Holter ECG- It records your heart's activity for 24-hour period which provides your doctor with a prolonged

look at your heart rhythms

Echocardiogram- Use sound waves to produce images of your heart and identify heart disease

Electrophysiology studies- to assess for abnormal heartbeats or arrhythmia

Atropine- increase automatic stimulation to increase HR

Vasopressor e.g. Dobutamine, dopamine- increase the strength of heart muscle contraction and increase
heart rate

Transcutaneous pacing- Regulate heart beats by delivering electrical pulses

Beta-blocker- blocking the effects of the hormone epinephrine to cause heart beats more slowly

Calcium blocker- slowing the movement of calcium into heart which makes it easier for heart pump and
widens blood vessels

Catheter ablation- By scarring or destroying tissue in the heart, it prevents abnormal electrical signals and
stops the arrhythmia

Vagal maneuvers- Stimulate the parasympathetic nerve resulting in slower conduction of electrical impulses
through AV node

Adenosine- Normalize heartbeat by slowing the electrical conduction in the heart

Digitalis- Slows your heart rate and makes your heart beat stronger

Anti-arrhythmic drug- suppress abnormal rhythms of the heart

Anti-coagulant drug- prevent blood clots

Cardioversion- restores a normal heart rhythm in people with certain types of abnormal heartbeats
(arrhythmias)

Defibrillation- restore a normal heartbeat by sending an electric pulse or shock to the heart

Implantable cardioverter-defibrillator- specialized implantable electronic device designed to directly treat a

cardiac tachyarrhythmia

Emergency pacing- Improve an irregular heartbeat

Arterial blood gas- check how well lungs are able to move oxygen and remove carbon dioxide

Cardiac markers- diagnosis and monitoring of cardiac disease

Lipid profile- initial screening tool for abnormalities in lipids

Fasting glucose- determine how much glucose is in a blood sample after an overnight fast
C-reactive protein- detect inflammation

Fibrinogen level- determine possibility of bleeding disorders

12-lead ECG- determine the location of myocardial damage, screen patients for possible cardiac ischemia

Echocardiogram- provides moving pictures and information on heart

Coronary angiogram- check for blocked or narrowed blood vessels in your heart

Beta-blocker- block the release of the stress hormones adrenaline and noradrenaline in certain parts of the
body. This results in a slowing of the heart rate.

ACE inhibitor- widen, or dilate, your blood vessels.

Statins- lower your cholesterol

Plavix- inhibitor of platelet activation and aggregation

Glycoprotein inhibitor- preventing platelet aggregation and thrombus formation

Anticoagulant agent- prevent the formation of blood clots and to maintain open blood vessels

Cardiac biomarkers- diagnose acute coronary syndrome (ACS) and cardiac ischemia

PCI- open up blood vessels in the heart that have been narrowed by plaque

Thrombolytic therapy- dissolve blood clots

Alteplase/ streptokinase- dissolve blood clots that have formed in the blood vessels

Coronary artery bypass graft- creates a new passage, and oxygen-rich blood is routed around the blockage to
the heart muscle

Adenosine slows or blocks antegrade (atrial to ventricular) conduction through the AV node but doesn't
affect accessory or bypass tracts like those seen in WPW syndrome. Because of this, adenosine can be
dangerous when given to patients with atrial fibrillation, especially if they have a bypass track.

CVP is normally in the range of 0 to 8 cm H2O

The central venous pressure (CVP) is the pressure measured in the central veins close to the heart. It
indicates mean right atrial pressure and is frequently used as an estimate of right ventricular preload. The
CVP does not measure blood volume directly, although it is often used to estimate this. In reality the CVP
value is determined by the pressure of venous blood in the vena cava and by the function of the right heart.

high blood pressure can cause arteries around the kidneys to narrow, weaken or harden. These damaged
arteries are not able to deliver enough blood to the kidney tissue.
high blood pressure can cause damage to the retina's blood vessels, limit the retina's function, and put
pressure on the optic nerve, causing vision problems.

Chest X-ray- shows enlargement of the right ventricle of the heart or the pulmonary arteries, which can
occur in pulmonary hypertension. It can also check for other lung conditions that can cause pulmonary
hypertension.

Aldomet- allows your blood vessels (veins and arteries) to relax (widen)

The blood vessels expand, the nasal membranes become engorged, and the nose becomes congested.

ACEIs, ARBs, and DRIs increase serum potassium levels by interfering with angiotensin II-mediated
stimulation of aldosterone secretion from the adrenal gland and by decreasing renal blood flow and GFR in
special patient populations.

Acute renal failure (ARF) is their major complication directly related to the hemodynamic consequences of
ACE inhibition. Acute renal failure is induced by reduction of intrarenal perfusion pressure associated with
blocking of the angiotensin II-induced resistance at the efferent glomerular arteriole.

The DASH diet encourages you to reduce the sodium in your diet and eat a variety of foods rich in nutrients
that help lower blood pressure, such as potassium, calcium and magnesium.

COPD patients tend to have chronically elevated levels of carbon dioxide due to the nature of their illness.
The theory goes then that because of this chronically elevated level of carbon dioxide in the chemo receptors
become tolerant of these high levels and therefore the carbon dioxide ceases to be that person’s drive to
breathe. What therefore drives them to breathe is the hypoxic drive, or the lower levels of oxygen.

The hypoxic drive theory then goes on to say that if you give these patients too much oxygen you blunt their
hypoxic drive. As their chemo receptors are already tolerant of high levels of carbon dioxide, and therefore
they have also lost that drive, their respirations will begin to slow causing a further rise in carbon dioxide
levels, and a consequent acidosis.

Activity pacing has 2 parts to it:

1. conserving energy for activities you value (for example, playing with your kids; undertaking a pleasurable
recreational activity)

2. setting graduated activity quotas to help you to increase your ability to do activities (tolerance) and reduce
your disability

Eat a good source of protein at least twice a day to help maintain strong respiratory muscles.
As previously stated, for people with COPD, excessive, sticky mucus can make breathing difficult. Drinking
enough water can thin the mucus, making it easier to cough up. However, there are more benefits to staying
hydrated with COPD. Drinking enough water can also help people with COPD fight off infections better.

The most important action of corticosteroid medications is to reduce inflammation.

Antibiotics are often used in acute exacerbations of COPD (AECOPD) as bacteria are commonly implicated
in these patients

Positive-pressure ventilators work by increasing the patient's airway pressure through an endotracheal or
tracheostomy tube. The positive pressure allows air to flow into the airway until the ventilator breath is
terminated.

Corticosteroids- Corticosteroids are classified as either: glucocorticoids (anti-inflammatory) which suppress

inflammation and immunity and assist in the breakdown of fats, carbohydrates, and proteins

Beta-2 receptor agonist- β2 adrenergic agonists' effects on smooth muscle cause dilation of bronchial
passages, vasodilation in muscle and liver, relaxation of uterine muscle, and release of insulin.

Theophylline- It has two distinct actions in the airways of patients with reversible obstructions: smooth
muscle relaxation (i.e., bronchodilation) and suppression of the response of the airways to stimuli

Leukotriene- Leukotrienes cause tightening of airway muscles and the production of excess mucus and fluid.

Immunomodulators modify the activity of the immune system, in turn, decreasing the inflammatory
response.

Cromolyn sodium- A so-called “mast cell stabilizer.” This means it stops mast cells from releasing
histamine and other inflammatory chemicals in the first place.
With a chest tube in the pleural space, the water level should fluctuate in the water seal chamber. This

is known as tidaling, and should correspond with respiration.

When there is no air leak, the water level in the water seal chamber should rise and fall with the patient's

respiration. During spontaneous respiration, the water level will rise during inhalation and fall during
exhalation.
https://www.vnhcsb.org/media/data/papers/pdf/146_9.03.3.pdf

NUR3111 tutorial 1

1) Supraventricular tachycardia

(AVNRT) - An impulse is conducted to an area in the AV node that causes the impulse to be rerouted back
into the same area over and over again at a very fast rate.

2) When your heart is beating too fast, it may not pump enough blood to the rest of your body. This can
starve your organs and tissues of oxygen

Increased heart workload, insufficient cardiac output, inadequate filling time between ventricle, ischemia=>
coronary artery spasm

3-5) Antiarrhythmic medication such as Amiodarone

Amiodarone slows the speed of electrical conduction and prolongs repolarisation

Ask for patient’s health history

Previous health history such as diabetes may increase the risk of supraventricular tachycardia.

Apply cardioversion on the patient

It restores a normal heart rhythm in people with certain types of abnormal heartbeats

Apply defibrillation on the patient

It resets the electrical state of the heart

Administer Adenosine according to patient’s prescription if necessary

It normalizes heartbeat by slowing the electrical conduction in the heart

Administer Calcium channel blocker according to doctor’s prescription

It slower the movement of calcium into heart to facilitate heart pump and widens blood vessels

Administer beta blocker according to doctor’s prescription

It blocks the effects of the hormone epinephrine to cause heart beats more slowly

Administer anticoagulant such as Warfarin.

It prevents blood clots

Ensure IV access ready

For earlier Adenosine infusion

Provide oxygen therapy to the patient

Increase oxygen supply to heart reduce oxygen demand of heart and reduce heart rate

Continuous ECG monitoring

Earlier detection of heart rate abnormality and treatment option needed

Continue to assess vital sign such as GCS, blood pressure, heart rate, RR

Vital signs such as increased heart rate and blood pressure indicate severity of SVT

Encourage earlier verbalisation of pain and discomfort

For earlier detection of the severity of the disease

Assess skin condition following cardioversion

Cardioversion may cause side effects such as erythema and skin burn
Holter monitoring

It records your heart's activity for 24-hour period for looking at heart rhythm

Electrophysiology test

It assesses for abnormal heartbeats or arrhythmia

Have the patient for Echocardiogram check

It provides moving pictures and information on heart

Get a chest X-ray from the patient

It assesses heart size and widened mediastinum

Stress test

It assesses heart function while exercise

Get a coronary angiogram scan

To study the flow of blood through your heart and blood vessels.

Blockage inside the blood vessel may be the reason for tachycardia

Magnetic resonance imaging (MRI)

It provides pictures of how blood is flowing through the heart and detect irregularities

Computerized tomography (CT)

Get a CT scan from the patient

CT scans combine X-ray images to provide a more detailed cross-sectional view of the heart
 PQRST method for assess chest pain

It helps accurate determination of the heart problem

Q3 carotid sinus massage, adenosine, ensure IV access available, continue ECG monitoring, assess
dizziness, ensure complete bed rest, prevent fall risk, evaluate effect during injection and after 15 mins.
When stabilize, give beta-blocker, calcium-blocker

Withhold HR<60 bpm SBP <100 mmHg

Electrophysiology test, catheter ablation, cardioversion, ICD

Bradycardia- Atropine via IV, observe blood pressure and heart rate, dopamine or dobutamine,
pacemaker, carotid sinus massage, beta blocker, EPS, catheter ablation, synchronised cardioversion

AF Af- Warfarin, digoxin

Anxiety care plan

1. Assess the reasons of anxiety

To solve the problem of stress at an earlier time as long-term stress can promotion of plagues in the
arteries and increase blood pressure which cause heart disease.

2. Assess and monitor vital signs Q4H to identify signs and symptoms of anxiety.

Anxiety stimulates sympathetic nervous system resulting in high BP, fast P and RR.

3. Give reassurance for psychological support to comfort the patient.

To alleviate the problem of anxiety.

4. Explain health condition to the patient to foster understanding of his medical condition
 To relieve stress on patient’s condition.

5. Carry out thrombolytic therapy according to doctor’s prescription.

To dissolve blood clots as blood clots obstruct blood flow which may cause heart failure.

6. Administer MONA according to doctor’s prescription.

Morphine to reduce anxiety and pain, vasodilation effect to improve coronary circulation.

Oxygen therapy to increase oxygen supply to myocardium.

Nitroglycerin as vasodilator to increase oxygen and nutrient supply to myocardium.

Aspirin to prevent platelet aggregation which may block blood vessel and cause heart failure.

7. Explain possible medical treatment such as cardiac catherization.

It involves placing a long thin tube through the blood vessel into the heart to carry out procedures such as
angioplasty, measure oxygen and pressure in different parts of the heart and locate areas that cause chest
pain.

8. Refer to physician

For further health concerns to reduce anxiety and stress.

9. Allow family members to accompany the patient to receive further support.

Family members are someone in which the patient may feel confident to tell things to. It help reduces
patient’s stress and anxiety.

10. Refer to psychologist for expertise advice if necessary.

Psychologist helps assess patient’s stress and anxiety level.

 No Chest pain

1. Assess and monitor vital signs Q4H to assess hemodynamic status, including BP, HR and RR

For example, people with high blood pressure may have a pounding feeling in their chest, causing chest pain
 2. Assess and evaluate chest pain by PQRST

It helps accurate determination of the heart problem

3. Monitor 12-Lead ECG

It helps determine the location of myocardial damage and screen patients for ischemia

4. Put on continuous cardiac monitoring to identify related cardiac problem

Earlier detection of heart rate abnormality and treatment option needed

5. Monitor circulation over upper and lower extremities

For example, excess blood circulates in lower extremities cause lack of blood supply to the heart, causing
heart failure.

6. Ensure complete bedrest

To prevent rising blood pressure which worsens the problem of chest pain

7. Ensure quiet environment for the patient

Noisy environment put patient into stress and anxiety which cause increase in blood pressure

8. Provide call bell for patient

In case chest pain occurs again, the patient can notify nurses or doctors immediately

9. Refer to doctor about patient’s complaint

For further health concerns to reduce anxiety and stress

10. Blood taking for arterial blood gas.

check how well lungs are able to move oxygen and remove carbon dioxide
 11. Administer thrombolytic therapy according to doctor’s prescription.

To dissolve blood clots as blood clot obstructs blood flow which may cause heart failure.

12. Ensure IV access available

For IV infusion immediately in case of doctor’s prescription

13. Observe bleeding tendency and prevent injury

For example, in case of excessive blood loss, inadequate blood supply to the heart may worsen the
problem of heart failure.

14. Observe reperfusion waveform

For evaluation of effectiveness of thrombolytic therapy.

15. Follow the protocol to have regular blood taking for Troponin and cardiac enzymes

For diagnosis and monitoring of cardiac disease

16. Administer MONA if prescribed (for NSTEMI especially)

Morphine to reduce anxiety and pain, vasodilation effect to improve coronary circulation.

Oxygen therapy to increase oxygen supply to myocardium.

Nitroglycerin as vasodilator to increase oxygen and nutrient supply to myocardium.

Aspirin to prevent platelet aggregation which may block blood vessel and cause heart failure.

17. Inform when abnormalities are found for further management

For further diagnosis of disease and intervention

Vital sign, RR, SpO2, continuous ECG monitoring

Heart failure- Chest X ray

AMI- track cardiac enzyme

Complete bed rest, reduce patient anxiety (psychological support), increase oxygenation as prescribed

Dyspnoea

1. Monitor vital signs

To see the extent of severeness of dyspnoea

2. Monitor 12-L ECG

Dyspnoea is a common sign of heart failure

3. Continuous ECG monitoring

To see extent of heart failure that affect dyspnoea

4. Assess respiratory function, such as use of accessory muscle, cyanosis, frothy sputum, etc

To see the extent of severeness of dyspnoea

5. Carry out blood test (NT-proBNP, cardiac biomarkers, ABG, etc)

A blood test called a BNP can indicate if you have fluid buildup in your lungs

6. Chest X-ray

A chest x-ray to look for pneumonia, or lung inflammation or scarring.

7. Complete bedrest and provide holistic care

To reduce oxygen consumption

8. Sitting position / High Fowler’s position

To promote chest expansion

9. High concentration oxygen (mask)→ NIPPV→ intubation

It helps many lung disease patients feel less breathless during everyday activities.

10. Reduce physical activity to reduce O2 demand

It helps many lung disease patients feel less breathless during everyday activities.

11. Provide adequate assistance for daily activity

To reduce O2 demand

12. Reduce fluid overload /fluid and electrolyte imbalance

As the pressure in these blood vessels increases, fluid is pushed into alveoli in the lungs

13. Intravenous diuretics (lasix)

To remove excessive water in the lung

14. Foley catheter insertion

To facilitate removal of urine more easily

15. Check serum K

A severe potassium deficiency can cause breathing difficulties.

This is because potassium helps relay signals that stimulate the lungs to contract and expand

16. Fluid restriction

Pulmonary edema is a condition caused by excess fluid in the lungs.

 This fluid collects in the numerous air sacs in the lungs, making it difficult to breathe.

17. Low salt diet

Sodium makes the body hold on to fluid. To pump the added fluid, the heart has to work harder.

18. Daily body weight

To monitor extent of accumulation of fluid in the body

19. CVP monitoring

Central venous pressure (CVP), an estimate of right atrial pressure, has been used to assess cardiac preload
and volume status in critically ill patients, assist in the diagnosis of right-sided heart failure and fluid
resuscitation.

Low limb oedema

1. Assess vital signs

For example, oedema causes excess blood pooling in lower extremities which causes lack of blood to
heart, causing increase in heart rate.

2. Assess oedematous level, such as pitting oedema and capillary refill

In heart failure, heart lose ability to pump blood. As a result, blood can back up in legs, causing oedema.

3. Measure calf circumference daily.

To assess the effectiveness of medicine and the extent of heart failure.

4. Daily body weight

Higher body weight, higher chance for fluid accumulation in lower extremities which cause oedema.

5. Renal function test

Rule out possibility of renal failure causing oedema.

6. Consider Intravenous diuretics (lasix)

To remove water in the body which causes oedema

7. Restrict fluid to 1.5L

Prevent excess water accumulation

8. Low salt diet

To prevent fluid overload in the lower legs or abdomen

9. Elevate both lower limbs if no contraindication

Promote blood and lymph return to the heart

10. Massage the area with oedema

pushing the excess fluid from the body

11. Exercise such as ankle/ lower limb exercise

pushing the excess fluid from the body

12. Prevent injury

Injury causes inflammation and swelling, further worsens the problem of oedema
Week 4 tutorial 2

1. Smoking- Smoking increases the formation of plaque in blood vessels. The disease occurs when arteries
that carry blood to the heart muscle are narrowed by plaque or blocked by clots. Chemicals in cigarette
smoke cause the blood to thicken and form clots inside veins and arteries.

Hypertension- The excess strain and resulting damage from high blood pressure (HBP or hypertension)
causes the coronary arteries serving the heart to slowly become narrowed from a buildup of fat, cholesterol
and other substances that together are called plaque.

2. A coronary artery becomes occluded following the rupture of an atherosclerotic plaque, which then leads
to the formation of a blood clot (coronary thrombosis). This event can also trigger coronary vasospasm. If a
vessel becomes completely occluded, the myocardium normally supplied by that vessel will become
ischemic and hypoxic. Without sufficient oxygen, the tissue dies.

3. Power point P.23

4. Have been done an ECG, shows an ST elevation in V2 and V3. New ST elevation at the J point in 2
contiguous leads of >0.1mV in all leads other than leads V2-3.

Location: Left atrium

Can be done: 12-Lead ECG, blood taking, stress test, cardiac catheterization +/- coronary angiogram

Cardiac biomarkers: Creatine kinase, myoglobin, troponin, LDH, C-reactive protein

5. Aims of treatment: Heart rhythm and vital signs return to normal, no chest pain

6. MONA, beta-blocker, calcium blocker, low molecular weight heparin, thrombolytic therapy