The cardiovascular system min

MEDICAL SURGICAL
NURSING (MSN)
The Cardiovascular system: General cardiovascular system,
Congenital heart defects, Disorders associated with the conducting
system, Congestive cardiac failure, Cardiac trauma, Myocardial
infarction & Angina
By C.Settley

Orientation to MSN
(Please see subject guide)
 Lecturer Ms C Settley Room 1
 023 347 0732/ 0844892450
 MSN Group
 settleyc@cput.ac.za /c.settley@gmail.com
 Work integrated learning
 Students must complete 80% of clinical hours as calculated per
year level will be allowed to enter for all the assessments
 Teaching methodology/strategies
 Emphasis is placed on self-directed learning!
Compiled by C.Settley 2018

Orientation to MSN
 Blackboard
 SDL
 Class attendance
 Compulsory prescribed books
 Recommended books
 Subject credits
 Purpose of this subject

Orientation to MSN
 Chapters with outcomes in subject guide
 Activities
 Assessment policy
 Guidelines for assignments
 Referencing, etc.
 Evaluation sheets

Orientation to MSN
ASSESSMENT WEIGHTING DATE
Summative 1 25% 16 February 2018
Deferred 1 03 April 2018
Summative 2 25% 23 March 2018
Deferred 2 16 April 2018
Summative 3 25% 09 April 2018
Deferred 3 ASAP
Summative 4 25% 18 May 2018
Deferred 4 04 June 2018

Outcomes
Apply knowledge regarding:
 Haematological studies
 Patho-physiology
 disease process
 clinical manifestations
 specific diagnostic and therapeutic interventions (tests and examinations)
Distinguish between the different health problems:
medical and surgical conditions of various body
systems
 Congenital defects
 Conducting system
 Congestive cardiac failure
 Coronary artery disease
 Angina
 Myocardial infarction
 Blood vessels disorders
 Peripheral arterial disease
 Deep vein thrombosis
 Cardiovascular disease in the elderly
Compiled by C.Settley
2018

 What is the cardio vascular system?
 What is it comprised of?
 What is its purpose? What does it circulate?
 How is the heart shaped?
 Where is it located?
 What are the 3 layers that the heart is made up, called?
 How many valves are in the heart?

Anatomy of the heart

Location of the heart The three layers of the heart wall

Compiled by C.Settley 2018Valves of the heart

Valves of the heart
 TRICUSPID VALVE: Closes off the upper right chamber (or
atrium) that holds blood coming in from the body.
 Opens to allow blood to flow from the top right chamber to
the lower right chamber (or from right atrium to right
ventricle).
 Prevents the back flow of blood from the ventricle to the
atrium when blood is pumped out of the ventricle.

Valves of the heart
 PULMONARY VALVE: Closes off the lower right chamber (or
right ventricle).
 Opens to allow blood to be pumped from the heart to the
lungs (through the pulmonary artery) where it will receive
oxygen.

Valves of the heart
 MITRAL VALVE: Closes off the upper left chamber (or left
atrium) collecting the oxygen-rich blood coming in from the
lungs.
 Opens to allow blood to pass from the upper left side to the
lower left side (or from the left atrium to the left ventricle).

Valves of the heart
 AORTIC VALVE: Closes off the lower left chamber that holds
the oxygen-rich blood before it is pumped out to the body.
 Opens to allow blood to leave the heart (from the left
ventricle to the aorta and on to the body).

Blood flow through the heart

Blood flow through the heart
 Watch video:
 Normal blood flow through the heart

Diagnostic tests- pg. 621
 Electrocardiography (ECG)
 A graphic representation of the electrical activity
of the heart muscle as it contracts and relaxes.
 A standard 12-lead electrocardiogram is used to
access the electrical activity of the heart and the
conduction of the cardiac impulse.
 Most cardiac conditions give rise to abnormal
recordings on the ECG.
 Video:
 ECG

Electrocardiography
(ECG) Compiled by C.Settley 2018

How to read an ECG
 HEART RATE
 Heart rate can be calculated using the following method
(if regular):
 Count the number of large squares present within one R-R
interval
 Divide 300 by this number to calculate the heart rate
 e.g. 4 large squares in an R-R interval: 300/4 = 75 beats
per minute

How to read an ECG
HEART RHYTHM
The heart rhythm can be regular or
irregular.
Irregular rhythms can be either:
Regularly irregular (i.e. a recurrent pattern
of irregularity)
Irregularly irregular (i.e. completely
disorganised)

How to read an ECG Compiled by C.Settley 2018

How to read an ECG
 Pre atrial contractions (pg636):
 Premature atrial contractions (PACs), also known as atrial
premature complexes (APC) or atrial premature beats (APB),
are a common cardiac dysrhythmia characterized
by premature heartbeats originating in the atria.
 While the sinoatrial node typically regulates the heartbeat
during normal sinus rhythm, PACs occur when another region of
the atria depolarizes before the sinoatrial node and thus triggers
a premature heartbeat.

How to read an ECG
Cardioversion is a medical procedure by which
an abnormally fast heart rate or other cardiac
arrhythmia is converted to a normal rhythm using
electricity or drugs

How to read an ECG
 Cardio pulmonary resuscitation and adrenalin
 Flatline:

Atrial flutter- pg636
 Irregular and fast heartbeat
 Cardio version may be required
 May be due to fluid overload, etc

 Exercise ECG (Stress test)
 An exercise electrocardiogram (EKG or ECG) is a test that
checks for changes in your heart while you exercise.
 Sometimes ECG abnormalities can be seen only during
exercise or while symptoms are present. This test is
sometimes called a "stress test“.
 See box 32.2 INFORMATION REQUIRED
BEFORE A STRESS TEST IS DONE

Exercise ECG (Stress test)Compiled by C.Settley 2018

 Chest radiography (CXR)
 An X-ray is an imaging test that uses small
amounts of radiation to produce pictures of the
organs, tissues, and bones of the body.
 When focused on the chest, it can help spot
abnormalities or diseases of the airways, blood
vessels, bones, heart, and lungs.
 Chest X-rays can also determine if patients have
fluid or air in their lungs.
 Heart size, etc. can be examined.

Chest radiography Compiled by C.Settley 2018

 Echocardiography
An echocardiogram, often referred to as a
cardiac echo or simply an echo.
It is a sonogram of the heart.
Echocardiography uses standard two-
dimensional, three-dimensional, and
Doppler ultrasound to create images of the
heart.

Echocardiography Compiled by C.Settley 2018

 Cardiac catherisation
Cardiac catheterisation is the insertion of a
catheter into a chamber or vessel of the
heart.
This is done both for diagnostic and
interventional purposes.

Cardiac catherisation Compiled by C.Settley 2018

Cardiac catherisation- pg 622
 VIDEO*:
 Cardiac catherisation
 Nursing responsibilities
 Consent
 NPO
 Cleansing and shaving of patient
 ECG as baseline to be taken
 Record any allergy history as the patient may react to x-ray dyes.
 Bedpan/urinal (empty bladder).
 Make patient comfortable as far as possible.
 Remove dentures, hearing aids, glasses, etc.
 Post procedure: monitor patient for dysrhythmias
and bleeding from catherisation site.
- Bedrest.

 Angiography
 Angiography or arteriography is a medical imaging technique
used to visualize the inside, or lumen, of blood vessels and
organs of the body, with particular interest in the arteries,
veins and the heart chambers.
 VIDEO *
 Coronary angiogram

 Doppler studies
A Doppler ultrasound is a test that uses
high-frequency sound waves to measure the
amount of blood flow through your arteries
and veins, usually those that supply blood to
your arms and legs.
Vascular flow studies, also known as blood
flow studies, can detect abnormal flow
within an artery or blood vessel.

 Pulse oximetry
 Pulse oximetry is a non-invasive method for monitoring a
person's oxygen saturation (SO2).

Haematological tests in
cardiovascular conditions- pg. 623
TYPE OF TEST RATIONALE
SERUM ELECTROLYTES Potassium, sodium, calcium and
magnesium affect cardiac function.
Hypernatremia may be indicative of
dehydration while potassium deficit may
result in dysrhythmias.
BLOOD GASES Arterial gasses indicate the levels of
oxygen and carbon dioxide in the blood,
and are indicators of cardiac functioning.
SERUM ENZYMES Presence of enzymes are indicative of
damage to muscle tissue and indirect
indicator of damage to myocardium. The
following enzymes’ presence are however,
direct indicators of damage to the
myocardium: CPK, LDH, SGOT,
MB(CKMB), Trop T.
SERUM LIPIDS Presence of serum lipids indicates the
presence of atherosclerosis.

 Haematological tests in
cardiovascular conditions- pg. 623
 REFER TO HANDOUT
 Haematological tests can help diagnose anaemia, infection,
haemophilia, blood-clotting disorders, and leukaemia.

Classification of the cardiac
disorders- pg. 629
Causative factor Conditions
Congenital defects Septal defects
Defects affecting the valves
Defects affecting major arteries
Mixed defects
Disturbances of conduction Atrial dysrhythmias
Atrioventricular/junctional dysrhythmias
Ventricular dysrhythmias
Infection and inflammatory disorders Rheumatic fever
Infective endocarditis
Valvular heart disease
Myocarditis
Pericarditis
Structural disorders Mitral valve disease
Aortic valve disease
Tricuspid and pulmonic valve disease
cardiomyopathy
Congestive conditions
Trauma
Heart failure
Cardiac contusion
Cardiac tamponade
Pericardial rupture
Rupture of the heart wall, papillary muscles, heart valves

Risk factors for
cardiac disorders- pg. 629
 Lifestyle
 Unhealthy diet, high blood cholesterol and other fats
 Obesity & overweight
 Tabacco use
 Hypertension
 Diabetes Mellitus
 Stress

Congenital heart defects- pg. 630
 Congenital heart disease (CHD) is a problem with the
heart's structure and function that is present at birth.
 Congenital heart defects are the most common type of
birth defect.
 The defects can involve the walls of the heart, the valves
of the heart, and the arteries and veins near the heart.
 They can disrupt the normal flow of blood through the
heart.
 The blood flow can slow down, go in the wrong direction or
to the wrong place, or be blocked completely.

Congenital heart defects
Aetiology and risk factors- pg.
630
Viral infections during pregnancy. Especially the
1st trimester, eg Rubella.
Nutritional deficiencies during pregnancy.
Exposure to environmental factors such as
toxins and radiation.
Excessive alcohol consumption during
pregnancy.
Drugs or medication abuse.
Family history.

Pathophysiology- pg 630
Defects form during early pregnancy
between the 6th and 12th week.
Heart of fetus develops from a single tube to
a heart with 4 chambers, veins and arteries

Pathophysiology- pg. 630
 In congenital defects, part of the heart may thus not develop
(partially or not at all).
 Defects may include: a hole in the septum or the formation of
abnormal connections of the arteries and veins of the heart.
 This results in the mixing of deoxygenated and oxygenated
blood.
 Congenital defects are structural in nature and cause problems
because of their effect on blood flow through the heart.
 Sometimes the conducting system is involved.
 Defects range from simple to severe.
 VIDEO* (atrial defect blood flow)

Septal defects
Septal defects,
Heart valve defects &
major blood vessel defects- pg. 631
 Hole in the septum that divides
the R & L side of the heart.
 Small septal defects may close
with time or not, causing
defective flow.
 Larger holes can cause more
problems with functioning of the
heart.
 Major presentation: palpitations
and irregular pulse, poor colour
of blood.

Heart valve defects
Septal defects,
major blood vessel defects- pg 631
 Heart valves allow blood to flow
in one direction.
 They open and close passively.
 Due to valve defects, these
valves may not open or close
properly (valve incompetence).
 Blood may flow backwards
(regurgitate).
 The heart now works harder and
it cannot get sufficient blood to
the lungs and body.

Septal defects,
 Major blood vessel defects
 Coarctation of the aorta
 Constriction of a segment of the aorta resulting in
obstruction of blood flow from the left ventricle.

Septal defects,
 Transposition of the great arteries
 When the pulmonary artery arises from the left ventricle
and the aorta from the right ventricle sends
deoxygenated blood from the right atrium back to the
systemic circulation.

Septal defects,
 Patent ductus arteriosus
 Before birth, the aorta and the pulmonary artery are
connected by a blood vessel called the ductus arteriosus
which is an essential part of the fetal circulation.
 Soon after birth, the vessel is supposed to close as part of
the normal changes occurring in the baby’s circulation.
 In some babies, it does not close, and the opening allows
oxygenated blood from the aorta to mix with deoxygenated
blood from the pulmonary artery.
 See other defects- pg. 632, Table 33.2 + figures

Clinical manifestations of
congenital defects- pg. 631
 Family history
 Child develops slow
 Tachypnea/cyanosed/dyspnea
 History of frequent chest infections
 The child, may squat when distressed- it increases blood
flow to the heart
 Clubbing of fingers and toes
 Enlarged liver or spleen
 Oedema of extremities
 ECG abnormalities
 Cardiac enlargement may be seen on x-ray and abnormal
heart sound may be heard
 Echocardiography and cardiac catherisation may be done
to confirm septal and valvular defects.

Management- pg. 631
Surgical correction of the defect which may involve
the use of catheters or open cardiac surgery.
The sooner the defect is corrected, the better in terms
of the child’s physical and mental health.
If the defect cannot be corrected, then conservative
management directed at preventing cardiac failure
and optimising pulmonary blood flow should be done.

What do you understand under
Decreased cardiac output?
 Inadequate blood pumped by the heart to meet the metabolic
demands of the body.
 Cardiac output is the amount of blood pumped by the heart
per minute.
 It is the product of the heart rate, which is the number of
beats per minute, and the stroke volume, which is amount
pumped per beat.

How would you assess a patient to evaluate
whether the patient has decreased cardiac
output?
 Abnormal heart sounds
 Angina
 Anxiety & restlessness
 Change in level of consciousness
 Breathing pattern
 Decreased activity tolerance/fatigue
 Decreased peripheral pulses; cold, clammy skin/poor capillary refill
 Decreased venous and arterial oxygen saturation
 Dysrhythmias
 Ejection fraction less than 40% (Ejection fraction is a measurement of the percentage
of blood leaving your heart each time it contracts. During each heartbeat pumping cycle,
the heart contracts and relaxes. When your heart contracts, it ejects blood from the two
pumping chambers (ventricles). When your heart relaxes, the ventricles refill with
blood.)
 Hypotension
 Weight gain, oedema, decreased urine output

Interventions for decreased
cardiac output?
Interventions Rationales
Record intake and output. If patient is acutely ill,
measure hourly urine output and note decreases in
output.
Reduced cardiac output results in reduced perfusion of
the kidneys, with a resulting decrease in urine output.
For patients with increased preload, limit fluids
and sodium as ordered.
Fluid restriction decreases extracellular fluid volume
and reduces demands on the heart.
Closely monitor fluid intake including IV lines. Maintain
fluid restriction if ordered.
In patients with decreased cardiac output, poorly
functioning ventricles may not tolerate increased fluid
volumes.
Auscultate heart sounds
The new onset of a gallop rhythm, tachycardia, and
fine crackles in lung bases can indicate onset of heart
failure. If patient develops pulmonary edema, there
will be coarse crackles on inspiration and severe
dyspnea.
Closely monitor for symptoms of heart failure and
decreased cardiac output, including diminished quality of
peripheral pulses, cold and clammy skin and extremities,
increased respiratory rate, presence of paroxysmal
nocturnal dyspnea or orthopnea, increased heart rate,
neck vein distention, decreased level of consciousness,
and presence of edema.
As these symptoms of heart failure progress, cardiac
output declines.

output?
Note chest pain. Identify location, radiation, severity,
quality, duration, associated manifestations such as
nausea, and precipitating and relieving factors.
Chest pain/discomfort is generally suggestive of an
inadequate blood supply to the heart, which can
compromise cardiac output. Patients with heart failure
can continue to have chest pain with angina or can
reinfarct.
If chest pain is present, have patient lie down, monitor
cardiac rhythm, give oxygen, run a strip, medicate for
pain, and notify the physician.
These actions can increase oxygen deliveryto
the coronary arteries and improve patient prognosis.
Place on cardiac monitor; monitor for dysrhythmias,
especially atrial fibrillation.
Atrial fibrillation is common in heart failure.
Examine laboratory data, especially arterial blood gases
and electrolytes, including potassium.
Patient may be receiving cardiac glycosides and the
potential for toxicity is greater
with hypokalemia; hypokalemia is common in heart
patients because of diuretic use.
Monitor laboratory tests such as complete blood
count, sodium level, and serum creatinine.
Routine blood work can provide insight into the
etiology of heart failure and extent of decompensation.
A low serum sodium level often is observed with
advanced heart failure and can be a poor prognostic
sign. Serum creatinine levels will elevate in patients
with severe heart failure because of decreased
perfusion to the kidneys. Creatinine may also elevate
because of ACE inhibitors.

output?
Administer medications as prescribed, noting side effects
and toxicity.
Depending on etiological factors, common medications
include digitalis therapy, diuretics, vasodilator
therapy, antidysrhythmics, angiotensin-converting
enzyme inhibitors, and inotropic agents.
Review results of EKG and chest Xray.
EKG can reveal previous MI, or evidence of left
ventricular hypertrophy, indicating aortic stenosis or
chronic systemic hypertension. Xray may provide
information on pulmonary edema, pleural effusions, or
enlarged cardiac silhouette found in dilated
cardiomyopathy or large pericardial effusion.

Describe interventions for activity
intolerance with possible rationales.
Assessment Rationales
Assess the physical activity level and mobility of the
patient.
 Take the resting pulse, blood pressure, and
respirations.
 Consider the rate, rhythm, and quality of the pulse.
 If the signs are normal, have the patient perform
the activity.
 Obtain the vital signs immediately after activity
 Have the patient rest for 3 minutes and then take
the vital signs again.
Provides baseline information for formulating nursing
goals during goal setting.
Discontinue the activity if the patient responds with:
 chest pain, vertigo, and/or dizziness
 decreased pulse rate, systemic blood pressure,
respiratory response
Reduce the duration and intensity of the activity if:
 Pulse takes longer than 3 to 4 minutes to return to
within 6-7 beats of the resting pulse.
 RR increase is excessive after the activity.
Investigate the patient’s perception of causes of activity
intolerance.
Causative factors may be temporary or permanent as
well as physical or psychological. Determining the cause
can help guide the nurse during the nursing intervention.
Assess the patient’s nutritional status. Adequate energy reserves are needed during activity.
Observe and monitor the patient’s sleep pattern and
the amount of sleep achieved over the past few days.
Sleep deprivation and difficulties during sleep can affect
the activity level of the patient – these needs to be
addressed before successful activity progression can be
achieved.

Determine the patient’s daily routine and over-the-
counter medication.
Fatigue can limit the patient’s ability to perform needed
activity. It can also be a medication side effect. Pay
attention to the patient’s use of beta-
blockers, calciumchannel blockers, tranquilizers,
antihistamines, relaxants, alcohol, and sedatives.
Assess the need for ambulation aids (e.g., cane, walker)
for ADLs.
Assistive devices enhance the mobility of the patient by
helping him overcome limitations.
Use portable pulse oximetry to assess for oxygen
desaturation during activity.
May determine the use of supplemental oxygen to help
compensate for the increased oxygen demands during
physical activity.
Assess the patient’s baseline cardiopulmonary status
(e.g., heart rate, orthostatic BP) before initiating
activity.
In normal adults, HR should not increase more than 20
to 30 beats/min above resting with routine activities.
Older patients are more susceptible to orthostatic
drops in BP with position changes.
Observe and document response to activity.
Close monitoring will serve as a guide for optimal
progression of activity.
Assess emotional response to limitations in physical
activity.
Depression over the inability to perform activities can
be a source of stress and frustration.

Establish guidelines and goals of activity with the patient
and/or SO.
Motivation and cooperation are enhanced if the patient
participates in goal setting.
Evaluate the need for additional help at home.
Coordinated efforts are more meaningful and effective
in assisting the patient in conserving energy.
Have the patient perform the activity more slowly, in a
longer time with more rest or pauses, or with assistance
if necessary.
Helps in increasing the tolerance for the activity.
Gradually increase activity with active range-of-motion
exercises in bed, increasing to sitting and then standing.
Gradual progression of the activity prevents
overexertion.
Dangle the legs from the bed side for 10 to 15 minutes. Prevents orthostatic hypotension.
Refrain from performing nonessential activities or
procedures.
Patient with limited activity tolerance need to prioritize
important taks first.
Assist with ADLs while avoiding patient dependency.
Assisting the patient with ADLs allows conservation of
energy. Carefully balance provision of
assistance; facilitating progressive endurance will
ultimately enhance the patient’s activity tolerance and
self-esteem.

Provide bedside commode as indicated.
Use of commode requires less energy expenditure
than using a bedpan or ambulating to the bathroom.
Encourage physical activity consistent with the
patient’s energy levels.
Helps promote a sense of autonomy while being
realistic about capabilities.
Instruct patient to plan activities for times when they
have the most energy.
Activities should be planned ahead to coincide with
the patient’s peak energy level. If the goal is too
low, negotiate.
Encourage verbalization of feelings regarding
limitations.
This helps the patient to cope. Acknowledgment that
living with activity intolerance is both physically and
emotionally difficult.
Gradually progress patient activity with the following:
 Range-of-motion (ROM) exercises in bed,
gradually increasing duration and frequency (then
intensity) to sitting and then standing.
 Deep-breathing exercises three or more times
daily.
 Sitting up in a chair 30 minutes three times daily.
 Walking in room 1 to 2 minutes TID.
 Walking down the hall 20 feet or walking through
the house, then slowly progressing walking
outside the house, saving energy for the return
trip.
Duration and frequency should be increased before
intensity.

Describe interventions for compromised family
coping with possible rationales.
Nursing Interventions Rationale
Observe for erratic behaviors (anger, tension, disorganization),
perception of crisis situation.
Information affecting the ability of the family to cope with
infant/child’s cardiac condition.
Encourage expression of feelings and provide factual
information about infant/child.
Reduces anxiety and enhances family’s understanding of the
condition.
Assess usual family coping methods and effectiveness.
Identifies need to develop new coping skills if existing
methods are ineffective in
changing behaviors exhibited.
Assess need for information and support.
Provides information about need for interventions to
relieve anxiety and concern.
Clarify any misinformation and answer questions
regarding disease process.
Prevents unnecessary anxiety resulting from
inaccurate knowledge or beliefs.
Assist in identifying and using
techniques to cope with and solve
problems and gain control over the situation.
Provides support for problem solving and management of the
situation.
Encourage to maintain the health of
family members and social contacts.
Chronic anxiety, fatigue, and isolation as result of infant care
will affect health and care capabilities of family.

Describe interventions for compromised family
coping with possible rationales.
Teach that overprotective behavior
may hinder growth and development
during infancy/ childhood.
Knowledge will enhance family understanding of the condition
and of adverse effects of behaviors.
Suggest and reinforce appropriate
coping behaviors, support family
decisions.
Promotes behavior change and adaptation to care for
infant/child.
Encourage parents to include ill infant/ child in family
activities rather than family revolving around needs of
infant/child.
Promotes normal growth and development of family
and infant/child.
Encourage to maintain consistent
behavior limits and modification
techniques.
Prevents behavioral problems and child control over family,
which interfere with child’s growth and family relationships.
Instruct parents in nutritional and
activity needs and/or limitations
and approaches that will assist
in establishing an effective pattern.
Assists in coping with effects and special needs of
infant/child with a cardiac defect.
Refer family for additional support
and counseling if indicated.
Referral supplies more assistance with coping than is
available from nursing personnel.

Disorders associated with
the conducting system- pg. 633
What is the conducting system?
 The cardiac conduction system is a group of
specialized cardiac muscle cells in the walls of the
heart that send signals to the heart muscle causing it
to contract.
 The main components of the cardiac conduction
system are the SA node, AV node, bundle of His,
bundle branches, and Purkinje
fibers.

- The SA node – sends out regular electrical impulses from the top chamber
(the atrium) causing it to contract and pump blood into the bottom chamber
(the ventricle).
- Also called the pacemaker, because it initiates each heartbeat.
- The electrical impulse then travels to the AV node. This causes the atria to
contract.
- From the AV node, the impulse passes down the ventricular septum to the
left and right bundle branches and the fibres of Purkinje to stimulate the
ventricles to contract.
- As a result of ventricular contraction, the blood is ejected into the aorta and
pulmonary circulation respectively.
- The normal rhythm of the heart is known as sinus rhythm as it is initiated
by the sinoatrial node.

The characteristics of normal sinus rhythm
are:
 The rhythm is regular.
 Rate is between 60-100 bpm.
 Each beat consists of a P - wave, QRS complex and a T – wave.
 Every P - wave is followed by a QRS complex
 The complexes are tall and narrow.

- Cardiac conducting system Video*
CLASSIFICATION OF DYSRYTHMIAS ACCORDING
TO:
- The rate of the dysrhythmia, whether fast or slow
- Whether life threatening or not
- The area of origin

Atrial dysthymias- pg. 636
 PAC
 Originates in the atria
 May occur in healthy individuals and are frequently due to
emotion, exertion or stimulants
 Mostly due to sympathetic over activity, hypoxia, stress,
smoking or anxiety
 Can also be associated with valvular heart disease, atrial
chamber enlargement and coronary artery disease
 May mark the onset of arterial fibrillation or heart failure
 P-waves are premature and differs from normal sinus P
waves
 Described as palpitations
 Underlying cause should be investigated

 Atrial flutter
 Irregular and fast
 A saw tooth pattern as baseline
 Common in rheumatic heart disease (Rheumatic fever is an inflammatory disease that
sometimes happens after an infection caused by a bacteria called group A streptococcus, like strep throat or scarlet fever.
Rheumatic fever happens when the infection is not completely treated with medicine (antibiotics). It may affect the heart,
joints, skin and brain).
 Fluid overload
 Cardioversion

 Atrial Fibrillation
 Atrial fibrillation is an irregular and often rapid heart rate that
can increase your risk of stroke, heart failure and other heart-
related complications.
 During atrial fibrillation, the heart's two upper chambers (the
atria) beat chaotically and irregularly — out of coordination with
the two lower chambers (the ventricles) of the heart.
 Atrial fibrillation symptoms often include heart palpitations,
shortness of breath and weakness.

 Atrial Fibrillation
 Episodes of atrial fibrillation can come and go, or you may
develop atrial fibrillation that doesn't go away and may require
treatment. Although atrial fibrillation itself usually isn't life-
threatening, it is a serious medical condition that sometimes
requires emergency treatment.
 It may lead to complications. Atrial fibrillation can lead to blood
clots forming in the heart that may circulate to other organs
and lead to blocked blood flow (ischemia).
 Treatments for atrial fibrillation may include medications and
other interventions to try to alter the heart's electrical system.

Atrial Fibrillation
 Some people with atrial fibrillation have no symptoms and are unaware of their
condition until it's discovered during a physical examination. Those who do have
atrial fibrillation symptoms may experience signs and symptoms such as:
 Palpitations, which are sensations of a racing, uncomfortable, irregular heartbeat
or a flip-flopping in your chest
 Weakness
 Reduced ability to exercise
 Fatigue
 Light-headedness
 Dizziness
 Confusion
 Shortness of breath
 Chest pain

Ventricular dysthymias - pg. 638
Ventricular tachycardia
 A condition in which the lower chambers of the heart (ventricles) beat very quickly.
 Heart rate above 100 beats per minute
 May be up to 180 beats per minute
 Treatment depends on haemodynamic status of the patient:
 A raised BP- Cardioversion will be required, anti arrhythmic agents (amiodarone)
and correction of electrolyte and acid-base balance must be implemented.
 If patient collapses then standard CPR must be commenced

 Ventricular fibrillation
 Complete disorganisation of the cardiac rhythm
 Irregular heart waves on ECG
 Varies in size and shape
 No contraction therefore no cardiac output
 Patient would appear clinically dead as there would be no pulse
 Treatment: defibrillation and CPR

 Ventricular asystole
 Ventricular asystole is indicative of cardiac arrest. It requires
immediate attempts at resuscitation, with a poor prognosis at that.
It is characterized by the absence of electrical activity for a length
of time with intermittent ventricular complexes of abnormal
configuration.

Nb:
 In emergencies due to arrhythmias, rapid and correct diagnosis is necessary for adequate
therapy.
 The clinical symptoms, the physical examination, and the 12-lead electrocardiogram are
important sources of information for making a correct diagnosis
 It is essential to get information about the underlying heart disease, understand the mechanism
of the present arrhythmia
 Amiodarone is currently regarded as the most effective antiarrhythmic drug available for the
treatment of patients with both supraventricular and ventricular tachy arrhythmias.
 Beta blockers. Beta blockers work by blocking the effect of hormones such as adrenaline on
the heart. They are commonly prescribed to people with heart failure or angina, or following
a heart attack. They are used to treat high blood pressure alongside another drug.
 The use of atropine in cardiovascular disorders is mainly in the management of patients with
bradycardia. Atropine increases the heart rate and improves the atrioventricular conduction by
blocking the parasympathetic influences on the heart.

Management of restoring a normal rhythm
 The application of electrical ‘shock’ therapy, defibrillation or cardioversion.
 The implantation of a temporary pacemaker (A pacemaker is a small
device that's placed in the chest or abdomen to help control abnormal heart
rhythms. This device uses electrical pulses to prompt the heart to beat at a
normal rate).
 Pacemakers can be temporary or permanent. Temporary pacemakers are
used to treat temporary heartbeat problems, such as a slow heartbeat
that's caused by a heart attack, heart surgery, or an overdose of medicine.
 They're used until a permanent pacemaker can be implanted or until the
temporary condition goes away.
 The use of medications.
 Cardiac ablation (Catheter ablation is a minimally-invasive procedure
used to remove or terminate a faulty electrical pathway from sections of
the hearts of those who are prone to developing cardiac arrhythmias)
 An implantable cardiac defibrillator.
 Surgery.

Congestive heart failure- pg. 643
• When the heart’s function as a pump is inadequate to
deliver oxygen rich blood to the body.
• Can be caused by diseases which weaken the heart
muscle
• Increased oxygen demand by the body beyond the
capability of the heart to deliver adequate oxygen
rich blood to the tissues.
• Aetiology
- Coronary artery disease
- Valvular disorders
- Hypertension
- Infections
- Arrhythmias

Congestive heart failure
 The normal heart is able to meet the body’s need for oxygen by
increasing its output in response to increased demand for
oxygen. BUT, in heart failure:
 The heart’s capacity to increase the force of contraction has been
exceeded and the heart cannot respond to the body’s demands.
 The heart does not function adequately due to a problem within the
heart itself, such as ischaemic heart diseases, cardiomyopathy and
constrictive pericarditis.
 If ↓ contractility of the heart muscle due to cardiac failure, the
cardiac output is compromised leading to ↓ stroke volume and
systemic arterial blood pressure.

Classification of
congestive cardiac heart failure
(CCF)- pg. 644
1. Systolic heart failure/ Diastolic heart failure

Classification of congestive cardiac heart failure
(CCF)- pg. 644
2. Right-sided heart failure/ Left sided heart failure
The failure of the pumping action of the right side of the heart causes swelling in the legs
and abdomen while that of the left side, causes congestion of the lungs.

Classification of congestive cardiac heart failure
(CCF)- pg. 644
3. Forward heart failure/ Backward heart failure
- Inability of the heart to pump sufficient blood to meet the
oxygen needs of the body during an exercise or rest leads
to forward heart failure;
- Whilst the inability of the heart to meet the oxygen needs
when the heart pressures are very high is backward
heart failure.

congestive cardiac heart failure (CCF)- pg. 644
 Respiratory symptoms
 Difficulty breathing, dyspnoea (Dyspnea: Difficult or labored breathing;
shortness of breath), orthopnoea (Orthopnea or orthopnoea is shortness of breath
(dyspnea) that occurs when lying flat, causing the person to have to sleep propped up in bed
or sitting in a chair).
 Disturbances in sleep
 Pleural effusion
 Gastrointestinal symptoms
 Enlarged liver & spleen
 Increased venous pressure
 Abdominal pain, digestive problems, anorexia, nausea and
vomiting & ascites (Ascites refers to abnormal accumulation fluid in the abdominal cavity).

congestive cardiac heart failure (CCF)- pg. 644
 Oedema
 Due to congestion and high pressure in the capillaries
 Prevents fluid from moving back into the blood vessels thus
collects in the tissues
 Retention of sodium and water
 Renal symptoms
 Renal impairment
 Poor perfusion
 Inadequate blood supply

congestive cardiac heart failure
(CCF)- pg. 644
 Neurological symptoms
 Cerebral hypoxia due to respiratory insufficiency
 Confusion
 Mental clouding
 Other symptoms
 Weakness and fatigue
 Cold extremities
 Distended neck veins due to congestion of circulation
 Physical examination

Diagnostic test results: CCF- PG. 646
 Chest x-ray
 Will show cardiac enlargement
 Congestion of the lungs
 Possible pleural effusion
 ECG
 Large complexes typical of cardiac strain and cardiac enlargement
 Blood gases
 Hypoxia
 Respiratory and metabolic acidosis
 Blood chemistry
 ↑ sodium levels
 Levels of urea
 These levels may be elevated due to renal insufficiency
 Liver enzymes may be raised (impaired liver function)

General nursing care plan for a patient with a
disorder of the cardiovascular system- pg.624
PROBLEM/NEED NURSING
DIAGNOSES
EXPECTED
OUTCOMES
NURSING
INTERVENTIONS &
RATIONALE
EVALUATION
Dyspnea, fatigue &
weakness
-Altered breathing
pattern related to
pulmonary congestion
and insufficient supply
to the lungs
Inadequate circulation,
poor oxygenation and
perfusion due to
reduces cardiac output
and impaired cardiac
function.
Relief from respiratory
distress
Rest and comfort
Adequate circulation
and tissue perfusion
O2, monitor
respiration, tissue
perfusion to improve
cardiac function and
circulation, enhances
metabolism to provide
energy and strength.
Semi fowlers position
Support with pillows,
armchair to improve
ventilation.
Monitor vital signs
Encourage deep
breathing and
coughing of
secretions. Remove
secretions
Administer medication
as prescribed.
Respiratory rate, blood
pressure within normal
ranges.
Perfusion and colour
of patient.

DIAGNOSES
EXPECTED
OUTCOMES
NURSING
INTERVENTIONS &
RATIONALE
EVALUATION
Chest pain and
discomfort
Possible abdominal
distention
Congestion
Organ dysfunction due
to congestion and poor
circulation to gastro
intestinal organs
manifested by the
expression of pain,
dyspnea & tachycardia
Rest and comfort
Pain relief
Reduced fluid
retention
Fluid restrictions
Sodium restrictions
Note abdominal
distention increase
Monitor intake and
output
Semi fowlers position
Test urine daily for
proteins and blood +
weight
Abdominal girth is
reduced
Oedema is reduced
Clear urine
Weight
Oedema Fluid volume deficit
due to renal
impairment and
sodium retention
Optimum fluid and
electrolyte balance
Reduced oedema
comfort
Administer diuretics as
prescribed
Intake and output
monitor
Fluid restrictions, Salt
restrictions
Oedema test, Elevate
legs & Pressure care
Output=intake
Fluid balance

DIAGNOSES
EXPECTED
OUTCOMES
NURSING
INTERVENTIONS &
RATIONALE
EVALUATION
Potential for anxiety Knowledge related to
condition, treatment
and medication of
lifestyle
Risk of complications
related to
cardiovascular
disorders
Health education
Compliance enhanced
Condition stabilised
Complication risk
reduced
Educate patient:
medication, complying
with treatment, self
management
Advise about intake
and output, oedema
Patient should be able
to manage condition
as far as possible at
home
Complications should
be detected early and
managed/referral

Nursing management- pg.624
 Bed rest. Balance.
 Diet.
 Oxygen therapy.
 Oedemous area care.
 Expression of feelings, concerns, etc.
 Health education.

Cardiac trauma- pg.647
TYPE OF TRAUMA SPECIFIC INJURIES
Blunt trauma, eg crushing of the chest
wall, blow to the anterior chest and
deceleration
• Pericardial rupture, rupture of the
heart wall
• Traumatic septal defects
• Injuries to the heart valves, papillary
muscles
• Cardiac contusion
Penetrating trauma, eg gunshots, stab
wounds
• Gunshots, stab wounds, injuries
from flying objects, intra-cardiac
catheters, pacemaker electrodes,
CVP lines
• Patients with structural damage
• Accompanied by massive
haemorrhage

Cardiac surgery- pg. 647
 Surgery may be performed to:
 Correct defects
 Repair or replace damaged heart valves
 Restore coronary circulation
 Repair cardiac structures
 Transplant the heart
 2 types: open and closed
 Open-heart surgery is any type of surgery where the chest is cut open and
surgery is performed on the muscles, valves, or arteries of the heart.
 Closed-heart surgery can be carried out without interrupting the flow of
blood through the heart and visualising internal structures.

Cardiac surgery:
preoperatively- pg.648
 Admission usually few days prior to surgery for work-up and
preparation.
 Cardiac function will be evaluated via studies: ECG, cardiac
catherisation, blood studies, echocardiography.
 Evaluation of respiratory function via pulmonary tests.
 Severe problems like dysrhythmias, congestive heart failure and
angina should be controlled before the patient goes to theatre.
 Psychological preparation.
 Skin preparation to guard against infections.

Cardiac surgery:
postoperatively- pg.648
 ICU care (for about 48 hours depending on condition).
 Ventilated.
 Vital signs, cardiac function should be monitored.
 Medication as prescribed.
 Fluids as prescribed to replace blood loss and electrolytes.
 Neurological status (complication).
 Chest drains monitored.
 Analgesics as prescribed.
 Slight pyrexia is normal as response to trauma (as the body
handles the operated body tissues). Monitor thoroughly for
infection.
 Early ambulation once tubes are removed depending on
progress.
 Encouragement.

Cardiac surgery:
complications- pg.648
 Dysrhythmias
 Haemorrhage.
 Renal shutdown.
 Cardiogenic shock.
 Cardiac tamponade.
 Electrolyte imbalance.
 Pneumothorax
 Emboli.
 Stress ulcers.

Coronary artery disease
- pg. 650
 Coronary artery disease (CAD) is the most common type of heart
disease.
 CAD happens when the arteries that supply blood to heart muscle
become hardened and narrowed.
 This is due to the build-up of cholesterol and other material, called
plaque, on their inner walls.
 This build-up is called atherosclerosis.
 As it grows, less blood can flow through the arteries.
 As a result, the heart muscle can't get the blood or oxygen it
needs. This can lead to chest pain (angina) or a heart attack.

Coronary artery disease
- pg. 650
 Most heart attacks happen when a blood clot suddenly cuts off the
hearts' blood supply, causing permanent heart damage.
 Over time, CAD can also weaken the heart muscle and contribute
to heart failure and arrhythmias.
 Heart failure means the heart can't pump blood well to the rest of
the body.
 ALSO KNOWN AS ISCHAEMIC CARDIAC DISEASE

Coronary artery disease-
pg. 650

pg. 650
Risk factors
 Direct cause not known. The following are specific risk
factors:
Increasing age
 Increases the chances of developing
arteriosclerosis & atherosclerosis
Gender
 Males are more prone to develop atherosclerosis
 Due to protective effect of oestrogen
 After menopause, the risk is equal

pg. 650
Risk factors
Heredity
 Family history
Stress factors
 Cardiac output increases
 It thus increases myocardial oxygen demand and
workload
 Mobilisation of fat from fat stores to provide
energy in response to stress may contribute to
developing the disease

pg. 650
Risk factors
Elevated serum cholesterol
 Increased amounts of cholesterol increases the risk
of developing the disease
Obesity
 Associated with higher levels of cholesterol,
hypertension & diabetes mellitus
 Increased cardiac workload by making the heart
work harder to pump blood through the tissues

pg. 650
Risk factors
Existing diseases
 HPT & DM increases the risk of developing the
disease
Diet
 High calorie diet
 Contribute to high blood lipid levels
 Abnormal metabolism
 Mobilisation of fats increases lip levels
 Hyperlipidaemia
 Gout

pg. 650
Risk factors
Smoking
 Nicotine, tar and carbon monoxide damages the
blood vessel
 Vasoconstriction
 Obstruction
Physical inactivity
Relationship between inactivity and
development of the disease

Coronary artery disease:
 Disruption in blood supply through arteries gets disrupted, or the
oxygen content of the blood is not adequate to meet the demands
of the body.
 In CAD, the arteries are blocked aby Atherosclerotic lesions
caused by the deposit of plaques on the arteries.
 These plaques protrude into the lumen of the artery, leading to
narrowing and obstruction of the blood flow.
 The vascular endothelium in the involved areas become necrotic,
narrow and rough, making them susceptible to clot formation.

 Thrombi forms on the surface of the plaque and the effects of
fibrin consolidate the thrombus, causing bleeding to the thrombus.
 This worsens by further deposits and enlargement takes place.
 The myocardial cells become ischaemic within ten seconds of
coronary occlusion, and the pumping function of the heart
deprives the ischaemic cells of the needed oxygen and glucose,
resulting in chest pain.

Coronary artery disease Compiled by C.Settley 2018

Subjective data- pg. 652
Chest pain
Frequency, duration, location, character
Aggravating & relieving factors
Associating factors
Dyspnoea
Exertion
Pallor
Diaphoresis
Dizziness
Nausea & vomiting

Subjective data-
pg. 652
Psychosocial information
 Lifestyle, e.g. Age & gender
Lifestyle & habits
 Smoking
 Alcohol intake
 Exercise
 Stress
 Occupation

Subjective data-
pg. 652
 Medication history
 Prescribed and over the counter medication
 Contraceptives, hormone therapy
 Past medical history
 As contribution
 Family medical history
 Familial tendency
 CVD
 DM
 HPT
 Hyperlipidaemia

Objective data-
pg. 652
 Physical assessment on examination with the following signs:
 Chest pain
 Pallor or cyanosis
 Distended neck veins
 Abnormal heart sounds
 Baseline:
 Pulse rate and rhythm
 Peripheral pulses
 Respiration rate, rhythm and depth
 Blood pressure
 Level of consciousness
 Urinary output

Diagnostic test results
- pg. 653
ECG
Exercise stress test
Coronary angiography
Echocardiogram

Diagnostic test results
- pg. 653
 Blood chemistry
 Creatine phosphokinase (CPK): raised levels indicate
that muscle have been damaged.
 Lactic dehydrogenase (LDH): muscle protein
 Creatine kinase - MB (CKMB): type of creatine that is
specific to myocarduim and raised levels indicate that
damage to the myocarduim has taken place
 Troponin (Trop T): protein found in muscle. Raised
levels indicates that myocardial damage has taken
place.

Angina pectoris-
pg. 653
A substernal pain
Radiates to the left arm, may radiate to other
areas such as the jaw, neck, back or epigastrium
region

Stable Unstable
Angina pectoris-
pg. 653
Types
Related to known
triggering factors.
Always relieved by
rest and/or a known
dose of nitrate.
Duration and
intensity is
predictable.
The condition never
varies much.
Unpredictable pattern.
Number of attacks,
intensity and duration,
has a tendency to
increase.
Strongly correlated with
myocardial infarction.
Unstable angina is
angina at rest or on
minimal exertion, and is
of recent onset.

Noctural Decubitus
Angina pectoris-
pg. 653
Types
Attacks occur at
night
Only during
REM sleep
Attacks occur
when the patient
is lying down
The pain is
relieved when the
patient stands

Intractable Variant
Angina pectoris-
pg. 653
Types
Severe
Incapacitating pain
Does not respond to
treatment
Indicative of
myocardial
infarction
Should not be
ignored
Urgent attention
As result of coronary
artery spasm
Unpredictable
During sleep
Pain usually relieved
by calcium channel
blockers

Angina:
Management-
pg. 653
Control of risk factors.
Dietary & lifestyle changes.
Follow-ups.
Nitrates (meds).
Educate patient: e.g. inform about
triggers such as eating a heavy meal.

Myocardial infarction (MI)-
pg. 654
 Heart attack: usually occurs
when a blood clot blocks
blood flow to the heart.
Without blood, tissue loses
oxygen and dies.
 Symptoms include tightness
or pain in the chest, neck,
back or arms, as well as
fatigue, light-headedness,
abnormal heartbeat and
anxiety. Women are more
likely to have atypical
symptoms than men.

Myocardial infarction (MI)
Clinical manifestations-
pg. 654
 Chest pain (retrosternal)
 Radiates to left arm- epigastrium or jaw
 Varies in intensity
 Lasts more than 30 minutes
 Associated with dyspnoea, sweating, nausea & vomiting
 Shock due to drop in cardiac output- drop in BP
 Clammy, cold, dizziness
 Tachycardia
 Distressed
 Breathless
 Fear and anxiety

Medical management-
pg. 654
 Priority is to limit the extent of infarct
 Thrombolytic therapy (IV to dissolve the clot and re establish
coronary perfusion)
 Criteria: chest pain, S-T elevation in two contiguous ECG leads
 Complications of thrombolytic therapy: haemorrhage, pyrexia,
dysthymias, cardiac rupture

Medical management-
pg. 654
To re establish coronary perfusion: (Coronary
perfusion pressure (CPP) refers to the pressure gradient that
drives coronary blood pressure, meaning the difference between
the diastolic aortic pressure and the right atrial end diastolic
pressure).
1. Percutaneous transluminal coronary angioplasty (PTCA)
 Treat narrowing of the coronary arteries of the heart found in coronary
artery disease.
2. Coronary artery bypass graft (CABG)
 Is a type of surgery that improves blood flow to the heart.

Nursing management-
pg. 654
 Diagnosis
 Discomfort
 Decreased cardiac output
 Expected outcomes
 Reduced and controlled pain
 Optimised cardiac output
 Decreased anxiety

Nursing management-
pg. 654-655
 Nursing interventions
 Severity of pain, radiation, duration, associating symptoms
 Vital signs monitoring (2-4 hourly)
 ECG, pulse oximetry, chest x-rays, blood tests
 O2 – 40%
 Nitrates to dilate coronary blood vessels and increase bloodflow
 Opioid analgesics- Morphine IV.
 Calcium channel blockers to relieve the coronary artery spasm
and increase blood flow
 Sedatives to promote rest.
 Βadrenergic blocking agents as prescribed to reduce contractility
of the myocardium (β1)
 Rest, quiet environment, calm activities

Complications-
pg. 655-656
 Dysthymias
 Common in post myocardial infarction
 Cardiac monitoring important
 Cardiogenic shock
 Rupture
 Control dysthymias
 Monitor patient
 Stabilisation of fluids
 Thrombolytic therapy

Complications-
pg. 655-656
 Cardiac failure
 Impairment in maintaining circulation
 Left sides heart failure occurs more often than right sided
heart failure as complication
 Digoxin contraindicated post myocardial infarction as it may
increase myocardial oxygen demand and lead to ischemia.
 Post infarction syndrome and extension of infarction
 Ongoing chest pain
 ECG monitoring
 Treat with nitrates, beta blockers & thrombolysis

Complications-
pg. 655-656
 Cardiac rupture
 Necrotic tissue
 Fatal
 Rupture of intra cardiac structures
 Diagnosed by echocardiography
 Left ventricular aneurysm
 Takes weeks to develop
 A left ventricular aneurysm is a swelling of a weakened area
in the muscular wall of the left ventricle, the main pumping
chamber of the heart.

Complications-
pg. 655-656
 Deep vein thrombosis and embolisms
 Due to increased immobility
 Treated with anti coagulants
 Pericarditis & Dressler’s syndrome
 Dressler's syndrome is a type of pericarditis — inflammation
of the sac surrounding the heart (pericardium).
 Health information
 Cardiac rehabilitation: diet, exercise, weight control, smoking
habits and suggestions on how to stop, stress management.
 Activities & self care

Reference list
 https://www.cardiachealth.org/heart-disease-tests/cardiac-
catheterization/
 http://alexisartscience.blogspot.co.za/2011/01/
 http://www.scielo.br/scielo.php?pid=S0102-
76382017000100057&script=sci_arttext
 https://topsy.one/hashtag.php?q=%23myocardial
 https://www.slideshare.net/10NEEL10/science-ppt-50633643
 https://www.mayoclinic.org/diseases-conditions/deep-vein-
thrombosis/symptoms-causes/syc-20352557
 https://embryology.med.unsw.edu.au/embryology/index.php/
Advanced_-_Cardiac_Conduction
 https://schoolworkhelper.net/coronary-artery-disease-
ischemic-heart-disease-overview-coronary-artery-disease-
ischemic-heart-disease-overview-pathophysiology/

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