The most beautiful things in life cannot be seen or even touched, They must be felt with the heart.

-Helen KellerRESPONSES TO ALTERED OXYGENATION, CARDIAC AND TISSUE PERIPHERAL PERFUSION/ TRANSPORTLOURADEL ULBATA-ALFONSO, MAN, RN

People are living longer than ever before. However, they are living increasingly with chronic conditions or sequelae of acute ones. Of these conditions, disorders related to cardiovascular systems are currently one of the leading causes of death most countries worldwide, including the Philippines.

We, nurses will be caring for clients with cardiovascular disorders more often, in all health care settings. Therefore we will increasingly assume significant roles in providing individualized comprehensive, holistic, ethical, and quality care among the clients.

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Discuss the different assessment parameters for cardiac functioning.Describe nursing care of clients undergoing diagnostics tests to assess cardiac functioning.Describe treatment modalities for clients with cardiac disorders.Explain the pathophysiology, clinical manifestations and collaborative management of cardiac disorders.Make a nursing care plan for clients with cardiac disorders.Teach clients with cardiac disorders about prevention, management and rehabilitation factors that optimize health.Learning outcomes

To provide effective care for these clients, we need a clear understanding of cardiovascular structures and functions, assessment techniques, diagnostic tests, pathophysiology, complications and collaborative management of the disorders. Moreover, we must include client education on the management of the disorders to empower the clients and assist them assume self responsibility in their health care.On the whole, such knowledge, skills and attitudes allow us, nurses better promote recovery, improve client compliance, and ensure adequate home care. And finally, enable the clients achieve quality life.

3Overview of anatomy and Physiology of the HeartThe heart is a small organ that weighs 300 g. and is approximately the size of a fist. It is located in the middle of the mediastinum.

Heart Wall

The three layers of the heart are as follows: epicardium, outermost layermyocardium, the cardiac muscle;endocardium, the endotheliumThe heart is enclosed by the pericardium which consist of two layers: visceral pericardium (inner layer) parietal pericardium (outer layer)There is is 5 to 20 mls. Of fluid in the pericardial sac which prevents friction between the two pericardial layers.

5Chambers of the Heart

The four chambers of the heart are as follows: right atrium, right ventricle, left atrium and left ventricle. The right atrium receives venous blood returning to the heart via the superior and inferior vena cavae.The right ventricle receives venous blood from the right atrium, and ejects this blood into the lungs via the pulmonary artery.The left atrium receives oxygenated blood from the four pulmonary veins and serves as a reservoir during ventricular systole.The left ventricle receives blood from the left atrium and ejects blood into the systemic arterial circulation via the aorta.

Valves of the HeartThe two types of cardiac valves are the atrioventricular (AV) valves and the semilunar valves.

The AV valves are the tricuspid valve and bicuspid (mitral) valve. The tricuspid valve is located between the right atrium and right ventricle. The mitral valve is located between the left atrium and left ventricle.

The AV valves are held in place by the chordae tendinae cordis, which in turn are anchored to the ventricular wall by the papillary muscles. The chordae tendinae cordis supports the AV valves during ventricular systole to prevent valvular prolapsed into the atrium.

The semilunar valves are the aortic valve and the pulmonic valve. The aortic valve lies between the left ventricle and the aorta. The pulmonic valve lies between the right ventricle and the pulmonary artery. These valves open during ventricular systole, and they close during ventricular diastole.Valves of the Heart

9The coronary arteries originate from the aorta, behind the cusps of the aortic valve, in an area known as Vasalvas sinus.The two main coronary arteries are the left coronary artery (LCA) and the right coronary artery (RCA).The LCA divides into two branches namely, the circumflex coronary artery (CCA) and the left anterior descending artery (LADA).

Coronary Arteries

The LADA supplies the anterior wall of the left ventricle, the anterior interventricular septum, the anterior papillary muscles and apex of the heart. The RCA supplies the right atrium, right ventricle, a portion of the septum, SA node, AV node, and inferior portion of the left ventricle. Coronary artery blood flow to the myocardium occurs during diastole, when coronary vascular resistance is reduced. During diastole, blood enters the coronary artery, which is called diastolic filling.

Coronary ArteriesCardiac Conduction System:The normal pacemaker of the heart is the sinoatrial (SA) node. The Sa node triggers electrical impulses at a rate of 60 to 100 beats per minute. The atria are then depolarized and the impulse is transmitted via the intermodal tracts into the atriventricular (AV) node. The impulse is delayed in the AV node, which enables atrial contraction to complete before the ventricles are stimulated and contract.The electrical impulse is then transmitted into the Bundle of His, and into the Purkinje fibers -> ventricles contract

The conduction system consists of specialized cells that create and transport electrical impulses. These electrical impulses initiate depolarization (contraction) of the myocardium and ultimately a cardiac contraction.

Each electrical impulse starts at the SA node (located in the right atrium), travels to the AV node (located at the atrioventricular junction), through the bundle of His, down the right and left bundle branches (located in the ventricular septum), terminating in the Purkinje fibers.

The electrical activity of the heart is recorded on the electrocardiogram (ECG).

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Cardiac CycleThe two phase of the cardiac cycle are diastole and systole. Systole, contraction of the myocardium, results in ejection of blood from the ventricles. Relaxation of the myocardium, or diastole, allows for filling of the ventricles.

14Electrophysiologic Properties of the heartThe electro physiologic properties of the heart are as follows: automaticity, excitability, conductivity, contractility, and refractioriness. Automaticity is the ability of the heart to initiate impulses repetively and spontaneously (also called rhythmicity). Excitability is the ability of cardiac cells to respond to a stimulus by initiating a cardiac impulse.Conductivity is the ability of cardiac cells to respond to an impulse by transmitting the impulse along cell membranes.Contractility is the ability of cardiac cells to respond to an impulse by contracting.

Refractoriness is the inability of the cardiac cells to respond to a new stimulus while it is in contraction in response to a previous stimulusCardiac OutputCardiac output (C.O) is the volume of blood ejected from the left ventricle into the aorta per minute. C.O = Stroke Volume x Heart Rate (70 mls X 70 bpm = 4,900 mls or approximately 5 L)The average cardiac output is approximately 5L/minute.Stroke volume (SV) is the mount of blood rejected by the left ventricle into the aorta per beat. The stroke volume is determined by three factors, namely: preload, contractility and afterload. It is approximately 70 mls.

Preload is the degree of myocardial fiber stretch before contraction. It is related to the volume of blood distending the ventricles at the end of diastole. It is determined by the amount of venous return.Frank starling law of the heart conceptualizes that the greater the myocardial fiber stretch, within physiologic limits, the more forceful the ventricular contraction, thereby increasing stroke volume.Contractility refers to a change in the inotropic state of the muscle without a change in myocardial fiber length or preload.Afterload is the amount of tension the ventricle musty develop during contraction to eject blood from the left ventricle into the aorta.

Autonomic Influences on cardiac Activity Autonomic nervous system provides an external influence on myocardial contractility and rate.

The sympathetic nervous system (SNS) releases norepinephrine which increases the heart rate and the force of contraction of the heart.

The parasympathetic nervous system (PNS) releases acetycholine from vagal fibers which slows the heart rate and causes slight decrease in ventricular contractility.BaroreceptorsThe baroreceptors in the carotid and aortic bodies are pressure sensitive structures. Decreased BP causes a reflex SNS response with increased pulse, increased contractility and vasoconstriction. Increased BP causes reflex vagal responces, which results in decreased heart rate and passive vasidilation in the systemic arterioles. This phenomenon is known as Marcys Law of the heart.

Chemoreceptors:The major chemoreceptor of the heart is the medulla oblongata, and special receptors are found in the carotid and aortic bodies. A decreased pH or paO level causes a reflex SNS response that results in tachycardia

Arterial blood pressure (BP)Arterial blood pressure (BP) measures the pressure exerted by blood against the walls of the arterial system. The systolic blood pressure (SBP) is the peak pressure exerted against the arteries when the heart contracts. The diastolic blood pressure (DBP) is the residual pressure of the arterial system during ventricular relaxation (or filling). Normal blood pressure is systolic BP less than 120 mm Hg and diastolic BP less than 80 mm Hg.The two main factors influencing BP are cardiac output (CO) and systemic vascular resistance (SVR), which is the force opposing the movement of blood.

Arterial blood pressure (BP)BP can be measured by invasive (catheter inserted in an artery) and noninvasive techniques (using a sphygmomanometer and a stethoscope).

Pulse pressure is the difference between the SBP and DBP and it is normally about one third of the SBP.

Mean arterial pressure (MAP) is the perfusion pressure felt by organs in the body, and a MAP of greater than 60 is necessary to sustain the vital organs of an average person under most conditions.

Physiologic Changes in the Heart with AgingDecreased myocardial contractility. This reduces cardiac reserve.General thickening of endocardium and valves. The valves tend to become rigid and incompetent. Heart murmurs develop.Conducting fibers are replaced by fibrous tissue. This reduces the effectiveness of pacemaker cells, decreases conductivity and leads to dysrhythmias.

Assessment of the clients with Cardiovascular DisordersNursing historyPhysical examinationCommon Clinical ManifestationsDiagnostic TestsAssessment of the clients with Cardiovascular DisordersNURSING ASSESSMENTSUBJECTIVE DATA1. Health HistoryIdentifying the risk factorsHPIPast medical historyMedicationsFamily HistoryLifestyleWhen conducting a health assessment of the cardiovascular system, a thorough history should include the following:1. Risk factors:28Risk FactorsThe risk factors cardiovascular disorders may be classified as follows:Non-modifiable Risk factors (Unavoidable risk factors)Modifiable Risk factors (Avoidable risk factors)

29Non- Modifiable Risk factorsAge persons above 40 years of age are at high risk to develop cardiovascular diseased. This is due to degenerative changes in the heart and blood vessels.

Gender males are more prone to cardiovascular disorders before the age of 65 years. However, females have higher propensity to cardiovascular disorders after the age of 65 yearsThis is due to decreased estrogen levels in menopause. HDL (high density lipoprotein/ good cholesterol) decreases, LDL (low density lipoprotein/ bad cholesterol) increases. This causes development atherosclerosis.

30Race cardiovascular disorders are among the 10 leading causes of death worldwide. In the U.S., cardiovascular disorders rank the number one causes of morbidity.

Heredity person with family history for cardiovascular disorders are at risk to develop these diseases.Non- Modifiable Risk factorsModifiable Risk factorsStress sympathetic response stimulation causes increased secretion of norepinephrine. This results to vasoconstriction and tachycardia. Increased BP and increased cardiac workload occur.Diet increased dietary intake of foods high in sodium, fats and cholesterol predisposes a person to cardiovascular disorders. Sodium retains water and increases blood volume. This may cause hypertension. High fats and high cholesterol diet predisposes a person to atherosclerosis.Exercise regular pattern of exercise improves circulation to different body parts including the heart and blood vessels; maintains vascular tone; and enhances release of chemical activators (tissue type plaminogen activators), which prevent platelet aggregation and prevent blood clotting. Sedentary lifestyle increases risk to cardiovascular disorders.Cigarette smoking nicotine causes vasoconstriction and spasm of the arteries; increases myocardial oxygen demands; and adhesion of platelets. In addition, cigarette smoking has been associated with decreased levels of HDL. In cigarette smoking, more carbon dioxide is inhaled than oxygen.

Modifiable Risk factorsAlcohol it positively correlates with high blood pressure. Alcohol causes vasoconstriction. Thirty mls. Of alcohol is stimulant and causes vasodilatation. More than 30 mls. Of alcohol causes vasoconstriction and elevation of blood pressure.Hypertension increased systemic vascular resistance, endothelial damage, increased platelet adherence, and increased permeability of endothelial lining, result from elevated blood pressure.Hyperlipidemia hypercholesterolemia. Increased LDL cholesterol damages endothelium and causes accumulation of fatty plaques on endothelial lining and proliferation of smooth muscle cells.

Modifiable Risk factorsDiabetes MellitusGlucose from carbohydrates cannot be transported into the cells due to insulin deficiency or increased resistance to insulin.The body then, mobilizes fats (lipolysis), to become a source of glucose. However, not all of the fats mobilized are converted into glucose. Most of it remain as lipids. Hyperlipidemia results, which enhances the risk of atherosclerosis.

Modifiable Risk factorsObesity this results to increased cardiac workload. The heart has to pump blood supply to a larger body surface area. May also be characterized by rise in serum lipid levels.Personality type or Behavioral Factors the type A behavior pattern characterized by competitiveness, impatience, aggressiveness and time urgency has been correlated to coronary artery diseases (Cad). Although the mechanism is unknown.Modifiable Risk factorsContraceptive pills may precipitate thromboembolism and hypertension. The estrogen component of oral contraceptive pills increase blood viscosity, thereby increasing the risk to thromboembolism. It also stimulates the liver to synthesize angiotensinogen. The angiotensinogen triggers production of pulmonary converting enzymes. This in turn causes conversion of angiotensinogen to angiotensin I, a vasoconstrictor. Angiotensin I is further acted upon by pulmonary converting enzyme and converted to Angiotensin II, a very potent vasoconstrictor.

Modifiable Risk factorsHISTORY OF PRESENT ILLNESSWhat other symptoms has the patient noticed?How long has the patient been ill? What has the course of the illness been?Obtain the review of systemsHISTORY OF PRESENT ILLNESSPast medical history

Medical and surgical HistoryHypertension, DM, Hyperlipidemia or other chronic diseases which cause or aggravate cardiovascular disease.

Past illness/hospitalizations: trauma to chest ( possible myocardial contusion; sore throat/ dental extractions (possible endocarditis); rheumatic fever (valvular dysfunction, endocarditis); thromboembolism (MI, Pulmonary embolism)Information about specific treatments, past surgeries, or hospital admissions related to cardiovascular problems40MEDICATIONSCurrent and past use of medicationsMany cardiac drugs must be tapered off to prevent a rebound effect.Many drugs affect heart rate and may cause orthostatic hypotensionEstrogen preparation may lead to thromboembolismFAMILY HISTORYAsk for cardiovascular illnesses of blood relatives LIFESTYLEAssess for risk factors to cardiovascular disease such as smoking, obesity, pattern of recurrent weight gain after dieting, sedentary lifestyle, stress, alcohol consumption.A typical days diet 2. Common Clinical manifestations of Cardiovascular Disorders

1. CHEST PAINthis may be due to decreased coronary tissue perfusion and oxygenation. Anaerobic metabolism causes production of lactic acid. Lactic acid causes irritation of nerve endings in the myocardium. This results to chest pain.

2. Common Clinical manifestations of Cardiovascular Disorders

2. Common Clinical manifestations of Cardiovascular Disorders

1. CHEST PAINCHARACTERIZATION:A. Nature and intensityAsk pt to describe in own words what the pain is like- dull, sharp, crushing, burning, heaviness, ache, pressure?Ask pt to rate pain relative to pain experienced in the past, using a scale of 1-10 ( 10 being the most severe pain and 1 the least)B. Onset and durationWhen did the pain startHow long did the pain episode last?C. Location and radiationAsk pt to point to area where it hurts most. Ask the pt if the pain seems to travel.

c. a. POSITIVE LEVINES SIGN: Clenched fist brought to pstients chest; indicative of diffuse visceral pain assoc with unstable cardiac dse. b. Most commonly radiates to left arm, jaw, back and abdominal region46Pain Assessment TechniquesThe patient's self-reported pain is often measured by using pain scales Numeric Pain Intensity Scale uses a 0-10 scale to assess the degree of pain. Simple Description Intensity Scale, uses such words as "mild", "moderate", and "severe" to describe the patient's pain intensity. Visual Analog Scale (VAS) requires patients to mark a point on a 10 cm horizontal or vertical line to indicate their pain intensity, with 0 indicating "no pain and 10 indicating "the worst possible pain". Pain Assessment Techniques

TYPES OF CHEST PAINAngina Pectoris

Substernal or retrosternal pain spreading across chest; may radiate to inside of arm, neck, or jaw5-15minUsually related to exertion, emotion, eating, coldRest, nitroglycerin,oxygenMyocardial Infarction

MISubsternal pain or pain over precordium; may spread widely throughout chest. Pain in shoulders and hands may be present.>15 minOccurs spontaneously but may be sequela to unstable anginaMorphine sulfate,successful reperfusion of blockedcoronary arteryEsophageal Pain

Substernal pain;may be projectedaround chest to shoulders.560 minRecumbency, cold liquids, exercise.May occurSpontaneously.Food, antacid. Nitro-glycerin relieves Spasm.anxietyPain over chest; may be variable. Does not radiate. Patient may complain of numbness and tingling of hands and mouth.23 minStress, emotionaltachypneaRemoval of stimulus,relaxation1. CHEST PAIND. Precipitating and relieving factorsWhat activity was patient doing just before pain (rapid walking, exposure to cold, eating a spicy meal, sitting quietly, awakened from sleep?What relieves the pain ( rest, medication, change of position)

E. Associated signs and symptoms; observe for nausea, diaphoresis, dyspnea, fatigue, palpitations, disorientations.2. Common Clinical manifestations of Cardiovascular Disorders

CHEST PAINSignificance:Excruciating shearing pain radiating to the back and flanks may indicate acute dissecting aneurysm of the aorta.Sharp precordial pain radiating to the left shoulder and upper back, aggravated by respirations indicates acute pericarditis.2. Common Clinical manifestations of Cardiovascular Disorders

PRECORDIAL- OVER THE HEART AREA562. DYSPNEA (SHORTNESS OF BREATH)CHARACTERIZATION:A. What precipitates or relieves dyspnea?B. How many pillows does patient sleep with at night?C. How far can patient walk or how many flights of stairs can pt climb before becoming dyspneic?D. Determine the type of dyspnea

2. Common Clinical manifestations of Cardiovascular Disorders

PILLOWS- Using several pillows is indicative of advanced heart failure57TYPES OF DYSPNEA1. Exertional/ Dyspnea on exertion (DOE). Breathlessness on moderate exertion that is relieved by rest.This may indicate decreased cardiac reserve (hearts ability to adjust and adapt to increased demands).2. Paroxysmal nocturnal Sudden dyspnea at night; awakens patient with feeling of suffocation; sitting up relieves breathlessnesssevere shortness of breath usually occurs 2 to 5 hours after the onset of sleep. During waking hours, the client usually assumes upright position most of the time. This causes venous pooling. When the client lies recumbent during the night, the blood from the lower extremities are distributed to the upper parts of the body and lung congestion may occur and the client experiences difficulty of breathing. It takes 2 to 5 hours for the blood from the lower extremities to be distributed to the upper parts of the body.

2. Common Clinical manifestations of Cardiovascular Disorders

TYPES OF DYSPNEA3. OrthopneaShortness of breath when lying down. Patient must keep head elevated with more than one pillow to minimize dyspnea.usually a symptom of more advanced heart failure

SIGNIFICANCE:It may be a sign of left ventricular failure or transient congestive heart failure2. Common Clinical manifestations of Cardiovascular Disorders

Orthopnea: Because of pulmonary congestion when lying down593. PALPITATIONSCHARACTERIZATION:A. Do you feel your heart pound, beat too fast, or skip beats?B. Do you feel dizzy or faint when you experience these sensations?What brings on these sensations?How long does it last?What do you do to relieve these sensations?SIGNIFICANCE:Pounding, jumping sensations in chest usually due to tachydysrhythmia.Skipped beats usually due to premature atrial or ventricular beats.Common Clinical manifestations of Cardiovascular Disorders

4. WEAKNESS & FATIGUECHARACTERIZATION:A. What activities can you perform without becoming tired?B. What activities cause you to become tired?C. Is the fatigue relieved by rest?D. Is leg weakness accompanied by pain or swelling?SIGNIFICANCE:Fatigue is produced by low cardiac output. The heart is unable to provide sufficient blood to meet the increased metabolic needs of cells.As heart disease advances, fatigue is precipitated by less effort.Weakness or tiring of the legs may be caused by peripheral arterial or venous disease.Common Clinical manifestations of Cardiovascular Disorders

5. DIZZINESS AND SYNCOPECHARACTERIZATION:A. How many episodes of syncope/near syncope have been experienced?B. Did a hot room, hunger, sudden position change, or pressure on your neck precipitate the episodes?C. How long does dizziness last?D. What relieves dizziness?SIGNIFICANCE:Syncope is transient loss of consciousness due to a fall in cardiac output with resulting cerebral ischemia. Near syncope refers to lightheadedness, dizziness, temporary confusion.Dysrhythmias related to cardiac disease may cause syncope.Common Clinical manifestations of Cardiovascular Disorders

This is due to decreased cerebral tissue perfusion.

626. Edema Increased hydrostatic pressure in the venous system causes shifting of plasma. Therefore, accumulation of fluids in the interstitial compartment occurs.

Common Clinical manifestations of Cardiovascular Disorders

Pulmonary and peripheral edemaAUSCULTATEEDEMA GRADING 63

PITTING EDEMA GRADING SYSTEM

7. CoughCough with dyspnea may also occur with cardiac disease such as left-sided CHF.

8. CYANOSIS9. CLUBBING OF FINGERSCommon Clinical manifestations of Cardiovascular Disorders

CLUBBING-Clubbing of the fingers is associated with decreased oxygen. In clubbing, the distal tips of the fingers become bulbous, the nails are thickened hard, and curved at the tip, and the nail bed feels boggy when squeezed. - Separation from the nail bed produces a white, yellowish, or greenish color on the non-adherent portion of the nail.CLUBBINGOBJECTIVE DATA:PHYSICAL EXAMINATIONA thorough physical examination can provide clues to the presence and severity of cardiovascular disease, and alert one to the presence of life-threatening conditions even before the results of any diagnostic workup are available.

69PHYSICAL EXAMINATIONA. GENERAL APPEARANCE:Dyspnea, tachypnea, use of accessory respiratory muscles, discomfort from pain, diaphoresis, and cyanosis may all indicate underlying cardiac disease.

B. VITAL SIGNS1. PULSETime for 1 full minute; note irregularity.Compare apical and radial pulse (pulse deficit)TYPES:Collapsing: Aortic insufficiencyBisferiens (double beat): Combined aortic stenosis (AS) and insufficiencyPulsus parvus (weak) et tardus (delayed): Severe aortic stenosisPulsus alternans (alternating strong and weak pulse): Severe LV dysfunctionPulsus paradoxus (marked inspiratory decrease in strength of pulse): Cardiac tamponade, pericardial constriction, severe obstructive airway disease.PHYSICAL EXAMINATIONThe pulse should be examined for rate, regularity, volume, and character. Some abnormalities in the character of the pulse may be diagnostic for certain cardiovascular conditions:

pulse deficit n. The difference between the heart rate and the palpable pulse, as is often seen in atrial fibrillation.71B. VITAL SIGNS2. BLOOD PRESSURETake pressure on both arms and note differences (5-10 mmhg difference is normal). Difference > 10 may indicate subclavian steal syndrome or dissecting aortic aneurysm.Determine pulse pressure (systolic pressure minus diastolic pressure) to evaluate cardiac output (30-40 mmHg is NORMAL; less than 30 mmHg indicates decreased cardiac output).Note presence of pulsus alternans- loud sounds alternate with soft sounds with each auscultatory beat (hallmark of left ventricular failure)Note presence of pulsus paradoxus- abnormal fall in blood pressure during inspirations (cardiac sign of cardiac tamponade)

PHYSICAL EXAMINATIONB. VITAL SIGNS3. ASSESS FOR POSTURAL OR ORTHOSTATIC HYPOTENSIONOrthostatic hypotension prompt hypotension occurs with assumption of the upright positionMay be due to volume depletion, bed rest, drugs such as beta or alpha adrenergic blockers or neurologic disease.Note changes in heart rate and blood pressure in at least two of three positions: lying, standing, sitting; allow at least 3 minutes between position changes before obtaining rate and pressure.Orthostatic changes evident if BP decreases by 15 mmHg (systolic) or 5 mmHg diastolic and/or HR increases 15 beats with position changes. Keep in mind that patients on beta blockers may not exhibit a compensatory increase in heart rate.PHYSICAL EXAMINATIONC. SKIN AND EXTREMITIESA. PALPATE FOR TEMPERATURE AND EVIDENCE OF DIAPHORESISWarm/dry skin indicates adequate cardiac output.Cool, clammy skin indicates compensatory vasoconstriction due to low cardiac output.B. OBSERVE FOR CYANOSIS, JAUNDICE AND FATTY SKIN DEPOSITTS (XANTHOMAS)1. CyanosisPHYSICAL EXAMINATIONC. SKIN AND EXTREMITIESB. OBSERVE FOR CYANOSIS, JAUNDICE AND FATTY SKIN DEPOSITTS (XANTHOMAS)1. CYANOSIS bluish discoloration of the skin and mucous membranesA. CENTRAL CYANOSIS low oxygen saturation of arterial blood. Noted on tongue, buccal mucosa and lips.Indicative of cardiorespiratory disease; may be evident in heart failure or pulmonary edema.B. PERIPHERAL CYANOSIS Reduced blood flow through extremities due to vasoconstriction.Noted on distal aspects of extremities, tip of the nose and earlobesDue to cold exposure or obstructive peripheral vascular disease

PHYSICAL EXAMINATION

C. SKIN AND EXTREMITIESB. OBSERVE FOR CYANOSIS, JAUNDICE AND FATTY SKIN DEPOSITTS (XANTHOMAS)2. JAUNDICE yellow discoloration of the sclera of eyes or skinmay be a sign of right sided heart failure or chronic hemolysis from prosthetic heart valve3. YELLOW PLAQUE (fatty deposits) on the skinAssociated with hyperlipidemia and coronary artery disease

PHYSICAL EXAMINATION

YELLOW PLAQUES

C. SKIN AND EXTREMITIESC. INSPECT THE NAIL BEDS FOR SPLINTER HEMORRHAGES and CLUBBINGSplinter hemorrhagesThin brown lines in nail beds associated with endocarditisClubbing swollen nail base and loss of normal angleAssociated with congenital heart disease and cor pulmonale

PHYSICAL EXAMINATION

Capillary refill time:

is a quickly test to assess the adequacy of circulation in an individual with poor cardiac output. An area of skin is pressed firmly by (say) a fingertip until it becomes white; the number of seconds for the area to turn pink again indicates capillary refill time. Normal capillary refill takes around 2 seconds.C. SKIN AND EXTREMITIESD. INSPECT AND PALPATE FOR EDEMAEdema is an abnormal accumulation of serous fluid in soft tissues.Location of edema is influenced by gravity fluid collects bilaterally in lower parts of the body: sacral area (bedridden patients), ankles, and feet (ambulatory pts) and pits with pressure (dependent-pitting edema)Weight gain occurs before clinical evidence of edema. Edema is a late sign of heart failure.Describe the degree of edema in terms of depth of pitting that occurs with slight pressure:Mild 0 to inch, moderate- inch, severe- to 1 inch

PHYSICAL EXAMINATION

C. SKIN AND EXTREMITIESE. PALPATE ARTERIAL PULSES1. Examine the pulses bilaterally; peripheral pulses should be equal.Note amplitude (fullness), which depends on pulse pressure ( difference between systolic and diastolic pressures); this gives an estimate of stroke volumeSmall volume pulse may be from low stroke volume and peripheral vasoconstriction (MI, shock, constrictive pericarditis, vasoconstrictive drugs)Large volume pulse produced by large stroke volume (aortic regurgitation, pregnancy, thyrotoxicosis, bradycardia, PDA)Palpate carotid artery- reveals character of pulse in the proximal aorta and provides indication of any abnormality causing disease of left ventricle.

PHYSICAL EXAMINATIONCHEST and NECK

JUGULAR VEIN

Measuring Jugular Venous Pressure-Position patient with the head of bed at 30 to 45-degree angle.

- Place a ruler vertically, perpendicular to the chest at the angle of Louis (sternal angle).

-identify the highest level of the jugular vein pulsation; if unable to see pulsations, use the highest level of jugular vein distension.Place another ruler horizontally at the point of the highest level of the venous pulsation.Measure the distance up from the chest wall.The normal JVP is less than 3 cm. A central venous pressure can be estimated by adding 5 cm to the JVP

INTERPRETATION: Elevated JVP: Right-sided CHF, constrictive pericarditis, tricuspid stenosis, or superior vena cava obstruction.Low JVP: Hypovolemia.PalpationPalpating the Carotid

Palpating the Carotid

-Lightly palpate each carotid separately.

- Note rate, rhythm, amplitude, contour, symmetry, elasticity, thrills.PALPATING THE PRECORDIUMRight 2nd intercostal space Aortic Area

Left 2nd intercostal space Pulmonic Area

Left lower sternal border Tricuspid areaApex over apical impulse Mitral area

LandmarksPalpating the Precordium

- Identify and palpate each cardiac site for pulsations, and thrills: - Apex (left ventricular area), or mitral area fifth intercostal space, midclavicular line.

- Base right (aortic area), second intercostal space right sternal border.

Palpating the Precordium

- LLSB (tricuspid area), fourth to fifth intercostal space at left sternal border.

Palpating the Precordium

- Base left (pulmonic area), second intercostal space left sternal border.

Palpating the Precordium

- Listen at each site with both the bell and the diaphragm.

ABNORMAL RESULTS:Thrills are palpable vibrations created by turbulent blood flow. Bruit "vascular murmur is the abnormal sound generated by turbulent flow of blood in an artery due to either an area of partial obstruction; or a localized high rate of blood flow through an unobstructed artery.Lifts or heaves are diffuse, lifting impulses.A thrust is a rocking movement. AUSCULTATIONDiaphragm medium and high frequency soundsBell low frequency sounds

Normally hear closure of valve Sounds from left side of heart louder than equivalent sounds from right side of heartHEART SOUNDSS1 closure of mitral and tricuspid valves

S2 closure of aortic and pulmonic valves

Low pitched sounds S3, S4, mitral stenosisRight 2nd intercostal space Aortic Area

Left 2nd intercostal space Pulmonic Area

Left lower sternal border Tricuspid areaApex over apical impulse Mitral areathe aortic and pulmonic areas are correlated anatomically with the base of the heart.

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Landmarksthe aortic and pulmonic areas are correlated anatomically with the base of the heart.

ABNORMAL FINDINGSS3 (also called a ventricular gallop) may be heard in the tricuspid and mitral areas during the early to mid-diastole following the S2 sound.S3 is heard well when the client is in the left lateral recumbent positionS3 gallop (may indicate ventricular failure)S4 (also called atrial diastolic gallop) may be heard in the tricuspid and mitral areas during the late phase of diastole, before S1 of the next cardiac cycle. S4 is heard well when the client is in the supine positionS4 gallop ( present in left ventricular hypertrophy, pulmonary or aortic stenosis and hypertension

S3 may be normal in people under 40 years of age and some trained athletes but should disappear before middle age106Murmurs and Stenosis A valve that does not close efficiently, results in the backflow of blood (i.e., insufficiency or regurgitation).

A valve that does not open wide enough may cause turbulent backflow secondary to obstruction or narrowing (i.e., stenosis). Assessment of other systemsLungsAbdomen

Diagnostic Tests and ProceduresCardiovascular function and disease are evaluated by a variety of blood tests, ultrasound techniques, fluoroscopy and nuclear imaging studies and electrocardiography.109LABORATORY STUDIESA. ENZYME and ISOENZYME TESTS1. Creatinine Kinase (CK)2. Lactic Dehydrogenase (LDH)3. Aspartate Aminotransferase (AST, formerly known as SGOT)

These enzymes are widely distributed in tissues and elevated in condition NOT associated with MI such as damage to the skeletal tissues, liver, brain, kidneys and other organs.When myocardial tissue is damaged( myocardial infarction), certain cardiac enzymes are released into the bloodstream and result in elevated peripheral blood enzyme levels:These include the ff:110CREATININE KINASECreatine kinase (CK) is an enzyme found in the muscles The level of the CK enzymes rises when the muscles are damaged.The three types of CK are called isoenzymes. They are:CK-MMwhich is found in the skeletal muscleCK-MBwhich is found in the heart and rises when heart muscle is damagedCK-BBwhich is found mostly in the brainLactic Dehydrogenase (LDH)

LDH is an enzyme that is found in almost all of the body's cells and is released from cells into the fluid portion of blood (serum or plasma) when cells are damaged or destroyed. Thus, the blood level of LDH is a general indicator of tissue and cellular damage.Aspartate Aminotransferase (AST, formerly known as SGOT)

AST is normally found in red blood cells, liver, heart, muscle tissue, pancreas, and kidneys. AST formerly was called serum glutamic oxaloacetic transaminase (SGOT).When body tissue or an organ such as the heart or liver is diseased or damaged, additional AST is released into the bloodstream. The amount of AST in the blood is directly related to the extent of the tissue damage.CARDIAC TROPONINSTroponin, a complex of three contractile regulatory proteins, troponin C, T and I, controls the calcium-mediated interactions between actin and myosin in cardiac and skeletal muscles. Troponin-I and T are specific to cardiac muscles, unlike troponin-C which is associated with both cardiac and skeletal muscles. Hence, troponin-C is not used in the diagnosis of myocardial damage. MYOGBLOBINSIs a protein in heart and skeletal muscles.When muscle is damaged, myoglobin is released into the bloodstream.NURSING AND PATIENT CARE CONSIDERATIONSEnsure that enzymes are drawn in a serial pattern, usually on admission and every 6 to 24 hours until 3 samples are obtained; enzyme activity is then correlated to the extent of heart muscle damage.Normal values, rise and peak of enzymes following MI include:A. CK rise in 12 hours, peak in 36 to 72 hours, normalize (35- 232 IU) in 3-5 daysB. LDH rise in 12 hours, peak in 12- 24 hours; normalize ( 100-190 IU) in 10 daysC. AST rise in 8-12 hours; peak in 18-36 hours; normalize in 3-4 daysD. CK-MB rise in 4-8 hours; peak in 24 hours, normalize (< 5 IU) in 72 hoursE. LDH1 and LDH2 - LDH2 is normally > LDH1 but in heart damage LDH1 > LDH2 within 12-24 hoursF. CARDIAC TROPONIN T rise 3 to 5 hours, remain elevated for 14-21 days.G. CARDIAC TROPONIN I rise 3 hours, peak at 14 to 18 hours and remain elevated for 5-7 daysH. MYOGLOBIN detected as early as 2 hours, peak in 3-15 hours

NURSING ALERT!!!The greater the peak in enzyme activity and the length of time an enzyme remains at peak level correlate with serious damage of the heart muscle and poorer prognosis for the patient.NURSING AND PATIENT CARE CONSIDERATIONSRed blood cell count increases in conditions characterized by inadequate tissue oxygenation

The white blood cell count increases in infectious and inflammatory diseases of the heart and after myocardial infarction

Decreases in hematocrit and hemoglobin can indicate anemia

COMPLETE BLOOD COUNT118an increase in coagulation factors can occur during and after MI, which places the client at greater risk of thrombophlebitis and extension of clots in the coronary arteriesBLOOD COAGULATION STUDIES119It measures the cholesterol, triglyceridesThe lipid profile is used to assess the risk of developing coronary artery diseaseThe desirable range for serum cholesterol is < 200 mg/Dl LDL of < 130 mg/dL, HDL of > 70 mg/dL

SERUM LIPIDS120Potassium- causes dysrhythmias and increased risk of digitalis toxicity

Sodium - it decreases with the use of diuretics, it decreases in heart failure, indicating water excess

Calcium - can cause ventricular dysrhythmiasELECTROLYTES121NONINVASIVEElectrocardiographyThe most commonly used test for evaluating cardiac status.Graphically records the electrical current (electrical potential) generated by the heart. This current radiates from the heart in all directions and, on reaching the skin, is measured by electrodes connected to an amplier and strip chart recorder. The standard resting ECG uses five electrodes to measure the electrical potential from 12 different leads; the standard limb leads (I,II,III), the augmented limb leads (aVf, aVL, and aVr), and the precordial, or chest, leads (V1 through V6)

ECG tracings normally consist of three identifiable waveforms: The P waveThe P wave depicts atrial depolarization The QRS complexventricular depolarizationThe T waveventricular repolarization.Electrocardiography

A client wears a holter monitor and an electrocardiogram tracing is recorded continuously over a period of 24 hours or moreIt identifies dysrhythmias if they occur and evaluates effectiveness of medications or pacemaker therapyInstruct to resume normal activities and to maintain a diary documenting activities and any symptom that may develop

HOLTER MONITORING126

127

128

129Electrocardiography (ECG) ProcedurePatient Preparation for Electrocardiography (ECG)Explain to the patient the need to lie still, relax, and breathe normally during the procedure.Note current cardiac drug therapy on the test request form as well as any other pertinent clinical information, such as chest pain or pacemaker.Explain that the test is painless and takes 5 to 10 minutes.ImplementationPlace the patient in a supine or semi-Fowlers position.Expose the chest, ankles, and wrists.Place electrodes on the inner aspect of the wrists, on the medical aspect of the lower legs, and on the chest.After all electrodes are in place, connect the lead wires.Press the START button and input any required information.Make sure that all leads are represented in the tracing. If not, determine which electrode has come loose, reattach it, and restart the tracing.All recording and other nearby electrical equipment should be properly grounded.Make sure that the electrodes are firmly attached.

Nursing InterventionsDisconnect the equipment, remove the electrodes, and remove the gel with a moist cloth towel.If the patient is having recurrent chest pain or if serial ECGs are ordered, leave the electrode patches in place.Interpretations : NORMAL RESULTP wave that doesnt exceed 2.5 mm (0.25 mV) in height or last longer than 0.12 second.PR interval (includes the P wave plus the PR segment) persisting for 0.12 to 0.2 second for heart rates above 60 beats/min.QT interval that varies with the heart rate and lasts 0.4 to 0.52 second for heart rates above 60 beats/min.Voltage of the R wave leads V1 through V6 that doesnt exceed 27 mm.Total QRS complex lasting 0.06 to 0.1 second.

Abnormal ResultsMyocardial infarction (MI), right or left ventricular hypertrophy, arrhythmias, right or left bundle-branch block, ischemia, conduction defects or pericarditis, and electrolyte abnormalities.Abnormal wave forms during angina episodes or during exercise.Is a noninvasive procedure based on the principles of ultrasound

It evaluates structural and functional changes in the heartECHOCARDIOGRAM

136CARDIAC UTZIs done to determine the size, silhouette, and position of the heart

Interventions: prepare the client, explain the procedure and remove jewelryCHEST RADIOGRAPHY

137Cardiac stress testa test used to measure the heart's ability to respond to external stress in a controlled clinical environment.The stress response is induced by exercise or drug stimulation. Cardiac stress tests compare the coronary circulation while the patient is at rest with the same patient's circulation observed during maximum physical exertion, showing any abnormal blood flow to the heart's muscle tissue (the myocardium). This test can be used to diagnose ischemic heart disease, and for patient prognosis after a heart attack (myocardial infarction).The cardiac stress test is done with heart stimulation, either by exercise on a treadmill, pedalling a stationary exercise bicycle ergometer or with intravenous pharmacological stimulation, with the patient connected to an electrocardiogram (or ECG).

Heart CT scanA computed tomography (CT) scan of the heart is an imaging method that uses x-rays to create detailed pictures of the heart and its blood vessels.A computer creates separate images of the body area, called slices.These images can be stored, viewed on a monitor, or printed on film.3D or three-dimensional models of the heart can be created.Contrast can be given through a vein (IV) in hand or forearm. If contrast is used, pt is asked not to eat or drink anything for 4-6 hours before the test. And to inc fluid intake post procedureALLERGY TO SEAFOOD140

MRIHeart magnetic resonance imaging (MRI) is an imaging method that uses powerful magnets and radio waves to create pictures of the heart. It does not use radiation (x-rays).

PROSTHESIS, JEWELRIES, METALS143INVASIVE DIAGNOSTIC PROCEDUREInvolves insertion of a catheter into the heart and surrounding vessels

Obtains information about the structure and performance of the heart valves and circulatory systemCARDIAC CATHETERIZATION145

SITE: FEMORAL VEIN OR ANTECUBITAL VEIN

146

RIGHT CARDIAC CATHETERIZATION

LEFT CARDIAC

147Obtain informed consentAssess for allergies to seafood, iodine, or radiopaque dyesNPO for 6-8 hoursObtain baseline vital signs, note the quality and presence of peripheral pulses for postprocedure comparisonPreprocedure

148Local anesthetic will be administered before catheter insertion

The client may feel a flushed warmed feeling when the dye is injected and a desire to cough

PROCEDURE149Monitor vital signs and cardiac rhythm at least every 30 minutes for 2 hours initiallyAssess for chest pain, and notify the physicianMonitor peripheral pulses and the color, warmth and sensation of the extremity distal to insertion site at least every 30 minutes for 2 hours initiallyNotify the physician if the client complains of numbness and tingling, if extremities becomes cool, pale or cyanotic or loss of peripheral pulsesPostprocedure

150Monitor the pressure dressing for bleeding or hematoma formationApply a sandbag or compression device to the insertion site to provide additional pressure Keep the extremity extended for 4-6 hoursIf the antecubital vessel was used, immobilized the arm with an armboardEncourage fluid intake to promote renal excretion of the dyePostprocedure

151Coronary angiographyCoronary angiography is a procedure that uses a special dye (contrast material) and x-rays to see how blood flows through the arteries in the heart.Coronary angiography is often done along with cardiac catheterization.Once the catheter is in place, dye (contrast material) is injected into the catheter. X-ray images are taken to see how the dye moves through the artery. The dye helps highlight any blockages in blood flow.The procedure may last 30 to 60 minutes.

Nursing responsibilitiesSAME WITH CARDIAC CATHETERIZATION

Bone marrow aspirationBone marrow aspiration is the removal of a small amount of this tissue in liquid form for examination.

Purpose of Bone Marrow Aspiration and Biopsy:To diagnose thrombocytopenia, leukemia, granulomas, anemias, and primary and metastatic tumors.To determine the causes of infection.To help stage disease such as with Hodgins disease.To evaluate chemotherapy.To monitor myelosuppression.Bone marrow is the soft tissue inside bones that helps form blood cells. It is found in the hollow part of most bones. 155Nursing InterventionsWhile the marrow slides are being prepared, apply pressure to the biopsy site until bleeding stops.Clean the biopsy site and apply a sterile dressing.Monitor the patients vital signs and the biopsy site for signs and symptoms of infection.ComplicationsHemorrhage and infectionPuncture of the mediastinum (sternum)PrecautionsKnow that bone marrow biopsy is contraindicated in the patient with a severe bleeding disorder.Send the tissue specimen or slide to the laboratory immediately.Hemodynamic monitoringIs the pressure within the superior vena cava and reflects the pressure under which blood is returned to the superior vena cava and right atriumNormal CVP pressure is 3-8 mmHgCENTRAL VENOUS PRESSURE

160CVP represents the filling pressure of the right ventricle and it indicates the ability of the right side of the heart to manage a fluid load. Hence, essentially speaking, central venous pressure and right atrial pressure are just the same.

Importance of CVP MonitoringMeasuring CVP in patients is one of the most important assessments to determine cardiovascular function due to the following reasons:The change in CVP correlated with the patients clinical status is a useful indication of adequacy of venous blood volume and alterations of cardiovascular function.CVP reflects the pumping ability of the right atrium and ventricle.

CVP MonitoringWhen measuring CVP it is very important that the zero mark on the manometer is placed at a standard reference point which is called the phlebostatic axis.

ABNORMAL RESULT:Elevated measurement indicates an increased in blood volume as a result of sodium and water retention, excess IV fluids or renal failure

Pulmonary wedge pressure (PWP) is both a diagnostic and therapeutic medical tool for taking measurements, using a wedged balloon in a pulmonary catheter and inflated within a pulmonary artery. Upon inflation, the balloon can measure left ventricular end diastolic pressure. Normal value : 215 mmHg

ASSIGNMENT!!!Describe the following diagnostic procedures and laboratory studies. (Definition, procedure, normal value, significance of abnormal values, nursing responsibilities pre,during and post procedure) Intraarterial BP monitoringC-Reactive ProteinBrain (B-type) Natriuretic PeptideC-reactive ProteinHomocysteineESR, ASO-TiterTorniquet Test

ANALYSIS/ NURSING DIAGNOSIS:1.Decreased Cardiac Output as evidenced by increasedHeart rate, fatigue, SOB, decreased urine output,2.Impaired mental processing, decreasing LOC3.Activity Intolerance as evidenced by weakness, fatigue, vital signs changes4.Fatigue as evidenced by difficulty completing usual daily activities, frequent desire to rest 5.Risk for peripheral neurovascular dysfunction as evidenced by changes in color, temperature, sensation of extremities

6.Impaired tissue integrity (Nutrional Metabolic)7.Ineffective Breathing Patterns8.Fluid Volume Excess9.Nutrition, Altered, less than body requirement10.Growth and development, altered11.Family Process, Altered12.Pain13.Activity IntoleranceANALYSIS/ NURSING DIAGNOSIS:TREATMENT MODALITIES170Definition of cardiac pacingIt is an electric device that delivers direct electrical stimulation to stimulate the myocardium to depolarize ,initiating a mechanical contraction.171Clinical IndicationSymptomatic bradycardiaSymptomatic heart block2nd degree heart block 3rd or complete heart blockBifasicular or transfasicular bundle branch blocks.Prophylaxis

172Pacemaker DesignPulse generatorleads173Pacemaker DesignPulse generatorIn permanent pacemaker is encapsulated in a metal can ,to protect the generator from electromagnetic interference

174Pacemaker DesignPulse generatorTemporary pacing system generator is externally contained in a small box

175Pacemaker DesignPulse generatorTranscutanus external pacing system house the generator in a piece of equipment similar to portable ECG monitor.

176Pacemaker DesignPacemaker leadSingle chamber (unipolar) pacemakerLead placed in atrium or ventricle Produce large spike on the ECGSensing and pacing in the chamber where the lead is locatedMore likely to be affected by electromechanically interference177Single chamber (unipolar

2008/F.ABUDAYAH178

179Pacemaker DesignDual-chamber (bipolar) pacemakerOne Lead located in the atrium and one in the ventricleSensing and pacing in both chambers mimicking the normal heart function Produce in visible spic in the ECGLess affected by electromechanical interference.

2008/F.ABUDAYAH180Dual-chamber (bipolar) pacemaker

2008/F.ABUDAYAH181

182Pacemaker functionPacing functionSensing functionCapture function183Pacing functionAtrial pacing: stimulation of RT atrium produce spike on ECG preceding P wave

184Pacing functionVentricle pacing :stimulation of RT or LT ventricle produce a spike on ECG preceding QRS complex.

185Pacing functionAVpacing:direct stimulation of RT atrium and either ventricles mimic normal heart conduction

186Sensing functionSensing :Ability of the cardiac pace maker to see intrinsic cardiac activity when it occurs.187Sensing functionDemand: pacing stimulation delivered only if the heart rate falls below the preset limit.Fixed: no ability to sense. constantly delivers the preset stimulus at preset rate.188Capture function

Capture: Ability of the pacemaker to generate a response from the heart (contraction) after electrical stimulation.189Pacing typesPermanentTemporarybiventricular190Types of pacingPermanent pacemakerUsed to treat chronic heart condition Surgically placed transvenuosly under local anesthesiaPulse generator placed in a pocket subcutaneously ,can be adjusted externally

2008/F.ABUDAYAH191Permanent pacemaker

192

Types of pacing

Temporary pacemakerPlaced during emergenciesIndicated for pts high degree heart block or unstable bradycardiaCan be placed transvenosly, epicardially,transcutanusly or transthorasicly193

Biventricular pacemakerUsed in severe heart failureUtilize three leads, in right atrium, right ventricle and left ventricle to coordinate ventricular coordination and improve cardiac out putTypes of pacing

194Nursing interventionMaintain adequate cardiac outputRecord information after insertion pacemaker model ,mode, program setting,pts rhythm Attach ECG for continues monitoringAnalyze rhythm strips as per protocolMonitor vital signs Monitor urine outputObserve for dysrhythmia195

Nursing interventionAvoid injuryObtain chest x-ray to check lead wire position

Monitor for sign and symptom of hemothoraxMonitor for sign and symptom of pneumothoraxEvaluate evidence for bleeding

196Nursing interventionMonitor for evidence of lead migration and perforation of heartObserve for muscle twitching and hiccups Evaluate chest painAuscultate foe friction rubObserve for signs of cardiac tamponade

197Nursing interventionProvide electrically safe environmentProtect exposed parts of electrode leads with rubber Wear rubber gloves when touching a temporary pacing lead

198Nursing interventionBe aware of hazards in the facility that can interfere pacemaker and cause failure Avoid use of electrical razorAvoid direct placement of defibrillator paddles over the generator, should be placed 4-5 inches away.Pts with permanent pacemaker should never exposed to MRI because it may alter and erase the program memory.Caution must be used if pt will receive radiation therapy. 199Nursing interventionPrevent accidental pacemaker malfunctionsUse external plastic covering over external generator all timesSecure temporary pace maker over pts chest or wrist never hang it over iv pole200Nursing interventionPlace a sign over pt's bed alerting personnel to the presence of pacemaker.

201Nursing interventionPreventing infectionTake temp every 4hrs Observe for sign and symptoms of infectionClean incision site with sterile techniqueMonitor vein which pacing placed in for phlipaitis Administer antibiotic as ordered.202Patient educationAnatomy and physiology of the heartPacemaker functionActivitySpecific instruction include Not to lift items over 1.4kg or perform difficult arm maneuver.Avoid excessive stretching or bending excessive.Avoid contact sport,tennis,gulfing until advised by doctor.Sexual activity can be resumed when desired 203

Patient educationPacemaker failureTeach pt to check own pulse at least weekly for 1 minReport slowing on the pulse less or greater than the setting rate Report sign and symptom as palpitation ,fatigue ,dizziness ,prolonged hiccups Wear identification bracelet and carry a pacemaker identification cared.204Patient educationElectromagnetic interferenceCaution pt that EMI could interfere with pacemaker function.Explain that high energy radar, TV and radio transmetters,MRI,large motors may affect the pacemaker function.Teach pt to move 4-6 m away from source and check pulse. it should return to normal.

2008/F.ABUDAYAH205Patient education

Most pacemaker equipped with internal filters to prevent interaction with cell phone. Tell pt that antitheft devices and airport security alarms may affect pacemaker and trigger security alarm.Household and kitchen appliance will not affect pacemaker.

206Patient educationCare of pacemaker site.Wear loose-fitting clothes around pacemakerWatch sign and symptom of infectionKeep incision site clean and dry. not to scrub site Advise well balanced diet.

DEFIBRILLATION AND CARDIOVERSION

DEFINITIONThe therapeutic use of controlled electric current over a brief period of time.

DEFINITIONDefibrillation is the non-synchronized delivery of energy during any phase of the cardiac cycle. Cardioversion is the delivery of energy that is synchronized to the large R waves or QRS complex.

ELECTRICAL ACTIVITY OF HEART AND ECGGOALS OF CARDIOVERSION & DEFIBRILLATION

To disrupt the abnormal electrical circuits in the heart.To restore a normal heart beat.

CARDIOVERSIONINDICATIONS CONTRAINDICATIONSDysrhythmias due to enhanced automaticity (digitalis toxicity and catecholamine-induced arrhythmia)Multifocal atrial tachycardia

For dysrhythmias due to enhanced automaticity such as in digitalis toxicity and catecholamine-induced arrhythmia, a homogeneous depolarization state already exists. Therefore, cardioversion is not only ineffective but is also associated with a higher incidence of postshock ventricular tachycardia/ventricular fibrillation214DEFIBRILLATION

INDICATIONS CONTRAINDICATIONSAwake, responsive patients

Any arrhythmias witha pulse

TYPES OF DEFIBRILLATOR ELECTRODES Spoon shapedPaddle typePad type

SIZE OF PADDLESAdult size (10-13cm diameter)Pediatric size ( 4.5 cm diameter) for patient weight < 10 kg.Children > 10 kg 8 cm.Contd

SIZE OF PADDLESSmall paddles concentrate current, burns heart.Large paddles reduces current density. In pediatric patient ensure 3 cm distance between pads.

PADDLE PLACEMENTANTEROLATERALANTEROPOSTERIOR

PROCEDURE EQUIPMENTSDefibrillators with paddle or adhesive patchConductive gelCrash Cart with emergency drugsSedativesIntubation setSuction apparatus & catheters The use of hand-held paddle electrodes may be more effective than self-adhesive patch electrodes. The success rates are slightly higher for patients assigned to paddled electrodes because these hand-held electrodes improve electrode-to-skin contact and reduce the transthoracic impedance223PREREQUISITES FOR CARDIOVERSIONExplain the procedureObtain Informed consent Maintain NPO for 4-6 hours prior to elective cardioversionDigitalis is usually discontinued 24-36 hours prior cardioversionContdPREREQUISITES FOR CARDIOVERSIONCheck defibrillator prior to useCrash cart should be ready Obtain 12 lead ECGCheck serum K+ levelRemove dentures/ jewelleriesContdits presence may result in an increased risk of cardioversion induced arrhythmias.225PREREQUISITES FOR CARDIOVERSIONEmpty bladderEnsure a patent IV cannulaAnaesthetic agents and oxygen to maintain airway with induced unconsciousness.

PROCEDURE

POST PROCEDURE CAREMonitor the patient closelyEnsure patent airway.Check and record vitalsObtain 12 lead ECGRecord joules administered, number of shocks, result of defibrillation/cardioversionRecord any pre-medications givenContd

POST PROCEDURE CARERecord condition of skinProvide continuous O2Administer antiarrhythmics as per orderOral fluids can be started after 2 hrsCare of defibrillator

COMPLICATIONS Arrhythmias (premature beats) Ventricular Fibrillation Thromboembolization Myocardial necrosis Pulmonary edema Skin burns

resulting from high amounts of electrical energy, digitalis toxicity, severe heart disease or improper synchronization of the shock with the R wave.Thromboembolization is associated with cardioversion in 1-3% of patients, especially in patients with atrial fibrillation who have not been anticoagulated prior to cardioversion.Myocardial necrosis can result from high-energy shocks. ST segment elevation can be seen immediately and usually lasts for 1-2 minutes. ST segment elevation that lasts longer than 2 minutes usually indicates myocardial injury unrelated to the shock.Pulmonary edemais a rare complication of cardioversion and is probably due to left ventricular dysfunction or transient left atrial standstill.231

PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA)

PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA)

DESCRIPTIONOne or more arteries are dilated with a balloon catheter to open the vessel lumen and improve arterial blood flowThe client can experience reocclusion after the procedure, thus the procedure may need to be repeated PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA)

DESCRIPTIONComplications can include arterial dissection or rupture, immobilization of plaque fragments, spasm, and acute myocardial infarction (MI)Firm commitment is needed on the clients part to stop smoking, lose weight, alter exercise pattern, and stop any behaviors that lead to progression of artery occlusion NORMAL ARTERY AND ATHEROSCLEROSIS

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. SaundersPERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA)

From Mosbys Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA)

PREPROCEDURE Maintain NPO status after midnightPrepare the groin area with antiseptic soap and shave per institutional procedure and as prescribedAssess baseline VS and peripheral pulses PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA)

POSTPROCEDURE Monitor VS closelyAssess distal pulses in both extremitiesMaintain bed rest as prescribed, keeping the limb straight for 6 to 8 hoursAdminister anticoagulants and antiplatelets as prescribed to prevent thrombus formation PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA)

POSTPROCEDURE Monitor IV nitroglycerin that may be prescribed to prevent coronary artery spasmInstruct the client in the administration of nitrates, calcium channel blockers, antiplatelet agents, and anticoagulants as prescribedInstruct the client to take daily aspirin permanently if prescribedAssist the client with planning lifestyle modifications CORONARY ARTERY STENTS

DESCRIPTIONUsed instead of PTCA to eliminate the risk of acute coronary vessel closure and to improve long-term patency of the vesselA balloon catheter bearing the stent is inserted into the coronary artery and positioned at the site of occlusionWhen placed in the coronary artery, the stent reopens the blocked artery CORONARY ARTERY STENT

From Monahan FD, Neighbers M: Medical-surgical nursing: foundations for clinical practice, ed. 2, Philadelphia, 1998, W.B. Saunders. CORONARY ARTERY STENTS

POSTPROCEDURE Acute thrombosis is a major concern following the procedure, and the client is placed on antiplatelet and anticoagulation therapy for several months following the procedureMonitor for complications of the procedure, such as stent migration or occlusion, coronary artery dissection, and bleeding due to anticoagulation ATHERECTOMY

DESCRIPTIONRemoves plaque from an artery by the use of a cutting chamber on the inserted catheter or a rotating blade that pulverizes the plaqueUsed to improve blood flow to ischemic limbs in individuals with peripheral arterial diseasePOSTPROCEDURE Monitor for complications of perforation, embolus, and reocclusion ATHERECTOMY

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3, St. Louis: Mosby. CORONARY ARTERY BYPASS GRAFT (CABG)

DESCRIPTIONThe occluded coronary arteries are bypassed with the clients own venous or arterial blood vesselsThe saphenous vein, radial artery, or internal mammary artery is used to bypass lesions in the coronary arteriesPerformed when the client does not respond to medical management of coronary artery disease (CAD) or when disease progression is evident CORONARY ARTERY BYPASS GRAFT (CABG)

From Lewis SM, Heitkemper M, Dirksen S: Medical-Surgical Nursing: Assessment and Management of Clinical Problems (5th ed), St. Louis, 2000, Mosby. CORONARY ARTERY BYPASS GRAFT (CABG)PREOPERATIVE Familiarize the client and family with the cardiac surgical critical care unitInstruct the client how to splint the chest incision, cough and deep breathe, and perform arm and leg exercisesInstruct the client to inform the nurse of any postoperative pain, as pain medication will be available CORONARY ARTERY BYPASS GRAFT (CABG)PREOPERATIVE Infoincision(s), one or two chest tubes, a Foley catheter, and several IV fluid cathetersInform the rm the client to expect a sternal incision, possible arm or leg client that an endotracheal (ET) tube will be in place and connected to a ventilator for 6 to 24 hoursAdvise the client to breathe with the ventilator and not fight it CORONARY ARTERY BYPASS GRAFT (CABG)PREOPERATIVE Inform the family that the client will not be able to talk while the ET tube is in placeNote that prescribed medications are to be discontinued preoperatively (diuretics 2 to 3 days prior to surgery, digitalis 12 hours prior to surgery, and aspirin and anticoagulants 1 week prior to surgery) CORONARY ARTERY BYPASS GRAFT (CABG)PREOPERATIVE Administer medications as prescribed, which may include potassium chloride, antihypertensives, antidysrhythmics, and antibioticsEncourage the client and family to discuss anxieties and fears related to surgery Progression with activities at home Limit pushing or pulling activities for 6 weeks following dischargeIncisional care and to record signs of redness, swelling, or drainageSternotomy incision heals in about 6 to 8 weeksAvoid crossing legs, wear elastic hose as prescribed until edema subsides, and elevate surgical limb when sitting in a chairHOME CARE INSTRUCTIONS FOLLOWING CARDIAC SURGERYHOME CARE INSTRUCTIONS FOLLOWING CARDIAC SURGERYUse of prescribed medicationsDietary measures including the avoidance of saturated fats and cholesterol and the use of salt Sexual intercourse can be resumed on the advice of the physician after exercise tolerance is assessed; if the client can walk one block or climb two flights of stairs without symptoms, they can safely resume sexual activity END