NUR 4110 Medsurg 2 FINAL EXAM REVIEW LATEST UPDATE FOR
A+RESULTS
Generates and transmits electrical impulses that
stimulate contraction of the myocardium
➢ SA node AV node Bundle of his (branches into right and left) purkinjie fibers
➢ SA node which is the primary pacemaker of the heart
o A patient has a HR of 90. Means The SA node is working because normal HR is
60-100
o If the HR falls below the normal value, there is a problem!
➢ AV node which is the secondary pacemaker of the heart
o If the SA node malfunctions. The AV node will take over which has a lower
rate such as 40-60 bpm
Cardiac Action Potential
Is the electrical cells generate and transmit impulses across the heart which will stimulate cardiac
myocytes to contract. Stimulation of these myocytes occurs due to the exchange of electrically
charged particles (ions) across the channels located in the cell membrane
➢ In resting or polarized state
o Sodium is the primary extracellular ion
o Potassium is the primary intracellular ion
Terms of Cardiac Action Potential
o Depolarization: electrical activation of cell caused by influx of sodium into cell while
potassium exits cell. THIS CREATES A POSITIVELY CHARGED
INTRACELLULAR SPACE AND NEGATIVELY CHARGED EXTRACEULAR
SPACE
o Repolarization: return of cell to resting state caused by re-entry of potassium into cell
while sodium exits
o Refractory periods – cardiac cells must completely repolarize before they can depolarize
AGAIN
o 2 phases of refractory period
o Effective refractory period: phase in which cells are incapable of depolarizing. It is
completely unresponsive to ANY electrical stimulus
o Relative refractory period: phase in which cells require stronger-than-normal
stimulus to depolarize
Cardiac Hemodynamics
• HR x SV Cardiac Output
• =Cardiac output refers to the total amount of blood ejected by one of the ventricles in liters
per minute.
• The cardiac output in a resting adult is 4 to 6 L/min but varies greatly depending on
metabolic needs
• Cardiac output responds to changes in the metabolic demands of the tissues
associated with stress, physical exercise, and illness
o HR is affected by central nervous system activity and baroreceptor activity.
NUR 4110 Medsurg 2 FINAL EXAM REVIEW LATEST UPDATE FOR
A+RESULTS
,NUR 4110 Medsurg 2 FINAL EXAM REVIEW LATEST UPDATE FOR
A+RESULTS
o HR is determined by rate and rhythm – if it is regular or irregular
o If HR is affected so is CO
o If the heart is not stretching enough – cardiac output is affected
o If the heart is not pumping – cardiac output is affected
• Stroke volume is determined by preload, afterload, and contractility
o Preload: refers to the degree of stretch of the ventricular cardiac muscle fibers at
the end of diastole. The end of Diastole is the period when filling volume in the
ventricles is the highest and the degree of stretch on the muscle fibers is the
greatest (when it is filled with more and more blood = the greater the stretch =
the greater the force of contraction)
o Diastole is the relaxation/filling phase of the ventricles and once these have filled
this is the preload. We can also
refer to preload as the EVD (it is at the end of the diastolic phase). Preload is the
amount the ventricle stretched!
▪ Think of a balloon (such as the more air you blow in, the greater the stretch)
o Afterload: resistance to ejection of blood from the ventricles. This is the
pressure required to overcome aortic pressure. The higher the aortic pressure the
harder the ventricles have to work – (the LV must overcome the aortic pressure).
The pressure in the ventricles work against to open the SL valves to pump blood
out of the heart
o Contractility: refers to the force generated by the contracting myocardium (the
more forceful the more blood that is ejected)
• If there is an issue with cardiac output = perfusion issue because there is an
issue with oxygenation and flow components
• Low HR = CO is affected
• Increase in SV and HR = increase in CO
Age Related changes in cardiac
-Atria, LV, Valves (stiffen and no longer close properly), Conduction system, SNS (decreased
response), aorta (stiffen), arteries (stiffen), baroreceptor response (more sensitive)
History and Physical
Health History which refers to the patient’s ability to recognize cardiac symptoms to know
what to do when they occur it is essential for effective self-care management
• Want CLEAR information when talking to the patient Chief complaint, Hx present
illness & past medical history/social history, Home meds, Nutrition, Allergies
Physical Assessment (Cardiac specific)
• General appearance, Skin and extremities
• Blood pressure pulse, and postural BP Below 30 is reduction in CO
• Arterial pulses rate, rhythm, amplitude
• Jugular venous pulsations fluid accumulation/overload
• Heart inspection and auscultation
• Any deviations from normal? Meaning changes in how the patient responds to how
they are feeling. Such as a patient with HF or circulatory issues will change their shoes
due to their feet being swollen
NUR 4110 Medsurg 2 FINAL EXAM REVIEW LATEST UPDATE FOR
A+RESULTS
,NUR 4110 Medsurg 2 FINAL EXAM REVIEW LATEST UPDATE FOR
A+RESULTS
o Heart as a pump
o Atrial/ventricular filling volumes
o Cardiac output
o Compensatory mechanisms
▪ What position does the patient lay in when they sleep?
▪ Tripod position patient is leaning forward. This is an indication of respiratory
distress
MOST common clinical manifestation
• Ask why the pt would feel like this?
• Chest pain
• SOB, dyspnea fluid overload/pulmonary issue can lead to dyspnea
• Peripheral edema
• Weight gain
• Abd distention
• Fatigue
• Dizziness, Syncope, Changes LOC due to perfusion and oxygenation issues (brain likes
oxygen)
• We know diuretic is working if the pt is peeing a lot and they feel less fatigue/dyspnea
Chest Pain
• Identify Quantity, location, quality, radiation, duration of pain , Associated S/S
• Assess for other cardiac conditions and for other significant conditions
• Angina Pectoris: uncomfortable pressure, squeezing, or fullness in substernal
chest area. It can radiate across chest to the medial aspect of one of both arms and
hands, jaw, shoulders, upper back, or epigastrium. (BOOK)
• ACS: is the same as angina pectoris. Pain and discomfort ranges from mild to severe
associated with SOB, diaphoresis, palpitations, unusual fatigue, and n/v (BOOK)
• Pericarditis: sharp, severe substernal or epigastric pain which can radiate to necks, arms,
and back.
• Pneumonia, pulmonary embolism sharp, severe substernal or epigastric pain arising
from interior portion of pleura
• Hiatal hernia, GERD substernal pain described as sharp, burning, or heavy. Often
mimics angina and can radiate to neck, arm, or shoulders.
• Costochondritis musculoskeletal disorders. This is a sharp or stabbing pain
localized in anterior chest. Most often is unilateral and can radiate across chest to
epigastrium or back
• Vascular
Diagnostic
(laboratory values)
Hematologic Studies
• CBC identifies the total number of white and red blood cells and platelets and
measures the Hgb and Hct. The CBC is carefully monitored in a patient with
cardiovascular disease
• Hct: 45%
• Hgb: 15%
NUR 4110 Medsurg 2 FINAL EXAM REVIEW LATEST UPDATE FOR
A+RESULTS
, NUR 4110 Medsurg 2 FINAL EXAM REVIEW LATEST UPDATE FOR
A+RESULTS
• Platelets: 150,000-450,000
• WBC: 4,500-10,500
• RBC: 5
Cardiac
Biomarker –
• serum biomarkers (can be used for a diagnosis of an MI)
• CK: 22-198 U/L. A high amount = damage
• CK-MB: 0-3. Elevated CK-MB is indicator of acute MI; the level begins to increase
within a few hours.
• Myoglobin: 0-85 ng/mL. This is a protein which can tell if tissues are damaged
• Troponin: 0-0.4. This is a protein that is a marker for the heart. Elevated means the
patient is having a problem with their heart such as a heart attack
• Myocardial cells that become necrotic from prolonged ischemia or trauma release
specific enzymes (mentioned above). These substances leak into the interstitial spaces
of the myocardium and are carried by the lymphatic system into general circulation
• This bundle becomes important, timing is important. Look at when do you see these
levels start to rise (usually within 4- 6hrs), when do they peak (15-20hrs), and when
should you start to see a resolution (2-3 days)
• If levels are not coming down, can mean that injury is extending….
Blood Chemistry
• BUN: 10-20 mg/dL An elevated BUN can mean dehydration
• Creatinine: 0.7-1.4 mg/dL This is a good indicator for renal function
• Sodium: 135-145 mEq/L Low or high do not directly affect cardiac function
• Potassium: 3.5-5 mEq/L Plays a major role in cardiac electrophysiologic function
o Hypo: dysrhythmia, life-threatening ventricular tachycardia or ventricular
fibrillation and predispose patients taking digitalis preparations to digitalis toxicity
o Hyper: heart block, asystole, life threatening ventricular dysrhythmia
• Magnesium (this is sometimes ADDED, it is not always on the blood chemistry): 1.8-
3.0 mg/dL This is necessary for the absorption of calcium, maintenance of potassium
stores, metabolism of adenosine triphosphate. It plays a major role in protein and carb
synthesis
o Hypo: atrial and ventricular tachycardias
o Hyper: depress contractility and excitability of the myocardium, causing heart
block and if severe, asystole
• Calcium: 8.5-10.5 mg/dL This is necessary for blood coagulation, neuromuscular
activity, and automaticity of the nodal cells
o Hypo: slow nodal function and impair myocardial contractility which can put the
patient at risk for a heart attack
o Hyper: ventricular fibrillation
Coagulation studies
• Injury to a vessel wall or tissue can initiate the formation of a thrombus. This injury
activates the coagulation cascade
o PTT: 60-70 seconds Measures the activity of intrinsic pathway and is used to assess the
effects of heparin
o aPTT: 20-39 seconds
o PT: 9.5-12 seconds. This is used to monitor the level of anticoagulation with
warfarin
NUR 4110 Medsurg 2 FINAL EXAM REVIEW LATEST UPDATE FOR
A+RESULTS
A+RESULTS
Generates and transmits electrical impulses that
stimulate contraction of the myocardium
➢ SA node AV node Bundle of his (branches into right and left) purkinjie fibers
➢ SA node which is the primary pacemaker of the heart
o A patient has a HR of 90. Means The SA node is working because normal HR is
60-100
o If the HR falls below the normal value, there is a problem!
➢ AV node which is the secondary pacemaker of the heart
o If the SA node malfunctions. The AV node will take over which has a lower
rate such as 40-60 bpm
Cardiac Action Potential
Is the electrical cells generate and transmit impulses across the heart which will stimulate cardiac
myocytes to contract. Stimulation of these myocytes occurs due to the exchange of electrically
charged particles (ions) across the channels located in the cell membrane
➢ In resting or polarized state
o Sodium is the primary extracellular ion
o Potassium is the primary intracellular ion
Terms of Cardiac Action Potential
o Depolarization: electrical activation of cell caused by influx of sodium into cell while
potassium exits cell. THIS CREATES A POSITIVELY CHARGED
INTRACELLULAR SPACE AND NEGATIVELY CHARGED EXTRACEULAR
SPACE
o Repolarization: return of cell to resting state caused by re-entry of potassium into cell
while sodium exits
o Refractory periods – cardiac cells must completely repolarize before they can depolarize
AGAIN
o 2 phases of refractory period
o Effective refractory period: phase in which cells are incapable of depolarizing. It is
completely unresponsive to ANY electrical stimulus
o Relative refractory period: phase in which cells require stronger-than-normal
stimulus to depolarize
Cardiac Hemodynamics
• HR x SV Cardiac Output
• =Cardiac output refers to the total amount of blood ejected by one of the ventricles in liters
per minute.
• The cardiac output in a resting adult is 4 to 6 L/min but varies greatly depending on
metabolic needs
• Cardiac output responds to changes in the metabolic demands of the tissues
associated with stress, physical exercise, and illness
o HR is affected by central nervous system activity and baroreceptor activity.
NUR 4110 Medsurg 2 FINAL EXAM REVIEW LATEST UPDATE FOR
A+RESULTS
,NUR 4110 Medsurg 2 FINAL EXAM REVIEW LATEST UPDATE FOR
A+RESULTS
o HR is determined by rate and rhythm – if it is regular or irregular
o If HR is affected so is CO
o If the heart is not stretching enough – cardiac output is affected
o If the heart is not pumping – cardiac output is affected
• Stroke volume is determined by preload, afterload, and contractility
o Preload: refers to the degree of stretch of the ventricular cardiac muscle fibers at
the end of diastole. The end of Diastole is the period when filling volume in the
ventricles is the highest and the degree of stretch on the muscle fibers is the
greatest (when it is filled with more and more blood = the greater the stretch =
the greater the force of contraction)
o Diastole is the relaxation/filling phase of the ventricles and once these have filled
this is the preload. We can also
refer to preload as the EVD (it is at the end of the diastolic phase). Preload is the
amount the ventricle stretched!
▪ Think of a balloon (such as the more air you blow in, the greater the stretch)
o Afterload: resistance to ejection of blood from the ventricles. This is the
pressure required to overcome aortic pressure. The higher the aortic pressure the
harder the ventricles have to work – (the LV must overcome the aortic pressure).
The pressure in the ventricles work against to open the SL valves to pump blood
out of the heart
o Contractility: refers to the force generated by the contracting myocardium (the
more forceful the more blood that is ejected)
• If there is an issue with cardiac output = perfusion issue because there is an
issue with oxygenation and flow components
• Low HR = CO is affected
• Increase in SV and HR = increase in CO
Age Related changes in cardiac
-Atria, LV, Valves (stiffen and no longer close properly), Conduction system, SNS (decreased
response), aorta (stiffen), arteries (stiffen), baroreceptor response (more sensitive)
History and Physical
Health History which refers to the patient’s ability to recognize cardiac symptoms to know
what to do when they occur it is essential for effective self-care management
• Want CLEAR information when talking to the patient Chief complaint, Hx present
illness & past medical history/social history, Home meds, Nutrition, Allergies
Physical Assessment (Cardiac specific)
• General appearance, Skin and extremities
• Blood pressure pulse, and postural BP Below 30 is reduction in CO
• Arterial pulses rate, rhythm, amplitude
• Jugular venous pulsations fluid accumulation/overload
• Heart inspection and auscultation
• Any deviations from normal? Meaning changes in how the patient responds to how
they are feeling. Such as a patient with HF or circulatory issues will change their shoes
due to their feet being swollen
NUR 4110 Medsurg 2 FINAL EXAM REVIEW LATEST UPDATE FOR
A+RESULTS
,NUR 4110 Medsurg 2 FINAL EXAM REVIEW LATEST UPDATE FOR
A+RESULTS
o Heart as a pump
o Atrial/ventricular filling volumes
o Cardiac output
o Compensatory mechanisms
▪ What position does the patient lay in when they sleep?
▪ Tripod position patient is leaning forward. This is an indication of respiratory
distress
MOST common clinical manifestation
• Ask why the pt would feel like this?
• Chest pain
• SOB, dyspnea fluid overload/pulmonary issue can lead to dyspnea
• Peripheral edema
• Weight gain
• Abd distention
• Fatigue
• Dizziness, Syncope, Changes LOC due to perfusion and oxygenation issues (brain likes
oxygen)
• We know diuretic is working if the pt is peeing a lot and they feel less fatigue/dyspnea
Chest Pain
• Identify Quantity, location, quality, radiation, duration of pain , Associated S/S
• Assess for other cardiac conditions and for other significant conditions
• Angina Pectoris: uncomfortable pressure, squeezing, or fullness in substernal
chest area. It can radiate across chest to the medial aspect of one of both arms and
hands, jaw, shoulders, upper back, or epigastrium. (BOOK)
• ACS: is the same as angina pectoris. Pain and discomfort ranges from mild to severe
associated with SOB, diaphoresis, palpitations, unusual fatigue, and n/v (BOOK)
• Pericarditis: sharp, severe substernal or epigastric pain which can radiate to necks, arms,
and back.
• Pneumonia, pulmonary embolism sharp, severe substernal or epigastric pain arising
from interior portion of pleura
• Hiatal hernia, GERD substernal pain described as sharp, burning, or heavy. Often
mimics angina and can radiate to neck, arm, or shoulders.
• Costochondritis musculoskeletal disorders. This is a sharp or stabbing pain
localized in anterior chest. Most often is unilateral and can radiate across chest to
epigastrium or back
• Vascular
Diagnostic
(laboratory values)
Hematologic Studies
• CBC identifies the total number of white and red blood cells and platelets and
measures the Hgb and Hct. The CBC is carefully monitored in a patient with
cardiovascular disease
• Hct: 45%
• Hgb: 15%
NUR 4110 Medsurg 2 FINAL EXAM REVIEW LATEST UPDATE FOR
A+RESULTS
, NUR 4110 Medsurg 2 FINAL EXAM REVIEW LATEST UPDATE FOR
A+RESULTS
• Platelets: 150,000-450,000
• WBC: 4,500-10,500
• RBC: 5
Cardiac
Biomarker –
• serum biomarkers (can be used for a diagnosis of an MI)
• CK: 22-198 U/L. A high amount = damage
• CK-MB: 0-3. Elevated CK-MB is indicator of acute MI; the level begins to increase
within a few hours.
• Myoglobin: 0-85 ng/mL. This is a protein which can tell if tissues are damaged
• Troponin: 0-0.4. This is a protein that is a marker for the heart. Elevated means the
patient is having a problem with their heart such as a heart attack
• Myocardial cells that become necrotic from prolonged ischemia or trauma release
specific enzymes (mentioned above). These substances leak into the interstitial spaces
of the myocardium and are carried by the lymphatic system into general circulation
• This bundle becomes important, timing is important. Look at when do you see these
levels start to rise (usually within 4- 6hrs), when do they peak (15-20hrs), and when
should you start to see a resolution (2-3 days)
• If levels are not coming down, can mean that injury is extending….
Blood Chemistry
• BUN: 10-20 mg/dL An elevated BUN can mean dehydration
• Creatinine: 0.7-1.4 mg/dL This is a good indicator for renal function
• Sodium: 135-145 mEq/L Low or high do not directly affect cardiac function
• Potassium: 3.5-5 mEq/L Plays a major role in cardiac electrophysiologic function
o Hypo: dysrhythmia, life-threatening ventricular tachycardia or ventricular
fibrillation and predispose patients taking digitalis preparations to digitalis toxicity
o Hyper: heart block, asystole, life threatening ventricular dysrhythmia
• Magnesium (this is sometimes ADDED, it is not always on the blood chemistry): 1.8-
3.0 mg/dL This is necessary for the absorption of calcium, maintenance of potassium
stores, metabolism of adenosine triphosphate. It plays a major role in protein and carb
synthesis
o Hypo: atrial and ventricular tachycardias
o Hyper: depress contractility and excitability of the myocardium, causing heart
block and if severe, asystole
• Calcium: 8.5-10.5 mg/dL This is necessary for blood coagulation, neuromuscular
activity, and automaticity of the nodal cells
o Hypo: slow nodal function and impair myocardial contractility which can put the
patient at risk for a heart attack
o Hyper: ventricular fibrillation
Coagulation studies
• Injury to a vessel wall or tissue can initiate the formation of a thrombus. This injury
activates the coagulation cascade
o PTT: 60-70 seconds Measures the activity of intrinsic pathway and is used to assess the
effects of heparin
o aPTT: 20-39 seconds
o PT: 9.5-12 seconds. This is used to monitor the level of anticoagulation with
warfarin
NUR 4110 Medsurg 2 FINAL EXAM REVIEW LATEST UPDATE FOR
A+RESULTS
