BLOOD WORK ▪ If not taking blood thinning
COAGULATION STUDIES
- Coagulation studies are used to determine how
well your blood clots. This evaluation may
involve prothrombin time (PT) and partial
thromboplastin time (PTT) tests, as well as a
calculation called the international normalized
ratio (INR).
- Coagulation, also known as clotting, is the
process in which blood turns from a liquid to a
gel to form a clot.
- It is a normal process that prevents excessive
bleeding, but there are times when the clotting
process is abnormal and can cause harm
- PURPOSE: Coagulation studies are used to
detect blood clotting disorders, monitor a
person’s response to anti-clotting or pro-
clotting therapies, or establish a person’s risk
of bleeding prior to surgery
• PROTHROMBIN TIME (PT)
o Prothrombin time (PT) is a blood test
that measures the time it takes for the
liquid portion (plasma) of the blood to
clot.
o Used to monitor prothrombin levels if
taking blood thinner medications such
as warfarin.
o If injured and bleeding, the body
creates clots that stop the bleeding.
That process involves proteins, called
clotting factors or coagulation factors.
o The most common reason to perform
this test is to monitor the levels when
taking a blood-thinning medicine like
warfarin.
o Find the cause of abnormal bleeding or
bruising
o May be used to screen for initial
coagulation disorders.
o NORMAL VALUES:
▪ Measured in seconds.
▪ If not taking blood thinning
medicines (e.g. warfarin), the
normal range for PT is:
➢ 11 to 13.5 seconds
➢ INR of 0.8 to 1.1
▪ If taking warfarin to prevent blood
clots, the INR will be most likely to
be between 2.0 and 3.0.
o ABNORMAL VALUES:
medicines an INR result above 1.1
it is a sign of a coagulation disorder.
▪ If the PT is lower than 0.8, it means
that the clot is formed very fast and
the bleeding stops quickly.
However, it may be related to a
hypercoagulable state.
▪ A PT result that is too high or too
low in someone who is taking blood
thinning medicine may be due to:
➢ The wrong dose of medicine
➢ Drinking alcohol
▪ Have liver disease
▪ Taking certain OTC medicines,
vitamins, supplements, cold
medicines, antibiotics, or other
medicines
▪ Eating food that changes the way
the blood -thinning medicine works
in the body
o NURSING CONSIDERATION:
▪ BEFORE
➢ Patient is not required to do
fasting prior the test
➢ The doctor will advise the
patient to stop taking any blood-
thinning medications
➢ Inform the patient that this test
can assist in evaluating
coagulation and monitor
therapy.
➢ Explain that the patient may feel
slight discomfort from the
tourniquet and the needle
puncture.
➢ Observe for symptoms of
altered coagulation such as
bruising, bleeding gums or
blood in the urine.
▪ AFTER
➢ Patient is not required to do
fasting prior the test • The
doctor will advise the patient to
stop taking any blood-thinning
medications • Explain that the
patient may feel slight
discomfort from the tourniquet
and the needle puncture.
• PARTIAL THROMBOPLATIN TIME (PTT)
o Partial thromboplastin time (PTT) is a
blood test that looks at how long it takes
for blood to clot. It can help tell if one
 have a bleeding problem or if blood
does not clot properly.
o This test problems with bleeding or if
blood doesn't clot properly. When one
bleed, a series of actions involving
many different proteins (clotting
factors) take place in the body that help
the blood clot. This is called the
coagulation cascade.
o The PTT test looks at some of the
proteins or factors involved in this
process and measures their ability to
help blood clot.
o The test may also be used to monitor
patients who are taking heparin, a
blood thinner
o NORMAL VALUES: 25 to 35 seconds
▪ If the person is taking blood
thinners, clotting takes up to 2 ½
times longer
o ABNORMAL VALUES:
▪ An abnormal (too long) PTT result
may also be due to:
➢ Bleeding disorders (a group of
conditions in which there is a
problem with the body's blood
clotting process)
➢ Disorder in which the proteins
that control blood clotting
become overactive
(disseminated intravascular
coagulation)
➢ Liver disease
➢ Difficulty absorbing nutrients
from food (malabsorption)
➢ Low level of vitamin K
o NURSING CONSIDERATIONS:
o BEFORE
▪ To perform the test, the
phlebotomist or nurse takes a
sample of blood from the arm of the
patient.
▪ Clean the site with an alcohol swab
and insert a needle into the vein.
▪ A tube attached to the needle
collects the blood.
o AFTER
▪ Tell the patient that with any blood
test, there’s a slight risk of bruising,
bleeding, or infection at the
puncture site. In rare cases, the
vein may become swollen after a
blood draw. This condition is known
as phlebitis. Applying a warm
compress several times a day can
treat phlebitis.
▪ Ongoing bleeding could be a
problem if they have a bleeding
disorder or are taking blood thinning
medication, such as warfarin or
aspirin.
• INTERNATIONAL NORMALIZED RATIO
(INR)
o It is a test based from PT and is used to
assess the risk of bleeding or the
coagulation status of the patients.
o It is the preferred test of choice for
patients taking vitamin K antagonists
(VKA)-e.g. Warfarin. Because they vary
between persons, patients taking oral
anticoagulants must monitor their INR
in order to adjust their VKA doses.
o INDICATION: INR goal range can vary
from person to person depending on
many factors.
o NORMAL VALUES:
▪ Patients who are not on
anticoagulation – 1.1
▪ Patients who are on anticoagulation
therapy – 2.0 to 3.0
LIPID PROFILE
- Also called a lipid panel or lipid profile is a blood
test that determines the concentration of
certain fat molecules known as lipids in the
blood, which is closely linked to the risk of
artery disease.
- PURPOSE:
• High fat and cholesterol levels have a
propensity to block the arteries, raising the
risk of vascular disease, heart attacks, and
strokes.
• A lipid panel gives a report on blood's
estimated level of fat, which is directly tied
to risk of developing artery disease. With a
lipid panel, different kinds of fat can be
assessed.
- DEFINITION OF TERMS:
• LIPID - Lipids are hydrocarbon-containing
compounds that serve as the foundation for
 the structure and function of living cells.
Lipids include fats, oils, waxes, vitamins
(such as A, D, E, and K), hormones, and
the majority of the cell membrane that is not
formed of protein
• CHOLESTEROL – a lipid required for
hormone synthesis and cell membrane
formation. It is found in large quantities in
brain and nerve tissue.
• LIPOPROTEIN - this are particles made of
protein and fats. They carry cholesterol
through the bloodstream to the body cells.
A high level of lipoprotein may mean you
have a high risk for heart disease and
stroke.
• TOTAL CHOLESTEROL
o a measurement of your blood's total
cholesterol content
o FORMULA:
▪ HDL + LDL + 20% Triglycerides
➢ DESIRABLE – 3.9 – 5.5 mmol/L
➢ BORDERLINE – 5.5 – 6.5
mmol/L
➢ HIGH - > 6.5 mmol/L
o NORMAL VALUE:
▪ KIDS (19 AND BELOW) – less than
170 mg/dL
▪ ADULT – less than 200 mg/dL
➢ LOW – <120 mg/dL
➢ BORDERLINE HIGH – 200 to
239 mg/dL
➢ HIGH – At or above 240 mg/Dl
• HIGH DENSITY LIPOPROTEINS (HDL)
o It is also known as “good” cholesterol
since it transports cholesterol from
other parts of the body back to the liver.
The cholesterol is then removed from
the body via the liver.
o Helps clear the arteries and carries the
cholesterol away from the blood,
helping to reduce the risk of heart
disease.
o A high reading is desirable.
o NORMAL VALUE: > 1.5 mmol/L
• LOW DENSITY LIPOPROTEINS (LDL)
o It is sometimes called the “bad”
cholesterol because a high LDL level
leads to a buildup of cholesterol in your
arteries which causes a blockage and
increases the risk to contract heart
disease.
o NORMAL VALUE:
▪ DESIRABLE – 1.7 – 3.5 mmol/L
▪ BORDERLINE – 3.6 – 4.5 mmol/L
▪ HIGH - > 4.5 mmol/L
• TRIGLYCERIDES
o are composed of free fatty acids and
glycerol, are stored in the adipose
tissue and are a source of energy. This
usually increases after meals and are
affected by stress.
o Most common type of fat found in the
body.
o When high levels are introduced, the
blood becomes thick and sticky.
o NORMAL VALUE:
▪ DESIRABLE – 0.5 – 1.7 mmol/L
▪ BORDERLINE – 1.8 – 2.5 mmol/L
▪ HIGH - > 2.5 mmol/L
• LDL: HDL RATIO
o This ratio compares the amount of LDL
cholesterol to your HDL cholesterol
levels.
o FORMULA: LDL divided to the HDL
o Higher ratios mean a higher risk of
heart disease.
oTo protect against heart disease and
stroke HDL levels should stay within the
safe limit.
▪ Men - 40 to 60 mg/dL)
▪ Women - 50 to 60 mg/dL
• VERY LOW-DENSITY LIPOPROTEIN
(VLDL)
o Since the VLDL helps in the cholesterol
build up on the walls of arteries it is
classified as "bad cholesterol
o NORMAL VALUE: 2 to 30 mg/dL
o ABNORMAL VALUE: > 30 mg/dL
(elevated)
- NURSING CONSIDERATIONS
 • BEFORE
o Instruct the client to fast for 9-10 hours
prior the procedure
o In other circumstances lipid test without
fasting is possible
• DURING
o Assist patient to sit in a chair and locate
arm for easily accessible vein. Place
Elastic Band on the upper arm of client
Locate and disinfect the puncture site.
o Inform patient about the minimal pain
during the insertion of needle in blood
vessel.
• AFTER
o Instruct the patient to keep the cotton
swab placed over the puncture site for
an hour or more Encourage patient to
eat after the procedure
o Patient may be advised to restrict
intense exercise or physical activity for
a few hours after the test.
• HEALTH EDUCATION
o Take statin medications as prescribed
o Become physically active
o Do not smoke
o Control your blood pressure and
monitor at home
o Control your blood sugar
o Follow up with your clinician
o Reduce your body weight
o Eat a low-fat diet
o Decrease stress engage in an active
lifestyle
BIOMARKERS
- A substance used as an indicator of a
biological state
- It is elevated as an indicator of normal biologic
processes, pathogenic processes, or
pharmacologic responses to a therapeutic
intervention
- A biomarker (short for biological marker) is an
objective measure that captures what is
happening in a cell or an organism at a given
moment. Biomarkers can serve as early
warning systems for your health.
a. CARDIAC BIOMARKERS
• Biomarkers are measured to evaluate
heart function
• It is used to measure cardiac enzymes.
Elevated heart enzyme levels can
indicate acute coronary syndrome or
ischemia. Heart disorders like acute
coronary syndrome, coronary heart
disease, and atherosclerosis are
diagnosed, screened for, and treated
by healthcare professionals using
cardiac biomarkers.
- NORMAL VALUES/RESULTS AND
INDICATIONS:
• TROPONIN
o TnI: Less than 0.3 mcg/L
o TnT: Less than 0.1 mcg/L
▪ If a person’s troponin levels are
low or normal after experiencing
chest pain, he/she probably have
not experienced a heart attack. If its
levels are high, the likelihood of
heart damage or heart attack is
high.
▪ High troponin values may indicate
Cardiac muscle injury. Troponin
level increases in 4 hours and
reaches the highest level in 24
hours after the cardiac muscle
injury. Troponin level returns to
normal levels in 10 days following
the cardiac muscle injury.
• TOTAL CREATININE PHOSPHOKINASE
o Men: 55 to 170 IU/L
o Women: 30 to 135 IU/L
▪ Low levels may indicate that
muscles are less strong or are
deteriorating. Elevated CPK points
to recent tissue damage.
▪ High total creatine
phosphokinase values may
indicate cardiac muscle injury or
tissue injury. Total creatine
phosphokinase increases in 4
hours and reaches the highest level
in 24 hours after the cardiac muscle
injury. Total creatine
phosphokinase level returns to
normal levels in 3 days following the
cardiac muscle injury
• CPK-MB: Less than 3.0 ng/Ml
o High CPK-MB values may indicate
cardiac muscle injury. CPK-MB
increases within 2 hours and reaches
the highest level within 24 hours after
the cardiac muscle injury. CPK- MB
level returns to normal levels in 3 days
following the cardiac muscle injury. If
levels are high after 3 days, then
 additional cardiac muscle is being
damaged and the myocardial infarction
is continuing.
- PROCEDURE:
a. LETTER OF INTENT (LOI) – initiates the
qualification process of a biomarker for a
proposed context of use (COU) in drug
development
b. QUALIFICATION PLAN (QP) – Defines
the intended development to generate the
necessary supportive data to qualify the
biomarker for the proposed COU
c. FULL QUALIFICATION PACKAGE (FQP)
– Contains all accumulated data to support
the qualification of the biomarker for the
proposed COU
d. QUALIFICATION RECOMMENDATION –
contains FDA’s determination on whether
the biomarker is qualified for the proposed
COU based on a comprehensive review of
the FQP.
e. GENOMIC FINGERPRINT
f. ISOLATION
g. DATA INTERPRETATION
h. CLINICAL INTERPRETATION
- NURSING CONSIDERATIONS:
• BEFORE
o Ask patients if they are taking any
anticoagulants or have any conditions
that cause coagulopathy; check their
medications for any that can cause
coagulopathy such as platelet
inhibitors.
o Question patients about recent alcohol
consumption.
o Assess if the patient performed
strenuous activities.
o Explain why the blood sample is taken.
• DURING
o The nurse should perform an
immediate assessment when the
patient arrives in the Emergency
Department and reports chest pain.
o When cardiac pain is present,
administer three sublingual
nitroglycerin tablets (0.4 mg): one at a
time every 5 minutes (or three aerosol
sprays under the tongue every 5
minutes). Be mindful of
contraindications for nitroglycerin.
o Administer diuretics.
o If the patient does not really exhibit
symptoms of heart failure,
hemodynamic compromise,
bradycardia, or severe reactive airway
illness, give them a beta blocker.
• AFTER
o Discuss discharge instructions and
provide patient education, which
includes following a low-fat diet, taking
nitroglycerin for chest pain, exercising,
managing medication, making lifestyle
changes (such as smoking cessation,
blood pressure control, and stress
management), and scheduling regular
medical checkups.
BRAIN (B-TYPE) NATRIURETIC PEPTIDE
- Brain natriuretic peptide is released mainly
from the ventricles but also from atria as well
as the brain, but it is mainly released from the
ventricles due to any overstretch of ventricular
walls particularly associated with congestive
heart failure.
- A blood sample is needed. The blood is taken
from a vein (venipuncture).
- Brain natriuretic peptide (bnp) test is a blood
test that measures levels of a protein called
BNP that is made by your heart and blood
vessels.
- Testing may be ordered to assess the severity
of the disease and its likely course or
prognosis. Less often, BNP or NT-PROBNP
tests may be considered when determining
what type of treatment to prescribe or when
monitoring a patient’s health over time.
- ROLES OF BNP:
• Acts of vascular smooth muscle.
• Acts on the renal system.
- PURPOSE:
• Screen for heart failure.
• Assess the treatment of heart failure.
- PROCEDURE:
- NORMAL VALUES AND INDICATIONS:
• 0 to 99 pg/mL
• Low level of BNP is normally found in
blood. However, BNP level increases when
the heart works harder for long periods
such as in heart failure. The BNP test
measures the level of BNP in the blood.
• Elevations in BNP can occur from a
number of other conditions such as
pulmonary embolus, myocardial infarction,
and ventricular hypertrophy.
 • SLIGHTLY HIGH LEVEL: (100 to 300
pg/ml or 100 to 300 ng/l) may indicate
minimum heart failure.
• MODERATELY HIGH LEVEL: (300 pg/ml
or 300 ng/l) may indicate mild heart failure.
• HIGH LEVEL: (600 pg/ml or 600 ng/l) may
indicate moderate heart failure.
• VERY HIGH LEVEL: (900 pg/ml or 900
ng/l) may indicate severe heart failure.
- NURSING CONSIDERATIONS:
- BEFORE
• You don't need any special preparations for
a BNP test or an NT-PROBNP test.
• Assess if the patient:
o has eaten or drunk anything except
water for 12 hours before the test is
administered.
o Is taking diuretics or cardiac
glycosides.
o has myocardial infarction, kidney
disease and is on dialysis, and chronic
obstructive pulmonary disease (copd).
o is taking echinacea, valerian, or other
herbs.
• Teach the patient what to expect
• Inform the patient this test can assist in
diagnosing heart failure.
• Explain that a blood sample is needed for
the test.
• Carry out hand hygiene before and after
each patient procedure.
- DURING
• Put on gloves and select a suitable site for
venipuncture
• Clean the venipuncture site with an alcohol
swab, working in a circular motion from the
site outward
• Wait at least 1 minute for the patient’s skin
to dry
• Apply the tourniquet
• For a BNP test or an NT-PROBNP test, a
health care professional will take a blood
sample from a vein in your arm, using a
small needle. After the needle is inserted, a
small amount of blood will be collected into
a test tube or vial. You may feel a little sting
when the needle goes in or out. This
usually takes less than five minutes.
- AFTER
• Apply direct pressure to the venipuncture
site until bleeding stops
• Assess the venipuncture site for hematoma
formation; if one develops, apply direct
pressure
• Prepare to initiate the antimicrobial
therapy, as needed.
NT-proB-TYPE-NATRIURETIC PEPTIDE (BNP)
- Levels of NT-proBNP help diagnose and
estimate the severity of heart failure.
- The test is particularly useful in hospital
emergencies to help distinguish heart failure
from severe lung damage.
- The test is helpful for checking disease
progression and the impacts of therapy.
- NORMAL VALUES/RESULTS AND
INDICATIONS:
• If NT-PRO-BNP level is higher than the
normal value it means you have heart
failure.
- NURSING CONSIDERATION:
• BEFORE
o Inform patient that the test can assist in
diagnosing heart failure.
o Explain that a blood sample is needed
for the test
o Inform patient that there's a slight pain
and bruising at the spot where the
needle was put in.
• DURING
o Assist patient during the procedure
o Monitor the patient conditions
o Provide comfort measures to divert
patient pain or discomfort.
• AFTER
o Instruct the patient to consume a
variety of food within the basic food
groups.
o Teach patient and SO about
medication management, low sodium
diet, exercise, and activity and learning
to recognize the S/Sx of worsening
heart failure.
- PROCEDURE: This type of test follows the
procedure of a regular blood test and the blood
sample from the patient.
ERYTHOCYTE SEDIMENTATION RATE (ESR)
- NURSING CONSIDERATIONS
- The ESR is a measure of the rate of
sedimentation of red blood cells (RBCs) in an
anticoagulated whole blood sample over a
specified period of time.
- PURPOSE:
• To assist in diagnosing acute infection in
diseases such as tissue necrosis, chronic
infection, and acute inflammation.
• Assist in the diagnosis of acute infection,
such as tuberculosis or tissue necrosis
• Assist in the diagnosis of acute
inflammatory processes
• Assist in the diagnosis of chronic infections.
• Assist in the diagnosis of rheumatoid or
autoimmune disorders.
• Assist in the diagnosis of temporal arteritis
and polymyalgia rheumatica.
• Monitor inflammatory and malignant
disease.
- NORMAL VALUES AND INDICATIONS:
HOMOCYSTEINE
- Homocysteine, an amino acid, linked to the
- PURPOSE:
• Elevated ESR level may indicate the
following:
o Bacterial infection
o Chronic renal failure
o Hyperfibrinogenemia
o Inflammatory disease
o Macroglobulinemia
o Malignant diseases
o Severe anemias such as vitamin B12
deficiency or iron deficiency
• Decreased ESR level may indicate:
o Hypofibrinogemia
o Polycythemia vera
o Sickle cell anemia
o Spherocytosis
• BEFORE
o Inform the patient that this test can
assist in identification of inflammation.
o To decrease client’s anxiety, explain
that a blood sample is needed for the
test.
o Ask client for ongoing medications as
this may cause false result
o If the patient is a female, ask for
ongoing menstruation as this may
cause an increase within the test
results.
• DURING
o Immediately perform test on the
collected specimen, should not be
delayed for more than 4 hrs if stored at
room temperature. Inaccurate timing or
a delay in performing the test once the
specimen has been collected will
invalidate test results.
• AFTER
o Teach how to perform hand hygiene to
decrease risk of infection
o Teach how to take and document
temperature to remind the patient that
elevations are to be reported to the
health-care provider
development of atherosclerosis because it can
damage the endothelial lining of arteries and
promote thrombus formation. The blood
homocysteine level is determined by the
homocysteine test.
• Help diagnose homocystinuria, a rare,
inherited disorder that prevents the body
from breaking down certain proteins. It can
cause serious health problems and usually
starts in early childhood.
• Find out if you have deficiency in vitamin
B12, B6, or folic acid.
• Screen for heart disease in people at high
risk for heart attack or stroke
 • Monitor people who have heart disease.
- NORMAL VALUES:
• Optimal: less than 12 mcmol/L
• Borderline: 12 to 15 mcmol/L
• High risk: greater than 15 mcmol/L
• Moderate: 15-30 mcmol/L
• Intermediate: 30-100 mcmol/L
• Severe: greater than 100 mcmol/L
o High Homocysteine levels may mean:
▪ You are not getting enough vitamin
B12, B6, or folic acid in your diet.
▪ You are at a higher risk for CAD,
stroke, and peripheral vascular
disease.
▪ Homocystinuria. If high levels of
homocysteine are found, more
testing will be needed to rule out or
confirm a diagnosis.
o Low levels may indicate that the body
won’t be able to respond to oxidative
damage sufficiently.
- NURSING CONSIDERATIONS:
• BEFORE
o 12-hour fast is necessary before
drawing a blood sample for an accurate
serum measurement
C-REACTIVE PROTEIN (CRP)
- C-reactive protein (CRP) is produced as part of
the inflammatory process. Inflammation is
thought to play a role in the development and
progression of atherosclerosis. It is not specific
enough to diagnose a disease but serves as a
general marker for infection, inflammation etc.
- CRP is made by the liver and released into the
blood within a few hours after an injury,
infection or an inflammation.
- PURPOSE:
• Screen for inflammation for patients with
inflammatory disease.
o Irritable bowel disease
o Arthritis
o Autoimmune conditions
o Infections
o Pelvic inflammatory disease
• The high-sensitivity test is used to assess
the risk for cardiovascular disease.
- NORMAL VALUES:
• Low CRP - less than 1 mg/ml
▪ The treatment for inflammation is
working.
• Moderate CRP - 1-3 mg/ml
• High CRP - greater than or equal to 3
mg/ml
o There is an inflammation and at risk for
cardiovascular disease (CVD).
- NURSING CONSIDERATIONS:
• BEFORE
o Wash hands
o Explain the purpose, procedure, and
site.
o Explain that the patient may feel a pinch
or nothing at all when the needle is
inserted into the vein.
o There are no food, fluid, activity, or
medication restrictions unless by
medical direction.
• DURING
o Wrap a tourniquet around the patient’s
upper arm to stop blood flow, making
veins easier to identify.
o Clean the puncture site with alcohol.
o Insert the needle into the vein with the
bevel up.
o Attach the appropriate test tube to the
needle. Allow the blood to fill the test
tube.
o Remove the tourniquet to restore blood
flow.
o Place a gauze pad over the site while
withdrawing the needle.
o Apply firm pressure to the site until
bleeding has stopped.
• AFTER
o There might be a small bruise at the
site.
o Discard waste materials.
o Ask the patient to wait for the results.
o Explain the results to the patient.
CENTRAL VENOUS PRESSURE (CVP)

- Measurement of the pressure in the vena cava
or right atrium
- NORMAL VALUE: 2-6 mmHg
- INDICATIONS:
• Elevated CVP – right ventricular preload
• Low CVP – reduced ventricular preload
- NURSING CONSIDERATIONS:
• BEFORE
o Understanding of procedure
o History of heart failure, COPD, head
injury, cerebral bleeding risk
o Allergies to povidone iodine, tape,
latex, and ointments
• DURING
o Wash hands
o Prepare pressurized and heparinized
flush solution.
o Flush pressurized closed transducer
tubing with luer-lok connections and
ports.
o Don sterile gloves, protective gown,
and mask.
o Assist with skin preparation.
o Position patient in trendelenburg
position.
o Assist physician or advanced practice
nurse with flushing central venous
catheter ports with sterile solution and
capping ends with luer-lok caps.
o The patient will be instructed to take a
deep breath and hold it prior to the
insertion procedure.
o The central venous catheter will be
inserted a 3 – 5 inches.
o Pressure tubing will be connected to
distal port of central venous catheter as
soon as the catheter has been inserted.
o Level the transducer with the patient's
phlebostatic axis and "zero" the
transducer.
o Monitor cardiac monitor and
hemodynamic waveform during
catheter insertion. Observe waveform
and perform a dynamic response test
(square wave test).
o Record central venous mean pressure
and waveform.
o Apply sterile transparent occlusive
dressing over insertion site.
• AFTER
o MONITORING CVP WITH
ELECTRONIC TRANSDUCER
SYSTEM
▪ Position patient supine with head-
of-bed 0 – 60-degree elevation.
▪ Check level of transducer with
phlebostatic axis.
▪ During first assessment of shift,
zero transducer to air.
▪ Assess waveform for dampness.
▪ Maintain tight luer-lok connections
and nonvented caps on stopcocks
of pressure tubing.
▪ Record cvp pressure from the
monitor
o Monitoring cvp with water
manometer
▪ Position patient supine with head-
of-bed 0 – 60-degree elevation.
▪ Turn stopcock of water manometer
off to patient and fill water
manometer up to 20 cm h2o.
▪ Align 0 (zero) of water manometer
with phlebostatic axis.
▪ Turn stopcock of water manometer
off to iv solution bag.
▪ Encourage the patient to take some
normal breaths while the water
descends the water manometer to
the resting pressure.
▪ Read the water meniscus (bottom
of water level) during end expiration
of the patient's respiratory cycle.
▪ As soon as a pressure is read, turn
the stopcock of the water
manometer off to the water column
and flush the iv tubing of any blood
backed up in the tubing. leave the
stopcock in the off position to the
manometer when not in use
CARDIAC ENZYMES
- also known as cardiac biomarkers
- our heart releases enzymes when there’s heart
damage or stress due to low oxygen into the
bloodstream
CK-MB
- It is the cardiac-specific isoenzyme, found
mainly in cardiac cells and therefore increases
when there has been damage to these cells
- PURPOSE: Assess the results of
percutaneous coronary intervention (PCI) or
thrombolytic medication to restore blood flow
through the coronary artery. Specifically, it
checks for Myocardial Infarction, heart muscle
injury, and unstable angina.
- NORMAL VALUE: < 3.0 ng/mL
- INDICATIONS:
• BELOW NORMAL - Linked to fainting and
at risk of death. Critically ill and chronic
kidney disease patients with below normal
creatine kinase levels had higher mortality
rates.
• ABOVE NORMAL - Any kind of heart
muscle damage can cause an increase in
CK and CK-MB, including physical damage
from trauma , surgery, inflammation &
decreased oxygen (ischemia). Strenuous
exercise may also increase both CKC and
CK-MB, but usually with a lower relative
index. Kidney failure can Cause a high CK-
MB level. CK-MB concentration Gradually
rises in blood in 4 to 6 hrs after onset of
chest pain, peaks by around 24 hrs. and.
returns rapidly to baseline in 48 in.
- NURSING CONSIDERATIONS:
• BEFORE
o Inform the patient that no fasting is
required prior test and can be carried
out at any hour.
o Inform the client that an IM injection is
not allowed 1 hour before the test
o Ask the patient about any current
medications or any recent physical
activity.
o Inform the client that insertion of needle
in the forearm is needed and might feel
slight prick
• DURING
o Apply manual pressure and dressings
over puncture site
• AFTER
o Discuss the results gathered from the
data with the client and further
explaining indications of the result
TROPONIN
- a protein found in myocardial cells, regulates
the myocardial contractile process. Troponins I
and T are specific for cardiac muscle, and
recognized as reliable and critical markers of
myocardial injury
- PURPOSE:
• Diagnose heart attack
• Monitor angina
• Assess changes in troponin levels
a. TROPONIN I
- NORMAL VALUE: < 0.03 ng/mL
- INDICATIONS:
• BELOW NORMAL - Normally, there
should be no detectable troponin, or a very
low level—below 0.04 nanograms per
milliliter (ng/ml) in your blood. A troponin
level between 0.04 ng/ml and 0.39 ng/ml
often indicates a problem with the heart. If
an individual experienced chest pain, the
possibility of a heart attack is unlikely
especially if troponin levels are still low or
normal 12 hours after the chest pain
started.
• ABOVE NORMAL - Sign that a heart
attack has occurred. Most patients who
have had a heart attack have increased
troponin levels, the underlying cardiac
injury is usually a myocardial in function. It
also appears to be a more specific marker
of risk of composite cardiovascular disease
& coronary heart disease.
b. TROPONIN T
- NORMAL VALUE: < 0.01 ng/mL
- INDICATIONS:
• ABOVE NORMAL - It's more strongly
associated with risk of non-cardiovascular
disease death. Elevated troponin levels
can occur as a result of both Cardiac and
non-Cardiac conditions possible causes
includes: sepsis, which is a severe &
potentially life-threatening reaction to an
infection entering the bloodstream's kidney
failure on Chronic kidney disease
- NURSING CONSIDERATIONS:
• BEFORE
o Inform the client about the procedure
o Assess client’s knowledge about the
procedure
o Inform the client that insertion of needle
in the forearm is needed and might feel
slight prick
• DURING
o Provide comfort during the collection of
specimens
• AFTER
o Discuss the results gathered from the
data with the client and further
explaining indications of the result
o Apply direct pressure to the
venipuncture site until bleeding stops.
o Assess the venipuncture site for
hematoma formation, if one develops,
apply direct pressure.
o Prepare to initiate antimicrobial
therapy, as ordered.
 IMAGING STUDIES
POSITRON EMISSION TOPOGRAPHY (PET)
SCAN
- It is ordered to study blood flow and metabolic
activity within a patient's body.
- Healthcare providers frequently combine
results from the PET scan with the CT scan
results to obtain a thorough understanding of
how well tissues and organs are being infused
with blood
- PURPOSE: To check the following
• Blood flow to organ and tissue
• Metabolic activity of organs
• Stroke and Transient ischemic attack
• Multiple sclerosis
• Parkinson’s disease
• Alzheimer’s disease
• Epilepsy
• Coronary Artery Disease
• Presence of Cancer
- PROCEDURE: Tracers are given by injection;
one compound is used to determine blood in
the myocardium, and another determines the
metabolic function. The PET camera provides
detailed three-dimensional images of the
distributed compounds. The viability of the
myocardium is determined by comparing the
extent of glucose metabolism in the
myocardium to the degree of blood flow.
- NORMAL FINDINGS:
• Normal blood flow
• No growth
• No blockages
• Normal metabolic activity
- ABNORMAL FINDINGS: Cancer Cells show
up as bright spots on a PET Scan because they
have a higher metabolic rate than do normal
cells. Abnormal results may indicate areas of
heart muscle are not receiving enough blood,
or there is heart damage or scar tissue in the
heart, and or there is a buildup of abnormal
substances in the heart muscle.
- NURSING CONSIDERATIONS
• BEFORE
o The nurse instructs the patient to refrain
from using alcohol and caffeine for 24
hours before undergoing PET
o For patients with diabetes and who are
taking insulin, the nurse needs to
discuss insulin doses and food
restrictions with the primary provider.
o The nurse assesses patients for fear of
closed spaces or claustrophobia
o The nurse also reassures patients that
radiation exposure is at safe and
acceptable levels, similar to those of
other diagnostic x-ray studies.
• DURING
o To prepare the patient for PET, the
nurse inserts an IV or assesses the
existing IV catheter
o The patient is positioned on a table with
hands above the head. The table then
slides into a donut shaped scanner.
o While in the scanner, the patient must
lie still
o A baseline scan is performed, which
takes about 30 minutes. Then a tracer
is injected into the IV and the scan is
repeated.
o The patient's glucose level is monitored
throughout the procedure.
• AFTER
o Patient will typically be in the recovery
room for about one hour for biopsies
and about two hours for ablations.
o Chest x-rays are obtained for lung
interventions and certain liver and
adrenal interventions.
o Special considerations are taken by the
post-anesthesia care nurse
o Patients will have radioactive material
in their body for 24 hours and will
receive a card stating so.
o Patients receive educational handouts
about the FDG isotope injection
including recommendations to increase
water and liquids to help flush out the
isotope.
o Other instructions include limiting close
contact with infants or pregnant women
for 24 hours and stop breast feeding for
24 hours post-scan.
o Patients can resume their diet as
instructed.
o Patients are given special instructions
warranting notification of the clinical
team including excessive pain, fever,
difficulty breathing and signs and
symptoms indicative of infection.
2D ECHO
- Echocardiography is a noninvasive ultrasound
test that is used to measure the ejection
 fraction and examine the size, shape, and
motion of cardiac structures. It is particularly
useful for diagnosing pericardial effusions;
determining chamber size and the etiology of
heart murmurs; evaluating the function of heart
valves, including prosthetic heart valves; and
evaluating ventricular wall motion.
- PURPOSE: To check the following
• Blood flow to the organ and tissue
• Metabolic activity of organs
• Stroke and transient ischemic attack
• Multiple sclerosis
• Parkinson’s disease
• Alzheimer’s disease
- NORMAL FINDINGS:
• Normal cardiac function
• Normal cardiac growth
• No fluid build-up
• Normal ejection fraction
- ABNORMAL FINDINGS: Abnormal results
include congenital heart diseases, blood clots
or tumors, malfunctioning of the heart valve,
and there is an abnormality of blood flow within
the heart.
- NURSING CONSIDERATIONS:
• BEFORE
o Inform the patient that no fasting is
required prior test
o Ask the patient about any current
medications.
o Inform the patient about the test,
explaining that it is painless, remove
clothing from the waist up, a gel would
be applied, devices will be placed on
the chest, and would take 30-45
minutes with the room in dim
• DURING
o Instruct the client to remove the clothing
from the waist up and provide gown.
o Apply gel to the skin
o Instruct the patient to turn periodically
onto the left side or hold a breath.
• AFTER
o Inform the patient that the ultrasound
images and Doppler recordings will be
submitted to physician or Cardiologist
who will interpret the images and wait
for the results.
o Inform the patient can already go home
and there will be no recovery or
rehabilitation stage
CARDIAC CATHETER
- Cardiac catheterization (also called cardiac
cath, heart cath, or coronary angiogram) is a
procedure that allows your doctor to see how
well your blood vessels supply your heart
- PURPOSE:
• To check for heart disease and how well
the heart is working
• To place a stent if any blockage/s was
found.
- NORMAL VALUES:
• Pressures
• Volumes
- NORMAL FINDINGS:
• A gradual clogging of the arteries by fatty
materials and other substances in the
blood stream indicates atherosclerosis.
Enlargement of the heart due to thickening
or weakening of the heart muscle indicates
cardiomyopathy. Defects in one or more
heart structures that occur during fetal
development, such as a ventricular septal
defect (hole in the wall between the two
lower chambers of the heart) indicates
congenital heart defects which may lead to
abnormal blood flow within the heart.
• Heart muscle that is too weak to pump
blood well, causes fluid buildup
(congestion) in the blood vessels and
lungs, and edema (swelling) in the feet,
ankles, and other parts of the body
indicates heart failure. Malfunction of one
or more of the heart valves that can affect
blood flow within the heart indicates heart
valve disease
- NURSING CONSIDERATIONS:
• BEFORE
 o Before the patient undergoes cardiac o Instruct patient to report chest pain and
catheterization a precardiac bleeding or sudden discomfort form the
catheterization patient teaching plan catheter insertion sites promptly
must be established and initiated. This o Ensure patient safety
cardiac catheterization teaching plan ELECTROCARDIOGRAM (ECG)
must be individualized to fit the patient’s - An electrocardiogram (abbreviated as EKG or
needs ECG) represents a recording of the heart's
o Inform the patient not to eat or drink electrical activity and is recorded non-
anything for 8 to 12 hours before the invasively from the surface of the body.
examination, or as directed by the - PURPOSE: ECG is increasingly being used for
Doctor. Having food or drink in the monitoring patients on antiarrhythmics and
stomach can increase the risk of other drugs, as an integral part of preoperative
complications from anesthesia or assessment of patients undergoing non-
sedation cardiac surgery, and for screening individuals
o Ensure the patient to bring all his/her in high-risk occupations and those participating
medications to the examination. It is in sports. Also, ECG serves as a research tool
important to bring the bag of medicine for surveillance and experimental trials of drugs
prescription sheet. with recognized cardiac effects.
o Ask the client to relax and tell the - SUPPLIES:
patient that it is common to all patients • Electrodes (sensors)
who undergo cardiac catheterization to
feel anxious or nervous
• DURING
o Monitor the patient’s heart rate and
rhythm, respiratory and pulse rates,
and blood pressure frequently to
ensure patient’s vital signs are in
normal range during the procedure.
o Check the patient’s color, skin
temperature, and peripheral pulse
below the puncture site and observe
the insertion site for a hematoma or
blood loss.
• AFTER
o Observing the catheter access site for
bleeding or hematoma formation and
assessing peripheral pulses in the
affected extremity every 15 minutes for
1 hour, every 30 minutes for 1 hour, and
hourly for 4 hours or until discharge.
o BP and heart rate are also assessed
during these same time intervals.
o Assess for affected extremity pain,
numbness, tingling sensation
o Screen carefully for arrhythmias by
observing the cardiac monitor or by
o To ensure accurate test results,
assessing the apical and peripheral
position chest electrodes as follows:
pulses for changes in rate and rhythm.
o V1: Fourth intercostal space at right
o Maintain activity restrictions for 2 to 6
border of sternum
hours after procedure
o V2: Fourth intercostal space at left
border of sternum
o V3: Halfway between V2 and V4
 o V4: Fifth intercostal space at
midclavicular line
o V5: Fifth intercostal space at anterior
axillary line (halfway between V4 and
V6)
o V6: Fifth intercostal space at
midaxillary line, level with V4
• Gauze and skin prep solution (as approved
by your facility)
• Razor or clippers and a roll of tape (for hair
removal)
• Skin adhesive and or antiperspirant
• EKG Paper (if your machine is required to
provide a hard-copy)
- NORMAL VALUES:
- ABNORMAL VALUES:
- INDICATIONS:
• The abnormal value of the heart beat does
not lie between the ranges of 60 to 100
beats/ minutes. Slower rate than 60
beats/min represents a lower heart rate
and it is called as bradycardia. The higher
rate of the heart beat than 100 beats/ min
is a fast heart rate and it is called as
tachycardia.
- PROCEDURE:
• BEFORE
o Before the procedure, a brief history
regarding drugs and allergies to
adhesive gel is necessary.
o The temperature of the room must be
kept optimal to avoid shivering.
o The patient should be in a gown, and
electrode sites identified.
o For good contact between the body
surface and electrodes, it is advised to
shave the chest hair and then apply the
electrocardiographic adhesive gel to
the electrodes.
o Any metallic object, like jewelry or a
watch, requires removal.
o Limb and precordial leads should be
accurately placed to avoid vector
misinterpretation.
o Finally, the patient must lie down and
relax before recording the standard
10-second strip.
o Explain the procedure to the patient.
o No special preparation is needed.
o Ensure to empty the bladder.
o Encourage the patient to cooperate.
o Explain the need to darkened the
examination field.
• DURING
o Inform that a conductive gel is applied
to the chest area.
o A conductive gel will be applied to his
chest and that a quarter-sized
transducer will be placed over it.
o Warn him that he may feel minor
discomfort because pressure is exerted
to keep the transducer in contact with
the skin.
o Position the patient on his left side.
o Explain that transducer is angled to
observe different areas of the heart and
that he may be repositioned on his left
side during the procedure.
• AFTER
o Remove the conductive gel from the
patient’s skin.
 o When the procedure is completed,
remove the gel from the patient’s chest
wall.
o Inform the patient that the study will be
interpreted by the physician.
o An official report will be sent to the
requesting physician, who will discuss
the findings with the patient.
o Instruct patient to resume regular diet
and activities.
o There is no special type of care given
following the test.
PULMONARY ARTERY PRESSURE MONITOR
- It is an invasive hemodynamic monitoring.
- It is used in critical care for assessing left
ventricular function, diagnosing the etiology of
shock, and evaluating the patient’s response to
medical interventions (e.g., fluid
administration, vasoactive medications).
- A pulmonary artery catheter and a pressure
monitoring system are used. A variety of
catheters are available for cardiac pacing,
oximetry, cardiac output measurement, or a
combination of functions.
- SWAN GANZ CATHETER:
- COMPLICATIONS
• Dysrrhythmia
• Pulmonary thromboembolism
• Air embolization
• Pulmonary artery rupture
• Pulmonary infarction
• Infection and sepsis
- ADVANTAGES:
• Detect heart failure and sepsis shock
• Pulmonary artery pressure and wedge
pressure
• Indirectly measure the left heart pressure
• Monitor effectiveness of therapy
• Drug effectiveness
- NURSING CONSIDERATIONS:
• BEFORE
o Get informed consent signed.
o Patient has to be monitored with
continuous ECG throughout the
procedure.
o Aseptic precautions must be employed.
o Selection of insertion site.
o Position the patient in Trendelenburg
position.
o Prepare the patient and equipment.
• DURING
o Assist the procedure.
o Monitor and record HR, rhythm and BP
during catheter insertion and passed
through each chamber.
o Balloon should not be inflated more than
8 - 10 sec.
o Not more than 1.5ml of air should be used
to inflate the balloon.
o Keep the emergency medications ready.
o Watch for dysrhythmia.
• AFTER
o Secure the catheter.
 o Apply sterile occlusive dressing.
o Obtain a chest X-ray.
o Position the patient with supine legs
extended, head end elevated to 30 - 60
degree.
o Continuously monitor the patient.
o Adequate flushing of line using
heparinized saline.
o Adhere to aseptic technique using
dressing.
o After insertion measurement of catheter
length in centimeters is documented.
DEFIBRILLATION
- In defibrillation, electrode paddles are used to
direct an electric current through the patient’s
heart.
- Electrical defibrillation is the most effective
treatment for ventricular fibrillation. The goal is to
depolarize the irregularly beating heart
temporarily and allow more coordinated
contractile activity to resume. In this procedure, it
automatically detects and interprets the heart's
rhythm and informs the operator if a shock is
indicated.
- PURPOSE:
• Decreased Cardiac Output
• Impaired Gas Exchange
• Ineffective Airway Clearance
• Risk for Ineffective Cerebral Tissue Perfusion
• Impaired Spontaneous Ventilation
• Risk for Injury
- NORMAL VALUES/RESULTS:
• Normal vital sign ranges for the average adult
while resting are:
o Blood pressure: 90/60 mm Hg to 120/80
mm Hg
o Breathing: 12 to 18 breaths per minute
o Pulse: 60 to 100 beats per minute
o Temperature: 97.8°F to 99.1°F (36.5°C to
37.3°C); average 98.6°F (37°C)
- INDICATIONS: Elevated and below normal
• If a patient has no pulse after three attempts
at defibrillation, resume CPR and give
supplemental oxygen and medications such as
epinephrine. If the patient's rhythm still does
not convert after repeated defibrillations,
consider possible causes for failure, such as
acidosis and hypoxia
- NURSING CONSIDERATIONS:
• BEFORE
o Assemble equipment:
▪ Automated external defibrillator (AED)
▪ Self-adhesive, pregelled monitor-
defibrillator pads (6)
▪ Cables to connect the pads and AED
▪ Razor
▪ Towel
o Assessment:
▪ AED should be used only when a
patient is unresponsive, not breathing,
and without signs of circulation.
▪ Choose correct electrode pad for
size/age of patient. If available, use
child pads or a child system for
children less than 8 years of age.
▪ Check pads and electrodes on an AED
to ensure they are firmly attached to
the patient's skin.
▪ If the patient has a hairy chest:
➢ Press firmly on the current pads to
attempt to provide sufficient
adhesion. If unsuccessful, briskly
remove the current pads and
shave the area with the razor in
the AED case.
➢ Dry the chest with a cloth or towel
before attaching the electrode
pads. The electrode pads will not
attach firmly to wet or diaphoretic
skin.
▪ General Considerations:
➢ Appropriate maintenance of the
AED is critical for proper
operation. Check the AED for any
visible signs of damage. Check the
‘ready for use’ indicator on the
AED daily.
➢ Anteroposterior placement of
electrode pads can avoid
difficulties associated with
increased breast size in patients
who are pregnant (Castle, 2007)

• DURING
o Assess responsiveness.
o Prepare the AED. Power on the AED. Push
the power button.
o Attach AED connecting cables to the AED
(may be preconnected). Attach AED cables
to the adhesive electrode pads (may be
preconnected).
o Stop chest compressions
o Once the pads are in place and the device
is turned on, follow the prompts given by
the device. Clear the patient and analyze
the rhythm. Ensure no one is touching the
patient
o If ventricular tachycardia or ventricular
fibrillation is present, the device will
announce that a shock is indicated and
begin charging
o Before pressing the ‘Shock’ button, loudly
state a “Clear the patient” message
o Immediately resume CPR, beginning with
chest compressions
o Remove gloves, if used. Perform hand
hygiene.
• AFTER
o The expected outcome is achieved when
AED is applied correctly without adverse
effect to the patient and the patient
regains signs of circulation.
o Obtain baseline ABG levels and a 12-lead
ECG to assess the patient and provide
supplemental oxygen, medications and
ventilation.
o Document the procedure, including the
number of times defibrillation was
performed and the voltage used also, the
patient's outcome.
o
Documentation guidelines
▪ Document the time you discovered the
patient unresponsive and started CPR.
Document the time(s)
▪ AED shocks are initiated. Continued
intervention, such as by the code
team, is typically documented on a
code form, which identifies the actions
and drugs provided during the code.
Provide a summary of these events in
the patient’s medical record.
▪ Ex. 09/11/22 0830 Called to patient’s
room by wife. Patient noted to be
without evidence of respirations or
circulation. Emergency response
system activated, CPR initiated. AED
applied at 2232. See code sheet. —C,
Caoile, RN
PERCUTANEOUS TRANSLUMINAL
CORONARY ANGIOPLASTY
- Coronary angioplasty, also called
percutaneous coronary intervention, is a
procedure used to open clogged heart arteries
- Angioplasty is often combined with the
placement of a small wire mesh tube called a
 stent. It can improve symptoms of blocked
arteries, such as chest pain and shortness of
breath.
- PURPOSE:
• Angioplasty is used to treat the buildup of
fatty plaques in the heart's blood vessels.
This buildup is a type of heart disease
known as atherosclerosis
• Angioplasty may be a treatment option if a
patient has:
o chest pain (angina) that is worsening
o tried medications or lifestyle changes
but have not improved heart health
o heart attack
- NURSING CONSIDERATIONS:
• BEFORE
o Remind patient on the instructions from
physician regarding adjusting or
stopping taking certain medications
before angioplasty, such as aspirin,
nonsteroidal anti-inflammatory drugs
(NSAIDs) or blood thinners.
o Instruct patient to stop eating or
drinking six to eight hours before an
angiography.
o Take approved medications with only
small sips of water on the morning of
your procedure.
o Gather all of medications to take to the
hospital with client, including
nitroglycerin.
o Arrange for transportation home.
• DURING
o Pt. receive fluids, medications to relax
and blood-thinning medications
(anticoagulants) through an IV catheter
in hand or arm.
o Pt. heart rate, pulse, blood pressure
and oxygen level will be monitored
during the procedure.
• AFTER
o If Pt. had a nonemergency procedure,
he/she will probably remain at the
hospital overnight while the heart is
monitored and medications are
adjusted.
o Pt. generally should be able to return to
work or do normal routine the week
after angioplasty.
o Educate patient to drink plenty of fluids
to help flush your body of the contrast
dye when at home and to avoid
strenuous exercise and lifting heavy
objects for at least a day afterward.
o Instruct client to call the doctor's office
or hospital staff immediately if:
▪ The site where the catheter was
inserted starts bleeding or swelling
▪ Develops pain or discomfort at the
site where the catheter was
inserted
▪ Presence of signs of infection, such
as redness, swelling, drainage or
fever
▪ Change in temperature or color of
the leg or arm that was used for the
procedure
▪ Feels faint or weak
▪ Develops chest pain or shortness of
breath
CORONARY ARTERY BYPASS GRAFT
(CABG)
- Coronary artery bypass grafting is a surgical
technique for improving myocardial blood flow
in patients with ischemic heart disease. This
involves a median sternotomy and the use of
cardiopulmonary bypass
- The area of the coronary artery obstruction is
bypassed with a graft. The coronary arteries
distal to the area of obstruction need to be
normal. A CABG procedure is usually
performed where there is obstruction of a
vessel greater than 50-70%.
- PURPOSE:
• Restore blood flow to the heart.
• Relieve chest pain & ischemia.
• Improves the patient’s quality of life.
• Enables the patient to resume a normal life
cycle.
• Lower the risk of a heart attack
- NURSING CONSIDERATIONS:
• BEFORE
o Nurse should carefully examine the
patient’s medical history for factors that
 might predispose to complications,
such as the following:
▪ Recent myocardial infarction (MI)
▪ Previous cardiac surgery or chest
radiation
▪ Conditions predisposing to
bleeding
▪ Renal dysfunction
▪ Cerebrovascular disease
▪ Electrolyte disturbances
▪ Infection including urinary tract
infection, skin infections, and dental
abscesses
▪ Respiratory function
o AFTER
▪ Protamine is given to reverse the
effects of heparin.
▪ Chest tubes are placed in the
mediastinal and pleural space to
drain blood from around the heart
and lungs.
▪ The sternum is wired together and
the incisions are sutured closed.
▪ The patient is moved to an intensive
care unit (ICU) or cardiac universal
bed (CUB) to recover.
▪ After awakening and stabilizing in
the ICU for 18 to 24 hours, the
person is transferred to the cardiac
surgery ward.
▪ Assess for signs of hemodynamic
compromise
➢ Hypotension
➢ Decreased cardiac output
➢ Shock
▪ Monitor VS, ECG, MAP (70-110
mm Hg)
▪ I&O- fluid and electrolyte imbalance
▪ Monitor ABG’S
▪ Encourage effective post-operative
pulmonary toileting
▪ Maintain airway patency
▪ Perform peripheral and
neurovascular assessments hourly
for the first 8 hours.
PACEMAKER
- A pacemaker is a battery - operated electronic
device that monitors cardiac activity. The
pacemaker sends a pulse of electricity to the
heart, causing cardiac muscles to contract and
reestablish normal sinus rhythm when an
abnormal rhythm is detected. The pacemaker
is connected to the heart by one or more
electrodes. An electrode is an electrical
connector that is placed directly into the
cardiac muscle.
- PURPOSE: Pacemakers provide life - saving
therapy for some patients and the reduction of
symptoms in others. The device works by a
generator box producing an electrical impulse,
which is relayed down into the chambers of the
heart via an electrical lead.
- NORMAL VALUES
• Maximum heart rate is about 220 minus
your age.
• Target heart rate during moderate intensity
activities is about 50-70% of maximum
heart rate, while during vigorous physical
activity its about 70-85% of maximum.
- ABNORMAL VALUES:
• If the heart rate is closer to 150 bpm or
higher, it is a condition known as
supraventricular tachycardia.
• Bradycardia is a condition where the heart
rate is too low, typically less than 60 bpm
- NURSING CONSIDERATIONS:
• BEFORE
o Provide privacy and explain the
preoperative and postoperative care to
the client.
o Provide and review literature from the
manufacturer or the American Heart
Association so that the client can learn
about the pacemaker and how it works.
o Teach the client that, immediately after
the procedure, he will have to limit
motion on the surgical side.
o Inform the client that he will likely be
awake during the surgery to implant the
 pacemaker, which typically takes a few
hours. However, a specialist will insert
an IV into the forearm or hand and give
a medication called a sedative to help
relax.
• DURING
o A leadless pacemaker is smaller and
typically requires a less invasive
surgery to implant the device.
o The pulse generator and other
pacemaker parts are contained in a
single capsule.
o The doctor inserts a flexible sheath
(catheter) in a vein in the groin and then
guides the single component
pacemaker through the catheter to the
proper position in the heart.
• AFTER
o Instruct the patient to report any fever,
redness, or drainage from the insertion
site and that he/she will experiencing
discomfort after the procedure.
o Shoulder exercises—patients must
have physiotherapy advice to prevent
‘frozen shoulder’ occurring as a result
of their restricted range of arm
movement during the first week.
o If there is any return of fainting,
dizziness, palpitations, or development
of pain, tenderness, swelling, fever, or
wound discharge, the patient must
contact their pacing clinic urgently—if
symptoms occur ‘out of hours’, they
should contact their GP service or
Minor Injuries Unit or, and if symptoms
are acute, they should contact the
emergency services
CARDIAC STRESS TEST
- CST (Cardiac Stress Test) is a diagnostic and
prognostic tool to evaluate cardiovascular
performance in patients with known or
suspected heart disease.
- PURPOSE: An exercise stress test can identify
issues with the heart' s blood flow since activity
causes it to beat quicker and harder
• Determine heart rhythm problems such as
arrythmias, coronary artery diseases,
causes of chest pain and functional
capacity of the heart. Guide treatment
decisions Diagnose severity of heart
condition Check the heart before surgery
Identify obstructive sleep apnea
• NOTE: A person should not undergo
exercise stress test if he/she
o is pregnant (due to the added
cardiovascular pressure)
o has certain heart/cardiovascular
conditions
o cannot exercise due to conditions such
as arthritis
o recently had a stroke or heart attack.
- COMPONENTS:
• ECG
o Formula for HR after recovery:
▪ Peak HR – HR (1 minute after
exercise)
• BLOOD PRESSURE (BP)
• METABOLIC EQUIVALENTS (METS) - to
check how well a person can tolerate
exercise.
• RESPIRATION
- PROCEDURE: A stress test usually takes
about an hour, including both prep time and the
time it takes to do the actual test. The actual
exercise test takes only around 15 minutes.
The patient will usually walk on a treadmill or
pedal a stationary bicycle. But if the patient is
unable to exercise, a drug through an IV will be
given that helps to mimic the effect of exercise
on the heart.
1. A nurse or technician will place sticky
patches (electrodes) on the chest, legs and
arms. The wires connect the sensors to a
computer, which records the heart' s
electrical activity. A cuff on the arm checks
the blood pressure during the test. The
patient may be asked to breathe into a tube
during the test to show how well he/she is
able to breathe during exercise.
a. EXERCISE STRESS TEST
 • Patient will exercise on a treadmill or
stationary bike, starting slowly. As the
test continues, the exercise gets
more difficult. The of use of the railing
on the treadmill is recommended for
balance. Instruct the patient to not
hang on tightly, as this may affect the
results.
• The patient will continue exercising
until his/her heart rate has reached a
target level (85% of the Maximum
HR=220 - Age of pt.) or until he/she
shows any signs and symptoms that
don 't allow you to continue. These
include:
a. Moderate to severe chest pain
b. Severe shortness of breath
c. Abnormally high or low blood
pressure
d. An abnormal heart rhythm
e. Dizziness
f. Fatigue
g. Certain changes in the
electrocardiogram
b. PHARMACOLOGIC STRESS TEST
• To mimic the effects of exercise,
vasodilating drugs such
dipyridamole, adenosine, or
regadenoson are used to maximally
dilate healthy coronary arteries and
identify stenotic arteries that cannot
vasodilate.
• The negative effects of these drugs,
which are related to their vasodilating
effect, include chest pain,
headaches, flushing nausea, heart
block, and dyspnea.
• The chemicals that function in
conjunction with radioactive imaging
techniques are known as
vasodilators.
• Dobutamine is an additional
medication. The metabolic needs on
the heart are increased by this
medication, which also increases
blood pressure, myocardial
contractility, and heart rate. This drug
is a synthetic sympathomimetic. It is
the chosen agent when using
echocardiography because of its
effects on altering the cardiac wall
motion (due to enhanced
contractility).
- NURSING CONSIDERATIONS:
• BEFORE
o Patient may be asked not to eat, drink
or smoke for at least 5 hours before a
stress test. (NPO 5 hours)
o Avoid any products containing caffeine
the day before and the day of the test.
o Patients taking dipyridamole,
theophyline, or aminophylline are
advised to discontinue taking these
drugs 24 to 48 hours before to the test
(if tolerated).
o Wear or bring comfortable clothes and
walking shoes.
o Chest part may be shaved to allow
electrode patches to stick better. If
patient uses an inhaler for asthma or
other breathing problems, let them
bring it to the test. Make sure the doctor
and the health care team member
monitoring the stress test know that
he/she uses an inhaler.
o The doctor will ask questions about the
patient’s medical history and how often
and at what level of intensity they
exercise. This helps determine the
amount of exercise that' s appropriate
for the patient during the test
o The doctor will also listen to the heart
and lungs for any health problems that
might affect the test results
• DURING
o The patient is told to report any stated
symptoms as well as discomfort to the
cardiologist or nurse.
• AFTER
o After the exercise, the patient may be
asked to stand still for several seconds
and then lie down for a period of time
with the monitors in place. The doctor
can watch for any problems as your
heart rate and breathing return to
normal.
o When the exercise stress test is
complete, the patient may be able to
return to their normal activities unless
the doctor tells the patient otherwise.
o If the results are normal and the
symptoms continue to worsen, the
doctor might recommend a nuclear
 stress test or another stress test that
includes an echocardiogram before
and after exercise or medications to
increase blood flow to the heart. These
tests are more accurate and provide
more information about the heart
function, but they are also more
expensive.
o If the stress test results suggest
coronary artery disease or show an
arrhythmia, the doctor will use the
information to develop a treatment
plan. Additional tests, such as a
coronary angiogram will be needed.
o If the patient had a stress test to help
determine treatment for a heart
condition, the doctor will use the results
to plan or change the treatment
IMPLANTABLE CARDIOVERTER
DEFIBRILLATORS
- Implantable Cardioverter Defibrillators (ICD) is
a small battery-powered device placed in the
chest to stop and detect irregular heartbeats
(arrythmias). Delivers electric shock to restore
a regular heart rhythm.
- Arrythmia, a problem with the rate or rhythm
of your heartbeat. It means that your heart
beats too quickly, too slowly, or with an
irregular pattern. When the heart beats faster
than normal, it is called tachycardia. When the
heart beats too slowly, it is called bradycardia.
- TYPES OF ICD:
• A traditional ICD is implanted in the chest,
and the wires (leads) attach to the heart.
The implant procedure requires invasive
surgery.
• A subcutaneous ICD (S-ICD) is another
option that' s implanted under the skin at
the side of the chest below the armpit. It' s
attached to an electrode that runs along the
breastbone. An S-ICD is larger than a
traditional ICD but doesn't attach to the
heart
- PURPOSE:
• Correct arrhythmia, such as a heart rate or
rhythm that’s irregular, too fast
(tachycardia) or too slow (bradycardia).
Prevent sudden cardiac arrest. Gather data
about your heart’s function to help your
healthcare providers make treatment
recommendations.
• Your health care provider may recommend
an ICD if you’ve had sustained ventricular
tachycardia, including fainting or if survived
a cardiac arrest.
• A history of coronary artery disease and
heart attack that has weakened the heart
• An enlarged heart muscles
• A genetic heart condition that increases the
risk of dangerously fast heart rhythms,
such as some types of long QT syndrome
• Other rare conditions that may affect the
heartbeat
- PROCEDURE:
• BEFORE
o Fast for at least 8 hours beforehand
(not eat or drink anything except water).
o Get blood tests, urine tests and an
electrocardiogram to ensure you’re
healthy enough for the procedure.
o Inform them if you have any bleeding
disorders or if you’re taking any blood
thinners.
o Report any allergies to contrast dye,
iodine, bee stings, shellfish or
medications.
o Tell the healthcare team if you have
asthma, diabetes, kidney disease or
any other medical conditions.
• DURING
o An intravenous (IV) line will be started
in your hand or arm for injection of
medicine and fluids, if needed.
o You will be connected to an
electrocardiogram (ECG) monitor that
records the electrical activity of the
heart during the procedure using. Your
vital signs (heart rate, blood pressure,
breathing rate, and oxygenation level)
will be monitored during the procedure.
o The surgical site is cleaned. In some
cases, hair may be shaved or clipped.
Large electrode pads will be placed on
the front and back of the chest.
o Give you anesthesia through an IV to
help you relax or put you to sleep
(general anesthesia) and numb an area
on the skin with a local anesthetic.
o Once the anesthetic has taken effect,
the doctor will make a small incision at
the insertion site (near the collarbone,
chest or abdomen (belly).
 o A sheath, or introducer, is inserted into
a blood vessel, usually under the
collarbone. The sheath is a plastic tube
through which the ICD lead wire will be
inserted into the blood vessel and
advanced into the heart.
o The lead wire will be inserted through
the introducer into the blood vessel.
The doctor will advance the lead wire
through the blood vessel into the heart.
o Once the lead wire is inside the heart, it
will be tested to verify proper location
and that it works. There may be 1, 2, or
3 lead wires inserted, depending on the
type of device your doctor has chosen
for your condition. Fluoroscopy, (a
special type of X-ray that will be
displayed on a TV monitor), will be used
to position the lead.
o For subcutaneous ICDs, one or two
small incisions are made near the top
and bottom of the sternum or breast
bone. The lead wire is then tunneled
underneath the skin next to the sternum
and from the sternum to the incision on
the left side of the chest.
o The ICD generator will be slipped under
the skin through the incision (just below
the collarbone for traditional ICDs and
on the left side of the chest for S-ICDs)
after the lead wire is attached to the
generator. Generally, if you are right-
handed, the device will be placed in
your upper left chest. S-ICDs are
implanted on the left side of the chest
near the heart. If you are left-handed, or
have a contraindication to a left sided
device a traditional ICD can be placed
in your upper right chest.
o The ECG will be observed to monitor
ICD function. Certain tests may then be
done to assess the device function.
Low-energy pacing or a higher energy
shock
o The skin incision will be closed with
sutures, adhesive strips, or special
glue.
o A sterile bandage or dressing will be
applied
• AFTER
o After ICD implantation, you may feel
tired and sore, especially near the
incision. Your healthcare provider may
suggest pain medications to make you
more comfortable. Many people go
home 24 hours or the day after surgery.
Depending on your health and the type
of procedure you had, you may have to
stay in the hospital for a few days. Just
before you go home, your healthcare
provider may test the ICD system again
- LABORATORY RESULTS AND
DIAGNOSTIC STUDIES:
• CBC
• Comprehensive Metabolic Panel
• Lipid Profile
• Troponins
• Chest X-Ray
• ECG
• Echocardiography
• Holter monitoring
• Event recorder
• Electrophysiology studies
- NURSING CONSIDERATION:
• BEFORE
o NPO 8 hrs before procedure
o Assessment on medication used
• DURING
o Sedative is given first prior to insertion
and or General Anesthesia
o Low-Energy Pacing
o Higher Energy Shock
o If shock is felt in the small span of hour
call the Physician
• AFTER
o May go home after procedure.
o Aspirin and Ibuprofen must not be
given.
o Swollen insertion site for few days.
o Avoid abrupt movements for weeks.
o Not allowed during the first few weeks:
▪ Vigorous, above-the-shoulder
activities or exercises, including
golf, tennis, swimming, bicycling,
bowling or vacuuming
▪ Heavy lifting
▪ Strenuous exercise programs
INTRA AORTIC BALLOON PUMP (IABP)
- An intra-aortic balloon pump (IABP) is a type
of therapeutic device. It helps your heart
pump more blood. You may need it if your
heart is unable to pump enough blood for your
body
- PROCEDURE: IABP therapy involves
inserting the balloon-tipped catheter into a
 blood vessel and advancing it to the heart. The
device is hooked up to a machine that tells the
balloon when to get bigger and when to get
smaller. It uses helium to blow up the balloon
because helium won’t cause problems in your
body if it leaks.
- OTHER TESTS, TREATMENTS, OR
PROCEDURES THAT MAY BE NECESSARY
BEFORE OR AFTER MANAGING A
PATIENT WITH AN IABP:
• Chest X-rays may be ordered daily to verify
correct placement of the IABP
• ABGs are routinely ordered to evaluate the
effectiveness of the IABP and the patient’s
oxygenation and respiration status
• The patient’s hematologic status is closely
monitored, especially for infection and
bleeding. Laboratory tests include
o CBC with differential and platelets. The
platelet count is assessed for the
increased risk of thrombocytopenia
o Hct and Hgb values to monitor for
hemorrhage
o PTT levels if the patient is receiving
heparin therapy in order to monitor that
a level 1.5–2 times the normal value is
maintained
- NURSING CONSIDERATIONS:
• BEFORE
o Baseline assessment is performed
incorporating lower and upper limb
perfusion
o Documentation of palpation of the
relevant pulses, assessing capillary
refill, temperature and color of the
limbs.
o A set of baseline vital signs is recorded
o Patient education should include the
reasons why the IABP is being inserted,
what the pump does, potential
complications, nursing care involved
such as hourly nursing assessments,
and limitations.
o The patient is assessed for their
tolerance of lying flat and also their
need for sedation or anxiolytics as per
hospital guidelines.
• DURING
o Cardiovascular assessment is
performed hourly or more frequently if
hemodynamic status deteriorates.
o Pump should be checked hourly for
correct settings
o Patient should be no higher than 30º
o Encourage deep breathing exercises to
promote adequate ventilation and lung
expansion preventing the development
of chest infections
o Check all connections, observe the
balloon catheter for presence of blood
which may indicate balloon
puncture/rupture hourly
o Monitor for signs of pulmonary edema
or ischemia.
o Provide ongoing psychological support
and education as required
• AFTER
o Once the patient’s condition has
stabilized the IABP is considered for
removal. This is preceded by a process
of weaning the pump.
o Observe the patient for ischemic chest
pain or development of heart failure
symptoms such as breathlessness,
hypotension and tachycardia.
o After removal, let the patient on bed
rest with the leg kept straight as per
local guidelines.
o Observe for recurrence of symptoms
o Check the insertion site for hematoma
formation ooze or symptoms
suggestive of retroperitoneal bleed
every 15 minutes for the first hour, half
hourly for the next two hours and
thereafter hourly or as clinical acuity
dictates.
o Assess for lower limb perfusion
confirming adequate perfusion and
presence of pedal pulses
- NOTIFY DOCTOR IF:
• Blood in tubing.
• Any vascular changes (diminished pulses,
lost signals).
• Augmentation pressure less than 5mmHg
above systolic BP. Bleeding or hematoma
at insertion site or signs of retroperitoneal
bleed. Drop in hematocrit unexplained by
other bleeding sites.
• Abrupt stop in urinary output.
• Any signs of dissecting aorta (sudden or
recurrent chest pain, back pain,
discrepancy of upper extremity blood
pressure).