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By: zmiraflores

· Translated as pain (angina) in the chest (pectoris).
· Usually last a few minutes (3 to 5 minutes) and subsides with rest.

Precipitating factors

· Physical exertion
· strong emotions
· consumption of heavy meals
· temperature extremes
· cigarette smoking
· sexual activity
· stimulants (cocaine)

4 E’s of Angina Pectoris

1. Excessive physical exertion – heavy exercises

2. Exposure to cold environment
3. Extreme emotional response – fear, anxiety, excitement
4. Excessive intake of foods rich in saturated fats – skimmed milk

Types of Angina

· Stable angina

· unstable angina (unpredictable)

· Prinzmental’s angina (occurs a rest usually in response to spasm of a major coronary artery.
Signs and Symptoms

1. Levine’s Sign – initial sign that shows the hand clutching the chest
2. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back,
shoulder, arms, axilla and jaw muscles, usually relieved by rest or taking nitroglycerine
3. Dyspnea
4. Tachycardia
5. Palpitations
6. Diaphoresis

Risk Factors

· Cigarette smoking
· Drugs and alcohol
· Hypertension
· Elevated Serum lipids
· Stressful lifestyle
· Obesity
· Physical inactivity

· Genetic disposition
· Diabetes
· Age
· Gender (men>women until 60 yr of age)
· Race (african-amercians<Caucasians)

· Arrhythmia’s
· Premature contractions
· Fibrillation

Diagnostic studies
· History and physical
· Cardiac troponin
· lipid levels
· Stress test
· Nuclear studies
· PET Scan
· Echo

Collaborative Care

· Stent placement
· Angioplasty

Nursing Management :

1. Enforce complete bed rest

2. Administer medications as ordered

a. Nitroglycerine (NTG) – when given in small doses

will act as venodilator, but in large doses will act as vasodilator

Give first dose of NTG (sublingual) 3 – 5 minutes Angina is usually caused by

ATHEROSCLEROTIC Disease. narrowing of artery lipid or fat deposits tunica intima

Give second dose of NTG if pain persist after giving first dose with interval of 3 5 minutes

Give third and last dose of NTG if pain still persists at 3 – 5 minutes interval

Nursing Management when giving NTG

Keep the drug in a dry place, avoid moisture and exposure to sunlight as it may inactivate the drug.
Monitor side effects Orthostatic hypotension Transient headache and dizziness.
Instruct the client to rise slowly from sitting position.
Assist or supervise in ambulation.
When giving nitrol or transdermal patch :
Avoid placing near hairy areas as it may decrease drug absorption
.Avoid rotating transdermal patches as it may decrease drug absorption.
Avoid placing near microwave ovens or duringdefibrillation as it may lead to burns (most important
thing to remember)

b. Betablockers (lol)
Propanolol side effects PNS : broncho constriction, vasodilation
Not given to COPD cases because it causes Bronchospasm
c. ACE Inhibitors (pril)
Enalapril, captopril

d. Calcium Antagonist
calciblock Nifedipine, diltiazem

3. Administer oxygen inhalation

4. Place client on semi fowler’s position
5. Monitor strictly vital signs, intake and output and ECG tracing
6. Provide decrease saturated fats sodium and caffeine
7. Provide client health teachings and discharge planning
a. Avoidance of 4 E’s
b. Prevent complication (myocardial infarction)
c. Instruct client to take medication before indulging into physical exertion to achieve the m
aximum therapeutic effect of drug
d. The importance of follow up care

Nursing Diagnosis

· Pain r/t ischemic myocardium

· Anxiety r/t awareness of having a heart disease, uncertainty about the future
· decreased CO r/t myocardial ischemia affecting contractility
· Activity intolerance r/t myocardial ischemia

Nursing Implementation

If the nurse is present during an anginal attack

· administer o2
· get vital signs
· 12 lead EKG
· nitrates
· physical assessment of the chest
· make patient comfortable
Myocardial Infarction
Clinical Manifestations
*******areas in myocardial cells in the heart are permanently destroyed.

Common: Heart attack

Terminal stage of coronary artery disease characterized by malocclusion, necrosis and scarring.

A. Types
1. Transmural Myocardial Infarction-
most dangerous type characterized by occlusion of both right and left coronary artery

2. Subendocardial Myocardial Infarction –

characterized by occlusion of either right or left coronary artery

B. The Most Critical Period Following Diagnosis of Myocardial Infarction

** 6 – 8 hours because majority of death occurs due to arrhythmia leading to PVC’s

Signs and Symptoms

1. Chest pain Excruciating visceral, viselike pain located at substernal and rarely in precordial
Usually radiates from back, shoulder, arms, axilla, jaw and abdominal muscles (abdominal
ischemia) and hands Not usually relieved by rest or by nitroglycerine
2. Dyspnea
3. Increase in blood pressure (initial sign)
4. Hyperthermia
5. Ashen skin (pale), cool, clammy, diaphoretic
6. Mild restlessness and apprehension, anxiety
7. Occasional findings
a. Pericardial friction rub
b. Split S1 and S2
c. Rales/Crackles upon auscultation
d. S4 or atrial gallop

Diagnostic Procedure:

1. Cardiac Enzymes
a. CPK – MB Creatinine phosphokinase is increased Heart only, 12 – 24 hours
b. LDH – Lactic dehydroginase is increased
c. SGPT – Serum glutamic pyruvate transaminase is increased
d. SGOT – Serum glutamic oxalacetic transaminase is increased

2. Troponin Test – is increased (protein in myocardial)

3. ECG tracing reveals

a. ST segment elevation
b. T wave inversion
c. Widening of QRS complexes indicates that there is arrhythmia in MI

4. Serum Cholesterol and uric acid are both increased

5. CBC – increased WBC

Nursing Management

Goal: Decrease myocardial oxygen demand

1. Decrease myocardial workload (rest heart)

Administer narcotic analgesic/morphine sulfate

Side Effects: respiratory depression Antidote: Narcan/Naloxone

Side Effects of Naloxone Toxicity is tremors

2. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min

3. Enforce CBR without bathroom privileges a. Using bedside commode

4. Instruct client to avoid forms of valsalva maneuver 5. Place client on semi fowler’s position

6. Monitor strictly vital signs, intake and output and ECG tracing

7. Provide a general liquid to soft diet that is low in saturated fats, sodium and caffeine

8. Encourage client to take 20 – 30 cc/week of wine, whisky and brandy to induce vasodilation

9. Administer medication as ordered :

a. Vasodilators Nitroglycerine ISD (Isosorbide Dinitrate, Isordil) sublingual

b. Anti Arrythmic Agents Lidocaine (Xylocane Side Effects: confusion and dizziness Brutylium

c. Betablockers (lol) d. ACE Inhibitors (pril)

e. Calcium Antagonist amlodipine, verapamil, diltiazem

f. Thrombolytics/ Fibrinolytic Agents :

Streptokinase Side Effects: allergic reaction, pruritus
Urokinase TIPAF (tissue plasminogen activating factor) Side Effects: chest pain
Monitor for bleeding time

g. Anti Coagulant
…Heparin (check for partial thrombin time) Antidote: protamine sulfate
…Coumadin/ Warfarin Sodium (check for prothrombin time) Antidote: Vitamin K
h. Anti Platelet …PASA (Aspirin) Anti thrombotic effect Side Effects of Aspirin  Tinnitus 
Heartburn  Indigestion/Dyspepsia Contraindication  Dengue  Peptic Ulcer Disease 
Unknown cause of headache

10. Provide client health teaching and discharge planning concerning

a. Avoidance of modifiable risk factors Arrhythmia

(caused by premature ventricular contraction) b. Cardiogenic shock late sign is oliguria
c. Left Congestive Heart Failure d. Thrombophlebitis homan’s sign e. Stroke/CVA

Nutritional Therapy

· Low fat diet

· Low cholesterol
· Low salt

Ambulatory and Home Care

· ASA 80-325 mg per day

· Patient education (cause and effect, terms, s/s, risk factors)
· Rest
· Diet
· Dietary restrictions
· Management of risk factors
· Exercise
· Sexual activity

f. Post MI Syndrome/Dressler’s Syndrome

Client is resistant to pharmacological agents; administer 150,000 – 450,000 units of

streptokinase as ordered

g. Resumption of ADL particularly sexual intercourse is 4 – 6 weeks

post cardiac rehab, post CABG and instruct to make sex as an appetizer rather than dessert
instruct client to assume a non weight bearing position

Client can resume sexual intercourse if can climb staircase

h. dietary modification

i. Strict compliance to mediation and importance of follow up care

Sudden Cardiac death

· -Unexpected death from cardiac causes.
· -In SCD there is a disruption in cardiac function, producing an abrupt loss of cerebral blood flow.
· -Death occurs within 1 hour of the onset of acute symptoms.
· Occurs to approximately 350,000 deaths a year in the U.S.
· Only 20% of SCD are discharge form the hospital without neurological problems.

Risk Factors

· -Male gender
· -Family history of premature atherosclerosis
· -Cigarette smoking
· _DM
· -Hypercholesterolemia
· -HTN
· -Cardiomeagely
· -Ejection fraction of less than 40%
· -History of ventricular arrhythmia

Collaborative Management
· -Several cardiac enzymes
· -EKG
· -Cardiac cath
· -24 hour holter monitor if they are known to have arrhythmia’s
· -Electrophysiology study (EPS)

Nursing Care

· *Mostly talking to patients and educating the patient and families to relieve some anxieties and fears.
· -Must patients have a feeling that they are a “time bomb” waiting to happen.
· -Wives usually blames themselves for this occurrence.
· -Patients and families have a lot of fear and anxiety.
· -Depression

Woman and CAD

· Number one killer in the American women.
· Approximately 500,000 deaths a year.
· Women manifest CAD 10 years later than men.
· Most women have symptoms of angina than men.
· The stress test has a low sensitivity in women, and 30-40% jfo women have false-positive results. (This is
due to women having low HCT, higher pulmonary and systolic BP responses to exercise, and ST segment
depression form circulating estrogen).
· Women have a higher mortality rate within one year following an MI than men. (due to developing CAD
later than men)

Woman and CAD

· More likely to have Diabetes, HTN, and heart failure.

· Women after CABG have higher mortality rate than men and more complications (this is because women
have smaller arteries, are older, and are referred more frequently for CABG with severe angina or
unstable angina requiring urgent or emergency surgery).
· Women also have higher rate of coronary dissection and hospital mortality than men following PTCA, but
men have a higher incidence of restenosis.
Implication for nursing

· -Aggressive education about the reduction of risk factors.

· -Education, education, education

ODE to the Node

ODE to a Node
Have a heart, and have no fear
The SA node is over here
Beating at a constant rate
60-100 is really great.
The AV node can make a show
If SA node has gone too slow.
40-60 is not bad
If it’s all you’ve got you will be glad.
Should the whole thing drop its speed
His and bundle branches will take the lead.
And that, my friend is the whole and part,
Of the conduction system of your heart.

Common disorders of CAD

Congestive Heart Failure
· CHF is a cardiovascular condition in which the heart is unable to pump an adequate amount of blood to
met the metabolic needs of the body’s tissue.
· It is not a disease……..IT IS A SYNDROME
· CHF is characterized by LVH, reduced exercise intolerance, diminished quality of life, and shortened life

· Is associated with HTN and CAD.
· More than half of the deaths from heart disease is associated to end-stage CHF.
· 4.9 million people in the U.S. have CHF.
· AHA says that about 400,000 get CHF/year.
· Mortality rate is 50%
· About 20% of people who had MI will be disabled with heart failure within 6 years.

· CHF is the single most frequent cause of hospitalization for people age 65 and older.
· CHF has a poor prognosis and is likely to remain a major clinical and health care problem.

Risk factors

· diabetes
· cigarette smoking
· obesity
· High cholesterol
· proteinuria


· CHF may be caused by any interference with the normal mechanisms regulating cardiac output.
· CO depends on: Preload, afterload, myocardial contractility, heart rate and metabolic state of the
· Any alteration of these results in CHF.

Compensatory Mechanisms
· Dilation
· Hypertrophy
· Sympathetic nervous system
· Hormonal response

Common causes

· Rheumatic heart disease
· Congenital heart disease
· Cor Pulmonale
· Anemia
· Acute MI
· Arrhythmias
· Pulmonary emboli
· Hypertensive crisis
· Ventricular septal defect

Type of CHF
· Left sided CHF
· Right sided CHF

Left sided

· Results from LV dysfunction, which causes blood to back up through the left atrium and into the
pulmonary veins.
· This increase causes to go from the pulmonary capillaries bed to the interstitium and then the alveoli,
causing pulmonary congestion and edema.
· Pulmonary congestion
· pulmonary edema
· Fatigue
· Dyspnea
· dry, hacking cough
· Nocturia
· Crackles

Right-sided heart failure

· Failure from the right ventricular that causes backflow to the right atrium and venous circulation.
· The primary cause of right-sided failure is left sided failure

Right-sided heart failure

· Dependent edema
· Weight gain
· Juglar vein distention
· Hepatomegaly (liver engorgement)
· Fatigue
· Right upper quadrant pain
· Anorexia and GI bloating
· Nausea

Complication of heart failure

· Pleural effusion
· Arrhythmia’s
· Left Ventricular thrombus
· Hepatomegaly

Diagnostic studies

· History and physical

· ABG’s
· Liver profile
· 12 lead EKG
· Echo
· Nuclear studies
· Cardiac cath
Nursing management for acute CHF and pulmonary edema

Goal therapy is to improve:

· left ventricular function by decreasing intravascular volume
· decrease afterload
· Improve gas exchange
· Improve O2, CO and reduce anxiety

Nursing management for Chronic Heart Failure

· Positive Inotropic drugs
· Digitalis preparation
· Beta-adrengeric agonist
· Diuretics
· Vasodilator drugs
· Sodium Nirtoprusside
· Nitrates
· Angiotension-converting enzyme inhibitors
· Beta-adrenergic blocking agents

Nutritional therapy
· Diet education
· Weight management
· Low sodium (2 g NA diet)
More severe is 500-1000mg.
· Fluid restrictions
· Weight Daily (THIS IS IMPORTANT)
same day everyday, preferably before breakfast.

Nursing Diagnosis
· Activity intolerance
· sleep pattern disturbance
· fluid volume excess
· Risk for skin integrity
· Impaired gas exchange
· Anxiety

Patient teaching
· Rest
· Drug therapy
· Dietary therapy
· Activity program
· Ongoing monitoring
ECG reading


· Rhythm is regular
· Rate is 60-100 beats/min
· PR Interval is 0.12-0.20 seconds
· Upright P wave
· QRS is 0.12 seconds or less
Sinus Bradycardia

· Rhythm is regular
· Definition : rate is lower than normal ; Rate is below 60 beats/min
· PR Interval is 0.12-0.20 seconds
· Upright P wave
· QRS is 0.12 seconds or less
· Resting heart rates below 60 might be normal in athletes
· Watch for hypotension

Sinus Tachycardia

· Rhythm is regular
· Def; sinus rhythm with an elevated rate of impuses ; Rate is between 101 and 150 beats/min
· PR Interval is 0.12-0.20 seconds
· Upright P wave
· QRS is 0.12 seconds or less
· Is considered SVT when greater than 150 unless in children
Atrial Flutter

· Rhythm may be regular or irregular

· Def: abnormal heart rhythm that starts in the atrial chambers of the heart ; Atrial rate is 230-350
· Ventricular rate varies
· PR Interval is usually nonexistent
· Flutter waves replace the P waves; they resemble a “saw tooth”
· QRS is 0.12 seconds or less
· Will see the saw tooth waves across the baseline

Atrial Fib

· Rhythm is irregular and usually erratic

· Def: irregular rapid heart rate that causes symptoms like heart palpitation, fatigue, shortness of breath.
Atrial rate is 350-400 beats/min
· Ventricular rate varies
· There is usually no PR Interval
· P waves are erratic and baseline appears “wavy”
· QRS is 0.12 seconds or less
· If on medications, can see a slower atrial rate but still a-fib

· Rhythm is usually regular

· Def: fast heart rhythm that begins in the ventricles; Ventricular rate is greater than 100 beats/min
· QRS is wide and is greater than 0.12 seconds
· There is no P wave
· Can be stable or unstable
· Can have a pulse or no pulse
· If have more than 3 is a run of v-tach


· Heart quivers instead of pumping due to disorganized electrical activity of the ventricles. Rhythm is
chaotic and no regularity noted
· No identifiable QRS complexes
· No P waves
· Total chaotic electrical activity creates the baseline
· Can be coarse or fine
· No pulse

· Baseline straight or slightly wavy
· Must be confirmed in 2 leads
· No pulse

Peripheral Vascular Disease


· Intermittent claudication due to an inadequate oxygen supply.

· It occurs when the patient is walking, exercising, etc. Patient will get leg pain and cramps.

· Assess skin color, hair distribution, and venous blood flow.

· Extremities should be assessed for thromophlebitis, varcoise veins, and lesions such as stasis ulcers.
· Check capillary refills, edema, pulses
· Homan’s sign: Presence of calf pain during sharp dorsiflexion of foot. This is nonspecific and can be
elicited from any painful condition of the calf.


· 0- absent
· 1t= weak, thready
· 2t= normal
· 3t= full, bounding

· If the artery is narrowed or bulging it will create an abnormal buzzing sound (BRUIT).
Other things you can hear:
· Bounding: sharp and brisk rising pulse
· thready: weak, slow rising pulse
· Thrill: vibration

Things that can occur

Pulmonary Embolism

· most common pulmonary complication in hospitalized patients.

· Estimated that about 500,000 die each year for PE.
· Most arise in the deep veins of the legs.
· Other sites are the right side of the heart (AFIB), upper ext. (rare) and pelvic veins (especially after

· Mobil clot that generally do not stop moving until they lodge at a narrowed part of the circulatory
· The lungs are an ideal location for emboli to lodge because of their extensive arterial and capillary
network.The presence of a deep vein thrombosis is usually unsuspected until a pulmonary embolism
· Thrombi in the deep vein can dislodge spontaneously.
Assessment of DVT: a warm, reddish blue extremity.
· More common mechanism that throws a clot is sudden standing and changes of the rate of blood flow,
such as valsalva’s maneuver.

Clinical Manifestations

This depends on the size of the emboli and the number of blood vessels occluded.
· Sudden onset of unexplained dyspnea
· Tachypnea
· Tachycardia
· Cough
· Chest pain
· hemoptysis
· crackles
· fever
· changes in mental status

Massive Emboli

The patient will suddenly collapse and experience.

· shock, pallor, have sever dyspnea, and crushing chest pain.
· Pulse is rapid and weak
· BP is low
When rapid obstruction of 50% or more occurs, acute Cor Pulmonale may result because of right ventricle
can no
longer pump blood into the lungs.
Death occurs in over 60% of patients.

Medium-sized emboli
Can cause pleuritic chest pain accompanied by:
· Dyspnea
· slight fever
· productive cough with blood streaked sputum
· Tachycardia
· Friction rub

Small emboli

· Undetected or produce vague, transient symptoms.


Pulmonary Infarction
· Death of lung tissue occurs in less than 10% of patients with emboli.
· It is more likely to occur in patients with:
occlusion of a large or medium-sized pulmonary vessel (<2mm)
Insufficient collateral blood flow from the bronchial circulation
Preexisting lung disease

Pulmonary Hypertension

· Occurs when more than 50% of the area of the pulmonary bed is compromised.
· Also results form hypoxemia.
· Only if the emboli is massive will this occur.
· But small to medium emboli that are recurrent can cause pulmonary hypertension.

Diagnostic test
· History and physical
· Venous studies (venous Doppler’s, lung scans, pulmonary arteriogram).
· ABG’s

Collaborative care

· Oxygen mask or cannula.

· IV site
· IV heparin
· Bed rest
· Narcotics for pain
· Thrombolytic agents
· Vena cava filter
· Pulmonary embolectomy

Drug therapy

· Diuretics (if heart failure occurs).

· Heparin
· Coumadin


· It is an anticoagulant.
· Should be started immediately.
· The dosage of heparin is adjusted according to its effect on the PTT.
· Normal PTT is 35-45
· Bolus is always given first
· PTT should be one and half to two and half times normal to be therapeutic.


· Anticoagulant
· PT is monitored
· Doc adjusted according to PT levels. The most significant is the INR.
· PT is always drawn with the INR.

Nursing management

· Health promotion
· Bed rest
· Semi-fowler’s position.
· IV line for medications and fluid therapy.
· Careful monitoring of ABG’s, ECG, and lung sounds.
· Nurse should explain the situation to patient/family.


Educate patient with s/s and explain what is going on because they feel:
· Pain
· sense of doom
· inability to breathe
· explain situation and provide emotional support.

Ambulatory and home care

· Emotional support
· teach, teach, teach

· Adequate tissue perfusion.
· Adequate cardiac output
· Increased level of comfort

Arterial Blood gases

Normal ABG Values

Ph- 7.35-7.45
Sat- 95-100%
PaO2- 80-100
pCO2- 35-45
HCO3- 22-28

· Use pH, pCO2 and HCO3 components to determine acid-base balance.

· Begin at pH. Based on you answer to questions, follow the sequence of the diagram.
· Determine what you primary disturbance is. Be sure to check all components (remember you have 2
primary disturbances I.e., metabolic and respiratory acidosis)
· Once the primary disturbance is identified, determine if compensation is present.
Ask yourself is the pH normal
· YES: then ask is the pCO2 WNL
· YES: Normal-acid base balance
Is the pH normal
· NO: if decreased it is acidosis and if it’s increased it’s alkalosis.
Now ask if the pH is not normal:
pH is decreased (acidosis) look at the pCo2. If it is HIGH it is Respiratory Acidosis if the HCO3 is also High
then it is Respiratory acidosis compensated with Metabolic acidosis.
· pH is decreased: acidosis now look at the HCO3 if low it is metabolic acidosis if the pCO2 is low. It is
metabolic acidosis compensated with respiratory alkalosis.
· IF pH is elevated (ALKALOSIS)
· look at pCO2 if low = Respiratory alkalosis
and if HCO3 is low it is respiratory alkalosis compensated with metabolic acidosis.
· If HCO3 is high= metabolic alkalosis
and pCO2 is high=metabolic alkalosis compensating with respiratory acidosis.
© 2011

Good luck and God bless!

Ma’am Zar