MEDICAL-SURGICAL NURSING
PART I: ASSESSMENT AND DIAGNOSTIC EVALUATION
The heart pumps oxygenated blood to the body,
moves a one-way flow providing oxygen and
nutrients and regulates blood supply. The heart
has different activities:
1. Circulation
● Systemic – Left
● Pulmonary – Right
2. Cardiac conduction system – Conducts
electrical impulse to the heart
3. Cardiac cycle
● Complete heartbeat
● Contraction and relaxation
4. Cardiac output
● Volume of blood that is ejected from the
heart
● Indicates the pumping functions of the
heart
2 DIVISIONS
1. Systemic – Supplies oxygen and nutrients to
the body tissue and brings blood back to the
heart
2. Pulmonary – Brings blood to the lungs for
removal of carbon dioxide and oxygen update
The heart has four chambers which functions as
a two sided pump:
STRUCTURE OF THE HEART
1. Pericardium – Has 2 layers
2. Valve
3. Arteries
LAYERS OF PERICARDIUM
1. Parietal - Outer layer
2. Visceral - Inner layer
● Also known as epicardium
● Adheres to the outside of the heart
Pericardial space – Space between the
parietal and visceral layer
● Consists of at least 10 to 50 mL in order
to lubricate the surface of the heart,
allowing easy movement during
contraction and expansion of the heart
● Silent rapid filling as little as 100 mL can
compromise the cardiac function and
cause cardiac tamponade
THREE LAYERS OF CARDIAC MUSCLE
1. Endocardium – Inner layer
● Consists of endothelial tissue and
lines inside the heart valves
● Only layer that receives oxygen and
nutrients from blood circulating the
heart
2. Myocardium – Middle layer or
contracting layer
3. Epicardium – Exterior layer, also known
as visceral.
- Thickness of the cardium varies
according to the pressure generated to
move blood to its destination
- Left ventricle is thicker than right ventricle
CHAMBERS OF THE HEART
1. Atria – Collecting chamber
2. Ventricles – Pumping chamber
 HEART VALVES
Valves - Ensures one-way blood flow and
prevents back flow that produces heart sounds
1. Atrioventricular valve
● Produces S1 heart sounds that
separates atria from the ventricle
● Contains mitral and tricuspid valve
2. Semilunar valve
● Produces S2 heart sounds
● Closure of the aortic and pulmonic
valve
ARTERIES
Arteries are blood vessels that carry oxygenated
blood away from the heart. They keep blood flow
away from the heart except pulmonary arteries
which carry blood towards the lungs for
oxygenation.
The arterioles system is the higher-pressure
portion of the circulatory system. During heart
contraction it is called systemic pressure. When
the heart expands and refills it is called diastolic
pressure.
Arteries also help the heart pump blood. As blood
moves to the periphery, arteries subdivide to
become arterioles which can dilate or constrict in
response to autonomic nervous system control.
Dilation decreases resistance to flow.
Constriction increases resistance to flow.
Therefore the arterioles distribute blood to the
capillaries and function in controlling systemic
vascular resistance, which is referred to as
arterial pressure.
Coronary arteries are the vessels that deliver
oxygen-rich blood to the myocardium. Cardiac
veins are the vessels that remove the
deoxygenated blood from the heart muscles.
Collateral circulation is a network of capillaries
that supplies myocardial cells. There are
numbers of functional and nonfunctional
anastomosis that exist between the coronary
vessels, which can enlarge by flow if one of the
arterial branches increases. Enlargement of
anastomosis can improve blood flow to
myocardial segment and provide collateral
circulation.
Arteries – High pressure
Arterioles – Response to ANS control
● Responsible for dilation or constriction
Coronary arteries – Delivers oxygen-rich blood
to the myocardium
Collateral circulation – Alternate circulation
around a blocked artery or vein via another path,
such as nearby minor vessels
MAJOR CORONARY ARTERIES
There are two major coronary arteries:
1. Right coronary artery, or RCA –
Extends to the R and continues to R AV
sulcus to the posterior surface of the
heart
2. Left coronary artery, or LCA – Extends
to the L then divides into major branches
 CO = HR × SV (4 to 8 LPM)

The average cardiac output in a resting adult is 4

to 6 L/min.

Stroke volume – Volume of blood ejected with

each heartbeat

Cardiac cycle is one contraction and one

relaxation of the heart to form one heartbeat.

The circulating volume of the blood to the heart

varies according to the needs of the tissue cells.
Increase in the work of the cell causes an
increase in blood flow and the subsequent
increase in the work of the heart and the
myocardial oxygen consumption.

The cardiac function is based on the cardiac

output. This is the total volume. Cardiac output
indicates how well the heart is functioning as it
pumps. It also depends on the stroke volume and
heart rate.

Stroke volume is the volume of blood ejected from

each heartbeat. The blood is ejected from each
ventricle due to the contractions of the heart
muscle which compresses the ventricles. Stroke
volume is expressed in mL per beat. Decrease in
stroke volume will decrease heart rate.

Cardiac Cycle – 2 phases

1. Diastole – Is the atrial contraction and

ventricular relaxation
2. Systole – Is the ventricular contraction
and atrial relaxation

Causes of Low CO:

1. Inadequate left ventricular ejection –

CAD, cardiomyopathy, HTN, aortic
stenosis, mitral regurgitation, drugs that
are negative inotropes, and metabolic
These pictures show how the coronary arteries
disorders
supply blood to the myocardium.
2. Inadequate left ventricular filling –
CARDIAC OUTPUT Hypovolemia, tachycardia, stenosis,
rhythm disturbance, high CO due to
Amount of blood pumped by the ventricles into exercise, fear, anxiety and sepsis
the pulmonic and systemic circulation per one
minute. Cause of High CO – Exercise, fear, anxiety and
sepsis
The average stroke volume in a resting adult is
about 60 to 130 mL. The average heart rate in a
resting adult is 60 to 100 bpm. Cardiac output is
computed by multiplying the stroke volume by the
heart rate.
FACTORS THAT REGULATE STROKE
VOLUME

1. Preload
● Gives the volume of blood that the
ventricle has available to pump
● Depends on the venous return
2. Contractility
● Is the force that the muscle can
create at a given length
● The force of the contraction is
generated by the myocardium
3. Afterload – Is the arterial pressure
against which the muscle will contract

These factors establish the volume of blood

pumped with each heartbeat

FACTORS THAT AFFECT CARDIAC OUTPUT

Cardiac output can increase or decrease by

changes in heart rate. This can lead to
dysrhythmia or arrhythmia. Increase in heart rate MEDICATIONS THAT LOWERS HR
reduces the time the heart is in diastole and 1. Adenosine
results in the decrease of left ventricular filling and 2. Beta blockers
coronary blood flow to the myocardium. Heart 3. Calcium channel blockers
rate and contractility are increasing factors. The 4. Digoxin
characteristics of the cardiac tissue are
influenced by the humoral and neural MEDICATIONS THAT INCREASES HR
mechanism. Preload and afterload depend on the
1. Epinephrine
characteristics of the heart rate and vascular
2. Norepinephrine
system.
3. Atropine
1. Heart rate, or HR – Changes in CO affects
CONDITIONS THAT INCREASE PRELOAD
HR
2. Preload – Starling’s Law There is an increase in blood returning to the
3. Afterload – Resistance of left ventricular heart
ejection
4. Contractility – Inotropic agents 1. Increase in circulating blood volume –
Overtransfusion, polycythemia
PRELOAD AND AFTERLOAD 2. Mitral or aortic insufficiency
3. Heart failure or hypovolemia
Preload is based on the principle of starling’s law
of the heart. The greater the volume, the greater Treatment:
the stretch of the cardiac muscle fibers and the
greater the force in which the fibers contract. ● Diuretics – Furosemide
Preload is affected by the venous blood pressure ● Vasodilators – Nitrates and morphine
and the rate of the venous return. There are
factors that affect preloading:

● Blood volume
● Distribution of blood
● Ventricular function
● Ventricular compliance
 CONDITIONS THAT DECREASE PRELOAD CONDITIONS THAT AFFECT AFTERLOAD

There is a reduction in the volume of blood 1. Ventricular outflow obstructions – Aortic

returning to the ventricle. Very common example valve stenosis
is blood loss. 2. SNS stimulation – Epinephrine release
causes increase PVR
1. Decrease in circulating blood volume –
3. Hypertension
Bleeding, dehydration
4. Hypercoagulability
2. Mitral or aortic stenosis
3. Vasodilator Treatment:
4. Atrial fibrillation
If there is a decrease in afterload..
5. Cardiac tamponade
1. Vasodilators – Morphine, nitroprusside,
Treatment:
hydralazine, Clonidine, ACE inhibitors,
● Fluids – Isotonic solution, 0.9% NS, LR ARBs
● Blood and blood products
2. Intra-Aortic Balloon Pump, or IABP
● Vasopressor – Not effective if full tank
● Volume expander If there is an increase in afterload..
AFTERLOAD 1. Vasopressor – Dopamine, dobutamine,
norepinephrine, epinephrine
The resistance or pressure which the ventricle
must overcome to eject its volume of blood during Dopamine – Increases contractility and
contraction oxygen consumption
Right ventricle – Pulmonary Vascular Correct hypovolemia with volume
Resistance, or PVR – The right ventricle ejects replacement before considering
blood through the pulmonic valve against the low vasopressors
pressure of the pulmonary circulation, or
pulmonary vascular resistance

Left ventricle – Systemic Vascular Resistance,

or SVR – The left ventricle ejects blood through
the aortic valve against the high pressure of the
systemic circulation, also known as systemic
vascular resistance

Afterload is the resistance in blood flow as it

leaves the ventricle. Increase in vascular
resistance can increase ventricular contractility to Intra-aortic Balloon Pump – Increases
maintain stroke volume and cardiac output. myocardial perfusion, increasing cardiac output
and coronary blood flow
Afterload is directly related to arterial blood
pressure through ejection of blood in the systemic CONTRACTILITY
circulation. Increase in arterial pressure requires
Refers to the inherent ability of the myocardium
more energy to eject blood. Increase in energy
to contract normally and influenced by preload
requirement for ventricular systole increases
myocardial oxygen demand. May be affected by:

Vascular resistance must be overcome to push 1. Ventricular muscle mass

blood to the circulatory system. Systemic 2. Heart rate
vascular resistance is resistance by the systemic 3. Oxygen status
circulation. Pulmonary vascular resistance is the 4. Chemical or pharmacological effects
resistance by the pulmonary circulation.
Contractility is influenced by preloading. This is
sometimes called an inotropic state.
 CONDITIONS THAT INCREASE TERMS
CONTRACTILITY
Ejection Fraction – Normal: 55% to 70%
1. Sympathetic stimulation – Fear or anxiety
Depolarization – Contraction
2. Calcium
3. Inotropes – Digitalis, epinephrine, and In depolarization, once electrical impulse is
dobutamine generated, movement of sodium into the cell exits
to the potassium. It is known as contraction of the
ventricle.
CONDITIONS THAT DECREASE
Repolarization – Relaxation
CONTRACTILITY
Repolarization – Return of ions to previous
1. Negative inotropes – Beta blockers, calcium
resting state which corresponds to relaxation of
blockers, barbiturates, and most
the myocardial muscles
antidysrhythmics
2. Infarction Action Potential – The change in electrical
3. Cardiomyopathy potential associated with the passage of an
4. Vagal stimulation impulse along the membrane of a muscle cell or
5. Hypoxemia nerve cell
6. Acidosis
Action potential is any stimulus that decreases
the permeability of the membrane to generate
electrical potential. It is the nerve impulse that
causes permeability of an ion to cross the cell
membrane.

ELECTROPHYSIOLOGIC PROPERTIES OF
CARDIAC MUSCLE

1. Automaticity or rhythmicity – Spontaneous

initiation of an impulse without control
- Automaticity and rhythmicity discharge
electrical impulse in the SA node where the
sodium moves into the cell. Rhythmicity
refers to the regular discharging of action
potentials

2. Excitability – Ability of the cell to respond to

Ejection fraction is an indicator of the heart’s
ability to maintain contractility. It is also the
relationship between the diastolic volume and the
stroke volume.
Decrease in ejection fraction is a sign of
ventricular failure.
Systolic Dysfunction – The ejection fraction falls
below 40%.
This is measured by echocardiogram, nuclear
studies, MRI, and CT scan.
an electrical impulse or stimulus
- Excitability indicates how well the response to
electrical stimulus. Conductivity is the ability
of the cell to respond to an electrical impulse
from one cell to the next. Excitability and
conductivity are both related. Excitability
refers to the ability to respond to a stimulus.
Conductivity allows the stimulus to pass from
one cell to the next
3. Conductivity – Propagate electrical
impulses *ability to transmit an electrical
impulse from one cell to another

4. Refractoriness – Inability to respond to a

new stimulus while still in a state of
contraction from an earlier stimulus
- Refractory period is when the myocardial
cells depolarize before they can depolarize
again

2 phases:

● Absolute – Cell is complete

unresponsive to any electrical stimulus
and noncapable to initiate to any
depolarization; Normal
● Relative – Electrical stimulus is stronger
than normal, which can cause premature
contraction, placing the patient at risk

CARDIAC CONDUCTION SYSTEM

1. Sinoatrial node, or SA, or pacemaker – 60

to 100 bpm
● Primary or dominant pacemaker
● Located at the junction of the
superior vena cava and the right
atrium
2. Atrioventricular node, or AV, or junction –
40 to 60 bpm
● Located at the lower portion of the
right atrium
● The slow conduction of the AV node
allows filling of the ventricle
3. Bundle of His or AV bundle – 40 to 60 bpm
● Fuse with the AV node to form
another pacemaker
● It is divided into left bundle branch
and right bundle branch
4. Purkinje fibers – Inherent the rate of 30 to
40 bpm or less
● Not activated as a pacemaker unless
conduction through the bundle of His
becomes blocked, or in a higher
node such as SA or AV nodes
Pulse Pressure – Difference between systolic
and diastolic pressure, 30 to 40 mm Hg
Mean Arterial Pressure – Average pressure
maintained in the aorta, 70 to 110 mm Hg
Peripheral Resistance – A resistance of all
peripheral vasculature in the systemic circulation
Pulse pressure reflects the stroke volume,
ejection velocity, and systemic vascular
resistance. It indicates how well the patient can
maintain cardiac output. Increase in pulse
pressure increases stroke volume. It also
increases peripheral volume, increases in
vascular resistance, and reduces the sensitivity of
arteries due to high pressure in the aorta.
Examples include light exercise, fever, anxiety,
atherosclerosis. Decrease in pulse pressure
reflects decrease in stroke volume. It means
there is a decrease in the left ventricular volume
and insufficient preloading. It also means
decrease in cardiac output. Examples include
hypovolemia, blood loss, heart failure, or shock.

Mean arterial pressure is the pressure at which

the blood moves for the cells to receive adequate
oxygen and nutrients needed to metabolize
energy in an amount sufficient to sustain life.
Decrease in mean arterial pressure indicates
decrease in blood flow which leads to decrease
perfusion to the vital organs. Increase in mean
arterial pressure increases cardiac flow.
Peripheral resistance is the resistance of
peripheral vasculature in the systemic circulation.
Blocked vessels and vasoconstriction can
increase peripheral resistance. Vasodilation can
decrease in peripheral resistance

VENOUS PRESSURE

Blood flows back to the heart via venous system

with assistance from vessel wall tone, pumping
action of the skeletal muscle

Central venous pressure – Approximation of

right atrial pressure; normal: 5 to 10 cm H2O

Brunner – 4 to 12 mm Hg

CAPILLARY PRESSURE

Capillary pressure is the pressure exerted by the CHANGES IN RESPONSE TO

blood against the capillary. The balance of the
interstitial fluid depends on the capillary pressure
and plasma oncotic pressure
25 to 30 mm Hg at arterial
PARASYMPATHETIC AND SYMPATHETIC
NERVOUS SYSTEM
Baroreceptor – Sends impulses to the medulla
oblongata to stimulate either vagal response

10 to 15 mm Hg at venous ● Reports abnormal blood pressure to the

REGULATION OF CARDIAC FUNCTION AND
BLOOD PRESSURE
1. Neural or ANS
A. PNS – Inhibitory effects
B. SNS – Acceleratory effects
2. Endocrine control – Hormones contribute to
regulation of the circulation of the heart
3. Local control or peripheral receptors – pH, O2
and CO2 concentration
Parasympathetic nervous system releases neural
transmitter acetylcholine that can decrease the
rate of SA node firing or decrease in heart rate, or
even decrease in atrial or ventricular contractility
and conductivity
Sympathetic nervous system releases neural
transmitter norepinephrine, producing
acceleratory effects on the heart, such as
increase heart rate, increase conduction speed,
or even increase in atrial or ventricular
contractility and peripheral vasodilation
CNS, which responds by regulating the
rate
Stretch receptors – Sends impulses to the CNS
to stimulate HR and blood vessel constriction to
regulate circulatory volume status that affect BP
Chemoreceptor – Sensitive to hypoxemia and 2°
to ↑ CO2 and ↓ arterial pH
Baroreceptor is sometimes called a
pressoreceptor. It is located in the wall of the
aortic arch and carotid sinus. It is a sensory nerve
in the blood vessels that reports abnormal blood
pressure to the CNS
Stretch receptors respond to pressure changes
that affect circulating blood volume
Chemoreceptor senses chemical changes in the
blood. Usually, chemical changes in blood
including pH, carbon dioxide, and oxygen level
alters the cardiac and respiratory activity

A. Chief Complaint
Categories of mechanism in the circulation in
addition to neural include:
Autocrine Control. Several hormones contribute
to the regulation of the heart circulation.
Catecholamine are released in response to
physical activity and stress, which influences
heart rate, myocardial contractility, and peripheral
vascular resistance. Other hormones include
angiotensin, adrenocortical hormones,
vasopressin, bradykinin, and prostaglandin.
Local Control. Meets all the metabolic needs of
the surrounding cells
HEALTH ASSESSMENT
SUBJECTIVE DATA
1. Chest pain or discomfort – SOCRATES
Angina pectoris – 5 to 15 min;
uncomfortable pressure, squeezing or
fullness in substernal chest area
Acute coronary syndrome, or ACS – >
15 min
Pulmonary disorders – Sharp, severe
epigastric pain or substernal arising from
inferior portion of pleura
● Location – Substernal or cordial
● Characteristics – Pressure, burning,
crushing
● Intensity – Mild, moderate, or severe
● Onset – Sudden or gradual
● Duration – Intermittent or continuous
● Precipitating factors – Emotion
2. Palpitations – Rapid or irregular
heartbeat
3. Dyspnea – EOD, PND, orthopnea
such as ACS, cardiogenic shock, HF
and valvular heart disease
4. Cough – Dry, paroxysmal with
exertion
5. Unusual fatigue – Inability to perform
activities of daily living
6. Peripheral edema – Grading scale
7. Syncope – Medical term for fainting
or passing out, loss of
consciousness, because of decrease
 blood flow to the brain, usually from
low blood pressure
8. Weight gain
9. Hepatosplenomegaly, or HF –
Common in patients with right-sided
heart failure
10. Dizziness
11. Postural hypotension
B. Patient History
1. Past medical history
2. Medications history – Vitamins, herbal,
and other OTC medications
3. Family history
4. Diet and nutrition – Height and weight,
food preferences and preparation
5. Elimination – Bowel and bladder habits
Nocturia – Very common in patients with heart
failure because of the increase in circulatory
volume during nighttime
Valsalva maneuver – Breathing method when
the heart is beating too fast
6. Socio-cultural – Education level,
occupation, sleep pattern, exercise,
tobacco use, economic resources
Sleeping pattern – Recent changes such as
upright position is common in patients with heart
failure
7. Psychological – Self-perception and
self-concept, coping and stress
strategies, prevention strategies;
depression, behavioral changes
OBJECTIVE DATA
5. Pulse – PR, rhythm, quality,
configuration or contour, bruits, and
palpation of arterial pulse
Precordium
1. Inspection – Apical pulse, retraction
in 5th ICS MCL
Apical Pulse – Can indicate pericardial disease
2. Palpation – Thrills
Thrills – Palpable vibration over the precordium.
It can indicate aortic stenosis or pulmonic
stenosis
3. Auscultation – Murmurs, abnormal
heart sounds
4. Jugular veins – 1 to 3 cm above the
level of manubrium
5. Blood pressure - SBP, DBP,
pulse pressure
Patients might have postural hypotension in
which there is a systolic increase of at least 20
mm Hg within 3 minutes of moving from lying,
sitting, or standing, accompanied by dizziness
and lightheadedness due to reduced preloading
which compromises the cardiac output
There is a risk for coronary artery disease if
abdominal fats are greater than 40 inches for
male and 35 inches for female
JUGULAR VEIN

Head to toe physical exam – IPPA techniques

A. General Appearance
1. LOC, mental status, and the size,
height and weight, and BMI –
Normal, over-, or underweight,
cachectic
Cachexia – Weakness due to severe chronic
illness
2. Skin – Color, ecchymosis, turgor,
temperature, moisture – Pallor,
peripheral and central cyanosis
3. Nail – Color, shape, thickness,
symmetry, clubbing of fingers
Clubbing – Due to prolonged lack of oxygen,
which can activate local vasodilators that secrete
growth factors that causes changes in the distal
part of the fingers
4. Extremities – Edema, ulcerations,
capillary refill time

B. Diagnostic Studies
Laboratory Tests
A. Serum Enzymes
1. Creatinine Kinase, or CK – CK-MB
● Found in the heart
● Rise within 6 hours of injury
● Peak at 18 hours post injury
● Returns to normal in 2 to 3 days.
● Normal CK – 36 to 188 u/L.
● Normal CK-MB – < 25 u/L
Creatine kinase is formerly known as creatine
phosphokinase. The three isoenzymes are CK-
MM, CK-MB, and CK-BB. Elevated CK-MB might
indicate myocardial infarction. Avoid IM injection
prior to extraction
2. Lactate Dehydrogenase, or LDH – L1 and
L2
● Useful in diagnosis of MI
● Detected within 24 to 72 hours
● Peaks within 3 to 4 days
● Elevated 14 to 24 hours after onset of MI
● LDH – 90 to 176 units/L
● Returns to normal after 2 weeks
3. Aspartate Transaminase
● Serum Glutamic Oxaloacetic
Transaminase, or SGOT
● Heart failure can lead to generalized
swelling of the body that causes elevated
AST, which can result to liver damage or
an insult to the heart
● 10 to 40 u/L
4. Myoglobin
➔ Oxygen-binding protein found in striated
muscle
➔ Skeletal muscle injuries releases
myoglobin
➔ Increase within 2 hours after AMI
➔ Returns to normal about 12 hours
➔ 30 to 90 mcg/L
➔ Not specific in diagnosing MI but can help
in diagnosing the oxygen-carrying
capacity to the muscle tissue
➔ Hemoglobin transforms oxygen.
Myoglobin stores oxygen. Oxygen is the
carrying pigment of the muscle tissue
5. Troponin
➔ Normal cardiac troponin level is very low.
The level increases rapidly with
myocardial infarction
➔ Released only when myocardial
necrosis occurs
➔ Preferred marker for myocardial injury.
Physicians might suspect myocardial
injury or ischemia in an elevated troponin
➔ There are two levels. Troponin T might
indicate myocardial ischemia. Troponin I
are for patients with unstable angina
➔ Increase within 3 to 12 hours from the
onset of chest pain
➔ Peak at 24 to 48 hours
➔ Returns to baseline at 5 to 14 days
➔ Troponin level increase earlier than
CK-MB level
➔ Normal Troponin T – < 0.2 mcg/L
➔ Normal Troponin I – < 0.35 mcg/L
6. C-reactive Protein, or CRP
➔ CRP is produced by the liver. It increases
in response to tissue inflammation or
injury
➔ Marker for systemic inflammation
➔ Identifies myocardial injury
➔ Better predictor for MI than cholesterol
 ➔ < 1 mg/dL
7. Lipid Profile
➔ Cholesterol – < 200 mg/dL
Required for hormone synthesis and
cell membrane formation, found in
large quantities of the brain and
nerve tissue.
➔ Triglycerides – 100 to 200 mg/dL
Free fatty acids and glycerol. Stored in adipose
tissue and it is a source of energy
Physical activities are needed to decrease
triglycerides if it gets too high
Lipoproteins
a. Low Density Lipoprotein, or LDL – < 160
mg/dL
Primary transporters of cholesterol and
triglycerides into the cell
Harmful effect:
Deposition of these substances in the walls of
arterial vessels, causes coronary artery disease
B. High Density Lipoprotein, or HDL
M – 35 to 70 mg/dL
F – 35 to 85 mg/dL
Transport of cholesterol to the peripheral can
result to coronary artery disease
Triglycerides – Stored calories that provides the
body with energy
HDL – Has a protective action in which it
transports cholesterol away from the tissue and
cells of the arterial wall to the liver for excretion
8. Coagulation studies
● Coagulation studies are performed before
invasive procedures
Prothrombin time – 10 to 14 seconds
● Prothrombin time evaluates the extrinsic
coagulation system and screens coagulation
deficiency factors 1, 2, 5, 7, 10
● Monitor patients who take anticoagulants and
screen patients with Vitamin K deficiency
● Measure the time to form a clot
If < 10 seconds – Patient is at risk for
thrombus formation
If > 30 seconds – Patient is critical and at
risk for bleeding
Activated Partial Thromboplastin Time, or
aPTT – 20 to 39 seconds
● Evaluates intrinsic coagulation system
● Identifies bleeding and clotting disorders
● Monitors the effect of heparin
● Measures the seconds needed for a clot
to form. If there is prolonged PTT, then it
will take longer for a clot to form and
thrombus may not occur or develop
9 Brain Natriuretic Peptide, or BNP – < 100
ng/L
● BNP is a neurohormone that helps regulate
blood pressure and fluid volume
● It is secreted from the ventricles to increase
preload which can result in an increase in
ventricular pressure. If there is an increase in
BNP, there is also an increase in ventricular
wall pressure. This is significant to patients
with heart failure, acute MI, and hypovolemic
state like renal failure
● Used to diagnose heart failure, MI, and
pulmonary embolism
● Decrease in BNP decreases sodium
retention and decreases renin angiotensin
secretion
10. Homocysteine – Indicates high risk for CAD,
stroke, and peripheral vascular disease. Normal:
5 – 15 umol/L
● Homocysteine is an amino acid that links to
the development of atherosclerosis
● Patients might indicate high risks for coronary
artery disease, stroke, and peripheral
vascular disease. This is to determine
patients at risk for cardiovascular diseases
● Increase in homocysteine indicates a risk for
coronary artery disease due to genetic factor
and vitamins B6, B12, and folate deficiencies
● Vitamins B6, B12, and folate supplements
can lower homocysteine
11. Atrial Natriuretic Peptide, or ANP –
Controls body water, Na, and K release by the
atria in response to blood volume
● Regulates excess cellular volume. It reduces
water and sodium in the circulatory system to
reduce blood pressure
● Counteracts secretion of aldosterone
● Patients with heart failure have high ANP
because of hypervolemic state
12. Electrolytes
A. Sodium – Diuretic therapy; 135 to 145
mEq/L
Low or high sodium do not necessarily affect
cardiac function.
Decreased sodium may indicate fluid
excess, heart failure and administration of
diuretics. Increased sodium may indicate
 fluid deficit, diarrhea, diaphoresis, loss of ● Necessary for absorption of calcium,
water. maintenance of potassium and metabolism
of ATP
Prolong use of diuretics may put pxs at risk ● Necessary factor for the conservation of
for Hyponatremia. potassium in the kidney
● Major roles include: Protein and
B. Potassium Carbohydrate synthesis, Muscular
● 3.5 to 5.5 mEq/L Contraction and Neuromuscular Activity
● Affects heart muscle ● Neuromuscular activity causes decrease in
● Ventricular dysrhythmias calcium and potassium
● Presence of U wave in the ECG tracing ● Mg is a factor for the conservation of
● Hypokalemia - may be caused by potassium in the kidney
administration of potassium excreting - ⬇ Mg could cause irregular
diuretic which may lead to heart rhythm, atrial or
dysrhythmia, ventricular tachycardia / ventricular tachycardia or v.
ventricular fibrillation. If the client is taking arrhythmia
digitalis, then hypokalemia may put client at - ⬆ Mg could depress myocardial
risk for digitalis toxicity. Presence excitability and contractility
of U wave is visible in ECG tracing. that will cause heart block,
● Hyperkalemia - may be caused by or worse, acistole as well as
increased intake of potassium, decreased hypotension and bradycardia
renal excretion of potassium, use of
● NORMAL VALUE: 1.8 to 3 mg/dl
potassium sparing diuretics eg. Aldactone.
Other Laboratory Tests:
Hyperkalemia may result in heart block,
acistole, ventricular dysrhythmia. Digitalis Basal Metabolic Panel > determine glucose
toxicity increases electrical instability. level in the blood;

NORMAL FASTING: 10 - 12 hours

Creatinine and BUN > assesses kidney

function and fluid balance .

CREATININE NORMAL VALUE: 0.7 to 1 mg/dl

BUN NORMAL VALUE: 10 to 20mg/dl
C. Calcium – 8.5 to 10.5 mg/dL Bicarbonate & Chloride
● Hypocalcemia – Dysrhythmia and prolong QT
interval 14. Complete Blood Count, or CBC
● Will slow nodal function and impair ● RBC – Hemoglobin and hematocrit
myocardial contractility which increases ● WBC
the risk for Heart Failure. ● Platelets
● Hypercalcemia – Could result from
administration of thiazide diuretics which Hemodynamics – Circulation
reduces renal excretion of calcium. ● Invasive procedure to closely monitor left
Shortens QT interval which results to ventricular pressure and cardiac output by
AV block/heart block. the use of Arterial Line and Pulmonary Artery
● Both Hyper/Hypocalcemia could result to Catheter
cardiac arrest ● Studies the movement and forces of blood in
D. Magnesium - 1.8 - 3 mg/dl the cardiovascular system
● Decreased Mg could cause irregular heart ● To test the effectiveness of cardiac
rhythm, atrial/ventricular tachycardia, or function
ventricular arrhythmia ● Used to patients in ICU
● Increased Mg could depress myocardial ● Close examination of cardiac function in
excitability and contractility that will cause acutely ill patients
heart block, or worse, asystole as well as ● Rapid identification of completions after
hypotensionand bradycardia MI
 ● Differentiates pulmonary disease from
left ventricular failure
● Guide in the management of low CO
Methods that can be used to obtain
Hemodynamics
➔ Obtaining the Heart Rate - Use of
Dinamap or Doppler (Non invasive)
➔ Arterial Line, Swan-Ganz and
Pulmonary Artery Catheter (Invasive for
Patients in ICU)
HEMODYNAMIC PARAMETERS
1. Central venous pressure, or CVP –
Measures the blood volume and venous
return;
Indicates mean right atrial pressure; 5 to
10 cm H2O or 4 to 12 mm Hg
2. Systemic intra-arterial pressure –
Allows continuous monitoring of systolic
and diastolic blood pressure and mean
arterial pressure, or MAP
MAP
Systolic BP + (2 Diastolic BP)
3
Normal - 70 to 110 mm Hg
Pulmonary Artery Pressure, or PAP and
Pulmonary Capillary Wedge Pressure, or
PCWP
Swan-Ganz catheter – A catheter is passed
through the right side of the heart and into the
pulmonary artery
● Assesses the right and left
pumping action of the heart
● Could quantify cardiac output
● Calculation of oxygen level
between the arterial and venous
● Used to prevent overhydration
and pulmonary edema during
open heart surgery
● Helps to improve conditions such
as:
- Cardiac tamponade
- Myocardial infarction
- Cardiogenic shock
- Pulmonary Hypertension
- Restrictive cardiomyopathy
SWAN-GATZ CATHETERIZATION
PAP – Assess the left heart pressure, left
ventricle
PCWP – Indirectly measure left atrium
SWAN-GANZ MONITOR
Heart function – Right and left pumping action of
the heart
Blood flow – Quantitative measurement of
cardiac output
Calculation of O2 level – Between arterial and
venous
Radiographic Techniques
1. Chest X-ray, or CXR
● To assess contour, size and position of
the heart
● Reveals any cardiac and pericardial
calcification
● Demonstrate physiology alteration in
pulmonary circulation
2. Cardiac Catheterization – An invasive
procedure used to obtain details information
about structure and performance of the heart,
valves and circulatory system
● Visualize structure and performance of
the heart chambers, valves, great
vessels and coronary arteries and
circulation
● Assesses the coronary artery patency,
extent of atherosclerosis
● To determine the benefits of
percutaneous coronary intervention
● Standard test for CAD
 ● Can be diagnostic and therapeutic 7. Determine the efficacy of a heart
intervention transplant
● Includes electrophysiologic studies,
For Evaluation of:
hemodynamic monitoring
● For percutaneous transluminal ● Any Coronary Heart Diseases with
angioplasty Unstable Angina that does not respond to
● Palliative procedure for congenital heart treatment of medications
defect ● The end of coronary artery surgery or
● Could diagnose pulmonary arterial Angioplasty
hypertension
To Diagnose:
Right – Myocardial biopsy and measure PAP
● Atypical chest pain
● More safe ● Complications for MI
● Inserted through basilica or femoral vein ● Aortic Dissection
● Potential complications may include:
- Dysrhythmia or arrhythmia To Assess for valvular function
- Venous spasm
To Determine the efficacy of heart transplant
- Infection
- Perspiration PREPARATION FOR CARDIAC
CATHETERIZATION
Left – Visualize coronary arteries and ventricular
function 1. Written consent
2. History taking – Allergies to shellfish
● Used to evaluate aortic arc and major
3. Laboratory results
branches
4. Baseline vital signs
● Monitor mitral and aortic valve function
5. NPO AMN
and shunting
6. Explain to patient the flushing sensation
● Inserted through brachial and femoral
during procedure
artery
7. Voiding; no jewelries and dentures
8. Pre-op medications – Antihistamine,
corticosteroids
9. Withheld Metformin 48 hours prior to
procedure
10. Shaving the operative site
11. Health teaching

POST PROCEDURE CARE FOR CARDIAC

CATHERTERIZATION

1. CBR - First 24 hours in hospital setting,

INDICATIONS OF CARDIAC
CATHETERIZATION
1. Evaluate CAD with unstable angina
2. Diagnose atypical chest pain
3. Diagnose complications for MI
4. Diagnose aortic dissection
5. Assess for valvular function
6. Evaluate the end for coronary artery
surgery or angioplasty
theoretically 6 to 12 hours
2. Monitor vital signs - Without hypertension,
hypotension, and bleeding which causes
elevated pulse rate
3. Immobilize the affected extremities
4. Elevate HOB at 30° angle
5. Check for the pressure dressing - Use 6 lbs
sandbag to prevent bleeding
6. Refer chest pain, bleeding, dysrhythmias,
hematoma formation, and any untoward
signs and symptoms
● Manual pressure that is applied
during the removal of catheter may
cause vagal stimulation could result
 to bradycardia, hypotension, nausea - Patient is in supine position
and distended bladder with arm raised above the
● To reverse this effect, elevate the head while the camera move
lower extremities of the px higher around the patient chest in
than the heart, administer bolus of 180 to
intravenous fluid and atropine to treat - 360 degree to precisely
bradycardia identify areas of decreased
7. Hydration - Encourage increase fluid intake Myocardial perfusion.
for the excretion of contrast dye if it is not ● Positron Emission Tomography, or
contraindicated to the condition of the patient PET – Determine the blood flow in
the myocardium and metabolic
CONTINUATION OF RADIOGRAPHIC
function such as cardiac and tissue
TECHNIQUES
perfusion
3. Coronary Angiography – Technique of
- safer and faster than SPECT
injecting a contrast agent into the
due to lower exposure to
vascular system to outline the heart and
radiation
blood vessels
- Evaluate tissue and organ
● Visualizes coronary arteries
functions by identifying body
● Technique of injecting contrast agent
changes at the cellular level
into the vascular system to outline
which make a disease
the heart and blood vessels
evident prior to other
4. Radionuclide Testing – Uses
imaging tests.
radioisotopes to evaluate coronary artery
- Eg. Ischemia tissue,
perfusion
decreased blood flow and
● To evaluate coronary artery
increase metabolism
perfusion, left ventricular functions
using radioisotopes NURSING RESPONSIBILITIES
● Assess Myocardial Ischemia and
1. Assess patient for fear of closed spaces or
Myocardial Infarction
claustrophobia
Types of radionuclide testing:
2. Refrain from alcohol or caffeine 24 hours
● Thallium 201 - TI201; exercise
prior to PET
- Must be tested positive
3. ALARA Principle; explain that radiation
before undergoing Cardiac
exposure is safe and in acceptable levels
Catheterization
4. Monitor glucose level, or PET before the test
- Stress testing, to determine
5. IV access – Patent
Myocardial perfusion
6. Scan takes 1 to 3 hours to complete
immediately after exercise
and at rest GRAPHIC STUDIES
- Areas that doesn't show
current update may indicate 1. Echocardiography
Myocardial Ischemia or MI ● Evaluate internal structure and
● Technetium 99m – Tc99m; motions of the heart and great
sestamibi vessels; may be performed with an
- uses various chemical exercise and pharmacologic stress
compounds that gives test
affinity to different types of ● Doppler techniques are also used to
cell determine the direction of blood flow
- Can be taken during resting and velocity
period, before and after an
● may be performed with an exercise
exercise
and pharmacologic stress test
● Single Photon Emission Computed
Tomography, or SPECT ● Monitors overall cardiac
- provides 3D images of the performance including the
heart
 chambers, size, motion and cardiac
great vessels
● As well as the intraventricular
septum, posterior left ventricular wall,
valve motion, the directions and
velocity of blood flow to determine
any leaking valve
Persantine Scan
● Monitor if there's an increased
pericardial fluid.
● Modes:
Motion Modes
- shows 1D view of the heart
- Shows an image of a narrow area
within the ultrasonic beam
2D Echo
- produces a cross sectional view
- Shows structure, lateral movement
and spatial relationship between the
heart structure
- Doppler technique - to determine
direction of blood flow and velocity
- May be performed with an
exercise and pharmacologic
stress test
Doppler Ultrasonography – Records the
direction of blood flow through the heart; detects
presence, direction, speed and character of
arterial or venous blood flow within the vascular
lumen; could be done in Carotid Area
Color Flow Doppler, or CFD – Records flow
frequencies into different colors
2. Stress Test
● Increases the demand placed on the
heart by increasing physical activity
and determines whether the heart is
able to meet the increased oxygen
demand
● Dipyridamole scan, or Persantine
● Determines whether the heart is able
to meet increased oxygen demand
after physical activity
● If the patient cannot exercise,
Dipyridamole/Adenosine (shorter
duration span) can be administrated for
vasodilation that has the same response
after a physical activity
● This scan will allow increased heart rate
to the point of 85% of the maximum heart
heart rate
● Eg. If the heart rate is 80 x 85% = 68 + 80
= 148 beats per minute, the final answer
should not exceed beyond 148 beats per
minute
● This scan is contraindicated with patients
that has:
- Hypertension
- Aortic stenosis
- Coronary Artery Disease
- Heart Failure
- Unstable Angina
3. Duplex Scan – Arterial and venous
● Visualize the flow or movement of a
structure, typically used to image
blood within an artery
● Determine the flow velocities through
a region of narrowing or resistance of
a vein or artery
● Is combined with doppler flow
information
4. Electrophysiologic Studies
● Evaluate the electrical conduction
system of the heart
● Assess the effectiveness of anti-
arrhythmic medications and devices
● Treat certain dysrhythmias through
the destruction of the causative cells
● Identify the location and mechanism
● Assess function of SA and AV node
● To distinguish atrial from ventricular
tachycardia
● To treat dysrhythmias by destruction
of causative cells
● For patients who often experiences
syncope, palpitations, dysrhythmia
Assesses:
 ● Efficiency of Anti arrhythmic
medications
● Function of Nodes (SA,AV,BoH,PF)
● The needs to alternate interventions
like pacemaker, radiofrequency
ablation, implantable cardioverter
defibrillator
5. Transesophageal Echocardiography, or
TEE
● Gives higher quality picture of the heart
and useful in clients who have thickened
lung tissue or thick chest walls or who are
obese
● Provides higher quality image of the
heart because the sound wave does not
need to pass through skin, muscle, or
bone tissue.
● Appropriate for patients who are obese,
has pulmonary disease and
emphysema.
● Certain conditions of the heart that
could also be viewed under
TransEsophageal Echo:
a. Mitral valve disorder
b. Blood clots
c. Muscles inside the heart
d. Dissections of the lining of the aorta
e. Implanted prosthetic heart valve
Indications:
Assess heart function and structure
Evaluate the heart after heart surgery
procedure such as coronary artery
bypass / valve replacement.
Evaluates cardiac status of px with
known heart disease during cardiac surgery.
TEE NURSING RESPONSIBILITIES Pre-op
1. Obtain consent
2. Restrict foods and fluids - NPO for 6-8 prior
to procedure
3. IV access - No jewelry, Void before the
procedure, no dentures
4. Vital signs -
5. Lab result
6. Emotional support
POST-OP
1. Monitor vital signs
2. Position client at 45°
3. Monitor for dyspnea, LOC
4. Check for gag reflex - O2 saturation and
shortness of breath
5. Inform of sore throat and dysphagia for the
next 24 hours
6. Cool liquids - would soothe sore throat
7. Avoid talking
6. CT Scan – Determines cardiac masses
and diseases of the aorta and
pericardium
7. Magnetic Resonance Angiography –
Evaluates physiologic and anatomic
properties of the heart
- more higher technology than the
CT Scan
8. Electrocardiogram – ECG, EKG
● Records the heart’s electrical activity
by detecting magnitude and direction
of electrical currents produced in the
heart
HOLTER MONITORING - >24 hrs monitoring of
the heart activity
 ABNORMALITIES

1. Inverted P-wave
2. Wide P-wave – P mitrale
3. Peaked P-wave – P pulmonale
4. Saw-tooth appearance – Atrial flutter
5. Absent normal P wave – Atrial fibrillation

NORMAL P-R INTERVAL

• The time the impulse from the atria to the AV

node, the His-Purkinje system and through
the ventricles
• PR interval time 0.12 seconds to 0.20
seconds
➢ 0.20 sec – Delay in conduction from
SA node to the ventricle
• Three small squares to five small squares

PR ABNORMALITIES
ECG TRACING
1. Short PR interval – WPW syndrome
2. Long PR interval – First degree heart block

QRS COMPLEX

• Electrical depolarization and contraction of

the ventricles
• QRS duration 0.04 0.12 seconds
• Less than almost three small squares
• Morphology: progression from Short R and
deep S (rS)

QRS ABNORMALITIES

• Wide QRS Complex

• Tall R in V1
• Abnormal Q Wave – > 25% of R wave

ST SEGMENT

• The period between completion of

depolarization and the beginning of
repolarization of the ventricles
• Beginning of the ventricular repolarization
• Elevated or depressed indicates cardiac
ischemia
• ST elevation indicates myocardial injury; ST
depression changes in the ventricular wall
ECG WAVEFORM COMPONENTS

P WAVE
❏ Electrical activity associated with SA node
impulse and depolarization of the aorta
❏ Atrial depolarization and contraction
❏ Impulse is from the SA node
❏ In all leads except aVR

● Pharmacologic / Chemical Cardioversion -
T WAVE
• Recovery or repolarization phase of the
ventricles
• Ventricular Repolarization
• Abnormal T wave indicates: myocardial
ischemia or injury or electrolyte imbalances
SUMMARY OF ECG TIMING
Seconds
P 0.06 – 0.12
QRS 0.04 – 0.12
ST Segment 0.12
T 0.16
PR Interval 0.12 – 0.20
QT Interval 0.32 – 0.40
ADJUNCTIVE MODALITIES – Countershock
1. Cardioversion – Treats tachydysrhythmias
by delivering an electrical current that
depolarizes a critical mass of myocardial cells
● Synchronized – Low energy
➔ Use of electricity synchronized with
the peak of QR
➔ Option: Engage in Defibrillator
➔ Timing of electrical delivery should
be synchronized
➔ Used in patients with ventricular
tachycardia, atrial flutter and atrial
fibrillation
➔ Use of therapeutic dose of electrical
current to the heart using a rod at the
specific unit in the cardiac cycle
● Unsynchronized cardioversion - done in non-
emergency basis
➔ Patient is conscious and
hemodynamically stable
uses anti arrhythmic medications instead of
electrical shock
➔ If the cardioversion is elective,
not lasts not longer than 48 hrs
anticoagulation for few weeks
before cardioversion
➔ Digoxin is withheld for 48 hrs
prior to cardioversion > to assure
resumption of sinus rhythm and
conduction
● Non-emergency basis
● Patient is sedated with either IV
diazepam or midazolam prior to the
procedure.
2. Defibrillation – Unsynchronized
● High energy shock
● Fall randomly anywhere within the
cardiac cycle – QRS complex
● 200 to 360 J
● AED
● Emergency procedure - px is
unconscious
● Delivers high energy shock randomly
within the cardiac cycle (QRS complex)
● Discharge of unsynchronized impulse
● Most effective method in treating
ventricular fibrillation, dysrhythmia,
ventricular tachycardia
● Initial Shock: 200 joules
● Secondary Shock: 200 - 300 joules
● Third Shock: 360 joules
Defibrillator is the device both used in
cardioversion and defibrillation
ECG monitor is both needed in
cardioversion and defibrillation.
NURSING CONSIDERATIONS IMPLANTED CARDIOVERTER-
DEFIBRILLATOR, OR ICD
1. Withheld digoxin 48 hours before
cardioversion • Similar with a pacemaker; implanted inside
2. NPO at least 4 hours before the procedure the body
3. Defibrillation: Epinephrine is given after initial • Delivers low level and high level of electrical
unsuccessful defibrillation impulses
4. Anti-arrhythmia: • Prophylaxis for patient who are at risk to have
➔ Amiodarone sudden cardiac death, ventricular fibrillation
➔ lidocaine
FUNCTIONS OF ICD
➔ magnesium
if ventricular dysrhythmia persists 1. To reset abnormal heart beat
5. Continuous CPR 2. Send high energy shock if an arrhythmia
➔ Two safety measure for the placement of become severe
Defibrillator paddle on the patient: 3. Treatment of certain fast rhythm
➔ Maintain good contact between the paddle 4. Detect sudden cardiac arrest or shock
and the skin of the patient
➔ No one should be in contact with the patient LINK OR CHAIN OF SURVIVAL
when the shock is being discharged

KEY POINTS TO REMEMBER WHEN ● Early access Early CPR

ASSISTING EXTERNAL DEFIBRILLATION ● Early defibrillation
● Integrated cardiac life support
1. Conducting medium – Gel – is used – DO ● Integrated post cardiac care
NOT use gel or paste with poor electrical
conductivity like UTZ gel
2. Paddles are placed on the chest wall –
One in the left of the pericardium and the
other on the right of the sternum just below
the clavicle
3. Apply 20 to 25 pounds of pressure to the
paddles
4. The operator calls ALL CLEAR

Adjunctive therapy and RFA will be discussed in

cardiac dysrhythmias