EXAM 3 BLUEPRINT
Nsg4100
Unit 5
Required Reading:
Ch. 21: Assessment of Cardiac Function, pp. 650-689
Ch 22 Management of Patients with Dysrhythmias and Conduction Problems
Ch 23 Management of Patients with Coronary Vascular Disorders, pp. 725-764
Ch. 25: Management of Patients with Complications from Heart Disease, 813-814
Cardiovascular function:
➢ Baroreceptors are specialized nerve cells that are located in the aortic arch and both right/left carotid arteries.
▪ Baroreceptors are influenced by the autonomic nervous system and hormones, especially
thyroid
• Autonomic nervous system
o Sympathetic nervous system (SNS)=(fight/flight)→causes vasoconstriction
▪ Decrease in arterial pressures→Decreased stimulation of
baroreceptors=SNS activation (vasoconstriction/increased HR)
▪ Stimulation of the SNS (exercise, anxiety, fever, or administration
of catecholamines/dopamine) =causes positive Chronotropy,
dromotropy, and inotropy
o Parasympathetic nervous system(PNS)= (rest/digest)→causes vasodilation
▪ Increased arterial pressures→Increased stimulation of
baroreceptors=PNS activation(vasodilation, decreased HR)
▪ Activation of PNS (rest, anxiety reduction methods such as
therapeutic communication, or medication, or administration of
beta-adrenergic blocking agents causes negative chronotropy,
dromotropy, inotropy
• Chronotropy→affects the heart rate
• Dromotropy→affects AV conduction
• Inotropy→affects force of myocardial contraction
EX. Decreased arterial pressure→decreased stimulation of
baroreceptors=SNS stimulation→positive chronotrophs, dromotrophs,
inotrophs= increased HR, Conduction and contraction
▪ Are sensitive to BP changes
▪ Hypertension=baroreceptors will increase rate of discharge →initiates parasympathetic
activity→lowers HR
▪ Hypotension=baroreceptors decrease rate/stimulation→initiates sympathetic
activity→increases HR
▪ Age-related changes: review box 21.1 on pg 657
• Baroreceptor sensitivity decreases and is unable to regulate HR and vascular tone
→can lead to decreased response to postural changes = orthostatic hypo/hyper—
monitor paint can lead to dizziness/fainting when changing positions
➢ Stroke Volume→3 factors
o Preload→degree of stretch of ventricles cardiac muscle @ the end of diastole
▪ Initial stretching of ventricles prior to contracting→getting ready for the next big squeeze of the
ventricles
, o Afterload→resistance of ejection of blood from the ventricles
▪ The amount of resistance the heart must overcome to open the aortic valve and push the blood
volume out into the systemic circulation
o Contractibility→refers to the force generated by the contracting myocardium
➢ Cardiac Output=total amount of blood ejected by one of the ventricles in L/min
o Normal 4-6 L/min
➢ Stroke volume = amount of blood ejected from one of the ventricles per HB
o Average stroke volume is 60-130 ml
Medications that affect HR
• Inotropic Agents: Medications like digoxin increase the force of heart contractions, improving cardiac output.
• Dromotropic Agents: Drugs such as adenosine affect the conduction speed of electrical impulses in the heart, helping
to regulate heart rhythm.
• Chronotropic Agents: Medications like atropine increase heart rate by blocking vagal effects on the heart.
• Beta-Agonists: These can enhance both inotropic and chronotropic effects, increasing heart rate and contractility.
• Calcium Channel Blockers: While primarily dromotropic, some can also influence heart rate and contractility
indirectly..
• ACE Inhibitors: Though not directly inotropic, they improve heart function by reducing afterload and preload,
indirectly supporting contractility.
Monitoring Cardiac Function:
❖ Labs
o BNP
▪ < 100 pg/mL: no HF
▪ >100-300 pg/mL: HF present
▪ > 300 pg/mL: mild HF
▪ > 600 pg/mL: moderate HF
▪ > 900 pg/mL: severe HF
o Troponin T:
▪ 0-0.2 ng/mL (onset: 3-4 hrs; peak: 10-24 hrs; return to normal: 10-14 days)
o Troponin 1:
▪ 0-0.1 ng/mL (onset: 4-6 hrs, peak: 12-24 hrs, return to normal: 4-7 days)
o CK-MB (creatine kinase, myocardial muscle)
o Myoglobin (protein found in heart and skeletal muscle)—level will rise within 2 hours of cell
death but not cardiac specific)
o C-Reactive protein
o CBC
o Blood coagulation factors
▪ aPPT (30-40 seconds →1.5-2.5 x normal on heparin)
▪ PT (11-12.5 conds→1.5-2.5 x normal on warfarin)
▪ PTT (20-30 seconds→1.5-2.5 x normal on heparin)
▪ INR (0.9- 1.2 seconds →2-3 x normal on warfarin is therapeutic)
▪ Hgb (12-18)
▪ Hct (37-52)
▪ Platelets (150-400,000)
▪ RBC (4.2-6.1)
, ▪ WBC (5-10000)
o Serum lipids
o Electrolytes/BMP
▪ K+ (3.5-5)
▪ Ca (9-10.5)
▪ Mg (1.5-2.5)
❖ ECG
o Change electrodes Q24 hrs
o Rotate electrodes
o Assess skin per shift
❖ Cardiac Stress Testing
o Exercise stress testing
▪ NPO for several hours before test→meds can be taken w/sip of H2O
▪ Avoid stimulants, alcohol, and smoking on the day of the test
▪ Wear loose-fitting, comfortable clothes and comfortable rubber-soled shoes
▪ Dr may hold meds such as Beta blockers, calcium channel blockers and digitalis
❖ Echocardiography
o Transesophageal Echocardiograph (TEE)—pg.705
▪ threads a small transducer thru the mouth and into the esophagus
o Think AIRWAY/BREATHING FOR PRIORITIES
• Assess pt for dysphagia or hx of radiation therapy to the chest: can increase risk of
complications
• Topical anesthetic and sedation are used
o Complications include:
▪ Respiratory depression and aspiration (due to meds)
▪ Vasovagal response or esophageal perforation (due to manipulation
of the transducer into the esophagus and stomach
▪ NPO for 6 hrs prior to procedure
▪ During Procedure→monitor ECG, consciousness, & respirations
▪ After procedure→ assess if the gag reflex is present→pt can start w/sips of water then progress
to normal diet
▪ Education→ teach pt that they may have a sore throat for the next 24 hrs but if precist longer to
call dr and pt will have to have driver if in outpatient setting
❖ Cardiac Catheterization
▪ Left heart Cath→ Cath inserted into right radial/femoral artery→aorta→left ventricle
▪ Right heart Cath→from right brachial/internal jugular or femoral vein---Right atria→Right ventricle→pulmonary
artery—pulmonary arterioles
**Nursing intervention→know these for exam! Pg.682-683
→PREOP
✓ pt must be NPO for 8-12 hrs before procedure
✓ Assess if pt has allegy to contrast/ iodine/shellfish
o -The procedure involves contrast→if pt had a reaction to contrast before, antihistamines and corticosteroids
will be prescribed
✓ Blood work completed: CBC, aPPT, PT, INR, and electrolytes and glucose
✓ Prepare insertion site—electric shave/clip hair clean w/antiseptic
➢ Assess if pt diabetic and takes metformin. It will need to be STOPPED for 48 hours before and 48 hours after
➢ Assess the patient for risk of CIN (contrast-induced nephropathy)
o Risks include CKD, renal insufficiency, diabetes, HF, Hypotension, dehydration, use of nephrotoxic
meds, and advanced age
, o CIN is defined as →creatinine increase of 25% or an absolute increase of 0.5mg/dl within 48-72 hours
of the procedure (it’s a form of acute kidney injury and is reversible)→monitor after procedure
➢ Inform pt about procedures:
o Pt will be on a flat surface, usually no more than 2 hours
o will be on bed rest 2-6 hours after procedure, varies on what artery was used, size of catheter, meds
used, and method used to maintain hemostasis
▪ Radial closure device used→pt pay sit in chair until sedation wears off, then early
ambulation encouraged.
▪ Femoral→bed rest up to 6 hrs, affected leg straight, and HOB no more than 30 degrees
(may be turned side to side, keeping affected leg straight!)
→POSTOP
➢ Pt will have multiple IV catheters for fluids, sedatives, heparin, and other meds
➢ Assess peripheral pulses on the affected extremity
o Q15 min for 1 hr, then Q30 min for 1 hr., and hourly for 4 hrs. or until discharged
o Also evaluate color, temp, and cap refill: assess for pain, numbness tingling –evaluate by comparing
to unaffected extremity
➢ Have resuscitation equipment at bedside
➢ Monitor for arrhythmias—observe cardiac monitor & assess apical and radial pulse for rate or rhythm changes
→a vasovagal reaction can occur
o hypotension, bradycardia, and nausea precipitated by abdominal distention and discomfort from
manual pressure that is applied with the removal of the catheter
o reversed by promptly elevating lower extremities above the heart, give IV fluid bolus, and atropine
for bradycardia
➢ Before /during/after monitor pt for chest pain, dyspnea, changes in BP or ECK,
o Teach pt to report any chest pain/dyspnea/changes in BP (can mean MI or hemodynamic
instability/arrythmias
o Monitor for CIN→evaluate creatinine levels→ Iv hydration to flush contrast
➢ Pt teachings:
o Call for help first time getting out of bed—assess pt for orthostatic hypotension
(dizziness/lightheadedness)
o Ensure pt hydration—give IV fluid to wash out contrast and monitor I’s and Os
o Education for pt discharged on the same day→
▪ If wrist is accessed—avoid strenuous activities of the wrist such as tennis, manual labor,
driving until you get a release from the dr→can resume all other normal activities
▪ If groin is accessed—do not bend at the waist, strain or lift heavy objects for the next 24 hr
▪ Do not submerge in water; may take showers
▪ Talk to the doctor about when you can return to work/drive c
▪ If bleeding occurs, sit/ lie down, put pressure on the site, and call DR. If a large amount of
blood * call 911
o Make lifestyle changes-lose weight, quit smoking, eat right
o Take all meds as prescribed: call dr if side effects, never discontinue without talking w/dr
o Instruct pt to report chest pain or sudden discomfort from the insertion site
❖ Percutaneous Coronary Interventions(PCIs)→invasive interventional procedures to treat CAD
o Percutaneous Transluminal Coronary Angioplasty (PTCA) → ballon tipped catheter used to open blocked
coronary vessels and resolve ischemia. Threaded thru the femoral/radial, up through aorta to coronary
arteries.
• Carried out in cath lab
• During procedure pt may complain of chest pain and ECG may show ST segment changes
• Stents may be place at this time as well, medications such as Paclitaxel may be coated on stent to
prevent thrombi/scarring
▪ Performed within 60 min from arrival @ ED (door to balloon time)
▪ → ***Know Postop Care *** same at catherization
▪ Post procedure
→ Keep pt flat w/affected leg straight until the sheath is removed
→ Monitor for immediate complications→ bleeding, hematomas, and AKI
→**if pt reports chest pain**notify dr immediately indicates possible occlusion
Nsg4100
Unit 5
Required Reading:
Ch. 21: Assessment of Cardiac Function, pp. 650-689
Ch 22 Management of Patients with Dysrhythmias and Conduction Problems
Ch 23 Management of Patients with Coronary Vascular Disorders, pp. 725-764
Ch. 25: Management of Patients with Complications from Heart Disease, 813-814
Cardiovascular function:
➢ Baroreceptors are specialized nerve cells that are located in the aortic arch and both right/left carotid arteries.
▪ Baroreceptors are influenced by the autonomic nervous system and hormones, especially
thyroid
• Autonomic nervous system
o Sympathetic nervous system (SNS)=(fight/flight)→causes vasoconstriction
▪ Decrease in arterial pressures→Decreased stimulation of
baroreceptors=SNS activation (vasoconstriction/increased HR)
▪ Stimulation of the SNS (exercise, anxiety, fever, or administration
of catecholamines/dopamine) =causes positive Chronotropy,
dromotropy, and inotropy
o Parasympathetic nervous system(PNS)= (rest/digest)→causes vasodilation
▪ Increased arterial pressures→Increased stimulation of
baroreceptors=PNS activation(vasodilation, decreased HR)
▪ Activation of PNS (rest, anxiety reduction methods such as
therapeutic communication, or medication, or administration of
beta-adrenergic blocking agents causes negative chronotropy,
dromotropy, inotropy
• Chronotropy→affects the heart rate
• Dromotropy→affects AV conduction
• Inotropy→affects force of myocardial contraction
EX. Decreased arterial pressure→decreased stimulation of
baroreceptors=SNS stimulation→positive chronotrophs, dromotrophs,
inotrophs= increased HR, Conduction and contraction
▪ Are sensitive to BP changes
▪ Hypertension=baroreceptors will increase rate of discharge →initiates parasympathetic
activity→lowers HR
▪ Hypotension=baroreceptors decrease rate/stimulation→initiates sympathetic
activity→increases HR
▪ Age-related changes: review box 21.1 on pg 657
• Baroreceptor sensitivity decreases and is unable to regulate HR and vascular tone
→can lead to decreased response to postural changes = orthostatic hypo/hyper—
monitor paint can lead to dizziness/fainting when changing positions
➢ Stroke Volume→3 factors
o Preload→degree of stretch of ventricles cardiac muscle @ the end of diastole
▪ Initial stretching of ventricles prior to contracting→getting ready for the next big squeeze of the
ventricles
, o Afterload→resistance of ejection of blood from the ventricles
▪ The amount of resistance the heart must overcome to open the aortic valve and push the blood
volume out into the systemic circulation
o Contractibility→refers to the force generated by the contracting myocardium
➢ Cardiac Output=total amount of blood ejected by one of the ventricles in L/min
o Normal 4-6 L/min
➢ Stroke volume = amount of blood ejected from one of the ventricles per HB
o Average stroke volume is 60-130 ml
Medications that affect HR
• Inotropic Agents: Medications like digoxin increase the force of heart contractions, improving cardiac output.
• Dromotropic Agents: Drugs such as adenosine affect the conduction speed of electrical impulses in the heart, helping
to regulate heart rhythm.
• Chronotropic Agents: Medications like atropine increase heart rate by blocking vagal effects on the heart.
• Beta-Agonists: These can enhance both inotropic and chronotropic effects, increasing heart rate and contractility.
• Calcium Channel Blockers: While primarily dromotropic, some can also influence heart rate and contractility
indirectly..
• ACE Inhibitors: Though not directly inotropic, they improve heart function by reducing afterload and preload,
indirectly supporting contractility.
Monitoring Cardiac Function:
❖ Labs
o BNP
▪ < 100 pg/mL: no HF
▪ >100-300 pg/mL: HF present
▪ > 300 pg/mL: mild HF
▪ > 600 pg/mL: moderate HF
▪ > 900 pg/mL: severe HF
o Troponin T:
▪ 0-0.2 ng/mL (onset: 3-4 hrs; peak: 10-24 hrs; return to normal: 10-14 days)
o Troponin 1:
▪ 0-0.1 ng/mL (onset: 4-6 hrs, peak: 12-24 hrs, return to normal: 4-7 days)
o CK-MB (creatine kinase, myocardial muscle)
o Myoglobin (protein found in heart and skeletal muscle)—level will rise within 2 hours of cell
death but not cardiac specific)
o C-Reactive protein
o CBC
o Blood coagulation factors
▪ aPPT (30-40 seconds →1.5-2.5 x normal on heparin)
▪ PT (11-12.5 conds→1.5-2.5 x normal on warfarin)
▪ PTT (20-30 seconds→1.5-2.5 x normal on heparin)
▪ INR (0.9- 1.2 seconds →2-3 x normal on warfarin is therapeutic)
▪ Hgb (12-18)
▪ Hct (37-52)
▪ Platelets (150-400,000)
▪ RBC (4.2-6.1)
, ▪ WBC (5-10000)
o Serum lipids
o Electrolytes/BMP
▪ K+ (3.5-5)
▪ Ca (9-10.5)
▪ Mg (1.5-2.5)
❖ ECG
o Change electrodes Q24 hrs
o Rotate electrodes
o Assess skin per shift
❖ Cardiac Stress Testing
o Exercise stress testing
▪ NPO for several hours before test→meds can be taken w/sip of H2O
▪ Avoid stimulants, alcohol, and smoking on the day of the test
▪ Wear loose-fitting, comfortable clothes and comfortable rubber-soled shoes
▪ Dr may hold meds such as Beta blockers, calcium channel blockers and digitalis
❖ Echocardiography
o Transesophageal Echocardiograph (TEE)—pg.705
▪ threads a small transducer thru the mouth and into the esophagus
o Think AIRWAY/BREATHING FOR PRIORITIES
• Assess pt for dysphagia or hx of radiation therapy to the chest: can increase risk of
complications
• Topical anesthetic and sedation are used
o Complications include:
▪ Respiratory depression and aspiration (due to meds)
▪ Vasovagal response or esophageal perforation (due to manipulation
of the transducer into the esophagus and stomach
▪ NPO for 6 hrs prior to procedure
▪ During Procedure→monitor ECG, consciousness, & respirations
▪ After procedure→ assess if the gag reflex is present→pt can start w/sips of water then progress
to normal diet
▪ Education→ teach pt that they may have a sore throat for the next 24 hrs but if precist longer to
call dr and pt will have to have driver if in outpatient setting
❖ Cardiac Catheterization
▪ Left heart Cath→ Cath inserted into right radial/femoral artery→aorta→left ventricle
▪ Right heart Cath→from right brachial/internal jugular or femoral vein---Right atria→Right ventricle→pulmonary
artery—pulmonary arterioles
**Nursing intervention→know these for exam! Pg.682-683
→PREOP
✓ pt must be NPO for 8-12 hrs before procedure
✓ Assess if pt has allegy to contrast/ iodine/shellfish
o -The procedure involves contrast→if pt had a reaction to contrast before, antihistamines and corticosteroids
will be prescribed
✓ Blood work completed: CBC, aPPT, PT, INR, and electrolytes and glucose
✓ Prepare insertion site—electric shave/clip hair clean w/antiseptic
➢ Assess if pt diabetic and takes metformin. It will need to be STOPPED for 48 hours before and 48 hours after
➢ Assess the patient for risk of CIN (contrast-induced nephropathy)
o Risks include CKD, renal insufficiency, diabetes, HF, Hypotension, dehydration, use of nephrotoxic
meds, and advanced age
, o CIN is defined as →creatinine increase of 25% or an absolute increase of 0.5mg/dl within 48-72 hours
of the procedure (it’s a form of acute kidney injury and is reversible)→monitor after procedure
➢ Inform pt about procedures:
o Pt will be on a flat surface, usually no more than 2 hours
o will be on bed rest 2-6 hours after procedure, varies on what artery was used, size of catheter, meds
used, and method used to maintain hemostasis
▪ Radial closure device used→pt pay sit in chair until sedation wears off, then early
ambulation encouraged.
▪ Femoral→bed rest up to 6 hrs, affected leg straight, and HOB no more than 30 degrees
(may be turned side to side, keeping affected leg straight!)
→POSTOP
➢ Pt will have multiple IV catheters for fluids, sedatives, heparin, and other meds
➢ Assess peripheral pulses on the affected extremity
o Q15 min for 1 hr, then Q30 min for 1 hr., and hourly for 4 hrs. or until discharged
o Also evaluate color, temp, and cap refill: assess for pain, numbness tingling –evaluate by comparing
to unaffected extremity
➢ Have resuscitation equipment at bedside
➢ Monitor for arrhythmias—observe cardiac monitor & assess apical and radial pulse for rate or rhythm changes
→a vasovagal reaction can occur
o hypotension, bradycardia, and nausea precipitated by abdominal distention and discomfort from
manual pressure that is applied with the removal of the catheter
o reversed by promptly elevating lower extremities above the heart, give IV fluid bolus, and atropine
for bradycardia
➢ Before /during/after monitor pt for chest pain, dyspnea, changes in BP or ECK,
o Teach pt to report any chest pain/dyspnea/changes in BP (can mean MI or hemodynamic
instability/arrythmias
o Monitor for CIN→evaluate creatinine levels→ Iv hydration to flush contrast
➢ Pt teachings:
o Call for help first time getting out of bed—assess pt for orthostatic hypotension
(dizziness/lightheadedness)
o Ensure pt hydration—give IV fluid to wash out contrast and monitor I’s and Os
o Education for pt discharged on the same day→
▪ If wrist is accessed—avoid strenuous activities of the wrist such as tennis, manual labor,
driving until you get a release from the dr→can resume all other normal activities
▪ If groin is accessed—do not bend at the waist, strain or lift heavy objects for the next 24 hr
▪ Do not submerge in water; may take showers
▪ Talk to the doctor about when you can return to work/drive c
▪ If bleeding occurs, sit/ lie down, put pressure on the site, and call DR. If a large amount of
blood * call 911
o Make lifestyle changes-lose weight, quit smoking, eat right
o Take all meds as prescribed: call dr if side effects, never discontinue without talking w/dr
o Instruct pt to report chest pain or sudden discomfort from the insertion site
❖ Percutaneous Coronary Interventions(PCIs)→invasive interventional procedures to treat CAD
o Percutaneous Transluminal Coronary Angioplasty (PTCA) → ballon tipped catheter used to open blocked
coronary vessels and resolve ischemia. Threaded thru the femoral/radial, up through aorta to coronary
arteries.
• Carried out in cath lab
• During procedure pt may complain of chest pain and ECG may show ST segment changes
• Stents may be place at this time as well, medications such as Paclitaxel may be coated on stent to
prevent thrombi/scarring
▪ Performed within 60 min from arrival @ ED (door to balloon time)
▪ → ***Know Postop Care *** same at catherization
▪ Post procedure
→ Keep pt flat w/affected leg straight until the sheath is removed
→ Monitor for immediate complications→ bleeding, hematomas, and AKI
→**if pt reports chest pain**notify dr immediately indicates possible occlusion
