FUNDAMENTAL CARDIAC WORKBOOK

FUNDAMENTAL CARDIAC WORKBOOK SELF DIRECTED TESTS A MARK OF 100% MUST BE ACHIEVED IN ALL TESTS IN ORDER TO RECEIVE A CERTIFICATE AND PROGRESS TO THE ADVANCED CARDIAC STUDY DAY

COMPREHENSION EXERCISES MODULE ONE The heart is comprised of: a. two atria and two ventricles b. four atria and four ventricles c. two atria and one ventricle d. one atria and two ventricles The middle layer of the heart is the: a. epicardium b. endocardium c. subendocardium d. myocardium The mitral valve separates the: a. right and left ventricle b. the left atria and ventricle c. the right and left atria d. the right and left ventricle The left ventricles blood is supplied by the: a. the right coronary artery b. the circumflex artery c. the left anterior descending artery d. the femoral artery The initial spread of impulses across the heart is known as a: a. repolarisation b. automaticity c. depolarisation d. diastole COMPREHENSION EXERCISES MODULE TWO The P wave represents a. atrial depolarisation b. ventricular depolarisation c. atrial diastole d. ventricular systole Ventricular diastole is represented by the a. P wave b. T wave c. QRS wave d. R wave

The normal PR interval is a. 0.04 seconds b. 0.12-0.20 seconds c. 0.20-0.24 seconds d. 0.16-0.20 seconds Each small square on the ECG paper is equal to a. 0.05 seconds b. 0.05 mm c. 0.04 mm d. 0.04 seconds The width of a normal QRS complex should be a. greater than 0.12 seconds b. less than 0.12 seconds c. equal to 0.20 seconds d. 0.12-0.20 seconds COMPREHENSION EXERCISES MODULE THREE The standard leads are: a. unipolar b. bipolar c. augmented d. negative In regards to chest leads the V stands for: a. augmented b. standard c. unipolar d. bipolar The axes of the three bipolar leads from: a. Einthoven s triangle b. Einthoven s square c. Einthoven s triad d. Einthoven s circle The lead attached to the right lower limb is a: a. chest lead b. AVR c. AVL d. a n ear thing lead How many chest leads are there? a. Five b. Six c. Four d. Twelve

COMPREHENSION EXERCISE MODULE FOUR If electrical currents flow towards an electrode the deflection on the ECG paper will be a. negative b. isoelectric c. positive d. downward Normal sinus rhythm originates from the a. SA node b. AV node c. bundle of HIS d. purkinje fibres On a normal 12 lead ECG AVR should be a. positive b. totally negative c. show R wave progression d. biphasic In lead V6 the R wave should be totally a. negative b. biphasic c. downward d. positive Lead II, III and AVF represent what wall of the heart? a. inferior b. posterior c. lateral d. anterior COMPREHENSION EXERCISE MODULE FIVE Angina results from a. widening of the coronary arteries b. narrowing of the coronary arteries c. increased arterial flow d. increased oxygen to the heart Angina is a. transient and reversible b. results in permanent scarring c. stops the heart d. c a n only happen once in a person s life The primary ECG change seen with angina is a. ST elevation b. T wave elevation c. ST depression d. absence of p waves The most common symptom associated with angina is a. feeling tired b. pain in legs c. chest pain d. head ache

Whilst ST depression is the most often seen ECG change in angina, what other ECG change may be seen? a. long PR interval b. T wave elevation c. no P waves d. T wave flattening or inversion COMPREHENSION EXERCISE MODULE SIX An ensuing acute myocardial infarction is most often characterised by a. ST depression 0.5 mm in 2 or more limb leads b. ST elevation of 2mm in 2 or more chest leads c. long CT interval d. short PR interval Q waves form as a result of a. angina b. non -STEMI c. STEMI d. chest pain An anterior AMI results form occlusion of the LAD or one of its branches. Which leads would it be most evident? a. V3, V4 b. AVL, Lead I, V5, V6 c. Lead II, III and AVF d. V1, V2 Right ventricular infarctions are common in the setting of a. atrial fibrillation b. anterior infarctions c. angina d. inferior infarctions ST segment depression occurring in the leads opposite the affected wall are referred to as a. recent changes b. reciprocal changes c. evolving changes d. permanent changes What leads directly represent the posterior wall of the heart? a. all leads b. V3, V4 c. none d. II, III, AVF

COMPREHENSION EXERCISE MODULE SEVEN The first line treatment for VF or pulseless VT is a. DCR b. amiodarone c. lignocaine d. adrenaline For cardioversion to be successful which pacemaker in the heart must be the first to fire? a. AV node b. pacing node c. bundle branches d. SA node Aystole is recognised as a. spikes on the ECG b. a b s e n c e of all electrical activity on the ECG signal c. chaotic rhythm d. fast heart rate COMPREHENSION EXERCISE MODULE EIGHT Premature atrial contractions originate in the: a. SA node b. a n ectopic focus in the ventricles c. AV node d. a n ectopic focus in the atria Atrial flutter rates are usually in divisions of 300. Hence the rate for 2:1 would be: a. 75 beats per minute b. 150 beats per minute c. 100 beats per minute d. 300 beats per minute SVT frequently exhibits a heart rate of: a. less than 100 beats per minute b. less than 50 beats per minute c. between 140 and 220 beats per minute d. between 50 and 100 beats per minute A unifocal PVC results from: a. t h e same ventricular focus b. m a n y different ventricular foci c. the same atrial focus d. many atrial foci

MODULE NINE ASSESSMENT AND TREATMENT OF CHEST PAIN Please read the following article located in the additional readings folder and answer the questions below: Tough. J. (2004). Assessment and treatment of chest pain. Nursing Standard. 18(37). COMPREHENSION EXERCISE MODULE NINE Name the five causes of cardiac related chest pain? 1. 2. 3. 4. 5. It is important that a good current history is taken from the patient in order to establish cardiac pain as the cause or rule it out. Once chest pain has been established a number of prompts can be used. Please fill in the spaces for the prompts: a. Site b. c. Character d. Exacerbating or e. f. Frequency g. What are the main symptoms a patient would demonstrate when suffering an acute coronary event, name five? a.. b.. c.. d.. e..

It is also important to ascertain a past medical history, including previous cardiac history, cardiac interventions and drug history. It is also important to determine the patient s risk factors, these include (please list); a... b... c... d. e... f. g... Which observations and actions must be performed within ten minutes of onset of chest pain? a... b... c. d... e... The patient must be reviewed by a doctor within.. minutes. Which blood test is the preferred biomarker should be considered when undertaking venepuncture on the cardiac patients? When administering oxygen to cardiac patients, what oxygen saturation should be aimed for? a. 99% b. 76% c. 80% d. None of the above

What two drugs should be given to patients to help to relieve chest pain? Please list the symptoms and precipitating factors which are associated with angina (name 5); Please describe the difference between a Non ST elevation myocardial infarction and a ST elevation myocardial infarction. What is the golden amount of time for door to needle time in coronary artery thrombolysis? a. 16 hours b. 60 minutes c. 1 minute d. 120 minutes

MODULE TEN CARDIAC BLOODS Please read the following articles located in the additional readings folder and answer the questions below: Woodrow. P. (2003) Assessing blood results in older people: Cardiac enzymes and biochemistry. Nursing Older People. 14(4). And Tough. J. (2004). Assessment and treatment of chest pain. Nursing Standard. 18(37). COMPREHENSION EXERCISE MODULE TEN At what stages should troponin I be tested in the patient with chest pain? Troponin I can be elevated on occasion when there is no cardiac specific involvement, please name four conditions in which Troponin I can present as a false positive. What is the normal serum potassium level for an adult? a. 3.5 5 b. 4.5 7 c. 1.1 3 d. 1.1 7 Name five causes of hyperkalemia. a.. b.. c.. d... e..

What could you observe on an ECG from a patient with high potassium? What could you observe on an ECG from a patient with low potassium? The component of the blood responsible for carrying oxygen is the a. Leukocytes b. Plasma c. Haemoglobin d. Platelets How much of the arterial blood s oxygen does the myocardium use? a. 21% b. 100% c. 70-80% d. 25-30% Give two effects over digoxin overdose on an ECG. Which drugs given in Acute Coronary Syndrome (ACS) effect clotting

MODULE ELEVEN HEART FAILURE Please read the following article located in the additional readings folder and answer the questions below: Buckler. L. (2009) Managing heart failure. Nursing made incredibly easy. May/June COMPREHENSION EXERCISE MODULE ELEVEN Name two causes of heart failure and describe/explain the pathophysiology behind each cause. Cause One.. Cause Two.. Describe the pathophysiological steps which contribute heart failure over a period of time. Please name three symptoms of left sided heart failure and the mechanism behind each. Symptom One.. Symptom Two. Symptom Three.. Which of the below are not symptoms of right heart failure a. Lower extremity oedema b. Reduced urine output c. Ascites d. Weight gain

Name two tests which can be undertaken to help confirm heart failure. What does the term ejection fraction mean and what is the normal ejection fraction in a healthy adult? Please explain the pharmacological effects and actions of ACE inhibitors in relation to heart failure. What should be monitored carefully when first starting on ACE inhibitors? Please explain the pharmacological effects and actions of Beta-blockers in relation to heart failure. Name two important aspects of heart failure management that patients should be educated on.

MODULE TWELVE CARDIOVASCULAR RISK Please read the following article located in the additional readings folder and answer the questions below: Foxton. J., Nuttall. M., & Riley. J. (2004) Coronary heart disease: Risk Factor Management. Nursing Standard. 19(13) COMPREHENSION EXERCISE MODULE TWELVE List the three main risk factors for coronary heart disease. List two other associated risk factors. Please explain what modifiable risk reduction means.

What does LDL mean?.. What does HDL mean?.. Of the two, which one is beneficial to the heart? What is the recommended total cholesterol level in the general population of the United Kingdom? a. Less than 2.0 mmol/l b. Less than 1.0 mmol/l c. Less than 5.0 mmol/l d. Less than 10.0 mmol/l When should weight loss be considered in men? a. When the waist size is above 102cm b. When the waist size is above 110cm c. When the waist size is above 88cm d. When the waist size is above 94cm Please list the food or food groups which should be encouraged in a healthy diet (list at least 8). What is the minimum recommended amount of physical activity a person should take per day? How many days per week should this occur if able? What is the single biggest cause of avoidable death in the UK? a. Smoking b. Alcohol excess c. Heart attack d. Car accident

What effect does moderate alcohol intake have on the body? List the main types of cholesterol lowering drugs/product available and briefly explain their affect on the body. MODULE THIRTEEN ADMINISTRATION OF AMIODARONE Please read the following article located in the additional readings folder and answer the questions below: Name the Five Rights of giving an IV drug Name two things that the patient must NOT be allergic too, to administer IV amiodarone. What crystalloid must amiodarone be mixed with? a. Normal saline b. Hartmans c. 5% dextrose d. Gelofusin

What is the dose and how much fluid is the amiodarone mixed with for the first infusion? How long does the first infusion run over? a. 30 minutes b. 1 hour c. 12 hours d. 10 hours What is the dose and how much fluid is the amiodarone mixed with for the second infusion? How long does the second infusion run over? a. 3 hours b. 1 hour c. 12 hours d. 10 hours What is the dose and how much fluid is the amiodarone mixed with for the third or forth infusions? How long do the third and fourth infusions run over? a. 3 hours b. 1 hour c. 12 hours d. 10 hours

What is the main side effect of amiodarone? MODULE FOURTEEN CARDIAC REHABILITATION Please read the following article located in the additional readings folder and answer the questions below: New Zealand Guidelines Group (2002) Cardiac rehabilitation. Best practice Evidence Based Guideline. COMPREHENSION EXERCISE MODULE FOURTEEN Please describe the different phases of cardiac rehabilitation Phase 1: Phase 2: Phase 3: What are the inclusion criteria for cardiac rehabilitation?

Name five of the key components of cardiac rehabilitation. Name six of the goals and related interventions of cardiac rehabilitation. MODULE FIFTEEN CARDIAC PHARMACOLOGY Please read the following article located in the additional readings folder and answer the questions below: Cohen. L., et al (n.d.) Cardiovascular Drugs. COMPREHENSION EXERCISE MODULE FIFTEEN Name the five reasons for using cardiac medications.

How do beta blockers decrease blood pressure (please explain)? What area of the body do nitrate drugs work on? a. the heart b. the brain c. veins and arteries d. the kidneys What areas of the body do ACE inhibitors work on? What cardiac condition are ACE inhibitors most commonly used? What electrolyte needs to be monitored more closely when a patient is taking Digoxin?

MODULE SIXTEEN Cardiac Scenarios Scenario One A 72 year old woman who is on the ward with a chest infection has started to complain to you that she has chest pain. The pain is centralised and crushing in nature. The pain is also radiating down the left arm. She is clammy to the touch and is complaining of feeling nauseous. On examination her blood pressure is 100/56, Pulse 100, Temperature 36.4 C and the pain is 8 out of 10. An ECG is taken showing T Wave flattening in leads V3, V4, V5 and V6. What would you suspect? Which area of the heart would be affected? What would your treatment be? What other test would you order?

Scenario Two A 65 year old man admitted for debridement of a leg ulcer is complaining of acute shortness of breath. On examination it is noted that his pulse has become fast, with a rate of 110 Bpm and irregular. His Blood pressure has dropped from 146/73 to 105/50. An ECG is taken showing an irregular fast pulse with no P waves present. What is the possible new diagnosis for this patient? What would the treatment be for this patient? What would the blood test would you carry out? Scenario Three A 48 year old man is admitted with renal failure. On a routine ECG he is noted to have peaked T waves. What could this signify?

What tests would you undertake to confirm diagnosis? What would the treatment be for this patient? Scenario Four A 77 year old female arrives in A&E with increased SOB (worse when lying flat), pedal oedema (Grade 3) and an elevated JVP (+4cm). A chest x ray is taken showing cardiomegaly and Kerley s lines. She is also noted to be in atrial fibrillation and has a BNP of 900. A recent history taken shows she has had a number of heart attacks over the past two years. What condition is this patient most lightly to have? What is the gold standard test to confirm this?

What would the treatment be for this patient?

WHERE TO GO NOW!!! If you have enjoyed completing the Fundamental Cardiac Workbook, please enrol for the Advanced Cardiac Study Day (see below). Aim/Purpose The aim of the study day is to extend your knowledge and skills in working with patients who have cardiac disease. Content Advance chest/cardiac assessment Cardiac care pathways ECG analysis Cardiac Pharmacology Interventions We hope you have enjoyed this workbook and gained a valuable insight into basic cardiology and its components. Full acknowledgement goes to Michelle Shanahan for the use of the basic ECG learning pack, Gippsland Regional Health. Paul Boden (RN)

REFERENCES Buckler. L. (2009) Managing heart failure. Nursing made incredibly easy. May/June Conover, M. (1996) Understanding Electrocardiography, 7 th Ed. Mosby, St Lois. Foxton. J., Nuttall. M., & Riley. J. (2004) Coronary heart disease: Risk Factor Management. Nursing Standard. 19(13) Guyton, A.C. (1991) Textbook of Medical Physiology, 8 th Ed. W.B. Saunders Company, Philadelphia McCance, K.L. & Huether, SE. (2002) Pathophysiology, The basis for disease in adults and children 4 th Ed. Mosby, St Louis. New Zealand Guidelines Group (2002) Cardiac rehabilitation. Best practice Evidence Based Guideline. Tough. J. (2004). Assessment and treatment of chest pain. Nursing Standard. 18(37). Web sites accessed for images used in this package: Accessed 14 th October, 2005. Woodrow. P. (2003) Assesing blood results in older people: Cardiac enzymes and biochemistry. Nursing Older People. 14(4). http://medstat.med.utah.edu/kw/ecg/ecg_outline/lesson9/#rvmi http://connection.lww.com/products/smeltzer10e/documents/thumbnails/c27/t 27_019.jpg http://www.txai.org/edu/irregular/bradycardias.htm http://members.evansville.net/ict/ekg-ami-antlat-500.jpg http://medstat.med.utah.edu/kw/ecg/ecg_outline/lesson9/ http://www.cardiologist.uk.com/main/main_symp toms.htm http://www.dummies.com/wileycda/dummiesarticle/id -1211.html http://www.emedu.org/ecg/voz.php http://www.vetgo.com/cardio/concepts/concsect.php?conceptkey=20104 http://connection.lww.com/prod ucts/morton/documents/images/ch17/jpg/ch17-035.jpg http://www.heartfoundationjm.org/p/servicesaboutheart.htm http://www.chelation.co.uk/ gfx/heart.jpg http://media.wiley.com/assets/8/01/0-7645-5422-0_0901.jpg http://www.heartfoundationjm.org/v/deco/servicesabouthumanheartheartwal l.jpg http://www.aic.cuhk.edu.hk/web8/ecg.htm

http://www.heartfoundationjm.org/p/servicesaboutheart.htm http://media.wiley.com/assets/8/10/0-7645-5422-0_0902.jpg http://www.biosbcc.net/b100cardio/images/fg21_06b.jpg http://www.ajronline.org/cgi/content-nw/full/177/6/1447/fig1 http://medstat.med.utah.edu/kw/ecg/mml/ecg_ccs.gif http://199.33.141.196/faculty/webpages/stodd/oceanweb/bio2/bio2lectures/lec ture3/img029.jpg http://www.ce5.com/ekg.gif http://www.monroecc.edu/depts/pstc/backup/ekggraph.gif www.cvphysiology.com/ Arrhythmias/A013a.htm http://www.studentbmj.com/issues/01/12/education/ecg7.gif http://www.anaesthetist.com/icu/organs/heart/ecg/images/leads.jpg http://en.wikipedia.org/wiki/ecg http://www.resus.org.au/ http://www.txai.org/edu/irregular/ventricular_tachyarrhythmias.htm http://www.publicsafety.net/image/precord_view.gif http://cardiology.ucsf.edu/ep/imagesheart/normalecg.jpg