Care of Clients with

Problems Related To The

Cardiovascular System

Earl Francis R. Sumile, RN

Instructor, College of Nursing
University of Santo Tomas
Properties of the Heart
Muscles
 Contractility – ability to respond an
impulse by contracting the
myocardium
 Rhythmicity – stimulus;
transmission; contract – relax
 Irritability or Excitability – ability to
respond to a stimulus or electric
impulse
Properties of the Heart
Muscles
4. Conductivity – ability to respond to a
heart impulse by transmitting the
impulse along cell membranes
– SA node – 60 to 80 beats per minute
– AV node or Junctional tissue – 50 to 60
beats per minute
– Bundle of His – 40 to 50 beats per
minute
– Purkinje Fibers – 30 to 40 beats per
minute
Properties of the Heart
Muscles
5. Automaticity – ability to initiate
impulses regularly and
spontaneously
SA node – pacemaker
6. Refractoriness – prevents from
responding to a new stimulus while
heart is in contraction
7. Extensibility or expansibility –
ability to stretch as the heart fills
with blood between contractions
Risk Factors
 Non-modifiable risk factors
– Age – 40 years and above
– Gender – men
– Race – whites
– Genetic history – positive family history
Risk Factors
 Modifiable risk factors
– Hypertension – precursor to
atherosclerosis and ischemic heart
disorders
– Hyperlipidemia
– Smoking – nicotine is a vasoconstrictor
– Sedentary lifestyle – decreased activity
leads to peripheral pooling, venous
stasis, varicosities, thrombophlebitis
Risk Factors
 Modifiable risk factors
– Obesity
– Stress
– Glucose intolerance
– Alcohol abuse
– Caffeine – increased heart rate
– Environmental risk – food, drugs
Cardinal Symptoms of Heart
Diseases
 Dyspnea – most common symptom
of heart disease
 Dyspnea on exertion – symptom of heart
dysfunction provoked by effort and relieved
promptly by rest
 Orthopnea – symptom of advanced heart
failure
 Paroxysmal nocturnal dyspnea –cardiac
asthma; severe attacks of shortness of
breath after 2 to 5 hours of sleep; usually
accompanied by sweating and wheezing
Cardinal Symptoms of Heart
Diseases
 Chest pain – present in ischemic heart diseases
– characteristics – ‘strange feeling”; indigestion; dull
heavy pressure; burning crushing aching, stabbing;
tightness
– location – substernal or precordial areas, anterior
chest; diffuse or localized; radiated to neck, jaw, left or
both arms
– duration – in angina – 20 to 30 minutes; in MI longer
than 30 minutes
– severity – scale 1–10
– precipitating or aggravating symptoms
– associated symptoms – SOB, diaphoresis, palpitations
– alleviating factors
Cardinal Symptoms of Heart
Diseases
 Edema – accumulation of excess fluid in
interstitial space; weight gain of over 7
kg. water before edema occurs
 Syncope – general muscle weakness with
inability to stand upright with loss of
consciousness
 Palpitations (subjective) – unpleasant
awareness of heartbeat; sensation of
pounding, racing, skipping; thumping
heartbeat often accompanied by
anxiousness
Physical Assessment
– Inspection – skin color, cyanosis, neck
vein distention; respiration; peripheral
edema, pitting edema (does not
disappear with elevation of extremity);
clubbing or blanching
– Palpation – peripheral and apical pulses
– Percussion
Physical Assessment
 Auscultation – heart sound at apex
or PMI (point of maximal impulse
located at:
 5th left ICS; left, mid-clavicular line
 2 inches below left nipple
– Normal heart sound:
 lubb – first sound; ventricular systole;
closure of AV valve
 dubb – second sound; ventricular diastole;
closure of semilunar valve
Physical Assessment
– Abnormal Heart Sounds:
 murmur – audible vibrations because of turbulent
blood flow through the heart and large blood vessels
 gallop – extra heart sounds mimicking a horse’s
gallop because of sudden changes of inflow volume
on valves and supporting structures
Variations of cardiac rate
 Due to:
– Exercise – increase activity, increase heart rate
– Size of individual – larger person, lesser heart
rate
– Age – fetus – 120 – 160 per min; adult – 65 – 80
per min; higher age = lower heart rate
– Sex – women has higher heart rate
– Hormones – epinephrine and thyroxine
increase heart rate
– Increase temperature – increase heart
– Blood pressure – decrease blood pressure,
increase heart rate
Effects of electrolytes to heart
rate
– increase potassium = decrease pulse
– decrease sodium = weaker contractions,
increase pulse, decrease blood pressure
– increase calcium = stronger and
prolonged systole
Diagnostic Assessment
1.Chest X-ray – shows heart size, contour and
position, reveals heart and pericardial
calcifications and demonstrates physiologic
alterations in the pulmonary circulation.
2.Fluoroscopy – provides visual observations of
the heart on a luminescent x-ray screen
3.Cardiac enzymes – present in myocardial cells
and released into blood when damaged
– LDH – Lactic Dehydrogenase
– N=100-225 mU per ml; elevated in 48 hours
– CPK – Creatinine Phospokinase
– N=50-325mU per ml; elevated from 4-24 hours
Diagnostic Assessment
 Electrocardiography (ECG) – graphic
record of electrical activity of the heart
– Atrial Depolarization
 P wave – depolarization of atria (0.8 secs.)
 PR interval – conduction from atria to ventricle
(0.16 secs.)
– Ventricular Depolarization
 QRS complex – depolarization of Bundle of His,
purkinje fibers and ventricles (0.6 – 1.2 secs)
 ST segment – recovery or repolarization of
ventricles; elevation or depression = ischemia or
infarction of heart muscles (0.12 secs)
 T wave – ventricular repolarization; recovery after
contraction of ventricles (0.16 secs); if inverted =
ischema or infarct
Diagnostic Assessment
 Stress test (treadmill) – exercise testing
on a treadmill or a bicycle like device
carried out to identify ischemic heart
disease,
– Nursing Consideration - stop procedure if
patient complains of dyspnea or chest pain
 Echocardiogram – ultrasound
cardiography; record of high frequency
sound vibrations which have been sent
into the heart through chest wall
Diagnostic Assessment`
 Transesophageal Echocardiography (TEE) –
gives a higher quality picture of the heart than
echocardiogram; probe inserted with
esophageal scope and placed behind the heart
 Angiocardiography – injection of contrast
medium into the vascular system to outline
heart and heart vessels; usually done with
cineangiograms (rapidly changing films on an
intensified fluoroscopic screen
Diagnostic Assessment
 Coronary arteriography – radiopaque catheter is
introduced into right brachial artery or femoral
artery (via arteriotomy with percutaneous
puncture) to ascending aorta to coronary artery
on fluoroscopy.
– Nursing interventions:
 NPO – to minimize pulmonary aspiration after
 Vital signs
 Check for bleeding at puncture site
 Check color of extremity and pulses
Diagnostic Assessment
 Position Emission Tomography (PET) – scanner
that allows visualization and information of
perfusion and metabolism images providing
assessment of regional cardiac viablility.
 Cardiac catheterization – catheter is inserted to
the heart and blood vessels to measure O2
concentration, saturation, tension and pressure
on heart chambers.
– Right Cardiac Catheterization – catheter is inserted
into the antecubital vein to vena cava, right atrium
and right ventricle to pulmonary artery.
– Left Cardiac Catheterization – catheter is inserted into
the brachial or femoral artery; retrograde up the aorta
and light ventricle; usually done with angiography.
Diagnostic Assessment
 Cardiac Catheterization
Nursing interventions:
– Before – NPO, allergic history, mark distal
pulses, instruct patient that there will be
occasional thudding sensation in chest and
strong desire to caugh and transient heat.
– After – VS, check peripheral pulses, check site,
check for chest pain, bed rest for 12-24hours;
– for femoral site – check for bleeding,
inflammation, tenderness, apply sandbag and
ice on site, HOB > 30degrees avoid flexing
femoral region;
– for brachial – arm straight for several hours
Diagnostic Assessment
 Hemodynamic monitoring – assessment
of circulatory status
– CVP – (N=5-12 cms. H20) obtained by
inserting a catheter into the
– external jugular, antecubital or femoral vein
and threading it into the vena cava
Purposes:
– Provides information concerning blood
volume and adequacy of central venous
return
– Reveals right atrial pressure
– Route for drawing blood samples,
administration of fluids or medication and
inserting pacing catheters.
Diagnostic Assessment
 Hemodynamic monitoring
Nursing interventions:
– Place the patient in supine position. Inaccuracies in CVP
readings can be due to changes in position, coughing or
straining during the reading.
– The zero point of the manometer should be on a level
with the patient’s right atrium. (midaxillary line)
– To measure CVP: Turn the stopcock so that the IV
solution flows into the manometer filling to about 20-25
cm. level. Then turn stopcock so that solution in
manometer flows into patient.
– Observe the fall in the height of the column of fluid in
manometer. Record the level at which the solution
stabilized or stops moving downward. This is the CVP.
Classification Of Patients With
Heart Disease
Functional Capacity
 Class I: Patients with heart disease but
without resulting limitations of physical
activity.
 Class II: Patients with heart disease
resulting in slight limitation of physical
activity. .
 Class III: Patients with heart disease
resulting in marked limitation of physical
activity.
 Class IV: Patients with heart disease
resulting in inability to carry on with
Classification Of Patients With
Heart Disease
Therapeutic Classification
 Class A: Patients with heart disease whose
ordinary physical activity need not be
restricted.
 Class B: Patients with heart disease whose
ordinary physical activity need not be
restricted, but who should be advised against
severe or competitive physical efforts.
 Class C: Patients with heart disease whose
ordinary physical activity should be moderately
restricted and whose more strenuous efforts
should be markedly restricted.
 Class D: Patients with heart disease whose
ordinary physical activity should be markedly
restricted.
 Class E: Patients with heart disease who should
Common cardiac problems
1. Conduction arhytmias – disruption in normal
heart cycle
a. Sinus tachycardia – heart rate over 100 beats per
minute originating from the SA node. (rate 100-160 per
minute)
May be secondary to:
Fever, apprehension, physical activity,
anemia, hyperthyroidism, drugs; epinephrine,
theophylline myocardial ischemia or caffeine;
rhythm regular
Nursing management:
– correction of underlying cause
– no stimulants
– sedative
– drug of choice – propranolol (Inderal)
 Conduction Arhytmias
 Sinus bradycardia – heart rate of less than 60
beats per minute; regular.
May be caused by:
-excessive vagal or decreased sympathetic
tone
-myocardial infarction
-intracranial tumors
-meningitis
-normal variation of heart rate in well trained
athlete
Nursing management:
– not needed, unless cardiac output is inadequate
– pharmacotherapeutics – Atropine, Isuprel
– Pacemakers – pulse generator to control of potentially
dangerous dysrrhytmias
 Conduction Arhytmias
-Pacemakers
Methods of pacing:
*Temporary – done at the bedside under
fluoroscopy through an emergency transthoracic
percutaneous insertion of heart needle direct to
myocardium
*Permanent – subcutaneous or subclavicular
insertion through transvenous (antecubital, femoral,
jugular or subclavian) or direct application to
epicardial surface through thoracotomy.
Modes of pacing:
*Pre-set (fixed or asynchronous) – fires electrical
stimulus regardless of rate and rhythm; usually set
at 72 beats/min.
*Demand (stand by) – stimulated only when heart
rate drops below pre-set rate; usually below 60
beats per minute.
 Conduction Arhythmias
-Pacemakers
Nursing Management:
-assess wound daily, report signs of
inflammation
-check pulse daily, notify physician if pulse
is slower than set rate
-avoid areas with high voltage, magnetic
force fields or radiation (no MRI,
microwave oven)
-avoid wearing constrictive clothing
-avoid vigorous movement of arms and
shoulder and weight lifting
 Conduction Arhythmias
 Atrial fibrillation – rapid, irregular contractions
of the heart with ectopic foci. (350 to 600
beats/min)
Management:
-pharmacotherapeutics – digitalis,
propranolol, verapamil
-Cardioversion – elective procedure in which
electric current is delivered to the heart to
terminate potentially dangerous or
exhausting arrhytmias refractory to drug
therapy
-50 to 400 watt sec
-synchronizer on – during QRS complex
-never on T wave
 Ventricular Tachycardia – a run of 3 or more
conservative premature ventricular contractions
from repetitive firing of an ectopic foci in the
ventricles. (atrial – 60 to 100 beats/min;
ventricular – 110 to 250 beats/min)
Management:
-Lidocaine; Procainamide, Bretylium
-Defibrillation – emergency procedure in
which an electric current is delivered to the
heart to terminate life threathening arrhythmia
(400 watt sec or joules); synchronizer off
Common Cardiac Problems
 Coronary Artery Disease
– Arteriosclerosis – narrowing of arterial lumen secondary to
aging; increased in 30-50 years
– Atherosclerosis – narrowing of arterial lumen secondary to
cholesterol and lipids on artery walls; increased men and
non-whites
Management:
*PTCA – Percutaneous Trans-luminal Coronary
Angioplasty – specially designed catheter is inserted
under fluoroscopy, balloon tip is inflated, compresses
and ruptures an atherosclerotic plaque (danger-
thrombosis)
*CABGS – Coronary Arterial Bypass Graft Surgery – use
of autologous or prosthetic Teflon or Dacron (open
heart surgery) to bypass the affected area.
Common Cardiac Problems
 Angina Pectoris – transient, paroxysmal chest pain
secondary to insufficient blood flow to myocardium
resulting in myocardial ischemia.
Signs and Symptoms:
– Chest pain characterized by:
S udden; sub-sternal
A nterior chest
V ague
E xertion related
R elieved by rest or nitrites
S hort duration
– Palpitations or tachycardia
– Dyspnea
– Diaphoresis
– Shortness of breath
 Angina Pectoris
Diagnostic Assessment:
-ECG – reveals depressed ST segment; T wave inversion;
-Stress test – abnormal ECG during exercise

Nursing management:
-O2 inhalation
-Semi to high fowler’s position
-Heart monitoring
-Proper relief of pain with nitrates
- nitroglycerine tablets – given sublingual
*take 1 tab in anticipation of strenuous activity
*1 tab every 5 mins (3 tabs within 15 mins)
*headache – frequent side effects (transient)
*hypotension
*keep cap tight; prevent exposure to light, air and heat
 Angina Pectoris
Nursing Management:
- nitro ointments or nitrodisc
*rotate sites to prevent dermal inflammation
*avoid massage or rub because of increased absorption
and interferes
with drug’s sustained action
*avoid skin contact with medication
-patient education to minimize precipitating events
-reduce stress and anxiety
-avoid overexertion and smoking
-decrease cholesterol and saturated fat diet
-small, frequent meals
-avoid extremes of temperature
-dress warmly in called weather
Common Cardiac Problems
 Myocardial Infarction – death of myocardial cells
from inadequate oxygenation, often caused by
a sudden, complete blockage of a coronary
artery characterized by localized formation of
necrosis with subsequent healing by scar
formation and fibrosis.
Signs and Symptoms:
– Pain usually substernal radiating to neck, arm , jaw or
back, severe and crushing, sudden onset unrelieved
by rest or nitrates; may be referred pain (epigastric
pain)
– Nausea and vomiting
– Dyspnea
– Cool, clammy and
 Myocardial Infarction
Signs and Symptoms:
– Initially increased blood pressure ashen skin
– Increased temperature and pulse rate then decrease
blood pressure
– Increased WBC, CPK and CPK-MB, increased SGOT,
increased LDH, increased ESR
*CPK and SGOT – increases in 4 to 6 hours, and decreases
in 3 to 7 days
– ECG changes – ST elevation, presence of U-waves, T
wave inversion
 Myocardial Infarction
Nursing interventions:
Objective of care – restore ability of heart to
maintain adequate circulation;
-IV lines – pain relief – IV morphine sulfate (no
IM injections-stimulates increase CPK)
-O2 inhalation
-Bedrest, semi-fowlers position; ambulate after
3 days
-Antiarrhytmics – lidocaine bolus 50-100 mg +
drip at 1-4 mg/min; procainamide, quinidine
-Full liquid to soft diet, decreased sodium and cholesterol,
no caffeine
-Stool softeners to prevent straining
 Myocardial Infarction
Nursing Interventions:
-Fibrinolytics – streptokinase drip to lyse the
thrombose
-Anticoagulants
*heparin – serial PT; antidote – protamine sulfate
*coumadin or warfarin sodium – serial PTT;
antidote – Vitamin K
-TPA (tissue type plasminogen activator or
platelet deagreggator)
*low doses of aspirin a day
*persantine or dipyridamole
-Resumption of sexual activity in 4 to 6 weeks
Common Cardiac Problems
 Congestive heart failure – inability of heart
to pump blood to adequately meet the
metabolic needs of body
-Left sided heart failure – (forward failure)
causes blood to back up through left
atrium into pulmonary veins; pulmonary
congestion.
Signs and Symptoms – dyspnea,
orthopnea, paroxysmal nocturnal
dyspnea, wheezing, moist rales,
cyanosis, pallor, cough with frothy
sputum
 Congestive Heart Failure
-Right sided heart failure – (backward
failure) right valve is unable top pimp
blood into pulmonary system; systemic
venous congestion
Signs and Symptoms­ – dependent and
pitting edema, jugular vein
distention, bounding pulse, weight
gain, decreased renal function, oliguria,
ascitis, anasarca
 Congestive Heart Failure
Nursing management
– Control of underlying cause
– O2 therapy
– Sodium restricted diet
– Pharmacotherapeutics
*vasodilators (nitoglycerine, isosorbide, morphine
sulfate) to decrease? amount of blood return to
heart
*digitalis therapy (lanoxin, cedilanid) to improve
cardiac output
Signs and Symptoms of digitalis toxicity:
*CV symptoms: bradycardia, tachycardia, bigeminy,
ectopic beats
 Congestive Heart Failure
Nursing Management:
Signs and Symptoms of digitalis toxicity:
*GI symptoms: anorexia, nausea and vomiting,
diarrhea, abdominal pain
*Neuro symptoms: headache, double vision, blurred or
colored vision; drowsiness, confusion, restlessness,
irritability, muscle weakness
*diuretics – relieve fluid retention
 Congestive Heart Failure
Nursing Management:
– Rotating tourniquets (bloodless phlebotomy) – to
retard venous return to heart
General Principles of Care
– Use 3 tourniquets or 3 BP cuffs on 4 extremities
cuff inflated at pulse pressure
– Apply tourniquet using one direction –
clockwise
– Tourniquet is applied one at a time at 15
minutes interval
– Tourniquet is removed one at a time at 15
minutes interval
– Maximum time of stay in each extremity is 45
minutes
- Phlebotomy – removal of 300-500cc blood from
peripheral vein
- Intraaortic balloon pump, heart
transplant,mechanical heart