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SESSION 1: RESPONSES TO ALTERED TISSUE PERFUSION

Blood Flow Through The Heart: Modifiable:
1. The oxygenated blood enters right atrium through superior and • Lifestyle (Diet, cigarette smoking, Physical inactivity/sedentary
inferior vena cava lifestyle)
2. Blood enters right ventricle through tricuspid valve • Body Weight (Overweight/Obesity)
3. Blood exits right ventricle through pulmonary valve and enters • Physiologic (High BP, DM, Hyperlipidemia)
pulmonary artery
4. Left and right pulmonary artery send blood to the lungs, where gas CIGARETTE SMOKING
exchange occurs.  is the leading independent risk factor for coronary heart disease. It
5. Oxygenated blood returns to heart via the pulmonary veins -> enters is the primary target of risk factor management for people of all age
left atrium. groups.
6. Blood enters left ventricle through mitral valve  Encourage patients not to smoke.
7. Blood exits left ventricle through aortic semilunar valve to enter
aorta PATHOPHYSIOLOGY
8. Aorta distributes the blood to body  Atheromas develop in the lining of the arteries. When a coronary
blood vessel is significantly occluded, the cells it's supplies become
Veins - blood vessels containing blood flowing to the heart ischemic, without blood and oxygen to meet their metabolic needs.
Arteries - blood vessels containing blood flowing from the heart Ischemic CHD is divided into two categories:
Valves - keep the blood moving in the right direction and not flow 1. Chronic Ischemic Heart Disease
backwards. - Stable Angina
- Asymptomatic Myocardial Infarction
CORONARY HEART DISEASE (CHD) 2. Acute Coronary Syndrome
 It is leading cause of death among men and women globally. It is - Unstable Angina
caused by narrowing of the coronary arteries that supply blood to - Acute Myocardial Infarction
the heart muscle. Atherosclerosis is the primary cause of Ventricle - Primary heart pumping action, pumping house that
obstructed blood flow which reference to the build up of fats, distributes the blood within the body.
cholesterol, and other substances (plaque) in the artery walls. *Certain chambers in the heart is affected.
 This disease happens overtime.
 Atheromas makes it hard to receive oxygen and nutrients from the INTERDISCIPLINARY CARE
heart to the rest of the body. The blood vessels that carry the oxygen Diagnostic Tests:
and nutrients become thick and stiff (sometimes restricting blood a. Total serum cholesterol and lipid panel - to monitor the lifestyle.
flow to the organs and tissues) The normal cholesterol level is less than 200 mg/dl.
b. Serum C-reactive protein
RISK FACTORS c. Blood glucose level - to asses if there is diabetes mellitus
Non-modifiable:
• Age Risk Factor Management
• Gender a. Smoking cessation
• Race b. Low-fat, low cholesterol diet
• Heredity (Family History) c. Exercise - having inactive predisposes you to have the coronary
heart disease

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Pharmacological Management: Nicotinic Acid:
✤ Cholesterol-Lowering Drugs • Niacin
a. STATINS
 Maintenance for older people, hypertensive drugs. Bile Acid Sequestrants
 Can help lower the level of low-density lipoprotein cholesterol in • Cholestyramine (Questran) - most common one in the hospital.
the blood. • Colestipol (Colestid)
 Works by lowering the cholesterol by blocking an enzyme. LDLs
are less healthy while HDLs are healthy. Example: when you Chest pain (Angina pectoris) that occurs because of imbalance in
have a clinical duty, the family of the client or the client might myocardial supply and demand. The heart does not get enough blood
ask why you’re giving that kind of medication which is why you and oxygen.
need to know and monitor the patient card and read the case. 1. STABLE ANGINA
While you asses the patient, get information = subjective data  most common form and can be relieved by rest and nitrates.
Nitrates are vasodilators. Nitroglycerin is the most common nitrate.
b. FIBRIC ACID AGENTS
 lowers the LDLs and cholesterol. 2. UNSTABLE ANGINA
 occur with increasing frequency, severity, and duration. Pain is
c. ANTILIPEMIC unpredictable and may occur at rest.
 cholesterol lowering drug.
 Acts on the small intestine to block cholesterol absorption and 3. VARIANT OR PRINZMETAL’S ANGINA
lowers the triglyceride and cholesterol.  occurs without precipitating cause; caused by coronary artery spasm.
Associated to certain spams of the coronary artery.
d. NICOTINIC ACID
 Vitamin B3, Niacine. Acts in lowering cholesterol levels, very SILENT MYOCARDIAL ISCHEMIA
LDLs, and triglyceride and enhances and increases HDLs  Asymptomatic myocardial ischemia associated with increase chance
for myocardial infarction and death. Certain atheroma and
e. BILE ACID SEQUESTRANTS thrombosis can rupture and affects the blood flow and the certain
 bile acids are produced in the liver and secreted in the gall area. Causes ischemia which is why there is low oxygen.
bladder but can also be found in the small intestine.
 Emulsifies fats and lowers LDLs. INTERDISCIPLINARY CARE:
Diagnostic Tests:
MEDICATIONS a. Electrocardiography
Statins: b. Serum C-reactive protein
• Atorvastatin (Lipitor) ❖ ECHOCARDIOGRAM - ultrasound of the heart. You can see
• Rosuvastatin (Crestor) the position and the image of the heart, and the atrium and
• Simvastatin (Zocor) ventricles.
❖ TRANSESOPHAGEAL ECHOCARDIOGRAPHY - invasive
Fibric Acid Agents: ❖ RADIONUCLEAR SCANNING
• Fenofibrate (Tricor) - most common
• Gemfibrozil (Lopid)

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❖ CORONARY ANGIOGRAPHY - gold standard in the MEDICATIONS
diagnosis of the myocardial ischemia. Also known as cardiac Nitrates:
catheterization. • Nitroglycerin - most common
• Isosorbide dinitrate (Isordil) - Preventing chest pains
• Isosorbide Mononitrate (Ismo) - this is usually a standing order,
Pharmacological Management: meaning there is a specific time. Usually given once but it also depends
Anti-Anginal Drugs on the severity.
a) NITRATES
 potent vasodilater, reduces the pre load and after load of Beta Blockers:
the heart. • Atenolol
 Precaution: Nitroglycerin can be given 3 times and the • Metoprolol (Lopressor)
interval is 5 minutes (if the 3 times are finished, inform the • Propanolol (Inderal) - most common
physician) and the route is sublingual (buccal mucosa or
under the tongue). Calcium Channel Blockers:
 Certain erectile dysfunction drugs (like viagra) should not • Amlodipine (Norvasc)
be given with because it would potentiate the action. Do • Nifedipine (Procardia)
not chew nor crush, just let it dissolve. • Diltiazem (Cardizem)
 The blood pressure and heart rate should be assessed • Verapamil (Calan) - one of the common ones
because they lower that is why the baseline data is needed. • Nicardipine (Cardene)
 Availability of the extended release capsule (means long
period of time), it is a standing order and usually given *Take note of the blood pressure and the heart rate, a baseline data is
once a day usually in the morning. needed. Assessment is important, don’t just follow orders.
 Nitroglycerin Transdermal Patch - put it on a clean, dry,
hairless area where there are no oils. No breaks and the PRIORITY NURSING ACTIONS
skin should be intact. To maxims the use. It lasts 12-14 1. Quickly assess the client, specifically characteristics of pain, heart
hours. You should take note of when you put it as there is a rate, and rhythm and blood pressure (BP).
resting period of 10-12 hours where you should not put on 2. Administer a nitroglycerin tablet.
another patch, Ointment - you need gloves and be careful 3. Stay with the client.
because if you touch it, it might lower your BP. 4. Reassess in 5 minutes. As necessary, if pain is not relieved.
5. Administer another nitroglycerin tablet if pain is not relieved and the
b) BETA-BLOCKERS BP is stable.
 common, beta antagonist agent, blocks epinephrine, fight 6. Reassess in 5 minutes.
or flight response. 7. Administer the third nitroglycerin tablet if pain is not relieved and
BP is stable.
c) CALCIUM CHANNEL BLOCKERS 8. Reassess in 5 minutes; contact the physician if the third nitroglycerin
 blocks the calcium in intended channels, decreased the tablet does not relieve the pain.
blood pressure to improve blood flow. 9. Document the event, actions taken, and the client's response to
treatment.

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NURSING CARE
 Maintaining adequate coronary blood flow and perfusion of the
heart muscle is the highest priority of care for the client with CHD
and angina.
1. ASSESSMENT:
a. Pain: Location, character, intensity, radiation, timing, duration,
aggravating and relieving factors, and associated manifestations.
COLDSPA
b. History of angina or other heart disease, treatment (regimens
the client is doing), drugs, invasive procedures, or surgery.
c. Risk Factors
*Identify potential complications
 Angina is often a precursor to an acute cardiac event such as Acute
Coronary Syndrome or Myocardial Infarction.
2. DIAGNOSIS:
a. Risk for Decreased Cardiac Tissue Perfusion
b. Readiness for Enhances Self-Health Management (prevention is
better than cure, you need to know how to better your lifestyle
and activities)
3. PLANNING:
A. Acute Pain related to decreased myocardial blood flow
1) Assess for vital signs and symptoms of pain such as facial
grimacing, rubbing of neck or jaw, reluctant to move, increased
BP, and tachycardia. (certain stress, anxiety commonly causes
tachycardia)
2) Note onset, duration, location, and pattern of pain.
3) 12-lead ECG immediately during acute chest pain.
4) Use a pain rating scale to assess the patient’s perception and the
pain’s severity. (assessing pain should be complete)
5) Administer sublingual NTG as ordered. (Note contraindicated
for PT on vasodilators like Viagra) It would potentiate.
6) Instruct the patient to notify a nurse immediately when
experiencing pain. Have the patient stop current activity, and
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please him on bedrest in a semi-to high Fowler’s position.
Adhering to the regimen and limiting activity.
7) Administer oxygen as ordered.
GOAL: The patient will be free from pain, maintain stable vital signs,
and relaxed body posture. To prevent heart attacks and episodes.
Electrical Activity of the Heart
P WAVE - it is the atrial contraction or depolarization. Starts at atrial
contraction and ends in ventricular contraction.
PR INTERVAL - Begins with P and ends at the start of Q.
QRS COMPLEX - pertains to ventricular contraction, depolarization of
the ventricles.
T WAVE - ventricular repolarization
RR INTERVAL - the elapse time between the 2 QRS Complex
PR SEGMENT - starts from the beginning od the P wave until the
beginning of the QRS complex.
ST SEGMENT - starts at the end of S wave and ends at the beginning of
the T wave.
ACUTE CORONARY SYNDROME
 An umbrella term used for any condition brought about by sudden,
reduce blood flow to the heart (severe cardiac ischemia).
 It includes your unstable angina, (NSTEMI) Non-ST segment
elevation Myocardial Infarction and (STEMI) ST Segment
Elevation Myocardial Infarction/heart attack.
PATHOPHYSIOLOGY
 ACS is associated to narrowing (stenosis) one or more coronary
arteries. The most common cause of acute reduction of blood flow is
rupture or erosion of atherosclerotic plaque. Acute ischemia
results to injured myocardial cells, potentially reducing cardiac
output of the heart. The body is doing something to compensate if
something is imbalance like if there is a blockage happening. The
condition or phenomenon that maintains hemostasis is called
collateral circulation. Tiny vessels that paves way for the blood
flow.
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 Collateral Circulation slightly elevated and may return to normal ranges within 12 to 24
 a network of tiny blood vessels that enlarge and become active hours. During the acute episode of chest pain, the ECG shows acute
when blood flow becomes limited. ischemia and cell injury. An echocardiogram may show abnormal
movement of the myocardial wall during an acute episode of ACS.
MANIFESTATIONS
 The cardinal symptom of ACS is CHEST PAIN (Angina); usually MEDICATIONS
substernal or epigastric. This pain often radiates to the neck, • Nitrates (nitroglycerin)
shoulder, left arm, or jaw and develop at rest and is usually longer • Beta-blockers
than 10-20 minutes. • Fibrinolytic/Thrombolytic drugs
 Dyspnea a) Streptokinase (Streptase)
 Diaphoresis • Antiplatelet/Anticoagulant drugs
 Pallor, cool and clammy skin a) Aspirin - common
 Nausea b) Clopidogrel (Plavix)
 Lightheadedness c) Ticlopidine (Ticlid)
 Tachycardia d) Warfarin Sodium (Coumadin)
 Hypotension
 Feeling restless/apprehensive What is the difference of thrombolytics and anticoagulants?
COMPARISON  Thrombolytics dissolve the thrombus, the anticoagulants prevent
ANGINA ACUTE ACUTE the clotting factors.
PECTORIS CORONARY MYOCARDIAL Heparin - is an anticoagulant.
SYNDROME INFARCTION
NURSING INTERVENTIONS
CHEST ‣ Stable and ‣ Often occurs ‣ Begins abruptly, 1. Evaluate chest pain in order to accurately evaluate, treat, and
PAIN predictable; at rest or an unrelated to prevent further ischemia.
precipitated arising rest or exercise 2. Monitor effectiveness of oxygen therapy to increase oxygenation of
by exertion or ‣ Increasing ‣ Severe, myocardial tissue prevent further ischemia. Certain metabolisms are
emotion, frequency and “crushing” being affected.
relieved by severity ‣ Radiates to 3. Administer medications to relieve/prevent pain and ischemia to
rest ‣ Radiate to neck, arms, jaw decrease anxiety and cardiac workload.
‣ May radiate neck, left, ‣ Unrelieved by 4. Obtain 12-lead ECG during pain episode to help differentiate angina
to neck, shoulder, arm rest and from extension of MI or pericarditis.
shoulder, ‣ Lasts 10 nitroglycerin 5. Monitor cardiac rhythm and rate and trends in blood pressure and
arms minutes or hemodynamic parameters to monitor for hypotension and
‣ Usually lasts longer bradycardia which may lead to hypoperfusion. To prevent patient
2 to 5 ‣ Adhere to from getting shocked. Instruct patient not to exert effort.
minutes nitrates 6. Monitor for vital signs frequently to determine baseline and ongoing
changes.
DIAGNOSTIC TESTS
7. Monitor for cardiac dysrhythmias.
 The ECG and serum cardiac markers are used to diagnose ACS.
Cardiac muscle troponin and creatinine kinase levels are initially
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8. Monitor respiratory status for symptoms of heart failure or to
maintain appropriate levels of oxygenation and observe for signs of
pulmonary edema.
9. Monitor fluid balance. (INO) Restrictions in water or fluid intake. Or
for example, sodium intake as it might pave way to fluid retention.
That is why there are medications like sodium channel blockers to
prevent fluid imbalances.
10. Arrange exercise and rest periods to avoid fatigue and decreased the
oxygen demand of myocardium. Plan out activities and rest periods
to conserve the patient’s energy. It should be timely scheduled and
must be appropriate for the patient.
MANAGEMENTS
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY
 An invasive procedure used to increase blood flow to heart muscle.
a) The balloon catheter with the stent is threaded into affected
coronary artery.
b) The stent is positioned across the blockage.
c) The balloon is inflated, compressing the plaque and expanding
the stent.
d) The balloon is deflated and removes, leaving the stent in place.
CORONARY ARTERY BYPASS GRAFT (CABG)
 A vein or arterial graft is used to bypass or bridge the coronary
artery he obstruction and provide blood to the ischemic portion of
the heart. The internal memory artery (IMA) in the chest and the
saphenous vein from the leg are commonly used vessels. The
distal end of IMA is sutured to the coronary artery distal to the
obstruction. When the saphenous vein is used, it is removed from
the leg, reversed so that its valves do not interfere with the blood
flow, the grafted to the aorta and the coronary artery, distal to the
occlusion.
 The procedure is most effective when good ventricular function
remains and ejection is more than 40% to 50%.
INJECTION FRACTION
 how well the left ventricle pumps blood with each heart beat. Refers
to the amount of blood being pumped out of the left ventricle each
time it contracts. The normal is 50% - 70%. Can cause dyspnea
because of back flow.
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NURSING CARE
A. Risk for decreased cardiac output may be related to altered
myocardial contractility secondary to temporary factors such as
ventricular wall surgery, recent myocardial infarction, responds to
certain medication, and drug interactions.
1. Monitor and document trends in HR and BP, especially noting
hypertension. Tachycardia is most common.
2. Observe for bleeding from incisions and chest tube (if in place). So
complications can be avoided.
3. Observe changes in mental status, orientation, and body movement
or reflexes. Assess for level of consciousness and GCS.
4. Record skin temperature and color, quantity, quality of peripheral
pulses. Adequate cardiac output - warm, pink
5. Measure and document and take an output and calculate fluid
imbalance. To assess certain fluid needs. To improve cardiac output.
6. Schedule uninterrupted rest and sleep periods. Inspect for jugular
vein distention. To prevent and monitor complications.
7. Review serial ECGs.
8. Administer supplemental oxygen as indicated.
GOAL: The patient was able to demonstrate and display have a dynamic
stability such as stable blood pressure and cardiac output.
VIDEOS:
BLOOD FLOW THROUGH THE HEART
‣ The superior vena cava receives blood from the head, neck, upper
limbs, and chest while the inferior vena cava receives blood from the
trunk, viscera, and lower limbs. Both the superior and inferior vena
cava end up in the right atrium. Blood exists the right atrium through
the tricuspid valve and enters the right ventricle, the blood exists the
right ventricle through the pulmonary valve then enters the
pulmonary artery, the pulmonary artery then splits into the left and
right arteries, which go to each respective lung. In the lungs, gas
exchange occurs. The blood discards CO2 and picks up oxygen. Now,
blood comes back from the lungs through the pulmonary veins,
entering the left atrium. Next, the blood is pumped into the left
ventricle through the mitral, or bicuspid valve. finally, the oxygenated
blood leaves the left ventricle through the aortic semi-lunar valve,
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entering the aortic arch. The aorta distributes the oxygenated blood ‣ While the doppler ultrasound test is performed, you will hear a
to the rest of the body. The aortic arch has three major branches,
which supply the head and arms with blood. Then, the aorta curls
downward from behind the heart, forming the descending aorta,
which descends through the chest and continues down through the
abdomen. In the abdomen, the descending aorta splits to supply the
pelvis and legs with blood.
TESTS AND PROCEDURES
ECHOCARDIOGRAM
- A non-invasive test that uses high-frequency sound waves or
ultrasound to examine the hearts anatomy and function. This test
provides information about your heart size, the appearance of the
valves, and the thickness of the heart muscle.
PREPARING FOR THE TEST:
• No special preparation is needed
• You may drink and/or eat before hand
• You can go about your normal activities unless otherwise informed
• Do continue all your medications prescribed by your doctor follow
your doctor's orders as usual
THE TEST:
‣ The entire test takes less than an hour.
‣ The echocardiogram will be performed by a sonographer, specially
trained ultrasound technologist.
‣ You will be left to disrobe from the waist up and will be provided with
a gown.
‣ You were lie on the examining table in the sonographer well
attaching small adhesive patches with wires to record the timing of
your heartbeat
‣ Your sonographer will update ultrasound pictures of your heart using
a small handheld transducer water soluble gel
‣ The lights will be to reduce glare so the sonographer can better see
the picture monitor
‣ Changes in body position or sometimes needed to get enhanced
pictures
‣ At times the technologist may need to apply added pressure with the
scanning probe to visualize certain areas requiring additional views.
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swishing sound as the instrument receives and processes the signals.
‣ Doppler ultrasound is particularly helpful in the evaluation of heart
murmurs
‣ Color ultrasound imaging provides additional informational about
direction and distribution of blood flow, when this is being performed
you will notice multiple colors on the screen
‣ The echocardiogram test includes Doppler and color evaluations of
your heart
IS IT SAFE?
- Sound waves do not cause pain, the only discomfort you may
experience would be related to the pressure of the transducer against
your skin.
- There are no reports of complications related the use of diagnostic
ultrasound
WHEN WILL I RECEIVE THE RESULTS?
➡ Your test will be reviewed and interpreted by a cardiologist and the
report will be provided to your physician who will contact you.
TRANSOPHAGEAL ECHOCARDIOGRAM (TEE):
‣ To make this test more comfortable, your nurse will spray a numbing
medication into your back of your throat or you may gargle with it,
this may be slightly bitter.
‣ This will make your mouth and throat numb for approximately 30
minutes.
‣ Then you will be positioned on your left side with your left arm
behind your back.
‣ A small plastic mouthpiece or guard will be put in your mouth to
prevent you to accidentally biting the tube or the doctor’s finger
when the tube is slowly place into your esophagus or food pipe.
‣ In order to help relax the muscles in the back of your throat and help
open up the passageway, you will need to take slow, deep breaths.
‣ You will then be instructed to put your chin to your chest and open
your mouth.
‣ As the doctor begins to push the tube in, you will be asked to swallow.
‣ Swallowing makes good to go down more easily.
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‣ If you gag when the tube enters your food pipe, the nurse will spray
more numbing medicine on your throat to decrease your gag reflex
and make you more comfortable.
‣ Your doctor will insert the tube 14 to 18 inches down the length of
you food pipe.
‣ A nearby video screen will confirm that the tube is in exactly the right
place to create images of your heart.
‣ The actual procedure takes about 15 to 30 minutes.
‣ When the test is done, your doctor Will slowly pull the tube, out
through your mouth.
CORONARY ANGIOGRAPHY | CARDIAC CATHETERISATION
- is an x-ray examination of the vessels and chambers of the heart
- Often done to identify any narrowed or clogged coronary arteries that
are preventing blood from reaching the heart muscle.
- The study can also be used to measure the size and function of the
Chambers of the heart and the function of the heart valves.
BEFORE THE PROCEDURE:
‣ When you arrive at the hospital, an intravenous line will be started.
‣ You will be pleased with a heart monitor
‣ You may be given an oral or intravenous sedative to help you relax
‣ Most coronary angiography procedures last between one and two
hours.
‣ Before the procedure, you will be placed on a table equipped with the
fluoroscope, an x-ray imaging device.
DURING THE PROCEDURE:
‣ The fluoroscope will move around your chest in all directions to
record pictures of your heart and coronary arteries from multiple
angles.
‣ Most cardiac catheterizations take please through femoral artery in
the groin but can also be done through an artery in the arm.
‣ The doctor numbs the skin in your groin area and inserts a needle
into your femoral artery.
‣ Once the needle is placed, a wire is passed to the needle and gently
guided through the arterial system to the heart.
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‣ The needle will be withdrawn and exchange for a small flexible tube
called a sheath, the permit is access to your femoral artery.
‣ Next, a soft flexible catheter will be slipped over the wire through the
sheath and threaded up to your heart.
‣ Your physician will watch the movement of the catheter on the
fluoroscope.
‣ You may feel pressure as the wire and sheath are inserted but you will
not feel their movement inside your arteries.
‣ To evaluate the coronary arteries, your doctor will remove the guide
wire, position the tip of the catheter just inside the arteries, one at a
time, and inject a special dye that allows the fluoroscope to take x-
ray images and angiograms of the arteries, any blockages will be
clearly identified as the arteries fill with dye.
‣ You may still flushed or slightly nauseated when the dye is injected.
AFTER THE PROCEDURE:
‣ After sufficient images of both coronary arteries and their tributaries
have been recorded, the catheter will be removed through groin.
‣ Pressure must be applied over the femoral artery to prevent bleeding.
‣ You will then be taken to the recovery room for 30 to 60 minutes of
observation.
‣ After which you will be required to lie on your back for several hours
with a pressure bandage in place over your groin.
‣ You may either be discharged home on the same day or after an
overnight stay in the hospital.
12 LEAD ECG PLACEMENT OF ELECTRODES | EKG STICKER LEAD
PROCEDURE
- In the hospital and clinic setting, you will be expected to obtain a 12
lead EKG on a patient. This is done at the bedside with a machine.
The machine analyzes various angles of the heart and interprets the
patient’s heart rhythm and rate.
- You can tell so much about a patient’s cardiac status from an EKG. For
instance, if a patient is having chest pain, you can look at an EKG and
tell if they are having an active myocardial infraction (in most
patients). In addition, you can tell if they are in any type of abnormal
rhythm such as atrial fibrillation or atrial flutter etc.
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SUPPLIES YOU WILL NEED: • V1: Placed in the fourth intercostal space to the right of the
• 10 Electrode Stickers sternum
• 1 strip of abrasive tape (this roughs up the epidermis so you can • V2: Placed in the fourth intercostal space to the left of the
get a good connection) sternum
• Alcohol prep pads (cleans the skin’s oils so you can get a good • V3: Placed directly between leads V2 and V4
connection) • V4: Placed in the fifth intercostal space in the mid-clavicular line
• Hair Trimmers (used to remove excessive hair on men) • V5: Placed level with V4 at the left anterior mid-axillary line
• V6: Placed level with V5 at the mid-axillary line
PREP THE SKIN:
✓ First clean the electrode site placements with alcohol prep to remove HEART BYPASS SURGERY (CABG)
oils and dirt from the skin. - is performed to improve circulation to the heart muscle in people with
✓ Then gently “rough up” the area with the abrasive tape so the severe coronary artery disease.
electrodes will stick properly.
- In this procedure, a healthy artery or vein from another part of the
Tip: Always make sure your electrodes are not expired or the gel is dry body is connected or draft to block coronary artery.
because this can affect the connection. In addition, never place an - The draft that artery or vein, bypasses the back portion of the
electrode over an implanted device in the skin. coronary artery, carrying oxygen rich blood to the heart muscle.
- One or more coronary artery maybe a bypassed during a single
operation.
EKG 12 LEAD PLACEMENT:
There are a total of 10 leads (4 limb leads & 6 chest/precordial leads) and BEFORE THE SURGERY:
they are the following: ‣ An IV line will be started
• Right arm (RA) ‣ You may be given an oral or intravenous sedative to help you relax
• Left arm (LA ‣ CABG procedures are done under general anesthesia which will put
• Right leg (RL) you to sleep for the duration of the operation.
• Left leg (LL) ‣ A breathing tube will be inserted into your throat to help you
• V1 breathe.
• V2 ‣ A catheter will be placed in your bladder to drain your urine.
• V3 ‣ The surgery generally takes 3 to 6 hours.
• V4
• V5 DURING THE SURGERY:
• V6 ‣ The surgeon begins by making an incision in the skin over your
breastbone or sternum.
LOCATION OF EKG 12 LEAD PLACEMENT: ‣ they will then cut the sternum and move the ribcage in order to get
• RA: Placed on the right arm or right below the right clavicle to your heart.
• LA: Placed on the left arm or right below the left clavicle ‣ Throughout the procedure your circulatory system will be connected
• RL: Placed on the right leg or upper right quadrant to a cardiopulmonary bypass pump or heart-lung machine. This
• LL: Placed on the left leg or upper left quadrant will temporarily perform the functions of your heart and lungs during

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the surgery allowing your heart to be stopped while the surgeon sews
the graft into place.
‣ One of two blood vessels is typically used for the grafts, the internal - often abbreviated to angioplasty
thoracic artery in the chest or the saphenous vein in the leg.
✓ Internal Thoracic Artery Graft - the surgeon will leave the
upper and attached to the subclavian artery and divert the
lower end from your chest wall to your coronary artery, just
beyond the blockage. He will then sew the graft into place.
✓ Saphenous Vein Graft - the surgeon will suture one end to
the aorta and the other end to the narrowed artery just
beyond the blockage. With the graft securely in place, he will
use electrical signals to restore the heartbeat and attach a
temporary pacemaker to the heart.
‣ Once your heart is beating normally, the heart-lung machine will be
disconnected, he will wire the breastbone back together and suture
the skin incision closed.
‣ A temporary draining tube will be placed through the skin beneath
the incision.
‣ Two other types of CABG procedures have recently been
developed:
✓ Off-pump bypass surgery - also called beating heart bypass
grafting because the heart isn’t stopped and a heart-lung
machine isn’t used, instead a mechanical device is used to
steady the part of the heart where grafting is being done.
✓ Minimally invasive bypass surgery - being performed with
specially designed instruments inserted through small
incisions or ports in the chest. Sometimes this requires a
heart-lung machine.
AFTER SURGERY:
‣ You will be taken to the intensive care unit
‣ The activity of your heart will be carefully monitored
‣ If necessary, pacing wires will be used to temporarily control your
heart rate.
‣ The test tube will temporarily remain in place to drain excess blood
and air from the chest cavity.
‣ Once you can breathe on your own, it will be replaced with an oxygen
mask.
‣ The bladder catheter will remain in place.
‣ As you recover 3 to 4 days, all these devices will be gradually removed.
10
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY
(PTCA)
- A procedure to reopen a narrowed coronary artery.
- The heart muscle is supplied by blood arriving through the coronary
arteries, if these arteries or narrowed by fatty deposits, the heart
becomes starved of oxygen which causes pain in the chest called
Angina.
- Coronary Angioplasty - a guiding catheter is passed through a large
artery in the groin or arm to the heart.
- A guide wire is done threaded through the catheter and manipulated
beyond the site of the blockage.
- With the guide wire in place, a balloon catheter is insert that over the
guide wire and advanced.
- Once in place, the balloon is gently inflated in the narrowed segment
and then deflated after a few minutes, this reopens the artery to allow
improved flow of blood.
- Sometimes, the physician can decide to place a small tubed called a
stent inside the reopened artery to hold it open.
- The stent is passed along to the tip of the catheter and then opened
up.
- The balloon catheter, guide wire, and guide catheter are then removed.
ACUTE MYOCARDIAL INFARCTION
 Cells in an area of cardiac muscle is infarct or necrose due to lack
of blood and oxygen (signals death). It is a life-threatening event. If
circulation is not rapidly restored, this can lead to cardiogenic shock
or death.
PATHOPHYSIOLOGY
 MI occurs when a coronary artery is totally occluded, blocking
blood flow to a portion of cardiac muscle for a prolonged period of
time. It usually affects the LV because it is the major workhorse of
the heart.
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 Occlusion of the left anterior descending artery damages the
anterior portion of the LV; occlusion of the left circumflex artery
causes lateral damage.
 Right ventricular, inferior, and posterior MI involved occlusion of
right coronary artery and posterior descending artery. Vital arteries 5. Administers supplemental oxygen as indicated.
and most common affected areas.
MYOCARDIAL INFARCTION (HEART ATTACK)
 Pain is the classic manifestation of MI. Chest pain is described as
crushing and severe; the client may call it a pressure, heavy, or
squeezing sensation, or complain of chest tightness or burning.
 The pain begins in the substernal region and may radiate to
shoulders, neck, jaw, or arms. It lasts more than 15 to 20 minutes
and it is not relieved by rest or NTG; accompanied by decreased BP,
tachycardia/bradycardia.
 The client often experiences a sense of impending doom and death.
INTERDISCIPLINARY CARE:
Diagnostic Tests:
a. Serum Cardiac Markers
 Creatinine kinase and cardiac specific troponin. CK levels rise
rapidly after AMI; it is detectable in the serum within 3 to 6
hours; peaks within 12 to 24 hours, then declines during the
next 48 to 72 hours. The greater the amount of infarcted tissue,
the higher the CK level. CK-MB isoenzyme is the most sensitive
indicator of MI. Troponins remain in the blood for 10 to 14 days.
b. ECG Results
• Inversion of the T wave (T waves within the ventricles)
• Depression or elevation of the ST segment
• Formation of Q wave
c. Elevated White Blood Cell
d. Echocardiogram
NURSING CARE
A. Pain r/t (related) tissue ischemia (coronary artery occlusion)
1. Obtain full description of pain. Assess patient to quantify pain by
comparing it to other experiences. Verify and clarify.
11
2. Instruct patient to report pain immediately.
3. Provide quiet environment, activities, and comfort measures. Use
therapeutic techniques.
4. Assist/instruct in relaxation techniques.
6. Administer medications (e.g. antianginals, beta-blockers, analgesics)
as indicated.
GOAL: The patient verbalized relief/control of chest pain with an
appropriate time frame for administered medications.
MANAGEMENT
INTRAAORTIC BALLOON PUMP (IABP)
- Temporarily supports cardiac function by decreasing myocardial
workload and oxygen demand by increasing coronary artery perfusion.
The balloon inflates during diastole to help perfuse coronary, renal,
and cerebral arteries. During systole, the balloon is deflated, allowing
blood to freely flow past it.
CARDIAC REHABILITATION
- Planned program of activity and exercises, psychologic support, and
education for clients who have had an MI. Its goal is to improve the
quality of life by reducing risk factors for heart disease. It begins with
admission in the hospital; followed by 3 to 6 months of supervised OP
program and the maintenance program with or without supervision,
physical fitness, and risk factor reduction.
CARDIAC DYSRHYTHMIAS
- Disturbance or irregularity in the electrical system of the heart. Any
arrhythmia can affect cardiac output. Ectopic beats are impulses that
develop more rapidly or more slowly than normal and may originate
outside the SA node (pacemaker of the heart). Heart block (AV
Block) refers to blocked or delayed impulse in the conduction
pathway of the heart. Common cause of AV Block is the coronary
artery disease, and extremes of age.
- Has two categories, the one that originates in the Atria
(Supraventricular rhythms) and the other that originates in the
ventricles (Ventricular rhythms).
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SUPRAVENTRICULAR RHYTHMS
SINUS TACHYCARDIA
 Regular; rate is greater than 100 bpm
 Treated only if symptomatic or if the client is at risk for MI
 May be triggered by anxiety, caffeine consumption, having
fever, been exposed to certain alcohols, and nicotine.
SINUS BRADYCARDIA
 Regular; rate is less than 60 bpm
 Treated only if symptomatic; may give atropine or require
pacemaker
 Anticipated if patient has heart defects, inflammatory disorders
that affects the heart, obstructive sleep apnea, certain problems
in generating cardiac impulse in SA Node (Sick Sinus
Syndrome).
PREMATURE ATRIAL CONTRACTIONS (PAC)
 Irregular, ectopic atrial beat occurring earlier than expected
 Usually do not require treatment
 Associated to patient who has exposure to nicotine, caffeine,
alcohol abuse, and Hypertension.
 Advice smoking cessation, reduced caffeine and alcohol intake
ATRIAL FLUTTER
 Usually regular with sawtooth appearance or P waves
 Atrial rate more than 240 bpm; VR less than 150 bpm
 Synchronized cardioversion
 Associated to patients with heart failure, cardiomyopathy,
conditions that affects the heart valves, thyroid conditions, DM
ATRIAL FIBRILLATION
 Irregularly irregular; no identifiable P waves; variable (chaotic)
VR
 Synchronized cardioversion
 Medication to slow VR
 Anticoagulants to reduce risk of stroke
 Associated to patient with coronary artery disease, heart defects,
and valve problems.
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VENTRICULAR RHYTHMS
PREMATURE VENTRICULAR CONTRACTIONS (PVC)
 Irregular, ectopic (outside) ventricular beat interrupts normal
rhythm; ectopic QRS wide and bizarre
 Abstain from nicotine and caffeine
 Medication is given if symptomatic or if a result of recent MI
 Associated with MI, Cardiomyopathy, Heart Failure
VENTRICULAR TACHYCARDIA
 Regular, rate of 100 to 250 bpm, no identifiable P waves, QRS
wide and bizarre
 Treated if symptomatic, IV drugs
 Accompanied by dizziness, shortness of breath, lightheadedness,
palpitations, and chest pain.
 As to severity, patient may lose consciousness
 Cardioversion or defibrillation if unconscious or unstable
 Can predispose previous heart attack, and cardiomyopathy
VENTRICULAR FIBRILLATION
 Grossly irregular; rate too rapid to count, no P waves, QRS
bizarre and variable (chaotic)
 Immediate defibrillation is necessary
 Cardiomyopathy, shock, prior heart attack, drowning episode
AV CONDUCTION BLOCKS
 First-degree AV block - prolonged PR interval
 Second-degree AV block - PR internal progressively longer,
QRS complex is absent or dropped (inverted)
 Third-degree AV block - atrial rate (60 to 100 bpm) VR - 30 to
40 bpm; immediate pacemaker therapy; life-threatening
 Anomaly to SA and AV node
*watch youtube vid: EKG Training - interpreting Defibrillator monitor
INTERDISCIPLINARY CARE:
Diagnostic Tests:
a. Serum cardiac markers (CK, cardiac troponins)
b. Serum electrolytes (sodium, potassium, calcium, magnesium,
chloride)
c. Cardiac monitoring (continuous/portable)
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Pharmalogical Management: fibrillation and treats supraventricular tachycardia and atrial
ANTIDYSRHYTHMIC DRUGS fibrillation.
a. Sodium Channel Blockers
 Quinidine - used to treat VTach, prevent PVC; commonly
used; Procainamide
b. Beta-Blockers
 Esmolol, Propanolol: used to treat supraventricular
tachycardia, V-Tach and V-Fib
c. Potassium Channel Blockers
 Amiodarone - drug of choice to treat VTach and VFib
(because it is very potent to the nodes); blocks postassium,
sodium and calcium channel; the repolarization and
depolarization of the heart is slow down; slows down
electrical activity of the heart so monitor patient’s BP and
HR (due to high tendency of Hypotension and low HR).
 IV Infusion/D5Water - is administered after giving
Amiodarone; do it with titration (there is a certain episode
to increase or decrease drops per minute)
d. Calcium Channel Blockers
 Verapamil, Diltiazem - most common, used to manage
Supraventricular Tachycardia
e. Miscellaneous drugs
 Adenosine - treats paroxysmal (on and off)
supraventricular tachycardia; restores normal sinus rhythm
by vasodilation of vessels and slows the conduction from
SA to AV node; primarily affect coronary artery vessel;
given as dilution (with Saline solution) or IV bolus
depending on the dosage; in emergency cases given after as
an IV bolus with or without dilution
 Digoxin - as a cardiac glycoside it causes (+) inotropic
effect: improves contractility of the heart and (-)
chronotropic effect: slows heart rate
MANAGEMENTS
CARDIOVERSION
- Treats rhythms that affects CO and the client’s welfare. An electrical
shock administered depolarize all cells of the heart; this stops
abnormal rhythm and allows the sinus node to resume control of the
rhythm. Synchronize cardioversion is given to prevent ventricular
13
DEFIBRILLATION
- An emergency treatment that delivers an electrical charge without
regard to the cardiac cycle. Initiation of CPR and external
defibrillation may be performed by any trained healthcare provider.
Cardiac rhythm is evaluated after each shock is delivered.
PACEMAKER IMPLANTATION
- Pacemakers is used to treat AV blocks. They have sensing and pacing
functions. Sensing detects the heart’s own beats. When it senses a
heart rate within preset limits, it provides no electrical stimuli.
Pacing or delivery of an electrical impulse to stimulate the heart to
contract occurs when the HR falls outside the programmed limits.
SURGICAL ABLATION
- is the removal of a part or pathway. The affected tissue is excised (cut
out) or destroyed by freezing with the liquid nitrogen, laser, or an
electric current.
NURSING CARE
A. Decreased in CO associated with Cardiac Arrhythmias
1. Monitor cardiovascular status by using a heart monitor.
2. Assessed and record apical pulse, peripheral pulses, blood pressure,
the capillary filling time, fluid intake and output and skin
characteristics.
3. Provide cardiovascular treatment as directed.
4. Help the client save energy through grouping of nursing care.
REMEMBER: Treat the client, not the monitor!
GOAL: The patient expressed understanding of the disease, reason for
hospitalization, and home care instructions and demonstrate procedures
for home care.
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SESSION 1: RESPONSES TO ALTERED TISSUE PERFUSION
CARDIOGENIC SHOCK decrease in cardiac output. If there is no effective intervention, the shock
 Occurs when the heart fails to act as an effective pump, so cardiac will progress to the refractory stage, when the chance of survival is
output and adequate tissue perfusion cannot be maintained. MI is extremely limited.
the most common cause of cardiogenic shock. Excess blood is left in
the ventricle. This blood backs up to the lungs leading to MANIFESTATIONS
pulmonary edema. When CO drops, the client becomes  Hypotension
hypotensive. A compensatory rise in HR increase myocardial oxygen  Rapid, weak, thready pulse
consumption and decreases coronary perfusion. Until it overworks  Distended neck veins
the myocardium and eventually fails.  Pale, labored respirations
 Crackles
INITIAL STAGE  Pale, cold, moist skin
 there is diminished cardiac output without any clinical symptoms.  Restlessness, agitation, or disorientation
 Oliguria to anuria
COMPENSATORY STAGE
 the baroreceptors respond to the decreased cardiac output by MEDICATIONS
stimulating the SNS to release catecholamines to improve Vasopressors Inotropics Others
myocardial contractility and vasoconstriction, activation of the
 Dopamine  Dobutamine  Nitroglycerin
RAAS, whose end product, angiotensin II., causes sodium and water
(Inotropin) (Dobutrex)
retention as well as vasoconstriction (to increase BP).
 Constricts BP  Diuretics
 Norepinephrine  Increase HR
PROGRESSIVE STAGE
(Levophed)  Amrinone  Digoxin
 follows the compensatory stage if there is no intervention or if the
(Inocor)
intervention fails to reverse the inadequate tissue perfusion.
NURSING INTERVENTIONS
Compensatory Mechanism aimed at improving cardiac output and
1. Administer oxygen by face mask or artificial airway to ensure adequate
tissue perfusion, place an increased demand on an already compromised
oxygenation of tissues.
myocardium.
2. Administer an osmotic diuretic such as mannitol, if ordered to
increase renal blood flow and urine output.
As tissue perfusion remains inadequate the following occurs:
3. To ease emotional stress, allow frequent rest periods as possible.
A. Metabolic Acidosis
4. Allow family members to comfort and visit the patient as much as
B. Decrease in Circulating Volume
possible.
C. Increase in Blood Viscosity may cause clotting in the capillaries and
5. Monitor and record blood pressure, pulse, respiratory rate, and
tissue death.
peripheral pulse every 1 to 5 minutes until the patient stabilizes.
6. Record hemodynamic pressure readings every 15 minutes.
As the body break down the clots, disseminated intravascular
7. Monitor ABG values , CBC, and electrolyte levels.
coagulation (DIC) may occur. Lactic acidosis causes depression of the
8. Assess skin color and temperature and note changes. Cold and
myocardium and a decrease in the vascular responsiveness to
clammy skin may be a sign of continuing peripheral vascular
catecholamines. Severe Cerebral Ischemia causes depression of the
constriction, indicating progressive shock.
vasomotor center and loss of sympathetic stimulation, resulting a

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HEART FAILURE HEART FAILURE CLASSIFICATION
 Inability of the heart to pump to meet the needs of the body; CLASS OBJECTIVE ASSESSMENT
there is impairment in the contraction of the heart muscle and increase No objective evidence of
in the workload of the heart acutely or chronically. A cardiovascular disease.
No symptoms and no limitation in
Cardiac Output
ordinary physical activity
 refers to the amount of blood pumped by the ventricles with each
Objective evidence of minimal
contraction and the HR.
B cardiovascular disease. Mild
Cardiac Reserve symptoms and slight limitation
 is the ability of the heart to adjust its output to meet metabolic during ordinary activity.
needs of the body. Comfortable at rest.
Objective evidence of moderately
Pathophysiology of Heart Failure C severe cardiovascular disease.
 Damage to the heart muscle is the most common cause of HF. Marked limitation in activity due
When the CO drops, compensatory mechanisms are activated to to symptom, even during less than-
maintain blood flow to body tissues. A decrease in CO also activates ordinary activity. Comfortable only
the RAAS. Salt and water retention increases blood volume to at rest.
restore CO. Objective evidence of severe
D cardiovascular disease. Severe
HEART FAILURE CLASSIFICATIONS limitations. Experiences symptoms
CLASS PATIENT’S SYMPTOMS even at rest.
No limitation of physical activity.
I Ordinary physical activity does not 1) A patient with minimal or no symptoms but with a large
cause undue fatigue, palpitation, pressure gradient across the aortic valve or severe obstruction in
dyspnea (SOB). the left coronary artery is classified as?
Slight limitation of physical  Class 1 and objective assessment D
II activity. Comfortable at rest. 2) A patient with severe anginal syndrome but with
Ordinary physical activity results angiographically normal coronary arteries is classified as?
in fatigue, palpitation, dyspnea  Class 4 and objective assessment A
(SOB).
Marked limitation of physical HEART FAILURE CLASSIFICATION
III activity. Comfortable at rest. Less ACC/AHA STAGE SYMPTOMS
than ordinary activity causes A High risk for HF, but no current
fatigue, palpitation, or dyspnea. structural or functional damage.
Unable to carry on any physical Structural heart disease, but
IV activity without discomfort. B without signs and symptoms of
Symptoms of HF at rest. If any HF.
physical activity is undertaken, C Structural heart disease with
discomfort increases. current or prior symptoms of HF.
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SESSION 1: RESPONSES TO ALTERED TISSUE PERFUSION
Advanced heart disease with options:
D symptoms of HF at rest despite 1. Heart transplant
treatment and requires specialized 2. VAD
interventions. 3. Surgery
4. Continuous infusion of inotropic
ACC/AHA STAGE TREATMENTS drugs
 Quit smoking. 5. End-of-life car
A  Exercise regularly. (palliative/hospice care)
 Treat high blood pressure and
lipid disorders. MANIFESTATIONS
 If you have CAD, DM, High Left-Sided Right-Sided
BP, or other vascular/cardiac Results from ventricular muscle The most common cause is LVHF.
conditions, take medications damage or overloading. Increase pressures in the
as prescribed. pulmonary system or damage to
 Should take ACE inhibitor or Acute pulmonary edema is the the RV impair blood flow into the
B ARB. accumulation of fluid in the luminary circulation. The RV and
 Beta-blockers should be interstitial space and alveoli of the atrium become distended and
prescribed after a heart attack. lungs that may occur with severe blood accumulates in the systemic
 Surgery options should be LVHF. venous system. Increase venous
discussed for coronary or valve pressures lead to abdominal organ
disease. congestion and peripheral tissue
 Hydralazine/nitrate edema.
C combination may be
prescribed if symptoms
persist.
 Diuretics and digoxin may be
prescribed.
 An aldosterone inhibitor may
be given when symptoms are
severe.
 Restrict dietary sodium (salt).
 Monitor weight.
 Restrict fluids (as
appropriate).
 Pacemaker or ICD may be
recommended.
 Patient should be evaluated to
D determine if the following
treatments are available

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Central Venous Pressure (CVP)
 8 to 12 mmHg (amount of blood returning to the heart and the
BIVENTRICULAR FAILURE
 occurs when both ventricles fail to function adequately and has
manifestations of both right and left-sided HF.
PAROXYSMAL NOCTURNAL DYSPNEA
 is a condition in which the client awakens at night acutely short of
breath, occurs when the fluid accumulated during the day is
reabsorb during circulation at night causing fluid overload and
pulmonary congestion.
INTERDISCIPLINARY CARE
Diagnostic Tests:
 Atrial Natriuretic peptide (ANP)
 Brain Natriuretic peptide (BNP)
 Serum electrolytes
 Chest X-ray – pulmonary vascular congestion and cardiomegaly
 Echocardiogram – evaluate LV function, dilation and hypertrophy
 ECG – dysrhythmias, MI
 Hemodynamic monitoring (Swan-Ganz Catheterization/ Right
Heart Pulmonary Artery Catheterization)
Hemodynamic parameters includes:
Mean Arterial Pressure (MAP)
 60 to 100mmHg (average pressure in the atria in one cardiac cycle)
 Best indicator of adequate tissue perfusion
17
ability of the heart to pump the blood back
Pulmonary Artery Pressure (PAP)
 Less than 25 mmHg (mean); less than 40mmHg (systolic) - indicates
pulmonary HTN8
Pulmonary Capillary Wedge Pressure (PCWP)
 Evaluates the role of Left ventricle; 4 to 12mmHg
Systemic Vascular Resistance (SVR)
 Afterload; 700 to 1500 dynes/sec/cm
Pulmonary Vascular Resistance (PVR)
 37 to 250 dynes/sec/cm (resistance against the blood flow from the
pulmonary artery to the Left Atrium
Cardiac Output (CO)
 4 to 8 L/min
Cardiac Index (CI)
 2 to 4 L/min/m2 (correlation of blood volume to body surface area)
SWAN-GANZ CATHETERIZATION
 The test can be done while you are in bed in an ICU of a hospital. It
can also be done in special procedure areas such as a catheterization
laboratory.
 Before the test start, you may be given a sedative to help you relax.
You will lie on a padded table. Your doctor will make a puncture
into a vein near the groin or in your arm, or neck. A flexible tube
(catheter or sheath) is placed through the puncture. Sometimes, it
will be placed in your leg or your arm. You will be awake during the
procedure. A longer catheter is inserted. It is then carefully move
into the upper chamber of the right side of the heart. X-ray images
may be used to help the healthcare provider see where the catheter
should be placed. Blood may be removed from the catheter. This
blood is tested to measure the amount of oxygen in the blood.
During the procedure, your heart’s rhythm will be constantly
watched using an electrocardiogram (ECG).
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SESSION 1: RESPONSES TO ALTERED TISSUE PERFUSION
MEDICATIONS MANAGEMENT
ACE INHIBITORS ARBS DIURETICS HEART TRANSPLANTATION *watch youtube vid of heart transplant*
(prevents the (blocks  Primary treatment for end-stage HF. Bleeding is a major concern in
production of Angiotensin II the early postoperative period. Chest tube drainage, urinary output,
Angiotensin II or receptors) heart rhythm and hemodynamic parameters are monitored.
Renin)
 Enalapril  Candesartan  Hydrochlorothiazide  Cardiac tamponade can develop, interfering with the heart’s ability
(Vasotec) (Atacand) to fill and contract. Infection and rejection of the transplanted
 Furosemide (Lasix) organs are the leading causes of death in transplant recipients.
 Captopril  Losartan Acute rejection is the leading cause of death within the first year
(Capoten) (Cozaar)  Spironolactone after surgery.
(Aldactone)
 Lisinopril  Telmisartan  Potassium-sparing  Immunosuppressive drugs are given to prevent rejection.
(Prinivil Zestril) (Micardis) diuretic Prevention of infection is vital through limiting visitors with
communicable diseases, pulmonary hygiene measures, early
 Acetazolamide ambulation, and strict aseptic technique.
(Diamox)
NURSING CARE
A. Decreased cardiac output
MEDICATIONS 1) Auscultate heart and breath sounds regularly.
Intotropics Sympathomimetics Phosphodiesterase Vasodilators 2) Report manifestations of decreased CO.
Inhibitors 3) Administer oxygen as needed.
 Digoxin  Dopamine  Hydrochloroth  Nitroglyc 4) Administer medications as ordered.
(Lanoxi (Intropin) iazide erin 5) Encourage rest.
n) 6) Maintain a quiet environment.
 Dobutamine  Furosemide  Nitroprus B. Excess Fluid Volume
(Dobutrex) (Lasix) side 1) Monitor intake and output.
2) Weigh daily.
 Spironolacton 3) Place in Fowler’s or High Fowler’s position.
e (Aldactone) 4) Administer antibiotics and other medications as ordered. (infections)
5) Restrict fluids as ordered.
 Acetazolamide C. Activity Intolerance
(Diamox) 1) Assess VS and heart rhythm before and after activity.
2) Organize nursing care to allow rest periods.
3) Assist as needed with self-care. Encourage independent
performance of ADLs with prescribed limits.
End Stage Heart Failure - requires heart transplant; immunosupressive 4) Plan and implement progressive activity plan. Employ passive and
drugs are being used. active ROM exercises as appropriate.
5) Encourage small frequent meals.
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CARDIOMYOPATHY
 A disorder that affects the structure and function of the heart
muscle; it affects the filling and output of the heart that can lead to
Heart Failure, and is being categorized according to its
characteristics and effects on the heart.
1) Dilated cardiomyopathy is the most common. The heart
chambers dilate and ventricular contraction is impaired.
2) Hypertrophic cardiomyopathy is characterized by
hypertrophy and decrease compliance of the LV.
3) Restrictive cardiomyopathy is rigidity of the ventricular walls
which impairs filling, resulting in decrease valvular size and
decreased CO. Without definitive treatment, client will develop
end stage HF.
MEDICAL MANAGEMENT
Focuses on minimizing heart failure, treating dysrhythmias, and
preventing sudden cardiac death.
1) Restrict strenuous physical activities
2) Dietary and sodium restrictions
SURGICAL MANAGEMENT
 Cardiac transplant is the definitive treatment for dilated
cardiomyopathy. Hypertrophic cardiomyopathy is treated by
resecting excess muscle away from the aortic valve outflow tract.
19
HYPERTENSION
 Blood pressure is the pressure of blood pushing against the walls of
your arteries. Arteries carry blood from your heart to other parts of
your body.
 Systolic blood pressure, measures the pressure in your arteries
when your heart beats while;
 Diastolic blood pressure, measures the pressure in your arteries
when your heart rests between beats.
 A normal blood pressure level is less than 120/80 mmHg. High
blood pressure, also called hypertension, is blood pressure that is
higher than normal. Your blood pressure changes throughout the
day based on your activities. The higher your blood pressure levels,
the more risk you have for other health problems, such as heart
disease, heart attack, and stroke.
Pathophysiology of Hypertension
 Overactivity of the SNS
 Alterations in RAAS
 Chemical mediators in the endothelium - increase in blood vol.
 Insulin Resistance
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SESSION 1: RESPONSES TO ALTERED TISSUE PERFUSION
30 minutes) during a hypertensive urgency. This requires immediate
treatment to prevent irreversible damage to the brain, kidneys, and
heart.

Hypertensive Urgency Symptoms

 Headache
 Lightheadedness
 Shortness of Breath
 Nausea
 Heart Palpitations
 Bloody Nose
Classifications:  Anxiety
1) Primary/Essential HTN – has no identified cause although with
associated risk factors The Effects of Hypertension on your Body
2) Secondary HTN – results from a known cause (e.g. kidney disease) Aneurysm  An aneurysm forms after long-
term damage to the artery
NON-MODIFIABLE RISK FACTORS: walls from high blood
a) Family History pressure.
b) Age Problems with Memory and  Trouble with memory and
c) Race Understanding understanding could be an
early sign that high blood
MODIFIABLE RISK FACTORS: pressure is effecting your
a) High sodium intake brain.
b) Low potassium, calcium, and magnesium intake Sleep Apnea  This sleep disorder has been
c) Obesity linked to high blood pressure
d) Insulin resistance and may be triggered by it.
e) Excess alcohol consumption Dementia  Some forms of dementia may
f) Smoking be directly related to a lack of
g) Physical and/emotional stress blood flow to the brain.
Choriodopathy or Bleeding in  Damage blood vessels can
MANIFESTATIONS the Eye burst behind the eye, causing
 Headache fluid build up known as
 Blurred vision choriodopathy.
 Dizziness/Unsteadiness
Blurred or Loss of Vision  can result from damage blood
 Nocturia
vessels behind the eye.
Chest pain  Can be a sign of a heart attack
HYPERTENSIVE CRISIS
or of reduced blood flow to
 Also known as Malignant Hypertension a rapid increase in
the heart.
systolic pressure to greater than 180 mmHg and or diastolic pressure
Kidney Damage or Failure  Happens when high blood
to greater than 120 mmHg. Frequently monitoring of BP (every 5 to
NCM 118 (FINALS) - MISS PENDON

Arrythmias
Left Ventricular Hypertrophy
Heart Attack or Stroke
Heart Failure
Artery Damage
Hardening of Arteries
Erectile Dysfunction
Vaginal Dryness or Lowered
Sexual Desire
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SESSION 1: RESPONSES TO ALTERED TISSUE PERFUSION
pressure damage arteries Narrow blood vessels can
leading to the kidneys and contribute to lower sexual
small vessels in the kidneys. desire and dryness.
Over time the kidneys lose Blood Clot  If arteries are narrower,a blood
their ability to filter waste clot that might normally travel
from the body. through can get stuck. This
 An irregular heartbeat, or causes a blockage leading to a
arryhtmia can be a sign of heart attack or stroke.
blocked arteries in the heart. Osteoporosis  High blood pressure causes
 When the heart has to work the body to eliminate more
harder to pump blood through calcium, which can lead to
the body it can lead to an osteoporosis.
enlarged left ventricle, called
left ventricular hypertrophy.
 Untreated high blood pressure INTERDISCIPLINARY CARE
can lead to a heart attack or Lifestyle Modifications
stroke when arteries become a. Diet (DASH) - Grains, Lean Protein, Legumes or Nuts/Seeds, Fresh
blocked. Fruits and vegetables, low-fat Dairy, Fats and Sweets
 high blood pressure and b. Alcohol and Smoking
narrowed arteries make the c. Physical activity
heart work harder over time, d. Stress Reduction
which can eventually lead to a
heart failure.
 High blood pressure wears
away at healthy artery walls,
causing tears.
 Over time, damaged artery
walls collect cholesterol
deposits from blood travelling
through. When this build up
gets thick and hard, it reduced
blood flow.
 During arousal, the penis
needs extra blood. Narrow
blood vessels can prevent this
and make it hard to get and
keep an erection.
 The vagina relies on extra
blood flow during an arousal.
NCM 118 (FINALS) - MISS PENDON
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SESSION 1: RESPONSES TO ALTERED TISSUE PERFUSION
MEDICATIONS 4. Suggest frequent position changes, leg exercises when lying
Ace Inhibitors ARBS Beta- Centrally Acting down.
Adrenergic Sympathomimetics 5. Help patient identify sources of sodium intake.
Blockers 6. Encourage patient to decrease or eliminate caffeine (tea,
 Captopril  Candesartan  Atenolol  Clonidine coffee, cola, and chocolates).
(Capoten) (Atacand) (Tenormin) (Catapres) 7. Stress importance of accomplishing daily rest periods.
 Enalapril  Losartan  Bisoprolol  Methyldopa
(Vasotec) (Cozaar) (Zebeta) (Aldomet)
COLLABORATIVE
 Given 1. Provide information regarding community resources, and
 Telmisartan  Propranolol usually for support patient in making lifestyle changes.
(Micardis) (Inderal) pregnant
women, ADDITIONAL INFO:
 Valsartan and
(Diovan) lactating
mothers  Defibrillation and Cardioversion are methods of delivering electrical
*understand how these medications aids in Hypertensive Crises energy to the heart through the chest wall in an attempt to restore
Vasodilators Alpha- Calcium Channel Blockers the heart’s normal rhythm
Adrenergic
Blockers DEFIBRILLATION
 Diazoxide  Prazosin  Amlodipine (Norvasc) - Is the asynchronous delivery of energy, such as the shock is delivered
(Hyperstat (Minipress) randomly during the cardiac cycle. It is the treatment for immediately
IV)  Diltiazem (Cardizem) life-threatening arrythmias with which the patient does not have a
pulse, e.g. ventricular fibrillation (VF) or pulseless ventricular
 Hydralazi  Nicardipine (Cardene)
tachycardia (VT).
ne
(Apresoline  Nifedipine (Procardia) - Medications used: Adenosine - could be given before and after

 Nitroprus  Verapamil (Isoptin)

side CARDIOVERSION
(Nitropress
- Is the delivery of energy that is synchronized to the QRS Complex
(ventricular depolarization). Electrical cardioversion is used when the
NURSING CARE
patient has a pulse but is either unstable, or chemical cardioversion
A. Risk for prone behavior related to lack of knowledge
(the utilization of certain medication in relation to improving the
about the disease
contractility of the heart) has failed or is unlikely to be successful.
These scenarios may be associated with chest pain, pulmonary edema,
INDEPENDENT
syncope, or hypotension. It is also used in less urgent cases like atrial
1. Define and state the limits of desired BP.
fibrillation to revert the rhythm back to sinus (the normal sinus
2. Assist the patient in identifying modifiable risk factors.
rhythm).
3. Reinforce the importance of adhering to treatment regimen
and keeping follow up appointments.

NCM 118 (FINALS) - MISS PENDON

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SESSION 1: RESPONSES TO ALTERED TISSUE PERFUSION

Medications used in Chemical Cardioversion

 Beta-Blockers: could given before and after
 Blood thinners (Clopidogrel),: to prevent clots, could be given
before and after

*Watch Youtube video: Defibrillation & Cardioversion

What is the most dangerous type of Arrythmia?

 Ventricular Fibrillation - uncontrolled irregular beat, instead of
one misplaced beat from the ventricle, there are several impulses
that begin at the same time from different location resulting to
much faster, chaotic heartbeat that at times can reach to 300bpm.
At this rate, little or inadequate blood is pump from the heart to the
brain and body, and can result in fainting.
 Medical attention is needed right away. If cardiopulmonary
resuscitation can be started, or if electrical energy is used to shock
the heart back to normal rhythm, then the heart may not be too
damaged. About 220,000 deaths from heart attacks each year are
thought to be caused by V-Fib.
 People who have heart disease or a history of heart attack have the
highest risk of V-Fib.

*watch Youtube Video: Heart Transplantation

Tacrolimus (Prograf)
 in a class of medication called immunosupressants; used together
with Prednisone (corticosteroid), most common drug used to
prevent rejection in people who have received a liver or heart
transplant.
 Prevents certain enzymes (calcineurin) that activates T-Cells

Bicaval Technique - used during heart transplantation; the heart must

be transplanted within 4-6 hours that it was obtain from the donor due
to sensitivity to blood loss

Lung Transplant - within 6 to 8 hours

Liver Transplant - within 12 hours

NCM 118 (FINALS) - MISS PENDON