Cardio System

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 –

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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

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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

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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 

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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:  

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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

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Atrial Depolarization

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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,

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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` 

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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.

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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

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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:

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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

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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 

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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 (dangerthrombosis) *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 

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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:

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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