Coronary Artery Disease Cad2

ALTERATIONS IN ALTERATIONS IN OXYGENATIONOXYGENATION

ALTERATIONS IN ALTERATIONS IN OXYGENATIONOXYGENATION

Assessing Clients with Cardiac DisordersAssessing Clients with Cardiac Disorders Anatomy, Physiology and Functions of the Anatomy, Physiology and Functions of the

Heart Heart Systemic, Pulmonary and Coronary Systemic, Pulmonary and Coronary

CirculationCirculation Gas TransportGas Transport Cardiac Cycle and Cardiac OutputCardiac Cycle and Cardiac Output

NURSING ASSESSMENT OF THE NURSING ASSESSMENT OF THE CARDIAC PATIENTCARDIAC PATIENT

Effective cardiac nursing requires application of Effective cardiac nursing requires application of critical thinking to patient care activities. The critical thinking to patient care activities. The challenge to the cardiovascular nurse is to anticipate challenge to the cardiovascular nurse is to anticipate precipitous changes in the patient’s condition by precipitous changes in the patient’s condition by using data derived from physical assessment and using data derived from physical assessment and sophisticated bedside hemodynamic monitoring sophisticated bedside hemodynamic monitoring equipment. equipment.

The nursing process, a systematic problem solving The nursing process, a systematic problem solving method, is the recognized framework for patient care. method, is the recognized framework for patient care. As in all other areas of nursing, assessment is the As in all other areas of nursing, assessment is the vital first phase of the nursing process.vital first phase of the nursing process.

ComponentsComponents

INTERVIEW, to obtain subjective dataINTERVIEW, to obtain subjective data PHYSICAL EXAMINATION, to obtain PHYSICAL EXAMINATION, to obtain

objective dataobjective data

NURSING HISTORYNURSING HISTORY Asking relevant questions about the patient’s current and past Asking relevant questions about the patient’s current and past

health status and practices can elicit valuable information about health status and practices can elicit valuable information about the patient’s prior experiences within the health care system, the patient’s prior experiences within the health care system, his or her attitudes regarding health, and etiologic factors that his or her attitudes regarding health, and etiologic factors that may have contributed to the development of cardiovascular may have contributed to the development of cardiovascular disease.disease.

Chief ComplaintChief Complaint

Determining WHY the person sought medical treatment helps Determining WHY the person sought medical treatment helps to establish priorities of care and evaluates the person’s to establish priorities of care and evaluates the person’s perception of the illness. Common c/o include CHEST PAIN, perception of the illness. Common c/o include CHEST PAIN, SHORTNESS OF BREATH, FATIGUE, PALPITATION, and SHORTNESS OF BREATH, FATIGUE, PALPITATION, and PERIPHERAL SKIN CHANGES. If the patient has more than PERIPHERAL SKIN CHANGES. If the patient has more than one c/o, priority should be assigned according to the amount of one c/o, priority should be assigned according to the amount of concern they generate in the patient. concern they generate in the patient.

NURSING HISTORYNURSING HISTORY

Answers to the following questions can Answers to the following questions can provide information about the perceived provide information about the perceived significance of these symptoms:significance of these symptoms: How long has the symptoms been experienced?How long has the symptoms been experienced? What tends to trigger the symptom?What tends to trigger the symptom? What interventions or activities alleviate the What interventions or activities alleviate the

symptoms?symptoms? How does the symptom affect the patient’s How does the symptom affect the patient’s

lifestyle?lifestyle?

NURSING HISTORYNURSING HISTORY

The patient’s perception of the illness may or may not The patient’s perception of the illness may or may not correlate with the actual physical condition. correlate with the actual physical condition. Perception of the disease state is dependent upon Perception of the disease state is dependent upon three factors:three factors: The patient’s understanding or knowledge of the illnessThe patient’s understanding or knowledge of the illness The patient’s immediate concerns. A problem at work or at The patient’s immediate concerns. A problem at work or at

home may have a higher priorityhome may have a higher priority Outcome expected by the patient regarding present illness Outcome expected by the patient regarding present illness

and hospitalization. These include the perceived impact on and hospitalization. These include the perceived impact on a coronary event on lifestyle, the symbolic meaning of a coronary event on lifestyle, the symbolic meaning of heart disorders, fear of impending death, and anxiety heart disorders, fear of impending death, and anxiety regarding the necessity for and length of a hospital stay.regarding the necessity for and length of a hospital stay.

Medical HistoryMedical History Information about childhood diseases, particularly RH fever or Information about childhood diseases, particularly RH fever or

Congenital anomalies, should be obtain. Any history of Congenital anomalies, should be obtain. Any history of previous hospitalization and chronic or major illnesses must previous hospitalization and chronic or major illnesses must also be determined. Of particular interest are conditions that also be determined. Of particular interest are conditions that influence current cardiovascular performance, such as DM. influence current cardiovascular performance, such as DM. HTN. Thyroid disorders, Kidney disease, Stroke, Anemia, HTN. Thyroid disorders, Kidney disease, Stroke, Anemia, Gout, Thrombophlebitis, or bleeding disorders.Gout, Thrombophlebitis, or bleeding disorders.

Because many drugs can affect the overall performance of the Because many drugs can affect the overall performance of the cardiovascular system, it is imperative to assess current use of cardiovascular system, it is imperative to assess current use of prescription or over- the- counter drugs; not only prescription or over- the- counter drugs; not only cardiovascular drugs but also anticoagulants, bronchodilators, cardiovascular drugs but also anticoagulants, bronchodilators, steroids, antidepressants, contraceptives, antihistamines, and steroids, antidepressants, contraceptives, antihistamines, and antineoplastic agents.antineoplastic agents.

Identifying Risks FactorsIdentifying Risks Factors

Based on the determination of existing risk Based on the determination of existing risk factors, a plan can be formulated to assist the factors, a plan can be formulated to assist the patient in making necessary lifestyle changes patient in making necessary lifestyle changes to promote health and lessen the impact of to promote health and lessen the impact of heart disease.heart disease.

NON-MODIFIABLE RISK FACTORS NON-MODIFIABLE RISK FACTORS (Factors that can not be change)(Factors that can not be change)

AgeAge- persons above 40 years of age are at risks to develop - persons above 40 years of age are at risks to develop cardiovascular diseases. This is due to degenerative changes in cardiovascular diseases. This is due to degenerative changes in the heart and blood vessels.the heart and blood vessels.

GenderGender- males are more prone to cardiovascular disorders - males are more prone to cardiovascular disorders before the age of 65 years. However, females have higher before the age of 65 years. However, females have higher propensity to cardiovascular disorder after the age of 65 years. propensity to cardiovascular disorder after the age of 65 years. This is due to decrease estrogen levels I menopause. HDL This is due to decrease estrogen levels I menopause. HDL decreases, LDL increases. Atherosclerosis develops.decreases, LDL increases. Atherosclerosis develops.

RaceRace- cardiovascular disorders are among the 10 leading - cardiovascular disorders are among the 10 leading causes of death worldwide.causes of death worldwide.

HeredityHeredity- persons with family history for cardiovascular - persons with family history for cardiovascular disorders are at risk to develop these diseases.disorders are at risk to develop these diseases.

MODIFIABLE RISK FACTORS MODIFIABLE RISK FACTORS (Factors that can be change)(Factors that can be change)

Lifestyle or behavioral factors can be controlled or completely eliminatedLifestyle or behavioral factors can be controlled or completely eliminated

Cigarette smoking-Cigarette smoking- Nicotine causes vasoconstriction and spasm of the Nicotine causes vasoconstriction and spasm of the arteries; increased myocardial oxygen demands; and adhesion of platelets; arteries; increased myocardial oxygen demands; and adhesion of platelets; in addition cigarette smoking has been associated with decreased levels of in addition cigarette smoking has been associated with decreased levels of HDL (good cholesterol). Male cigarette smoker has 2-3X the risk of HDL (good cholesterol). Male cigarette smoker has 2-3X the risk of developing heart disease of the non-smoker; the female who smokes has up developing heart disease of the non-smoker; the female who smokes has up to 4X the risk. For both men and women who stop smoking, the risk of to 4X the risk. For both men and women who stop smoking, the risk of mortality is reduced by half.mortality is reduced by half.

Second-hand (or environmental) tobacco smoke also increases the risk of Second-hand (or environmental) tobacco smoke also increases the risk of death from CHD, by as much as 30%death from CHD, by as much as 30%

Tobacco smoke promotes CHD is several ways:Tobacco smoke promotes CHD is several ways: Carbon monoxide damages vascular endothelium, promoting cholesterol Carbon monoxide damages vascular endothelium, promoting cholesterol

deposition.deposition. Nicotine also constricts arteries, limiting tissue perfusion (blood flow and Nicotine also constricts arteries, limiting tissue perfusion (blood flow and

oxygen delivery). Further nicotine reduces HDL levels and increases platelet oxygen delivery). Further nicotine reduces HDL levels and increases platelet aggregation, increasing risk of thrombus formation.aggregation, increasing risk of thrombus formation.

FACTS: Cigarette smoking is the leading independent risk factor for CHD FACTS: Cigarette smoking is the leading independent risk factor for CHD and a primary target of risk factor management.and a primary target of risk factor management.

MODIFIABLE RISK FACTORS MODIFIABLE RISK FACTORS (Factors that can be change)(Factors that can be change)

AlcoholAlcohol. Positively correlates with high blood pressure.. Positively correlates with high blood pressure. StressStress. Sympathetic response stimulation causes increased secretion of . Sympathetic response stimulation causes increased secretion of

norepinephrine; this results to vasoconstriction and tachycardia. Increased BP and norepinephrine; this results to vasoconstriction and tachycardia. Increased BP and increased cardiac workload occur.increased cardiac workload occur.

Diet.Diet. Increased dietary intake of foods high in sodium, fats and cholesterol Increased dietary intake of foods high in sodium, fats and cholesterol predisposes a person to cardiovascular disorder.predisposes a person to cardiovascular disorder.

Exercise.Exercise. Regular pattern of exercise improves circulation to different body parts, Regular pattern of exercise improves circulation to different body parts, maintains vascular tone and enhances release of chemical activators (tissue-type maintains vascular tone and enhances release of chemical activators (tissue-type plasminogen activators), which prevent platelet aggregation.plasminogen activators), which prevent platelet aggregation.

Hypertension.Hypertension. Increased systemic vascular resistance, endothelial damage, increased Increased systemic vascular resistance, endothelial damage, increased platelet adherence, increased permeability of endothelial lining, result from elevated platelet adherence, increased permeability of endothelial lining, result from elevated BP.BP.

Hyperlipidemia, HypercholesterolemiaHyperlipidemia, Hypercholesterolemia. Increased LDL cholesterol (“bad . Increased LDL cholesterol (“bad cholesterol”) damages endothelium and causes accumulation or endothelial lining and cholesterol”) damages endothelium and causes accumulation or endothelial lining and proliferation of smooth muscle cells. Low-density lipoproteins (LDLs) are the proliferation of smooth muscle cells. Low-density lipoproteins (LDLs) are the primary carriers of cholesterol; high levels promotes atherosclerosis because LDL primary carriers of cholesterol; high levels promotes atherosclerosis because LDL deposits cholesterol on artery walls; (LDLs=less desirable lipoproteins). In contrast, deposits cholesterol on artery walls; (LDLs=less desirable lipoproteins). In contrast, high-density lipoproteins (HDLs=highly desirable lipoproteins) help clear cholesterol high-density lipoproteins (HDLs=highly desirable lipoproteins) help clear cholesterol from the arteries transporting it to the liver for excretion.from the arteries transporting it to the liver for excretion.

MODIFIABLE RISK FACTORS: MODIFIABLE RISK FACTORS: (Factors that can be change)(Factors that can be change)

Diabetes MellitusDiabetes Mellitus. Glucose from carbohydrates cannot be . Glucose from carbohydrates cannot be transported into the cells due to insulin deficiency or increased transported into the cells due to insulin deficiency or increased resistance to insulin. resistance to insulin.

The body then, mobilizes fats (lipolysis), to become a The body then, mobilizes fats (lipolysis), to become a source of glucose. However, not all of the fats mobilized are source of glucose. However, not all of the fats mobilized are converted into glucose.converted into glucose.

Hyperlipidemia Hyperlipidemia results, which enhances the risk of results, which enhances the risk of atherosclerosis.atherosclerosis.

Obesity.Obesity. This results to increased cardiac workload. May also This results to increased cardiac workload. May also be characterized by rise in serum lipid levels.be characterized by rise in serum lipid levels.

Personality type or Behavioral FactorsPersonality type or Behavioral Factors. The type A behavioral . The type A behavioral pattern, characterized by competitiveness, impatience, pattern, characterized by competitiveness, impatience, aggressiveness and time urgency has been correlated to CAD, aggressiveness and time urgency has been correlated to CAD, although the mechanism is unknown.although the mechanism is unknown.

Contraceptive Pills.Contraceptive Pills.May precipitate thromboembolism and May precipitate thromboembolism and HPN.HPN.

SUBJECTIVE FINDINGS SUBJECTIVE FINDINGS (clinical manifestations)(clinical manifestations)

The common symptoms of cardiac patients The common symptoms of cardiac patients described below are usually caused by one or described below are usually caused by one or all of three physiologic disorders: cardiac all of three physiologic disorders: cardiac ischemia, pump insufficiency, and rhythm ischemia, pump insufficiency, and rhythm disturbances.disturbances.

CHEST PAIN.CHEST PAIN. Pain (or related discomfort) Pain (or related discomfort) caused by an O2 supply inadequate to meet caused by an O2 supply inadequate to meet myocardial oxygen demand is a cardinal myocardial oxygen demand is a cardinal symptom of heart disease.symptom of heart disease.


The following elements of pain are usually assessed to confirmed The following elements of pain are usually assessed to confirmed ischemic cardiac pain and to differentiate angina from ischemic cardiac pain and to differentiate angina from myocardial infarction.myocardial infarction. Characteristics. Chest pain maybe described as a “strange feeling”, Characteristics. Chest pain maybe described as a “strange feeling”,

discomfort, dull heavy pressure, indigestion, crushing, burning, discomfort, dull heavy pressure, indigestion, crushing, burning, constricting, acting, stabbing, and tightness.constricting, acting, stabbing, and tightness.

Location. Pain maybe substernal, precordial, across the chest, or Location. Pain maybe substernal, precordial, across the chest, or around the nipple line. It maybe diffuse or localized.around the nipple line. It maybe diffuse or localized.

Radiation. The pain may also radiate to the jaw, teeth, neck, left Radiation. The pain may also radiate to the jaw, teeth, neck, left shoulder, left arm or both arms, and the back. In some patients, the shoulder, left arm or both arms, and the back. In some patients, the radiated pain rather than the chest pain is the only presenting radiated pain rather than the chest pain is the only presenting discomfort.discomfort.

Severity. Using a scale of 1(least severe) to 10(most severe), ask the Severity. Using a scale of 1(least severe) to 10(most severe), ask the patient to indicate the intensity of the pain.patient to indicate the intensity of the pain.

The following elements of pain are usually assessed to confirmed ischemic The following elements of pain are usually assessed to confirmed ischemic cardiac pain and to differentiate angina from myocardial infarction.cardiac pain and to differentiate angina from myocardial infarction.

Duration. The exact time period of a continuous pain episode lay last Duration. The exact time period of a continuous pain episode lay last from minutes to hours. Several intermittent small episodes, however, from minutes to hours. Several intermittent small episodes, however, are not considered a long pain period.are not considered a long pain period.

Precipitating or Aggravating Factors. Such factors as exertion, Precipitating or Aggravating Factors. Such factors as exertion, emotional excitement, nervousness, extreme coldness, deep breathing, emotional excitement, nervousness, extreme coldness, deep breathing, position changes, and deep sleep are known to precipitate chest pain. position changes, and deep sleep are known to precipitate chest pain. However, pain may occur spontaneously without apparent precipitating However, pain may occur spontaneously without apparent precipitating factors.factors.

Accompanying Symptoms. Chest pain is often accompanied by Accompanying Symptoms. Chest pain is often accompanied by anxiousness, shortness of breath, palpitation, sweating, nauseas, or anxiousness, shortness of breath, palpitation, sweating, nauseas, or vomiting.vomiting.

Alleviating Factors. Interventions taken by the patient to relieve chest Alleviating Factors. Interventions taken by the patient to relieve chest pain may include resting, sublingual nitroglycerine, oxygen pain may include resting, sublingual nitroglycerine, oxygen administration, and change of position. Pain lasting more than 20 administration, and change of position. Pain lasting more than 20 minutes without relief is usually suggestive of MI.minutes without relief is usually suggestive of MI.


FATIGUEFATIGUE. Increasing weakness and fatigue are common . Increasing weakness and fatigue are common complaints of cardiac patients when ventricular function fails complaints of cardiac patients when ventricular function fails and cannot supply sufficient blood to meet even slight increases and cannot supply sufficient blood to meet even slight increases in the metabolic needs of the body cells. It is important to note in the metabolic needs of the body cells. It is important to note what amount of activity is tolerated by the patient (e.g., walking what amount of activity is tolerated by the patient (e.g., walking to the main entrance gate), when changes in activity tolerance to the main entrance gate), when changes in activity tolerance were first noted, and wether fatigue Is relieved by rest.were first noted, and wether fatigue Is relieved by rest.

SHORTNESS OF BREATH.SHORTNESS OF BREATH. In cardiac patients, dyspnea is In cardiac patients, dyspnea is usually due to pulmonary congestion caused by left ventricular usually due to pulmonary congestion caused by left ventricular failure. It may occur at rest or with exertion. failure. It may occur at rest or with exertion.

PALPITATION. PALPITATION. This is a sensation of rapid, skipping, This is a sensation of rapid, skipping, irregular, or pounding heartbeats. It is often caused by a irregular, or pounding heartbeats. It is often caused by a tachyarrhythmia, premature ectopic beats, or increased force of tachyarrhythmia, premature ectopic beats, or increased force of myocardial contraction ( as can occur with stress and anxiety or myocardial contraction ( as can occur with stress and anxiety or ingestion of caffeine). ingestion of caffeine).


SYNCOPE SYNCOPE . Episodes of dizziness, lightheadedness, or . Episodes of dizziness, lightheadedness, or momentarily loss of consciousness may result from momentarily loss of consciousness may result from momentary reduction in blood flow to the brain due to momentary reduction in blood flow to the brain due to precipitous drop in cardiac output.precipitous drop in cardiac output.

WEIGHT CHANGES AND EDEMA. WEIGHT CHANGES AND EDEMA. Recent weight gain and Recent weight gain and ankle swelling may suggest sodium and water retention ankle swelling may suggest sodium and water retention associated with CHF and HTN. A weight gain of 3lb or more associated with CHF and HTN. A weight gain of 3lb or more in 24 hours is highly suggestive of fluid retention.in 24 hours is highly suggestive of fluid retention.

EXTREMITY PAIN. EXTREMITY PAIN. Ischemia from peripheral vascular Ischemia from peripheral vascular disease can cause pain in the extremities, especially in anching disease can cause pain in the extremities, especially in anching sensation in the legs. If this pain is associated with activity and sensation in the legs. If this pain is associated with activity and is relieved with rest, intermittent claudication (arterial is relieved with rest, intermittent claudication (arterial insufficiency) is indicated. Pain related to dependency of the insufficiency) is indicated. Pain related to dependency of the extremities indicates venous insufficiency. Thrombophlebitis extremities indicates venous insufficiency. Thrombophlebitis is often made evident by eliciting a positive Homan’s is often made evident by eliciting a positive Homan’s sign(pain in the calf) when the foot is dorsiflexed).sign(pain in the calf) when the foot is dorsiflexed).

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

Objective FindingsObjective Findings

General Appearance. At a glance, the nurse should observe the patient’s General Appearance. At a glance, the nurse should observe the patient’s facial expression, affect, level of consciousness, tone of voice, posture, facial expression, affect, level of consciousness, tone of voice, posture, movements, respiration rate and pattern, skin color and turgor, status in movements, respiration rate and pattern, skin color and turgor, status in regard to diaphoresis and cachexia, nutritional state and reactions to regard to diaphoresis and cachexia, nutritional state and reactions to surroundings.surroundings.

Inspection of Neck Veins. The distensibility of the neck veins reflects the Inspection of Neck Veins. The distensibility of the neck veins reflects the pressure and volume changes of the right atrium. Therefore, purposed of pressure and volume changes of the right atrium. Therefore, purposed of neck vein inspection is to estimate CVP and to evaluate the pressure wave neck vein inspection is to estimate CVP and to evaluate the pressure wave form.form.

Palpation of the Carotid Arteries. Cardiac activity, such as stroke volume Palpation of the Carotid Arteries. Cardiac activity, such as stroke volume and aortic competency, can be assessed indirectly through palpation of the and aortic competency, can be assessed indirectly through palpation of the carotid arteries. A Bruit (a blowing sound) maybe heard by a stethoscope. A carotid arteries. A Bruit (a blowing sound) maybe heard by a stethoscope. A bruit usually indicates a narrowing of the carotid artery or a radiation of an bruit usually indicates a narrowing of the carotid artery or a radiation of an aortic valve murmur.aortic valve murmur.

Inspection and Palpation of the Precordium. This is performed to determined Inspection and Palpation of the Precordium. This is performed to determined presence of normal and abnormal pulsations.presence of normal and abnormal pulsations.

Objective FindingsObjective Findings

Apical Impulse (Point of Maximal Impulse, PMI). A visible pulsation Apical Impulse (Point of Maximal Impulse, PMI). A visible pulsation maybe observed in the area of the midclavicular line in the fifth left inter maybe observed in the area of the midclavicular line in the fifth left inter costal space. It corresponds with ventricular systole, and is a single faint, costal space. It corresponds with ventricular systole, and is a single faint, instantaneous “tap” approximately 2 cm in diameter. In the presence of instantaneous “tap” approximately 2 cm in diameter. In the presence of hypertrophy or dilation and aneurysm, the apical impulse maybe larger in hypertrophy or dilation and aneurysm, the apical impulse maybe larger in size and more laterally or inferiorly located.size and more laterally or inferiorly located.

Retractions. Marked or actual retraction of a rib just medial to the left Retractions. Marked or actual retraction of a rib just medial to the left midclavicular line in the 5th inter costal space is abnormal and may result in midclavicular line in the 5th inter costal space is abnormal and may result in pericardial disease.pericardial disease.

Heaves (Lifts). A diffuse lifting impulse observed along the the left sternal Heaves (Lifts). A diffuse lifting impulse observed along the the left sternal border or at the apex implies an increased contact of right ventricle with border or at the apex implies an increased contact of right ventricle with chest wall as found with dilatation-hypertrophy associated with various chest wall as found with dilatation-hypertrophy associated with various disorders such as valvular diseases and hypertension.disorders such as valvular diseases and hypertension.

Thrills. The abnormal turbulent blood flow causing an audible murmur of Thrills. The abnormal turbulent blood flow causing an audible murmur of Grade V and VI intensity also results in palpable thrills. Best felt over the Grade V and VI intensity also results in palpable thrills. Best felt over the left precordium. It may occur as a resuly of severe mitral regurgitation or a left precordium. It may occur as a resuly of severe mitral regurgitation or a ruptured ventricular septum.ruptured ventricular septum.

AuscultationAuscultation

Heart SoundsHeart Sounds S1 is produced by asynchronous closure of the mitral and tricuspid valves. It S1 is produced by asynchronous closure of the mitral and tricuspid valves. It

signals the onset of ventricular systole “lubb”.signals the onset of ventricular systole “lubb”. S2 is produced by asynchronous closure of the aortic and pulmonic valves. It S2 is produced by asynchronous closure of the aortic and pulmonic valves. It

signals the onset of ventricular diastole “dub”.signals the onset of ventricular diastole “dub”. S3 or ventricular diastolic gallop is a faint, low pitched sound produced by rapid S3 or ventricular diastolic gallop is a faint, low pitched sound produced by rapid

ventricular filling in early diastole. It is normal in children and young adults. It ventricular filling in early diastole. It is normal in children and young adults. It indicates CHF in older adults.indicates CHF in older adults.

S4 or atrial diastolic gallop is a low frequency sound which is present in CHF.S4 or atrial diastolic gallop is a low frequency sound which is present in CHF. MurmursMurmurs

These are audible vibrations of the heart and great vessels that are produced by These are audible vibrations of the heart and great vessels that are produced by turbulent blood flow. turbulent blood flow.

Pericardial Friction RubPericardial Friction Rub It is an extra heart sound originating from the pericardial sac. This maybe a It is an extra heart sound originating from the pericardial sac. This maybe a

sign of inflammation, infection or infiltration. It is described as a short, high sign of inflammation, infection or infiltration. It is described as a short, high pitched, scratchy sound.pitched, scratchy sound.

ASSESSMENT OF MURMURSASSESSMENT OF MURMURS

Note the following characteristics:Note the following characteristics: Timing and Duration of maximal intensity:Timing and Duration of maximal intensity:

Systolic: early, mid, or late systoleSystolic: early, mid, or late systole Diastolic: early, mid, or late diastoleDiastolic: early, mid, or late diastole

Quality: blowing, harsh, rumblingQuality: blowing, harsh, rumbling Pitch: high, heard best with the diaphragmPitch: high, heard best with the diaphragm low, heard best with the belllow, heard best with the bell Location: where heard the loudest; 3rd or 4th left Location: where heard the loudest; 3rd or 4th left

inter costal space, apical area, or base of the heartinter costal space, apical area, or base of the heart Radiation: transmission of soundRadiation: transmission of sound

Intensity Intensity (not necessarily equal to degree of disease)(not necessarily equal to degree of disease)

Grade I Faint, not heard with every beat.Grade I Faint, not heard with every beat. Grade II Soft, but heard with every beat.Grade II Soft, but heard with every beat. Grade III Moderately loud without accompanying Grade III Moderately loud without accompanying

thrillthrill Grade IV Loud with possible palpable thrillGrade IV Loud with possible palpable thrill Grade V Very loud, heard only with the Grade V Very loud, heard only with the

stethoscope and accompanied by a thrill.stethoscope and accompanied by a thrill. Grade VI Very loud, heard without the Grade VI Very loud, heard without the

stethoscope and accompanied by a thrill.stethoscope and accompanied by a thrill.

AUSCULTATION OF AUSCULTATION OF LUNG SOUNDSLUNG SOUNDS

Is an essential component of cardiovascular Is an essential component of cardiovascular assessment and provides information about assessment and provides information about cardiac function, especially left ventricular cardiac function, especially left ventricular performance.performance.

Types:Types: Normal breath soundsNormal breath sounds Adventitious breath soundsAdventitious breath sounds

ASSESSMENT OF THE ASSESSMENT OF THE ABDOMENABDOMEN

On inspection, the abdomen should be symmetrical in On inspection, the abdomen should be symmetrical in contour and should appear flat or slightly rounded. A contour and should appear flat or slightly rounded. A distended abdomen may result from fluid (ascites), distended abdomen may result from fluid (ascites), adipose tissue, gas. Feces, or malignancy and adipose tissue, gas. Feces, or malignancy and warrants further investigation.warrants further investigation.

On Auscultation, bowel sounds should be assessed in On Auscultation, bowel sounds should be assessed in all four abdominal quadrants. Decreased motility all four abdominal quadrants. Decreased motility accompanies electrolyte disturbances, peritonitis, or accompanies electrolyte disturbances, peritonitis, or pneumonia.pneumonia.

ASSESSMENT OF PERIPHERYASSESSMENT OF PERIPHERY

Skin. As the body’s largest organ, the skin Skin. As the body’s largest organ, the skin reflects changes in the internal environment.reflects changes in the internal environment.

Color. Cyanosis, a dusky blue color, is best Color. Cyanosis, a dusky blue color, is best detected in areas of least pigmentation---lips, oral detected in areas of least pigmentation---lips, oral mucosa, nail beds, ear lobes, conjuctiva, palms, mucosa, nail beds, ear lobes, conjuctiva, palms, and soles. It results from increased amount of and soles. It results from increased amount of reduced hemoglobin (deoxygenation) of venous reduced hemoglobin (deoxygenation) of venous blood seen in severe pulmonary disease and blood seen in severe pulmonary disease and cardiovascular incompetence.cardiovascular incompetence.

Pallor. Is observed as peripheral blood flow Pallor. Is observed as peripheral blood flow diminishes or hemoglobin decrease.diminishes or hemoglobin decrease.

ASSESSMENT OF PERIPHERYASSESSMENT OF PERIPHERY Temperature. Skin temp. reflects blood flow to dermis. Temperature. Skin temp. reflects blood flow to dermis.

Decreased cardiac output, shock, and stress precipitate an Decreased cardiac output, shock, and stress precipitate an outpouring of catecholamines. The resulting widespread outpouring of catecholamines. The resulting widespread vasoconstriction produces cool, moist, clammy skin.vasoconstriction produces cool, moist, clammy skin.

Clubbing. A chronic decrease in oxygenation may result in Clubbing. A chronic decrease in oxygenation may result in clubbing of the fingers (“drumstick fingers”). Nails become clubbing of the fingers (“drumstick fingers”). Nails become wide and flattened and lie at an angle of 180 degrees or more wide and flattened and lie at an angle of 180 degrees or more to the nail base.to the nail base.

Turgor. Skin elasticity is determined by picking up a fold of Turgor. Skin elasticity is determined by picking up a fold of skin on the lower abdomen, radial surface of the wrist, or inner skin on the lower abdomen, radial surface of the wrist, or inner thigh and observed how quickly it returns to its normal shape. thigh and observed how quickly it returns to its normal shape. Loss of turgor reflects an extra cellular volume deficit or the Loss of turgor reflects an extra cellular volume deficit or the normal changes that occur with aging, excessive weight loss, normal changes that occur with aging, excessive weight loss, and chronic steroid used.and chronic steroid used.

DIAGNOSTIC TESTS OF DIAGNOSTIC TESTS OF CARDIAC DISORDERSCARDIAC DISORDERS

Laboratory Studies:Laboratory Studies:

Complete Blood CountComplete Blood Count For evaluation of general health status.For evaluation of general health status. Elevated RBC”s suggests inadequate tissue oxygenation. Hypoxia Elevated RBC”s suggests inadequate tissue oxygenation. Hypoxia

stimulates renal secretion of erythropoietin. This stimulates the bone stimulates renal secretion of erythropoietin. This stimulates the bone marrow to increase rbc production (polycythemia)marrow to increase rbc production (polycythemia)

Elevated WBC”s may indicate infectious heart diseases and myocardial Elevated WBC”s may indicate infectious heart diseases and myocardial infarction.infarction.

Erythrocyte Sedimentation Rate (ESR)Erythrocyte Sedimentation Rate (ESR) It is a measurement of the rate at which RBc’s “settle out” of It is a measurement of the rate at which RBc’s “settle out” of

anticoagulated blood in an hour.anticoagulated blood in an hour. It is elevated in infectious heart disorders or MIIt is elevated in infectious heart disorders or MI Normal range is as follows:Normal range is as follows:

Male : 15-20 mm/hr.Male : 15-20 mm/hr. Females : 20-30 mm/hr.Females : 20-30 mm/hr.


Blood Coagulation TestsBlood Coagulation Tests Prothrombin time (PTTTT, Pro-time)Prothrombin time (PTTTT, Pro-time)

It measures the time required for clotting to occur after It measures the time required for clotting to occur after thromboplastin and calcium are added to decalcified plasma.thromboplastin and calcium are added to decalcified plasma.

It is valuable in evaluating effectiveness if coumadin. Therapeutic It is valuable in evaluating effectiveness if coumadin. Therapeutic range is 1.5 to 2 times the normal or control.range is 1.5 to 2 times the normal or control.

Normal range is 11 to 16 seconds.Normal range is 11 to 16 seconds. Partial Thromboplastin Time (PTT)Partial Thromboplastin Time (PTT)

it measures the time required for clotting to occur after a “partial it measures the time required for clotting to occur after a “partial thromboplastin reagent” is added to blood plasmathromboplastin reagent” is added to blood plasma

it is the best single screening test for disorder of coagulationit is the best single screening test for disorder of coagulation it is determined to evaluate the effectiveness of heparin. Therapeutic it is determined to evaluate the effectiveness of heparin. Therapeutic

range is 2 to 21/2 times the normal or control.range is 2 to 21/2 times the normal or control. Normal range is 60 to 70 secs.Normal range is 60 to 70 secs.


Activated Partial Thromboplastin Time (APTT)Activated Partial Thromboplastin Time (APTT) It has the same purpose as PTT. It is most specific It has the same purpose as PTT. It is most specific Test to evaluate effectiveness of heparin. Therapeutic range Test to evaluate effectiveness of heparin. Therapeutic range

is 2-2.5 times the normal or control.is 2-2.5 times the normal or control. Normal range is 30-45 secs.Normal range is 30-45 secs.

Blood Urea Nitrogen (BUN)Blood Urea Nitrogen (BUN) it is an indicator of renal function.it is an indicator of renal function. decreased cardiac output leads to low renal tissue perfusion decreased cardiac output leads to low renal tissue perfusion

and reduction in glomerular filtration rate (GFR). The BUN and reduction in glomerular filtration rate (GFR). The BUN level becomes elevated.level becomes elevated.

Normal range is 10-20 mg/dl.Normal range is 10-20 mg/dl.

Blood LipidsBlood Lipids CholesterolCholesterol

the client should be on NPO for 10-12 hoursthe client should be on NPO for 10-12 hours normal range is 150-250 mg/dlnormal range is 150-250 mg/dl

TriglyceridesTriglycerides fasting for 10-12 hoursfasting for 10-12 hours normal range 140-200 mg/dlnormal range 140-200 mg/dl

Blood CultureBlood Culture to assist in the diagnosis of infectious diseases of to assist in the diagnosis of infectious diseases of

the heart; e.g., pericarditisthe heart; e.g., pericarditis

Enzyme studiesEnzyme studies Enzymes are proteins that catalyzed chemical reactions found in Enzymes are proteins that catalyzed chemical reactions found in

every cells of various organs in the body and skeletal muscle as every cells of various organs in the body and skeletal muscle as well as in the plasma (small amount). Cardiac enzymes are well as in the plasma (small amount). Cardiac enzymes are organ-specific enzymes that are present in high concentration in organ-specific enzymes that are present in high concentration in myocardial tissue.myocardial tissue.

Isoenzymes often has slightly different molecular forms. Both Isoenzymes often has slightly different molecular forms. Both creatinine kinase (CK) and lactic dehydrogenase (LDH) have creatinine kinase (CK) and lactic dehydrogenase (LDH) have isoenzymes specific for the heart.isoenzymes specific for the heart.

Rationale:Rationale: Tissue damage can release enzymes from their intracellular storage Tissue damage can release enzymes from their intracellular storage

areas. MI cause cellular anoxia w/c alters membrane permeability and areas. MI cause cellular anoxia w/c alters membrane permeability and allows leakage of cellular contents. Prolonged anoxia leads to edema allows leakage of cellular contents. Prolonged anoxia leads to edema and rupture, with consequent spillage of enzymes into surrounding and rupture, with consequent spillage of enzymes into surrounding tissue. Enzymes are liberated into the blood stream via the coronary tissue. Enzymes are liberated into the blood stream via the coronary lymphatic drainage system.lymphatic drainage system.

Types of Major cardiac enzymesTypes of Major cardiac enzymes

a. Creatine Phosphokinase (CK-MB)a. Creatine Phosphokinase (CK-MB) it is the most cardiac specific enzymeit is the most cardiac specific enzyme it is an accurate indicator of myocardial damageit is an accurate indicator of myocardial damage normal range is:normal range is:

males : 50-325 mu/mlmales : 50-325 mu/ml females : 50-250 mu/ml.females : 50-250 mu/ml.

Range with MI:Range with MI: Onset : 3-6 hoursOnset : 3-6 hours Peaks : 12-18 hrs.Peaks : 12-18 hrs. Returns to normal : 3-4 daysReturns to normal : 3-4 days

Types of Major cardiac enzymesTypes of Major cardiac enzymes

b. Lactic Dehydrogenase (LDH)b. Lactic Dehydrogenase (LDH) among the five LDH isoenzymes, LDH1 is the among the five LDH isoenzymes, LDH1 is the

most indicator of myocardial damage.most indicator of myocardial damage. In MI, LDH is elevated and its level exceeds In MI, LDH is elevated and its level exceeds

LDH2. LDH2. this makes LDH1/LDH2 ratio this makes LDH1/LDH2 ratio “flipped”“flipped”

Normal range is 100-225 mu/mlNormal range is 100-225 mu/ml Range with MIRange with MI

Onset : 12 hrs.Onset : 12 hrs. Peaks : 48 hrs.Peaks : 48 hrs. Returns to normal : 10-14 daysReturns to normal : 10-14 days

c. Aspartate Aminotransferase (AST)c. Aspartate Aminotransferase (AST) formerly, SGOTformerly, SGOT elevated level indicates tissue necrosiselevated level indicates tissue necrosis normal range is 7 to 40 mu/ml.normal range is 7 to 40 mu/ml. range with MIrange with MI

Initial elevation : 4-6 hrs.Initial elevation : 4-6 hrs. Peaks : 24-36 hrs.Peaks : 24-36 hrs. Returns to normal: 4-7 daysReturns to normal: 4-7 days

d. Hydroxybutyrate Dehydrogenase (HBD)d. Hydroxybutyrate Dehydrogenase (HBD) elevation of HBD is always accompanied by elevation of elevation of HBD is always accompanied by elevation of

LDH levelLDH level it is valuable in detecting “silent MI” because it remains it is valuable in detecting “silent MI” because it remains

elevated for a long period of time,even after the other elevated for a long period of time,even after the other enzymes have returned to normal.enzymes have returned to normal.

The HBD/LDH ratio maybe increase in MIThe HBD/LDH ratio maybe increase in MI Normal range is 140-350 mu/ml.Normal range is 140-350 mu/ml. Range with MIRange with MI

Onset : 10-12 hrs.Onset : 10-12 hrs. Peaks : 48-72 hrs.Peaks : 48-72 hrs. Returns to normal : 12-13 days.Returns to normal : 12-13 days.

UrinalysisUrinalysis This test is performed to assess the effects of cardiovascular disease on This test is performed to assess the effects of cardiovascular disease on

renal function and the existence of concurrent renal or systemic disease; renal function and the existence of concurrent renal or systemic disease; e.g., glumerolunephritis, HTN or DMe.g., glumerolunephritis, HTN or DM

Albuminuria is detected in client with malignant HTN and CHF.Albuminuria is detected in client with malignant HTN and CHF. Myoglobinuria supports diagnosis of MI.Myoglobinuria supports diagnosis of MI.

Blood Uric Acid (BUA)Blood Uric Acid (BUA) This test reflects adequacy of renal tissue perfusion thereby glomerular This test reflects adequacy of renal tissue perfusion thereby glomerular

filtration of metabolites.filtration of metabolites. Cardiovascular disorders result to decreased renal tissue perfusion. This Cardiovascular disorders result to decreased renal tissue perfusion. This

will cause impairment of the ability of the kidneys to clear the plasma of will cause impairment of the ability of the kidneys to clear the plasma of end products of metabolism like uric acid.end products of metabolism like uric acid.

Normal range is 2.5-8 mg/dl.Normal range is 2.5-8 mg/dl.

Serologic TestsSerologic Tests VDRL helps indicates presence of syphilis. This VDRL helps indicates presence of syphilis. This

disease involves development of aortic disorder.disease involves development of aortic disorder.

Serum ElectrolytesSerum Electrolytes Electrolytes affect cardiac contractility, specifically Electrolytes affect cardiac contractility, specifically

Na, K, Ca.Na, K, Ca. Normal range is as follows:Normal range is as follows:

Na : 135 – 145 mEq/LNa : 135 – 145 mEq/L K : 3.5 – 5.0 mEq/LK : 3.5 – 5.0 mEq/L Ca : 4.5 – 5.5 mEq/LCa : 4.5 – 5.5 mEq/L

HEMODYNAMIC MONITORING WITH HEMODYNAMIC MONITORING WITH NON-INVASIVE PROCEDURESNON-INVASIVE PROCEDURES

ELECTROCARDIOGRAPHY AND CARDIAC MONITORINGELECTROCARDIOGRAPHY AND CARDIAC MONITORINGDefinitions:Definitions:

Polarized StatePolarized State The cell is at rest in a polarized state. Although, the inside of the cell is The cell is at rest in a polarized state. Although, the inside of the cell is

negative with respect to the outside its membrane remains electrically negative with respect to the outside its membrane remains electrically intact. The membrane resting potential (MRP) is -90 mv.intact. The membrane resting potential (MRP) is -90 mv.

DepolarizationDepolarization It is the propagation of an electrical impulse due to an abrupt change It is the propagation of an electrical impulse due to an abrupt change

in the permeability of the cell membrane, allowing the inside of the cell in the permeability of the cell membrane, allowing the inside of the cell to become increasingly positive with respect to outside (Na+ and Ca++ to become increasingly positive with respect to outside (Na+ and Ca++ enters the cell and K+ leaves).enters the cell and K+ leaves).

RepolarizationRepolarization The cell returns to its resting state (Na+ leaves the cell and K+ enters).The cell returns to its resting state (Na+ leaves the cell and K+ enters).


Electrocardiogram (EKG,ECG)Electrocardiogram (EKG,ECG) An electrocardiogram is a recorded graph of waves that represent An electrocardiogram is a recorded graph of waves that represent

variations in the time sequence of the electrical potentials produced by variations in the time sequence of the electrical potentials produced by depolarization and repolarization of the myocardium.depolarization and repolarization of the myocardium.

ElectrocardiographyElectrocardiography Is the science of taking and interpreting electrocardiograms in order to Is the science of taking and interpreting electrocardiograms in order to

diagnose cardiac disease by consistent correlation of characteristic diagnose cardiac disease by consistent correlation of characteristic patterns.patterns.

RationaleRationaleThe movement of ions that produces the depolarization and The movement of ions that produces the depolarization and repolarization of the myocardium can be detected on the body repolarization of the myocardium can be detected on the body surface. Electrodes placed upon the surface of the body will surface. Electrodes placed upon the surface of the body will pick up various components of this ionic movement. By pick up various components of this ionic movement. By connecting this electrodes to an ECG machine, the electrical connecting this electrodes to an ECG machine, the electrical potentials of the heart are recorded depicted as wave forms.potentials of the heart are recorded depicted as wave forms.


An upright deflection represents a positive electrical potential and occurs An upright deflection represents a positive electrical potential and occurs when the current travels towards the recording electrode.when the current travels towards the recording electrode.

A downward deflection represents a negative electrical potential and occurs A downward deflection represents a negative electrical potential and occurs when the current travels away from the recording electrode.when the current travels away from the recording electrode.

Indications:Indications: Arrhythmia Arrhythmia pericarditispericarditis Chest Pain Chest Pain effect of drugs (cardiac)effect of drugs (cardiac) MI MI electrolyte disturbances (K+)electrolyte disturbances (K+) Determination of heart rate effect of certain systemicDetermination of heart rate effect of certain systemic Chamber dilation or hypertrophy diseases on the heartChamber dilation or hypertrophy diseases on the heart Pacemaker function Pacemaker function

Limitation:Limitation: The ECG should always be correlated with the patient’s clinical assessment. A The ECG should always be correlated with the patient’s clinical assessment. A

patient with a normal heart may show non-specific ECG changes, whereas a patient with a normal heart may show non-specific ECG changes, whereas a patient with a diseased heart may have a normal ECG.patient with a diseased heart may have a normal ECG.


ECG GridECG Grid VoltageVoltage

1mm = 0.1mv1mm = 0.1mv 5mm = 0.5mv5mm = 0.5mv

Time Time 1 mm = .04 second1 mm = .04 second 5 mm = .20 second5 mm = .20 second

Is a graph that allows for measurement of electrical activity Is a graph that allows for measurement of electrical activity during the cardiac cycle. The horizontal axis represents time, during the cardiac cycle. The horizontal axis represents time, whereas the vertical axis represents voltage. All fine whereas the vertical axis represents voltage. All fine horizontal and vertical lines are present at 1-mm intervals, horizontal and vertical lines are present at 1-mm intervals, with a heavier line present every 5mm.with a heavier line present every 5mm.

Routine recording speed is 25mm per second.Routine recording speed is 25mm per second.

COMPONENTS OF ECGCOMPONENTS OF ECGP waveP wave represents atrial depolarizationrepresents atrial depolarization contourcontour in leads I,II, and AVF, it is upright, usually rounded, although it maybe slightly in leads I,II, and AVF, it is upright, usually rounded, although it maybe slightly

pointed or slightly notched.pointed or slightly notched. In V1 it maybe diphasic or negativeIn V1 it maybe diphasic or negative Normal range lead IINormal range lead II Height is 0.3 to 2.0 mmHeight is 0.3 to 2.0 mm Duration is 0.05 second to 0.12 secondDuration is 0.05 second to 0.12 second

P-R IntervalP-R Interval Represents atrioventricular conduction time, including the normal delay in the AV Represents atrioventricular conduction time, including the normal delay in the AV

junction.junction. Measured from the beginning of the P wave to the beginning of the QRS complex.Measured from the beginning of the P wave to the beginning of the QRS complex. Normal range is 0.12 second to 0.20 secondNormal range is 0.12 second to 0.20 second The portion of this interval from the end of the P wave to the beginning of the QRS The portion of this interval from the end of the P wave to the beginning of the QRS

complex (P-R segment) is normally isoelectric.complex (P-R segment) is normally isoelectric.

COMPONENTS OF ECGCOMPONENTS OF ECG

QRS ComplexQRS Complex Represents ventricular depolarization.Represents ventricular depolarization. Measured from the beginning of the Q wave (or R Measured from the beginning of the Q wave (or R

wave if no Q is present) to the end of the S wavewave if no Q is present) to the end of the S wave Normal range is up to .11 second in duration. Normal range is up to .11 second in duration.

Q-T IntervalQ-T Interval Represents the duration of ventricular systole.Represents the duration of ventricular systole. Measured from the beginning of Q wave to the end of Measured from the beginning of Q wave to the end of

the T wavethe T wave normal range should be a corrected figure (QT), as it normal range should be a corrected figure (QT), as it

varies with heart rate.varies with heart rate.


J PointJ Point This is the point marking the end of the QRS complex and the beginning of This is the point marking the end of the QRS complex and the beginning of

the ST segment.the ST segment.

S-T SegmentS-T Segment represents the time during which the ventricle remain in the depolarized represents the time during which the ventricle remain in the depolarized

state until the time ventricular repolarization beginsstate until the time ventricular repolarization begins measured from the end of the S wave (J point) to the beginning of the T measured from the end of the S wave (J point) to the beginning of the T

wave.wave. normal rangenormal range

Usually isoelectricUsually isoelectric In precoridal leads may vary from (-0.5mm) to + 2.0mm from the baselineIn precoridal leads may vary from (-0.5mm) to + 2.0mm from the baseline In standard leads may vary from ( -0.5mm) to + 1.0mm to the baseline.In standard leads may vary from ( -0.5mm) to + 1.0mm to the baseline.


T waveT wave Represents ventricular depolarization.Represents ventricular depolarization. Contour.Contour. normally upright in leads I,II, and V3-6normally upright in leads I,II, and V3-6 slightly rounded and slightly asymmetricalslightly rounded and slightly asymmetrical Normal rangeNormal range

Standard limb leads, 1.0 to 5.0 mm in height.Standard limb leads, 1.0 to 5.0 mm in height. Precordial leads, n o greater than 10mm in height.Precordial leads, n o greater than 10mm in height.

U WaveU Wave Significance is not known, however, it maybe noted in association with Significance is not known, however, it maybe noted in association with

low serum potassium levels, high serum calcium levels, bradycardia, left low serum potassium levels, high serum calcium levels, bradycardia, left ventricular hypertrophy, and subarachnoid hemorrhageventricular hypertrophy, and subarachnoid hemorrhage

Immediately follows the T wave and precedes the next P waveImmediately follows the T wave and precedes the next P wave Same polarity as the T waveSame polarity as the T wave Normal range in height is not more than 1 mmNormal range in height is not more than 1 mm


T-P IntervalT-P Interval Represents the electrical resting potential of the heartRepresents the electrical resting potential of the heart Measured from the end of the T wave to the beginning of the P waveMeasured from the end of the T wave to the beginning of the P wave Contour is isoelectric and represents the baseline; i.e., elevation or Contour is isoelectric and represents the baseline; i.e., elevation or

depression of other ECG components are determined by comparison to the depression of other ECG components are determined by comparison to the isoelectric line.isoelectric line.

Normal range varies with the heart rate; i.e., the T-P interval shortens with Normal range varies with the heart rate; i.e., the T-P interval shortens with tachycardia and lengthens with bradycardias.tachycardia and lengthens with bradycardias.

P-P IntervalP-P Interval Represents atrial rateRepresents atrial rate Measured as the distance between two successive P waves.Measured as the distance between two successive P waves.

R-R IntervalR-R Interval Represents ventricular rateRepresents ventricular rate Measured as the distance between two successive R wavesMeasured as the distance between two successive R waves If rhythm is regular, R-R interval maybe used to compute heart rate.If rhythm is regular, R-R interval maybe used to compute heart rate.

Leads of the ElectrocardiogramLeads of the Electrocardiogram

DefinitionDefinition A lead is defined as the connection of a positive and a negative electrode A lead is defined as the connection of a positive and a negative electrode

through an ECG machine (galvanometer) for continuous recording the through an ECG machine (galvanometer) for continuous recording the potential differences (voltages) between the two electrodes during the potential differences (voltages) between the two electrodes during the cardiac cycle.cardiac cycle.

TypesTypes Standard 12 Leads:Standard 12 Leads:

Standard Limb Leads. Leads I,II, and III are the standard limb leads. These are Standard Limb Leads. Leads I,II, and III are the standard limb leads. These are bipolar leads used to compare the electrical potential of a positive and negative bipolar leads used to compare the electrical potential of a positive and negative electrode, representing two limbs ( except right leg)electrode, representing two limbs ( except right leg)

Augmented Limb Leads. AVR,AVL, and AVF are unipolar leads used to Augmented Limb Leads. AVR,AVL, and AVF are unipolar leads used to compare the electrical potential of an exploring electrodes (positive) placed on compare the electrical potential of an exploring electrodes (positive) placed on one limb and a central terminal (negative), which represents an average potential one limb and a central terminal (negative), which represents an average potential ( close to zero) of two other limbs.( close to zero) of two other limbs.

Precordial (Chest) Leads. Leads V1,V2,V3,V4,V5, and V6 are also unipolar Precordial (Chest) Leads. Leads V1,V2,V3,V4,V5, and V6 are also unipolar leads used to compare the electrical potential of a positive exploring electrode leads used to compare the electrical potential of a positive exploring electrode (in various location on the chest) and a central terminal (negative), which (in various location on the chest) and a central terminal (negative), which represents an average potential of right arm, left arm, and left leg.represents an average potential of right arm, left arm, and left leg.

CALCULATION OF CALCULATION OF HEART RATEHEART RATE

If the rhythm is irregular, heart rate should be determined by If the rhythm is irregular, heart rate should be determined by counting the number of heartbeats (QRS) in a full-minute counting the number of heartbeats (QRS) in a full-minute ECG strip.ECG strip.

If the rhythm is regular, any of the following methods can be If the rhythm is regular, any of the following methods can be used.used.

Count the number of small squares in the ECG paper within Count the number of small squares in the ECG paper within one R-r interval and divide this number into 1500 (1-minute one R-r interval and divide this number into 1500 (1-minute length of ECG paper consist of 1500 small squares)length of ECG paper consist of 1500 small squares)

Count the numbers of big squares within one R-R interval and Count the numbers of big squares within one R-R interval and divide this number into 300 (1-minute length of ECG paper divide this number into 300 (1-minute length of ECG paper consist of 300 big squares). This method can be simplified by consist of 300 big squares). This method can be simplified by using the following formulas.using the following formulas.

CALCULATION OF CALCULATION OF HEART RATEHEART RATE

If the number of big If the number of big

Squares between R-R is Heart Rate should beSquares between R-R is Heart Rate should be1 1 3003002 2 1501503 3 1001004 4 75755 5 60606 6 50507 7 43438 8 37379 9 333310 10 3030

Count the number of QRS complexes within a 6-second time period on the Count the number of QRS complexes within a 6-second time period on the ECG strip and multiply by 10ECG strip and multiply by 10

ANALYSIS OF ECG RHYTHMANALYSIS OF ECG RHYTHM A systematic approach to analysis is recommended to ensure A systematic approach to analysis is recommended to ensure

accuracy and inclusiveness. The following items are accuracy and inclusiveness. The following items are suggested content. Analysis may begin with any of these suggested content. Analysis may begin with any of these steps. However it should begin with the most striking feature steps. However it should begin with the most striking feature noted noted

1. Regularity of the rhythm (R-R interval).1. Regularity of the rhythm (R-R interval).2. Ventricular rate2. Ventricular rate3. Width of the QRS complex3. Width of the QRS complex4. Presence of P wave.4. Presence of P wave.5. P-QRS relationship5. P-QRS relationship6. Regularity of P-P interval6. Regularity of P-P interval7. Atrial rate7. Atrial rate8. P-R interval and its consistency8. P-R interval and its consistency 9. Consistency of the shapes and contours of the waves and 9. Consistency of the shapes and contours of the waves and

complexes.complexes.

NORMAL SINUS RHYTHM (NSR)NORMAL SINUS RHYTHM (NSR)

ECG CriteriaECG Criteria Rate and Rhythm. Rate is 60 to 100 beats per minute, and rhythm is regularRate and Rhythm. Rate is 60 to 100 beats per minute, and rhythm is regular QRS Complex. This is usually normal, 0.08 to 0.11 second.QRS Complex. This is usually normal, 0.08 to 0.11 second. P wave. This is upright in lead I and II and is negative in AVR. Normal contour.P wave. This is upright in lead I and II and is negative in AVR. Normal contour. P-QRS Relationship. There is one P wave per one QRS complex; P precedes QRS P-QRS Relationship. There is one P wave per one QRS complex; P precedes QRS

with a P-R interval of normal and constant duration, 0.12 to 0.20 second.with a P-R interval of normal and constant duration, 0.12 to 0.20 second. Origin. NSR originates in the sinus nodeOrigin. NSR originates in the sinus node Significance. NSR indicates that electrical conductions normal.Significance. NSR indicates that electrical conductions normal.

Holter MonitoringHolter Monitoring It is continuous (24hr.) ECG monitoring.It is continuous (24hr.) ECG monitoring. The portable monitoring system is called telemetry unit.The portable monitoring system is called telemetry unit. This attempts to assess the activities which precipitate dysrhythmias, and the time of This attempts to assess the activities which precipitate dysrhythmias, and the time of

the day when the client experiences dysrhythmias.the day when the client experiences dysrhythmias. The nurse should log/record the activities of the client, and any unusual sensations The nurse should log/record the activities of the client, and any unusual sensations

experienced.experienced.

INVASIVE HEMODYNAMIC INVASIVE HEMODYNAMIC MONITORINGMONITORING

Central Venous PressureCentral Venous Pressure

Monitors the pressures within the right antrium.Monitors the pressures within the right antrium. Monitors blood volume, adequacy of venous return to the heart, pump function Monitors blood volume, adequacy of venous return to the heart, pump function

of the right side the the heart.of the right side the the heart. The O level of the manometer be placed at the right, mid-axillary, 4th ICS, the The O level of the manometer be placed at the right, mid-axillary, 4th ICS, the

approximate level of right atrium when in supine position.approximate level of right atrium when in supine position. Place the client in supine position or in the same position as during the initial Place the client in supine position or in the same position as during the initial

reading.reading. Practice strict asepsis. Cleanse catheter insertion site and change sterile Practice strict asepsis. Cleanse catheter insertion site and change sterile

dressings daily.dressings daily. Normal readings:Normal readings:

Superior vena cava: 0-12cm. H20Superior vena cava: 0-12cm. H20 Right atrium: 5-12cm. H20Right atrium: 5-12cm. H20

Use other parameters to validate CVP reading-BP, urine output, pulse.Use other parameters to validate CVP reading-BP, urine output, pulse.


Pulmonary Artery Pressure & Pulmonary Artery Pressure & Pulmonary Capillary Wedge PressurePulmonary Capillary Wedge Pressure

Swan- Ganz catheter is inserted via antecubital vein into the right side of Swan- Ganz catheter is inserted via antecubital vein into the right side of the heart and is floated into the pulmonary artery. It reflects pressures in the heart and is floated into the pulmonary artery. It reflects pressures in the left heart.the left heart.

Swan- Ganz catheter is a flow- directed, balloon- tipped, 4- lumen Swan- Ganz catheter is a flow- directed, balloon- tipped, 4- lumen catheter.catheter.

The catheter allows continuous monitoring of the following:The catheter allows continuous monitoring of the following: Right and left ventricular function.Right and left ventricular function. Pulmonary artery pressures (PAP, PCWP).Pulmonary artery pressures (PAP, PCWP). Cardiac output.Cardiac output. Arterial – venous oxygen difference.Arterial – venous oxygen difference.

Normal range:Normal range: PAP : 4-12 mmHgPAP : 4-12 mmHg PCWP : 4-12 mmHgPCWP : 4-12 mmHg PCWP reading above 25 mmHg suggests impending pulmonary edema.PCWP reading above 25 mmHg suggests impending pulmonary edema.


Nursing Interventions:Nursing Interventions: Inflate balloon only for PCWP readings; Inflate balloon only for PCWP readings;

deflate betweens readings.deflate betweens readings. Observe catheter insertion site; culture site Observe catheter insertion site; culture site

every 48 hrs.every 48 hrs. Assess extremity for color, temperature, Assess extremity for color, temperature,

capillary fillings and sensation.capillary fillings and sensation.

SONIC STUDIESSONIC STUDIES

Echocardiography.Echocardiography. Uses ultra sound to assess cardiac structure and mobility.Uses ultra sound to assess cardiac structure and mobility. NO special preparation is required.NO special preparation is required. It is painless and takes approximately 30 to 60 minutes to It is painless and takes approximately 30 to 60 minutes to

complete.complete. The client has to remain still, in supine position slightly turned The client has to remain still, in supine position slightly turned

to the left side, with HOB elevated 15 to 20 degrees.to the left side, with HOB elevated 15 to 20 degrees.

Transesophageal Echocardiography (TEE)Transesophageal Echocardiography (TEE) Allows ultrasonic imaging of the cardiac structures and great Allows ultrasonic imaging of the cardiac structures and great

vessels via esophagus.vessels via esophagus.


Nursing Intervention Before TEE.Nursing Intervention Before TEE. Ascertain history of esophageal surgery, malignancy, or Ascertain history of esophageal surgery, malignancy, or

allergy to anesthetic or sedatives.allergy to anesthetic or sedatives. NPO for 4 to 6 hrs. before the procedure.NPO for 4 to 6 hrs. before the procedure. Encourage to void before the procedure.Encourage to void before the procedure. Remove dentures and the other oral prosthetics.Remove dentures and the other oral prosthetics. Administer sedatives as ordered.Administer sedatives as ordered. Keep suction and resuscitation equipment readily available.Keep suction and resuscitation equipment readily available. Cardiac monitoring is done during the entire procedure.Cardiac monitoring is done during the entire procedure. Topical spray anesthetic is administered to depress gag reflex.Topical spray anesthetic is administered to depress gag reflex. Place the patient in chin – to – chest position to facilitate Place the patient in chin – to – chest position to facilitate

passage of endoscope.passage of endoscope.


Nursing Interventions after TEENursing Interventions after TEE After the procedure: NPO until gag reflex returns.After the procedure: NPO until gag reflex returns. Place in latheral or semi – Fowler’s position.Place in latheral or semi – Fowler’s position. Encourage to cough.Encourage to cough. Throat lozengers or rinses may be used to relieve Throat lozengers or rinses may be used to relieve

throat soreness.throat soreness. Observe for signs and symptoms of complication, e.g. Observe for signs and symptoms of complication, e.g.

pharyngeal bleeding, cardiac dysrhytmias, vasovagal pharyngeal bleeding, cardiac dysrhytmias, vasovagal reaction, and transient hypoxemia.reaction, and transient hypoxemia.


PhonocardiographyPhonocardiography Involves the use of electrically recorded Involves the use of electrically recorded

amplified cardiac soundsamplified cardiac sounds It is helpful in assessing the exact timing and It is helpful in assessing the exact timing and

characteristic of murmurs and extra heart characteristic of murmurs and extra heart sounds.sounds.

Preparation of client is similar to Preparation of client is similar to echocardiogramechocardiogram

STRESS TESTING OR STRESS TESTING OR EXERCISE TESTINGEXERCISE TESTING

ECG is monitored during exercise on a ECG is monitored during exercise on a treadmill or a bicycle – like device.treadmill or a bicycle – like device.

The purpose of stress test are as follows:The purpose of stress test are as follows: Identify ischemic heart diseaseIdentify ischemic heart disease Evaluate patients with chest painEvaluate patients with chest pain Evaluate effectiveness of therapyEvaluate effectiveness of therapy Develop individual firmness programDevelop individual firmness program

STRESS TESTING OR STRESS TESTING OR EXERCISE TESTINGEXERCISE TESTING

NURSING INTERVENTIONS: Treadmill TestNURSING INTERVENTIONS: Treadmill Test Get adequate sleep the night before the test.Get adequate sleep the night before the test. Avoid tea, coffee and alcohol on the day of the test.Avoid tea, coffee and alcohol on the day of the test. Avoid smoking and taking nitroglycerine, 2 hours before the Avoid smoking and taking nitroglycerine, 2 hours before the

testtest Wear comfortable, loose – fitting clothesWear comfortable, loose – fitting clothes Eat a light breakfast / lunch at least 2 hours before the test.Eat a light breakfast / lunch at least 2 hours before the test. Wear low – heeled, rubber – soled pair of shoes.Wear low – heeled, rubber – soled pair of shoes. Inform the physician if any unusual sensations develop during Inform the physician if any unusual sensations develop during

the test.the test. Rest after the test.Rest after the test.

RADIOLIGIC TESTSRADIOLIGIC TESTS

Chest Roentgenograms ( X – Rays)Chest Roentgenograms ( X – Rays) To determine overall size and configuration of the heart and size of the To determine overall size and configuration of the heart and size of the

cardiac chambers.cardiac chambers.

Cardiac FluoroscopyCardiac Fluoroscopy Facilitates observation of the heart fro varying views while is is in motion.Facilitates observation of the heart fro varying views while is is in motion.

Cardiac CatheterizationCardiac Catheterization The purpose of the test are as follows:The purpose of the test are as follows:

Assess: oxygen levels, pulmonary blood flow, cardiac ouput, heart structures.Assess: oxygen levels, pulmonary blood flow, cardiac ouput, heart structures. Coronary artery visualization.Coronary artery visualization.

Right – sided heart catherization is done by passing a catheter via a Right – sided heart catherization is done by passing a catheter via a cutdown into a large vein, e.g. medial cubital or brachial vein.cutdown into a large vein, e.g. medial cubital or brachial vein.

Left – sided heart catherization is done by passing a catheter into the aorta Left – sided heart catherization is done by passing a catheter into the aorta via the brachial or femoral artery.via the brachial or femoral artery.


NURSING INTERVENTIONS: Cardiac CatheterizationNURSING INTERVENTIONS: Cardiac CatheterizationBefore the Procedure:Before the Procedure: Provide psychosocial Provide psychosocial support.support. Asses for allergy to iodine/seafoodAsses for allergy to iodine/seafood Obtain baseline VSObtain baseline VS Withhold meals before the procedureWithhold meals before the procedure Have client voidHave client void Administer sedative as orderedAdminister sedative as ordered Mark distal pulsesMark distal pulses Do cardiac monitoringDo cardiac monitoring Done under local anesthesiaDone under local anesthesia May experience warm or flushing sensation as the contrast medium is May experience warm or flushing sensation as the contrast medium is

injected.injected. ““fluttering” sensation is felt, as the catheter enters the chambers of the fluttering” sensation is felt, as the catheter enters the chambers of the

heart.heart.


NURSING INTERVENTIONS: Cardiac CatheterizationNURSING INTERVENTIONS: Cardiac CatheterizationAfter the ProcedureAfter the Procedure Bed rest: if the catheter insertion site is an upper extremity, Bed rest: if the catheter insertion site is an upper extremity,

until VS are stable; while if it is a lower extremity , for 24 hrs.until VS are stable; while if it is a lower extremity , for 24 hrs. Monitor VS, especially peripheral pulsesMonitor VS, especially peripheral pulses Monitor ECG, note for dysrhythmiasMonitor ECG, note for dysrhythmias Apply pressure dressing and a small sand bag or ice ovet the Apply pressure dressing and a small sand bag or ice ovet the

puncture site to prevent bleedingpuncture site to prevent bleeding Immobilize affected extremity in extension to promote Immobilize affected extremity in extension to promote

adequate circulationadequate circulation Do not elevate HOB more than 30 degrees if femoral site was Do not elevate HOB more than 30 degrees if femoral site was

usedused Monitor extremities for color, temperature and tingling.Monitor extremities for color, temperature and tingling.

ANGIOGRAPHY/ ANGIOGRAPHY/ ARTERIOGRAPHYARTERIOGRAPHY

Involves introduction of contrast medium into Involves introduction of contrast medium into the vascular system to outline the heart and the vascular system to outline the heart and blood vesselsblood vessels

It may be done during cardiac catheterizationIt may be done during cardiac catheterization Nursing interventions are similar to that of Nursing interventions are similar to that of

cardiac catheterizationcardiac catheterization Observe the hypotension after the procedure Observe the hypotension after the procedure

because the contrast medium may cause because the contrast medium may cause profound diuretic effectprofound diuretic effect

MAGNETIC RESONANCE MAGNETIC RESONANCE IMAGING (MRI)IMAGING (MRI)

Strong magnetic field and radiowaves are used to Strong magnetic field and radiowaves are used to detect and define difference between healthy and detect and define difference between healthy and diseased tissuesdiseased tissues

MRI can actually show the heart beating and the MRI can actually show the heart beating and the blood flowing in any directions, it can image over blood flowing in any directions, it can image over three spatial dimensions and over time.three spatial dimensions and over time.

It is used for examination of the aorta, detection of It is used for examination of the aorta, detection of tumors, cardiomyopathies and pericardiac disease.tumors, cardiomyopathies and pericardiac disease.

MAGNETIC RESONANCE MAGNETIC RESONANCE IMAGING (MRI)IMAGING (MRI)

NURSING INTERVENTION: MRINURSING INTERVENTION: MRI Secure written consent.Secure written consent. Inform the client that the procedure lasts 45 to 60 minutes.Inform the client that the procedure lasts 45 to 60 minutes. Asses for claustrophobia. The client will be placed in a tunnel Asses for claustrophobia. The client will be placed in a tunnel

– like device.– like device. Remove all metal items, e.g. watch, eyeglasses and jewelry.Remove all metal items, e.g. watch, eyeglasses and jewelry. Instruct the client to remain still during the procedure.Instruct the client to remain still during the procedure. Inform the client that MRI unit makes a loud, knocking noise.Inform the client that MRI unit makes a loud, knocking noise.

CAUTION: client with pacemakers, prosthetic valves or recently CAUTION: client with pacemakers, prosthetic valves or recently implanted clips or wires are not eligible for MRI scans.implanted clips or wires are not eligible for MRI scans.

MYOCARDIAL SCINTIGRAPHYMYOCARDIAL SCINTIGRAPHY

The procedure involves intravenous injection of a The procedure involves intravenous injection of a radioactive isotope via a catheter.radioactive isotope via a catheter.

Myocardial function, motion and perfusion are Myocardial function, motion and perfusion are studied through the use of an external gamma camera.studied through the use of an external gamma camera.

Techniques used are as follow:Techniques used are as follow: Thallium 201 scintigraphyThallium 201 scintigraphy Dipyridamole – thallium – 201 testDipyridamole – thallium – 201 test Technetium 99m ventriculographyTechnetium 99m ventriculography First – pass cardiac studyFirst – pass cardiac study

MYOCARDIAL SCINTIGRAPHYMYOCARDIAL SCINTIGRAPHY

NURSING INTERVENTIONS: Myocardial ScintigraphyNURSING INTERVENTIONS: Myocardial Scintigraphy Inform client that ECG or treadmill test may be done during Inform client that ECG or treadmill test may be done during

the procedurethe procedure Asses for pregnancy because the test involves radiation Asses for pregnancy because the test involves radiation

exposure.exposure. Instruct the client a light meal, to prevent nausea and stomach Instruct the client a light meal, to prevent nausea and stomach

cramping during exercise and for better uptake of the cramping during exercise and for better uptake of the radioisotoperadioisotope

Omit the usual dose of prescribed beta – blockers, calcium – Omit the usual dose of prescribed beta – blockers, calcium – channel blockers and xanthenes before the procedurechannel blockers and xanthenes before the procedure

Instruct the client to report any chest pain experienced during Instruct the client to report any chest pain experienced during procedureprocedure

NON–INVASIVE HEMODYNAMIC MONITORING: NON–INVASIVE HEMODYNAMIC MONITORING: INTRA–ARTERIAL PRESSURE MONITORINGINTRA–ARTERIAL PRESSURE MONITORING

This provides continuous detection of arterial BP via an This provides continuous detection of arterial BP via an indwelling intra – arterial catheterindwelling intra – arterial catheter

It is valuable in monitoring the BP of the clients with low It is valuable in monitoring the BP of the clients with low cardiac output, fluctuating hemodynamic status and excessive cardiac output, fluctuating hemodynamic status and excessive peripheral vasoconstriction and in whom cuff BP measurements peripheral vasoconstriction and in whom cuff BP measurements are undetectable.are undetectable.

Intra – arterial readings are at least 10 mmHg higher than cuff Intra – arterial readings are at least 10 mmHg higher than cuff BP readings.BP readings.

The intra – arterial BP line can be used for obtaining blood The intra – arterial BP line can be used for obtaining blood samples for ABG and blood studies.samples for ABG and blood studies.

Heparinize the catheter to maintain patencyHeparinize the catheter to maintain patency Check catheter insertion site for hemorrhage, hematoma, Check catheter insertion site for hemorrhage, hematoma,

redness or signs of infection.redness or signs of infection. Do neurovascular check distal to catheter insertion site – color, Do neurovascular check distal to catheter insertion site – color,

temperature, capillary filling and sensation. temperature, capillary filling and sensation.

CORONARY CORONARY ARTERY DISEASE (CAD)/ARTERY DISEASE (CAD)/

CORONARY CORONARY ATHEROSCLEROTIC ATHEROSCLEROTIC

HEART DISEASE (CABD)HEART DISEASE (CABD)

SELF MANAGEMENT EDUCATION GUIDE:SELF MANAGEMENT EDUCATION GUIDE:DECREASING RISK FOR CORONARY ARTERY DISEASEDECREASING RISK FOR CORONARY ARTERY DISEASE

Daily management of hypertension. Take medication at regular Daily management of hypertension. Take medication at regular basis. Do not stop.basis. Do not stop.

Stop smoking as soon as possible. Smoking reduces available Stop smoking as soon as possible. Smoking reduces available oxygen to the heart and can precipitate angina. Smoking oxygen to the heart and can precipitate angina. Smoking increases heart rate and blood pressure.increases heart rate and blood pressure.

Avoid passive smoke. Two hours of passive smoke decreases Avoid passive smoke. Two hours of passive smoke decreases oxygen to the heart, decreases exercise time and increases heart oxygen to the heart, decreases exercise time and increases heart rate and blood pressure.rate and blood pressure.

Plan a regular exercise under medical supervision.Plan a regular exercise under medical supervision. If overweight, lose weight. Seek help from professionals.If overweight, lose weight. Seek help from professionals. Follow a healthy heart diet. Reduce cholesterol and increase Follow a healthy heart diet. Reduce cholesterol and increase

fiber.fiber. Reduce stress.Reduce stress. Allow adequate time for rest and relaxation.Allow adequate time for rest and relaxation. These are life – long life – style changes.These are life – long life – style changes.

HEART VALVESHEART VALVES

CORONARY ARTERY DISEASE (CAD) CORONARY ATHEROSCLEROTIC HEART DISEASE (CAHD)

Pathophysiology: ATHEROGENESIS

RISK FACTORS

Nonmodifiable Age

Gender Race

Heredity

Modifiable Stress Diet

Sedentary Living Smoking Alcohol

Hypertension Diabetes Mellitus

Obesity Hyperlipidemia / Hypercholesterolema

Behavioral Factors Contraceptive Pills

A. Nonspecific injury to Arterial Wall (Endothelial Injury)

Desquamation of Endothelial Lining

Increased Permeability / Adhesion Molecules

B. Lipids (LDL, VLDL) and Platelets Assimilate into the Area

C. Oxydized LDL attracts Monocytes And Macrophages to the Site

D. Plaques Begin to Form from cells Which Imbed into the Endothelium

E. Lipids are Engulfed by the Cells (foam cells) and Smooth Muscle Cells Develop

Coronary Atherosclerotic Heart Disease

Decreased Coronary Tissue Perfusion

Coronary Ischemia

Decreased Myocardial Oxygenation

Causes Coronary Atherosclerotic heart Disease Coronary Thrombosis / Embolism Decreased Blood Flow with Shock and / or Hemorrhage Direct Trauma

Myocardial Ischemia Myocardial Oxygen Supply

Cellular Hypoxia

Cardiac Output Myocardial Contractility

Altered Cell Membrane Int.

Arterial Pressure

Stimulation of Baroreceptors

Stimulation of Sympathetic Receptors

Peripheral Vasoconstriction

Afterload

Myocardial Contractility

Heart Rate

Diastolic Filling

Decreased Myocardial tissue per.

Myocardial Oxygen Demand

CLINICAL MANIFESTATIONS CLINICAL MANIFESTATIONS OF ANGINA PECTORISOF ANGINA PECTORIS

Pain Pain Transient, paroxysmal subternal or precoridal painTransient, paroxysmal subternal or precoridal painDescribed as heaviness or tightness of the chest, “indigestion”, crushingDescribed as heaviness or tightness of the chest, “indigestion”, crushingRadiates down one or both arms, left shoulder, jaw, neck and backRadiates down one or both arms, left shoulder, jaw, neck and backPrecipitated by activity/exertionPrecipitated by activity/exertionRelieved by rest and nitroglycerineRelieved by rest and nitroglycerine

PallorPallor DiaphoresisDiaphoresis DyspneaDyspnea PalpitationsPalpitations DizzinessDizziness Digestive disturbances (due to vagal stimulation)Digestive disturbances (due to vagal stimulation)

TYPES OF ANGINA PECTORISTYPES OF ANGINA PECTORIS Stable AnginaStable Angina

Chest pain lasts for less than 15 minutesChest pain lasts for less than 15 minutesRecurrence is less frequentRecurrence is less frequent

Unstable Angina (Preinfarction Angina, Crescendo Angina, Intermittent Coronary Syndrome)Unstable Angina (Preinfarction Angina, Crescendo Angina, Intermittent Coronary Syndrome)Chest pain last for more than 15 minutes but less than 30 minutesChest pain last for more than 15 minutes but less than 30 minutesRecurrence is more frequent, may occur at nightRecurrence is more frequent, may occur at nightIntensity of pain increasesIntensity of pain increases

Variant Angina (Prinzmetal’s Angina)Variant Angina (Prinzmetal’s Angina)Chest pain is of longer duration and may occur at restChest pain is of longer duration and may occur at restThe attacks tend to occur in the early hours of the dayThe attacks tend to occur in the early hours of the dayMay result from coronary artery spasmMay result from coronary artery spasm

Nocturnal AnginaNocturnal Angina Occurs only during the night and is possibly associated with rapid eye movement (REM) Occurs only during the night and is possibly associated with rapid eye movement (REM) sleepsleep

Angina DecubitusAngina DecubitusParoxysmal chest pain that occurs when the client sits or stands up Paroxysmal chest pain that occurs when the client sits or stands up

Intractable AnginaIntractable AnginaChronic, incapacitating angina unresponsive to interventionChronic, incapacitating angina unresponsive to intervention

Postinfarction AnginaPostinfarction AnginaOccurs after MI, when residual ischemia may cause episodes of anginaOccurs after MI, when residual ischemia may cause episodes of angina

PRECIPITATING EVENTS OF PRECIPITATING EVENTS OF ANGINA PECTORISANGINA PECTORIS

Exertion. Vigorous exercise done very Exertion. Vigorous exercise done very sporadicallysporadically

Emotions. Excitement, sexual activity.Emotions. Excitement, sexual activity. Eating Heavy meal.Eating Heavy meal. Environment. Exposure to coldEnvironment. Exposure to cold These events increase myocardial oxygen These events increase myocardial oxygen

demands. Further disequilibrium between demands. Further disequilibrium between oxygen supply and oxygen demand occurs.oxygen supply and oxygen demand occurs.

COLLABORATIVE MANAGEMENT COLLABORATIVE MANAGEMENT OF ANGINA PECTORISOF ANGINA PECTORIS

MedicationsMedications

Vasodilators: Nitroglycerine, Amyl Nitrate, Vasodilators: Nitroglycerine, Amyl Nitrate, IsosorbideIsosorbideEffects: Effects: Direct relaxing effect on vascular smooth muscle, resulting in Direct relaxing effect on vascular smooth muscle, resulting in generalized vasodilationgeneralized vasodilationDecrease peripheral resistance, decrease systolic pressure, Decrease peripheral resistance, decrease systolic pressure, produce venouspooling, and decrease preloadproduce venouspooling, and decrease preloadCoronary vasodilation redistributes myocardial blood flow Coronary vasodilation redistributes myocardial blood flow more efficientlymore efficiently


Beta – adrenergic blocking agentsBeta – adrenergic blocking agentsPropranolol (Inderal)Propranolol (Inderal)Metoprolol (Lopressor)Metoprolol (Lopressor)Nadolol (Corgard)Nadolol (Corgard)Atenolol (Tenormin)Atenolol (Tenormin)Pindolol (Visken)Pindolol (Visken)Esmolol (Brevibloc)Esmolol (Brevibloc)

Effects:Effects:Decrease myocardial oxygen demand by decreasing heart rate, Decrease myocardial oxygen demand by decreasing heart rate, blood pressure, myocardial contractility and calcium outputblood pressure, myocardial contractility and calcium output


Calcium – channel blockersCalcium – channel blockersVerapamil (Isoptin, Calan)Verapamil (Isoptin, Calan)Nifedipine (Procardia, Adalat, Calcibloc)Nifedipine (Procardia, Adalat, Calcibloc)Diltiazen (Cardizem)Diltiazen (Cardizem)

Effects:Effects:Inhibit calcium ion transportation into myocardial cells to Inhibit calcium ion transportation into myocardial cells to

depress inotropic and chronotropic activity, decreasing depress inotropic and chronotropic activity, decreasing cardiac workload cardiac workload

It has vasodilation effectIt has vasodilation effectIt reduces coronary vasospasmIt reduces coronary vasospasm


Other MedicationsOther Medications

Platelet Aggregation InhibitorsPlatelet Aggregation InhibitorsASAASADipyridamole (Persantin)Dipyridamole (Persantin)Ticlopidine (Ticlid)Ticlopidine (Ticlid)

Effect: inhibit platelet aggregation, thereby prevent thrombus Effect: inhibit platelet aggregation, thereby prevent thrombus formationformation

AnticoagulantsAnticoagulantsHeparin SodiumHeparin Sodium

Effect: inactivates thrombin and other clotting factors inhibiting Effect: inactivates thrombin and other clotting factors inhibiting conversion of fibrinogen to fibrin, fibrin clot formation is prevented.conversion of fibrinogen to fibrin, fibrin clot formation is prevented.Warfarin Sodium (Coumadin)Warfarin Sodium (Coumadin)DicumarolDicumarol

Effect: Inhibit hepatic synthesis of Vitamin KEffect: Inhibit hepatic synthesis of Vitamin K

Nitroglycerine TherapyNitroglycerine Therapy

Assume sitting or supine position when taking the drug. To prevent orthostatic Assume sitting or supine position when taking the drug. To prevent orthostatic hypotension.hypotension.

Take maximum of three doses at five-minute interval.Take maximum of three doses at five-minute interval. Gradual change of position to prevent orthostatic hypotension.Gradual change of position to prevent orthostatic hypotension. If taken sublingual, the medication causes burning or stinging sensation under If taken sublingual, the medication causes burning or stinging sensation under

the tongue.the tongue. Sublingual route produces onset of action within 1 to 2 minutes, duration of Sublingual route produces onset of action within 1 to 2 minutes, duration of

action is 30 minutes.action is 30 minutes. Offer sips of water before giving sublingual nitrates; dryness of mouth may Offer sips of water before giving sublingual nitrates; dryness of mouth may

inhibit drug absorption.inhibit drug absorption. Instruct client to avoid drinking alcohol, to avoid hypotension, weakness and Instruct client to avoid drinking alcohol, to avoid hypotension, weakness and

faintness.faintness. Advise client to always carry three tablets in his pocket.Advise client to always carry three tablets in his pocket.

NURSING INTERVENTIONS IN NURSING INTERVENTIONS IN DRUG THERAPYDRUG THERAPY

Store nitroglycerine in cool, dry place; use dark/amber – Store nitroglycerine in cool, dry place; use dark/amber – colored, air-tight container, may be destroyed by heat, light or colored, air-tight container, may be destroyed by heat, light or moisture.moisture.

Change stock of nitroglycerine every 6 months.Change stock of nitroglycerine every 6 months. Observe for side effects: headache, flushed face, dizziness, Observe for side effects: headache, flushed face, dizziness,

faintness, tachycardia; these are common during first few faintness, tachycardia; these are common during first few doses of the medication. Do not discontinue the drug.doses of the medication. Do not discontinue the drug.

Transderm – Nitropatch is applied once a day, usually in the Transderm – Nitropatch is applied once a day, usually in the morning.morning.

Rotation of skin sites is necessary, usually on the chest wall.Rotation of skin sites is necessary, usually on the chest wall. Evaluate effectiveness relief of chest pain.Evaluate effectiveness relief of chest pain.


Beta–adrenergic BlockersBeta–adrenergic Blockers Assess pulse rate before administration of the drug, withhold if Assess pulse rate before administration of the drug, withhold if

bradycardia is present.bradycardia is present. Administer with food to prevent GI upset.Administer with food to prevent GI upset. Do not administer propranolol to clients with asthma. It causes Do not administer propranolol to clients with asthma. It causes

bronchoconstriction.bronchoconstriction. Do not administer propranolol to clients with DM. It causes Do not administer propranolol to clients with DM. It causes

hypoglycernia. hypoglycernia. Give with extreme caution in clients with heart failure.Give with extreme caution in clients with heart failure. Observe for side-effects which are as follows: nausea, Observe for side-effects which are as follows: nausea,

vomiting, mental depression, mild diarrhea, fatigue, and vomiting, mental depression, mild diarrhea, fatigue, and impotence.impotence.


Calcium-channel BlockersCalcium-channel Blockers Assess heart rate and BPAssess heart rate and BP Monitor hepatic and renal functionMonitor hepatic and renal function Administer 1 hour before or 2 hours meals. Food delays Administer 1 hour before or 2 hours meals. Food delays

absorption and decreases plasma levels of the drug.absorption and decreases plasma levels of the drug.

Platelet Aggregation InhibitorsPlatelet Aggregation Inhibitors Assess for signs and symptoms of bleedingAssess for signs and symptoms of bleeding Avoid straining at stoolAvoid straining at stool Do not give ASA with coumadinDo not give ASA with coumadin ASA should be given with foodASA should be given with food Observe for ASA toxicity – tinnitusObserve for ASA toxicity – tinnitus


Heparin SodiumHeparin Sodium Assess for signs and symptoms of bleedingAssess for signs and symptoms of bleeding Keep protamine sulfate available. It is the antidote of heparin NaKeep protamine sulfate available. It is the antidote of heparin Na If administered s.c., do not aspirate, do not massage, to prevent If administered s.c., do not aspirate, do not massage, to prevent

hematoma formationhematoma formation Monitor PTT or APTT levelsMonitor PTT or APTT levels Used for a maximum of 2 weeksUsed for a maximum of 2 weeks

CoumadinCoumadin Assess for signs and symptoms of bleedingAssess for signs and symptoms of bleeding Keep vitamin K readily available. It is the antidote of coumadin.Keep vitamin K readily available. It is the antidote of coumadin. Monitor Prothrombin Time.Monitor Prothrombin Time. Minimize green leafy vegetables in the diet. These contain vitamin Minimize green leafy vegetables in the diet. These contain vitamin

K.K.

TREATMENTTREATMENT

Percutaneous Transluminal Coronary Angioplasty Percutaneous Transluminal Coronary Angioplasty (PTCA)(PTCA)

Mechanical dilatation of the coronary vessel wall by Mechanical dilatation of the coronary vessel wall by compressing the atheromatous plaque.compressing the atheromatous plaque.

It is recommended for clients with single – vessel It is recommended for clients with single – vessel coronary artery disease.coronary artery disease.

A specially designed balloon – tipped catheter is A specially designed balloon – tipped catheter is inserted under fluoroscopic guidance and advanced inserted under fluoroscopic guidance and advanced to the site of the coronary obstruction.to the site of the coronary obstruction.

TREATMENTTREATMENT

Intravascular StentingIntravascular Stenting

Biologic stent is produced through coagulation of Biologic stent is produced through coagulation of collagen, elastin and other tissues in the vessel wall collagen, elastin and other tissues in the vessel wall by laser, photocoagulation or radio frequency-by laser, photocoagulation or radio frequency-induced heat.induced heat.

Prosthetic intravascular cylindric stents maintain Prosthetic intravascular cylindric stents maintain good luminal geometry after balloon deflation and good luminal geometry after balloon deflation and withdrawal withdrawal

Intravascular stenting is done to prevent restenosis Intravascular stenting is done to prevent restenosis after PTCA[after PTCA[

TREATMENTTREATMENT

Laser TherapyLaser Therapy

Laser light produces necrosis, hemostatis, Laser light produces necrosis, hemostatis, coagulation, evaporation of tissue.coagulation, evaporation of tissue.

NURSING INTERVENTIONSNURSING INTERVENTIONS

DietDiet Low Na, low fat and low cholesterol, high fiber dietLow Na, low fat and low cholesterol, high fiber diet Avoid saturated fats (animals fats)Avoid saturated fats (animals fats) White meat, e.g. chicken without skin, fish are low in White meat, e.g. chicken without skin, fish are low in

cholesterol.cholesterol. Read labelsRead labels

ActivityActivity No restrictions are placed on activity within the No restrictions are placed on activity within the

patient’s limitationspatient’s limitations

SURGICAL MANAGEMENT OF SURGICAL MANAGEMENT OF ANGINA PECTORISANGINA PECTORIS

Coronary Artery Bypass Graft (CABG)Coronary Artery Bypass Graft (CABG) Reduces angina and improves activity Reduces angina and improves activity

tolerancetolerance It is recommended if severe narrowing of one It is recommended if severe narrowing of one

or more branches of the coronary arteries exist.or more branches of the coronary arteries exist. The main purpose of CABG is myocardial The main purpose of CABG is myocardial

revascularizationrevascularization The commonly used grafts are the saphenous The commonly used grafts are the saphenous

vein and internal mammary arteryvein and internal mammary artery

NURSING MANAGEMENT IN NURSING MANAGEMENT IN CABGCABG

Promoting comfortPromoting comfort Relieve painRelieve pain Nitroglycerine is the drug of choice for relief of pain Nitroglycerine is the drug of choice for relief of pain

from acute ischemic attacksfrom acute ischemic attacks

Promoting tissue perfusionPromoting tissue perfusion Instruct the client to avoid over-fatigueInstruct the client to avoid over-fatigue Stop activity immediately in the presence of chest Stop activity immediately in the presence of chest

pain, dyspnea, lightheadedness or faintness which pain, dyspnea, lightheadedness or faintness which indicate low tissue perfusionindicate low tissue perfusion

NURSING MANAGEMENT IN NURSING MANAGEMENT IN CABGCABG

Promoting activity and restPromoting activity and rest Encourage slower activity or shorter periods of activity with more rest Encourage slower activity or shorter periods of activity with more rest

periods. Avoid overexertions.periods. Avoid overexertions. Plan for regular activity programPlan for regular activity program Take nitroglycerine before exerciseTake nitroglycerine before exercise Increase extent of exercise graduallyIncrease extent of exercise gradually

Facilitating learningFacilitating learning Promote a positive attitude and active participation of the client and the Promote a positive attitude and active participation of the client and the

family to encourage compliancefamily to encourage compliance

Promoting relief of anxiety and feeling of well-beingPromoting relief of anxiety and feeling of well-being Facilitate reduction in the client’s present level of anxietyFacilitate reduction in the client’s present level of anxiety Advise the client to minimize emotional outbursts, worry and tension.Advise the client to minimize emotional outbursts, worry and tension. Encourage to maintain an optimistic outlook to help relieve the work of the Encourage to maintain an optimistic outlook to help relieve the work of the

heartheart

MYOCARDIAL INFARCTIONMYOCARDIAL INFARCTION

The formation of localized necrotic areas The formation of localized necrotic areas within the myocardium. MI usually follows within the myocardium. MI usually follows sudden coronary and the abrupt cessation of sudden coronary and the abrupt cessation of blood and oxygen flow to the heart muscle.blood and oxygen flow to the heart muscle.

Prolonged ischemia lasting more than 35 to 45 Prolonged ischemia lasting more than 35 to 45 minutes produces irreversible cellular damage minutes produces irreversible cellular damage and necrosis of the myocardiumand necrosis of the myocardium

Causes Coronary Atherosclerotic heart Disease Coronary Thrombosis / Embolism Decreased Blood Flow with Shock and / or Hemorrhage Direct Trauma

Myocardial Ischemia Myocardial Oxygen Supply

Cellular Hypoxia

Cardiac Output Myocardial Contractility

Altered Cell Membrane Int.

Arterial Pressure

Stimulation of Baroreceptors

Stimulation of Sympathetic Receptors

Peripheral Vasoconstriction

Afterload

Myocardial Contractility

Heart Rate

Diastolic Filling

Decreased Myocardial tissue per.

Myocardial Oxygen Demand

PATHOPHYSIOLOGY OF PATHOPHYSIOLOGY OF MYOCARDIAL INFARCTIONMYOCARDIAL INFARCTION

Ischemic injury evolves over several hours toward complete Ischemic injury evolves over several hours toward complete necrosis and infarction.necrosis and infarction.

Ischemia almost immediately alters the integrity and permeability Ischemia almost immediately alters the integrity and permeability of the cell membrane to vital electrolytes, thereby decreased of the cell membrane to vital electrolytes, thereby decreased myocardial contractility.myocardial contractility.

The autonomic nervous system attempts to compensate for the The autonomic nervous system attempts to compensate for the depressed cardiac performance. This results to further imbalance depressed cardiac performance. This results to further imbalance between myocardial oxygen supply and demand.between myocardial oxygen supply and demand.

MI almost always occurs in the left ventricle and often MI almost always occurs in the left ventricle and often significantly depresses left ventricular function. This is due to significantly depresses left ventricular function. This is due to occlusion of the LADA ((left anterior descending artery). This is occlusion of the LADA ((left anterior descending artery). This is referred to as anterior wall infarction.referred to as anterior wall infarction.

Alterations in function depend on the size and location of an Alterations in function depend on the size and location of an infarct.infarct.

Contractile function in the necrotic area ceases permanently.Contractile function in the necrotic area ceases permanently.


The three areas which develop MI are as follows:The three areas which develop MI are as follows: Zone of infarction which records pathologic Q wave in the ECGZone of infarction which records pathologic Q wave in the ECG Zone of injury which gives rise to elevated ST segmentZone of injury which gives rise to elevated ST segment Zone of ischemia which produces inversion of T waveZone of ischemia which produces inversion of T wave

MI may be classified as follows:MI may be classified as follows: Transmural infarct, which extends from endocardium to Transmural infarct, which extends from endocardium to

epicardium.epicardium. Subendocardial infarct, which affects the endocardial muscles and Subendocardial infarct, which affects the endocardial muscles and Intramural infarct, which is seen in patchy areas of the Intramural infarct, which is seen in patchy areas of the

myocardium and is usually associated with longstanding angina pectoris.myocardium and is usually associated with longstanding angina pectoris. Healing requires formation of scar tissues that replace the Healing requires formation of scar tissues that replace the

necrotic myocardial muscle; scar tissue inhibits contractility.necrotic myocardial muscle; scar tissue inhibits contractility.

CLINICAL MANIFESTATIONS CLINICAL MANIFESTATIONS OF MYOCARDIAL INFARCTIONOF MYOCARDIAL INFARCTION

PainPain Crushing severe, prolonged, unrelieved by rest or nitroglycerine; often Crushing severe, prolonged, unrelieved by rest or nitroglycerine; often

radiating to one or both arms, the neck and the back.radiating to one or both arms, the neck and the back. Characterized by “Levine’s sign”Characterized by “Levine’s sign”

Pathophysiologic BasisPathophysiologic Basis Cessation of blood supply to myocardium caused by thrombotic Cessation of blood supply to myocardium caused by thrombotic

occlusion causes accumulation of metabolites within ischemic part of occlusion causes accumulation of metabolites within ischemic part of myocardium, this affects nerve endings.myocardium, this affects nerve endings.

Anxiety and apprehensionAnxiety and apprehension Feeling of “doom”, restlessnessFeeling of “doom”, restlessness Pathophysiologic BasisPathophysiologic Basis

Severe pain of a heart attack is terrifying; most clients are aware of the Severe pain of a heart attack is terrifying; most clients are aware of the significance of a heart attack; restlessness from shock and pain.significance of a heart attack; restlessness from shock and pain.


ShockShock Systolic pressure below 80mmHg, gray, facial color, lethargy, Systolic pressure below 80mmHg, gray, facial color, lethargy,

cold diaphoresis, peripheral cyanosis, tachycardia/bradycardia, cold diaphoresis, peripheral cyanosis, tachycardia/bradycardia, weak pulse weak pulse

Pathophysiologic BasisPathophysiologic BasisThis may be due to severe pain, severe reduction in cardiac This may be due to severe pain, severe reduction in cardiac

output and inadequate tissue perfusion, thereby tissue hypoxia.output and inadequate tissue perfusion, thereby tissue hypoxia.

OliguriaOliguria Urine flow of less than 30 ml/hrUrine flow of less than 30 ml/hr Pathophysiologic BasisPathophysiologic Basis

This indicates renal hypoxia due to inadequate renal This indicates renal hypoxia due to inadequate renal tissue perfusiontissue perfusion


FeverFever Slight elevation of temperature occurs within 24 hrs and extends 3 to 7 days Slight elevation of temperature occurs within 24 hrs and extends 3 to 7 days

accompanied by leukocytosis and elevated ESRaccompanied by leukocytosis and elevated ESR Pathophysiologic BasisPathophysiologic Basis

Fever and leukocytosis result from destruction of Fever and leukocytosis result from destruction of myocardial tissue and ensuing inflammatory processmyocardial tissue and ensuing inflammatory process

IndigestionIndigestion Gas pains around the heart, nausea and vomitingGas pains around the heart, nausea and vomiting Pathophysiologic BasisPathophysiologic Basis

Client may prefer to believe that pain is caused by “gas” or Client may prefer to believe that pain is caused by “gas” or “indigestion” rather than by heart disease; nausea and vomiting “indigestion” rather than by heart disease; nausea and vomiting may result from severe pain or from vasovagal reflexes conducted may result from severe pain or from vasovagal reflexes conducted from an area of damaged myocardium to gastrointestinal tract.from an area of damaged myocardium to gastrointestinal tract.


Acute pulmonary edemaAcute pulmonary edema Sense of suffocation, dyspnea, orthopea, gurgling/bubbling respiration Sense of suffocation, dyspnea, orthopea, gurgling/bubbling respiration Pathophysiologic BasisPathophysiologic Basis

Left ventricle becomes severely weakened in pumping action owing to infarction; severe Left ventricle becomes severely weakened in pumping action owing to infarction; severe pulmonary congestion resultspulmonary congestion results

ECG changesECG changes MI causes elevation of ST segment, inversion of T wave and enlargement of Q waveMI causes elevation of ST segment, inversion of T wave and enlargement of Q wave Pathophysiologic BasisPathophysiologic Basis

Pathologic Q wave develops from the area of infarction; elevated ST segment results from the areaPathologic Q wave develops from the area of infarction; elevated ST segment results from the areaof injury; and inverted T wave originated from the zone of ischemiaof injury; and inverted T wave originated from the zone of ischemiaElevation of ST segment heralds a pattern of injury and usually occurs as an initial change in acute Elevation of ST segment heralds a pattern of injury and usually occurs as an initial change in acute

MIMI

Elevated Ck-MB, elevated LDH, elevated ASTElevated Ck-MB, elevated LDH, elevated AST Pathophysiologic BasisPathophysiologic Basis

These cardiac enzymes are produced in abnormally large amounts because of cellular These cardiac enzymes are produced in abnormally large amounts because of cellular damage and death.damage and death.Elevation of Ck-MB is the most definitive finding in MI, especially in the presence of Elevation of Ck-MB is the most definitive finding in MI, especially in the presence of increased levels of LDHincreased levels of LDH

COLLABORATIVE MANAGEMENT COLLABORATIVE MANAGEMENT OF MYOCARDIAL INFARCTIONOF MYOCARDIAL INFARCTION

MedicationsMedications

AnalgesicAnalgesic For relief of pain. This is priority. Pain may cause shock.For relief of pain. This is priority. Pain may cause shock. Morphine sulfate, lidocaine or nitroglycerine administered intravenously.Morphine sulfate, lidocaine or nitroglycerine administered intravenously.

Thrombolytic therapy.Thrombolytic therapy. To disintegrate blood clot by activating the fibrinolytic processesTo disintegrate blood clot by activating the fibrinolytic processes Streptokinase, urokinase and tissue plasminogen activator (TPA) are currently used.Streptokinase, urokinase and tissue plasminogen activator (TPA) are currently used. Detect for occult bleeding during and after thrombolytic therapyDetect for occult bleeding during and after thrombolytic therapy Assess neurologic status changes which may indicate G.I. bleeding or cardiac Assess neurologic status changes which may indicate G.I. bleeding or cardiac

tamponade.tamponade.

Anticoagulant and antiplatelet medications are administered after thrombolytic Anticoagulant and antiplatelet medications are administered after thrombolytic therapy to maintain arterial patency.therapy to maintain arterial patency.

Other medications: Beta-adrenergic blocking agents; diazepam (valium)Other medications: Beta-adrenergic blocking agents; diazepam (valium)

TREATMENTTREATMENT Goals Goals

Prevention of further tissue injury and limitation of infarct sizePrevention of further tissue injury and limitation of infarct size Maximize myocardial tissue perfusion and reduce myocardial tissue Maximize myocardial tissue perfusion and reduce myocardial tissue

demandsdemands Supplemental oxygen by nasal cannula. This increases Supplemental oxygen by nasal cannula. This increases

myocardial oxygen supply and relieves painmyocardial oxygen supply and relieves pain Cardiac monitoring to detect occurrence of dysrhythmiasCardiac monitoring to detect occurrence of dysrhythmias Percutaneous transluminal coronary angioplasty may be done Percutaneous transluminal coronary angioplasty may be done

to reopen an occluded artery.to reopen an occluded artery. Diet: low-cholesterol, low-salt diet is prescribed.Diet: low-cholesterol, low-salt diet is prescribed. Activity: Bed rest is usually prescribed for 24 to 48 hours to Activity: Bed rest is usually prescribed for 24 to 48 hours to

decrease oxygen demand. Progressive ambulation is decrease oxygen demand. Progressive ambulation is implemented as soon as possible, unless complications implemented as soon as possible, unless complications occurred.occurred.

NURSING MANAGEMENTNURSING MANAGEMENT Promoting oxygenation and tissue perfusionPromoting oxygenation and tissue perfusion

Instruct the patient to avoid overfatigue, stop activity immediately in the Instruct the patient to avoid overfatigue, stop activity immediately in the presence of chest pain, dyspnea, lightheadedness or faintness.presence of chest pain, dyspnea, lightheadedness or faintness.

Oxygen therapy by cannula for the first 24 to 48 hours or longer if pain, Oxygen therapy by cannula for the first 24 to 48 hours or longer if pain, hypotension, dyspnea or dysrhythmias persist. Monitor VS changes, hypotension, dyspnea or dysrhythmias persist. Monitor VS changes, indicative of complications.indicative of complications.

Position the client in semi-Fowler’s to allow greater diaphragm expansion Position the client in semi-Fowler’s to allow greater diaphragm expansion thereby lung expansion and better carbon dioxide-oxygen exchange.thereby lung expansion and better carbon dioxide-oxygen exchange.

Promoting adequate cardiac outputPromoting adequate cardiac output Monitor the following parameters:Monitor the following parameters:

Dysrhythmias on ECG tracingsDysrhythmias on ECG tracings VSVS Effects of daily activities on cardiac statusEffects of daily activities on cardiac status Rate and rhythm of pulseRate and rhythm of pulse

Administer pharmacotherapy as prescribedAdminister pharmacotherapy as prescribed Promote rest and minimize unnecessary disturbancesPromote rest and minimize unnecessary disturbances

NURSING MANAGEMENTNURSING MANAGEMENT Promoting comfortPromoting comfort

Relieve pain. Administer morphine sulfate as ordered. This is to decrease Relieve pain. Administer morphine sulfate as ordered. This is to decrease sympathetic stimulation, which increase myocardial oxygen demand. In addition, sympathetic stimulation, which increase myocardial oxygen demand. In addition, this will prevent shock which may result from severe pain.this will prevent shock which may result from severe pain.

Providing testProviding test The client is usually placed on bed rest with commode privileges for 24 to 48 hoursThe client is usually placed on bed rest with commode privileges for 24 to 48 hours Administer diazepam (valium) as orderedAdminister diazepam (valium) as ordered Explain that the purpose of CCU is for continuous monitoring and safety during the Explain that the purpose of CCU is for continuous monitoring and safety during the

early recovery period.early recovery period. Provide psychosocial support to the client and his family. Calmness and Provide psychosocial support to the client and his family. Calmness and

competency are extremely reassuring.competency are extremely reassuring.

Promoting activityPromoting activity Gradual increase in activity is encouraged after the first 24 to 48 hours. May be Gradual increase in activity is encouraged after the first 24 to 48 hours. May be

allowed to sit on a chair for increasing periods of time and begins ambulation on the allowed to sit on a chair for increasing periods of time and begins ambulation on the 4th and 5th day.4th and 5th day.

Monitor for signs of dysrhythmias, chest pain, and changes in VS during the Monitor for signs of dysrhythmias, chest pain, and changes in VS during the activity.activity.

NURSING MANAGEMENTNURSING MANAGEMENT Promoting nutrition and eliminationPromoting nutrition and elimination

Provide small, frequent feedingsProvide small, frequent feedings Provide low-calorie, low cholesterol, low-sodium dietProvide low-calorie, low cholesterol, low-sodium diet Avoid stimulantsAvoid stimulants Avoid taking very hot or very cold beverages and gas-forming foods. Vasovagal Avoid taking very hot or very cold beverages and gas-forming foods. Vasovagal

stimulation may occur, thereby bradycardia and cardiac arrest.stimulation may occur, thereby bradycardia and cardiac arrest. Use of bedpan and straining at stool should be avoided. Valsalva maneuver causes Use of bedpan and straining at stool should be avoided. Valsalva maneuver causes

changes in blood pressure and heart rate, which may trigger ischemia, changes in blood pressure and heart rate, which may trigger ischemia, dysrhythmias, pulmonary embolism or cardiac arrest.dysrhythmias, pulmonary embolism or cardiac arrest.

Use bedside commodeUse bedside commode Administer stool softener as ordered, e.g. sodium decussate (colace).Administer stool softener as ordered, e.g. sodium decussate (colace).

Promoting relief of anxiety and feeling of well-beingPromoting relief of anxiety and feeling of well-being Provide an opportunity for the client and family to explore their concerns and to Provide an opportunity for the client and family to explore their concerns and to

identify alternative methods of coping as necessaryidentify alternative methods of coping as necessary Facilitating learningFacilitating learning

Teaching is started once the client is free of pain and excessive anxietyTeaching is started once the client is free of pain and excessive anxiety Promote a positive attitude and active participation of the client and the family.Promote a positive attitude and active participation of the client and the family.

CARDIAC REHABILITATIONCARDIAC REHABILITATION

Is a process by which a person is restored to Is a process by which a person is restored to health and maintains optimal physiologic, health and maintains optimal physiologic, psychosocial, vocational and recreational psychosocial, vocational and recreational functions.functions.

It begins the moment a client is admitted to the It begins the moment a client is admitted to the hospital for emergency care, it continues for hospital for emergency care, it continues for months and even years after the client is months and even years after the client is discharged from the health care facility.discharged from the health care facility.

GOALS OF REHABILITATIONGOALS OF REHABILITATION To live as full, vital and productive a life as possibleTo live as full, vital and productive a life as possible Remain within the limits of the heart’s ability to respond to activity and stressRemain within the limits of the heart’s ability to respond to activity and stress

Progressive activityProgressive activity Activity progression is based on the metabolic equivalent of the task (MET), Activity progression is based on the metabolic equivalent of the task (MET),

the energy expenditure for various activitiesthe energy expenditure for various activities In the hospital, exercise may be gradually implemented as follows:In the hospital, exercise may be gradually implemented as follows:

Lying or sitting exercises (arms, legs and trunk), then exercises progress to Lying or sitting exercises (arms, legs and trunk), then exercises progress to standing and slow walking in the hall. (VS and heart rhythmns are constantly standing and slow walking in the hall. (VS and heart rhythmns are constantly monitored)monitored)An exercise session is terminated if any one of the following occurs:An exercise session is terminated if any one of the following occurs:

Cyanosis, cold sweats, faintness, extreme fatigue, severe dyspnea, pallor, chest pain, Cyanosis, cold sweats, faintness, extreme fatigue, severe dyspnea, pallor, chest pain, PR more than 100 beats/min, dysrhythmias, BP greater than 160/95 mmHg.PR more than 100 beats/min, dysrhythmias, BP greater than 160/95 mmHg.

Exercise must be done twice a day for about 20 minutesExercise must be done twice a day for about 20 minutesExercise provides the clients a positive sign of progress and recovery, a sense Exercise provides the clients a positive sign of progress and recovery, a sense of control over their bodies, and tends to decrease anxiety and depression of control over their bodies, and tends to decrease anxiety and depression during the recovery period.during the recovery period.Home exercise program includes 2 to 12 weeks structured walking program.Home exercise program includes 2 to 12 weeks structured walking program.

TEACHING AND COUNSELLINGTEACHING AND COUNSELLINGSELF-MANAGEMENT EDUCATION GUIDE:SELF-MANAGEMENT EDUCATION GUIDE:

DISCHARGE AFTER MI.DISCHARGE AFTER MI.

Discontinue smokingDiscontinue smoking Control hypertension with continued medical supervisionControl hypertension with continued medical supervision Eat a diet low in calories, saturated fats and cholesterol; decrease in salt intake.Eat a diet low in calories, saturated fats and cholesterol; decrease in salt intake. Participate in weight reduction programParticipate in weight reduction program Progressive exercise based on the discharge MET level under medical Progressive exercise based on the discharge MET level under medical

supervision supervision Take prescribed medications at regular basisTake prescribed medications at regular basis Resumption of sexual activity after 4 to 6 weeks from discharge, if appropriate. Resumption of sexual activity after 4 to 6 weeks from discharge, if appropriate.

Or when the client with uncomplicated MI (no dysrhythmias, shock of CHF) is Or when the client with uncomplicated MI (no dysrhythmias, shock of CHF) is capable of walking two flights of stair without difficulty.capable of walking two flights of stair without difficulty.

Stress management techniquesStress management techniques Return to usual home activities, relationships and to work at earliest Return to usual home activities, relationships and to work at earliest

opportunity would be beneficial.opportunity would be beneficial.

TEACHING GUIDE ON RESUMPTION ON TEACHING GUIDE ON RESUMPTION ON SEXUAL ACTIVITYSEXUAL ACTIVITY

Assume less fatiguing positionAssume less fatiguing position The non-MI partner takes the active roleThe non-MI partner takes the active role Perform sexual activity in a cool, familiar Perform sexual activity in a cool, familiar

environmentenvironment Take nitroglycerine before sexual activityTake nitroglycerine before sexual activity Refrain from sexual activity during a fatiguing day, Refrain from sexual activity during a fatiguing day,

after eating a large meal or after drinking alcoholafter eating a large meal or after drinking alcohol If dyspnea, chest pain, dizziness, or palpitations If dyspnea, chest pain, dizziness, or palpitations

occur, moderation should observed; if symptoms occur, moderation should observed; if symptoms persist, stop sexual activitypersist, stop sexual activity

Develop other means of sexual expressionDevelop other means of sexual expression

COMPLICATIONS OF MICOMPLICATIONS OF MI

DysrhythmiasDysrhythmias Cardiogenic shockCardiogenic shock ThromboembolismThromboembolism PericarditisPericarditis Rupture of the myocardiumRupture of the myocardium Ventricular aneurysmVentricular aneurysm Congestive heart failureCongestive heart failure

DYSRHYTHMIASDYSRHYTHMIAS Abnormal cardiac rhythms which are due to the following factors:Abnormal cardiac rhythms which are due to the following factors:

Tissue ischemiaTissue ischemia HypoxemiaHypoxemia SNS and PNS influencesSNS and PNS influences Lactic acidosisLactic acidosis Hemodynamic abnormalitiesHemodynamic abnormalities Drug toxicityDrug toxicity Electrolyte imbalancesElectrolyte imbalances

These are due to abnormal automaticity, abnormal conduction or These are due to abnormal automaticity, abnormal conduction or both. both.

The most common complications and most major cause of death The most common complications and most major cause of death among clients with MIamong clients with MI

The most common dysrhythmias in MI is premature ventricular The most common dysrhythmias in MI is premature ventricular contractions (PVCs)contractions (PVCs)

PVCs of 6 or more per minute is life-threateningPVCs of 6 or more per minute is life-threatening

COMMON DYSRHYTHMIAS COMMON DYSRHYTHMIAS AFTER MIAFTER MI

SinusSinus Sinus tachycardiaSinus tachycardia Sinus bradycardiaSinus bradycardia Sinus dysrhythmiasSinus dysrhythmias Sick sinus syndromeSick sinus syndrome

AtrialAtrial Premature atrial contractionPremature atrial contraction Paroxysmal atrial tachycardiaParoxysmal atrial tachycardia Atrial flutterAtrial flutter Atrial fibrillationAtrial fibrillation

VentricularVentricular Premature ventricular contractionsPremature ventricular contractions Ventricular bigeminyVentricular bigeminy Ventricular fibrillationVentricular fibrillation Ventricular tachycardiaVentricular tachycardia

Conduction defectsConduction defects First degree AV blockFirst degree AV block Second degree AV blockSecond degree AV block Third degree AV blockThird degree AV block

SINUS DYSRHYTHMIASSINUS DYSRHYTHMIAS Sinus tachycardia is a dysrhythmias that is normal, except that the Sinus tachycardia is a dysrhythmias that is normal, except that the

rate exceeds 100 beats per minute.rate exceeds 100 beats per minute. Etiology:Etiology:

The sympathetic fibers are stimulated thereby, speed up excitation of the SA The sympathetic fibers are stimulated thereby, speed up excitation of the SA nodenode

Treatment:Treatment: Digitalis administrationDigitalis administration Treat underlying cause (fever, shock, electrolyte disturbances, etc)Treat underlying cause (fever, shock, electrolyte disturbances, etc)

Sinus bradycardia is a dysrhythmias that is normal, except that the Sinus bradycardia is a dysrhythmias that is normal, except that the rate falls below 60 beats per minute.rate falls below 60 beats per minute. Etiology:Etiology:

The parasympathetic fibers (vagal tone) are stimulated and cause the sinus node The parasympathetic fibers (vagal tone) are stimulated and cause the sinus node to slow.to slow.

Treatment:Treatment: Atropine 0.5 to 1.0 mg/IV push to block vagal stimulationsAtropine 0.5 to 1.0 mg/IV push to block vagal stimulations Isoproterenol 1 mg/500 ml D5W to stimulate sympathetic response Isoproterenol 1 mg/500 ml D5W to stimulate sympathetic response PacemakerPacemaker

SINUS DYSRHYTHMIASSINUS DYSRHYTHMIAS

Sinus arrhythmia is a regular irregularity in rhythm Sinus arrhythmia is a regular irregularity in rhythm which is related to respiratory exchange. No which is related to respiratory exchange. No treatment.treatment.

Sick sinus syndrome is a dysrhythmias that is caused Sick sinus syndrome is a dysrhythmias that is caused by a diseased sinus node. The sinus node conducts at by a diseased sinus node. The sinus node conducts at a slow rate or may fail to conduct at all, producing a slow rate or may fail to conduct at all, producing sinus block or pauses. There is related tachycardia, sinus block or pauses. There is related tachycardia, thus it is also “brady-tachycardia syndrome”.thus it is also “brady-tachycardia syndrome”. Treatment:Treatment:

Treatment of ischemia due to arteriosclerotic heart disease, MI.Treatment of ischemia due to arteriosclerotic heart disease, MI. PacemakerPacemaker

ATRIAL DYSRYTHMIASATRIAL DYSRYTHMIAS Premature atrial contraction (PAC) is an ectopic beat that Premature atrial contraction (PAC) is an ectopic beat that

originates in the atria and is discharged at a rate faster that that originates in the atria and is discharged at a rate faster that that of the sinus node.of the sinus node. Treatment:Treatment:

Generally does not require treatmentGenerally does not require treatment Quinidine or calcium-channel blocker if it increases in frequency.Quinidine or calcium-channel blocker if it increases in frequency.

Paroxysmal atria tachycardia (PAT) is a suddent onset of an Paroxysmal atria tachycardia (PAT) is a suddent onset of an atrial tachycardia which rates that vary between 140 and 250 atrial tachycardia which rates that vary between 140 and 250 beats per minute.beats per minute. Treatment:Treatment:

Valsalva maneuver to reduce the heart rate through vagal stimulation.Valsalva maneuver to reduce the heart rate through vagal stimulation. DigitalisDigitalis Beta adrenergic blockers (propranolol)Beta adrenergic blockers (propranolol) Calcium-channel blockers (verapamil)Calcium-channel blockers (verapamil) CardioversionCardioversion Morphine sulfate, diazepamMorphine sulfate, diazepam

Avoid excess use of alcohol, cigarettes, caffeine.Avoid excess use of alcohol, cigarettes, caffeine.

PATHOPHYSIOLOGY OF PREMATURE VENTRICULAR CONTRACTIONS

Premature Ventricular Contractions

Ventricular Fibrillations

Cardiac Standstill / Arrest

Dysrhythemias

Cardiac Output

Cardiac Irritability

Myocardial Perfusion

ATRIAL DYSRYTHMIASATRIAL DYSRYTHMIAS Atrial flutter is a dysrhythmias in which an ectopic atrial focus Atrial flutter is a dysrhythmias in which an ectopic atrial focus

captures the heart rhythm and discharges impulses at a rate of captures the heart rhythm and discharges impulses at a rate of between 200 and 400 times per minute.between 200 and 400 times per minute. Treatment:Treatment:

Digitalis preparationDigitalis preparation QuinidineQuinidine Calcium-channel blockersCalcium-channel blockers Beta-adrenergic blockersBeta-adrenergic blockers CardioversionCardioversion

Atrial fibrillation is a dysrhythmia that is caused by the rapid and Atrial fibrillation is a dysrhythmia that is caused by the rapid and chaotic firing of atrial impulses by a multitude of foci.chaotic firing of atrial impulses by a multitude of foci. Treatment:Treatment:

Digitalis, if uncontrolled fibrillation (rate is above 100 beats per minute)Digitalis, if uncontrolled fibrillation (rate is above 100 beats per minute) QuinidineQuinidine Beta adrenergic blockersBeta adrenergic blockers

VENTRICULAR VENTRICULAR DYSRHYTHMIASDYSRHYTHMIAS

Premature ventricular contraction (PVC) is a dysrhythmia that is Premature ventricular contraction (PVC) is a dysrhythmia that is produced by an ectopic beat originating in a ventricle and being produced by an ectopic beat originating in a ventricle and being discharged at a rate faster than that of the next normally occurring discharged at a rate faster than that of the next normally occurring beat. PVC’s of 6/minute or more is life threatening.beat. PVC’s of 6/minute or more is life threatening. Treatment:Treatment:

Lidocaine/IV push, dripLidocaine/IV push, drip Initial bolus dose: 75-100 mg then 50-100 mg within 10-15 minutes as neededInitial bolus dose: 75-100 mg then 50-100 mg within 10-15 minutes as needed Continuous IV drip in D5W 4:1 concentrationContinuous IV drip in D5W 4:1 concentration

Procainamide IV push, drip bolus dos: 300 mgProcainamide IV push, drip bolus dos: 300 mg Bretylium/continuous infusion if lidocaine and procainamide are ineffective.Bretylium/continuous infusion if lidocaine and procainamide are ineffective.

Ventricular bigeminy is a PVC where every other beat is a Ventricular bigeminy is a PVC where every other beat is a ventricular complex.ventricular complex. Treatment:Treatment:

Refer to PVCRefer to PVC

VENTRICULAR VENTRICULAR DYSRHYTHMIASDYSRHYTHMIAS

Ventricular tachycardia is a life threatening dysrhythmia that Ventricular tachycardia is a life threatening dysrhythmia that originates from an irritable focus within the ventricle. It is an originates from an irritable focus within the ventricle. It is an ineffective rhythm for maintaining cardiac output. It is an ineffective rhythm for maintaining cardiac output. It is an emergency.emergency. Treatment:Treatment:

Lidocaine, bolus dose; followed by a continuous IV drip from 1-4 mg/minLidocaine, bolus dose; followed by a continuous IV drip from 1-4 mg/min Defibrillation, if loss of consciousness occursDefibrillation, if loss of consciousness occurs Cardioversion if consciousCardioversion if conscious

Ventricular fibrillation is a dysrhythmia that is characterized by Ventricular fibrillation is a dysrhythmia that is characterized by the random chaotic discharging of impulses within the ventricle the random chaotic discharging of impulses within the ventricle at rates that exceed 300 beats per minute. It produces clinical at rates that exceed 300 beats per minute. It produces clinical death and must be reversed immediately. It is an emergency.death and must be reversed immediately. It is an emergency. Treatment:Treatment:

Immediate defibrillation; use 200-400 watt/sec (joules)Immediate defibrillation; use 200-400 watt/sec (joules) Na bicarbonate to relieve lactic acidosis, which causes unsuccessful Na bicarbonate to relieve lactic acidosis, which causes unsuccessful

defibrillationdefibrillation EpinephrineEpinephrine

TREATMENT OF AV BLOCKSTREATMENT OF AV BLOCKS

First degree AV block requires no treatmentFirst degree AV block requires no treatment Second degree AV block requires treatment if Second degree AV block requires treatment if

the ventricular rate falls too low to maintain the ventricular rate falls too low to maintain effective cardiac output.effective cardiac output.

Third degree AV block requires treatment if Third degree AV block requires treatment if C.O. is compromised.C.O. is compromised. Treatment of choice: Ventricular pacemakerTreatment of choice: Ventricular pacemaker

CONDUCTION DEFECTS/HEART CONDUCTION DEFECTS/HEART BLOCKS/AV BLOCKSBLOCKS/AV BLOCKS

Conduction is altered at the level of the AV nodeConduction is altered at the level of the AV node First degree AV block – the impulse is transmitted First degree AV block – the impulse is transmitted

normally, but it is delayed longer at the level of the normally, but it is delayed longer at the level of the AV node.AV node.

Second degree AV block – some, but not all of the Second degree AV block – some, but not all of the impulses are transmitted. The AV node becomes impulses are transmitted. The AV node becomes selective about which impulses are conducted to the selective about which impulses are conducted to the ventricles.ventricles.

Third degree AV block – no impulse from the SA Third degree AV block – no impulse from the SA node is transmitted by the AV node.node is transmitted by the AV node.

SUMMARY OF THERAPEUTIC SUMMARY OF THERAPEUTIC MODALITIES FOR DYSRHYTHMIASMODALITIES FOR DYSRHYTHMIAS

Antidysrhythmic drugsAntidysrhythmic drugs Artificial cardiac pacemakerArtificial cardiac pacemaker Cardioversion/defribillationCardioversion/defribillation Cardiopulmonary resuscitationCardiopulmonary resuscitation

ANTIDYSRHYTHMIC DRUGSANTIDYSRHYTHMIC DRUGS

Class IClass I Fast (Sodium) channel blockers IFast (Sodium) channel blockers I

Disopyramide (norpace)Disopyramide (norpace) Procainamide (pronestyl)Procainamide (pronestyl) Quinidine sulfate (cardioquin)Quinidine sulfate (cardioquin)

Fast (Sodium) channel blockers IIFast (Sodium) channel blockers II Lidocaine (xylocaine)Lidocaine (xylocaine) Mexilitine Hcl (mexitil)Mexilitine Hcl (mexitil)

Fast (Sodium) channel blockers IIIFast (Sodium) channel blockers III Flecainide (tambocor)Flecainide (tambocor) Propafenone (rhythmol)Propafenone (rhythmol) Tocainide (tonocard)Tocainide (tonocard)

ANTIDYSRHYTHMIC DRUGSANTIDYSRHYTHMIC DRUGS Class IIClass II

Beta – adrenergic blockersBeta – adrenergic blockers Acebutolo (sectral)Acebutolo (sectral) Propranolol (inderal)Propranolol (inderal)

Class IIIClass III Prolong repolarizationProlong repolarization

Adenosine (adenocard)Adenosine (adenocard) Amiodarone (cardarone)Amiodarone (cardarone) Bretylium tosylate (bretylol)Bretylium tosylate (bretylol)

Class IVClass IV Calcium channel blockersCalcium channel blockers

Verapamil HCl (calan)Verapamil HCl (calan) Diltiazem (cardizem)Diltiazem (cardizem)

OthersOthers Phenytoin (dilantin)Phenytoin (dilantin) Digoxin (lanoxin)Digoxin (lanoxin)

PACEMAKERSPACEMAKERS

A cardiac pacemaker is an electronic device A cardiac pacemaker is an electronic device that delivers direct stimulation to the heart, that delivers direct stimulation to the heart, causing electrical depolarization and cardiac causing electrical depolarization and cardiac contraction.contraction.

The pacemaker initiates and maintains the The pacemaker initiates and maintains the heart rate when the natural pacemakers of the heart rate when the natural pacemakers of the heart are unable to do so.heart are unable to do so.

CLINICAL INDICATIONSCLINICAL INDICATIONS Symptomatic bradyarrhythmiasSymptomatic bradyarrhythmias

Sinoatrial bradyarrhythmiasSinoatrial bradyarrhythmias Sinoatrial arrestSinoatrial arrest Sick sinus syndromeSick sinus syndrome

Heart blockHeart block Second degree heart blockSecond degree heart block Complete heart blockComplete heart block

ProphylaxisProphylaxis Following acute MI; arrhythmias and conduction defectsFollowing acute MI; arrhythmias and conduction defects Before or following cardiac surgeryBefore or following cardiac surgery During coronary arteriographyDuring coronary arteriography Before permanent pacingBefore permanent pacing

TachyarrhythmiasTachyarrhythmias SupraventricularSupraventricular VentricularVentricular

PACING MODESPACING MODES Demand (synchronous, non-competitive) Demand (synchronous, non-competitive)

atrial/ventricular.atrial/ventricular. It triggers electrical firings only when the heart rate goes It triggers electrical firings only when the heart rate goes

slow.slow. It does not compete with the heart’s basic rhythm.It does not compete with the heart’s basic rhythm. If the client’s heart rate falls below a predetermined escape If the client’s heart rate falls below a predetermined escape

interval (programmed into pulse generator), an electrical interval (programmed into pulse generator), an electrical stimulus is delivered to the heartstimulus is delivered to the heart

Fixed rate (asynchronous, competitive) Fixed rate (asynchronous, competitive) atrial/ventricularatrial/ventricular It delivers an electrical stimulus at a preset constant rate It delivers an electrical stimulus at a preset constant rate

that is independent of the patient’s own rhythm.that is independent of the patient’s own rhythm. Does not allow atrial contribution to the cardiac output. Does not allow atrial contribution to the cardiac output.

May be valuable in complete heart block.May be valuable in complete heart block.

PACING MODESPACING MODES

Synchronous atrial/ventricularSynchronous atrial/ventricular A demand form of pacing which is able to increase A demand form of pacing which is able to increase

heart rate to accompany the physiological demands heart rate to accompany the physiological demands of the bodyof the body

An actual electrode senses the patient’s atrial An actual electrode senses the patient’s atrial depolarization, waits for a preset interval (simulated depolarization, waits for a preset interval (simulated PR interval) and triggers firing of ventricular pacer.PR interval) and triggers firing of ventricular pacer.

If rapid atrial rhythm occurs, the ventricular If rapid atrial rhythm occurs, the ventricular pacemaker stimulates the ventricle at a fixed rate pacemaker stimulates the ventricle at a fixed rate independent of atrial activity.independent of atrial activity.

TEMPORARY PACEMAKERSTEMPORARY PACEMAKERS

Temporary pacing of the heart is usually done as Temporary pacing of the heart is usually done as an emergency procedure that allows an emergency procedure that allows observation of the effects of pacing on heart observation of the effects of pacing on heart function before a permanent pacemaker is function before a permanent pacemaker is implanted.implanted. Transvenous approach to position the electrode in Transvenous approach to position the electrode in

the apex of right ventricle is done.the apex of right ventricle is done. The external pulse generator is attached to the The external pulse generator is attached to the

patient.patient.

PERMANENT PACEMAKERSPERMANENT PACEMAKERS Permanent pacing of the heart may be implanted through the Permanent pacing of the heart may be implanted through the

following techniques:following techniques: Transvenous (endocardial)Transvenous (endocardial)

The electrode is threaded through cephalic or external jugular vein into the The electrode is threaded through cephalic or external jugular vein into the right ventricle. This is done under local anesthesia.right ventricle. This is done under local anesthesia.

The peripheral end of the electrode is connected to the pulse generator The peripheral end of the electrode is connected to the pulse generator which is implanted underneath the skin below the right or left pectoral which is implanted underneath the skin below the right or left pectoral region.region.

Treansthoracic (epicardial)Treansthoracic (epicardial) Anterior chest is opened and electrodes are sutured to the surface of the Anterior chest is opened and electrodes are sutured to the surface of the

right or left ventricle atrium, then threaded subcutaneously to the right or left ventricle atrium, then threaded subcutaneously to the abdominal wall either above or below the waist.abdominal wall either above or below the waist.

Note:Note:Paced beats are characterized by sharp spikes that precede each Paced beats are characterized by sharp spikes that precede each

ECG complex.ECG complex.

NURSING INTERVENTIONS FOR CLEINTS NURSING INTERVENTIONS FOR CLEINTS WITH ARTIFICIAL CARDIAC PACEMAKERSWITH ARTIFICIAL CARDIAC PACEMAKERS

Monitor ECG following implantation of pacemaker, including VSMonitor ECG following implantation of pacemaker, including VS Observe for indications of pacemaker malfunction as dizziness, Observe for indications of pacemaker malfunction as dizziness,

faintness, lightheadedness, chest pain, shortness of breath.faintness, lightheadedness, chest pain, shortness of breath. Make sure all equipment in the client’s unit is grounded, to Make sure all equipment in the client’s unit is grounded, to

prevent ventricular fibrillationprevent ventricular fibrillation Practice sterile technique for dressing changes to prevent wound Practice sterile technique for dressing changes to prevent wound

infection.infection. Provide psychosocial support:Provide psychosocial support:

Explore concerns of the clientExplore concerns of the client Encourage to utilize coping mechanismsEncourage to utilize coping mechanisms Ensure client comfortEnsure client comfort Maintain a positive body imageMaintain a positive body image


Provide client education which includes the following:Provide client education which includes the following: Take daily pulse for one full minuteTake daily pulse for one full minute

Report any sudden slowing of pulse greater than 4 to 5 beats per minutes or any Report any sudden slowing of pulse greater than 4 to 5 beats per minutes or any increase in pulse rate.increase in pulse rate.

The best time to take the daily pulse is in the morning upon awakening The best time to take the daily pulse is in the morning upon awakening

Report signs and symptoms of dizziness, fainting, Report signs and symptoms of dizziness, fainting, palpitation, prolonged hiccupspalpitation, prolonged hiccupsand chest pain to the physician (indicative of pacemaker failure)and chest pain to the physician (indicative of pacemaker failure)

May use electrical devices with cautionMay use electrical devices with caution If dizziness occurs, stop using the deviceIf dizziness occurs, stop using the device Sources of electromagnetic inference (EMI) that may effect some pulse Sources of electromagnetic inference (EMI) that may effect some pulse

generators are as follows:generators are as follows: High-energy radarHigh-energy radar Tv and radio transmittersTv and radio transmitters Electrocautery machinesElectrocautery machines Airport screening devicesAirport screening devices Antitheft devicesAntitheft devices

Move 5 to 10 feet away from the source of EMI if dizziness occursMove 5 to 10 feet away from the source of EMI if dizziness occurs


Avoid going near or using microwave ovenAvoid going near or using microwave oven Move 3 feet away from the deviceMove 3 feet away from the device

Wear loose-fitting clothing around the near of Wear loose-fitting clothing around the near of the pacemakerthe pacemaker

Observe for signs and symptoms of infection Observe for signs and symptoms of infection around generator and leads – fever, heat, pain, around generator and leads – fever, heat, pain, skin impairment at the implant site.skin impairment at the implant site.

Avoid contact sports.Avoid contact sports. Electrode may be displaced.Electrode may be displaced.

CARDIOVERSON AND CARDIOVERSON AND DEFIBRILLATIONDEFIBRILLATION

Cardioversion is the synchronous application of an Cardioversion is the synchronous application of an electrical shock of short duration to the heart through electrical shock of short duration to the heart through the use of chest paddles.the use of chest paddles. It is done to convert cardiac dysrhythmia (other than It is done to convert cardiac dysrhythmia (other than

ventricular fibrillation) into a more hemodynamically ventricular fibrillation) into a more hemodynamically stable, sinus rhythmstable, sinus rhythm

Electric shock is applied during the R wave; never Electric shock is applied during the R wave; never on the T waveon the T wave

Defribillation is unsynchronized passing of an electric Defribillation is unsynchronized passing of an electric shock of short duration through the heart to terminate shock of short duration through the heart to terminate ventricular fibrillation or ventricular tachycardia ventricular fibrillation or ventricular tachycardia without pulse.without pulse.

NURSING INTERVENTIONS DURING NURSING INTERVENTIONS DURING CARDIOVERSION AND FIBRILLATIONCARDIOVERSION AND FIBRILLATION

Place the client in a flat, firm surfacePlace the client in a flat, firm surface Apply interface material (gel, paste, saline pads) to the paddlesApply interface material (gel, paste, saline pads) to the paddles

This is for better contact with the skin and to prevent burnsThis is for better contact with the skin and to prevent burns Grasp the paddles only by the insulated handles. To prevent Grasp the paddles only by the insulated handles. To prevent

electrocution.electrocution. Give command for personnel to STAND CLEAR of the client Give command for personnel to STAND CLEAR of the client

and the bedand the bed Apply the chest paddles as follows: one at the right of the Apply the chest paddles as follows: one at the right of the

sternum, third ICS; and the other one on the left midaxillary, sternum, third ICS; and the other one on the left midaxillary, fifth ICS.fifth ICS.

Push the discharge buttons in both paddles simultaneouslyPush the discharge buttons in both paddles simultaneously For defribillation, release 200 to 360 watts/sec (joules); for For defribillation, release 200 to 360 watts/sec (joules); for

cardioversion, power energy is requiredcardioversion, power energy is required Defibrillation is done before initiating CPRDefibrillation is done before initiating CPR

CARDIOPULMONARY CARDIOPULMONARY RESUSCITATION (CPR)RESUSCITATION (CPR)

IndicationIndication Cardiopulmonary arrest/clinical death (breathlessness, Cardiopulmonary arrest/clinical death (breathlessness,

pulselessnesls)pulselessnesls) Crucial timeCrucial time

CPR is instituted within 4 to 6 minutes after the arrest, to CPR is instituted within 4 to 6 minutes after the arrest, to prevent brain deathprevent brain death

Two types of CPRTwo types of CPR Basic life support (BLS)Basic life support (BLS)

Involves the use of the hands, mouth and the sincere desire to give Involves the use of the hands, mouth and the sincere desire to give the person a second chance for lifethe person a second chance for life

Advanced cardiac life support (ACLS)Advanced cardiac life support (ACLS) Involves BLS and the use of equipment, emergency drugs and Involves BLS and the use of equipment, emergency drugs and

fluids to monitor the client and stabilize his conditionfluids to monitor the client and stabilize his condition

CPR involves the ABCD CPR involves the ABCD of life supportof life support

A – open airwayA – open airway

B – restore breathingB – restore breathing

C – restore circulationC – restore circulation

D – provide definitive treatment (ACLS)D – provide definitive treatment (ACLS)

TECHNIQUES OF BASIC LIFE TECHNIQUES OF BASIC LIFE SUPPORTSUPPORT

Step I. Assess level of consciousnessStep I. Assess level of consciousness Shake the victim’s shoulders and ask “Are you okey?”Shake the victim’s shoulders and ask “Are you okey?” If no response, place the client in supine position on a firm surface.If no response, place the client in supine position on a firm surface.

Step II. Open the airway.Step II. Open the airway. The tongue is the most common cause of airway obstruction in the unconscious The tongue is the most common cause of airway obstruction in the unconscious

person.person. Use the head tilt – chin lift and the jaw thrust methods for opening and maintaining Use the head tilt – chin lift and the jaw thrust methods for opening and maintaining

airway.airway. Jaw thrust is recommended for clients with suspected neck injuryJaw thrust is recommended for clients with suspected neck injury Take 3 to 5 seconds to look, listen and feel for spontaneous breathingTake 3 to 5 seconds to look, listen and feel for spontaneous breathing

Step III. Initiate artificial ventilationStep III. Initiate artificial ventilation Mouth-to-mouth ventilationMouth-to-mouth ventilation Mouth-to-nose ventilationMouth-to-nose ventilation Mouth-to-stoma ventilationMouth-to-stoma ventilation Mouth-to-barrier ventilationMouth-to-barrier ventilation

Note:Note:Give 2 initial breaths lasting for 1 ½ to 2 seconds. If no rise and fall of the chest is Give 2 initial breaths lasting for 1 ½ to 2 seconds. If no rise and fall of the chest is

observed, consider airway obstruction.observed, consider airway obstruction.


Step IV. Assess CirculationStep IV. Assess Circulation Check carotid pulse (adult) for 5 to 10 seconds; brachial pulse for infant and childCheck carotid pulse (adult) for 5 to 10 seconds; brachial pulse for infant and child No pulse, cardiac compressions are initiatedNo pulse, cardiac compressions are initiated

Step V. Initiate External Cardiac Compression/External Cardiac MassageStep V. Initiate External Cardiac Compression/External Cardiac Massage Place the heel of the hand of the area of 2 fingerbreadths from the xiphoid process Place the heel of the hand of the area of 2 fingerbreadths from the xiphoid process

(adult); midsternum for infant(adult); midsternum for infant Depress the sternum with heels of both hands, one on top of the other 1 ½ to 2 Depress the sternum with heels of both hands, one on top of the other 1 ½ to 2

inches (adult); heel of one hand 1 to 1 ½ inches (child); 2 fingers ½ to 1 inch inches (adult); heel of one hand 1 to 1 ½ inches (child); 2 fingers ½ to 1 inch (infant)(infant)

If 2 – man rescue: 80-100 cardiac compressions per minute; with ratio of 5:1 If 2 – man rescue: 80-100 cardiac compressions per minute; with ratio of 5:1 (compression to ventilation)(compression to ventilation)


Reassess the client after 4 cycles; if pulse is absent, continue CPRReassess the client after 4 cycles; if pulse is absent, continue CPR Recheck pulse every 3 to 4 minutes thereafterRecheck pulse every 3 to 4 minutes thereafter Most common complication of CPR is fracture of ribs. Most commonly punctured Most common complication of CPR is fracture of ribs. Most commonly punctured

internal organ during CPR is the liverinternal organ during CPR is the liver


Step IV. Assess CirculationStep IV. Assess Circulation Check carotid pulse (adult) for 5 to 10 seconds; brachial pulse for infant and childCheck carotid pulse (adult) for 5 to 10 seconds; brachial pulse for infant and child No pulse, cardiac compressions are initiatedNo pulse, cardiac compressions are initiated

Step V. Initiate External Cardiac Compression/External Cardiac MassageStep V. Initiate External Cardiac Compression/External Cardiac Massage Place the heel of the hand of the area of 2 fingerbreadths from the xiphoid process Place the heel of the hand of the area of 2 fingerbreadths from the xiphoid process

(adult); midsternum for infant(adult); midsternum for infant Depress the sternum with heels of both hands, one on top of the other 1 ½ to 2 Depress the sternum with heels of both hands, one on top of the other 1 ½ to 2

inches (adult); heel of one hand 1 to 1 ½ inches (child); 2 fingers ½ to 1 inch inches (adult); heel of one hand 1 to 1 ½ inches (child); 2 fingers ½ to 1 inch (infant)(infant)



Reassess the client after 4 cycles; if pulse is absent, continue CPRReassess the client after 4 cycles; if pulse is absent, continue CPR Recheck pulse every 3 to 4 minutes thereafterRecheck pulse every 3 to 4 minutes thereafter

Most common complication of CPR is fracture of ribs. Most commonly Most common complication of CPR is fracture of ribs. Most commonly punctured internal organ during CPR is the liverpunctured internal organ during CPR is the liver


When to stop CPR?When to stop CPR? When the client is revivedWhen the client is revived When the EMS has been activatedWhen the EMS has been activated When the rescuer is exhaustedWhen the rescuer is exhausted When the client is deadWhen the client is dead

CARDIOGENIC SHOCK CARDIOGENIC SHOCK (POWER/PUMP FAILURE)(POWER/PUMP FAILURE)

Is a shock state which results from profound Is a shock state which results from profound left ventricular failure usually from massive left ventricular failure usually from massive MIMI

It results to low cardiac output, thereby It results to low cardiac output, thereby systemic hypoperfusionsystemic hypoperfusion

It has a high mortality rateIt has a high mortality rate PathophysiologyPathophysiology


Perform hemodynamic monitoring PAP, PCWP Perform hemodynamic monitoring PAP, PCWP measurements, Intra-arterial BP.measurements, Intra-arterial BP.

Administer oxygen therapyAdminister oxygen therapy Correct hypovolemia. Administer IV fluids as orderedCorrect hypovolemia. Administer IV fluids as ordered Pharmacotherapy:Pharmacotherapy:

Vasodilators: nitroprusside, phentolamine, Vasodilators: nitroprusside, phentolamine, nitroglycerinenitroglycerine

Isotropic agents: digitalis, dopamine, dobutamineIsotropic agents: digitalis, dopamine, dobutamine Diuretics: furosemide.Diuretics: furosemide. Na bicarbonate to relieve lactic acidosisNa bicarbonate to relieve lactic acidosis

Monitor hourly urine output, LOC, arrhythmiasMonitor hourly urine output, LOC, arrhythmias Provide psychosocial supportProvide psychosocial support

NURSING INTERVENTIONSNURSING INTERVENTIONS Decrease pulmonary edemaDecrease pulmonary edema

Ausculate lung fields for crackles and wheezesAusculate lung fields for crackles and wheezes Note for dyspnea, cough, hemoptysis, orthopneaNote for dyspnea, cough, hemoptysis, orthopnea Monitor ABG for hypoxia and metabolic acidosisMonitor ABG for hypoxia and metabolic acidosis Place in Fowler’s position to reduce venous returnPlace in Fowler’s position to reduce venous return Administer during therapy as ordered:Administer during therapy as ordered:

Morphine sulfate to reduce venous returnMorphine sulfate to reduce venous return Aminophylline to reduce bronchospasm caused by severe Aminophylline to reduce bronchospasm caused by severe

congestioncongestion Vasodilators to reduce venous return (nitroprusside, Vasodilators to reduce venous return (nitroprusside,

nitroglycerine)nitroglycerine) Diuretics to decrease circulating volumeDiuretics to decrease circulating volume

NURSING INTERVENTIONSNURSING INTERVENTIONS Utilize counterpulsation to decrease ventricular work of the client with Utilize counterpulsation to decrease ventricular work of the client with

severe shock.severe shock. Counterpulsation (mechanical cardiac assistance/diastolic Counterpulsation (mechanical cardiac assistance/diastolic

augmentation) involves introduction of the intra-aortic balloon catheter augmentation) involves introduction of the intra-aortic balloon catheter via the femoral artery.via the femoral artery.

The intra-aortic balloon pump (IABP) augments diastole, resulting in The intra-aortic balloon pump (IABP) augments diastole, resulting in increased perfusion of the coronary arteries and the myocardium and a increased perfusion of the coronary arteries and the myocardium and a decrease in left ventricular workload.decrease in left ventricular workload.

The balloon is inflated during diastole; it is deflated during systole. The balloon is inflated during diastole; it is deflated during systole. Indications:Indications:

Cardiogenic shockCardiogenic shock AMI (acute myocardial infarction)AMI (acute myocardial infarction) Unstable angina pectorisUnstable angina pectoris Open heart surgeryOpen heart surgery

THROMBOEMBOLISMTHROMBOEMBOLISM

It results when platelets aggregate at the area of It results when platelets aggregate at the area of necrosis, an attempt of the body to repair the necrosis, an attempt of the body to repair the tissue injury.tissue injury.

Emboli occur because clots formed in the Emboli occur because clots formed in the healing area of the myocardium break loose healing area of the myocardium break loose and escape into the circulationand escape into the circulation

Pulmonary embolism may develop and proves Pulmonary embolism may develop and proves to be fatalto be fatal

NURSING INTERVENTIONSNURSING INTERVENTIONS Administer pharmacotherapy as ordered:Administer pharmacotherapy as ordered:

AnticoagulantsAnticoagulants ThrombolyticsThrombolytics Observed for signs and symptoms indicative of Observed for signs and symptoms indicative of

pulmonary embolismpulmonary embolism DyspneaDyspnea Chest painChest pain CoughingCoughing HemoptysisHemoptysis Rapid, weak pulseRapid, weak pulse PallorPallor

Early ambulation is encouraged to prevent venous Early ambulation is encouraged to prevent venous stasis. Venous stasis enhances thromboembolism.stasis. Venous stasis enhances thromboembolism.

PERICARDITIS/DRESSLER’S PERICARDITIS/DRESSLER’S SYNDROMESYNDROME

Is an inflammation of the pericardium which occurs Is an inflammation of the pericardium which occurs approximately 1 to 6 weeks after acute MIapproximately 1 to 6 weeks after acute MI

In MI, pericarditis results as an antigen – antibody response. In MI, pericarditis results as an antigen – antibody response. The necrotic tissues play the role of an antigen, which trigger The necrotic tissues play the role of an antigen, which trigger antibody formation. Inflammatory process follows.antibody formation. Inflammatory process follows.

Pericardial effusion/cardiac tamponade is outpouring of fluid Pericardial effusion/cardiac tamponade is outpouring of fluid into the ventricular sac. Compression of the heart occurs, into the ventricular sac. Compression of the heart occurs, followed by decrease in ventricular emptying. This further, followed by decrease in ventricular emptying. This further, may lead to cardiac failure, shock and death. This may follow may lead to cardiac failure, shock and death. This may follow pericarditis.pericarditis.

Constrictive pericarditis is a condition in which a chronic Constrictive pericarditis is a condition in which a chronic inflammatory thickening of the pericardium compresses the inflammatory thickening of the pericardium compresses the heart so that it is unable to fill normally during diastole.heart so that it is unable to fill normally during diastole.

PERICARDITIS/DRESSLER’S PERICARDITIS/DRESSLER’S SYNDROMESYNDROME

Clinical manifestations of pericarditis include the Clinical manifestations of pericarditis include the following:following: Pain in the anterior chest, aggravated by coughing, Pain in the anterior chest, aggravated by coughing,

yawning, swallowing, twisting and turning the torso; yawning, swallowing, twisting and turning the torso; relieved by upright, leaning forward position.relieved by upright, leaning forward position.

Pericardial friction rub – scratchy, grating or creaking Pericardial friction rub – scratchy, grating or creaking soundsound

DyspneaDyspnea Fever, sweating, chillsFever, sweating, chills Joint painsJoint pains ArrhythmiasArrhythmias


Elevate head of bed, place pillow on the Elevate head of bed, place pillow on the overbed table so that the patient can lean on it.overbed table so that the patient can lean on it.

Bed rest.Bed rest. Administer prescribed pharmacotherapy:Administer prescribed pharmacotherapy:

ASA to suppress inflammatory processASA to suppress inflammatory process Conticosteroids for more severe symptomsConticosteroids for more severe symptoms

Assist in pericardiocentesis if cardiac Assist in pericardiocentesis if cardiac tamponade is presenttamponade is present

Pericardiocentesis is aspiration of blood/fluid Pericardiocentesis is aspiration of blood/fluid from pericardial sacfrom pericardial sac

RUPTURE OF THE RUPTURE OF THE MYOCARDIUMMYOCARDIUM

It is common in transmural MIIt is common in transmural MI It causes immediate cardiac tamponade and It causes immediate cardiac tamponade and

deathdeath

VENTRICULAR ANUERYSMVENTRICULAR ANUERYSM

It involves thinning, ballooning and hypokinesis of It involves thinning, ballooning and hypokinesis of the left ventricular wall after a transmural MIthe left ventricular wall after a transmural MI

The dysfunctional area often becomes filled with The dysfunctional area often becomes filled with necrotic debris and clot and sometimes is rimmed by necrotic debris and clot and sometimes is rimmed by the calcium ring.the calcium ring.

The debris or clot may fragment and travel into the The debris or clot may fragment and travel into the systemic arterial circulation thereby embolization.systemic arterial circulation thereby embolization.

The aneurysm may rupture causing cardiac tamponade The aneurysm may rupture causing cardiac tamponade and death.and death.

CONGESTIVE HEART FAILURECONGESTIVE HEART FAILURE

It is a state of circulatory congestion produced by It is a state of circulatory congestion produced by myocardial dysfunctionmyocardial dysfunction

MI compromises myocardial function by reducing MI compromises myocardial function by reducing contractility and producing abnormal wall motioncontractility and producing abnormal wall motion

The ability of the ventricle to empty lessens, the The ability of the ventricle to empty lessens, the stroke volume falls, residual volume increasesstroke volume falls, residual volume increases

Heart failure is the inability of the heart to pump the Heart failure is the inability of the heart to pump the amount of oxygenated blood necessary to effect amount of oxygenated blood necessary to effect venous return and to meet the metabolic requirements venous return and to meet the metabolic requirements of the bodyof the body

CAUSES OF CONGESTIVE CAUSES OF CONGESTIVE HEART FAILUREHEART FAILURE

Direct change to the heart, e.g. mintral myocarditis, Direct change to the heart, e.g. mintral myocarditis, ventricular aneurysm.ventricular aneurysm.

Ventricular overloadVentricular overload Increased preload, e.g. mitral aortic regurgitation, Increased preload, e.g. mitral aortic regurgitation,

atrial or ventricular septal defects, or rapid infusion of large atrial or ventricular septal defects, or rapid infusion of large volumes of IV fluidsvolumes of IV fluids

Increased afterload, e.g. aortic or pulmonary valve Increased afterload, e.g. aortic or pulmonary valve stenosis, systemic hypertension, pulmonary hypertensionstenosis, systemic hypertension, pulmonary hypertension

Constriction of the ventricles,e.g. cardiac tamponade, Constriction of the ventricles,e.g. cardiac tamponade, pericarditis, restrictive cardiomyhopathiespericarditis, restrictive cardiomyhopathies

CLASSIFICATION OF CLASSIFICATION OF HEART FAILUREHEART FAILURE

Backward heart failure results from damming Backward heart failure results from damming up of blood in the vessels proximal to the heartup of blood in the vessels proximal to the heart

Forward heart failure results from inability of Forward heart failure results from inability of the heart to maintain cardiac outputthe heart to maintain cardiac output

COLLABORATIVE COLLABORATIVE MANAGEMENTMANAGEMENT

MedicationsMedications Digitalis therapyDigitalis therapy

It is the major therapy for CHFIt is the major therapy for CHF It has positive inotropic (strengthens force of cardiac contractility) as It has positive inotropic (strengthens force of cardiac contractility) as

negative chronotropic effects (decreases heart rate)negative chronotropic effects (decreases heart rate) Assess heart rate before administration of digitalis, if the heart rate is below Assess heart rate before administration of digitalis, if the heart rate is below

60 bpm or above 120 bpm, withhold the drug. Bradycardia rebound 60 bpm or above 120 bpm, withhold the drug. Bradycardia rebound tachycardia may occur.tachycardia may occur.

Monitor secrum postassium (K) level; hypokalemia enhances digitalis Monitor secrum postassium (K) level; hypokalemia enhances digitalis toxicity because it potentiates the effect of the drug.toxicity because it potentiates the effect of the drug.

Commonly used digitalis/cardiac glycosides.Commonly used digitalis/cardiac glycosides. Lanoxin (digoxin)Lanoxin (digoxin) Cyrstodigin (digitoxin)Cyrstodigin (digitoxin) Lanatoside C (cedilanid C)Lanatoside C (cedilanid C) Deslanoside (cedilanid D)Deslanoside (cedilanid D)


Assess for signs and symptoms of digitalis toxicity:Assess for signs and symptoms of digitalis toxicity:BradycardiaBradycardiaG.I. manifestationsG.I. manifestations

AnorexiaAnorexia Nauseas and vomitingNauseas and vomiting DiarrheaDiarrhea

Dysrhythmias (most dangerous)Dysrhythmias (most dangerous) Altered visual perceptions (yellow or green vision; Altered visual perceptions (yellow or green vision;

halos around the light among elderly)halos around the light among elderly) In males:In males:

GynecomastiaGynecomastia Decreased libidoDecreased libido ImpotenceImpotence


Diuretic therapyDiuretic therapy The purpose is to decrease cardiac workload by reducing The purpose is to decrease cardiac workload by reducing

circulating volume and thereby reduce preloadcirculating volume and thereby reduce preload Assess for signs and symptoms for hypokalemia when Assess for signs and symptoms for hypokalemia when

administering Thiazides and loop diureticsadministering Thiazides and loop diuretics Give potassium supplement and potassium-rich foodsGive potassium supplement and potassium-rich foods Diuretics are best administered early morning and/or early Diuretics are best administered early morning and/or early

afternoon to prevent sleep pattern disturbance related to afternoon to prevent sleep pattern disturbance related to nocturianocturia

If Thiazides are ineffective, an oral aldosterone antagonist If Thiazides are ineffective, an oral aldosterone antagonist (potassium sparing diuretic) may be given Thiazide(potassium sparing diuretic) may be given Thiazide


The diuretics used in the treatment of CHF are as The diuretics used in the treatment of CHF are as follows:follows:

ThiazidesThiazides Chlorothiazide (Diuril)Chlorothiazide (Diuril) Hydrochlorothiazide (Esidrix, Hydrodiuril)Hydrochlorothiazide (Esidrix, Hydrodiuril)

Loop DiureticsLoop Diuretics Furosemide (Lasix)Furosemide (Lasix) Bumetazmide (Bumex)Bumetazmide (Bumex)

Potassium-sparingPotassium-sparing Spironolactone (Aldactone)Spironolactone (Aldactone) Triamterene (Dyrenium)Triamterene (Dyrenium)


VasodilatorsVasodilators To decrease afterload by decreasing resistance to To decrease afterload by decreasing resistance to

ventricular emptying. ventricular emptying. The most commonly used drugs are as follows:The most commonly used drugs are as follows:

Nitroprusside (Nipride)Nitroprusside (Nipride) Hyralazine (Apresoline)Hyralazine (Apresoline) Nifedipine (a calcium-channel blocker with vasodilator Nifedipine (a calcium-channel blocker with vasodilator

effect)effect) Captopril (Capoten) – also has a vasodilator effectCaptopril (Capoten) – also has a vasodilator effect Other drugs:Other drugs:

SympathomimeticsSympathomimetics DopamineDopamine DobutamineDobutamine

TREATMENTTREATMENT

Diet-sodium – restricted diet to prevent fluid Diet-sodium – restricted diet to prevent fluid excessexcess

Acitivity-balanced program of activity and restAcitivity-balanced program of activity and rest Oxygen therapy – to increase oxygen supplyOxygen therapy – to increase oxygen supply

NURSING MANAGEMENTNURSING MANAGEMENT Providing oxygenationProviding oxygenation

Administer oxygen therapy per nasal cannula at 2 to 6 L/min as orderedAdminister oxygen therapy per nasal cannula at 2 to 6 L/min as ordered Evaluate arterial blood gas analysis resultsEvaluate arterial blood gas analysis results Maintain semi-Fowler’s or high Fowler’s position to maximize oxygenation by Maintain semi-Fowler’s or high Fowler’s position to maximize oxygenation by

promoting greater lung expansionpromoting greater lung expansion Promoting rest and activityPromoting rest and activity

Bed rest or limited activity may be necessary during the acute phase.Bed rest or limited activity may be necessary during the acute phase. Provide an overbed table close to the patient to allow resting the head and armsProvide an overbed table close to the patient to allow resting the head and arms The arms may be supported on pillows to reduce the pull on the shoulder muscles The arms may be supported on pillows to reduce the pull on the shoulder muscles

when in high-Fowler’s position, which is most comfortable for the patientwhen in high-Fowler’s position, which is most comfortable for the patient Administer diazepam (valium) 2 to 10 mg 3 to 4 times a day as ordered allay Administer diazepam (valium) 2 to 10 mg 3 to 4 times a day as ordered allay

apprehensionapprehension Gradual ambulation is encouraged to prevent risk of venous thrombosis and Gradual ambulation is encouraged to prevent risk of venous thrombosis and

embolism due to prolonged immobilityembolism due to prolonged immobility Activities should progress through dangling, sitting up in a chair and then walking Activities should progress through dangling, sitting up in a chair and then walking

in increased distances under close supervisionin increased distances under close supervision Assess for signs of activity intolerance such as dyspnea, fatigue and increased pulse Assess for signs of activity intolerance such as dyspnea, fatigue and increased pulse

rate that does not stabilize readilyrate that does not stabilize readily

NURSING MANAGEMENTNURSING MANAGEMENT Decreasing anxietyDecreasing anxiety

Identifying feelings and the concerns related to those feelingsIdentifying feelings and the concerns related to those feelings Identify strengths that can be used for copingIdentify strengths that can be used for coping Learn what can be done to decrease anxietyLearn what can be done to decrease anxiety

Note:Note:Anxiety causes increased breathlessness which may be perceived Anxiety causes increased breathlessness which may be perceived

by the client as an increase in the severity of the heart failure by the client as an increase in the severity of the heart failure and this is turn increases the anxietyand this is turn increases the anxiety

Facilitating fluid balanceFacilitating fluid balance Control of sodium intakeControl of sodium intake Administer diuretics and digitalis as prescribedAdminister diuretics and digitalis as prescribed Monitor 1 and 0, weight and VSMonitor 1 and 0, weight and VS Dry phlebotomy (rotating tourniquet)Dry phlebotomy (rotating tourniquet)

NURSING MANAGEMENTNURSING MANAGEMENT Providing skin careProviding skin care

Edematous skin is poorly nourished and susceptible to Edematous skin is poorly nourished and susceptible to pressure sorespressure sores

Change position at frequent intervalsChange position at frequent intervals Assess the sacral area regularlyAssess the sacral area regularly Use protective devices to prevent pressure soresUse protective devices to prevent pressure sores

Promoting nutritionPromoting nutrition Provide bland, low-calorie low-residue with vitamin Provide bland, low-calorie low-residue with vitamin

supplement during the acute phasesupplement during the acute phase Frequent small feedings minimize exertion and reduce Frequent small feedings minimize exertion and reduce

gastrointestinal blood requirementsgastrointestinal blood requirements There may be no need to severely restrict sodium intake of There may be no need to severely restrict sodium intake of

the client who receives diuretic. However, “no added salt” the client who receives diuretic. However, “no added salt” diet is prescribed. Salty foods must be omitted.diet is prescribed. Salty foods must be omitted.

NURSING MANAGEMENTNURSING MANAGEMENT Promoting eliminationPromoting elimination

Advise to avoid straining at defecation which involves Valsalva’s Advise to avoid straining at defecation which involves Valsalva’s maneuver. Valsalva maneuver increases cardiac workloadmaneuver. Valsalva maneuver increases cardiac workload

Administer laxative as ordered e.g. colaceAdminister laxative as ordered e.g. colace Encourage use of bedside commodeEncourage use of bedside commode

Facilitating learningFacilitating learning Teach the client and his family about the disorder and self-careTeach the client and his family about the disorder and self-care

Monitor signs and symptoms of recurring CHF, e.g. weight gain, loss of Monitor signs and symptoms of recurring CHF, e.g. weight gain, loss of appetite, dyspnea, orthopnea, edema of the legs, persistent cough and report appetite, dyspnea, orthopnea, edema of the legs, persistent cough and report these to the physicianthese to the physician

Avoid fatigue, balance rest with activityAvoid fatigue, balance rest with activity Observe prescribed sodium restrictionsObserve prescribed sodium restrictions Eat small, frequent meals rather than 3 large meals a dayEat small, frequent meals rather than 3 large meals a day Take prescribed medications at regular basis, e.g. digitalis, diuretics, Take prescribed medications at regular basis, e.g. digitalis, diuretics,

vasodilatorsvasodilators Observe regular follow-up care as directedObserve regular follow-up care as directed

NURSING MANAGEMENTNURSING MANAGEMENT

If acute pulmonary edema occurs in the client with CHF, If acute pulmonary edema occurs in the client with CHF, the following are the appropriate management:the following are the appropriate management: Place in high-Fowler’s positionPlace in high-Fowler’s position Morphine sulfate 10 to 15 mg/IV as ordered to ally anxiety, Morphine sulfate 10 to 15 mg/IV as ordered to ally anxiety,

reduced preload and afterloadreduced preload and afterload Oxygen therapy ast 40% to 70% by nasal cannula or face maskOxygen therapy ast 40% to 70% by nasal cannula or face mask Aminophylline/IV to relieve bronchospasm, increase urinary Aminophylline/IV to relieve bronchospasm, increase urinary

output and increase cardiac outputoutput and increase cardiac output Rapid digitalizationRapid digitalization Diuretic therapyDiuretic therapy VasodilatorsVasodilators Dopamine or dobutamineDopamine or dobutamine Monitor serum potassium. Diuresis may result to hypokalemiaMonitor serum potassium. Diuresis may result to hypokalemia

PHLEBOTOMYPHLEBOTOMY Dry phlebotomy or rotating tourniquets intends to allow pooling of blood in the Dry phlebotomy or rotating tourniquets intends to allow pooling of blood in the

lower extremities, thereby reducing preloadlower extremities, thereby reducing preload Three extremities are occluded at a timeThree extremities are occluded at a time Rotate the tourniquets clockwise every 15 minutesRotate the tourniquets clockwise every 15 minutes Each extremity is occluded for a maximum of 45 minutesEach extremity is occluded for a maximum of 45 minutes If BP compression cuff is used as tourniquet, inflate up to slightly above If BP compression cuff is used as tourniquet, inflate up to slightly above

diastolic pressure (10 to 40 mmHg). This allows occlusion of venous return diastolic pressure (10 to 40 mmHg). This allows occlusion of venous return but, arterial flow remains patentbut, arterial flow remains patent

Perform neurovascular check distal to the tourniquet application:Perform neurovascular check distal to the tourniquet application: Skin colorSkin color Skin temperatureSkin temperature Presence of pulsePresence of pulse Presence of numbness or tinglingPresence of numbness or tingling

If tourniquet application is too tight, tissue ischemia may occurIf tourniquet application is too tight, tissue ischemia may occur Asses for signs and symptoms of thrombosis and embolismAsses for signs and symptoms of thrombosis and embolism Remove tourniquet one at a time every 15 minutesRemove tourniquet one at a time every 15 minutes

CLASSIFICATION OF CLIENTS CLASSIFICATION OF CLIENTS WITH DISEASES OF THE HEARTWITH DISEASES OF THE HEART

Functional CapacityFunctional CapacityClass I. Class I. Patients with cardiac disease but without resulting limitations of physical activity. Patients with cardiac disease but without resulting limitations of physical activity.

Ordinarily, physical activity does not cause undue fatigue, palpitation, dyspnea or Ordinarily, physical activity does not cause undue fatigue, palpitation, dyspnea or anginal pain.anginal pain.

Class II. Class II. Patients with cardiac disease resulting in slight limitation of physical activity. They are Patients with cardiac disease resulting in slight limitation of physical activity. They are

comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea or comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea or anginal pain.anginal pain.

Class III.Class III.Patients with cardiac disease resulting in marked limitation of physical activity. They are Patients with cardiac disease resulting in marked limitation of physical activity. They are

comfortable at rest. Less than ordinary physical activity causes in fatigue, palpitation, comfortable at rest. Less than ordinary physical activity causes in fatigue, palpitation, dyspnea or anginal pain.dyspnea or anginal pain.

Class IV.Class IV.Patients with cardiac disease resulting inability to carry on any physical activity without Patients with cardiac disease resulting inability to carry on any physical activity without

discomfor. Symptoms of cardiac insufficiency or of the anginal syndrome are present discomfor. Symptoms of cardiac insufficiency or of the anginal syndrome are present even at rest. If any physical activity is undertaken discomfort increased.even at rest. If any physical activity is undertaken discomfort increased.

Therapeutic ClassificationTherapeutic ClassificationClass A.Class A.Patients with cardiac disease whose ordinary physical activity need not be restricted.Patients with cardiac disease whose ordinary physical activity need not be restricted.

Class B.Class B.Patients with cardiac disease whose ordinary physical activity need not be restricted but who Patients with cardiac disease whose ordinary physical activity need not be restricted but who

should be advised against severe or competitive physical efforts.should be advised against severe or competitive physical efforts.

Class C.Class C.Patients with cardiac disease whose ordinary physical activity should be moderately Patients with cardiac disease whose ordinary physical activity should be moderately

restricted and whose more strenuous efforts should be discontinued.restricted and whose more strenuous efforts should be discontinued.

Class D.Class D.Patients with cardiac disease whose ordinary physical activity should be marked restricted.Patients with cardiac disease whose ordinary physical activity should be marked restricted.

Class E.Class E.Patients with cardiac disease who should be at complete rest, confined to bed or chair.Patients with cardiac disease who should be at complete rest, confined to bed or chair.

Coronary Artery Disease Cad2

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