Invasive, nonsurgical technique One or more arteries are dilated

with a balloon catheter to openthe vessel lumen and improve

arterial blood flow Client can experience re-occlusion

after the procedure Complications:

Arterial rupture Immobilization of plaque Spasm

MI


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PRE

NPO post midnight Informed consent, allergy

assessment, hold metformin Prepare the groin area with

antiseptic soap and shave Assess VS and peripheral pulses Instruct client to report chest pain

during balloon inflation


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POST

Monitor VS, pulses Keep the leg (insertion site) extended

and straight 6-8 hours Bed rest

Administer anticoagulants (heparin)to prevent thrombus formation

Increase OFI to excrete dye


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Percutaneous coronary interventionstenting.flv

3D stent animation

A gioplasty


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Angioplasty

Laser probe is inserted to theaffected artery

Heat from the laser vaporizes theplaque

Similar care as PTCA


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Coronary Artery Stents

Used in conjunction with PTCA To provide a supportive scaffold to

eliminate the risk of acute coronaryvessel closure and to improve long term

patency of the vessel Balloon catheter bearing the stent isinserted into the coronary artery andpositioned at the site of occlusion

Balloon inflation deploys the stent When placed in the coronary artery,stent reopens the blocked artery

d


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PRE and POST

Similar with PTCA Client is placed on antiplatelet

therapy for several months after theprocedure because of acute

thrombosis Clopidogrel (Plavix)Aspirin

Bleeding precaution

Atherectomy


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Atherectomy

Removes plaque from a coronaryartery by the use of a cuttingchamber on the inserted catheter ora rotating blade that pulverizes the

plaque Used to improve blood flow toischemic limbs in individuals withperipheral arterial disease

Care similar to PTCA


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Coronary Artery BypassG f


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Graft

Occluded arteries are bypassed withclients own blood vessels

Saphenous veins, internal mammaryartery may be used to bypass

Performed when client does notrespond to medical management orwhen vessels are severely occluded


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Heart bypass.flv Beating heart surgery.flv


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cardiovascular system - normal

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