CARDIO

NURSING CARE OF CLIENTS WITH CARDIAC DISORDER

1. HEART FAILURE: Heart can’t do its function w/c is to pump blood.

- Pump failure (ventricle)
A. TERMS
o Stroke volume: amount of blood pumped/beat (e.g. 5ml)
o Heart rate: number of beats/min (e.g. 70bpm)
o Cardiac output: amount of blood pumped per min (e.g 350ml)
 SV X HR=CO
o FACTORS

PRELOAD
-Degree of ventricular stretch
- gaano na stretch yung
Heart
- determine by blood return
-inc Preload> inc force of
contraction > inc work load >
inc O2 demand
AFTERLOAD
-Degree of resistance to blood
ejection
Resistance determines by blood
vessel diameter/size
-inc AL>inc WL>INC o2 demand

B. CARDIAC HEMODYNAMIC (movement of blood inside the heart)

o Artery: Away
o Vein: towards (Valik)

o VENA CAVA: Largest vein in the body

Return blood to the heart
Blood that goes to Vena cava comes from the systemic circulation.
o LVF (all symptoms are pulmonary)
o RVF (all symptoms are systemic
C. TYPES
o RIGHT VENTICULAR FAILURE
 S/SX: Distended neck vein
Generalized edema (Anasarca)
 Liver; Hepatomegaly
 Spleen : Splenomegaly
 Nocturnal Diuresis (Increase urine output at night)
 Weight gain
o LEFT VENTICULAR FAILURE
 S/SX: Use of respiratory muscle
Pulmonary edema
 Crackles
 Dry hacking cough
 DOB
 Pink-tinge frothy sputum (Indicator of Pulmonary Edama)
 Paroxysmal Nocturnal Dyspnea
 Weight loss

D. DIAGNOSIS
o Cardiac Catheterizaton (Swan-ganz): Catheter is being inserted to the heart to measure the two-pressure w/c is:
 PCWP (Pulmonary Capillary Wedge Pressure)
 Reflects the pressure on the left side of the heart
 Catheter is inserted to the femoral vein and there is a balloon inflated the balloon will go to the
flow of the blood to the lungs until it will stuck sa isang ugat termed as “wedge”. Once it is
stuck at stopped it will start to measure the pressure.
 NORMAL: 4.5-13mmHg
 RESULT: Increased/elevated PCWP

o CVP (Central Venous pressure); Vein in the middle of the body w/c is the vena cava.
 If increased there is an increased CVP
 Catheter is being inserted from femoral vein up until the vena cava
 NORMAL; 0-8 mmHg
 RESULT: Increased/elevated CVP

 NURSING CONSIDERATION
 Insertion site (Femoral Vein)
 WOF: Pulmonary embolism – this occur because once the catheter removed the cut will form
clot to stop the bleeding and when the clot removed it can go the heart to the lungs that resulted
to Pulmonary embolism.

o Manual (Water Manometer) : Measures CVP only.

 Check the level of the IV fluids in the Cylinder. If where it fluctuates that is your CVP.
 NORMAL: 3-8 crH2O
 LANDMARK: Phlebostatic axis: level of RV (level of cylinder should be equal the level of
Right ventricle. It will be found in:
o 5th Intercostal space
o Mid Axillary line
E. MANAGEMENT
o Diet
 Low Na (processed, instant, canned)
 High K (eat: fruits and vegetables)
 Fluid restriction
o Diuretics
 Mode of action: increase Urine output > decrease Blood volume > decrease Edema
 Example:
 Loop Diuretics (Furosemide)
  Thiazide Diuretics (Indapamide)
 Major Considerations: Functional Kidney

o Digoxin/Digitalis/Cardiac Glycosides (Drug of choice for heart failure)

 Mode of Action:
 Positive effect: + inotropic effect (force of contraction) pampalakas ng contraction of heart to
restore cardiac output (decreases pulmonary edema)
 Negative effect: - chronotropic effect (heart rate): slows heart rate (bradycardia)

 Nursing Consideration
 Check Apical Pulse ( it is the most accurate pulse) Prior giving the meds
o Differ/ do not give if Hr is < or equal 60bpm
 Check for digoxin toxicity.
o Visual disturbances (green halos around light)
o Nausea and vomiting
o Anorexia
o Possible cause of digoxin toxicity
 Overdosage: measure blood level of digoxin ( Normal range: 0.5-2mg/dl or .6-
2mg/dl)
 Hypokalemia: Normal K level is 3.5-5mg/L
 ANTIDOTE: Digibind

2. DYSRHYTHMIA: abnormal rate (fast or slow) and rhythm (irregular)

A. PACEMAKERS: Has Automaticity (they can generate their own electricity), Conductivity (transmit electricity) and
Excitability (respond to electricity)
o SA Node: 60-100x/min
o AV node: <60/min, delays electricity
o Purkinje Fiber: <40/min

o Electricity=” contract”
 B. Physiology of contraction
- Cell > Tissue > organ > system > organism

o PISO ( Potassium inside, Sodium outside)

o Diffusion: movement of electrolytes from higher concentration to lower concentration ( Na wants to go in K wants
to go out.
 Charge inside the cell should be negative

 Once SA fired the cell will open. Once it will open Sa and Ca will go inside and K go outside.Na and Ca
makes the inside of the cell + charge. Since inside is already positive it will depolarized or contract to
release Na and Ca and K will go back inside but since K is from outside it become positive and to make the
inside of the cell to become negative again it will relax ( need mailabas ulit n g k kasi ito yung mas marami)
C. ECG
o Purpose: reflects the electrical activity of the heart and location of abnormality
o Placement: 4 and 5th intercostal space only
 RSB ( right sternal boarder), LSB ( left sternal boarder)
 V1 is located in RSB
 V2 is located in LSB
 Before putting V3 put V4 first.
 V4 should put in 5th intercostal space mid clavicular line.
 V3 is located diagonally between V2 and V4
 V5 5th ICS anterior mid axillary line
 V6 5th ICS Mid axillary line
o Interpretation: Normal sinus rhythm
 Size of small box is 1mm = 0.04sec
 Size of big box is 5mm=0.20sec
 PR interval: Beginning of P wave to the beginning of QRS; shows how fast the electricity travel form atria
to ventricle.
 QT Interval: Ending of QRS to the beginning of T wave; shows how long it took for the ventricle to
contract and relax.
 ST segment: ending of QRS to the beginning of t wave; shows the duration on how long it waits for the
heart to relax
 PP interval; beginning of P wave to the beginning of another P wave.

o Parameters: Normal Sinus Rhythm (NSR)

 P wave: 0.11sec; hindi dapat lalagpas ng tatlong small box
 Pag lumagpas ng 3 boxes it is call widened P wave
 QRS wave: not > .12sec ( not >3SB)
  PR interval: 0.12-0.20 (3-5 small boxes)
 If more than 5 it is called prolonged PR interval
o Prolonged PR interval Indicates AV Block
o Degrees of AV Block
 Mobitz type 1: Prolonged PR interval but uniformed in size.
 Mobitz type 2: Prolonged PR interval but lengthening. (e.g. Lead 1 7, lead 2 8,
Lead 3 9 etc.)
 Mobitz type 3: A complete block. Atrial rate > Ventricular rate.
 QT Interval: 0.32-0.40secs (8-10 small boxes)
 If >.40sec/10 sb is called Prolonged QT Interval
o Prolonged QT interval may lead to Torsades de pointes ( twisting of points)
 DOC: MgSO4 (Magnesium Sulfate)
o Torsades de point can lead to Ventricular Fibrillation
 ST SEGMENT: Should be along the isoelectric line (Normal)
 Above iel: ST segment elevation
o Seen in Myocardial Infarction
 Below iel: ST segment depression.
o Seen in Angina
 PP & RR Interval: Uniformed ( Dapat mag kakaparehas ng size)
 P to QRS Ratio: 1:1
 1:2 Indicates Premature Ventricular Contraction.

D. Management
o Anti-arrhythmic Drug
 MOA: Delay Contraction/ relaxation (slow down)
 Category I:
 Na Channel Blocker ; Blocks the Na from entering the cell. Therefore, it delays the contraction
of heart.
o Lidocaine, Procainamide, Quidinine
 Category II:
 Beta Blocker
o Blocks the B1 receptor to stimulate SA node.
o Epineprine/Norepinephrine stimulates B1 receptor in SA node that leads to firing
rate of SA node to increase.
 -lol ( metoprolol, atenolol)
 Category III
 K Channel Blocker: Delays the relaxation of the heart.
o Amioderone
 Category IV
 Ca Channel Blocker: Blocks the Calcium from entering the cell. Therefore, it delays the
contraction of heart.
o Verapamil & Diltiazem
 All these drugs Prolonged QT interval

o Pacemaker Implantation
 Used when HR is too slow. Meaning SA node is not working.
 This replace SA node function.
 Indication: For Bradydysrthymia
 Nursing Consideration
 Avoid contact sports.
 Avoid MRI
 Avoid airport security gate
 Avoid tight clothing
  Avoid leaning on devices
 Allowed to swim but deep diving is not allowed.
o Defibrillation
 Asynchronized delivery of electricity ( walang sinasabayan)
 Indication: Ventricular Fibrillation (vFib), pulseless Ventricular Tachycardia (pVT)
 Patient is unstable and unconscious.
 Nursing Consideration
 Put gel to the paddle
 Ensure no one is touching the patient and the bed.
 Do CPR in between defibrillation.
 Administer shock
o Initial: 120J if Biphasic
360J if monophasis
o Cardioversion
 Synchronized delivery of electricity.
 Kasabay ng R wave
 V Tach with Pulse
 Patient is stable and Conscious.
 Nursing Consideration
 Sedation
o NPO 6-8 hours prior to procedure. This is to prevent vomiting during the procedure
that can lead to Aspiration.
o Avoid driving/ No operating heavy machineries after the procedure.
o Administer Anticoagulant (Heparin). This prevents clot formation.

3. CORONARY ARTERY DISEASE (CAD)

A. Coronary Arteries
o Right Main Coronary Artery (RMCA)
 Right Posterior Descending Artery
o Left Main Coronary Artery (LMCA)
 2 Branch : Circumflex and Left Anterior Descending Artery
o Function of CA
 Supply heart with blood (during relaxation)
 CA twist and turn ( Reason why CA is prone in fats build up)

B. Lipid Metabolism
o Source:
 Liver > can synthesize cholesterol > Used to produce Bile (night)
 Simvastatin: Inhibits liver to produce cholesterol. Taken at night because liver synthesize
cholesterol at night
 Diet: Cholesterol, carbs (energy > excess > triglycerides > adipose tissue)
o Trasporters
 Lipoprotein
 LDL (goes to Blood Vessel)
 HDL (goes to Liver)
o Dyslipidemia: Increased Triglycerides, Cholesterol and LDL but low HDL
 Termed as Atherosclerosis. An accumulation of fats (plaque/atheroma) inside the blood vessels.
 This is enhanced by Diabetes Mellitus.
 Reason why HDL is low:
 Alcoholic
 Sedentary Lifestyle
 Chronic Smoker
C. Development of Coronary Artery Disease
o Parts of Artery
 Outer: Tunica Adventitia
 Middle: Tunica Media (smooth muscle)
 Inner: Tunica Intima (Endothelium)
o Ischemia: O2 Supply < O2 Demand > Lactic Acid Formation > nerve > Pain > Chest > Angina Pectoris ( Chest
pain due to Ischemia)

o Sudden Obstruction > Myocardial Infarction/Acute Coronary Syndrome

 Damage/Injury/necrosis occur
 Thrombolytics is given to melt the clot.

D. Assessment and Diagnosis

o CA
 S/Sx
 Asymptomatic
 Elevated Cholesterol
o Skin > xanthelasma
o Sclera > arcus lipodes
o Dx
 Lipid Profile
 Purpose: To measure lipid level
 Result: Abnormal Lipid Profile
 Normal Values
o Triglycerides: <200mg
o Cholesterol: <200mg
o LDL: <160mg/dL (if no Risk factor)
<130mg/dL (2 or more risk factor)
< 100mg/dL (if pt has CAD)
o HDL: 35-70mg/dL (male)
35-85mg/dL(female)
 Nursing Consideration
o NPO post midnight
 Cardiac Catheterization
 Purpose: To visualized if there is any blocked coronary Arteries (Coronary Angiogram)
 Nursing Considerations
o Dye Procedure
o Check Allergy to seafood (Dye is Iodine base) (+) allergy > premedicate with
Antihistamine/corticosteroid.
o Check for kidney Function. (Contrast Dye will excrete through urine)
 Check for normal urine output, BUN and Creatinine
o Check if patient is taking metformin because metformin + Dye can lead to Lactic
Acidosis
o Insertion Site: Femoral Artery
 Position the patient Flat on bed with Lower extremities kept straight.
 Apply pressure using sandbag over the side
 Monitor distal pulses (Popliteal, posterior tibial, dorsalis pedis) because clot
from the wound can block the artery.

o ANGINA PECTORIS
 S/Sx:
  Retrosternal Chest Pain (Ischemia)
 Radiation Pain (Left Jaw, neck, shoulder, arm (inner/pinky side)
 Relieved by Nitroglycerine

 Diagnosis
 ECG (2 changes)
o T wave inversion
o ST segment
 Types
 Stable
o Predictable
o “exertional” chest pain occur when you are doing something
o Relieved by rest
o <15 minutes
 Silent Angina
o (-) chest pain; (+) ECG
o Who: DM (neuropathy)
Elderly (degeneration)
Women (atypical Symptom)

 Unstable
o Unpredictable
o “pre-infarction”
o Persists even with rest
o >15 minutes

 Variant/Vasospastic/Prinzmetal
o Due to vasospasm of coronary artery (sumikipa ng coronary artey)
 E.g. cold exposure
o ST segment elevation (reversible)
o DOC: Calcium Channel Blocker
 E.g -dipine
 Cardiac Markers (Enzymes)
 Not elevated

o MYOCARDIAL INFARCTION
 S/Sx:
 Retrosternal Chest Pain (Cardiac Damage)
 Radiation Pain (Left Jaw, neck, shoulder, arm (inner/pinky side)
 Relieved by Morphine Sulfate

 Diagnosis
 ECG (3 changes)
o Ischemia : T wave inversion
o Injury: ST segment elevation
o Necrosis: Pathologic Q wave
 Width: >1 small box (thickness)
 Depth: >2 boxes
 Types
 STEMI
o (+) ST elevation
o Complete obstruction
 NSTEMI
o (-) ST elevation
o Partial obstruction
  Q wave MI
o (+) pathologic Q wave
o All layers are infarcted.
 Non-Q wave MI
o (-) pathologic Q wave
o One layer Infarction

 Cardiac Markers (Enzymes)

 Elevated
o Myoglobin- earliest to increase ( >90mcg/L)
o CKMB – Most specific ( only seen in the heart) (>3% of total CK)
o Troponin- truest indicator of MI. (>.40ng/ml)

E. Management

CORNARY ARTERY ANGINA PECTORIS MYOCARIAL INFARCTION

DRUGS: Antilipidemic
 
Beta-blocker: to decrease heart rate

Blood thinner: to prevent clot Thrombolytics: dissolves clot
formation.
4. Anticoagulant
5. Antiplatelet

Nitroglycerine: for pain.

6. This relieved ischemia

7. Decrease the preload
(stretching of heart) by
promoting venous dilation
Morphine Sulfate
8. To relieve pain
9. Vasodilation effect
ACE Inhibitor
10. Decrease the risk of
heart failure
Percutaneous Coronary Intervention (PCI)
- Percutaneous Transluminal
Coronary Angioplasty (PTCA)
o AKA “Balloon Catheterization.
- Coronary Stent
o To prevent vasospasm
- Brachytherapy
o Radioactive
o To prevent endothelial
proliferation

Coronary Bypass Graft

- Grafts
 
o Saphenous Vein: emergency
bypass
o Mammary Artery: Preferred
o Gastroepiploic Artery: Least
desireable
Therapeutic Lifestyle Change (TLC)
- Low fat diet
 
- High fiber diet
- Physical Activity (3x per week
minimum of 30mins/day)