KURSK STATE MEDICAL UNIVERCITY

DEPARTMENT OF PROPEDEUTICS
OF INTERNAL DISEASES

General principles of care of patients

with cardiovascular system pathology
Lecturer: Ph. D.,
assistant professor
Serikova L.N

KURSK – 2021
 Complains

Main
Secondary
1. Chest pain
2. Palpitation, intermission 1. General weakness
3. Cough (working capacity
4. Haemoptysis decrease)
5. Dyspnea 2. Fatigue
6. Suffocation 3. Sleep disorders
7. Edema (insomnia)
8. Headache, dizziness 4. Irritability
9. Syncope 5. Fever
10. Discomfort, pain, heaviness
in the right hypochondrium
 Reasons of pain in the heart region

myocardial infarction ischemic pain

angina pectoris
endocardatis
pericarditis
myocarditis
aortic aneurysm
cardioneurosis
myocardiodystrophy
Сauses of inconsistency oxygen demand and delivery:
 narrowing (atherosclerosis) coronary artery;
 increased mass of the myocardium (hypertrophic
cardiomyopathy);
 spasm of the coronary arteries (vasospastic angina -
Prinzmetal's angina).
Blood circulatory system
CHEST PAIN
Angina pectoris
Myocardial infarction
symptoms
Plan
detailing Myocardial Angina pectoris
of pain infarction
Location Behind the sternum, rarely Behind the sternum (in
and in the heart projection. middle), rarely in the heart
radiation projection.

Radiation of the pain to the

left arm, left shoulder, left
side of jaw, neck, ear,
scapular, possible to
epigastric regoin

Radiation of the pain to the

left arm, left shoulder, left
side of jaw, neck, ear,
scapular, possible to
epigastric regoin

Character pressing, squeezing, pressing, squeezing, burning,

burning, heaviness heaviness.
Intensity very intensive Intensive

Duration More than 30 min. 3-15 min

Time of the During exertion, In the form of attacks

appearance/ emotional stress. on exertion, cold
reasons for the weather, emotional
increasing and Pain relief: narcotic stress, walking against
decreasing and seminarcotic the wind.
analgetics. Pain relief at the
termination of
exercise, use of
sublingual
nitroglycerine (effect
after 1-2 min).
Associated General excitation, Fear of death, dyspnea,
symptoms fear of death, weakness.
dyspnea (rise to
suffocation).
 First aid to a patient in
angina pectoris
• to call a doctor
• to give complete rest
• to calm down
• to check vital signs
• nitroglycerin sublingually, if a
patient’s systolic pressure is not
lower than 100 mmHg (after doctor’s
prescribtion !!!!!!!!!)
• rarely the application of a mustard
plaster on the heart area (if this aid
is given outside the hospital!!!!!!)
 Palpitation
Palpitation - the feeling of frequent and (or)
amplified contractions of the heart.
Physiological reasons:
• great exercise, excitement, smoking, alcohol,
strong tea and coffee).
Pathological causes:
• Arrhythmias (atrial fibrillation, paroxysmal
tachycardia, sinus tachycardia, atrial
flutter etc.).
• Hyperdynamic circulation (thyrotoxicosis,
anemia,).
• Sympathetic activity (hypoglycemia, panic
disorders,hypoxia, heart failure, etc.).
 Intermissions of the heart
The reasons (arrhythmia)
• premature cardiac contraction
(ectopic extrasystole),
• atrial fibrillation,
• atrial flutter,
• sinoatrial heart block, AV block II
degree
• sinus arrhythmia
 Cough
The reasons
Pulmonary venous
congestion (left ventricular
failure, mitral stenosis) -
dry or moist nocturnal
cough associated with
dyspnea.
Compression of one of the
bronchi and recurrent
laryngeal nerve (aneurysm of
the aorta, pulmonary artery,
enlarged left atrium).
Pulmonary venous hypertension.
 Dyspnea
The main reasons:

1. Heart failure.
2. Pulmonary embolism;
3. Cardiac arrhythmias
4. Pulmonary edema
5. Hypoxia (pulmonary edema or
intracardiac shunting)
6. Orthopnea – dyspnea in recumbency
7. Paroxismal nocturnal dyspnea (30
min – 2 hoursafter going to bed,
relieved by sitting up or standing up)
 Heart failure
Inability of the heart to maintain
sufficient cardiac output to meet
the demands of the body

• Acute & chronic

• Right-sided & left-sided (or
biventricular heart failure)
Heart failure symptoms
 Acute left-sided heart failure
Stages of pulmonary edema
Interstitial pulmonary
edema - fluid infiltration
throughout the lung tissue,
including perivascular and
peribronchial spaces.

Alveolar edema - the

destruction of the
surfactant, the
accumulation of transudate
in the alveoli, bronchi,
trachea.
 Pulmonary edema
• usually occurs at night,
• extreme shortness of breath or dyspnea that
worsens when lying down,
• suffocation,
• cough with foamy, pink sputum
• orthopnea,
• cold sweat,
• pale and skin cyanosis
• anxiety, restlessness, fear of death,
• continues from several minutes to several
hours.
• a lot of crackles in the lungs by auscultation
• tachycardia
 Pulmonary edema. First aid
• necessary to call a doctor first of all;
• to give a patient a sitting position;
• to unbutton tight clothes
• to take a patient's blood pressure and other vital signs
• to begin an oxygenotherapy with antifoamer
through a mask or a nasal catheter (as an antifoamer
96% alcohol solution);
• tourniquets are applied on the legs and the arms
with the purpose of blood deposition in the systemic
circulation and delay of its inflow to lungs. (but if this
aid is given outside the hospital!!!!!!)
• it is necessary to aspirate a foamy sputum by an
electroaspirator
• after doctor’s prescribtion !!!!!!!!! to give a patient
nitroglycerin sublingually, if a patient’s systolic
pressure is not lower than 100 mmHg;
• narcotics, diuretics, inhibitors of ACE, inhibitors of
phosphodiesterase, creatine phosphate, cardiac
glycosides, etc.
 Right ventricular failure
Symptoms
Tissue congestion (inability of heart to
empty properly)
• cerebral: headache, insomnia, restlessness
• pulmonary: cough, dyspnoe
• portal: anorexia, nausea, vomiting – pain
in right hypochondrium due to hepatic
congestion which stretches the hepatic
capsule  stimulates pain receptor &
produces pain
• renal : oliguria and nocturia
• peripheral edema : edema of feet in
ambulatory & sacral region in bed-bound
patient
 Peripheral edema
The severity of the edema syndrome
Swelling of the Accumulation of fluid in
subcutaneous fat. serous cavities
(ascites, hydrothorax,
hydropericardium).
The main reasons:
- reduced contractility of the right heart (right ventricular
infarction, etc.);
- pulmonary hypertension;
- cardiomyopathy;
- myocarditis.
Characteristics of cardiac edema
 begin from the lower extremities (malleols, shins),
extends up;
 appear in the evening and during the night decreases;
 combined with cyanosis of the skin;
 solid consistency and warm.
 Care of patients with heart
failure
• Daily control of the water balance (the comparison
of the amount of consumed and parenterally
introduced liquids with that of excreted for a day
(daily diuresis)
• The daily diuresis is 1,5-2 l (70-80% of the liquid
volume consumed for a day).
• If the amount of the excreted urine is less than 70-
80% of the liquid consumed for a day, then a
negative diuresis is stated, i.e. some part of
liquid is detained in an organism.
• If the amount of urine exceeds the amount of
drunk liquid for a day, the diuresis is positive.
• The water balance condition can be supervised by the
weighting of a patient when the increase in the
body weight testifies liquid retention.
 Headache, dizziness

Reasons
- inflammatory processes (myocarditis,
pericarditis, endocarditis) accompanied
by fever;
- arterial hypotension;
- arterial hypertension;
- ischemic heart disease (heart failure,
myocardial infarction);
- heart valves defects.
 Syncope (fainting)
Syncope is a short-term loss of
consciousness, caused by acute sudden
failure of cerebral blood supply.
• Usually syncope occurs due to strong
psychological influences (fear, severe pain,
sight of blood, etc.), a stuffy room,
overstrain.
Symptoms:
• Paleness of skin and mucosa,
• coldness of the extremities, cold and
clammy sweat,
• sharp decrease of BP, small and thready
pulse are marked.
• As a rule syncope lasts 20-30 seconds and
after that a patient recovers his
consciousness.
Syncope (fainting). First aid
 Collapse
Collapse is a clinical manifestation of
acute vascular insufficiency with
sharp decrease of BP and
peripheral circulatory failure.
It is observed in:
• acute hemorrhage,
• myocardial infarction,
• dehydratation due to recurrent
vomiting, diarrhea.
Clinical manifestations are similar to
those in syncope, but collapse is not
always accompanied by the loss of
consciousness
Collapse. First aid.
 Discomfort, pain,
heaviness in the right hypochondrium
Observed in heart failure due to congestion in
the liver and extension Glisson's capsule

slowly progressive heart

failure
pain dull, aching
rapidly developing heart disease
(myocardial infarction)
pain can be severe and acute
 Arterial pulse
Arterial pulse is the rhythmic expansion of an artery that may be
felt with the finger.

brachial artery
temporal artery

axillary artery
carotid artery
subclavian artery

«Homo pulsans» - posterior tibial artery dorsalis pedis artery

pulsation of the
superficial
arteries (aortic popliteal artery
insufficiency
sign). femoral artery bono-esse.ru
 Symmetry
Arterial pulse palpable on both sides,
to identify pulsus symmetric or differens
(aortic aneurysm, mediastinal tumor, the expansion of the left
atrium in mitral stenosis, etc.)

Rhythm
Rhythm is regulare if pulse waves follow one another at regular
intervals.
Identify irregular pulse (ectopic beats or atrial fibrillation, sinus
arrhythmia, AV block II degree),
Difference between the heart rate and pulse rate – pulse deficit
(pulsus deficiens) (ectopic beats or atrial fibrillation)
 Pulse rate
The pulse rate is counted for half of a
minute if pulse is regular and
multiplied 2
The pulse rate is counted for 1 minute if
pulse is irregular
Normal: 60-100 beat per minute
Tachysphygmia: more than 100 beat per
minute (pulsus frequens)
Bradysphygmia: less than 60 beat per
minute(pulsus rarus)
 Pulse pressure or tension

Pulse pressure is determined by the

force that should be applied to the
pulsating artery to compress it
completely.
This property of pulse depends on
the level of the systolic arterial
pressure.
• Pulsus durus – hard pulse
• Pulsus mollis – soft pulse, arterial
pressure is small
 Pulse volume

Pulse volume shows the artery filling

with blood
Pulse volume depends on the stroke
volume, on the total amount of
circulating blood, and its distribution
in the body.
Pulsus plenus - full pulse
Pulsus vacuus – pulse volume
decreases
 Pulse size
• The pulse size implies its filling and
tension. It depends on the expansion of
the artery during systole and on its
collapse during diastole. It depends on
the pulse volume, fluctuation of the
arterial pressure during both systole and
diastole, and expansibility of the arterial
wall.

• Pulsus magnus (altus) – high pulse (aortic

valve incompetence )
• Pulsus parvus – small pulse (stenosis of
the aortic orifice )
• Pulsus filiformis – quite, insignificant
pulse (massive loss of blood)
 Pulse size
• Pulsus alternans - high and small pulse
(pulse is due to alternation of heart contractions
that vary in force. It usually occurs in severe
myocardial affections)

Pulsus paradoxalis - is defined as an

abnormally decrease in systolic blood
pressure and pulse wave amplitude
during inspiration.
 Pulse character or form
This depends on the rate of
change in the arterial pressure
during systole and diastole.

• Pulsus celer – quick pulse

• Pulsus altus – high pulse
• Pulsus tardus - slow pulse
 Blood Pressure Measurement
• Korotkoff sounds are
the sounds that
medical personnel
listen when they are
taking blood pressure
using a non-invasive
procedure. Pulsus altus
• They are named after
Dr. Nikolai Korotkoff,
a Russian physician
who discovered them
in 1905, when he was
working at the
Imperial Medical
Academy in St.
Petersburg. https://en.wikipedia.org/wiki/Korotkoff_sounds
PhilippN - drawn by myself, using openoffice.org
 5 Korotkoff sounds:

Phase I — The first appearance of faint, repetitive, clear

tapping sounds which gradually increase in intensity for
at least two consecutive beats is the systolic blood
pressure.
Phase II — A brief period may follow during which the
sounds soften and acquire a swishing quality.
Phase III — The return of sharper sounds, which become
crisper to regain, or even exceed, the intensity of phase I
sounds.
Phase IV — The distinct abrupt muffling of sounds, which
become soft and blowing in quality.
Phase V — The point at which all sounds finally disappear
completely is the diastolic pressure.
 Blood Pressure Measurement

• The second and third Korotkoff sounds have no known clinical

significance.
• In some patients, sounds may disappear altogether for a short
time between Phase II and III which is referred to as
auscultatory gap.
 Recommended Technique for
Blood Pressure Measurement

• Measurements should be taken with a sphygmomanometer

known to be accurate.
• A validated electronic device should be used. If not available, a
recently calibrated aneroid device can be used.
• Aneroid devices or mercury columns need to be clearly visible
at eye level.
• Choose a cuff with an appropriate bladder size matched to the
size of the arm.
• For measurements taken by auscultation, bladder width should
be close to 40% of arm circumference and bladder length
should cover 80 – 100% of arm circumference.
• When using an automated device, select the cuff size as
recommended by its manufacturer.

This information is based on the Hypertension Canada guidelines published in Leung, Alexander A. et al. Hypertension Canada’s 2016 Canadian Hypertension Education Program Guidelines for
Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension. Can J Cardiol 2016; 32(5): 569-588.
 Technique for Blood Pressure Measurement
• Place the cuff so that the lower edge is 3 cm above the
elbow crease and the bladder is centered over the
brachial artery.
• The patient should be resting comfortably for 5 minutes
in the seated position with back support.
• The arm should be bare and supported with the BP cuff
at heart level, as a lower position will result in an
erroneously higher SBP and DBP.
• There should be no talking, and patients’ legs should not
be crossed.
• BP should also be assessed after 2 minutes standing
(with arm supported) and at times when patients report
symptoms suggestive of postural hypotension.
• Supine BP measurements may also be helpful in the
assessment of elderly and diabetic patients.
This information is based on the Hypertension Canada guidelines published in Leung, Alexander A. et al. Hypertension Canada’s 2016 Canadian Hypertension Education Program Guidelines for
Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension. Can J Cardiol 2016; 32(5): 569-588.
 Measuring the blood pressure
1. Palpate the radial pulse
2. Inflate the cuff until you can no longer feel
this pulse
3. Note the reading on the sphygmomanometer
4. Inflate the cuff 20–30 mm Hg above this
level
5. deflate the cuff pressure 2 mm Hg per
second, and listen for Korotkoff sounds
 Measuring the blood pressure
Properly document accurate BP readings
1. Record SBP and DBP. If using the auscultatory
technique, record SBP and DBP as onset of the first
Korotkoff sound and disappearance of all Korotkoff
sounds, respectively, using the nearest even number.
2. At the first visit, record BP in both arms. Use the
arm that gives the higher reading for subsequent
readings.
3. Separate repeated measurements by 1–2 min.
4. If the first two readings differ by more than 5 mm
Hg, take additional readings.
Average the readings
Use an average of ≥2 readings obtained on ≥2
occasions to estimate the individual’s level of BP.
Provide BP readings to patient
Provide patients the SBP/DBP readings both verbally
and in writing.
Classification of arterial blood pressure
 Measuring the blood pressure
in the leg
• To determine blood pressure
in the leg, use a wide, long
thigh cuff that has a bladder
size of 18 ×42 cm, and apply
it to the midthigh.
• Center the bladder over the
posterior surface, wrap it
securely, and listen over the
popliteal artery.
• If possible, the patient should
be prone.
• Alternatively, ask the supine
patient to flex one leg
slightly, with the heel resting
on the bed.
The Hypertensive Patient with Systolic Blood Pressure
Higher in the Arms than in the Legs.

Coarctation of the aorta

arises from narrowing of the
thoracic aorta, usually
distal to origin of the left
subclavian artery, and
classically presents with
systolic hypertension greater
in the arms than the legs.

In normal patients, the systolic blood pressure

should be 5 to 10 mm Hg higher in the lower
extremities than in the arms
 Definition
• Hypertension is defined as a
sustained elevation of systolic blood
pressure ≥ 140 mm Hg and/or a
diastolic blood pressure ≥ 90 mm Hg
in adults.
• Blood pressure should be based on an
average of ≥ 2 careful readings on ≥ 2
occasions
 Hypertension
• Hypertension has been called the “silent
killer” because it usually produces no
symptoms.
• can lead to hypertensive heart disease or
coronary artery disease.
• a major risk factor for stroke, aneurysms of
the arteries (aortic aneurysm), peripheral
artery disease and chronic kidney disease.
 High blood pressure symptoms

- the most frequent symptom, headache, is also very

nonspecific, suboccipital pulsating headaches
- noise in the ears;
- dizziness, confusion, syncope;
- drowsiness;
- nose bleeds;
- polyuria;
- loss of vision or double vision;
-Dyspnoea
-Pain in the heart
- nausea and vomiting (hypertensive encephalopathy);
- inability to concentrate during work, deranged sleep;
- sometimes palpitation;
-general weakness
-signs of secondary causes of hypertension
check for D anger
S end for help
check R esponse
check A irways
check for B reathing
give C PR
apply a D efibrillator
Check for Danger
(Hazards/Risks/Safety?)
– to you
– to others
– to casualty

For example; electrical

wires, gases, aggressive
relatives, water, etc.

Remove yourself and

the casualty to an area
of safety
 Response
Check the casualty for a
response.

Use the COWS Method

• C an you hear me?
• O pen your eyes
• W hat is your name?
• S queeze my hand
Gently squeeze shoulders
(i.e. the trapezoid muscle)

If casualty is unresponsive
call for help.
 Call 112 to reach
emergency services
virtually anywhere
in the world.

Call 911 for USA,

000 for Australia

Or
notify your Cardiac
Arrest team within
the hospital.
 Airway
Check the airway is
open and clear of
obstructions.
Use a head tilt, chin lift
to open the airway.

Use a jaw thrust for patients

with suspected spinal cord,
head, neck and facial trauma.
(usually done on patient’s with a
GCS < 8. Not recommended for
unexperienced people).
 Airway
In an unconscious
patient, the tongue is
the most common cause
of obstruction.

Also check the airway

for blood, vomit & any
other foreign materials.

If breathing begins
place in recovery
position.
 Breathing
Look, listen and feel for
breathing, up to 10
seconds.
• is chest rising and falling?
• can you hear or feel air from mouth
or nose?

In Australia it is no longer
recommended to deliver
rescue breaths but rather
continue straight to CPR.
In clinical situations
use a face mask to CPR should be the chief
administer the priority.
breaths.
 CPR
If no signs of life –
unconscious, not
breathing and not
moving,
start CPR
(cardiopulmonary
resuscitation)

CPR involves giving;

30 compression and 2
breaths The recommended point of
compresions is the midline
100 compressions per over the lower half of the
minute sternum.
• Place the heel of one hand in
the centre of the chest
• Place other hand on top
• Interlock fingers
• Remember to push hard and
fast, straight arms.

• Revival checks conducted

every 2 minutes
(look for pulse & signs of life)

Should swap person doing

compressions every 2min (so
they don’t become tired and
perform ineffective
compressions)
If Defibrillator is
available, apply
and follow voice
prompts.

Remember when
shocking to get The Lifepak 500 is the standard product in Australia

everyone to stand
well back.

Keep checking for signs of life.

Thanks for your attention