Welcome to Cardiovascular Nurse Essentials. I'm so excited you've decided to come join us and deepen your knowledge of cardiology. So today we're gonna cover an introduction, the first module, but we're gonna go over 12 modules during this series. We're gonna start kind of broad and we're gonna really hone in and get into some of the specialized cardiology areas. And my goal is really not only to increase your understanding of cardiology, but I want you to understand the different areas where you can grow and develop. I also wanna make sure you feel invigorated, your passion is ignited. We have really hard times within cardiology and healthcare right now, and your work matters. So I wanna make sure that you have that fire lit inside of you. And I'm really grateful for you being here and all the work you're doing to make a difference in your community. So as you know, heart disease is a leading cause of death in the U.S. That's one person's life lost every 33 seconds. So how can we as our medical community help? It's our responsibility to be armed, to be vigilant and to be proactive in serving our patients. So let's dive in. We're gonna start today with just a brief introduction to cardiovascular nursing. My name is Jenny Kennedy. I am a nurse by training, VP of Care Transformation with MedAxiom. These are my disclosures. So just high level, here's our objectives today. We're gonna review some common things that we'll encounter in cardiology. As you know, there's some readings. We do have a great resource book that I encourage you to really dive into and keep as a reference. There are also additional resources. So these are really great for you to review and supplement your education. Also, some of them are great for reference sheets to print off and keep with you at your workstations and maybe even share with some of your coworkers. So we're gonna start by talking through cardiac anatomy. And as you know, we've got plumbing and electricity in the heart. So when we're talking about cardiac anatomy, we know there's four chambers. We have two atria, of course, the right and the left, and then two ventricles also right and left. So we know that our blood flows into the heart, into the right atrium, through the superior vena cava. This blood is unoxygenated, so obviously we need to get some oxygen to feed to the rest of the body. Once it's in the right atria, it comes through the tricuspid valve into the right ventricle. From here, it goes up into your pulmonary arteries, and it's gonna circulate through the lungs to pick up oxygen. From here, it's dumped back into the left atrium, goes through the mitral or bicuspid valve into the left ventricle. This is where it gets pumped up into the aorta and out to the body. So this blood flow is very important for volume management. So it's important to understand the anatomical structures, the atria, the ventricles, and the valves. Also noting the septal wall, which separates the left and the right side. So again, this is just showing those two sides, how blood does flow from the right to the left. It comes in unoxygenated and leaves the heart with oxygen. The blood cells carry oxygen to the rest of the body and the organs to keep it oxygenated. So we wanna think about flow in two circuits, pre-lungs and post-lungs. And keeping in mind these valves, and we know there's sometimes issues with these valves, they're really, you'll see they're leaflets. Tricuspid, that's tri for three, has three leaflets. And your bicuspid on the left side has two. You can kind of think of them as doors that open and close. And this helps maintain fluid volume management as the blood is pumping. So in addition to the plumbing system, we also have an electrical system, often referred to as electrophysiology. So not only do we need the plumbing, which promotes blood flow, we need that conduction, the electrical pathway, which stimulates the heart to pump and beat. So what you can see is we've got a very intricate electrical system within the heart. So each contraction of the ventricle is considered a contraction. So what happens is a signal starts in the atria. The atria contract just very briefly right before the ventricles do to pump the blood out of the aorta, out of the ventricle, into the aorta and to the rest of the body. So it all starts at the SA node. The sinoatrial node is known as your heart's natural pacemaker. This is where the electrical stimulus starts. And it actually conducts and travels down to this second node. So it starts in the SA node and it travels down to the AV or atrioventricular node, which is also in the atria. This is what causes those two atria to contract immediately before the signal goes further into what's called the bundle of hiss. This bundle you can see deviates into the left and the right branches. So these are your bundle branches. This electrical impulse triggers those ventricles to contract. And that's where that blood pumps out of the heart into the rest of the body. So it's a very intricate system and both have to function in order for a person to be healthy. We also know that a healthy normal heart rate is firing, your SA node is firing at 60 to 100 beats per minute. So when we start seeing challenges with heart rates above or below that, we know that there's something else going on. So none of this is possible without our myocardial cells. And what we need to understand is that the myocardial cells are really just the cardiac muscle. They really just make up the heart and its muscle and they all contain some sarcomeres or proteins that are fibers that are really the basis of what makes the heart contract. So these jobs, as you can see, are very important and it's important that we keep them healthy. Again, when we have heart disease, these fibers, these proteins, everything can be impacted and cause problems for this patient. These cells, even though they are small, are very mighty. They have to be able to be functional and produce electricity without outside nerve stimulation. So that SA node is producing electrical activity on its own. It's the initiation and the firing of that impulse. They have to be able to respond to an electrical stimulus. As we know, in some other conditions, there can be multiple electrical impulses outside of these nodes. So they can be very excitable, which can produce other problems. They must be able to transmit electrical stimuluses from cell to cell throughout the heart muscle or the myocardium. They also have to be able to contract when they are stimulated. So all of these things must work together to ensure that the body is getting blood flow, which in turn means it's getting the oxygen that it needs. So next, we're gonna talk briefly about cardiovascular medical terminology, because it's very important that we understand the medical terms for any healthcare specialty. But when you're in cardiology, you do have to know what you're reading, what you're communicating. It makes a difference. So you may be familiar with some of these terms, but maybe you're not as familiar with others. So I really urge you to take the time to review these terms and make sure you're comfortable with them. We're only gonna go over a few briefly today. However, in your resource guide, there is a comprehensive list. Please make sure you go through that and just become familiar with those that you're not as comfortable with. And as I mentioned, please feel free to print those out, share them with your coworkers, keep them at your desk or your workstation so you can reference them. So common terms. We obviously wanna know the difference between systole and diastole. These are the two phases of the cardiac cycle. And it's basically, we wanna think of it in terms of when the heart is contracting or pumping versus when it's relaxing. We know the heart has to be relaxed so it has the time to fill up with blood and get ready for that next squeeze. So an easy way to think of systole, which is the contraction or squeeze, is systole Superman. Your heart muscle is really squeezing to get that blood out into the rest of your body. So diastole then on the other hand is that relaxation phase where your heart is just trying to take a moment and fill up with blood. The amount of blood that goes out with each contraction is measured as an ejection fraction. And this is simply the percentage of blood volume that is ejected from that left ventricle during systole. So you'll see this commonly on echoes, stress tests, sometimes casts. And it's, again, it's documented in a percentage. So normal percentage or ejection fraction is gonna be 55 to about 65 or 70%. So we're not expecting 100% by any means. But if we see numbers below that, obviously that's gonna be cause for concern and further follow-up. So we also know that coronary is of the heart. We know there's coronary arteries, there's coronary vessels, everything relating and of the heart. Infarction, this word is a fancy word for local death. So when we have tissue, so we think of myocardial infarction, that means there's been a severe injury to the heart muscle and it's actually caused death to that tissue. This is different to know than an injury. So injury does not always mean there's been tissue death. Some other common words, ablation. We think of this most commonly when we're thinking about arrhythmias, AFib, AFlutter, SVTs, tachycardias. And this means really to take away or remove. So we're removing a pathway or an electrical pathway that's causing atrial fib or other issues. So valvular, we've talked about the mitral and the tricuspid valves. There's also pulmonic and aorta. So valvular can be addressing any of those valves. Issues with the leaflets or those doors opening and closing can cause pretty bad repercussions. So it's something you wanna be aware of. Itis is infection of, typically you don't think of too many infections in the heart, but we do see pericarditis. So it is possible. Isis is condition of, and opathy is any sort of abnormality. So I know that's a very short list, but I think it's a nice refresher. And again, please refer back to that comprehensive list. So I wanna move on into some really common cardiovascular symptoms and descriptors that you're gonna see. And it's very important, especially in the ambulatory or the clinic side, that you have keen assessment skills. So sometimes your patient will be in front of you, but often you're gonna be receiving phone calls or messages through portals. You can't use your sight, all your skills to really assess that patient as you would if they're in person. So you really have to kind of hone in and anticipate the things that you need to ask. And not that every patient will present in this way, but you do need to be aware when they're saying these things. Those are indicators that you might need to do some more investigating. So making sure that you're really in tune with your patient, that you're listening and asking follow-up questions is gonna be critical. So one of the most common ones is dyspnea or shortness of breath. Patients get short of breath for multiple reasons. So it is difficult sometimes to distinguish if it's cardiac related or if it's pulmonary related or something else. So patients will call, shortness of breath. Okay, well, I need to ask some more questions. Is that shortness of breath when you're sitting, when you're at rest? Is it with activity? Is it more severe than it was yesterday or normal? We need to be able to ask these questions. Even though you can't see, maybe on the phone you can hear it. Are they talking to you? Can you hear them kind of breathing heavier, maybe wheezing? All of those are keys that you can take in as you're building this picture to make decisions on how to proceed with this patient. Some other breathing issues are common in cardiac patients are orthopnea and paroxysmal nocturnal dyspnea. So orthopnea is shortness of breath when they're laying flat. So this obviously occurs mostly at night or when patients are napping. The patient's not going to say I have orthopnea. So what that means is you've got to listen to what they're telling you to know that that's what they're talking about. So if my patient is saying I just don't feel great today, I lay down flat and I couldn't get comfortable. I couldn't breathe well. So this patient starts telling me that they're raising the numbers of pillows. They've gone from two to four pillows and then they progress to a recliner to sleep. That tells me that this patient is not able to lay flat without getting short of breath and that they have orthopnea. P and D on the other hand is a little bit different, obviously still issues with breathing and occurs at night typically. And again, when a patient is flat, what happens is all the fluid kind of settles in the bases of their lungs. So again, they're not going to say I have P and D, but they're going to tell you I woke up last night, coughing, gasping for air. I could, I had to sit bolt upright and I could not catch my breath for a few minutes. That's a key sign that they have additional fluid and they're experiencing P and D. Many patients will feel syncope or express that they passed out or come close to passing out with positional changes. This can be very common. So that's a very common complaint, nausea. So within cardiology patients, a lot of them will feel nauseous. Maybe they feel like they're going to vomit. Maybe it's they just feel bloated or they have a decreased appetite. Some patients will even get what we call cardiac cachexia and that's when there's prolonged nausea or vomiting and they actually lose a lot of weight or muscle and it weakens them. So these are common findings that we shouldn't just dismiss within our cardiac patients. We talked about vomiting. Sometimes our patients can have what we call parasesias or that sudden numbing or tingling. These can sometimes be vascular issues that need to be addressed. Fatigue is very, very common. Most patients that you talk to, most anybody these days feels tired. So how do you differentiate that? Is it they feel more exhausted than usual? Is it related to some of their medications? Metablockers are known to really zap our energy. So trying to understand, is it a severe fatigue and almost exhaustion versus being their normal baseline tired? Malaise, maybe feeling uncomfortable, like kind of body aches, pains, things of that. And then other times they may complain of palpitations. They may say, I feel my heart racing. It feels like a flutter in my chest. These are all things that are going to help you decide how you communicate these findings to your physician, how you create a care plan to move forward and treat this patient. So in addition to our symptom assessment, as you're talking or looking at your patients, you're clarifying things, we've got to know what's actually happening through their vital signs. So these two components are critical to make sure we're getting the information to the physician or your APP, your providers, that is accurate. So I urge you to not take these for granted. Cardiac vitals are very, very important. They paint a picture and it's going to guide the next steps in the treatment of these patients. So I know that in the world of offices and just short staffing, time is of the essence. We're crunched. We're trying to see more patients and do more things. I urge you to take the time to do this the right way. It will be advantageous in the long run to get the right information to the providers on the patient. So we know the vital signs. We know there's temperature, pulse, respiratory rate, blood pressure, oxygen saturation, height, weight, and BMI, also pain. So if you're having concerns or your patients are having concerns, we always advise logs. So if they're worried about their heart rate, say they're feeling heart palpitations or that flutter in their chest, ask them to check their pulse on occasion, keep a log. We do this commonly with blood pressures. So we never go based on one high blood pressure. We're not going to treat that. So it's very common that we're going to ask them to do a log. We need to see what their blood pressure is doing when they're out of the office setting. They may be experiencing white coat syndrome. They may just be stressed from the drive into the office and maybe there's a parking deck and a lot of people. So it's really great to reference and use logs to get a true understanding of what the trends are for the patient. When we take blood pressure, there's two ways. Can you use a stethoscope and auscultate it or we can use our blood pressure machines. So if we're auscultating, we're using our stethoscope, we're locating that brachial artery and we're detecting corticot sounds. When the blood pressure machine gets to that number and you hear that first corticot sound, that's your systolic blood pressure. Then you get the diastolic blood pressure when that sound goes away. It's not as common to use a stethoscope and auscultate anymore. However, if you're having issues with your blood pressure machine or you think someone's low or high, always good to have that skill and double check it with a manual blood pressure. I will say with our machines, please make sure that they're calibrated, they're kept up. We really want to make sure that that equipment is well taken care of because if they're not, they can impact those readings. We are going to talk a little bit about some key steps. I know this may seem kind of elementary, but I think sometimes we forget some of the things in the proper way, just in the rush and getting through the days and seeing all the patients. These steps are maybe simple, but they're so important. I can't stress it enough. We want to make sure we're communicating with our patients so that they're prepared. As we mentioned, there's challenges, there's stress, there's white coat syndrome. We want to make sure that they're kind of relaxed as best as they can be. We're going to use our own technique, making sure that it's proper so we get the best measurement. We're going to make sure it's documented correctly. We're going to average readings and we're going to provide that blood pressure back to the patient. So when we talk a little bit more in depth, what is preparing that patient look like? Generally, these visits are stressful, so patients are nervous. We want them relaxed, okay? So we want to make sure that they're mentally prepared, they're in a state of relaxation as much as they can be. We do prefer that they're sitting in a chair and that they're sitting there for three to five minutes with their feet flat and their back supported before you check their blood pressure. This is the ideal position. And I know, again, we're speeding through office visits, so that three to five minutes can feel like a long time, but it gives that patient the time to get acclimated. Also note that we want feet flat. We do not want them to have their legs crossed. That can increase their blood pressure. So it's just kind of something, you know, people sit down, they get trying to get relaxed, they cross their legs. Just be aware of that so that you can gently remind them to uncross their legs so it's not falsely elevated. We can't always control this, but patients should avoid caffeine, any kind of exercise or smoking for at least 30 minutes before a blood pressure reading. Other stressors, so emptying bladders, if they come in and they've got a full bladder, that can falsely elevate their blood pressure as well. I know a lot of these are social visits for patients. So they come to the office, you've got a relationship, they want to talk. It is best that nobody talks. So you can hear if you're doing a manual blood pressure cuff, but it also can elevate their blood pressure. So just asking for that moment where nobody's talking so you can get that blood pressure. And then as soon as it's done, you can go ahead and restart that conversation. And I know, you know, a lot of patients come in with layers or maybe winter or whatnot. It is best to remove any covering if you can, so you're directly on the arm and you're getting no additional layers and that you have the proper cuff placement. So if the patient can get their arm available outside of a sleeve or roll that, you know, pull it up if that's possible, that is best. So proper technique, again, these are simple steps, but they're so important. So we want to make sure, I think that I mentioned it already, but make sure that you're, if you're using an automatic cuff that has been calibrated, that it's taken care of, you should have someone in the office checking all your equipment and machines. We want to make sure their arm is supported. So their arms shouldn't, you know, they shouldn't be holding their arm up straight out. It should be relaxed. If you have a pillow or an arm rest, just have them rested on that. And it should be at the level of the heart. So you really want to position their arm. So it's relaxed kind of at the level of their heart as much as possible. You want the cuff positioned on that patient's upper arm at the level of the right atrium. So when you think of that, that's really kind of at that midpoint of their sternum in terms of cuff placement. We also know that the cuff size matters. So we don't want one that's too big or too little. So you want one that will have a bladder that encircles 75 to 100% of the arm. If you need a bigger cuff, you know, take the time to find that. Or if it's a smaller cuff, do that as well. And then we've talked about using the stethoscope. You can use the diaphragm or the bell for those manual pressures and readings. Another technique, and it's very commonplace in cardiology, again, it's not as popular because it is time consuming, but orthostatic vital signs. We do these frequently because we've got to check for orthostatic hypotension. Again, the way we do this is imperative because it drives decisions on how we need to treat the patient. And basically with this, all it means is we're obtaining a pulse, your heart rate and your blood pressure while the patient is supine, laying flat, seated and standing. Again, we do have to allow for adequate time. So ideally the patient would lay flat supine for five minutes before we check that first blood pressure. After that, we want to move them from laying to sitting. Again, they've got to kind of recalibrate and we want them to wait three to five minutes and recheck their blood pressure. We do the same thing when they go from sitting to standing. I always caution people because sometimes, you know, when they're changing those positions, they can lose balance. So be alert to that, please, and make sure you're prepared for any kind of wobbly situation. Again, we're going to wait another five minutes and recheck that blood pressure. So when we go from sitting to standing, we want to make sure that we're having them wait for five minutes and rechecking. So why are we checking for orthostatic vitals? We're looking to see if that change in blood pressure is significant. So initially our blood pressure does change, but it should recover pretty immediately. It is significant in general if there's a systolic drop of 20 millimeters of mercury or more or 10 millimeters of mercury or more in diastolic blood pressure. So that does indicate that it's possible that patient has orthostatic hypotension. We do not rely solely on those readings. We want to use our clinical information and patients will typically complain about weakness. They feel dizzy when they change position. You may even see them kind of lose balance. And there's several reasons that this can happen. It can be volume depletion. Maybe they're dehydrated. Maybe there's certain medications that are causing that. And a lot of patients, you know, we are seeing an increase in something called POTS after COVID and other viruses where it's a tachycardic syndrome with those position changes. So again, you know, we want to make sure that we're looking at that whole clinical picture. With that, we do conclude our first module. I hope this has been a helpful overview. I look forward to seeing you for the next module. If you have any questions or comments, please feel free to email us at academy at medaxiom.com. Thank you.

Cardiovascular Nurse Essentials

Jenny Kennedy

cardiology

cardiac anatomy

vital signs

patient communication