Assessment of the Cardiac System

by: Mr. Robert F. Angeles, RN

REVIEW OF CARDIOVASCULAR SYSTEM
 al signs
pulse - is the expansion and contraction of an artery in
a regular, rhythmic pattern.
- this happens when the left ventricle of the heart
ejects blood through the superior venae cavae
as it contracts, causing waves of pressure.
blood pressure – the pressure exerted by the circulating
volume of blood on the walls of the arteries
the veins, and the chambers of the heart.
- a person’s blood pressure is maintained by
the complex interaction of the homeostatic
mechanism of the body and is influenced
by the volume of blood, the lumen of the
arteries and arterioles, and the force of the
cardiac contraction.
• Cardiac output - refers to the amount of blood pumped
out by the heart in 1 minute and is
determined by the stroke volume.
• Stroke volume - the amount of blood ejected with each
heartbeat multiplied by the number
of beats per minute.
ontractility - refers to the ability of the myocardium
to contract normally.
reload - is the stretching of muscle fibers in the
ventricles. This stretching results from the
volume of blood in the ventricles at the
end of diastole.
fterload - refers to the pressure the ventricular
muscle must generate to overcome the
higher pressure in the aorta.
 How to calculate for the cardiac output?
Stroke volume X heart rate
70 ml/beat X 72 beats/min.

Formula:

CO = SV X HR
= 70ml/beats X 72 beats/min
= 5040 ml/min (approximately 5L/min)

ote:the heart rate and stroke volume vary considerably

among people.

CO = 115L/min X 190bpm
= 21,850 ml/min (approximately 22L/min)
ystolic blood pressure – is the blood pressure caused by the
contraction phase or systole of the
left ventricle of the heart.
iastolic blood pressure- the pressure during the heart’s
relaxation phase, or diastole.
ulse pressure – the numerical difference between systolic an
diastolic.( normal 30 to 40 mm/hg).

normalities in the physical examination:

cyanosis - a bluish discoloration of the skin and mucous

membranes that result from an excessive amount
deoxygenated hemoglobin in the blood.
- comes from the greek word cyanos which means
dark blue.
pallor - fancy term for paleness, or a decrease or absence
of color in the skin.
edema – the accumulation of abnormal amounts of fluids in
the intercellular tissue, pericardial sac, pleural cavity
peritoneal cavity, or joint capsules.
diaphoresis – profuse perspiration associated with an elevate
body temperature, physical exertion, heat
exposure and mental or emotional stress.

nostic test
ivated partial thromboplastin time
- the test to measure the time required for
formation of a fibrin clot.
diac enzymes – test used to determine if cardiac tissue
been damage.
- normally present in high concentrations in
the heart, cardiac enzymes are released
into the blood stream from their normal
intracellular area during cardiac trauma.
• cardiac troponin test
- a blood sample is used to measure the cardiac
protein called troponin. This is the most precise
way to diagnose an MI.

Radiologic test

cardiac catheterization
- a diagnostic procedure in which a catheter is
inserted into a large vein and then threaded
through the vein to the patient’s heart.
angiocardiography – creates an x-ray of the heart and great
vessels after injection of contrast medi
into a blood vessels or one of the heart
chambers.
angiography – produces an x-ray of the blood vessels after
injection of radiopaque contrast medium.
 Cardiac catheter

Cardiac
catheter

angiocardiography
angiocardiography
 • radio nuclide scan – is a test that helps to measure heart
function and damage.
- during the test, a mildly radioactive
material is injected into the patient’s
blood stream. Computer generated
pictures are used to locate the radio-
active elements in the heart.
thallium stress test - helps diagnose coronary artery diseas
- the patients is given a thallium isotope
IV after a treadmill stress test.
rrhytmia - the lack of normal heart rhythm.
trial flutter - is an arrhytmia in which atrial rhythm
is regular, but the rate is 250 – 400 bpm.
radycardia - is a slow heartbeat, usually less than 60
beats per minute.
brillation - refers to an uncoordinated, irregular
contraction of the heart muscle, which may
originate in the atria.
eart block - describes an impaired conduction of the
heart’s electrical impulses, which commonly
leads to a slow heartbeat.
aroxysnal
trial tachycardia-is an arrhytmia in which the atrial and
ventricular rate are regular and exceeds
160 beats per minute.
achycardia - refers to a heartbeat greater than 100bpm
8. Atrial septal defect - is an opening between the 2 atria.
- because the left atrial pressure is
slightly higher than the right atria
pressure, blood shunts from the le
to the right.
9. Coartication of the
aorta - is narrowing of the lumen which
results in high pressure above and
low pressure below the stricture.
10. Endocarditis - is a bacterial or fungal infection of
the heart valves.
11. Myocarditis - is an inflammation of the heart
muscle that can be acute or long
term.
12. Pericarditis - is an inflammation of the
pericardium(protective sac)
3. Rheumatic fever - is a childhood disease caused by
streptococcal bacteria.
4. Aneurysm - occurs commonly in the aorta but
can happen in any vessels.
- ruptured bloodvessels
5. Stenosi - a thickening of valvular tissue that
result in narrow valve openings.
6. Coronary artery
disease - occurs when the arteries that serve
the heart are obstructed or narrowed.
7. Coronry artery bypass
graft - surgery restores circulation when
occluded coronary arteries prevent
normal blood flow to the heart muscle.
8. PTCA - percutaneous transluminal coronary
angioplasty.
- is a non-surgical alternative to CABG
- a guided catheter is thread to the
coronary artery and position @ site of a
occlusion.
9. Cardiac Tamponade – a life threatening complication
caused accumulation of fluid in the pericardiu
this fluid, which can be blood, pus, or air in th
pericardial sac, accumulates fast enough and
sufficient quantity to compress the heart and
restrict blood flow in and out of the ventricles
CARDIAC TAMPONADE
A build up of blood or other
fluid in the pericadial sac
puts pressure on the heart,
which may prevent it from
pumping effectively.
Fluid build up
within the pericardial
sac
 sment:
process of data collection and inter-
tation.
es of data
tory
ysical examination
oratory testing
gnostic imaging
Principles
torical information, laboratory testing
nd physical findings directs appropriate
boratory and diagnostic testing.
Basic principles cont…..
2. Assessment data are used to formulate
clinical
diagnosis, established patients goals, plan
care and evaluate outcomes.
3. Patient condition and the purpose of the
encounter determine areas that are included
in an assessment.
4. Elements of the history and physical
elimination
are the same whether performed by a
physician,
nurse or other clinician.
Assessment of the cardiovascular system involves:
• incorporating data from history taking relating
the information to the physical examination
and diagnostic test.
• correlating the data with the underlying
pathophysiology.

istory:
a record of past events.
a systemic account of the medical and psychosocial
occurrences in a patient’s life and of factors in
family ancestors and environment that may have
a bearing on the patients condition.
alth history
the patients story of his or her diseases,
ymptoms, illness experiences and responses t
ctual and potential health problems.
dentifying information
primary data source - patient
secondary data source - family members
clinical record
: “significant cardiovascular data are obtained by assessme
of the following area’’
-risk factor analysis -current health/history of present il
-biographical -demographic data
-chief complaint -associated manifestation
k factor analysis:
- a factor that causes a person or a group o
person to be particularly vulnerable to a
unwanted, unpleasant or unhealthy even
Examples:
age and gender
women after menopause high risk
men older than 60y/0 high risk
family history of
increase BP
two or three or more
blood relatives
systolic 160 – 200
diastolic 90 – 110
cholesterol level
240 – 280 above high
risk
triglycerides level
200 – 499 high risk
above 500
highest risk
percentage of fat in diet
30 – 50% high
Above 50%
highest risk
frequency of recreational
exercise
no activity
highest
smoking
Biographical/Demographic data
• name
• age
• gender
• place of birth
• race
• marital status
• occupation
• ethnic background
note:
economic transition, urbanization, industrializatio
and globalization bring about lifestyle changes th
promote heart disease.
Current health/ History of present illness
documenting the progression of the first manifestatio
to the current complaints or problems helps organize
the history and reveals the sequence of events that le
the client to seek help.

CHIEF COMPLAINT
he reason why the person has sought health care
o establish priorities for interventions and to evaluate
how well the client understands the presenting condit
ommon clinical manifestations important/
mportant manifestations of cardiac disease.
chest pain irregularities of heart rhythm
cyanosis respiratory manifestations
fatigue syncope
hemoptysis weight gain
dependent edema
clubbing of fingers

te:
r the symptomatic patient obtaining the history of the
esent illness starts with a more detailed discussion of
ief complaint
mptom analysis
ubjective indication of a disease or a change i
ndition as perceived by the patient.
evaluate and clarify the chief complaint.
Chest pain
ne of the most important manifestations of
ardiac disease.
gina Pectoris
- is the true manifestation of coronary artery
disease.
- a paroxysmal thoracic pain caused most
often by myocardial anoxia as a result of
atherosclerosis of the coronary arteries
e:
words used to described chest pain.
related to exercise, emotional stress, exposure to
intense cold.
ification of Angina
able / Classic Angina
haracterized by transient episodes of substernal
hest pain or discomfort

ivities that increase myocardial demand

terns are usually predictable
t:
t or sublingual nitroglycerin usually relieves the
comfort within a few minutes.
Anginal Equivalents
- characterized by a sensation of dyspnea, excessive
fatigue or weakness, isolated arm or jaw pain.
Variant Angina
- less common form of angina
- episodes of chest pain that occurs @ rest, discomfo
tends to be prolonged, severe and not yet readily
relieved by nitroglycerin
- caused by spasm of coronary arteries
Unstable Angina
- intermediate in severity between stable angina and
myocardial infarction
- recent onset of angina, prolonged angina @ rest or
change in pattern of angina.
te:
lieve result from rupture of atherosclerosis plaque
. Timing
describe the evolution of the symptom
onset
frequency
duration
frequency onset durat
angina may occur or gradual less than
predictable 30min
pectoris recur spontaneously
pattern
more than
myocardialresidual soreness sudden 30min
infarction1 to 3 days to 2 hours
Quality
scribe the character of pain
est pain may be described as a strange feeling of
digestion,a dull heavy pressure,burning,crushing,
nstricting,aching,stabbing or tightness.

angina pectoris shooting or squeezing, burning

pressure or indigestion.

myocardial heaviness, crushing pressure or

infarction constriction

e: quality is particularly difficult to describe, so when

possible it is important to use patient’s own word.
uantity
-describe the severity, intensity or amount of the
symptom in measurable term.
-refers to the size, extent or amount of the symptom

te:
better quantify pain use a scale of 1 to 10 and should
corded as fraction.
ocation
describe the specific body location where the symptom
is experienced, include any area of location.
it provides additional information for determining its
cause.

Anginal painretrosternal, felt slightly to the left on

the midline or partly under the sternum

Myocardial radiates bilaterally across the chest int

ischemia the arms, left greater than right, and
Into the neck and lower jaw
 • cardiac pain is diffuse and patients often rubs a hand ov
the sternum, and precordium.
• if pain is radiating, patients should trace it’s path with a
finger tip.
• ask patient to describe exact location of symptom by
pointing to it.

Precipitating/Aggravating factor
-describe events that initiate symptom.
-describe what makes the symptom worse.

eg:
• emotional excitement
• position changes
• deep breathing
• eating/ deep sleep
 chest discomfort that is reliably associated wit
activity is a specific indicator of cardiac ischem

. Alleviating factor/ Relieving factor

-describes which relieves symptoms.

Anginal rest, vasodilators,change in position

pain

Myocardial cannot be relieve by above interventions

infarction and last for 20min
Differential diagnosis
of chest pain
Associated manifestation
-symptoms rarely occur in isolation
- if patient mention associated symptoms, these
should be described in the same manner as the
chief complaint.
- it is important to note whether these associated
symptoms occur consistently with the chief compl
or occur independently @ other times.

• irregularities of heart rhythm

• respiratory manifestations
• paroxysmal nocturnal dyspnea
• syncope
• easy fatigability/fatigue
• weight gain and dependent edema
• other associated manifestations
 regularities of heart rhythm
alpitations - a sensation of rapid heartbeats, skipping
irregularity, thumping, or pounding and
maybe accompanied by anxiousness.
chycardia – rapid heart rate due to increase force of
myocardial contraction.
: ingestion of caffeine
emotional/physical stress
any condition in which there is an increase
stroke volume.

the volume ejected by

the ventricle in a single
contraction
 The onset and termination of palpitations are often abrupt
• medications frequency of palpitations
• precipitating factorsany manifestations
• aggravating / -dizziness
relieving factors - shortness of breath with
palpitations
Dysrhytmia/Arrhythmia(used interchangeably)
lack of normal heart rhythm
abnormal heart rhythm
erent types of arrhytmia

adysrhytmia/bradycardia – a slow hear beat (below 60 b

: heart block
- an interference with the normal conduction of electri
impulses that control activity of the heart muscle
chydysrhytmia/ tachycardia
refers to a heart beat greater than 100 bpm
atrial fibrilation
uncoordinated, irregular contraction of the heart muscle
originates in the atrium.
atrial flutter
is an arrhythmia in which atrial rhythm is regular; but the
rate is 250 – 400 bpm
trasystole
cardiac contraction that is abnormal in timing or in origin
of impulse with respect to the fundamental rhythm of the
heart
premature atrial contraction
a cardiac rhythm characterized by an atrial beat occuring
before the expected excitation
premature vetricular contraction
Respiratory Manifestations
a. dyspnea – shortness of breath/labored breathing
- although dyspnea can develop in any
form of heart disease. It usually occurs
with cardiac enlargement and other
pathologic, cardiovascular,structural
and physiologic changes.

orms of dyspnes
exertional dyspnea – most common of cardiac related
dyspnea.
- occurs during mild to moderate
exercise or activity and disappear
with rest.
- can limit activity tolerance
 ask the client to describe the degree of activity
that typically precipitate the onset of dyspnea.
eg: walking one flight stairs
b. Orthopnea – difficulty of breathing except when
sitting or standing.
- result from increase hydrostatic pressur
in the lungs when the person is lying fla
and is relieved when the person assum
an upright or semiventrical position.

1. ask client what action they take to facilitate

breathing?
2. what position do they sleep?
3. how many pillows do they sleep with?
4. record the degree of head elevation required to
breath?
paroxysmal nocturnal dyspnea
- dyspnea during sleep, that awakens the sleeper with
a terrifying breathing attack.
- commonly occurs 2 to 3 hours after the person goes
to sleep.
eg: severe left ventricular failure with pulmonary edema
syncope/fainting
- a transient loss of consciousness related to inadequat
cerebral perfusion.
eg: cardiac dysrhtymia can precipitate a sudden decrease
in cardiac output
easy fatigability/ fatigue
- common manifestation of decrease cardiac output
- progressive deterioration of activity tolerance results
from the hearts inability to pump an effective
volume of blood to meet the varying metabolic deman
of the body.
weight gain and dependent edema
- body weight is a sensitive indicator of water and sodium
retention and increases even before edema occurs.
- daily weight measurements is important for client with
cardiac problem.
other associated manifestation
cyanosis - bluish discoloration
( from birth - - congenital heart disease )
> peripheral cyanosis
- decrease blood flow to the periphery.
- increase oxygen extraction in states of low cardiac
output. ( more time needed to extract oxygen to hgb ).

maybe physiologic, associated with vasoconstrict

eg: anxiety, cold environment, cardiogenic shock
> central cyanosis - observe the buccal mucosa
- implies serious heart or lung disease and
accompanied by peripheral cyanosis.
- a right to left shunt exits in which blood
passes through the lungs without fully
oxygenated.
clubbing of fingers
associated with significant cardiopulmonar
disease.

• hemoptysis–coughing up of blood
recurrent episodes of hemoptys
may result from mitral stenosis.
 SSESSMENT
st health history ( ask the client about the following areas )
childhood and infectious disease
ask about the client’s experiences with rheumatic fever,
scarlet fever and severe streptococcal infections.
( conditions associated with structural/ mitral valve disease)
immunization
lients with chronic conditions, such as cardiovascular
disorder should be vaccinated yearly against influenze.
major illness and hospitalization
note conditions that influence the clients current cardio-
vascular performance
eg: diabetes mellitus, anemia, chronic obstructed lung
disease, kidney disease, hypertension, stroke, gout

explore previous hospitalization,surgical procedure,obstetr

history and outpatient intervention
 the result of each studies provide baseline data for
comparative analysis when later studies are performed

. medications
-evaluate the use of prescription medications, over the
counter medications, herbals and recreational drugs.
- use brand names instead of generic names if possible

• time, dose, frequency of administrations

• how often they are taken?
• reason client stop taking medications?
- taking too many pills
- experiencing unwanted side effects
- believe the problem has resolved
- worry about the cost
. allergies – describe any environmental, food or drug allergi

the past history include past illnesses and interventio

not directly related to present illness.

. family history
- purpose is to asses risk factors affecting the patients
current or future health.
• non-modifiable risk factor.
eg: age, gender, ethnicity, genes
• notations regarding the age and health status of ea
first degree family members.
• the possible or confirmed diagnosis or death.
psychosocial history
includes on data of lifestyle, household members, marital
status, children, relationship with significant others, education
military service or health habits.
ccupation
inquire about all occupations the client has had and the
duration of each job worked.
eographical location
nvironment
-the home, types of dwelling, no of steps
-mode of transportation
-access to public transport
-the neighborhood (noise, pollution)
-access to family and friends, store, pharmacy
xercise
ask about the type and amount of exercise routinely engaged
in during an average week.
 sedentary lifestyle potentates the lethality of myo
cardial infarction and it is considered a significant
risk factor in the development of coronary artery
disease.
. nutrition
examine not only daily food habits but also attitudes
toward food, and resistance to therapeutic alterations
in diet.
note for special diet such as low sodium or low fat diets.
assess excess or deficit caloric intake and the clients
appropriate intake of food, high in sodium, cholesterol
saturated fat and caffeine.

its
caffeine or alcohol use, smoking habits, inquire the
duration/ pack per day.
hers
> perceived health and coping challenges
the patients perception of his or her current health
status as either good or bad.
being aware of patients goal in terms of health an
lifestyle are important in determining whether the
expectations are realistic.
eg: what do you see yourself doing 3 months from now

 resources and support system

it is important to consider the patients strength a
support system.
eg: spouse to provide home care, economic support suc
as adequate insurance.
k. FUNCTIONAL HEALTH PATTERN

• health perception
• nutrition – metabolism
• elimination
• activity – exercise
• cognitive – perceptual
• sleep – rest
• roles and relationship
• sexuality
• coping – stress
• values - beliefs
Thank you!
PHYSICAL ASSESSMENT
hysical Assessment ( IPPA )
cardiac physical assessment should include an evaluation
f: [ things to consider]
The heart as a pump
> reduce pulse pressure
> cardiac enlargement
> presence of murmur/gallop rhythm
Filling volumes and pressure
> the degree of jugular venous pressure
> presence of crackles
> peripheral edema
> postural changes in blood pressure
Cardiac output
> heart rate >blood pressure
> pulse pressure >systemic vascular resistance
> urine output >central nervous system manifestation
 . Compensatory mechanism
> increase filling volumes
> peripheral vasoconstriction
> elevated heart rate
e cardiac physical examination includes the following
a general inspection
assessment of BP, arterial pulse, jugular venous pulse
percussion, palpation and auscultation of heart
evaluation of edema

. GENERAL APPEARANCE
the patients appearance and response provide cues to the
cardiovascular status.
note general build, skin color, presence of shortness of
breath and distention of neck veins.
 • does the client lie quietly, or is he restless or contin
moving about.
• can the client lie flat or is only an upright/erect
position tolerated.
• does the facial expression reflect pain or obvious
manifestation of respiratory distress.
• can the client answer questions without dyspnea
during the interviews.
• capillary refill/ edema presence

eg:
myocardial pain constant, moving

anginal pain sitting quietly

pericarditis leaning forward

EVEL OF CONSCIOUSNESS
reflects the adequacy of cerebral perfusion and
oxygenation.
appropriate behavior for the surroundings.

• what is the client affect?

• are there obvious manifestations of anxiety, fear
depression, or anger?
• how does the client react to those in the immediat
vicinity, including significant others.
. HEAD, NECK, NAILS AND SKIN
cial characteristics
arlobe crease coronary heart disease/> 45
alar flushed cyanotic lipid rheumatic heart disease with
th without jaundice) mitral stenosis
cial flushing tricuspid valve disease/severe
hypertension
observe for cyanosis
central cyanosis indicates serious heart or lung disea
in which hemoglobin is not fully
saturated with oxygen
(skin/ mucous membrane)
peripheral cyanosis - suggest peripheral vasoconstriction
(capillary refill, clubbing of fingers)
EDEMA
- occur in right sided heart failure when the excess when
the excess intravascular volume begins to increase cap
lary hydrostatic pressure and force fluids into interstitiu

mobile client – edema is best seen in feet, ankle, an

lower leg.
bedridden - edema maybe palpated over the
sacrum or abdomen
.BLOOD PRESSURE – measure in both arms initially, if arm i
inaccessible obtain pressure in the thigh
popliteal area.
recommended BP to prevent heart attac
or stroke, BP maintained or below 140/90

Kidney failure 130/85

Heart failure 130/85
Diabetes 130/80

• postural blood pressure

note the clients position @ the time of reading

> supine 140/80

> sitting 124/76 15 to 30 seconds interval
> standing104/68
paradoxical bp/pulsus paradoxus
- an abnormal decrease in systolic pressure and puls
wave amplitude during inspiration (below 10mm/hg

postural hypotension is indicated by a BP decrease

of more than 10 to 15 mm/hg systolic pressure and
more than 10mm/hg diastolic pressure
significant:
 pericardial tamponade
 pericarditis
 pulmonary hypertension

radoxical pressure is the difference between the BP when the

unds are first heard during expiration and the BP when the
unds are heard both expiration and inspiration.
pulse
-assess for pulse deficit by taking radial and apical pulse
simultaneously, noting difference in rate.
respiration
-note the rate rhythm, depth, and quality of the breathin
pattern.
-auscultate for the presence of crackles, ronchi or other
abnormal breath sounds.
-frothy sputum ( pulmonary congestion, left ventricular
congestion ).

head and neck / carotid arteries

- neck vein distention can be used to estimate central
venous pressure.
entral venous pressure:
TEPS:
Note the highest point @ which the internal jugular pulse ca
seen.
Place a ruler ventrically on the sternal angle
gnificance:
The value is usually less than 3 to 4 cm above the sternal a
when the head of the bed is elevated 30 to 40 degrees.
Increase values indicate increase right atrial/ventricular
pressure.
g;
ght ventricular failure
icuspid regurgitation
ericardial tamponade

ently palpate for the carotid artery and note for the rate and
hythm and bruit sounds.
 • ------------------ PMI
• -------------- STERNAL
ANGEL

45 degrees
 bruit sounds are similar to cardiac murmurs that
occurs with turbulence of blood flow.

hest
bserve for size, shape and symmetry of movement and
vident pulsation.

left lateral position allows the heart to move closer

to the chest wall, accentuating precordial movemen
and certain heart sounds.

record the location of pulsation in relation to the intercoasta

space and midclavicular line.
point of maximu intensity (apical pulse)
seen @ the apex/ 5th intercoastal space medial to the left MC
hrills – abnormal pulsation
rushing vibrations represents turbulent blood flow thro
the heart especially across abnormal heart valves
5 cardiac landmarks

• aortic area right 2nd intercoastal

space
• pulmonic area left 2nd intercoastal space
left sternal boarder
• erb’s point/ 3rd intercoastal space
left
second pulmonic area sternal boarder
• tricuspid area left intercoastal space mid
sternal line
• mitral/apex area left intercoastal space
mid
clavicular space
 HEART SOUNDS
rst heart sound – S1 – lub sounds -closure of the mitral
and tricuspid valve
entricular contraction -marks the onset of
systole
econd heart sound – S2– dub sounds- closure of pulmonic
and aortic valves
entricular filling -end of systole and th
onset of diastole

Systole – the contraction of the heart driving bloo

into the aorta and pulmonary arteries
Diastole – the period of time between contraction
the aorta or ventricle during which blood
enters the relaxed chambers from the
systemic circulation.
INSERT HEART SOUNDS
ABNORMAL HEART SOUNDS
many abnormal heart sounds may indicate a serious
heart disease or change in cardiac function.
Pathologic splitting of S2
due to any mechanism that causes late aortic valve
closure
g; right bundle branch blocked, aortic stenosis, left ventricul
failure or ischemia and patent ductus arteriosus
Gallops/dyastolic filling sounds
also called 3rd or 4th heart sounds (S3 and S4)
sudden changes of inflow volume cause vibrations of
the valves and ventricular supporting structures
producing low pitched sounds that occur either early
or late diastole.
g: left ventricular contraction dysfunction (tachycardia)
 • normal to children and young adult
• above 30y/o abnormal
eg; ventricular hypertrophy, ischemia, myocardial
infarction
Quadruple rhythm
when both S3 and S4 is audble

Clients with this unusual heart sounds often have

Tachycardia which causes the diastolic filling sound t
Fuse forming a summation gallops.

Clicks – having a clicking quallity

are extra cardiac sound that can be heard anytime
during the cardiac cycle in client with aortic stenosis
valve prolapsed, or prosthetic valve.
simple clicks – occur during systole, usually caused by a
prolapsed mitral valve.
ejection clicks – high pitched sound heard in systole.

eg: septal defects, patent ductus arteriosus, or aortic

valvular stenosi.

Opening snap
result of high pitched sound with a snapping quali
it is heard early in diastolic @ the apex using a
diaphragm.
MURMURS
- a consequences of turbulent blood flow through the he
and large vessels.
- results of faulty valves.
- an incompetent valve fails to close tightly and blood
leaks through the valve when it closed.
 diastolic murmurs is always abnormal.
eg: aortic or pulmonary valve insufficiency, mitral or
tricuspid insufficiency.
ericardial friction rub
characterized by scratchy, creaking or grating sounds
eg: pericarditis
-maybe present during the first week after myocardia
infarction.
-the roughed parietal and visceral layers of the peri-
cardium rub against each other during cardiac motio

0. Lungs
because the cardiovascular and respiratory system are
timately related, assessment of cardiovascular system must
clude evaluation of the respiratory system.
OMMON RESPIRATORY FINDINGS:
Tachypnea – rapid respirations is often associated with pa
anxiety accompanying myocardial ischemia.
Crackles - frequently signals left ventricular failure
etiology:
pulmonary capillary pressure increase because of back-
ward pressure of left ventricle pressure, fluids shift into
intra – alveolar spaces and crackles can be auscultated.
Blood tinged sputum – frank hemoptysis maybe associated
with pulmonary embolus.
Cheyne stroke respirations – characterized by abnormal peri
of deep breathing alternating with
period of apnea.

asically you have to assess for the rate, rhythm and effort.
1. ABDOMEN
abdominal obesity is highly correlated with metabolic ris
ctors that is an elevated body mass index.
spection and palpation may reveal abdominal distention or
ascites and enlarge liver, both indicates liver failure which ca
be sequel to right ventricular heart failure
an increase in jugular vein distention during and immediately
after liver compression indicates chronically elevated right
ventricular pressure

I. Diagnostic Test
a. Laboratory test
b. Graphical procedure
. Radiographic procedure
d. Hemodynamic Studies
a. Laboratory test
1. complete blood count

red blood cells – heart disease characterized by

inadequate tissue oxygenation
red blood cells - decrease in rheumatic fever and
ineffective endocarditis.
white blood cells – to infectious and inflammatory
disease of the heart.
• avoid hemolysis
minimized duration of tornique
use appropriate needle size
• do not draw blood from an arm where solution i
infussing intravenously.
• color of tube stopper indicates additives
 . cardiac enzymes (high concentration in myocardial tissue)
- special proteins that catalyze chemical reactions in liv
cells.
creatinine kinase – an enzyme present in brain, myocardium
and skeletal muscle.
- it is released from cells after irreversible
injury.
CK isoenzymes are specific to each type of tissue.

a. ck- mb myocardial cells

b. ck-bb brain cells
c. ck-mm myocardial and skeletal muscle
reference range
ck 30-180iu/l 57% to 88% accurate
ck –mb 0-15iu/l 93% to 100% accurate
gnificance:

ck-mb -0 – 15iu/L myocardial -elevated

-peak level damage within
after MI are 93% to 100% 3 to 6 hours
more than accurate after the
onset
6x the
normal of signs &
values symptoms of
-return to MI.
normal w/n -maximum

48 to 72 levels are
 avoid IM injection prior to examination of ck and
ck-mb.
samples should be taken immediately on admissio
and every 6 to 8 hours for the 1st 24hrs.
smaller elevation maybe seen after reperfusion.
Myoglobin -Increase myocardial elevates 1
protein -return to N damage. to
found in in 12 to 30 useful marker 3 hrs. after
myocardium hrs of myocardial MI
& skeletal -great necrosis that
muscle that potential for is rapidly
is release from
false
released positive the
into circulation
test.
w/n 1 to
blood after
2hrs
cell injury
 Lactic -peak w/n Increase w/n
dehydrogenase 48 to 72 14 to 24 hrs.
-plenty in hrs. after the
heart muscle -returns to onset of MI
normal
w/n
3 to 4
days
roponin ( cardiac enzymes )
components:
1. Troponin I – modulates the contractile states
2. Troponin C- binds to calcium
3. Troponin T – binds with I and C
roponi I and T
- although it is present in all striated muscle it has a diff
ammino acids sequence in cardiac muscle.

Troponi I and T 98% to 99% useful for

-it correlates accurate diagnosis
with 4 to 6 hours
the have
development elapsed.
of new area of once present
regional troponin I persist
dysfunction for 4 to 7 days.
blood coagulation test
- used to examine the ability of blood to clot.
ignificance:
- increase in coagulation factors during and after a
myocardial infarction increase the risk for thrombophleb
and extension of clot in the coronary artery.
- serve as a guide for antithrombolitic therapy.

platelet 150,000 to 400,000

bleeding time 3 to 7 minutes
history of aspirin therapy
- aspirin reduces platelet adhesions and
prolonged bleeding time.
- aspirin effect is not reversible ( last 10 day
. prothrombin time ( 10 to 13 seconds )
- instruct patient to avoid variable intake of vitamin
and to observe for any signs of bleeding.
. partial thromboplastine time/activated PTT
- used for patient receiving unfractional heparin
PTT --- 60 to 70 seconds
aPTT -- 20 to 35 seconds
. serum Lipids
- clinical evidence shows that an ELEVATED cholesterol
Is a major risk factor in the development of atherosclerosis

• low density lipoprotein cholesterol ( LDL )

- composed of fatty substance that are insoluble
- used to assess for the risk of ATHEROSCLEROSIS an
development of CAD.
c – reactive protein
- a glycoprotein thought to be synthesized in the live
- it is done to determine the presence of inflammator
process or wide spread tissue destruction.
eg: myocardial infarction, rheumatic fever
can occur in the blood serum 18 to 24 hours afte
tissue injury occurs.
8. serum electrolytes
- maybe affected by cardiovascular disorder.
- can also be altered by certain medications.
- electrolytes level can alter cardiac muscle contraction
• potassium – decrease as a result of diuretic therapy
- a major intracellular cation
> hypokalemia – increases cardiac instability
ventricular instability
 hypokalemia or hyperkalemia
- can cause ventricular dysrrhytmia.

sodium – a major cation in the extracellular fluid

- maintenace of osmotic pressure.
- regulation of acid base balance.
- transmission of nerve impulses.
may decrease with heart failure, stress, intravenous
infussion of hypotonic fluids, use of diuretics and
sodium restrictions.
• calcium – an important mediator of many cardiovascular
eg: cardiac excitability, contractility and vascular
tone.
• magnesium – helps regulate intracellular metabolism
- activates essential enzymes
- aids transport of sodium and potassium across
cell membrane. /neuromuscular excitability.
 hypomagnesemia – may result from prolonged
use of diuretics.
hypermagnesemia - may result from chronic renal
failure.
. blood urea nitrogen/ creatinine
- indicators of renal failure
- increase during cardiac disorder that adversely affect
renal circulation.
0. Blood glucose
- diabetes mellitus is a major risk factor for the
development of atherosclerosis.
- stress of an acute cardiac event can greatly eleva
blood glucose causing unstable hyperglycemia.
Graphic procedure
a. electrocardiogram
a non invasive test. It is performed for clients olde
than 40 y/o to detect any unknown heart disease,
and frequently used for clients with known or sus-
pected heart disease.
Types:
• continous monitoring
• 12 lead ECG
• holter monitoring
dications for Electrocardiogram:
dysrhytmia pre-operative assessment pericardit
hest pain effects of medications heart rate
MI effects of medication
hamber dilation /hypertrophy
effects of systemic disease on the heart
 V1 – 4th ICS R sternal
V2 – 4th ICS L sternal
V3 – 4th ICS midway
bet. L sternal
boarder & MCL
V4 - 5th ICS @ L MCL
V5 – 5th ICS midway
bet. L MCL &
AAL
v1 v2
v3 v6 V6 – 5th ICS @ L AAL
v4 v5

Pls. Inset video:

Electrode placement for
ECG and cardiac monitorin

ECG placement / precordial leads.

nal average electrocardiogram/ 12 lead ECG
se to detect electrical impulses called late potentials
o determine whether the client is susceptible to ventricu
achycardia that could result in sudden death.
ter monitor
ortable ecg that can record ECG tracing continously for
ay or longer
se to detect dysrhytmia that may not appear on a routin
cg, but occur when patient is ambulating @ home or wo
rcise electrocardiogram / stress test
efines the body’s reaction to measured increases in adu
xercises.
> changes in heart rate > blood pressure
> perceived level of exertion > respirations
> provides data for quantitative estimation of
cardiovascular condition and function
 1. Obtain baseline data – blood pressure, heart
rate and rhythm strips.
2. Prepare the skin for electrode placement.
3. Inform patient that chest pain may occur
4. Records the clients vital signs, rhythm strips and
activity level and time
5. Monitor the client for chest pain or dysrhytmia.

eason for terminating the test

chest pain or fatigue
untoward manifestation of myocardial ischemia
failure of systolic BP to increase or decrease in BP below rest
stage.
sudden development of bradycardia
serious cardiac dysrhythmia.
severe hypertension.
severe dyspnea
• greatly increased heart rate:
20 to 29 170 bpm

30 to 39 160 bpm
40 to 49 150 bpm
50 to 59 140 bpm
60 to 69 130 bpm
ctrophysiologic studies
hed light on the mechanism of dysrhytmias.
ifferentiate supraventricular and ventricular dysrhytmia
valuate SA/AV node dysfunction.
etermine the need for pacemaker
valuate the effects if antidysrhytmic agents.
 ardiac diagnostic imaging
hest x- ray
help to determine size, silhoutte and position of the heart.
Magnetic resonance imaging
provide information on chamber size, wall motion, valvular
function and great vessel blood flow.
ositron emission tomography
physiologic and biochemical changes
detection of coronary artery disease
assessment of myocardial viability
assessment of progression of coronary artery disease
documentation of collateral coronary circulation
differentation of ischemia from dilated cardiomyopathy
chocardiography ( 2D echo )
non-invasive diagnostic procedure based on the principles
of ultrasonography/ structural and functional changes.
Transesophageal echocardiography
> yields a higher quality picture of the heart, than does
regular echocardiography.

• explain the procedure to the client

• obtain an informed consent
• NPO @ least 6 to 8 hours
• monitor vital signs, ecg, respiratory status and
pulse oximetry.
• keep patient npo until gag reflex has returned

Phonocardiography
> recording of audible vibrations from the heart and
great vessels.
> use to assess the timing of cardiac sounds and murm
. Myocardial scintigraphy
> use to measure function, motion and perfusion on the
myocardium
> involve IV injection of radioactive isotope to produce
radionucleoide image.
types:
> thallium 201
> dipyridamole thallium 201 test
> technitium 99m ventriculography
. Cardiac catheterization
> involves insertion of catheter into the heart and
sorrounding vessels to obtain detailed information
about the structure and performance of the heart,
the vessels, and circulatorysystem.
 Right sided Left sided
Catheterization Catheterization
physicians insert a The catheter can be
radiopaque passed
catheter through the retrograde from the
antecu- brachial
bital or femoral vein. or femoral artery into the
aorta and then to the left
ventricle

rarely during right sided

catheterization the middle
of
lower third of the atrial
septum is punctured and
 i. Angiography
> involves IV injection of
contrast material into the
heart during cardiac cathete-
rization.
> a series of x-ray film are
obtained that reveal the
course of the contrast
material.
Cineangiography
> a technique in which moving pictures are obtaine
during cardiac catheterization.
 Hemodynamic studies
entral venous pressure ( CVP )
ulmonary artery pressure
ardiac output
ntra- arterial pressure

each parameters are obtained through an invasive procedure

ntral venous pressure

– 2 to 12mm/hg
rease ------- increase in blood volume.
crease ------ decrease in circulating blood volume.
monary artery pressure
rdiac output measurement
e amount of blood pumped out of the left ventricle into the
erial system. ( stroke volume X heart rate) ave. 70ml
ntra – arterial pressure monitoring
> provides continuous monitoring of arterial BP via a
indwelling catheter.
mmon complications:
Hemmorhage
Hematoma
Infection
embolism

myocardial ischemia occurs when either supply

demand is altered.
Factors influencing myocardial supply and demand

Factors that decrease supply

Coronary artery Circulation Blood disorder

disease disorder
atherosclerosis hypotension anemia
coronary aortic stenosis hypoxemia
arteritis aortic polycythemia
arterial spasm insufficiency
 Factors that increase demand

Increased cardiac Increased oxygen

output Demand

exercise damage
emotions myocardium
anemia myocardial
digestion of hypertropy
large aortic stenosi
meal diastolic
hyperthyroidism hypertension
heavy exertion
art medications:
Digitalis - an extract of foxglove plants that slows and
strengthens contractions of the heart muscle.
Nitroglycerin – causes dilation of all of the veins and
arteries without an increased in heart
rate or stroke volume.
eta-adrenergic blocking agents
- reduce the rate and strength of cardiac muscle
contraction thus reducing the oxygen demand
of the heart.
Calcium channel blockers
- use to control the force of heart contraction
and reduce arrhytmia.
- dilate coronary blood vessels and increase blood
flow to cardiac muscle.
Adrenergics - help treat serious hypotension.
Angiotensin converting enzymes inhibitor
- are used to treat hypertension and heart
failure.
Cardiac glycosides
- are used manage heart failure and
certain types of arrhythmia.
Diuretics - treat edema and hypertension by reduc
circulating fluid volume.
Antihypertensive – reduce cardiac output or decrease
peripheral vascular resistance to
lower blood pressure.
hrombolytic therapy – is used to dissolve clots. Aspirin
therapy is one type of treatment.
uctural Cardiac Disorder
adequate tissue perfusion is essential to good health and
n to life. Perfusion to tissue is critical for their function,and
dequate tissue perfusion from cardiac disorder often leads
onfusion or anxiety related to the brain’s continual needs
glucose and blood and muscle pain resulting from the
scles’ continual need for blood. Failure to pump blood can
ult in adequate tissue perfusion.

VALVULAR HEART DISEASEINFECTIOUS DISORDER

• mitral valve disease • rheumatic fever
• aortic valve disease • infective endocarditi
• tricuspid valve disease• myocarditis
• pulmonic valve disease• acute pericarditis
• cardiomyopathy
FUNCTIONAL CARDIAC DISORDER
1. Coronary heart disease
• Angina Pectoris
• Myocardial Infarction
• Congestive Heart Failure
CORONARY ARTERY
DISEASE
The heart muscle must have an adequate
blood
supply to contract properly. When
coronary artery is narrowed or blocked, the
area of the heart muscle supplied by that
artery becomes ischemic and injured and
infarction ( tissue death ) may result.
The major disorder due to insufficient blood
supply to the myocardium are: angina
pectoris, congestive heart failure, and
myocardial infarction.
 NON-MODIFIABLE RISK MODIFIABLE RISK
FACTORS FACTORS
 HEREDITARY  SMOKING
 INCREASING AGE  HYPERTENSION
 GENDER  ELEVATED SERUM
CHOLESTEROL LEVEL
 PHYSICAL INACTIVITY
 OBESITY
 DIABETES MELLITUS

CONTRIBUTING RISK
FACTORS
 RESPONSE TO STRESS  INFLAMMATORY
 MENOPAUSE RESPONSE
 HOMOCYSTEIN LEVEL
Angina Pectoris – is a term used to describe chest
pain resulting from
myocardial ischemia.
Etiology:
1. Condition that decrease blood or oxygen supply to
the heart.
> atherosclerosis > aortic stenosis or
insufficiency
> arterial spasm > anemia and
hypoxemia
> hypotension > polycythemia
2. Conditions that increase demands on the
myocardium
> exertion >
hyperthyroidism
> emotion > myocardial
damage
nical Manifestation:
> transient paroxysmal attacks of substernal or precordia
pain.
> dyspnea > pallor
> pallor > sweating
> palpitations
Medical Management:
> vasodilators – relaxes smooth muscle of coronary and
peripheral blood vessels, decreasing
work load of the heart and promoting
greater flow of blood and
oxygen to heart muscle.
eg: nitroglycerin / isosorbide dinitrate (isordil).
> beta – blocking agents – decrease myocardial
workload and oxygen demand by
decreasing contractility, heart rate,
and blood pressure.
eg: inderal, metoprolol, atenolol
  Calcium channel blockers – reduce vascular smooth musc
tone by interfering with the ability of calcium ions
to initiate muscular contraction.
> eg: diltiazem, nifedipine, verapamil.
Analgesic –morphine sulfate is most commonly used as it als
reduces venous return ( preload) thereby
decreasing myocardial workload.
Dietary modifications – low fat, low cholesterol, low calorie
and high fiber diet.

rsing Management:
onitor cardiac rhythm > notify physician if c
rovide restful envirnment pain is not relieved by
dminister PRN analgesic 3 nitroglycerin tablets
dminister supplemental oxygen or ordered analgesics.
btain 12 lead ECG
onitor BP/nitroglycerin adm.
yocardial Infarction
also known as heart attack or coronary occlusion.
a formation of localized necrotic areas within the myocardium
usually follows the sudden occlusion of a coronary artery
and the abrupt cessation of blood and oxygen flow to
he heart muscle.

Clinical Manifestation:
 Chest pain > hypotension
 gray facial color > cold diaphoresis
 weak pulse > peripheral cyanosis
 tachycardia/bradycardia
 lethargy > nausea and vomiting
 great fear of death > apprehension
 dyspnea/ orthopnea > palpitations
 ECG changes
edical management:
the first 24 hours after an MI are the time of highest risk
for sudden cardiac death. The crucial time frame for the
salvage of the myocardium is the first 6hours.
pain control is priority.
continued pain is a sign of myocardial ischemia
pain also stimulates the autonomic nervous system and
increases preload, increasing myocardial demand.

nalgesic and nitrate

upplemental oxygen
uids and vasopressors to reverse ensuing shock
nvasive hemodynamic monitoring
ed rest and sedation to ease restlessness and fear
nticoagulant therapy
nti-dysrhytmic therapy
thrombolytic therapy – to dissolve the clot.
continous ecg monitoring
Nursing Management:
 assess characteristics of chest pain/associated
symptoms
 assess respirations and blood pressure.
 obtain 12 lead ECG.
 administer analgesic/ nitrates and monitor response to
therapy
 administer thrombolytic therapy
 provide restful, quiet environment.
 maintain continous cardiac monitoring.
 administer antidysrhytmic as ordered.
 monitor serum enzymes levels.
 assess apical pulse for murmur, pericardial friction rub,
S3 & S4
 monitor oxygen saturation
monitor hemodynamic parameters
eg: cardiac output, pulmonary artery pressure
assess for sign of decreased cardiac output
eg: decreased urine output, change in mental status
hypotension.
assess for signs of congestive heart failure
eg; ronchi, S3 and S4, dependent edema
monitor effectiveness of stool softeners and laxatives
assisst client in identifying own risk factors.

ngestive Heart Failure

fined as a physiologic states in which the heart is
able to pump enough blood to meet the metabolic needs
the body at rest or during exercise, even though filling press
e adequate.
art failure is not a disease itself: instead the term
notes a group of manifestation related to inadequate pump
nt.
erformance from either the cardiac valves or myocardiu
ump failure results in hypoperfused tissue, followed by
ulmonary and systemic congestion.

compensatory mechanism

ventricular dilation
ventricular hypertrophy
sympathetic nervous system stimulation
cardiac decompensation occurs when the heart
despite these mechanism fails to meet the deman
Output upon it, and symptoms of CHF develop.
auses of congestive heart failure include:
congenital heart defects
systemic hypertension
pulmonary hypertension
myocardial infarction
valvular stenosis or regurgitation
cardaic tamponade
constrictive pericarditis
hypervolemia
cardiomyopathy
conditions that precipitate heart failure
- dysrhytmia - pulmonary disord
- physical or emotional stress
- infection
- anemia
- thyroid disorder
 LEFT VENTRICULAR RIGHT VENTRICULAR
FAILURE FAILURE
Weakness Weight gain
Mental confusion Ankle or pretibial swelling
Insomia Abdominal distention
Anorexia Anorexia, nausea, gastric
Diaphoresis distress
Anxiety Pitting edema

Orthopnea Ascites

Tachycardia Jugular vein distention

Premature atrial contraction Hepatomegally

Pulmonary crackles Increased central venous

Enlarge PMI pressure

Signs of acute pulmonaryedema Subcoastal pain


Cough
S3 and S4
edical management;
oxygen administration
digitalis therapy to improve contractility
Pre-load reduction
- diuretics – furosimide
- sodium and fluid restrictions (1000ml/24hrs.)
- high fowlers position>after load reduction
afterload reduction
- vasodilators
- physical/emotional stress reduction
notropic agents to facilitate myocardial contractility and
enhanced stroke volume.
dopamine, dobutamine
angiotensin converting enzyme – captopril
dietary modifications – low sodium, high potassium
water restriction.
ursing management:
Monitor intake and output
Maintain fluid restriction
Provide frequent oral care
Daily weights
Monitor laboratory results
Assess for sign and symptoms of decrease cardiac outp
Assess heart rate and rhythm
Auscultate heart sounds
Monitor blood pressure(diuretics and vasodilator drugs)
Assess for jugular vein distention, edema,pain
Administer oxygen therapy and monitor ABG
Maintain sodium restriction diet
Assess lung sounds
Monitor for signs of hypokalemia,lethargy,hypotension
muscle cramping.
NURSING DIAGNOSIS FOR CLIENTS WITH STRUCTURAL
CARDIAC DISORDER

activity intolerance
chronic pain
decreased cardiac output
imbalance nutrition: less than body requirements
impaired gas exchange
impaired physical mobility
risk for ineffective airway clearance
risk for ineffective therapeutic regimen
management: individual
risk for ineffective tissue perfusion: cerebral
risk for infection
NURSING DIAGNOSIS FOR CLIENT WITH FUNCTIONAL
CARDIAC DISORDER

• acute pain
• decreased cardiac output
• excess fluid volume
• impaired gas exchange
• ineffective airway clearance
• ineffective tissue perfusion
• risk for activity intolerance
• risk for anxiety
• risk for impaired skin integrity
• risk for infection
 CONGENITAL HEART
DISEASES
ongenital means present at birth. Infants with
ongenital heart problems have structural defects o
e heart or its blood vessels.
al septal defects – is an opening between the two atrial.
because left atrial pressure is slightly higher than right
atrial pressure,blood shunts from left to right. This shun
causes an overload on the right side of the heart,
which enlarges to accommodate the increase volume.
majority asymptomatic..right ventricular hypertrophy, frequ
respiratory infection, feeding difficulties, dyspnea,fatigabilit
oartication of the aorta – is narrowing of the lumen (opening
of the aorta), which results in high pressure above and
low pressure below the stricture.
atent ductuc arteriosus – occurs when the ductus arteriosus
passage between the aorta and pulmonary artery tha
normally closes at birth remains open,sending oxygenat
blood back through the lungs.

the signs and symptoms depend on the volume of the

shunt(asymptomatic)..pulmonary congestion/heart failu
etralogy of fallot – got its name because it involves 4 major
defects of the heart and great vessels.
> pulmonary stenosis (narrowing)
- an abnormal cardiac condition, generally
characterized by concentric hypertrophy
of the right ventricle.
> ventricular septal defect
- opening between the two ventricles which
allows blood to shunt between them
> transposition of the great vessels
- a congenital cardiac anomaly in which the
the pulmonary artery arises from the left
ventricle and the aorta from the right ventricle,
so that there is no communication between
the systemic and pulmonary circulation.
> hypertrophy of the right ventricle
- enlargement of the right ventricle
nical Manifestations:

yanosis(severe and may deepens during exertion)

ubbing of fingers(depend on the degree of hypoxia)
ypoxia
olycythemia(compensatory mechanism/increase blood v
usceptibility to infection
2 saturation in arterial system is 80% or lower
enous oxygen saturation maybe below 60% (75%-80%)
izziness and convulsion (due to periods of cerebral anox
quatting (habitual response to relieve dizziness).

mplications:
ulmonary infections -heart failure
erebral embolism -subacute bacterial endocarditis
rain damage
SAMPLE NURSING
CARE PLAN
ample Nursing Care Plan:

Nursing management of the patient with CHD or MI

ay caring for the patient in varying stages of the disease
ocess.

Chest discomfort
related to imbalance between myocardial oxygen supply
and demand.
oals:
To detect the early chest discomfort and associated ECG an
homodynamic changes.
To reduce or eliminate chest discomfort.
To prevent the occurrence of chest discomfort.
nterventions:
The balance between myocardial supply and demand can
be improved by intervention that decrease myocardial O2
consumption or increase coronary blood flow.
oal 1:
nstruct patient to report chest discomfort immediately @ on
of discomfort.
Assess and document the patient’s description of chest
iscomfort.
Assess blood pressure, heart rate, and rhythm and respirator
rate.
Assess the skin for temperature and moistness.
Obtain 12 lead ECG during discomfort.
Report the findings of these assessment to the physician.
- ck-mb
- troponin
Goal 2:
Immediately reduce patient’s physical activity
Administer oxygen.
Administer morphine sulfate, nitroglycerine or
other
medications as ordered.
- morphine sulfate ( 2mg to 4mg IV q 5 min.
max. 25mg to 30mg)
-relieves pain and anxiety and reduce
the patients
restlessness.
-dilates venous and arterial bed.
-decrease ventricular preload.
-reduces the activity of the symphathetic
nervous with a resultant decrease
in the oxygen consumption by a
decrease in heart rate and blood
 Side effects:
respiratory depression, hypotension.
-nitroglycerine ( 12 to 14 hrs. followed by a free interval
of 10 to 12 hrs.).
- recommended for the first 24 to 48 hrs.
- decrease preload by peripheral vasodilation.
de effects:
Hypotension and increase intracranial pressure.

Continuously evaluate the patients response to therapy.

rovide restful environment.
romote the physical comfort by elevating the head of th
bed to 20 to 30 degrees or higher.
ndividualized basic nursing care.
oal 3
Provide care in a calm, competent manner.
Provide a restful environment.
Provide small portions of easily digested foods.
Assist the patient with ADL.
Offer stool softener or laxative to prevent straining wit
bowel movement (valsalva manuever).
Teach patient to recognize precipitating factor.
Teach patient to practice relaxation technique.
come criteria;
hest discomfort, changes in the 12 lead ECG, and hemody-
amic responses are detected at onset.
thin 5 minutes of interventions patients states that chest
scomfort is relieved or reduce; patients appears comfor-
able; heart and respiratory rates and BP are returning or
ave returned to baseline level and skin is warm & dry.
3. Patient denies chest discomfort; patient’s appears
comfortable; heart and respiratory rates and blood pressur
are within patient’s normal range; skin is warm and dry.

. Decrease myocardial tissue perfusion

Decreased myocardial tissue perfusion related to an
imbalance between myocardial oxygen supply and
demand.
Goals:

1. To detect early manifestation and etiologies of decrease

myocardial tissue myocardial tissue perfusion.
2. To reduce or eliminate manifestations of decreased
myocardial tissue perfusion.
 Interventions:
interventions are designed to detect manifestations of
the imbalance between myocardial oxygen supply and
demand and to improve this imbalance.

1
Monitor patient’s heart rate and rhythm
ssess and document cardiac rhythm every 1 to 4 hours
epending on the patient’s condition, before and after
ach dose of antiarrhytmic or vasoactive drug.
ssess blood pressure and obtain 12 lead ECG with changes
cardiac rhythm or if the patient complain of palpitations.
patient’s experience arrhythmias, perform a cardiovascular
hysical examination.
. Obtain venous blood for electrolytes, hemoglobin, arterial
blood for blood gas analysis and obtain a chest radiograph
as ordered by the physician.
. Assess, document and report to the physician the following
> new S3 and S4 (murmur/gallops)
> mitral regurgitation
> crackles
> reduce activity intolerance

Goal 2
- - - same in goal # 1
Out come criteria:
1. Arrythymias and conduction disturbances and signs and
symptoms of heart failure are detected at onset.