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The most beautiful things in life

cannot be seen or even touched,


They must be felt with the heart.
-Helen Keller

RESPONSES TO ALTERED
OXYGENATION, CARDIAC AND
TISSUE PERIPHERAL PERFUSION/
TRANSPORT

LOURADEL ULBATA-ALFONSO, MAN, RN

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

Overview of anatomy and Physiology of


the Heart
The heart is a small
organ that weighs 300
g. and is
approximately the
size of a fist.
It is located in the
middle of the
mediastinum.

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

Chambers of the Heart


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

Valves of the Heart

The two types of cardiac valves are the


atrioventricular (AV) valves and the semilunar
valves.

The AV valves are the tricuspid valve and


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

The AV valves are held in place by the chordae


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

Valves of the Heart


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

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

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

Cardiac Conduction System:


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

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

Electrophysiologic Properties of the heart


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

Cardiac Output
Cardiac output (C.O) is the volume of blood ejected from
the left ventricle into the aorta per minute.
C.O = Stroke Volume x Heart Rate
(70 mls X 70 bpm = 4,900 mls or approximately 5 L)
The average cardiac output is approximately 5L/minute.
Stroke volume (SV) is the mount of blood rejected by the
left ventricle into the aorta per beat. The stroke volume
is determined by three factors, namely: preload,
contractility and afterload.
It is approximately 70 mls.

Preload is the degree of myocardial fiber stretch before contraction.


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

Autonomic Influences on cardiac Activity


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

The sympathetic nervous system (SNS) releases


norepinephrine which increases the heart rate
and the force of contraction of the heart.

The parasympathetic nervous system (PNS)


releases acetycholine from vagal fibers which

Baroreceptors
The baroreceptors in the carotid and
aortic bodies are pressure
sensitive structures.
Decreased BP causes a reflex SNS
response with increased pulse,
increased contractility and
vasoconstriction.
Increased BP causes reflex vagal
responces, which results in
decreased heart rate and passive
vasidilation in the systemic
arterioles. This phenomenon is
known as Marcys Law of the heart.

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

Arterial blood pressure (BP)


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

Arterial blood pressure (BP)


BP can be measured by invasive (catheter inserted in an
artery) and noninvasive techniques (using a
sphygmomanometer and a stethoscope).
Pulse pressure is the difference between the SBP and DBP and
it is normally about one third of the SBP.
Mean arterial pressure (MAP) is the perfusion pressure felt by
organs in the body, and a MAP of greater than 60 is necessary
to sustain the vital organs of an average person under most
conditions.

Physiologic Changes in the Heart with


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

Assessment of the clients


with Cardiovascular
Disorders

Assessment of the clients with


Cardiovascular Disorders
Nursing history
Physical examination
Common Clinical Manifestations
Diagnostic Tests

NURSING ASSESSMENT
SUBJECTIVE DATA

1. Health History
Identifying the risk factors
HPI
Past medical history
Medications
Family History
Lifestyle

Risk Factors

Non- Modifiable Risk factors


Age persons above 40 years of age are at high risk to
develop cardiovascular diseased. This is due to
degenerative changes in the heart and blood vessels.
Gender males are more prone to cardiovascular
disorders before the age of 65 years. However, females
have higher propensity to cardiovascular disorders after
the age of 65 years

Non- Modifiable Risk factors


Race cardiovascular disorders are among the 10
leading causes of death worldwide. In the U.S.,
cardiovascular disorders rank the number one
causes of morbidity.
Heredity person with family history for
cardiovascular disorders are at risk to develop these
diseases.

Modifiable Risk factors


Stress sympathetic response stimulation causes
increased secretion of norepinephrine. This results to
vasoconstriction and tachycardia. Increased BP and
increased cardiac workload occur.
Diet increased dietary intake of foods high in sodium,
fats and cholesterol predisposes a person to
cardiovascular disorders. Sodium retains water and
increases blood volume. This may cause hypertension.
High fats and high cholesterol diet predisposes a
person to atherosclerosis.

Modifiable Risk factors


Exercise regular pattern of exercise improves circulation to
different body parts including the heart and blood vessels;
maintains vascular tone; and enhances release of chemical
activators (tissue type plaminogen activators), which
prevent platelet aggregation and prevent blood clotting.
Sedentary lifestyle increases risk to cardiovascular disorders.
Cigarette smoking nicotine causes vasoconstriction and
spasm of the arteries; increases myocardial oxygen
demands; and adhesion of platelets. In addition, cigarette
smoking has been associated with decreased levels of HDL.
In cigarette smoking, more carbon dioxide is inhaled than
oxygen.

Modifiable Risk factors


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

Modifiable Risk factors


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

Modifiable Risk factors


Obesity this results to increased cardiac workload. The
heart has to pump blood supply to a larger body surface
area. May also be characterized by rise in serum lipid
levels.
Personality type or Behavioral Factors the type A
behavior pattern characterized by competitiveness,
impatience, aggressiveness and time urgency has been
correlated to coronary artery diseases (Cad). Although
the mechanism is unknown.

Modifiable Risk factors


Contraceptive pills may precipitate thromboembolism and
hypertension.
The estrogen component of oral contraceptive pills increase blood
viscosity, thereby increasing the risk to thromboembolism.
It also stimulates the liver to synthesize angiotensinogen. The
angiotensinogen triggers production of pulmonary converting
enzymes. This in turn causes conversion of angiotensinogen to
angiotensin I, a vasoconstrictor. Angiotensin I is further acted
upon by pulmonary converting enzyme and converted to
Angiotensin II, a very potent vasoconstrictor.

HISTORY OF PRESENT
ILLNESS

HISTORY OF PRESENT ILLNESS


What other symptoms has the patient
noticed?
How long has the patient been ill? What
has the course of the illness been?
Obtain the review of systems

Past medical history


Medical and surgical History
Hypertension, DM, Hyperlipidemia or other
chronic diseases which cause or aggravate
cardiovascular disease.
Past illness/hospitalizations: trauma to chest
( possible myocardial contusion; sore throat/
dental extractions (possible endocarditis);
rheumatic fever (valvular dysfunction,
endocarditis); thromboembolism (MI, Pulmonary
embolism)

MEDICATIONS
Current and past use of medications
Many cardiac drugs must be tapered off to
prevent a rebound effect.
Many drugs affect heart rate and may cause
orthostatic hypotension
Estrogen preparation may lead to
thromboembolism

FAMILY HISTORY
Ask for cardiovascular illnesses of
blood relatives

LIFESTYLE

Assess for risk factors to


cardiovascular disease such as
smoking, obesity, pattern of recurrent
weight gain after dieting, sedentary
lifestyle, stress, alcohol consumption.
A typical days diet

2. Common Clinical
manifestations of
Cardiovascular Disorders

2. Common Clinical manifestations of


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

2. Common Clinical manifestations of


Cardiovascular Disorders
1. CHEST PAIN
CHARACTERIZATION:
A. Nature and intensity
Ask pt to describe in own words what the pain is like- dull, sharp, crushing,
burning, heaviness, ache, pressure?
Ask pt to rate pain relative to pain experienced in the past, using a scale of 1-10
( 10 being the most severe pain and 1 the least)
B. Onset and duration
When did the pain start
How long did the pain episode last?
C. Location and radiation
Ask pt to point to area where it hurts most.

Pain Assessment Techniques


The patient's self-reported pain is often
measured by using pain scales
Numeric Pain Intensity Scale uses a 0-10
scale to assess the degree of pain.
Simple Description Intensity Scale, uses
such words as "mild", "moderate", and
"severe" to describe the patient's pain
intensity.

Pain Assessment Techniques


Visual Analog Scale (VAS) requires patients
to mark a point on a 10 cm horizontal or
vertical line to indicate their pain intensity,
with
0 indicating "no pain and 10 indicating
"the worst possible pain".

TYPES OF CHEST PAIN

Angina Pectoris
Substernal or
5-15min
retrosternal pain
spreading across
chest; may radiate to
inside of arm, neck,
or jaw

Usually related Rest,


to exertion,
nitroglycerin,
emotion,
oxygen
eating, cold

Myocardial Infarction

MI

Substernal pain or pain over


>15
precordium; may spread
min
widely throughout chest. Pain
in shoulders and hands may
be present.

Occurs
spontaneousl
y but may be
sequela to
unstable
angina

Morphine
sulfate,
successful
reperfusion of
blocked
coronary
artery

Esophageal Pain
Substernal pain;
may be projected
around chest to shoulders.

560 min

Recumbency, cold Food, antacid. Nitroliquids, exercise.


glycerin
relieves
May occur
Spasm.
Spontaneously.

anxiety
Pain over chest; may be 23 min
variable. Does not radiate.
Patient may complain of
numbness and tingling of
hands and mouth.

Stress, emotional
tachypnea

Removal of stimulus,
relaxation

2. Common Clinical manifestations of


Cardiovascular Disorders
1. CHEST PAIN
D. Precipitating and relieving factors
What activity was patient doing just before pain (rapid
walking, exposure to cold, eating a spicy meal, sitting quietly,
awakened from sleep?
What relieves the pain ( rest, medication, change of position)

E. Associated signs and symptoms; observe for


nausea, diaphoresis, dyspnea, fatigue, palpitations,
disorientations.

2. Common Clinical manifestations of


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

2. Common Clinical manifestations of


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

2. Common Clinical manifestations of


Cardiovascular Disorders
TYPES OF DYSPNEA
1. Exertional/ Dyspnea on exertion (DOE).
Breathlessness on moderate exertion that is relieved by rest.
This may indicate decreased cardiac reserve (hearts ability to adjust and adapt to
increased demands).

2. Paroxysmal nocturnal
Sudden dyspnea at night; awakens patient with feeling of suffocation; sitting up relieves
breathlessness
severe shortness of breath usually occurs 2 to 5 hours after the onset of sleep. During
waking hours, the client usually assumes upright position most of the time. This causes
venous pooling. When the client lies recumbent during the night, the blood from the lower
extremities are distributed to the upper parts of the body and lung congestion may occur
and the client experiences difficulty of breathing.

2. Common Clinical manifestations of


Cardiovascular Disorders
TYPES OF DYSPNEA
3. Orthopnea
Shortness of breath when lying down. Patient must keep head elevated
with more than one pillow to minimize dyspnea.
usually a symptom of more advanced heart failure

SIGNIFICANCE:
It may be a sign of left ventricular failure or transient congestive heart
failure

Common Clinical manifestations of


Cardiovascular Disorders
3. PALPITATIONS
CHARACTERIZATION:
A. Do you feel your heart pound, beat too fast, or skip beats?
B. Do you feel dizzy or faint when you experience these sensations?
What brings on these sensations?
How long does it last?
What do you do to relieve these sensations?

SIGNIFICANCE:
Pounding, jumping sensations in chest usually due to tachydysrhythmia.
Skipped beats usually due to premature atrial or ventricular beats.

Common Clinical manifestations of


Cardiovascular Disorders
4.

WEAKNESS & FATIGUE

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

Common Clinical manifestations of


Cardiovascular Disorders
5. DIZZINESS AND SYNCOPE
CHARACTERIZATION:
A. How many episodes of syncope/near syncope have been experienced?
B. Did a hot room, hunger, sudden position change, or pressure on your neck precipitate the
episodes?
C. How long does dizziness last?
D. What relieves dizziness?

SIGNIFICANCE:
Syncope is transient loss of consciousness due to a fall in cardiac output with resulting
cerebral ischemia. Near syncope refers to lightheadedness, dizziness, temporary confusion.
Dysrhythmias related to cardiac disease may cause syncope.

Common Clinical manifestations of


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

PITTING EDEMA GRADING SYSTEM

Common Clinical manifestations of


Cardiovascular Disorders
7. Cough
Cough with dyspnea may also occur with
cardiac disease such as left-sided CHF.
8. CYANOSIS
9. CLUBBING OF FINGERS

CLUBBING

CLUBBING
-Clubbing of the fingers is associated with
decreased oxygen.
In clubbing, the distal tips of the fingers
become bulbous, the nails are thickened
hard, and curved at the tip, and the nail bed
feels boggy when squeezed.
- Separation from the nail bed produces a
white, yellowish, or greenish color on the
non-adherent portion of the nail.

OBJECTIVE DATA:
PHYSICAL EXAMINATION

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

PHYSICAL EXAMINATION
B. VITAL SIGNS
1. PULSE
Time for 1 full minute; note irregularity.
Compare apical and radial pulse (pulse deficit)
TYPES:

Collapsing: Aortic insufficiency


Bisferiens (double beat): Combined aortic stenosis (AS) and insufficiency
Pulsus parvus (weak) et tardus (delayed): Severe aortic stenosis
Pulsus alternans (alternating strong and weak pulse): Severe LV dysfunction
Pulsus paradoxus (marked inspiratory decrease in strength of pulse): Cardiac
tamponade, pericardial constriction, severe obstructive airway disease.

PHYSICAL EXAMINATION
B. VITAL SIGNS
2. BLOOD PRESSURE
Take pressure on both arms and note differences (5-10 mmhg
difference is normal). Difference > 10 may indicate subclavian steal
syndrome or dissecting aortic aneurysm.
Determine pulse pressure (systolic pressure minus diastolic pressure)
to evaluate cardiac output (30-40 mmHg is NORMAL; less than 30
mmHg indicates decreased cardiac output).
Note presence of pulsus alternans- loud sounds alternate with soft
sounds with each auscultatory beat (hallmark of left ventricular
failure)
Note presence of pulsus paradoxus- abnormal fall in blood pressure
during inspirations (cardiac sign of cardiac tamponade)

PHYSICAL EXAMINATION
B. VITAL SIGNS
3. ASSESS FOR POSTURAL OR ORTHOSTATIC
HYPOTENSION
Orthostatic hypotension prompt hypotension occurs with
assumption of the upright position
May be due to volume depletion, bed rest, drugs such as beta
or alpha adrenergic blockers or neurologic disease.
Note changes in heart rate and blood pressure in at least two
of three positions: lying, standing, sitting; allow at least 3
minutes between position changes before obtaining rate and
pressure.
Orthostatic changes evident if BP decreases by 15 mmHg
(systolic) or 5 mmHg diastolic and/or HR increases 15 beats

PHYSICAL EXAMINATION
C. SKIN AND EXTREMITIES
A. PALPATE FOR TEMPERATURE AND EVIDENCE OF
DIAPHORESIS
Warm/dry skin indicates adequate cardiac output.
Cool, clammy skin indicates compensatory
vasoconstriction due to low cardiac output.
B. OBSERVE FOR CYANOSIS, JAUNDICE AND FATTY SKIN
DEPOSITTS (XANTHOMAS)
1. Cyanosis

PHYSICAL EXAMINATION
C. SKIN AND EXTREMITIES
B. OBSERVE FOR CYANOSIS, JAUNDICE AND FATTY SKIN DEPOSITTS
(XANTHOMAS)
1. CYANOSIS bluish discoloration of the skin and mucous membranes
A. CENTRAL CYANOSIS

low oxygen saturation of arterial blood.

Noted on tongue, buccal mucosa and lips.


Indicative of cardiorespiratory disease; may be evident in heart failure or pulmonary edema.
B. PERIPHERAL CYANOSIS

Reduced blood flow through extremities due to vasoconstriction.


Noted on distal aspects of extremities, tip of the nose and earlobes
Due to cold exposure or obstructive peripheral vascular disease

PHYSICAL EXAMINATION
C. SKIN AND EXTREMITIES
B. OBSERVE FOR CYANOSIS, JAUNDICE AND FATTY SKIN
DEPOSITTS (XANTHOMAS)
2. JAUNDICE yellow discoloration of the sclera of eyes
or skin
may be a sign of right sided heart failure or chronic
hemolysis from prosthetic heart valve
3. YELLOW PLAQUE (fatty deposits) on the skin
Associated with hyperlipidemia and coronary artery
disease

YELLOW PLAQUES

PHYSICAL EXAMINATION
C. SKIN AND EXTREMITIES
C. INSPECT THE NAIL BEDS FOR SPLINTER HEMORRHAGES
and CLUBBING
Splinter hemorrhages
Thin brown lines in nail beds associated with endocarditis

Clubbing swollen nail base and loss of normal angle


Associated with congenital heart disease and cor pulmonale

Capillary refill time:


is a quickly test to assess the adequacy of
circulation in an individual with poor cardiac
output.
An area of skin is pressed firmly by (say) a
fingertip until it becomes white; the number of
seconds for the area to turn pink again indicates
capillary refill time.
Normal capillary refill takes around 2 seconds.

PHYSICAL EXAMINATION
C. SKIN AND EXTREMITIES
D. INSPECT AND PALPATE FOR EDEMA
Edema is an abnormal accumulation of serous fluid in soft tissues.
Location of edema is influenced by gravity fluid collects bilaterally in lower
parts of the body: sacral area (bedridden patients), ankles, and feet
(ambulatory pts) and pits with pressure (dependent-pitting edema)
Weight gain occurs before clinical evidence of edema. Edema is a late sign of
heart failure.
Describe the degree of edema in terms of depth of pitting that occurs with
slight pressure:
Mild 0 to inch, moderate- inch, severe- to 1 inch

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

CHEST and NECK

JUGULAR VEIN

Measuring Jugular Venous Pressure


-Position patient with
the head of bed at 30 to
45-degree angle.

- Place a ruler vertically,


perpendicular to the
chest at the angle of
Louis (sternal angle).

-identify the highest level of the jugular


vein pulsation; if unable to see pulsations,
use the highest level of jugular vein
distension.
Place another ruler horizontally at the
point of the highest level of the venous
pulsation.
Measure the distance up from the chest
wall.
The normal JVP is less than 3 cm.
A

central

venous

pressure

can

be

INTERPRETATION:

Elevated JVP: Right-sided CHF,


constrictive
pericarditis,
tricuspid
stenosis, or superior vena cava
obstruction.

Low JVP: Hypovolemia.

Palpation
Palpating the Carotid

Palpating the Carotid


-Lightly

palpate

each

carotid

separately.
- Note rate, rhythm, amplitude,
contour, symmetry, elasticity, thrills.

PALPATING THE PRECORDIUM


Right 2nd intercostal space

Aortic Area

Left 2nd intercostal space

Pulmonic Area

Left lower sternal border


Tricuspid area
Apex over apical impulse Mitral area

Landmarks

Palpating the Precordium


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

Palpating the Precordium


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

Palpating the Precordium


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

Palpating the Precordium


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

- Listen at each site with both the bell and


the diaphragm.

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

AUSCULTATION

Diaphragm medium and high frequency sounds


Bell low frequency sounds
Normally hear closure of valve Sounds from left side of
heart louder than equivalent sounds from right side of
heart

HEART SOUNDS
S1 closure of mitral and tricuspid
valves
S2 closure of aortic and pulmonic
valves
Low pitched sounds S3, S4, mitral

Right 2nd intercostal space

Aortic Area

Left 2nd intercostal space

Pulmonic Area

Left lower sternal border


Tricuspid area
Apex over apical impulse Mitral area

Landmarks

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

Murmurs and Stenosis


A valve that does not close efficiently, results in
the backflow of blood (i.e., insufficiency or
regurgitation).
A valve that does not open wide enough may
cause turbulent backflow secondary to
obstruction or narrowing (i.e., stenosis).

Assessment of other systems

Lungs
Abdomen

Diagnostic Tests and


Procedures

LABORATORY STUDIES
A. ENZYME and ISOENZYME TESTS
1. Creatinine Kinase (CK)
2. Lactic Dehydrogenase (LDH)
3. Aspartate Aminotransferase (AST, formerly known as
SGOT)
These enzymes are widely distributed in tissues and
elevated in condition NOT associated with MI such as
damage to the skeletal tissues, liver, brain, kidneys and
other organs.

CREATININE KINASE
Creatine kinase (CK) is an enzyme found in the
muscles
The level of the CK enzymes rises when the muscles
are damaged.
The three types of CK are called isoenzymes. They are:
CK-MM
which is found in the skeletal muscle
CK-MB
which is found in the heart and rises when heart muscle is
damaged
CK-BB

Lactic Dehydrogenase (LDH)


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

Aspartate Aminotransferase (AST,


formerly known as SGOT)
AST is normally found in red blood cells, liver,
heart, muscle tissue, pancreas, and kidneys.
AST formerly was called serum glutamic
oxaloacetic transaminase (SGOT).
When body tissue or an organ such as the heart or
liver is diseased or damaged, additional AST is
released into the bloodstream.
The amount of AST in the blood is directly related
to the extent of the tissue damage.

CARDIAC TROPONINS
Troponin, a complex of three contractile regulatory
proteins, troponin C, T and I, controls the calciummediated interactions between actin and myosin in
cardiac and skeletal muscles.
Troponin-I and T are specific to cardiac muscles,
unlike troponin-C which is associated with both
cardiac and skeletal muscles.
Hence, troponin-C is not used in the diagnosis of
myocardial damage.

MYOGBLOBINS
Is a protein in heart and skeletal muscles.
When muscle is damaged, myoglobin is
released into the bloodstream.

NURSING AND PATIENT CARE


CONSIDERATIONS
Ensure that enzymes are drawn in a serial pattern, usually on admission and
every 6 to 24 hours until 3 samples are obtained; enzyme activity is then
correlated to the extent of heart muscle damage.
Normal values, rise and peak of enzymes following MI include:
A. CK rise in 12 hours, peak in 36 to 72 hours, normalize (35- 232 IU) in 3-5 days
B. LDH rise in 12 hours, peak in 12- 24 hours; normalize ( 100-190 IU) in 10
days
C. AST rise in 8-12 hours; peak in 18-36 hours; normalize in 3-4 days
D. CK-MB rise in 4-8 hours; peak in 24 hours, normalize (< 5 IU) in 72 hours
E. LDH1 and LDH2 - LDH2 is normally > LDH1 but in heart damage LDH1 > LDH2
within 12-24 hours

NURSING AND PATIENT CARE


CONSIDERATIONS
F. CARDIAC TROPONIN T rise 3 to 5 hours, remain elevated for 1421 days.
G. CARDIAC TROPONIN I rise 3 hours, peak at 14 to 18 hours and
remain
elevated for 5-7 days
H. MYOGLOBIN detected as early as 2 hours, peak in 3-15 hours
NURSING ALERT!!!
The greater the peak in enzyme activity and the length of time an
enzyme remains at peak level correlate with serious damage of the
heart muscle and poorer prognosis for the patient.

COMPLETE BLOOD COUNT

Red blood cell count increases in conditions


characterized by inadequate tissue oxygenation

The white blood cell count increases in infectious


and inflammatory diseases of the heart and after
myocardial infarction

Decreases in hematocrit and hemoglobin can


indicate anemia

BLOOD COAGULATION STUDIES

an increase in coagulation factors can occur


during and after MI, which places the client at
greater risk of thrombophlebitis and extension of
clots in the coronary arteries

SERUM LIPIDS

It measures the cholesterol, triglycerides


The lipid profile is used to assess the risk of
developing coronary artery disease
The desirable range for serum cholesterol is <
200 mg/Dl
LDL of < 130 mg/dL,
HDL of > 70 mg/dL

ELECTROLYTES

Potassium- causes dysrhythmias and increased


risk of digitalis toxicity

Sodium - it decreases with the use of diuretics, it


decreases in heart failure, indicating water excess

Calcium - can cause ventricular dysrhythmias

NONINVASIVE

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

Electrocardiography
ECG tracings normally consist
of three identifiable
waveforms:
The P wave
The P wave depicts atrial
depolarization

The QRS complex


ventricular depolarization

The T wave

HOLTER MONITORING

A client wears a holter monitor and an


electrocardiogram tracing is recorded
continuously over a period of 24 hours or more
It identifies dysrhythmias if they occur and
evaluates effectiveness of medications or
pacemaker therapy
Instruct to resume normal activities and to
maintain a diary documenting activities and any
symptom that may develop

Electrocardiography
(ECG) Procedure

Patient Preparation for


Electrocardiography (ECG)
Explain to the patient the need to lie still, relax,
and breathe normally during the procedure.
Note current cardiac drug therapy on the test
request form as well as any other pertinent
clinical information, such as chest pain or
pacemaker.
Explain that the test is painless and takes 5 to
10 minutes.

Implementation
Place the patient in a supine or semi-Fowlers
position.
Expose the chest, ankles, and wrists.
Place electrodes on the inner aspect of the
wrists, on the medical aspect of the lower legs,
and on the chest.
After all electrodes are in place, connect the lead
wires.
Press the START button and input any required
information.
Make sure that all leads are represented in the
tracing. If not, determine which electrode has
come loose, reattach it, and restart the tracing.
All recording and other nearby electrical

Nursing Interventions
Disconnect the equipment, remove the
electrodes, and remove the gel with a moist
cloth towel.
If the patient is having recurrent chest pain
or if serial ECGs are ordered, leave the
electrode patches in place.

Interpretations : NORMAL RESULT


P wave that doesnt exceed 2.5 mm (0.25
mV) in height or last longer than 0.12
second.
PR interval (includes the P wave plus the
PR segment) persisting for 0.12 to 0.2
second for heart rates above 60
beats/min.
QT interval that varies with the heart
rate and lasts 0.4 to 0.52 second for heart
rates above 60 beats/min.
Voltage of the R wave leads V1 through
V6 that doesnt exceed 27 mm.
Total QRS complex lasting 0.06 to 0.1
second.

Abnormal Results
Myocardial infarction (MI), right or left
ventricular hypertrophy, arrhythmias,
right or left bundle-branch block,
ischemia, conduction defects or
pericarditis, and electrolyte abnormalities.
Abnormal wave forms during angina
episodes or during exercise.

ECHOCARDIOGRAM

Is a noninvasive
procedure based on
the principles of
ultrasound

It evaluates structural
and functional
changes in the heart

CHEST RADIOGRAPHY

Is done to determine
the size, silhouette,
and position of the
heart

Interventions: prepare
the client, explain the
procedure and remove
jewelry

Cardiac stress test


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

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

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

INVASIVE DIAGNOSTIC
PROCEDURE

CARDIAC CATHETERIZATION

Involves insertion of a catheter into the heart


and surrounding vessels

Obtains information about the structure and


performance of the heart valves and circulatory
system

SITE: FEMORAL VEIN


OR ANTECUBITAL
VEIN

RIGHT CARDIAC
CATHETERIZATION
LEFT CARDIAC

Preprocedure

Obtain informed consent


Assess for allergies to seafood, iodine, or
radiopaque dyes
NPO for 6-8 hours
Obtain baseline vital signs, note the quality
and presence of peripheral pulses for
postprocedure comparison

PROCEDURE

Local anesthetic will be administered before


catheter insertion

The client may feel a flushed warmed feeling


when the dye is injected and a desire to cough

Postprocedure

Monitor vital signs and cardiac rhythm at least


every 30 minutes for 2 hours initially
Assess for chest pain, and notify the physician
Monitor peripheral pulses and the color,
warmth and sensation of the extremity distal
to insertion site at least every 30 minutes for
2 hours initially
Notify the physician if the client complains of
numbness and tingling, if extremities becomes

Postprocedure

Monitor the pressure dressing for


bleeding or hematoma formation
Apply a sandbag or compression
device to the insertion site to
provide additional pressure
Keep the extremity extended for 46 hours
If the antecubital vessel was used,
immobilized the arm with an
armboard
Encourage fluid intake to promote

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

Nursing responsibilities

SAME WITH CARDIAC


CATHETERIZATION

Bone marrow aspiration


Bone marrow aspiration is the removal of a small amount of this tissue
in liquid form for examination.
Purpose of Bone Marrow Aspiration and Biopsy:
To diagnose thrombocytopenia, leukemia, granulomas, anemias, and
primary and metastatic tumors.
To determine the causes of infection.
To help stage disease such as with Hodgins disease.
To evaluate chemotherapy.
To monitor myelosuppression.

Nursing Interventions
While the marrow slides are being prepared,
apply pressure to the biopsy site until
bleeding stops.
Clean the biopsy site and apply a sterile
dressing.
Monitor the patients vital signs and the
biopsy site for signs and symptoms of
infection.

Complications

Hemorrhage and infection


Puncture of the mediastinum
(sternum)

Precautions
Know that bone marrow biopsy is
contraindicated in the patient with a severe
bleeding disorder.
Send the tissue specimen or slide to the
laboratory immediately.

Hemodynamic monitoring

CENTRAL VENOUS PRESSURE

Is the pressure within


the superior vena cava
and reflects the pressure
under which blood is
returned to the superior
vena cava and right
atrium
Normal CVP pressure is
3-8 mmHg

Importance of CVP Monitoring


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

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

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

Pulmonary wedge pressure (PWP)


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

ASSIGNMENT!!!
Describe the following diagnostic procedures and laboratory studies.
(Definition, procedure, normal value, significance of abnormal values, nursing
responsibilities pre,during and post procedure)
Intraarterial BP monitoring
C-Reactive Protein
Brain (B-type) Natriuretic Peptide
C-reactive Protein
Homocysteine
ESR, ASO-Titer
Torniquet Test

ANALYSIS/ NURSING DIAGNOSIS:


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

ANALYSIS/ NURSING DIAGNOSIS:


6. Impaired tissue integrity (Nutrional Metabolic)
7. Ineffective Breathing Patterns
8. Fluid Volume Excess
9. Nutrition, Altered, less than body requirement
10. Growth and development, altered
11. Family Process, Altered
12. Pain
13. Activity Intolerance

TREATMENT MODALITIES

Definition of cardiac pacing

It is an electric device that


delivers direct electrical
stimulation to stimulate the
myocardium to depolarize
,initiating a mechanical
contraction.
170

Clinical Indication
1. Symptomatic bradycardia
2. Symptomatic heart block
.

2nd degree heart block

3rd or complete heart block

Bifasicular or transfasicular bundle branch


blocks.

3. Prophylaxis

171

Pacemaker Design
1. Pulse generator
2. leads

172

Pacemaker Design
Pulse generator
In permanent pacemaker is
encapsulated in a metal can ,to
protect the generator from
electromagnetic interference

173

Pacemaker Design
Pulse generator
Temporary pacing system generator is externally
contained in a small box

174

Pacemaker Design
Pulse generator
Transcutanus external pacing
system house the generator
in a piece of equipment
similar to portable ECG
monitor.

175

Pacemaker Design
Pacemaker lead
1. Single chamber (unipolar) pacemaker
.

Lead placed in atrium or ventricle

Produce large spike on the ECG

Sensing and pacing in the chamber where the


lead is located

More likely to be affected by electromechanically


interference
176

Single chamber (unipolar

177

2008/F.ABUDAY
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178

Pacemaker Design
2. Dual-chamber (bipolar) pacemaker
.

One Lead located in the atrium and one in


the ventricle

Sensing and pacing in both chambers


mimicking the normal heart function

Produce in visible spic in the ECG

Less affected by electromechanical


interference.

179

Dual-chamber (bipolar) pacemaker

2008/F.ABUDAY
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180

2008/F.ABUDAY
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181

Pacemaker function

1. Pacing function
2. Sensing function
3. Capture function

182

Pacing function
Atrial pacing:
stimulation of RT atrium produce spike
on ECG preceding P wave

183

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

184

Pacing function
AVpacing:
direct stimulation of RT atrium and either
ventricles mimic normal heart conduction

185

Sensing function
Sensing :
Ability of the cardiac pace maker
to see intrinsic cardiac activity
when it occurs.

186

Sensing function
Demand:
pacing stimulation delivered only if the heart
rate falls below the preset limit.
Fixed:
no ability to sense. constantly delivers the
preset stimulus at preset rate.

187

Capture function

Capture:
Ability of the pacemaker to
generate a response from the
heart (contraction) after
electrical stimulation.

188

Pacing types
Permanent
Temporary
biventricular

189

Types of pacing
1. Permanent pacemaker
.

Used to treat chronic heart condition

Surgically placed transvenuosly under local


anesthesia

Pulse generator placed in a pocket


subcutaneously ,can be adjusted externally

190

Permanent pacemaker

2008/F.ABUDAYAH

191

Types of pacing

2. Temporary pacemaker
.

Placed during emergencies

Indicated for pts high degree


heart block or unstable
bradycardia

Can be placed transvenosly,


epicardially,transcutanusly or
transthorasicly

192

Types of pacing
3. Biventricular pacemaker
.

Used in severe heart failure

Utilize three leads, in right


atrium, right ventricle and
left ventricle to coordinate
ventricular coordination
and improve cardiac
out put
193

Nursing intervention
1. Maintain adequate cardiac output
.

Record information after insertion pacemaker


model ,mode, program setting,pts rhythm

Attach ECG for continues monitoring

Analyze rhythm strips as per protocol

Monitor vital signs

Monitor urine output

Observe for dysrhythmia


194

Nursing intervention

2. Avoid injury
.

Obtain chest x-ray to check lead wire

position

Monitor for sign and symptom of hemothorax

Monitor for sign and symptom of pneumothorax

Evaluate evidence for bleeding


195

Nursing intervention
3. Monitor for evidence of lead migration and
perforation of heart
.

Observe for muscle twitching and hiccups

Evaluate chest pain

Auscultate foe friction rub

Observe for signs of cardiac tamponade

196

Nursing intervention
4. Provide electrically safe environment
.

Protect exposed parts of electrode leads with


rubber

Wear rubber gloves when touching a temporary


pacing lead

197

Nursing intervention

5. Be aware of hazards in the facility that can interfere


pacemaker and cause failure
.

Avoid use of electrical razor

Avoid direct placement of defibrillator paddles over the


generator, should be placed 4-5 inches away.

Pts with permanent pacemaker should never exposed


to MRI because it may alter and erase the program
memory.

Caution must be used if pt will receive radiation


therapy.

198

Nursing intervention
6. Prevent accidental pacemaker malfunctions
.

Use external plastic covering over external


generator all times

Secure temporary pace maker over pts chest or


wrist never hang it over iv pole

199

Nursing intervention
Place a sign over pt's bed alerting
personnel to the presence of
pacemaker.

200

Nursing intervention
7. Preventing infection
.

Take temp every 4hrs

Observe for sign and symptoms of infection

Clean incision site with sterile technique

Monitor vein which pacing placed in for


phlipaitis

Administer antibiotic as ordered.

201

Patient education
1. Anatomy and physiology of the heart
2. Pacemaker function
3. Activity
Specific instruction include
.

Not to lift items over 1.4kg or perform


difficult arm maneuver.

Avoid excessive stretching or bending


excessive.

Avoid contact sport,tennis,gulfing until


advised by doctor.

202

Patient education
4. Pacemaker failure
.

Teach pt to check own pulse


at least weekly for 1 min

Report slowing on the pulse


less or greater than the setting rate

Report sign and symptom as


palpitation ,fatigue ,dizziness
,prolonged hiccups

Wear identification bracelet and carry


a pacemaker identification cared.

203

Patient education
5. Electromagnetic interference
.

Caution pt that EMI could interfere with


pacemaker function.

Explain that high energy radar, TV and radio


transmetters,MRI,large motors may affect the
pacemaker function.

Teach pt to move 4-6 m away from source and


check pulse. it should return to normal.

204

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

2008/F.ABUDAY
AH

205

Patient education
6. Care of pacemaker site.
.

Wear loose-fitting
clothes around pacemaker

Watch sign and symptom


of infection

Keep incision site clean


and dry. not to scrub site

Advise well balanced diet.


206

DEFIBRILLATIO
N AND
CARDIOVERSIO
N

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

DEFINITION
Defibrillation is the nonsynchronized delivery of energy during
any phase of the cardiac cycle.
Cardioversion is the delivery of
energy that is synchronized to the
large R waves or QRS complex.

ELECTRICAL ACTIVITY OF HEART AND


ECG

GOALS OF CARDIOVERSION &


DEFIBRILLATION
To
restore a
normal
heart
beat.

To disrupt the
abnormal
electrical
circuits in the
heart.

CARDIOVERSION

INDICATIONS
Supra
ventricul
ar
tachycar
dia

Atrial
fibrillati
on

Atrial
flutter

Ventricul
ar
tachycar
dia

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

DEFIBRILLATION

INDICATIONS

Pulseless ventricular
tachycardia (VT)
Ventricular fibrillation(VF)

CONTRAINDICATIONS
Awake, responsive patients

Any arrhythmias witha pulse

TYPES OF DEFIBRILLATOR
ELECTRODES
Spoon shaped
Paddle type
Pad type

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

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

PADDLE PLACEMENT
ANTEROLATERAL

ANTEROPOSTERIOR

PROCEDU
RE

EQUIPMENTS
Defibrillators with paddle or adhesive
patch
Conductive gel
Crash Cart with emergency drugs
Sedatives
Intubation set

PREREQUISITES FOR CARDIOVERSION


Explain the procedure
Obtain Informed consent
Maintain NPO for 4-6 hours prior to elective
cardioversion
Digitalis is usually discontinued 24-36
hours prior cardioversion

PREREQUISITES FOR CARDIOVERSION


Check defibrillator prior to use
Crash cart should be ready
Obtain 12 lead ECG
Check serum K+ level
Remove dentures/ jewelleries
Contd

PREREQUISITES FOR CARDIOVERSION


Empty bladder
Ensure a patent IV cannula
Anaesthetic agents and oxygen to maintain
airway with induced unconsciousness.

PROCEDURE

POST PROCEDURE CARE


Monitor the patient closely
Ensure patent airway.
Check and record vitals
Obtain 12 lead ECG
Record joules administered, number of
shocks, result of defibrillation/cardioversion
Record any pre-medications given
Contd

POST PROCEDURE CARE


Record condition of skin
Provide continuous O2
Administer antiarrhythmics as per order
Oral fluids can be started after 2 hrs
Care of defibrillator

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

PERCUTANEOUS TRANSLUMINAL CORONARY


ANGIOPLASTY (PTCA)

PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA)

DESCRIPTION
One or more arteries are dilated with a
balloon catheter to open the vessel
lumen and improve arterial blood flow
The client can experience reocclusion
after the procedure, thus the procedure
may need to be repeated

PERCUTANEOUS TRANSLUMINAL
CORONARY ANGIOPLASTY (PTCA)

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

NORMAL ARTERY AND ATHEROSCLEROSIS

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for


clinical practice, ed 2, Philadelphia: W.B. Saunders

PERCUTANEOUS TRANSLUMINAL CORONARY


ANGIOPLASTY (PTCA)

From Mosbys Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby.

PERCUTANEOUS TRANSLUMINAL CORONARY


ANGIOPLASTY (PTCA)

PREPROCEDURE
Maintain NPO status after midnight
Prepare the groin area with antiseptic
soap and shave per institutional
procedure and as prescribed
Assess baseline VS and peripheral
pulses

PERCUTANEOUS TRANSLUMINAL
CORONARY ANGIOPLASTY (PTCA)

POSTPROCEDURE
Monitor VS closely
Assess distal pulses in both extremities
Maintain bed rest as prescribed, keeping
the limb straight for 6 to 8 hours
Administer anticoagulants and
antiplatelets as prescribed to prevent
thrombus formation

PERCUTANEOUS TRANSLUMINAL CORONARY


ANGIOPLASTY (PTCA)

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

CORONARY ARTERY STENTS


DESCRIPTION
Used instead of PTCA to eliminate the risk
of acute coronary vessel closure and to
improve long-term patency of the vessel
A balloon catheter bearing the stent is
inserted into the coronary artery and
positioned at the site of occlusion
When placed in the coronary artery, the
stent reopens the blocked artery

CORONARY ARTERY STENT

From Monahan FD, Neighbers M: Medical-surgical nursing: foundations for


clinical practice, ed. 2, Philadelphia, 1998, W.B. Saunders.

CORONARY ARTERY STENTS


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

ATHERECTOMY
DESCRIPTION
Removes plaque from an artery by the use of a cutting
chamber on the inserted catheter or a rotating blade that
pulverizes the plaque
Used to improve blood flow to ischemic limbs in individuals
with peripheral arterial disease

POSTPROCEDURE
Monitor for complications of perforation, embolus, and
reocclusion

ATHERECTOMY

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3, St. Louis: Mosby.

CORONARY ARTERY BYPASS GRAFT (CABG)

DESCRIPTION
The occluded coronary arteries are bypassed with the
clients own venous or arterial blood vessels
The saphenous vein, radial artery, or internal mammary
artery is used to bypass lesions in the coronary arteries
Performed when the client does not respond to medical
management of coronary artery disease (CAD) or when
disease progression is evident

CORONARY ARTERY BYPASS GRAFT (CABG)

From Lewis SM, Heitkemper M, Dirksen S: Medical-Surgical Nursing: Assessment


and Management of Clinical Problems (5th ed), St. Louis, 2000, Mosby.

CORONARY ARTERY BYPASS GRAFT (CABG)


PREOPERATIVE
Familiarize the client and family with the cardiac surgical
critical care unit
Instruct the client how to splint the chest incision, cough
and deep breathe, and perform arm and leg exercises
Instruct the client to inform the nurse of any postoperative
pain, as pain medication will be available

CORONARY ARTERY BYPASS GRAFT (CABG)


PREOPERATIVE
Infoincision(s), one or two chest tubes, a Foley catheter, and
several IV fluid catheters
Inform the rm the client to expect a sternal incision, possible
arm or leg client that an endotracheal (ET) tube will be in
place and connected to a ventilator for 6 to 24 hours
Advise the client to breathe with the ventilator and not fight
it

CORONARY ARTERY BYPASS GRAFT (CABG)


PREOPERATIVE
Inform the family that the client will not be able to talk while
the ET tube is in place
Note that prescribed medications are to be discontinued
preoperatively (diuretics 2 to 3 days prior to surgery,
digitalis 12 hours prior to surgery, and aspirin and
anticoagulants 1 week prior to surgery)

CORONARY ARTERY BYPASS GRAFT (CABG)


PREOPERATIVE
Administer medications as prescribed, which may include
potassium chloride, antihypertensives, antidysrhythmics,
and antibiotics
Encourage the client and family to discuss anxieties and
fears related to surgery

HOME CARE INSTRUCTIONS FOLLOWING


CARDIAC SURGERY
Progression with activities at home
Limit pushing or pulling activities for 6 weeks
following discharge
Incisional care and to record signs of redness,
swelling, or drainage
Sternotomy incision heals in about 6 to 8 weeks
Avoid crossing legs, wear elastic hose as
prescribed until edema subsides, and elevate
surgical limb when sitting in a chair

HOME CARE INSTRUCTIONS


FOLLOWING CARDIAC SURGERY
Use of prescribed medications
Dietary measures including the avoidance of
saturated fats and cholesterol and the use of
salt
Sexual intercourse can be resumed on the
advice of the physician after exercise tolerance
is assessed; if the client can walk one block or
climb two flights of stairs without symptoms,
they can safely resume sexual activity

END