Electrocardiogram (ECG)

1. Noninvasive ECG – a graphic record of the electrical activity of the heart

2. Portable recorder (Holter monitor) – provides continuous recording of ECG for up to 24 hrs.

ECG

1. Strip: small square: 0.04secs.

2. Large square: 0.2secs.
2. P wave:
 produced by atrial depolarization;
 indicates SA node function
3. P-R interval (N˚= 0.12 - 0.20 secs.)
 indicates AV conduction time or the time it takes an impulse to travel from the atria down and
through the AV node
 measured from beginning of P wave to beginning of QRS complex
4. QRS complex (N˚= 0.06-0.10 secs.)
 indicates ventricular depolarization
 measured from onset of Q wave to end of S wave
5. ST segment
 indicates time interval between complete depolarization of ventricles and repolarization of ventricles
 measured after QRS complex to beginning of T wave
6. T wave
 represents ventricular repolarization
 ST segment
Nursing Consideration
 Tell the patient that an ECG only takes about 10 minutes and causes no discomfort.
 Explain that he must remain still, relax, breathe normally, and remain quiet.
 Prepare the skin on the chest for electrode attachment; cleanse area with alcohol to remove dirt and
oils; shave area if necessary.

Cardiac catheterization:
 Invasive, but often definitive test for diagnosis of cardiac disease.
 A catheter is inserted into the right or left side of the heart to obtain information
 Purpose: to measure intra-cardiac pressures and oxygen levels in various parts of the heart; with injection
of a dye, it allows visualization of the heart chambers, blood vessels and blood flow (angiography)
Nursing care:
1. Informed consent
 2. Prior to the test, ask patient for any allergies especially to iodine
3. Keep client on NPO for 8-12 hrs
4. Record height, weight, V/S
5. Inform client that a feeling of warmth and fluttering sensation is normal as catheter is being inserted
6. Explain that a mild I.V or oral sedatives may be given before or during the procedure and that a local
anesthetics will be used at the insertion site.
7. Warn him that he may feel light-headed, warm, or nauseated for a few moments after the dye injected.
8. He may also receive nitroglycerin during the test to dilate coronary vessels and aid visualization

Nursing Care:
Post test
1. Assess circulation to the extremity used for catheter insertion
2. Check peripheral pulses, color, sensation of affected extremity
3. If protocol requires, keep affected extended straight for approximately 8 hrs.
4. Observe catheter insertion site for swelling, bleeding
5. Assess V/S and report for significant changes

CENTRAL VENOUS PRESSURE (CVP)

 Normal range is 4-10 cmH20; 3-8 mmHg
 Elevation indicates hypervolemia, poor cardiac contractility
 Decreased level indicates hypovolemia
 Is the pressure within the superior vena cava and right atrium
 It reflects the pressure under which the blood is returned to the superior vena cava and right atrium (preload).
 Obtained by inserting a catheter into the external jugular, antecubital, or femoral vein and threading it into the
vena cava.
 The catheter is attached to an IV infusion and H2O manometer by a three way stopcock.
 Provides an IV route for:
1. drawing blood samples administering fluids
2. Medication
3. possibly inserting a pacing catheter
Nursing care
1. Ensure client is relaxed
2. Maintain zero point of manometer always at level of right atrium (midaxillary line)
3. Client should be in supine position, with the head of the bed 30 - 45 degrees.
4. Determine patency of catheter by opening IV infusion line
5. Turn stopcock to allow IV solution to run into manometer to a level of 10-20cm above expected pressure
reading
6. Turn stopcock to allow IV solution to flow from manometer into catheter; fluid level in manometer fluctuates
with respiration
7. If the client is on a ventilator, the reading should be taken at the point of end-expiration
8. After CVP reading, return stopcock to IV infusion position
9. Record CVP reading and position of client

DISORDERS OF THE CARDIOVASCULAR SYSTEM

HEART
CORONARY ARTERY DISEASE (CAD)
A. General Information
1. Is a disease characterized by the accumulation of plaque within the layers of the coronary arteries, that
cause narrowing or obstruction of the coronary arteries, resulting in decreased blood supply to the
myocardium.
2. Major causative factor: Atherosclerosis
3. Between 30-50 years old., men>women
4. May manifest as Angina pectoris or MI
Risk factors:
Non-modifiable
 Hereditary
 Race
 Age
 Gender
Modifiable
 Cigarette smoking
 Hypertension
 Elevated serum cholesterol
 DM
 Physical inactivity
 Obesity
 stress
ANGINA PECTORIS
 Transient, paroxysmal chest pain produced by insufficient blood flow to the myocardium resulting in
myocardial ischemia.
 The inability of the coronary artery to deliver blood to the myocardium is impaired because of obstruction
by a significant coronary lesions.
 Usually precipitated by physical exertion or emotional stress with puts an increase demand on the heart
to circulate more blood and oxygen.
 Angina is caused by an imbalance between oxygen supply and demand.
 Relieved by REST and nitroglycerin
 Pain: Substernal, crushing, squeezing with possible radiation to the neck, jaw, back and arms( usually left
arm)
Signs and symptoms:
1. Dyspnea
2. Pallor
3. Sweating
4. Palpitations and tachycardia
5. Dizziness and fainting
6. Hypertension
7. Mild indigestion
2. Risk factors:
1. CAD
2. DM
3. hypertension
4. Aortic insufficiency
5. Severe anemia
6. Atherosclerosis
7. Thromboangiitis obliterans
Precipitating factors:
1. Physical exertion
2. Sexual activity
3. Strong emotions/stress
4. Cigarette smoking
5. Consumption of a heavy meal
6. Extremely cold weather
Types of Angina
1. Stable angina
 Also called exertional angina
 Predictable, consistent pain and is relieved by rest
2. Unstable angina
 Also called pre-infarction angina or crescendo angina
 Pain occur more frequently and last longer than stable angina
3. Variant angina
 Also called Prinzmetal’s angina
  Results from coronary artery spasm
 Pain occur at rest
 With ST segment elevation
4. Intractable angina
 Chronic, incapacitating angina not responsive to interventions
5. Silent ischemia
 Objective evidence of ischemia on ECG but patient report no symptoms
Medical Management:
1. Rest
2. Drug therapy:
A. Nitrates
1. Dilates primarily the veins causes venous pooling of blood throughout the body.
2. Reduces oxygen consumption, which decreases ischemia and relieves the pain.
B. Beta-Adrenergic blocking agent
Types:
1. Cardioselective- Metoprolol, Atenolol
 Reduce myocardial oxygen consumption by blocking the beta-adrenergic symphatetic stimulation
to the heart.
2. Non-cardioselective
 Propranolol, Nadolol
 S/E- bronchoconstriction; contraindicated in asthma and copd.
C. Calcium channel blocking agent
1. Inhibits movement of calcium within the heart muscle and coronary vessels; promotes vasodilation
and prevents/control coronary spasm.
2. Increases myocardial oxygen supply by dilating the smooth muscle wall of the coronary aterioles.
3. Decreases the SA node automaticity and AV node conduction, resulting in a slower heart rate and
decrease in the strength of the heart muscle contraction (negative inotropic effect)
4. Most commonly used are amlodipine (Norvasc), diltiazem (Cardizem), and felodipine (Plendil)
D. Antiplatelet and anticoagulation drugs
 Antiplatelet medication are administered to prevent platelet aggregation to inhibit thrombosis
formation , which impedes blood flow
 Aspirin- 160 – 325 mg/day
 Clopidogrel (plavix)- few days to achieve antiplatelet effects
 Ticlopidine (ticlid)
 Heparin
E. Antilipids
 Reduces cholesterol and triglyceride levels.
 Atorvastatin (lipitor)
 Use for lowering blood cholesterol.
 It also stabilizes plaque and prevents strokes through anti-inflammation and other mechanisms.
 Hepatotoxic- check liver function test regularly
F. Folic Acid and Vit.B compex - to treat increased homocysteine levels.
 Homocysteine is a common amino acid in your blood. You get it mostly from eating meat.
 High levels of it are linked to early development of heart disease.
 High level of homocysteine is a risk factor for heart disease.
 It's associated with low levels of vitamins B6, B12, and folate, as well as renal disease
3. Oxygen administration
 2 to 6 L/min by nasal cannula
4. Lifestyle modification
5. Surgery:
 Coronary bypass surgery
 PTCA
 Intracoronary atherectomy
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA)
 Aim: to revascularize the myocardium decrease angina and increase survival.
1. The balloon-tipped catheter is placed in the coronary vessel narrowed by plaque.
2. The balloon is inflated and deflated to stretch the vessel wall and flatten the plaque.
3. The blood flow freely through the unclogged vessel of the heart.
4. A balloon tipped catheter is inserted into the stenotic, diseased coronary artery.
5. The balloon is inflated with a controlled pressure and thereby. decreases the stenosis of the vessel
6. PTCA can be performed instead of coronary artery bypass graft surgery in various clients with single vessel
CAD.

CORONARY ARTERY BYPASS SURGERY (CABG)

1. A coronary artery bypass graft is the surgery of choice for clients with severe CAD
2. The graft “bypasses” the obstructive lesion in the vessel, and adequate blood flow is restored to the heart
muscle supplied by the artery.
3. Procedure requires use of extracorporeal circulation (heart-lung machine, cardiopulmonary bypass)
Nursing interventions:
Preoperative
1. Explain anatomy of the heart, function of coronary arteries, effects of CAD
2. Explain events of the day of surgery
3. Orient to the critical and coronary care units and introduce to staff
4. Explain equipments to be used (monitors, hemodynamic procedures, ventilators, ET,)
5. Demonstrate activity and exercise
6. Reassure availability of pain medications
Nursing interventions:
Post-operative
1. Maintain patent airway
2. Promote lung re-expansion
3. monitor cardiac status
4. maintain fluid and electrolyte balance
5. maintain adequate cerebral circulation
6. provide pain relief
7. prevent abdominal distension
8. Monitor for and prevent the following complications:
 Thrombophlebitis / pulmonary embolism
 Cardiac tamponade
 Arrhythmias
 CHF
9. Provide client teaching and discharge plannin concerning:
 limitation with progressive increase in activities
rd th
 sexual intercourse can usually be resumed by 3 or 4 week post-op
 medical regimen
 meal planning with prescribed modifications
 wound cleansing daily with mild soap and H2O and report for any signs of infection
 Symptoms to be reported: - fever, dyspnea, chest pain with minimal exertion
MYOCARDIAL INFARCTION
General information:
1. The death of myocardial cells from inadequate oxygenation, often caused by a sudden complete blockage of a
coronary artery.
2. The myocardium is permanently damaged.
3. Characterized by localized formation of necrosis (tissue destruction) with subsequent healing by scar formation
and fibrosis.
4. Profound imbalance exists between myocardial oxygen supply and demand.
Assessment findings:
1. Pain same as in angina, crushing, viselike with sudden onset; UNRELIEVED by rest or nitrates
2. Premature ventricular contractions
3. nausea/vomiting, indigestion, hiccups
4. Dyspnea/shortness of breath
5. Skin: cool, clammy, ashen, diaphoresis
6. Elevated temperature
7. initial increase in BP and pulse, with gradual drop in BP
8. Restlessness, disorientation, confusion, fainting
Diagnostic Evaluation
1. Cardiac Markers/Cardiac enzymes elevated
 Troponin I and T
 CPK-MB
 LDH
 SGOT
 Myoglobin
2. Increased ESR and WCB
3. Elevated serum cholesterol
4. ECG changes (specific changes dependent on location of myocardial damage and phase of the MI:
 Inverted T wave- indicates ischemia.
 Depression of ST segment- indicate ischemia
 Elevated ST segment- indicates injury.
 Presence Q wave seen- indicate tissue necrosis and are permanent.
Nursing interventions:
1. Administer O2 at to 2-4 L/min (92% and above) as ordered to relieve dyspnea and prevent arrhythmias
2. Establish a patent IV line
3. Provide pain relief
Morphine sulfate IV bolus
 Relieve pain
 Reduces preload and afterload.
 Morphine also relaxes bronchioles to enhance oxygenation.
 Decreases anxiety
Nursing Considerations
a. Monitor vital signs especially respiratory rate.
b. Monitor LOC and provide safety all the time.
4. Administer antihypertensive drugs
1. Administer IV nitroglycerin
 Nitrates in higher dose also relax the systemic arterial bed, lowering blood pressure and
decreasing after load.
2. Give beta blockers
 Metoprolol, atenolol, propranolol
 Reduce myocardial oxygen consumption by blocking the beta-adrenergic sympathetic stimulation
to the heart.
3. Give ACE inhibitor
 Enalapril, Accupril
 Prevents conversion of angiotensin I into II.
 This causes decrease in blood pressure and sodium and water excretion in the kidneys, decreasing
oxygen demand to the heart.
5. Administer anti-arrhythmic drugs
  Lidocaine, Procainamide, Cordarone
 Because tachycardia and PVCs frequently occur in the first few hours of MI
6. Administer anticoagulants, thrombolytics (tpa or streptokinase)
 To prevent platelet aggregation, and subsequent thrombosis, which impedes blood flow.
 Reestablish blood flow on the coronary vessels by dissolving thrombus.
 Given through IV or intracoronary
7. Provide bed rest with semi fowler’s position
8. Maintain quiet environment
7. Monitor ECG and hemodynamic procedures
8. Monitor I & O, report if UO <30 ml/hour
 Maintain full liquid diet with gradual increase to soft, low salt
 Administer stool softeners as ordered
 Relieve anxiety associated with CCU environment
9. Provide client teaching and discharge instruction concerning
 Effects of MI, healing process and treatment regimen
 Medication regimen: name, purpose, schedule, dosage, S/E
 Risk factors with necessary lifestyle modification
 Dietary restrictions:
 Avoid heavy meals; advise 4 to 5 meals a day
 Low salt
 Low cholesterol
 Avoidance of caffeine and alcohol
10. Resumption of sexual activity as ordered
 Usually 4-6weeks after MI
 Usually after exercise tolerance is assessed
 If patient can climb two flights of stairs without chest discomfort
 Sexual activity should be avoided after eating a heavy meal, after drinking alcohol.
11. Need to report the ff. symptoms:
 increased persistent chest pain
 Pain
 Dyspnea
 Weakness
 fatigue
 persistence palpitations
 light headedness
 Enrollment of client in a cardiac rehabilitation program