2010

Cardiovascular System Medical Surgical Nursing

RESOURCE UNITS

Jann Carlo Luigi R. Naz BScN, RN,MAN( c ) Health Professional Consultancy

Table of Contents
REVIEW OF THE STRUCTURE OF THE HEART y y Conducting Systems of the Heart Heart Sounds

y S heart sounds y Heart Rate y Blood Pressure y Rationale for Laboratory test DIAGNOSTICS RELATED TO CARDIOVASCULAR FUNCTION

y y y y y y y y y y y y y y y y y y y y y y y

Complete Blood Count Erythrocyte Sedimentation Rate (ESR) Blood Coagulation Test Prothrombin Time (PT, Pro Time) Partial Thromboplastin Time (PTT) Activated Partial Thromboplastin Time (APTT) Blood Urea Nitrogen BUN) [BLOOS LIPIDS] Cholesterol Triglycerides Blood Cultures [Enzymes Studies] Aspartate Aminotransferase AST) Creatine Phosphokinase CK-MB) Lastic Dehydrogenase (LDH) Hydroxybutyrate Dehydrogenase (HBD) Urinalysis Blood Uric Acid (BUA Serologic Tests Serum Electrolytes Electrocardiography (ECG, EKG) Common ECG Changes Holter Monitoring Central Venous Pressure Pulmonary Artery Pressure & Pulmonary Capillary Wedge Pressure
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[Sonic Studies] y Echocardiography y Transesophageal Echocardiography (TEE) y Phonocardiography y Chest Roentgenograms (X-rays) y Cardiac Fluoroscopy y Cardiac Catheterization y Angiography/Arteriography y Magnetic Resonance Imaging (MRI) y Myocardial Scintigraphy y Non Invasive Hemodynamic Monitoring: Intra-arterial Pressure Monitoring CARDIAC ASSESSMENTS CARDIAC DISEASES           CORONARY ARTERY DISEASE (CAD) Angina Pectoris / Myocardial Ischemia Myocardial Infarction Congestive Heart Failure Acute Coronary Syndrome Buerger s Disease Raynaud s phenomenon Cardiogenic Shock Cardiogenic Tamponade Hypertension

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Brief Review of the Heart Structure: Anatomy

The heart is located in the LEFT side of the mediastinum Consists of three layersEPICARDIUM, MYOCARDIUM AND ENDOCARDIUM The Cardiovascular System EPICARDIUM-Covers the outer surface of the hear MYOCARDIUM- Middle muscular layer of the heart ENDOCARDIUM- lines the chambers and the valves With 20-30 ml of serous fluid which protects the heart from trauma &

The layer that covers the heart is the PERICARDIUM There are two parts- PARIETAL AND VISCERAL PERICARDIUM

Parietal pericardium

Visceral pericardium

The space between the two pericardial layers is the pericardial space The heart also has four chambers -2 ATRIAS AND 2 VENTRICLES The LEFT atrium and the RIGHT atrium The LEFT ventricle and the RIGHT ventricle The heart chambers are guarded by valves

The atrioventricular valves Tricuspid and bicuspid The semi-lunar valves- Pulmonic and aortic valves The Blood supply of the heart comes from the Coronary arteries 1. Right coronary artery supplies the RIGHT atrium and RIGHT ventricle, inferior portion of the LEFT ventricle, the POSTERIOR septal wall and the two nodes AV and SA node 2. Left coronary artery- branches into the LAD and the circumflex branch The LAD supplies blood to the anterior wall of the LEFT ventricle , the anterior septum and the Apex of the left ventricle The Circumflex branch supplies the left atrium and the posterior ventricle
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The CONDUCTING SYSTEMS OF THE HEART CONSISTS OF THE: 1. SA node- the pacemaker 2. AV node- slowest conduction 3. BUNDLE OF HIS- branches into the right and the left bundle branch 4. PURKINJE FIBERS- fastest conduction HEART SOUNDS Heart sounds are heard through a stethoscope at 2nd/3rd ribsand 5th/6th ribs and can indicate the condition of the heart valves FIRST LUBB-DUBB goes with the transport to lungs SECOND LUBB-DUBB goes with the transport to the body Follow one volume through the heart: 1stLubb: aortic valve open, R and L AV-valves close = emptying of the ventricles to the body and emptying of the atria 1stDubb:aortic valve close, R and L AV-valves open = filling of the R ventricles and filling of the atria 2nd Lubb:pulmonary valve open, R and L AV-valves = close emptying of the ventricles to the lungs and filling of the atria 2nd Dubb:pulmonary valve close, R and L AV-valves open = filling of the ventricles and emptying of the atria Vibrations: due to blood flow and opening and closing of the heart valves Murmurs: abnormal heart sound The S heart sounds 1. S1- due to closure of the AV valves 2. S2- due to closure of the semi lunar valves 3. S3- due to increased ventricular filling 4. S4- due to forceful atrial contraction Heart Rate Normal Range is 60-100 beats per minute Tachycardia is greater than 100 bpm Bradycardia is less than 60 bpm Sympathetic system INCREASES heart rate Parasympathetic system (vagus)DECREASES heart rate

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Blood Pressure Cardiac Output X peripheral resistance Control is neural (central and peripheral) and hormonal Baroceptors in the carotid and aorta Hormones ADH, aldosterone, epinephrine can increase BP; ANF can decrease BP The vascular system consists of the arteries, veins and capillaries The arteries are vessels that carry blood away from the heart to the periphery The veins are the vessels that carry blood to the heart The capillaries are lines with the squamous cells, they connect the veins and arteries The lymphatic system also is part of the vascular system and the function of this system is to collect the extravasated fluid from the tissues and returns it to the blood. Reasons for Laboratory tests To assist in diagnosing disease To identify abnormalities To assess inflammation To determine baseline value To monitor serum level of medications To assess the effects of medications

1. 2. 3. 4. 5. 6.

Diagnostic Tests Related to Cardiovascular Function

Complete Blood Count For evaluation of general health status Elevated RBC s suggest inadequate tissue oxygenation. Hypoxia stimulates renal secretion of erythropoietin. This stimulates the bone marrow to increase rbc production (polycythemia) Elevated WBC c may indcate infectious heart disease and myocardial infarction Erythrocyte Sedimentation Rate (ESR) It is a measurement of the rate at which RBC s settle out of anticoagulated blood in an hour. It is elevated in infectious heart disorders or myocardial infarction Normal range is as follows: Males : 15 20 mm/hr Females : 20 30 mm/hr
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Blood Coagulation Test 1. Prothrombin Time (PT, Pro Time) 2. Partial Thromboplastin Time (PTT) 3. Activated partial Thromboplastin Time (APTT) Prothrombin Time (PT, Pro Time) It measures the time required for clotting to occur after thromboplastin and calcium are added to decalcified plasma. It is valuable in evaluating the effectiveness of coumadin. Therapeutic range is 1.5 to 2 times the normal or control. Normal range is 11 to 16 seconds. Partial Thromboplastin Time (PTT) It measures the time required for clotting to occur after a partial thromboplastin reagent is addedd to blood plasma. It is the best single screening test for disorders of coagulation. It is determined to evaluate the effectiveness of heparin. Therapeutic range is 2 to 2 times the normal or control. Normal range is 60 to 70 secs. Activated Partial Thromboplastin Time (APTT) It has the same purpose as PTT. It is most specific test to evaluate effectiveness of heparin. Therapeutic range is 2 to 2.5 times the normal or control. Normal range is 30 to 45 secs. Blood Urea Nitrogen BUN) It is indicator of renal function. Decreased cardiac output leads to low renal tissue perfusion and reduction in glomerular filtration rate. The BUN level becomes elevated. Normal range is 10 to 20mg/dl

[BLOOS LIPIDS] Cholesterol The client should be on NP for 10 to 12 hours. Normal range is 150 to 250 mg/dl

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Triglycerides The client should observe fasting for 10 12 hours. Normal range is 140 to 200 mg/dl Blood Cultures To assist in the diagnosis of infectious disease of the heart e.g. pericarditis Caution is taken to prevent contamination of the specimen. [Enzymes Studies] Aspartate Aminotransferase AST) Formerly, SGT Elevated level indicates tissue necrosis Normal range is 7 to 40 mu/ml Range with Myocardial Infarction - Initial elevation : 4 to 6 hours - Peaks: 24 to 36 hours. - Returns to normal : 4 to 7 days Creatine Phosphokinase CK-MB) It is the most cardiac specific enzymes It is an accurate indicator of myocardial damage Normal range is : y Males : 50 325 mu/ml y Femaes : 50 250 mu/ml Range with Myocardial Infarction - Onset : 3 to 6 hours - Peaks: 12 to 18 hours - Returns to normal : 3 to 4 days Lastic Dehydrogenase (LDH) Among five LDH isoenzymes, LDH1 is the most sensitive indicator of myocardial damage. In MI, LDH1 is elevated and its level exceeds LDH2. This makes LDH1/LDH2 ratio flipped . Normal range is 100 to 225 mu/ml Range with Myocardial Infarction Onset: 12 hours Peaks : 48 hours Returns to normal: 10 to 14 days
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Hydroxybutyrate Dehydrogenase (HBD) Elevation of HBD is always acconpanied by elevation of LDH levels It is valuable in detecting silent MI because it remains elevated for a long period of time, even after the other enzymes have returned to normal. The HBD/LDH ratio may be increased in MI Normal range with M.I. Onset : 10 to 12 hours Peaks : 48 to 72 hours Returns to normal : 12 to 13 days Urinalysis This is test is performed to assess the effects of cardiovascular disease on renal function and the existence of concurrent renal or systemic disease. E.g. glomerulunephritis, hypertension or diabetes. Albuminuria is detedted in clients with malignant hypertension and CHF. Myoglobinuria supports diagnosis of MI Blood Uric Acid (BUA This reflects adequacy of renal tissue perfusion thereby glomerular filtration of metabolites. Cardiovascular disorders results to decreased renal tissue perfusion. This will cause impairement of the ability of the kidneys to clear plasma of end products of metabolism. Normal range is 2.5 to 8 mg/dl Serologic Tests VDRL helps indicate presence of syphilis. This disease involves development of aortic disorders. Serum Electrolytes Electrolytes affect cardiac contractility, specifically Na, K, Ca Normal range is as follows: Na: 135 to 145 mEq/ml K : 3.5 to 5 mEq/ml Ca: 4.5 to 5.5 mEq/ml Electrocardiography (ECG, EKG) It is the graphical recording of the electrical activities of the heart. It indicates alterations in myocardial oxygenation.
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It is the first diagnostic test done when cardiovascular disorder is suspected. Inform the client that the procedure is painless. He will not experience electrocution or a shock. Waves, complexes and intervals P wave. Depolarization of atria. Duration is 0.04 to 0.11 secs. PR interval. Time of impulse transmission from SA node to the AV node. Duration is 0.12 to 0.20 secs. QRS complexes. Depolarization of the ventricles. Duration is 0.05 to 0.10 secs. ST segment. Represents the plateau phase of the action potential. T wave. Ventricular repolarization. Should not exceed 5 mm amplitude. Common ECG Changes - Hypokalemia U-wave Depressed ST segment Short T wave - Hyperkalemia Prolonged QRS complex Elevated ST segment Peaked T wave - C.Myocardial Infarction Elevated St segment (this is the first to occur in MI) Inverted T wave Pathologic Q wave (this becomes permanent in the ECG complexes of the post M.I. Client) Holter Monitoring It is continuous (24 hours) ECG monitoring The portable monitoring system is called telemetry unit. This attempts to assess the activities which precipitate dysrhythmias, and the time of the day when the lient experiences dysrhythmias. The nurse should log/record the activities of the client, and any unusual sensations experienced. [Invasive Hemodynamic Monitoring] Central Venous Pressure Monitors the pressures within the right atrium

1. 2. 3. 1. 2. 3. 1. 2. 3.

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Monitors blood volume, adequacy of venous return to the heart, pump function of the right side of the heart. The O level of the manometer be placed at the right, mid-axillary, 4th ICS, the approximate level of right atrium when supine position. Place the client in supine position or in the same position as during the initial reading. Practice strict asepsis. Cleanse catheter insertion site and change sterile dressing daily. Normal readings:  Superior vena cava : 0-2 cm. H20  Right atrium : 5 12 H20 Use other parameters to validate CVP reading BP, urine output, pulse. Pulmonary Artery Pressure & Pulmonary Capillary Wedge Pressure Swan Ganz catheter is inserted via antecubital vein into the right side of the heart and is floated into the pulmonary artery. It reflects pressure in the left heart. Swan Ganz catheter is a flow directed, baloon tipped -, 4 lumen catheter. The catheter allows continuous monitoring of the following: Right and Left ventricular function. Pulmonary artery pressures (PAP,PCWP) Cardiac output Arterial venous oxygen difference. Normal range  PAP : 4 12 mmHg  PCWP : 4 12 mmHg PCWP reading above 25 mmHg suggest impending pulmonary edema. Nursing Interventions: Inflate baloon only for PCWP readings; deflate between readings. Observe catheter insertion site; culture site every 48 hours. Assess extremity for color, temperature, capillary filling sensation. [Sonic Studies] Echocardiography Uses ultrasound to assess cardiac structure and mobility. No special preparation is required. It is painless and takes approximately 30 to 60 minutes to complete. The client has remain still, in supine position slightly to the left side, with HOB elevated 15 to 20 degrees.

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Transesophageal Echocardiography (TEE) Allows ultrasonic imaging of the cardiac structures and great vessels via esophagus. Nursing Intervention Before TEE: Ascertain history of esophageal surgery, malignancy, or allergy to anesthetic or sedatives. NPO for 4 to 6 hours before the procedure. Encourage to void before the procedure Remove dentures and other oral prosthetics. Administer sedatives as ordered. Keep suction and resuscitation equipment readily available. Cardiac monitoring is done during the entire procedure. Topical spray anesthetic is administered to depress gag reflex. Place the patient in chin to chest position to facilitate passage of endoscope. Nursing Intervention after TEE NPO until gag reflex returns. Place in Lateral or semi Fowler s position. Encourage to cough. Throat lozenges or rinses may be used to relieve throat soreness. Observe for sings and symptoms of complications, e.g. pharyngeal bleeding, cardiac dysrhythmias, vasovagal reaction, and transient hypoxemia. Phonocardiography Involves the use of electrically recorded amplified cardiac sounds. It is helpful in assessing the exact timing and characteristics of murmurs and extra heart sounds. Preparation of client is similar to echocardiogram. Stress Testing or Exercise Testing ECG is monitored during exercise on a treadmill or a bicycle like device. The purpose of stress are as follows. Identify ischemic heart disease. Evaluate patients with chest pain. Evaluate patients with chest pain. Develop individual fitness program. Nursing Interventions Treadmill Test Get adequate sleep the night before the test. Avoid teas, coffee and alcohol on the day of the test. Avoid smoking and taking nitroglycerine, 2 hours before the test. Wear comfortable, loose fitting clothes. Eat a light breakfast/lunch at least 2 hours before the test.
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Wear low-heeled, rubber soled pair of shoes Inform the physician if any unusual sensations develops during the test. Rest after the test. Radiologic Test Chest Roentgenograms (X-rays) To determine overall size and configuration of the heart and size of the cardiac chambers. Cardiac Fluoroscopy Facilitates observation of the heart from varying views while it is in motion. Cardiac Catheterization The purpose of the test are as follows: Assess: oxygen levels, pulmonary blood flow, cardiac output, heart structures. Coronary Artery Visualization Right-sided heart catherization is done by insertion of a catheter via a cutdown into a large vein, e.g. medial cubital or brachial vein. Left-sided heart catherization is done by passing a catheter into the aorta via the brachial or femoral artery. Nursing Interventions: Cardiac Catheterization Before the Procedure Provide psychosocial support Assess for allergy to iodine/seafoods Obtain baseline VS Withold meals before the procedure Have client void Administer sedatives as ordered. Mark distal pulses. Do cardiac monitoring Done under local anesthesia May experience warm or flushing sensation as the contrast medium injected. Fluttering sensation is felt, as the catheter enters the chambers of the heart. After the procedure: Bed rest: if the catheter insertion site is an upper extremity, until VS are stable, while if it is a lower extremity, for 24 hours. Monitor VS, especially peripheral pulses. Monitor ECG, note for dysrhythmias. Apply pressure dressing and a small sand bag or ice over the puncture site. To prevent bleeding. Immobilize affected extremity in extension. To promote adequate circulation.
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Do not elevate HOB more than 30 degrees if femoral site was used. Monitor extremities for color, temperature and tingling. Angiography/Arteriography Involves introduction of contrast medium into vascular system to outline the heart and blood vessels. It may be done during cardiac catheterization Nursing interventions are similar to that of cardiac catheterization. Observe for hypotension after procedure because the contrast medium may cause profound diuretic effect. Magnetic Resonance Imaging (MRI) Strong magnetic field and radiowaves are used to detect and define differences between healthy and diseased tissues. MRI can actually show the heart beating and the blood flowing in any direction. It can image over 3 spatial dimension and overtime. It is used for examination of the aorta, detection of tumors, cardiomyopathies and pericardiac disease. Nursing Interventions: MRI Secure written consent. Inform the client that the procedure lasts 45 to 60 minutes. Assess for claustrophobia. The client will be laced in a tunnel like device. Remove all metal items, e.g. watch, eyeglassess and jewelry. Instruct the client to remain still during the procedure. Inform the client that MRI unit makes a loud , knocking noise. Caution: client with pacemakers, prosthetics valves or recently implanted clips or wires are not eligible for MRI scans. Myocardial Scintigraphy The procedures involves intravenous injections of a radioactive isotopes via a catheter. Myocardial function, motion and perfusion are studied through the use of an external gamma camera. Techniques used are as follows: Thallium 201 scintigraphy Dipyridamole thalium 201 test Technetium 99m Ventriculography First pass cardiac study Nursing Interventions: Myocardial Scintigraphy Inform client that ECG or treadmill test may be done during the procedure.
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Assess for pregnancy because the test involves radiation exposure. Instruct the client to take a light meal, to prevent nausea and stomach cramping during exercise and for better uptake of the radioisotopes. Omit the usual dose of prescribe beta-blockers, calcium channel blockers and xanthines before the procedure. Instruct the client to report any chest pain experienced during the procedure. Non Invasive Hemodynamic Monitoring: Intra-arterial Pressure Monitoring This provides continuous detection of arterial BP via an indwelling intra-arterial catheter. It is valuable in monitoring the BP of the clients with low cardiac output, fluctuating hemodynamic status and excessive peripheral vasoconstriction and with whom cuff Bp measurements are undetectable. Intra-arterial readings are at least 10mmHg higher than cuff BP readings. The intra-arterial BP line can be used for obtaining blood samples for ABG and blood studies. Heparinize the catheter to maintain patency. Check catheter insertion site for hemorrhage, hematoma, redness or signs of infection. Do neurovascular check distal to catheter insertion site color, temperature, capillary filling and sensation.

CARDIAC ASSESSMENTS
Health History 1. Obtain Description of present illness and chief complain 2. Chest pain, SOB, Edema etc 3. Assess Risk factors Physical Examination 1. Vitals Signs 2. Inspection of the skin 3. Inspection of the thorax 4. Palpation of the PMI,pulses 5. Auscultation of the heart sounds Laboratory and Diagnostic Studies 1. CBC 2. Cardiac Catheterization 3. Lipid profile 4. Arteriography 5. Cardiac enzymes and proteins
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6. CXR 7. CVO 8. EEG 9. Holter Monitoring 10. Exercise ECG

CARDIAC DISEASES
Physiologic Changes of Aging 1. Aorta & arteries tend to become less distensible 2. Heart becomes less responsive to catecholamines 3. Maximal exercise heart rate declines 4. Decreased rate of diastolic relaxation ( in BP is more pronounced for systolic BP than diastolic BP) a. Note that hypertensionisNOT a normal age-related process 5. Compensatory mechanism are delayed/insufficient = orthostatic hypotension is common 6. Thickness of LV wall may increase with age due to blood vessel changes

CORONARY ARTERY DISEASE (CAD)

Also known as coronary HEART disease (CHD) Describes heart disease caused by impaired coronary blood flow Common cause: atherosclerosis CAD can cause the following:  Angina  Myocardial Infarction (MI) = heart attack  Cardiac dysrhythmias  Conduction defects  Heart failure  Sudden death Men are more often affected than women Approximately 80% who die of CHD are 65+ y/o Pathophysiology Physical Assessment Inspection:  Skin color  Neck vein distention (jugular vein)  Respiration  Peripheral edema

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 Palpation:  Peripheral pulses Auscultation:  Heart sounds (presence of S3 in adults & S4)  Murmurs audible vibrations of the heart & great vessels produced by turbulent blood flow  Pericardial friction rub extra heart sound originating from the pericardial sac - may be a sign of inflammation, infection, or infiltration - described as a short, high-pitched scratchy sound Common Clinical Manifestations Dyspnea  Dyspnea on exertion may indicate decreased cardiac reserve  Orthopnea a symptom of more advanced heart failure  Paroxysmal nocturnal dyspnea severe SOB that usually occurs 2-5hrs after onset of sleep Chest Pain may be due to decreased coronary tissue perfusion or compression & irritation of nerve endings Edema increased hydrostatic pressure in venous system causes shifting of plasma resulting to interstitial fluid accumulation Syncope due to decreased cerebral tissue perfusion Palpitations Fatigue

Diagnostics  ECG (Electrocardiography) graphical recording of the heart s electrical activities; 1st diagnostic test done when cardiovascular disorder is suspected  Waves: P wave atrial depolarization (contraction/stimulation) QRS complex ventricular depolarization (changes are irreversible) ST segment ventricular repolarization (changes are reversible) U wave hypokalemia  PR interval (time for impulse to travel) = 0.12-0.20s (3-5 squares) for AV block  QRS = 0.10s or (<2squares) for electrolyte &/or ventricular imbalance  Abnormalities: a. absent P wave = atrial fibrillation b. saw-tooth pattern = atrial flutter c. elevated ST segment = MI d. 3rd degree heart block = prolonged PR then progressively prolonged Electrical Heart Conduction ECG Sample Tracings Cont  Cardiac Enzymes (Cardiac Markers): st 1 : Myoglobin a. urine = 0 2mg/dL ( within 30mins 2hrs after MI)
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b. blood = <70mg/dL 2 : Troponin* - regulates calcium-mediated contractile process released during MI (Troponin T & I) - blood = <0.6mg/dL - within 3-6hrs after MI & remains elevated for 21 days upon onset of attack 3rd: Creatinine kinase (CK) intracellular enzymes found in muscles converting ATP to ADP CK-MB specific to myocardial tissue ( within 4-6hrs & decreases to normal within 2-3days) male = 12-70 mg/dL female = 10-55 mg/dL th 4 : LDH (specifically LDH1- most sensitive indicator of myocardial damage) = 45-90mg/dL - within 3-4 days & remains elevated for 14 days  Stress Test / Treadmill Test (Treadmill Stress Test) ECG monitoring during a series of activities of patient on a treadmill  Purposes: identify ischemic heart disease evaluate patients with chest pain evaluate effectiveness of therapy develop appropriate fitness program  Instructions to patient: get adequate sleep prior to test - avoid: caffeinated beverages, tea, alcohol, on the day before until the test day - wear comfortable, loose-fitting clothes & rubber-soled shoes on the test day - light breakfast on the day of the test - inform physician of any unusual sensations during the test - rest after the test
nd

Pharmacologic Stress Test use of intravenous injection of pharmacologic vasodilator (dipyridamole, adenosine, or dobutamine) in combination of radionuclide myocardial imaging  To evaluate presence of significant CHD for patients contraindicated in TST  Dipyradamole blocks cellular re-absorption of adenosine (endogenous vasodilator) & increases coronary blood flow 3-5x above baseline levels  If with CHD, the resistance vessels distal to the stenosis already are maximally dilated to maintain normal resting flow, thus, further vasodilatation does not produce increased blood flow  Dobutamine used in patients with bronchospastic pulmonary disease - increases myocardial O2 demand by increasing cardiac contractility, HR, & BP Cardiac Catheterization involves passage of flexible catheters into great vessels & heart chambers under local anesthesia - lab is equipped for viewing & recording fluoroscopic images & for measuring pressures in the heart & great vessels, cardiac output studies, & for obtaining ABG samples - Epinephrine to counteract possible allergic reactions  Right heart Catheterization catheter inserted into peripheral veins (basilic or femoral) then advanced into the right heart  Left heart Catheterization catheter inserted retrograde through peripheral artery (brachial or femoral) into the aorta & left heart

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 Coronary Angiogram injection of radiographic contrast medium into the heart so that an outline of moving structures are visualized & filmed  Coronary Arteriography - injection of radiographic contrast medium into the coronary arteries permits visualization of lesions in these vessels Nursing Interventions for Cardiac Catheterization Before Procedure:  Check consent form  for allergies to seafood & iodine  NPO post midnight  Baseline V/S  Explain that warm or flushing sensation may be felt upon administrationof the dye; fluttering sensation may be felt as catheter enters the heart  Administer sedatives as ordered  Have the client void prior to transport to cath lab After Procedure:  Bed rest upper extremity catheter = until stable v/s, HOB not more than 30 - lower extremity = 24hrs, flat on bed for 6hrs  Apply pressure (5lb-sand bag) over puncture site & monitor for bleeding  Monitor v/s q15 for 1st 2hrs then q1 until stable v/s, esp. peripheral pulses  Immobilize affected extremity in extension for adequate circulation  Monitor for color & temperature changes of extremities  Instruct client to report tingling sensations  Swan-Ganz Catheterization to determine & monitor cardiovascular status; inserted via antecubital vein into the right side of the heart & is floated into the pulmonary artery 4 lumens: 1. CVP specific to right heart RA = 0-12 RV = 5-12  Indications: increased CVP = heart failure -decreased CVP = hypovolemia 2. Pulmonary pressures:  PAP (pulmonary artery pressure) = 20-30mmHg  PCWP (pulmonary capillary wedge pressure) = 8-13mmHg ( for pulmonary edema) 3. Specimen collection tube also used for administering meds 4. Balloon  Echocardiography uses ultrasound to assess cardiac structure & mobility  Doppler U/S to detect blood flow of artery & vein specifically of lower extremities (No smoking 1hr before the test)  Holter Monitoring portable 24hr ECG monitoring which attempts to assess activities which precipitate dysrhythmias & its time of the day  MRI magnetic fields & radiowaves are used to detect & define abnormalities in tissues (aorta, tumors, cardiomyopathy, pericardiac disease) - shows actual beating & blood flow; image over 3 spatial dimensions  Secure consent
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 Assess for claustrophobia  Remove metal items (jewelries, eyeglasses)  Instruct client to remain still during the entire procedure  Inform client of the duration (45-60mins)  CI: clients with pacemakers, prosthetic valves, recently implanted clips or wires Types of CHD

Angina Pectoris / Myocardial Ischemia

    Ischemia suppressed blood flow Angina to choke Occurs when blood supply is inadequate to meet the heart s metabolic demands Symptomatic paroxysmal chest pain or pressure sensation associated with transient ischemia

Types A. Stable angina the common initial manifestation of a heart disease  Common cause: atherosclerosis (although those with advance atherosclerosis do not develop angina)  Pain is precipitated by increased work demands of the heart (i.e.. physical exertion, exposure to cold, & emotional stress)  Pain location: precordial or substernal chest area  Pain characteristics: - constricting, squeezing, or suffocating sensation - Usually steady, increasing in intensity only at the onset & end of attack - May radiate to left shoulder, arm, jaw, or other chest areas - Duration: < 15mins - Relieved by rest (preferably sitting or standing with support) or by use of NTG B. Variant/Vasospastic Angina (Prinzmetal Angina)  1st described by Prinzmetal & Associates in 1659  Cause: spasm of coronary arteries (vasospasm) due to coronary artery stenosis  Mechanism is uncertain (may be from hyperactive sympathetic responses, mishandling defects of calcium in smooth vascular muscles, reduced prostaglandin I2 production)  Pain Characteristics: occurs during rest or with minimal exercise - commonly follows a cyclic or regular pattern of occurrence (i.e.. Same time each day usually at early hours)  If client is for cardiac cath, Ergonovine (nonspecific vasoconstrictor) may be administered to evoke anginal attack & demonstrate the presence & location of spasm Nocturnal Angina - frequently occurs nocturnally (may be associated with REM stage of sleep) Angina Decubitus paroxysmal chest pain occurs when client sits or stands up Post-infarction Angina occurs after MI when residual ischemia may cause episodes of angina  Dx: detailed pain history, ECG, TST, angiogram may be used to confirm & describe type of angina  Tx: directed towards MI prevention\ - Lifestyle modification (individualized regular exercise program, smoking cessation)
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Stress reduction Diet changes Avoidance of cold PTCA (percutaneous transluminal coronary angioplasty) may be indicated if with severe artery occlusion

 

Drug Therapy Nitroglycerin (NTGs) vasodilators:  patch (Deponit, Transderm-NTG)  sublingual (Nitrostat)  oral (Nitroglyn)  IV (Nitro-Bid) -adrenergic blockers:  Propanolol (Inderal)  Atenolol (Tenormin)  Metoprolol (Lopressor) Calcium channel blockers:  Nifedipine (Calcibloc, Adalat)  Diltiazem (Cardizem) Lipid lowering agents statins:  Simvastatin Anti-coagulants:  ASA (Aspirin)  Heparin sodium  Warfarin (Coumadin)

Classification Class I angina occurs with strenuous, rapid, or prolonged exertion at work or recreation Class II angina occurs on walking or going up the stairs rapidly or after meals, walking uphill, walking more than 2 blocks on the level or going more than 1 flight of ordinary stairs at normal pace, under emotional stress, or in cold Class III angina occurs on walking 1-2 blocks on the level or going 1 flight of ordinary stairs at normal pace Class IV angina occurs even at rest Nursing Management Diet instructions (low salt, low fat, low cholesterol, high fiber); avoid animal fats  E.g.. White meat chicken w/o skin, fish Stop smoking & avoid alcohol Activity restrictions are placed within client s limitations NTGs max of 3doses at 5-min intervals  Stinging sensation under the tongue for SL is normal  Advise clients to always carry 3 tablets  Store meds in cool, dry place, air-tight amber bottles & change stocks every 6months
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 Inform clients that headache, dizziness, flushed face are common side effects.  Do not discontinue the drug.  For patches, rotate skin sites usually on chest wall  Instruct on evaluation of effectiveness based on pain relief Propanolols causes bronchospasm & hypoglycemia, do not administer to asthmatic & diabetic clients Heparin monitor bleeding tendencies (avoid punctures, use of soft-bristled toothbrush); monitor PTT levels; usedfor 2wks max; do not massage if via SC; have protamine sulfate available Coumadin monitor for bleeding & PT; always have vit K readily available (avoid green leafy veggies)

Myocardial Infarction
Death of myocardial tissue in regions of the heart with abrupt interruption of coronary blood supply Etiology 1. CAD 2. Coronary vasospasm 3. Coronary artery occlusion by embolus and thrombus 4. Conditions that decrease perfusion-hemorrhage,shock Risk factors 1. Hypercholesterolemia 2. Smoking 3. Hypertension 4. Obesity 5. Stress 6. Sedentary lifestyle


 

Assessment findings 1. Chest pain- chest pain is described as severe, persistent, crushing substernal discomfort Radiates to the neck, arm,jaw and back Occurs without cause, primarily early morning NOT relieved by rest or nitroglycerin Lasts 30 minutes or longer 2. Dyspnea 3. Dyphoresis 4. Cold clammy skin 5. Nausea and vomiting 6. Restlessness, sense of doom 7. Tachycardia or bradycardia 8. Hypotension 9. S3 and dysrhythmias
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 Laboratory findings
1. 2. 3. 4.

ECG- the ST segment is elevated. T wave inversion and presence of Q wave Myocardial enzymes- elevated CK-MB, LDH and Troponin levels CBX- may show elevated WBC count Test after the acute stage- Exercise tolerance test, thallium scans, cardiac catheterization

1. Provide Oxygen at 2 L/m, semi fowlers 2. Adminster medications  -Morphine to relieve pain  Nitrate, thrombolytics, aspirin and anticoagulants  Stool softener and hypolipidemic 3. Minimize patient anxiety  Provide information as to procedures and drug therapy 4. Provide adequate rest periods 5. Minimize metabolic demands  Provide soft diet  Provide a low-sodium, low cholesterol and low fat diet 6. Minimize anxiety  Reassure client and provide information as needed 7. Assist in treatment modalities such as PTCA and CABG 8. Monitor for complications of MI- especially dysehythmias, since ventricular tachycardia can happen in the first few hours after MI 9. Provide client teaching.

 Nursing Interventions

 Nursing Interventions after acute episode

1. 2. 3. 4. 5.

Maintain bed rest for the first 3 days Provide passive ROM exercise Progress with dangling of the feet at the side of the bed Proceed with sitting out of bed, on the chair for 30 minutes TID Proceed with ambulation in the room, toilet and hallway TID

 Cardiac Rehabilitation
  

To extend and improve quality of life Physical conditioning Patient who are able to walk 3-4 mph are usually ready to resume sexual activities

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Congestive Heart Failure

 Inability of the heart to pump sufficiently  The heart is unable to maintain adequate circulations to meet the metabolic needs of the body  Classified according to the major ventricular dysfunction- LEFT or RIGHT

 Etiology of CHF
1. 2. 3. 4. 5. 6. 7. 8. CAD Valvular heart disease Hypertension MI Cardiomyopathy Lung diseases Post-partum Pericarditis and cardiac tamponade  Left Sided CHF 1.Dyspnea 2. PND 3. Orthopnea 4. Pulmonary crackles/rales 5. cough with pinkish frothy sputum 6. tachycardia 7. cool extremities 8. cyanosis 9. decreased peripheral pulses 10. fatigue 11. oliguria 12. signs of cerebral anoxia  Right Sided CHF Peripheral dependent, pitting edema Weight gain Distended neck vein Hepatomegaly Ascited Body weakness Anorexia, nausea Pulsus alternans Laboratory findings 1. CXR may reveal cardiomegaly 2. ECG may identify cardiac hypertrophy
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1. 2. 3. 4. 5. 6. 7. 8.

3. Echocardiogram may show hypokinetic heart 4. ABG and pulse oximetry may show decreased O2 saturation 5. PCWP is increased in LEFT sided CHF and CVP is increased in RIGHT sided CHF Nursing interventions 1. Assess patient s cardio-pulmonary status 2. Assess VS, CVP and PCWP. Weigh patient daily to monitor fluid retention 3. Administer medications- usually cardiac glycosides are given- DIGOXIN or DIGITOXIN. Diuretics, vasodilators and hypolidemics are prescribed. 4. Provide adequate rest periods to prevent fatigue 5. Position in semi-fowler s to fowler s for adequate chest expansion 6. Prevent complications if immobility Nursing interventions after the acute stage 1. Provide oppurtunities for verbalization of feelings 2. Instruct the patient about the medication regimen- digitalis, vasodilators and diuretics 3. Instruct to avoid OTC drugs, Stimulants, smoking and alcohol 4. Provide potassium supplements 5. Instruct about fluid restriction 6. Provide adequate rest periods and schedule activities 7. Monitor daily weight and report signs of fluid retention

Acute Coronary Syndrome

 Unstable Angina/Non ST-Segment Elevation MI a clinicalsyndrome of myocardial ischemia  Causes: atherosclerotic plaque disruption or significant CHD, cocaine use (risk factor)  Defining guidelines: (3 presentations) 1. Symptoms at rest (usually prolonged, i.e.. >20mins) 2. New onset exertional angina (increased in severity of at least 1 class to at least class III) in <2months 3. Recent acceleration of angina to at least class III in <2months  Dx: based on pain severity & presenting symptoms, ECG findings & serum cardiac markers  When chest pain has been unremitting for >20mins, possibility of ST-Segment Elevation MI is usually considered ST-Segment Elevation MI (Heart Attack)  Characterized by ischemic death of myocardial tissue associated with atherosclerotic disease of coronary arteries  Area of infarction is determined by the affected coronary artery & its distribution of blood flow (right coronary artery, left anterior descending artery, left circumflex artery)

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 Dx: based on presenting S/Sx, serum markers, & ECG (changes may not be present immediately after symptoms except dysrhythmias; PVCs/premature ventricular contractions are common after MI)  Typical ECG changes: ST-segment elevation, Q wave prolongation, T wave inversion  Manifestations:  chest pain severe crushing, constricting, someone sitting on my chest - substernal radiating to left arm, neck or jaw - prolonged (>35mins) & not relieved by rest  Shortness of breath, profuse perspiration  Feeling of impending doom  Complications: death (usually within 1 hr of onset)  Heart failure & cardiogenic shock profound LV failure from massive MI resulting to low cardiac output  Thromboemboli leads to immobility & impaired cardiac function contributing to blood stasis in veins  Rupture of myocardium  Ventricular aneurysms decreases pumping efficiency of heart & increases work of LV Tissue Changes After MI Management of MI Initial Management: OMEN - O2 therapy via nasal prongs - adequate analgesia (Morphine via IV also has vasodilator property) - ECG monitoring -sublingual NTG (unless contraindicated; IV may be given to limit infarction size & most effective if given within 4hrs of onset) Thrombolytic Therapy best results occur if initiated within 60-90mins of onset (Streptokinase & Urokinase promote conversion of plasminogen to plasmin) Anti-arrhythmics: lidocaine, atropine, propanolol Anticoagulants & antiplatelets: ASA, heparin Stool softeners Surgery : 1. Revascularization PTCA Coronary stent implantation Coronary Artery Bypass Graft (CABG) no response to medical treatment & PTCA 2. Resection aneurysm Nursing Management Promote oxygenation & tissue perfusion (place client on semi-fowler s, O2 via nasal cannula, monitor v/s changes, remind client on his activity limitations & restrictions)
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Promote comfort & rest Monitor the ff perimeters: v/s, ECG, rate & rhythm of pulse, effects of ADLs on cardiac status Diet: low salt, low cholesterol, low calories, avoid alcohol & smoking Take prescribe meds at regular basis Stress management Resume sexual activity after 4-6wks from discharge or when client can go up 2 flights of stairs without difficulty 1. Assume less tiring position (non-MI partner takes active role). 2. Perform sexual activity in a cool, familiar place. 3. Take prescribed NTG before sexual activity 4. Refrain from sexual activity after a large meal or during a tiring day. 5. Moderation should be observed if palpitations, dizziness or dyspnea is observed

Alterations in Blood Flow in the Systemic Circulation

Buerger s Disease
Also known as Thromboangiitis obliterans Usually a disease of heavy cigarette smoker/tobacco user men, 25-40y/o Inflammatory arterial disorder that causes thrombus formation often extends to adjacent veins & nerves Affects medium-sized arteries (usually plantar & digital vessels in the foot or lower legs) unknown pathogenesis but it had been suggested that: 1. tobacco may trigger an immune response or 2. unmask a clotting defect; these 2 can incite an inflammatory reaction of the vessel wall Manifestations Pain predominant symptom; R/T distal arterial ischemia  Intermittent claudication in the arch of foot & digits Increased sensitivity to cold (due to impaired circulation Absent/diminished peripheral pulses Color changes in extremity (cyanotic on dependent position; digits may turn reddish blue) Thick malformed nails (chronic ischemia) Disease progression ulcerate tissues & gangrenous changes may arise; may necessitate amputation Diagnosis & Treatment Diagnostic methods those that assess blood flow (Doppler ultrasound & MRI) Tx: mandatory to stop smoking or using tobacco  Meds to increase blood flow to extremities  Surgery (surgical sympathectomy)  amputation  Rynaud s Disease Mechanism: intensive vasospasm of arteries & arterioles in thefingers Cause: unknown
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 Usually affects young women Precipitated by exposure to cold &strong emotions

Raynaud s phenomenon
associated with previous injury (i.e.. Frostbite, occupational trauma associated with use of heavy vibrating tools, collagen diseases, neuro d/o, chronic arterial occlusive d/o) Manifestations Period of ischemia (ischemia due to vasospasm)  change in skin color = pallor to cyanotic  1st noticed at the fingertips later moving to distal phalanges  Cold sensation  Sensory perception changes (numbness & tingling) Period of hyperemia intense redness  Throbbing  Paresthesia Return to normal color Note: although all of the fingers are affected symmetrically, only 1-2digits may be involved Severe cases: arthritis may arise (due to nutritional impairment)  Brittle nails  Thickening of the skin of fingertips  Ulceration & superficial gangrene of fingers (rare occasions) Diagnosis & Treatment Dx: initial = based on Hx of vasospastic attacks  Immersion of hand in cold water to initiate attack aids in the Dx  Doppler flow velocimetry used to quantify blood flow during temperature changes  Serial Computed thermography (finger skin temp) for diagnosing the extent of disease Tx: directed towards eliminating factors causing vasospasm & protecting fingers from injury during ischemic attacks  PRIORITIES: Abstinence in smoking & protection from cold  Avoidance of emotional stress (anxiety & stress may precipitate vascular spasm)  Meds: avoid vasoconstrictors (i.e.. Decongestants) -Calcium channel blockers (Diltiazem, Nifedipine, Nicardipine) decrease episodes of attacks Care Plan for Clients with Altered Cardiovascular Oxygenation Assessment: 1. Hx of symptoms (pain, esp. chest pain; palpitations; dyspnea) 2. v/s Nursing Dx: 1. ineffective tissue perfusion (cardiopulmonary) 2. Impaired gas exchange 3. Anxiety due to fear of death (clients with MI or Angina) Goals: 1. Relief of pain & symptoms
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B.

C.

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2. Prevention of further cardiac damage D. Nursing Interventions: 1. Pain control 2. Proper medications 3. Decrease client s anxiety 4. Health teachings (meds, activities, diet, exercise, etc)

Cardiogenic Shock
 Heart fails to pump adequately resulting to decreased cardiac output and decreased tissue perfusion  1. 2. 3. 4. 5. Etiology Massive MI Sever CHF Cardiomyopathy Cardiac trauma Cardiac tamponade

 Assessment findings: 1. HYPOTENSION 2. Oliguria (less than 30 ml/hour) 3. Tachycardia 4. Narrow pulse pressure 5. Weak peripheral pulses 6. Cold clammy skin 7. Changes in sensorium/LOC 8. Pulmonary congestion  Laboratory findings 1. Increased CVP

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Cardiogenic Tamponade
 A condition where restricts ventricular filling resulting to decreased cardiac output  Acute tamponade may happen when there is a sudden accumulation of about 50 ml in the pericardial sac  Assessment findings: 1. BECK s Triad Jugular vein distention  Hypotension  Distant/muffled heart sound 2. Pulsus paradoxus 3. Increased CVP 4. Decreased cardiac output  Nursing interventions 1. Assist in pericardiocentesis 2. Administer IVF 3. Monitor BCG, urine output and BP 4. Monitor for recurrence of tamponade

Hypertension
 A systolic BP greater than 140 mmHg and a diastolic pressure greater than 90 mmHG over a sustained period, based on two or more BP measurements  Types of hypertension: 1.Primary or ESSENTIAL- most common type 2. Secondary- due to other conditions like pheochromocytoma, renovascular hypertension, Cushing s. Conn s SIADH  Assessment findings 1. Headache 2. Visual changes 3. Chest pain 4. Dizziness 5. Nausea and vomiting  Major risk factors: 1. Smoking 2. Hyperlipidemia 3. DM 4. Age older than 60 5. Gender 6. Family history

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 Diagnostics Studies 1. Health history and PE 2. Routine laboratory-urinalysis,ECG, lipid profle, BUN, creatinine, FBS 3. Other lab CXR, creatinine clearance, 24 hours urine protein  Medical Management 1. Provide health teaching to patient  Teach about the disease process  Elaborate on lifestyle changes  Assist in meal planning to lose weight  Provide list of LOW fate, low sodium diet of less than 3 grams/day  Limit alcohol intake to 30 ml/day  Regular aerobic exercise  Stop smoking 2. Provide information about antihypertensive drugs  Instruct proper compliance and not abrupt cessation of drugs even if patient becomes asmpytomatic/improved condition  Instruct to avoid ove the counter drugs that may interfere with the current medication 3. Promote home care management  Instruct regular monitoring of BP  Involve family members in care  Instruct regular follow-up 4. Manage hypertensive emergency and urgency properl

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