Ms. Sophie is a 74 year old female who will be admitted to your floor for complaint of shortness of breath with activity and wound on left ankle. She reports a regular diet of fast food, potato chips, and chocolate. Loves salty food. She also states that she often feels stressed and depressed because of her weight however, she eats ice cream when she gets stressed. She does not exercise and often feels very tired. She has had two toes amputated from her left foot and she complains that her feet “fall asleep” easily. Patient states “feet look puffy.” She also has “moments” of chest pain. She walks with a cane.

Smoker High cholesterolDiabetesMI x 3 yearsCardiac stentDNRCHF AnginaPVDCADHTNPTCAMeds: Furosemide, Nitroglycerin,Captopril, Metoprolol

Smoker - ↑BP, dysrhythmia, PVD

High Cholesterol – occlusion of arteries

Diabetes - ↑risk of MI & CVA (TIA)

MI – ischemia, damage

Cardiac stent – open occluded artery

CHF – Left sided Lungs

R ight sided Rest of body

Angina – chest pain associated with ↓coronary artery blood flow

PVD - ↑thrombus

HTN – sex, aging, HX, overweight, inactivity

Obesity - ↑demand, ↑adipose tissue

Stress - ↑ cortisol

Nutrition - ↑ salt

Age

Fall Risk

Metabolic syndrome risk

Activity level

Blood pressure: 160/90 RR 16 Pulse 74 Fingerstick: 450 Height: 5’2” Weight: 180 lbs. Pedal pulses not palpable Lower extremity edema Left lower extremity edematous, red, warm BLE shiny, lack of hair, cool to touch Stage III wound on LLE ankle

PVD – mostly affects lower extremities - Risk factors: age > 50, HX of heart disease, Type I diabetes, HTN, obesity, physical inactivity, smoking - Symptoms: fragile skin on legs/feet, hair loss on legs, non-healing wounds, gangrene, complaint of “numbness” - Diagnosis: angiogram - Complications: Stroke, MI, amputation

Most common type of heart disease Arteries to heart become hardened and narrow Plaque →↑cholesterol→atherosclerosis→ ↓blood supply→angina or MI Over time = heart failure

MEDS: Furosemide,Heparin,Captopril,MetoprololEKGTelemetryEchocardiagramStress testUltrasoundAngiogramTEDS/SCD’s right legDoppler LLE

Furosemide Nitroglycerin Heparin

Insert drug table here

MEDICATION EXPECTED OUTCOME

Cardiac glycosides Increase cardiac contractility; decrease heartrate

Antihypertensives Decrease blood pressure

Vasopressors Increase blood pressure

Antiarrhythmics Regulate heart rhythm

Nitrates Relieve angina

Antilipids Decrease cholesterol levels

Diuretics Reduce fluid volume

Anticoagulants Decrease potential for clot formation

4th ICS &

5th ICS

Normal Sinus RhythmP wave – atrial depolarization

Q,R,S complex- ventricular depolarization

ST segment-complete depolarization of ventricles

T wave- ventricular repolarization

PR interval = 0.12 – 0.20 seconds (or 3 small – 1 large box)QRS complex = 0.06 – 0.12 seconds (or 1.5 – 3 small boxes)QT interval = 0.34-0.43 seconds (or 8.5 – 11 small boxes)Heart rate = # of PQRST complexes that occur in 6 seconds multiplied by 10

Small square = 0.04 secondsLarge square = 0.20 seconds Five small squares = a large squareFive large squares = 1 second

Leads I, II, III, aVR, aVL & aVF are measurements of the frontal plane

V1, V2, V3, V4, V5 & V6 are measurements of the horizontal plane

RA LA

HEART

RL LL

-continuous monitoring

Clouds over grass Smoke over fire Chocolate is good

for your heart

EKG

Telemetry

Assist with leg exercises, positioning, SCDs/TEDS

Medication :Anticoagulation prophylaxis, diuretics, I & O

Assessment

Education

TEDS(Thromboembo

lic Deterrent Stockings)

SCD’s(Sequential Compression Device)

o Test to see how blood moves through arteries and veinso Combines traditional ultrasound with dopplero No preparation needed

http://www.youtube.com/watch?v=yzxSrLa1d0g

o Use of radiopaque dye to outline vessels looking for blockage or narrowing

http://www.youtube.com/watch?v=N7nghr9TpSU

o Percutaneous Transluminal Coronary Angioplastyo Catheter placed through IV in neck, arm or groino Balloon tip inflated to compress blockageo Possible stent placement

Placed with balloon catheter

Locks in open position

Monitor for dysrythmias

Check peripheral pulses & VS Assess pain Assess bleeding or hematoma formation at

insertion site Maintain pressure dressing & immobilize limb for

approximately 6 hours Monitor for urination within 6 hours Administer fluids Document

http://www.youtube.com/watch?v=x_Z0GF6AuTw

Records cardiovascular response to increased activity

http://www.youtube.com/watch?v=2XR6etAY_-w&feature=related

-Ultrasonic waves- Detect structural defects-Can be done at bedside

DNR – do not rescusitate

DNI – do not intibate

MOLST – Maryland Order for Life Sustaining Treatment

1. Smoking – most modifiable risk factor for cardiovascular disease

2. Medication3. Edema4. Pain management5. Activity intolerance6. Diet

Peripheral intravascular device

Inserted by nurses/techs

Short term

Triple Lumen Central Line Can be placed at bedside Placed into internal jugular Risk of pneumothorax or air

embolism Short term

Hickman Placed on OR Terminates in superior vena cava

near entrance to right atrium Tunnelling Long term

Peripherally Inserted Central Catheter

Terminates in subclavian or superior vena cava

Small diameter Long term

Mediport Placed in OR Terminates in superior

vena cava near entrance to right atrium

Self sealing port Long term

Huber needle Non-coring needle used

to access mediport

oFirst responderoBedside nurseoCharge nurseoTeam/Code LeaderoRecorderoRunneroRespiratory/AnesthesiaoCode cart nurseoNursing supervisoroSecurity

Emergency meds

Defibrillator

Blood drawing supplies

Central line kit

Backboard

Laryngoscope

Oropharyngeal airway

60-100 pbm

Bradycardia - <60 bpm

Tachycardia - >100 bpm

Ectopic foci in walls of ventricles

↓ cardiac output

Intrinsic ventricular rate is only 20-40 bpm

Premature ventricular contraction Irritable focus in ventricle More likely to occur during bradycardia A beat, not a rhythm CauseBigeminy – PVC’s with every other beatTrigeminy – PVC’s every third beatQuadreminy – PVC’s with every fourth beat

• Foci in ventricles takes over

• When 3 or more PVC’s occur in a row at a rate greater than 100 bpm lasting longer than 30 seconds

• Treatment: cardioversion & CPR. Long term-antiarrythmic drugs

Rapid, disorganized depolarization of ventricles

No coordination of ventricular and atrial contractions

No palpable pulse

Treatment: Defibrillation & CPR. Long term: ICD

Pulseless electrical activityElectrical activity is present but no

contractionNo cardiac output, no tissue

perfusion, death

No electrical activity

Immediate loss of oxygen supply to brain, heart and tissue

Holter monitoro Worn for 1-3 dayso Records activity of heart

Pacemakero Used to augment or replace

the natural pacemaker of the heart

o Can be used for bradycardia/tahcycardia, damage to heart from MI, CHF

ICD – Implantable Cardiac Defibrillator

o To treat ventricular tachycardia and ventricular fibrillation

o Patients say a shock is like being kicked in the chest

o Another person touching the person will feel the shock