Nursing Students
CARDIAC WARD Learning outcome Pack Welcome to the Cardiac Ward. We are a 40-bedded unit, comprising of six, six bedded bays (2 female, 4 male) and four single rooms. We form part of the department of cardiology. CARDIOLOGY
CARDIAC WARD
CCU (8 BEDS)
CARDIAC CENTRE (ECHO, ETT, ANGIO,PPM,OUTPATIENT CLINICS)
PATIENT ADMISSIONS • Emergency: We accept patients from other wards and departments, most commonly: CCU, A&E, Medical admissions. • Elective: These are planned admissions. These patients are admitted for investigations or for specific cardiac procedures. CARDIAC CONDITIONS The most common cardiac conditions that our patients are treated and managed for are: Acute Coronary Syndromes (Myocardial Infarction, Unstable Angina Pectoris), Cardiac Arrhythmias (e.g. Atrial Fibrillation, Atrial flutter and Heart block etc.), Aortic Stenosis, Cardiomyopathy, Infective Endocarditis and Pericarditis. USEFUL WARD INFORMATION • Patient Meal times approximately: Breakfast 7 am; Lunch 12 noon; Supper 5pm. Visiting times: 2pm to 3.30pm and 6pm to 8pm. Rest period: From 12.30pm to 2pm. Ward telephone Numbers: (01225) 825701, 824424, 824444. • Staff
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Nursing Students
Shifts: Long days: 0730am – 9.30pm; Nights: 9pm – 8am or Normal shifts: Early: 7.30am – 3.30pm; Late: 1.30pm – 9.30pm; Nights: 9pm – 8am. Your shifts should match those of your mentor to enhance your learning. If you need to alter your allocated shifts, please discuss any problems with your mentor. Sickness: Please contact the ward and speak to the nurse in charge on a daily basis to report your sickness. Your sickness will be recorded on the duty rota. Mentoring: We operate team mentoring on the ward. This means that you may have up to 4 mentors. Don’t panic, it’s not to scare you but purely, to ensure that you are always working with one of your designated mentors. Learning opportunities on the ward: Informal: Mentors, learning pack, books, articles, information displayed on ward, British Heart Foundation booklets. Formal: Regular teaching on the ward by medical reps and ward nursing staff. Additionally, we can arrange for you to spend time in the other areas of cardiology (CCU, Cardiac centre and Cath Lab, Cardiac rehabilitation) and also with other members of the multi-disciplinary team as appropriate. Useful websites: www.bhf.org.uk (British Heart Foundation) www.dh.gov.uk (National Service Framework for Coronary Heart Disease) www.aaaw.org.uk (Heart rhythm charity) www.guch.org.uk (Congenital heart disorders)
We hope you enjoy your placement with us!!
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Nursing Students
LEARNING PACK The aim of this pack is to help structure your learning whilst you are on placement with us. To assist you in meeting your course objectives, some learning outcomes have been written to assist you. These outcomes are based on the four domains: Professional/ Ethical Practice, Care Delivery, Care Management, Personal/ Professional Development. Domain 1 – Professional/ Ethical Practice
Activity 1). Cultures & Religions 2). Confidentiality 3). Ethical Dilemmas
Suggested Nursing Practice Placement NP1 & NP2 NP1, NP2, NP5 & NP6 NP1, NP5 & NP6
1). By the end of your placement, discuss the care of a patient who has a different cultural/ religious origin and the impact that this has had, on the delivery of nursing care. Consider:•
What are the cultural/ religious differences?
Write a care plan that could be used by the rest of the ward team when they care for this patient. Nursing Problem
Goal of Care
Nursing Care
September 2009
Evaluation
Nursing Students
2). By the end of your allocation, demonstrate how confidentiality is maintained within the ward area and discuss with your mentor where it may be breached? Consider:• The definition of confidentiality –
•
To whom do you give patient information?
•
When answering the telephone how do ascertain who the caller is?
•
What sources of knowledge did you use to achieve this objective?
3). Choose one of the following issues and discuss with your mentor/s the reasons for and against the issue. • Not for Resuscitation • Use of cot sides • Use of drugs to sedate a confused/ aggressive patient. Consider:• NMC Code of Conduct • Clinical Governance • Patient Advocacy • Acts of Parliament (Mental Health Act etc.) Domain 2 – Care Delivery Activity 1). Care Plan/ Pathway 2). Observations 3). Assessment
Suggested Nursing Practice Placement NP2, NP5 & NP6 NP1, NP2, NP5 & NP6 NP1, NP2, NP5 & NP6
1). By the end of your placement, admit, write a plan of care and discharge a patient from the ward that has been admitted with one of the following:• Myocardial Infarction • Unstable Angina • Cardiac arrythmia/ Palpatations/ syncope • Pacemaker Insertion • A patient for coronary angiography
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Nursing Students •
A patient for DC Cardioversion
Once you have identified the patient that you wish to do your care study on consider: Signs & Symptoms of the patient How pain is assessed and managed The treatment options Actual & Potential complications The goal of care – including rehabilitation, role of physio, OT etc. Discharge Information/ Health Promotion Include a copy of your Admission document and plan of care paperwork BUT REMOVE THE PATIENTS DETAILS TO ENSURE CONFIDENTIALITY AND ANONYMITY IS MAINTAINED AT ALL TIMES. 2). By the end of your placement, demonstrate the significance of observations on patient care. To help you achieve this objective, please complete the following table:OBSERVATION
Normal Parameters
Reasons for low reading with signs and symptoms
Reasons for Rationale for high reading performing with signs and observation symptoms
RESPIRATIONS
TEMPERATURE
PULSE
O2 SATURATION
NEUROVASCULAR
FLUID BALANCE •
What sources of knowledge did you use to achieve this objective?
September 2009
Nursing Students 3). By the end of your placement, demonstrate how you would use 2 of the following when delivering care:• Wound Assessment • Pressure sore risk assessment • Pain Assessment • Manual Handling Assessment • Nutrition Assessment For the 2 chosen, consider:• Why would you use them?
•
How would you use them?
•
When would you use them?
•
How would you evaluate their effectiveness?
•
What sources of knowledge did you use to achieve this?
Domain 3 – Care Management
Activity 1). Medication Issues 2). Infection Quiz 3).Management Scenarios
Suggested Nursing Practice Placement NP2, NP5 & NP6 NP1, NP2, NP5 & NP6 NP5 & NP6
September 2009
Nursing Students 1). By the end of the placement demonstrate that you are competent in drug administration (From NP2 onwards). • Fill out the following table to demonstrate the pros & cons of various drug routes Drug Route IM
Pros
Cons
Example
IV
SC
•
To be safe and competent when administering drugs, knowledge of drugs is required. Please fill out the following table.
Drug Group Diuretics
Examples
Routes
Antihypertensives Anti-coagulants
Beta Blockers
Statins
Analgesics
Anti-emetics
Antibiotics
Nitrates
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Mode of Action
Side Effects
Nursing Students
•
What checks should you undertake prior to administering any drug to any patient?
•
What sources can you use to obtain information about drugs?
•
Why are some drugs locked away and signed out in a book?
•
Which drugs are they?
•
What knowledge did you use to achieve this objective?
2). To assist you build your knowledge of infections, consider:•
What is infection and what are the signs and symptoms?
•
What is colonisation?
•
What is septicaemia?
•
Discuss the route of transmission and the port of entry of infection?
•
How can the transmission of infection be prevented?
•
Explain what you understand by the term MRSA and describe the management of patient care.
September 2009
Nursing Students Take one area you have seen on the ward where infection control can be improved and look at it in greater depth. How can this be implemented in practice?
3). Care Management The aim of this section is to improve your ability to manage realistic situations by the end of your allocation on the ward. Choose 3 – 4 of the following: a). A member of staff rings the ward before an early shift to say they are ill. What is the ward policy for such situations and what action should be taken?
b). You are told that you are in charge of the ward for the shift. You start by allocating staff to patients♦ On what basis will this be done? ♦ How will skill mix affect this? ♦ What would you do if you had a very dependent patient(s)?
c). A patient you are caring for becomes verbally abusive towards you. What action is appropriate in such a scenario?
d). A relative makes a verbal complaint over an alleged drug error ♦ How would you respond to such a complaint?
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♦ What procedure is required if they wish to make a formal complaint?
e). You are on a shift and feel that the lack of staff and the dependency of patients are compromising patient care. ♦ Who should be informed and why?
♦ What other action could you take in this situation?
f). You see smoke coming from the kitchen. ♦ What action do you take? ♦ When should patients be physically moved? ♦ Who should be in charge of the situation? g). You find a patient collapsed in the toilet after apparently slipping in a pool of water. ♦ What action should be taken?
♦ What documentation should be completed and whom should it be reported to?
h). You find a patient in the chair that appears to be unresponsive. ♦ At what stage might you put out an arrest call and how would you do it? ♦ What action do you take whilst you are waiting for the crash team to arrive? September 2009
Nursing Students
♦ You are involved in the arrest. What are you asking the other staff to do?
♦ If the resuscitation is unsuccessful what do you need to do?
♦ Where is the replacement equipment for the Resuscitation Trolley kept?
Domain 4 – Personal/ Professional Development
Activity 1). Reflection 2). Teaching Session 3). Support & Supervisory skills
Suggested Nursing Practice NP1, NP2, NP5& NP6 NP5 & NP6 NP5 & NP6
1). By the end of your placement, discuss with your mentor an area of your nursing care that through reflection you have changed or developed.
2). By the end of your placement, give a 10-15mins teaching session on an aspect of care on the ward to a small group of staff (can be HCA’s, nursing students, ward nurses).
3). During your placement, through a team mentorship approach, support and supervise a junior student or HCA for an agreed period. This should include an assessment of their learning outcomes relating to their stage of training and an action plan and an evaluation on progress. Consider:• Your role as part of the Mentor team and as a senior student • How would individual learning be identified • How would learning outcomes be measured and evaluated • Giving and receiving feedback
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Nursing Students
Evaluation Form 1. How often were you able to work with your named mentor?
2. Were you able to work with your associate mentors when your named mentor was not available?
3. At what stage in your placement was your learning contract/ action plan agreed?
4. How was your experience with your mentor? Any positive feedback or concerns?
5. What were the positive aspects of your placement?
6. Were there any negative aspects of your placement?
Please return this form to Cath (Key Mentor), Liz Richards or Jules Webber.
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Nursing Students
CARDIOLOGY LEARNING PACK (2010 Edition)
This learning pack contains specific questions designed to enhance your cardiac knowledge. Enjoy!!!
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Nursing Students
THE HEART Label the structures on the diagram below: Aortic Arch, Pulmonary Artery, Aortic Valve, Pulmonary vein, Left Atrium, Mitral Valve, Left Ventricle, Pericardium, Endocardium, Myocardium, Septum, Right Ventricle, Tricuspid Valve, Inferior vena Cava, Right Atrium, Superior Vena Cava.
STRUCTURES WITHIN THE HEART
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Nursing Students
Q
Name the 3 layers of the heart wall. 1. 2. 3.
(Name the conditions that affect these structures).
Q
Name the structure dividing the ventricles.
(Discuss the condition that can occur congenitally or as a complication of an MI with your colleagues).
Q
The chambers of the heart have varying wall thickness –
Approximate sizes are: Right atrium 2mm Right ventricle 3 – 5mm Left atrium 3mm Left ventricle 13 – 15mm Why do they differ in size?
Q
What is the function of the heart valves?
Q
Describe the role of the papillary muscles and chordae tendinae.
CIRCULATION
September 2009
Nursing Students The diagram below, illustrates the circulation of oxygenated and deoxygenated blood, within the heart.
Fill in the gaps:Venous blood enters the right ___________ via the vena cavae. This blood is now ________________ and returns from the head and arms via the ____________ vena cava, whilst the supply from the trunk and legs enters via the _______________ vena cava.
From the right atrium, the blood passes into the ________ ____________ via the _____________ valve, and then flows out of the ventricle through the ________________ valve, and is carried via the _____________ ____________ to the lungs to become _________________. The _____________ veins carry the oxygenated blood back from the lungs to the left _________. The blood flows through the ___________ valve into the left ___________. Blood is then ejected through the ____________ valve into the _________ and thus into the systemic circulation.
CORONARY CIRCULATION
September 2009
Nursing Students As the heart’s function is so essential, in order to perfuse all the body’s tissues, the heart must ‘feed’ itself first, to keep the cycle going. It does this via the coronary arteries, which surround the heart in a network, penetrating the epicardial layers to deliver oxygen-rich blood to the myocardium. These arteries arise in the region of the sinus of valsalva, just behind the aortic valve. They fill during diastole (relaxation) to enable maximum filling and perfusion.
On the diagram above, label: The Inferior surface of the heart The Anterior surface of the heart The Apex of the heart
THE CORONARY ARTERIES
Right Coronary Artery (RCA) The RCA perfuses the right ventricle and a major proportion of the posterior left ventricle. The RCA supplies the sino-atrial node in 70% of individuals. The posterior branch of the bundle of His is perfused by the RCA in 90% of the population, and by the left circumflex in the remaining 10%.
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Nursing Students
Left Coronary Artery This artery, at its initiation, is known as the left main stem (LMS). It then divides into two – The left anterior descending artery (LAD) and the circumflex that branches laterally to the posterior surface of the heart. LAD: The LAD supplies the anterior surface of the left ventricle, the septum and the right branch of the bundle of His. Circumflex: The circumflex supplies the left ventricle laterally and a posterior portion of this ventricle. The circumflex also perfuses the sino-atrial node in 30% of the population and the posterior branch of the bundle of His in 10% of the population.
The Cardiac Cycle
Systole: When blood is pumped from the heart. This stage normally lasts about 0.24s, or 1/3rd of the total time of the cardiac cycle. Diastole: In relation to the heart, it involves the re-filling of the heart. On average, this lasts about 0.6s, or the remaining 2/3rd of the cardiac cycle.
Q What does the term ‘pre-load’ refer to and what can affect it?
Q What does the term ‘afterload’ refer to and what can affect it?
Q What is stroke volume?
Q Heart Rate x Stroke Volume is the calculation used to determine what? ELECTROPHYSIOLOGY
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Nursing Students
Label the diagram below: Bundle Branches, Bundle of His, Sinoatrial Node, Left and Right Bundle Branches, Atrioventricular Node.
The mechanical contraction of the heart is the product of a stimulus response process. The resting myocardial cell has an intrinsic membrane potential (that is, an electrical charge) as a result of the relative distribution of extracellular and intracellular sodium and potassium ions. Whenever the cell is stimulated the membrane potential undergoes a change. A graphic record of this change forms the basis of an electrocardiogram (ECG). The change in electrical potential in response to a stimulus is known as the ‘action potential’. The two components of the action potential are depolarization (generation of the impulse) and repolarisation (return of the cell to a resting state). The electrical current stimulates the release of calcium ions, which catalyse the reaction of myocardial contraction.
Q What special qualities does the cardiac cell possess? Q When an impulse is initiated by the sino-atrial node the ‘intrinsic rate’ is 60-80bpm. What are the other intrinsic rates of the conduction system?
September 2009
Nursing Students S. A. Node → 60 – 80 bpm Junctional rate → Ventricular rate →
THE ELECTROCARDIOGRAM (ECG)
In clinical practice, the 12 lead ECG is used as a diagnostic tool. Draw a PQRST complex in normal conduction (ie sinus rhythm).
Q What do the following waves represent? P Wave – QRS Complex – T Wave –
Q What has to be present for a rhythm to be termed sinus?
Q What paper speed is used on the standard 12 lead ECG?
Q On the ECG paper, what do the squares represent in terms of time? Q On an ECG, how do you calculate the heart rate?
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Nursing Students
Q Where is the PR interval measured? Which part of the cycle does this interval represent?
Q Where is the QT interval measured?
Q What are the normal range measurements for: PR Interval – QRS Interval –
Prevention of Cardiovascular disorders
Q There are risk factors associated with Coronary Heart Disease. Name the Nonmodifiable risk factors 1. 2. 3.
Q Name the Modifiable risk factors associated with Coronary Heart Disease. 1. 2. 3. 4. 5. 6.
Assessment of individuals with altered cardiovascular function
September 2009
Nursing Students A cardiovascular assessment includes: Patient/health history, physical examination and diagnostic procedures. Patient/health history Q What information would be useful to collect from the patient?
Physical examination (Most of the techniques are carried out by medical staff) 1. General appearance (e.g. Colour, facial expression, alertness etc.). 2. Palpation of skin (Capillary refill, skin turgor, oedema) and peripheral arterial pulses. 3. Blood pressure 4. Auscultation of heart sounds
Clinical diagnostic studies Blood tests
Q Which blood tests are normally performed on cardiac patients? Why are they performed?
N.B. It is useful to know the normal ranges of the most common blood tests.
Echocardiography (ECHO) Q What does the test involve and what abnormalities can it detect?
Chest X-ray Q What valuable information about the heart and lungs can be provided by a Chest Xray?
Coronary angiography (also known as cardiac catheterisation)
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Nursing Students
Q What does this procedure assess and what does the test involve? What are the risks associated with performing an angiogram? What nursing input is require pre and post the procedure?
Electrophysiology studies (EPS) Q What does this procedure involve and what does it assess?
Central Venous Pressure (CVP) monitoring Q What does CVP monitoring assess? What is the normal Central Venous Pressure?
Clinical Characteristics of impaired cardiac function
Q What common symptoms are presented by cardiac patients?
Chest Pain September 2009
Nursing Students
Q How do we assess a patient who is experiencing chest pain?
Q How do we manage the patient with chest pain?
Causes and types of heart disorders Heart disorders can be classified into 6 areas: 1. Congenital cardiovascular defects 2. Disorders of the cardiac muscle 3. Disorders of the myocardial blood supply 4. Disorders of electroconduction 5. Disorders of myocardial pumping capacity 6. Disorders of the vascular system
1. Congenital Cardiovascular Defects Q What is meant by a congenital cardiovascular defect? Give examples of heart disorders. (www.guch.org.uk – might be a useful starting point for information)
Aortic Stenosis Q What is aortic stenosis?
Q What are the symptoms of aortic stenosis?
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Nursing Students
Q How is the patient with aortic stenosis managed?
2. Disorders of Cardiac Muscle Cardiomyopathy Q What is cardiomyopathy? With what common symptoms do patients with cardiomyopathy present? How is cardiomyopathy managed?
Infective endocarditis
Q What is infective endocarditis? What are the symptoms of endocarditis? How is endocarditis managed?
Pericarditis Q What is pericarditis? What are the symptoms of pericarditis? How is pericarditis managed?
3. Disorders of Myocardial blood supply Coronary Atherosclerosis Q What is atherosclerosis? How does it the affect blood supply to the myocardium?
Angina Pectoris Q What is (stable) angina? How is it managed?
Q What is unstable angina?
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Nursing Students
Q What are the signs and symptoms of unstable angina?
Q What investigations diagnose unstable angina?
Q What happens to the ECG in unstable angina?
Q What medications are given to angina patients?
Myocardial Infarction
Q What is a Myocardial Infarction (MI)?
Q Name the different types (sites) of Myocardial Infarction. Additionally, for each type of MI identify the specific coronary artery which is occluded.
Q What signs and symptoms might a patient having an MI have?
Q What happens to the ECG in an acute MI?
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Nursing Students
Q Which blood tests confirm an MI? Initial Management of an acute MI focuses on the control of symptoms (chest pain, nausea etc.), acute myocardial reperfusion and the recognition and management of complications. Q What drug therapies or interventions are used to reperfuse the myocardium?
Q Identify the common complications of Myocardial Infarction.
Q What medications are administered to patients post MI?
Q What information is given to MI patients to aid their rehabilitation?
4. Disorders of electroconduction (To assist your learning, it may be helpful to either draw the following rhythms or to obtain ECG printouts of them). Q What is sinus rhythm (SR)?
Q What is sinus tachycardia?
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Nursing Students
Q What is sinus bradycardia?
Q How is profound bradycadia treated?
Q What is an ectopic beat?
Q What is atrial fibrillation (AF)?
Q How is atrial fibrillation treated?
Q What is ventricular tachycardia (VT)?
Q How is ventricular tachycardia treated?
Q What is ventricular fibrillation (VF)? September 2009
Nursing Students
Q How is ventricular fibrillation treated?
Q What is asystole?
Q How is asystole treated?
Q What is pulseless electrical activity (PEA)?
Q How is PEA treated?
Artificial Pacemakers A pacemaker (or artificial pacemaker, so as not to be confused with the heart’s natural pacemaker) is a medical device which uses electrical impulses, delivered by electrodes contacting the heart muscles, to regulate the beating of the heart.
Methods of Pacing a. b. c. d.
External Pacing Temporary Pacing Permanent Pacing Q How is external pacing performed and when would you use it on a patient?
Q What is the difference between a Temporary Pacing system and a Permanent Pacemaker system? When is each pacing system used on patients? September 2009
Nursing Students
Basic function of Permanent Pacemakers Pacemakers usually can perform multiple functions. The most basic form monitors the heart’s native electrical rhythm. When the pacemaker doesn’t sense a heartbeat within a normal beat-to-beat time period, it stimulates the ventricle of the heart with a short low voltage pulse. This sensing and stimulating activity continues on a beat by beat basis. The more complex forms include the ability to sense and/or stimulate both the atrial and ventricular chambers The NASPE/BPEG generic code for antibradycardia pacing: I Chamber(s) Paced 0 = None
II Chamber(s) sensed 0 = None
III Response to sensing 0 = None
IV Rate modulation 0 = None
V Multisite pacing 0 = None
A = Atrium
A = Atrium
T = Triggered
R = Rate modulation
A = Atrium
V = Ventricle
V = Ventricle
I = Inhibited
V = Ventricle
D = Dual (T+I)
D = Dual (A+V)
D = Dual D = Dual (A+V) (A+V) (Source: www.wikipedia.org)
Q A patient has a VVIR pacemaker inserted. How many leads have been inserted and to which chamber(s)? How is the pacemaker functioning?
Q A patient has a DDDR pacemaker inserted. How many leads have been inserted and to which chamber(s)? How is the pacemaker functioning?
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Nursing Students
Biventricular Pacing Q What is biventricular pacing and what are the indications for its use?
September 2009
Nursing Students Implantable Cardioverter-defibrillators (ICDs) ICDs are devices which are often used in the treatment of patients at risk from sudden cardiac death. An ICD has the ability to treat many types of heart rhythm disturbances by means of pacing, cardioversion, or defibrillation. Short form of NASPE/BPEG Defibrillator code ICD-S ICD with shock capability only ICD-B ICD with bradycardia pacing as well as shock capability ICD-T ICD with tachycardia (and bradycardia) pacing as well as shock capability (Source: www.wikipedia.org)
5. Disorders of myocardial pumping capacity (Heart Failure)
Q What is heart failure?
Q What are the symptoms of heart failure?
Q What is the medical management for a patient with heart failure?
Q What is the nursing care of a patient with heart failure?
September 2009
Nursing Students 6. Disorders of the Vascular system (Blood circulation) Hypertension Q What is hypertension?
Q Identify the symptoms of hypertension?
Q How is hypertension managed medically?
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Nursing Students
Glossary of terms ABG - Arterial blood gas ACS - Acute Coronary Syndrome AF - Atrial Fibrillation AMI - Acute Myocardial Infarction Angio - Angiogram/ angiography APTT - Actual pro-thrombin time AS - Aortic stenosis AVR - Aortic valve replacement CABG – Coronary artery bypass graft CCF – Congestive cardiac failure CHB - Complete heart block CPAP - Continuous positive airways pressure CPK - Creatinine phosphokinase CVP - Central venous pressure CXR - Chest X-ray ECG - Electrocardiogram ECHO - Echocardiogram EPS - Electrophysiological studies ETT - Exercise tolerance test GTN - Glyceryl trinitrate ICD - Implantable cardiac defibrillator IHD - Ischaemic heart disease INR - International normalised ratio LVF - Left ventricular failure MBETT - Modified Bruce exercise tolerance test MI - Myocardial Infarction PEA - Pulseless electrical activity PPM - Permanent pacemaker PTCA - Percutaneous transluminal coronary angiogram TOE - Trans-oesophageal echocardiogram TPA - Tissue plasminogen activator TPW - Temporary pacing wire Trop T - Troponin T USS - Ultrasound scan VF - Ventricular fibrillation VT - Ventricular tachycardia
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Nursing Students
The Giant Cardiac Wordsearch M S B U N D L E O F H I S O L L M P L M A R G O I G N A
N Y A H E A R T F A I L U R E H F A N G I N A N M P L T
L F O D C M B P R B R E A T H L E S S Y N R P W I L V R
A S S C A N C W U E N D O C A R D I T I S U A A T H T I
D I L E A Y H T A P O Y M O I D R A C M P F G A R R A A
F N L G T R I S K F A C T O R S B J L T A E H R A T C L
A U A X I V D I G O X I N R L O D V U R O E T T L M H F
I S N C P L I I O M D L L X U M W E I U R P N E V A Y I
D R E O S I C P A O R T I C S T E N O S I S I R A R C B
R H T P L D S J A L W M K M P T N K M A D C A Y L G A R
A Y I L T A N F T N I N J U O K I X N U N U P D V O R I
C T B N P U O U R P R N H T Y L N I E N V I T B E I D L
Y H A R I L M T O G T V F I I F O C B F L M S A H D I L
D M S P E E B S A S Y E T A R R P P M T M B E S J R A A
A T R I U M V A P H A O F B R E O A A D Y U H P U A G T
R E N V Z N I W L R G R H C A C R F S P E X C I R C R I
B C L O P I D O G R E L T D T A T C I I I S J R T O G O
B F H P L O N T N D F N C L D B Q I L B C A L I E H O N
M V E N T R I C L E S P T S U G U O O T A R M N B C U M
E L E C T R O C A R D I O G R A M V O N P N O T V E M S
ACS, ANGINA, ANGIOGRAM, AORTA, AORTIC STENOSIS, ARTERY, ASPIRIN, ATRIAL FIBRILLATION, ATRIUM, BRADYCARDIA, BREATHLESS, BUNDLE OF HIS, CABG, CARDIOMYOPATHY, CHB, CHEST PAIN, CIRCUMFLEX, CLOPIDOGREL,CXR, DIGOXIN, ECHOCARDIOGRAM, ELECTROCARDIOGRAM, ENDOCARDITIS, EPS, ETT, GTN, HEART FAILURE, ICD, IHD, LAD, LMS, LVF, MITRAL VALVE, MYOCARDIAL INFARCTION, PPM, RCA, RISK FACTORS, SEPTUM, SINUS RHYTHM, TACHYCARDIA, TIROFIBAN, TNK, TPW, TROPONIN, ULTRASOUND SCAN, VEIN, VENTRICLE, WARFARIN
September 2009
