Cardiovascular Disorders

Judith Maely Kong-Tarrazona, US-RN

Nursing History

Nurse has three goals when obtaining health history:

Identify present and potential health problems. Identify possible familial and lifestyle risk factors. Involve the client in planning long-term health care.

Manifestations of Heart Disease

Dyspnea laboured or difficult breathing

Types:

Exertional Orthopnea shortness of breath when lying down Paroxysmal nocturnal dyspnea sudden dyspnea at night while lying down Cheyne-Stokes periodic breathing characterized by gradual increase in depth of respiration followed by a decrease in respiration resulting in apnea

Chest Pain
Characteristic Location Examples Substernal, precordial, jaw, back, localized or diffuse.

Character/ Quality Pressure; tightness; crushing, burning, or aching quality; heaviness; dullness; heartburn or indigestion

Chest Pain
Characteristic Timing: onset, duration and frequency Examples Onset: Sudden or gradual? Duration: How many minutes does the pain last Frequency: continuous or periodic

Chest Pain
Characteristic Examples Setting/precipitating Awake, at rest, sleep factors interrupted? With activity? With eating, exertion, exercise, elimination, emotional upset?

Chest Pain
Characteristic
Intensity/Severity

Examples
Can range from 0 (which is no pain) to 10 (which is worst pain
ever felt)

Aggravating factors and Relieving factors

Activity, breathing, temperature Medication (nitroglycerin, antacid), rest; there may be no

relieving factors

Chest Pain
Characteristic
Associated symptoms

Examples
Fatigue, shortness of breath, palpitation, nausea and vomiting, sweating, anxiety, light-headedness or dizziness

Edema
abnormal accumulation of serous fluid in the connective tissues Causes:

CHF, Na retention, liver disease, hypoproteinemia, venous or lymphatic obstruction

Types:

ascites excessive fluid in peritoneal cavity hydrothorax excessive fluid in pleural cavity anasarca gross generalized edema

Edema
Edema Rating: +0 = non pitting +1 = 0 pitting (mild) +2 = pitting (moderate) +3 = 1 pitting (severe) +4 = greater than 1 pitting (severe)

Palpitation

a rapid, forceful or irregular heartbeat felt by the patient

Hemoptysis

is coughing up of blood Small quantities of dark-clotted blood indicates mitral stenosis Mixture of blood and pus indicates pulmonary suppuration Pink, frothy Sputum in acute pulmonary edema Blood-streaked Sputum in acute pulmonary congestion Frank hemoptysis due to lung pathology

Other Manifestations of Heart Disease

Fatigue Syncope and Fainting may be caused by anoxemia or reduced cardiac output resulting to inadequate circulation Cyanosis bluish discoloration of the skin and mucus membranes Abdominal pain or discomfort Clubbing of fingers angle of the nail is 1800 due to chronic hypoxia Jaundice yellowish discoloration of the skin and sclera

Physical Assessment of the Heart

Inspection and Palpation

Aortic area 2nd ICS to the right of the sternum Pulmonic Area 2nd ICS to the left of the sternum

Inspection and Palpation

Right Ventricular Area a circle around the 5th cartilage to the patients left of MSL (Midsternal Line)

Inspection and Palpation

Apical or Left Ventricular Area 5th ICS at MCL (Midclavicular line). Observe for cardiac movement at the PMI located at MCL at the 5th ICS. Thrills are vibration that occur as blood flow through a narrow or damaged valves

Percussion

Cardiac Area of Dullness (CAD)

Auscultation: Heart Sounds

S1 first heart sound due to closure of atrioventricular valves loudest at the apex S2 second heart sound due to closure of semilunar valves loudest at the base

Auscultation: Heart Sounds

S3 ventricular gallop 3rd heart sound which is normal in children and young adult S4 atrial gallop 4th heart sound which is normal in children and young adult; in adults, it is associated with systemic or pulmonary hypertension, MI, and other cardiac diseases

Auscultation: Heart Rate

Normal 60-100 beats per minute (BPM) Bradycardia =<60 bpm Tachycardia => 100 bpm

Auscultation
Murmurs sounds produced by vibrations within the heat and great vessels caused by turbulence of flow Rubs sounds produced by the interfacing of parietal and visceral surfaces of the pericardium

Auscultatory Areas

Physical Assessment of Blood Vessels

Inspection
Color inadequate circulation may produce pallor, rubor, cyanosis. Cyanosis is best visualized with good lighting. Vascular nail beds offers best visualization. Circulation of extremities

Note for the following

Hair growth absence means inadequate circulation Clubbing results from long standing hypoxia Capillary refill prolong filling time is indicative of inadequate circulation

Palpation
Edema assess over a bony prominence such as the medial malleolus, anterior tibia, sacrum. Press for 5 seconds and measure for pitting Pulse carotid, dorsalis pedis, poplitial, posterial tibial

Diagnostic Assessment
Non-invasive Procedures

Electrocardiography
is a graphic recording of electrical activity of the heart Resting electrocardiogram (ECG) presents a single recorded picture of the electrical activity of the heart secure electrodes to appropriate locations on the chest and extremities instruct the client to remain still during the test reassure client that he or she will not receive any electrical shock or impulses

Holter Monitoring

continuous ambulatory ECG monitoring over time (usual 24 hours with small, timed, portable ECG recording devices secure electrodes to appropriate locations on the chest instruct client to continue normal activity instruct client to maintain a log of activities and any symptoms

Stress test

continuous multilead ECG monitoring during controlled and supervised exercise, usually on treadmill

Stress Test
Client preparation obtain written consent explain procedure instruct client to eat a light meal 1 to 2 hours before the exam no caffeine, alcohol, smoking wear comfortable clothing and rubbersoled walking shoes

Stress Test
Nursing care during procedure secure electrodes to appropriate locations on chest obtain baseline BP and ECG tracing instruct client to exercise as instructed instruct client to report any pain, weakness, shortness of breath, or other symptoms immediately monitor BP and ECG continuously record at frequent intervals and with any symptoms or changes in vital signs, ST segments, or cardiac rhythm.

Stress Test
Post procedure nursing care continue to monitor ECG and NP until client returns completely to baseline and is symptom-free. once stable, patients may resume their usual activity.

Echocardioagraphy

is an ultrasound of the heart to evaluate structure and function of the heart chambers and valves

Echocardioagraphy
Client preparation instruct client to remain still during the test secure electrodes for simultaneous ECG tracing explain that there will be no pain or electrical shocks, however, the lubricant placed on skin will be cool Post-procedure: cleanse the lubricant from the clients chest wall

Phonocardiography
is a graphic recording of heart sounds with simultaneous ECG Client preparation instruct client to remain quiet and still during test secure electrodes for simultaneous ECG tracing explain that there will be no pain or electrical shocks

Diagnostic Tests
Invasive Procedures

Coronary Angiography/Arteriography

is an invasive procedure during which the physician injects dye into coronary arteries and immediately takes a series of x-ray films to assess the structure of the arteries.

Coronary Angiography/Arteriography
obtain written consent explain procedure assess client for history of allergies to dye or to shellfish initiate IV site with fluids as ordered

Cardiac Catheterization

is the insertion of a catheter into the heart and surrounding vessels to obtain diagnostic information about the structure and function f the heart. It can be performed on the right or left side of the heart

Cardiac Catheterization

Cardiac Catheterization
client on NPO, usually for 8-12 hours before procedure Explain to the client that Procedure involves lying on a hard table for less than two hours Mild sedative will be given intravenously Occasional pounding sensation (palpitation) may be felt particularly when catheter tip touches the myocardium.

Cardiac Catheterization
Client may be asked to cough or breathe deeply, especially after injection of contrast agent. coughing may help to disrupt a dysrhythmia and to clear the contrast agent from the arteries; breathing deeply helps lower the diaphragm for better visualization of heart structures. Injection of contrast agent may procedure a flushed feeling throughout the body

Cardiac Catheterization
Post-procedure Nursing Care observe catheter access site for bleeding or hematoma formation assess the peripheral pulses, temperature and color in the affected extremity every 15 min, for 1 hour, and then every 1 to 2 hours until pulses are stable encourage fluids to flush out dye orthostatic hypotension may occur when getting out of bed the first time.

Radionuclide Tests
are safe methods of evaluation left ventricular muscle function and coronary artery blood distribution can procedure some of the same information as radiographic angiography with less risk to client

Radionuclide Tests
Client preparation obtain written consent if required explain procedure instruct client that fasting may be required for a short period before the exam contrast material will be injected through a venipuncture it will be necessary to alternately change position and remain still during the exam there is an associated pain or discomfort

Radionuclide Tests

Nursing care during procedure none; procedure is performed in nuclear medicine Post-procedure nursing care encourage client to drink fluids to facilitate the excretion of the contrast material assess venipuncture site for bleeding or hematoma if stress testing was performed, assess clients BP and pulse at frequent intervals and maintain continuous ECG monitoring as indicated

Radionuclide Tests
MUGA (gated pool imaging or multi-gated acquisition) scan Thallium imaging used to assess myocardial ischemia (decreased supply of oxygenated blood) during stress testing PET (Positron Emission Tomography) Scan evaluates cardiac metabolism and assesses tissue perfusion

Radionuclide Tests

Magnetic Resonance Imaging (MRI) uses strong magnetic field to examine both physiologic and anatomic properties of the heart. screen out patient to determine whether the patient has pacemaker, metal plates, prosthetic joints, or other metallic implants; these can be dislodged if exposed to MRI explain to the client to expect intermittent clanking or thumping sound from the magnetic coils that can be annoying to the patient (offer headset to listen to the music). instruct the client to remain still and not move. Nursing Alert no metal can be in the MRI room because metal objects can become dangerous

Bone Marrow examination

Sites for bone marrow aspiration: Sternum iliac crest (most common) Tibia Most common site for bone marrow biopsy posterosuperior iliac spine; the sternum also is used. During the withdrawal of aspirate, the client will experience sharp pain often described as a burning pain

Bone Marrow examination

After the needle is removed, a pressure dressing is applied over the puncture site, where only minimal bleeding should occur if the patient has thrombocytopenia, pressure is applied for 3 to 5 minutes Most clients experience little, if any, pain or discomfort after the procedure; some persons will complain of tenderness and ache at the aspiration site for a few days. Bone Marrow Aspiration this is used to determine the presence and size of RBC, WBC, and megakaryocytes as they develop in the bone marrow

Diagnostic Procedures
Blood Studies

CBC

indication of the type and number of formed elements in the blood

CBC
Laboratory Test Red blood cell count Men Women Normal Value 4.2-5.4 million/mm3 3.6-5.0 million/mm3

Reticulocytes
Hemoglobin (Hgb) Men Women Hematocrit Men Women

1.0-1.5% of total RBC

14-16.5 g/dL 12-15 g/dL 40-50% 37-47%

CBC
Mean Corpuscular Volume 85-100 fL/cell (MCV)
Mean corpuscular 31-35 g/dL haemoglobin concentration ( MCHC) Mean corpuscular 27-34pg/cell haemoglobin (MCH) Platelet count 150,000-400,000/mm3

Hemoglobin and Hematocrit

Hemoglobin measures the haemoglobin available n circulation, which is the gascarrying capacity of an erythrocyte Hematocrit the ratio of the BBC volume to the volume of whole blood

RBC indexes

MCV (mean corpuscular volume) estimates size of the RBC MCH (mean corpuscular haemoglobin) measures the content of HgB in RBCs from a single cell MCHC (mean corpuscular haemoglobin concentration) a more accurate measurement of the HgB as it measures the entire volume of RBCs

Serum ferritin, transferrin, and total iron-binding capacity (TIBC)

these tests are used to evaluate iron levels Ferritin measures the iron in plasma, which is also a direct reflection of total iron stores Transferrin is the major iron-transport protein

While blood cell count

Abnormal elevation of the WBC is referred to as leukocytosis Leukopenia is a decrease in the number of white blood cells Differential count refers to the breakdown of the different types of cells

While blood cell count

Laboratory Test WBC count Differential Neutrophils Eosinophils Bashophils Lymphocytes Monocytes Value 5,000-10,000/mm3
60-70% or 3,000-7,000/mm3 1-3% or 50-400/mm3 0.3-0.5% or 25-200/mm3 20-30% or 1,000-4,000/mm3 3-8% or 100-6--/mm3

Coagulation studies
Bleeding time normal range is 1 to 4 minutes used in evaluation of platelet function extended bleeding times are seen with thrombocytopenia and aspirin therapy

Coagulation studies
Prothrombin time (PT) is the rapidity of blood clotting normal range is 11 to 16 seconds; PT evaluates extrinsic coagulation pathway which include factors I, II, V, VII, ZX; INR is often currently used instead of PT because it is a standardized value (therapeutic range often varies from 2 to 3 depending on the condition)

Coagulation studies
Partial thromboplastin time (PTT) normal range is 60 to 70 seconds, which evaluates the intrinsic coagulation pathway or fibrin clot formation

Coagulation studies
Activated partial thromboplastin time (APTT) normal range is 30 to 45 seconds; is a modified PTT< preferred because it is quicker to perform used in heparin therapy and in the evaluation of haemophilia increased in anticoagulation therapy, liver disease, vitamin K deficiency, and disseminated intravascular coagulation (DIC)

Serum lipid profile

a measurement used to determine risk of developing atherosclerosis Total serum lipids normal value 400 to 800 mg/dL

Triglycerides lipids stored in fat tissue, readily available for energy production; normal serum value is generally accepted at 10 to 190 mg/dL (without elevated cholesterol, up to 250 mg/dL may be accepted)
Cholesterol the main lipid associated with atherosclerotic disease normal serum value generally accepted is <200 mg/dL in adults

Serum lipid profile

Lipoproteins proteins in the blood to transport cholesterol, triglycerides, and other fats
High-density lipoproteins (HDL) transport cholesterol, to liver for excretion HDL/total cholesterol ratio should be at least 1:5, 1:3 more ideal Low-density lipoproteins (LDL) transport cholesterol to peripheral tissues, associated with increased risk of coronary artery disease

Pre-procedure nursing care instruct client to fast for 12 to 13 hours before testing to ensure accurate results

Serum enzymes

increased in blood with heart damage; measurement of serum enzyme levels evaluates myocardial tissue infarction (injury to myocardium from decreased oxygenation) serial testing over time detects trend and determines peak time and extent of injury

Serum enzymes
Creatinine kinase (CK)

formerly known as creatine phosphokinase (CPK) elevation indicates muscle injury CK-MB

specific to myocardial muscle; rises within 6 hours of injury, peaks at 18 hours post-injury and returns to normal in 2 to 3 days is useful for early diagnosis of myocardial infarction

Serum enzymes
Lactic dehydrogenase (LDH)

is found in many body tissues cardiac origin is confirmed with analysis of isoenzymes (L1 is greater than L2; flipped from normal levels) elevation is detected within 24 to 72 hours after MI peaks in 3 to 4 days returns to normal around 2 weeks; is useful in delayed diagnosis of MI

Serum enzymes
Troponin onset is before CK-MB n MI peaks at 24 hours and returns to normal around 2 weeks provides early sensitivity, extended blood levels, and is more specific to cardiac injury for diagnosis of MI with an uncertain timeframe

Serum electrolytes level

Serum potassium

affected by renal function and may be decreased by diuretic agents that are used to treat heart failure decrease in potassium causes cardiac irritability and predisposes the client receiving digitalis preparation to digitalis toxicity and dysrhythmia increased potassium is manifested by myocardial depression and ventricular irritability. Both hypokalemia and hyperkalemia can lead to the ventricular irritability. Both hypokalemia and hyperkalemia can lead to the ventricular fibrillation or cardiac standstill

Serum electrolytes level

Calcium necessary for blood coagulability and neuromusclular activity hypocalcemia and hypercalcemia can cause dysrhythmia
Sodium reflects relative fluid balance hyponatermia indicates fluid excess; hypernatremia indicates fluid deficit

Serum electrolytes level

Serum glucose level many patients with cardiac disease also have diabetes mellitus Fasting blood sugar serum glucose level drawn in a fasting state Glycosylated haemoglobin reflects the blood glucose level over 2 to 3 months

Serum glucose level

Fasting blood sugar serum glucose level drawn in a fasting state Glycosylated haemoglobin reflects the blood glucose level over 2 to 3 months

Hemodynamics Monitoring

Evaluate cardiovascular system

Pressure, flow, resistance

Establish baseline values and evaluate trends

Determine presence and degree of dysfunction

Implement and guide interventions

Provides criteria for determination of CV efficacy

CVP (Central Venous Pressure)

reflects the pressure of the blood in the right atrium. engorgement is estimated by far the venous column can be observed as it rises from an imagined angle at the point of manubrium (angle of Louis). With normal physiologic condition, the jugular venous column rises no higher than 2-3 cm above the clavicle with the client in a sitting position at a 450 angle.

CVP is a measurement of:

Cardiac efficiency Blood volume Peripheral resistance

Right Ventricular Pressure

a catheter is passed from a cut-down in the antecubital, subclavian, jugular, or basilica vein to the right atrium and attached to a precalibrated manometer or transducer Normal CVP is 2 to 8 cm H2O or 2 to 4 mm Hg. Decrease indicates decreased circulating volume Increase indicates increased blood volume or right heart failure.

Right Ventricular Pressure

the patient should be flat on bed with zero point of the manometer at the same level of right atrium which corresponds to the mid-axillary line or approximately 5 cm below the sternum.

Right Ventricular Pressure

Fluctuations follow patients respiratory function:

fall on inspiration and rise on expiration due to changes in intrapulmonic pressure. Reading should be obtained at the highest point of fluctuation.

If the patient is using ventilator, its use should be discontinued during the reading of CVP Increase indicates fluid overload or congestive heart failure; decrease indicates low blood volume and more parenteral infusions needed.

Pulmonary Artery Pressure (PAP)

appropriate for critically ill clients requiring more accurate assessments of left heart pressures, including clients undergoing open heart surgery, clients in shock or with serious MIs. Pulmonary artery (Swan-Ganz) catheter has the tip in the pulmonary artery. Pressure measurement from this catheter is obtained after catheter tip is wedged in a pulmonary capillary, and is called the pulmonary capillary wedge pressure or PCWP; it is a good indicator of left ventricular end diastolic pressure (LVEDP). Allows calculation of actual cardiac output and other hemodynamic parameters at frequent intervals in critically ill clients

110-130 70-80 15-25 8-15 4-12

PAP

CVP
0-8

15-25
0-8

110-130

PCWP

4-12

Pulmonary Artery Pressure (PAP)

Client preparation

obtain consent according to policy insertion is under strict sterile technique, usually at the bedside explain to client that sterile drapes may cover the face (with an internal jugular or subclavian insertion site) assist to position client flat or slightly Trendelenburg as tolerated and instruct the client to remain still during the procedure

Pulmonary Artery Pressure (PAP)

Nursing care during insertion procedure assist physician in maintaining a sterile field administer medications as ordered monitor and document HR, BP, and ECG during procedure reassure client through procedure.

Pulmonary Artery Pressure (PAP)

Post-procedure nursing care monitor vital signs (VS) ECG at frequent intervals post-insertion maintain client on bed rest and avoid unnecessary movements follow policy to maintain patency and sterility of catheter.

Pulmonary Artery Pressure (PAP)

Nursing responsibilities in hemodynamic monitoring position the transducer at the level of the right atrium (phlebostatic axis) level the CVP or pulmonary artery catheter (Swan-Ganz) transducer to this point at regular intervals according to policy (usually each shift) and before each measurement maintain patency of catheter with a constant small amount of fluid delivered under pressure.

Intra-arterial Blood Pressure

Measurement of systolic, diastolic, and mean blood pressure by using an intraarterial catheter flushed with heparinised saline inserted usually in the radial artery. If the radial artery is used, it is necessary to verify the presence of ulnar artery flow by an Allens Test

PLANNING
Health Promotion

Cardiovascular Risk Factors

Non-Modifiable Age Gender Race Genetic/Family History

Cardiovascular Risk Factors

Modifiable Significant: Hypertension Hypercholesteriolemia Hyperlipidemia Hypertriglycedemia Smoking

Cardiovascular Risk Factors

Contributory Obesity Glucose intolerance Sedentary lifestyle Stress

Cardiovascular Risk Factors

Associated Alcohol abuse Caffeine Decreased lung vital capacity Gout

Risk Management

Age

atherosclerosis is a disease of middle age (40-50). Cardiovascular disease is greater in men until 65 when the incidence equalizes. higher estrogen levels of premenopausal women because there may be a relationship between increase in estrogen level to high density lipoproteins

Gender

Risk Management

Race IHD (Ischemic Heart Disease)

is higher in whites HPN is twice greater in blacks

Genetic history
family history appears to be a significant risk factor for predisposition to heart disease. For example, heart attack or stroke.

Risk Management

Race IHD (Ischemic Heart Disease)

is higher in whites HPN is twice greater in blacks

Genetic history
family history appears to be a significant risk factor for predisposition to heart disease. For example, heart attack or stroke.

Hyperlipidemia

refers to the increase in serum level with two of the plasma lipids, cholesterol and triglycerides in the blood. Lipid are mixed group of biochemical substances that may be manufactured by the body or derived from metabolism of ingested substances Cholesterol a fat-related compound and excessive amount deposited in blood vessels may be a factor causation of atherosclerosis. Example: egg yolk, organ meats such as liver and kidneys Triglycerides a fatty acid compound and consistently elevated levels of triglycerides may be conductive to premature arteriosclerosis.

Types of Hyperlipedemia

Primary hyperlipedimia caused by inborn error of lipid metabolism. Secondary hyperlipedemia related to such conditions as DM or hypothyroidism. For lipids to be used and transported by the body, they need to become soluble in blood by combining with protein to form macromolecules called lipoproteins. Lipoproteins are vehicle for fat mobilization and transport.

Classification of Lipoprotein
1. Chylomicrons removes cholesterol form the liver Composition: Protein (2%), Phospholipids (6%-9%), Cholesterol (2%), and Triglycerides (85-95%) Source: Dietary fat and exogenous lipid (foods that are high in fats) 2. Very low-density lipoprotein (VLDL) It carries triglycerides Transport triglyceride from the liver to periphery and serves as precursor to low-density lipoprotein Elevated triglycerides levels are less associated with coronary artery disease than Hypercholesterolemia

Classification of Lipoprotein
High VLDL concentration may increase the risk of premature atherosclerosis when associated with other factors such as diabetes, hypertension, and cigarette smoking Source: High dietary intake of carbohydrates such as bread and rice
Intermediate low-density lipoprotein (ILDL) it carries 60 to 70 percent of cholesterol and therefore more closely associated with Hypercholesterolemia

Classification of Lipoprotein
Low-density lipoprotein (LDL) transport cholesterol from the liver to the periphery derived mainly from catabolism of VLDL. contains more cholesterol than any of the other lipoproteins and has an affinity for arterial walls. Elevated LDL correlate most closely with an increased incidence of atherosclerosis. High-density lipoprotein (HDL) contain more protein by with and less lipid than any other lipoprotein. carry lipids away from arteries and to the liver for metabolism. Therefore, high serum LDL is desirable. Composition: Protein (35%-60%), Phospholipids (34%-44%), Cholesterol (20%-28%) and Triglycerides (14%) Source: Liver

Prevention

Lifetime diet, low in saturated fat to prevent hypercholesterolemia Triglycerides, the simple lipid, should be restricted in the diet Example: lard, butterfat, olive oil, coconut oil, and soybean oil Carbohydrate restricted to lower serum triglyceride levels by reducing serum prebetalipoprotein, a combination of lipid and protein that is produced from carbohydrate Diet low in cholesterol and saturated fat are advised to maintain a serum cholesterol below 140 mg/dL Low cholesterol diets

Antilipemic Drugs

lower the level of circulating blood lipid and may prevent further atheromatous formation Example: Clofibrate (Atromid-S); Cholestyramine (Cuemid)

Nursing Care: Eat salmon and tuna at least several times per week Increased intake of high-fiber food such as fruits, vegetables, cereal grain, and legumes (string beans) Administer medications with meals to reduce GI irritation Monitor serum cholesterol and triglyceride levels during therapy

Hypertension

is the increased blood pressure, a systolic BP greater than 140mmHg and diastolic pressure greater than 90 mmHg over a sustained period. known to be as a precursor of atherosclerosis, as yellow cheeselike fatty streaks containing cholesterol that develop into hardened plaques in the inner lining (intima) of major blood vessels and is associated with risk ischemic heart disease. Increased systemic blood pressure increases resistance to left ventricular ejection and there will be subsequently left ventricular hypertrophy and increased cardiac workload with ultimate heart failure.

an even greater risk factor for atherosclerosis in the presence of diabetes mellitus and cigarette smoking.

Prevention
Controlling sodium and calorie intake on the diet Formula of getting the total calorie intake for a day 1 kilo calorie (kCal) x body weight in kilogram (kG) x 24 hour Example: Weight: 52 kGs 1 kCal x body weight x 24 1 x 52 x 24 1240 kcal/day salt may be used lightly in cooking. No salty processed foods are used, such as pickles, olives, bacon, ham, and corn chips, or potato chips

Therapeutic Management
Diuretic drugs

used to increase urine output, which reduces hypervolemia, decreases the preload and aferload Example: Chlorothiazide (Diuril); furosemide (Lasix)

Nursing care: Monitor intake and output daily and record Weigh the client daily (same time, scale, and clothing) Administer drugs in the morning so that the maximal effect will occur during the waking hours Assess vital signs, especially pulse and blood pressure, during the course of therapy Instruct the client to change position slowly to prevent hypotension (decrease blood pressure) Evaluate the client response to the medication

Therapeutic Management
Antihypertensive drug
used to promote dilation of peripheral blood vessels, thus decreasing blood pressure and afterload. Example: methyldopa (aldomet); captopril (capoten), clonidine (catapress) Nursing care: Monitor blood pressure in standing and lying positions during the course of therapy. Instruct client to follow a low sodium diet

Smoking
1.

2.

3.

It contributes to the development and severity of coronary artery disease in three ways: The inhalation of smoke increases the blood carbon monoxide level reducing the oxygen carrying capacity of the blood and put added workload on the heart Nicotine is a vasoconstrictor and also triggers the release of cathecolamines that in turn have an effect on adrenergic nerve endings, causing an increased heart rate and blood pressure. Cigarette smoking increases platelet adhesion, leading to a higher probability of thrombus formation which results to decreased blood supply.

Smoking
Prevention: not to acquire the habit appropriate stress management strategies initiate smoking cessation programs to manage habit and totally eradicating it.

Sedentary Lifestyle

Inactivity may contribute to peripheral pooling and stress the cardiovascular system Prolonged inactivity of sitting or lying in one position particularly contributes to venous stasis and problems of venous circulation, such as varicosities and thrombophlebitis

Sedentary Lifestyle
Prevention

Engage in regular exercises, to improve cardiac efficiency, decrease heart rate and blood pressure, and increase cardiac output Encourage the client to include exercise as a lifelong health habit

Risk Management

Participate in regular exercise program such as aerobic activities fitness prescription program which includes exercise to promote strength flexibility and endurance Muscle strength weight lifting Flexibility stretching exercise Endurance high intensity exercises such as jogging, walking, bicycling or swimming

Sedentary Lifestyle
3 Components of Exercise Program: Warm up is used to increase cardiovascular and musculoskeletal efficiency and limber up muscle. It lasts 5 to 10minutes. Example: walking Workout improve cardiac conditions and designed to reach a specific target heart rate. The duration or intensity depends on the individual health and objective for exercise. Cool down allows slowing of the cardiovascular system, dissipation of heat and removal of lactic acid. It has a slow rate for 5 to 10 minutes.

Obesity

defined as 20% over the ideal weight % IBW = (Adult weight (kG) divided by DBW/IBW) x 100 BMI Actual weight divided by height in meter squared; BMI greater or equal to 27 is obesity

Obesity

Dietary and exercise habit to present obesity Instruct about diet restriction in sodium, sugar, and calories. It is essential for rearing healthy children of normal weight. To overweight client and particularly hypertensive clients, weight reduction can be instituted like meal planning and program of behaviour modification

Stress
a positive relationship exist between psychological stress and cardiovascular disease Management: Stress management: includes behaviour modification Incorporating exercise to ones life style Use of relaxation techniques Cognitive reframing or thorough stopping Temporary use of sedative or tranquilizers

Glucose intolerance

serum glucose levels greater than 120 mg/100 mL are at twice the risk for heart disease

Prevention Maintaining weight at normal level by using the Tanhauser method Formula: height in cm minus one hundred Take the 10% reminder and subtract answer from the remainder

Glucose intolerance
Example: height = 54 5 x 12 = 60 60 + 4 = 64 64 x 2.54 cm 162.56 cm 162.56 cm 100 = 63 cm 63 x 10% - 6.3 63 6.3 = 56.7 kG 57 kG x 2.2 lbs. 125.4 lbs

Glucose intolerance
Increased exercise Risk Management: Encourage the patient to exercise and follow a therapeutic plan for prevention Plan as to the prevention of hyperglycemia and glucosuria Pharmacological agent, insulin to lower serum glucose level

Alcohol Abuse

It is a vasodilator Enhance high density lipoprotein Continuous consumption of large amount of alcohol has recently been associated with cardiac toxicity Alcohol cardiomyopathy may decrease myocardial and precipitate heart failure or dysrhythmias Prolonged alcohol use cause structural changes in the myocardium and myocardial capillaries and sclerosis, fibrosis in the small arteries may lead to microinfarcts

Alcohol Abuse

Prevention Instruct the client about the danger of alcohol Risk Management Referred client to individual or group of counselling or to community withdrawal programs.

Caffeine
Excessive amount of caffeine cause cardiac dysrthymias, tachycardia, and extra systoles Prevention Instruct the client to limit intake of caffeine Example: coffee, tea, softdrinks, and chocolates

Environmental Risk

Contaminants in foods, air, water, and drugs have been linked to cardiovascular disease Minerals in the clients water may contribute to heart disease Side stream smoke from cigarette smoking, driving in traffic with carbon monoxide wastes, or working in tunnels in which carbon monoxide build-up is evident, may contribute to risk of cardiovascular disease Client experiencing chest pain in smoke-filled rooms; it is believed that the increased carboxyhemoglobin levels cause hypoxia and increase cardiac oxygen demand.

Environmental Risk
Prevention Client who live in areas with high sodium content in water supply may be advised to use distilled water or purified water Other risks Decreased lung vital capacity have a higher incidence of heart disease due to changes in oxygenation that increase cardiac workload Gout twice the risk for ischemic heart disease

Promotion of Circulation

Constricting clothing can impede arterial circulation and should not be worn Example: a round garter, girdles, panty girdle, and belt Avoid long period of pressure on the blood vessels, such as: Sitting with legs crossed at the knee obstructs circulation in the popliteal area Sitting with the thigh flexed because it can constrict femoral circulation Avoid standing for a long period of time, because this may produce strain on the valves as the attempt t overcome gravity

Promotion of Circulation

Encourage the client to wear support stocking when she must stand for a long period of time; the hose compress the muscles of the leg, which help overcome gravity The hose should be put before the person gets out of bed and pull on evenly from the toes to below the knee or to the groin Encourage the client to walk and flex their leg as much as possible to promote venous return by the pressure of the muscle on the vein The body shuld be kept warm which cause vasodilatation with clothing suitable for the weather Blanket should be used as needed at night to keep the person warm Alcoholic beverages may be ordered which produce peripheral vasodilatation to promote circulation Smoking must be avoided and not advised

Prevention of Infection
Syphilis is one disease that can cause permanent damage to the myocardium or cardiac valve and treatment is imperative Stapylococcus and Streptococcus organisms can enter the body through the oral route during dental procedures; prophylactic antibiotics may be given to individuals at risk for heart disease to prevent infections

Prevention of Infection

Streptococcal throat infections are thought to precede rheumatic fever and it should be evaluated by a physician and treated before further systemic damage Women should have adequate prenatal care and immunization against rubella to prevent congenital heart defects because German measles may cause damage during first trimester of pregnancy Prophylactic antibiotic may be given as prescribed Prenatal care an immunization for the pregnant mother

Role of Nutrition
Well-balanced diet and that which contain sufficient calorie is needed to meet the metabolic demand of an individual and because adequate nutrition is essential in promoting oxygen to the cells Small frequent meals are preferable Diet must contain sufficient vitamin and iron

Health Maintenance and Restoration

Cardiac Surgeries and Endovascular Interventions

Percutaneous transmural coronary angioplasty (PTCA)

purpose is to improve blood flow within a coronary artery by cracking the atheroma. Because of the anticoagulants used during the procedure, the site may have vice-type pressure device requiring a longer period of hourly site checks monitor closely for any changes in ECG or sings of chest pain (even minor changes may be indicators if ischemia) obtain a 12-lead ECG and notify physician of any complications. Post procedure care similar to catheterization.

Percutaneous transmural coronary angioplasty (PTCA)

Coronary artery bypass grafting (CABG)

Client preparation Instruct the client in routine preoperative teaching, including turning and deep breathing vigorous coughing is discouraged because it may increase intrathoracic pressure and cause instability in the sterna area incentive spirometry to prevent respiratory complications leg exercises to prevent emboli formation

Coronary artery bypass grafting (CABG)

Post-procedure Instruct that client may resume sexual activity when he or she can walk up two full flights of stairs without shortness of breath or chest pain client should be rested, not after a heavy meal or alcohol consumption Instruct client about symptoms to report to MD upon discharge including chest pain, shortness of breath, decrease in activity tolerance, fever, redness, swelling or drainage from surgical incisions

Coronary artery bypass grafting (CABG)

Post-procedure Instruct client that clinical depression occurs in about 20 percent of clients up to 6 months after cardiac surgery, and client should notify physician because antidepressant are very effective; include family in teaching and planning for discharge. Instruct the client that many patients have difficulties in cognitive functions after the procedure. Reassure client and family that the difficulty is temporary and will subside, usually 6-8 weeks

Coronary artery bypass grafting (CABG)

Coronary artery bypass grafting (CABG)

Valvular surgery repair and replacement procedure

Valvuloplasty reconstruction including repair or removal of calcification or vegetation Annuloplasty narrowing a dilated valve with a prosthetic ring or purse string sutures, or enlarging a stenosed valve with a balloon Repair is the preferred option, because of the lower incidence of post-surgical complications or mortality than valve replacement

Valvular surgery repair and replacement procedure

Client preparation and post-procedure nursing care include instruction about preventing infection including prophylactic antibiotic therapy prior to prevent bacteria from entering the bloodstream through the gums management of anticoagulation therapy if appropriate

Pacemakers
permanent pacemakers are inserted in the operating room to treat permanent cardiac conduction defects Client Preparation obtain consent instruct client that bed rest is required for 24 hours and activity will gradually be increased to prevent dislodging of the leads

Pacemakers
Post-procedure nursing care monitor ECG continuously to ensure that pacing beats are being captured and that intrinsic heartbeats are sensed monitor the pacemaker site for signs of bleeding or infection dressing should remain clean and dry with no temperature elevation, swelling, redness, or tenderness right arm and shoulder movements may be minimized immediately post-procedure to ensure that pacemaker wire remains in contact with ventricular wall.

Pacemakers

II

III

Electrode Placement

Electrodes that Sense Underlying Electrical Activity

Pacemaker Response to Sensation

Cardioverting Options

A= atrium

A= atrium

T= triggers*

P= pacing

V= ventricle

V= ventricle

I= inhibits**

S= shocking

D= dual (A+V)

D= dual (A+V)

D= dual (T+I)

D= dual (P+S)

O= none

O= none

O= none

O= none

II

III Description

Dual-lead pacemaker that paces and senses in atrium and ventricle

Same as DDD plus it speeds up or slows down atrial and ventricular rate in response to sensor output (such as body temperature, resp. rate, etc. as in exercise)

Single-lead pacemaker in the ventricle that is set at a fixed rate. Pacing activity is inhibited by a detected ventricular beat.

Common Cardiac Disorders

Coronary or Ischemic Heart Disease

Arteriosclerotic Heart Disease (ASHD)

a slowly progressive heart condition characterized by: Internal thickening and plaque formation within the coronary arteries due to the depression of fatty substances along the intima. Results in fibrosis, calcification and narrowing of coronary arteries A slow constriction of the blood supply to the myocardium, which can finally give rise to symptoms of angina. Most common form of coronary heart disease. Nursing care centers around prevention and treatment of the specific manifestation of particular disease process.

Angina Pectoris

a clinical entity describing the chest pain associated with transient myocardial ischemia

Types of Angina

Stable angina (classic) chest pain occurring intermittently over a long period of time with the same pattern of onset, duration and intensity of symptoms Unstable angina (progressive crescendo or preinfraction unpredictable and easily provoked by minimal or no stress, during sleep or even at total rest)

Types of Angina

Prinzmetals angina (variant angina) often occurs at rest, usually in response to spasm of a major coronary artery (e.g. histamine angiotensin prostaglandin and epinephrine)
Nocturnal angina occurs only at night but not necessarily when the person is in the recumbent position or during sleep Angina decubitus chest pain that occurs only while lying down and is usually relieved by standing or sitting.

Signs and symptoms of Angina

substernal or precordial pain radiating to left shoulder or pressure/heaviness/tightness/squeezing precipitated by exertion, emotion, and exposure to cold relieved by rest and use of nitroglycerine tablets. Pain is temporary lasting 3-5 minutes. Myocardial tissues are not permanently damaged

Cause: atherosclerosis is by far the most common cause Diagnosis:

Nitroglycerine test (0.4 or 1/150 gr. of nitroglycerine) shorten pain or increase tolerance to exercises

Nursing Goals

Increasing oxygen to the myocardium and relief of acute attacks Reducing the demand for oxygen Helping client prevent future episodes of angina

Increasing Oxygen Supply

Anti-platelet aggregation therapy

first line of pharmacological intervention in the treatment of angina Aspirin is the drug of choice Dipyridamole (Presantine)

Increasing Oxygen Supply

Nitrates: Rapid Acting

Nitroglycerine

is the drug of choice and acts to relieve the pain in about 3 minutes and has a duration of approximately 45 minutes by producing dilation of coronary blood vessels. Usual dose is 0.3 mg (1/200 gr.) taken sublingually; allow to dissolve completely; retain saliva before swallowing. Purchase a new supply every 6-9 months Clients will experience a burning sensation under his tongue and a full throbbing sensation in his head of the tablet have full potency.

Increasing Oxygen Supply

Nitrates: Rapid Acting

Nitroglycerine

Stored in a dark, airtight container because it is sensitive to heat, light, and moisture and decomposes rapidly. Supply is refrigerated and only a few tablets carried with the client. Repeat dosage every 5-10 minutes from 2 or 3 times. If no relief; see a physician. Not habit-forming. Taken prior to exercising; eating a large meal; stressful situation sexual intercourse Side effects: headache; dizziness, flushing Can be used prophylacticaly by taking the tablet 5-10 minutes before beginning the activity

Increasing Oxygen Supply

Nitrates: Rapid Acting

Nitrostat a stabilized form of nitroglycerine, Has uniform potency and can be carried without fear of decomposition. Amyl Nitrate given in form of pearls ampoules which are crushed and inhaled. Dose is 0.2 mg and must not be taken repeatedly because it produces syncope

Increasing Oxygen Supply

Nitrates: Long Acting

act to maintain coronary artery vasodilation, thereby promoting a greater flow of blood and oxygen to heart muscle.

Isosorbide dinitrate (Isordil, Sorbitrate)

maybe taken sublingually for acute attack or per Orem for their longacting action Side effects: headache; flushing; nausea and vomiting; hypertension; vertigo; syncope

Nitroglycerine ointment (Nitrol and Nitropaste)

is a 2% nitroglycerine topical ointment and provides vasodilation up to 36 hours. Is particularly useful for management of nocturnal angina if applied before sleep.

Increasing Oxygen Supply

Nitrates: Long Acting

Transdermal controlled Release Nitrates types: 1. Reservoir type in which the drug migrates to the absorption site through a rate-controlled permeable membrane e.g. Transderm-Nitro 2. Matrix type in which the drug is slowly dispersed through a polymeratrix to the skin absorption site e.g. Nitro-Dur; Nitro-Disc

Increasing Oxygen Supply

Nitrates: Long Acting

Intravenous Nitroglycerine (Nitrol IV; Nitrostat IV; Ntirobid IV, Tridil) has an immediate onset of action used in MI to increase the collateral blood flow to the ischemic area and reduce myocardial oxygen demand. Titrate the dose down at night and titrate up during the day.

Increasing Oxygen Supply

Beta-adrenergic blocking agents

act to decrease oxygen requirement by decreasing heart rate and redistributing blood flow to non-ischemic portion of the heart. Used if nitrates are not effective in managing pain. E.g. Propanolol (Inderal) 10-30 mg TID

Increasing Oxygen Supply

Beta-adrenergic blocking agents

Side Effects: Nausea and vomiting Diarrhea extreme fatigue broncho-constriction sexual difficulties heart failure Bradycardia heart block hypoglycaemia

Increasing Oxygen Supply

Beta-adrenergic blocking agents

Nursing Care caution client not to discontinue drug, since abrupt withdrawal may cause dysrhythmias, angina or MI from sudden increase in responsiveness to sympathetic stimuli

Increasing Oxygen Supply

Calcium-blocking agent
e.g. Nifedipine (Procardia), Verapamil (Calan, Isoptin), Diltiazem (Cardizem), Nicardipine (Cardene) Effects: Systemic vasodilation with decrease systemic vascular resistance (SVR) Decrease myocardial contractility Coronary vasodilatation

Increasing Oxygen Supply

Calcium-blocking agent

potentiate the action of Digoxin by increasing serum Digoxin levels during early part (first week) of therapy. Digoxin levels should be closely monitored upon institution of this therapy client should be taught the sign and symptoms of Digoxin toxicity

Increasing Oxygen Supply

Whisky or brandy
(30-60 mL) acts to promote dilations of blood vessels and general relaxation

Reducing the demand for oxygen

Limiting activities Moderate amount of exercise to increase myocardial strength Sedatives, tranquilizers, and anti-depressants Radioactive Iodine (131I) occasionally given to clients who have been refractory to treatment for 3 months in order to decrease activity of the thyroid gland which slows patients metabolism and lower workload of the heart.

prevent future episodes of angina

Diet low in calorie and saturated fats to curtail obesity 5 to 6 small meals instead of 3 main meals Inform client that all forms of tobacco are hazardous to his health Stress produces epinephrine leading to vasoconstriction Regular program of daily exercise

Myocardial Infarction

occlusion of one of the coronary artery or its branches by a clot or sclerotic condition.

Myocardial Infarction

Incidence: men in middle life are often the persons who have MI. They usually have some degree of atherosclerosis and may or may not have hypertension

Myocardial Infarction
Signs and Symptoms steady, constrictive, sub-sternal chest pain severe and not relieve by rest symptoms of shock elevation of temperature nausea and vomiting

Myocardial Infarction
ECG changes: ST elevation reflects ischemic area. ST elevation and T-wave inversion a recent MI Q-wave necrosis formation

Myocardial Infarction
Laboratory Test: elevated CK with MB isoenzymes > 5% (early diagnosis) elevated troponin (early to late diagnosis) elevated LDH with flipped isoenzymes (late diagnosis)

Diagnostics
CPK-MB 4-8o 12-24o Myoglobin 1-3o 4-12o Troponin I or T 3-4o 4-24o

3-4 days 12o 1-3 wks

SGOT (AST), ESR, Troponin levels LDH, LDH1, LDH2

Treatment and Nursing Care

Relief of pain Demerol or morphine may be ordered. Demerol is less frequently given because it is more likely to induce vomiting and to initiate vaso-vagal response. IV NTG may reduce pain and decrease preload and afterload while increasing myocardial oxygen supply. Antidysrhythmic drugs Positive inotropic drugs increase hearts contractility

Caution: this drug increases the hearts demand for oxygen

Beta blockers bradycardia and hypotension may result

Treatment and Nursing Care

Oxygen by tent, mask, or nasal catheter ECG monitoring; CVP; evaluation of apical pulse Administer anticoagulant (IV Heparin) and aspirin (antiplatelet) as ordered to prevent additional clot formation. Monitor PTT to maintain heparin at therapeutic level Diet no iced or very hot drinks because they may precipitate cardiac arrhythmias; food known to be gas producing should be avoided Bowel elimination be regulated by mild laxatives; client is not permitted to strain at defecation

Treatment and Nursing Care

Percutaneous transluminal coronary angioplasty (PTCA) transluminal dilation can increase the diameter of the artery with the use of percutaneous fluoroschopically guided catheter to relive lesions in the coronary artery.

Treatment and Nursing Care

Thrombolytic therapy dissolving the thrombus in the coronary artery and reperfusing the myocardium before cellular death occur e.g. alteplase recombinant (activase) tissue plasminogen activator (t-PA) streptokinase (Streptase)

Congestive Heart Failure

Heart failure is failure of the heart to pump an adequate amount of blood necessary for venous return and for the metabolic requirements of the body

Congestive Heart Failure

failure of the heart to eject blood form the ventricles as quickly as it enters the atria, leading to venous stasis of blood and fluid in organs (backward failure). ventricular failure results in poor nutrition and anoxia to tissue (forward failure) Failure of one side will shortly affect the other side of the heart.

Clinical manifestation
1. 2.

3.

The vital organs are no longer perfused adequately with arterial blood, thus oxygen and nutritional requirements fail to be met and they suffer from deprivation The pulmonary vascular bed no longer is emptied effectively by the left atrium and ventricle, with the result that pulmonary vessels become engorged, pulmonary HPN develops and pulmonary edema supervene. Blood returning to the heart from the periphery is not dispatched onward into the pulmonary vessels rapidly enough to avoid congestion in the systemic veins and venules, thus venous pressure rises, the liver and other organs become congested, and fluid escapes through the walls of engorged capillaries to form dependent edema and ascites.

Left Failure

dyspnea on exertion (often the first clinical sign) Orthopnea paroxysmal nocturnal dyspnea new S3 (ventricular gallop) as early sign; pulmonary edema is acute lifethreatening left heart failure, as previously described

Right failure

lower extremity edema jugular venous distension (JVD) is visible more than a few millimetre above the clavicle with the client supine at a 45-degree angle abdominal discomfort and nausea occur from fluid congestion in the abdominal organs

Diagnostic Findings

Chest x-ray may show cardiomegaly or vascular congestion Echocardiogram shows decreased ventricular function and decreased ejection fraction CVP elevated in right-sided failure Pulmonary artery pressure monitoring may be used to guide treatment in serious case of pulmonary edema to reduce the cardiac load by lessening the tissue demand for blood and eliminating factors that tend to stimulate cardiac activity unnecessarily rest and sedation with barbiturates, opiates Demerol and morphine sulphate.

Treatment and nursing care:

To reduce the cardiac load rest and sedation with barbiturates, opiates Demerol and morphine sulphate

Treatment and nursing care:

To reinforce the pumping action of the heart giving Cardiac Glycosides (digitalis) which: Increase efficiency of cardiac contraction; Slows the conduction of impulses through the AV node; Prolongs refraction period of the node, and Increases irritability of heart muscle whether the K level is normal or lower but the effect is more marked in the presence of lower K. So when administering with diuretics especially give KCl. Ex. Digitoxin (Lanoxin PO; IV); Lanatoside C (Cedilanid PO; IV), Deslanoside (Cediland-D IM; IV) Gitalin (Getaligin PO) Quabain (IV;IM)

Treatment and nursing care:

Signs and symptoms of digitalis toxicity arrhythmia (most important) anorexia, nausea and vomiting Diarrhea Bradycardia disturbances in color vision headache, and malaise

Guidelines in Administration of Digitalis

Observe the desirable and undesirable effects desirable effects include the slowing pulse to 75-80 beats/minute; diminishing pulse deficit; greater force of cardiac contraction; increase in output of urine All patients receiving digitalis must take it for prolonged period of time Take HR if below 60 or above 120 call the physician

Reduction of NA absorption and fluid retention

Diuretics suppress the reabsorption of salt and water by the kidneys; may lead to K depletion because it also blocks the reabsorption of Cl, Na, and K ion in the proximal tubules.

Thiazides

chorothiazides (diuril); chlorthalidone (hygroton); hydrochlorothiazide (HydroDiuril); Indapamide (Lozol); Metolazone (Zaroxolyn). Mechanism of Action depress the ability of the convoluted tubules to reabsorb sodium and chloride. Where water goes, so goes sodium

Thiazides

Side effects of electrolytes imbalance:

Muscle weakness Dizziness

take diuretic in the morning take with food if GI upset occurs weigh self every morning report weight gain of more than 2 to 3 lbs eat foods high in potassium (oranges, bananas, broccoli, tomato juice, apricots, etc) avoid black licorice may precipitate hypokalemia Drug increases lithium toxicity.

Loop diuretics

very potent Bumetanide (Mumex) Furesemide (Lasix) Ethacrynic (Edecrin) Mechanism of action inhibit reabsorption of sodium and chloride in the proximal and distal tubules and loop of Henle.

Loop diuretics

Nursing responsibilities explain that this type of drug is very fast acting. Teach client to:

Take diuretic in the morning Take with food or milk Avoid orthostasis Use sunscreen as increased photosensitivity may occur Take potassium supplement as ordered Weigh self daily and report increases of 2 to 3 lbs

Potassium-sparing

Amiloride (Midamor) Spironolactone (Aldactone) Trianteren (Dyrenium) Mechanism of action block sodiumpotassium exchange mechanism in the distal portion of the tubule; prevent sodium reabsorption and retain potassium

Potassium-sparing
Teach client to: Take with food or milk Weigh self several times a week and report a gain of over 3 lbs. Adverse side effects include: Gynecomastia Decreased libido

Potassium-sparing

urine output must be measured weight patient accurately, watch for signs and symptoms of electrolyte depletion decreasing Na intake watch out for toxicity stomatitis, gingivitis, increased salivation, diarrhea, albuminuria, hematurea, skin eruptions, flushing and febrile reaction to the drug. Diuretics are given early in the morning to excrete fluid and the patients frequent need will not disturb his night time rest. Increase of 3 to 5 pounds most sensitive indicator of increasing fluid overload

Diet

0.5 gm of salt daily is the maximum sodium intake for patient of rigid Na restriction.

Complications of Congestive Heart Failure

Intractable heart failure Pulmonary infarction MI Digitalis toxicity Cardiac arrhythmias Pneumonia

Infective Disorders
Endocarditis Pericarditis

ENDOCARDITIS

inflammatory disease involving the inner surface of the heart including the valves

Infective Endocarditis

Inflammation of the endocardium; platelets and fibrin deposit on the mitral and/or aortic valves causing deformity, insufficiency, or stenosis. Caused by bacterial infection: commonly S. aureus, S. viridans, B-hemolytic streptococcus, gonococcus Precipitating factors: rheumatic heart disease, open-heart surgery procedures, GU/Ob-Gyn instrumentation/surgery, dental extractions, invasive monitoring, septic thrombophlebitis

Infective Endocarditis

Risk Factors
RHD CHD IV drug abuse Cardiac surgery Immunosuppression Dental Procedures Invasive procedures

Signs and Symptoms

Fever, Chills Malaise, fatigue Night sweats Murmurs S/S HF Atrial Embolization

Signs and Symptoms

Petichiae -conjunctiva, mucus membranes Splinter hemorrhages Janeways lesions light pink macules on palms and soles, non tender (early sign) Oslers nodes painful red nodes on pads of fingers and toes (late sign)

Management

Drug therapy
Antibiotics specific to sensitivity of organism cultured Penicillin G and streptomycin if organism not known Antipyretics

Cardiac surgery to replace affected valve

Pericarditis

inflammation of the visceral and parietal pericardium

Causes
Post-MI Trauma Neoplasm Connective Tissue Disease Post Cardiac Surgery Idiopathic Infectious

Signs and Symptoms

Pain - sudden, sharp, severe, increases with inspiration Pericardial Friction Rub Fever

Interventions
Monitor hemodynamic Status Antibiotic Therapy Erythromycin prophylaxis prior to dental procedures (AHA) Anticoagulant Therapy Inform dentist or other hcare provider regarding history

Valvular Defects

STENOSIS - heart valves are unable to fully open REGURGITATION - heart valves are unable to fully close

Causes
Rheumatic Fever CHD Syphillis Endocarditis Hypertension

Signs and Symptoms

Fatigue Dyspnea Orthopnea Hemoptysis Pulmonary Edema Dysrhythmia (Aflutter, A-fib) Angina

Interventions
Valve Repair Valve Replacement

Dysrhythmias

Dysrhythmias
Disturbance in heart rate and/or heart rhythm Caused by a disturbance in the electrical conduction of the heart Asymptomatic until CO is altered

Cardiac Conduction
SA NODE - primary pacemaker; 60-100 beats/min AV NODE - provides conduction delay; 40-60 beats/min HIS PURKINJE SYSTEM provides for orderly depolarization of the ventricles; 20-40 beats/min

Common causes
drugs digoxin, caffeine acid-base / electrolyte imbalance (K+, Ca+, Mg+) marked thermal changes disease and trauma stress

The nurse realizes that a pacemaker is used in some clients to sere the function normally performed by the
a. b. c. d.

AV node SA node Bundle of His Accelerator nerves to the heart

S/S
change in pulse rate and/or rhythm EKG changes Palpitatios Syncope Pain Dyspnea Diaphoresis hypotension

VERY BASIC ECG

The ECG Paper

Now What is Normal?

Standard 12-Lead ECG

P

wave

Atrial

activation Height < 0.2 mV (2 mm) Duration < 0.12 sec

Standard 12-Lead ECG

P-R

Interval

Intraatrial,

internodal, His purkinje conduction Duration 0.12 to 0.20

Standard 12-Lead ECG

THE

QRS COMPLEX
Ventricular

activation Duration <0.12 sec

Standard 12-Lead ECG

THE

ST-SEGMENT

Phase

2 of transmembrane potential Isoelectric

Standard 12-Lead ECG

THE

T WAVE
after the age

Upright

of 16 Juvenile T wave

Standard 12-Lead ECG

THE

U WAVE

Surface

reflection of negative after potential Repolarization of Purkinje fibers Ventricular relaxation

Standard 12-Lead ECG

THE QT INTERVAL
From beginning of QRS to end of T wave Reflects the duration of depolarization and repolarization Bazett: Q-Tc Interval = Q-Ta / R-R

Normal Values
WAVE INTERVAL DURATION (sec.)

P wave duration
PR interval QRS duration QT interval (corrected)

< .12
.12 - .20 <.12 < .44 - .55

 ORIGIN RHYTHM Sinus AND RATE Atrial Tachycardia OTHER Nodal or Junctional Bradycardia VARIATIONS Ventricular Premature Complexes Fibrillation Flutter

How to interpret?

What is this?

NORMAL SINUS RHYTHM

Rate Rhythm
P waves PR interval QRS

60-100 beats per minute Atrial regular Ventricular regular

Uniform in appearance, upright, normal shape, one preceding each QRS complex 0.12-0.20 second 0.10 second or less.

Sinus Rhythms Sinus Bradycardia

Rate Rhythm
P waves

PR interval QRS

Less than 60 beats per minute Atrial regular Ventricular regular Uniform in appearance, upright, normal shape, one preceding each QRS complex 0.12-0.20 second Usually 0.10 second or less

Sinus Rhythms
Sinus Tachycardia
Rate Rhythm P waves Usually 100-160 beats per minute Atrial regular Ventricular regular Uniform in appearance, upright, normal shape, one preceding each QRS complex 0.12-0.20 second Usually 0.10 second or less

PR interval QRS

Sinus Rhythms
Sinus Dysrhythmia (Arrhythmia)
Rate Rhythm Usually 100-160 beats per minute but may be faster or slower Irregular (R-R intervals shorten during inspiration and lengthen during expiration) Uniform in appearance, upright, normal shape, one preceding each QRS complex 0.12-0.20 second Usually 0.10 second or less

P waves

PR interval QRS

Sinus Rhythms
Sinoatrial (SA) Block
Rate Rhythm Usually normal but varies because of pause Irregular the pause is the same as (or an exact multiple of) the distance between two other P-P intervals Uniform in appearance, upright, normal shape, one preceding each QRS complex 0.12-0.20 second Usually 0.10 second or less

P waves

PR interval QRS

Sinus Rhythms
Sinus Arrest
Rate Rhythm Usually normal but varies because of the pause Irregular the pause is of undetermined length (more than one PQRST complex is omitted) and is not the same distance as other P-P intervals. Uniform in appearance, upright, normal shape, one preceding each QRS complex 0.12-0.20 second Usually 0.10 second or less

P waves

PR interval QRS

What is this?

Atrial Rhythms
Premature Atrial Complexes
1. 2.

Early (premature) P waves Upright P waves that differ in shape from normal sinus P waves in Lead II
P waves may be biphasic (partly positive, partly negative), flattened, notched or pointed

3.

The early P wave may or may not be followed by a QRS complex

Vagal Maneuvers
baroreceptors in the internal carotid arteries and the aortic arch vagus nerve acetylcholine PNS slows conduction in the AV node heart rate

Bearing down Squatting Breath-holding Immersion of the face in ice water Stimulation of the gag reflex Carotid sinus pressure (massage)

*****Carotid pressure should be avoided in older patients. Simultaneous, bilateral carotid pressure should never be performed.

What is this?

Atrial Rhythms
Supraventricular Tachycardia
Rate Rhythm P waves 150-250 beats per minute Regular Atrial P waves may be seen which differ from sinus P waves (may be flattened, notched, pointed, or biphasic). Usually not measurable because the P wave is difficult to distinguish from the preceding T wave. If P waves are seen, the RR interval will usually measure 0.12-0.20 second. Less than 0.10 second unless an intraventricular conduction defect exists.

PR interval

QRS

CARDIOVERSION
Synchronized Countershock
reduces the potential for delivery of energy during the vulnerable period of the T wave (relative refractory period). A synchronizing circuit allows the delivery of a countershock to be programmed. The machine searches for the peak of the QRS complex (R wave deflection) and delivers the shock a few milliseconds after the highest part of the R wave.
Indications: SUPRAVENTRICULAR TACHYCARDIA ATRIAL FIBRILLATION ATRIAL FLUTTER UNSTABLE VENTRICULAR TACHYCARDIA WITH PAUSE

A nurse is evaluating a clients response to cardioversion. Which of the following observations would be of highest priority to the nurse?
a. b. c. d.

Oxygen flow rate Status of airway Blood pressure Level of consciousness

What is this?

Atrial Rhythms
Wandering Atrial Pacemaker (Multiformed Atrial Rhythm) Rate 60-100. If the rate is greater than 100 beats per minute, the rhythm is termed multifocal (or chaotic) atrial tachycardia. Rhythm Atrial irregular Ventricular - irregular P waves Size, shape, and direction may change from beat to beat. At least three different P waves are required for a diagnosis of wandering atrial pacemaker PR interval Variable QRS Usually less than 0.10 second unless an intraventricular conduction defect exists

What is this?

Atrial Rhythms
Atrial Flutter
Rate Atrial rate 250-350 beats per minute; ventricular rate variable determined by AV blockade. The ventricular rate will usually not exceed 180 beats per minute due to the intrinsic conduction rate of the AV junction. Atrial regular Ventricular may be regular or irregular Not identifiable P waves; saw-toothed flutter waves Not measurable Usually less than 0.10 second but may be widened if flutter waves are buried in the QRS complex or if an intraventricular conduction defect exists.

Rhythm
P waves PR interval QRS

What is this?

Atrial Rhythms
Atrial Fribrillation
Rate Rhythm Atrial rate usually greater than 350-400 beats per minute; ventricular rate variable Ventricular rhythms usually very irregular; a regular ventricular rhythm may occur because of digitalis toxicity. No identifiable P waves; fibrillatory waves present. Erratic wavy baseline. Not measurable Usually less than 0.10 second but may be widened if an intraventricular conduction defect exists.

P waves
PR interval QRS

A client has developed atrial fibrillation, with a

ventricular rate of 150 beats per minute. A nurse assess the client for
a. b. c. d.

Hypotension and dizziness Nausea and vomiting Hypertension and headache Flat neck veins

What is this?

Atrial Rhythms
Wolff-Parkinson-White (WPW) Syndrome
Rate If the underlying rhythm is sinus in origin, the rate is usually 60-100 beats per minute. Regular unless associated with atrial fibrillation Normal and upright unless WPW is associated with atrial fibrillation If P waves are seen, less than 0.12 second Usually greater than 0.12 second. Slurred upstroke of the QRS complex (delta wave) is often seen in one or more leads)

Rhythm
P waves

PR interval QRS

What is this?

Ventricular Rhythms
Premature Ventricular Complexes Rate Usually normal but depends on the underlying rhythm Rhythm Essentially regular with premature beats. If the PVC is an interpolated PVC, the rhythm will be regular. P waves There is no P wave associated with the PVC PR interval None with the PVCs because the ectopic beat originates in the ventricle QRS Greater than 0.12 second. Wide and bizarre. T wave frequently in opposite direction of the QRS complex.

Ventricular Rhythms
Patterns of PVCs
1. 2.

3.
4. 5.

Pairs (couplets) two sequential PVCs Runs or bursts three or more sequential PVCs are called vntricular tachycardia (VT) Bigeminal PVCs (ventricular bigeminy) every other beat is a PVC Trigeminal PVCs (ventricular trigeminy) every third beat is a PVC Quadrigeminal PVCs (ventricular quadrigeminy) every fourth beat is a PVC

A client is having frequent premature ventricular

contractions. A nurse would place priority on assessment of which of the following items
a. b.

c.
d.

Blood pressure and peripheral perfusion Sensation of palpitations Causative factors such as caffeine Precipitating factors such as infection

Ventricular Rhythms
Warning Dysrhythmias

Six or more PVCs per minute PVCs that occurred in pairs (couplets) or in runs or three or more (ventricular tachycardia) PVCs that fell on the T wave of the preceding beat (R-on T phenomenon) PVCs that differed in shape (multiformed PVCs)

What is this?

Ventricular Rhythms
Ventricular Tachycardia (VT)
Rate Atrial rate not discernible, ventricular rate 100250 beats per minute Atrial rhythm not discernible Ventricular rhythm is essentially regular May be present or absent; if present they have no set relationship to the QRS complexes appearing between the QRSs at a rate different from that of the VT. None Greater than 0.12 second. Often difficult to differentiate between the QRS and the T wave.

Rhythm
P waves

PR interval QRS

Ventricular Rhythms
CAUSES

Hypoxia Exercise R-on T PVCs Catecholamines Digitalis toxicity Myocardial ischemia Acid-base imbalance Electrolyte imbalance Ventricular aneurysm Coronary artery disease Rheumatic heart disease Acute myocardial infarction CNS stimulants (cocaine, amphetamines)

What is this?

Torsades de Pointes (TdP)

Rate Rhythm P waves PR interval QRS Atrial rate not discernible, ventricular rate 150-250 beats per minute Atrial not discernible Ventricular may be regular or irregular None None Greater than 0.12 second. Gradual alteration in the amplitude and direction of the QRS

What is this?

Ventricular Rhythms
Ventricular Fibrillation
Rate Cannot be determined since there are no discernible waves or complexes to measure Rapid and chaotic with no pattern or regularity Not discernible Not discernible Not discernible

Rhythm P waves PR interval QRS

Defibrillation
Unsynchronized Countershock
random delivery of there is no relation

energy of the discharge of energy to the cardiac cycle Purpose: to produce momentary asystole to completely depolarize the myocardium and provide an opportunity for the natural pacemaker centers of the heart to resume normal activity.

Ventricular Rhythms
Unstable

Ventricular Tachycardia with a Pulse Pulseless Ventricular Tachycardia Ventricular Fibrillation Sustained Torsades de Pointes

What is this?

Ventricular Rhythms
Asystole
Rate

Rhythm
P waves PR interval QRS

Ventricular usually indiscernible but may see some atrial activity. Atrial may be discernible. Ventricular indiscernible. Usually not discernible Not measurable Absent

What is this?

Ventricular Rhythms
Causes of Pulseless Electrical Activity (MATCHx4ED)
Myocardial infarction (massive acute) Acidosis Tension pneumothorax Cardiac tamponade Hypovolemia (most common cause) Hypoxia Hyperkalemia Hypothermia Embolus (massive pulmonary) Drug overdoses (cyclic antidepressants, calcium channel blockers, beta-blockers, digitalis)

What is this?

AV Blocks
1st Degree AV Block
Rate Atrial and ventricular rates the same; dependent upon underlying rhythm. Rhythm Atrial and ventricular regular P waves Normal in size and shape Only one P wave before each QRS PR interval Prolonged (greater than 0.20 second) but Constant QRS Usually 0.10 second or less unless an intraventricular conduction exists

What is this?

AV Blocks
2nd Degree AV Block, Type I (Wenckebach)
Rate Rhythm P waves Atrial rate is greater than the ventricular rate. Both are often within normal limits. Atrial regular (Ps plot through) Ventricular irregular. Normal in size and shape. Some P waves are not followed by a QRS complex (more Ps than QRSs). Lengthens with each cycle (although lengthening may be very slight), until a P wave appears without a QRS complex. The PRI after the nonconducted beat. Usually 0.10 second or less but is periodically dropped.

PR interval

QRS

What is this?

AV Blocks
2nd Degree AV Block, Type II (Mobitz)
Rate Rhythm P waves Atrial rate is greater than the ventricular rate. Ventricular rate is often slow. Atrial regular (Ps plot through) Ventricular irregular. Normal in size and shape. Some P waves are not followed by a QRS complex (more Ps than QRSs). Within normal limits or prolonged but always constant for the conducted beats. There may be some shortening of the PRI that follows a nonconducted P wave. Usually 0.10 second or greater, periodically absent after P waves.

PR interval

QRS

What is this?

AV Blocks
2nd Degree AV Block, 2:1 Conduction
Rate Rhythm P waves Atrial rate is greater than the ventricular rate. Atrial regular (Ps plot through) Ventricular regular. Normal in size and shape; every other P wave is followed by a QRS complex (more Ps than QRSs) Constant Within normal limits if the block occurs above the bundle of His (probably type I); wide if the block occurs at or below the bundle of His (probably type II); absent after every other P wave.

PR interval QRS

What is this?

AV Blocks
Complete (Third-Degree) AV Block
Rate Rhythm Atrial rate is greater than the ventricular rate. The ventricular rate is determined by the origin of the escape rhythm. Atrial regular (Ps plot through). Ventricular regular. There is no relationship between the atrial and ventricular rhythm. Normal in size and shape. None the atria and ventricles beat independently of each other, thus there is no true PR interval. Narrow or broad depending on the location of the escape pacemaker and the condition of the intraventricular conduction system. Narrow = junctional pacemaker; wide = ventricular pacemaker.

P waves PR interval
QRS

AV Blocks
Classification of AV Blocks
Second-Degree AV Block Type I Ventricular Rhythm PR Interval QRS Width Irregular Second-Degree AV Block Type II Irregular

Lengthening Usually narrow

Constant Usually wide

AV Blocks
Classification of AV Blocks
Second-Degree AV Block, 2:1 Conduction Complete (Third-Degree) AV Block

Ventricular Rhythm
PR Interval

Regular

Regular

Constant

None no relationship between P waves and QRS complexes May be narrow or wide

QRS Width

May be narrow or wide