Care of Clients with Care of Clients with Problems Related To The Problems Related To The Cardiovascular SystemCardiovascular System

Earl Francis R. Sumile, RNEarl Francis R. Sumile, RNInstructor, College of NursingInstructor, College of Nursing

University of Santo TomasUniversity of Santo Tomas

Properties of the Heart Properties of the Heart MusclesMuscles1.1. ContractilityContractility – ability to respond an – ability to respond an

impulse by contracting the impulse by contracting the myocardiummyocardium

2.2. RhythmicityRhythmicity – stimulus; – stimulus; transmission; contract – relaxtransmission; contract – relax

3.3. Irritability or ExcitabilityIrritability or Excitability – ability to – ability to respond to a stimulus or electric respond to a stimulus or electric impulseimpulse

Properties of the Heart Properties of the Heart MusclesMuscles4.4. Conductivity Conductivity – ability to respond to a – ability to respond to a

heart impulse by transmitting the heart impulse by transmitting the impulse along cell membranesimpulse along cell membranes– SA node – 60 to 80 beats per minuteSA node – 60 to 80 beats per minute– AV node or Junctional tissue – 50 to 60 AV node or Junctional tissue – 50 to 60

beats per minutebeats per minute– Bundle of His – 40 to 50 beats per minuteBundle of His – 40 to 50 beats per minute– Purkinje Fibers – 30 to 40 beats per Purkinje Fibers – 30 to 40 beats per

minuteminute

Properties of the Heart Properties of the Heart MusclesMuscles5.5. Automaticity Automaticity – ability to initiate – ability to initiate

impulses regularly and impulses regularly and spontaneously spontaneously

SA node – pacemakerSA node – pacemaker

6.6. Refractoriness Refractoriness – prevents from – prevents from responding to a new stimulus while responding to a new stimulus while heart is in contractionheart is in contraction

7.7. Extensibility or expansibility – ability Extensibility or expansibility – ability to stretch as the heart fills with blood to stretch as the heart fills with blood between contractionsbetween contractions

Risk FactorsRisk Factors

Non-modifiable risk factorsNon-modifiable risk factors– Age – 40 years and aboveAge – 40 years and above– Gender – menGender – men– Race – whitesRace – whites– Genetic history – positive family historyGenetic history – positive family history

Risk FactorsRisk Factors

Modifiable risk factors Modifiable risk factors – Hypertension – precursor to Hypertension – precursor to

atherosclerosis and ischemic heart atherosclerosis and ischemic heart disorders disorders

– Hyperlipidemia Hyperlipidemia – Smoking – nicotine is a vasoconstrictorSmoking – nicotine is a vasoconstrictor– Sedentary lifestyle – decreased activity Sedentary lifestyle – decreased activity

leads to peripheral pooling, venous leads to peripheral pooling, venous stasis, varicosities, thrombophlebitis stasis, varicosities, thrombophlebitis

Risk FactorsRisk Factors

Modifiable risk factorsModifiable risk factors– ObesityObesity– StressStress– Glucose intoleranceGlucose intolerance– Alcohol abuseAlcohol abuse– Caffeine – increased heart rateCaffeine – increased heart rate– Environmental risk – food, drugsEnvironmental risk – food, drugs

Cardinal Symptoms of Heart Cardinal Symptoms of Heart DiseasesDiseases Dyspnea – most common symptom Dyspnea – most common symptom

of heart diseaseof heart disease Dyspnea on exertion – symptom of heart Dyspnea on exertion – symptom of heart

dysfunction provoked by effort and relieved dysfunction provoked by effort and relieved promptly by restpromptly by rest

Orthopnea – symptom of advanced heart Orthopnea – symptom of advanced heart failurefailure

Paroxysmal nocturnal dyspnea –cardiac Paroxysmal nocturnal dyspnea –cardiac asthma; severe attacks of shortness of asthma; severe attacks of shortness of breath after 2 to 5 hours of sleep; usually breath after 2 to 5 hours of sleep; usually accompanied by sweating and wheezingaccompanied by sweating and wheezing

Cardinal Symptoms of Heart Cardinal Symptoms of Heart DiseasesDiseases Chest pain – present in ischemic heart diseases Chest pain – present in ischemic heart diseases

– characteristics – ‘strange feeling”; indigestion; dull characteristics – ‘strange feeling”; indigestion; dull heavy pressure; burning crushing aching, stabbing; heavy pressure; burning crushing aching, stabbing; tightnesstightness

– location – substernal or precordial areas, anterior location – substernal or precordial areas, anterior chest; diffuse or localized; radiated to neck, jaw, left or chest; diffuse or localized; radiated to neck, jaw, left or both armsboth arms

– duration – in angina – 20 to 30 minutes; in MI longer duration – in angina – 20 to 30 minutes; in MI longer than 30 minutesthan 30 minutes

– severity – scale 1–10severity – scale 1–10– precipitating or aggravating symptoms precipitating or aggravating symptoms – associated symptoms – SOB, diaphoresis, palpitationsassociated symptoms – SOB, diaphoresis, palpitations– alleviating factorsalleviating factors

Cardinal Symptoms of Heart Cardinal Symptoms of Heart DiseasesDiseases Edema Edema – accumulation of excess fluid in – accumulation of excess fluid in

interstitial space; weight gain of over 7 interstitial space; weight gain of over 7 kg. water before edema occurskg. water before edema occurs

Syncope – general muscle weakness with Syncope – general muscle weakness with inability to stand upright with loss of inability to stand upright with loss of consciousnessconsciousness

Palpitations (subjective) – unpleasant Palpitations (subjective) – unpleasant awareness of heartbeat; sensation of awareness of heartbeat; sensation of pounding, racing, skipping; thumping pounding, racing, skipping; thumping heartbeat often accompanied by heartbeat often accompanied by anxiousnessanxiousness

Physical AssessmentPhysical Assessment

– Inspection – skin color, cyanosis, neck Inspection – skin color, cyanosis, neck vein distention; respiration; peripheral vein distention; respiration; peripheral edema, pitting edema (does not edema, pitting edema (does not disappear with elevation of extremity); disappear with elevation of extremity); clubbing or blanchingclubbing or blanching

– Palpation – peripheral and apical pulsesPalpation – peripheral and apical pulses– Percussion Percussion

Physical AssessmentPhysical Assessment

Auscultation – heart sound at apex Auscultation – heart sound at apex or PMI (point of maximal impulse or PMI (point of maximal impulse located at:located at:

5th left ICS; left, mid-clavicular line5th left ICS; left, mid-clavicular line 2 inches below left nipple2 inches below left nipple

– Normal heart sound:Normal heart sound: lubb – first sound; ventricular systole; lubb – first sound; ventricular systole;

closure of AV valveclosure of AV valve dubb – second sound; ventricular diastole; dubb – second sound; ventricular diastole;

closure of semilunar valveclosure of semilunar valve

Physical Assessment Physical Assessment

– Abnormal Heart Sounds:Abnormal Heart Sounds: murmur – audible vibrations because of turbulent murmur – audible vibrations because of turbulent

blood flow through the heart and large blood vesselsblood flow through the heart and large blood vessels gallop – extra heart sounds mimicking a horse’s gallop – extra heart sounds mimicking a horse’s

gallop because of sudden changes of inflow volume gallop because of sudden changes of inflow volume on valves and supporting structureson valves and supporting structures

Variations of cardiac rateVariations of cardiac rate

Due to:Due to:– Exercise – increase activity, increase heart rateExercise – increase activity, increase heart rate– Size of individual – larger person, lesser heart Size of individual – larger person, lesser heart

rate rate – Age – fetus – 120 – 160 per min; adult – 65 – 80 Age – fetus – 120 – 160 per min; adult – 65 – 80

per min; higher age = lower heart rateper min; higher age = lower heart rate– Sex – women has higher heart rate Sex – women has higher heart rate – Hormones – epinephrine and thyroxine Hormones – epinephrine and thyroxine

increase heart rateincrease heart rate– Increase temperature – increase heartIncrease temperature – increase heart– Blood pressure – decrease blood pressure, Blood pressure – decrease blood pressure,

increase heart rateincrease heart rate

Effects of electrolytes to heart Effects of electrolytes to heart raterate

– increase potassium = decrease pulse increase potassium = decrease pulse – decrease sodium = weaker contractions, decrease sodium = weaker contractions,

increase pulse, decrease blood pressureincrease pulse, decrease blood pressure– increase calcium = stronger and increase calcium = stronger and

prolonged systoleprolonged systole

Diagnostic AssessmentDiagnostic Assessment

1.Chest X-ray – shows heart size, contour and 1.Chest X-ray – shows heart size, contour and position, reveals heart and pericardial position, reveals heart and pericardial calcifications and demonstrates physiologic calcifications and demonstrates physiologic alterations in the pulmonary circulation.alterations in the pulmonary circulation.

2.Fluoroscopy – provides visual observations of 2.Fluoroscopy – provides visual observations of the heart on a luminescent x-ray screenthe heart on a luminescent x-ray screen

3.Cardiac enzymes – present in myocardial cells 3.Cardiac enzymes – present in myocardial cells and released into blood when damagedand released into blood when damaged

– LDH – Lactic Dehydrogenase LDH – Lactic Dehydrogenase – N=100-225 mU per ml; elevated in 48 hoursN=100-225 mU per ml; elevated in 48 hours– CPK – Creatinine PhospokinaseCPK – Creatinine Phospokinase– N=50-325mU per ml; elevated from 4-24 hoursN=50-325mU per ml; elevated from 4-24 hours

Diagnostic AssessmentDiagnostic Assessment Electrocardiography (ECG) – graphic Electrocardiography (ECG) – graphic

record of electrical activity of the heartrecord of electrical activity of the heart– Atrial DepolarizationAtrial Depolarization

P wave – depolarization of atria (0.8 secs.)P wave – depolarization of atria (0.8 secs.) PR interval – conduction from atria to ventricle PR interval – conduction from atria to ventricle

(0.16 secs.)(0.16 secs.)– Ventricular DepolarizationVentricular Depolarization

QRS complex – depolarization of Bundle of His, QRS complex – depolarization of Bundle of His, purkinje fibers and ventricles (0.6 – 1.2 secs)purkinje fibers and ventricles (0.6 – 1.2 secs)

ST segment – recovery or repolarization of ST segment – recovery or repolarization of ventricles; elevation or depression = ischemia or ventricles; elevation or depression = ischemia or infarction of heart muscles (0.12 secs)infarction of heart muscles (0.12 secs)

T wave – ventricular repolarization; recovery after T wave – ventricular repolarization; recovery after contraction of ventricles (0.16 secs); if inverted = contraction of ventricles (0.16 secs); if inverted = ischema or infarct ischema or infarct

Diagnostic AssessmentDiagnostic Assessment

Stress test (treadmill) – exercise testing Stress test (treadmill) – exercise testing on a treadmill or a bicycle like device on a treadmill or a bicycle like device carried out to identify ischemic heart carried out to identify ischemic heart disease, disease,

– Nursing Consideration - stop procedure if Nursing Consideration - stop procedure if patient complains of dyspnea or chest painpatient complains of dyspnea or chest pain

Echocardiogram – ultrasound Echocardiogram – ultrasound cardiography; record of high frequency cardiography; record of high frequency sound vibrations which have been sent sound vibrations which have been sent into the heart through chest wall into the heart through chest wall

Diagnostic Assessment`Diagnostic Assessment` Transesophageal Echocardiography (TEE) – Transesophageal Echocardiography (TEE) –

gives a higher quality picture of the heart than gives a higher quality picture of the heart than echocardiogram; probe inserted with echocardiogram; probe inserted with esophageal scope and placed behind the heartesophageal scope and placed behind the heart

Angiocardiography – injection of contrast Angiocardiography – injection of contrast medium into the vascular system to outline medium into the vascular system to outline heart and heart vessels; usually done with heart and heart vessels; usually done with cineangiograms (rapidly changing films on an cineangiograms (rapidly changing films on an intensified fluoroscopic screenintensified fluoroscopic screen

Diagnostic AssessmentDiagnostic Assessment Coronary arteriography – radiopaque catheter is Coronary arteriography – radiopaque catheter is

introduced into right brachial artery or femoral introduced into right brachial artery or femoral artery (via arteriotomy with percutaneous artery (via arteriotomy with percutaneous puncture) to ascending aorta to coronary artery puncture) to ascending aorta to coronary artery on fluoroscopy.on fluoroscopy.– Nursing interventions:Nursing interventions:

NPO – to minimize pulmonary aspiration afterNPO – to minimize pulmonary aspiration after Vital signsVital signs Check for bleeding at puncture siteCheck for bleeding at puncture site Check color of extremity and pulses Check color of extremity and pulses

Diagnostic AssessmentDiagnostic Assessment Position Emission Tomography (PET) – scanner Position Emission Tomography (PET) – scanner

that allows visualization and information of that allows visualization and information of perfusion and metabolism images providing perfusion and metabolism images providing assessment of regional cardiac viablility.assessment of regional cardiac viablility.

Cardiac catheterization – catheter is inserted to Cardiac catheterization – catheter is inserted to the heart and blood vessels to measure O2 the heart and blood vessels to measure O2 concentration, saturation, tension and pressure concentration, saturation, tension and pressure on heart chambers.on heart chambers.

– Right Cardiac Catheterization – catheter is inserted Right Cardiac Catheterization – catheter is inserted into the antecubital vein to vena cava, right atrium into the antecubital vein to vena cava, right atrium and right ventricle to pulmonary artery.and right ventricle to pulmonary artery.

– Left Cardiac Catheterization – catheter is inserted into Left Cardiac Catheterization – catheter is inserted into the brachial or femoral artery; retrograde up the aorta the brachial or femoral artery; retrograde up the aorta and light ventricle; usually done with angiography.and light ventricle; usually done with angiography.

Diagnostic AssessmentDiagnostic Assessment Cardiac CatheterizationCardiac Catheterization Nursing interventions:Nursing interventions:

– Before Before – NPO, allergic history, mark distal – NPO, allergic history, mark distal pulses, instruct patient that there will be pulses, instruct patient that there will be occasional thudding sensation in chest and occasional thudding sensation in chest and strong desire to caugh and transient heat.strong desire to caugh and transient heat.

– After After – VS, check peripheral pulses, check site, – VS, check peripheral pulses, check site, check for chest pain, bed rest for 12-24hours; check for chest pain, bed rest for 12-24hours;

– for femoral site – check for bleeding, for femoral site – check for bleeding, inflammation, tenderness, apply sandbag and inflammation, tenderness, apply sandbag and ice on site, HOB > 30degrees avoid flexing ice on site, HOB > 30degrees avoid flexing femoral region; femoral region;

– for brachial – arm straight for several hours for brachial – arm straight for several hours

Diagnostic AssessmentDiagnostic Assessment Hemodynamic monitoring – assessment Hemodynamic monitoring – assessment

of circulatory status of circulatory status – CVP – (N=5-12 cms. H20) obtained by CVP – (N=5-12 cms. H20) obtained by

inserting a catheter into the inserting a catheter into the – external jugular, antecubital or femoral vein external jugular, antecubital or femoral vein

and threading it into the vena cavaand threading it into the vena cavaPurposes:Purposes:

– Provides information concerning blood volume Provides information concerning blood volume and adequacy of central venous returnand adequacy of central venous return

– Reveals right atrial pressureReveals right atrial pressure– Route for drawing blood samples, Route for drawing blood samples,

administration of fluids or medication and administration of fluids or medication and inserting pacing catheters.inserting pacing catheters.

Diagnostic AssessmentDiagnostic Assessment Hemodynamic monitoringHemodynamic monitoring

Nursing interventions:Nursing interventions:– Place the patient in supine position. Inaccuracies in CVP Place the patient in supine position. Inaccuracies in CVP

readings can be due to changes in position, coughing or readings can be due to changes in position, coughing or straining during the reading.straining during the reading.

– The zero point of the manometer should be on a level The zero point of the manometer should be on a level with the patient’s right atrium. (midaxillary line) with the patient’s right atrium. (midaxillary line)

– To measure CVP: Turn the stopcock so that the IV To measure CVP: Turn the stopcock so that the IV solution flows into the manometer filling to about 20-25 solution flows into the manometer filling to about 20-25 cm. level. Then turn stopcock so that solution in cm. level. Then turn stopcock so that solution in manometer flows into patient.manometer flows into patient.

– Observe the fall in the height of the column of fluid in Observe the fall in the height of the column of fluid in manometer. Record the level at which the solution manometer. Record the level at which the solution stabilized or stops moving downward. This is the CVP.stabilized or stops moving downward. This is the CVP.

Classification Of Patients With Classification Of Patients With Heart DiseaseHeart DiseaseFunctional CapacityFunctional Capacity Class I: Patients with heart disease but without Class I: Patients with heart disease but without

resulting limitations of physical activity. resulting limitations of physical activity. Class II: Patients with heart disease resulting in Class II: Patients with heart disease resulting in

slight limitation of physical activity. . slight limitation of physical activity. . Class III: Patients with heart disease resulting Class III: Patients with heart disease resulting

in marked limitation of physical activity. in marked limitation of physical activity. Class IV: Patients with heart disease resulting Class IV: Patients with heart disease resulting

in inability to carry on with physical activity in inability to carry on with physical activity without discomfort. without discomfort.

Classification Of Patients With Classification Of Patients With Heart DiseaseHeart DiseaseTherapeutic Classification Therapeutic Classification Class A: Patients with heart disease whose ordinary Class A: Patients with heart disease whose ordinary

physical activity need not be restricted.physical activity need not be restricted. Class B: Patients with heart disease whose ordinary Class B: Patients with heart disease whose ordinary

physical activity need not be restricted, but who physical activity need not be restricted, but who should be advised against severe or competitive should be advised against severe or competitive physical efforts.physical efforts.

Class C: Patients with heart disease whose ordinary Class C: Patients with heart disease whose ordinary physical activity should be moderately restricted physical activity should be moderately restricted and whose more strenuous efforts should be and whose more strenuous efforts should be markedly restricted.markedly restricted.

Class D: Patients with heart disease whose ordinary Class D: Patients with heart disease whose ordinary physical activity should be markedly restricted.physical activity should be markedly restricted.

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

Common cardiac problemsCommon cardiac problems

1.1. Conduction arhytmias – disruption in normal heart Conduction arhytmias – disruption in normal heart cyclecyclea. Sinus tachycardia – heart rate over 100 beats per minute a. Sinus tachycardia – heart rate over 100 beats per minute

originating from the SA node. (rate 100-160 per minute)originating from the SA node. (rate 100-160 per minute)

May be secondary to:May be secondary to:Fever, apprehension, physical activity, anemia, Fever, apprehension, physical activity, anemia,

hyperthyroidism, drugs; epinephrine, theophylline hyperthyroidism, drugs; epinephrine, theophylline myocardial ischemia or caffeine; rhythm regularmyocardial ischemia or caffeine; rhythm regularNursing management:Nursing management:– correction of underlying causecorrection of underlying cause– no stimulants no stimulants – sedativesedative– drug of choice – propranolol (Inderal)drug of choice – propranolol (Inderal)

Conduction ArhytmiasConduction Arhytmias Sinus bradycardia – heart rate of less than 60 beats Sinus bradycardia – heart rate of less than 60 beats

per minute; regular.per minute; regular. May be caused by:May be caused by:

-excessive vagal or decreased sympathetic tone-excessive vagal or decreased sympathetic tone-myocardial infarction -myocardial infarction -intracranial tumors-intracranial tumors-meningitis -meningitis -normal variation of heart rate in well trained -normal variation of heart rate in well trained

athleteathleteNursing management:Nursing management:– not needed, unless cardiac output is inadequatenot needed, unless cardiac output is inadequate– pharmacotherapeutics – Atropine, Isuprel pharmacotherapeutics – Atropine, Isuprel – Pacemakers – pulse generator to control of potentially Pacemakers – pulse generator to control of potentially

dangerous dysrrhytmiasdangerous dysrrhytmias

Conduction ArhytmiasConduction Arhytmias--PacemakersPacemakersMethods of pacing:Methods of pacing:

*Temporary – done at the bedside under fluoroscopy *Temporary – done at the bedside under fluoroscopy through an emergency through an emergency transthoracic percutaneous transthoracic percutaneous insertion of heart needle direct to myocardiuminsertion of heart needle direct to myocardium*Permanent – subcutaneous or subclavicular insertion *Permanent – subcutaneous or subclavicular insertion through through transvenoustransvenous (antecubital, femoral, jugular or (antecubital, femoral, jugular or subclavian) or direct application to epicardial surface subclavian) or direct application to epicardial surface through thoracotomy.through thoracotomy.

Modes of pacing:Modes of pacing:*Pre-set (fixed or asynchronous) – fires electrical *Pre-set (fixed or asynchronous) – fires electrical stimulus regardless of rate and rhythm; usually set at 72 stimulus regardless of rate and rhythm; usually set at 72 beats/min.beats/min.*Demand (stand by) – stimulated only when heart rate *Demand (stand by) – stimulated only when heart rate drops below pre-set rate; usually below 60 beats per drops below pre-set rate; usually below 60 beats per minute.minute.

Conduction ArhythmiasConduction Arhythmias

--PacemakersPacemakersNursing Management:Nursing Management:

-assess wound daily, report signs of -assess wound daily, report signs of inflammationinflammation-check pulse daily, notify physician if pulse -check pulse daily, notify physician if pulse is slower than set rateis slower than set rate-avoid areas with high voltage, magnetic -avoid areas with high voltage, magnetic force fields or radiation (no MRI, microwave force fields or radiation (no MRI, microwave oven)oven)-avoid wearing constrictive clothing-avoid wearing constrictive clothing-avoid vigorous movement of arms and -avoid vigorous movement of arms and shoulder and weight liftingshoulder and weight lifting

Conduction ArhythmiasConduction Arhythmias Atrial fibrillation – rapid, irregular contractions of Atrial fibrillation – rapid, irregular contractions of

the heart with ectopic foci. (350 to 600 beats/min)the heart with ectopic foci. (350 to 600 beats/min)Management:Management:

-pharmacotherapeutics – digitalis, -pharmacotherapeutics – digitalis, propranolol, propranolol, verapamilverapamil

-Cardioversion – elective procedure in which -Cardioversion – elective procedure in which electric electric current is delivered to the heart to current is delivered to the heart to terminate terminate potentially dangerous or exhausting potentially dangerous or exhausting arrhytmias arrhytmias refractory to drug therapyrefractory to drug therapy

-50 to 400 watt sec-50 to 400 watt sec

-synchronizer on – during QRS -synchronizer on – during QRS complexcomplex

-never on T wave-never on T wave

Ventricular Tachycardia – a run of 3 or more Ventricular Tachycardia – a run of 3 or more conservative premature ventricular contractions conservative premature ventricular contractions from repetitive firing of an ectopic foci in the from repetitive firing of an ectopic foci in the ventricles. (atrial – 60 to 100 beats/min; ventricles. (atrial – 60 to 100 beats/min; ventricular – 110 to 250 beats/min)ventricular – 110 to 250 beats/min)Management:Management:

-Lidocaine; Procainamide, Bretylium-Lidocaine; Procainamide, Bretylium-Defibrillation – emergency procedure in -Defibrillation – emergency procedure in

which an which an electric current is delivered to the electric current is delivered to the heart to terminate heart to terminate life threathening life threathening arrhythmia (400 watt sec or arrhythmia (400 watt sec or joules); joules); synchronizer offsynchronizer off

Common Cardiac ProblemsCommon Cardiac Problems Coronary Artery DiseaseCoronary Artery Disease

– Arteriosclerosis – narrowing of arterial lumen secondary to Arteriosclerosis – narrowing of arterial lumen secondary to aging; increased in 30-50 yearsaging; increased in 30-50 years

– Atherosclerosis – narrowing of arterial lumen secondary to Atherosclerosis – narrowing of arterial lumen secondary to cholesterol and lipids on artery walls; increased men and cholesterol and lipids on artery walls; increased men and non-whites non-whites

Management:Management:*PTCA – Percutaneous Trans-luminal Coronary *PTCA – Percutaneous Trans-luminal Coronary

Angioplasty – Angioplasty – specially designed catheter is inserted specially designed catheter is inserted under fluoroscopy, under fluoroscopy, balloon tip is inflated, compresses balloon tip is inflated, compresses and ruptures an and ruptures an atherosclerotic plaque (danger-atherosclerotic plaque (danger-thrombosis)thrombosis)

*CABGS – Coronary Arterial Bypass Graft Surgery – *CABGS – Coronary Arterial Bypass Graft Surgery – use of use of autologous or prosthetic Teflon or Dacron (open autologous or prosthetic Teflon or Dacron (open heart surgery) heart surgery) to bypass the affected area.to bypass the affected area.

Common Cardiac ProblemsCommon Cardiac Problems Angina Pectoris – transient, paroxysmal chest pain Angina Pectoris – transient, paroxysmal chest pain

secondary to insufficient blood flow to myocardium secondary to insufficient blood flow to myocardium resulting in myocardial ischemia.resulting in myocardial ischemia.Signs and Symptoms:Signs and Symptoms:

– Chest pain characterized by: Chest pain characterized by: SS udden; sub-sternal udden; sub-sternal

AA nterior chest nterior chestVV ague agueEE xertion related xertion related RR elieved by rest or nitrites elieved by rest or nitritesSS hort duration hort duration

– Palpitations or tachycardia Palpitations or tachycardia – DyspneaDyspnea– Diaphoresis Diaphoresis – Shortness of breathShortness of breath

Angina PectorisAngina PectorisDiagnostic Assessment:Diagnostic Assessment:-ECG – reveals depressed ST segment; T wave inversion;-ECG – reveals depressed ST segment; T wave inversion;-Stress test – abnormal ECG during exercise-Stress test – abnormal ECG during exercise

Nursing management: Nursing management: -O2 inhalation -O2 inhalation -Semi to high fowler’s position -Semi to high fowler’s position -Heart monitoring-Heart monitoring-Proper relief of pain with nitrates-Proper relief of pain with nitrates

- nitroglycerine tablets – given sublingual- nitroglycerine tablets – given sublingual*take 1 tab in anticipation of strenuous activity *take 1 tab in anticipation of strenuous activity *1 tab every 5 mins (3 tabs within 15 mins)*1 tab every 5 mins (3 tabs within 15 mins)*headache – frequent side effects (transient)*headache – frequent side effects (transient)*hypotension*hypotension*keep cap tight; prevent exposure to light, air and heat*keep cap tight; prevent exposure to light, air and heat

Angina PectorisAngina Pectoris Nursing Management:Nursing Management:

- nitro ointments or nitrodisc- nitro ointments or nitrodisc *rotate sites to prevent dermal inflammation *rotate sites to prevent dermal inflammation *avoid massage or rub because of increased absorption *avoid massage or rub because of increased absorption

and and interferesinterferes with drug’s sustained actionwith drug’s sustained action

*avoid skin contact with medication*avoid skin contact with medication-patient education to minimize precipitating events-patient education to minimize precipitating events-reduce stress and anxiety-reduce stress and anxiety-avoid overexertion and smoking-avoid overexertion and smoking-decrease cholesterol and saturated fat diet-decrease cholesterol and saturated fat diet-small, frequent meals-small, frequent meals-avoid extremes of temperature-avoid extremes of temperature-dress warmly in called weather-dress warmly in called weather

Common Cardiac ProblemsCommon Cardiac Problems Myocardial Infarction – death of myocardial cells Myocardial Infarction – death of myocardial cells

from inadequate oxygenation, often caused by from inadequate oxygenation, often caused by a sudden, complete blockage of a coronary a sudden, complete blockage of a coronary artery characterized by localized formation of artery characterized by localized formation of necrosis with subsequent healing by scar necrosis with subsequent healing by scar formation and fibrosis. formation and fibrosis. Signs and Symptoms: Signs and Symptoms:

– Pain usually substernal radiating to neck, arm , jaw or Pain usually substernal radiating to neck, arm , jaw or back, severe and crushing, sudden onset unrelieved back, severe and crushing, sudden onset unrelieved by rest or nitrates; may be referred pain (epigastric by rest or nitrates; may be referred pain (epigastric pain)pain)

– Nausea and vomitingNausea and vomiting– DyspneaDyspnea– Cool, clammy and Cool, clammy and

Myocardial InfarctionMyocardial InfarctionSigns and Symptoms:Signs and Symptoms:– Initially increased blood pressure ashen skinInitially increased blood pressure ashen skin– Increased temperature and pulse rate then decrease Increased temperature and pulse rate then decrease

blood pressureblood pressure– Increased WBC, CPK and CPK-MB, increased SGOT, Increased WBC, CPK and CPK-MB, increased SGOT,

increased LDH, increased ESRincreased LDH, increased ESR*CPK and SGOT – increases in 4 to 6 hours, and decreases *CPK and SGOT – increases in 4 to 6 hours, and decreases in 3 to 7 daysin 3 to 7 days– ECG changes – ST elevation, presence of U-waves, T ECG changes – ST elevation, presence of U-waves, T

wave inversionwave inversion

Myocardial InfarctionMyocardial Infarction

Nursing interventions:Nursing interventions: Objective of care Objective of care – restore ability of heart to – restore ability of heart to

maintain adequate circulation;maintain adequate circulation; -IV lines – pain relief – IV morphine sulfate (no -IV lines – pain relief – IV morphine sulfate (no

IM injections-stimulates increase CPK)IM injections-stimulates increase CPK) -O2 inhalation -O2 inhalation -Bedrest, semi-fowlers position; ambulate after -Bedrest, semi-fowlers position; ambulate after

3 days 3 days -Antiarrhytmics – lidocaine bolus 50-100 mg + -Antiarrhytmics – lidocaine bolus 50-100 mg +

drip at 1-4 mg/min; procainamide, quinidinedrip at 1-4 mg/min; procainamide, quinidine-Full liquid to soft diet, decreased sodium and cholesterol, -Full liquid to soft diet, decreased sodium and cholesterol, no caffeineno caffeine-Stool softeners to prevent straining -Stool softeners to prevent straining

Myocardial InfarctionMyocardial Infarction

Nursing Interventions:Nursing Interventions:-Fibrinolytics – streptokinase drip to lyse the -Fibrinolytics – streptokinase drip to lyse the thrombosethrombose-Anticoagulants-Anticoagulants *heparin – serial PT; antidote – protamine sulfate *heparin – serial PT; antidote – protamine sulfate *coumadin or warfarin sodium – serial PTT; *coumadin or warfarin sodium – serial PTT; antidote – Vitamin Kantidote – Vitamin K-TPA (tissue type plasminogen activator or -TPA (tissue type plasminogen activator or platelet deagreggator)platelet deagreggator) *low doses of aspirin a day*low doses of aspirin a day *persantine or dipyridamole*persantine or dipyridamole-Resumption of sexual activity in 4 to 6 weeks-Resumption of sexual activity in 4 to 6 weeks

Common Cardiac ProblemsCommon Cardiac Problems Congestive heart failure – inability of heart Congestive heart failure – inability of heart

to pump blood to adequately meet the to pump blood to adequately meet the metabolic needs of bodymetabolic needs of body-Left sided heart failure – (forward failure) -Left sided heart failure – (forward failure)

causes blood to back up through left causes blood to back up through left atrium into pulmonary veins; pulmonary atrium into pulmonary veins; pulmonary congestion.congestion.Signs and Symptoms – Signs and Symptoms – dyspnea, dyspnea, orthopnea, paroxysmal nocturnal orthopnea, paroxysmal nocturnal dyspnea, wheezing, moist rales, cyanosis, dyspnea, wheezing, moist rales, cyanosis, pallor, cough with frothy sputumpallor, cough with frothy sputum

Congestive Heart Failure Congestive Heart Failure

-Right sided heart failure – (backward -Right sided heart failure – (backward failure) right valve is unable top pimp failure) right valve is unable top pimp blood into pulmonary system; systemic blood into pulmonary system; systemic venous congestionvenous congestion

Signs and Symptoms Signs and Symptoms – dependent – dependent and and pitting pitting edema, jugular vein edema, jugular vein distention, distention, bounding pulse, bounding pulse, weight weight gain, decreased gain, decreased renal function, renal function, oliguria, oliguria, ascitis, ascitis, anasarcaanasarca

Congestive Heart FailureCongestive Heart Failure

Nursing managementNursing management– Control of underlying causeControl of underlying cause– O2 therapyO2 therapy– Sodium restricted dietSodium restricted diet– PharmacotherapeuticsPharmacotherapeutics

*vasodilators (nitoglycerine, isosorbide, morphine *vasodilators (nitoglycerine, isosorbide, morphine sulfate) to decrease? amount of blood return to sulfate) to decrease? amount of blood return to heartheart*digitalis therapy (lanoxin, cedilanid) to improve *digitalis therapy (lanoxin, cedilanid) to improve cardiac outputcardiac outputSigns and Symptoms of digitalis toxicity:Signs and Symptoms of digitalis toxicity:

*CV symptoms:*CV symptoms: bradycardia, tachycardia, bigeminy, bradycardia, tachycardia, bigeminy, ectopic ectopic beatsbeats

Congestive Heart FailureCongestive Heart Failure

Nursing Management:Nursing Management: Signs and Symptoms of digitalis toxicity:Signs and Symptoms of digitalis toxicity:

*GI symptoms: *GI symptoms: anorexiaanorexia, , nausea and vomiting, nausea and vomiting, diarrhea, diarrhea, abdominal painabdominal pain

*Neuro symptoms: *Neuro symptoms: headache, double vision, blurred headache, double vision, blurred or colored or colored vision; drowsiness, confusion, restlessness, vision; drowsiness, confusion, restlessness, irritability, muscle irritability, muscle weaknessweakness

*diuretics – relieve fluid retention*diuretics – relieve fluid retention

Congestive Heart FailureCongestive Heart FailureNursing Management:Nursing Management:

– Rotating tourniquets (bloodless phlebotomy) – to retard Rotating tourniquets (bloodless phlebotomy) – to retard venous return to heart venous return to heart General Principles of CareGeneral Principles of Care

– Use 3 tourniquets or 3 BP cuffs on 4 extremities cuff Use 3 tourniquets or 3 BP cuffs on 4 extremities cuff inflated at pulse pressure inflated at pulse pressure

– Apply tourniquet using one direction – clockwise Apply tourniquet using one direction – clockwise – Tourniquet is applied one at a time at 15 minutes Tourniquet is applied one at a time at 15 minutes

intervalinterval– Tourniquet is removed one at a time at 15 minutes Tourniquet is removed one at a time at 15 minutes

intervalinterval– Maximum time of stay in each extremity is 45 Maximum time of stay in each extremity is 45

minutesminutes - - Phlebotomy – removal of 300-500cc blood from Phlebotomy – removal of 300-500cc blood from

peripheral veinperipheral vein-- Intraaortic balloon pump, heart transplant,mechanical Intraaortic balloon pump, heart transplant,mechanical heartheart