cardiovascular review
TRANSCRIPT
Cardiovascular DisordersJudith Maely Kong-Tarrazona, US-RN
Nursing History
Nurse has three goals when obtaining health history: Identify present and potential health
problems. Identify possible familial and lifestyle risk
factors. Involve the client in planning long-term health
care.
Manifestations of Heart Disease
Dyspnea – laboured or difficult breathing
Types: Exertional Orthopnea – shortness of breath when lying
down Paroxysmal nocturnal dyspnea – sudden
dyspnea at night while lying down Cheyne-Stokes – periodic breathing
characterized by gradual increase in depth of respiration followed by a decrease in respiration resulting in apnea
Chest Pain
Characteristic Examples
Location Substernal, precordial, jaw, back, localized or diffuse.
Character/ Quality Pressure; tightness; crushing, burning, or aching quality;
heaviness; dullness; “heartburn” or indigestion
Chest Pain
Characteristic Examples
Timing: onset, duration and frequency
Onset: Sudden or gradual?
Duration: How many minutes does the pain last
Frequency: continuous or periodic
Chest Pain
Characteristic Examples
Setting/precipitating factors
Awake, at rest, sleep interrupted? With activity? With eating, exertion, exercise, elimination, emotional upset?
Chest Pain
Characteristic Examples
Intensity/Severity Can range from 0 (which is no pain) to 10 (which is worst pain
ever felt) Aggravating factors
and Relieving factors Activity, breathing, temperature
Medication (nitroglycerin, antacid), rest; there may be no
relieving factors
Chest Pain
Characteristic Examples
Associated symptoms
Fatigue, shortness of breath, palpitation, nausea and vomiting, sweating, anxiety, light-headedness or dizziness
Edema
– abnormal accumulation of serous fluid in the connective tissues
Causes: CHF, Na retention, liver disease, hypoproteinemia,
venous or lymphatic obstruction
Types: ascites – excessive fluid in peritoneal cavity hydrothorax – excessive fluid in pleural cavity anasarca – gross generalized edema
Edema
Edema Rating: +0 = non pitting +1 = 0 – ¼” pitting (mild) +2 = ¼” – ½” pitting (moderate) +3 = ½” – 1 pitting (severe) +4 = greater than 1” pitting (severe)
Palpitation
a rapid, forceful or irregular heartbeat felt by the patient
Hemoptysis is coughing up of blood Small quantities of dark-clotted blood –
indicates mitral stenosis Mixture of blood and pus – indicates
pulmonary suppuration Pink, frothy Sputum – in acute pulmonary
edema Blood-streaked Sputum – in acute pulmonary
congestion Frank hemoptysis – due to lung pathology
Other Manifestations of Heart Disease
Fatigue Syncope and Fainting – may be caused by
anoxemia or reduced cardiac output resulting to inadequate circulation
Cyanosis – bluish discoloration of the skin and mucus membranes
Abdominal pain or discomfort Clubbing of fingers – angle of the nail is 1800
due to chronic hypoxia Jaundice – yellowish discoloration of the skin
and sclera
Physical Assessment of the Heart
Inspection and Palpation
Aortic area – 2nd ICS to the right of the sternum
Pulmonic Area – 2nd ICS to the left of the sternum
Inspection and Palpation
Right Ventricular Area
a circle around the 5th cartilage to the patient’s left of MSL (Midsternal Line)
Inspection and PalpationApical or Left Ventricular
Area 5th ICS at MCL
(Midclavicular line). Observe for cardiac
movement at the PMI located at MCL at the 5th ICS.
Thrills are vibration that occur as blood flow through a narrow or damaged valves
Percussion
Cardiac Area of Dullness (CAD)
Auscultation: Heart Sounds
S1 first heart sound due to closure of
atrioventricular valves loudest at the apexS2 second heart sound due to closure of
semilunar valves loudest at the base
Auscultation: Heart SoundsS3 “ventricular gallop” 3rd heart sound which is normal in children and
young adultS4 “atrial gallop” 4th heart sound which is normal in children and
young adult; in adults, it is associated with systemic or
pulmonary hypertension, MI, and other cardiac diseases
Auscultation: Heart Rate
Normal – 60-100 beats per minute (BPM) Bradycardia =<60 bpm Tachycardia => 100 bpm
Auscultation
Murmurs – sounds produced by vibrations within the heat and great vessels caused by turbulence of flow
Rubs – sounds produced by the interfacing of parietal and visceral surfaces of the pericardium
Auscultatory Areas
Physical Assessment of Blood Vessels
Inspection
Color – inadequate circulation may produce pallor, rubor, cyanosis. Cyanosis is best visualized with good lighting. Vascular nail beds offers best visualization.
Circulation of extremities
Note for the following
Hair growth – absence means inadequate circulation
Clubbing – results from long standing hypoxia
Capillary refill – prolong filling time is indicative of inadequate circulation
Palpation
Edema – assess over a bony prominence such as the medial malleolus, anterior tibia, sacrum. Press for 5 seconds and measure for pitting
Pulse – carotid, dorsalis pedis, poplitial, posterial tibial
Diagnostic Assessment
Non-invasive Procedures
Electrocardiography is a graphic recording of electrical activity of the
heartResting electrocardiogram (ECG) presents a single recorded picture of the
electrical activity of the heart secure electrodes to appropriate locations on
the chest and extremities instruct the client to remain still during the test reassure client that he or she will not receive
any electrical shock or impulses
Holter Monitoring continuous ambulatory
ECG monitoring over time (usual 24 hours with small, timed, portable ECG recording devices
secure electrodes to appropriate locations on the chest
instruct client to continue normal activity
instruct client to maintain a log of activities and any symptoms
Stress test
continuous multi-lead ECG monitoring during controlled and supervised exercise, usually on treadmill
Stress Test
Client preparation obtain written consent explain procedure instruct client to eat a light meal 1 to 2
hours before the exam no caffeine, alcohol, smoking wear comfortable clothing and rubber-
soled walking shoes
Stress TestNursing care during procedure secure electrodes to appropriate locations on
chest obtain baseline BP and ECG tracing instruct client to exercise as instructed instruct client to report any pain, weakness,
shortness of breath, or other symptoms immediately
monitor BP and ECG continuously record at frequent intervals and with any
symptoms or changes in vital signs, ST segments, or cardiac rhythm.
Stress Test
Post procedure nursing care continue to monitor ECG and NP until
client returns completely to baseline and is symptom-free.
once stable, patients may resume their usual activity.
Echocardioagraphy
is an ultrasound of the heart to evaluate structure and function of the heart chambers and valves
Echocardioagraphy
Client preparation instruct client to remain still during the test secure electrodes for simultaneous ECG tracing explain that there will be no pain or electrical
shocks, however, the lubricant placed on skin will be cool
Post-procedure: cleanse the lubricant from the client’s chest wall
Phonocardiography is a graphic recording of heart sounds with
simultaneous ECG
Client preparation instruct client to remain quiet and still during
test secure electrodes for simultaneous ECG tracing explain that there will be no pain or electrical
shocks
Diagnostic Tests
Invasive Procedures
Coronary Angiography/Arteriography
is an invasive procedure during which the physician injects dye into coronary arteries and immediately takes a series of x-ray films to assess the structure of the arteries.
Coronary Angiography/Arteriography
obtain written consent explain procedure assess client for history of allergies to dye
or to shellfish initiate IV site with fluids as ordered
Cardiac Catheterization
is the insertion of a catheter into the heart and surrounding vessels to obtain diagnostic information about the structure and function f the heart. It can be performed on the right or left side of the heart
Cardiac Catheterization
Cardiac Catheterization client on NPO, usually for 8-12 hours
before procedureExplain to the client that Procedure involves lying on a hard table
for less than two hours Mild sedative will be given intravenously Occasional pounding sensation
(palpitation) may be felt particularly when catheter tip touches the myocardium.
Cardiac Catheterization Client may be asked to cough or breathe
deeply, especially after injection of contrast agent.
coughing may help to disrupt a dysrhythmia and to clear the contrast agent from the arteries; breathing deeply helps lower the diaphragm for better visualization of heart structures.
Injection of contrast agent may procedure a flushed feeling throughout the body
Cardiac CatheterizationPost-procedure Nursing Care observe catheter access site for bleeding or
hematoma formation assess the peripheral pulses, temperature and
color in the affected extremity every 15 min, for 1 hour, and then every 1 to 2 hours until pulses are stable
encourage fluids to flush out dye orthostatic hypotension may occur when getting
out of bed the first time.
Radionuclide Tests
are safe methods of evaluation left ventricular muscle function and coronary artery blood distribution
can procedure some of the same information as radiographic angiography with less risk to client
Radionuclide Tests
Client preparation obtain written consent if required explain procedure instruct client that fasting may be required for a
short period before the exam contrast material will be injected through a
venipuncture it will be necessary to alternately change
position and remain still during the exam there is an associated pain or discomfort
Radionuclide Tests Nursing care during procedure – none;
procedure is performed in nuclear medicine Post-procedure nursing care encourage client to drink fluids to facilitate the
excretion of the contrast material assess venipuncture site for bleeding or
hematoma if stress testing was performed, assess client’s
BP and pulse at frequent intervals and maintain continuous ECG monitoring as indicated
Radionuclide Tests
MUGA (gated pool imaging or multi-gated acquisition) scan
Thallium imaging – used to assess myocardial ischemia (decreased supply of oxygenated blood) during stress testing
PET (Positron Emission Tomography) Scan – evaluates cardiac metabolism and assesses tissue perfusion
Radionuclide Tests Magnetic Resonance Imaging (MRI) – uses strong
magnetic field to examine both physiologic and anatomic properties of the heart.
screen out patient to determine whether the patient has pacemaker, metal plates, prosthetic joints, or other metallic implants; these can be dislodged if exposed to MRI
explain to the client to expect intermittent clanking or thumping sound from the magnetic coils that can be annoying to the patient (offer headset to listen to the music).
instruct the client to remain still and not move. Nursing Alert – no metal can be in the MRI room
because metal objects can become dangerous
Bone Marrow examination
Sites for bone marrow aspiration: Sternum iliac crest (most common) TibiaMost common site for bone marrow biopsy posterosuperior iliac spine; the sternum also is
used. During the withdrawal of aspirate, the client will
experience sharp pain often described as a burning pain
Bone Marrow examination After the needle is removed, a pressure dressing is
applied over the puncture site, where only minimal bleeding should occur
if the patient has thrombocytopenia, pressure is applied for 3 to 5 minutes
Most clients experience little, if any, pain or discomfort after the procedure; some persons will complain of tenderness and ache at the aspiration site for a few days.
Bone Marrow Aspiration – this is used to determine the presence and size of RBC, WBC, and megakaryocytes as they develop in the bone marrow
Diagnostic Procedures
Blood Studies
CBC
indication of the type and number of formed elements in the blood
CBC
Laboratory Test Normal Value
Red blood cell count Men Women
4.2-5.4 million/mm3
3.6-5.0 million/mm3
Reticulocytes 1.0-1.5% of total RBC
Hemoglobin (Hgb) Men Women
14-16.5 g/dL12-15 g/dL
Hematocrit Men Women
40-50%37-47%
CBC
Mean Corpuscular Volume (MCV)
85-100 fL/cell
Mean corpuscular haemoglobin concentration ( MCHC)
31-35 g/dL
Mean corpuscular haemoglobin (MCH)
27-34pg/cell
Platelet count 150,000-400,000/mm3
Hemoglobin and Hematocrit
Hemoglobin – measures the haemoglobin available n circulation, which is the gas-carrying capacity of an erythrocyte
Hematocrit – the ratio of the BBC volume to the volume of whole blood
RBC indexes MCV (mean corpuscular volume) – estimates
size of the RBC MCH (mean corpuscular haemoglobin) –
measures the content of HgB in RBCs from a single cell
MCHC (mean corpuscular haemoglobin concentration) – a more accurate measurement of the HgB as it measures the entire volume of RBCs
Serum ferritin, transferrin, and total iron-binding capacity (TIBC)
these tests are used to evaluate iron levels
Ferritin – measures the iron in plasma, which is also a direct reflection of total iron stores
Transferrin – is the major iron-transport protein
While blood cell count
Abnormal elevation of the WBC is referred to as leukocytosis
Leukopenia is a decrease in the number of white blood cells
Differential count refers to the breakdown of the different types of cells
While blood cell count
Laboratory Test Value
WBC countDifferential Neutrophils Eosinophils Bashophils Lymphocytes Monocytes
5,000-10,000/mm3
60-70% or 3,000-7,000/mm3
1-3% or 50-400/mm3
0.3-0.5% or 25-200/mm3
20-30% or 1,000-4,000/mm3
3-8% or 100-6--/mm3
Coagulation studies
Bleeding time normal range is 1 to 4 minutes used in evaluation of platelet function extended bleeding times are seen with
thrombocytopenia and aspirin therapy
Coagulation studies
Prothrombin time (PT) is the rapidity of blood clotting normal range is 11 to 16 seconds; PT evaluates
extrinsic coagulation pathway which include factors I, II, V, VII, ZX; INR is often currently used instead of PT because it is a standardized value (therapeutic range often varies from 2 to 3 depending on the condition)
Coagulation studies
Partial thromboplastin time (PTT) – normal range is 60 to 70 seconds, which
evaluates the intrinsic coagulation pathway or fibrin clot formation
Coagulation studies
Activated partial thromboplastin time (APTT) – normal range is 30 to 45 seconds; is a modified PTT< preferred because it is quicker to perform used in heparin therapy and in the evaluation of
haemophilia increased in anticoagulation therapy, liver
disease, vitamin K deficiency, and disseminated intravascular coagulation (DIC)
Serum lipid profile a measurement used to determine risk of developing
atherosclerosisTotal serum lipids normal value 400 to 800 mg/dL
Triglycerides lipids stored in fat tissue, readily available for energy
production; normal serum value is generally accepted at 10 to 190
mg/dL (without elevated cholesterol, up to 250 mg/dL may be accepted)
Cholesterol the main lipid associated with atherosclerotic disease normal serum value generally accepted is <200 mg/dL in
adults
Serum lipid profile Lipoproteins proteins in the blood to transport cholesterol, triglycerides, and
other fats
High-density lipoproteins (HDL) transport cholesterol, to liver for excretion HDL/total cholesterol ratio should be at least 1:5, 1:3 more ideal
Low-density lipoproteins (LDL) transport cholesterol to peripheral tissues, associated with
increased risk of coronary artery disease
Pre-procedure nursing care – instruct client to fast for 12 to 13 hours before testing to ensure accurate results
Serum enzymes
increased in blood with heart damage; measurement of serum enzyme levels evaluates myocardial tissue infarction (injury to myocardium from decreased oxygenation)
serial testing over time detects trend and determines peak time and extent of injury
Serum enzymes
Creatinine kinase (CK) formerly known as creatine phosphokinase
(CPK) elevation indicates muscle injury CK-MB
specific to myocardial muscle; rises within 6 hours of injury, peaks at 18 hours post-injury and returns to normal in 2 to 3 days
is useful for early diagnosis of myocardial infarction
Serum enzymes
Lactic dehydrogenase (LDH) is found in many body tissues cardiac origin is confirmed with analysis of
isoenzymes (L1 is greater than L2; “flipped’ from normal levels)
elevation is detected within 24 to 72 hours after MI
peaks in 3 to 4 days returns to normal around 2 weeks; is useful in
delayed diagnosis of MI
Serum enzymes
Troponin onset is before CK-MB n MI peaks at 24 hours and returns to normal
around 2 weeks provides early sensitivity, extended
blood levels, and is more specific to cardiac injury for diagnosis of MI with an uncertain timeframe
Serum electrolytes level
Serum potassium affected by renal function and may be decreased by
diuretic agents that are used to treat heart failure decrease in potassium causes cardiac irritability and
predisposes the client receiving digitalis preparation to digitalis toxicity and dysrhythmia
increased potassium is manifested by myocardial depression and ventricular irritability.
Both hypokalemia and hyperkalemia can lead to the ventricular irritability. Both hypokalemia and hyperkalemia can lead to the ventricular fibrillation or cardiac standstill
Serum electrolytes levelCalcium necessary for blood coagulability and
neuromusclular activity hypocalcemia and hypercalcemia can cause
dysrhythmia
Sodium reflects relative fluid balance hyponatermia indicates fluid excess;
hypernatremia indicates fluid deficit
Serum electrolytes level
Serum glucose level – many patients with cardiac disease also have diabetes mellitus
Fasting blood sugar – serum glucose level drawn in a fasting state
Glycosylated haemoglobin – reflects the blood glucose level over 2 to 3 months
Serum glucose level
Fasting blood sugar – serum glucose level drawn in a fasting state
Glycosylated haemoglobin – reflects the blood glucose level over 2 to 3 months
Hemodynamics Monitoring Evaluate cardiovascular system
Pressure, flow, resistance Establish baseline values and evaluate
trends Determine presence and degree of
dysfunction Implement and guide interventions
Provides criteria for determination of CV efficacy
CVP (Central Venous Pressure) reflects the pressure of the blood in the right atrium. engorgement is estimated by far the venous column
can be observed as it rises from an imagined angle at the point of manubrium (angle of Louis).
With normal physiologic condition, the jugular venous column rises no higher than 2-3 cm above the clavicle with the client in a sitting position at a 450 angle.
CVP is a measurement of: Cardiac efficiency Blood volume Peripheral resistance
Right Ventricular Pressure a catheter is passed from a cut-down in the
antecubital, subclavian, jugular, or basilica vein to the right atrium and attached to a pre-calibrated manometer or transducer
Normal CVP is 2 to 8 cm H2O or 2 to 4 mm Hg. Decrease indicates decreased circulating
volume Increase indicates increased blood volume or
right heart failure.
Right Ventricular Pressure the patient should
be flat on bed with zero point of the manometer at the same level of right atrium which corresponds to the mid-axillary line or approximately 5 cm below the sternum.
Right Ventricular Pressure Fluctuations follow patient’s respiratory function:
fall on inspiration and rise on expiration due to changes in intrapulmonic pressure.
Reading should be obtained at the highest point of fluctuation.
If the patient is using ventilator, its use should be discontinued during the reading of CVP
Increase indicates fluid overload or congestive heart failure; decrease indicates low blood volume and more parenteral infusions needed.
Pulmonary Artery Pressure (PAP) appropriate for critically ill clients requiring more
accurate assessments of left heart pressures, including clients undergoing open heart surgery, clients in shock or with serious MIs.
Pulmonary artery (Swan-Ganz) catheter has the tip in the pulmonary artery.
Pressure measurement from this catheter is obtained after catheter tip is wedged in a pulmonary capillary, and is called the pulmonary capillary wedge pressure or PCWP; it is a good indicator of left ventricular end diastolic pressure (LVEDP).
Allows calculation of actual cardiac output and other hemodynamic parameters at frequent intervals in critically ill clients
CVP
0-8
15-25
0-8
4-12
110-130
4-12
15-25
8-15
110-130
70-80PAP
PCWP
Pulmonary Artery Pressure (PAP)
Client preparation obtain consent according to policy insertion is under strict sterile technique,
usually at the bedside explain to client that sterile drapes may cover
the face (with an internal jugular or subclavian insertion site)
assist to position client flat or slightly Trendelenburg as tolerated and instruct the client to remain still during the procedure
Pulmonary Artery Pressure (PAP)
Nursing care during insertion procedure assist physician in maintaining a sterile
field administer medications as ordered monitor and document HR, BP, and
ECG during procedure reassure client through procedure.
Pulmonary Artery Pressure (PAP)
Post-procedure nursing care monitor vital signs (VS) ECG at frequent intervals post-insertion maintain client on bed rest and avoid
unnecessary movements follow policy to maintain patency and
sterility of catheter.
Pulmonary Artery Pressure (PAP)
Nursing responsibilities in hemodynamic monitoring position the transducer at the level of the right
atrium (phlebostatic axis) level the CVP or pulmonary artery catheter
(Swan-Ganz) transducer to this point at regular intervals according to policy (usually each shift) and before each measurement
maintain patency of catheter with a constant small amount of fluid delivered under pressure.
Intra-arterial Blood Pressure
Measurement of systolic, diastolic, and mean blood pressure by using an intra-arterial catheter flushed with heparinised saline inserted usually in the radial artery.
If the radial artery is used, it is necessary to verify the presence of ulnar artery flow by an Allen’s Test
PLANNING
Health Promotion
Cardiovascular Risk Factors
Non-Modifiable Age Gender Race Genetic/Family History
Cardiovascular Risk Factors
Modifiable Significant: Hypertension Hypercholesteriolemia Hyperlipidemia Hypertriglycedemia Smoking
Cardiovascular Risk Factors
Contributory Obesity Glucose intolerance Sedentary lifestyle Stress
Cardiovascular Risk Factors
Associated Alcohol abuse Caffeine Decreased lung vital capacity Gout
Risk Management Age
atherosclerosis is a disease of middle age (40-50). Cardiovascular disease is greater in men until 65
when the incidence equalizes.
Gender higher estrogen levels of premenopausal women
because there may be a relationship between increase in estrogen level to high density lipoproteins
Risk Management
Race IHD (Ischemic Heart Disease) is higher in whites HPN is twice greater in blacks
Genetic history family history appears to be a significant risk
factor for predisposition to heart disease. For example, heart attack or stroke.
Risk Management
Race IHD (Ischemic Heart Disease) is higher in whites HPN is twice greater in blacks
Genetic history family history appears to be a significant risk
factor for predisposition to heart disease. For example, heart attack or stroke.
Hyperlipidemia refers to the increase in serum level with two of the
plasma lipids, cholesterol and triglycerides in the blood. Lipid – are mixed group of biochemical substances that
may be manufactured by the body or derived from metabolism of ingested substances
Cholesterol – a fat-related compound and excessive amount deposited in blood vessels may be a factor causation of atherosclerosis.
Example: egg yolk, organ meats such as liver and kidneys
Triglycerides – a fatty acid compound and consistently elevated levels of triglycerides may be conductive to premature arteriosclerosis.
Types of Hyperlipedemia Primary hyperlipedimia – caused by inborn
error of lipid metabolism. Secondary hyperlipedemia – related to such
conditions as DM or hypothyroidism. For lipids to be used and transported by the body, they need to become soluble in blood by combining with protein to form macromolecules called lipoproteins. Lipoproteins are vehicle for fat mobilization and transport.
Classification of Lipoprotein1. Chylomicrons – removes cholesterol form the liver Composition: Protein (2%), Phospholipids (6%-9%),
Cholesterol (2%), and Triglycerides (85-95%) Source: Dietary fat and exogenous lipid (foods that
are high in fats)2. Very low-density lipoprotein (VLDL) It carries triglycerides Transport triglyceride from the liver to periphery and
serves as precursor to low-density lipoprotein Elevated triglycerides levels are less associated with
coronary artery disease than Hypercholesterolemia
Classification of LipoproteinHigh VLDL concentration may increase the risk of
premature atherosclerosis when associated with other factors such as diabetes, hypertension, and cigarette smoking
Source: High dietary intake of carbohydrates such as bread and rice
Intermediate low-density lipoprotein (ILDL) it carries 60 to 70 percent of cholesterol and
therefore more closely associated with Hypercholesterolemia
Classification of LipoproteinLow-density lipoprotein (LDL) transport cholesterol from the liver to the periphery derived mainly from catabolism of VLDL. contains more cholesterol than any of the other lipoproteins and
has an affinity for arterial walls. Elevated LDL correlate most closely with an increased incidence of atherosclerosis.
High-density lipoprotein (HDL) contain more protein by with and less lipid than any other
lipoprotein. carry lipids away from arteries and to the liver for metabolism.
Therefore, high serum LDL is desirable. Composition: Protein (35%-60%), Phospholipids (34%-44%),
Cholesterol (20%-28%) and Triglycerides (14%) Source: Liver
Prevention Lifetime diet, low in saturated fat to prevent
hypercholesterolemia Triglycerides, the simple lipid, should be restricted in the
diet Example: lard, butterfat, olive oil, coconut oil, and
soybean oil Carbohydrate restricted to lower serum triglyceride
levels by reducing serum prebetalipoprotein, a combination of lipid and protein that is produced from carbohydrate
Diet low in cholesterol and saturated fat are advised to maintain a serum cholesterol below 140 mg/dL
Low cholesterol diets
Antilipemic Drugs lower the level of circulating blood lipid and may prevent
further atheromatous formation Example: Clofibrate (Atromid-S); Cholestyramine
(Cuemid)
Nursing Care: Eat salmon and tuna at least several times per week Increased intake of high-fiber food such as fruits,
vegetables, cereal grain, and legumes (string beans) Administer medications with meals to reduce GI irritation Monitor serum cholesterol and triglyceride levels during
therapy
Hypertension is the increased blood pressure, a systolic BP greater than
140mmHg and diastolic pressure greater than 90 mmHg over a sustained period.
known to be as a precursor of atherosclerosis, as yellow cheese-like fatty streaks containing cholesterol that develop into hardened plaques in the inner lining (intima) of major blood vessels and is associated with risk ischemic heart disease.
Increased systemic blood pressure increases resistance to left ventricular ejection and there will be subsequently left ventricular hypertrophy and increased cardiac workload with ultimate heart failure.
an even greater risk factor for atherosclerosis in the presence of diabetes mellitus and cigarette smoking.
PreventionControlling sodium and calorie intake on the diet Formula of getting the total calorie intake for a day
1 kilo calorie (kCal) x body weight in kilogram (kG) x 24 hourExample:Weight: 52 kGs1 kCal x body weight x 241 x 52 x 241240 kcal/day
salt may be used lightly in cooking. No salty processed foods are used, such as pickles,
olives, bacon, ham, and corn chips, or potato chips
Therapeutic Management
Diuretic drugs used to increase urine output, which reduces hypervolemia,
decreases the preload and aferload Example: Chlorothiazide (Diuril); furosemide (Lasix)
Nursing care: Monitor intake and output daily and record Weigh the client daily (same time, scale, and clothing) Administer drugs in the morning so that the maximal effect will
occur during the waking hours Assess vital signs, especially pulse and blood pressure, during the
course of therapy Instruct the client to change position slowly to prevent hypotension
(decrease blood pressure) Evaluate the client response to the medication
Therapeutic Management
Antihypertensive drug used to promote dilation of peripheral blood
vessels, thus decreasing blood pressure and afterload.
Example: methyldopa (aldomet); captopril (capoten), clonidine (catapress)
Nursing care: Monitor blood pressure in standing and lying
positions during the course of therapy. Instruct client to follow a low sodium diet
Smoking It contributes to the development and severity of
coronary artery disease in three ways:1. The inhalation of smoke increases the blood carbon
monoxide level reducing the oxygen carrying capacity of the blood and put added workload on the heart
2. Nicotine is a vasoconstrictor and also triggers the release of cathecolamines that in turn have an effect on adrenergic nerve endings, causing an increased heart rate and blood pressure.
3. Cigarette smoking increases platelet adhesion, leading to a higher probability of thrombus formation which results to decreased blood supply.
Smoking
Prevention: not to acquire the habit appropriate stress management
strategies initiate smoking cessation programs to
manage habit and totally eradicating it.
Sedentary Lifestyle
Inactivity may contribute to peripheral pooling and stress the cardiovascular system
Prolonged inactivity of sitting or lying in one position particularly contributes to venous stasis and problems of venous circulation, such as varicosities and thrombophlebitis
Sedentary LifestylePrevention
Engage in regular exercises, to improve cardiac efficiency, decrease heart rate and blood pressure, and increase cardiac output
Encourage the client to include exercise as a lifelong health habit
Risk Management Participate in regular exercise program such as aerobic activities
fitness prescription program which includes exercise to promote strength flexibility and endurance
Muscle strength – weight lifting Flexibility – stretching exercise Endurance – high intensity exercises such as jogging, walking,
bicycling or swimming
Sedentary Lifestyle3 Components of Exercise Program: Warm up – is used to increase cardiovascular and
musculoskeletal efficiency and limber up muscle. It lasts 5 to 10minutes. Example: walking
Workout – improve cardiac conditions and designed to reach a specific target heart rate. The duration or intensity depends on the individual health and objective for exercise.
Cool down – allows slowing of the cardiovascular system, dissipation of heat and removal of lactic acid. It has a slow rate for 5 to 10 minutes.
Obesity
defined as 20% over the ideal weight % IBW = (Adult weight (kG) divided by
DBW/IBW) x 100 BMI – Actual weight divided by height in
meter squared; BMI greater or equal to 27 is obesity
Obesity Dietary and exercise habit to present obesity Instruct about diet restriction in sodium, sugar,
and calories. It is essential for rearing healthy children of normal weight.
To overweight client and particularly hypertensive clients, weight reduction can be instituted like meal planning and program of behaviour modification
Stress a positive relationship exist between
psychological stress and cardiovascular disease
Management: Stress management: includes behaviour
modification Incorporating exercise to one’s life style Use of relaxation techniques Cognitive reframing or thorough stopping Temporary use of sedative or tranquilizers
Glucose intolerance serum glucose levels greater than 120 mg/100 mL are
at twice the risk for heart disease
Prevention Maintaining weight at normal level by using the
Tanhauser method Formula: height in cm minus one hundred Take the 10% reminder and subtract answer from the
remainder
Glucose intolerance
Example: height = 5’4”
5’ x 12” = 60”
60 “ + 4” = 64”
64” x 2.54 cm – 162.56 cm
162.56 cm – 100 = 63 cm
63 x 10% - 6.3
63 – 6.3 = 56.7 kG
57 kG x 2.2 lbs. – 125.4 lbs
Glucose intolerance Increased exerciseRisk Management: Encourage the patient to exercise and
follow a therapeutic plan for prevention Plan as to the prevention of
hyperglycemia and glucosuria Pharmacological agent, insulin to lower
serum glucose level
Alcohol Abuse It is a vasodilator Enhance high density lipoprotein Continuous consumption of large amount of alcohol
has recently been associated with cardiac toxicity Alcohol cardiomyopathy may decrease myocardial
and precipitate heart failure or dysrhythmias Prolonged alcohol use cause structural changes in the
myocardium and myocardial capillaries and sclerosis, fibrosis in the small arteries may lead to microinfarcts
Alcohol Abuse
Prevention Instruct the client about the danger of
alcohol Risk Management Referred client to individual or group of
counselling or to community withdrawal programs.
Caffeine
Excessive amount of caffeine cause cardiac dysrthymias, tachycardia, and extra systoles
Prevention Instruct the client to limit intake of
caffeine Example: coffee, tea, softdrinks, and
chocolates
Environmental Risk
Contaminants in foods, air, water, and drugs have been linked to cardiovascular disease
Minerals in the client’s water may contribute to heart disease
Side stream smoke from cigarette smoking, driving in traffic with carbon monoxide wastes, or working in tunnels in which carbon monoxide build-up is evident, may contribute to risk of cardiovascular disease
Client experiencing chest pain in smoke-filled rooms; it is believed that the increased carboxyhemoglobin levels cause hypoxia and increase cardiac oxygen demand.
Environmental Risk
Prevention Client who live in areas with high sodium
content in water supply may be advised to use distilled water or purified water
Other risks Decreased lung vital capacity – have a higher
incidence of heart disease due to changes in oxygenation that increase cardiac workload
Gout – twice the risk for ischemic heart disease
Promotion of Circulation Constricting clothing can impede arterial circulation and
should not be worn Example: a round garter, girdles, panty girdle, and belt Avoid long period of pressure on the blood vessels,
such as: Sitting with legs crossed at the knee obstructs
circulation in the popliteal area Sitting with the thigh flexed because it can constrict
femoral circulation Avoid standing for a long period of time, because this
may produce strain on the valves as the attempt t overcome gravity
Promotion of Circulation Encourage the client to wear support stocking when she must
stand for a long period of time; the hose compress the muscles of the leg, which help overcome gravity
The hose should be put before the person gets out of bed and pull on evenly from the toes to below the knee or to the groin
Encourage the client to walk and flex their leg as much as possible to promote venous return by the pressure of the muscle on the vein
The body shuld be kept warm which cause vasodilatation with clothing suitable for the weather
Blanket should be used as needed at night to keep the person warm
Alcoholic beverages may be ordered which produce peripheral vasodilatation to promote circulation
Smoking must be avoided and not advised
Prevention of Infection Syphilis is one disease that can cause
permanent damage to the myocardium or cardiac valve and treatment is imperative
Stapylococcus and Streptococcus organisms can enter the body through the oral route during dental procedures; prophylactic antibiotics may be given to individuals at risk for heart disease to prevent infections
Prevention of Infection Streptococcal throat infections are thought to
precede rheumatic fever and it should be evaluated by a physician and treated before further systemic damage
Women should have adequate prenatal care and immunization against rubella to prevent congenital heart defects because German measles may cause damage during first trimester of pregnancy
Prophylactic antibiotic may be given as prescribed
Prenatal care an immunization for the pregnant mother
Role of Nutrition
Well-balanced diet and that which contain sufficient calorie is needed to meet the metabolic demand of an individual and because adequate nutrition is essential in promoting oxygen to the cells
Small frequent meals are preferable Diet must contain sufficient vitamin and
iron
Health Maintenance and Restoration
Cardiac Surgeries and Endovascular Interventions
Percutaneous transmural coronary angioplasty (PTCA) purpose is to improve blood flow within a coronary
artery by “cracking” the atheroma. Because of the anticoagulants used during the
procedure, the site may have vice-type pressure device requiring a longer period of hourly site checks
monitor closely for any changes in ECG or sings of chest pain (even minor changes may be indicators if ischemia)
obtain a 12-lead ECG and notify physician of any complications.
Post procedure care similar to catheterization.
Percutaneous transmural coronary angioplasty (PTCA)
Coronary artery bypass grafting (CABG)
Client preparation Instruct the client in routine preoperative
teaching, including turning and deep breathing vigorous coughing is discouraged because it
may increase intrathoracic pressure and cause instability in the sterna area
incentive spirometry to prevent respiratory complications
leg exercises to prevent emboli formation
Coronary artery bypass grafting (CABG)
Post-procedure Instruct that client may resume sexual activity
when he or she can walk up two full flights of stairs without shortness of breath or chest pain
client should be rested, not after a heavy meal or alcohol consumption
Instruct client about symptoms to report to MD upon discharge including chest pain, shortness of breath, decrease in activity tolerance, fever, redness, swelling or drainage from surgical incisions
Coronary artery bypass grafting (CABG)
Post-procedure Instruct client that clinical depression occurs in about 20
percent of clients up to 6 months after cardiac surgery, and client should notify physician because antidepressant are very effective; include family in teaching and planning for discharge.
Instruct the client that many patients have difficulties in cognitive functions after the procedure.
Reassure client and family that the difficulty is temporary and will subside, usually 6-8 weeks
Coronary artery bypass grafting (CABG)
Coronary artery bypass grafting (CABG)
Valvular surgery repair and replacement procedure
Valvuloplasty – reconstruction including repair or removal of calcification or vegetation
Annuloplasty – narrowing a dilated valve with a prosthetic ring or purse string sutures, or enlarging a stenosed valve with a balloon
Repair is the preferred option, because of the lower incidence of post-surgical complications or mortality than valve replacement
Valvular surgery repair and replacement procedure
Client preparation and post-procedure nursing care
include instruction about preventing infection including prophylactic antibiotic therapy prior to prevent bacteria from entering the blood-stream through the gums
management of anticoagulation therapy if appropriate
Pacemakers permanent pacemakers are inserted in the
operating room to treat permanent cardiac conduction defects
Client Preparation obtain consent instruct client that bed rest is required for 24
hours and activity will gradually be increased to prevent dislodging of the leads
PacemakersPost-procedure nursing care monitor ECG continuously to ensure that pacing beats
are being captured and that intrinsic heartbeats are sensed
monitor the pacemaker site for signs of bleeding or infection
dressing should remain clean and dry with no temperature elevation, swelling, redness, or tenderness
right arm and shoulder movements may be minimized immediately post-procedure to ensure that pacemaker wire remains in contact with ventricular wall.
Pacemakers
I II III V
ElectrodePlacement
Electrodes that Sense Underlying Electrical Activity
Pacemaker Response to Sensation
Cardioverting Options
A= atrium A= atrium T= triggers* P= pacing
V= ventricle V= ventricle I= inhibits** S= shocking
D= dual (A+V) D= dual (A+V) D= dual (T+I) D= dual (P+S)
O= none O= none O= none O= none
I II III
Description
D D D Dual-lead pacemaker that paces and senses in atrium and ventricle
D D D Same as DDD plus it speeds up or slows down atrial and ventricular rate in response to sensor output (such as body temperature, resp. rate, etc. as in exercise)
V V I Single-lead pacemaker in the ventricle that is set at a fixed rate. Pacing activity is inhibited by a detected ventricular beat.
Common Cardiac Disorders
Coronary or Ischemic Heart Disease
Arteriosclerotic Heart Disease (ASHD) a slowly progressive heart condition characterized by: Internal thickening and plaque formation within the coronary
arteries due to the depression of fatty substances along the intima.
Results in fibrosis, calcification and narrowing of coronary arteries
A slow constriction of the blood supply to the myocardium, which can finally give rise to symptoms of angina.
Most common form of coronary heart disease. Nursing care centers around prevention and treatment of the
specific manifestation of particular disease process.
Angina Pectoris
a clinical entity describing the chest pain associated with transient myocardial ischemia
Types of Angina
Stable angina (classic) – chest pain occurring intermittently over a long period of time with the same pattern of onset, duration and intensity of symptoms
Unstable angina (progressive crescendo or pre-infraction – unpredictable and easily provoked by minimal or no stress, during sleep or even at total rest)
Types of Angina Prinzmetal’s angina (variant angina) – often
occurs at rest, usually in response to spasm of a major coronary artery (e.g. histamine angiotensin prostaglandin and epinephrine)
Nocturnal angina – occurs only at night but not necessarily when the person is in the recumbent position or during sleep
Angina decubitus – chest pain that occurs only while lying down and is usually relieved by standing or sitting.
Signs and symptoms of Angina substernal or precordial pain radiating to left
shoulder or pressure/heaviness/tightness/squeezing precipitated by exertion, emotion, and exposure to cold
relieved by rest and use of nitroglycerine tablets.
Pain is temporary lasting 3-5 minutes. Myocardial tissues are not permanently
damaged
Cause: atherosclerosis is by far the most common cause
Diagnosis: Nitroglycerine test (0.4 or 1/150 gr. of
nitroglycerine) shorten pain or increase tolerance to exercises
Nursing Goals
Increasing oxygen to the myocardium and relief of acute attacks
Reducing the demand for oxygen Helping client prevent future episodes of
angina
Anti-platelet aggregation therapy
first line of pharmacological intervention in the treatment of angina
Aspirin is the drug of choice Dipyridamole (Presantine)
Increasing Oxygen Supply
Nitrates: Rapid Acting
Nitroglycerine is the drug of choice and acts to relieve the pain in
about 3 minutes and has a duration of approximately 45 minutes by producing dilation of coronary blood vessels.
Usual dose is 0.3 mg (1/200 gr.) taken sublingually; allow to dissolve completely; retain
saliva before swallowing. Purchase a new supply every 6-9 months Clients will experience a burning sensation under his
tongue and a full throbbing sensation in his head of the tablet have full potency.
Increasing Oxygen Supply
Nitrates: Rapid Acting
Nitroglycerine Stored in a dark, airtight container because it is sensitive to heat,
light, and moisture and decomposes rapidly. Supply is refrigerated and only a few tablets carried with the
client. Repeat dosage every 5-10 minutes from 2 or 3 times. If no relief;
see a physician. Not habit-forming. Taken prior to exercising; eating a large meal; stressful situation
sexual intercourse Side effects: headache; dizziness, flushing Can be used prophylacticaly by taking the tablet 5-10 minutes
before beginning the activity
Increasing Oxygen Supply
Nitrates: Rapid Acting
Nitrostat – a stabilized form of nitroglycerine, Has uniform potency and can be carried without fear of decomposition.
Amyl Nitrate given in form of pearls ampoules which are
crushed and inhaled. Dose is 0.2 mg and must not be taken
repeatedly because it produces syncope
Increasing Oxygen Supply
Nitrates: Long Acting act to maintain coronary artery vasodilation, thereby promoting a greater
flow of blood and oxygen to heart muscle.
Isosorbide dinitrate (Isordil, Sorbitrate) maybe taken sublingually for acute attack or per Orem for their long-
acting action Side effects: headache; flushing; nausea and vomiting; hypertension;
vertigo; syncope
Nitroglycerine ointment (Nitrol and Nitropaste) is a 2% nitroglycerine topical ointment and provides vasodilation up to 3-
6 hours. Is particularly useful for management of nocturnal angina if applied
before sleep.
Increasing Oxygen Supply
Nitrates: Long Acting
Transdermal controlled – Release Nitrates – types:
1. Reservoir type – in which the drug migrates to the absorption site through a rate-controlled permeable membrane e.g. Transderm-Nitro
2. Matrix type – in which the drug is slowly dispersed through a polymeratrix to the skin absorption site
e.g. Nitro-Dur; Nitro-Disc
Increasing Oxygen Supply
Nitrates: Long Acting
Intravenous Nitroglycerine (Nitrol IV; Nitrostat IV; Ntirobid IV, Tridil)
has an immediate onset of action used in MI to increase the collateral blood flow to the ischemic area and reduce myocardial oxygen demand.
Titrate the dose down at night and titrate up during the day.
Increasing Oxygen Supply
Beta-adrenergic blocking agents
act to decrease oxygen requirement by decreasing heart rate and redistributing blood flow to non-ischemic portion of the heart.
Used if nitrates are not effective in managing pain.
E.g. Propanolol (Inderal) 10-30 mg TID
Increasing Oxygen Supply
Beta-adrenergic blocking agents
Side Effects: Nausea and vomiting Diarrhea extreme fatigue broncho-constriction sexual difficulties heart failure Bradycardia heart block hypoglycaemia
Increasing Oxygen Supply
Beta-adrenergic blocking agents
Nursing Care caution client not to discontinue drug,
since abrupt withdrawal may cause dysrhythmias, angina or MI from sudden increase in responsiveness to sympathetic stimuli
Increasing Oxygen Supply
Calcium-blocking agent
e.g. Nifedipine (Procardia), Verapamil (Calan, Isoptin), Diltiazem (Cardizem), Nicardipine (Cardene)
Effects: Systemic vasodilation with decrease
systemic vascular resistance (SVR) Decrease myocardial contractility Coronary vasodilatation
Increasing Oxygen Supply
Calcium-blocking agent
potentiate the action of Digoxin by increasing serum Digoxin levels during early part (first week) of therapy.
Digoxin levels should be closely monitored upon institution of this therapy
client should be taught the sign and symptoms of Digoxin toxicity
Increasing Oxygen Supply
Whisky or brandy
(30-60 mL) acts to promote dilations of blood vessels and general relaxation
Increasing Oxygen Supply
Reducing the demand for oxygen
Limiting activities Moderate amount of exercise to increase
myocardial strength Sedatives, tranquilizers, and anti-depressants Radioactive Iodine (131I) – occasionally given
to clients who have been refractory to treatment for 3 months in order to decrease activity of the thyroid gland which slows patient’s metabolism and lower workload of the heart.
prevent future episodes of angina
Diet – low in calorie and saturated fats to curtail obesity
5 to 6 small meals instead of 3 main meals Inform client that all forms of tobacco are
hazardous to his health Stress produces epinephrine leading to
vasoconstriction Regular program of daily exercise
Myocardial Infarction
occlusion of one of the coronary artery or its branches by a clot or sclerotic condition.
Myocardial Infarction Incidence: men in
middle life are often the persons who have MI. They usually have some degree of atherosclerosis and may or may not have hypertension
Myocardial Infarction
Signs and Symptoms steady, constrictive, sub-sternal chest
pain severe and not relieve by rest symptoms of shock elevation of temperature nausea and vomiting
Myocardial Infarction
ECG changes: ST elevation
reflects ischemic area.
ST elevation and T-wave inversion – a recent MI
Q-wave – necrosis formation
Myocardial Infarction
Laboratory Test: elevated CK with MB isoenzymes > 5%
(early diagnosis) elevated troponin (early to late
diagnosis) elevated LDH with “flipped isoenzymes”
(late diagnosis)
Diagnostics
↑ CPK-MB 4-8o 12-24o 3-4 days
↑ Myoglobin 1-3o 4-12o 12o
↑ Troponin I or T 3-4o 4-24o 1-3 wks
↑ SGOT (AST), ESR, ↑ Troponin levels LDH, LDH1, LDH2
Treatment and Nursing Care Relief of pain Demerol or morphine may be ordered. Demerol is less frequently given because it is more
likely to induce vomiting and to initiate vaso-vagal response.
IV NTG – may reduce pain and decrease preload and afterload while increasing myocardial oxygen supply.
Antidysrhythmic drugs Positive inotropic drugs – increase heart’s contractility
Caution: this drug increases the heart’s demand for oxygen Beta blockers – bradycardia and hypotension may
result
Treatment and Nursing Care Oxygen by tent, mask, or nasal catheter ECG monitoring; CVP; evaluation of apical pulse Administer anticoagulant (IV Heparin) and aspirin
(antiplatelet) as ordered to prevent additional clot formation. Monitor PTT to maintain heparin at therapeutic level
Diet – no iced or very hot drinks because they may precipitate cardiac arrhythmias; food known to be gas producing should be avoided
Bowel elimination be regulated by mild laxatives; client is not permitted to strain at defecation
Treatment and Nursing Care
Percutaneous transluminal coronary angioplasty (PTCA)
transluminal dilation can increase the diameter of the artery with the use of percutaneous fluoroschopically guided catheter to relive lesions in the coronary artery.
Treatment and Nursing Care
Thrombolytic therapy dissolving the thrombus in the coronary
artery and reperfusing the myocardium before cellular death occur
e.g. alteplase recombinant (activase) tissue plasminogen activator (t-PA) streptokinase (Streptase)
Congestive Heart Failure
Heart failure – is failure of the heart to pump an adequate amount of blood necessary for venous return and for the metabolic requirements of the body
Congestive Heart Failure
failure of the heart to eject blood form the ventricles as quickly as it enters the atria, leading to venous stasis of blood and fluid in organs (backward failure).
ventricular failure results in poor nutrition and anoxia to tissue (forward failure)
Failure of one side will shortly affect the other side of the heart.
Clinical manifestation 1. The vital organs are no longer perfused adequately with arterial
blood, thus oxygen and nutritional requirements fail to be met and they suffer from deprivation
2. The pulmonary vascular bed no longer is emptied effectively by the left atrium and ventricle, with the result that pulmonary vessels become engorged, pulmonary HPN develops and pulmonary edema supervene.
3. Blood returning to the heart from the periphery is not dispatched onward into the pulmonary vessels rapidly enough to avoid congestion in the systemic veins and venules, thus venous pressure rises, the liver and other organs become congested, and fluid escapes through the walls of engorged capillaries to form dependent edema and ascites.
Left Failure dyspnea on exertion (often the first
clinical sign) Orthopnea paroxysmal nocturnal dyspnea new S3 (ventricular gallop) as early sign; pulmonary edema is acute life-
threatening left heart failure, as previously described
Right failure
lower extremity edema jugular venous distension (JVD) is
visible more than a few millimetre above the clavicle with the client supine at a 45-degree angle
abdominal discomfort and nausea occur from fluid congestion in the abdominal organs
Diagnostic Findings Chest x-ray may show cardiomegaly or vascular
congestion Echocardiogram shows decreased ventricular function
and decreased ejection fraction CVP elevated in right-sided failure Pulmonary artery pressure monitoring may be used to
guide treatment in serious case of pulmonary edema to reduce the cardiac load by lessening the tissue demand for blood and eliminating factors that tend to stimulate cardiac activity unnecessarily – rest and sedation with barbiturates, opiates – Demerol and morphine sulphate.
Treatment and nursing care:
To reduce the cardiac load rest and sedation with barbiturates,
opiates Demerol and morphine sulphate
Treatment and nursing care: To reinforce the pumping action of the heart giving Cardiac Glycosides (digitalis) – which:
Increase efficiency of cardiac contraction; Slows the conduction of impulses through the AV
node; Prolongs refraction period of the node, and Increases irritability of heart muscle whether the K
level is normal or lower but the effect is more marked in the presence of lower K. So when administering with diuretics especially give KCl. Ex. Digitoxin (Lanoxin PO; IV); Lanatoside C (Cedilanid PO; IV), Deslanoside (Cediland-D IM; IV) Gitalin (Getaligin PO) Quabain (IV;IM)
Treatment and nursing care:
Signs and symptoms of digitalis toxicity arrhythmia (most important) anorexia, nausea and vomiting Diarrhea Bradycardia disturbances in color vision headache, and malaise
Guidelines in Administration of Digitalis
Observe the desirable and undesirable effects – desirable effects include the slowing pulse to 75-80 beats/minute; diminishing pulse deficit; greater force of cardiac contraction; increase in output of urine
All patients receiving digitalis must take it for prolonged period of time
Take HR – if below 60 or above 120 call the physician
Reduction of NA absorption and fluid retention
Diuretics – suppress the reabsorption of salt and water by the kidneys; may lead to K depletion because it also blocks the reabsorption of Cl, Na, and K ion in the proximal tubules.
Thiazides
chorothiazides (diuril); chlorthalidone (hygroton); hydrochlorothiazide (HydroDiuril); Indapamide (Lozol); Metolazone (Zaroxolyn).
Mechanism of Action – depress the ability of the convoluted tubules to reabsorb sodium and chloride. “Where water goes, so goes sodium”
Thiazides Side effects of electrolytes imbalance:
Muscle weakness Dizziness
take diuretic in the morning take with food if GI upset occurs weigh self every morning – report weight gain of more
than 2 to 3 lbs eat foods high in potassium (oranges, bananas,
broccoli, tomato juice, apricots, etc) avoid black licorice – may precipitate hypokalemia Drug increases lithium toxicity.
Loop diuretics very potent Bumetanide (Mumex) Furesemide (Lasix) Ethacrynic (Edecrin) Mechanism of action – inhibit
reabsorption of sodium and chloride in the proximal and distal tubules and loop of Henle.
Loop diuretics Nursing responsibilities – explain that this type
of drug is very fast acting. Teach client to:
Take diuretic in the morning Take with food or milk Avoid orthostasis Use sunscreen as increased photosensitivity may
occur Take potassium supplement as ordered Weigh self daily and report increases of 2 to 3 lbs
Potassium-sparing Amiloride (Midamor) Spironolactone (Aldactone) Trianteren (Dyrenium) Mechanism of action – block sodium-
potassium exchange mechanism in the distal portion of the tubule; prevent sodium reabsorption and retain potassium
Potassium-sparing
Teach client to: Take with food or milk Weigh self several times a week and
report a gain of over 3 lbs. Adverse side effects include: Gynecomastia Decreased libido
Potassium-sparing urine output must be measured weight patient accurately, watch for signs and
symptoms of electrolyte depletion decreasing Na intake watch out for toxicity – stomatitis, gingivitis, increased
salivation, diarrhea, albuminuria, hematurea, skin eruptions, flushing and febrile reaction to the drug.
Diuretics are given early in the morning to excrete fluid and the patient’s frequent need will not disturb his night time rest.
Increase of 3 to 5 pounds – most sensitive indicator of increasing fluid overload
Diet
0.5 gm of salt daily is the maximum sodium intake for patient of rigid Na restriction.
Complications of Congestive Heart Failure
Intractable heart failure Pulmonary infarction MI Digitalis toxicity Cardiac arrhythmias Pneumonia
Infective Disorders
Endocarditis
Pericarditis
ENDOCARDITIS
inflammatory disease involving the inner surface of the heart including the valves
Infective Endocarditis Inflammation of the endocardium; platelets and
fibrin deposit on the mitral and/or aortic valves causing deformity, insufficiency, or stenosis.
Caused by bacterial infection: commonly S. aureus, S. viridans, B-hemolytic streptococcus, gonococcus
Precipitating factors: rheumatic heart disease, open-heart surgery procedures, GU/Ob-Gyn instrumentation/surgery, dental extractions, invasive monitoring, septic thrombophlebitis
Infective Endocarditis
Risk Factors
RHD CHD IV drug abuse Cardiac surgery Immunosuppression Dental Procedures Invasive procedures
Signs and Symptoms
Fever, Chills Malaise, fatigue Night sweats Murmurs S/S HF Atrial Embolization
Signs and Symptoms
Petichiae -conjunctiva, mucus membranes
Splinter hemorrhages Janeway’s lesions – light pink macules on
palms and soles, non tender (early sign) Osler’s nodes – painful red nodes on
pads of fingers and toes (late sign)
Management
Drug therapy Antibiotics specific to sensitivity of organism
cultured Penicillin G and streptomycin if organism not
known Antipyretics
Cardiac surgery to replace affected valve
Pericarditis
inflammation of the visceral and parietal pericardium
Causes
Post-MI Trauma Neoplasm Connective Tissue Disease Post Cardiac Surgery Idiopathic Infectious
Signs and Symptoms
Pain
- sudden, sharp, severe, increases with inspiration
Pericardial Friction Rub Fever
Interventions
Monitor hemodynamic Status Antibiotic Therapy Erythromycin prophylaxis prior to dental
procedures (AHA) Anticoagulant Therapy Inform dentist or other hcare provider
regarding history
Valvular Defects
STENOSIS - heart valves are unable to fully open
REGURGITATION - heart valves are unable to fully close
Causes
Rheumatic Fever CHD Syphillis Endocarditis Hypertension
Signs and Symptoms Fatigue Dyspnea Orthopnea Hemoptysis Pulmonary Edema Dysrhythmia (A-
flutter, A-fib) Angina
Interventions
Valve Repair Valve Replacement
Dysrhythmias
Dysrhythmias
Disturbance in heart rate and/or heart rhythm
Caused by a disturbance in the electrical conduction of the heart
Asymptomatic until CO is altered
Cardiac Conduction
SA NODE - primary pacemaker; 60-100 beats/min
AV NODE - provides conduction delay; 40-60 beats/min
HIS PURKINJE SYSTEM - provides for orderly depolarization of the ventricles; 20-40 beats/min
Common causes
• drugs – digoxin, caffeine…
• acid-base / electrolyte imbalance (K+, Ca+, Mg+)
• marked thermal changes
• disease and trauma• stress
The nurse realizes that a pacemaker is used in some clients to sere the function normally performed by the
a. AV node
b. SA node
c. Bundle of His
d. Accelerator nerves to the heart
S/S
• change in pulse rate and/or rhythm
• EKG changes• Palpitatios• Syncope• Pain• Dyspnea• Diaphoresis• hypotension
VERY BASIC ECG
The ECG Paper
Now What is Normal?
Standard 12-Lead ECG
P wave Atrial activation Height < 0.2 mV
(2 mm) Duration < 0.12
sec
P-R Interval Intraatrial,
internodal, His purkinje conduction
Duration 0.12 to 0.20
Standard 12-Lead ECG
THE QRS COMPLEX Ventricular
activation Duration <0.12
sec
Standard 12-Lead ECG
THE ST-SEGMENT Phase 2 of transmembrane potential Isoelectric
Standard 12-Lead ECG
THE T WAVEUpright after the age
of 16Juvenile T wave
Standard 12-Lead ECG
THE U WAVE Surface reflection
of negative after potential
Repolarization of Purkinje fibers
Ventricular relaxation
Standard 12-Lead ECG
THE QT INTERVAL From beginning of
QRS to end of T wave
Reflects the duration of depolarization and repolarization
Bazett: Q-Tc Interval = Q-Ta / √R-R
Standard 12-Lead ECG
WAVE INTERVAL DURATION (sec.)
P wave duration < .12
PR interval .12 - .20
QRS duration <.12
QT interval (corrected) < .44 - .55
Normal Values
How to interpret?ORIGIN
Sinus
Atrial
Nodal or Junctional
Ventricular
RHYTHM AND RATETachycardiaBradycardia
OTHER VARIATIONSPremature ComplexesFibrillationFlutter
What is this?
NORMAL SINUS RHYTHM
Rate Rhythm
P waves
PR interval QRS
60-100 beats per minute Atrial regular Ventricular regular
Uniform in appearance, upright, normal shape, one preceding each QRS complex
0.12-0.20 second 0.10 second or less.
Sinus BradycardiaRateRhythm
P waves
PR intervalQRS
Less than 60 beats per minuteAtrial regularVentricular regularUniform in appearance, upright, normal
shape, one preceding each QRS complex
0.12-0.20 secondUsually 0.10 second or less
Sinus Rhythms
Sinus TachycardiaRateRhythm
P waves
PR intervalQRS
Usually 100-160 beats per minuteAtrial regularVentricular regularUniform in appearance, upright, normal
shape, one preceding each QRS complex
0.12-0.20 secondUsually 0.10 second or less
Sinus Rhythms
Sinus Dysrhythmia (Arrhythmia)Rate
Rhythm
P waves
PR intervalQRS
Usually 100-160 beats per minute but may be faster or slower
Irregular (R-R intervals shorten during inspiration and lengthen during expiration)
Uniform in appearance, upright, normal shape, one preceding each QRS complex
0.12-0.20 secondUsually 0.10 second or less
Sinus Rhythms
Sinoatrial (SA) BlockRate
Rhythm
P waves
PR intervalQRS
Usually normal but varies because of pause
Irregular – the pause is the same as (or an exact multiple of) the distance between two other P-P intervals
Uniform in appearance, upright, normal shape, one preceding each QRS complex
0.12-0.20 secondUsually 0.10 second or less
Sinus Rhythms
Sinus ArrestRate
Rhythm
P waves
PR intervalQRS
Usually normal but varies because of the pause
Irregular – the pause is of undetermined length (more than one PQRST complex is omitted) and is not the same distance as other P-P intervals.
Uniform in appearance, upright, normal shape, one preceding each QRS complex
0.12-0.20 secondUsually 0.10 second or less
Sinus Rhythms
What is this?
Atrial Rhythms
Premature Atrial Complexes1. Early (premature) P waves2. Upright P waves that differ in shape from normal
sinus P waves in Lead II• P waves may be biphasic (partly positive, partly
negative), flattened, notched or pointed3. The early P wave may or may not be followed by a
QRS complex
Vagal Maneuversbaroreceptors in the internal carotid arteries and the aortic arch → vagus nerve → acetylcholine → PNS → slows conduction in the AV node → ↓ heart rate
Bearing down Squatting Breath-holding Immersion of the face in ice water Stimulation of the gag reflex Carotid sinus pressure (massage)
*****Carotid pressure should be avoided in older patients. Simultaneous, bilateral carotid pressure should never be performed.
What is this?
Atrial Rhythms
Supraventricular TachycardiaRateRhythmP waves
PR interval
QRS
150-250 beats per minuteRegularAtrial P waves may be seen which differ from
sinus P waves (may be flattened, notched, pointed, or biphasic).
Usually not measurable because the P wave is difficult to distinguish from the preceding T wave. If P waves are seen, the RR interval will usually measure 0.12-0.20 second.
Less than 0.10 second unless an intraventricular conduction defect exists.
CARDIOVERSION
Synchronized Countershockreduces the potential for delivery of energy during the vulnerable
period of the T wave (relative refractory period). A synchronizing circuit allows the delivery of a countershock to be
“programmed”. The machine searches for the peak of the QRS complex (R wave deflection) and delivers the shock a few milliseconds after the highest part of the R wave.
Indications: SUPRAVENTRICULAR TACHYCARDIA ATRIAL FIBRILLATION ATRIAL FLUTTER UNSTABLE VENTRICULAR TACHYCARDIA WITH PAUSE
A nurse is evaluating a client’s response to cardioversion. Which of the following observations would be of highest priority to the nurse?
a. Oxygen flow rate
b. Status of airway
c. Blood pressure
d. Level of consciousness
What is this?
Atrial Rhythms
Wandering Atrial Pacemaker (Multiformed Atrial Rhythm)
Rate
Rhythm
P waves
PR intervalQRS
60-100. If the rate is greater than 100 beats per minute, the rhythm is termed multifocal (or chaotic) atrial tachycardia.
Atrial – irregularVentricular - irregularSize, shape, and direction may change from
beat to beat. At least three different P waves are required for a diagnosis of wandering atrial pacemaker
Variable Usually less than 0.10 second unless an
intraventricular conduction defect exists
What is this?
Atrial Rhythms
Atrial FlutterRate
Rhythm
P wavesPR intervalQRS
Atrial rate 250-350 beats per minute; ventricular rate variable – determined by AV blockade. The ventricular rate will usually not exceed 180 beats per minute due to the intrinsic conduction rate of the AV junction.
Atrial regularVentricular may be regular or irregularNot identifiable P waves; saw-toothed “flutter waves”Not measurableUsually less than 0.10 second but may be widened if
flutter waves are buried in the QRS complex or if an intraventricular conduction defect exists.
What is this?
Atrial Rhythms
Atrial FribrillationRate
Rhythm
P waves
PR intervalQRS
Atrial rate usually greater than 350-400 beats per minute; ventricular rate variable
Ventricular rhythms usually very irregular; a regular ventricular rhythm may occur because of digitalis toxicity.
No identifiable P waves; fibrillatory waves present. Erratic wavy baseline.
Not measurableUsually less than 0.10 second but may be
widened if an intraventricular conduction defect exists.
A client has developed atrial fibrillation, with a ventricular rate of 150 beats per minute. A nurse assess the client for
a. Hypotension and dizziness
b. Nausea and vomiting
c. Hypertension and headache
d. Flat neck veins
What is this?
Atrial Rhythms
Wolff-Parkinson-White (WPW) SyndromeRate
Rhythm
P waves
PR intervalQRS
If the underlying rhythm is sinus in origin, the rate is usually 60-100 beats per minute.
Regular unless associated with atrial fibrillation
Normal and upright unless WPW is associated with atrial fibrillation
If P waves are seen, less than 0.12 secondUsually greater than 0.12 second. Slurred
upstroke of the QRS complex (delta wave) is often seen in one or more leads)
What is this?
Ventricular RhythmsPremature Ventricular Complexes
Rate
Rhythm
P wavesPR interval
QRS
Usually normal but depends on the underlying rhythm
Essentially regular with premature beats. If the PVC is an interpolated PVC, the rhythm will be regular.
There is no P wave associated with the PVCNone with the PVCs because the ectopic beat
originates in the ventricleGreater than 0.12 second.Wide and bizarre.T wave frequently in opposite direction of the
QRS complex.
Ventricular RhythmsPatterns of PVCs
1. Pairs (couplets) – two sequential PVCs2. Runs or bursts – three or more sequential PVCs are
called vntricular tachycardia (VT)3. Bigeminal PVCs (ventricular bigeminy) – every other
beat is a PVC4. Trigeminal PVCs (ventricular trigeminy) – every third
beat is a PVC5. Quadrigeminal PVCs (ventricular quadrigeminy) –
every fourth beat is a PVC
A client is having frequent premature ventricular contractions. A nurse would place priority on assessment of which of the following items
a. Blood pressure and peripheral perfusion
b. Sensation of palpitations
c. Causative factors such as caffeine
d. Precipitating factors such as infection
Ventricular Rhythms
Warning Dysrhythmias Six or more PVCs per minute PVCs that occurred in pairs (couplets) or in
runs or three or more (ventricular tachycardia) PVCs that fell on the T wave of the preceding
beat (R-on T phenomenon) PVCs that differed in shape (multiformed
PVCs)
What is this?
Ventricular Tachycardia (VT)Rate
Rhythm
P waves
PR intervalQRS
Atrial rate not discernible, ventricular rate 100-250 beats per minute
Atrial rhythm not discernibleVentricular rhythm is essentially regularMay be present or absent; if present they have
no set relationship to the QRS complexes – appearing between the QRS’s at a rate different from that of the VT.
NoneGreater than 0.12 second.Often difficult to differentiate between the QRS
and the T wave.
Ventricular Rhythms
CAUSES Hypoxia Exercise R-on T PVCs Catecholamines Digitalis toxicity Myocardial ischemia Acid-base imbalance Electrolyte imbalance Ventricular aneurysm Coronary artery disease Rheumatic heart disease Acute myocardial infarction CNS stimulants (cocaine, amphetamines)
Ventricular Rhythms
What is this?
Torsades de Pointes (TdP)Rate
Rhythm
P wavesPR intervalQRS
Atrial rate not discernible, ventricular rate 150-250 beats per minute
Atrial not discernibleVentricular may be regular or irregularNoneNoneGreater than 0.12 second.Gradual alteration in the amplitude and
direction of the QRS
What is this?
Ventricular FibrillationRate
Rhythm
P wavesPR intervalQRS
Cannot be determined since there are no discernible waves or complexes to measure
Rapid and chaotic with no pattern or regularity
Not discernibleNot discernibleNot discernible
Ventricular Rhythms
Unsynchronized Countershock random delivery of energy there is no relation of the discharge of
energy to the cardiac cycle Purpose: to produce momentary asystole to completely depolarize the
myocardium and provide an opportunity for the natural pacemaker centers of the heart to resume normal activity.
DefibrillationDefibrillation
Unstable Ventricular Tachycardia with a Pulse
Pulseless Ventricular TachycardiaVentricular FibrillationSustained Torsades de Pointes
Ventricular Rhythms
What is this?
AsystoleRate
Rhythm
P wavesPR intervalQRS
Ventricular usually indiscernible but may see some atrial activity.
Atrial may be discernible.Ventricular indiscernible.Usually not discernibleNot measurableAbsent
Ventricular Rhythms
What is this?
Causes of Pulseless Electrical Activity (MATCHx4ED)Myocardial infarction (massive acute)AcidosisTension pneumothoraxCardiac tamponadeHypovolemia (most common cause)HypoxiaHyperkalemiaHypothermiaEmbolus (massive pulmonary)Drug overdoses (cyclic antidepressants, calcium channel
blockers, beta-blockers, digitalis)
Ventricular Rhythms
What is this?
1st Degree AV BlockRate
RhythmP waves
PR interval
QRS
Atrial and ventricular rates the same; dependent upon underlying rhythm.
Atrial and ventricular regularNormal in size and shapeOnly one P wave before each QRSProlonged (greater than 0.20 second) but
ConstantUsually 0.10 second or less unless an
intraventricular conduction exists
AV Blocks
What is this?
2nd Degree AV Block, Type I (Wenckebach)Rate
Rhythm
P waves
PR interval
QRS
Atrial rate is greater than the ventricular rate. Both are often within normal limits.
Atrial regular (P’s plot through)Ventricular irregular.Normal in size and shape. Some P waves are
not followed by a QRS complex (more P’s than QRS’s).
Lengthens with each cycle (although lengthening may be very slight), until a P wave appears without a QRS complex. The PRI after the nonconducted beat.
Usually 0.10 second or less but is periodically dropped.
AV Blocks
What is this?
2nd Degree AV Block, Type II (Mobitz)Rate
Rhythm
P waves
PR interval
QRS
Atrial rate is greater than the ventricular rate. Ventricular rate is often slow.Atrial regular (P’s plot through)Ventricular irregular.Normal in size and shape. Some P waves are
not followed by a QRS complex (more P’s than QRS’s).
Within normal limits or prolonged but always constant for the conducted beats. There may be some shortening of the PRI that follows a nonconducted P wave.
Usually 0.10 second or greater, periodically absent after P waves.
AV Blocks
What is this?
2nd Degree AV Block, 2:1 ConductionRate
RhythmP waves
PR intervalQRS
Atrial rate is greater than the ventricular rate.Atrial regular (P’s plot through)Ventricular regular.Normal in size and shape; every other P wave
is followed by a QRS complex (more P’s than QRS’s)
ConstantWithin normal limits if the block occurs above
the bundle of His (probably type I); wide if the block occurs at or below the bundle of His (probably type II); absent after every other P wave.
AV Blocks
What is this?
Complete (Third-Degree) AV BlockRate
Rhythm
P wavesPR interval
QRS
Atrial rate is greater than the ventricular rate. The ventricular rate is determined by the origin of the escape rhythm.
Atrial regular (P’s plot through). Ventricular regular. There is no relationship between the atrial and ventricular rhythm.
Normal in size and shape.None – the atria and ventricles beat
independently of each other, thus there is no true PR interval.
Narrow or broad depending on the location of the escape pacemaker and the condition of the intraventricular conduction system.
Narrow = junctional pacemaker; wide = ventricular pacemaker.
AV Blocks
Classification of AV Blocks
Ventricular Rhythm
PR Interval
QRS Width
Second-Degree AV Block Type I
Irregular
Lengthening
Usually narrow
Second-Degree AV Block Type II
Irregular
Constant
Usually wide
AV Blocks
Classification of AV Blocks
Ventricular Rhythm
PR Interval
QRS Width
Second-Degree AV Block, 2:1 Conduction
Regular
Constant
May be narrow or wide
Complete (Third-Degree) AV Block
Regular
None – no relationship between P waves and
QRS complexesMay be narrow or wide
AV Blocks