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Cardio Toprank - None

Nursing Care Of Clients With Life Threatening Conditions, Acutely Ill/ Multi-Organ
Problems, High Acuity And Emergency Situation, Acute And Chronic (Nueva Ecija
University of Science and Technology)

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TOPRANK - CARDIOLOGIC NURSING

RN MAY 2023: BATCH HIRAYA
Lecturer/s: Sir Pocholo Yamsuan

CARDIOVASCULAR SYSTEM
● Cardiovascular system consists of:
1. Heart
2. Arteries
3. Veins
4. Capillaries

● Function
1. Circulation of blood
a. Primary function
2. Delivery of O2 and other nutrients of the body Pericardium
a. If there will be problems in the ● Invaginated sac
cardiovascular system this may result to ● Protects the entire heart
problems in other system e.g. respi ○ Visceral
system ■ Attached to the exterior of myocardium
3. Removal of CO2 and other cellular products of ○ Parietal
metabolism ■ Attached to the great vessels and
diaphragm
ANATOMY OF THE HEART

Heart
● Muscular pumping organ that propels and receives blood from
the venous system of the body.
○ Muscle can be controlled through contractions →
pumping organ
● Hollow muscular organ that weighs 300 400 grams
● Resembles like a close fist
● Located in Papillary Muscle
○ Behind the sternum and between the lungs ● Arise from the endothelial and myocardial surface of the
■ Transcends to the left side (left lungs) ventricles and attached to the chordae tendineae.
○ On the middle of mediastinum
○ Chordae Tendineae
● Kaya merong 2 na hati ung heart
● Hair like structures that divide the left and right heart
● Attached to the TV and MV
○ Structures na kasama sa right and left parts of the
heart
● Prevent eversion during systole.
● Separated into 2 pumps
1. Right heart
a. Pump blood through the lungs
2. Left Heart
a. Pump blood through the peripheral
organs

Layers of the Heart

Endocardium Myocardium Epicardium

Lines the inner Muscular Layer Thin covering covers

chamber of the Middle layer the outer surface of
heart, valves , the heart
chordae tendinae
and papillary
muscles

Responsible for For outer protection

major pumping (purpose)
Chambers of the Heart
action of the
ventricles

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TOPRANK - CARDIOLOGIC NURSING

RN MAY 2023: BATCH HIRAYA
Lecturer/s: Sir Pocholo Yamsuan

TMAP RL 52

Tricuspid Right 5th ICS

Mitral Left 5th ICS

Aortic SL Right 2nd ICS

Pulmonic SL Left 2nd ICS

NORMAL CARDIAC CYCLE

● 4 chambers of the heart 1. Systole
a. Period of chamber contraction
2. Diastole
BOARD QUESTION: a. Period of chamber relaxation
b. Para mag relax kailangan ba ng Droga? Yes!
How many chambers does the heart have? 3. Cardiac cycle
a. All events of Systole and Diastole during one heart
Answer: 4 chambers
flow cycle
b. S + D = CC
● 2 major chambers c. Normal CC adult: HR
○ Atrium
○ Ventricle BLOOD FLOW

BOARD QUESTION:

How many MAJOR chambers does the heart have?

Answer: 2 chambers

Atria / Atrium
● 2 chambers
● Function : receiving chambers
● Upper chamber ––(connecting or receiving chamber)
● Location : lies above the ventricles

1. Right atrium
a. Receives systemic venous blood through SVC ,
IVC and coronary sinuses
b. Receives deoxygenated blood ● SVC & IVC → right atrium → tricuspid Valve → right
2. Left Atrium ventricle → left & right pulmonary artery → lungs → left &
a. Receives oxygenated blood returning to the heart right pulmonary veins → left atrium → mitral / bicuspid valve
from the lungs through pulmonary veins → left ventricle → aortic valve → aorta
b. Had undergone pulmonary circulation →
oxygenated blood CARDIAC OUTPUT
● Pumping capacity of the heart
● ↑ CO → ↑ BP
Ventricles
● ↓ CO → ↓ BP
● 2 thick walled chambers
● Function : responsible for forcing out of blood
● Location : lie between the atria Which is better ↑ CO or ↓ CO? NONE.
● Lower chamber ––(contracting and pumping)
It should be NORMAL cardiac output.
1. Right ventricles
a. Contracts and propels deoxygenated blood into the General Concept
pulmonary circulation via Aorta during systole 1. Stroke volume
2. Left ventricles a. The amount of blood ejected with each heart beat
a. Propels blood into the systemic circulation via aorta 2. Cardiac output
during ventricular systole. a. Amount of blood pumped by the ventricles in liters
per minute
3. Pre load
Heart Valves

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TOPRANK - CARDIOLOGIC NURSING

RN MAY 2023: BATCH HIRAYA
Lecturer/s: Sir Pocholo Yamsuan

a. Degree of stretch of the cardiac muscle fibers in the b. Thyroxine

end of diastole i. released by thyroid → increases HR in
4. Contractility large qty, amplifies effect of epinephrine
a. Ability of the cardiac muscle t shorten in response c. Electrolytes
to an electrical impulse i. Potassium → cardiac dysrhythmia
5. Afterload 1. Normal: 3.5 - 5.5
a. The resistance to ejection of blood from the 2. ↓ K → hypokalemia →
ventricles prominent U wave
6. Ejection fraction 3. ↑ K → Tall Peak T wave
a. The percent of end diastolic volume ejected with 4. Usage of diuretics
each heart beat a. Loop (K wasting) →
b. CHF Furosemide (Lasix)
b. K sparing →
Aldactone
BOARD QUESTION:
ii. Calcium → heart function and contraction
What is the normal ejection fraction (EF)? phase
iii. Sodium → high Na >> blocks Na
Answer: 55 - 80% transport and muscle contraction
● ↑ 80 = very good EF (nagtatrabaho nang maigi ung puso) 1. Normal: 134 - 145

HEART SOUNDS
General Variables
● HR = S + D
1. Cardiac Output (CO) CO)= blood pumped per minute
● CC = S + D 1 minute
a. Affected by HR and BP
b. CO (ml/min) = HR x SV
1. S1 (lub)
2. Heart rate = cardiac cycles per minute
a. Normal
a. CC = (S + D)
b. Due to closure of AV valves
b. Normal range (60 - 100 bpm)
c. Timing : beginning of systole
c. Tachycardia
d. Loudest at the apex
d. Bradycardia
2. S2 (dub)
e. Symphatetic response = increases HR
a. Normal
f. Parasymphatetic response = decreases HR
b. Due to the closure of semilunar valves
3. Blood Pressure = CO x Peripheral resistance
c. Timing: diastole
a. Control is neural and hormonal
d. Location : apex ( LV ) or RV
b. Neural baroreceptors
e. Pitch : loudest
c. Hormonal - ADH , Aldosterone
3. S3 (ventricular diastolic gallop)
d. Epinephrine
a. Abnormal
b. Vibration resulting from resistance to rapid
Regulation of Heart Rate
ventricular filling secondary to poor compliance
1. Autonomic regulation
c. Timing : early diastole
a. Sympathetic
i. Lub dub dub
i. Norepinephrine increases HR >
ii. Somobra ung filling ng dugo kaya
maintains SV > increases CO
nagkaroon ng extra relaxation
ii. biliS
d. Pitch : faint and low pitched
iii. All ↑ except GU and GI
4. S4 ( atrial diastolic gallop)
b. Para sympathetic
a. Abnormal
i. Acetylcholine decreases HR
b. Vibration resulting from resistance to late
ii. All ↓ except GU and GI
ventricular filling during atrial systole
c. Vagal tone
c. Timing : late diastole
i. parasympathetic inhibition of inhere tent
i. Lub dub lub lub dub
rate of SA node > allowing normal HR
ii. Too late ang relaxation → nagkaroon na
ii. SA node = firing structure of the heart
ng another contraction
(stimulates atria to contract)
d. Location Apex
d. Baroceptors and Presoreceptors
e. Pitch : low ( use bell )
i. monitor changes in BP and allow reflex
5. Heart murmur
activity with the ANS .
a. Sound other than lub dub , caused by any
2. Hormonal and chemical regulation
disruption in the blood flow.
a. Epinephrine
b. There is problem in circulation
i. hormones release by adrenal medulla
during stress → increases HR
ii. Adrenaline rush
6. Pericardial friction rub

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TOPRANK - CARDIOLOGIC NURSING

RN MAY 2023: BATCH HIRAYA
Lecturer/s: Sir Pocholo Yamsuan

a. Extra heart sounds originating from pericardial sac i. identify deficiencies of coagulation
as it moves factors , prothrombin and fibrinogen
i. Wala masyadong fluid sa sac → friction ii. monitors in Heparin therapy
→ friction rub sound iii. NV : 60-70 secs
b. Timing : with each heart beat
c. Location : over pericardium >> upright position ,
BOARD QUESTION:
leaning forward
d. Pitch : high pitch and scratchy, grating, crackling
What is the parenteral form of anti clotting meds?
i. 2 scratch papers (sound)
e. Significance : inflammation , infection and
Answer: Heparin
infiltration.
Warfarin - oral form (tablet)
Pleural Friction Rub (3I)
1. Infection What is the antidote of Heparin?
2. Inflammation
3. Infiltration Answer: Protamine Sulfate

DIAGNOSTIC TESTS What is the antidote of Warfarin?

1. Blood studies
a. RBC Count (4 - 6) Answer: Vitamin K
i. To diagnose anemia and polycythemia
ii. NV – M ( 4.7- 6.1 ) F (4.2- 5.4 ) million
c. pT
/mm3
i.determines activity and interaction of the
b. Hgb (12 - 18)
prothrombin group
i. To measure oxygen carrying capacity of
ii. monitors in warfarin therapy
the blood (kung nagbababind ang O2 sa
d. NV : 12-14 seconds
hema)
3. ESR (Erythrocyte Sedimentation rate)
ii. Once hema and O2 binds, it helps
a. Measurement of the rate at which RBC settle out of
pulmonary circulation for gas exchange
anticoagulated blood in an hour
to happen
b. Elevated in infectious heart disorder or M.I.
iii. NV M (13-18 ) F 12-16 g /dl
c. ↑ ESR
c. Hct (36 - 54%) (Hgb x 3)
i. Pericarditis
i. Measure the volume of RBC in proportion
ii. Endocarditis
to plasma
iii. Myocarditis
ii. Important factor: blood viscosity
4. Cardiac proteins and Enzymes
iii. Helps in diagnosing anemia , PCV and
a. Time sensitive → dapat accurate ang hx
hydration statuses.
iv. NV M (42-48 %) F (36-42 %)
d. Platelet count (150 - 450) CKMB ● Most cardiac specific
i. To diagnose thrombocytopenia and ● Indicator of myocardial damage
bleeding tendencies. ● Elevates in 4 hrs
ii. To maintain hemostatis ● Peak at 18 hrs up to 3 days
iii. NV 150,000-450,000 / mm3
LDH ● Most sensitive indicator
e. WBC (5 - 10)
● Elevates in 24 hrs
i. To detect infection and inflammation ● Peaks at 48 - 72 hrs
ii. NV 5,000- 10,000 / mm3
2. Coagulation studies Trop I and Trop T ● Elevates within 3-4 hrs
a. Bleeding time (skeletal muscle ● Peak at 4 - 24 hrs
i. Ability to stop bleeding after small Trop T) ● Persists 7 days to 3 weeks
puncture wound ● Most indicative of myocardial
ii. NV : 2.75- 8 min damage

Serum Lipids ● Measures the cholesterol,

BOARD QUESTION: triglycerides and lipoprotein

What procedure is the bleeding time checked?

● Myoglobin
○ Cardiac enzyme but not very specific
Answer: Paracentesis, thoracentesis, pericardiocentesis, bone
○ Increases if px has renal and muscular disease
marrow aspiration

b. pTT

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RN MAY 2023: BATCH HIRAYA
Lecturer/s: Sir Pocholo Yamsuan

c. Catheter insertion at the best site towards the

Normal Levels
desired location → dye administration → series of
x ray
Cholesterol 200 mg/dl i. Femoral
ii. Subclavian
Triglycerides 40 - 150 mg/dl iii. Brachial
iv. Radial
LDL (bad) 130 mg/dl d. Pre test
i. Ensure consent
HDL (good) 30 - 70 mg/dl ii. Assess for allergy , seafoods and iodine
1. Once px is allergic →
prophylactic therapy of
Non Invasive Procedures
corticosteroids is given
1. ECG
2. Allergy is NOT an ABSOLUTE
a. Electrical activity of the heart
contraindication
P Wave (PSA) Depolarization from SA node to Atrium iii. Kidney Function test
1. Check for creatinine clearance
QRS Complex Depolarization of AV node to both Ventricles 2. Renal failure → hindi
(QAV) maeexcrete or maceclear ng
body ung dye
T Wave Repolarization of atrial contraction to beginning iv. NPO
Ventricular contraction
v. Document Weight , Height , VS and
peripheral pulses
PR Interval Beginning of atrial contraction to beginning
vi. Orientation
Ventricular contraction
1. Metallic taste
QT Interval Ventricular contraction from beginning of 2. Warmth and Fluttery feeling
ventricular depo to end of repo upon injection of dye.
3. Withholding of OHA 2-3 days
prior to procedure
2. Holter monitoring
a. Prevention of
a. Wearing holter monitor and records an ECG tracing
damage to the
record continuously for over 24 hours period.
kidney (excretion of
b. Maintain normal activity of the patient and keep of
dye)
his diary for the 24 hours period
b. To prevent lactic
c. Perform regular activities
acidosis
d. Diary (task, chest pain - yes or no & time, what did
e. Post test
you eat?
i. Monitor VS and Peripheral perfusion
e. Not accurate (px will be the one to input activities →
prone to manipulation)
3. Stress test BOARD QUESTION:
a. Evaluates heart during activity and detects and
evaluates CAD. The px had undergone catheterization via femoral artery where will
you check the pulse during VS monitoring?
b. Most common test : Treadmill testing
a. Popliteal
c. Prepare for possible emergency resuscitative b. Dorsalis pedis
equipment (pinapagod ung px) c. Brachial pulse
4. Echocardiogram
a. Studies the structural and functional changes of the Answer: B - Dorsalis pedis
heart with the use of Ultrasound. Artery carries oxygenated blood to supply for the body; once
b. Ultrasound of the heart checking for pulse rate assess for adequacy of peripheral perfusion
also so check the distal pulses below the femoral artery.
c. No preparation needed
If femoral lang nagcheck pwedeng ok pa ung perfusion pero hindi
Invasive Procedure na adequate enough to reach sa dorsalis pedis.
● Needs consent
DISTAL pulses!
1. Cardiac catheterization
a. Insertion of catheter into the heart and surrounding ii. Assess for hematoma and bleeding
vessels. tendencies
b. Injects dye into the coronary arteries and 1. Bleeding is normal s/p
immediately takes a series of x ray films catheterization but only within
or <4 mm

PASCUAL I PAULO I 5

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TOPRANK - CARDIOLOGIC NURSING

RN MAY 2023: BATCH HIRAYA
Lecturer/s: Sir Pocholo Yamsuan

2. Maintain Sand Bag or 1. Non modifiable

pressure dressing a. Age
Hemodynamic Monitoring b. Sex
1. CVP c. Race (american african)
a. Reflects the pressure in the Right Atrium d. Family history
b. It is a measurement of 2. Modifiable
i. Cardiac efficacy a. CV disease
ii. Blood volume i. HTN
iii. Peripheral resistance ii. Dyslipidemia
iv. Hydration status (fluid overload or b. Lifestyle
dehydration) i. Stress
c. NV : 2-8 cm H20 / 2-6 mmHg ii. Obesity
d. Decreased CVP = dec circulating volume → iii. High Na intake
dehydration iv. Smoking
e. Increased CVP = increase blood volume / RHF – c. DM
congestion i. Poor Medication Adherence
2. Pulmonary Artery pressure
a. Appropriate for critically ill patient to measure and Diagnostics
accurate assessment of the left heart pressure. 1. Blood pressure reading - only diagnostic test that could
determine if you have HTN

BOARD QUESTION:
Other Diagnostics Tests - helps management of ↑ BP
What type of catheter is used for the measurement of pulmonary 1. CBC
artery pressure? 2. Lipid profile
3. ECG
Answer: Schwam Ganz Catheter 4. Urinalysis
5. Glucose

Signs and Symptoms

CARDIAC DISORDERS AND DISEASES 1. Headache
2. Epistaxis
HYPERTENSION 3. Dizziness
● Abnormal elevation of Blood Pressure 4. Blurred vision - complication
● Narrowed passageway of blood → elevation of BP 5. Retinopathy - complication

Pathophysiology Complications
● Vasoconstriction → vasospasm → Increase PVR → decrease 1. Peripheral vascular disease
blood flow to the organ → heart compensates by pumping 2. Retinal damage
more blood 3. Nephrosclerosis
4. CVA
Etiology 5. Hypertensive heart disease
1. Primary Hypertension
a. Idiopathic HYPERTENSIVE CRISIS
i. Possible factors
1. Increase SNS activity Types
2. Increase Na retaining 1. Hypertensive urgency
hormone a. Manifest days to weeks
3. Increase alcohol consumption b. BP 180/110 mm/Hg
4. DM c. No organ damage
5. Obesity d. Pt can delay consultation (kayang tiisin)
2. Secondary hypertension 2. Hypertensive emergency
a. Identifiable causes (there is related reason) a. Manifest Hours to days
i. Contributing factors b. BP 220/140 mmHg
1. Kidney disease c. Potential organ damage
2. Neurologic disorder i. Encephalopathy
3. Coarctation of aorta ii. ICH
4. Drug iii. LVF
5. Pregnancy iv. MI
v. Renal failure
Risk Factors vi. Retinopathy
- Always assess what you can change for risk factors
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TOPRANK - CARDIOLOGIC NURSING

RN MAY 2023: BATCH HIRAYA
Lecturer/s: Sir Pocholo Yamsuan

Pathophysiology a. -olol
● Increased capillary permeability → symptoms of HTN b. 2 types
encephalopathy → cerebral Edema → damage to cerebral i. Cardio selective
function ii. Non cardioselective
1. Do not give to px with
Pharmacologic Interventions respiratory problems → may
lead to bronchospasm →
death
c. Contraindicated to those with respiratory diseases
d. Do not give if:
i. HR: <60 bpm
ii. BP: <90/60 mmHg
e. S/E:
i. Fatigue
ii. Impotence
5. Alpha 1 Adrenergic Blocker
a. -zosin
i. Prazosin
1. ACE Inhibitors ii. Terazosin
a. -pril iii. Doxazosin
i. Captopril b. Not first line of drugs
ii. Enalapril c. Not for long term use
iii. Perindopril
b. ↓ CO → ↓ BP
c. S/E: Dry cough
d. Fatal A/E: Angioedema
e. Contraindicated to pregnant women

6. Alpha 2 Adrenergic Agonist

a. Clonidine
b. Methyldopa
c. S/E: dry mouth
2. ARB 7. Calcium Channel Blockers (CCB)
a. -sartan a. Very Nice Drug
i. Losartan i. Verapamil
ii. Olmesartan ii. Nifedipine
iii. Telmisartan iii. Diltiazem
iv. Walsartan
b. Lesser S/E
c. Contraindicated to pregnant women
3. Direct Vasodilator
a. Not a first line DOF

8. Diuretics
a. Osmotic - mannitol (↓ IOP & ICP)
b. Combination ( K sparing + Loop Diuretics)
c. Most common electrolyte imbalance: K

4. Beta Adrenergic Blocker Non Pharmacological Management

PASCUAL I PAULO I 7

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TOPRANK - CARDIOLOGIC NURSING

RN MAY 2023: BATCH HIRAYA
Lecturer/s: Sir Pocholo Yamsuan

1. Reduce modifiable factors d. Alcohol intake

a. Avoid or cessation of smoking e. Drug abuse
i. Smoking → narrows blood vessels f. High fat diet
b. Reduce alcohol intake g. Obesity
i. 2 glass 3x times a week (240 ml per 2. Non modifiable
glass) a. Elderly
c. Avoid sedentary lifestyle b. Familial (genetics)
d. Promote exercise c. Sex
i. 30 mins 3x a week d. Race
ii. E.g. brisk walking, ADL
e. Weight control Signs and Symptoms
i. Weight management reduction program 1. Dyspnea
2. Healthy diet 2. Tachycardia
a. LSLF a. ↓ dec blood supply → ↓ O2 supply → hypoxia →
b. Increase in fruits and Vegetables compensatory mechanism of the heart is to pump
3. Maintain DM in control faster to meet the perfusion and O2 requirements
of the body
Interventions 3. Palpitations
1. Admission to hospital 4. Diaphoresis
2. Antihypertensive drugs 5. Chest Pain
3. Monitor for blood works
Diagnostic Test
Causes 1. Serum cholesterol
● Abrupt discontinuation of medications 2. Cardiac catheterization
● Poor management of HTN
Treatment
CORONARY ARTERY DISEASE / ISCHEMIC HEART DISEASE 1. Surgical
1. Atherosclerosis and Arteriosclerosis a. Percutaneous Transluminal Coronary angioplasty
2. Angina pectoris (PTCA)
3. Myocardial Infarction i. Mechanical dilatation of the coronary
vessel wall by compressing the
atheromatous plaque
AtherosclerosIs MyocardIal Injury
ii. Recommended for clients with single
AngIna PectorIs MyocardIal Ischemia vessel CAD

Myocardial Infarction Myocardial Necrosis = Cell Death

ATHEROSCLEROSIS
● Narrowing and hardening of coronary artery and plaque
formation.
● Lipid or fat deposits (FOOD intake)
● Tunica intima innermost layer

ARTERIOSCLEROSIS
● Hardening of artery
● Calcium and protein deposits
● Tunica media middle coat b. Intravascular stenting
i. is done to prevent restenosis after PTCA
Pathophysiology c. Coronary Artery Bypass Graft Surgery
● Blood vessel occlusion → Dec blood flow → Dec O2 supply i. Greater and lesser saphenous veins are
→ Ischemia → Anaerobic respiration → Lactic acid formation commonly used for bypass graft
→ toxic → Lactic acidosis → chest pain → angina pectoris procedures
● Atherosclerosis is asymptomatic at first but if the occlusion is ii. 2 or more vessel occlusion
severe only then will s/sx occur iii. 3 complications of CABG
1. Pneumonia
Predisposing Factors 2. Shock
1. Modifiable 3. Thrombophlebitis
a. Sedentary lifestyle 2. Medical
b. Stress a. DOF: -statins
c. Smoking 3. Nursing Considerations

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Lecturer/s: Sir Pocholo Yamsuan

a. STATINS should be given HS (hour of sleep)

(can be occurrence angina (w/o
b. Monitor for side effect : Blurred Vision
relieved by and in severity exertion)
i. If rx is given at night → risk for injury rest)
ii. Avoid driving <15 mins > 30
iii. Avoid operating heavy machinery Resolves <15 mins
iv. Avoid alcohol mins
c. Health teaching
i. Lifestyle modifications ECG Finding ● ST ● ST ● Transient
1. Low fat diet depression depression ST
● T wave ● ST elevation
2. Smoking and alcohol
inversion elevation
cessation ● T wave
3. Active lifestyle (20 - 30 mins inversion
per day)
4. Stress management
Risk Factors
5. Weight management program
1. Non modifiable
2. Modifiable
ANGINA PECTORIS
● Chest pain is produced by insufficient blood flow to the
4 E’s of Angina Pectoris
myocardium
1. Excessive physical exertion
● Reversible damage to the Heart.
a. Nag effort ung puso masyado due to physical
exertion
Pathophysiology
2. Exposure to cold environment
● Risk Factor (Atherosclerosis) plaque deposition in the arteries
3. Extreme emotional response
>> Dec blood flow to the heart >>> Decreased oxygen supply
4. Excessive intake of foods or heavy meal
>> increases Oxygen demand >> Myocardial Ischemia >>
a. Higher O2 demand
Necrosis

Signs and Symptoms

Screening Tests / Diagnostic Test
1. Common symptoms
● Diagnosis is a combination of proper and accurate hx taking
a. Shortness of Breath
and diagnostics / screening tests (not diag tests alone)
b. Dull, Substernal pain that can radiate jaw,,
1. ECG
shoulder and arm
a. ST elevation or normal ECG in some clients
c. Pressure and discomfort
2. Exercise tolerance test Treadmill Test
d. Gets worse with exertion
a. Is the heart compensating with work / stress?
e. Improves with rest and nitroglycerin.
3. Confirmatory : Coronary Angiogram
2. Atypical symptoms
4. Serum Lipid Profile levels
a. Vomiting
b. Weakness
Types of Angina
c. Fainting ( elderly and DM )
1. Stable angina
a. Pain is less than 15 min , less frequent in
Management
occurrence
1. Goal
2. Unstable angina
a. provide relief from acute episode of angina
a. Pain is more than 15 min, but not with more than 30
b. identify the cause and balance the supply and
min, more frequent and intensity of pain increases.
demand of oxygen
3. Variant angina
c. prevent any further damage to myocardium
a. AKA Prinz metal angina
d. reduce the risk of future episode through health
b. Longer in duration , may occur at rest .
education.
c. Result from coronary vasospasm.
2. Acute episodes
a. Nitroglycerin
Types of Stable Unstable Prinzmetal i. Nitrates
Angina Angina Angina Angina ii. Causes vasodilation → prevents Mi
3. Additional medical therapy
Description Inadequate Inadequate Due to spasm a. Antiplatelet
blood supply blood supply of coronary
b. Anticoagulant
artery
c. ACE Inhibitors
d. ARB
Causes Due to Unpredictable Can occur at
exertion / pattern rest e. Beta adrenergic Blockers
stress f. CCB

Pattern Stable pattern Increase in Atypical Nitrates

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RN MAY 2023: BATCH HIRAYA
Lecturer/s: Sir Pocholo Yamsuan

● Coronary vasodilation → Decrease preload and afterload →

Inc blood flow → Inc oxygen supply
● Peripheral vasodilation → Dec cardiac workload → Dec O2
demand → lesser chance to progress to myocardial ischemia
● Side effects:
○ Dizziness and Blurry vision
○ Orthostatic hypotension
■ Priority is Safety !
■ Avoiding of driving, operating heavy
machineries
■ Avoid drinking alcohol

NTG Tablet
● Sublingual
○ Dark colored container (amber colored)
○ Change every 6 months
■ Exposure to sunlight may damage the
chemical component → decreased
potency
○ Dry place and avoid moisture to sunlight

BOARD QUESTION:

Where will you place NTG tablets?

a. Bedside
b. Bathroom

Answer: medication cabinet in the bathroom

● For storage purposes only
● Palaging naka on ang light sa bedroom

○ Offer sips of water before giving sublingual

medication
○ S/E orthostatic hypotension
■ Sudden drop of BP > 20 mmHg
■ Best position : rise slowly from sitting Non Pharmacological Interventions
position 1. Oxygen inhalation
● Dangle legs at beside to 2. Position : semi fowlers to high fowler's position
prevent orthostatic 3. Monitor VS , I and O , ecg tracing and CP function
hypotension 4. Lifestyle modifications
● NTG patch a. Most crucial
○ Given once a day in a non hairy areas, non bony, 5. Health teaching
non greasy areas a. Avoidance of 4E so f Angina pectoris
○ No of hours: b. Prevent complication
■ 10 14 hrs free from nitrates to prevent c. Reduce stress and anxiety
tolerance d. Smoking cessation
■ > 24 NTG patch = rebound phenomenon e. Ff up care
→ ↑ chest pain
● Effectiveness MYOCARDIAL INFARCTION
● Death of myocardial cells from inadequate oxygenation often
○ Must feel burning/tingling sensation, every 5
caused by sudden complete blockage of coronary artery
minutes, max. of 3 doses
● Terminal stage of CAD
■ 1st dose - 6pm
● Pathophysiology
■ 2nd dose - 6:05 pm
○ Ischemia → injury→ necrosis → infarction
● Call for help
■ Prolonged ischemia → MI
■ 3rd dose - 6:10 pm
■ ↓ O2 (angina pectoris) + build up of fat &
● OTW to hospital
Ca in BV (atherosclerosis) = ischemia =
MI
Pharmacological Interventions

Types of Myocardial Infarction

1. Transmural MI

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a. Most dangerous type characterized by occlusion of cardiac demand to meet O2

both RCA and LCA requirements
b. 2 BV affected iv. Withdrawal symptoms
c. Subject for CABG 1. Irritability
2. Subendocardial MI 2. altered loc
a. Occlusion of either Right or Left coronary Artery 3. Headache
b. 1 BV affected 4. Diaphoresis
c. Subject for stenting v. Toxicity : Depressed vs RR HR AND BP
vi. Antidote : Naloxone (Narcan)
Predisposing Factors c. Oxygen inhalation
1. Sex d. CBR without BRP
2. Race e. SFP
3. Smoking f. Avoid forms of Valsalva maneuver
4. Obesity i. Stool softener (prevent straining)
5. CAD
6. Thrombus formation Medical Management
7. Hyperlipidemia 1. Vasodilators
a. NTG
Signs and Symptoms b. ISOSORBIDE Dinitrates
1. Chest pain c. Isordil ( SL )
a. Excruciating visceral viselike pain with sudden 2. Antiarrhythmic agents
onset located at substernal and rarely a. Lidocaine
precordial 3. Beta Blockers
b. Radiates from neck back , shoulder , arms , jaw and a. Propranolol
abdominal muscles 4. ACE inhibitors
c. Not usually relieved by rest or nitroglycerine a. -pril
2. Nausea and vomiting 5. Calcium antagonist
3. Dyspnea a. -difine
4. Hypertension , then gradual drop 6. Thrombolytics
a. Obstruction of O2 a. -kinase
5. Hyperthermia 7. Anti coagulant
6. Cool , clammy skin a. Heparin
a. Due to hypoxia b. Warfarin
8. Antiplatelet
a. ASA
Diagnostic Test b. Clopidogrel
1. Cardiac enzymes 9. Health teaching
2. ECG a. Diet - LSLF, High fiber
3. Cholesterol levels i. High fiber to prevent straining
4. CBC → increase WBC b. Activity
a. Secondary to inflammation i. Sex needs clearance prior
c. Prevention
Interventions
● MONOTAS PERICARDITIS
○ Morphine ● Inflammation of the pericardium which occurs approximately
○ O2 1 - 6 week after MI
○ Nitrates ● Result as an antigen antibody response.
○ Antiarrhythmic
○ Thrombolytics Signs and Symptoms
○ Anticoagulants 1. Pain in the anterior chest , aggravated by coughing, yawning,
○ Stool softener swallowing, twisting, and turning the torso relieved by upright
1. Decreased cardiac workload , leaning forward position
a. IV line 2. Pericardial friction rub scratchy grating sound
b. Morphine sulfate 3. Dyspnea
i. Opioid analgesic - addictive 4. Fever
ii. Decrease CNS function - dec RR , HR 5. Sweating and chills
and BP → cardiac workload , decreased 6. Joint pains
O2 demand 7. Arrhythmias
iii. Morphine is given not because of the
pain but to ↓ cardiac workload = ↓

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a. Pwedeng makita
4. Hemodynamic Monitoring

Signs and Symptoms

1. Becks Triad
a. Jugular vein distention
b. Distant heart sound (muffled heart sound)
c. Hypotension
2. Pulsus paradoxus
3. Tachycardia
4. Breathlessness
5. Decreased LOC

Nursing Intervention
1. Oxygen therapy
Nursing Intervention 2. Elevate the head of the bed. Place the pillow in the over bed
1. Elevate the head of the bed so that patient can lean on it.
a. For proper vasodilation 3. Bed rest
2. Bed rest 4. Pericardiocentesis
3. Administer medications a. Removal of pericardial fluid
a. ASA suppress inflammatory response b. No preparation
b. Corticosteroids
4. Assist in pericardiocentesis
a. Normal pericardial fluid: 10 - 15
b. Pericardial effusion: >15 - 30
c. Cardiac Tamponade: > 30

CARDIAC TAMPONADE
● AKA pericardial tamponade
● > 30 pericardial fluid
● Emergency situation
● Fluid accumulation in the pericardium
● Interfere with ventricular filling and pumping as
● The pericardium does not stretch.

Predisposing Factors
1. Chest trauma
2. Myocardial rupture
3. Cancer
4. Pericarditis
a. Unresolved issue
5. Cardiac surgery
6. Thrombolytic therapy

Diagnostic
1. ECG ( Diffuse ST segment elevations )
2. Echocardiogram
a. Confirmatory
3. Chest X Ray

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10. Hepatomegaly - right

HEART FAILURE 11. anorexia , weight loss, weakness due to decreased
● Occurs when heart cannot meet body's oxygen demand metabolism - right
● No proper pumping capacity (inadequacy) 12. Clubbing of fingers - left
13. Splenomegali right
Pathophysiology 14. Central venous pressure 15 cm H20 - right
● Reduced pumping efficacy of the LV → Decrease CO → 15. Pulmonary artery pressure 25 mmHg - left
backflow occurs (regurgitation) → LVF or RVF 16. Hemoptysis - left
17. Yellowish sclera - right
Definitions 18. O2 saturation 90% - left
● Acute HF 19. Faintness - left (fainting due to cerebral hypoxia)
○ Sudden deterioration of Signs and Symptoms of HF 20. Internal hemorrhoids - right
● Chronic HF
○ A long term condition of the heart that is Non Pharmacological Interventions
characterized by decreased pumping power of the 1. Diet ; salt restriction = 1.5 2g Na/day
cardiac muscle a. Prevent water retention
○ Secondary to HTN, MI 2. Eliminate high salt foods
● Cor Pulmonale 3. Fluid restriction
○ Enlargement of the Right side of the heart due to 4. Frequent weight monitoring
Pulmonary Congestion a. Accurate indicator of congestion
Etiology 5. Control HF risk factors
1. Uncontrolled hypertension
2. High fluid or high sodium intake
a. Water follows (water retention)
3. Cardiac events
4. Anemia , stress , infections and thyrotoxicosis
5. Medications

Diagnostic
1. JVD (Jugular Vein Disten)
a. most reliable sign of fluid Overload, 4cm distention
in 45 degree angle
2. ECG
3. ECHO
a. determine wall thickness chamber size, most
sensitive test for HF
b. EF (Normal: 55 - 80)
4. BNP (B-Type Natriuretic PeptideBiomarker) for Diagnosis of
HF
a. Normal value <100NG/ML
b. Indicator that there is fluid congestion

Signs and Symptoms

UDAN Concept:
1. Right sided CHF
a. “VENOUS BACK - UP”
b. “SYSTEMIC MANIFESTATIONS”
2. Left sided CHF “ LEFT LUNGS”
a. “CELLULAR HYPOXIA”
b. “RAAS ACTIVATION” (HPN, HypoK)

Drills
1. Jugular vein distention - right
2. Needs 3 pillows for sleeping (orthopnea)- left
3. Leg edema - right
4. Rales / crackles - left
5. Portal hypertension - left
6. Severe anemia - right
7. BP 150/100 mmHg - left
8. Hypokalemia - left - Diuretics to decrease fluid congestion
9. Polycythemia - right

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- Common electrolyte imbalance due to diuretics: Potassium

(hypokalemia)

- DOC for HF

Digitalis
● MOA: PINC = Positive Inotropic , Negative Chronotropic
○ Pababagalin ung tibok ng puso pero papalakin ung
contraction
● Normal level= 0.5 - 1.5 ng/dl
● Antidote: Digibind

Nursing Considerations
1. Monitor HR before administration. Withhold if HR is <60bpm
2. Increase potassium in Diet
a. If low K → increased chances for toxicity
3. Monitor for digitalis Toxicity
a. V-Visual disturbances ( halo around light , green
halo lights )
i. Most common
b. A-Anorexia
c. N-Nausea and Vomiting
i. Most common
d. D-Diarrhea
e. A-Abdominal Discomfort

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