Adult Nursing III

Unit II: Cardiovascular

Anatomy and the Heart:

- Heart Chambers
- Heart valves
- Coronary arteries figure 26.2

Function of the heart:

- Conduction system SA node, AV node (slow and divide pathways of the signal), left and right
bundle of hiss, purkinjie fibers
o Preload related to vascular volume which determines the degree of stretching of the
myocardium
o Afterload related to peripheral vascular resistance
o Ejection fraction the percentage of the blood that is in the chamber that is ejected
with each stroke
- Physiology of cardiac conduction
- Cardiac hemodynamics
o Cardiac cycle
o Chamber pressures move from high pressure to low pressure
o Pressure measurement
- Cardiac output amount of blood ejected from the heart over a minute (5 L of blood at rest is
normal)
 o Heart rate 60 100 is normal at rest
o Stroke volume = ejection fraction

Age-related changes
- Page 653
- Ventricles becomes hypertrophied (increase in size without the increase of cells) or LVH
- Valves tend to calcify and murmurs are noted during auscultation
- Conduction system slows down
- Decrease in response of the sympathetic nervous system
- Aortic and arteries become less compliant (arteriosclerosis)
- Receptor response tend to also be less compliant (blood pressure compensation mechanism is
lost)

Differences by gender:
- Structural female heart is smaller, smaller coronary arteries, cardiac catheterization is
difficult, more prone to occlusion
- Hormones female is protected to certain extent by estrogen (estrogen decreases
atherosclerosis, estrogen increases the amount of coagulation protein which they may have higher
risk for DVT), risk for heart disease during menopause

Cardiovascular Physical Assessment:

- he complete assessment:
T
o General appearance do they appear ill, hair appearance
o Pain chest pain, duration, location, alleviation, when moving, 1-10 scale
o Skin inspection changes in skin, mucous membrane, cyanosis (central -tongue, oral
buccal mucosa; peripheral - nails, skin, nose, lips, earlobes) late sign of decrease cardiac
output
o Blood pressure pulse pressure (difference between systolic and diastolic), less than
30 pulse pressure represents a cardiac myopathy
o Pulses during dysrhythmia must take apical pulse, assess quality, pulse deficit
o Jugular venous distention indicative of right-sided heart failure (CVP central venous
pressure)
45 degree angle position (semi-fowlers)
Look for sternal notch
The higher CVP the higher is the pulsation noted
Put a ruler on sternal notch and measure the level of JVD from the neck with the
ruler standing upright from the sternal notch
o Heart inspection and palpation PMI (point of maximal impulse) movement of the
apical of the heart when the ventricles contract
o Chest excursion
o Chest auscultation aortic, pulmonic, tricuspid, mitral, S1 and S2 (closure of the
valves), S3 (splitting of the S1 Tennessee, splitting of the S2 Kentucky) and S4 (cardiac
gallops), murmurs 1 to 6 / 6 (ex: 2/6 SEM (systolic ejection murmur) R SB (sternal border))
o Inspection of extremities
 o Other systems abdomen, skin, renal insufficiency, medication

- ge related changes:
A
o Systolic blood pressure will increase with age
o Widening pulse pressure
o Isolated systolic hypertension (systolic is high) over 160 must be treated
o Low diastolic pressure is not of concern
o Effects of osteoporosis which affects more women related to the change of their
skeletal system (kyphosis, lordosis)

Diagnosis Evaluation:
- Laboratory tests:
o Assisting in diagnosis
o Lipid profile (watch for increase lipids)
o C-reactive protein leads to finding of inflammation of the coronary arteries
o Screen for risk factors
o Monitor for medicational levels (coumadin, heparin, lanoxin)

- ardiac enzymes:
C
o CKMB enzymes that is released by injured cardiac muscle cells
o Lactic dehydrogenase
 o Myglobin levels
o Troponin goal standard for assessing myocardial infarction
Highly cardiac specific (increase means damage in myocardial cells)
Will increase rapidly and last for a week or ten days
- Blood chemistry:
o Lipid profile accurate lipid profile (accurate 12 hour fasting)
o Cholesterol HDL (good), LDL (bad), triglycerides
o Electrolytes sodium and potassium is more important
o BUN increased is indicative of dehydration
o Creatinine
o Coagulation PTT, INR (more likely to be used due to testing accuracy), Protime
Coumadin antidote is V itamin K or FFP (fresh frozen plasma) for serious incident
Heparin antidote is P
rotamine Sulfate
o CBC WBC, RBC (H and H), platelets, BNP (Brain Naturetic Peptide is a hormone
produced by the cells embedded in the wall of the heart, it is released when the heart is
stretched too much so that the heart can work less)
- Chest X-ray:
o Size, position, and contours of the heart, pulmonary circulation
- Electrocardiography or EKG:
o Hard wire restricts their movement due to wires
o Telemetry sent to the machine and they can move
o Holter monitor monitoring over 24 hour period with a detailed log made by the patient
about their activities
 o Signal averaged EKG 150 to 300 QRS to study and identify problems
o Transtelephonic
- Cardiac stress testing:
o Exercise EKG monitoring and specifically ST segment, if ST d epression i s showing
myocardial ischemia it will be a positive test and the test will be stopped, ST e levation
signifies myocardial infarction
o Pharmacologic simulate exercise by using drugs that stimulates sympathetic nervous
system looking for the ST depression/elevation
- Echocardiography:
o Non invasive
o Structures of the heart and valves, movement of the myocardium
o It is replaced now by TEE

- ransesophageal echocardiography (TEE):

T
o Much clearer picture related to going into the esophagus
o More invasive
o Heavy sedation
o Monitor EKG and vital signs continuously during procedure
o Esophageal rupture is the major complications and also cardiac dysrhythmias
- Radionuclide Imaging:
 o Coronary artery perfusion
- Multiple-gated acquisition scan (MUGA)
- Computed tomography (CT):
o Cardiac masses
o Disease of the aorta
- Positron emission tomography (PET):
o Non invasive
o Myocardial perfusion
- Magnetic resonance imaging (MRI):
o Diseases of the aorta
o Congenital heart defects
- Cardiac catheterization:
o More common
o Right (venous access) or left (femoral artery) side of the heart
o Monitor before and after the surgery
o Monitor the puncture site for hematomas and bleeding
o Semi-fowlers with legs extended and monitor distal pulses
- Angiography:
- Electrophysiology testing:
o Serious dysrhythmias
o Very invasive
o Better idea about the heart
Cardiac Pharmacology:
- Beta blockers (OLOL):
o Blocks the activation of sympathetic nervous system
o Decrease glucose production in the liver
o Bradycardia occur
o B1 cardiac specific
o B2 bronchial specific
o Selective
o Non-selective blocks both B1 and B2 not good for respiratory problems
o GI distress, constipation, and impotence are side effects

- alcium channel blockers:

C
o Blocks the movement of calcium into and out of the cardiac smooth muscle cells and
interfere with the ability of muscle to contract resulting in the relaxation of the myocardium
and the smooth muscle of the heart
o Slows nerve conduction to the heart
- Angiotensin converting enzyme inhibitors (ACE-I):
o Stops conversion of Angiotensin II which decreases the production of renin (responsible
for preload) and aldosterone (responsible for afterload)
o Increase in potassium is the side effect of the drugs
- ngiotensin II receptor blockers (ARB):
A
o Blocks the receptor sites where Angiotensin II attaches
o Just as effective as ACE-I but more expensive
- Digitalis:
o Cardiac glycoside for heart failure to decrease heart workload but increases cardiac
contractility for efficient cardiac output
o Chronotopic (heart rate) positive will increase the rate (such as epinephrine),
negative will decrease the rate (such as digitalis)
o Inotropic (contractility) positive will increase the contractility of the heart (such as
digitalis), negative will decrease the hearts contractility
o Dromotropic (electrical conduction) positive will increase electrical conduction,
negative will decrease electrical conduction (such as calcium channel blockers)
- Nitrates:
o Vasodilators
o Used for cardiac ischemia
o Patch (more common used Nitrex), paste, and sublingual are types of administration
o Headache is common side effect
o Must have a drug holiday (period of time within 24 hours where there is no drug infusing
into the body)
- Diuretics:
o HCTZ (hydrochlorothiazide) low side effects
o Loop diuretics Lasix are potassium wasting, A ldactone is potassium sparring meds
- Thrombolytics:
 o Ends in ase clot busters used for embolism and DVT
- Statins:
o Such as Zocor, they block synthesis of cholesterol in the liver
o Decrease LDL by 40-50%, increase HDL by 20%
o Monitor liver profiles
o Schedule drugs at HS related to the production of cholesterol at this time
o Niacin must be tried first before you put the patient in this medication due to costs but
flushing is the common side effect
- Questran:
o Binds to the three cholesterol in the GI tract to be eliminated in the GI
o Constipation is the side effects of this drug
Heart Transplantation:
- Indications for heart transplant:
o Cardiomyopathy lifelong uncontrolled hypo/hypertension
o Ischemic heart disease/coronary artery disease
o Valvular disease, congenital heart disease
o Rejection of previous transplanted hearts
- Screening of candidates:
o Age 90 years of age is not a good candidate due to health conditions
o Pulmonary status
o Chronic health conditions
o Psychosocial status posttransplant psychosis can lead to suicide
o Family support prognosis is greater if support is present
 o Infections
o History of other transplantations
o Compliance
o Current health status
- Potential recipient checklist:
o ABO blood group compatibility
o Size
o Geography 6 hour timeframe from donor to recipient
- Transplant techniques:
o Orthopic transplantation:
Most common
Hearts connection to the superior/inferior vena cava, pulmonary artery, and aorta is
removed
The new heart is then connected to the superior/inferior vena cava, pulmonary
artery, and aorta
o Heterotopic transplantation:
Less common
The recipients heart is not removed and the donors heart is placed to the right and
slightly anterior
This is done so that the patients heart can protect the implanted heart from organ
rejection. Pulmonary hypertension and small donors heart are also some reason this is
done
 o nerve connections and sympathetic/vagus nerves do not affect the implanted
N
heart
Atropine does not increase the heart rate
- Life postoperatively (6-10 days in hospital):
o Must comply with:
Regimen of diet, low sodium, low fat
Medications (Cyclosporine, Imuran, CellCept, Prednisone, Statins are most
commonly used)
Activity mild treadmill use
Follow-up laboratory studies
Biopsies (to diagnose rejection)
Clinic visits as needed
- Complications:
o Accelerated atherosclerosis of the coronary arteries (Cardiac Allograft Vasculopathy
CAV)
o Accelerated Graft Atherosclerosis (AGA)
o Hypertension related to antibiotics
o Osteoporosis related to the side effects of anti-rejection medications
o Posttransplantation lymphoproliferative disease and cancer of the skin and lips are
most common malignancies caused by immunosupression
o Weight gain, obesity, diabetes, dyslipidemias, hypotension, renal failure, and central
nervous system, respiratory and gastrointestinal disturbances are complications caused by
immunosuppressant
 o Immunosuppressant toxicities
o Guilt, depression, anxiety, fear, and difficulty with family role changes can also be seen
in patients with heart transplant
o Cardiogenic cancer

Coronary Artery Bypass Graft:

- Indications for surgery:
o Angina that cannot be controlled by medical therapies
o Unstable angina
o A positive exercise tolerance test (ST segment depression) and lesions or blockage
that cannot be treated by PCI
o Left main coronary artery lesions or blockage of more than 60%
o Blockages of two or three coronary arteries, one of which is the proximal left anterior
descending artery
o Left ventricular dysfunction with blockages in two or more coronary arteries
o Complications from or unsuccessful PCIs (Percutaneous Coronary Interventions)
- Vessels used for surgery:
o Saphenous veins (greater first followed by lesser) are used in emergency
o Cephalic and basilica veins
o Left or right internal mammary artery (disadvantages include the length of the artery)
o Gastroepiploic artery (greater curvature of the stomach)
- ardiopulmonary bypass:
C
o Uses as a heart-lung machine to maintain perfusion
o It is done by placing a cannula in the right atrium, vena cava, or femoral vein to
withdraw blood from the body
o Venous blood is removed and filtered, oxygenated, cooled or warmed, and then
returned to the body
o Potassium Chloride is used to stop the heart
o Heparin is administered to prevent thrombus formation
o Protamine Sulfate is administered after the procedure to reverse the effects of
Heparin
o Urine output, blood pressure, ABGs, electrolytes, coagulation studies, and ECG are
monitored during the procedure
- Nursing process for a patient who has had cardiac surgery:
o Assessment:
 Neurologic, psychosocial, physical, and history status
Cardiac status
Respiratory status
Peripheral vascular status
Renal function
Fluid and electrolyte status (hyper/hypo-kalemia, natremia, manganesemia, and
calcemia)
Pain
o Nursing Diagnosis:
Decreased cardiac output
Ineffective cardiopulmonary, cerebral, peripheral, and renal tissue perfusion
Impaired gas exchange
Activity intolerance
Anxiety
o Assess for complications:
MI
Dysrhythmias higher incidence
Hemorrhage hemodynamic monitoring for the first 24 hours post-op to assess for
hemorrhage

Hemodynamic Monitoring:
- When is hemodynamic monitoring utilized and why?
 o For critically ill patients that require continuous assessment of their cardiovascular
system
o To manage their complex medical conditions
- What is the purpose of measuring central venous pressure (pressure within the right
atrium)?
o To assess right ventricular function and venous blood return to the right side of the
heart
o Normal CVP measurement is 4-8 mmHg
o Anasarca generalized edema
- What is one important nursing intervention if your patient is being monitored by central
venous pressure?
o Clean and sterile dressing frequent checks
o Watch for signs of infection
o Right ventricular function is monitored
- What is measured with pulmonary artery catheter, most commonly known as Swan-Ganz
catheter?
o Pulmonary artery pressure (normal is 25/9 mm Hg)
o Left ventricular function, to evaluate patient response to medical interventions
- Name two nursing interventions you need to be aware of if your patient has a Swan-Ganz
catheter.
o Transducer must be positioned at the phlebostatic axis to ensure accurate readings
o Complications must be monitored (infection, pulmonary artery rupture, pulmonary
thromboembolism, pulmonary infarction, catheter kinking, dysrhythmias, and air embolism)
 - hy would you want to have an intra-arterial blood pressure monitor, also known as an
W
A-line or art-line?
o When u need to obtain direct and continuous BP measurements in critically ill patients
who have severe hypo/hypertension

Cardiogenic Shock (life threatening):

- Definition:
o It occurs when the heart cannot pump enough blood (similar to heart failure but more
acute than chronic) to supply the amount of oxygen needed by the tissues
o It occurs due to multiple infarctions in which more than 40% of myocardium becomes
necrotic
o It can also occur due ventricular rupture, trauma, valvular disease
o Can occur with cardiac tamponade, pulmonary embolism, cardiomyopathy, and
dysrhythmias
- Pathophysiology:
o Contractility of the heart muscle is loss
o Damage of the myocardium results in decreased oxygen supply
o Reduces arterial blood pressure and tissue perfusion in the vital organs
o Increased pulmonary pressure, pulmonary congestion, and pulmonary edema can
result due to inadequate emptying of the ventricles
- Clinical manifestations:
o Tissue hypoperfusion manifested by cerebral hypoxia
o Low blood pressure, rapid and weak pulse, cold and clammy skin
 o Increased respiratory crackles
o Hypoactive bowel sounds
o Decreased urinary output
o Dysrhythmias
o Pulmonary congestion
- Assessment and diagnostic findings:
o PA catheter to measure left ventricular pressures and CO
o Fluid retention and vasoconstriction
o Continuous central venous oximetry and measurement of blood lactic acid levels
o ABGs
o Chest X-ray, CBC, cardiopulmonary catheter
- Medical management:
o Correcting the underlying problems, improve oxygenation, restore tissue perfusion,
reduce any further demand on the heart
o Ventricular assist devices temporary pacemaker
o Diuretics, vasodilators, and mechanical devices (filtration and dialysis) Debutamine
o Intravenous volume expanders (normal saline, lactated ringers solution)
o Strict bedrest
o Oxygen administration
o Intubation and sedation to maintain oxygenation
o IABP Intra-Aortic Balloon Pump during diastole, the balloon is inflated and quickly
deflates during systole
- Nursing management:
 o Constant monitoring and intensive care
o Monitor cardiac rhythm, hemodynamic parameters, fluid intake and output
o Frequent assessments and timely adjustments to medications

Pericardial Effusion and Cardiac Tamponade:

- Pathophysiology:
o Increased right and left ventricular end-diastolic pressures
o Decreased venous return
o Inability of the ventricles to distend adequately and to fill
- Clinical manifestations:
o Feeling of fullness within the chest
o Engorged neck veins
o SOB and hypotension
o Pulsus Paradoxus systolic blood pressure is greater than 10 mmHg that is detected
during exhalation but nut heard with inhalation (let the patient hold their breath for at least 10
seconds)
o Distant heart sounds (muffled)
- Assessment and diagnostic findings:
o Chest percussion
o Flatness across the anterior of the chest is noted
o ECHO
o Clinical symptoms with chest X-ray definitive diagnosis
o Cardiac enzyme to rule out MI
 - edical management:
M
o Pericardiocentesis is done
o Pericardiotomy
Pericarditis:
- Definition:
o Inflammation of the pericardium
- Pathophysiology:
o Idiopathic
o Infection (viral, rarely bacterial, and fungal)
o Disorders of connective tissue (rheumatic fever, rheumatoid arthritis)
o Immune reactions
o MI
o Neoplastic disease
o Radiation therapy
o Trauma
o Renal failure, uremia, and tuberculosis
- Clinical manifestations:
o Chest pain (beneath the clavicle, neck, left scapula region) which can worsten during
deep inspiration and when lying down or turning
o It may relieved with a forward-leaning or sitting position
o Friction rub is the most characteristic sign of pericarditis fourth intercostal space and
left sternal border would friction rub be heard more
 o Mild fever, increased WBC, increased ESR, dyspnea, signs and symptoms of heart
failure are also some clinical manifestations
o Let them hold their breath for 5 seconds to differentiate pericarditis from pneumothorax
o Distant and muffled heart sounds
o Tachycardia, severe hypotension
- Assessment and diagnostic findings:
o Patients history
o Signs and symptoms
o ECHO for diagnosis
o 12-lead ECG ST segment elevation in the absence of any of the cardiac enzyme
markers, depressed R wave
o Chest X-ray
- Medical management:
o Rule out MI
o Bed rest until fever, chest pain, and friction rub have subsided
o Analgesics and NSAIDs (Aspirin or Ibuprofen) for pain
o Prednisone if analgesics wont work
o Pericardiocentesis may be performed to determine the causative agent
o Pericardectomy can also be performed
- Nursing management:
o Must be alert for cardiac tamponade
o Monitor for heart failure
o Gradual increase of activity is recommended when pain subside
 o Educate the patients family about health lifestyle

Endocarditis:
- Definition:
o Inflammation of the inner layer of the heart which are the valves (mitral more common)
- Pathophysiology:
o Usually is bacterial
o Strep and Staph that becomes systemic
o Will cause incompetence of mitral valve, mitral regurgitation, decreased cardiac output
- Clinical manifestations:
o Slight fever, headache, malaise, fatigue during the first stage
o Marked fever and chills, anorexia, develop dark purple lines on fingernails (splinter
hemorrhages diagnostic for this disease) as the disease progress
o Heart failure symptoms will develop
o Murmur in the mitral valve will be noted
- Assessment and diagnostic findings:
o Blood culture
o ECHO will show vegetations
- Complications:
o Heart failure
o Vegetations may brake off and becomes an emboli that will lead to cerebral embolism
(mitral) or pulmonary embolism (tricuspid)
 - edical management:
M
o Long term antibiotic therapy
o Surgery (replacement of mitral valve) if delayed medical attention
- Nursing management:
o Teaching about medications
o Enforced activity restrictions
o Need for antibiotics throughout lifespan
o Antibiotics before and after procedures

Blood Transfusions:
- Reason for Transfusions:
o Restore and maintain blood volume trauma, accidents
o Improve the oxygen-carrying capacity of blood whole blood (main reason is anemia
and low H and H) are most common
o Replace deficient blood components and improve coagulation plasma
- Blood types:
o O is the universal donor
o + AB is the universal recipient
- Transfusion reactions:
o Fever, chills, itching, SOB, profound hypotension, tachycardia, feeling of impending
doom
 - ypes of transfusion reactions:
T
o ylenol and Benadryl
Febrile, nonhemolytic fever, chills, pre-medicate with T
o Acute hemolytic (most dangerous and lethal) occurs when given the wrong type of
blood
o ylenol and Benadryl
Allergic hives due to proteins of the blood, pre-medicate with T
o Bacterial due to contaminated blood
- What to do when a transfusion reaction occurs:
o Stop infusions and continue the normal saline (only normal saline (0.9% Sodium
Chloride) can be mixed with the blood) and ask for help

EKG interpretations:
- Normal Electrical Conductions
o P wave - signal from the SA node and initiate the depolarization of the atria
o PR interval time lag between the contraction of atria and contraction of the ventricles,
it allow the filling of the blood to the ventricles
o QRS complexes depolarization of bilateral ventricles
o ST segment
o T wave repolarization of ventricles
- Influences of heart rate and contractility:
o Inotropic force of contraction
o Chronotropic speed of contraction (heart rate)
o Dromotropic electrical conduction
- Waves and complexes:
 o Positive deflection above
o Negative deflection below
o P wave 2.5 mm height and 1.1 sec or less in duration
o Q wave negative deflection, 0.04 sec in duration
o R wave positive deflection
o T wave
o U wave follows the T wave
o PR interval 0.12 0.2 sec in duration
o ST segment (decreased) Myocardial ischemia or (elevated) MI
- Electrocardiograph paper analysis:
o 0.04 sec every tiny box
o Dark line is 5 boxes
o Vertically, small boxes is 0.1 millivolts of electricity
- Heart rate configuration:
o Spikes are three seconds
o Measure the number of R wave within those intervals

- ormal sinus rhythm:

N
o Both atrial and ventricular rate is between 60 100 for adult
o Both atrial and ventricular rhythm is normal
 o QRS shape and duration is typically WNL
o P to QRS ratio is 1:1
o PR interval is consistent to 0.12 to 0.2 sec
- Sinus bradycardia:
o Identical to normal sinus rhythm except of much longer space during diastole, both
atrial and ventricular rate is less than 60
o Pain, medications can influence this
- Sinus tachycardia:
o Identical to normal sinus rhythm except of much lesser space during diastole, both atrial
and ventricular rate is more than 100
- Atrial flutter:
o Multiple signal from SA node, multiple contractions of atria for each contraction of
ventricles
o Regular ventricular contractions
o Atrial () rate and ventricular (75 100) rate but rhythms for both is regular
o QRS shape and duration is normal
o P wave appearance is s aw tooth
- Atrial fibrillation:
o Multiple signals coming from multiple places in the atrium
o Dysfunction of SA node
o AV node is not able to process the signal and response by doing an irregular
contraction
o Atrial rate (300 600) and ventricular rate (100 200)
 o Both rhythms are irregular
o Age, coronary artery disease, manipulation within the heart (surgery) due to irritation,
holiday heart (due to alcoholism) can cause this
- Ventricular tachycardia:
o Lethal dysrhythmias
o Ventricular rate (100 200) usually regular
o No P waves
o Emergency situation
o Patient is non-responsive and precursor to ventricular fibrillation
- Ventricular fibrillation:
o No pattern whatsoever
o Random movement
o 10 seconds before asystole
o Cardiac arrest is eminent
o QRS complex are irregular without pattern
- Asystole:
o Flatline
o No electrical stimulation

Pacemaker Therapy:
- Pacemaker design and types:
- Pacemaker generator function:
 o Does not help with tachycardia but help with bradycardia associated with heart block
- Complications:
o Local infection in the insertion
o Hemothorax or pneumothorax
o Ventricular tachycardia secondary to irritation
o Movement or dislocation (restrict activities)
o Phrenic nerve or muscle stimulation
o Cardiac tamponade
- Surveillance of pacemaker:
o Transphonic
- Nursing process of a patient with a pacemaker